Master Shoulder Tests: Know the Author & Year for Each Technique

SHOULDER

● A TENDON TESTS

Speed’s test

Yergason’s test
Empty/full can tests
External rotation lag sign
Lift-off sign 3

● B IMPINGEMENT TESTS

34

• Neer’s sign
  
  Hawkins–Kennedy impingement test
  Internal rotation resistance strength test
  Posterior impingement test
  ● C LABRAL TESTS

Crank test

Biceps load II test
Anterior slide test
SLAP prehension test
● D INSTABILITY TESTS

Apprehension and relocation test

Load and shift test
Norwood stress test
Sulcus sign
● E ACROMIOCLAVICULAR JOINT

(ACJ) TESTS

Active compression test
Scarf test 79
Shear test 81

● A TENDON TESTS

Speed’s test

• Aka
  
  Biceps test Straight arm test
• Purpose
  
  To identify biceps tendon pathology in the bicipital groove and unstable superior labral anterior posterior (SLAP) lesions.
• Technique
  
  Patient position
  Sitting or standing with the affected shoulder in 60–90° of forward flexion. The elbow is fully extended and forearm supinated.
  Clinician position
  Standing on the affected side, one hand stabilizes the patient’s shoulder while the other is placed on the anterior surface of the lower forearm.
  Action
  The patient is asked to maintain the start position as downward pressure on the lower forearm is applied by the clinician.
  Positive test
  Pain localized to the bicipital groove may indicate a tendinopathy or a true tenosynovitis of the long head of biceps. Deeper-seated pain may implicate biceps/labral complex injury.
  
  Fig. 2.1 ● Speed’s test.
• Clinical context
  
  A number of studies ( Bennett 1998 , Guanche & Jones 2003 , Parentis et al 2006 ) have evaluated the diagnostic accuracy of Speed’s test for biceps, general labral and SLAP lesions against a reference standard of arthroscopy in secondary and tertiary care populations with shoulder pain of mixed causes. None have found Speed’s test particularly useful at ruling biceps tendon pathology or unstable SLAP lesions either in or out ( Table 2.1).
  TABLE 2.1 SPEED’S TEST
  Author and year
  | LR +
  | LR–
  | Target condition
  Bennett 1998
  | 1.38
  | 0.96
  | Biceps or SLAP lesion
  Guanche & Jones 2003
  | 0.35
  | 1.23
  | Any SLAP lesion
  Kim et al 2003a
  | 1.48
  | 0.82
  | Any SLAP lesion
  Parentis et al 2002, 2006
  | 1.50
  | 0.76
  | Any SLAP lesion
  SLAP  superior labral anterior posterior
• Clinical tip
  
  It might be expected that a ruptured long head of biceps would result in painless weakness on Speed’s test but a more obvious diagnostic indicator is the so-called Popeye sign where a marked bulge appears just above the elbow on contraction of the biceps. More proximally the muscle is notably absent.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Speed’s test
  Used regularly if either a biceps or SLAP lesion is suspected.
• Variations
  
  The first written description of Speed’s test was by Crenshaw & Kilgore (1966), who cited as their source a personal communication with the test’s originator. Their description implied, but did not explicitly state, that the test should be performed isotonically
  against the tester’s resistance. The starting and finishing positions were not specified. Perhaps not surprisingly, interpretations have varied. The description used above mirrors that of Bennett (1998), which is clear and likely to be reproducible.
  

Yergason’s test

• Purpose
  
  To identify a lesion of the long head of biceps tendon or an unstable superior labral anterior posterior (SLAP) lesion.
• Technique
  
  Patient position
  Sitting or standing with the arm in the anatomical position.
  Clinician position
  Standing on the affected side, the examiner takes the forearm and flexes the elbow to 90° leaving the forearm in a pronated position. The elbow is stabilized with one hand, keeping the upper arm adjacent to the patient’s side. The heel of the hand is placed over the dorsal surface of the lower radius with fingers wrapped around the lateral aspect of the forearm in preparation to provide resistance.
  Action
  The patient moves the forearm into supination against resistance.
  Positive test
  Reproduction of the patient’s pain suggests the presence of a lesion of the long head of biceps or a SLAP lesion. If during the test the biceps tendon is felt to reproduce a ‘clicking’ sensation familiar to the patient, laxity or a tear of the transverse humeral ligament (that contains the tendon in the groove) should be suspected (see Fig. 2.2).
• Clinical context
  
  Yergason originally devised this manoeuvre for detecting bicipital tendinitis ( Yergason 1931) but it is now apparent that all parts of the tendon complex are loaded and pain may emanate from a genuine tenosynovitis (as the tendon passes through the bicipital groove), tendinopathy or a SLAP lesion (as the long head of biceps attaches to its glenoid-labral origin). It also tests the ability of the transverse humeral ligament to maintain the tendon in the groove. The biceps tendon can be involved in an isolated overuse injury in the younger population
  
  Fig. 2.2 ● Yergason’s test showing resisted supination.
  although it is most commonly associated with rotator cuff disease in the older patient.
  This test has found increasing acceptance in diagnosing SLAP lesions (see labral tests, p. 46). So much so, that studies exploring its diagnostic value have all measured its ability to detect labral injury rather than biceps pathology ( Guanche & Jones 2003 ; Oh et al 2008 ; Parentis et al 2002, 2006 ; Table 2.2).
  TABLE 2.2 YERGASON’S TEST
  Author and year LR + LR— Target condition
  Guanche & Jones 2003
  | 3.00
  ★
  | 0.92
  | Any SLAP lesion
  Oh et al 2008
  | 0.92
  | 1.01
  | Any SLAP lesion
  Parentis et al 2002, 2006
  | 1.86
  | 0.94
  | Any SLAP lesion
  SLAP  superior labral anterior posterior
• Clinical tip
  
  As an alternative, providing the elbow is fixed adequately between the waist/hips of the examiner and patient, the free hand can palpate over the bicipital groove at the shoulder to detect any abnormal subluxation or ‘snapping’ during the test.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Yergason’s test
  Used if instability of the biceps tendon in the groove or a SLAP lesion is suspected.
• Variations
  
  A commonly used variation of the original test has been described where the patient simultaneously moves the shoulder into external rotation and forearm supination against resistance. This is a more complex movement for patients to perform and getting them to rehearse it without resistance initially may help to elicit an effective test when resistance is added. Elbow flexion can also be added to the combined movement. As it was the original version of the test utilized in all the studies, any perceived additional benefit of using this variation must therefore be speculative.
• Related tests
  
  Moving the biceps tendon from side to side in the bicipital groove ( Lippman’s test ) may expose localized tenderness or more usefully identify excess movement of the tendon, suggesting laxity or a tear of the transverse humeral ligament. The tendon is easily palpated between the greater and lesser tuberosities with the shoulder in the anatomical position and the elbow flexed to 90°; however, many of the tendons around the shoulder are tender on palpation and, where tenderness is used as a primary indicator, the possibility of recording false positives is very high.
• Gilchrest’s sign is positive when pain and/or snapping over the bicipital groove is elicited as the affected shoulder is lowered from a fully elevated position, through abduction, with the arm externally rotated and holding a 2 kg weight. This finding also points towards a bicipital lesion. The pain and snapping are most likely to appear when the arm is in the mid-position.
  
  Injury to the biceps insertion on the radial tuberosity can be detected by resisting elbow flexion with the forearm in a pronated position. Normally the biceps would assist brachialis in flexing the elbow and generate some supination of the forearm in the process – a feature known as Heuter’s sign . A biceps insertional tear will inhibit the extent of the flexion/supination contraction, leaving brachialis
  to generate the bulk of flexion power and resulting in an obvious absence of supination, i.e. a negative Heuter’s sign.
• Ludington’s test requires the patient to place both hands on top of the head with the fingers interlocked. The patient then contracts and relaxes the biceps on both sides as the clinician attempts to palpate the biceps tendon proximally. If it is not possible to palpate the tendon on the affected side, a complete rupture of the long head is possible.
  
  

Empty/full can tests

• Aka
  
  Supraspinatus strength test Jobe’s test
  Scaption test
• Purpose
  
  To detect the presence of supraspinatus tendinopathy, a partial/ complete tear or neurogenic weakness of supraspinatus.
• Technique
  
  Patient position
  Standing or sitting on the edge of a treatment couch.
  Clinician position
  Standing on the affected side facing the patient.
  Action
  The shoulder is passively elevated to 90° in the scapular plane and taken into full internal rotation with the forearm in pronation so that the thumb is pointing to the floor (empty can test, Fig. 2.3 ). The clinician stabilizes the scapula with one hand and places the other on the upper surface of the patient’s forearm. Downward pressure is then applied to the arm while the patient maintains this position. The test is then repeated with the arm externally rotated so that the thumb points upwards (full can test, Fig. 2.4).
  Positive test
  Reproduction of the patient’s pain without weakness is suggestive of supraspinatus impingement or tendinopathy while painful weakness may indicate a partial or complete tear.
  
