Orthopaedic special tests for the shoulder Kate Harman 3rd year Physiotherapy BSc undergraduate University of Essex February 2014

Basic Shoulder Anatomy

The Rotator Cuff Supraspinatus - Abducts Origin - Supraspinatus fossa of the scap Insertion Greater tubercle of the humerus Infraspinatus - Lat rotates Origin - Infraspinatus fossa of the scap Insertion - Greater tubercle of the humerus Teres Minor - Lat rotates Origin - Upper 2/3 of lat border of scap Subscapularis - Med rotates Origin - Sub scap fossa Insertion - Lesser tubercle of the humerus Supraspinatus - Abducts Origin - Supraspinatus fossa of the scap Insertion Greater tubercle of the humerus Infraspinatus - Lat rotates Origin - Infraspinatus fossa of the scap Insertion - Greater tubercle of the humerus Teres Minor - Lat rotates Origin - Upper 2/3 of lat border of scap Subscapularis - Med rotates Origin - Sub scap fossa Insertion - Lesser tubercle of the humerus

Sensitivity and Specificity in Special Tests Sensitivity is how well the test can identify a patient as having a specific pathology (true +ve) Specificity is how well the test can identify a patient as NOT having a pathology (true -ve) These are scored out of 1 (which can converted into a %) The higher the score the more reliable the test)

5 Categories of tests 1. Rotator cuff integrity 2. Impingement of the rotator cuff 3. Labral tears and biceps pathology 4. Instability of the GH joint 5. ACJ

Rotator Cuff integrity Tests Supraspinatus - External Rotation Lag Sign (ERLS) and or Empty Can Infraspinatus - ERLS, Infraspinatus muscle strength test Teres minor - Hornblowers (deterioration of the tendon) Subscapularis - Belly Press (more reliable that lift off test)

External Rotation Lag Sign Patient positioned in sitting or standing. The shoulder is positioned into full lat rot, assisted by the PT, elbows at 90 degrees flexion. Pt is asked to hold this position, the PT then releases the arms. A +ve test is an inability for the pt to maintain this position meaning the arms drop back to neutral. Complete lag = complete tear, slight lag or loss of position = partial tear. Patient positioned in sitting or standing. The shoulder is positioned into full lat rot, assisted by the PT, elbows at 90 degrees flexion. Pt is asked to hold this position, the PT then releases the arms. A +ve test is an inability for the pt to maintain this position meaning the arms drop back to neutral. Complete lag = complete tear, slight lag or loss of position = partial tear.

Empty Can The patient elevates the arms to 90 degrees and horizontally adducts 30 degrees to the scapular plane with thumbs down to the empty can position. The physiotherapist provides downward pressure to test the patient’s strength in this position. A +ve test for rotator cuff tear is weakness, pain or both. The pt elevates the arms to 90 degrees and horizontally adducts 30 degrees to the scapular plane with thumbs down to the empty can position. The PT provides downward pressure to test the pt’s strength in this position. A +ve test for rotator cuff tear is weakness, pain or both

Infraspinatus Muscle Strength Test The patient stands with the arms at the side with the elbow at 90 degrees and the humerus medially rotated to 45 degrees. The physiotherapist applies a medial rotation force that the patient resists. Pain or the inability to resist medial rotation indicates a +ve test for an infraspinatus strain. The pt stands with the arms at the side with the elbow at 90 degrees and the humerus medially rotated to 45 degrees. The PT applies a medial rotation force that the pt resists. Pain or the inability to resist medial rotation indicates a +ve test for an infraspinatus strain

Hornblower’s The physiotherapist elevates the patient’s arm to 90 degrees in the scapular plane. The physiotherapist then flexes the elbow to 90 degrees, and the patient is asked to laterally rotate the shoulder. A +ve test occurs with weakness and/or pain. The PT elevates the pt’s arm to 90 degrees in the scapular plane. The PT then flexes the elbow to 90 degrees, and the patient is asked to laterally rotate the shoulder. A +ve test occurs with weakness and/or pain.

