PCA Study Review: Shoulder Pain, Rotator Cuff Tears, and the Problem with One Test Thinking

PCA Study Review: Shoulder Pain, Rotator Cuff Tears, and the Problem with One Test Thinking

PCA Study Review: Shoulder Pain, Rotator Cuff Tears, and the Problem with One Test Thinking In this episode of PCA Study Review, a service of the Pennsylvania Chiropractic Association, we review research on shoulder exams, rotator cuff tears, and subacromial impingement. Shoulder exams can get crowded quickly: Neer, Hawkins, Jobe, Drop Arm, Lift Off, Painful Arc, and lag signs. Most doctors know the names. The deeper issue is whether we understand what each test actually tells us. The literature reinforces one clear point: no single shoulder test is perfect. This review focuses on lag signs, particularly the External Rotation Lag Sign at 90 Degrees and the Internal Rotation Lag Sign, to identify full-thickness rotator cuff tears. The larger lesson is not that doctors need one magic test. Better clinical reasoning requires test clusters, context, documentation, and knowing when referral, imaging, or co-management may be appropriate. For chiropractors, this matters because musculoskeletal care depends on skilled examination early in the care pathway. The opportunity is to evaluate carefully, recognize red flags, document clearly, and treat conservatively when appropriate. In This Episode * Why one test thinking can weaken the shoulder diagnosis * Why lag signs deserve attention in shoulder evaluation * How high specificity and low sensitivity should affect interpretation * Why familiar tests are not always the strongest tests * How test clusters improve clinical reasoning * When shoulder findings may require referral, imaging, or co-management * Why evidence-informed documentation strengthens care and credibility Reference Articles Zhao, Q., Palani, P., Kassab, N. S., Terzic, M., Olejnik, M., Wang, S., Tomassini-Lopez, Y., Dean, C., & Shellenberger, R. A. Evidence-based approach to the shoulder examination for subacromial bursitis and rotator cuff tears: a systematic review and meta-analysis. BMC Musculoskeletal Disorders, 25, Article 1028, 2024. [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-024-08144-z] Hermans, J., Luime, J. J., Meuffels, D. E., Reijman, M., Simel, D. L., & Bierma-Zeinstra, S. M. A. Does This Patient With Shoulder Pain Have Rotator Cuff Disease? The Rational Clinical Examination Systematic Review. JAMA, 310(8), 837–847, 2013. [https://jamanetwork.com/journals/jama/fullarticle/1733724] Castoldi, F., Blonna, D., & Hertel, R. External rotation lag sign revisited: Accuracy for diagnosis of full-thickness supraspinatus tear—Journal of Shoulder and Elbow Surgery, 18(4), 529–534, 2009. [https://www.sciencedirect.com/science/article/pii/S1058274609000081] Miller, C. A., Forrester, G. A., & Lewis, J. S. The Validity of the Lag Signs in Diagnosing Full-Thickness Tears of the Rotator Cuff: A Preliminary Investigation. Archives of Physical Medicine and Rehabilitation, 89(6), 1162–1168, 2008. [https://www.sciencedirect.com/science/article/pii/S0003999308002098] The shoulder is complex. Rotator cuff disease is common. Pain provocation tests can mislead when used carelessly. The opportunity is to read the research, revisit the exam, and sharpen the clinical reasoning that protects patients and strengthens the profession. PCA Website: https://pennchiro.org/ [https://pennchiro.org/] PCA Email: pca@pennchiro.org [pca@pennchiro.org]

PCA Deep Dive: Pennsylvania’s Chiropractic Scope Fight; Modern Care vs. Outdated Laws

