Tests of The Shoulder Joints and Physical Examination (PETS) are clinical examination maneuvers designed to aid the assessment of shoulder complaints. Despite more than 180 PETS described in the literature, evidence of their validity and usefulness in diagnosing the shoulder is questioned.
The complex structure of the shoulder, with its variable pathological conditions of rotator cuff disease, degenerative joint disease, and Type II SLAP lesions, makes clinical examination and assessment difficult for both new and experienced practitioners. With this text, you will gain a full understanding of shoulder anatomy and the principles of physical shoulder examination, and the nature and presentation of the pathological processes causing shoulder pain.
This text discusses a range of motion measurements, laxity testing, shoulder instability and presents a critical analysis of the usefulness and accuracy of examination practices. Thorough and accessible, this text is ideal for all clinicians called upon to perform shoulder exams and interpret findings.
Anatomy and Physiology
The shoulder girdle consists of the scapula and clavicle, which articulate with the chest wall, and the proximal humerus, which articulates with the scapula (the glenoid). The humeral head and the glenoid vault of the scapula form the osseous components of the glenohumeral joint of the shoulder. [rx][rx][rx]
The glenohumeral joint is a complex, mobile, multiaxial, ball-and-socket articulation that allows coordinated motion in the frontal, transverse, and sagittal planes. The latter allows for 360 degrees of circumduction. The relatively shallow glenoid fossa articulates with the much larger humeral head to allow for a wide range of physiologic motion. Also, the joint capsule is relatively lax. Shoulder movements occur secondary to the dynamic and coordinated articulations at four distinct joints:
Static and Dynamic Stabilizers
The static stabilizers include the glenohumeral articulation, the labrum, the glenohumeral ligaments, rotator cuff interval structures, and the negative intraarticular pressure. The dynamic stabilizers consist of the rotator cuff muscles, the deltoid, and the scapular and periscapular stabilizers.
The Rotator Cuff Muscles
- Arises from the medial two-thirds of supraspinatus fossa of the scapula, passes across the superior aspect of the glenohumeral joint, and inserts into the superior and middle facet of the greater tuberosity of the humerus.
- Primarily initiates shoulder abduction.[rx][rx]
Important for the initial 0 to 15 degrees of shoulder abduction motion when the arm is adducted against the side of the trunk
Beyond 15 degrees of abduction, the deltoid moment arm acts synergistically to assist in shoulder/arm abduction.
Along with the other rotator cuff muscles and provides dynamic stabilization of the shoulder.
Innervation: Suprascapular nerve (C4,C5,C6)
Blood supply: Suprascapular artery
Occupies the majority of the infraspinatus fossa, coursing posterior to the supraspinatus before inserting on the posterior impression and middle facet of the greater tuberosity of the humerus; the tendinous insertion becomes confluent with fibers from the supraspinatus to create a seamless anatomic blend at the rotator cuff footprint.
External rotator of the shoulder
Along with the other rotator cuff muscles, it provides dynamic stabilization of the shoulder.
Innervation: Suprascapular nerve (C5, C6)
Blood supply: Suprascapular and circumflex scapular arteries
Broad muscle arising from the subscapular fossa of the scapula and inserts into the lesser tuberosity of the humerus; anteriorly, the fibers coalesce and blend with the anterior shoulder joint capsule.
Internal rotator of the shoulder
Important dynamic anterior shoulder stabilizer
Innervation: Upper and lower subscapular nerves (C5, C6, C7)
Blood supply: Subscapular artery
Narrow and long muscle, which takes origin from the dorsal surface of the lateral border of the scapula and insert on the inferior facet of the greater tuberosity of the humerus
External rotator of the shoulder
Along with the other rotator cuff muscles, it provides dynamic stabilization of the shoulder.
Innervation: Axillary nerve (C5, C6)
Blood supply: Subscapular and circumflex scapular arteries
The long head of the biceps brachii tendon (LHBT) originates at the supraglenoid tubercle and superior glenoid labrum. The labral origin is predominantly posterior in more than half of cases. Inside the joint, the tendon is extra synovial, passing obliquely heading toward the bicipital groove. The long head tendon distally joins the short head of the biceps tendon (SHBT) as both transitions to their respective muscle bellies in the central third of the brachium, and after crossing the volar aspect of the elbow, forms a common tendon and inserts on the radial tuberosity and medial forearm fascia. The latter occurs via bicipital aponeurosis.
The short head of the biceps originates from the coracoid process, and the long head originates from the supraglenoid tubercle, passing through the intertubercular groove of the proximal humerus. The biceps brachii is not a shoulder muscle but does originate from the shoulder. [rx][rx][rx]
The bicipital groove is an anatomic landmark located between the greater and lesser tuberosities of the humerus and serves as a critical location for proximal biceps stability. The soft tissue components of the groove create a tendoligamentous sling to support the LHB tendon and include portions of the rotator cuff muscles (subscapularis and supraspinatus) coracohumeral ligament (CHL), and the superior glenohumeral ligament (SGHL).
Biomechanically, the LHBT has a controversial role in the dynamic stability of the shoulder joint. It has been demonstrated, mostly in biomechanical cadaveric-based studies and animal models, that the tendon at least plays a passive stabilizing role in the shoulder. Neer proposed in the 1970s that the LHBTs stabilizing role varied depending on the position of the elbow.[rx] Several subsequent studies refuted the theory that the LHBT played any active shoulder stabilizing effect. Jobe and Perry evaluated the activation of the biceps during the throwing motion in athletes. The authors reported the peak muscle stimulation occurred in relation to elbow flexion and forearm deceleration, with very little proximal biceps activity during the earlier phases of throwing.
Thus, in most healthy patient populations, the LHBT plays a negligible role in the dynamic stability of the shoulder. The main function of the biceps muscle is forearm supination and elbow flexion. The biceps also contribute 10% of the total power in shoulder abduction when the arm is in external rotation.
