A large percentage of my current caseload consists of shoulder pain. Often these referrals come from family practice physicians or other generalists who utilize physical therapy as a conservative precursor to an orthopedic physician. As a link in this referral chain, I look at early establishment of a appropriate rehab prognosis to be an essential function of my job.
Physical therapists are not diagnosticians, but the use of clinical diagnostic testing can give us some indication of the patients potential to respond to conservative care. A 2005 article in the Journal of Bone and Joint Surgery attempts to determine which of the numerous clinical tests of rotator cuff disease has the most clinical utility. The tests were investigated to determine their utility in assessing three degrees of rotator cuff pathology: bursitis, partial-thickness rotator cuff tear, and full-thickness rotator cuff tear. The following eight clinical tests were examined:
- Neer impingement sign
- Hawkins-Kennedy impingement sign
- Painful-arc sign
- Supraspinatus muscle strength test
- Infraspinatus muscle strength test
- Speed test
- Cross-body adduction sign
- Drop-arm sign
The authors found that sensitivity, specificity, PPV, NPV, and overall accuracy of each test showed considerable variability. The combination of Hawkins-Kennedy sign, painful arc sign, and infraspinatus muscle strength test yielded a 95% post-test probability for any type of impingement syndrome. Full thickness rotator cuff tears were found with a 91% post-test probability using a combination of the drop-arm test, painful arc sign, and infraspinatus test.
Studies such as the one cited above lend support to the notion that batteries of tests are capable of adding tremendous strength to a clinical exam for a physical therapist. Future research in our profession could look into how patients fitting into one of the three degrees of rotator cuff disease respond to various modes of physical therapy.
Park, H.B. (2005). Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. The Journal of Bone and Joint Surgery, 87(7), 1446-1455. DOI: 10.2106/JBJS.D.02335