PHYSICIAN UPDATE:Rethinking Best Practices on Rotator Cuff-Related Shoulder Pain Special Testing... How strong is the evidence really? (July 2020)

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Peak Performance Physical Therapy & Sports Training

EVIDENCE-BASED PRACTICE UPDATE
July 2020

 

Rethinking Best Practices on Rotator Cuff-Related Shoulder Pain Special Testing...
How strong is the evidence really?

 

In this update we’re departing from the typical research article review to examine a “viewpoint” article recently appearing in the Journal of Orthopedic and Sports Physical Therapy that reviews the evidence base for the “old dog” of rotator cuff-related shoulder pain (RCRSP) special tests often used by physicians, surgeons, and therapists during clinical exams.  

 
When you see suspected RCRSP...

• What special tests do you presently use in clinical exams for RCRSP?
• What weight do you give them in making a diagnosis?
• Do special tests for RCRSP help identify specific structures generating pain?
• Do imaging findings consistently and accurately identify and explain  symptom causes?
• When patients undergo  acromioplasty, biceps tenodesis, type  II SLAP repairs, atraumatic RC tendon tear related surgery can they be certain  the tissue causing symptoms was  addressed?

 

Salamh P, Lewis J.   (Viewpoint) It is Time to Put Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture.  JOSPT.  2020.  50(11); 222-225. 

  

by Mike Napierala, PT, SCS,  CSCS, FAFS 

The full text review is available via the Read More link below.  We've begun using this summary of our article overview as a quick read version  In an effort to honor your time demands.

SUMMARY:
As musculoskeletal providers we’re  always called to reassess   our clinical practices  based  on   new evidence.   The concept of test validity requires so called “gold standards” for comparison.  The challenge  with most existing reference standards used for validating our existing list of RCRSP tests is that asymptomatic  shoulders, whether in healthy control groups and even as the contralateral healthy control shoulder in symptomatic individuals, often have comparable abnormalities present on imaging, despite the lack of symptoms.   
 
These facts challenge our reliance on the pathoanatomic model as the predominant basis for clinical exam diagnostic testing.  The underlying assumption that abnormal morphology on imaging is increasingly being called into question, and at least  is controversial or debatable.   Since RCRSP special tests are intended to identify specific structures, to the mutual exclusion of other  adjacent or nearby tissues, as the pain generator  the inability to have  clarity on what the “gold standard” really is leaves the use of special tests for RCRSP increasingly difficult to defend.  The authors contend that their best and more appropriate use may be as a symptom reproduction test rather than being used to name specific structures that are injured/damaged and thus a basis for non-surgical and surgical treatment  decision making.   
 

We find that high quality MSK care requires not only, or even most often or primarily always, the clear and undoubted pain generating tissue diagnosis but in the majority of cases, being atraumatic, a careful analysis of the "underlying shortcomings" or biomechanics causes  for the tissue overload is really the major key that directs non-operative care and decision making.  There is little difference in care of  inflamed or damaged tissues...Class  IV laser if you have it, iontophoresis, ultrasound, electric stimulation,  traction, taping - there are only so many modalities  that can be  used to promote healing.  Too often traditional physical therapy uses a microscopic approach addressing the pain  generating tissue and neglects to discover the telescopic view of the kinetic chain that created the overload to begin with.  Patients inevitably return with the same condition or others due to the need to compensate once again for the underperforming body parts.

Background:  
Rotator cuff-related shoulder pain (RCRSP) is an umbrella term  that includes common diagnoses such as impingement syndrome, RC tendinopathy, bursa  pathology, and atraumatic rotator cuff tears – any of which typically lead to a painful shoulder that demonstrates weakness in abduction and/or ER.  There are over 70 “special tests” developed  for identifying shoulder conditions, many of which are intended for RCRSP.  (Others are for labral pathology, scapular dyskinesis, instability, etc...which are not the focus of this article.)
 
Keypoints:  
Validity of RCRSP tests are typically established by comparison to a “gold standard” such as radiographs, MRI, diagnostic ultrasound,  or visualization at the time of arthroscopy/surgery.  Thus, if deemed a  valid test, the  (+) test would correspond to the reference or gold standard test showing pathology, and conversely (-) when the reference shows no pathology. 
 
The challenge arises when so many commonly termed gold standard or reference tests detect abnormal findings on the asymptomatic side as well.  Barretto et al in J Shoulder and Elbow Surgery in 2019 demonstrated that the asymptomatic shoulder of 123 patients with unilateral pain had as many abnormalities as the symptomatic side with the exception of full-thickness supraspinatus tears.  Also, GH osteoarthritis had a 10% higher incidence in symptomatic shoulders.
 
Isolating structures via special testing is also a necessary assumption if special tests are to have merit.  Yet, anatomic and histologic studies have shown how interwoven the relationship is between the cuff tendons and the capsule, ligaments and bursa tissues.  Discerning between these would be necessary for the various special tests to be accurate at distinguishing one tissue from an adjacent or connected tissue.  For example, Boettcher et al in testing the Empty Can test, typically viewed as a supraspinatus test, showed that 9 shoulder muscles were active...and 8 active during the full can test.  Findings like these challenge the clinical reasoning that exact symptom sources can be determined by special testing during clinical exams.  
 
