Cluster Testing, Neuro Screen, Imaging and Red Flags

A 2015 study by Hegedus showed that clustering tests improves accuracy. Grouping three to five tests for subacromial, instability or intra-articular problems, and trying to disprove the working hypothesis, gives more trustworthy findings than single tests. The neurological screen covers reflexes, myotomes, dermatomes and cutaneous nerve supply. X-ray is the first-line image and shows bony change, calcific tendinopathy, a high-riding humeral head, cuff arthropathy and arthritis. CT helps with surgical planning, ultrasound gives a dynamic, non-ionizing view of the cuff, nerve conduction studies help separate neck from shoulder causes, and MR arthrography helps show labral tears after dislocation. Local guidelines and seniors should guide requests. The cervical spine, AC joint and SC joint should be screened, since a C5 or C6 root problem often hides behind shoulder pain. Red flags include trauma with immediate stiffness, facial weakness, unremitting night pain, weight loss and upper limb sensory loss. If a presentation does not fit an MSK picture, escalate it.