  Fig. 2.3 ● Empty can test.
  
  Fig. 2.4 ● Full can test.
• Clinical context
  
  In an EMG study of normal subjects, the empty can and full can tests were shown to preferentially activate supraspinatus with the least co-activation of other muscles. The full can test was originally described in the context of strength assessment, not pain provocation ( Kelly et al 1996 ). Itoi et al (1999) compared the tests’ accuracy in diagnosing full thickness tears of supraspinatus and found them to be broadly equivalent. For strength assessment, however, the full can test is probably preferable, because its position is less likely to cause painful impingement and consequent inhibition ( Itoi et al 1999) (Tables 2.3–2.5).
  TABLE 2.3 PAIN ON THE TEST
  Author and year
  | Empty can
  | Full can
  | Target condition
  | LR +
  | LR —
  | LR +
  | LR —
  | Leroux
  et al 1995
  | 1.72
  | 2.8
  | |
  | Shoulder impingement syndrome
  Itoi et al 1999
  | 1.40
  | 0.67
  | 1.83
  | 0.53
  | Full thickness tear of supraspinatus
  TABLE 2.4 WEAKNESS ON THE TEST
  Author and year
  | Empty can
  | Full can
  | Target condition
  | LR +
  | LR —
  | LR +
  | LR —
  | Hertel
  et al 1996
  | 2.00
  
  | 0.38
  
  | |
  | Partial or full thickness tear of the postero superior rotator cuff
  Itoi et al 1999
  | 2.40
  
  | 0.34
  
  | 2.96
  
  | 0.31
  
  | Full thickness tear of supraspinatus
  TABLE 2.5 PAIN OR WEAKNESS OR BOTH
  Author and year
  | Empty can
  | Full can
  | Target condition
  | LR +
  | LR —
  | LR +
  | LR —
  | Holtby & Razmjou 2004
  | 1.36
  | 0.84
  | |
  | Full thickness tear of supraspinatus
  Itoi et al 1999
  | 1.78
  | 2.2
  | 2.00
  
  | 0.25
  
  | Full thickness tear of supraspinatus
• Clinical tip
  
  Weakness in the absence of any pain may result from a C5 palsy, suprascapular neuropathy or Parsonage–Turner syndrome, a viral neuritis affecting the brachial plexus.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Empty/full can test
  Gives a good indication of a cuff tear or impingement.
• Related tests
  
  In his seminal book on the shoulder, Codman (1934) vaguely described a test which has since become known as Codman’s test or the drop arm test . If positive it is suggestive of a full thickness tear of the rotator cuff with the supraspinatus tendon the most likely culprit. Conventionally, the patient is asked to actively lower the arm, under control, from above 90° in the sagittal plane. He or she will be unable to do so if supraspinatus is completely ruptured; instead, the arm will drop.
  

External rotation lag sign

• Aka
  
  Infraspinatus spring back test
• Purpose
  
  To assess the integrity of the infraspinatus tendon and expose weakness associated with suprascapular neuropathy.
• Technique
  
  Patient position
  Sitting or standing with the affected arm in a dependent position with the elbow flexed to 90°.
  Clinician position
  The clinician stands adjacent to the affected side, using one hand to support the patient’s elbow and the other to take hold of the patient’s arm just above the wrist. The shoulder is passively elevated 20° in the scapular plane, then taken to about 5° short of full external rotation ( Fig. 2.5A).
  Action
  Still supporting the patient’s elbow, the tester asks the patient to maintain the external rotation, and then releases the wrist ( Fig. 2.5B).
  Positive test
  A positive test is recorded if the patient is unable to maintain the rotated position and there is a ‘lag’ or ‘spring back’ towards the start position.
  A
  B
  
  
  
  
  Fig. 2.5 ● Starting position of external rotation lag sign with the shoulder held passively in position (A). A positive test is indicated by the arm ‘springing back’ towards the neutral position as the clinician releases the wrist (B).
• Clinical context
  
  A lag of 5–10° may indicate a complete tear of infraspinatus or supraspinatus. A 10–15° lag is strongly suggestive of a tear of both tendons or may result from neuropathy. This sign is one of several lag signs used to identify and evaluate rotator cuff tears as opposed to painful tendinopathies ( Hertel et al 1996).
  The diagnostic accuracy of the external rotation lag sign (ERLS) was evaluated in 87 patients with either a partial or complete rupture of supraspinatus, infraspinatus, a combination of both or a massive cuff tear (also involving the subscapularis) and a sensitivity of 70% and a specificity of 100% were reported ( Hertel et al 1996 ; Table 2.6).
  TABLE 2.6 EXTERNAL ROTATION LAG SIGN
  Author and year
  | LR +
  | LR —
  | Target condition
  Hertel et al 1996
  | 70.00
  
  | 0.30
  
  | Partial or full thickness tear of the postero superior rotator cuff
• Clinical tip
  
  According to the test’s originators, a lag as small as 5° may be detectable with practice, especially on the basis of a contralateral
  comparison. However, they caution against false positive and negative results due to reduced (e.g. capsular limitation) or increased (e.g. supraspinatus rupture) range of movement. Suprascapular palsy would also give a false positive result for cuff rupture.
  The mechanism of rotator cuff degeneration is such that the presence of an infraspinatus tear is very likely to be accompanied by a rupture to the supraspinatus tendon. It is therefore necessary to fully evaluate the integrity of the whole rotator cuff using the associated special tests and further investigations if appropriate.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | External rotation lag sign
  Used regularly to assess the rotator cuff providing the patient has enough range of external rotation to adopt the start position without pain.
• Variations
  
  The drop sign repeats the ERLS in 90° of abduction in the scapular plane ( Hertel et al 1996 ). Again, an inability to maintain the position signifies an infraspinatus tear or neuropathy. This test is unsuitable for patients with stiff shoulders ( Table 2.7).
  TABLE 2.7 DROP SIGN
  Author and year
  | LR +
  | LR —
  | Target condition
  Hertel et al 1996
  | 21.00
  
  | 0.79
  | Partial or full thickness tear of the postero superior rotator cuff
  The ‘ signe de Clairon’ or Patte’s test is a variation of the drop sign and is intended to isolate lesions of the smaller external rotator of the shoulder, teres minor. The patient’s shoulder is placed in the same start position but the examiner, standing on the affected side and slightly behind the patient, stabilizes the flexed elbow and adds resistance to external rotation by placing the other hand on the posterior aspect of the lower forearm. A positive test, pain and/ or weakness, is thought to indicate a tear of teres minor although,
  because infraspinatus is largely inseparable anatomically and functionally, an isolated tear is improbable.
  The hornblower’s sign is an indication of major posterior cuff disruption, i.e. a tear of infraspinatus and teres minor. The patient is unable to externally rotate the abducted arm so when asked to take both hands simultaneously to the mouth (as if holding a wind instrument) the position cannot be maintained on the affected side and the shoulder falls into an internally rotated position. The same demands on the rotator cuff are made by the professional darts player, who requires a combination of abduction and external rotation to position the shoulder in preparation for throwing a dart.
  

Lift-off sign

• Aka
  
  Gerber’s test Gerber’s lift-off test
  Internal rotation lag sign
  Medial rotation ‘spring back’ test
• Purpose
  
  To test for a partial or complete tear of subscapularis.
• Technique
  
  Patient position
  Standing or sitting on the edge of a treatment couch with the shoulder internally rotated so that the dorsum of the hand rests against the mid-lumbar spine.
  Clinician position
  Standing behind the patient, the distal end of the patient’s forearm is lifted away from the lumbar spine, so that the shoulder is fully internally rotated.
  Action
  With the arm passively ‘lifted off’, the patient is asked to maintain the position without extending the elbow as the support of the cli-nician’s hand is removed.
  Positive test
  An inability to maintain the lifted-off position signifies a complete tear of the subscapularis tendon.
  
