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Early detection of Early detection of

shoulder pathology in shoulder pathology in

the overhead athletethe overhead athlete

A clinical reasoning algorithmA clinical reasoning algorithm

Ann M. Cools, PT, PhD (Belgium)

A Cools Odense 2009A Cools Odense 2009

Impingement symptoms

ExternalSubacromial impingement

Internal(posterior) impingement

PrimaryImpingement

SecundaryImpingement

BicepsSLAP

Rotator cuffpathology

Scapular dyskinesis instability G.I.R.D.

(Cools et al. BJSM 2008)


Confirming impingement Confirming impingement

symptomssymptoms

�� Use Use ““impingementimpingement””--teststests

�� Only to confirm the presence of Only to confirm the presence of

impingementimpingement--related symptoms and to related symptoms and to

define possible biomechanical process define possible biomechanical process

(location of impingement)(location of impingement)

�� Not to diagnose underlying pathologyNot to diagnose underlying pathology

�� In general high sensitivity, low specificityIn general high sensitivity, low specificity

�� Very limited diagnostic valueVery limited diagnostic value


Impingement testsImpingement tests

�� JobeJobe testtest



�� HawkinsHawkins testtest



�� Neer testNeer test




PrimaryImpingement


BicepsSLAP



Jobe +Neer + antHawkins +

Jobe –Neer + postHawkins –



Confirming impingement Confirming impingement

symptomssymptoms

�� Limited information on internal impingementLimited information on internal impingement

�� No information on the cause of the problem No information on the cause of the problem

(primary versus secundary)(primary versus secundary)

�� Use Use ““instabilityinstability”” teststests

�� Interpretation on Interpretation on ““painpain”” in stead of in stead of

““instability symptomsinstability symptoms”” (Meister 2004)(Meister 2004)

�� Pain as criterion: low specificity in Pain as criterion: low specificity in

diagnosing instability (Speer 1994)diagnosing instability (Speer 1994)


A.A. Provocation testsProvocation tests–– ApprehensionApprehension

–– RelocationRelocation

–– Release Release

B.B. Laxity testsLaxity tests–– Load & Shift (anterior drawer)Load & Shift (anterior drawer)

–– Sulcus signSulcus sign

–– Posterior subluxation test Posterior subluxation test –– JerkJerk

(Speer AJSM 1994, Meister et al. 2004, Tennent AJSM 2003)

Testing shoulder instabilityTesting shoulder instability


InstabilityInstability teststests

�� Apprehension Apprehension –– Posterior Posterior

Impingement Sign (Meister 2004)Impingement Sign (Meister 2004)



�� relocationrelocation



�� Release testRelease test




PrimaryImpingement


BicepsSLAP



Relocation -Relocation+

Release +(pain)


Apprehension +(pain) ant

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

Relocation+Release +(pain)



Rotator cuff involvement?Rotator cuff involvement?

�� Empty can: testing of SS (Jobe 1987) Empty can: testing of SS (Jobe 1987)

AND impingement provocationAND impingement provocation

�� Use test for SS with less impingement Use test for SS with less impingement

provocationprovocation


Rotator Rotator cuffcuff tendinopathy?tendinopathy?

�� FullFull cancan testtest

(Reinold et al. JOSPT 2009)


Full Cann Full Cann (versus empty can) (versus empty can)

(Reinold et al. 2009):(Reinold et al. 2009):

�� Muscle activityMuscle activity: Similar SS activity as empty : Similar SS activity as empty

can, but lower amount of middle and can, but lower amount of middle and

posterior deltoid (Reinold et al. JAT 2007)posterior deltoid (Reinold et al. JAT 2007)

�� BiomechanicsBiomechanics: Resultant vector is always : Resultant vector is always

downward (caudal glide) and centering downward (caudal glide) and centering

(Poppen & Walker 1978): less impingement (Poppen & Walker 1978): less impingement

provocationprovocation


(Poppen & Walker 1978)




PrimaryImpingement


BicepsSLAP




Release +(pain)





Full Can +



Scapular involvement?Scapular involvement?

