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A user's guide to performance of the best shoulder physical examination tests
  1. Cortney A Myer1,
  2. Eric J Hegedus2,
  3. Daniel Thomas Tarara3,
  4. Daniel M Myer4
  1. 1Center for Orthopedics and Sports Medicine and Akron Children's Hospital, Akron, Ohio, USA
  2. 2Department of Physical Therapy, High Point University, School of Health Sciences, High Point, North Carolina, USA
  3. 3Department of Exercise Science, High Point University, School of Health Sciences, High Point, North Carolina, USA
  4. 4Fellow-Orthopaedic Sports Medicine, Orthopedic Research of Virginia, Richmond, VA and Crystal Clinic Orthopedic Center, Akron, Ohio, USA
  1. Correspondence to Daniel Thomas Tarara, Department of Exercise Science, High Point University, School of Health Sciences, High Point, NC 27262, USA; dtarara{at}highpoint.edu

Abstract

Background This article provides clinicians with a user's guide on the performance of the shoulder physical examination tests most supported by current evidence from a recent systematic review published in the British Journal of Sports Medicine.

Discussion A description of clinical shoulder tests is provided with explanations on exact testing procedures and complimentary photographs.

  • Shoulder Injuries
  • Evaluation

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Introduction

The musculoskeletal clinical examination is an important piece of any patient encounter. Yet, there are multiple studies that show the medical community, especially new practitioners, has a need to improve their collective examination skills.1–3

An important component of the clinical examination is physical examination tests designed to detect pathology. A challenge with these tests is the sheer volume reported in the literature.4 One way to solve this challenge for busy clinicians is to read systematic reviews that summarise large quantities of data from multiple articles in a concentrated area of interest. One such systematic review was published in 2008 and addressed physical examination tests of the shoulder.5 This study represented the largest review of shoulder tests with meta-analysis at that time. As a result of that article, a group of authors published a pictorial guide demonstrating how each test is performed.6 Recently, the 2008 systematic review was updated along with recommendations for the use of newer tests.7 While comprehensive in nature, the article did not provide detailed descriptions of these new tests and so, an updated pictorial guide may be in order. The goal of this paper was to provide busy clinicians with an additional user's guide on the performance of the most recently published shoulder physical examination tests most supported by evidence.

Clinical shoulder tests

Impingement tests

No new tests.

Labral tear tests

Modified dynamic labral shear test.8

Patient position: standing with arm flexed 90° at the elbow, abducted in the scapular plane >120° and externally rotated to tightness.

  • Test: examiner standing behind patient, guiding involved upper extremity into maximal horizontal abduction and applying a shear load to the joint by maintaining external rotation and horizontal abduction and lowering arm from 120° to 60° of abduction.

  • Confirmatory findings: reproduction of pain and/or painful click or catch in the posterior joint line between 120° and 90° abduction.

  • Test rationale: arm position and load application are ideal for reproducing the peel-back phenomenon and motion of the biceps, and to reproduce the shearing mechanism of the posterior rotator cuff against the posterosuperior labrum. The modified version of this test did not place the arm into maximal horizontal abduction until the arm was abducted above 120°. This was intended to decrease pain provocation throughout the entire ROM (figure 1).

Figure 1

Modified dynamic labral shear (A) starting position and (B) ending position. Access the article online to view this figure in colour.

Summary from systematic review on labral tears.

The modified dynamic labral shear test may be diagnostic of labral tears in general with both high sensitivity and specificity.

Superior labrum anterior to posterior lesion tests

Passive compression test9

  • Patient position: lateral decubitus position with affected side up.

  • Test: examiner standing behind patient, stabilising the affected shoulder by holding the acromioclavicular (AC) joint with one hand and the elbow with the other. The examiner externally rotates the shoulder in 30° of abduction and then pushes the arm proximally while extending the shoulder (figure 2).

  • Confirmatory findings: pain or a painful click in the glenohumeral joint.

  • Test rationale: with glenohumeral external rotation and extension (late cocking phase), the long head of the biceps tendon is placed under tensile forces while wrapping around the lesser tuberosity and ultimately shifting the superior labrum from the superior glenoid rim. Proximal migration of the humerus aggravates the displacement of the unstable labrum and passively displaces the superior labrum.

Figure 2

Passive compression (A) starting position and (B) ending position. Access the article online to view this figure in colour.

Passive distraction test10

  • Patient position: supine.

