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Special Tests: Rotator Cuff Pathology Audio

Special tests for the rotator cuff. Shoulder Impingement Testing Cluster, Infraspinatus Strength Test, Painful Arc Test, Drop Arm Test, and the Supine Impingement Test (screening tool). The reliability, specificity, sensitivity, validity, safety, and screening for shoulder pain, rotator cuff (supraspinatus) tears, and shoulder impingement. 

Special Tests: Rotator Cuff Pathology

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I have almost completed my CPT certification and am half-way through the Human Movement certification to inform my massage practice. The different modalities of reading, watching audiovisual materials, and attending live or recorded webinars have been important to my learning style and for review.

Brookbush Institute has the most detailed, specific and effective tools for online learning for movement and/or bodywork professionals. I love the combination of the videos as well as the text available online.

I recently completed the CPT course. It was demanding yet practical. I would highly recommend it for anyone wanting an education about human movement.

I have my personal trainer certificate through here and am almost finished my human movement specialist certification. Overall, the education that Brookbush has packaged together for clinicians and trainers is invaluable. I am a physio assistant so coming from more of a rehab background I appreciate that this education has been beneficial both as a trainer and in a rehab setting. I love that I have been able to do all learning at my own pace and able to work around my schedule. Thank you for setting up this platform! Highly recommend :)

I have been a massage therapist for 10 yrs and I feel like all the “pieces” I’ve learned throughout the yrs have been put into place and can see the full picture. I am also a member to tons of great content since I love to learn! I plan to get my CPT through them as well.

I have been following Brent Brookbush for nearly a decade- back when I was a personal Trainer and now as a Physical Therapist. BBI is an incredible resource for any movement nerds and corrective exercise specialists! The information is thorough with multiple real world applications. I am looking forward to an in-person Manual Therapist course the second they do one a little bit closer to Virginia ;)

I have taken both the Human Movement Specialist and Certified Personal Trainer certificate programs and have found the value in understanding the how and ways the body moves and functions and from evidence, non-biased, outcome, conceptual, theoretical, and practical approach to helping my clients/patients look better, feel better, and move better.

Over the last years I've returned time and again to Brookbush Institute for stellar coursework as I've worked toward a Human Movement Specialist certification. (I'm currently ACE CPT, and in training with Anatomy Trains for Structural Integration Manual Therapy.) Every Brookbush Institute module is fantastic and each one includes detailed informational videos, written descriptions of how to-do, and, more importantly, why to-do!

I am a 70 yr old chiropractor and no other healthcare provider was able to come up with an exercise protocol particular to my structural and balances and muscle deficits and keep me in the game. And as for continuing education on human skeletal movement, the website is phenomenal full of great exercises for particular mechanical dysfunction.

The H.M.S. is the most valuable certificate I have earned and was a fraction of the the cost of my others. Define the best bang for your buck!

Brookbush is the most efficient Personal Training Certification I have ever come across. All the lessons are well thought out and very straight to the point.

I am getting my Master's degree in Kinesiology, and I would like to say that I have benefited greatly from the rich, comprehensive, well-documented scientific content of Brookbush Institute that links theory to practical applications. Proudly I've got my CPT certificate, and I am on my way to get my HMS certificate.

Having courses count towards different certifications makes it so users can transition seamlessly from one certification to another. In my case, going from earning the BI CPT to earning the BI HMS was an easy decision and I am proud to have earned both certifications. I have also had the pleasure of going to a Live HMS workshop that was well taught by Instructor Boettcher and that was excellent to see how the methods and techniques are implemented.



I have been a member of BBI for years and every course I have taken has been incredibly informative. I learn more from these courses than I do at local CEU courses for my PTA license. I also earned my CPT and HMS certifications through the platform. It was so convenient and the content was top notch! Forever member.

We learn principles in academia, we learn cool new modalities via whatever specialty certification, but BBI really concentrates on the nuances of passive treatment and they do a fantastic job. The format in which BBI instructs soft tissue specialists (DPTs, Chiros, ATs) like myself feels like almost like an apprenticeship. You get a thoroughly detailed explanation of the “why’s”, and a visual comprehension of how to apply. Personally, I believe application is where the good and the great are distinguished.

Brookbush has been incredibly helpful since I was in massage school and now as I’m in my career! I run my own practice and it gives me the resources I need to not only improve what I already know, but also help me navigate better, more efficient ways of treatment.

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Park et al. Rotator Cuff Tear Testing Cluster

Rotator cuff pathology may be chronic, result from trauma, or may occur in conjunction with other diagnoses. For example, chronic rotator cuff pathology may be the result of biceps brachii and subscapularis tendonitis, or supraspinatus tendinopathy in conjunction with shoulder impingement syndrome. Both of these examples may be the result of scapula (shoulder blade) dyskinesis, which is likely to increase stress on the rotator cuff muscles during elevation of the upper arm. Acute trauma such as strains, rotator cuff tears, and shoulder dislocations (resulting in multiple tears) may occur during overhand throwing, falling on an outstretched arm, and/or direct impact on the arm or shoulder. Clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) should be aware of the signs and symptoms of rotator cuff injury and the special tests (clinical tests) that may aid in diagnosing and screening patients and clients. Although some rotator cuff tears may require surgery to optimally regain function, partial tears are most often best treated with exercise and interventions intended to improve lower cervical and thoracic mobility, scapular (shoulder blade) dyskinesis, and shoulder stabilization and strengthening.