PCA Deep Dive: Pennsylvania’s Chiropractic Scope Fight; Modern Care vs. Outdated Laws In this episode of PCA Deep Dive, we examine one of the most important questions facing chiropractic in Pennsylvania: What happens when modern chiropractic education, modern patient needs, and conservative care collide with an outdated scope-of-practice law built for another era? Pennsylvania’s chiropractic scope of practice is nearly 50 years old. While the profession, patient expectations, education standards, and healthcare delivery models have changed dramatically, Pennsylvania law has not kept pace. This episode explores the real-world impact of that mismatch, including restricted practice authority, rural access challenges, workforce pressure, delegation barriers, insurance friction, and the hidden cost of limiting conservative, non-pharmacological care. We also discuss research from West Virginia University showing that Pennsylvania ranks among the most restrictive states in the country for chiropractic scope of practice. The result is a paradox: highly trained doctors operating under low autonomy. But this is bigger than one bill. This is the scope fight. It is about whether Pennsylvania’s chiropractic law will finally reflect modern education, modern patient needs, and modern conservative care. In This Episode * Why Pennsylvania’s chiropractic scope of practice is nearly 50 years old * How outdated scope laws affect access, efficiency, and patient choice * Why does Pennsylvania rank among the most restrictive states for chiropractic scope * How regulatory ambiguity can function like a practical ban * Why rural communities feel these restrictions more sharply * How workforce shortages and limited training pipelines affect access * Why HB 1106 matters for delegation and clinic efficiency * How scope modernization connects to non-opioid care and the future of chiropractic in Pennsylvania Get Involved Policy does not change from the sidelines. PCA’s Lobby Day is June 9 in Harrisburg, and we need chiropractors from across Pennsylvania to show up, meet with elected officials, and help tell the story of this profession. We know it is a practice day. But this is one of the most important opportunities we have to show the strength, seriousness, and unity of chiropractic in Pennsylvania. If you cannot attend, please consider supporting the PCA PAC. One hundred percent of PCA PAC donations go directly toward supporting chiropractic advocacy and the future of the profession in Pennsylvania. WVU study on Pennsylvania’s outdated scope of practice: [https://knee.wvu.edu/publications/knee-center-research/2026/04/16/chiropractic-scope-of-practice-and-provider-distribution-in-pennsylvania] Register for PCA Lobby Day on June 9: [https://docs.google.com/forms/d/e/1FAIpQLSf6J5wmpJiZI6xMTwu5i7kmgQauR0IUW32S6YcIu5LAQsfcNw/viewform] Support the PCA PAC: [https://pca.ce21.com/donations] Learn more about HB 1106 and delegation restoration: [https://pennchiro.org/hb1106/] PCA: https://pennchiro.org/ [https://pennchiro.org/] Email the PCA: pca@pennchiro.org [pca@pennchiro.org]

PCA Study Spotlight: The Hidden Circuit of Chronic Pain

PCA Study Spotlight: The Hidden Circuit of Chronic Pain Stanford’s Hidden Chronic Pain Circuit: A Better Framework for Explaining Persistent Mechanical Pain This episode of PCA Study Spotlight reviews a Stanford Nature study describing a “hidden” looping circuit between the spinal cord and brain that appears to selectively drive chronic mechanical pain in mice while remaining distinct from pathways involved in acute, protective pain and normal touch. In mouse models, silencing nodes in the loop reduced injury-induced mechanical hypersensitivity due to inflammation or nerve injury, whereas repeated activation could create lasting hypersensitivity in healthy mice. The host emphasizes this is basic science, not a chiropractic or manipulation study, but argues it offers chiropractors a clearer framework for communicating chronic pain: persistent pain may reflect altered nervous system processing and sensitization rather than ongoing tissue damage, supporting more accurate, respectful patient conversations and reinforcing the value of conservative care without overclaiming mechanisms. 00:00 Series Purpose 00:25 Study Overview 01:09 Important Caveats 01:40 Why Pain Persists 02:22 Mapping The Loop 03:52 Clinical Communication 04:45 Fear And Function 05:34 Beyond Structural Stories 06:00 Touch Versus Pain 06:55 Layered Pain Biology 07:31 Practical Takeaways 08:16 Read And Reflect 08:47 Closing Thoughts Study Citation Wang, Q., Lee, J. H., Nachtrab, G., Yuan, Y., Yuan, L., Qi, W., Mohr, M. A., Xiong, J., Horowitz, M. A., & Chen, X. (2026). Deconstruction of a spino-brain–spinal cord circuit that drives chronic pain. Nature. Published online April 1, 2026. DOI: 10.1038/s41586-026-10296-y. Official article: Suggested Show Notes Format Study discussed in this episode: Wang, Q., Lee, J. H., Nachtrab, G., Yuan, Y., Yuan, L., Qi, W., Mohr, M. A., Xiong, J., Horowitz, M. A., & Chen, X. (2026). Deconstruction of a spino-brain–spinal cord circuit that drives chronic pain. Nature. Published online April 1, 2026. DOI: 10.1038/s41586-026-10296-y. Read the study here: Optional Short Version Wang Q, Lee JH, Nachtrab G, et al. Deconstruction of a spino-brain–spinal cord circuit that drives chronic pain. Nature. Published online April 1, 2026. DOI: 10.1038/s41586-026-10296-y. PCA Contact information: PCA Website: https://pennchiro.org/ [https://pennchiro.org/] PCA Email: pca@pennchiro.org [pca@pennchiro.org] PCA Study Spotlight, Chiropractic Research, Chronic Pain, Pain Science, Central Sensitization, Neuroscience, Musculoskeletal Care, Conservative Care, Patient Communication, Spine Care

