What is the primary impression and recommended physical exam tests for a patient presenting with shoulder pain on loaded shoulder extension, radiating inferiorly to the clavicle (collarbone), exacerbated by palpation and pressure on the shoulder joint?

From the Guidelines

The primary impression for this patient is likely acromioclavicular (AC) joint pathology, such as AC joint sprain or separation. Physical examination should include the cross-body adduction test (horizontal adduction), where the examiner moves the patient's arm across their body toward the opposite shoulder, which typically reproduces pain in AC joint disorders 1. The AC joint compression test, applying direct pressure over the AC joint, would likely be positive given the patient's symptoms with palpation. O'Brien's active compression test can help differentiate AC joint pathology from labral tears. The Neer and Hawkins impingement tests should be performed to rule out subacromial impingement. Range of motion testing in all planes will help assess functional limitations. Strength testing of the rotator cuff muscles (particularly supraspinatus with empty can test) is important to evaluate for associated rotator cuff pathology. Palpation of the AC joint, clavicle, and surrounding structures should be performed to assess for tenderness, deformity, or step-off indicating separation. These tests are recommended because AC joint disorders typically present with localized pain at the superior shoulder that may radiate to the clavicle and worsen with overhead activities or direct pressure, matching this patient's presentation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel 1.

Some key points to consider in the physical examination include:

• The cross-body adduction test to assess AC joint pathology
• The AC joint compression test to evaluate tenderness and pain
• O'Brien's active compression test to differentiate AC joint pathology from labral tears
• The Neer and Hawkins impingement tests to rule out subacromial impingement
• Range of motion testing to assess functional limitations
• Strength testing of the rotator cuff muscles to evaluate associated rotator cuff pathology
• Palpation of the AC joint, clavicle, and surrounding structures to assess for tenderness, deformity, or step-off indicating separation.

It is essential to note that the selection of appropriate imaging procedures or treatments should be based on the complexity and severity of the patient's clinical condition, and the ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination 1.

From the Research

Primary Impression

The primary impression for the patient presenting with shoulder pain on loaded shoulder extension with radiation inferiorly to the collarbone, aggravated by palpation and pressure placed on top of the shoulder joint, is subacromial impingement syndrome 2.

Physical Exam Tests

The following physical exam tests should be performed to diagnose subacromial impingement syndrome:

• Neer test: to assess for subacromial impingement 3, 4
• Hawkins test: to evaluate for subacromial impingement 3, 5, 4
• Painful arc test: to check for subacromial impingement and rotator cuff pathologies 5, 6
• Empty can test: to assess for supraspinatus tendon pathology 5, 6
• External rotation resistance test: to evaluate for subacromial impingement and rotator cuff pathologies 5, 6
• Palpation tests: to check for tenderness and pathology in the rotator cuff tendons, particularly the supraspinatus and biceps tendons 4

Diagnostic Accuracy

The diagnostic accuracy of these tests varies, with some studies showing:

• Neer test: sensitivity of 75-80% and specificity of 52-67% 3, 4
• Hawkins test: sensitivity of 62-92% and specificity of 47-88% 3, 5
• Painful arc test: sensitivity of 63.6% and specificity of 62.1% 5, 6
• Empty can test: sensitivity and specificity not consistently reported 5, 6
• External rotation resistance test: sensitivity and specificity not consistently reported 5, 6
• Palpation tests: sensitivity of 92% and specificity of 41% for supraspinatus tendon pathology 4