Wednesday, November 14, 2018

Shoulder Pain- Test, Test, Test...

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.

Pictures of Key Tests

Arc of pain (60-120 degrees)

Empty Can

Hawkins- Kennedy

Resisted ER


Blogpost by: Francisco dela Cruz, DPT, OCS, DNSP ------

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 Practitionera 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