Bicipital Groove Soft Tissue Pulley
The bicipital groove is an anatomic landmark that sits between the greater and lesser tuberosities, and its osseous and soft tissue components contribute to the inherent stability of the LHBT. The depth, width, and medial wall angle have been studied in relation to overall bicipital groove stability, with significant variability recognized in its components. Many authors attribute these parameters as predisposing factors to pain and instability in both primary and secondary LHBT pathologies.
The LHBT takes a 30-degree turn as it heads toward the supraglenoid tubercle, relying on the integrity of the enveloping soft tissue sling/pulley system. The most important elements in maintaining stability at this critical turn angle are the most medial structures at the proximal-most aspect of the groove’s exit point. The soft tissue components of the biceps pulley system include the following:
The coracohumeral ligament (CHL)
The superior glenohumeral ligament (SGHL)
The subscapularis has superficial and deep fibers that envelope the groove, creating the “roof” and “floor,” respectively. These fibers also coalesce with those from the supraspinatus and SGHL/CHL complex. These structures attach intimately at the lesser tuberosity to create the proximal and medial aspect of the pulley system, with soft tissue extensions serving to further envelope the LHBT in the bicipital groove.
The CHL is a dense fibrous structure connecting the base of the coracoid process to the greater and lesser tuberosities. At its origin, the ligament is thin and broad, measuring about 2 cm in diameter at the base of the coracoid. Laterally, the CHL separates into 2 distinct bands that envelop the LHBT at the bicipital groove’s proximal extent. Once the LHBT exits the groove, it takes a 30- to 40-degree turn as it heads toward the supraglenoid tubercle and glenoid labrum. Thus, the proximal soft tissue elements of the groove are especially critical for the overall stability of the entire complex. In addition to the CHL, the SGHL reinforces the complex at this proximal exit point. The SGHL travels from the superior labrum to the lesser tuberosity, becoming confluent with the soft tissue pulley as it takes on a U-shaped configuration. Warner and colleagues previously demonstrated that the cross-sectional area of the CHL is, on average, 5 times larger than that of the SGHL.
Historically, the transverse humeral ligament (THL) was thought to play a primary role in bicipital groove stability. However, more recently, its role in providing stability has been refuted, with many authors questioning its existence as a distinct anatomic structure. The latter remains fairly controversial, with most studies now reporting the THL is, at most, a continuation of fibers from the subscapularis, supraspinatus, and CHL. A histologic study in 2013 identified a distinct fibrous fascial covering in the “roof” of the groove. Neurohistology staining showed the presence of free nerve endings but no mechanoreceptors. Despite the controversial evidence concerning its definitive existence as an anatomic structure, its location at the distal extent of the bicipital groove inherently refutes the previous dogma of its potential role in LHBT stability. Furthermore, the presence of free nerve endings in recent histological studies suggests its possible role as a potential pain generator in the anterior shoulder.
The scapula provides attachment for several groups of muscles. The intrinsic muscles of the scapula include the rotator cuff muscles and teres major. These muscles attach to the scapular surface and assist with the abduction and external and internal rotation of the glenohumeral joint.[rx]
The extrinsic muscles include the triceps, biceps, and deltoid. The third group of muscles includes the periscapular stabilizers. These muscles play a pivotal role in a wide range of scapular-based pathologies, including shoulder instability, scapular dyskinesia, and scapulothoracic pathology. These muscles include the rhomboids, trapezius, levator scapulae, and serratus anterior.
The rhomboid minor originates from the nuchal ligament and spinous processes of C7-T1. The rhomboid major originates from the spinous processes of T2-T5. The rhomboid muscles insert on the medial border of the scapula and work in combination with the levator scapulae muscles to elevate the medial border of the scapula. The only muscle which acts to depress the shoulder is the lower trapezius, which is assisted by gravity in the upright position.
The trapezius is a large triangular-shaped muscle that overlies the shoulder posteriorly. The trapezius originates from the superior aspect of the nuchal line in the occipital, cervical, and upper thoracic region and inserts at the lateral aspect of the clavicle, the acromion, and spine of the scapula. The function of the trapezius muscle is both elevation and depression of the shoulder, depending on whether the upper or lower muscle fibers are activated. When the entire trapezius muscle contracts, the fibers are geometrically opposed, and the forces are balanced, resulting in no movement of the shoulder.
The deltoid muscle overlies the shoulder superficially and functions to abduct the humerus. The deltoid muscle has three origins; the body of the clavicle, the spine of the scapula, and the acromion. The deltoid muscle has its insertion on the deltoid tuberosity of the humerus. The function of the deltoid muscle is variable depending on which muscle fibers are activated. The anterior deltoid flexes and medially rotations the humerus, the middle deltoid abducts the humerus, and the posterior deltoid performs the actions of extension and external rotation of the humerus.
Originates on the superolateral surfaces of the upper 8 ribs at the side of the thoracic cavity. The serratus anterior inserts on the vertebral border of the scapula and acts to draw the scapula forward and upward. The serratus abducts and rotates the scapula while also dynamically stabilizing its vertebral border.
The levator muscle originates from the posterior tubercles of transverse processes C1 through C4 in the cervical spine. The muscle inserts on the superior and medial border of the scapula, and it acts to elevate the scapula and thereby to tilt the glenoid vault inferiorly.
Shoulder symptoms may be due to intrinsic causes or referred causes due to spine, thorax, or abdomen pathology. Hence it is important to rule out referred causes for shoulder pain.
Should include age, handedness, occupational and recreational activities, and shoulder symptoms. In patients with pain; ask for the exact size, duration, onset, progress, character, radiation, associated symptoms, aggravating factors, and relieving factors. In the case of left-sided shoulder pain ask for cardiac symptoms. The patient should be asked to point out the site of pain with a single finger. If the site is over the lateral arm especially during overhead activity, the cause is likely to be rotator cuff pathology or impingement. Superior pain especially on adduction is suggestive of acromioclavicular pathology. Anterior shoulder pain may be due to long head of biceps pathology. Deep shoulder pain is likely to be due to glenohumeral pathology or labral lesions.
