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Shoulder pain and dysfunction are most common
collective musculoskeletal illness in the overall population and seeking care
from physical medicine and rehabilitation. Impingement is a frequently
described pathological condition, which possibly the result of scapular
dyskinesis, muscle dysfunction and shoulder instability and consequently leads
to rotator cuff and biceps pathology eventually becoming chronic stiffness
adhesive capsulitis. Number of different shoulder tests have been enlightened
in literature and claimed with their individual diagnostic accuracy. However,
it is often challenged for the clinician to select the appropriate tests for
differential diagnosing the underlying pathology because the shoulder pain’s
symptomatology findings are various and overlapped each other however, a
successful outcome of shoulder pain is dependent on precise differential
diagnosis. It is attained by the systematic clinical diagnosis approach. The
purpose of this paper is to talk over a clinical algorithm which would be
applied in the early detection of the underlying causes of impingement
symptoms. In this algorithm, a specific chronology and selection of diagnostic
tests may offer the clinician a guideline in his physical examination of the
patient with shoulder pain.
Keywords: Sub
acromial impingement syndrome (SIS), Shoulder pain, Coracoacromial ligament
INTRODUCTION
Shoulder pain due to
subacromial Impingement Syndrome (SIS) is the most prominent reason. SIS is
that the soft tissue entrapping in the sub acromial space, which is built by
the under the surface of the acromion, head of humerus and coracoacromial
ligament. SIS is caused by various factors resulting from impingement on the
rotator cuff tendon, the long head of biceps and occasionally the overlying
subacromial bursa and superior portion of capsule against the anterior edge of
the acromion and its’ associated coracoacromial arch. Pain is located around
the acromion and lateral side of the upper shoulder. It is exaggerated by
overhead physical activity and pain getting worse at night. In the majority of
cases, the prevalence of shoulder pain and rotator cuff dysfunction get severe
with aging among women population. The shoulder pain symptomatology can be
overlapped by many findings and various conditions however, successful
prognosis in related to sub acromial impingement syndrome is dependent on
precise diagnosis. It can be brought by detailed knowledge of the regional
anatomy, the biomechanics of shoulder motion and the accurate interpretation of
the pathology determined through a detailed history, comprehensive physical examination
and diagnostic studies. A study reveals that conservative interventions
approach for shoulder impingement syndrome recovery of the problem in 70-90% of
cases [1].
PATHOPHYSIOLOGY OF
SUBACROMIAL SYNDROME
The subacromial space is superiorly designed
by the anterior edge and bottom of the anterior third of the acromion,
coracoacromial ligament and the acromioclavicular joint and inferiorly the
humeral head. The soft tissues that occupying in the sub
acromial space are supraspinatus, long head of the biceps brachii tendon, subacromial
bursa and the superior portion of the capsule. One or all of these soft tissues
may be affected by the narrowing of sub acromial space. The main pathology is inflammation and degeneration of the under-
Besides
the classification of impingement based on the location of encroachment, very
often impingement is classified by the cause of the problem, dividing it into
primary versus secondary impingement [4]. In
primary impingement, a structural narrowing of the subacromial space causes
pain and dysfunction, such as acromioclavicular arthropathy, type I acromion or
swelling of the soft tissue in the sub acromial space. In secondary
impingement, there are no structural obstructions causing the encroachment, but
rather functional problems, occurring such as scapula dykinesis. Secondary
impingement may occur in the sub acromial space as well as internally in the
glen humeral joint [5]. In view of the hypothesis that
impingement symptoms would be the result of various underlying ongoing
pathologies, thus it is important to describe the biomechanical relationship
between these symptoms and shoulder diagnosis. Rotator cuff pathology may be
associated with impingement symptoms in primary as well as secondary
impingement. In primary impingement, swelling of the injured rotator cuff
tendons causes the narrowing of the sub acromial space on the other hand in
secondary impingement due to rotator cuff dysfunction because rotator cuff
muscles perform a caudal glide arthrokinematic joint play motion of the humeral
head during elevation in order to avoid impingement but in the case of rotator
cuff muscles dysfunction more cranial migration of the humeral head, thus
causing secondary impingement [6].
