Evaluating
and figuring out which tissue is involved with shoulder pain can be easy and
also challenging at times. Just when you think you have figured it out, using
all the special tests you learned in school, you’ll get a patient that will
make you scratch your head and think otherwise.
As I reflected on how I approached evaluating
shoulder pain during my initial years of being a PT, I found that I performed a
heck of a lot of special tests. Speeds, Hawkins-Kennedy, Neer’s Impingement,
Biceps Load I and II, Crank, Clunk, Empty/Full can, ER lag, Lift off, Drop arm
test to name a few.
I thought that these
would help me figure out which tissue in the shoulder was the source of the
problem, resulting in a better choice of treatment.
Now, can you really know what is the “specific
source” of the pain from all these tests? Is it the bursae, ligaments, tendons, nerves,
etc? Most of the time, maybe NOT!
Through the years, I came to realize that I was
using less and less special tests. Now,
I use them mainly to inform patients of their prognosis and/or referral to
ortho, depending on age and the source tissues involved.
So,
which cluster of shoulder special tests did I find effective in helping manage
my patients ?
1.
Resisted tests : ER/MR/Abduction
2.
Empty Can Test and ER Lag Test
3.
Neer’s Impingement
4.
Hawkins
5.
Arc of Pain
A
course I took on managing shoulder pain supported what I practiced
clinically. One key piece of information shared was that “impingement”
might not be an appropriate term. Subacromial Pain Syndrome is
a better term, since it allows for uncertainty of the pain generator – tendons,
bursae, nerves, etc.
Also, there are cluster of tests that:
Increases
or Decreases the probability of a
Subacromal Pain Syndrome: 3/3 (Park HB, JBJS 2005)
1.
Painful Arc
2.
Resisted ER
3.
Hawkins
Subacromal Pain Syndrome: 3/5(Michener LA, PAMR, 2009)
1.
Painful Arc
2.
Resisted ER
3.
Hawkins
4.
Neer
5.
Empty can
How about other Diagnosis? Full Thickness Rotator Cuff Tears
Clusters
of tests that:
Increases
or Decreases the probability of a
Full Thickness Rotator Cuff Tears: 3/3 (Litaker D, et al: JAGS, 2000)
1.
>
65 yo
2.
Resisted
ER: Weak
3.
Night
pain
Full Thickness Rotator Cuff Tears: 3/3 (Park et al D, et al: JBJS, 2005)
1.
Drop
arm test
2.
Painful
arc
3.
Resisted
ER
This means
if a patient tests (+) for 3 of 3 then the probability they have that condition is
higher.
Now, if
all tests are (-), then the probability they have that condition is lower. In research, they call it LR (Likelihood
Ratio).
Now isn’t that much simpler than doing
every test in the book!
In the future blogs, let us get to the fun
part, TREATMENT!
Treatment
approach based on Movement Concept and Improving Coordination.
Arc of pain (60-120 degrees)
Empty Can
Hawkins- Kennedy
Resisted ER
Neer
Blogpost by: Francisco dela Cruz, DPT, OCS, DNSP ------
References
1.
Litaker D, Pioro M,
El Bilbeisi H, et al. Returning to the bedside: using the history and physical
examination to identify rotator cuff tears. J Am Geriatr Soc 2000;48:1633–7.
2.
Michener, L.A., Walsworth, M.K., Doukas, W.C., Murphy, K.P. Reliability
and diagnostic accuracy of 5 physical examination tests and combination of
tests for subacromial impingement. Arch Phys Med Rehabil 2009 Nov;90(11):1898-903.
3.
Park, H.B., Yokota, A., Gill, H.S., EI
RG, McFarland, E.G. Diagnostic accuracy of clinical tests for the different
degrees of subacromial impingement syndrome. J Bone Joint Surg Am 2005; 87(7),
1446-1455.
Francisco dela Cruz is a physical therapist at
Kaiser Permanente Baldwin Park,
CA. He is a DNS Certified Practitioner, a Movement Links Certified Clinician and instructor, and clinical faculty of the Kaiser Permanente
Orthopedic Physical Therapy Residency, Kaiser Permanente Spine Fellowship and
Azusa Pacific University Clinical Fellowship in Movement and Performance. Francisco has been published in the International Journal of Sports Physical
Therapy (IJSPT) for research on collegiate baseball pitchers