�� Scapular dyskinesis in association with Scapular dyskinesis in association with

impingement (Ludewig 2000)impingement (Ludewig 2000)

�� Scapular muscle dysfunction (strength, Scapular muscle dysfunction (strength,

timing, muscle balance) (Cools 2003, 2004, timing, muscle balance) (Cools 2003, 2004,

2007)2007)

�� Evaluation of scapular involvement in Evaluation of scapular involvement in

shoulder pathologyshoulder pathology

�� Evaluation of specific muscle dysfunctionEvaluation of specific muscle dysfunction


ScapularScapular involvementinvolvement??

�� ScapularScapular AssistanceAssistance Test: movement Test: movement

qualityquality

(Rabin et al. JOSPT 2006)


ScapularScapular involvementinvolvement??

�� ScapularScapular RetractionRetraction Test: scapular Test: scapular

stabilitystability

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


Scapular dyskinesis:Scapular dyskinesis:

serratus ant serratus ant oror lowerlower trap?trap?

(M. Kelley personal communicationaug 2003)




PrimaryImpingement


BicepsSLAP




Release +(pain)





SAT +SRT +

Full Can +



A.A. Provocation testsProvocation tests–– ApprehensionApprehension

–– RelocationRelocation

–– Release Release

B.B. Laxity testsLaxity tests–– Load & Shift (anterior drawer)Load & Shift (anterior drawer)

–– Sulcus signSulcus sign

–– Posterior subluxation test Posterior subluxation test –– JerkJerk

(Levy et al. 1999, Tennent AJSM 2003, Hegedus et al. BJSM 2008))

Testing shoulder instabilityTesting shoulder instability


Glenohumeral Glenohumeral instabilityinstability??

�� AnteriorAnterior laxity: Loadlaxity: Load & Shift test& Shift test


LOAD & SHIFTLOAD & SHIFT

�� Grade I (movement up Grade I (movement up

to glenoid rim)to glenoid rim)

�� Grade II (movement Grade II (movement

over glenoid rim + over glenoid rim +

spontaneous reduction)spontaneous reduction)

�� Grade III (movement Grade III (movement

over glenoid rim + no over glenoid rim + no

spontaneous reduction)spontaneous reduction)



�� InferiorInferior laxity:laxity:

SulcusSulcus signsign



�� PosteriorPosterior laxity: Posteriorlaxity: Posterior Subluxation Subluxation

TestTest




PrimaryImpingement


BicepsSLAP




Release +(pain)





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

SAT +SRT +

Full Can +



Involvement of Biceps and Involvement of Biceps and

superior labrum pathologysuperior labrum pathology

�� A large amount of SLAPA large amount of SLAP--lesion testslesion tests

�� ““hyperhyper--diagnoseddiagnosed”” and and ““hyperhyper--

operatedoperated--onon””??

�� Oh et al. AJSM 2008: choose 2 Oh et al. AJSM 2008: choose 2

sensitive and 1 specific testsensitive and 1 specific test


Biceps Biceps pathologypathology oror SLAP?SLAP?

�� OO’’ BrienBrien TestTest

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



�� SpeedSpeed’’ss TestTest




�� Biceps Biceps LoadLoad II testII test





PrimaryImpingement


BicepsSLAP




Release +(pain)





O’Brien+Speeds+Biceps load II+


SAT +SRT +

Full Can +



GIRDGIRD??

�� InternalInternal RotationRotation ROM in 90ROM in 90°°abductionabduction

(Trakis et al. AJSM 2008)




PrimaryImpingement


BicepsSLAP




Release +(pain)





IRROM↓

O’Brien+Speeds+Biceps load II+


SAT +SRT +

Full Can +



In general:In general:

�� HegedusHegedus, BJSM 2008, BJSM 2008

–– Large amount of studies on diagnostic Large amount of studies on diagnostic

accuracy shoulder tests, with conflicting accuracy shoulder tests, with conflicting resultsresults

–– Some tests far worse when used by other than Some tests far worse when used by other than

the originator of the testthe originator of the test

In general: In general: ““ we urge caution if a diagnostic test we urge caution if a diagnostic test

is only been studied once, and if the originator is only been studied once, and if the originator

of the test is the author of the paperof the test is the author of the paper””

((HegedusHegedus et al. BJSM 2008)et al. BJSM 2008)


More information?More information?

[email protected]


Thank you!!(Gent- Belgium)

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