Scapular
dyskinesis also has been well clarified in relation to impingement symptoms the
rationale behind this association is that, during arm elevation, impingement
may occur the insufficient scapula humeral rhyme motion because lack of
muscular function, which support upward rotation, posterior tilting, and
external rotation of scapular subsequently clearance the sub acromial space to
follow glen humeral joint play motion [7]. The association between impingement
symptoms and shoulder instability is well established excessive humeral head
translations, based on capsular laxity and instability lead to narrowing of the
sub acromial space or the glenohumeral joint relation, thus causing to
impingement symptoms and pain [8]. Since the biceps plays an important role in
shoulder stability and function, therefore biceps pathology causes secondary
impingement symptoms. Indeed, biceps tendon problems (tendinopathy or
tenosynovitis) as well as SLAP lesions (labral lesions at the site of origin of
the long head of the biceps) compromise optimal shoulder function, and may
result in impingement [4]. Glen humeral Internal Rotation Deficit is often
referred to as GIRD there are several theories concerning the occurrence and
development of GIRD. Burkhart et al. [8] report that GIRD takes place due to
the contracture of the posterior capsule this interrupting glenohumeral
arthrokinematic motion. Other researchers believe that GIRD begins in the early
years with a bony adaptation of the humerus or muscle hypertony in the external
rotators due to frequent eccentric loading [9].
Clinical reasoning in patient investigation
After gaining
the medical history, a comprehensive physical examination should be carried if
clinician suspects the impingement pain. It contains observing posture,
soft-tissue inspection, palpation, active; passive range of motion, strength
testing, neurologic assessment. It is vital that the clinician investigates the
impingement the patient involves, and find out the underlying pathology. This
paper emphasis on the algorithm offers the clinician for approaching the
specific tests that can be followed when screening the painful shoulder problems,
and intends a particular chronology in the performance of the individual tests (Figure 1).
IMPINGEMENT TESTS
The most
popular provocative impingement tests are the Jobe, Hawkins and Neer tests. The
Jobe test is positive for subacromial impingement but the test will be negative
if the patient has posterio-superior glenoid impingement. Interpretation of the
Hawkins test is a suggestion for sub acromial impingement but the test will be
negative in case of internal impingement. Painful Neer test depends upon the
location of the pain if the pain at the front of the shoulder is a sign for
subacromial impingement; whereas pain exhibits at the posterior aspect of the
shoulder will be internal impingement. Beyond these impingement tests, the instability
tests are very often applied as provocation tests for impingement [10].
Scholars interpret the Apprehension test and the Relocation test in relation to
pain rather than instability symptoms in order to further outline the cause of
impingement. Pain during the Apprehension test at the anterior aspect of the
shoulder will indicate sub acromial impingement, whereas pain at the posterior
aspect implies posterio-superior glenoid impingement [11]. The Relocation test
is done following to the Apprehension test, which is positive if the pain
exhibits during apprehension. The Relocation test provides the chance us to
differentiate between primary versus secondary impingement. If the test is
positive it means that the impingement pain is secondary as a result of
excessive anterior translation of the humeral head, but a negative test
advocates primary impingement, which is not dependent on the arthrokinematic
position of the humeral head [12,13]. Impingement tests are known to have high
sensitivity, but rather low specificity. A study established from their
extensive meta-analysis that sensitivity and specificity for the Neer test were
79% and 53%, respectively, and for the Hawkins test 79% and 59%, respectively.
However, number of the studies investigates accuracy of these tests by
considering rotator cuff tendon pathologies as a reference for sensitivity and
specificity diagnosis. On the other hand, most studies confirmed that the sub
acromial space narrowing during the Neer and Hawkins manoeuvre. In addition, Hegedus
et al. [14] suggested that using the Hawkins test as a screen and the
supraspinatus test may serve as a confirmatory test for impingement. These
tests should only be used to confirm the presence of impingement symptoms also
to identify the underlying pathomechanics. In the use of instability tests in
the evaluation of impingement, a study claimed that the overall accuracy of the
shoulder Relocation tests was less than 50% when the response of pain alone was
considered and was higher than 80% when the response of Apprehension alone was
considered. Based on their results, the authors advised the clinician not to
use the criterion of pain in the interpretation of these tests. However,
accuracy of this test was investigated in relation to the diagnosis of
instability and not impingement [12]. In the clinical examination of
impingement, investigators used the criteria “pain during apprehension and
disappearance of pain during relocation”. Moreover, recently, Meister et al.
