Expert Review Examination of the Shoulder Mickhaiel Barrow 1 Thomas W Hamilton2 and Parminder J Singh3 ……………………………………………………………………………………………………………………………………..

The Journal of Clinical Examination 2011 (11): 44-56

Abstract Shoulder pain is the second most common musculoskeletal condition seen in primary care. Specialists, general practitioners and medical students should be able to perform a thorough examination of the shoulder. This article describes techniques for shoulder examination in a simple ‘look, feel, move’ format and considers each method from a critical point of view. It is based on a review of the literature, textbook accounts and the author’s personal experience. Word count: 6241. Key Words: shoulder, examination, impingement, pain, movement. Address for correspondence: [email protected] Author affiliations: *1 Foundation Year 1 Doctor, High Wycombe Hospital. *2 Academic Foundation Year Doctor, John Radcliffe Hospital, Oxford. *3. Consultant Trauma and Orthopaedic Surgeon South West London Elective Orthopaedic Centre, Epsom, Surrey. ……………………………………………………………………………………………………………………………………..

  Introduction The glenohumeral or ‘shoulder’ joint is formed by the articulation of the glenoid fossa of the scapula and the head of the humerus. It has an open ball and socket structure and is held away from the chest wall by the clavicle as shown in Figure 1a. It is stabilised by the glenoid labrum and the intrinsic ligaments (glenohumeral and coracohumeral ligaments) within the fibrous capsule and by the tone of the rotator cuff muscles (supraspinatus, infraspinautus, teres minor and subscapularis) – see Figure 1b. Figure 1b Anatomy of shoulder joint The acromioclavicular (AC) joint is formed from the acromion of the scapula and the lateral tip of the clavicle. It is stabilised by the coracoclavicular, acromioclavicular and coracoacromial ligaments. The AC joint may become dislocated or subluxed by trauma.

Figure 1a Bony and soft tissue of shoulder joint

Other clinically important structures include the tendons of the rotator cuff muscles which pass between moving bones and may tear or become inflamed. Finally, the nerves of the brachial plexus with the accompanying brachial artery and vein

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            emerge from the axilla, just inferior to the glenohumeral joint and can be damaged as a result of shoulder dislocation, direct trauma or surgery. Shoulder pathology is common especially in middle and old age. The differential diagnosis for pain and reduced range of movement in the shoulder is long but there are only a few common causes. These will be the focus of this article and they are listed in Table 1. Subacromial impingement Rotator cuff tears Frozen Shoulder Instability of the glenohumeral joint Dislocation of the shoulder Osteoarthritis of the glenohumeral joint Osteoarthritis of the acromioclavicular joint Rupture of the long head of the biceps tendon Referred pain from the cervical spine Table 1 Common Disorders of the Shoulder Impingement is a syndrome of shoulder pain and reduced range of movement which usually occurs in patients over forty years old. Patients typically complain of pain during abduction from 70-120 degrees. Repetitive microtrauma to the supraspinatus tendon of the rotator cuff leads to degeneration of the hypovascular distal portion of the tendon and is more likely with increasing age. Swelling of rotator cuff leads to impingement beneath the acromion and coracoacromial ligament especially when the arm is elevated and internally rotated. This causes pain associated with lifting the arm over one’s head. Later in the life bony changes of the acromion occur which further contributes to wear of the rotor cuff and predisposes to rotator cuff tears. Rotator cuff tears typically occur in young patients following trauma or spontaneously in older patients secondary to degenerative changes. Tears in supraspinatus cause weakness in initiating abduction and this movement may be painful if the tear impinges on adjacent structures. Pain and limitation of movement in all directions (in the presence of a normal radiograph) is characteristic of adhesive capsulitis - also known as frozen shoulder. Rotation is especially affected and pain may be severe. In this condition, minor trauma or prolonged immobilization is believed to initiate low grade inflammation in the rotator interval

