How did it begin?
Gradual or traumatic onset; surgery, immobilisation, illness or another precipitating event.
PROFESSIONAL CLINICAL RESOURCE
Clinical assessment and differential considerations
A structured framework for recognising a frozen-shoulder presentation, identifying competing explanations and deciding when investigation or referral is appropriate.
HISTORYUnderstand onset, trajectory, irritability and context
EXAMINATIONCompare active and passive movement without forcing
REASONINGInterpret findings as a pattern—not an isolated test
SUBJECTIVE ASSESSMENT
Build the clinical story first.
The history should establish the presentation, relevant risk context, functional effect and features that do not fit a typical course.
How is it changing?
Relative behaviour of pain and stiffness, night symptoms, fluctuation and duration.
What matters to the person?
Dressing, hygiene, sleep, driving, work, caring roles, recreation and recovery priorities.
What modifies probability or care?
Diabetes, thyroid disease, previous shoulder problems, medication, systemic symptoms and comorbidity.
PHYSICAL EXAMINATION
Examine progressively and respectfully.
Select examination components according to the history, irritability, scope and the information needed for a decision.
Observe
Spontaneous use, guarding, scapular or trunk substitution, swelling, deformity and general presentation.
Assess active movement
Range, symptom response, movement strategy and willingness in relevant planes.
Assess passive movement
Available range, pain, resistance and side-to-side pattern without forcing a highly irritable shoulder.
Test selectively
Strength, cervical, neurological, elbow or other shoulder components where they inform a differential or referral decision.
ACTIVE AND PASSIVE RANGE
Why the comparison matters.
Restriction of both active and passive glenohumeral movement supports a capsular restriction pattern, but does not operate as a stand-alone diagnostic test.
The person moves the arm.
Pain, weakness, confidence, motor strategy and joint restriction can all influence available movement.
The relaxed arm is moved.
Frozen shoulder typically restricts this range as well, with external rotation commonly prominent in the pattern.
Interpret range in the context of irritability, measurement method, scapular contribution, end-feel limitations and the complete examination. Avoid turning one movement threshold into a universal diagnostic rule.
DIFFERENTIAL CONSIDERATIONS
What else may explain stiffness or limited use?
Alternatives may mimic frozen shoulder, coexist with it or require a different investigation and management pathway.
Glenohumeral osteoarthritis
Pain and passive stiffness with radiographic joint change.
Rotator-cuff-related disorder
Pain or weakness may limit active movement more than passive range.
Large rotator-cuff tear
Marked active-passive discrepancy and weakness may warrant further evaluation.
Calcific tendinopathy
Potentially severe pain and guarded movement, sometimes with a more acute course.
Cervical or neurological source
Neck features, altered sensation, reflex change or neurological weakness.
Trauma or instability event
Fracture, dislocation, structural injury or apprehension requires an appropriate pathway.
Inflammatory or infective process
Systemic illness, hot swollen joint or multisite symptoms change urgency and reasoning.
Postoperative or secondary stiffness
Interpret within the procedure, tissue-healing, immobilisation and complication context.
Non-musculoskeletal referral
Cardiopulmonary or other referred presentations must remain within the safety screen.
INVESTIGATION
Use imaging to answer a question.
Frozen shoulder remains primarily a clinical diagnosis. Investigation should be guided by uncertainty, differential considerations and the decision it will influence.
Exclude or identify bony pathology.
May help when osteoarthritis, fracture or another osseous explanation is relevant. Routine X-ray practice varies across pathways.
Use as an adjunct—not a solitary diagnosis.
Consider when another soft-tissue disorder is suspected or the result will change management.
Follow the broader clinical picture.
Not used to confirm frozen shoulder; may be relevant when metabolic, inflammatory, infective or systemic concerns arise.
DOCUMENTATION
Record what supports the decision.
Repeatable documentation improves review, communication and shared decision-making.
01
Onset, trajectory, irritability, night symptoms and relevant health context
02
Functional limitations, participation restrictions and personally meaningful goals
03
Active and passive movement method, pattern, symptom response and substitutions
04
Selected strength, cervical, neurological or other findings relevant to the differential
05
Working diagnosis, uncertainty, alternatives considered and safety-screen findings
06
Information provided, options discussed, consent, plan, review point and escalation criteria
ESCALATION AND REFERRAL
Act when the pattern is not routine.
Urgent or expedited pathways may be required for significant trauma, suspected fracture or dislocation, acute neurological deficit, infection, systemic illness, malignancy concern or cardiopulmonary referral features.
Non-urgent escalation may be appropriate where diagnostic uncertainty persists, function remains substantially limited, progress is not consistent with expectations, or investigation or intervention lies outside the clinician's scope.
Stage-based reasoningMove from assessment to management →Exercise and rehabilitationApply findings to progression →Professional CentreReturn to all clinical resources →
Key sources
- British Elbow and Shoulder Society patient care pathway: Frozen shoulder
- Clinical practice guideline for diagnosis and non-surgical treatment of primary frozen shoulder
- Diagnosis and clinical assessment of a stiff shoulder
- AAOS: Frozen Shoulder
Professional education only. Apply within qualification, scope, local guidance and the complete individual assessment. This resource does not create a universal diagnostic or referral protocol.