IMPINGEMENT-TESTSTESTS

Transcription

1 «thinking about.» DIFFERENTIAL DIAGNOSIS: Looking for the causes of Which special tests do you use in your shoulder examination? Ann Cools, PT, PhD Ghent University - Belgium Dept of Rehabilitation Sciences & Physiotherapy Ann.Cools@UGent.be. Clinical Examination shoulder - Ann Cools symptoms IMPINGEMENT TESTS Clinical Examination shoulder - Ann Cools Confirming symptoms Use -teststests Only to confirm the presence of -related symptoms and to define possible biomechanical process (location of ) Not to diagnose underlying In general high sensitivity, low specificity Very limited diagnostic value Clinical Examination shoulder - Ann Cools IMPINGEMENT-TESTSTESTS JOBE-TEST Jobe Hawkins Neer Shoulder in 90 scapular elevation and maximal internal rotation (empty-can), give resistance against elevation Test is (+) in subacromial Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools

2 HAWKINS-TEST NEER-TEST Passively rotate the shoulder into internal rotation in a 90 forward flexion position Test is (+) in subacromial Clinical Examination shoulder - Ann Cools Passively elevate (forward flexion) the shoulder with internal rotation and manual fixation scapula into depression Modify Neer test into full forward flexion with fixation of the scapula, inducing posterior conflict Anterior pain: subacromial Posterior pain (modified Neer): internal Clinical Examination shoulder - Ann Cools symptoms symptoms + INSTABILITY- TESTS INSTABILITY-TESTSTESTS APPREHENSION A. Provocation tests Apprehension Relocation Release B. Laxity tests Load & Shift (anterior drawer) Sulcus sign Posterior subluxation test Jerk Clinical Examination shoulder - Ann Cools Shoulder in 90 abduction & maximal external rotation: + end range external rotation; pain or apprehension? Clinical Examination shoulder - Ann Cools

3 RELOCATION RELEASE Shoulder in apprehension position: posterior translation humeral head: test is (+) if pain or apprehension decreases Patient in relocation position: suddenly release examiner s hand: test is (+) if pain/ apprehension reappears Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools symptoms involvement? Empty can: testing of SS (Jobe 1987) AND provocation Use test for SS with less provocation: FULL CAN ROTATOR CUFF TESTS Clinical Examination shoulder - Ann Cools FULL CAN Repeat Jobe-test, with thumbs up (full can) Empty can pain, full can no pain: based shoulder pain Empty can + full can pain: rotator cuff tendinopathy based shoulder pain Empty can + full can strength deficit: supraspinatus tear tears Supraspinatus: Empty Can (Jobe) Full Can Infraspinatus: Rotation Lag Sign Subscapularis Lift-off Test Rotation Lag Sign Belly-press Test Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools

4 EXTERNAL ROTATION LAG SIGN LIFT-OFF TEST Shoulder in 20 scapular elevation and (sub)maximal external rotation: patient holds position Hand on the back: lift off hand Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools INTERNAL ROTATION LAG SIGN BELLY-PRESS TEST Therapist lifts off hand patient: hold position Pull hand into belly without movement of the elbow Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools symptoms Assessment of Scapular Dyskinesis Observation Type I: anterior tilting (inf angle) Full can + SCAPULAR TESTS Type II: internal rotation (medial border) Type III: downward rotation (sup angle) Clinical Examination shoulder - Ann Cools

5 Scapular involvement? Neuromuscular coordination? Scapular Assistance Test (SAT) provocative test if (+): repeat test with manual assistance movement scapula pain decreases? Test is (+): scapular involvement in shoulder pain (Rabin et al. JOSPT 2006) Clinical Examination shoulder - Ann Cools Scapular involvement? Scapular stability? Scapular Retraction Test (SRT) provocative test if (+): repeat test with manual fixation scapula into retraction pain decreases? Test is (+): scapular involvement in shoulder pain (Kibler et al. AJSM 2006, Tate et al. AJSM 2008) Clinical Examination shoulder - Ann Cools Full Can + symptoms SAT + SRT + INSTABILITY TESTS Testing shoulder instability (Levy et al. 1999, Tennent AJSM 2003, Hegedus et al. BJSM 2008)) A. Provocation tests Apprehension Relocation Release B. Laxity tests Load & Shift (anterior drawer) Sulcus sign Posterior subluxation test Jerk Clinical Examination shoulder - Ann Cools LOAD & SHIFT load humeral head into glenoid and perform anterior translation SULCUS SIGN Perform inferior translation on humerus Grade I (movement up to glenoid rim) Grade II (movement over glenoid rim + spontaneous reduction) Grade III (movement over glenoid rim + no spontaneous reduction) Clinical Examination shoulder - Ann Cools Grade or interpretation of sulcus NP = ER: global capsular laxity ER >NP: rotator interval (rotator interval is under tension in ER) Clinical Examination shoulder - Ann Cools Nobuhara et al. JSES 5

