My Shoulder is Killing Me Doc

Shoulder pain is one of the most popular complaints in primary care and the third most common musculoskeletal complication that requires medical care.¹ Shoulder discomfort adversely affects your patient’s quality of life, often leading to disability and time off work. Of all the different shoulder pathologies, physicians see rotator cuff problems the most. This months’ Top Paper¹ presents a rational, evidence-based examination for rotator cuff injuries.

Two Case Studies

Case 1: A 60-year-old cleaning woman has complained of left shoulder pain for years, which has worsened in the last few weeks. She can abduct her arm in the scapular plane to 180°. With passive arm abduction, pain begins at 90°. X-rays of the shoulder are normal. 

Case 2: A 55-year-old man injured his shoulder skiing and placed his arm in a sling. He complains of discomfort with daily activities, such as brushing his teeth. On examination, he is unable to move his arm in any upward or sideways direction. X-rays are negative. 

Discussion

The authors performed a meta-analysis to identify the most accurate clinical examination findings for rotator cuff disease and tears. Although 28 studies assessed the shoulder examination of patients referred to specialists, only 5 had “rational clinical examination” quality scores appropriate for further review and reliability (all available in the Top Paper¹ references). 

The painful arc test, a so-called pain provocation, was the only examination finding with a positive likelihood ratio for rotator cuff disease greater than 2. The test is active abduction of the arm by the patient against light resistance (pictures and video available¹). If it is painful, it is positive. If the same test is negative, it also provides the lowest negative likelihood ratio for a rotator cuff injury (0.36). External and internal rotation lag tests were the most accurate when examining complete tears of the cuff.

Outcome of the Cases

Case 1: The first patient had a positive painful arc test in the affected shoulder consistent with rotator cuff injury. She was treated with NSAIDS and physical therapy initially. Other considerations include a corticosteroid injection and, if unsuccessful in relieving pain, an orthopedic surgery referral may be needed. 

Case 2: The second patient has a classic presentation for a tear with trauma followed by an inability to move his arm upward or sideways. In addition to a positive painful arc test, this patient also manifested a positive drop arm test—abduct the arm and hold in that position, if it cannot be held there or falls to the patient’s side with minimal pressure it is suggestive of a tear. 

A minimum of examination maneuvers reached an accurate diagnosis in both cases. 

This Top Paper has streamlined my approach to primary care shoulder evaluations. Since we have a litany of shoulder tests to choose from (ie, Neer, Hawkins, Yocum, Gerber, etc.), a better understanding of the available techniques can make office exams more efficient and accurate. Keep in mind that application can differentiate injury and tears to the rotator cuff muscles. ■

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

Reference:

1.Hermans J, Luime JJ, Meuffels DE, et al. Does this patient with shoulder pain have rotator cuff disease?: The rational clinical examination. JAMA. 2013;310:837-847.