Chiropractic Treatment of Shoulder Pain and Weakness

Shoulder pain and weakness are common symptoms in patients seeking chiropractic care. These symptoms can occur individually or in combination. Orthopedic testing helps isolate specific musculoskeletal tissues, sometimes eliciting pain, weakness, or a combination of both. Properly identifying these symptoms can lead to a more accurate diagnosis and prognosis.

Today’s blog will review two orthopedic tests for rotator cuff syndrome. If one test is positive, it causes pain, and if the other is positive, it causes weakness. When used together, these tests can help differentiate between simple rotator cuff irritation and a rotator cuff tear, ultimately influencing treatment decisions, rehabilitation exercises, and the duration of care.

The following four questions will be addressed:

1. Is there a test to identify isolated supraspinatus pain?

2. What test can identify weakness from a supraspinatus tear?

3. How does shoulder weakness affect my patient’s prognosis?

4. When should I consider referring a patient to a shoulder orthopedist?

Shoulder Pain Without Weakness

The most common rotator cuff injury involves the supraspinatus muscle. A simple way to apply strain to the supraspinatus is through the Internal Rotation & Shift Test. This test does NOT assess strength or range of motion; its purpose is to apply strain to the superior shoulder structures, particularly the supraspinatus. Pain in the area of the supraspinatus suggests an injury to this muscle.

The Internal Rotation & Shift Test can also irritate the biceps tendon or the labrum. If pain is present, refer to the condition reference protocol in ChiroUp to rule out involvement of the long head of the biceps or a SLAP lesion.

Test Description:

The patient is instructed to reach behind their back and slide their extended thumb as high up the spine as possible. The clinician then measures active shoulder internal rotation by noting the highest thoracic spinal level the patient can touch. Once the patient reaches their active range of motion, the clinician applies passive overpressure, moving the arm into greater adduction and internal rotation. This action causes the humeral head to shift anteriorly, placing tension on the superior rotator cuff. Increased pain at the anterior shoulder during overpressure has a high sensitivity (92%) and specificity (67%) for rotator cuff pathology, or potentially biceps tendon pathology. (1)

Shoulder Pain With Weakness

The DIME Test (The Dynamic Isokinetic Manipulation Evaluation) is a simple way to test the supraspinatus for weakness. Any tissue disruption within the supraspinatus will result in decreased tissue capacity. This test evaluates the muscle and tendon across all ranges of motion, allowing for the identification of weakness, which may indicate partial or full-thickness tissue damage.

Test Description:

1. Ask the patient to straighten and internally rotate their arm, then elevate it into full horizontal abduction in the coronal plane (straight out to the side and up).

2. The clinician grasps the patient’s wrist and forcefully adducts the arm back to the thigh in a smooth 5-second arc while the patient resists maximally.

3. The clinician observes for weakness or pain reproduction.

4. The test is repeated in the scapular plane (45 degrees forward).

The DIME Test should be performed bilaterally, starting with the asymptomatic side. Pain or weakness during DIME testing in the coronal or scapular plane has shown 93-100% sensitivity for diagnosing a full-thickness rotator cuff tear.

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"Pain during DIME testing had a sensitivity of 96.3% and 92.6%, with a negative predictive value (NPV) of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 demonstrated a sensitivity of 100% and 96.3%, with an NPV of 100% and 95.7%, respectively. Pain at ≤90° during unopposed active abduction in the coronal plane had a specificity of 100% and a positive predictive value of 100% for supraspinatus pathology, including tendinopathy, fraying, or tearing. Given its high sensitivity, a negative DIME test effectively rules out a full-thickness rotator cuff tear, providing valuable guidance for clinicians in deciding whether an MRI is necessary." (2)

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Chiropractic Treatment for Shoulder Weakness

A positive DIME test strongly suggests a full-thickness rotator cuff tear. In such cases, simple rehabilitation exercises are essential. Utilize the exercises outlined in the Rotator Cuff Syndrome condition report in ChiroUp. 

Phase 1 exercises focus on improving shoulder range of motion.

Phase 2 exercises are designed to strengthen the rotator cuff muscles and scapular stabilizers.

Strengthening takes time, so it’s important to educate the patient on the significance of adhering to at-home exercises. These protocols often require 4-6 weeks to show improvement. If the patient fails to meet appropriate functional improvement or pain relief goals, it may indicate the need for an MRI or a surgical referral. However, the vast majority of patients respond well to conservative measures.

Should I Refer a Patient to an Orthopedist?

If a patient presents with a positive DIME test and a confirmed full-thickness tear of the supraspinatus, and conservative care (4-6 weeks of manual therapy, spinal manipulation, patient education, and rehab) has failed, surgery may be a viable option. However, research by Jones et al. (2019) found that both operative and nonoperative groups reported improved pain and functional outcome scores. (3) Patients who opted for surgery experienced greater pain reduction and more significant improvements in outcome scores. Younger patients and those with a shorter symptom duration had better outcomes regardless of treatment.

While both operative and nonoperative treatments are viable options, surgical intervention may offer better outcomes, particularly for younger patients or those with shorter symptoms. Chiropractors can counsel their patients accordingly, presenting both treatment paths as legitimate choices, depending on individual circumstances.

Conclusion

Chiropractors can better diagnose and manage rotator cuff issues by understanding and applying orthopedic tests like the Internal Rotation & Shift Test and the DIME Test. With a combination of targeted rehabilitation, education, and, when necessary, referral to an orthopedist, patients can experience meaningful improvements in their shoulder health.

• References

  1. Fieseler G, Laudner K, Sendler J, et al. The internal rotation and shift-test for the detection of superior lesions of the rotator cuff: reliability and clinical performance. JSES Int. 2022;6(3):495-499. Published 2022 Feb 18. doi:10.1016/j.jseint.2022.01.011

  2. Abraham PF, Nazal MR, Varady NH, Gillinov SM, Quinlan NJ, Alpaugh K, Martin SD. The New Dynamic Isokinetic Manipulation Examination (DIME) is a Highly-Sensitive Secondary Screening Tool for Supraspinatus Full-Thickness Tears. Journal of Shoulder and Elbow Surgery. 2020 Jul 7.

  3. Jones, Grant L. MD Full-Thickness Rotator-Cuff Tears: Nonoperative Treatment Is Good, But Surgery May Be Better, The Journal of Bone and Joint Surgery: October 2, 2019 - Volume 101 - Issue 19 - p e105 doi: 10.2106/JBJS.19.00810

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Chiropractic Treatment of Shoulder Pain and Weakness