(capsuloligamentous structures between supraspinatus and subscapularis) which leads to scarring and contraction. Laxity is defined as looseness of the soft tissues around the shoulder joint. It is important to note that although joint laxity predisposes to instability, a lax joint can be stable so positive laxity tests should not be interpreted as instability [1,2]. See the section on ‘Special Tests’ for tests of joint laxity. Instability occurs when supportive structures around the shoulder joint fail to keep the humeral head correctly positioned in the glenoid fossa during movement. Dislocation occurs if there is complete separation of the humeral head from the glenoid fossa while subluxation is defined as symptomatic translational movement without complete separation [3]. If you suspect joint laxity, potential causes should be considered (eg. Ehlers-Danlos syndrome). Dislocation of the shoulder joint should always be considered following trauma. Anterior dislocation is the most common, and typically follows a fall forcing external rotation of the shoulder or a fall backwards onto an extended arm. These forces drive the humeral head anterior to the glenoid fossa and inferior to the coracoid process. Patients are in severe pain and do not permit the examiner to move the shoulder joint. Axillary nerve damage is a common complication and should be tested by examining the lateral aspect of the arm (commonly known as the ‘regimental badge’) for a loss of sensation. Chronic damage to this nerve results in wasting of the deltoid muscle. Posterior dislocation is less common and is associated with a direct blow to the anterior aspect of the shoulder, electric shock and seizures. Patients present with their arm locked in medial rotation - a scapular lateral and axillary radiograph is needed to make the diagnosis. Inferior dislocation (or ‘luxatio erecta’) is very uncommon and caused by a downwards axial force applied to the shoulder while the arm is fully abducted. Associated injuries include damage to brachial plexus, axilliary artery and fractures of the acromion, clavicle and greater tuberosity. Glenohumeral joint osteoarthritis is a relatively uncommon cause of shoulder pain. It is usually idiopathic but may follow trauma or dislocation of the shoulder. It is more common in patients over age 60 years and in women. It presents with gradual onset anterior shoulder pain and stiffness that is aggravated by activity and relieved by rest.

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            Creptius may be elicited on movement of the joint. Multiple joint involvement should always prompt the examiner to consider rheumatoid arthritis as a potential cause. Clinical examination may be unable to distinguish osteoarthritis from other causes of shoulder pain and a plain radiograph of the shoulder is needed for diagnosis. Osteoarthritis may also affect the acromioclavicular joint resulting in pain. Patients complain of stiffness and pain over the acromioclavicular joint especially when the arm is adducted across the chest (scarf test – see below) and in the end-range of flexion and abduction. On examination, the acromioclavicular joint may appear prominent, swollen and tender on palpation. Initial treatment is physiotherapy and steroid injections. Surgical excision of the distal end of the clavicle may be required in advanced disease. Rupture of the long head of the biceps tendon may occur following chronic inflammation or impingement in patients aged between forty and sixty years old. Traumatic rupture may be seen in younger patients. Some patients complain of a sharp, acute shoulder pain which may be accompanied by a snapping sound while others may simply experience recurrent pain during repetitive activities. On examination, there is a visible bulge on the anterior aspect of the arm (the ‘Popeye’ sign) during flexion of the elbow and tenderness in the bicipital groove. Finally, in patients presenting with shoulder pain, always consider the neck as the site of referred pain. As described below, the ‘Epaulette Sign’ can be use to differentiate localized pathology from referred neck pain. A full discussion of the causes of referred neck pain is beyond the scope of this article, but osteoarthritis of facet joints and degenerative disk disease are two of the most common pathologies. A full neurological examination of the upper limb is required to exclude neural damage if referred neck pain is suspected. Literature Search The following textbooks of clinical examination were searched: Evidenced Based Physical Diagnosis [11] The PubMed database was searched using the terms ‘shoulder AND examination’. Results were

entered into the clinical queries filter under ‘diagnosis’ and ‘narrow-specific search’. Additional searches were conducted for special orthopaedic tests including search terms such as ‘supraspinatus test’, ‘Neer’Iimpingement test’, ‘Hawkin’s impingement sign’, ‘Yegason’s sign’, ‘external rotator lag sign’, ‘drop sign’, ‘belly press test’, ‘lift off test’, ‘sulcus test’, ‘apprehension test’, ‘Jobe’s relocation test’, ‘cross arm adduction stress test’, ‘active compression test’, ‘Kim test’, and ‘biceps load test II’. The Cochrane Library was also searched using the keywords ‘shoulder pain’, ‘shoulder impingement syndrome’ and ‘shoulder joint’. Beginning the Examination Begin by introducing yourself, explain what you intend to do and take informed consent. The examination is best performed with the patient standing upright with good exposure of the shoulders, arms and neck – see Figure 2. This will allow examination of the anterior, posterior and lateral aspects of both shoulders. Men should be asked to remove their shirts and women may be examined with a gown tied around their backs or whilst wearing only a bra. The patient should be comfortable and relaxed and you should enquire about pain before proceeding with the examination.

