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Special tests for shoulder impingement. The Park et al. Shoulder Impingement Testing Cluster, Hawkin's Kennedy, Infraspinatus Strength Test, Painful Arc Test, Michiner et al. Shoulder Impingement Testing Cluster, Neer's Test, Empty Can Test, Supine Impingement Test (Screening Tool). The reliability, specificity, sensitivity, validity, safety, and screening for shoulder pain, rotator cuff tears, SLAP tears, supraspinatus pathology, bicep tendon tears, shoulder impingement syndrome (SIS), labrum (labral) tears, and general arm/shoulder pathology.

Special Tests: Shoulder Impingement Syndrome (SIS)

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Park et al. Shoulder Impingement Testing Cluster

Michener et al. Shoulder Impingement Testing Cluster

Shoulder impingement syndrome (SIS) may result from repetitive use injury, or trauma, or may occur in conjunction with other diagnoses. For example, repetitive use may result in biceps tendonitis, subacromial bursitis, or rotator cuff tendinopathy. Acute trauma such as strains, rotator cuff tears, and dislocations can result in impingement pain due to changes in glenohumeral (shoulder) joint arthrokinematics and generalized inflammation of the glenohumeral and acromioclavicular (AC) joint tissues. The diagnosis of shoulder impingement syndrome (SIS), sounds "specific", but should be considered a broad diagnosis of anterior shoulder pain, especially with shoulder flexion or shoulder abduction. Clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) should be aware of the signs and symptoms of SIS and the special tests that may aid in diagnosing and screening patients and clients. However, the special tests for SIS should likely only be used with additional special tests to "rule out" other diagnoses. Most often SIS is best treated with exercise and interventions intended to improve lower cervical and thoracic mobility, scapular (shoulder blade) dyskinesis, and shoulder mobility and strengthening.

Special Note on Shoulder Impingement Syndrome (SIS):

Impingement is a diagnosis given to those experiencing anterior shoulder pain, which is usually dull and achy, and made worse by arm elevation. This type of shoulder pain is common to so many shoulder diagnoses, that "impingement" or "SIS" becomes a very broad label in practice, and may inadvertently encompass issues other than the compression and irritation of subacromial tissues (e.g. rotator cuff tear, labrum tear, anterior instability, etc.). Because these symptoms are common to many diagnoses, special tests for impingement generally suffer from a lack of specificity. A diagnosis of SIS may be most accurately reached when "a test-item cluster demonstrates a high likelihood of impingement and is accompanied by negative tests results for other diagnoses". When considering practice and evaluation, this may imply that shoulder impingement special tests are unnecessary, have little if any predictive value, and may not significantly influence practice (28).



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

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

 includes two of the three tests used in the 

Park et al. Rotator Cuff Tear (RC) Testing 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: Acromioclavicular (AC) Joint Pathology

Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

Course Description: Special Tests: Shoulder Impingement

Introduction

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:

Impingement is a diagnosis given to those experiencing anterior shoulder pain, which is usually dull and achy, and made worse by arm elevation. This type of shoulder pain is common to so many shoulder diagnoses, that "impingement" or "SIS" becomes a very broad label in practice, and may inadvertently encompass issues other than the compression and irritation of subacromial tissues (e.g. rotator cuff tear, labrum tear, anterior instability, etc.). Because these symptoms are common to many diagnoses, special tests for impingement generally suffer from a lack of specificity. A diagnosis of SIS may be most accurately reached when "a test-item cluster demonstrates a high likelihood of impingement and is accompanied by negative tests results for other diagnoses". When considering practice and evaluation, this may imply that shoulder impingement special tests are not necessary, have little if any predictive value, and may not have a significant influence on practice (28).



Hawkins-Kennedy

Yocum's Test is also included in this video

The patient is seated while the examiner stands on the side of the involved shoulder.

One hand stabilizes the scapula and torso; fingers wrapped over the top of the scapula with palm firmly on the back.

Using the hand and a lumbrical grip over the elbow, the practitioner raises the patient's arm to 90 degrees of shoulder flexion, with 90 degrees of elbow flexion, and the forearm parallel to the floor.

The examiner forcibly applies an internal rotation force on the arm.

If concordant shoulder pain is present, the test is positive.

The Yocum's Test is a modification in which the hand of the patient's affected side is placed and held on the opposite shoulder. The examiner pushes up on the elbow to raise the arm further into flexion (2, 3, 17). If concordant shoulder pain is present, the test is positive.

Infraspinatus/External Rotation Resistance Test

(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.

Image of the Rotator Cuff

Painful Arc Test

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

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

Neer Test

The examiner uses the other hand to hand to raise the arm into end range flexion.

Some texts suggest that the arm is flexed in a medially rotated position, and/or an externally rotated position (2, 3)

The examiner applies forced flexion toward end-range (over-pressure) in an attempt to reproduce shoulder pain.

If the concordant shoulder pain is present, the test is positive.

Empty Can Test

The patient abducts their arms with elbows extended to 90° with thumbs pointing upward (holding "full cans")

The patient is asked to maintain their arms in this position as the practitioner applies a downward force.

The patient is again asked to abduct their arms with elbows extended to 90°, and then horizontally adduct their arms to 30° (scapular plane) and internally rotates their arms as if pouring out the contents of the "cans" ("empty cans").

A positive test for rotator cuff pathology is weakness in the empty can position; concordant pain in either position may be indicative of shoulder impingement.

Diagram of the shoulder joint 

Test-item Clusters

3 Positive Tests = 95% likelihood of impingement

2 Positive Tests = 90% likelihood of impingement

1 Positive Test = 63% likelihood of impingement

0 Positive Tests = 24% likelihood of impingement 

3 or more positive tests out of 5 indicate a high likelihood of SIS, and 2 or fewer positive tests out of 5 indicate a low likelihood of SIS.

Screening Tool

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.

X-Ray of the glenohumeral (shoulder) joint

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 Reistance 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. 

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

Salaffi, F., Ciapetti, A., Carotti, M., Gasparini, S., Filippucci, E., & Grassi, W. (2010). Clinical value of single versus composite provocative clinical tests in the assessment of painful shoulder. 

Bibliography

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