What special tests and treatments are used for shoulder pain?

Special Tests for Shoulder Pain

For shoulder pain evaluation, perform a systematic physical examination using specific provocative tests based on the suspected pathology: rotator cuff tests (empty can test, external rotation strength, lift-off test) for patients over 35 years, and instability tests (apprehension and relocation tests) for patients under 35 years, followed by appropriate imaging starting with standard radiographs. 1, 2, 3

Initial Clinical Assessment Framework

Age-Stratified Approach to Testing

For patients over 35-40 years:

• Focus testing on rotator cuff pathology as the predominant cause 1, 3
• Perform the empty can test (Jobe's test) for supraspinatus evaluation 2
• Test external rotation strength against resistance for infraspinatus and teres minor 2
• Perform lift-off test and belly press test for subscapularis function 2
• A positive clinical decision rule includes: pain with overhead activity, weakness on empty can test, weakness on external rotation test, and positive impingement sign 3

For patients under 35 years:

• Prioritize instability and labral pathology testing 1, 3
• Perform apprehension test: with patient supine, abduct shoulder to 90° and externally rotate; positive if patient feels shoulder will dislocate 3
• Perform relocation test: apply posterior force during apprehension position; positive if this relieves apprehension 3
• Both positive apprehension and relocation tests are consistent with glenohumeral instability 3

Specific Provocative Tests by Pathology

Rotator Cuff Evaluation

• Supraspinatus (empty can test): Patient abducts arm to 90° in scapular plane with thumb pointing down; examiner applies downward pressure 2
• Infraspinatus/teres minor: Test resisted external rotation with elbow at 90° flexion 2
• Subscapularis (lift-off test): Patient places hand behind back; inability to lift hand away from back indicates tear 2
• Subscapularis (belly press test): Patient presses hand against abdomen; inability to maintain wrist extension indicates weakness 2

Acromioclavicular Joint Testing

• Cross-body adduction test: Bring affected arm across body toward opposite shoulder; pain localized to AC joint is positive 3
• Palpate AC joint directly for tenderness 2
• Superior shoulder pain with AC joint tenderness suggests AC osteoarthritis 3

Impingement Testing

• Neer impingement sign: Examiner stabilizes scapula and passively flexes arm overhead; pain suggests impingement 3
• Hawkins-Kennedy test: Flex shoulder to 90°, then internally rotate; pain suggests subacromial impingement 4

Range of Motion Assessment

Active and Passive Testing

• Forward flexion: Normal 0-180°; restricted motion suggests adhesive capsulitis or arthritis 2
• External rotation: Normal 0-90°; assess with elbow at 90° flexion 2
• Internal rotation: Assess ability to reach up back; document vertebral level reached 2
• Key distinction: Adhesive capsulitis presents with restricted passive range of motion in all planes, unlike rotator cuff pathology where passive motion is preserved 3

Palpation Points

• Palpate proximal humerus and lateral aspect for fracture tenderness 2
• Assess bicipital groove for biceps tendinopathy 2
• Palpate AC joint and sternoclavicular joint 2
• Identify areas of swelling, warmth, or crepitus indicating inflammation 2

Scapular Assessment

• Observe scapular position at rest and during arm elevation 2
• Assess for scapular winging or dyskinesia, which may contribute to rotator cuff injury 2
• For athletes and throwers, evaluate scapular movement as part of kinetic chain assessment 2

Neurovascular Examination

• Perform thorough sensorimotor examination of upper extremity 5
• Screen for cervical radiculopathy: numbness, tingling, or radiation down arm 1
• Evaluate neck and elbow as potential pain sources 5

Critical Pitfalls to Avoid

Do not assume absence of trauma means absence of fracture in elderly patients, as osteoporotic fractures occur with minimal trauma 1

• Axillary or scapula-Y views are essential for detecting dislocations that may be missed on AP views alone 6
• Glenohumeral dislocation can be misclassified without proper orthogonal radiographic views 6
• Shoulder malalignment can be underrepresented on supine imaging; perform radiographs upright 6

Imaging Algorithm Following Physical Examination

Standard radiographs (AP in internal/external rotation plus axillary or scapula-Y view) are the initial imaging study for all shoulder pain 7, 6

If Radiographs Are Noncontributory:

For suspected rotator cuff tear:

• MRI without contrast or ultrasound are equivalent (rating 9/9) 7, 6
• Choose MRI for large body habitus, restricted range of motion, or suspected labral pathology 7

For suspected labral tear/instability (especially age <35):

• MR arthrography is the gold standard (rating 9/9) 7, 6
• In acute trauma, MRI without contrast may be preferred due to posttraumatic joint effusion providing natural distention 7

For suspected septic arthritis:

• Ultrasound or fluoroscopic-guided arthrocentesis (rating 9/9) 6
• Aspiration and fluid analysis are essential for diagnosis 6