In patients with instability; ask for the duration, onset, frequency, precipitating posture or activity, the position of the shoulder after the dislocation, and how it gets corrected after an episode. Also, ask for a history of epilepsy as posterior instability is more likely in such patients. Also, look for history suggestive of voluntary dislocation.
Glenohumeral instability has been classified according to the cause and direction. The cause can be classified into traumatic and atraumatic. Atraumatic instability develops either due to laxity or overuse. The direction of instability can be classified into anterior, posterior, inferior, and multidirectional. If a history of trauma is not present then a careful history of occupational and recreational activities must be made to identify overuse. The position of the arm at the moment of instability is very helpful in the identification of the direction of instability. In anterior instability, the shoulder will be abducted, externally rotated, and extended. In posterior instability, the shoulder is adducted, internally rotated, and flexed. In inferior instability, the arm is abducted and the hand is supported over the head.
Anterior instability causes pain during the late cocking phase of throwing due to anteroinferior capsule laxity. Posterior instability causes pain during the follow-through phase. Patients with anterior instability may present with dead arm syndrome; paralyzing pain in the maximally externally rotated, abducted, and extended position.
Different age groups have different causes for their presentation. Patients <25 years present due to traumatic dislocations, recurrent instability, or acromioclavicular pathology. Adults below 40 years present due to impingement, frozen shoulder, or ACJ arthritis; and those over 40 years present due to rotator cuff impingement or tear and osteoarthritis of the glenohumeral or acromioclavicular joint. The steps of physical examination of the shoulder are determined by the patient’s presenting complaints and history. The entire region from the cervical spine to the hand should be examined.
The patient should be dressed in such a manner that the shoulder can be assessed fully. Observe the posture and the bony and soft tissue contour of both shoulders and look for any asymmetry. Observe whether the pelvis is level and the spine is straight as their malalignment may cause secondary shoulder abnormality.
Drooping of the shoulder may be caused by trapezius palsy. Winging of the scapula is abnormal prominence of the vertebral border of the scapula. Winging can be produced by injury, dysfunction of muscles, and nerve palsy. It may be dynamic or static. Dynamic winging may be due to trapezius palsy or serratus anterior palsy. True winging is due to serratus anterior palsy. Serratus anterior supplied by the long thoracic nerve, and its action is protraction of the scapula. Its function is tested by asking the patient to stand at arm’s length from the wall and push against it. Pseudowinging is produced by trapezius palsy, acromioclavicular dislocation, and scapular dysrhythmia. In trapezius palsy, winging is more during abduction of the shoulder, the inferior angle of the shoulder is rotated laterally and it is more obvious when the patient stoops forward so that the body so parallel to the floor and then tries to abduct the shoulder. In serratus anterior palsy, winging is more pronounced during forwarding flexion of the shoulder and the inferior angle of the scapula is rotated medially. Winging may also occur due to scapular muscle dysrhythmia due to shoulder instability or rotator cuff tear. It may also occur acromioclavicular joint dislocation with ruptured coracoclavicular ligaments or fracture of the outer third of the clavicle.
A step deformity may be seen at the ACJ in dislocations of the ACJ. Contour of clavicle may be altered in case of clavicle malunion or nonunion. Popeye sign of abnormal prominence of biceps is seen in patients with long head of biceps rupture. The abnormal contour of the anterior auxiliary fold and pectoralis major has been seen in patients with pectoralis major tendon rupture and Poland syndrome. Wasting of supraspinatus and infraspinatus may be seen.
Feel for the local rise of temperature. Stand on the back of the patient and palpate the structures of the shoulder using Kocher’s method of palpation starting at the sternoclavicular joint and moving laterally over the clavicle, ACJ, coracoid, spine of the scapula, and down the humerus. Look for tenderness, irregularity, thickening, defect, abnormal mobility, etc. The Biceps tendon should be palpated in its groove anteriorly.
The tenderness over the glenohumeral joint is elicited anteriorly over a point 1cm inferior and lateral to the coracoid process and posteriorly over the point 2cm medial and inferior to the angle of the acromion. Diffuse tenderness over the trapezius and interscapular area may be seen in patients with shoulder instability and scapular dysrhythmia due to abnormal shoulder biomechanics.
Assess range of motion using the recommendations of the American Shoulder and Elbow Surgeons Research Committee 1. Abduction is tested in the scapular plane (30 degrees- anteriorly)and not in the coronal axis of the body. Ideally, the patient should be stripped to the waist and the examiner should stand behind the patient and both shoulders are abducted simultaneously. In the resting position, the vertebral border of both scapulae should be equidistant from the vertebral column. Both scapulae should move symmetrically when the arm is abducted, asymmetrical movement is noted as scapular dyskinesis. Normally the ratio of glenohumeral to scapulothoracic movement on abduction is 2:1.