Figure 2. Correct exposure for examination of the shoulder joint, women may be examined with a gown tied around their backs or whilst wearing only a bra. Inspect (‘Look’) Global Inspection Begin by looking at the whole patient. Always compare both sides of the body and look at the patient from the front, the back and the side – see Figure 3. Look for signs of disease in other systems which may be relevant to shoulder pathology. Once the global inspection is complete move on to look

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            more closely at the shoulders. As a memory aid, consider structures that are related to the skin, soft tissue and bones at each stage in the examination. Skin Look for bruising or scars (including incisions for arthroscopic surgery) that might suggest trauma or previous surgery. Inspect the skin for areas of erythema and check the axillae for sinuses both of which may be caused by an underlying infection. Soft Tissue Compare the curvature of both shoulders and look for asymmetry. Increased angularity or ‘squaring’ of the deltoid can occur as a result of deltoid wasting following axillary nerve damage in patients with a history of anterior shoulder dislocation. Similarly, inspect the muscle bulk above and below the spine of the scapula (supraspinatus and infraspinatus respectively). Wasting appears as hollow grooves and typically occurs 2-3 weeks after tears in the rotator cuff.

 

Figure 3 aspects.

Inspect the shoulder joint from all

Advanced rotator cuff disease can also be associated with tears in the long head of biceps tendon, which can be seen as a visible bulge when the patient flexes his elbow (Popeye sign). Bone Acute anterior dislocation of the humeral head is usually very painful and associated with a history of trauma. The arm is usually held at the side slightly away from the body with the forearm turned outward. You may see decreased shoulder roundness and a bump in front of the shoulder caused by the dislocated humeral head but swelling may obscure these signs.

 

A prominent bump at the distal end of the clavicle may indicate acromioclavicular joint subluxation. A painless bump in the middle of the clavicle may indicate an old malunited clavicle fracture.

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            When inspecting from behind, look at position of the scapula, which may be abnormal in neuromuscular disorders or in patients who have injured of the long thoracic nerve – this typically causes ‘winging’ of the scapula where the medial border appears to be lifted off the back like a wing. The Epaulette Sign Before palpation, ask whether there are any tender areas. As pain may be referred from the cervical spine, the Epaulette Sign is useful in differentiating this from localised shoulder pain. An epaulette, derived from the French word meaning ‘little shoulder’, is an ornamental shoulder piece worn by soldiers as an insignia or an indication of rank. When asked to point to the pain, a patient with localised shoulder pain will point to a specific area while someone with neck pain will rub the area typically covered by an epaulette. See figure 4.

Palpate (‘Feel’) Skin and Neurovascular Status Begin palpation by assessing the temperature of each shoulder using the dorsal surface of your hand. The neurovascular status of the arm should be assessed because nerves and vessels may be damaged by shoulder pathology especially acute dislocation. However, this does not form part of the routine examination of the shoulder except in major trauma or unless acute dislocation is suspected so it is included in the section ‘Completing the Examination’ at the end of this article. Soft Tissue Palpate the trapezius muscle from behind. Ask the patient if it is tender and look at the face for signs of pain. Tenderness in the trapezius is common in referred neck pain. Bone Palpate along the clavicle from the sternoclavicular joint to the acromioclavicular joint and then the shoulder. Ask the patient if it is tender and look at the face for signs of pain. Tenderness over the greater tuberosity may indicate rotator cuff pathology and tenderness over the acromioclavicular joint is strongly indicative of pathology in the acromioclavicular joint. Manipulate (‘Move’) Active Movements

Figure 4 Pain may be referred from the cervical spine, the Epaulette Sign is useful in differentiating this from localised shoulder pain. An epaulette, derived from the French word meaning ‘little shoulder’, is an ornamental shoulder piece worn by soldiers as an insignia or an indication of rank.

