Rotator Cuff Assessment
Rotator cuff tendinopathy diagnosis is typically made by a combination of history and physical examination. Traditionally the examination of the shoulder has been based on the assertion that it possible to isolate individual structures and mechanically stretching or compressing the tissue of interest will help with diagnosis. However muscle contraction does not occur in isolation with EMG results showing multiple muscle activations during shoulder special tests (Brookham et al. 2010).
Shoulder Assessment: Physical Assessment
KEY RESOURCE: BJSM SHOUDLER EXAM
https://www.youtube.com/playlist?list=PLB2E91E9C20E30B25
The assessment of the shoulder region often involves taking extensive history combined with physical assessment in an attempt to diagnose shoulder pathology such as rotator cuff tendinopathy. Historical musculoskeletal assessment owes its foundations to the concept that it is possible to isolate individual structures and apply mechanical procedures that either compresses of stretches the tissue of interest (Lewis 2009). Lewis (2009) argues that the commonly used orthopaedic special tests should be thought of as pain or symptom provocation tests, without the ability to contribute to a structural diagnosis.
The clinical tests used to identify structural pathology in current use include the O’Brien active compression test for superior labral pathology, the posterior capsule length test to assess the extensibility of the posterior glenohumeral capsule and Jobe’s ‘‘supraspinatus test’’ to assess the strength and pain response from the supraspinatus musculotendinous unit. Other tests include the Neer sign, which has been embraced with other tests, such as the Hawkins’ test and the Internal Rotation Resistance Stress Test, as clinical methods to implicate the acromion as the cause of the presenting shoulder symptoms (Lewis 2009).
A high quality systematic review and meta-analysis of various shoulder physical tests failed to recommend that any one test or combination of tests was appropriate in the diagnosing of shoulder conditions (Hegedus et al. 2012).
Is there a solution?
The diagnosis of Rotator tendinopathy is challenging, with both imaging-based and clinical diagnostic approaches having numerous flaws (Lewis 2009). As noted above, Hegedus et al (2012) reported that none of the shoulder clinical diagnostic tests provide an accurate diagnosis of pathology. However, the evidence does demonstrate that there was marginal better accuracy with a combination of tests. Michener et al (2009) found that, a cut-off of three out of five positive tests (painful arc, empty can, external rotation resistance, Neer, and Hawkins and Kennedy) best predicted rotator cuff tendinopathy, while less than three positive tests ruled it out (Michener et al. 2009).
A review by Hermans et al (2013) concluded that the painful arc sign and pain or weakness on resisted external rotation were the best predictors of any degree of Rotator Cuff disease (Hermans et al. 2013). The best indicators for rotator cuff tear were found to be a positive internal or external rotation lag sign. Figure 3.2 outlines the recommended tests for the clinical diagnosis and evaluation of rotator cuff disease. The review also produced an excellent summary of its findings which can be found here:
KEY RESOURCE
http://jama.jamanetwork.com/article.aspx?articleid=1733724#SummaryVideo