Shoulder Special Tests

Orthopedic Special Tests
for the Shoulder
James H. Lynch, MD, MS

Military Sports Medicine Fellowship
Modified from lecture by Keith Scorza, MD, MBA
History and Physical Exam
Cornerstone of the diagnostic process
Determine Treatment Path
Avoid unnecessary procedures
Orthopedic Encounter
History
Observation
Inspection
Palpation
Range of motion
Strength
Neurovascular exam
Imaging
Orthopedic Special
Tests (OSTs)
Limited number of
studies
Questionable reliability
and accuracy
What is the best evidence we

have to date?
Comprehensive systematic review published in

2008
Critiqued 45 studies
Hegedus et al. Physical examination tests of the shoulder: a systematic review

with meta-analysis of individual tests. Br J Sports Med 2008;42:80-92.
Only half were deemed well designed

Only two had adequate samples sizes
Close to 100 shoulder OSTs evaluated
Only three tests had adequate studies for metaanalysis
Five Categories of Tests
Impingement
Rotator Cuff Pathology
Labral Tears and Biceps Pathology
AC joint pathology
Instability
Impingement
AC joint pathology
Instability
Impingement
Hawkins-Kennedy
Neers sign
Supraspinatus Test
Infraspinatus Test
Hawkins-Kennedy Test and

Neers Sign
Supraspinatus (empty can*) and

Infraspinatus Tests
*Recent study with EMG data

suggests that the Supraspinatus
may be better isolated with a
full can position
Evidence Based Considerations

for impingement
Hawkins-Kennedy test and Neers sign
May serve as a screening test
Infraspinatus and Supraspinatus tests
May serve as a confirmation test
Impingement
AC joint pathology
Instability
Rotator Cuff Integrity
Supine Impingement Sign

External Rotation Lag
Sign (ERLS)
Drop Arm Test
Sensitive, any injury
Specific, any injury
Bear Hug Test

Belly Press Test
Hornblowers Test
Specific-subscapularis
Specific-teres minor
Supine Impingement Sign
External Rotation Lag Sign

Drop Arm Test
Bear Hug and Belly Press Tests
Hornblowers Sign
Evidence Based Recommendations

Rotator Cuff Integrity
Supine Impingement Tests
ERLS and Drop Arm Tests
May have value to rule in any rotator cuff tear when positive
Bear-Hug and Belly Press tests
May be a useful screening test for any rotator cuff tear.
May have value to rule in a subscapularis tear
Hornblowers
May be a sign of severe degeneration of the teres minor muscle
Impingement
AC joint pathology
Instability
Labrum and Biceps

Pathology
Labrum integrity and biceps

tendon pathology
Kim Test
Jerk Test
Biceps Load I
Biceps Load II
Posterior Labral lesions
SLAP lesions
Other Labral Tests
Active Compression test

Anterior slide test
Crank test
Rotation-compression test
Systematic Reviews in 2007 and 2009 showed
limited utility due to considerable variation
between independent evaluations
Jones, GL, Galluch DB. Clinical assessment of superior glenoid labral

lesions. Clin Ortho and Rel Rsrch 2007;455:45-51.
Calvert E et al. Special physical examination tests for superior labrum
anterior posterior shoulder tears are clinically limited and invalid: a
diagnostic systematic review. J Clin Epidem 2009;62:558-563.
Kim Test and Jerk Test
Biceps Load I and II Tests
Labrum and Biceps Pathology
Biceps Load II test
Kim and Jerk Tests
May be diagnostic for SLAP

Biceps load I can be considered with caution
May be diagnostic for posterior labrum pathology

Needs more studies
Biceps tendon tests
Have not fared well in current literature
Impingement
AC joint pathology
Instability
A-C Joint Pathology
Palpation
Active
Compression Test
Palpation and Active

Compression Test
Evidence Based Recommendation

A-C Joint Pathology
Palpation
May be a good screening test
Limited formal investigation
Active Compression Test
Likely a good specific test to rule in

pathology
Impingement
AC joint pathology
Instability
Instability
Apprehension Test
Relocation Test
Anterior Release Test
Diagnostic value increases if
apprehension is used as a positive finding
rather than pain
Apprehension, Relocation, and

Anterior Release Tests

Anterior Instability
Apprehension, Relocation, and Anterior

Release Tests
All appear to be diagnostic for anterior

instability
Use apprehension not pain as a positive

finding
Summary
Impingement
Rotator cuff integrity
Kim or Jerk tests for SLAP (not sensitive)

Biceps load I or II for posterior labrum (fairly sensitive, very
specific)
AC Joint Pathology
Supine Impingement Sign for screening

ERLS or Drop arm for confirmation of any tear
Bear Hug or Belly press for confirmation of subscapularis tear
Hornblowers for degeneration of teres minor
Labrum and Biceps Injury
Kennedy-Hawkins or Neer as a screening test