Apley Scratch Test Use the ‘Apley Scratch Test’ (see Figure 6) for a quick initial assessment. Stand behind the patient and ask them to scratch over the opposite scapula by reaching over the unaffected shoulder, then by reaching behind the neck and finally by moving their hand behind their back on the same side. Normal ranges of shoulder movement are listed in Table 2. Movement Flexion Extension Abduction External rotation Internal rotation

Range 180° 50° 180° 70° 50°

Table 2 Range of Movements

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Figure 7a Active shoulder flexion.

Figure 5 Assess the temperature of the shoulder using the dorsum of the hand (a). From behind palpate the trapezius muscle and look at the face for signs of pain (b). Palpate the bony structues methodically (c). Assess Individual Movements Individual movements of the shoulder can then be tested by asking the patient to copy you as you move your arms.

Figure 6 The Apley Scratch Test

Figure 7b Active shoulder extension.

Flexion and Extension Start by standing in-front of the patient and prompt them to move into full flexion and then full extension.

Abduction and Detection of a Painful Arc Then test abduction with the arms in the plane of the scapula (about 30° forwards) by lifting the arms slowly above the head as shown in Figure 8. The movement should be performed slowly and the patient should be asked to indicate if they feel any

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            pain – known as ‘painful arc’. Then repeat this movement whilst observing the patient from behind to assess the scapulohumeral rhythm. For the first 90° of abduction, there should be little movement at the scapula. Beyond 90° the scapula should rotate with the humerus at the same rate to facilitate abduction. Abnormal scapulohumeral rhythm could indicate damage to the scapula stabilizers or involuntary adaptation to avoid pain. Pain during abduction is known as a painful arc and it should be further characterised in terms of the point of maximal pain. Pain from 60-120° is typical of impingement syndrome whereas weakness especially in the absence of pain makes a rotator cuff tear more likely. Pain in the end-range of flexion and abduction (160-180°) is indicative of acromioclavicular joint pathology.

Move the forearm away from the midline and then back towards the midline.

Figure 9. Active external (a) and internal (b) rotation of the shoulder. Passive Movements With one hand over the shoulder joint, test passive flexion, extension, abduction and external rotation. For the sake of comfort, flexion can be tested with the patient seated and the examiner standing behind or adjacent to the patient as shown in Figure 10. Extension is best tested with both patient and examiner standing, with one hand over the shoulder joint and the other hand just above the elbow. Similarly, passive internal and external rotation are best tested with one hand stabilizing the elbow and the other examiner’s hand at the patient’s wrist as shown. Completing the Examination Complete the examination by thanking the patient, helping them redress and washing your hands.

Figure 8 Active shoulder abduction. The arms should be in the plane of the scapula (about 30° flexion).

The special tests listed in Table 3 and described below do not form part of the basic examination of the shoulder but they may give additional information when performed by examiners who are competent in the required techniques and their interpretation. Specialists may include some of them in their routine examination of the shoulder.

Internal and External Rotation Next test external and internal rotation by fully adducting the arm so the elbows are against the lateral chest wall and flexing the elbow to 90°.

A full assessment of the shoulder includes assessment of the neurovascular status of the arm. Check the radial pulse and capillary refill time and then test sensation. Formal examination of

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            dermatomal sensation should be carried out including testing sensation over the ‘regimental badge’ area supplied by the axillary nerve if an anterior glenohumeral joint dislocation is suspected. In medical school OSCEs and routine practice such a thorough assessment is usually not required and the extent of the examination should be tailored to the situation. See Examination of the Peripheral Nerves [4] and Examination of the Peripheral Arterial System[5] for a full account of how to perform these examinations

Hawkin’s Impingement Sign Standing adjacent to the seated patient, the examiner holds the patient’s arm with one hand and lifts it into 90° of forward flexion. The other hand grasps the patiens forearm and flexes the elbow to 90°. In this position, the shoulder is rotated internally by pushing the forearm towards the patient’s midline [6]. This forces the greater tuberosity against the coracoacromial ligament causing pain in impingement. Sensitivities and specificities for this test range from 72-92% and 2644% respectively [7,8]. See Evidence Box 1. Tests for Rotator Cuff Pathology Supraspinatus Test / Jobe’s Test / Empty Can Test This test is for supraspinatus integrity. Ask the patient to elevate arms in the plane of the scapula (90° forward) with full extension of the elbows. Arms are pronated so thumbs face downwards to the floor and then the examiner pushes down on the arms while the patient attempts to resist. Inability to maintain shoulder elevation is a sign of supraspinatus weakness. External Rotation Lag Sign (ERLS) With the patient’s back to the examiner, the elbow is passively flexed to 90° and the shoulder is held at 20° of elevation in the scapular plane by supporting the arm. The shoulder is maximally externally rotated minus 5° to avoid elastic recoil, and then released at the wrist. An angular drop indicates a failure in the integrity of the infraspinatus tendon [3].

