Name:
Job Hermans, MD, MSc, discusses the clinical examination for rotator cuff disease.
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Job Hermans, MD, MSc, discusses the clinical examination for rotator cuff disease.
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T00H09M05S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[ Music ] >> Hello, and welcome to JAMAevidence, our monthly podcast focused on core issues and evidence-based medicine. I'm David Simel, the Editor of the Rational Clinical Examination Series and Professor of Medicine at the Durham Veterans Affairs Medical Center in Duke University.
Today, we're discussing the clinical evaluation for shoulder pain. Joining me to talk about this topic is Job Hermans from the Department of Orthopaedic Surgery at the Erasmus University Medical Center in Rotterdam, the Netherlands. So, I should say good evening, Job. And it's great to talk to you. Could you tell us exactly what the rotator cuff does and why so many adults eventually experience shoulder discomfort? >> The rotator cuff itself consists of tendons of four muscles which are originating from around the scapula.
And they are all inserting around the humeral area. These muscles are, they are supraspinatus muscle, the infraspinatus muscle, the teres minor muscle, and the subscapularis muscle. And these muscles have two main functions. One function is creating movement. The glenohumeral joint has a relatively small glenoid fossa and a relatively large humeral head. And it allows for a wide range of motion in different directions by the rotator cuff muscles.
So, the shoulder movement is also facilitated by the subacromial bursa. And this bursa lies just above the supraspinatus muscle. And because of the position of the muscles around the scapula, the rotator cuff also plays a significant role in stabilizing the glenohumeral joint. So, shoulder discomfort by rotator cuff disease is mainly caused by either degenerations of the tendons of the rotator cuff or by inflammation of the subacromial bursa or one of the tendons of the rotator cuff.
A less common cause of rotator cuff disease is a rupture of one of the tendons due to a traumatic injury. >> Well, that sounds complicated with four muscles. So, from the perspective of the physician looking at a patient's shoulder, where does a patient actually report their pain? >> Well, pain from rotator cuff disease is mostly located in the region of the deltoid muscle. And I think one had to keep in mind that the deltoid muscle covers a relatively large area around the shoulder.
It originates from the clavicle, the acromion process, and the scapular spine, and eventually inserts in the midsection of the humerus. Pain from rotator cuff disease is mostly described as dull but becomes sharp and stabbing, especially when patients are doing overhead motions. >> Well, that last comment about overhead motions is a great segue to what I wanted to ask you next which is that aside from just the pain itself, what sorts of activities tend to give them a problem?
>> Patients with rotator cuff disease mainly report problems with overhead activity. And especially patients, for example, in an occupation that includes repetitive overhead motion like painters or patients active in sports with repetitive overhead motions like baseball players are at risk for developing rotator cuff disease. >> Okay, great. So, if we've got a patient with shoulder discomfort, we find out where the pain is and what sorts of activities make it worse.
I know we do a neurological examination to make sure the pain is not referred from cervical disease. But beyond that, what simple test can the generalist adapt from an orthopedist's examination? >> The clinical test for rotator cuff are divided in pain provocation tests, strength tests, and composite tests. So, a pain provocation test is considered positive when shoulder pain is induced when the rotator cuff is moved and subacromial bursa or one of the rotator cuff tendons is compressed between the surrounding structures.
Strength tests assess the muscle function of specific muscles. So, patients mostly are asked to move the arm in a certain position or to maintain the arm in a certain position against gravity. And the strength tests are considered positive when weakness sometimes combined with pain occurs. So, composite tests are considered positive when either inducing pain or weakness. So, based on the available evidence, I would recommend five clinical tests for the evaluation of rotator cuff disease.
One of the tests is the painful arc test. This is a pain provocation test. There are three strength tests one can do. And those are the internal rotation lag test, external rotation lag test, and the drop arm test. Finally, the fifth test is the external rotation resistance test which is a composite test. >> So, there are both strength test and provocation test. Does the order of testing make a difference? >> No, the order of testing does not make a difference.
I do suggest that physicians try to develop proficiency in the five tests we just mentioned. And the order, that's okay. >> Most of our listeners will likely be familiar with the painful arc and drop arm test. But the two lag tests mentioned, and the external rotational resistance test may not be familiar. Could you describe how to do those tests? >> Sure. Well, there are two lag tests we found in the evidence and one of them is an internal rotation lag test.
It's a, it is a strength test. And it assesses the subscapularis muscle. So, the patient's hand is brought behind its back and the elbow is flexed at 90 degrees. And the examiner lifts the hand of the patient off the back, and the patient is asked to remain the position of the hand off the back and the test is considered positive when the patient is unable to maintain this position. A similar mechanism goes for the external rotation lag test which assesses the supraspinatus and the infraspinatus muscles.
So, the patient has its elbow in 90-degree flexion and slight abduction about 20 degrees and the examiner passively rotates the patient's arm into full external rotation. And a test is positive when the patient is unable to maintain this position of full external rotation. The last test we are going to discuss is a composite test. It's the external rotation resistance test. This test assesses the infraspinatus muscle. So again, the elbow is brought into 90 degrees flexion with the fingers pointing forward.
The examiner applies pressure proximal to the patient's wrist and the patient is asked to externally rotate the arm. And the test is positive when the patient experiences either pain or weakness during this maneuver. >> So, a problem for many generalist physicians is that it's hard to keep eponym straight. And you did a nice job of describing the tests without using eponyms. But everyone remembers the Jobe test which I know was not named after you, as the empty can test.
Is that test useful? >> Well, given the evidence and although widely known, the Jobe test is not very accurate for diagnosing of or ruling out a diagnosis of rotator cuff disease. And I think the same goes for the other well-known and frequently used tests like the Neer test and the Hawkins test. These tests have shown to have a low accuracy in diagnosing of rotator cuff disease. >> Is there anything else you would like our listeners to know when evaluating the patient who has developed shoulder pain?
>> Well, I think the foremost important thing is, like you mentioned before, is that one needs to make sure that the shoulder pain is not caused by other conditions like, for example, cervical nerve root compression or a fracture of the shoulder. So, I think standard radiographs of the shoulder and the cervical and neurological examination can be helpful in differentiating between these conditions. And I think that is one of the most important things to remember in evaluating the shoulder. >> Well, thanks, Job, for this interesting discussion. More information about this topic on shoulder pain is available in the Rational Clinical Examination and on our website, JAMAevidence.com, where you can listen to our entire roster of podcasts.
For this particular topic, JAMA has an excellent video that you can access from the homepage of JAMA by searching on "Video of Shoulder Pain." I'm David Simel, and I'll be back with you soon for another edition of JAMAevidence. [ Music ]
