Frozen shoulder, also known as adhesive capsulitis, is characterized by stiffness, pain, and limited range of motion in the shoulder joint. The condition often progresses through three stages: freezing, frozen, and thawing, each with distinct clinical features. A thorough assessment, including both subjective and objective components, is essential for accurate diagnosis and effective management.
Here is a detailed, step-by-step guide to conducting both the subjective and objective assessments for frozen shoulder.
Subjective Assessment for Frozen Shoulder: A Step-by-Step Guide
The subjective assessment involves gathering comprehensive patient history and understanding the patient’s experience with their condition. This will guide the objective examination and help in formulating a diagnosis.
Step 1. Chief Complaint and History of Present Illness:
– Ask the patient to describe their main concern regarding their shoulder.
– Explore the onset, duration, and progression of symptoms.
– Example questions: “When did you first notice pain or stiffness in your shoulder?”, “How has your pain or stiffness changed over time?”, “Can you describe any activities or positions that make your symptoms better or worse?”
Step 2. Pain Assessment:
– Use a pain scale (e.g., Numeric Pain Rating Scale) to quantify pain intensity.
– Ask about the nature of the pain (sharp, dull, aching), its location, and any radiation.
– Inquire about pain patterns, including aggravating and alleviating factors, and whether the pain is worse at night or during certain activities.
– Example questions: “On a scale from 0 to 10, how would you rate your pain right now? How about at its worst?”, “Is the pain constant or does it come and go?”, “Do you feel pain more at night or during specific activities?”
Step 3. History of Trauma or Injury:
– Determine if there was any history of trauma, surgery, or significant injury to the shoulder or upper extremity.
– Ask about previous dislocations, fractures, or surgeries.
– Example questions: “Have you ever had an injury or surgery on this shoulder?”, “Did you experience a specific event or injury that caused your symptoms?”
Step 4. Functional Impact and Activity Limitation:
– Discuss how the shoulder symptoms affect daily activities, work, and recreational activities.
– Explore the impact on specific movements like reaching overhead, dressing, grooming, or lifting.
– Example questions: “What activities are most difficult for you because of your shoulder?”, “Are there any tasks you are unable to do now that you could do before?”, “Does your shoulder pain limit you from performing activities at work or during sports?”
Step 5. Medical and Surgical History:
– Gather information about the patient’s overall health, including any previous medical conditions, surgeries, or hospitalizations.
– Ask about conditions that might predispose them to frozen shoulder, such as diabetes, thyroid disorders, or cardiovascular diseases.
– Example questions: “Do you have any other medical conditions, such as diabetes or thyroid problems?”, “Have you had any recent surgeries or hospitalizations?”
Step 6. Medication Use:
– Inquire about current medications, including those taken for pain or inflammation.
– Ask if they are using over-the-counter or prescription pain relievers.
– Example questions: “Are you taking any medications for your shoulder pain or other conditions?”, “Do you take any anti-inflammatory medications or painkillers?”
Step 7. Social History and Lifestyle:
– Discuss the patient’s lifestyle, including occupation, hobbies, physical activity level, and daily routines.
– Consider psychosocial factors such as stress, support systems, and coping mechanisms.
– Example questions: “What do you do for work, and does your job involve any repetitive shoulder movements?”, “What hobbies or activities do you enjoy, and are they affected by your shoulder pain?”
Step 8. Family History:
– Inquire about any family history of shoulder problems or systemic conditions that could be relevant.
– Example questions: “Do any of your family members have a history of shoulder problems?”, “Is there a family history of conditions like diabetes or thyroid disorders?”
Step 9: Red Flag Screening
– Conduct a comprehensive screening to identify any red flags that may suggest serious underlying conditions requiring urgent medical attention.
– Key red flags for shoulder pain include:
— Severe, unrelenting pain not relieved by rest or position changes.
— Recent or significant trauma to the shoulder.
— Unexplained weight loss or history of cancer.
— Bowel or bladder dysfunction (e.g., potential systemic illness).
— Fever or systemic symptoms (potential infection).
– Example findings: “No red flags were identified during the examination.”
Step 10. Review of Systems:
– Perform a brief review of systems to identify any other health issues that may be related to or impact the shoulder condition.
– This includes cardiovascular, respiratory, gastrointestinal, genitourinary, neurological, and musculoskeletal systems.
– Example questions: “Have you experienced any chest pain or discomfort?”, “Have you noticed any other symptoms, such as numbness, tingling, or weakness in your arm?”, “Do you have any other pain or discomfort in your body?”
Step 11: Closing the Subjective Assessment
Summarize Findings:
— Recap the main points of the subjective assessment to confirm your understanding of the patient’s symptoms and concerns.
— Example Statement: “To summarize, you’ve been experiencing stiffness and pain in your shoulder, particularly noticeable when you try to move your arm. This has been ongoing for several months and seems to be progressively limiting your shoulder movement.”
Explain Next Steps:
— Outline the forthcoming steps in the assessment, including the physical examination and any further tests or evaluations that might be needed.
— Example Statement: “Next, we’ll perform a physical examination to assess the range of motion and any specific areas of discomfort in your shoulder. Based on our findings, we’ll discuss the most appropriate treatment plan to help improve your shoulder function.”
By following these steps, you will complete a thorough and detailed subjective assessment that will offer essential insights for diagnosing and managing frozen shoulder.
Objective Assessment for Frozen Shoulder: A Step-by-Step Guide
The objective examination aims to assess the physical findings and functional limitations associated with frozen shoulder. It involves inspection, palpation, range of motion testing, special tests, and functional assessments.
