What are the signs of frozen shoulder on physical examination?

Signs of Frozen Shoulder on Physical Examination

The hallmark examination finding in frozen shoulder (adhesive capsulitis) is restricted passive range of motion in a characteristic capsular pattern, with external rotation most severely limited, followed by abduction, then internal rotation. 1

Key Physical Examination Findings

Range of Motion Restrictions (Capsular Pattern)

• External (lateral) rotation is the most significantly affected motion and relates most strongly to the onset of shoulder pain 2, 1
• Abduction is severely restricted, particularly in the frozen stage of adhesive capsulitis 2
• Internal rotation is limited but typically less than external rotation and abduction 1
• Both active and passive range of motion are significantly reduced in all planes 3, 4
• The restriction follows a predictable capsular pattern that distinguishes frozen shoulder from other shoulder pathologies 1

Pain Characteristics on Examination

• Pain is present throughout the range of motion, particularly at end-range movements 3
• Pain at night is a prominent feature and correlates with the degree of motion restriction 5
• The shoulder demonstrates stage-dependent pain intensity, with worsening pain in the "freezing" stage 3
• Pain may limit accurate assessment of true passive range of motion due to muscle guarding 5

Additional Examination Findings

• No focal weakness is typically present, distinguishing frozen shoulder from rotator cuff pathology 6
• No swelling or atrophy is commonly observed 6
• Tenderness is generally diffuse rather than localized to specific structures 7
• The glenohumeral joint demonstrates global restriction rather than isolated plane limitations 4

Clinical Pearls and Diagnostic Considerations

Distinguishing Features

• The capsular pattern (external rotation > abduction > internal rotation) is pathognomonic for adhesive capsulitis and helps differentiate it from rotator cuff tears, impingement, or labral pathology 1
• Unlike rotator cuff dysfunction, patients with frozen shoulder do not demonstrate focal weakness with specific resistance testing 6
• The restriction is present in both active and passive motion equally, unlike conditions where active motion is more limited than passive 3, 4

Common Pitfalls to Avoid

• Pain and muscle contraction can falsely limit the apparent passive range of motion during examination 5
• Attempting to force motion during examination can worsen inflammation and pain 3
• Do not confuse frozen shoulder with rotator cuff pathology—the latter shows focal weakness and may have preserved passive motion 6
• External rotation measured in the supine position with the arm at the side is the most reliable measurement 2

Stage-Specific Examination Findings

• "Freezing" stage (first 4-6 months): Progressive loss of passive motion with worsening pain 3
• "Frozen" stage (months 4-12): Continuing stiffness with improvements in pain and inflammation 3
• "Thawing" stage (months 12-24): Gradual increase in range of motion with decreased pain 3

Structures Involved

• The rotator interval and axillary recess demonstrate capsular thickening and contracture 2
• When shoulder-hand syndrome is present, metacarpophalangeal and proximal interphalangeal joints may show pain, tenderness, and edema 2