Special Note on Tests on Rotator Cuff Pathology and Shoulder Impingement Syndrome (SIS):

There is a significant overlap between special tests for shoulder impingement syndrome (SIS) and rotator cuff pathology. A correlation between these diagnoses may be expected considering the contribution of 

 tendon inflammation to impingement pain, or the correlation between biceps tendon, supraspinatus tendon, and subscapularis tendons tears, or the contribution of rotator cuff pathology to altered recruitment, altered arthrokinematics, and subacromial compressive forces. Alternatively, when considered relative to the test positions for the majority of 

, and the considerable amount of lengthening or tension created on rotator cuff muscles, it seems reasonable these tests may provoke symptoms in individuals with rotator cuff pathology as well.

Special Tests: Shoulder Impingement Tests

, special tests for SIS are sensitive but lack specificity. This may imply an accurate diagnosis of SIS during a physical examination is dependent on "negative test results for other diagnoses"(28). That is, positive results on tests are indicative of rotator cuff pathology, and would reduce the likelihood that anterior shoulder pain is solely related to SIS.

In general, rotator cuff tests are more specific than impingement syndrome tests. In particular, the 

, adds a significant amount of specificity to physical evaluation for shoulder joint pain, shoulder joint injury, and rotator cuff pain specifically.

 recommends that all clinical professionals are aware of these special tests (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.). In particular, learning the 

Park et al. Rotator Cuff Tear (RC) Testing Cluster

 includes two of the three tests used in the 

Park et al. Shoulder Impingement (SIS) Test-item Cluster

 results in 4 tests that can be used to accurately identify impingement and/or rotator cuff pathology. The 

 recommends that if special tests for SIS are going to be used, they are used in this combined cluster to enhance the efficiency of shoulder evaluation protocols, and address some of the issues regarding the poor predictive value of SIS testing.

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:

Courses covering Special Tests for the Shoulder Girdle

Special Tests: Shoulder Impingement Syndrome (SIS)

Special Tests: Acromioclavicular (AC) Joint Pathology

Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

Course Description: Special Test: Rotator Cuff Pathology

Course Study Guide: Rotator Cuff Pathology

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use check out:

Special Note on Rotator Cuff Pathology and Shoulder Impingement Syndrome (SIS):

 results in 4 tests that can be used to accurately identify impingement and/or rotator cuff pathology. The 

 recommends combining these clusters to enhance efficiency of shoulder evaluation protocols, and addresses some of the issue regarding the poor predictive value of SIS testing.

Introduction

(The IRRST is also included in this video)

The patient is seated (or standing) with the elbow at 90° flexion, neutral supination/pronation, neutral shoulder rotation (forearm directed forward), and arm adducted against the body.

The examiner stands by the patient's side, placing one hand on the elbow to monitor for compensation, and applying an internal rotation force against the patient's forearm.

The patient is asked to resist the force (externally rotate) to maintain the arm position.

A positive test is giving way due to weakness or pain.

Park et al. (4) performed the test with the patient in full external rotation. An inability to maintain the position (lag sign) was also considered positive; a later study demonstrated some validity and reliability (30, 31).

Rotator Cuff Testing

Infraspinatus/External Rotation Resistance Test

The patient is asked to abduct the arm 180 degrees and report symptoms as they are felt.

A positive test is a concordant pain during an arc of motion from approximately 60 - 120°. Pain outside of this arc of motion is considered a negative test.

Painful Arc Test

The examiner grasps the patient's wrist and passively abducts the patient's shoulders to 90°

The examiner releases the patient's arm with instructions to slowly lower the arm.

The test is positive if the patient cannot lower the arm, or cannot control the speed of lowering the arm (the affected arm "drops" faster than the unaffected side).

Park et al. performed this test by asking the patient to abduct both arms to 90° and noting any inability to raise the arm or lag in the rate of raising the arm when compared to the other side.

Drop Arm Test

3 Positive Tests = 91% likelihood of full-thickness rotator cuff tear

2 Positive Tests = 69% likelihood of full-thickness rotator cuff tear

1 Positive Test = 33% likelihood of full-thickness rotator cuff tear

0 Positive Tests = 9% likelihood of full-thickness rotator cuff tear 

Image of the Rotator Cuff

Test-item Clusters

The patient assumes a supine position, and the examiner stands to the side of the patient's involved shoulder.

The examiner grasps the patient's wrist and elevates the arm to end range.

The examiner then externally rotates the arm and abducts the arm toward the patient's ear.

Last, the examiner internally rotates the shoulder to end range.

The test is positive if the concordant sign or significant pain is provoked.

