If you work in a general orthopaedic or sports clinic, chances are you see a lot of people with rotator cuff related shoulder pain (RCSRP). This condition has multiple names and sub-conditions including rotator cuff tendinopathy, rotator cuff strain/tear, subacromial impingement syndrome, subacromial pain or just plain shoulder pain. Regardless, it’s a common issue. In this article I will discuss the assessment of RCRSP, and how to lay the overall framework for successful rehabilitation.
If you’re interested in learning more about shoulder injury, be sure to check out The Sporting Shoulder Masterclass by Dr Rod Whiteley.
In the case of rotator cuff strains/tears there will usually be a definite mechanism of injury, such as when lifting an object or in the event of a fall. By contrast, subacromial pain and rotator cuff tendinopathies tend to come on more insidiously with repetitive movement, although I have had the odd reactive tendinopathy that started first thing in the morning for a client.
Pain may be intermittent or constant (although usually intermittent in the case of subacromial pain) and located in the anterior, lateral and/or posterior shoulder depending on the specific tendon involvement.
With regards to psychosocial factors, be sure to ask if there is any history of stress, anxiety or depression, and if there have been any recent life changes. Also ask if they’ve had any previous medical tests or treatment and what they’ve been told about their condition.
The main conditions to differentially diagnose are:
- Shoulder Osteoarthritis: while the treatment doesn’t really differ from a physio perspective, it will definitely differ with respect to medical and surgical treatment. Imaging would be needed to confirm OA, and OA may not have pain with resisted testing whereas a rotator cuff strain or tendinopathy likely would.
- Proximal long head of biceps tendinopathy: again the treatment is pretty similar and sometimes these conditions go together.
- Fracture of the humerus and/or scapula: this is important to keep in mind in the event of a traumatic mechanism, especially with a middle-aged or elderly client who may be more frail and have a prior history of deconditioning. Tuning fork and ultrasound tests can be helpful when suspecting a fracture, but are not perfect. While I’m not a fan of overusing imaging, I’d much rather be safe than sorry in these situations.
- Frozen Shoulder: this can mimic the symptoms of a rotator cuff tendinopathy in the early stages. I’ve quite often seen patients diagnosed by their doctor, or self-diagnosed, as having frozen shoulder when it’s really a pain-limited shoulder. The big things to remember for differential diagnosis are to:
- Look at passive range of motion – If active range of motion is limited whereas passive range of motion is full, it’s likely to be a more pain-limited shoulder vs a frozen shoulder. If both active and passive are limited, it’s more likely to be a frozen shoulder.
- Look at trajectory over time – If it’s continuing to worsen, even with treatment, then it may be a frozen shoulder. In the event of a suspected frozen shoulder I educate patients that it may be present but that we need to track the trajectory of symptoms over time.
- Parsonage Turner Syndrome: this is a very rare condition characterized by distal symptoms from the shoulders/upper trapezius down the arm, including muscle weakness and paresthesia in areas innervated by the brachial plexus.
- Classic red flags & medical conditions such as tumor, infection and digestive/pelvic health issues: As always make sure that you’re asking about systemic symptoms (fever, chills, night sweats, weight loss, changes in medication, and overall digestive and general health). If it’s something that can’t be consistently reproduced by you or the patient, this may indicate a red flag or non-musculoskeletal condition.
Postural Assessment, Observation and Cervical Testing
While research hasn’t shown a great correlation between pain and posture (1), I still like to (if possible and if consent if given) have the patient shirtless (or in a sports bra if female) to assess posture as well as potential muscle atrophy. It’s not uncommon to see high muscle tone in the scalenes, upper fibres of trapezius and levator scapulae in people with RCRSP. I believe, and some research supports this, that this is more of a result of pain rather than a cause, as people try to shrug their shoulders to avoid pain.
Neck range of motion in rotation and side flexion may be limited but shouldn’t be painful unless this is an overuse case where there may be neck and shoulder involvement together. In the case of the latter, if a client displays considerable atrophy it can indicate a potential ‘Parsonage Turner Syndrome’ or a client that is just really deconditioned and weak. In both cases it’s important to educate the patient that it may take a very long time (many months to a year or more) to really build appreciable strength in order to set realistic expectations and prevent them from becoming discouraged.
Active Range Of Motion And Strength Testing
Usually the most painful movements for both active, passive and resisted testing, in order from most to least common are:
- Abduction, particularly with the palms facing downward and with the thumbs turned down
- Hand behind back
- External rotation
- Internal rotation (with arms at 0 abduction)
The Empty Can, Neer’s and Hawkins-Kennedy tests are the special tests I use the most. The effectiveness of special tests for diagnosis purposes is debatable (2), but I do find these three helpful for assessing tolerance to elevation with internal rotation of the arm.
I usually informally integrate the Drop Arm and Belly Press tests into my assessment by having the client hold the arm in the air in abduction, and by having the client push into their belly during resisted internal rotation. As long as there’s not a major loss of strength I’m not too concerned normally.
Mechanical Diagnosis and Therapy (MDT)
I’m also a big believer in assessing Mechanical Diagnosis and Therapy (MDT, aka the McKenzie method) for people with shoulder pain. If you’re not familiar with the repeated movement/prolonged holds method of assessment, you basically assess some functional baselines which may be limited or symptomatic (i.e. push-up, shoulder flexion range of motion, hand behind back etc), have them do repeated movements or (more in the case of spinal pain) prolonged holds, and then repeat the baseline to see if there’s a difference.
Putting a more concrete example to this, I’ve found in the majority of cases that 2 sets of 10 repeated shoulder extensions and/or internal rotations (arm by the side) will often improve a client’s ability to do painful activities such as shoulder flexion, abduction, hand behind back, and/or pushups. If that’s the case – they have a directional preference and should do those exercises at least 3 times a day.
While the strict McKenzie therapists recommend doing these exercises for 10 repetitions, every 2 hours – I’ve found it extremely rare for patients to stick to it. I usually recommend 3-4 times a day (not all at once), and give patients the option to increase the frequency if they’re tolerating it well and have no increase in symptoms.
Additional Assessment Components
This can be combined with MDT as a functional baseline, but if the client is an athlete or weight training client I also like to look at the goal activity (if possible) that they are struggling with. Any activity can be an assessment in and of itself. This can help me determine if there’s a technique/body awareness issue, a kinetic chain issue (which I would assess in further detail), a workload issue, and/or psychosocial issues (i.e. anxiety or excessive guarding) that may be contributing to the client’s condition.
I hope this article provided some useful tips for you on how to assess clients with rotator cuff related shoulder pain. As always – thanks for reading!