Special Tests: Rotator Cuff Pathology

Special Tests Covered in this Lesson:

• Park et al. Rotator Cuff Tear Testing Cluster
  
  • Infraspinatus Strength Test
  • Painful Arc Test
  • Drop Arm Test
• Supine Impingement Test (Screening Tool)

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 supraspinatus and infraspinatus 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 shoulder impingement tests , 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.
• As mentioned in the course 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 Park et al. Rotator Cuff Tear Testing Cluster , adds a significant amount of specificity to physical evaluation for shoulder joint pain, shoulder joint injury, and rotator cuff pain specifically.

Brookbush Institute Recommendation:

• The Brookbush Institute 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 . Adding the Drop Arm Test to the SIS cluster , or the Hawkins-Kennedy Test to the RC cluster results in 4 tests that can be used to accurately identify impingement and/or rotator cuff pathology. The Brookbush Institute 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.
• Park et al. SIS and RC Tear Cluster
  
  • Hawkin's Kennedy
  • Infraspinatus Strength Test
  • Painful Arc Test
  • Drop Arm Test

For an Introduction to Special Tests:

• 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:
• Special Tests: Introduction

Courses covering Special Tests for the Shoulder Girdle

• Special Tests: Shoulder Impingement Syndrome (SIS)
• Special Tests: Rotator Cuff Pathology
• Special Tests: Acromioclavicular (AC) Joint Pathology
• Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Text and Illustrations
• Audio Voice-over
• Technique Videos
• Practice Exam
• Pre-approved Final Exam

1. Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.
2. Dutton, M. (2012). Dutton's Orthopaedic examination, evaluation, and intervention. McGraw-Hill Medical.
3. Magee, D. J. (2013). Orthopedic physical assessment. Elsevier Health Sciences.
4. 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. JBJS, 87(7), 1446-1455.
5. 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, 90(11), 1898-1903.
   • Hawkins-Kennedy (and Yocum's) (In addition to 4 - 5)
6. Hawkins, R. J., & Kennedy, J. C. (1980). Impingement syndrome in athletes. The American journal of sports medicine, 8(3), 151-158.
7. MacDonald, P. B., Clark, P., & Sutherland, K. (2000). An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. Journal of shoulder and elbow surgery, 9(4), 299-301.
8. Çalış, M., Akgün, K., Birtane, M., Karacan, I., Çalış, H., & Tüzün, F. (2000). Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Annals of the rheumatic diseases, 59(1), 44-47.
9. Bak, K., & Magnusson, S. P. (1997). Shoulder strength and range of motion in symptomatic and pain-free elite swimmers. The American Journal of Sports Medicine, 25(4), 454-459.
10. Kelly, S. M., Brittle, N., & Allen, G. M. (2010). The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy. Clinical rehabilitation, 24(2), 149-158.
11. 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, 466(11), 2813-2819.
12. 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. Annals of the rheumatic diseases, 63(10), 1288-1292.
13. 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, 26(6), 734-742.
14. 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), 400, 77-87.
15. 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. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 21(11), 1290-1295.
16. 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. The American journal of sports medicine, 35(8), 1334-1340.
17. Leroux, J. L., Thomas, E., Bonnel, F., & Blotman, F. (1995). Diagnostic value of clinical tests for shoulder impingement syndrome. Revue du rhumatisme (English ed.), 62(6), 423-428.
    • Infraspinatus/External Rotation Resistance Test (In addition to 4, 5, 10, 12)
18. 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?. The American journal of sports medicine, 34(2), 256-264.
    • Painful Arc Test (In addition to 4, 5, 8, 10, 13)
19. 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. Rheumatology, 47(5), 679-683.
20. 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, 48(12), 1633-1637.
21. 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. JBJS, 91(Supplement_6), 10-18.
    • Neer Test (In addition to 1-5, 7-10, 13 -16 19, 21-22)
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?. BioMed research international, 2017.
23. Post, M., & Cohen, J. (1986). Impingement syndrome. A review of late stage II and early stage III lesions. Clinical orthopaedics and related research, (207), 126-132.
    • Empty Can Test (In addition to 1-5, 10, 12, 13, 18)
24. 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?. The American journal of sports medicine, 27(1), 65-68.
25. 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. Acta Medica Okayama, 60(4), 223.
26. Jobe, F. W., & Moynes, D. R. (1982). Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. The American journal of sports medicine, 10(6), 336-339.
27. Blackburn, T. A. (1990). EMG analysis of posterior rotator cuff exercises. J Athl Train, 25, 40-45.
    1. Additional Studies
28. Hegedus, E. J., Cook, C., Lewis, J., Wright, A., & Park, J. Y. (2015). Combining orthopedic special tests to improve diagnosis of shoulder pathology. Physical Therapy in Sport, 16(2), 87-92.
29. Murrell, G. A., & Walton, J. R. (2001). Diagnosis of rotator cuff tears. The Lancet, 357(9258), 769-770.
30. Castoldi, F., Blonna, D., & Hertel, R. (2009). External rotation lag sign revisited: accuracy for diagnosis of full thickness supraspinatus tear. Journal of Shoulder and Elbow Surgery, 18(4), 529-534.
31. 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, 26(6), 734-742.
32. Fodor, D., Poanta, L., Felea, I., Rednic, S., & Bolosiu, H. (2009). Shoulder impingement syndrome: correlations between clinical tests and ultrasonographic findings. Ortop Traumatol Rehabil, 11(2), 120-126.
33. Fowler, E. M., Horsley, I. G., & Rolf, C. G. (2010). Clinical and arthroscopic findings in recreationally active patients. BMC Sports Science, Medicine and Rehabilitation, 2(1), 2.