  Fig. 2.6 ● Starting position of the lift-off sign.
• Clinical context
  
  Kelly et al (1996) reported Gerber’s ‘lift-off’ position ( Gerber & Krushell 1991) to be optimal for subscapularis contraction and this was supported by another study which demonstrated that the upper and lower subscapularis could produce a 70% maximal voluntary contraction when tested in this position while the other muscles (posterior deltoid, pectoralis major, infraspinatus, latissimus dorsi, teres major and serratus anterior) showed significantly lower levels of activity ( P _0.05). The test performed with the hand in the mid-lumbar spine produced one third more EMG activity than with the hand over the sacrum. When resistance was added to the standard test (see Gerber push-off test below), there was an increase in the activity of all muscles, though only a small increase in the activity of the pectoralis major muscle (which was significantly more active during resisted internal rotation with the arm at the front of the body) ( Greis et al 1996).
  In contrast, however, EMG and nerve block analysis were used to evaluate the activity of the subscapularis tendon in four positions (of increasing degrees of internal rotation), although none of these tested positions were the same as that originally defined by Gerber. EMG activity was identified in latissimus dorsi, posterior deltoid, the rhom-boids as well as subscapularis in what was described inaccurately
  as the conventional test position. With a subscapular nerve block in place the subjects were still able to perform the ‘lift-off’ sign, casting doubt over the validity of the test. The only tested position that could not be maintained with the nerve block in place was in maximum internal rotation, leading the authors to propose the maximum internal rotation lift-off test to be optimum for the detection of subscapularis tears ( Stefko et al 1997). However, the original test position (with the hand at the mid-lumbar level) was not evaluated and, when taken alongside the fact that the maximum internal rotation position is unattainable for many patients, the clinician should be wary about discarding the original test in favour of this variant.
  The original study that reported the lift-off sign demonstrated high levels of sensitivity and specificity although the authors conceded that the validity of the test is reliant on the existence of full passive internal rotation and that active range is not significantly limited by pain. An inability to ‘lift-off’, increased external rotation range and weakness of internal rotation were all reported to be indicative of a full thickness tear of subscapularis ( Gerber & Krushell 1991 ). In contrast, an independent evaluation of its diagnostic accuracy in a larger population, reported lower levels of sensitivity and specificity ( Kim et al 2003b). This highlights a tendency in the literature for originators of diagnostic tests to report higher levels of sensitivity and specificity than independent assessors; this may be due to various factors including differing levels of technical proficiency in applying and interpreting the test.
  TABLE 2.8 LIFT-OFF SIGN
  Author and year
  | LR +
  | LR —
  | Target condition
  Hertel et al 1996
  | 62
  
  | 0.38
  
  | Any lesion (including ruptures, whether partial or complete) of subscapularis
  Gerber & Krushell 1991
  | 88
  
  | 0.12
  
  | Full thickness tear of subscapularis
  Kim et al 2003b
  | 1.70
  | 0.92
  | Full thickness tear or joint side partial thickness tear of subscapularis
  Leroux et al 1995
  | 0.00
  | 1.64
  | Any lesion of subscapularis
• Clinical tip
  
  A partial tear is denoted by a limited ability to maintain the lifted-off position, such that the arm drops back less than 5° ( Gerber et al 1996 , Hertel et al 1996).
  If there is inadequate range to perform the lift-off sign , the alternative belly-press test (see Variations) may be used to identify weakness of the subscapularis tendon.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Lift-off sign
  Gives a good indication of a subscapularis tear, particularly if there are only subtle signs on examination. However, many patients with impingement and cuff pathology find the degree of internal rotation painful, which limits its usefulness in patients with significant/ acute pain or with limited shoulder range.
• Variations
  
  The belly-press test or Napoleon test has the patient seated with the palm of the hand pressing against the abdomen while keeping the shoulder in full internal rotation. The test is positive if this position cannot be maintained and the elbow swings posteriorly as the patient attempts to compensate by pulling the hand against the abdomen ( Gerber et al 1996). In a study of 25 patients listed for surgical repair of the subscapularis tendon, the findings of the belly-press test pre-operatively were compared with the findings in theatre ( Burkhart & Tehrany 2002). Of nine patients with positive tests, eight had complete tears. Positive tests correlated with full thickness, full-width tears of the tendon while negative tests were recorded in patients whose tears only involved the upper half of the tendon. As a modification, the clinician interposes one hand between the patient’s hand and the abdomen so that the amount of pressure the patient is able to exert can be gauged, although its value is speculative. Some clinicians modify further by bringing the elbow forward into the scapular plane, thereby increasing the degree of internal rotation while ensuring the patient keeps the wrist in a neutral position.
  The Gerber push-off test ( Kelly et al 1996 ) may be used if the patient is able to maintain the ‘lift-off’ position. The patient is asked to maintain the lift-off position while the clinician applies an anteriorly directed force against the lower forearm ( Fig. 2.7). This
  
  Fig. 2.7 ● Gerber push-off test: isometric contraction of subscapularis.
  supplementary isometric action preferentially activates subscapularis ( Kelly et al 1996) and is a pain-provocative manoeuvre.
  
  ● B IMPINGEMENT TESTS

Neer’s sign

• Aka
  
  Forward flexion impingement test
• Purpose
  
  The primary purpose of the sign is to identify symptomatic subacromial impingement involving the rotator cuff, subacromial bursa and long head of biceps.
• Technique
  
  Patient position
  Sitting or standing with the arm in the anatomical position.
  Clinician position
  The clinician stands on the affected side and stabilizes the scapula with one hand and grasps the arm below the elbow with the other hand.
  Action
  The arm is then passively elevated into full flexion with the scapula stabilized.
  Positive test
  Pain is reproduced at the end of the passive elevation movement.
  
  Fig. 2.8 ● Neer’s sign.
• Clinical context
  
  In a cadaveric study, Neer (1972) noted a potential for impingement between the acromion and supraspinatus, infraspinatus and the long head of biceps with the arm in the test position in approximately 10% of specimens. He cautioned that while his sign could signify impingement, there were many other conditions that could also provoke pain during the manoeuvre and that full elevation and external rotation range should be present to eliminate the presence of capsulitis and reduce the possibility of recording false positive findings ( Neer 1983 , Neer & Welsh 1977). Neer recommended that the sign was re-evaluated after subacromial injection of local anaesthetic and, if the pain was relieved (a positive Neer’s test ), a diagnosis of subacromial impingement could be made.
  In a much more detailed cadaveric study ( Valadie et al 2000 ), Neer’s manoeuvre was also shown to consistently bring the subacromial soft tissues, including the long head of biceps, into contact with the coraco-acromial arch (subacromial impingement) and the internal aspects of supraspinatus and infraspinatus into contact with the glenoid rim (internal impingement), a finding confirmed in a large arthroscopic study which identified internal impingement in 74% of shoulders that had tested positive to Neer’s sign ( Kim & McFarland 2004 ). According to other cadaveric studies ( Flatow et al 1994 , Jobe 1997 ) and an MRI evaluation of normal subjects ( Roberts et al 2002 ), performing Neer’s sign in the scapular plane appears to cause more internal impingement, although clinically no study has demonstrated higher levels of sensitivity or specificity in the diagnosis of subacromial impingement by altering the plane of elevation ( Kim & McFarland 2004 , Naredo et al 2002 , Parentis et al 2002, 2006).
  Neer himself regarded his eponymous sign as uninformative unless it was abolished by injection of local anaesthetic under the acromial arch. Several studies have evaluated the diagnostic accuracy of Neer’s sign ( Kim & McFarland 2004 , MacDonald et al 2000 , Parentis et al 2002, 2006) for a range of shoulder pathology, overlooking its origin as an impingement test as well as failing to evaluate Neer’s confirmatory test . The work done by Suder et al (1994), however, allowed head to head comparison of both sign and test in the same sample of patients. For each target condition of interest, performing the test after the sign resulted in decreased sensitivity and increased specificity, however, it was only in relation to full thickness tears that a positive sign and test provided sufficiently strong evidence to rule in the diagnosis with some degree of confidence.
  Types of impingement ( Magee 2008)
  Primary (outlet)
  Mechanical compression of the bursal/ superior side of the rotator cuff mainly involving the supraspinatus tendon.
  Because the impingement occurs anteriorly around the supraspinatus outlet region, primary impingement is sometimes known as anterior or outlet impingement syndrome
  | Intrinsic
  e.g. degeneration of the cuff
  Extrinsic
  e.g. where the shape of the acromion negatively impacts on the ability of
  Neer described three stages of primary impingement characterised by:
  Stage I reversible oedema and haemorrhage of the rotator cuff often seen in the younger patient.
  Stage II fibrosis occurring as a result of the ageing and degenerative process, and,
  Stage III bone spur development & tendon rupture
  | the greater tuberosity 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 which in turn results in abnormal movement patterns and anterior impingement
  Internal (non-outlet)
  Results from injury to the undersurface of the rotator cuff or the glenoid labrum caused by impingement of the supraspinatus and infraspinatus tendons between the posterosuperior aspect of
  the glenoid rim and the humeral head. The impingement occurs posteriorly and is sometimes known as non-outlet impingement
  TABLE 2.9 NEER’S SIGN
  Author and year
  | LR +
  | LR —
  | Target condition
  Suder et al 1994
  | 2.5
  
