NEW Shoulder Exam: D.I.M.E.

There is one orthopedic test you must add to your physical exam this month. It's called the Dynamic Isokinetic Manipulation Evaluation (DIME) of the shoulder. 

Today's blog will cover how to perform the test, how the DIME can be a valuable addition to your shoulder exam, and provide direction into how evidence-based chiropractors are using this test to confidently rule out the need for an MRI or surgical referral.

The Dynamic Isokinetic Manipulation Evaluation (modified)

Begin by asking 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 then up). The clinician grasps the patient’s wrist then forcefully adducts the patient’s arm back to their thigh in a smooth 5-second arc as the patient maximally resists. The clinician observes for weakness or reproduction of pain. For the second half of the test, the same maneuvers are repeated in the scapular plane (45 degrees forward). The DIME test should be compared bilaterally, starting with the asymptomatic side. Pain or weakness during DIME testing in the coronal or scapular plane demonstrates 93-100% sensitivity for full-thickness rotator cuff tear.

“Pain during DIME testing had a sensitivity of 96.3% and 92.6% and negative predictive value of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 had a sensitivity of 100% and 96.3% and NPV of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and positive predictive value of 100% for supraspinatus pathology of any kind (i.e. tendinopathy, “fraying”, or tearing). Given its high sensitivity, a negative DIME test rules out supraspinatus full-thickness tear well in these patients, and can therefore better inform clinicians which patients should undergo MRI.” (1)

What Is So Special About The DIME

The External Rotation Lag Sign and Drop Arm Test have excellent specificity for a supraspinatus full-thickness tear. However, these tests lack sufficient sensitivity to rule out a full-thickness tear (FTT) confidently. A screening test's sensitivity is the ability of a screening test to detect a true positive rate. A positive DIME can correctly identify nearly every person with an FTT.  Patients with full-thickness tears are at the highest risk for long-term disability or delayed return to sport. Shoulder pathology, including full-thickness tears, requires a multimodal approach that sometimes requires advanced imaging to identify all possible treatment options. MRI has long been the gold standard for identifying a structural etiology resulting in pain or dysfunction.

No single physical examination maneuver, in isolation, can reliably diagnose a supraspinatus full-thickness tear. Evidence-informed chiropractors must rely on clusters of tests to decide when to use advanced imaging. Here is the algorithm presented by Cortes (2019). To identify if an FTT is suspected.

The Clinical Utility Of The DIME

Every evidence-based chiropractor must diagnose and then determine the best course of action. The presence of a positive DIME should alert the provider to the very high likelihood of a full-thickness rotator cuff tear. Failure of the patient to meet appropriate functional improvement or pain relief goals may indicate the need for an MRI and subsequent surgical referral. A positive test answers two commonly occurring questions. 

1. Should I order an MRI? 

Use this algorithm above, created by Cortes et al., to decide when to order an MRI.

2. Do I need to refer this patient to an orthopedist? 

If a patient presents with a positive DIME, a confirmed FTT of the supraspinatus, and failed conservative care (4-6 weeks of manual therapy, spinal manipulation, patient education, and rehab), surgery may be a viable option. Jones et al. (2019) found that both operative and nonoperative groups report improved pain and functional outcome scores. Those patients who elected to have surgery reported a greater reduction of pain and more significant improvement in outcome scores. It also showed that younger patients and patients with a shorter symptom duration had better outcomes regardless of treatment. Therefore, we can counsel our patients with full-thickness rotator cuff tears that both treatments are viable options, but surgical treatment may produce better outcomes.

The entire protocol for Rotator Cuff Tendinopathy can be found in ChiroUp’s condition reference. This will come in handy the next time you need a refresher on any recommended test, treatment, or exercise for your patients. By actively providing the best possible care to our patients, we can help to make chiropractic THE top choice for our patients & payors. 

If you don’t already have access to a ChiroUp account, you can learn more about our plans & pricing on our site. 

• References

  1. 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.

  2. Cortes A, Quinlan NJ, Nazal MR, Upadhyaya S, Alpaugh K, Martin SD. A value-based care analysis 316 of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the 317 implicated role of conservative management. J Shoulder Elbow Surg 2019. 318 10.1016/j.jse.2019.04.003

  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