Evaluation of shoulder pain

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Applied Evidence

Evaluation of shoulder pain

J Fam Pract. 2002 July;51(7):605-611

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References

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The shoulder’s ROM should be evaluated both actively and passively. The shoulder is a mobile joint with a complexity of movements. These include flexion to 180 degrees, extension to 40 degrees, abduction to 120 degrees with palms down and 180 degrees with palms up, internal rotation to 55 degrees, and external rotation to 45 degrees with arms at the side. Although determining abduction ROM is consistent among examiners,²⁷ interrater reliability is poor for assessment of external rotation ROM. Lack of full ROM that is equally limited with both passive and active examination is found in arthropathies and adhesive capsulitis.

Pain between 60 and 120 degrees of abduction “the painful arc”) is associated with subacromial impingement, whereas pain after 120 degrees is an indication of acromioclavicular joint origin. However, Calis and coworkers¹⁷ found that the presence of subacromial impingement has a positive likelihood ratio of only 1.7.

After assessing the ROM, the next steps are to evaluate the rotator cuff and biceps tendon, perform impingement testing, check for instability, and finally assess the acromioclavicular joint. The tests are listed in Table 2 in our preferred order of examination and represent the tests best supported by the evidence; the results are based on a literature search of Medline, PubMed, DARE, and Sports Discuss. The technique of each examination maneuver has been published elsewhere and is not described in detail here. Figure 1 through 4 illustrate several common examination maneuvers described below. A Web site that demonstrates the physical examination more thoroughly can be found at http://www.nismat.org/orthocor/exam/shoulder.html#Evaluation.

TABLE 2
Use of history and physical examination to diagnose shoulder pain

History or maneuver	Study quality (1A–5)*	Sensitivity	Specificity	LR+	LR−	PV+	PV−
Rotator cuff tear
History of trauma¹⁹	2B	36	73	1.3	0.88	72	37
Night pain¹⁹	2B	88	20	1.1	0.6	70	43
Painful arc¹⁷	2B	33	81	1.7	0.83	81	33
Empty can test^18,20,21	1B	84–89	50–58	1.7–2	0.22–0.28	36–98	22–93
Drop sign²¹	1B	21	100	>25	0.79	100	32
Lift off test (for subscapularis tears)²¹	1B	62	100	>25	0.38	100	69
Impingement
Hawkin’s test^20,22	1B	87–89	60	2.2	0.18	71	83
Instability
Relocation test²³	2B	57	100	>25	0.43	100	73
Augmented apprehension²³	2B	68	100	>25	0.32	100	78
Labral tear
Crank test²⁴	2B	91	93	13	0.10	94	90
Active compression test²⁵	1B	100	99	>25	0.01	95	100
Acromioclavicular joint
Active compression test²⁵	1B	100	97	>25	0.01	89	100
*Based on the guidelines for evidence quality outlined by the Center for Evidence-Based Medicine (http://163.1.96.10/docs/levels.html).
LR+ = positive likelihood ratio; LR− = negative likelihood ratio; PV+ = positive predictive value; PV− = negative predictive value.

Figure 1
The empty can test

Rotator cuff tests

The drop arm test assesses the integrity of the rotator cuff, predominantly the supraspinatus muscle. The empty can test (Figure 1) isolates the supraspinatus against resistance. The lift off test (Figure 2) assesses the subscapularis integrity.

Figure 2
The lift off test

Impingement syndrome

Hawkin’s sign (Figure 3) is a test for evidence of impingement by re-creation of its symptoms.

Figures 3A & 3B
Hawkin’s sign

Glenohumeral joint stability

The augmented anterior apprehension test evaluates anterior shoulder instability. The relocation test, which helps confirm anterior instability, is carried out immediately after a positive anterior apprehension test.

Labral tears

The crank test is used to identify chronic labral injury, whereas the active compression test²⁵ (Figure 4) indicates labral injury if pain is deep in the shoulder.

Figure 4
The active compression test

Acromioclavicular joint

The active compression test²⁵ (Figure 4) indicates acromioclavicular joint inflammation, arthritis, or injury if pain is localized to the top of the shoulder.

Diagnostic tests

Imaging studies used in the evaluation of shoulder pain include plain radiographs, arthrography, computed tomography (CT), ultrasound (US), and magnetic resonance imaging (MRI). Often no imaging is required, or plain radiographs are the sole imaging study needed. Soft tissue injuries are best identified by MRI or US, whereas bony pathology is seen best with plain radiographs or CT. Indications for imaging include severe injury, uncontrolled pain, failure of conservative therapy, return to play considerations, and examiner discretion. Table 3 outlines the accuracy of imaging modalities organized by diagnosis.

TABLE 3
Imaging tests to diagnose shoulder pain

Diagnostic test	Study quality (1A–5)*	Sensitivity	Specificity	LR+	LR−	PV+	PV−
MRI
Rotator cuff tears
Partial²⁸	2B	82	85	5.5	0.21	82	85
Complete¹⁵	1B	81	78	3.7	0.24	—	—
Overall^16,29,30	2B	89–96	49–100	1.9 to >25	0.08	58	94
Impingement²⁸	2B	93	87	7.2	0.08	93	87
Labral tears^31-32	1B	75–89	97–100	>25	0.11–0.25	100	41
Plain arthrogram
Rotator cuff tears
Partial³³	1B	70	—	—	—	—	—
Complete¹⁵	1A	50	96	13	0.52	—	—
CT arthrogram
Rotator cuff tears
Partial³³	1B	70	—	—	—	—	—
Complete³³	1B	95	—	—	—	—	—
Overall³³	1B	86	98	>25	0.14	96	93
Ultrasound
Rotator cuff tears
Partial³³	1B	80	—	—	—	—	—
Complete³³	1B	90	—	—	—	—	—
Overall^33,34	1B	86	91	9.6	0.15	96	73
*Based on the guidelines for evidence quality outlined by the Center for Evidence-Based Medicine (http://163.1.96.10/docs/levels.html).
CT, computed tomography; LR+ = positive likelihood ratio; LR− = negative likelihood ratio; MRI, magnetic resonance imaging; PV+ = positive predictive value; PV− = negative predictive value.

Plain radiographs

Plain radiographs are the first step in diagnostic imaging. They can reveal fractures, dislocation, subluxation, bony lesions, outlet obstruction, acromioclavicular joint pathology, and arthritic changes. No definitive clinical studies on the needs of radiographs have been done. Plain radiographs should be taken when ROM is lost, especially when there is abduction of less than 90 degrees, severe pain, and after trauma. Our preferred x-rays include a glenohumeral anteroposterior (AP) view, a supraspinatus outlet view, and an axillary view. Anteroposterior views with internal and external rotation are added in cases of trauma to help rule out fracture. Positive acromioclavicular joint tests (crossover or palpation) should be followed by acromioclavicular joint radiographs because a shoulder series does not give a clear view of this joint. Additional views of the neck as well as a chest x-ray or abdominal imaging should be considered if a referred source of shoulder pain remains a possibility.