Belly Press The physiotherapist places a hand on the abdomen so that the he or she can feel how much pressure the patient is applying to the abdomen. The patient places his or her hand of the shoulder being tested on the physiotherapist’s hand and pushes as hard as he or she can into the stomach. The patient also attempts to bring the elbow forward in the scapular plane causing greater medial shoulder rotation. It is a +ve test if the patient is unable to maintain the pressure on the physiotherapist’s hand while moving the elbow forward or if the patient extends the shoulder. The PT places a hand on the abdomen so that the he or she can feel how much pressure the pt is applying to the abdomen. The pt places his or her hand of the shoulder being tested on the PT’s hand and pushes as hard as he or she can into the stomach. The pt also attempts to bring the elbow forward in the scapular plane causing greater medial shoulder rotation. It is a +ve test if the pt is unable to maintain the pressure on the PT’s hand while moving the elbow forward or if the pt extends the shoulder.

Impingement of the Rotator Cuff Primary (outlet) Intrinsic and extrinsic Secondary (outlet) Internal (non - outlet) Primary (outlet) - intrinsic e.g degeneration of the cuff Extrinsic e.g shape of acromion negatively impacts on the ability of the greater tuberous it and cuff tendons to navigate under the coraco-acromial arch without impingement Secondary (outlet) - caused by weak or imbalanced muscles leading to instability of the scapulohumeral complex thus leading to abnormal movement patterns Internal (non-outlet) - resulting from injury to the rotator cuff or the glenoid labrum caused by impingement of Supra and Infra between the posterosuperior aspect of the glenoid rim and the humeral head. The impingement occurs posteriorly. Primary (outlet) - intrinsic e.g degeneration of the cuff Extrinsic e.g shape of acromion negatively impacts on the ability of the greater tuberous it and cuff tendons to navigate under the coraco-acromial arch without impingement Secondary (outlet) - caused by weak or imbalanced muscles leading to instability of the scapulohumeral complex thus leading to abnormal movement patterns Internal (non-outlet) - resulting from injury to the rotator cuff or the glenoid labrum caused by impingement of Supra and Infra between the posterosuperior aspect of the glenoid rim and the humeral head. The impingement occurs posteriorly.

Rotator Cuff Tests Neer’s Sign Hawkins- Kennedy Test Neer’s Impingement test: Patient in standing, shoulder flexed to 20 degrees and fully med rotated. The physiotherapist (standing in front of patient) then takes arm passively through flexion. +ve test = pain anterolateral between 80-140 degrees Neer’s Sign Hawkins- Kennedy Test Subacromial impingement of rotator cuff, subacromial bursa and long head of biceps Neer’s Impingement test: Pt in standing, shoulder flexed to 20 degrees and fully med rotated. The PT (standing in front of pt) then takes arm passively through flexion. +ve test = pain anterolateral between 80-140 degrees Hawkins - Kennedy: The pt stands while the examiner forward flexes the arm to 90 degrees and then forcibly medially rotates the shoulder. The test may be performed in different degrees of forward flexion or horizontal adduction. +ve test = pain Hawkins - Kennedy: The patient stands while the examiner forward flexes the arm to 90 degrees and then forcibly medially rotates the shoulder. The test may be performed in different degrees of forward flexion or horizontal adduction. +ve test = pain Both are testing for: Subacromial impingement of rotator cuff, subacromial bursa and long head of biceps

Labral Tears and Biceps Pathology O’Briens Test (Active Compression test) Speeds test - long head biceps or SLAP Yergasons - long head of biceps

O’Briens Test This test is conducted with the physiotherapist standing behind the patient. The patient is asked to forward flex the affected arm 90° with the elbow in full extension. The patient then adducts the arm 10° to 15°. The arm is internally rotated so that the thumb pointed downward. The physiotherapist then applies a downward force to the arm. With the arm in the same position, the palm is then fully supinated and the movement repeated. The test is considered +ve if pain is felt with the first manoeuvre and was reduced or eliminated with the second manoeuvre. Pain localised to the acromio-clavicular joint or on top of the shoulder can be diagnostic as acromio-clavicular joint abnormality. Pain or painful clicking within the glen-ohumeral joint itself is indicative of labral abnormality. This test is conducted with the PT standing behind the pt. The pt was asked to forward flex the affected arm 90° with the elbow in full extension. The pt then adductes the arm 10° to 15°. The arm is internally rotated so that the thumb pointed downward. The PT then applies a downward force to the arm. With the arm in the same position, the palm is then fully supinated and the movement repeated. The test is considered +ve if pain is felt with the first manoeuvre and was reduced or eliminated with the second manoeuvre. Pain localised to the acromioclavicular joint or on top of the shoulder can be diagnostic as acromioclavicular joint abnormality. Pain or painful clicking within the glenohumeral joint itself is indicative of labral abnormality.