Shrug sign is seen in patients with supraspinatus dysfunction, the patient shrugs at the beginning of abduction to substitute glenohumeral abduction by supraspinatus with scapulothoracic motion. If there is abnormal prominence of the vertebral border then there is dynamic scapular winging. The maximum achievable angle between the humerus and thorax is recorded as shoulder elevation. Internal and external rotation are measured in 90 flexions of the elbow and with arm by the side of the body and in 90 abductions of the shoulder. Rotations are better tested in the supine position after applying pressure over the anterior shoulder to fix the scapula.
|Motion||Ranges of Motion (Degrees)|
|Dominant Side||Non-Dominant Side|
|Passive Abduction||165.7 ± 5.8||168.2 ± 18.9|
|Active Abduction||82.7 ± 12.0||92.2 ± 6.2|
|Active||48.8 ± 6.0||52.4 ± 4.7|
|Passive||52.5 ± 6.0||56.6 ± 7.0|
|Active||95.5 ± 12.6||98.3 ± 9.4|
|Passive||102.2 ± 6.3||110.4 ± 5.8|
|Active||65.9 ± 9.4||69.6 ± 6.3|
|Passive||71.5 ± 9.4||75.2 ± 9.4|
|Active||116.7 ± 8.6||122.9 ± 8.4|
|Passive||121.3 ± 5.5||125.1 ± 6.5|
|Active||27.7 ± 11.0||30.7 ± 9.4|
- The strength of rotator cuff muscles is measured. Supraspinatus is assessed in the empty can position; 90 abductions of the shoulder with elbow straight and shoulder in the fully internally rotated position with the thumb pointing downwards and the patient is asked to abduct further against resistance. The strength of the infraspinatus is measured with the arm in 90º abduction, the elbow at 90º flexion, and the patient is asked to externally rotate against resistance.
- It may be classified into
- Tests for impingement
- Tests for laxity
- Tests for instability
- Tests for rotator cuff disease
- Tests for SLAP
- Tests for biceps tendon
- Tests for ACJ
- Tests for cervical disc disease
1. Test For Impingement
A. Neer impingement sign- (Forced forward elevation test)
- Examiner position – Stand next to the patient with one hand over the top of the shoulder and the other hand holding the patient’s arm.
- Patient position – Standing.
- Joint position – Arm by the side of the body
- Procedure – Stabilise the scapula with one hand, passively flex the shoulder fully and then push further.
- Interpretation – Pain is due to rotator cuff impingement. The test is 79% sensitive and 53% specific.
B. Hawkins-Kennedy test (Forced internal rotation test)
- Examiner Position – Stand in front of the patient.
- Patient position – Standing.
- Procedure – Flex the arm and elbow to 90 degrees and then internally rotate the shoulder using the flexed forearm as a lever.
- Interpretation – Test is positive if the pain is reported. The test is 79% sensitive and 59% specific.
C. Neer impingement test
- Inject 10 ml of 1% lidocaine into the subacromial space using a sterile technique. Then ask the patient to actively abduct. Relief of pain for the duration of the anesthetic effect is confirmatory of impingement.
2. Tests for laxity
A. Anterior drawer test
As described by Gerber and Ganz.
- Examiner position – Stand on the affected side
- Patient position – Supine. The patient’s hand is stabilized in the axilla of the examiner.
- Joint position – Shoulder in 80-120 abduction, 0-20 forward flexion, 0-30 external rotation.
- Procedure – Stabilise the shoulder with one hand, grasp the proximal humerus with the other hand. Apply anterior translation force.
- Interpretation – Click and abnormal laxity indicate anterior instability. Grade the degree of translation.
0- None or minimal when compared to the contralateral shoulder.
1+ – Up to glenoid rim.
2+- Beyond the glenoid rim and spontaneously relocates.
3+- Dislocates and doesn’t reduce spontaneously.
B. Posterior drawer test
As described by Gerber and Ganz.
- Patient position – Supine.
- Joint position – Shoulder in 80-120 abduction, 20 forward flexions, 60-80 internal rotation.
- Procedure – Stabilise the shoulder, grasp the proximal humerus. Apply posterior translation force.
- Interpretation – Click and abnormal laxity indicate posterior instability. Grade the degree of translation.
C. Load and shift test
Described by Silliman and Hawkins
- Patient position – Sitting
- Joint position – Arm by the side and hand resting in the lap of the patient
- Procedure – Stabilise the shoulder with one hand, grasp the proximal humerus with the other hand. Load the humeral head against the glenoid and then slide the head anteriorly and posteriorly
Interpretation- Look for abnormal anterior translation, which suggests anterior instability. Grade the translation.
D. Sulcus sign
As described by Neer and Foster.
- Patient position – Sitting
- Joint position – Arm by the side and hand resting in the lap of the patient
- Procedure – Hold the elbow of the patient with one hand and then stabilize the shoulder with the other hand and then apply longitudinal traction.
- Interpretation – Appearance of a gap more than the other side below the acromion suggests inferior capsular laxity. It is indicative of multidirectional instability. Grading – 1+ -0-1cm, 2+- 1-2cm, 3+- >2cm.
Recent modification- Now externally rotate the shoulder, if the gap persists then rotator interval is likely to be defective.
E. Gagey hyperabduction test
- Principle – Tests inferior glenohumeral ligament complex.
- Patient position – Sitting
- Examiner position – Behind the seated patient
- Joint position – Arm by the side of the body.
- Procedure – Place the forearm of the examiner on the top of the shoulder to stabilize the scapula. Abduct the shoulder of the patient maximally and note the range of abduction till the scapula starts moving.
- Interpretation – Normal range of passive abduction is 105 degrees. If it is more then there is IGL laxity.
3. Tests for Instability
- Glenohumeral laxity is the ability to translate the humeral head to the glenoid rim. Glenohumeral instability is the pathological translation of the humeral head on the glenoid that compromises patient comfort and shoulder function. Multidirectional instability is instability in two or more directions. The hallmark of inferior instability is the positive sulcus sign.
A. Apprehension test
- Patient position – Supine,
- Joint position – Shoulder in 90 abductions, elbow in 90 flexions.
- Procedure – Maximally externally rotate shoulder while applying anteriorly directed pressure.
- Interpretation – Look for apprehension.
B. Jobe apprehension relocation test
- If apprehension is present with the previous test, repeat the test with posteriorly directed pressure. The absence of apprehension is confirmatory of anterior instability. This test is the gold standard for the diagnosis of anterior instability. With apprehension as the criteria for diagnosis; it shows 85% accuracy, 68% specificity, 100% sensitivity, 100% positive predictive value, and 78% negative predictive value.