[13] established a new test for internal impingement, “the posterior
impingement sign”, the clinician may be advised to use the Apprehension
position to detection and location of impingement symptoms.
Rotator cuff tests
To define the
involvement of rotator cuff pathology in the impingement symptoms, a modified
version of the Jobe test is a valuable tool. Indeed, Jobe et al. [15] described
the test to investigate the integrity of the rotator cuff muscles, particularly
the supraspinatus. However, based on this test one cannot define whether a
painful test is the result of functional impingement rather than rotator cuff
muscle dysfunction. Therefore, the examiner can perform the full-can test.
Research has indicated that rotator cuff muscles are also highly active in this
position [15]. If both tests are painful, rotator cuff pathology is present. If
only the Empty-can test is painful and the Full-can is negative, the patient
probably suffers from impingement symptoms, but not primarily related to
rotator cuff pathology. In the presence of rotator cuff pathology, the examiner
can perform a number of specific tests for the supraspinatus, subscapular is
and infraspinatus [16]. Several studies have been carried to compare the
effectiveness of Empty-can test and the Full-can test for diagnosing supraspinatus
pathology or impingement and revealed that both testing positions can be used
in diagnosing supraspinatus tears, however in general pain provocation is less
in the Full-can position. Thus, it has been advised to perform the Full-can
position in the detection of rotator cuff tears and the Empty-can test in the
diagnosis of sub acromial impingement symptoms [17].
Scapular involvement tests
Scapular
connection with shoulder impingement may be inspected by the Scapular
Assistance Test (SAT) and the Scapular Retraction Test (SRT). In the SAT,
scapular motion quality is scanned during this movement pain reduction
comparing with non-assistance confirms scapular involvement in the shoulder
impingement. The SRT evaluate scapular stability. The test is positive for
scapular association pain present while in the Empty-can position but
disappears during the SRT [18]. Besides anthropometric measurements of scapular
orientation and clinical qualitative observation of scapular movement patterns,
a few clinical tests have been introduced in literature. However, scapular
tests have been recently established in the literature these investigation
tools try to identify possible scapular involvement in relation to shoulder
impingement pain. A study examined the inter-tester reliability of the SAT on
patients with shoulder pain and concluded that the SAT possesses acceptable
inter-rater reliability for clinical use. Another study evaluated apparent and
absolute supraspinatus strength in patients with shoulder injury using the SRT.
The study showed that apparent supraspinatus muscle weakness on clinical
examination in symptomatic patients might be dependent on scapular position,
since the patients showed a significant increase in scapular elevation strength
during the SRT association with Jobe test compared with the normal Jobe test
[19].
Instability tests
The clinical
tests to observe shoulder instability are divided into provocative tests and
laxity tests. But provocative tests such as Apprehension and Relocation test
are commonly used for instability described earlier in this paper. In case of
instability, subjects will display instability symptoms, such as apprehensive
muscle tension, and subluxation, rather than pain. Differentiate the
provocative tests from the laxity tests by assessing humeral translation in
relation to the glenoid fossa. The Load and Shift test may be used for anterior
laxity the amount of laxity is graded from 1 means translation of humeral up to
the glenoid rim to 3 means subluxation without spontaneous reduction. The
sulcus sign reveals inferior laxity. The posterior laxity is pronounced by the
posterior subluxation test, which is considered to be positive if a clunk is
felt [20]. Speer et al. [13] examined the accuracy of the Apprehension and
Relocation tests with respect to diagnosing instability. In this study high
accuracy was found (85%) if the criterion was “apprehension” or reflexive muscle
reaction to protect the glenohumeral joint, but rather low accuracy (49%) if
the criterion was only pain. However, as mentioned earlier, in this study
instability was the only target diagnosis, and not pain based on impingement.
Meister et al. [12] found high sensitivity (75%) and specificity (85%) for the
“posterior impingement sign” in which the shoulder is placed in a position
similar to the apprehension position for diagnosing posterosuperior glenoid
impingement. With respect to the laxity tests, a reliability of 0.75 was found
for translations of the humeral head in anterior, posterior and inferior
positions, when grading the amount of translation from I to III. In general,
however, it is recommended to be cautious in interpreting laxity test results
and to combine laxity testing with provocative instability testing in view of
clinical reasoning and treatment determination [21].
