Shoulder special tests and the rotator cuff

• Created as a free resource by Clinical Edge

• Based on Physio Edge podcast 067 with Dr Chris Littlewood
• Get your free trial of online Physio education at clinicaledge.co

Classification of shoulder pathology

The following classifications can be used to sub-group patients with
shoulder pain:
• Cervical spine referred
• Painful shoulder
• Stiff shoulder
• Unstable shoulder

Subjective Assessment
Patient self-report is an important feature in the diagnosis of shoulder
instability. Patients may report apprehension, a loose/wobbly feeling, and
dislocation or pseudo dislocation. Contrasting this, subjectively
differentiating between a stiff shoulder and a painful shoulder may be
difficult as both groups will complain of pain and restriction or perceived
restriction of movement. In all groups it is important to identify how the
problem began, how long it has been a problem and how has it progressed
over time.

Subacromial impingement

A study by Cuff & Littlewood (2017) investigated what patients’
understanding of a diagnosis of subacromial impingement syndrome meant
to them. This study concluded that patients viewed the diagnosis from a
biomedical perspective, with the belief that bone spurs were irritating the
subacromial structures.

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Shoulder special tests and the rotator cuff

If a patient’s understanding of their condition is not explored and a painful
exercise program is prescribed, they may think that the exercise is causing
direct harm, impacting compliance. By understanding patient beliefs about
their problem and asking about their expectations, we can tailor our
approach to meet these needs.

Questions to explore patient beliefs:

“What do you think is the cause of your problem?”
“What are you expecting from today's visit?”

Patient expectations
The expectation of a negative outcome with physiotherapy treatment was
found to be the biggest predictor of patients with rotator cuff tears
progressing to surgical treatment (Dunn et al. 2016). This was irrespective
of the size of the tear, retraction, fatty infiltration, age and pain.

The role of the physiotherapist is to establish baseline capacity and to help

patients to understand their problem constructively. Additionally,
physiotherapists should aim to help patients develop confidence to retrain
and regain their capacity to be able to perform functional tasks. The
majority of patients have modifiable expectations which can be influenced
in a positive way in clinical practice. Positively reframing a patient’s
expectations that exercise is appropriate and effective for their condition
can improve engagement with physiotherapy and improve treatment
outcomes. Re-assure patients that physiotherapy and exercise
rehabilitation is not the second best treatment and that for most shoulder
conditions it is as effective as surgery.

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Shoulder special tests and the rotator cuff

Objective Assessment
Orthopedic tests are sensitive but not specific. This means they can identify
patients with painful shoulder structures but not what those structures are.
”The most special orthopedic test” i.e. an important task or movement
identified by the patient that is provocative, can be used as a special test.
This movement or task should reproduce their shoulder pain. It can be used
as a baseline measure to assess the impact of a treatment intervention.

The cervical spine is relevant in around 20% of patients who complain of

primary shoulder pain and assessment of the cervical spine will influence
treatment direction. If symptoms are reproduced during the cervical spine
examination, then treatment should initially focus on the neck.

Shoulder lateral (or external) rotation is a reliable test to differentiate

between patients with a stiff shoulder and patients with a painful shoulder.
Patients can be classified as having a stiff shoulder if they have less than
45° or less than 50% range of the unaffected shoulder.

In the absence of a stiff shoulder, aka those with movement limitations,

resisted movements should be performed in functional positions such as
tennis serve or changing gear when driving. A diagnosis of rotator cuff
tendinopathy is made if symptoms are reproduced with resisted testing.

Objective assessment:
• ‘The most special orthopedic test’
• Screen the cervical spine
• Shoulder lateral rotation in neutral
• Resisted movements in functional positions

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Shoulder special tests and the rotator cuff

Scapular dyskinesis
Emerging research evidence is showing that scapular dyskinesis is actually
normal movement variation. Patients with rotator cuff tendinopathy and
scapular dyskinesis report improvement in pain and function with exercise,
manual therapy and taping however the position and movement of the
scapular remains unchanged.

Patients with long thoracic nerve palsy have gross scapular winging but do
not complain of pain. If the scapular appears grossly abnormal then its role
in the patient’s problem may need to be considered. In this scenario the
shoulder is loaded at a low level to avoid gross scapular winging during
exercise.

Painful exercise
A systematic review by Smith et al. (2017) compared painful and non-
painful exercise in a variety of musculoskeletal conditions. This review
concluded that exercise approaches that worked into pain demonstrated
superior short term outcomes over pain free exercises.

Exercise should aim to push the patients’ boundaries and challenge their
beliefs. Knowledge of exercise within the general population may be limited.
Thus, a key role of physiotherapy is to educate patients about exercise and
help them develop confidence in the clinic. Within the clinical environment,
physiotherapists should work with their patients to identify exercises that
produce acceptable levels of pain during and after. Avoid prescribing low
level exercises that take a long time to progress.

Imaging
The rise in the use of diagnostic ultrasound has resulted in patients
presenting with imaging reports showing incidental findings. Scanning both
shoulders and reporting in the context of bilateral findings and the inclusion
of normative data may help to reduce fear amongst patients.

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Shoulder special tests and the rotator cuff

Webinar
As mentioned in this episode, Chris will be presenting a webinar which will
discuss:
• The mechanisms of action for exercise in rotator cuff tendinopathy
• How to improve exercise prescription
• The factors that contribute to shoulder pain and how to influence
these

This webinar will be available free for a short time, then for Clinical Edge
members on an ongoing basis at clinicaledge.co

Links mentioned in this episode:

• Twitter: @physiochris
• Research gate
• Keele University

Associated articles:
• Smith et al. 2017. Shoulder exercises be painful in the management
of chronic musculoskeletal pain? A systematic review and meta-
analysis

Previous episodes of interest:

• PE #043 Sporting shoulder with Jo Gibson
• PE #040 Shoulder simplified with Adam Meakins
• PE #021 Shoulder pain with Dr Jeremy Lewis

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