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outcome measures of this type. An indicative (by no means comprehensive) selection is shown in
TABLE 1.1. An obvious question when using an outcome measure in practice is, ‘how much change
must there be before I know my patient’s status has altered?’ The statistic of interest here is the
Minimum Clinically Important Difference (MCID). MCIDs have been reported for a number of
outcome measures. Some are duplicated here (TABLE 1.1), but note that these values are specific
to the populations, conditions and settings in relation to which they have been obtained.
Combined pain‒function outcome measures Abbrev. MCID Reference for
MCID
Flexi-level Scale of Shoulder Function FLEX-SF 3.02/50 Cook et al 2003 1
Shoulder Disability Questionnaire - Netherlands SDQ - NL 2‒3/16 (14.0%) Paul et al 2004 2
Shoulder Disability Questionnaire – UK SDQ-UK 1‒2/23 (4‒8.0%) Paul et al 2004 2
Shoulder Pain and Disability Index SPADI 8.0% Paul et al 2004 2
Shoulder Rating Questionnaire SRQ 13.0% Paul et al 2004 2
American Shoulder and Elbow Surgeons’ patient self-evaluation form ASES 6.4% Michener, McClure and
Sennett 2002 3
Pain outcome measures
100 mm Visual Analogue Scale 100 mm VAS 1.4 cm Tashjian et al 2009 4
11-point Numeric pain rating Scale 11-point NPRS 2.0 (or 33%) Salaffi et al 2004 5
TABLE 1.1. Examples of combined pain‒function and pain outcome measures, with Minimum
Clinically Important Differences (MCIDs) and references. 1 Patients with mixed-type shoulder pain
(the care setting was unclear); 2 Patients with first episode of shoulder pain in primary care;
3 Patients with mixed-type shoulder pain at various outpatient clinics 4 Patients undergoing nonoperative
treatment in secondary care for rotator cuff disease; 5 Chronic musculoskeletal pain in
secondary care.
1.6. Summary of key points in diagnosis and assessment
The principal diagnostic test is passive external rotation, which is restricted in contracted
(frozen) shoulder (but also in other conditions).
A finding of restricted passive external rotation should be corroborated by history
(screening for substantial trauma/serious disease), X-ray examination (which can exclude
the other causes of restriction) and palpation (screening for gross crepitus).
Measuring the range of passive external rotation reliably is difficult, and this should be
recognised. We suggest a method in standing which involves estimating range to the
nearest 30°. We also suggest that operational definitions are made explicit.
We recommend the terminology ‘pain-predominant’ and ‘stiffness-predominant’ to classify
the stage of the condition. Where there is doubt, pain should take precedence.
As a minimum, a validated region/condition-specific measure should be used to evaluate
patients’ status, progress and outcome.
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