Biceps pathology and SLAP lesion tests
The Speed’s
Test, the O’Brien Test and the biceps load II test are recommend for biceps
pathology and SLAP lesions based on recent literature. The Speeds test positive
if pain produces into the biceps region. The SLAP lesions is examined by
O’Brien test if pain is triggered in the first testing position, is diminished
or vanished in the second testing position. The Biceps Load II test is
considered positive if the patient complains of pain during the resisted elbow
flexion [20,22]. In general, the Speed’s test is considered to be a
non-specific but sensitive test for biceps and labral (SLAP) pathology. In
recent literature, there is a tremendous interest in the question of how to
diagnose with clinical testing the presence of SLAP lesions. Although a
definitive diagnosis of SLAP lesions is typically made by arthroscopic
observations, clinical suspicion is important before imaging study. However,
symptoms in most patients with SLAP lesions are very often non-specific;
patients often complain of clicking, “deep” shoulder pain, functional
instability and dead-arm syndrome. Various studies have been performed
examining the diagnostic value of SLAP tests, with conflicting results. In a
very recent paper, Oh et al. [23] examined the sensitivity, specificity and
overall accuracy of SLAP tests, earlier described in literature. The authors
concluded that some combinations of two relatively sensitive clinical tests
(such as the O’Brien and Apprehension tests) and one relatively specific
clinical test (such as the Biceps Load II test) increase the diagnostic
efficacy of SLAP lesions. Based on this study, and taking into account the
overall limited value of clinical SLAP tests, the above mentioned tests are
integrated into the clinical algorithm for impingement-related shoulder
pathology [23].
Clinical evaluation of GIRD
The assessment
of GIRD is measured by glen humeral internal rotation range of motion.
Goniometric assessment and interpretation of the “end-feel” are labeled as
criteria for GIRD evaluation. A side difference of 20 degree is considered to
be positive for GIRD [24]. In general, measurement of glenohumeral internal
rotation ROM (supine, with the shoulder in 90 degree abduction) and assessment
of horizontal adduction (side-lying) are suggested to indirectly evaluate
stiffness of the posterior shoulder structures [25]. Therefore, these measurements
should be performed with caution, and should be accompanied by thorough
physical examination and interpretation of the end-feel during accessory
movements such as posterior glenohumeral joint translation [26]. According to
Riddle et al. [27], goniometric measurements for the shoulder are highly
reliable when taken by the same physical therapist. The degree of inter-tester
reliability for these measurements appears to be range of motion specific.
Therefore it is advised that the same examiner performs both pre-treatment and
post-treatment assessments [27].
CONCLUSION
This article
highlights the clinical screening algorithm to have differential
diagnosis among painful shoulder problems because the greater understanding of
the causes of impingement can lead to a more specific and non-generalised
treatment approach to treat this disorder and consequently to
regain pain free functional daily livings among the shoulder pain suffering
population.
1. Morrison
DS, Frogameni AD, Woodworth P (1997) Non-operative treatment of sub acromial
impingement syndrome. J Bone Joint Surg Am 79: 732-737.
2. Neer
CS II (1972) Anterior acromioplasty for the chronic impingement syndrome in the
shoulder. A preliminary report. J Bone Joint Surg Am 54: 41-50.
3. Walch
G, Boileau P, Noel E (1992) Impingement of the deep surface of the
supraspinatus tendon on the poster superior glenoid rim: An arthroscopic study.
J Shoulder Elbow Surg 1: 238-245.
4. Borsa
PA, Laudner KG, Saurers EL (2008) Mobility and stability adaptations in the
shoulder of the overhead athlete: A theoretical and evidence-based perspective.
Sports Med 38: 17-36.
5. Hegedus
EJ, Goode A, Campbell S (2008) Physical examination tests of the shoulder: A
systematic review with meta-analysis of individual tests. Br J Sports Med 42:
80-92.
6. Blevins
F (1997) Rotator cuff pathology in athletes. Sports Med 24: 205-220.
7. Kibler
B (1998) The role of the scapula in athletic shoulder function. Am J Sports Med
26: 325-337.