  | 0.19
  
  | Full thickness tear of rotator cuff
  Suder et al 1994
  | 0.73
  | 1.27
  | Labral tear
  Suder et al 1994
  | 1.93
  | 0.51
  | Joint side partial thickness tear of rotator cuff
  TABLE 2.10 NEER’S TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  Suder et al 1994
  | 0.00
  | 1.11
  | Labral tear
  Suder et al 1994
  | 7.50
  
  | 0.89
  | Full thickness tear of rotator cuff
• Clinical tip
  
  Having established the presence of impingement at the shoulder, the clinician can then evaluate further to establish whether this is an internal or primary impingement (see posterior impingement test, p. 44, internal rotation resistance strength test, p. 42) as well as ascertaining any predisposing factors such as abnormal kinematics resulting from poor muscle control or labral injury (see crank test, p. 46).
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Neer’s sign/test
  This helps to form part of the total picture but is non-specific. If other tests, including
  ultrasonography, have been inconclusive, using local anaesthetic as a confirmatory test can be useful.
• Variations
  
  Many clinicians modify Neer’s manoeuvre by maintaining internal rotation at the shoulder throughout elevation ( flexion–internal rotation test ). Although the intention is to position the insertions of both supraspinatus and infraspinatus so that they are more vulnerable to subacromial compression, an open MRI study of normal subjects showed that this position consistently resulted in internal rather than subacromial impingement ( Jobe 1996).
  Although speculative, further differential testing can be used to make a distinction between pain predominantly emanating from the cuff or bursa. Given their anatomical intimacy this is challenging, but pain arising from isometric testing of the supraspinatus and infraspinatus may lessen when the tests are repeated under distraction if the bursa is the main culprit due to the decompression effect in the subacromial area. For resisted abduction (supraspinatus) the patient is supine, distraction is applied in a neutral position, coun-terpressure applied on the opposite hip while resistance to isometric abduction of the shoulder is applied at the elbow ( Fig. 2.9 ). For resisted external rotation (infraspinatus) the same principles are applied; the upper arm is wedged between the patient’s waist and the examiner’s thigh and the elbow flexed to 90°. The examiner then interlocks the elbow with the patient’s to apply the distraction, while the outer hand is placed on the lateral border of the lower forearm to provide resistance ( Fig. 2.10).
  
  
  Fig. 2.9 ● Resisted shoulder abduction under distraction.
  Fig. 2.10 ● Resisted shoulder external rotation under distraction.
  

Hawkins–Kennedy impingement test

• Aka
  
  Hawkins impingement test
• Purpose
  
  The primary purpose of the test is to identify subacromial or internal impingement.
• Technique
  
  Patient position
  Sitting or standing with the arm relaxed in the anatomical position.
  Clinician position
  Standing adjacent to the patient on the affected side, one hand is placed under the elbow, the other holds just above the wrist. The elbow is flexed to 90° and the shoulder taken passively into 90° of forward flexion.
  Action
  The shoulder is passively taken into internal rotation thereby rotating the greater tuberosity under the coracoacromial arch.
  Positive test
  Pain is reproduced increasingly towards the end of the rotation movement and indicates rotator cuff pathology involving the cuff itself, the adjacent bursa or the long head of biceps. The glenoid labrum is also vulnerable in this test.
  
  Fig. 2.11 ● Hawkins–Kennedy impingement test.
• Clinical context
  
  MRI analysis shows that the Hawkins–Kennedy impingement test brings the rotator cuff insertions against the acromion ( Roberts et al 2002 ) so the subacromial bursa, overlying the tendons, must also be compressed in this position. A cadaveric study also showed that the bursal side of the cuff is very likely to contact the acromion or coraco-acromial ligament. In two of four specimens the bursal side of the cuff contacted the acromion; in all four the bursal side of the cuff or the long head of biceps contacted the coraco-acromial ligament; and in one of the four, subscapularis was distorted by the coracoid ( Valadie et al 2000).
  The Hawkins–Kennedy test may also have a role in identifying internal impingement, as it has been shown to cause pinching of the internal aspect of the damaged rotator cuff (particularly subscapularis) against the glenoid labrum ( Struhl 2002 , Valadie et al 2000).
  TABLE 2.11 HAWKINS-KENNEDY IMPINGEMENT TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  MacDonald et al 2000
  | 1.65
  | 0.19
  
  | Subacromial bursitis
  Naredo et al 2002
  | 2.38
  
  | 0.48
  
  | Subacromial impingement and subacromial bursitis
  Kim & McFarland 2004
  | 0.97
  | 1.10
  | Internal impingement in flexion
  Kim et al 2003a
  | 1.14
  | 0.77
  | Any SLAP lesion
  Parentis et al 2002, 2006
  | 0.94
  | 1.15
  | Unstable SLAP lesion
  Kim et al 2003b
  | 0.88
  | 1.20
  | Full thickness tear or joint side tear of subscapularis
  SLAP  superior labral anterior posterior
• Clinical tip
  
  A positive result is highly likely in the presence of a capsulitis which should therefore be excluded to avoid a false positive result.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Hawkins-Kennedy impingement test
  Used regularly but its lack of specificity means it can be positive not only in impingement problems but also acromioclavicular joint pathology and even posterior instability.
• Related tests
  
  The coracoid impingement sign is a modification of this test and is thought to increase the contact between the lesser tuberosity and the coracoid process during the manoeuvre. The arm is taken into the same start position but 10–20° of horizontal adduction is added before applying the internal rotation component.
  

Internal rotation resistance strength test

• Purpose
  
  To distinguish between primary impingement and internal impingement following a positive Neer’s sign/test.
• Technique
  
  Patient position
  Standing or sitting.
  Clinician position
  The clinician stands adjacent to and slightly behind the patient. The patient’s elbow is flexed to 90°, the shoulder abducted to 90° and externally rotated to approximately 80°. The weight of the arm is supported throughout the test by the clinician’s hand placed under the patient’s elbow. The free hand is placed over the dorsum of the lower forearm in order to apply resistance to external rotation.
  Action
  An isometric test to external rotation is first carried out by the patient with resistance applied by the clinician ( Fig. 2.12 ). The cli-nician’s hand then swaps onto the palmar aspect of the wrist and isometric internal rotation is performed ( Fig. 2.13). This is a test of comparative strength of internal and external rotation and so the unaffected arm does not need to be tested.
  Positive test
  Comparative weakness of internal rotation represents a positive test and is suggestive of internal impingement. If internal rotation is stronger, primary impingement should be suspected.
• Clinical context
  
  Primary impingement occurs as a result of mechanical compression of the bursal/superior side of the rotator cuff, mainly involving the supraspinatus tendon. Internal impingement results from injury to the undersurface of the rotator cuff or the glenoid labrum caused by impingement of the supraspinatus and infraspinatus tendons between the posterosuperior part of the glenoid rim and the humeral head when the arm is abducted to 90° and fully externally rotated. The condition is most common in the athlete involved in overhead throwing events (see Fig. 2.8).
  
  
  Fig. 2.12 ● Isometric external rotation. Fig. 2.13 ● Isometric internal rotation.‌
  A group of 115 patients, all of whom had a positive Neer’s sign, were secondarily tested using the internal rotation resistance strength test (IRRST) prior to arthroscopy. Patients with confirmed internal impingement on arthroscopy who had a positive IRRST gave a sensitivity of 88% and those with primary impingement on arthroscopy with a negative IRRST showed a specificity of 96%, suggesting that a positive test provides strong evidence for the presence of internal impingement with a negative test indicating its absence ( Zaslav 2001).
  TABLE 2.12 INTERNAL ROTATION RESISTANCE STRENGTH TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  Zaslav 2001
  | 22.25
  
  | 0.11
  
  | Internal vs subacromial impingement
• Clinical tip
  
  The test is easy to perform although further investigations may be required to assist the clinician in differentiating the type of impingement.
  

