Based on the information provided, the patient’s symptoms and history suggest a possible shoulder injury. The limited range of motion (ROM), initial improvement with treatment, followed by a sudden onset of severe pain and return of limited ROM raises concerns for a specific diagnosis. However, it is important to consider multiple differential diagnoses and rule them in or out.
Diagnosis: Rotator Cuff Tear
The most likely diagnosis in this case is a rotator cuff tear. The mechanism of injury, fall with outstretched arm, is a common cause of rotator cuff tears. The limited ROM, initially improving with treatment but returning three months later with severe pain, is consistent with the progression of a rotator cuff tear. The negative x-ray ruling out fractures supports this diagnosis as well.
Treatment Plan:
Referral to an Orthopedic Specialist: Given the severity of symptoms and the possibility of a rotator cuff tear, it is crucial to refer the patient to an orthopedic specialist for further evaluation and management.
Imaging: The orthopedic specialist may order additional imaging tests such as an MRI or ultrasound to confirm the diagnosis and assess the extent of the rotator cuff tear.
Non-Surgical Treatment: Depending on the size and severity of the tear, conservative treatment options may be considered initially. These can include physical therapy to improve range of motion and strengthen the shoulder muscles, along with pain management through medications and anti-inflammatory drugs.
Surgical Intervention: If conservative measures fail to provide significant improvement or if the tear is large or complete, surgical intervention may be necessary. Surgical repair of the rotator cuff tear can be performed arthroscopically or through open surgery, depending on the specific characteristics of the tear.
Differential Diagnoses:
Adhesive Capsulitis (Frozen Shoulder): Adhesive capsulitis is characterized by pain, stiffness, and limited range of motion in the shoulder. However, the sudden onset of severe pain and return of limited ROM after a period of improvement make this diagnosis less likely.
Glenohumeral Joint Dislocation: While shoulder dislocation can cause limited ROM and severe pain, it is typically accompanied by visible deformity or swelling, which is not mentioned in the case. Furthermore, the absence of a fracture on x-ray makes this diagnosis less likely.
Biceps Tendonitis: Biceps tendonitis can cause shoulder pain and limited ROM, especially with overhead activities. However, the sudden onset of severe pain and return of limited ROM after an initial improvement are not typical for biceps tendonitis.
Conclusion:
The most likely diagnosis for this patient’s symptoms is a rotator cuff tear. Further evaluation by an orthopedic specialist is necessary to confirm the diagnosis through imaging and determine the appropriate treatment plan, which may include non-surgical measures or surgical intervention depending on the severity of the tear. Adhesive capsulitis, glenohumeral joint dislocation, and biceps tendonitis are less likely differentials that may need to be ruled out through clinical evaluation and additional diagnostic tests if necessary.
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