Screening Tool

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

Park, H. B., Yokota, A., Gill, H. S., El Rassi, G., & McFarland, E. G. (2005). Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. 

Michener, L. A., Walsworth, M. K., Doukas, W. C., & Murphy, K. P. (2009). Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. 

Archives of physical medicine and rehabilitation

Hawkins-Kennedy (and Yocum's) (In addition to 4 - 5)

Hawkins, R. J., & Kennedy, J. C. (1980). Impingement syndrome in athletes. 

MacDonald, P. B., Clark, P., & Sutherland, K. (2000). An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. 

Çalış, M., Akgün, K., Birtane, M., Karacan, I., Çalış, H., & Tüzün, F. (2000). Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. 

Bak, K., & Magnusson, S. P. (1997). Shoulder strength and range of motion in symptomatic and pain-free elite swimmers. 

Kelly, S. M., Brittle, N., & Allen, G. M. (2010). The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy. 

Jia, X., Ji, J. H., Petersen, S. A., Keefer, J., & McFarland, E. G. (2008). Clinical evaluation of the shoulder shrug sign. 

Clinical orthopaedics and related research

Ostor, A. J. K., Richards, C. A., Prevost, A. T., Hazleman, B. L., & Speed, C. A. (2004). Interrater reproducibility of clinical tests for rotator cuff lesions. 

Bak, K., Sørensen, A. K. B., Jørgensen, U., Nygaard, M., Krarup, A. L., Thune, C., … & Pedersen, S. T. (2010). The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study. 

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Parentis, M. A., Mohr, K. J., & ElAttrache, N. S. (2002). Disorders of the superior labrum: review and treatment guidelines. 

Clinical Orthopaedics and Related Research (1976-2007)

Nakagawa, S., Yoneda, M., Hayashida, K., Obata, M., Fukushima, S., & Miyazaki, Y. (2005). Forced shoulder abduction and elbow flexion test: a new simple clinical test to detect superior labral injury in the throwing shoulder. 

Gill, H. S., El Rassi, G., Bahk, M. S., Castillo, R. C., & McFarland, E. G. (2007). Physical examination for partial tears of the biceps tendon. 

Leroux, J. L., Thomas, E., Bonnel, F., & Blotman, F. (1995). Diagnostic value of clinical tests for shoulder impingement syndrome. 

Infraspinatus/External Rotation Resistance Test (In addition to 4, 5, 10, 12)

Itoi, E., Minagawa, H., Yamamoto, N., Seki, N., & Abe, H. (2006). Are pain location and physical examinations useful in locating a tear site of the rotator cuff?. 

Painful Arc Test (In addition to 4, 5, 8, 10, 13)

Silva, L., Andreu, J. L., Munoz, P., Pastrana, M., Millán, I., Sanz, J., … & Fernández-Castro, M. (2008). Accuracy of physical examination in subacromial impingement syndrome. 

Litaker, D., Pioro, M., Bilbeisi, H. E., & Brems, J. (2000). Returning to the bedside: using the history and physical examination to identify rotator cuff tears. 

Journal of the American Geriatrics Society

Jia, X., Petersen, S. A., Khosravi, A. H., Almareddi, V., Pannirselvam, V., & McFarland, E. G. (2009). Examination of the shoulder: the past, the present, and the future. 

Neer Test (In addition to 1-5, 7-10, 13 -16 19, 21-22)

Leschinger, T., Wallraff, C., Müller, D., Hackenbroch, M., Bovenschulte, H., & Siewe, J. (2017). Internal Impingement of the Shoulder: A Risk of False Positive Test Outcomes in External Impingement Tests?. 

Post, M., & Cohen, J. (1986). Impingement syndrome. A review of late stage II and early stage III lesions. 

Empty Can Test (In addition to 1-5, 10, 12, 13, 18)

Itoi, E., Kido, T., Sano, A., Urayama, M., & Sato, K. (1999). Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon?. 

Kim, E., Jeong, H. J., Lee, K. W., & Song, J. S. (2006). Interpreting positive signs of the supraspinatus test in screening for torn rotator cuff. 

Jobe, F. W., & Moynes, D. R. (1982). Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. 

Blackburn, T. A. (1990). EMG analysis of posterior rotator cuff exercises. 

Hegedus, E. J., Cook, C., Lewis, J., Wright, A., & Park, J. Y. (2015). Combining orthopedic special tests to improve diagnosis of shoulder pathology. 

Murrell, G. A., & Walton, J. R. (2001). Diagnosis of rotator cuff tears. 

Castoldi, F., Blonna, D., & Hertel, R. (2009). External rotation lag sign revisited: accuracy for diagnosis of full thickness supraspinatus tear. 

Fodor, D., Poanta, L., Felea, I., Rednic, S., & Bolosiu, H. (2009). Shoulder impingement syndrome: correlations between clinical tests and ultrasonographic findings. 

Fowler, E. M., Horsley, I. G., & Rolf, C. G. (2010). Clinical and arthroscopic findings in recreationally active patients. 

BMC Sports Science, Medicine and Rehabilitation

Bibliography

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