Posterior impingement test

• Purpose
  
  To test for internal impingement between the undersurface of the rotator cuff and the posterosuperior part of the glenoid labrum.
• Technique
  
  Patient position
  Lying supine towards the edge of the couch.
  Clinician position
  Standing adjacent to the patient, the clinician takes the affected shoulder passively to approximately 100° of abduction and about 10° extension, supporting the elbow with one hand and the lower forearm with the other.
  Action
  The shoulder is passively taken into full external rotation.
  
  Fig. 2.14 ● Posterior impingement test.
  Positive test
  Pain felt deeply in the posterior aspect of the shoulder may indicate posterior impingement.
• Clinical context
  
  Posterior internal impingement can occur in people who repeatedly position their arm in a combination of 90° abduction and external rotation (e.g. swimmers, throwers, painters and decorators), particularly where high load and velocity are involved. This position causes the articular aspect of the rotator cuff tendons to become pinched between the humeral head and the posterosuperior part of the glenoid labrum. The internal rotation resistance strength test (see p. 42) can help in making a distinction between internal and primary impingement.
• Clinical tip
  
  Internal impingement can occur in conjunction with shoulder instability, the test position being very similar to the apprehension test (see p. 56) ( Jobe et al 1989), so a positive test should be interpreted in the light of the patient’s history and other examination findings.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Posterior impingement test
  Diagnosis of internal impingement based on clinical examination alone is difficult and MRI/arthroscopy are usually required to make a definitive diagnosis.
• Variations
  
  The modified subluxation/relocation test for posterosuperior glenoid impingement ( Hamner et al 2000 ) is conducted in three positions of abduction: 90°, 100° and 120°. In each position the clinician applies an anterior, then a posterior force to the patient’s upper humerus. A positive response for posterosuperior glenoid impingement is pain (not apprehension) on the anteriorly directed force, which is relieved when the force is directed posteriorly ( Fig. 2.15).
  
  Fig. 2.15 ● Modified subluxation/reloca-tion test with an anteriorly directed force in 90° abduction.
  ● C LABRAL TESTS

Crank test

Aka

Labral crank test Compression rotation test
Purpose

To assess for an unstable superior labral anterior posterior (SLAP) lesion.
Technique

Patient position
Supine or sitting with the elbow flexed to 90°.
Clinician position
Standing adjacent to the affected shoulder, holding the patient’s flexed elbow and forearm.
Action
The patient’s arm is passively elevated in the scapular plane to full range. While applying a gentle axial load through the longitudinal axis of the humerus, the shoulder is taken into full external ( Fig. 2.16A ) and then internal ( Fig. 2.16B) rotation using the forearm as a lever.
Positive test
The patient’s pain, a catching sensation, painful clicking or a combination of these are considered positive indicators of a labral tear and are most likely to be elicited during the external rotation part of the test.
A
B




Fig. 2.16 ● Crank test in external rotation (A) and internal rotation (B). Arrows indicate direction of axial compression.
Clinical context

The glenoid labrum can be damaged at various parts of its circumference. Bankart lesions occur anteriorly as a result of anterior dislocations of the shoulder, GLAD (gleno-labral articular disruption) lesions occur antero-inferiorly through a forced adduction injury from an abducted and externally rotated position (Nevasier 1993) and the commonly reported SLAP lesions involve the superior labrum. Advances in imaging and arthroscopic techniques have improved the accuracy of labral injury identification, even allowing natural
variants of the labrum to be distinguished from true tears ( Liu et al 1996 ). SLAP lesions have been graded as follows ( Snyder et al 1990):
Type
| SLAP definition
| ---|---|
I
| There is fraying of the superior labrum which is probably degenerative and usually asymptomatic
II
| The superior labrum and attached long head of biceps have become detached from the glenoid
III
| There is a bucket-handle tear of the superior labrum, and the ‘handle’ can fold in on itself and displace into the joint
IV
| Similar to type III, except that the long head of biceps is attached to the ‘handle’; consequently, when the handle displaces into the joint, the proximal end of the biceps tendon goes in with it
A tear in the glenoid labrum is the most frequent cause of the ‘clicking’ shoulder, when accompanied by pain and a loss of function, particularly in the younger patient. The onset of symptoms often occurs as a result of repeated overarm sporting activities causing fatigue of the stabilizing cuff muscles, which then allows excessive translation of the humeral head over the labrum, resulting in a tear. The forceful eccentric contraction of the biceps during throwing (in which the biceps is attempting to decelerate the rapidly extending elbow) is also a known mechanism of injury ( Andrews et al 1985). Trauma, such as a fall on an outstretched arm where the superior labrum becomes ‘trapped’, can also generate symptoms.
There is a strong correlation between labral tears and other symptoms at the shoulder ( Liu et al 1996 ). In an arthroscopic study of 100 shoulders, 68% of patients with impingement symptoms were found to have superior labral tears whereas 92% of patients with recurrent anterior instability had antero-inferior tears identified ( Hurley & Anderson 1990).
Patients with functional instability report catching and locking of the shoulder during movement and feel unable to ‘trust’ their shoulder, particularly when loading the arm in elevated positions. It is thought that these symptoms result from the partially attached labral fragment becoming temporarily interposed between the articulating surfaces of the glenoid and humeral head, thereby
giving the transient but functionally impairing symptoms ( Pappas et al 1983).
The crank test combines axial loading with rotation movements and is broadly analogous to McMurray’s test at the knee. The first researchers to evaluate it were its originators ( Liu et al 1996 ), who reported a very high sensitivity and specificity, commensurate with impressive positive and negative likelihood ratios. On this basis, the crank test would be a very useful clinical tool, both in terms of a positive result ruling a SLAP lesion in and of a negative result ruling one out. Unfortunately these promising results have not been replicated in subsequent, independent studies ( Guanche & Jones 2003 , Parentis et al 2006 , Stetson & Templin 2002). In spite of this, the crank test remains popular among clinicians.
For the purposes of reporting, the following distinctions have been made in order to accurately represent the research relating to labral testing:
Type
| Labral injury definition
| ---|---|
Labral injury
| The study specifies a labral lesion but not a SLAP lesion specifically as the target condition
Unstable SLAP lesion
| The study specifies type II, III or IV or any combination of these as the target condition
Any SLAP lesion
| The study specifies SLAP lesions as the target condition, but does not specify a type
TABLE 2.13 CRANK TEST
Author and year
| LR +
| LR —
| Target condition
Liu et al 1996
| 13.00

| 0.10

| Labral injury
Stetson & Templin 2002
| 0.96
| 1.04
| Labral injury
Guanche & Jones 2003
| 1.18
| 0.91
| Any SLAP lesion
Parentis et al 2002, 2006
| 0.53
| 1.10
| Any SLAP lesion
SLAP  superior labral anterior posterior
Clinical tip

Controlling the compression element of the test is likely to be easier with the patient supine.
EXPERT OPINION
| COMMENTS
| ---|---|

| Crank test
Taken in the context of the patient’s history and other physical findings, this test is helpful, although MRI or arthroscopy is usually needed to identify the type of SLAP lesion.
Variations

The clunk test predated the crank and has subsequently been superseded by this more reliable variation. Descriptions of the clunk test varied widely, making reliable reproduction and analysis difficult. With the patient lying supine, the shoulder is abducted to about 160° ensuring that the upper arm is supported on the couch in order to help control the movement. An anterior force is applied on the posterior aspect of the humeral head as external and internal rotation movements are gently applied using the flexed elbow as a lever. As the rotation movement is applied the patient may feel a ‘clunk’ as the humeral head rotates over the disrupted or detached labrum and this may elicit pain and/or apprehension. Different sections of the labrum can be stressed by altering the degree of abduction during the test and although this cannot accurately localize a tear, a positive finding at any point through this range would increase the index of suspicion for a labral injury.
The compression/circumduction test keeps the shoulder at 90° abduction with the elbow flexed to 90°. A compressive force is applied along the line of the humerus while circumduction is carried out, producing a scouring action on the labrum. A positive test reproduces the patient’s familiar pain and/or a clunk.

Biceps load II test

• Purpose
  
  To assess for an unstable superior labral anterior posterior (SLAP) lesion.
• Technique
  
  Patient position
  Lying supine towards the side of the couch.
  Clinician position
  Standing adjacent to the affected shoulder, the patient’s elbow is flexed to 90° and with one hand placed just above the elbow joint and the other supporting the lower forearm, the arm is abducted to 120° before full external rotation is applied. The forearm is positioned in as much supination as possible in order to achieve maximum stress on the long head of biceps tendon during testing.
  Action
  Isometric resistance is given to elbow flexion in this position.
  Positive test
  Shoulder pain provoked by resisted elbow flexion.
  
