The Shoulder

Practical Questions

• There are probably 30 or more tests just for labrum tears of the shoulder. Many seem to be minor variations on a theme. Which ones have been tested and shown to be of value?

• What about instability and rotator cuff tears?

• Are there conservative approaches that work for shoulder problems?

What are the best tests for specific shoulder problems?

Impingement Syndrome

• In the Park et al. study, 913 patients underwent physical examination and diagnostic arthroscopy
• The combination of the Hawkin's-Kennedy, painful arc, and infraspinatus muscle tests yielded the best post-test probability (95%) for any degree of impingement

Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. Jul 2005;87(7):1446-1455.

Rotator Cuff Tear

• In a retrospective study by Ito et al. common sites of pain were evaluated using clinical charts of 149 patients diagnosed with either rotator cuff tears or adhesive capsulitis confirmed by arthroscopic findings
• The lateral and anterior shoulder were the most common sites of pain regardless of the existence of whether there was a tear or where the tear existed.
• Motion pain was more common than pain at rest for patients with rotator cuff tendonitis or tears.
• The authors conclude that pain location is not useful in locating the site of a tear, however, the physical exam based on positive results to muscle tests with appropriate thresholds for muscle weakness was clinically useful.
• The combination of the painful arc, drop-arm sign, and infraspinatus muscle test produced the best post-test probability (95%) for a full-thickness rotator cuff tear.

Itoi E, Minagawa H, Yamamoto N, Seki N, Abe H. Are pain location and physical examinations useful in locating a tear site of the rotator cuff? Am J Sports Med. Feb 2006;34(2):256-264

Glenoid Labrum Tears

• The diagnostic accuracy of individual tests without Hx findings is poor to moderate
• The combination of popping/clicking with a positive Crank OR Anterior Slide result

• A positive Anterior Slide with either a positive Active Compression OR Crank test result indicates a labral tear

• The absence of popping/clicking or absence of a positive Anterior Slide or Active Compression test suggests the absence of a labrum tear

Walswoth MK, Doukas WC, Murphy KP, et al. Reliability and Diagnostic Accuracy of History and Physical Examination for Diagnosing Glenoid Labral Tears. Am J Sports Med 2008;36, 162

Manipulation and exercise for management of shoulder pain

• In a Cochrane review by Green et al. (2003) exercise was demonstrated effective for short-term recovery in rotator cuff disease (RR 7.74 [1.97,30.32]) and a benefit for long term restoration of function (RR 2.45 [1.24, 4.86]).
  For rotator cuff disease a combination of exercise and mobilization resulted in additional benefit over exercise alone
  
  Green S, Buchbinder R, Glazier R, Forbes A. Interventions for shoulder pain. Cochrane Database Syst Rev; 2000:CD001156.
  
  In the Desmeules systematic review (2003), exercise or manual therapy were evaluated
  Four studies (rating of 67% for top three) suggested some benefit for therapeutic exercise or manual therapy when compared with other treatments such as acromioplasty, placebo, or no intervention
  
  Desmeules F, Fremont P. Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Clinical Journal of Sport Medicine. 2003;13(3):176
  
  Bang et al. performed an RCT with patients diagnosed with impingement, rotator cuff tendonitis, or “shoulder tendonitis”, and randomized them into two treatment groups
  The first group received supervised flexibility and strengthening exercises while the second group also received the same flexibility and strengthening program but also received manual therapy. Both groups received their respective interventions 6 times over a three week period.
  Subjects in the combined treatment group (manual therapy plus exercise) had significantly more improvement in pain and increases in function although both groups had some improvement. Strength in the manual therapy group improved significantly while not in the exercise group!
  Manual therapy as described in this study included “gliding” mobilization, not manipulation
  
  Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. Mar 2000;30(3):126-137.
  
  In an RCT assessing the effect of a standardized 8 week home exercise program on workers diagnosed with shoulder pain, Ludwig et al. randomized 67 male workers diagnosed with impingement syndrome into either the at-home exercise group or a no treatment control group
  The intervention group showed significantly greater improvements in the Shoulder Rating Questionnaire and shoulder satisfaction score compared to the control group.
  
  Ludwig R, Mariotti G, Schlumpf U. [Prognosis of shoulder calcifications after irrigation treatment and roentgen findings. A prospective study and literature review]. Schweiz Rundsch Med Prax. Apr 16 1996;85(16):526-533.