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Early detection of Early detection of
shoulder pathology in shoulder pathology in
the overhead athletethe overhead athlete
A clinical reasoning algorithmA clinical reasoning algorithm
Ann M. Cools, PT, PhD (Belgium)
A Cools Odense 2009A Cools Odense 2009
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Confirming impingement Confirming impingement
symptomssymptoms
�� Use Use ““impingementimpingement””--teststests
�� Only to confirm the presence of Only to confirm the presence of
impingementimpingement--related symptoms and to related symptoms and to
define possible biomechanical process define possible biomechanical process
(location of impingement)(location of impingement)
�� Not to diagnose underlying pathologyNot to diagnose underlying pathology
�� In general high sensitivity, low specificityIn general high sensitivity, low specificity
�� Very limited diagnostic valueVery limited diagnostic value
A Cools Odense 2009A Cools Odense 2009
Impingement testsImpingement tests
�� JobeJobe testtest
A Cools Odense 2009A Cools Odense 2009
Impingement testsImpingement tests
�� HawkinsHawkins testtest
A Cools Odense 2009A Cools Odense 2009
Impingement testsImpingement tests
�� Neer testNeer test
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Jobe +Neer + antHawkins +
Jobe –Neer + postHawkins –
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Confirming impingement Confirming impingement
symptomssymptoms
�� Limited information on internal impingementLimited information on internal impingement
�� No information on the cause of the problem No information on the cause of the problem
(primary versus secundary)(primary versus secundary)
�� Use Use ““instabilityinstability”” teststests
�� Interpretation on Interpretation on ““painpain”” in stead of in stead of
““instability symptomsinstability symptoms”” (Meister 2004)(Meister 2004)
�� Pain as criterion: low specificity in Pain as criterion: low specificity in
diagnosing instability (Speer 1994)diagnosing instability (Speer 1994)
A Cools Odense 2009A Cools Odense 2009
A.A. Provocation testsProvocation tests–– ApprehensionApprehension
–– RelocationRelocation
–– Release Release
B.B. Laxity testsLaxity tests–– Load & Shift (anterior drawer)Load & Shift (anterior drawer)
–– Sulcus signSulcus sign
–– Posterior subluxation test Posterior subluxation test –– JerkJerk
(Speer AJSM 1994, Meister et al. 2004, Tennent AJSM 2003)
Testing shoulder instabilityTesting shoulder instability
A Cools Odense 2009A Cools Odense 2009
InstabilityInstability teststests
�� Apprehension Apprehension –– Posterior Posterior
Impingement Sign (Meister 2004)Impingement Sign (Meister 2004)
A Cools Odense 2009A Cools Odense 2009
InstabilityInstability teststests
�� relocationrelocation
A Cools Odense 2009A Cools Odense 2009
InstabilityInstability teststests
�� Release testRelease test
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Rotator cuff involvement?Rotator cuff involvement?
�� Empty can: testing of SS (Jobe 1987) Empty can: testing of SS (Jobe 1987)
AND impingement provocationAND impingement provocation
�� Use test for SS with less impingement Use test for SS with less impingement
provocationprovocation
A Cools Odense 2009A Cools Odense 2009
Rotator Rotator cuffcuff tendinopathy?tendinopathy?
�� FullFull cancan testtest
(Reinold et al. JOSPT 2009)
A Cools Odense 2009A Cools Odense 2009
Full Cann Full Cann (versus empty can) (versus empty can)
(Reinold et al. 2009):(Reinold et al. 2009):
�� Muscle activityMuscle activity: Similar SS activity as empty : Similar SS activity as empty
can, but lower amount of middle and can, but lower amount of middle and
posterior deltoid (Reinold et al. JAT 2007)posterior deltoid (Reinold et al. JAT 2007)
�� BiomechanicsBiomechanics: Resultant vector is always : Resultant vector is always
downward (caudal glide) and centering downward (caudal glide) and centering
(Poppen & Walker 1978): less impingement (Poppen & Walker 1978): less impingement
provocationprovocation
A Cools Odense 2009A Cools Odense 2009
(Poppen & Walker 1978)
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
Full Can +
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Scapular involvement?Scapular involvement?
�� Scapular dyskinesis in association with Scapular dyskinesis in association with
impingement (Ludewig 2000)impingement (Ludewig 2000)
�� Scapular muscle dysfunction (strength, Scapular muscle dysfunction (strength,
timing, muscle balance) (Cools 2003, 2004, timing, muscle balance) (Cools 2003, 2004,
2007)2007)
�� Evaluation of scapular involvement in Evaluation of scapular involvement in
shoulder pathologyshoulder pathology
�� Evaluation of specific muscle dysfunctionEvaluation of specific muscle dysfunction
A Cools Odense 2009A Cools Odense 2009
ScapularScapular involvementinvolvement??
�� ScapularScapular AssistanceAssistance Test: movement Test: movement
qualityquality
(Rabin et al. JOSPT 2006)
A Cools Odense 2009A Cools Odense 2009
ScapularScapular involvementinvolvement??