Speed’s Test Biceps tendon Origin Long head supra-glenoid tubercle of the scapula Short head - Coracoid process Insertion - tuberosity of the radial and aponeurosis of the biceps brachii The patient’s arm is fully extended and into slight extension, wrist is in supination. The patient is asked to resist an eccentric movement into extension. A +ve test elicits increased tenderness in the bicipital groove. Biceps tendon Origin - Long head supraglenoid tubercle of the scap Short head - Coracoid process Insertion - tuberosity of the radial and aponeurosis of the biceps brachii The pt’s arm is fully extended and into slight extension, wrist is in supination. The pt is asked to resist an eccentric movement into extension. A +ve test elicits increased tenderness in the bicipital groove.

Yergason’s Test Resisted supination Looking at the biceps instability in the bicipital groove Patient sits while physiotherapist stands in front. The patient’s elbow is flexed to 90 degrees and the forearm is in a pronated position while maintaining the upper arm at the side. Pt is instructed to supinate arm while examiner concurrently resists forearm supination at the wrist. Localised pain at the bicipital groove indicates a +ve test Yergasons and Speed’s tests were found to have high specificity (0.83–0.86) and low sensitivity (0.23–0.36), indicating that these manoeuvres would be better at ruling out biceps disease than detecting it. Resisted supination Looking at the biceps instability in the bicipital groove Pt sits while PT stands in front. The patient’s elbow is flexed to 90 degrees and the forearm is in a pronated position while maintaining the upper arm at the side. Pt is instructed to supinate arm while examiner concurrently resists forearm supination at the wrist. Localised pain at the bicipital groove indicates a +ve test Yergasons and Speed’s tests were found to have high specificity (0.83–0.86) and low sensitivity (0.23–0.36), indicating that these manoeuvres would be better at ruling out biceps disease than detecting it.

Instability of the GH Joint Apprehension Relocation Test (also known as Fowler’s test) Posterior Subluxation Test (also known as the Jerk test) Apprehension Relocation Test - Anterior instability of the GHJ Posterior Sub lux Test - Post instability of the GHJ Most instability is anterior. Anterior tests have the most validity Apprehension Relocation Test - Anterior instability of the GHJ Posterior Sub lux Test - Post instability of the GHJ Most instability is anterior. Anterior tests have the most validity

Apprehension Relocation Test These tests are performed with the patient supine and the arm in abduction and external rotation. During the Apprehension Test, the physiotherapist pushes anteriorly on the posterior aspect of the humeral head. This movement will produce apprehension sometimes coupled with pain in patient’s with recurrent dislocations. Patient’s with anterior subluxation will experience pain but not apprehension with this test, and patient’s with normal shoulders will be asymptomatic. The Relocation Test is then performed by administering a posteriorly directed force on the humeral head. Patient’s with primary impingement will have no change in their pain, whereas patient’s with instability (subluxation) and secondary impingement will have pain relief and will tolerate maximal external rotation with the humeral head maintained in a reduced position. Apprehension Relocation Test -These tests are performed with the patient supine and the arm in abduction and external rotation. During the Apprehension Test, the PT pushes anteriorly on the posterior aspect of the humeral head. This movement will produce apprehension sometimes coupled with pain in pt’s with recurrent dislocations. Pt’s with anterior subluxation will experience pain but not apprehension with this test, and pt’s with normal shoulders will be asymptomatic. The Relocation Test is then performed by administering a posteriorly directed force on the humeral head. Pt’s with primary impingement will have no change in their pain, whereas pt’s with instability (subluxation) and secondary impingement will have pain relief and will tolerate maximal external rotation with the humeral head maintained in a reduced position.

