From the Guidelines
The diagnosis of frozen shoulder is primarily clinical, relying on specific physical examination tests, with imaging studies like MRI or ultrasound used to rule out other conditions when necessary. The most reliable physical examination tests include the passive range of motion test, which reveals significant limitation in external rotation, abduction, and internal rotation of the shoulder; the capsular pattern test, showing greater limitation in external rotation than abduction; and the Apley scratch test, where patients cannot reach behind their back 1. Additional diagnostic maneuvers include the shoulder shrug sign (compensatory scapular elevation during attempted abduction) and the coracoid pain test (tenderness over the coracoid process).
When it comes to imaging, the American College of Radiology suggests that MRI shoulder without contrast and ultrasound shoulder are equivalent and usually appropriate for evaluating questionable bursitis or long head of biceps tenosynovitis based on clinical findings, including physical examination 1. However, for traumatic shoulder pain, radiography of the shoulder is the most appropriate initial study, and in the setting of nonlocalized shoulder pain and negative radiographs, MRI of the shoulder without IV contrast is the most appropriate study 1.
Key points to consider in diagnosing frozen shoulder include:
- Performing physical examination tests bilaterally to compare with the unaffected shoulder
- Using imaging studies to rule out other conditions like rotator cuff tears or osteoarthritis
- Recognizing the characteristic pattern of progressive pain and stiffness followed by gradual resolution
- Considering the freezing, frozen, and thawing phases of the condition for appropriate treatment planning. Given the evidence, MRI or ultrasound are the preferred imaging modalities when needed, due to their high rating of appropriateness and low radiation levels 1.
From the Research
Diagnosis of Frozen Shoulder
- The diagnosis of frozen shoulder is based on pattern recognition and physical examination 2
- 'Rule-in' and 'rule-out' criteria can be used to increase the likelihood of the frozen shoulder diagnosis 2
- Imaging plays an ancillary role to narrow the differential diagnosis 3
- Diagnosis is clinical based on global motion restriction and pain 3
Physical Examination
- Physical examination is crucial in diagnosing frozen shoulder 2, 3
- The diagnosis is heavily based on physical examination and can be difficult depending on the stage of disease or if concomitant shoulder pathology is present 4
Tests for Frozen Shoulder
- There is no specific test mentioned in the studies for frozen shoulder, but physical examination and imaging are used to aid in diagnosis 2, 3, 4
- The studies focus more on the treatment and management of frozen shoulder rather than specific tests for diagnosis
Treatment and Management
- Treatment modalities for frozen shoulder include medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic capsular release, and open capsular release 5
- Conservative management leads to improvement in most cases, but the most effective treatment in isolation is uncertain 5, 6
- Physical therapy, nonsteroidal anti-inflammatories, and injection therapies are standard treatments, although none have been shown to alter the long-term course of the condition 3