Step 2: Examination
Examination shows a reduced range of movement of the right shoulder, with a 30 degree loss of abduction and a 20 degree loss of external rotation to passive and active movement. The shoulder joint itself is a little tender but you don’t notice any mass, swelling or effusion on your this exam. There is little else to find, he is a fit and well 52 year man.
Adhesive Capsulitis (“Frozen Shoulder”) would certainly be at the top of my list. It can be precipitated by a minor trauma and persist for 18-24 months. The loss of external rotation is common. I would also consider osteoarthritis as a cause of loss of range of movement. Other possibilities would include an unrecognized fracture that has gone on to heal or an injury to the rotator cuff.