Posterior Subluxation Test Jerk Test - Pt is positioned in supine, shoulder at 90 degrees with slight adduction and medial rot. The PT places one hand on the distal humerus and one one hand on the post aspect of the joint line. The PT then applies a downward force to the humerus. A +ve test is indicated by sharp pain in the shoulder with or without a clicking sound. Jerk Test - Patient is positioned in supine, shoulder at 90 degrees with slight adduction and medial rot. The physiotherapist places one hand on the distal humerus and one hand on the post aspect of the joint line. The physiotherapist then applies a downward force to the humerus. A +ve test is indicated by sharp pain in the shoulder with or without a clicking sound.

ACJ Pathologies Horizontal adduction test (scarf test) Palpation No single test has been found to accurately diagnose ACJ pathology but they should be used in combination. Pain for the ACJ can spread to the C4 dermatome (epaulette area, clavicle area). Adduction Test (good to rule out): With the patient in a sitting position the physiotherapist stands with one hand on the posterior aspect of the shoulder to stabilise the trunk and the other hand holding the subjects elbow of the arm being tested. With the trunk stabilised the physiotherapist passively moves the shoulder into maximum horizontal adduction. +ve test is when pain is felt over the ACJ. Horizontal adduction test (scarf test) Palpation O’Briens can also be used No single test has been found to accurately diagnose ACJ pathology but they should be used in combination. Pain for the ACJ can spread to the C4 dermotome (epaulette area, clavicle area). Adduction Test (good to rule out): With the patient in a sitting position the PT stands with one hand on the posterior aspect of the shoulder to stabilise the trunk and the other hand holding the subjects elbow of the arm being tested. With the trunk stabilised the PT passively moves the shoulder into maximum horizontal adduction. +ve test is when pain is felt over the ACJ.

Stats… Test Sensitivity Specificity ERLS 0.98 Empty Can 0.86 0.50 Infraspinatus muscle strength test 0.42 0.90 Hornblowers 1 0.93 Belly Press 0.40 Neer’s sign 0.68 0.69 Hawkins-Kennedy 0.92 0.25 O’Briens Test 0.47 0.55 Speeds 0.14 Yergasons 0.37 Apprehension Relocation Test 0.81 Posterior Subluxation Test 0.73 Horizontal Adduction Test 0.23 0.82 Hattam & Smeatham (2010)

Summary Rotator cuff integrity Labral tears and biceps pathology External Rotation Lag Sign O’Briens Test Empty Can Speeds test Infraspinatus muscle strength test Yergasons Hornblowers Belly Press Instability Apprehension Relocation Test Impingement of the rotator cuff Posterior Subluxation Test Neer’s Sign Hawkins-Kennedy ACJ Horizontal Adduction Test (scarf) Palpation

References Biederwolf NE (2013) A Proposed Evidence-Based Shoulder Special Testing Examination Algorithm: Clinical utility based on a systemic review of the literature International Journal of Sports Physical Therapy 8 (4): 427- 440 Online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812837/#!po=48.0769 [Accessed 2 February 2014] Day R, Fox J and Paul-Taylor G (2009) Neuro-Musculo-skeletal Clinical Tests Edinburgh: Churchill Livingstone Elsevier Hattam P and Smeatham A (2010) Special Tests in Musculoskeletal Examination: An Evidence-Based Guide for Clinicians Edinburgh: Churchill Livingstone Elsevier Tennent DT, Beach WR and Meyers JF (2003) A Review of the Special Tests Associated with Shoulder Examination Part I: The Rotator Cuff Tests American Journal of Sports Medicine 31 (1): 154-160 Online at: http://ajs.sagepub.com/content/31/1/154.full.pdf+html [Accessed on 2 February 2014] Tennent DT, Beach WR and Meyers JF (2003) ‘A Review of the Special Tests Associated with Shoulder Examination Part II: Laxity, Instability, and Superior Labral Anterior and Posterior (SLAP) Lesions’ The American Journal of Sports Medicine 31 (2): 301-307 Online at: http://ajs.sagepub.com/content/31/2/301.full.pdf+html [Accessed 3 February 2014] Therapy Haven (2014) Special Tests Online at: http://www.pthaven.com/page/show/102937-special-tests [Accessed 2 February 2014]