  Fig. 2.17 ● Biceps load II test.
• Clinical context
  
  According to Kim et al (2001), the starting position for the biceps load II test creates an oblique angle between the long head of biceps
  tendon and the posterosuperior glenoid labrum, accentuating the pain caused when the muscle contracts and simultaneously pulls on its attachment at the labrum. Indeed, the test replicates the winding up action prior to a throw, one of the mechanisms by which SLAP lesions are believed to be produced ( Burkhart & Morgan 1998).
  See the crank test for further labral clinical context (p. 46).
  TABLE 2.14 BICEPS LOAD II TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  Kim et al 2001
  | 30.00
  
  | 0.10
  
  | Any SLAP lesion
  SLAP  superior labral anterior posterior
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Biceps load II test
  The labral tests can only be used accurately if the patient is able to relax sufficiently to attain the starting position of the test.
  

Anterior slide test

• Purpose
  
  To assess for an unstable superior labral anterior posterior (SLAP) lesion.
• Technique
  
  Patient position
  Standing or sitting with the hand resting on the waist (iliac crest) with the thumb directed backwards.
  Clinician position
  Standing behind the patient, one hand is placed over the top of the scapula to stabilize while the other hand cups the elbow.
  Action
  The patient is instructed to keep the arm exactly where it is and resist the pressure applied by the examiner which comes from a
  
  Fig. 2.18 ● Anterior slide test.
  combined anterior and superiorly directed force applied by the hand on the patient’s elbow.
  Positive test
  If torn, the superior labrum is unable to resist forward displacement of the humerus as the force is applied and either apprehension is evoked or the humeral head shifts anteriorly causing pain and/or a click at the front of the shoulder as it rides over the labral tear. This will be reminiscent of the symptoms provoked by functional movements such as overarm activity.
• Clinical context
  
  In studies where the test was evaluated pre-arthroscopically, it was found to be highly specific for superior labral lesions ( Kibler 1995 , Parentis et al 2006 ). Overhead athletes often have reduced active and passive internal rotation of the shoulder. This limitation enhances the anterior translation of the humeral head during the test, which then exposes the superior labrum and biceps origin to further stress, making it a useful additional test for this category of patient.
  Its originator ( Kibler 1995) recommended against relying on its findings completely and suggested that it should be used in
  TABLE 2.15 ANTERIOR SLIDE TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  Kibler 1995
  | 9.75
  
  | 0.24
  
  | Unstable SLAP lesion
  Parentis et al 2002, 2006
  | 0.81
  | 1.04
  | Any SLAP lesion
  SLAP  superior labral anterior posterior
  conjunction with other special tests (crank, p. 46; active compression, p. 76; SLAP prehension, p. 54; and biceps II load, p. 50, tests) and in the light of the patient’s history.
  See the crank test for further labral clinical context (p. 46).
• Clinical tip
  
  According to its originator, this test is not difficult to learn, because it does not require accurate positioning ( Kibler 1995).
  

SLAP prehension test

• Aka
  
  Slapper test
• Purpose
  
  To assess for an unstable superior labral anterior posterior (SLAP) lesion.
• Technique
  
  Patient position
  Standing or sitting.
  Clinician position
  Standing adjacent to the affected arm and observing the patient’s response to the test. The clinician can place their hand over the shoulder to palpate for a click.
  Action
  The patient elevates the affected shoulder in the scapular plane to 90°, with the elbow extended and the forearm fully pronated, and
  horizontally adducts the arm across the chest ( Fig. 2.19A ). The presence of pain is noted and the arm is returned to the abducted start position. The same movement is then repeated with the forearm in supination and any pain noted ( Fig. 2.19B).
  Positive test
  Localized anterior shoulder pain, sometimes combined with an audible or palpable click that is more pronounced during the first test, is suggestive of an unstable SLAP lesion.
  A
  B
  
  
  
  
  Fig. 2.19 ● SLAP prehension test in pronation (A) and supination (B).
• Clinical context
  
  This test supposedly replicates the action of turning a steering wheel –the activity two patients reported as reproducing their shoulder pain ( Berg & Ciullo 1998 ). Their shoulders were evaluated further in theatre and both were found to have unstable SLAP lesions. The test was seen to cause the proximal part of the long head of biceps, and the labral fragment to which it was connected, to flip into the joint. This caused the test’s originators to postulate that the horizontal adduction movement has the capacity to trap an unstable biceps tendon and its labral fragment between the glenoid fossa and the head of the humerus. The pronation component increases the strain (and therefore pain) through the long head of biceps tendon with supination having the opposite effect ( Berg & Ciullo 1998).
  See the crank test for further labral clinical context (p. 46).
• Clinical tip
  
  The functional nature of this test (turning a steering wheel) makes it an easy one for the clinician to remember!
  ● D INSTABILITY TESTS

Apprehension and relocation test

Aka Subluxation/relocation test Jobe relocation test

Fowler’s sign Apprehension test Apprehension crank test
Purpose

To detect anterior instability of the glenohumeral joint.
Technique

This test has two distinguishable components: apprehension and relocation.
1. ### Apprehension
Patient position
Lying supine with the elbow flexed to 90°.
Clinician position
Standing by the couch on the affected side, one hand holds the lower forearm while the other supports above the elbow.
Action
The arm is abducted to 90° and the shoulder is then slowly externally rotated to 90° ( Fig. 2.20A ). This position may be enough to make the shoulder feel unstable and elicit a positive response from the patient, negating the need to proceed with the test further. If a positive response is not given, the hand supporting the elbow is then moved to the posterior aspect of the humeral head and an anteriorly directed force can then be applied to further challenge the stability of the shoulder ( Fig. 2.20B).
Positive test
The test is considered positive for anterior glenohumeral instability if the patient registers apprehension during the manoeuvre or resists attempts to move the shoulder further. The patient may also recognize the sensation as being similar to the original injury or episodes subsequently.
A
B




Fig. 2.20 ● If a positive test is not elicited by the combined action of abduction and external rotation (A), an anteriorly directed force can be applied to the humeral head (B).
2. ### Relocation
Action
The patient’s shoulder position of 90° abduction and external rotation is maintained and the clinician re-positions the heel of their hand over the anterior aspect of the humeral head and applies a firm posteriorly directed force ( Fig. 2.21).
Positive test
With the relocation, the feeling of apprehension lessens and the degree of external rotation available usually increases before further apprehension is provoked.

Fig. 2.21 ● Posteriorly directed (relocation) force over the anterior aspect of
the humeral head.
Clinical context

The apprehension component of the test, which is often considered as a separate test in itself, mimics the position most likely to cause acute shoulder dislocation (i.e. abduction, extension and external rotation), although more prolonged or habitual exposure to the same position in swimmers and plasterers, for example, can cause more subtle glenohumeral instability.
As the name implies, apprehension is the key finding for this test and a number of studies have shown that the diagnostic accuracy for shoulder instability improves if apprehension, rather than pain, is considered to be positive ( Farber et al 2006 , Hegedus et al 2008 , Liume et al 2004, Lo et al 2004 , Speer et al 1994 ). Interestingly, inter-rater reliability is also greater when apprehension, not pain, is assessed by clinicians ( Tzannes et al 2004 ). The anteriorly directed force on the humerus during the subluxation part of the test has also been reported to increase the specificity and sensitivity of the test ( Jobe & Bradley 1989 , Speer et al 1994).
The test position also stresses numerous other structures and a primary report of pain, rather than apprehension, should cast suspicion on other possible lesions. Patients with rotator cuff pathology are more likely to report increased pain in the apprehension position than patients with an instability problem and this would be expected to diminish when taken into the relocation position ( Speer et al 1994 ). Further, the test has also been reported to be 44% sensitive and 87% specific in diagnosing labral tears ( Guanche & Jones 2003).
Clinical tip