  • Test: examiner standing on the affected side of the patient and positions the extremity off the edge of the table, into 150° elevation in the coronal plane, the elbow extended, the forearm supinated, and the upper arm stabilised to prevent humeral rotation. The examiner pronates the forearm while maintaining steady position of the humerus (figure 3).

  • Confirmatory findings: pain reported deep inside the glenohumeral joint either anteriorly or posteriorly.

  • Test rationale: peel-back phenomenon of the superior labrum.

Figure 3

Passive distraction (A) starting position and (B) ending position. Access the article online to view this figure in colour.

Summary from systematic review on superior labrum anterior to posterior (SLAP) lesion tests.

The passive distraction test may be used for ruling in a SLAP lesion while the passive compression test may be used for both ruling in and ruling out a SLAP lesion.

Bony instability tests

Bony apprehension test11

  • Patient position: patient sitting or standing with elbow flexed to 90°.

  • Test: examiner standing behind patient holding the lateral forearm with one hand and placing the other hand on the posterior aspect of the humeral head. The examiner moves the affected arm into 45° abduction and 45° external rotation (figure 4).

  • Confirmatory findings: apprehension with or without pain.

  • Test rationale: authors arbitrarily chose positioning of the glenohumeral joint to provoke instability from a bony Bankart lesion and/or engaging Hill-Sachs bony lesion.

Figure 4

Bony apprehension. Access the article online to view this figure in colour.

Summary from systematic review on bony instability tests.

The bony apprehension test may be used for both ruling in and ruling out a diagnosis of bony instability.

Tendinopathy tests

Belly off sign12

  • Patient position: seated or standing.

  • Test: examiner standing in front of the patient while passively moving the affected upper extremity into flexion and maximal internal rotation with the elbow flexed at 90°. The examiner supports the patient's elbow while the other hand brings the arm into maximal internal rotation placing the palm of the hand on the abdomen. The patient is asked to keep the wrist straight and actively maintain this position of internal rotation as the examiner releases the wrist (maintaining elbow support; figure 5).

  • Confirmatory findings: the patient is unable to maintain the position, the wrist flexes or lag occurs and the hand is lifted off the abdomen.

  • Test rationale: the subscapularis muscle acts as a strong internal rotator and this test evaluates the integrity of the musculotendinous unit.

Figure 5

Belly off sign (A) starting position and (B) ending position. Access the article online to view this figure in colour.

Belly press test modified12

  • Patient position: seated or standing with the affected hand flat on the abdomen and elbow close to the body.

  • Test: examiner stands on the affected side of the patient and instructs the patient to bring the elbow forward and straighten the wrist. The examiner measures the final belly-press angle of the wrist with a goniometer (figure 6).

  • Confirmatory findings: belly-press angle difference of 10° between affected and unaffected side.

  • Test rationale: the subscapularis muscle acts as a strong internal rotator and this test evaluates the integrity of the musculotendinous unit. The modified version of this test measures between side differences in the belly-press angle unlike the original belly press test.13

Figure 6

Belly press test modified (A) starting position and (B) ending position. Access the article online to view this figure in colour.

Lateral Jobe14

  • Patient position: seated or standing.

  • Test: the examiner instructs the patient to abduct their affected shoulder to 90° in the coronal plane with the elbow flexed to 90° and the shoulder internally rotated so that the fingers point inferiorly and the thumbs medially. The examiner then applies an inferior force to the distal arm (figure 7).

  • Confirmatory findings: pain or weakness or inability to perform the test.

  • Test rationale: the author's did not provide an explanation as to why this test mechanically differs from the original Jobe test.

Figure 7

Lateral Jobe (A) starting position and (B) ending position. Access the article online to view this figure in colour.

Summary from systematic review on tendinopathy tests.

The three previously mentioned tests may be used for both ruling in and ruling out subscapularis and rotator cuff tendinopathy, respectively.

Other tests

Olecranon-manubrium percussion test15

  • Patient position: seated or standing with elbows flexed at 90°.

  • Test: the examiner places the stethoscope bell over the manubrium and percusses each olecranon process (figure 8).

  • Confirmatory findings: a decrease in pitch or the intensity of the affected side.

  • Test rationale: if there are any bony abnormalities, the affected side should have a duller sound than the normal side.

  • Shrug sign.16

  • Patient position: standing.

  • Test: the examiner instructs the patient to abduct both arms in the coronal plane (figure 9).

