What is the diagnosis and treatment for a patient with pain in the right shoulder and a positive Hawkins-Kennedy test?

Diagnosis and Treatment for Right Shoulder Pain with Positive Hawkins-Kennedy Test

A positive Hawkins-Kennedy test strongly suggests shoulder impingement syndrome, which is the most common cause of shoulder pain and requires a structured approach of conservative management before considering surgical options.

Diagnosis

The Hawkins-Kennedy test is a highly reliable clinical test (kappa coefficient 0.91-1.00) for identifying subacromial pain with an impingement phenomenon 1. When positive, it indicates potential compression of the rotator cuff tendons, which can be further categorized into:

1. Subacromial impingement - Most common form
2. Internal impingement - Often seen in overhead athletes
3. Subcoracoid impingement - Less common variant

Additional Diagnostic Steps:

• Radiography: Standard shoulder radiographs should be the initial imaging study, including anteroposterior views in internal and external rotation and an axillary or scapula-Y view 2
• Advanced imaging: If radiographs are negative but symptoms persist:
  • MRI: Preferred for evaluating soft tissue pathologies including rotator cuff tears, labral injuries, and glenohumeral ligament injuries 2
  • Ultrasound: May be considered as a diagnostic tool for shoulder soft tissue injury, particularly for rotator cuff evaluation 2

Treatment Algorithm

1. First-Line Treatment (0-6 weeks)

• Activity modification: Avoid overhead activities and positions that provoke pain
• Physical therapy: Focus on:
  • Rotator cuff strengthening
  • Scapular stabilization
  • Range of motion exercises
  • Proper posture training
• Medications:
  • NSAIDs for pain and inflammation
  • Acetaminophen as alternative if NSAIDs contraindicated

2. Second-Line Treatment (6-12 weeks if inadequate response)

• Corticosteroid injection: Consider subacromial injection if significant pain persists
  • Note: Evidence for subacromial or glenohumeral corticosteroid injections is not well established 2
• Continue physical therapy: Progress to more advanced exercises

3. Third-Line Treatment (if persistent symptoms beyond 3 months)

• Advanced imaging if not already performed:
  • MRI to evaluate for rotator cuff tears, labral injuries, or other structural abnormalities 2
• Consider referral to orthopedic specialist for evaluation of surgical options:
  • Arthroscopic subacromial decompression
  • Repair of any identified rotator cuff tears
  • Debridement of damaged tissue

Special Considerations

• Avoid overhead pulley exercises as these can worsen impingement symptoms 2
• Positioning and supportive devices may be reasonable if there is evidence of shoulder subluxation 2
• Botulinum toxin injections can be useful for cases with associated muscle hypertonicity 2

Common Pitfalls to Avoid

1. Misdiagnosis: While the Hawkins-Kennedy test is reliable for identifying subacromial pain 1, it has limitations as a structural discriminator. Consider other causes of shoulder pain such as:

   • Adhesive capsulitis (frozen shoulder)
   • Acromioclavicular joint pathology
   • Cervical radiculopathy
   • Glenohumeral arthritis

2. Premature surgical intervention: Most cases of shoulder impingement respond to conservative management 3. Surgery should be reserved for refractory cases that fail 3-6 months of appropriate conservative treatment.

3. Incomplete rehabilitation: Inadequate physical therapy or premature return to aggravating activities can lead to persistent symptoms or recurrence.

The term "impingement syndrome" has been criticized as an overly broad diagnostic label 4, but the mechanical impingement phenomenon remains a useful concept for guiding treatment. Focusing on modifiable movement patterns and specific impairments provides a more effective approach to management than simply labeling the condition.