PCA March President’s Address with Dr. Andrew Heck |

PCA March President’s Address with Dr. Andrew Heck | Legislative Progress, Advocacy & Northeast Chiro Summit In this special Spinal Chat episode from the Pennsylvania Chiropractic Association, PCA President Dr. Andrew Heck shares the March President’s Address with updates on spring momentum and ongoing legislative, regulatory, and reimbursement challenges. He reports progress on delegation restoration through House Bill 1106, scope modernization, copay reform, and the sports working group’s efforts on return-to-play physicals and sideline care, as well as continued Capitol meetings led by PCA leadership and staff. Dr. Heck thanks nearly 70 members and non-members for supporting the postcard campaign and emphasizes that engagement from doctors, staff, patients, and communities strengthens chiropractic’s voice. He also previews the Northeast Chiro Summit (May 1–3) at the Kalahari Resort, noting record attendance and encouraging participation, membership, PAC support, and advocacy involvement. 00:00 Welcome and Setup 00:39 Springtime Reflection 01:13 Legislative Progress 01:56 Member Advocacy Push 02:27 Northeast Summit Preview 03:08 Conference Details 03:25 Closing Thanks 03:33 Get Involved Call 04:11 Final Sendoff PCA Contact information: PCA Website: https://pennchiro.org/ [https://pennchiro.org/] PCA Email: pca@pennchiro.org [pca@pennchiro.org] Spinal Chat, Pennsylvania Chiropractic Association, Dr. Andrew Heck, President’s Address, Chiropractic Advocacy, HB1106, Scope Modernization, Copay Reform, Sports Chiropractic, PCA PAC, Northeast Chiro Summit, Pennsylvania Chiropractors

PCA Deep Dive: Covered but Not Accessible, The Chiropractic Copay Crisis in Pennsylvania

PCA Deep Dive: Covered but Not Accessible. The Chiropractic Copay Crisis in Pennsylvania This episode argues that rising deductibles, copays, visit caps, and administrative barriers are pricing patients out of conservative musculoskeletal care, reshaping treatment choices, and increasing downstream costs. Citing the RAND Health Insurance Experiment, it notes chiropractic use drops about 50% with 25%+ cost sharing and that chiropractic demand is more price-sensitive than general medical care. Studies on high-deductible health plans show patients reduce spending largely by skipping care, disproportionately harming lower-wage workers. In contrast,e a Johns Hopkins study links higher out-of-pocket costs to reduced non-pharmacologic care without reducing opioid use. Evidence shows that removing copays reduces downstream physician services, surgeries, and injections, and that chiropractic coverage correlates with lower total spending. The script highlights Pennsylvania billing data, federal Medicare parity bills (HR 539/S 106), DOJ comments on ERISA misuse, Massachusetts’ prior-authorization ban for non-opioid pain care, and Pennsylvania’s proposed 20% cost-sharing cap and Medicare fee payment floor, concluding with a call to action. 00:00 Why Care Costs More 00:51 The Bill Fear Factor 01:59 Rand Experiment Lessons 04:35 Smart Shopper Myth 06:25 Deductibles And Visit Caps 08:31 Maintenance Care Gap 10:06 When Patients Switch To Pills 11:05 Proof Reform Saves Money 14:02 Pennsylvania Billing Shock 14:59 Medicare Parity Fight 16:48 State Reforms In Motion 17:44 Pennsylvania Copay Blueprint 19:35 What You Can Do Now 20:35 Final Call To Action References Baicker, K., & Chandra, A. (2015). JAMA Internal Medicine. Johns Hopkins University study evaluating the impact of high deductible health plan enrollment on nonpharmacologic treatments. (2023). Legorreta, A. P., et al. (2004). JAMA Internal Medicine. Also referenced as: Comparative Analysis of Individuals With and Without Chiropractic Coverage. Lentz, T. A., et al.; ATI Physical Therapy and Duke Clinical Research Institute. (October 2025). Physical Therapy & Rehabilitation Journal. RAND Health Insurance Experiment. (1974–1982). Findings later analyzed in: Shekelle, P. G., Rogers, W. H., & Newhouse, J. P. (1996). Medical Care. Smith, M., & Stano, M. (1997). Journal of Manipulative and Physiological Therapeutics. Swedish randomized controlled trial on maintenance care. (2018). Texas A&M study evaluating employee behavior in high deductible health plans. University of California, Berkeley, and Harvard study on high deductible health plans. USC Schaeffer Center study on the financial burden of high deductible health plans. (2023). Whedon, J. M., et al. (2024). Journal of Integrative and Complementary Medicine. JAMA Network Open clinical trial analyzing the addition of chiropractic care to standard military medical care. Government, Legislative, and Policy Documents American Chiropractic Association. Chiropractic Medicare Coverage Modernization Act Talking Points. (2025). Chiropractic Future. Comments submitted to the Department of Justice Anticompetitive Regulations Task Force. (June 2025). Massachusetts Session Law, Chapter 285. (2024). Medicare. 2025 Physician Fee Schedule. PCA Website: https://pennchiro.org/ [https://pennchiro.org/] PCA Email: pca@pennchiro.org [pca@pennchiro.org]