  • Confirmatory findings: elevation of the scapula or shoulder girdle in order to achieve 90° of abduction. Measured with a goniometer, the magnitude of the shoulder shrug was defined as the angle between the arm and the horizontal point at which the shrug moment began.

  • Test rationale: the authors conclude the shrug sign can detect shoulder abnormalities, especially those associated with loss of range of motion or weakness on manual muscle testing.

Figure 8

Olecranon-manubrium percussion. Access the article online to view this figure in colour.

Figure 9

Shrug sign (A) starting position and (B) ending position. Access the article online to view this figure in colour.

Summary from systematic review on other tests.

The olecranon-manubrium test may be used to rule in or rule out bony abnormalities. The shrug sign may be used to rule out stiffness-related disorders as well as rotator cuff tendinopathy.

Discussion

There are an inordinate amount of physical examination tests pertaining to the shoulder complex,4 and it was not the intention of this paper to provide an exhaustive list. The purpose of this paper was to take the best tests from a recent update7 of a systematic review5 and create a user-friendly guide for clinicians on how to perform these tests. Since Moen et al6 produced a pictorial summary of the best tests from the original review, an updated examination description of the most recent evidence-based shoulder tests was warranted.

Notably absent from this guide are tests for impingement. The reasons for this absence were that meta-analysis showed no diagnostic benefit of popular impingement tests, and the review on which this paper is based questioned the value of the diagnostic label of impingement syndrome.7

While the label of impingement may be losing diagnostic favour, a diagnostic category attracting greater interest is the area of bone-related pathology. The olecranon-manubrium percussion test may be helpful in acute conditions like a fracture, where a determination of referral for x-ray may be required. Likewise, the bony apprehension test appears to have a high-enough sensitivity and positive likelihood ratio to serve as a screen for potential bony instability, such as a bony Bankart lesion. This may increase the diagnostician's awareness of needing referral or ordering further imaging.

Diagnosing a labral tear in the shoulder remains difficult but there is reason for optimism and some confusion- optimism because either the passive compression or the passive distraction test can be used to rule in a SLAP lesion. Some confusion surrounds the dynamic labral shear test, reportedly specific for a labral tear. This test was first reported by O'Driscoll in 200217 as a test for a specific type of labral tear, the SLAP lesion. The first peer-reviewed publication of the dynamic labral shear test was by Kibler et al8 but these authors called the test the modified dynamic labral shear test, assumedly because the original test is performed in supine and Kibler et al8 performed the test with the patient standing. Kibler et al8 also used the test in reference to all labral tears and not just SLAP tears. Finally, Cook et al (2012)18 used this test for its original purpose (to detect SLAP lesions) but modified the test yet again by performing the test in standing but externally rotating the arm to 90° instead of to the natural limitation of gravity-assisted external rotation. As authors have modified the original test, they have, in essence, produced a new test so it could be argued that the value of the original dynamic labral shear test is unknown. The modified dynamic labral shear test as described by Kibler et al8 is what is described in our paper. As evident by the continual emergence of new tests aimed at diagnosing labral tears in general and SLAP lesions specifically, the most efficient way to diagnose these pathologies is far from certain. The value of these three tests, the modified dynamic labral shear, the passive distraction and the passive compression, need to be confirmed by more than one study.

While we hope this guide eases the acceptance of the new physical examination tests into practice, we also echo the thoughts of the review and meta-analysis on which this paper is based:7 these physical examination tests are probably best used in the context of a comprehensive history and physical examination and few, if any, single tests have the sensitivity and specificity to rule in a diagnosis when positive and rule out a diagnosis when negative.

What this paper adds

  • The study is an update on the most clinically useful shoulder tests as found in the Hegedus et al 2012 systematic review and meta-analysis of shoulder physical examination tests.

  • It provides the busy clinicians with a user's guide on the performance of the shoulder physical examination with detailed descriptions and photographs.

References

View Abstract

Footnotes

  • Contributors This manuscript has four contributing authors. Individual contributions are as follows: (1) CAM, conceptual design; drafting and revision of the article for important intellectual content; (2) EJH, conceptual design; drafting the article or revising it critically for important intellectual content; final approval of the version to be published; (3) DTT, revising it critically for important intellectual content; final approval of the version to be published; (4) DMM, conceptual design; drafting and revision of the article for important intellectual content.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • ▸ References to this paper are available online at http://bjsm.bmj.com