differential diagnosis: looking for the causes of … part ii.pdf · differential diagnosis:...

DIFFERENTIAL DIAGNOSIS: Looking for the causes of impingement…

Ann Cools, PT, PhDGhent University - Belgium

Dept of Rehabilitation Sciences & Physiotherapy

Ann.Cools@UGent.be

A Cools clinical exam 2016

« thinking about…. »

Which special tests do you use in yourshoulder examination?

• …• …• …

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

JOBE-TEST

Shoulder in 90° scapular elevation and maximal internal rotation (empty-can), give resistance against elevation

Test is (+) in subacromial impingement

HAWKINS-TEST

Passively rotate the shoulder into internal rotation in a 90°forward flexion position

Test is (+) in subacromial impingement

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

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Jobe +Neer + antHawkins +

Jobe –Neer + postHawkins –

+ INSTABILITY-TESTS

INSTABILITY-TESTS

A. Provocation tests‣ Apprehension‣ Relocation‣ Release

B. Laxity tests‣ Load & Shift (anterior drawer)‣ Sulcus sign‣ Posterior subluxation test – Jerk

APPREHENSION

Shoulder in 90° abduction & maximal external rotation: + end range external rotation; pain or apprehension?

Ant pain: SA imppost pain: int imp

RELOCATION

Shoulder in apprehension position: posterior translation humeral head: test is (+) if pain or apprehension decreases

+ secondary imp- primary imp

RELEASE

Patient in relocation position: suddenly release examiner’s hand: test is (+) if pain/ apprehension reappears

Confirms second imp

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Relocation -Relocation+

Release +(pain)

Apprehension +(pain) ant

Jobe –Neer + postHawkins –Apprehension +(pain) post

Relocation+Release +(pain)

Conclusion: the cut point of 3 or more positive of 5 tests canconfirm the diagnosis of SAIS

(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”

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

Instability tests

Gross 1997⇒ Anterior Release test‣ positive predictive value 87%, neg pred val 93%

Impingement & Instability tests

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

ROTATOR CUFF TESTS

Rotator cuff involvement?

Empty can test vs full can test

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

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)

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

SCAPULARTESTSFull can +

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

Scapular involvement? Neuromuscular coordination?

(Rabin et al. JOSPT 2006)

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

Scapular involvement? Scapular stability?

(Kibler et al. AJSM 2006, Tate et al. AJSM 2008)

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

Full can + SAT +SRT +

Scapular tests are symptom relieftests rather than diagnostic tests

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

INSTABILITYTESTS

INSTABILITY-TESTS

A. Provocation tests‣ Apprehension‣ Relocation‣ Release

B. Laxity tests‣ Load & Shift (anterior drawer)‣ Sulcus sign‣ Posterior subluxation test – Jerk

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)

SULCUS SIGN

Perform inferior translation on humerus

Grade or interpretation of “sulcus”

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

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

Laxity tests +Appr + (appr)Relocation + (appr)Release + (appr)

SLAPTESTS

Biceps pathology –SLAP lesions

Speed’s Test O’Brien testBiceps-Load Test II

(Hegedus et al. BJSM 2008, Oh et al. AJSM 2008)

90° elevation in external rotation, elbow in extension & supination

R against elevation

!! Biceps pathology also gives (+) sign

Speed’s Test

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

120° abd, external rotation, elbow 90° flexion & supination

R against flexion+ if painful

Biceps-Load II test (Kim et al. Arthorscopy 2001)

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

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)

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

GIRDROM

• 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 )

Internal(posterior)

impingement

PrimaryImpingement

BicepsSLAP

Release +(pain)

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

Many ways to approach patient’s examination!

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)

differential diagnosis: looking for the causes of … part ii.pdf · differential diagnosis:...

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