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Best Special Tests for Subacromial Impingement

10/24/2013

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Subacromial Impingement Syndrome (SAIS) is reported to be the most frequent cause of shoulder pain in an OP physical therapy clinic. Despite the high prevalence, physical therapists still struggle to appropriately diagnose the syndrome. The gold standard for diagnosing SAIS in arthroscopic surgery. Since we do not have access to this tool everyday, we must reply on our patient examination skills. A study by Michener et al, Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement, assessed 5 special tests commonly used to help rule-in SAIS. The 5 tests were Neers, Hawkins-Kennedy, Painful Arc, Empty Can (Jobe), and External Rotation Resistance Test. Specifically this article wanted to assess the interrator reliability of the tests, diagnostic accuracy of each test, and finally if clustering the tests would confirm or rule-out SAIS.


     The results of the study were surprising. Moderate to Substantial strength of agreement between raters was found for the empty can test, the painful arc sign, and external rotation resistance test. Surprisingly Hawkins Kennedy had the lowest kappa value at .39. We found this surprising because Hawkins-Kennedy is graded as painful or not painful. There seems to be little room for subjectivity, yet it received the lowest reliability among raters of all the tests. The difference likely lies in how the test is performed and thus perceived. It is easy to forget to not horizontally adduct the shoulder sufficiently or to ignore the patient's compensation of elevating the tested shoulder during IR as a means of avoiding/minimizing the pain provocation. Something we must always be wary of in studies of manual techniques is accepting the fact that all examiners perform/analyze movements the same.


     When looking at the diagnostic accuracy of each test individually, the External rotation resistance test had the highest positive likelihood ratio (LR) of 4.39, empty can had the second highest with 3.9, and the painful arc sign came in third at positive LR 2.25. Finally, the article found that when clustering the tests a "combination of any 3 positive tests out of the 5 have the best ability to confirm SAIS, with small to moderate shifts in the pretest to posttest probability."    

      While this article provides interesting and useful clinical information, the results are different from other studies in the literature. A separate article on SAIS by Park et al found that the clustering Hawkins-Kennedy, Infraspinatus Muscle Test, and the Painful Arc Sign yielded a high +LR (10.56) for ruling-in SAIS. So what cluster should you use? Personally, we would use both. The etiology of SAIS is multifactorial. Several structures have the potential to be pain generators and the presentation of SAIS will vary based on posture, scapulohumeral rhythm, accessory joint mechanics, and more. The Michener article was quick to point out the importance of a thorough subjective history to help aide in the diagnostic process.  

Reference: Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination 
     tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. 2009 Nov;90(11):1898-903.
Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees 
     of subacromial impingement syndrome. J Bone Joint Surg Am. 2005 Jul;87(7):1446-55.

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  • Home
  • About Us
  • TSPT Academy
  • Resources
    • Newsletter
    • Orthopedic Blog
    • Featured Articles
    • Research Articles
    • Residency Corner
  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
      • Adam's Forward Bend Test
      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
      • Thoracic Foraminal Closure Test
    • Lumbar Spine/Sacroiliac Joint >
      • Active Sit-Up Test
      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
      • Biceps Squeeze Test
      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
      • Allen's Test
      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
    • Hip >
      • Craig's Test
      • Dial Test
      • FABER Test
      • FAIR Test
      • Fitzgerald's Test
      • Hip Quadrant Test
      • Hop Test
      • Labral Anterior Impingement Test
      • Labral Posterior Impingement Test
      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
      • Anterior Drawer
      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
      • Squeeze Test
      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test