Pathology of the Rotator Cuff and Subacromial Impingement Syndrome are considered to be very common causes of pain arising from the shoulder joint.

My first blog is therefore based on 3 very interesting articles I have read about objective testing to help identify pathology of the Rotator Cuff and/or Impingement Syndrome. The first 2 articles  (one from the BJSM and the other from the Australian Journal of Physiotherapy) talk about the accuracy of individual clinical tests and whether they are beneficial to clinical diagnosis. However, if you only have time to read one article, it has to be the 3rd article I read, by Jeremy Lewis in the British Journal of Sports Medicine (BJSM) about the shoulder symptom modification procedure (SSMP) for diagnosing shoulder pathology.

This paper focuses on the dilemmas associated with the current process of clinical examination of the shoulder and suggests an alternative method for both examination and clinical reasoning in treatment of the shoulder.

According to Lewis 2009, when performing clinical shoulder tests it is very difficult to isolate individual structures, which is why most tests have a high sensitivity and reproduce symptoms but have a low specificity and therefore cannot contribute to structural diagnosis.

You cannot isolate one tendon as the cause of the pathology, clinical tests are just not strong enough and there is evidence of confluence (a joining together) of tendon ligament and capsule, and therefore any tests trying to differentiate them are groundless.

A study by Frost et el (1999) reported that MRI imaging of symptomatic patients with a diagnosis of subacromial impingement syndrome were similar to those without shoulder pain.

So in conclusion clinical decision making based on clinical tests and imaging may be flawed and a new method of assessment needs to be developed.

THE SOLUTION:

Shoulder Symptom Modification Procedure or SSMP is a series of 4 mechanical techniques that are applied while the patient performs the movement that reproduces his symptoms. The test has to reduce the patients symptoms by 30%. If a test reduces the patients symptoms – this guides the therapist in terms of which techniques to use in the treatment of the patient. The 4 SSMP techniques are as follows:

1)      Humeral head Procedure: This involves using an AP or PA glide of the humerus (with a belt etc) or a static muscle contraction while the patient does the painful movement

2)      Scapular positioning: Elevation, Depression, Pro/retraction etc

3)      Cervical/Thoracic Techniques: SNAGS, NAGS to mention a few

4)      Thoracic Kyphosis technique-changing the patients kyphosis manually or with taping to see if it has an effect.

So for example, if an AP on the humerus decreases a patients symptoms, one may hypothesis for example that a tight posterior capsule leads to anterior translation of the humeral head causing impingement. The following techniques could help improve the patients symptoms: AP mobilization techniques in supine, Posterior capsule stretches or MWM technique with a belt to name a few.

If changing the patients thoracic kyphosis helped treatment, then treatment may be focused on postural correction or Tx mobility techniques and exercise to improve mobility and posture.

In conclusion this method of  performing specific movements/ treatment techniques in the assessment to try and improve a patients pain is a great way to guide treatment.

For further information, and a very interesting read you can refer to the article itself: Lewis, J (2009). Rotator Cuff Tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment. BJSM 43: 259-264

In my next post I will write about the evidence for specific objective tests of the shoulder and how to perform them.

 

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