Figure 10. Assess passive range of movement in the shoulder. Special Tests Tests for Impingement Syndrome Neer Impingement Sign With the examiner standing behind the seated patient, one hand is placed over the patient’s scapula to prevent it from moving during the test. The examiner then grasps the patient’s forearm with his other hand and draws the arm into forward elevation [6]. This action compresses the greater tuberosity against the anterior acromion, eliciting pain in impingement syndromes. This test has a 7589% sensitivity and 32-48% specificity [7]. See Evidence Box 1.

Lift-Off Test and Lift-Off ‘Lag Sign’ Described by Gerber and Krushell in 1991 [20], the Lift-Off test can also be used to diagnose an isolated subscapularis tendon rupture. The patient actively places his hand behind his back by internally rotating his shoulder and flexing the elbow. In this position, the patient is then asked to attempt lifting the dorsum of his hand away from his back. If there is a rupture in subscapularis, the patient would be unable to ‘lift-off’ his hand. In 1996, Gerber et al. developed the lift-off test (‘lag sign’) [3] as another means of detecting isolated rupture of subscapularis. In this test, the patient’s arm was passively placed in the same position as above and then the examiner’s hand was removed. Patients with subscapularis rotator cuff tears would not be able to maintain maximal internal rotation.

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            Tests for Impingement Syndrome Neer Impingement Sign Hawkins Impingement Sign Tests for Rotator Cuff Pathology Supraspinatus Test / Jobe’s Test / Empty Can Test External rotation lag sign (ERLS) Lift-Off Test and the Lift-Off Lag Sign Belly press test Drop sign / Hornblower’s Sign Tests for Biceps Tendon Pathology Speed’s Test Yeagson’s sign Tests for Instability, Laxity and Labral Pathology Anterior Pathology Apprehension Test (Anterior Instability) Jobe’s Relocation Test Load and Shift Test Posterior Pathology The Kim Test (Posterior Labral Tears) Jerk Test for Posterior Instability Superior Pathology Active Compression Test (O’Brien’s test) Inferior Pathology Sulcus Sign (Joint Laxity) Tests for Pathology of the Glenoid Labrum The Biceps Load Test II Tests for Hyperlaxity Beighton’s Hyperlaxity Score Tests for Acromioclavicular Joint Pathology Scarf Test / Cross Arm Adduction Stress Test Active Compression Test (O'Brien's test) Table 3 Special tests. Belly Press Test This tests aims to detect specific pathology in subscapularis [1]. It is performed by asking the patient to press his abdomen with the flat of his hand holding it in that position. If internal rotation is impaired, his elbow will move backward, moving behind the trunk. In addition, the patient will attempt to maintain the position by extending the shoulder or flexing the wrist rather than internally rotating the arm.

