Clinical examination of the shoulder: time to change direction from diagnosing the structural diagnosis towards symptom modification tests.

Ann Cools, Clinical Pearls / Friday, January 11th, 2019

The purpose of the physical examination of a patient with shoulder pain is multifactorial. The clinician seeks information about tissue irritability, pain mechanisms, activity and participation limits, the patient’s expectations and goals etc…During the clinical examination, one of the purposes it to examine possible underlying biomechanical factors causing or perpetuating the current movement limitations and/or pain. We can do that using either symptom provocation tests, in which complaints are provoked by putting the shoulder in specific positions or asking specific pain provoking movements, or symptom-reduction tests, in which we try to reduce the symptoms by performing maneuvers or correcting kinematics and posture (Lewis et al. BJSM 2009). The first set of tests tel lus what to avoid during rehabilitation, and the second set what to focus on during the therapy. From a clinical perspective, the latter group of sets is much more relevant in designing a treatment protocol, and following that principle, every symptom provocation test should be immediately followed by a symptom reduction test.

An example of this clinical reasoning process is the use of the apprehension and relocation test, both traditionally described as diagnostic tests for instability (Hegedus et al. BJSM 2012). In the traditional literature, these test are used as so-called “special orthopedic tests”. Their diagnostic value is only acceptable if the patient experiences a feeling of subluxation or functional instability when the shoulder is put into a position of 90° of abduction and 90° of external rotation (picture 1) , and these complaints disappear when a dorsal force is applied on the humeral head, “relocating” the humeral head into the glenoid (picture 2). In the same literature, we are warned not to take the presence of only pain during apprehension (and reduction of pain during relocation) as diagnostic indicators for instability. So, what does it mean when these tests provoke pain without instability symptoms?

Following the clinical reasoning according to symptom-provocation versus symptom-reduction, we can conclude that the pain, present in the 90°abd-90°ext rot position, may be reduced by changing the glenohumeral kinematics into a more dorsal position of the humeral head. Therefore, the relocation test is the most relevant of the 2 tests in view of the treatment strategy.

If relocation reduces symptoms, it means that our therapy should focus on exercises, manual therapy techniques, patient education, additional taping techniques… to stimulate a more dorsal position of the humeral head.

How can we do that? Read the next clinical pearl!

Written by: Ann Cools

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