Because pain may be the primary finding due to rotator cuff or labral involvement, it is essential that the clinician questions the patient carefully to establish whether it is pain or apprehension that is reproduced during the test, apprehension being a significant pointer to instability.
It may be necessary to repeat the test in varying degrees of external rotation and abduction, particularly if the patient is excessively mobile or habitually uses their shoulder in extreme positions of abnormal range.
Eliciting a positive response to all three components of this test –apprehension, relocation and the ‘surprise’ element (see Surprise test) – increases the probability of anterior instability being present ( Hegedus et al 2008 , Lo et al 2004).
TABLE 2.16 APPREHENSION & RELOCATION TEST
Author and year
| Finding
| Apprehension Relocation Surprise test test test
| Target condition
| LR +
| LR —
| LR +
| LR —
| LR +
| LR —
| Speer et al 1994
| Apprehension
| |
| 57

| 0.33

| |
| Anterior glenohumeral instability
Pain
| |
| 0.71
| 1.2
| |
Farber et al 2006
| Apprehension
| 20.2

| 0.29

| 10.4

| 0.2

| |
| Anterior glenohumeral instability
Pain
| 1.14
| 0.8
| 3.02

| 0.77
| |
Lo et al 2004
| Pain +
Apprehension
| 53

| 0.99
| 1.0
| 0.99
| 58

| 0.37

| Anterior glenohumeral instability
Liume et al 2004
| Unspecified
| |
| 6.5

| 0.18

| 8.3

| 0.09

| Anterior glenohumeral instability
Gross & Distefano 1997
| Pain
| |
| |
| 8.3

| 0.09

| Anterior glenohumeral instability

Instability tests
59
EXPERT OPINION
| COMMENTS
| ---|---|

| Apprehension & Relocation test
Helpful when used in combination with the sulcus and Rowe tests to assess for shoulder instability. In addition, glenohumeral abduction in excess of 120° with the scapula fixed can also indicate instability.
Variations

The apprehension/crank/fulcrum test can be performed for convenience in sitting or standing ( Fig. 2.22). The examiner stands adjacent to the affected side and slightly behind the patient. The arm is taken into 90° of abduction and full external rotation with one hand while the thumb of the other hand applies the anterior pressure on the back of the humeral head. The fingers are positioned anteriorly to assess the extent of anterior translation and to provide some restraint in the event of a sudden shift forwards.

Fig. 2.22 ● Apprehension/ crank/fulcrum test.
The surprise test can be included as part of the apprehension and relocation manoeuvre. The patient’s arm is taken into the test start position and a posteriorly directed pressure on the front of the shoulder is applied with the heel of the hand. With the arm abducted and fully externally rotated, the stabilizing hand is then suddenly released, eliciting significant apprehension, pain and rapid anterior translation of the humeral head. It has been described as the single most accurate test for anterior instability ( Lo et al 2004), although caution and clinical judgement regarding the suitability of
using this element of the test must be employed as the manoeuvre could well result in dislocation if the shoulder is very unstable.
The Rowe test ( Fig. 2.23) for anterior instability has the patient lying supine with the hand behind the head. The clinician places a clenched fist under the posterior aspect of the shoulder, causing an anteriorly directed pressure through the head of the humerus, while the other hand applies pressure to the anterior aspect of the elbow, causing further shoulder external rotation and abduction. Pain and/ or apprehension is indicative of anterior glenohumeral instability.

Fig. 2.23 ● Rowe test.

Load and shift test

• Purpose
  
  To detect anterior and posterior instability of the glenohumeral joint.
• Technique
  
  Patient position
  Sitting with the hand resting on the thigh. The patient’s position is crucial (see clinical tip).
  Clinician position
  The examiner stands just behind the patient on the affected side. One hand stabilizes the shoulder by fixing the spine of the scapula with the thumb and the clavicle with the fingers. The other hand is placed over the humeral head, the thumb posterior and fingers wrapped around the anterior aspect of the head.
  Action
  The hand around the upper humerus then pushes the humeral head into the glenoid, thereby generating the ‘load’. The humeral head is then moved anteriorly and posteriorly (‘shift’) to assess the extent of translation ( Fig. 2.24A and B).
  Positive test
  Apprehension or reproduction of the patient’s familiar sensation of instability is the most common positive finding, although an increase in anterior or posterior excursion of the humeral head compared to the unaffected side in a symptomatic patient, could also confirm a degree of instability.
  A
  B
  
  
  
  
  Fig. 2.24 ● Compression of the humeral head against the glenoid, combined with anterior
  (A) and posterior humeral glide (B).
• Clinical context
  
  The range of anterior/posterior humeral translation varies significantly in the adult population and asymmetry has been noted in the shoulders of normal volunteers, leading to a lack of consensus on what should be considered ‘normal’ ( Ellenbecker 2004 ). In the presence of anterior instability, however, there is a significant increase in anterior translation, and where there is multidirectional instability, both anterior and posterior translation will be greater than the unaffected side ( Hawkins et al 1996).
  TABLE 2.17 LOAD AND SHIFT TEST
  Author and year
  | Finding
  | LR +
  | LR —
  | Target condition
  Farber et al 2006
  | Apprehension
  | 3.6
  
  | 0.55
  | Traumatic anterior shoulder instability
  | Pain
  | 0.97
  | 1.01
  | Traumatic anterior shoulder instability
  | Laxity
  | 2.28
  
  | 0.54
  | Traumatic anterior shoulder instability
  Tzannes & Murrell 2002
  | Not specified
  | 50
  
  | 0.51
  | Anterior shoulder instability
  Tzannes & Murrell 2002
  | Not specified
  | 14
  
  | 0.87
  | Posterior shoulder instability
  Using a modified version of the test with the shoulder in 60–80° abduction, eliciting apprehension was found to be a more accurate predictor of anterior instability than either pain or laxity ( Farber et al 2006 ), although in a review of special tests at the shoulder, the load and shift test was considered to be less accurate than the apprehension and relocation test when testing for instability ( Luime et al 2004).
• Clinical tip
  
  The patient needs to be sitting in a relaxed, upright, ‘posture neutral’ position where possible, so that the starting position of the humeral
  head in relation to the glenoid can be gauged. A protracted shoulder girdle results in anterior translation of the humeral head and if this position is considered to be the ‘neutral’, a much greater degree of posterior translation is likely to be found during the ‘shift’ manoeuvre, giving a misleading false negative finding. There is a useful analogy at the knee (see anterior drawer test, p. 191), where an increase in anterior drawer may not be due to an anterior cruciate ligament injury but caused by posterior displacement of the tibia resulting from posterior cruciate ligament rupture, which leads to an abnormal starting position and the appearance of excessive anterior translation. The test does rely on the subjective assessment of movement by the examiner although there is evidence from a small study that inter-examiner reliability ranges from good to excellent for most variations of the load and shift test in patients with shoulder insta-
  bility ( Tzannes et al 2004).
  The following grading system can be used to try to establish the severity of anterior instability ( Magee 2008).
  Grade
  | Characteristics
  | ---|---|
  Normal
  | The humeral head translates anteriorly between 0–25% of its diameter
  Grade I
  | The head translates up to 50% of its diameter and can be felt to ‘butt up’ against the glenoid rim before spontaneously reducing
  Grade II
  | The head translates anteriorly more than 50% and can be felt to move over the glenoid rim but is still able to reduce spontaneously
  Grade III
  | The head translates over the rim and cannot reduce spontaneously
• Variations
  
  The load and shift test can be adapted to more specifically isolate and test different parts of the glenohumeral capsule. Starting with the patient in a supine position, the integrity of the inferior capsule is assessed ( Fig. 2.25A). For the anterior shift, the arm is elevated in the scapular plane to 60° with 0° of external rotation. The heel of one hand is placed over the deltoid muscle with the thumb positioned anteriorly over the humeral head and the fingers wrapped around the back. The other hand supports the lower forearm and applies an
  axial load while an anteriorly directed force is provided by the fingers posteriorly. The amount of anterior translation is then assessed with palpation. By incrementally adding external rotation during the ‘shift’ manoeuvre, if the anterior part of the inferior capsule is intact, anterior translation will reduce ( Fig. 2.25B). With an anteriorly displaced humerus, the amount of external rotation needed to reduce the head back into position can be a useful measure of the degree of capsular laxity. Similarly, performing the posterior shift in lying can also assess the integrity of the posterior element of the inferior capsule. The arm is elevated in the scapular plane to 60° with 45° of external rotation. This time the thumb provides the backward force applied to the humeral head as axial loading is applied and increasing movement towards internal rotation should reduce the extent of posterior translation provided the postero-inferior capsule is intact.
  A
  B
  
  
  
  
  
  Fig. 2.25 ● Load and shift variation selectively stressing the inferior (A) and anterior (B) capsules. Arrows show the direction of axial compression.
  The anterior and posterior drawer tests can also be used to assess the amount of humeral head translation. The patient lies supine with the arm initially in neutral. The clinician stands adjacent to the patient and gently places one hand in the patient’s axilla
  wrapping the fingers around the humerus while the other hand is placed over the lateral aspect of the upper arm. The patient’s forearm is supported between the clinician’s elbow and waist. An anterior glide of the humerus on the glenoid is performed by pulling the humerus anteromedially and a posterior glide by pushing posterolaterally (Figs 2.26 and 2.27). Increased range of movement, pain and/or apprehension may indicate laxity of the capsule ( Ellenbecker 2004) or a labral tear. The extent of anterior translation can also be assessed in increasing positions of abduction indicating:
  0°–30° laxity of the superior glenohumeral ligament 45°–60° laxity of the middle glenohumeral ligament 90° laxity of the inferior glenohumeral ligament.
  