C. Jerk test
- Patient position – Supine
- Joint position – Shoulder abducted to 90, elbow flexed to 90.
- Procedure – Grasp elbow. Axially load the shoulder. Adduct the shoulder horizontally across the body
- Interpretation – Clunk and pain in presence of posterior instability. Return to the abducted position may produce another jerk due to relocation of joint.
- Reliability – 90% sensitivity, 85% specificity, 72% positive predictive value and 94% negative predictive value. 10
4. Tests for rotator cuff disease
- Jobe empty can test – Ask the patient to actively abduct the shoulder in the scapular plane with the elbow in extension with the shoulder in full internal rotation and the thumb pointing down.
- Reinard identified by electrical studies that more fibers of supraspinatus are active if the test is done with the thumb pointing up (Full can test) and maybe more useful. Jobe test has 75% accuracy in the detection of supraspinatus tear.
- The integrity of the upper and lower fibers of subscapularis are tested separately.
i. Lift off test
- Lower fibers are tested by the lift-off test; ask the patient to place the dorsum of the hand against the small of the back and then lift the hand posteriorly away from the body against resistance. Inability to lift the hand indicates a subscapularis tear.
ii. Belly press test
- Upper fibers are tested by the belly press test; the patient is asked to place his palm against the umbilicus and push against the abdomen. Inability to do this indicates a subscapularis tear.
- Drop sign – Done to detect infraspinatus tear. The patient is asked to lie in the lateral decubitus position with the affected side up. Flex the shoulder and elbow to 90 degrees. Hold the wrist and externally rotate to the maximum. Now release the wrist and ask the patient to hold the limb in external rotation. In presence of an infraspinatus tear, he will not be able to do this.
5. Tests for Superior labrum Anterior-Posterior (SLAP) lesion
- Numerous tests are available, but they are of 2 types; active tests which try to recreate the torsional traction force that caused the injury, or passive tests that exert compressive stress on the labrum. O’Brien test is an active test and the crank test is a passive test.
O’Brien’s test (Active compression test)
- Patient position – Standing.
- Examiner position – By the side with one hand on the shoulder and another hand on the distal forearm.
- Joint position – Forward flexion of shoulder to 90, adduction of 10-15, fully internally rotated. Elbow straight. Thumb pointing down.
- Procedure – Elevate against resistance. Repeat with the shoulder in external rotation.
- Interpretation – Pain in internal rotated position and absence of pain in external rotation suggestive of a SLAP lesion. Ask about the location of pain, if it is over the acromioclavicular joint then the test is negative.
Crank test (Compression rotation test)
- Patient position – Supine
- Joint position – Shoulder in 160 abductions, 30 forward flexions. Elbow flexed
- Procedure – Stabilise scapula with one hand, grasp the elbow with the other hand. Axially load and rotate externally and internally.
- Interpretation – Pain, and reproduction of patient’s symptoms indicate labral pathology
Reliability – 91% sensitive, 93% specific, 94% positive predictive value, 90% negative predictive value.
Resisted supination external rotation test
- Patient position – Supine.
- Joint position – Shoulder 90 abducted, elbow 70 flexed, forearm semipronated.
- Procedure – Externally rotate the shoulder and ask the patient to supinate the forearm against resistance.
- Interpretation – Pain indicative of SLAP lesion.
Anterior slide test
- Patient position – Standing.
- Joint position – Hand on hips with the thumb pointing posteriorly.
- Procedure – Apply forward and axial pressure over the elbow and ask the patient to resist.
- Interpretation – Pain indicates superior labral pathology.
- Reliability – 78% sensitive and 90% sensitive for type II SLAP lesion.
6. Test for Biceps long head
Pathology may be tendinitis, tear, instability of the long head of the biceps, or synovitis of its sheath.
- Patient position – Standing.
- Examiner position – By the side of the patient with one hand over the shoulder and the other hands over the anterior aspect of the distal forearm.
- Joint position – Shoulder forward flexed by 60. Elbow extended. Forearm supinated.
- Procedure – Flex the shoulder against resistance with elbow kept straight.
- Interpretation – Anterior shoulder pain indicate the long head of biceps pathology.
- Sensitivity– 90%
- Specificity – 14%
- Reference – Bennet WF. Arthroscopy. 1998 Nov‐Dec;14(8):789‐96
7. Tests for acromioclavicular joint
- Horizontal adduction test– The shoulder is passively elevated to horizontal and the arm is adducted across the body beyond the full range. Ask the patient if there is pain and the site of pain. If pain is located over the ACJ then the test is positive for ACJ pathology. The test is 77% sensitive and 79% specific with an accuracy of 79%.
- Proximal Biceps – There are many different focused physical examination maneuvers reported in the literature. Specific testing targets either LHBT pathology localized to the bicipital groove or more proximally near its origin at the supraglenoid tubercle.
- Bicipital groove palpation: Direct palpation over the patient’s bicipital groove elicits a painful response in the setting of pathology.
- Speed’s test: A positive test consists of pain elicited in the bicipital groove when the patient attempts to forward elevate the shoulder against examiner resistance; the elbow is slightly flexed, and the forearm is supinated.
- Uppercut test: The involved shoulder is positioned at neutral, the elbow is flexed to 90 degrees, the forearm is supinated, and the patient makes a fist. The examiner instructs the patient to perform a boxing “uppercut” punch while placing their hand over the patient’s fist to resist the upward motion. A positive test is a pain or a painful pop over the anterior shoulder near the bicipital groove region.
- Ferguson’s test: The arm is stabilized against the patient’s trunk, and the elbow is flexed to 90 degrees with the forearm pronated. The examiner manually resists supination while the patient also externally rotated the arm against resistance. A positive test is noted if the patient reports pain over the bicipital groove and/or subluxation of the LHB tendon.[rx][rx]
The examiner brings the patient’s shoulder to 90 degrees of abduction and 90 degrees of external rotation. The examiner passively rotates the shoulder at this position in an attempt to elicit the patient-reported audible “popping” or “clicking” sensations. Sometimes passively maneuvering the shoulder from the extension to cross-body plan helps elicit instability symptoms.