Drop Sign / Hornblower’s Sign With the patient and examiner in the same position as the ERLS test the affected arm is passively elevated to 90° and fully externally rotated with the elbow flexed to 90°. In this position, TERES MINOR is principally responsible for maintaining external rotation. Releasing the wrist while supporting the arm will cause an angular drop if teres minor or its tendon is compromised. Tests for Biceps Tendon Pathology Speed’s Test Speed’s test is performed with the patient in a standing or sitting position with the examiner standing to the side of the patient. The patient’s arm is forwardly flexed to 60-90° with the elbow fully extended and the hand fully supinated. The examiner pushes downwards at the wrist. A positive result is obtained if this force produces pain in the bicipital groove or the anterior shoulder. Reported sensitivities and specificities are 90% and 14% respectively [13]. Yegason’s Sign Yegason’s Sign is used to detect bicipital tendonitis. The examiner stands in front of the patient and flexes the elbow while the patient’s arm remains in a neutral position. The wrist is then pronated by grasping the hand and the forearm of the patient. From this starting position, the test is then performed by asking the patient to supinate his wrist against resistance. With the elbow flexed, the biceps muscle is one of the main supinators of the forearm, this action applies tension on the biceps muscle and pain in the bicipital groove is indicative of bicipital tendonitis. This test has a 37% sensitivity and a 82% specificity [7]. If bicipital tendonitis is found, further tests should be conducted for rotator cuff injury associated with subacromial impingement which is often the underlying pathology. Also note that this test is of limited use in the presence of partial or complete rupture of the supinator muscle or tendons. Tests for Instability, Laxity and Labral Pathology Anterior Pathology ‘Apprehension Test’ (Anterior Instability) This test is best performed with the patient lying supine to stabilise the scapula. The patient’s arm is passively abducted to 90° and flexed at the elbow to

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            90°. Grasping the patient’s forearm, the shoulder joint is then gently externally rotated by pulling the forearm towards the examiner. While doing this, the examiner’s other hand is placed over the posterior aspect of the patient’s humeral head, and pressure is gently applied in an anterior direction. If the patient becomes apprehensive, and wants to stop the test because he feels that his shoulder joint is about to be dislocated by further applied pressure or movement, the test has a positive result. After the Apprehension Test the examiner should go on to perform Jobe’s Relocation Test. Jobe’s Relocation Test The same procedure is used as above for the ‘Apprehension Test’, but the examiner’s hand is placed on the anterior aspect of the shoulder to stabilise the glenohumeral joint. If this removes the patient’s apprehension, the test has a positive result. One review [1] reported a sensitivity of 68% and a specificity of 100% for this test. Importantly, the relief of apprehension rather than pain should be used as the diagnostic criterion as it was found that pain relief occurred in several different disorders when a posteriorly directed force was applied. Load and Shift Test The Load and Shift Test is performed with the patient seated, with his arm in a neutral position at the side, and the examiner positioned behind the patient. The examiner places one hand over the patient’s scapula to stabilise it and the other hand is used to grasp the humeral head. A loading force is applied by the examiner to ensure that the humeral head lies centrally within the glenoid fossa. From this ‘loaded position’, a translational force is applied anteriorly and then posteriorly and the distance moved can be used to quantify the degree of laxity. For example, 0-1cm, mild laxity; 1-2cm or translates to glenoid rim, moderate laxity; >2cm translation or over the rim of the glenoid, severe laxity. Both shoulders should be compared. The test can then be repeated with the patient in a supine position and the examiner at the side of the bed. The arm is held instead, and positioned into 20° of abduction and forward flexion. The humeral head is centred with a loading force and then shifting forces applied anteriorly and posteriorly. By varying the amount of abduction, the examiner can selectively target and test individual ligaments. With 0-60° of abduction, the superior glenohumeral ligament and

coracohumeral ligament are tested. With 60-90° of abduction, the middle glenohumeral ligament is tested, and the inferior glenohumeral ligament can be examined using more than 90° of abduction [14]. Posterior Pathology The Kim Test (Posterior Labral Tears) This test is performed with the patient sitting with his arm in 90° of abduction and his elbow flexed to 90°. The examiner supports the patient’s elbow and lateral forearm. An axial loading force and 45° upward diagonal elevation is applied to the distal arm, while inferior and posterior force is applied to the proximal arm. Sudden onset pain in the posterior shoulder is a positive test. It is important, while performing the test, to apply firm axial compression force to the glenoid surface by the humeral head, and sitting the patient against the back of a chair is useful for counter-support [15]. A review of this test [8] believed the Kim test to be virtually diagnostic for posteroinferior labral lesions, having sensitivities and specificities of 80% and 94% respectively. Jerk Test for Posterior Instability The Jerk Test can also be used to detect posterior labral tears and instability. This test is performed by placing the patient’s humerus in a dislocated or subluxed position at the start of the test and if the joint is relocated during the test, a positive result is obtained. The patient either sits or stands and the examiner stands to the affected side, placing one of his hands on the patient’s elbow and the other over the scapula for stabilisation. In order to sublux the humerus, the arm is flexed to 90° and internally rotated with elbow also flexed to 90°. The examiner pushes posteriorly at the elbow and maintains the pressure. From this starting position, the arm is slowly abducted while maintaining the humerus parallel to the floor. If there is laxity, this manoeuvre will relocate the humeral head into the glenoid fossa, while will be felt as a clunk or a jerk with the stabilising hand. In comparison to the Kim test, the Jerk test has a 73% sensitivity and 98% sensitivity for detecting posteroinferior labral lesions [15,16]. Superior Pathology Active Compression Test (O’Briens Test) Please see following section below Acriomioclavicular Joint Pathology.

