DIFFERENTIAL DIAGNOSIS: Looking for the causes of impingement

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1 DIFFERENTIAL DIAGNOSIS: Looking for the causes of Ann Cools, PT, PhD Ghent University - Belgium Dept of Rehabilitation Sciences & Physiotherapy Ann.Cools@UGent.be «thinking about.» Which special tests do you use in your shoulder examination? 1

2 symptoms IMPINGEMENT TESTS External Subacromial Internal (posterior) Primary Secondary Rotator cuff pathology Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) JOBE-TEST Shoulder in 90 scapular elevation and maximal internal rotation (empty-can), give resistance against elevation Test is (+) in subacromial 2

3 HAWKINS-TEST Passively rotate the shoulder into internal rotation in a 90 forward flexion position Test is (+) in subacromial NEER-TEST 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 3

4 symptoms Jobe + Neer + ant Hawkins + + INSTABILITY- TESTS Jobe Neer + post Hawkins External Subacromial Internal (posterior) Primary Secondary Rotator cuff pathology Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) INSTABILITY-TESTS A. Provocation tests Apprehension Relocation Release B. Laxity tests Load & Shift (anterior drawer) Sulcus sign Posterior subluxation test Jerk 4

5 APPREHENSION Shoulder in 90 abduction & maximal external rotation: + end range external rotation; pain or apprehension? Ant pain: SA imp post pain: int imp RELOCATION Shoulder in apprehension position: posterior translation humeral head: test is (+) if pain or apprehension decreases + secondary imp - primary imp 5

6 RELEASE Patient in relocation position: suddenly release examiner s hand: test is (+) if pain/ apprehension reappears Confirms second imp symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Rotator cuff pathology Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) 6

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8 Conclusion: the cut point of 3 or more positive of 5 tests can confirm the diagnosis of SAIS 8

9 (Lewis Man Ther 2016) - There is limited relationship between imaging, diagnostic tests and symptoms of the patient. - Shoulder tests are symptom-provocation tests rather than structural diagnostic tests - Patients will undergo surgical operations on tissues that are not related ant not the cause of their symptoms 9

10 Instability tests: instability symptoms vs pain during testing? Meister 2004 (compared to Speer 1994) Apprehension for internal? Posterior sign (+/- same position as apprehension test, posterior pain provocation Sensitivity 75%, specificity 85% Confirmation of posterior labrum tears and internal Instability tests Gross 1997 Anterior Release test positive predictive value 87%, neg pred val 93% 10

11 & Instability tests symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary ROTATOR CUFF TESTS Rotator cuff pathology Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) 11

12 Rotator cuff involvement? Empty can test vs full can test 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 12

13 Diagnostic value of full-can test? High EMG activity in supraspinatus during full can, empty can, prone external rotation (Reinold JOSPT 2009) However, specificity of the full can test is rather low diagnosing rotator cuff tears (Hegedus BJSM 2012) symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Full can + Rotator cuff pathology SCAPULAR TESTS Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) 13

14 Assessment of Scapular Dyskinesis Type I: anterior tilting (inf angle) Type II: internal rotation (medial border) Type III: downward rotation (sup angle) Scapular involvement? Neuromuscular coordination? Scapular Assistance Test (SAT) start from (+) ACTIVE provocative test (for instance painfull arc) if (+): repeat test with manual assistance movement scapula pain decreases? Test is (+): scapular involvement in shoulder pain (Rabin et al. JOSPT 2006) 14

15 Scapular involvement? Scapular stability? Scapular Retraction Test (SRT) start from ISOMETRIC provocative test (for instance Jobe) if (+): repeat test with manual fixation scapula into corrective position pain decreases? Test is (+): scapular involvement in shoulder pain (Kibler et al. AJSM 2006, Tate et al. AJSM 2008) symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Full can + SAT + SRT + Rotator cuff pathology Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) 15

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17 Scapular tests are symptom relief tests rather than diagnostic tests 17

18 symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Full can + SAT + SRT + Rotator cuff pathology INSTABILITY TESTS Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) INSTABILITY-TESTS A. Provocation tests Apprehension Relocation Release B. Laxity tests Load & Shift (anterior drawer) Sulcus sign Posterior subluxation test Jerk 18

19 LOAD & SHIFT load humeral head into glenoid and perform anterior translation Grade I (movement up to glenoid rim) Grade II (movement over glenoid rim + spontaneous reduction) Grade III (movement over glenoid rim + no spontaneous reduction) SULCUS SIGN Perform inferior translation on humerus Grade or interpretation of sulcus 19

20 POST. SUBLUXATION TEST Shoulder in 90 forward flexion, horizontal adduction, internal rotation Perform posterior translation Return to scapular plane with posterior force Relocation of humeral head symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Full can + SAT + SRT + Rotator cuff pathology Laxity tests + Appr + (appr) Relocation + (appr) Release + (appr) SLAP TESTS Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) 20

21 Biceps pathology SLAP lesions (Hegedus et al. BJSM 2008, Oh et al. AJSM 2008) Speed s Test O Brien test Biceps-Load Test II Speed s Test 90 elevation in external rotation, elbow in extension & supination R against elevation!! Biceps pathology also gives (+) sign 21

22 O Brien test 10 horizontal adduction and internal rotation R against elevation Repeat test with thumb up + if pain in internal rotation and no pain with thumb up Both positions painful: indifferent test for shoulder pathology (AC joint pathology?) Biceps-Load II test (Kim et al. Arthorscopy 2001) 120 abd, external rotation, elbow 90 flexion & supination R against flexion + if painful 22

23 symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Full can + SAT + SRT + Rotator cuff pathology Laxity tests + Appr + (appr) Relocation + (appr) Release + (appr) O Brien+ Speeds+ Biceps load II+ Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) SLAP-tests Hegedus BJSM 2008, Tennent AJSM 2003 Large amount of studies on diagnostic accuracy SLAP-tests 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) 23

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25 symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Full can + SAT + SRT + Rotator cuff pathology Laxity tests + Appr + (appr) Relocation + (appr) Release + (appr) O Brien+ Speeds+ Biceps load II+ GIRD ROM Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) GIRD? Internal Rotation ROM in 90 abduction Internal rotation ROM in 90 forward flexion (Trakis AJSM 2008, Borstad JOSPT 2011, Wilk AJSM 2011, Ishigaki JPTS 2015 ) 25

26 symptoms Jobe + Neer + ant Hawkins + Apprehension +(pain) ant External Subacromial Internal (posterior) Jobe Neer + post Hawkins Apprehension +(pain) post Relocation - Primary Secondary Full can + SAT + SRT + Rotator cuff pathology Laxity tests + Appr + (appr) Relocation + (appr) Release + (appr) O Brien+ Speeds+ Biceps load II+ Biceps Scapular dyskinesis instability G.I.R.D. SLAP (Cools et al. BJSM 2008) IR ROM Did we talk about «your» clinical tests? Numerous tests for the same pathology Numerous names for the same test Numerous modalities to perform a test Many ways to approach patient s examination! 26

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28 Take home message: Clinical examination of the shoulder with diagnostic tests, but remain critical and think clinically (Cools BJSM 2008, Hegedus BJSM 2012) Use the clinical tests in a shoulder symptom modification procedure in relation to functional impairments and treatment strategy (Lewis BJSM 2008) Start clinical reasoning from active movements deficits (Hultenheim Klintberg Int Orthop 2014) 28