Medical Mystery: What caused woman’s arm pain and weakness?

Ebony is a 51-year-old physician who had been experiencing arm pain and weakness for about a year. During that time, the pain had become worse, radiating to the shoulder blade and down the arm. The problem was starting to interfere with her work as an internal medicine physician, as well as her sleep, care of her family, and her hobbies. She had previously seen a neurosurgeon in New Jersey and was being evaluated for neck and shoulder problems.

The neurosurgeon performed an evaluation and ordered an MRI of her shoulder, which was normal, and her back, which showed a mild disc bulge in her cervical spine. Based on the severity of symptoms her surgeon thought that a cervical spine surgery was needed. She underwent a cervical spine decompression and fusion. After surgery, she had an uneventful recovery; however, the arm pain, stiffness and weakness persisted.

Ebony was referred to me three months after her neck surgery for a second opinion. She continued to have arm pain and, more concerning, severe stiffness of the shoulder.

On her exam she had 85% loss of motion in her shoulder with significant pain when attempting to perform any physical maneuvers with the arm. Pain radiated from the base of her neck and shoulder blade down to the forearm. The hand felt weak but on examination there was no objective evidence of any hand numbness or weakness. X-rays of her shoulder showed no evidence of arthritis. The MRI was also reviewed and showed normal soft tissues and cartilage.

In discussing her medical history, Ebony said she had a history of thyroid dysfunction, which proved integral to determining a diagnosis.

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It became very obvious to me at that point that she had frozen shoulder (medically called adhesive capsulitis). She had the classic presentation as far as age, gender, medical history, physical examination findings, and imaging studies.

Frozen shoulder is a common diagnosis that is often misdiagnosed for a variety of reasons. It affects about 2% of the population, mostly women in their 40s and 50s with a history of autoimmune disorders, such as diabetes, or in Ebony’s case, thyroid dysfunction.

Patients often develop frozen shoulder through injury or for no clear reason. It is an autoimmune mediated inflammation that targets the shoulder capsule or lining. The capsule goes from being a wispy tissue paper-like structure to a much thicker band of tissue with texture more like a piece of cardboard. Visually, if you had a camera to look inside the shoulder, the capsule (which usually is white like the sclera of your eye) becomes red and inflamed like pink eye.

Most patients start by having the onset of slow progressive pain, which eventually is complicated by stiffness and sometimes complaints of weakness. The problem can be mild in some patients but severe in others, especially in patients with insulin dependent diabetes mellitus.

The silver lining is that it eventually resolves and never recurs in the same arm. However, it can take anywhere from 18 months to five years to fully resolve. The bad news is there is a 15% chance of occurring in the opposite arm during a patient’s lifetime.

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This problem is often missed by a variety of physicians, including orthopedic specialists. The doctor must evaluate the physical exam and MRI in the context of the patient’s history. Often that history and exam are what solidify the diagnosis.

Ebony was at first skeptical and confused, given the mixed messages she was receiving from her neurosurgeon and from me. But after discussing this, she realized that this, indeed, was the right diagnosis.

Given the severity of her symptoms and their impact on her quality of life, we talked about what treatment made the most sense. Early on, a onetime cortisone injection can help symptoms and potentially accelerate recovery, but at the time of her diagnosis, this option was no longer helpful. We also talked about a short outpatient procedure to release the thickened, inflamed capsule we see in frozen shoulder.

Ebony elected to undergo arthroscopic surgery and we were able to release the adhesion around her shoulder to the point where we had her range of motion back to her baseline. Immediately after surgery (within one to two days) we started Ebony in physical therapy to maintain the range of motion we had attained. At her first postoperative visit Ebony felt markedly improved as far as stiffness, pain, and weakness. At eight weeks post-op, she felt normal and was very satisfied and grateful to be back to her normal life.

Joseph Abboud is a board certified orthopaedic surgeon at Rothman Orthopaedic Institute who specializes in the treatment of patients with shoulder and elbow disorders.