on

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            Inferior Sulcus Test (Joint Laxity) The Sulcus test is performed with the patient sitting or standing and facing the examiner. The patient’s arm is allowed to relax at his side in a neutral position. By holding the arm or forearm, the examiner gently applies a downward traction force and observes whether a groove is created between the humeral head and the acromion of the affected shoulder, indicating laxity. However, a recent review [3] reported the sensitivity and specificity as 31% and 89% respectively, suggesting that it was a poor test at detecting or confirming laxity. Tests for Pathology of the Glenoid Labrum The Biceps Load Test II A SLAP (Superior Labrum Anterior and Posterior) lesion is a labral detachment which originates posterior to the long head of biceps insertion and extends anteriorly [18]. With the patient lying supine and the affected shoulder at the edge of the bed, the examiner grasps the patient’s wrist and elbow. The arm is elevated to 120° and maximally externally rotated with the elbow in 90° of flexion and the forearm supinated. While resistance is applied, the patient is asked to flex the elbow. A positive result is pain experienced during resisted elbow flexion. No pain, or no change in pre-existing pain, is considered to be a negative result. A sensitivity and specificity of 89.7% and 96.9% has been reported [19]. Review of the biceps load test II found that it was one of the most promising tests for SLAP lesions, but the accuracy of the test was reduced when performed by investigators other than the originator of the test.

Tests for Acromioclavicular Joint Pathology Scarf Test / Cross Arm Adduction Stress Test This test is performed by passively adducting the arm across the body while the shoulder is flexed to 90° [21,22]. Pain is suggestive of acromioclavicular joint pathology. See Evidence Box 2 for a comparison of the tests described below. Active Compression Test (O’Brien Test) This test can be used to differentiate acromioclavicular and superior labral pathology. It is conducted by actively flexing the arm to 90° with the elbow fully extended [23]. The arm is then adducted 10-15° medial to the sagittal plane and then internally rotated until the thumb is directed downwards. The examiner then applies a downward force to the arm. The arm is then fully supinated while in the same position, and then force is again applied. A positive result is pain experienced on the first manoeuvre which is absent in full supination. Pain over the anterior shoulder or ‘clicking’ in the glenohumeral joint suggests superior labral pathology while pain localised to the AC joint was described as being diagnostic of AC joint pathology. Acknowledgements The authors would like to thank Jo Hunter and Professor Glasziou for their invaluable help with the literature review and evidence based review for the article. Thanks to Mr. Shahane for his advice and comments. Conflicts of Interest None declared.

Tests for Hyperlaxity Beighton’s Hyperlaxity Score If any of the above tests suggest joint laxity, further testing for Generalised Joint Laxity (GJL) should be considered. One scoring system is the Beighton Score. This index involves examination of extension of the fifth finger, thumb to forearm opposition with the wrist flexed, elbow extension, knee extension and flexion of the trunk and hip. Using a grading system, an overall score with a maximum of 9 points is produced. A score of 5 and above suggests GJL. One study [17] found that the intrarater and interrater reliability of the Beighton Score to have Spearman Rho values of 0.86 and 0.87 respectively.

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            References [1] Tennent TD, Beach WR, Meyers JF. Clinical Sports Medicine Update. 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

[13] Bennett WF. Specificity of the Speed’s test: Arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy 1998; 14(8): 789-796 [14] http://www.shoulderdoc.co.uk/article.asp? Section=583&article=749

[2] Luime JL, Verhagen AP, Miedema HS, Kuiper JI, Burdorf A, Verhaar JAN, Koes BW. Does this patient have an instability of the shoulder or a labrum lesion? JAMA 2004; 292(16): 1989-1999.

