Mastering the Shoulder Exam: Top Tests for Rotator Cuff & Impingement
Shoulder pain is the third most frequent musculoskeletal issue seen in primary care, following back and knee pain. (1,2) Some sources report that up to 70% of people will experience shoulder pain at some point in their lifetime. (3) Fortunately, evidence-based chiropractors are proficient in managing most of these patients... provided we accurately diagnose the issues.
This week's blog and video will delve into the crucial aspects of evaluation, featuring a comprehensive shoulder physical exam tutorial to help you elevate your diagnostic skills to the next level! In the next few minutes, you’ll review:
Shoulder exam tutorial webinar
Shoulder exam tests to assess for a rotator cuff injury
When to image a painful shoulder
Watch this webinar on performing a 2-minute shoulder physical exam.
What Are The Most Common Shoulder Diagnoses?
According to the 2021 ChiroUp Network Dataset Analysis of 631,970 clinical diagnoses collected from our 2,200 evidence-based chiropractic providers, the top three most common shoulder diagnoses in chiropractic offices were:
Scapular dyskinesis
Rotator cuff strain/ tendinopathy
Shoulder impingement syndrome
While it's no surprise that rotator cuff-related diagnoses top the list, providers must also consider various other potential diagnoses that can affect the bones, joints, cartilage, ligaments, tendons, muscles, and nerves in the region.
Essential Questions To Ask In A Shoulder Exam
Like most other musculoskeletal complaints, the patient history is the primary source of essential diagnostic information for shoulder-related issues. Key history questions during shoulder exams include:
Trauma history - FOOSH (fall on an outstretched hand) is a common mechanism for sprain, strains, cartilage injuries, fractures, separations, and dislocations.
Occupation and activities (aka Microtrauma history) - Overuse conditions, notably tendinopathies and neuropathies, often stem from a consistent pattern of repetitive microtrauma.
Symptom location and character - Pain location can provide diagnostic clues; however, several etiologies generate a similar pattern of discomfort involving the anterolateral shoulder.
In addition to the standard OPPQRST inquiry, other essential questions include:
Significant stiffness - Shoulder osteoarthritis patients commonly report morning stiffness. However, if this stiffness endures beyond 30 minutes, it may raise suspicion of adhesive capsulitis or an inflammatory arthropathy. Download a sample of the ChiroUp Inflammatory Arthropathy Quick Reference Card here for a handy refresher. *Note: ChiroUp Subscribers, access your full reference card in the forms library.
Health history - Conditions such as diabetes, thyroid disorders, vitamin D deficiency, psoriasis, and osteoporosis can increase the risk or serve as potential catalysts for various shoulder-related issues.
How To Perform A Shoulder Exam
The essential components of a shoulder physical exam include:
Inspection - swelling, deformity
Range of motion - active, passive, and resisted movements
General palpation - tenderness, swelling, warmth, muscle wasting
Joint palpation - stability testing, motion palpation
Orthopedic assessment - specific to the differential diagnoses
Isolated strength testing - rotator cuff, biceps
Functional assessment - scapular dyskinesis, upper crossed syndrome, etc.
Cervical evaluation - an estimated 47% of shoulder problems arise from an asymptomatic spine. (4) Up to one-third of impingement patients have cervical nerve root compression on the same side. (5)
How To Test For A Rotator Cuff Injury
Studies suggest that rotator cuff disorders are likely responsible for up to 65-85% of all painful shoulder presentations. (1,6,7)
The following section highlights the essentials of a rotator cuff exam, including how to test for shoulder impingement, an underlying culprit for up to 95% of all chronic rotator cuff tears. (8)
Shoulder Impingement Tests
How do you test for shoulder Impingement? Current literature endorses the following assessments. (9,10)
Neer shoulder impingement test
Hawkins Kennedy test
Rotator Cuff Tests
What’s the best rotator cuff tear test? Two simple rotator cuff tests have shown excellent ability to help detect tears. (11,12)
ERLS - External rotation lag sign
DIME test
Want more clinical pearls about a rotator cuff tear test, a test for shoulder impingement, and the best management for both? Listen to our latest rotator cuff podcast, or watch this webinar on the ChiroUp YouTube channel.
Pro Tip: ChiroUp subscribers can visit the Clinical Skills tab to access the entire video library, including hundreds of evaluations, treatments, and exercises.