Supraspinatus and Infraspinatus for confirmation
Palpation for screening

AC compression test for confirmation
Instability
Apprehension, relocation, and release tests all fairly diagnostic

Use apprehension rather than pain to improve diagnostic ability
Caveats
These tests were evaluated as a single evaluation
Diagnostic Values may increase when combining with:
Other OSTs
Historical data (Patients age)
Evolution of rehabilitative progress
Diagnostic injections
Experience
OSTs are not performed in a vacuum. They are part of

a comprehensive diagnostic process
References
Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a
subscapularis tear. Arthroscopy 2006;22:1076-84
Calvert E et al. Special physical examination tests for superior labrum anterior posterior shoulder
tears are clinically limited and invalid: a diagnostic systematic review. J Clin Epidem 2009;62:558563
Hegedus EJ, Goode A, Campbell S et al. Physical examination tests of the shoulder: a
systematic review with meta-analysis of individual tests. Br J Sports Med 2008;42:80-92
Jones, GL, Galluch DB. Clinical assessment of superior glenoid labral lesions. Clin Ortho and Rel
Rsrch 2007;455:45-51.
Kim SH, Ha KI, Ahn JH et al. Biceps load test II: A clinical test for SLAP lesions of the shoulder.
Arthroscopy 2001;17:160-4
Kim SH, Ha KI, Han KY. Biceps load test: a clinical test for superior labrum anterior and posterior
lesions in shoulders with recurrent anterior dislocations. Am J Sports Med 1999;27:300-3
Kim SH, Park JS, Jeong WK et al. The Kim test: a novel test for posteroinferior labral lesion of
the shoulder a comparison to the jerk test. Am J Sports Med 2005;33:1188-92
Litaker D, Pioro M, El Bilbeisi H et al. Returning to the bedside: using the history and physical
exam to identify rotator cuff tears. J Am Geriatr Soc 2000;48:1633-7
Park HB, Yokota A, gill HS et al. Diagnostic accuracy of clinical tests for the different degrees of
subacromial impingement syndrome. J Bone Joint Surg Am 2005;87:1446-55
Reinold MM, Macrina LC, Wilk KE et al. Electromyographic analysis of the Supraspinatus and
deltoid muscles during three common rehabilitation exercises. J Athletic Training 7007;42(4):464469
Tennent DT, Beach WR, Meyers JF. A review of the special tests associated with shoulder
examination. Part II: laxity, instability, and superior labral anterior and posterior (SLAP) lesions.
Am J Sports Med 2003;31:301-7.
Tennent TD, Beach WR, Meyers JF. A review of the special tests associated with shoulder
examination. Part I: the rotator cuff tests. Am J Sports Med 2003;31:154-60
Thank You
Questions???

Shoulder Special Tests

Uploaded by

Copyright:

Available Formats

Shoulder Special Tests

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Shoulder Special Tests

Uploaded by

Copyright:

Available Formats

Orthopedic Special Tests

for the Shoulder

James H. Lynch, MD, MS

Modified from lecture by Keith Scorza, MD, MBA

History and Physical Exam

Cornerstone of the diagnostic process

Determine Treatment Path

Avoid unnecessary procedures

What is the best evidence we

Comprehensive systematic review published in

Hegedus et al. Physical examination tests of the shoulder: a systematic review

Only half were deemed well designed

Close to 100 shoulder OSTs evaluated

Only three tests had adequate studies for metaanalysis

Five Categories of Tests

Rotator Cuff Pathology

Labral Tears and Biceps Pathology

Five Categories of Tests

Rotator Cuff Pathology

Labral Tears and Biceps Pathology

Hawkins-Kennedy Test and

Supraspinatus (empty can*) and

*Recent study with EMG data

Evidence Based Considerations

Hawkins-Kennedy test and Neers sign

May serve as a screening test

Infraspinatus and Supraspinatus tests

May serve as a confirmation test

Five Categories of Tests

Rotator Cuff Pathology

Labral Tears and Biceps Pathology

Rotator Cuff Integrity

Supine Impingement Sign

Sensitive, any injury

Specific, any injury

Bear Hug Test

Supine Impingement Sign

External Rotation Lag Sign

Bear Hug and Belly Press Tests

Evidence Based Recommendations

Supine Impingement Tests

ERLS and Drop Arm Tests

Bear-Hug and Belly Press tests

May be a useful screening test for any rotator cuff tear.

May have value to rule in a subscapularis tear

May be a sign of severe degeneration of the teres minor muscle

Five Categories of Tests

Rotator Cuff Pathology

Labral Tears and Biceps Pathology

Labrum and Biceps

Labrum integrity and biceps

Posterior Labral lesions

Other Labral Tests

Active Compression test

Jones, GL, Galluch DB. Clinical assessment of superior glenoid labral

Kim Test and Jerk Test

Biceps Load I and II Tests

Evidence Based Recommendations

Labrum and Biceps Pathology

Biceps Load II test