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elbow, disturbs sleep and prevents lying on the affected side (Cyriax 1982). Sleep disturbance,
often the patient’s main reason for seeking help, is not especially helpful diagnostically, because
the same symptom occurs with rotator cuff tears (reviewed by Hanchard, Cummins & Jeffries
2004). The pain abates leaving stiffness as the predominant complaint; then the condition ends—
more or less—in resolution. Codman (1934) wrote that resolution was the rule within about two
years, an assertion echoed by other authorities (e.g. Cyriax 1982); but a recent study of 223
patients referred to tertiary care with contracted (frozen) shoulder revealed that 38% had
persistent mild symptoms at a mean follow-up time of 4.4 years from onset of symptoms (range 2–
20 years), mostly pain; and that 3% had persistent severe symptoms with pain and loss of function.
Those with the worst symptoms at the outset had the worst prognosis (Hand et al 2008).
Cyriax (1982) established that restriction of passive movement 6 was necessary to make the
diagnosis of contracted (frozen) shoulder, and this is now a generally accepted principle. He also
introduced the concept of the capsular pattern, a pattern of limitation of passive movements which
is unique to each joint and which, theoretically, always denotes ‘capsulitis’ (literally capsule
inflammation). Cyriax defined the capsular pattern of the shoulder as the ratio between three
passive movements, whereby external rotation is most restricted, abduction less, and internal
rotation less still, with the rotations being tested in the elbow-at-side position (Cyriax 1982). In
theory, a capsular pattern would be expected in contracted (frozen) shoulder, since some degree of
capsulitis is likely to be present. Rundquist et al (2003) tested this hypothesis in 10 patients with
stiffness predominant primary contracted (frozen) shoulder, using electromagnetic sensors to track
the 3-dimensional positions of the trunk, scapula and humerus during external rotation, abduction
and internal rotation—although these movements were active, not passive—and found a classical
capsular pattern in seven. External rotation was the most restricted movement in eight, and the
most or second most restricted in nine. In a subsequent study of 23 patients, Rundquist and
Ludewig (2004) found that external rotation was most restricted, jointly most restricted, or second
most restricted in 92%. Setting the details of the capsular pattern aside, this involvement of
external rotation is not surprising. Contracted (frozen) shoulder is known to centre on the rotator
interval (Bunker 1997, 2009), and in experiments on eight cadaveric shoulders, Harryman et al
(1992) found that shortening the rotator interval capsule by approximately 1 cm reduced external
rotation by a mean value of 37.7º (± standard deviation 20.8º). In contrast, abduction and internal
rotation were hardly affected. At 60º of flexion, the reduction in external rotation dwindled to a
relatively modest 17.8º (± 6.3º): a persuasive argument, too, for testing external rotation in the
elbow-at-side position. In our survey of UK physiotherapists, we found the capsular pattern
concept popular, but often misinterpreted. Many other respondents—more among those with a
special interest—placed more emphasis on restriction of passive external rotation than its place in
a multi-component pattern in diagnosing contracted (frozen) shoulder. This approach, which is
simple, memorable, and unlikely to lead to confusion, is supported by Bunker (1997, 2009) and
ourselves.
6 Passive movements are those which are performed for the patient, while his or her muscles are relaxed. These are
distinct from active movements, which the patient produces of his or her own volition.
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