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DIFFERENTIAL DIAGNOSIS: Looking for the causes of impingement…
Ann Cools, PT, PhDGhent University - Belgium
Dept of Rehabilitation Sciences & Physiotherapy
A Cools clinical exam 2016
A Cools clinical exam 2016
« thinking about…. »
Which special tests do you use in yourshoulder examination?
• …• …• …
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Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
(Cools et al. BJSM 2008)
IMPINGEMENTTESTS
A Cools clinical exam 2016
A Cools clinical exam 2016
JOBE-TEST
Shoulder in 90° scapular elevation and maximal internal rotation (empty-can), give resistance against elevation
Test is (+) in subacromial impingement
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HAWKINS-TEST
Passively rotate the shoulder into internal rotation in a 90°forward flexion position
Test is (+) in subacromial impingement
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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 impingement
Posterior pain (modified Neer): internal impingement
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Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Jobe +Neer + antHawkins +
Jobe –Neer + postHawkins –
(Cools et al. BJSM 2008)
+ INSTABILITY-TESTS
A Cools clinical exam 2016
A Cools clinical exam 2016
INSTABILITY-TESTS
A. Provocation tests‣ Apprehension‣ Relocation‣ Release
B. Laxity tests‣ Load & Shift (anterior drawer)‣ Sulcus sign‣ Posterior subluxation test – Jerk
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APPREHENSION
Shoulder in 90° abduction & maximal external rotation: + end range external rotation; pain or apprehension?
Ant pain: SA imppost pain: int imp
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RELOCATION
Shoulder in apprehension position: posterior translation humeral head: test is (+) if pain or apprehension decreases
+ secondary imp- primary imp
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RELEASE
Patient in relocation position: suddenly release examiner’s hand: test is (+) if pain/ apprehension reappears
Confirms second imp
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
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Conclusion: the cut point of 3 or more positive of 5 tests canconfirm the diagnosis of SAIS
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(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”
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Instability tests:instability symptoms vs pain during testing?
Meister 2004 (compared to Speer 1994)⇒ Apprehension for internal impingement?‣ “Posterior impingement sign” (+/- same position as apprehension test, posterior pain provocation
‣ Sensitivity 75%, specificity 85%
‣ Confirmation of posterior labrum tears and internal impingement
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Instability tests
Gross 1997⇒ Anterior Release test‣ positive predictive value 87%, neg pred val 93%
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Impingement & Instability tests
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Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
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ROTATOR CUFF TESTS
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Rotator cuff involvement?
Empty can test vs full can test
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A Cools clinical exam 2016
FULL CAN
Repeat Jobe-test, with thumbs up (full can)
Empty can pain, full can no pain: impingement based shoulder pain
Empty can + full can pain: rotator cuff tendinopathy based shoulder pain
Empty can + full can strength deficit: supraspinatus tear
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Diagnostic value of full-can test?
High EMG activity in supraspinatusduring full can, empty can, proneexternal rotation… (Reinold JOSPT 2009)
However, specificity of the full cantest is rather low diagnosingrotator cuff tears…(Hegedus BJSM 2012)
A Cools clinical exam 2016
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
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SCAPULARTESTSFull can +
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Assessment of Scapular Dyskinesis
Type I: anterior tilting (infangle)
Type II: internal rotation(medial border)
Type III: downward rotation(sup angle)
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
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Scapular involvement? Neuromuscular coordination?
(Rabin et al. JOSPT 2006)
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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
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Scapular involvement? Scapular stability?
(Kibler et al. AJSM 2006, Tate et al. AJSM 2008)
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
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Full can + SAT +SRT +
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Scapular tests are symptom relieftests rather than diagnostic tests
A Cools clinical exam 2016
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Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
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Full can + SAT +SRT +
INSTABILITYTESTS
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INSTABILITY-TESTS
A. Provocation tests‣ Apprehension‣ Relocation‣ Release
B. Laxity tests‣ Load & Shift (anterior drawer)‣ Sulcus sign‣ Posterior subluxation test – Jerk
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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)
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SULCUS SIGN
Perform inferior translation on humerus
Grade or interpretation of “sulcus”
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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
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
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Full can + SAT +SRT +
Laxity tests +Appr + (appr)Relocation + (appr)Release + (appr)
SLAPTESTS
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Biceps pathology –SLAP lesions
Speed’s Test O’Brien testBiceps-Load Test II
(Hegedus et al. BJSM 2008, Oh et al. AJSM 2008)
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90° elevation in external rotation, elbow in extension & supination
R against elevation
!! Biceps pathology also gives (+) sign
Speed’s Test
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10° horizontal adduction and internal rotation – R againstelevation
Repeat test with thumb up+ if pain in internal rotation and no pain with thumb upBoth positions painful: indifferent test for shoulder pathology (AC
joint pathology?)
O’Brien test
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120° abd, external rotation, elbow 90° flexion & supination
R against flexion+ if painful
Biceps-Load II test (Kim et al. Arthorscopy 2001)
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Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
A Cools clinical exam 2016
Full can + SAT +SRT +
Laxity tests +Appr + (appr)Relocation + (appr)Release + (appr)
O’Brien+Speeds+Biceps load II+
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)
A Cools clinical exam 2016
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A Cools clinical exam 2016
A Cools clinical exam 2016
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Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
A Cools clinical exam 2016
Full can + SAT +SRT +
Laxity tests +Appr + (appr)Relocation + (appr)Release + (appr)
O’Brien+Speeds+Biceps load II+
GIRDROM
GIRD?
• Internal Rotation ROM in 90° abduction• Internal rotation ROM in 90° forward flexion
A Cools clinical exam 2016(Trakis AJSM 2008, Borstad JOSPT 2011, Wilk AJSM 2011, Ishigaki JPTS 2015 )
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Impingement symptoms
ExternalSubacromial impingement
Internal(posterior)
impingement
PrimaryImpingement
SecondaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
A Cools clinical exam 2016
Full can + SAT +SRT +
Laxity tests +Appr + (appr)Relocation + (appr)Release + (appr)
O’Brien+Speeds+Biceps load II+
IRROM↓
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
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Many ways to approach patient’s examination!
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A Cools clinical exam 2016
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Take home message:
Clinical examination of the shoulder with “diagnostictests”, but remain critical and think clinically (Cools BJSM 2008, Hegedus BJSM 2012)
Use the clinical tests in a shoulder symptommodification procedure in relation to functionalimpairments and treatment strategy (Lewis BJSM 2008)
Start clinical reasoning from active movementsdeficits (Hultenheim Klintberg Int Orthop 2014)
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