Musculoskeletal providers have been trained to associate, and therefore seek out in testing and for the sake of treatment, specific structural abnormality to attribute pain generation to.   Very complex anatomy, biomechanics, and physiology are often distilled down to simple special tests.  Yet, a systematic review by Hegedus et al in British Journal of Sports Medicine was unable to recommend a single test.  And Lin et al in the BJSM did not include special testing in their list of 11 best practices for musculoskeletal pain based on their systematic review.
 
Other challenges to rethinking the value of RCRSP special testing also include the time it can take for quality research to be incorporated into practice for experienced clinicians.  Conversely, many or most newer clinicians are taught in undergraduate or postgraduate training about special tests and may rationalize their application out of necessity early on.  
 
Conclusion:
The case is made that relying on special tests  or imaging  to inform patients on  the exact source of their pain or for decision making on invasive procedures of  non-traumatic RCRSP is “arguably unacceptable practice.”  RCRSP  special testing may be appropriate as a specific example of reproducing shoulder symptoms but without reference to specific anatomic structures involved  (ie.  pain provocation tests).
 
 
Peak Performance Perspective:
The pathoanatomic model has been a foundation for physicians, surgeons, physical therapists and athletic trainers for as long as most of us can remember.  From academic  foundations to internships/externships/fellowships  the reliance on and trust that abnormal findings on imaging explains the cause of symptoms  is taken with little  debate or confusion.  And for larger acute traumas, such as  lacerations or  fractures and ruptured tendons there’s certainly no debate.  The morphology changes are clear and the “leap of faith” needed to claim certainty regarding the “cause” or  the involved tissue isn’t really even a leap of faith at all.
 
But then comes along chronic musculoskeletal conditions.  Overuse.  Microtrauma.  Degenerative changes.  
 
And now research is showing us increasingly that for a host of the most common conditions we all see  clinically that so many are equally present on the contralateral side that is without  symptoms  in the very same person and in completely asymptomatic people as well.  
 
Disc bulges and even herniations.  Degenerative RC changes.   Tendinopathy.  Degenerative meniscal tears.  “Impingement” syndrome.  And within that the more encompassing label  of Rotator Cuff -Related Shoulder Pain (RCRSP).  
 
As clinicians  called to discern and rely upon “best  practices” we accept  that sometimes the research is lagging  but clinical thinking must still arrive at answers.  But,  when good new research mounts we are  called to reassess our clinical practices and grow.  Whether new findings reinforce our prior rationale or demands we modify clinical practices to incorporate new “truths” this  constant clinical process  must happen. 
 
Undoubtedly we must also guard against knee jerk reactionary swings of the pendulum based on singular studies.  Conversely, sometimes our assessment comes after recognition that the evidence was maybe really never there to begin with.  
 
The classic RICE and PRICE acronyms may be our most common proof of that.  Dr. Mirkin, who coined the term “R-I-C-E”  in 1978, has  since  indicated that common practice and theory was behind this recommendation, rather than sound  research evidence.  RICE has reached the level of powerful orthopedic dogma that all of us as musculoskeletal providers have surely used in the past...and for many, still use now.  Yet it lacks solid evidence. 
 
It’s orthopedic “comfort food”...but is it true?  Is it based on sound scientific findings?   No.
 
In the case of ice use for more extended times following injury or surgery there is now plenty of indication that pain control and temporary delay of swelling are benefits but that earlier or  better  recovery and consistent reduction of swelling are, in fact, NOT benefits that should be expected with ice.  
 
And our walls crumble. 
 
Ice, RICE, PRICE...these were maybe the most engrained and universal musculoskeletal recommendations  for the last 40 years.   Yet, an evidence base was lacking.  
 
We know better now.  But change can come slowly.  It’s a difficult process for professionals to alter their habitual thinking, decision making, educational talks and treatment recommendations.  And the strength and seeming common sense of the concept that ice would be helpful contributes to the self-fulfilling prophecy of internal bias we all have  that makes us even uncomfortable and hesitant to accept  that so many research papers do fail to support the repeated use of ice for musculoskeltal injury. 
 
Salamh and Lewis contend that we really are in the same place with RCRSP special testing.  A place where we must reconsider, reassess, our continued use of a comfortable and common practice that really lacks good evidence at this time. 
 
The lack of acceptable gold standards to even compare these tests to is a hard point to argue against.  Too many studies to mention have repeatedly shown us that a myriad of non-traumatic orthopedic related pains/conditions do not demonstrate, in fact, imaging abnormalities exclusive to the symptomatic side.  A clear thorn in the side of pathoanatomic based decision making...or maybe  more than a thorn.    
 