6 POST. SUBLUXATION TEST - JERK symptoms Shoulder in 90 forward flexion, horizontal adduction, internal rotation Perform posterior translation Return to scapular plane with posterior force Relocation of humeral head Clinical Examination shoulder - Ann Cools Full Can + SAT + SRT + Laxity tests + Appr + (appr) Relocation + (appr) Release + (appr) tests Involvement of and superior labrum A large amount of -lesion tests over-diagnosed? Oh et al. AJSM 2008: choose 2 sensitive and 1 specific test lesions Speed s Test O Brien test -Load Test II (Hegedus et al. BJSM 2008, Oh et al. AJSM 2008) Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools Speed s Test 90 elevation in external rotation, elbow in extension & supination R against elevation O Brien test (active compression test) 10 horizontal adduction and internal rotation R against elevation Repeat test in external rotation + if pain in internal rotation and no pain in external rotation Both positions painful: indifferent test for shoulder!! tendon also gives (+) sign Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools

7 -Load test symptoms 120 abd, external rotation, elbow 90 flexion & supination R against flexion + if painful (Kim et al. Arthorscopy 2001) Clinical Examination shoulder - Ann Cools Full Can + O Brien+ ROM SAT + SRT + Laxity tests + Speeds+ Appr + (appr) load II+ IR Relocation + (appr) Scapular dyskinesis instability G.I.R.D. GIRD? Rotation ROM in 90 abduction rotation ROM in 90 forward flexion (observation ROM in prone position) symptoms Clinical Examination shoulder - Ann Cools (Trakis et al. AJSM 2008, Borstad ICSET 2010, Wilk AJSM2011 ) Full Can + O Brien+ SAT + Laxity tests + Speeds+ IR SRT + Appr + (appr) load II+ ROM Relocation + (appr) Did we talk about «your» clinical tests? Numerous tests for the same Numerous names for the same test Numerous modalities to perform a test DIAGNOSTIC VALUE of shoulder tests? Sensitivity Specificity Positive predictive value Negative predictive value accuracy Clinical Examination shoulder - Ann Cools

8 Rotator Cuff tests Itoi 1999 Full Can vs Empty Can Diagnosis supraspinatus tendinopathy Isolation supraspinatus at 90 abd scap plane 45 ext rotation ( Jobe: empty can) If pain and/or strength are criteria: FC and EC high sens (>85%) low spec (50%) Conclusion: full can less provocative Rotator Cuff tests Greis 1996, Gerber 1996, Algunaer 2012 lift-off test vs belly-press Highest EMG activity subscapularis in lift-off test Total ROM and NO pain are conditions to perform test Conclusion: belly-press more comfortable, however validity? Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools Rotator Cuff tests Conclusion interpretation difficult because of 3 criteria (pain, strength deficit, or both) original test often based on clinical experience: diagnostic value? However: part of standard shoulder protocol original test very often modified and renamed Instability tests Levy 1999 laxity tests Low reliability when grading (0.47) 0-III When 0-I are combined: reliability +/-0.75 (0 = no translation) Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools Instability tests Instability tests Speer 1994 Apprehension - relocation High accuracy (85%) if criterion is apprehension Low accuracy (49%) if criterion is pain old study Gross 1997 Anterior Release test positive predictive value 87%, neg pred val Meister 2004 Apprehension for internal? Posterior sign (+/- same position as apprehension test, posterior pain provocation Sensitivity 75%, specificity 85% Confirmation of posterior labrum tears and internal 93% Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools

9 -teststests Leroux 1995; Calis 2000; Mc Donald 2000; Hawkins, Neer Neer sens 79%, Spec 53% Hawkins sens 79%, Spec 59% Hegedus 2008 tests no discriminatory ability in shoulder diagnosis Jobe: screening for Clinical Examination shoulder - Ann Cools teststests Toprak 2012 SS palpation versus tests Higher accuracy in diagnosing RC Algunaer Review tests are better to rule out than ruling in Clinical Examination shoulder - Ann Cools tests Hegedus BJSM 2008, Tennent AJSM 2003 Large amount of studies on diagnostic accuracy - tests Load test OK however tested on patients with dislocation? Some tests far worse when used by other than the originator of the test In general: we urge caution if a diagnostic test is only been studied once, and if the originator of the test is the author of the paper (Hegedus et al. BJSM 2008) Clinical Examination shoulder - Ann Cools tests Oh et al. AJSM 2008 Sensitivity, specificity of 10 diagnostic tests 2 sensitive tests + 1 specific test increases diagnostic accuracy O Brien Apprehension Load II Clinical Examination shoulder - Ann Cools Scapular tests Kibler okt 2006 influence SRT on strength and pain for Jobe-test SRT: strength increases Pain = Conclusion: strength deficit in Jobe test may be masked scapular dysfunction. Measurement of GH ROM Digital inclinometer (Acumar) Rabin et al. JOSPT 2006 reliability modified Scap Ass Test (= upward rotation + retraction) Acceptable inter-rater rater reliability for clinical use Tate et al. JOSPT 2008 Scapular reposition test (post tilt + ext rotation, no max retraction) During clinical -tests tests (Neer, Hawkins, Jobe) Small reduction in pain in 50% of the athletes, and increased strength However: healthy athletes Clinical Examination scoring shoulder positive - Ann Cools 2009 on -tests tests 53 Clinical Examination shoulder - Ann Cools

10 Measurement of GH and ST strength More information? HHD (compufet, Biometrics) Clinical Examination shoulder - Ann Cools Clinical Examination shoulder - Ann Cools