GPAtlas🧭 When to suspect
Shoulder pain is one of the most common musculoskeletal presentations in primary care, and most cases are atraumatic and self-limiting. The two conditions a GP must confidently distinguish are rotator cuff disorders (subacromial / rotator cuff-related pain) and frozen shoulder (adhesive capsulitis). The diagnosis is clinical – imaging is not routinely required at first presentation – and the single most useful discriminator is the pattern of active versus passive movement.
Suspect a rotator cuff disorder when pain is felt over the lateral upper arm, is worse on overhead activity and at night, and is reproduced by resisted movement, with passive range preserved. Suspect a frozen shoulder when there is progressive, painful global stiffness restricting both active AND passive movement, with external rotation lost first.
| Feature | Rotator cuff disorder (subacromial pain) | Frozen shoulder (adhesive capsulitis) |
|---|---|---|
| Typical patient | Any adult; overhead workers and athletes; degenerative with age | 40–70 years; more common in women; diabetes or thyroid disease |
| Pain pattern | Gradual; lateral upper-arm pain, worse reaching overhead and at night | Gradual; diffuse, deep, severe pain with marked night pain |
| Active movement | Painful arc 60–120°; pain and weakness on resisted testing | Globally reduced – limited first by pain, later by stiffness |
| Passive movement | Preserved (the key feature) | Restricted, external rotation lost first (the key feature) |
| Natural course | Variable; most improve with conservative care | Self-limiting over 1–3 years through freezing → frozen → thawing phases |
Raise suspicion of a frozen shoulder in anyone with diabetes or thyroid disease, and remember the two conditions can coexist over the age of 50. The most important early task is to exclude red flags – significant trauma, infection, malignancy and neurological deficit – and to screen the cervical spine, since neck pathology is a common mimic.
Source: BESS/BOA Patient Care Pathways
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