At the 90/90 shoulder abduction/external rotation position, the patient is asked to “throw forward” while the examiner resists this forward motion. A positive test for groove pain must be localized to the anterior aspect of the shoulder to enhance diagnostic sensitivity and specificity.
Proximal biceps pathology is often associated with concomitant shoulder pathologies. Thus, it is important to differentiate the primary sources of patient-reported pain and symptoms clinically. Other important, provocative testing categories include the AC joint, the glenohumeral labrum, and rotator cuff muscles. The latter includes special consideration for subscapularis given the common pathological associations.
- Observation and direct palpation: Patients presenting with chronic AC joint pain and/or arthritic pathology often will have clinically obvious AC joint hypertrophy that can be appreciated solely with observation and/or direct palpation over the joint.
- Cross-body adduction: The examiner may find it helpful to directly localize the AC joint with direct palpation before initiating any shoulder movement. Subsequently, the examiner brings the shoulder into about 90 degrees of flexion in front of the plane of the scapula, and a positive test includes patient-reported symptom reproduction as the arm is brought into cross-body adduction positions. The physician should be able to discern the exact location of pain reproduction with the cross-body adduction maneuvers.
Superior Labrum Anterior-Posterior (SLAP) Lesions
- O’Brien’s test/Active compression test: The patient is standing, and the arm of interest is positioned at 90 degrees of forwarding flexion, 10 degrees of adduction, and internally rotated so the thumb points toward the floor. The examiner places his or her hand over the patient’s elbow while instructing the patient to resist the examiner’s downward force applied to the arm. This maneuver is repeated with the patient’s arm now rotated, so the palm faces the ceiling. A positive test is denoted by pain located at the joint line during the initial maneuver (thumb down/internal rotation) in conjunction with reported improvement or elimination of the pain during the subsequent maneuver (palm up/external rotation).
- Anterior slide test: The patient stands with his or her hand of the involved arm placed on the ipsilateral hip with the thumb pointing posteriorly. The examiner places one hand on the joint line of the shoulder and the other hand on the elbow. The examiner then applies an axial load in an anterosuperior direction from the elbow to the shoulder. A positive test includes pain or a painful click on the anterior or posterior joint line.
- Modified O’Driscoll test/Modified dynamic labral shear test: The patient stands with his or her involved arm flexed 90 degrees at the elbow, and the shoulder is abducted in the scapular plane to above 120 degrees. The examiner then applies terminal external rotation until resistance is appreciated. Next, the examiner applies a shear force through the shoulder joint by maintaining external rotation and horizontal abduction and lowering the arm from 120 to 60 degrees abduction. A positive test includes a reproduction of the pain and/or a painful click or catch in the joint line along the posterior joint line between 120 and 90 degrees of abduction.
Jobe’s test: Positive test is pain/weakness with resisted downward pressure while the patient’s shoulder is at 90 degrees of forwarding flexion and abduction in the scapular plane with the thumb pointing toward the floor.
Drop arm test: The patient’s shoulder is brought into a position of 90 degrees of shoulder abduction in the scapular plane. The examiner initially supports the limb and then instructs the patient to adduct the arm to the side of the body slowly. A positive test includes the patient’s inability to maintain the abducted position of the shoulder and/or an inability to adduct the arm to the side of the trunk in a controlled manner.
Strength testing – is performed while the shoulder is positioned against the side of the trunk, the elbow is flexed to 90 degrees, and the patient is asked to externally rotate the arm while the examiner resists this movement.
External rotation lag sign: The examiner positions the patient’s shoulder in the same position, and while holding the wrist, the arm is brought into maximum external rotation (ER). The test is positive if the patient’s shoulder drifts into internal rotation (IR) once the examiner removes the supportive ER force at the wrist.
Strength testing – is performed with the shoulder positioned at 90 degrees of abduction and the elbow is also flexed to 90 degrees. Teres minor (TM) is best isolated for strength testing in this position while the examiner resists ER.
Hornblower’s sign: The examiner positions the shoulder in the same position and maximally ERs the shoulder under support. A positive test occurs when the patient cannot hold this position, and the arm drifts into IR once the examiner removes the supportive ER force.
The high rate of associated pathologies with the LHBT and the subscapularis (SubSc) makes the subscapularis evaluation component significantly important in this clinical setting. The diagnosis of injuries to the subscapularis remains a challenge in any setting of shoulder pathology. Multiple provocative maneuvers and special exams exist in the literature, with the bear-hug test being the most sensitive exam modality, although it only boasts a 60% sensitivity rate:
Bear-hug test: The patient places his or her hand on the contralateral (normal) shoulder in a “self-hug” position. The palm is on the anterior aspect of the contralateral shoulder, with the elbow flexed to 90 degrees. The examiner applies a perpendicular external rotational force to try and lift the patient’s hand off of the shoulder. A positive test results when the patient cannot hold the hand against the shoulder as the examiner applies an external rotation force.
IR lag sign: The examiner passively brings the patient’s shoulder behind the trunk (about 20 degrees of extension) with the elbow flexed to 90 degrees. The examiner passively IRs the shoulder by lifting the dorsum of the handoff of the patient’s back while supporting the elbow and wrist. A positive test occurs when the patient is unable to maintain this position once the examiner releases support at the wrist (i.e., the arm is not maintained in IR, and the dorsum of the hand drifts toward the back)
Passive ER ROM: A partial or complete tear of the SubSc can manifest as an increase in passive ER compared to the contralateral shoulder.