�� ScapularScapular RetractionRetraction Test: scapular Test: scapular
stabilitystability
(Kibler et al. AJSM 2006, Tate et al. AJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Scapular dyskinesis:Scapular dyskinesis:
serratus ant serratus ant oror lowerlower trap?trap?
(M. Kelley personal communicationaug 2003)
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
SAT +SRT +
Full Can +
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
A.A. Provocation testsProvocation tests–– ApprehensionApprehension
–– RelocationRelocation
–– Release Release
B.B. Laxity testsLaxity tests–– Load & Shift (anterior drawer)Load & Shift (anterior drawer)
–– Sulcus signSulcus sign
–– Posterior subluxation test Posterior subluxation test –– JerkJerk
(Levy et al. 1999, Tennent AJSM 2003, Hegedus et al. BJSM 2008))
Testing shoulder instabilityTesting shoulder instability
A Cools Odense 2009A Cools Odense 2009
Glenohumeral Glenohumeral instabilityinstability??
�� AnteriorAnterior laxity: Loadlaxity: Load & Shift test& Shift test
A Cools Odense 2009A Cools Odense 2009
LOAD & SHIFTLOAD & SHIFT
�� Grade I (movement up Grade I (movement up
to glenoid rim)to glenoid rim)
�� Grade II (movement Grade II (movement
over glenoid rim + over glenoid rim +
spontaneous reduction)spontaneous reduction)
�� Grade III (movement Grade III (movement
over glenoid rim + no over glenoid rim + no
spontaneous reduction)spontaneous reduction)
A Cools Odense 2009A Cools Odense 2009
Glenohumeral Glenohumeral instabilityinstability??
�� InferiorInferior laxity:laxity:
SulcusSulcus signsign
A Cools Odense 2009A Cools Odense 2009
Glenohumeral Glenohumeral instabilityinstability??
�� PosteriorPosterior laxity: Posteriorlaxity: Posterior Subluxation Subluxation
TestTest
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
Laxity tests +Appr + (appr)Relocation + (appr)
SAT +SRT +
Full Can +
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Involvement of Biceps and Involvement of Biceps and
superior labrum pathologysuperior labrum pathology
�� A large amount of SLAPA large amount of SLAP--lesion testslesion tests
�� ““hyperhyper--diagnoseddiagnosed”” and and ““hyperhyper--
operatedoperated--onon””??
�� Oh et al. AJSM 2008: choose 2 Oh et al. AJSM 2008: choose 2
sensitive and 1 specific testsensitive and 1 specific test
A Cools Odense 2009A Cools Odense 2009
Biceps Biceps pathologypathology oror SLAP?SLAP?
�� OO’’ BrienBrien TestTest
(Hegedus et al. BJSM 2008, Oh et al. AJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Biceps Biceps pathologypathology oror SLAP?SLAP?
�� SpeedSpeed’’ss TestTest
(Hegedus et al. BJSM 2008, Oh et al. AJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Biceps Biceps pathologypathology oror SLAP?SLAP?
�� Biceps Biceps LoadLoad II testII test
(Hegedus et al. BJSM 2008, Oh et al. AJSM 2008)
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
O’Brien+Speeds+Biceps load II+
Laxity tests +Appr + (appr)Relocation + (appr)
SAT +SRT +
Full Can +
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
GIRDGIRD??
�� InternalInternal RotationRotation ROM in 90ROM in 90°°abductionabduction
(Trakis et al. AJSM 2008)
Impingement symptoms
ExternalSubacromial impingement
Internal(posterior) impingement
PrimaryImpingement
SecundaryImpingement
BicepsSLAP
Rotator cuffpathology
Scapular dyskinesis instability G.I.R.D.
Relocation -Relocation+
Release +(pain)
Jobe +Neer + antHawkins +
Apprehension +(pain) ant
Jobe –Neer + postHawkins –Apprehension +(pain) post
Relocation+Release +(pain)
IRROM↓
O’Brien+Speeds+Biceps load II+
Laxity tests +Appr + (appr)Relocation + (appr)
SAT +SRT +
Full Can +
(Cools et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
In general:In general:
�� HegedusHegedus, BJSM 2008, BJSM 2008
–– Large amount of studies on diagnostic Large amount of studies on diagnostic
accuracy shoulder tests, with conflicting accuracy shoulder tests, with conflicting resultsresults
–– Some tests far worse when used by other than Some tests far worse when used by other than
the originator of the testthe originator of the test
In general: In general: ““ we urge caution if a diagnostic test we urge caution if a diagnostic test
is only been studied once, and if the originator is only been studied once, and if the originator
of the test is the author of the paperof the test is the author of the paper””
((HegedusHegedus et al. BJSM 2008)et al. BJSM 2008)
A Cools Odense 2009A Cools Odense 2009
Thank you!!(Gent- Belgium)