What is the management plan for a patient with a positive empty can test indicating pain?

Management of Pain with Positive Empty Can Test

A patient with a positive empty can test indicating shoulder pain should be managed with a comprehensive approach including physical therapy, NSAIDs, activity modification, and referral to orthopedic specialist if conservative treatment fails within 8-12 weeks.

Understanding the Empty Can Test

The empty can test is used to assess the supraspinatus muscle of the rotator cuff. When positive, it suggests potential supraspinatus tendon pathology, which may include:

• Supraspinatus tendinopathy
• Partial or full-thickness rotator cuff tears
• Subacromial impingement syndrome

Research shows that the empty can test does not exclusively isolate the supraspinatus muscle, as it also activates the infraspinatus and middle deltoid 1. This explains why a positive test may indicate various shoulder pathologies.

Initial Assessment

When evaluating a patient with a positive empty can test:

1. Pain characteristics assessment:

   • Location and radiation of pain
   • Intensity using a validated pain tool
   • Exacerbating and alleviating factors
   • Duration and onset of symptoms

2. Functional assessment:

   • Impact on activities of daily living
   • Work limitations
   • Sleep disturbances

3. Red flags to watch for:

   • Night pain unrelated to position
   • Unexplained weight loss
   • History of cancer
   • Neurological symptoms

Treatment Algorithm

Step 1: Non-pharmacological Interventions

• Physical therapy and exercise:

  • Individualized graded physical exercise program focusing on rotator cuff strengthening
  • Range of motion exercises
  • Scapular stabilization exercises 2

• Patient education:

  • Explanation of shoulder mechanics and pain mechanisms
  • Activity modification to avoid aggravating positions
  • Ergonomic adaptations at home and workplace 2, 3

• Orthotics if indicated:

  • Consider shoulder braces or sleeves for temporary support during painful activities 2

Step 2: Pharmacological Management

• First-line:

  • NSAIDs (oral or topical) for anti-inflammatory and analgesic effects
  • Regular dosing schedule rather than as-needed for consistent pain control

• Second-line:

  • Acetaminophen if NSAIDs are contraindicated
  • Short-term muscle relaxants if significant muscle spasm is present

• Monitoring:

  • Regular assessment of pain relief using validated tools
  • Monitoring for adverse effects, particularly with NSAIDs
  • Trial of analgesia with close monitoring, discontinuing if ineffective 2

Step 3: Advanced Interventions (if no improvement after 4-6 weeks)

• Corticosteroid injection:

  • Subacromial injection if impingement is suspected
  • Limited to 2-3 injections per year

• Imaging:

  • MRI or ultrasound to assess for rotator cuff tears
  • X-rays to evaluate for bony abnormalities or calcific tendinitis

Step 4: Specialist Referral (if no improvement after 8-12 weeks)

• Referral to orthopedic specialist for evaluation of surgical options 2
• Consider earlier referral if:
  • Significant functional limitation
  • Suspected full-thickness tear
  • Failed conservative management

Special Considerations

Psychosocial Factors

• Screen for anxiety and depression, as they are present in 67% of chronic pain cases 3
• Address pain catastrophizing and fear-avoidance behaviors
• Consider cognitive-behavioral therapy if psychological factors are impeding recovery 2

Sleep Management

• Assess impact on sleep quality
• Provide sleep hygiene education
• Consider sleep interventions if disturbances persist 2

Follow-up and Monitoring

• Initial follow-up within 2-4 weeks to assess response to treatment
• Regular reassessment of pain intensity, functional improvement, and treatment adherence
• If high risk of chronicity, review within 6 months 2
• Consider specialist assessment within 8-12 weeks if no improvement 2

Cautions and Pitfalls

1. Diagnostic accuracy: The empty can test alone is not definitive for diagnosing specific shoulder pathologies. Research shows it has limitations in isolating the supraspinatus 1, 4.

2. Differential diagnosis: A positive empty can test may indicate various conditions beyond supraspinatus pathology, including impingement syndrome or other rotator cuff tears 5.

3. Pain provocation: The full can test may be less painful while providing similar diagnostic accuracy compared to the empty can test 4.

4. Biomechanical considerations: During testing, there is a reduction in the acromiohumeral distance and changes in scapular kinematics that may contribute to pain 6.

By following this structured approach to management, patients with a positive empty can test can receive appropriate care that addresses both the physical and psychosocial aspects of their pain, improving outcomes and preventing chronic disability.