8. Burkhart
S, Morgan C, Kibler W (2003) The disabled shoulder: Spectrum of pathology part
III: The SICK scapula, scapular dyskinesis, the kinetic chain and
rehabilitation. Arthroscopy 19: 641-661.
9. Meister
K (2000) Injuries to the shoulder in the throwing athlete. Part one:
biomechanics/pathophysiology/classification of injury. Am J Sports Med 28:
265-275.
10. Tennent
TD, Beach WR, Meyers JF (2003) A review of the special tests associated with
shoulder examination. The rotator cuff tests. Am J Sports Med 31: 154-160.
11. Johanson
MA, Gonzalez-King BZ (2004) Differential soft tissue diagnosis. In: Donatelli
RA, ed. Physical therapy of the shoulder. New York: Churchill Livingstone.
12. Meister
K, Buckley B, Batts J (2004) The posterior impingement sign: diagnosis of
rotator cuff and posterior labral tears secondary to internal impingement in
overhand athletes. Am J Orthop 33: 412-415.
13. Speer
KP, Hannafin JA, Altchek DW (1994) An evaluation of the shoulder relocation
test. Am J Sports Med 2: 177-183.
14. Hegedus
EJ, Goode A, Campbell S (2008) Physical examination tests of the shoulder: A
systematic review with meta-analysis of individual tests. Br J Sports Med 42:
80-92.
15. Jobe
FW, Moynes DR, Brewster CE (1987) Rehabilitation of shoulder instabilities.
Orthop Clin North Am 18: 47-482.
16. Takeda
Y, Kashiwaguchi S, Endo K (2002) The most effective exercise for strengthening
the supraspinatus muscle: Evaluation by magnetic resonance imaging. Am J Sports
Med 30: 374-381.
17. Reinold
MM, Macrina LC, Wilk KE (2007) Electromyographic analysis of the supraspinatus
and deltoid muscles during 3 common rehabilitation exercises. J Athl Train 42:
464-469.
18. Burkhart
S, Morgan C, Kibler W (2003) The disabled shoulder: Spectrum of pathology part
III: The SICK scapula, scapular dyskinesis, the kinetic chain and
rehabilitation. Arthroscopy 19: 641-661.
19. Kibler
WB, Sciascia A, Dome D (2006) Evaluation of apparent and absolute supraspinatus
strength in patients with shoulder injury using the scapular retraction test.
Am J Sports Med 34: 1643-1647.
20. Tennent
TD, Beach WR, Meyers JF (2003) A review of the special tests associated with
shoulder examination. Part II: laxity, instability and superior labral anterior
and posterior (SLAP) lesions. Am J Sports Med 31: 301-307.
21. Park
HB, Yokota A, Gill HS (2005) Diagnostic accuracy of clinical tests for the
different degrees of sub acromial impingement syndrome. J Bone Joint Surg Am
87: 1446-1455.
22. Kim
SH, Ha KI, Ahn JH (2001) Biceps load test II: A clinical test for SLAP lesions
of the shoulder. Arthroscopy 17: 160-164.
23. Oh
JH, Kim JY, Kim WS (2008) The evaluation of various physical examinations for
the diagnosis of type II superior labrum anterior and posterior lesion. Am J
Sports Med 36: 353-359.
24. Burkhart
SS, Morgan CD, Kibler WB (2003) The disabled throwing shoulder: Spectrum of
pathology: Part I: pathoanatomy and biomechanics. Arthroscopy 19: 404-420.
25. Myers
JB, Laudner KG, Pasquale MR (2006) Glen humeral range of motion deficits and
posterior shoulder tightness in throwers with pathologic internal impingement.
Am J Sports Med 34: 385-391.
26. Ellenbecker
T (2006) Shoulder rehabilitation: Non-operative treatment. New York: Thieme, p:
180.
27. Riddle
DL, Rothstein JM, Lamb RL (1987) Goniometric reliability in a clinical setting.
Shoulder measurements. Phys Ther 67: 668-673.
28. Cools
AM, Cambier D, Witvrouw EE (2008) Screening the athlete's shoulder for
pathology algorithm for early detection of shoulder impingement symptoms: A
clinical reasoning. Br J Sports Med 42: 628-635.
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