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
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.
Critiqued 45 studies
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
Five Categories of Tests
Impingement Rotator Cuff Pathology
Labral Tears and Biceps Pathology
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
Five Categories of Tests
Impingement Rotator Cuff Pathology
Labral Tears and Biceps Pathology
AC joint pathology Instability
Rotator Cuff Integrity
Supine Impingement Sign External Rotation Lag Sign (ERLS) Drop Arm Test Bear Hug Test Belly Press Test Hornblowers Test
Sensitive, any injury
Specific, any injury
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
May be a useful screening test for any rotator cuff tear.
ERLS and Drop Arm Tests
May have value to rule in any rotator cuff tear when positive
Bear-Hug and Belly Press tests
May have value to rule in a subscapularis tear
Hornblowers
May be a sign of severe degeneration of the teres minor muscle
Five Categories of Tests
Impingement Rotator Cuff Pathology
Labral Tears and Biceps Pathology
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
Evidence Based Recommendations
Labrum and Biceps Pathology
Biceps Load II test
May be diagnostic for SLAP Biceps load I can be considered with caution
Kim and Jerk Tests
May be diagnostic for posterior labrum pathology Needs more studies
Biceps tendon tests
Have not fared well in current literature
Five Categories of Tests
Impingement Rotator Cuff Pathology
Labral Tears and Biceps Pathology
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
Five Categories of Tests
Impingement Rotator Cuff Pathology
Labral Tears and Biceps Pathology
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
Evidence Based Recommendations 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
Kennedy-Hawkins or Neer as a screening test Supraspinatus and Infraspinatus for confirmation 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 Kim or Jerk tests for SLAP (not sensitive) Biceps load I or II for posterior labrum (fairly sensitive, very specific) Palpation for screening AC compression test for confirmation Apprehension, relocation, and release tests all fairly diagnostic Use apprehension rather than pain to improve diagnostic ability
Rotator cuff integrity
Labrum and Biceps Injury
AC Joint Pathology
Instability
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???