Step 1. General Observation:
– Begin with a visual inspection of the shoulder girdle, looking for any asymmetry, swelling, muscle atrophy, or abnormal positioning.
– Note any compensatory movements or postural adaptations the patient may exhibit, such as guarding or holding the shoulder in a protected position.
– Example observation: “The patient holds the affected shoulder lower and closer to the body, with visible muscle wasting in the deltoid region.”
Step 2. Palpation:
– Palpate the bony landmarks of the shoulder, including the clavicle, acromion, scapula, and humeral head, for tenderness or deformity.
– Assess the soft tissues around the shoulder, such as the rotator cuff tendons, biceps tendon, and deltoid muscle, for tenderness, swelling, or abnormal masses.
– Example findings: “Palpation reveals tenderness over the anterior aspect of the shoulder near the biceps tendon.”
Step 3. Range of Motion (ROM) Testing:
– Active Range of Motion (AROM):
– Ask the patient to perform active movements of the shoulder, including flexion, extension, abduction, adduction, internal rotation, and external rotation.
– Observe for any limitations, compensatory movements, or pain during these motions.
– Example findings: “AROM shows significant limitation in abduction and external rotation, with pain at the end range.”
– Passive Range of Motion (PROM):
– Perform passive movements to assess the available ROM without active muscle contraction from the patient.
– Compare the affected side to the unaffected side, noting any differences or end-feel restrictions (e.g., capsular or bony).
– Example findings: “PROM is restricted in external rotation and abduction with a firm, capsular end-feel.”
Step 4. Strength Testing:
– Conduct manual muscle testing of the shoulder girdle muscles, including the rotator cuff, deltoid, trapezius, and serratus anterior.
– Grade the muscle strength on a scale from 0 (no contraction) to 5 (normal strength).
– Example findings: “Shoulder abduction strength is 3/5, indicating moderate weakness.”
Step 5. Resisted Isometric Testing:
– Perform isometric contractions of the shoulder muscles by asking the patient to resist applied force without moving the joint. Focus on testing muscles involved in shoulder movements, including the rotator cuff, deltoid, trapezius, and biceps brachii.
– Observe the patient’s strength and pain response during each isometric contraction. Note if the muscle contraction is strong or weak and if it is pain-free or painful.
– Record the findings based on the patient’s response. Use standard terminology such as “strong and pain-free,” “weak and pain-free,” “strong and painful,” or “weak and painful.”
– Example Findings: “Shoulder external rotation is strong and painful, suggesting a possible tendinopathy of the rotator cuff.”
Step 6. Special Tests for Frozen Shoulder:
– Perform special tests to differentiate frozen shoulder from other shoulder pathologies:
– Painful Arc Test: Identifies pain during active abduction, which may indicate impingement or rotator cuff pathology, with a sensitivity of 33% (4, 5) and specificity of 81% (4, 5).
– Apley’s Scratch Test: Assesses functional internal and external rotation of the shoulder, with a sensitivity of 60% (6) and specificity of 70% (6).
– Neer’s Impingement Test: Evaluates for subacromial impingement or inflammation, with a sensitivity of 72-79% (7, 8) and specificity of 53-60% (7, 8).
– Hawkins-Kennedy Test: Identifies subacromial impingement or rotator cuff tendinitis, with a sensitivity of 62-92% (9) and specificity of 25-100% (9).
– Example findings: “The Painful Arc Test is negative, while Neer’s Impingement Test produces mild discomfort, suggesting secondary impingement due to limited motion.”
Step 7. Capsular Pattern Assessment:
– Assess the shoulder for the classic capsular pattern associated with frozen shoulder, typically presenting as a progressive loss of external rotation, followed by abduction, and finally, internal rotation.
– Example findings: “The patient exhibits a capsular pattern with the greatest loss of external rotation, followed by abduction and internal rotation.”
Step 8. Functional Assessment:
– Evaluate the patient’s ability to perform functional movements and tasks that are commonly affected by frozen shoulder, such as reaching behind the back, overhead activities, and daily living tasks.
– Utilize functional outcome measures like the Shoulder Pain and Disability Index (SPADI) or the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire to quantify functional impairment and track progress.
– Example findings: “The patient is unable to reach behind their back to fasten a bra, and scores 60% on the SPADI, indicating significant disability.”
Step 9. Neurological Examination:
– Conduct a brief neurological assessment, including sensory testing and reflexes, to rule out cervical radiculopathy or peripheral nerve involvement.
– Example findings: “Neurological examination is unremarkable, with intact sensation and reflexes.”
Step 10: Summary and Clinical Impression
Summarize Findings:
— Compile and summarize the key findings from the objective examination, highlighting any significant deficits, positive tests, or areas of concern related to the shoulder.
— Example statement: “The objective examination reveals a significant reduction in shoulder range of motion in both active and passive movements, with marked restrictions in external rotation and abduction, consistent with a diagnosis of frozen shoulder (adhesive capsulitis).”
Formulate a Clinical Impression or Working Diagnosis:
— Based on the collected data, formulate a clinical impression or working diagnosis to guide the development of a treatment plan.
— Example statement: “The findings suggest adhesive capsulitis with restricted range of motion primarily in external rotation and abduction, indicative of frozen shoulder. This diagnosis will guide the formulation of a targeted treatment and rehabilitation plan.”
By following these detailed steps in both the subjective and objective examinations, you will thoroughly assess patients with suspected frozen shoulder, ensuring accurate diagnosis and appropriate management.
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