Lift-off test: More sensitive/specific for lower SubSc pathology. In the same position as the IR lag sign position, the examiner places the patient’s dorsum of the hand against the lower back and then resists the patient’s ability to lift the dorsum of the hand away from the lower back.
Belly press: More sensitive/specific for upper subscapularis pathology. The examiner has the patient’s arm at 90 degrees of elbow flexion, and IR testing is performed by the patient pressing the palm of his/her hand against the belly, bringing the elbow in front of the plane of the trunk. The examiner initially supports the elbow, and a positive test occurs if the elbow is not maintained in this position upon the examiner removing the supportive force.
Neer impingement sign: Positive if the patient reports pain with passive shoulder forward flexion beyond 90 degrees.
Neer impingement test: Positive test occurs after the examiner gives a subacromial injection and the patient reports improved symptoms upon repeating the forced passive forward flexion beyond 90 degrees.
Hawkins test: Positive test occurs with the examiner passively positioning the shoulder and elbow at 90 degrees of flexion in front of the body; the patient will report pain when the examiner passively internally rotates the shoulder.
Internal impingement test: The patient is placed in a supine position, and the shoulder is brought into terminal abduction and external rotation; a positive test consists of a reproduction of the patient’s pain.
Shoulder Instability Considerations
- Global tissue laxity should be assessed by examining glenohumeral translation and hypermobility at the shoulder joints and other joints in the body if applicable. Hyperlaxity at other joints (e.g., elbow and knee hyperextension) may aid in the clinical diagnosis of underlying MDI-related diagnoses or connective tissue disorders.
Anterior Apprehension Test
- The anterior apprehension test is performed by lying the patient supine on the examination table. The examiner positions the shoulder to 90 degrees of abduction and 90 degrees of external rotation. While an anteriorly directed force is applied to the proximal humerus. The test is positive if symptoms of anterior instability are reproduced.
- Apprehension at lower degrees of abduction may suggest glenoid bone loss. Patients may be guarded during the examination, but in most circumstances, the provider is able to elicit if the apprehensive position is reproducible the patient’s feelings of anterior shoulder instability.
- The Jobe relocation test is utilized with the previous apprehensive testing maneuver. Once the patient reports a subjective feeling of reproducing the shoulder instability symptoms, the examiner applies a posteriorly directed force while keeping the shoulder in the same apprehensive position. Resolution or improvement of symptoms indicates a positive test result.
- The examiner uses one hand to apply an axial load through the elbow to center the humeral head within the glenoid. An anterior and posterior directed force is then applied at 0-, 45-, and 90-degrees of shoulder abduction. Increased translation at increasing degrees of shoulder abduction implies a compromise of the IGHL.
The magnitude of humeral head translation is graded:
Grade 1 – Increased translation compared with the normal shoulder
Grade 2 – Indicates humeral head translation to, but not over, the glenoid rim
Grade 3 – indicates translation of the humeral head over the glenoid rim
Hawkins test: The Hawkins test is performed when the patient’s arm is passively internally rotated with the shoulder in 90 degrees of shoulder forward flexion and elbow flexion. Pain over the acromion indicates subacromial impingement but may be negative in internal impingement.[rx]
Neer sign: With the scapula fixed into a depressed position, this test is performed by the examiner maximally forward flexing the patient’s arm (passive range of motion testing). Localized pain on the anterior shoulder suggests subacromial impingement, whereas posterior shoulder pain suggests internal impingement.
Jobe test: Also known as the empty can test, this test is performed by placing the patient’s arms at 90 degrees of abduction within the scapular plane, maximally internally rotating the arms, and resisting further abduction by the patient. A positive test occurs with localized pain to the affected arm.[rx]
Painful arc of motion: The painful arc is a physical exam finding in which pain is appreciated with the abduction of the arm between 70 and 120 degrees and forced overhead movement.[rx]
Special tests to evaluate for shoulder instability include the sulcus sign, anterior apprehension, and relocation. Classically, these tests are negative in shoulder impingement syndrome.
Sulcus sign: With the patient sitting upright with arm resting at their side, the clinician stabilizes the shoulder proximally and applies an inferiorly-directed force at the elbow. A positive test is noted based on the inferior displacement of the humeral head.[rx]
Anterior apprehension: With the patient lying supine, this test is performed by placing the patient’s shoulder in 90 degrees of abduction and 90 degrees of external rotation. While supporting the proximal shoulder, the clinician then applies greater gentle external rotation movement. The exam is considered positive when the patient reports a subjective feeling of impending subluxation or near dislocation.[rx]
Relocation test: This test for shoulder instability requires a positive anterior apprehension test. After the patient reports the prodrome of dislocation or subluxation described above, the clinician applies a posteriorly directed force on the anterior humeral head, which relieves the patient’s symptoms.[rx]
|Active Compression||In the standing patient, the arm is forward flexed to 90° with the elbow in full extension and then adducted 10 – 15° medial to the sagittal plane of the body and internally rotated it so that the thumb pointed downward. The examiner, standing behind the patient, applies a uniform downward force to the arm. With the arm in the same position, the palm is then fully supinated and the maneuver is repeated. The test was considered positive if the pain is elicited during the first maneuver, and is reduced or eliminated with the second. Pain localized to the acromioclavicular joint or “on top” is due to acromioclavicular joint abnormality, whereas pain or painful clicking described as “inside” the shoulder is considered indicative of labral abnormality1.||67%||37%|
|Speeds test||The patient is seated. With the patient’s elbow extended and the forearm in full supination, the clinician resists active forward flexion from 0°to to 60°. A positive test is where the pain is increased in the shoulder, and the patient localizes the pain to the bicipital groove [rx].||20%||78%|