While we cannot “throw the baby out with the bathwater” on this topic – because so many conditions are very well identified by abnormal morphology on imaging, it may be that we merely need to step back and accept that many of the “special tests” that we’d come to rely upon for atraumatic  differential diagnostics during physical exams must instead be  considered a  group of likely potential tissues involved during a  provocative  postion/test that can be used later to  affirm progress rather than believing we have the ability to discern an exact tissue as the sole pain generator.  
 
So then what?
 
The good news from a treatment perspective  is that  from a functional biomechanics Physical Therapy perspective we’d  propose that symptom reproduction, functional biomechanics analysis,  and patient specific responses to exercise all have  a much greater implication on treatment decision making than a predetermined  anatomic tissue (word).  
 
Consider examples such as biceps tendinitis.   Impingement syndrome.  Supraspinatus tendinitis.  Any one of these diagnoses could present in a live patient somewhat differently.   And, could also easily be misdiagnosed or appear to be one of the others.  And as a  clinical instructor reminded me three decades ago  - “What makes you think that  each patient is allowed to have only ONE problem?”  
 
So often we strive to find THE diagnosis that we risk neglecting the fact that numerous tissues were experiencing whatever overuse or biomechanical compensation loading that occurred...not just one singular tissue alone.  
 
From a biomechanical analysis perspective we’d also submit that determining underlying shortcomings that resulted in microtrauma over time is the real key.  Too often physical therapy, or orthopedic care in general, fails because the focus is on the THE TISSUE generating pain rather than caring more about WHY it got that way.  
 
Any of those diagnoses above may have a host of adjacent or even distant biomechanical shortcomings that preceded the eventual inflammatory reaction and subsequent pain that led the patient to stop playing, stop working, alter life...and come to see you  for help.
 
We rarely find that simple progressive exercise loading to the local tissues from a generic sense is the answer.  For so many of the “failed PT” cases we see it ultimately comes down to discovering the underlying shortcomings...or as we say to patients, the “probable suspects” that led to the overuse, the asymmetric loading, the prolonged or early or excessively fast loading that caused the tissue to hurt.
 
For shoulders our keys are the thoracic cage, hip function, and scapular function.  Lacking thoracic extension and rotation, type I and II coupled motion issues related to specific sport or ADL/work biomechanics needs, serratus weakness (NOT as a protractor in the “plus” actions typically used in rehab) , hip extension and rotation lackings especially... these all are common issues behind shoulder overuse and eventual pain.  
 
Yes – our class IV laser, iontophoresis, ultrasound, therapeutic taping, instrument assisted  soft tissue release...there are many treatments that can be helpful at promoting healing and resolving pain of local tissues.   But the real key to treatment  is ultimately identifying underlying causes.  
 
And for that reason, it’s really all the “other” findings on patient physical exams that drive our treatment decision making  - and not, our  historic  reliance on  special testing to identify the exact  tissue involved.

Peak Patient Experience
Daphne said,” I’m painfree now.  I wasn’t sure my shoulder would ever be normal again.  I can do push ups and overhead pressing and pullups again now!” 

History:
50 yo female  with dominant R shoulder impingement diagnosis.  MRI showed supraspinatus tendinopathy and ACJ  DJD. Pt is a personal trainer who also regularly works out; exacerbated R  shoulder pain  during  vacation  despite no specific trauma or overuse. 
 
Subjective:
R shoulder pain reaching 3/10 with overhead pressing,  bench press,  push ups, pull ups and   turning car  wheel.  Self-reported function at  30% and QuickDash Sport 69% disability.

Objective:  
(Pt  was seen 10x  and then  released to independent HEP  -  returned  for final testing 3.5   mo after beginning PT)

*=pain

Test	Initial Evaluation	Discharge Evaluation
Pec  Minor	R>L mod loss	WNL
Thoracic Rotation	300/270	WNL
AROM Abd IR	270 *	WNL
Hor Add	380*	WNL
Isometric Jobe	50% *	84%
Abd  IR	33% *	96%
Abd	50% *	>100%
Serratus  Ant Wall Test	4+	5/5
Overhead Press	8# <46% *	15# 100%
Abd ER	NT	10#   85%

 
Treatment:
Manual Therapy:  
Thoracic cage ext and rotation mobilization.   Pec  Minor  soft  tissue mobilization.  Glenohumeral mobilization.

Exercise:  
Stretching/PROM-AROM, scapular  stability  Serratus Anterior work   as   “de-winger” action (NOT as scapular “plus” protraction) both nwb  and wb, low load endurance  based  - - -> strengthening for RC  and scapular muscles using modified gravity and lever  arm changes to customize sx-free ranges and loads.  Transitioning toward functional strengthening  for prepration to resume full personal training duties and fitness/wt lifting. 
 
Therapeutic Taping:  
Rocktape used for scapular awareness and RC unloading.
 
Discharge Evaluation:   Painfree.  Reported function at 95%.   Resumed personal training duties and fitness wt lifting progression toward pre-injury/symptom level  loads.  Quick Dash Sport reduced to 6%.