When To Image The Shoulder
Xrays
The American Journal of Radiology published a best practice guideline for imaging shoulder pain. (c) The following plain film views are recommended for the majority of chronic shoulder presentations:
AP (performed with shoulder internal rotation)
Grashey, aka Neer AP or True AP (performed with shoulder external rotation)
Lateral axillary
Arch/ Rockwood- if evaluation of the acromion is desired for impingement
MRI
“Over 90% of [rotator cuff] patients had premature MRI.” (13)
Magnetic resonance imaging is commonly employed as a diagnostic tool for assessing structural abnormalities in the shoulder. However, according to the Journal of Shoulder and Elbow Surgery (13), the use of MRI before a trial of conservative management provides negative value in patients with:
Atraumatic shoulder pain
Minimal to no strength deficits on physical examination
Suspected tendinopathy other than full-thickness tears
Want more? Check out this blog on Rotator Cuff Tears: When To MRI & When To Refer.
Diagnostic ultrasound
According to the AJR guidelines, in cases involving suspected rotator cuff tears or biceps tendinopathy, a diagnostic ultrasound performed by a skilled technologist has sensitivity and specificity equivalent to that of MRI and may be the preferred advanced imaging modality. (14,15)
Conclusion
ChiroUp subscribers can utilize the Shoulder evaluation form to guide your hand and wrist exam.
Pro Tip: ChiroUp subscribers can download exam forms for every region by visiting the Practice Resources forms library, then selecting Clinical/ Regional exam forms.
Once you've aced the diagnosis, you'll be poised to deliver precise and effective care to the right patient at the right time. ChiroUp subscribers can dive into an extensive Condition Reference library featuring comprehensive best-practice summaries for over 115 diagnoses, including the shoulder conditions mentioned earlier.
We’re honored to be your partner in automating clinical excellence! Together, we will become the undeniable best choice for patients and payors alike!
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1. Artus M, Holt TA, Rees J. The painful shoulder: an update on assessment, treatment, and referral. British Journal of General Practice. 2014 Sep 1;64(626):e593-5. Link
2. Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, Simmons A, Williams G. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Annals of the rheumatic diseases. 1998 Nov 1;57(11):649-55. Link
3. Luime JJ, Koes BW, Hendriksen IJ, Burdorf A, Verhagen AP, Miedema HS, Verhaar JA. Prevalence and incidence of shoulder pain in the general population; a systematic review. Scandinavian journal of rheumatology. 2004 Mar 1;33(2):73-81. Link
4. Rosedale R, Rastogi R, Kidd J, Lynch G, Supp G, Robbins SM. A study exploring the prevalence of Extremity Pain of Spinal Source (EXPOSS). Journal of Manual & Manipulative Therapy. 2020 Aug 7;28(4):222-30. Link
5. Dernek B, Aydomu S, Duymu TM, Adyeke L, Yardm MY, Kesikta FN, Sindel D, Ketenci A. The incidence of impingement syndrome in cases of cervical radiculopathy: An analysis of 220 cases. Journal of Back and Musculoskeletal Rehabilitation. 2019 Nov 29(Preprint):1-4. Link
6. Murphy RJ, Carr AJ. Shoulder pain. BMJ clinical evidence. 2010;2010. Link
7. Jain NB, Fan R, Higgins LD, Kuhn JE, Ayers GD. Does my patient with shoulder pain have a rotator cuff tear? A predictive model from the ROW cohort. Orthopaedic Journal of Sports Medicine. 2018 Jul 16;6(7):2325967118784897. Link
8. Neer CE III. Impingement lesions. Clin Orthop. 1983;173:70–77.
9. Batur EB, Sarıkaya PZ, Kaygısız ME, Gezer IA, Levendoglu F, Ilknur AG, Levendoglu F. Diagnostic Dilemma: Which Clinical Tests Are Most Accurate for Diagnosing Supraspinatus Muscle Tears and Tendinosis When Compared to Magnetic Resonance Imaging?. Cureus. 2022 Jun 13;14(6). Link
10. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British journal of sports medicine. 2012 Nov 1;46(14):964-78. Link
11. Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. Archives of physical medicine and rehabilitation. 2008 Jun 1;89(6):1162-8. Link
12. Abraham PF, Nazal MR, Varady NH, Gillinov SM, Quinlan NJ, Alpaugh K, Martin SD. The new dynamic isotonic manipulation examination (DIME) is a highly sensitive secondary screening tool for supraspinatus full-thickness tears. Journal of Shoulder and Elbow Surgery. 2020 Nov 1;29(11):2213-20. Link
13. Cortes A, Quinlan NJ, Nazal MR, Upadhyaya S, Alpaugh K, Martin SD. A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management. Journal of shoulder and elbow surgery. 2019 Nov 1;28(11):2153-60. Link
14. Tuite MJ, Small KM. Imaging evaluation of nonacute shoulder pain. American Journal of Roentgenology. 2017 Sep;209(3):525-33. Link
15. Shahabpour M, Kichouh M, Laridon E, Gielen JL, De Mey J. The effectiveness of diagnostic imaging methods for the assessment of soft tissue and articular disorders of the shoulder and elbow. European journal of radiology. 2008 Feb 1;65(2):194-200. Link