[15] Kim SH, Park JS, Jeong WK, Shin SK. 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

[3] Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis tendon. J Bone Joint Surg 1996; 78A: 1015-1023

[16] Rockwood CA, Matsen FA, Wirth MW, Lippitt SB. The Shoulder. Saunders; 2009. p.152-176.

[4] Shields, SA. Examination of the Peripheral Nervous System. Jour Clin Exam 2007; 2:36-43 [5] Ayre K, Handa A. Examination of the Peripheral Arterial System. Jour Clin Exam. 2008; 8: 49-61 [6] Neer CS II. Impingement Lesions. Clinical Orthop 1983;173: 70-77 [7] Steven McGee. Evidenced based physical diagnosis. Saunders; 2001. p. 628-638 [8] Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT, Cook C. Physical examination tests of the shoulder: a systemic review with meta-analysis of individual tests. Br J Sports Med 2008;42:80-92 [9] Mustafa C, Akgün K,Birtane M, Karacan I, Havva C, Tüzün F. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheu Dis 2000; 59: 44-47 [10] Hawkins RJ, Kennedy JC. Impingement Syndrome in athletes. Surg 2000; 9: 263-267 [11] Holtby R, Razmjou H. Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. J Orthop Sports Phys Ther 2004; 34:194-200 [12] Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis tendon. J Bone Joint Surg 1996; 78A:1015-1023

[17] Boyle KL, Witt P, Riegger-Krugh C. Intrarater and Interrater Reliability of the Beighton and Horan Joint Mobility Index. J Athl Train 2003; 38(4): 281– 285. [18] Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder Arthroscopy. 1990; 6(4): 274-9 [19] Kim SH, Ha KI, Ahn JH, Kim SH, Choi HJ. Biceps Load Test II: A Clinical Test for SLAP lesions of the shoulder. Arthroscopy 2001; 17(2): 160-164 [20] Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg 1991; 73B: 389-394 [21] McLaughlin HL. On the Frozen Shoulder. Bull Hosp Joint Dis 1951; 12: 383-390 [22] Chronopoulos E, Kim TK, Park HB, Ashenbrenner D, McFarland EG. Diagnostic value of physical tests for isolated acromioclavicular joint lesions. Am J Sports Med 2004; 32: 655 [23] O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The Active Compression test: A new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med 1998; 26: 610

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In a recent meta-analysis [8] it was shown that the Supraspinatus test had a sensitivity and specificity of 25-44% and 67-90% respectively. While having a low sensitivity, the high specificity of this test makes it useful to confirm the diagnosis of impingement. The Neer Impingement sign and the Hawkins-Kennedy test were not found to be diagnostically useful as both had pooled Diagnostic Odds Ratios (DORs) around 1 with confidence intervals including 1. One paper however [6] suggests that the Supraspinatus test may only significantly increase the posttest probability if the patient has a major rotator cuff tear, and may contribute little in diagnosis of mild pathology. An additional test that might add further diagnostic weight, is the injection of 1% 10ml of lignocaine (lidocaine) into the subacromial region (Neer’s Test). In patients with subacromial impingement, this quickly relieves pain on active and passive motion and restores nearly complete range of motion. It should be noted however, that other conditions, such as calcific tendonitis, and calcific subacromial bursitis, present in a similar way to impingement, and are also relieved by lignocaine injection [9]. Evidence Box 1 Examination of suspected impingement syndrome. No meta-analyses were found to compare the Active Compression Test and the Cross Arm Adduction Stress test. One study [8] attempted to combine evidence available. Sensitivities and specificities for the Active Compression test ranged from 16% to 93% and 90% to 96%. Sensitivities and specificities for the Cross Arm Adduction Stress test were found to be 77% and 79% respectively [19]. Further analysis of these studies led authors to conclude that the Active Compression test had the highest specificity of any special test to evaluate AC joint pathology and was virtually diagnostic if positive. As it has a variable sensitivity through the literature, they recommended using palpation of the acromioclavicular joint as a screening tool. Pain on palpation alone has a high sensitivity of 96% but a low specificity of just 10%. Incorporating this data into practice, pain on palpation of the AC joint could be used as a screening tool and then the Active Compression test could be used as a confirmatory test. Evidence Box 2 Tests for AC joint pathology.

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