Shoulder Painful Arc Test

Painful Arc Test of the shoulder is used to detect the presence of the subacromial impingement. The pain occurs in abduction between 60° and 120°. The pain results from the pinching of inflamed or tender structures under the acromion process and the coracoacromial ligament.

A painful arc may be caused by subacromial bursitis, calcium deposits, a peritenonitis or tendinosis of the rotator cuff muscles, or most commonly by an unstable scapula.

How do you perform the Painful Arc Test?

The patient stands and, while being observed by the clinician, is asked to actively abduct the involved arm in scapular plane to full elevation.

See Also: Neer Test

What is the positive Painful Arc Test?

A positive Painful Arc Test for subacromial impingement is indicated if the patient reports shoulder pain in the 60–120-degree range (Where the supraspinatus tendon becomes impinged between the greater tubercle of the humerus and the acromion in this phase of the motion “subacromial impingement”).

Pain outside this range is considered a negative test, and pain that increases in severity as the arm reaches 180 degrees is indicative of a disorder of the acromioclavicular joint pathology.

Initially, the structures are not pinched under the acromion process, so the patient is able to abduct the arm 45° to 60° with little difficulty. As the patient abducts further (60° to 120°), the structures (e.g., subacromial bursa, rotator cuff tendon insertions, especially supraspinatus) become pinched, and the patient is often unable to abduct fully because of pain. If full abduction is possible, however, the pain diminishes after approximately 120° because the pinched soft tissues have passed under the acromion process and are no longer being pinched.

Often, the pain is greater going up (against gravity) than coming down, and there is more pain on active abduction than on passive abduction.

See Also: Subacromial Impingement

Accuracy

It has been reported that the painful arc sign, a positive drop-arm test, and a positive infraspinatus test are strong indicators of a full-thickness rotator cuff tear.

Hermann found that the painful arc test was positive in 48.9% of 50 patients with degenerative impingement.

Although this test is good at detecting subacromial impingement, a positive finding is unlikely to aid the clinician in determining a specific diagnosis as there are a number of conditions that can be provoked with arm elevation.

Since both the Neer impingement sign and the Hawkins–Kennedy test each has low specificity values, addition of the painful arc sign (which has a higher reported specificity) may improve overall diagnostic accuracy when all three maneuvers are used in a composite exam to diagnose subacromial impingement.

A second painful arc in the shoulder may be seen during the same abduction movement. This painful arc occurs toward the end of abduction, in the last 10° to 20° of elevation, and is caused by pathology in the acromioclavicular joint or by a positive impingement test. In the case of the acromioclavicular joint lesion, the pain tends to be localized to the joint. With the impingement syndrome, the pain is usually found in the anterior shoulder region.

Notes

Initially till 45–60°, the structures are not pinched and hence the patient would be able to abduct with little difficulty. As the patient abducts further (60–120°), the structures impinge and he/she is often unable to abduct fully because of pain. If full abduction is possible, the pain diminishes after approximately 120° as the pinched soft tissues have passed under the acromion process.

In the evaluation of the active and passive ranges of motion, the patient can often avoid the painful arc by externally rotating the arm while abducting it. This increases the clearance between the acromion and the diseased tendinous portion of the rotator cuff , avoiding impingement in the range between 60 and 120°.

In addition to complete or incomplete rotator cuff tears, swelling and inflammation as a result of bursitis, scapulothoracic dyskinesias, abnormalities of the margin of the acromion, and occasionally osteoarthritis in the acromioclavicular joint lead to impingement with a painful arc.

Pain in the acromioclavicular joint occurs between 140 and 180° of abduction. Increasing abduction leads to increasing compression and torsion in the joint.

See Also: Scapulothoracic Dyskinesis

References

1. Kessel L, Watson M. The painful arc syndrome. Clinical classification as a guide to management. J Bone Joint Surg Br. 1977 May;59(2):166-72. doi: 10.1302/0301-620X.59B2.873977. PMID: 873977.
2. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov;46(14):964-78. doi: 10.1136/bjsports-2012-091066. Epub 2012 Jul 7. PMID: 22773322.
3. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am. 2005 Jul;87(7):1446-55. doi: 10.2106/JBJS.D.02335. PMID: 15995110.
4. Caliş M, Akgün K, Birtane M, Karacan I, Caliş H, Tüzün F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis. 2000 Jan;59(1):44-7. doi: 10.1136/ard.59.1.44. PMID: 10627426; PMCID: PMC1752990.
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