Initial Management of Positive Jobe's Test
A positive Jobe's test indicates supraspinatus pathology (rotator cuff tear or tendinopathy), not anterior shoulder instability, and should be managed with initial conservative treatment including NSAIDs, activity modification, and physical therapy focused on rotator cuff strengthening, with MRI reserved for patients who fail conservative management or have clinical features suggesting full-thickness tears. 1
Understanding the Jobe's Test
The Jobe's test (also called the "empty can" test) evaluates supraspinatus function by having the patient abduct the arm to 90° in the scapular plane with internal rotation (thumb pointing down), then resisting a downward force. 2 A positive test—indicated by pain or weakness—suggests rotator cuff pathology, most commonly involving the supraspinatus tendon. 2
Important caveat: The Jobe's test does NOT assess anterior shoulder instability. Tests for anterior instability include the apprehension test, relocation test, and anterior release/surprise test. 3 If you suspect instability based on history (traumatic dislocation, recurrent subluxations), you need different physical examination maneuvers and a different management approach entirely.
Initial Conservative Management
Immediate Steps
- Start with NSAIDs or acetaminophen for pain control if no contraindications exist 4
- Activity modification: Avoid overhead activities and movements that reproduce pain 1
- Consider subacromial corticosteroid injection if significant pain limits function or participation in physical therapy, though evidence for routine use is insufficient 1
Physical Therapy Protocol
Initiate structured rehabilitation focusing on: 1
- Rotator cuff strengthening exercises
- Periscapular muscle strengthening
- Core musculature stabilization
- Gentle range of motion exercises to prevent stiffness 4
The rehabilitation approach has demonstrated effectiveness in restoring shoulder function when applied systematically over 3 months. 5
When to Order Advanced Imaging
Do NOT rush to MRI in all cases. The decision for advanced imaging depends on clinical context:
Indications for MRI Without Contrast:
- Failure of conservative management after 6-12 weeks of appropriate physical therapy 6
- Clinical features suggesting full-thickness tear: 6
- Significant weakness on resisted external rotation
- Positive impingement signs
- Age >60 years with combination of above findings
- Inability to perform the lateral Jobe test (not just pain, but actual inability) 2
- Need for surgical planning if operative repair is being considered 6
MRI Findings That Guide Treatment:
- Full-thickness tears show increased signal intensity extending from inferior to superior tendon surface on all sequences 6
- Tendon retraction, muscle atrophy, and fatty infiltration help determine whether conservative vs. operative repair is appropriate and predict postoperative prognosis 6
- Partial-thickness tears may require MR arthrography (MRA) if distinction from full-thickness tear is unclear 6
Surgical Referral Criteria
Refer for orthopedic surgical evaluation if: 1
- Massive traumatic rotator cuff tear identified on imaging
- Significant functional impairment despite 3-6 months of conservative management
- Full-thickness tear with tendon retraction, muscle atrophy, or fatty infiltration on MRI 6
Common Pitfalls to Avoid
- Don't confuse rotator cuff pathology with shoulder instability—these require completely different management algorithms 3
- Don't order MRI immediately without attempting conservative management first, unless clinical features strongly suggest full-thickness tear requiring surgical planning 6
- Don't rely on Jobe's test alone—10% of rotator cuff tears are asymptomatic and present only with morphologic changes on imaging 6
- Don't forget that ultrasound is comparable to MRI for complete rotator cuff tears but inferior for partial tears, and is highly operator-dependent 1