|Anterior Slide test||Patient sitting with hands-on-hips and thumbs pointing posteriorly. The examiner places one hand on top of the affected shoulder and the other hand on point of the elbow. Examiner then applies a forward and superior force on the elbow. The patient asked to resist this force. Pain over the front of the shoulder or a click is positive2.||17%||86%|
|Crank test (Compression rotation test/ O’Brian’s test)||The patient is instructed to stand with his or her involved shoulder at 90° of flexion, 10° of horizontal adduction, and maximum internal rotation with the elbow in full extension. The examiner applies a downward force at the wrist of the involved arm. The patient is instructed to resist the force. The patient resists the downward force and reports any pain as “on top of the shoulder” (acromioclavicular joint) or “inside the shoulder” (SLAP lesion). The patient’s shoulder is then moved to a position of maximum external rotation, and the downward force is repeated. A positive test is indicated by pain or painful clicking in shoulder internal rotation and less or no pain in external rotation [rx].||34%||75%|
|Ferguson’s test||The patient’s elbow is flexed and their forearm pronated. The examiner holds their arm at the wrist. The patient actively supinates against resistance. A positive test indicates a labral tear or a biceps tendinopathy3.||12.4%||95.3%|
|Biceps load test||The patient is supine and the examiner sits at the side of the patient’s involved extremity. The examiner places the patient’s shoulder in 120° of abduction, the elbow in 90° of flexion, and the forearm in supination. The examiner moves the patient’s shoulder to end-range external rotation (apprehension position) and the examiner asks the patient to flex his or her elbow while the examiner resists this movement. A positive test is indicated as a reproduction of concordant pain during resisted elbow flexion [rx].||38.6%||66.7%|
|Modified dynamic labral shear test||With the patient standing, the involved arm is flexed to 90° at the elbow, abducted in the scapular plane to above 120°, and maximally externally rotated to tightness. It is then guided into maximal horizontal abduction. A shear load is then applied to the joint maintaining the external rotation and horizontal abduction while lowering the arm to 60°. A positive test is indicated by the reproduction of pain and/or click in the joint4.||72%||9|
Clinicians should obtain a true anteroposterior image of the glenohumeral joint, also known as the “Grashey” view. The true anteroposterior image is taken with the patient rotated between 30 and 45 degrees offset the cassette in the coronal plane. The beam can otherwise be rotated while the patient is neutral in the coronal plane. The distance between the acromion and the humeral head to compute the acromiohumeral interval. A normal interval is between 7 and 14 mm. This interval decreases in cases of advanced degenerative arthritis and RCA. Other standard views include the lateral, or “scapular Y,” view and an axillary view.
Ultrasound (US) is highly operator-dependent but is touted as a fast, cost-effective tool for diagnosing LHBT pathology. Characteristic findings include tendon thickening, tenosynovitis, synovial sheath hypertrophy, and fluid surrounding the tendon in the bicipital groove. The ability to perform a dynamic examination increases the sensitivity and specificity for detecting subtle instability. The diagnostic accuracy of US in detecting LHB pathology ranges from 50% to 96% (sensitivity) and 98% to 100% (specificity) when compared to Magnetic resonance arthrography (MRA).
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is useful in evaluating the LHBT, bicipital groove, and any fluid or edema that may be indicative of pathology. MRI helps define other associated shoulder pathologies, and in the setting of LHBT instability, particular attention should be given to evaluating for concomitant subscapularis injury. Most of the previous studies that have investigated the accuracy of preoperative MRI scans have used open surgical approaches to correlate MRI with surgical findings.
Over 90% of subscapularis tendon injuries begin on the articular side. Therefore, it is important to correlate suspected MRI pathology with direct visualization during shoulder arthroscopy. A 2010 study demonstrated that preoperative MRI interpretations (by radiologists) did not correlate with arthroscopic findings in the setting of suspected injury.
MRI is useful in identifying the LHBTs position with respect to the bicipital groove. The absence of the tendon within the groove would suggest subluxation and/or dislocation. Given the relatively poor reliability of MRI capabilities in diagnosing subscapularis injuries, the presence of LHBT subluxation/dislocation has been advocated for diagnostic capability improved accuracy by association. A 2015 study by Warner and colleagues investigated 100 patients with shoulder pathologies, of which 26 were diagnosed with LHBT subluxation based on preoperative MRI. Results indicated that the presence of LHBT subluxation was a predictor for full-thickness subscapularis tears, with a sensitivity of 82%, a specificity of 80%, a positive predictive value of 35%, and a negative predictive value of 97%. LHBT subluxation was directly correlated with the severity of the subscapularis tendon tear.
Other associated shoulder pathologies and rotator cuff integrity can also undergo an evaluation with MRI. Other common sources of acute or chronic shoulder pain can be evaluated on MRI, including subdeltoid and/or subacromial bursitis, acromioclavicular (AC) joint pathology, and morphology. A systematic approach to review shoulder MRIs is essential, especially when tying the MRI findings with patient-reported symptoms and clinical examination.
Many studies have suggested MR arthrography (MRA) as the best imaging modality for detecting biceps soft tissue pulley lesions. Walch previously described the “pulley sign” on MRA, suggesting a lesion to the soft tissue pulley structures. The “pulley sign” is an extra-articular collection of contrast material anterior to the upper subscapularis muscle. A 2012 study established MRA criteria for diagnosing biceps pulley lesions. The findings on MRA included:
LHBT displacement relative to subscapularis tendon on oblique sagittal series; Up to 86% sensitive, 98% specific
LHBT tendinopathy on oblique sagittal image series; Up to 93% sensitive, 96% specific
Medial LHBT subluxation on axial image series; Up to 64% sensitive, 100% specific
Discontinuity of the SGHL; Up to 89% sensitive, 83% specific
Other pertinent MRA findings include contrast material extending to the coracoid, indicating a potential lesion of the rotator interval. Recent studies have highlighted the importance of advanced imaging as well as diagnostic arthroscopy for evaluating for the presence and extent of biceps soft tissue pulley injuries. Advancements in imaging and arthroscopic techniques have become increasingly important as the clinical examination is prone to equivocal results.
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