  Fig. 2.26 ● Anterior drawer test. Showing an anteromedially directed glide of the humerus.
  
  Fig. 2.27 ● Posterior drawer test. Showing a posterolaterally directed glide of the humerus.
  

Norwood stress test

• Purpose
  
  To test the integrity of the posterior capsule in order to detect posterior instability at the shoulder.
• Technique
  
  Patient position
  Lying supine with the shoulder positioned in 90° of abduction and some external rotation so that the upper arm lies horizontally and the forearm is vertical. The elbow is flexed to 90° ( Fig 2.28A).
  Clinician position
  The clinician stands on the affected side and places one hand over the shoulder with the thumb positioned anteriorly and the fingers around the back of the humeral head. The other hand grasps the forearm just proximal to the wrist in order to control movement of the arm.
  Action
  Using the fingers around the back of the humeral head to detect any posterior translation, the arm is then passively adducted until the upper arm is vertical ( Fig. 2.28B).
  Positive test
  Recognition by the patient of their familiar sensation of instability, apprehension or pain would all indicate a positive finding but posterior subluxation may occur before the patient responds in any way. This excess translation is sometimes accompanied by a click as the humeral head rides over the glenoid labral rim.
  A
  B
  
  
  
  
  Fig. 2.28 ● Start (A) and end (B) positions of the Norwood stress test.
• Clinical context
  
  Posterior instability is the least common form of shoulder instability, representing only 2% of cases ( Cicak 2004 , Robinson & Aderinto 2005). Traumatic posterior shoulder dislocation may be a precursor to recurrent posterior instability but this predisposition is less common than the anterior instability seen as a result of an anterior dislocation ( Robinson & Aderinto 2005 ). Most patients who experience recurrent episodes of frank dislocation have previously experienced an initial traumatic dislocation (e.g. patients with epilepsy whose shoulders dislocate during seizures). Chronic posterior dislocation of the shoulder is commonly missed ( Cicak 2004).
  Recurrent posterior subluxation is a distinct and separate entity. The patient may recall a discrete traumatic injury (e.g. a fall on the outstretched arm or a direct blow to the anterior aspect of the shoulder) or a more insidious onset of symptoms resulting from microtrauma caused by repetitive shoulder flexion, adduction and internal rotation movements. Young, physically active men in their twenties are most commonly affected, particularly those involved in overhead or contact sports. Symptoms of poorly localized posterior shoulder pain and a sensation of instability are most often reproduced with the shoulder in flexion, adduction and internal rotation. In some patients this position will cause subluxation, which is followed by visible and audible relocation (a ‘clunk’ is usually evident) once the shoulder is moved back into abduction ( Robinson & Aderinto 2005). Many patients are able to reproduce this subluxation at their own volition and in a small subgroup of habitual or wilful dislocators (who often present bilaterally) this may manifest as part of a wider psychological problem ( Robinson & Aderinto 2005).
  In the normal shoulder, the test position of flexion and adduction causes tightening of the posterior capsule and this restricts posterior humeral translation. If excessive movement is detected, significant capsular and/or labral injury should be suspected ( Ellenbecker 2004).
• Clinical tip
  
  This test can be enhanced by either applying a posteriorly directed force with the thumb of the stabilizing hand in the test position ( Magee 2008) or by adding a small degree of internal rotation. Because of the tendency for this test to cause posterior subluxation without any prior warning, care should be taken when performing the test and the sensitizing elements only added if necessary.
  Additional tests should be used to support the diagnosis of instability such as the load and shift test (see p. 60) and the posterior drawer test (see p. 65) ( Robinson & Aderinto 2005).
• Variations
  
  The jerk test/posterior glide test/90° flexion test is very similar and performed with the patient in a sitting position. With the elbow flexed to 90° and the arm internally rotated across the waist, the shoulder is taken into 90° of forward flexion. With one hand around the elbow and the other providing some stabilization around the shoulder girdle, a load along the longitudinal axis of the humerus back towards the shoulder is applied as the arm is horizontally adducted ( Fig. 2.29). Instability leads to a pronounced and sudden shift or jerk as the humeral head slips off the glenoid followed by a similar sensation as the joint reduces. The glenoid labrum provides some restraint to the posterior shift but, unable to prevent the movement in the unstable shoulder, will usually cause a click as the humeral head rides over the rim.
  
  Fig. 2.29 ● Jerk test. Arrow shows the direction of axial compression.
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Jerk test
  Useful in combination with the other instability tests.
• Related tests
  
  The posterior apprehension stress test is also used to detect posterior instability. With the patient lying supine and the elbow flexed, the clinician passively elevates the arm through the scapular plane to about 90°. One hand holds the elbow joint while the other supports the forearm just above the wrist. Axial compression is then added and maintained while the arm is simultaneously adducted and internally rotated ( Fig. 2.30). Pain is the most common positive response although apprehension may initially be noted, particularly if the stress is applied gradually. The movement may be accompanied by a click as the humeral head over-rides the labral rim of the glenoid. Ultimately, if the patient permits, an increase in posterior translation will be evident with a shift of over 50% of the humeral head diameter considered to represent instability.
  
  Fig. 2.30 ● Posterior apprehension stress test. Arrow shows the direction of axial compression.
  The push–pull test has the patient lying supine towards the edge of the couch. The arm is taken into 90° of abduction and externally rotated so that the forearm is vertically orientated. One hand is placed over the upper humerus which produces a firm downward (or posterior) pressure (‘push’) while the other grasps the forearm just proximal to the wrist and ‘pulls’ in an upward direction ( Fig. 2.31). The resultant effect is a posterior translation which would not normally
  exceed 50% of the humeral head’s diameter. Excursion greater than this is suggestive of posterior instability.
  
  Fig. 2.31 ● Push–pull test.
  

Sulcus sign

• Aka
  
  Inferior humeral head translation test
• Purpose
  
  To detect the presence of inferior instability and the possibility of multidirectional instability (MDI) of the glenohumeral joint.
• Technique
  
  Patient position
  Sitting on a couch, elevated so that the examiner has a clear view of the lateral aspect of the shoulder with the arm dependent over the side of the couch.
  Clinician position
  Standing on the affected side, the middle finger and thumb of one hand are placed on the anterior and posterior angles of the acromion,
  leaving the index finger free to palpate the gap between the middle of the acromion and the humeral head. The other hand comfortably grasps the arm just above the elbow in readiness to apply distraction.
  Action
  The patient is instructed to relax the shoulder. A firm downward distraction is exerted gradually.
  Positive test
  A sulcus (a deep groove) develops between the lateral edge of the acromion and upper humerus with tautening of the overlying skin suggesting physiological glenohumeral laxity which can be assessed further with directional instability tests.
  
  Fig. 2.32 ● Sulcus test.
• Clinical context
  
  The significance of inferior instability is that it invariably partners anterior and/or posterior instability to create MDI.
  Over the years attempts have been made to classify shoulder instabilities to aid the condition’s diagnosis and management. One recent method avoids classification in terms of direction of instability, preferring instead to examine the underlying cause of the problem ( Lewis et al 2004).
  Type I
  | Traumatic instability – usually unilateral with an underlying Bankart’s defect but normal muscle control
  | ---|---|
  Type II
  | Atraumatic instability – commonly bilateral with capsular dysfunction, structural damage to the articular surfaces but normal muscle control
  Type III
  | Habitual or non-structural instability – often bilateral, with abnormal muscle control but no capsular dysfunction or structural damage to the articular surfaces
  Bilateral laxity is not always clinically relevant as significant levels of asymptomatic shoulder laxity have been found in the general population ( Bigliani et al 1997 , Emery & Mullaji 1991 , Lintner et al 1996 , McFarland et al 1996). Once benign laxity has been discovered, some patients are able to create the sulcus themselves with a downward distraction of the upper arm (a worthy ‘party piece’ for some). Laxity not accompanied by symptoms can therefore be considered ‘normal’ but if accompanied by pain, apprehension and a loss of functional movement, the shoulder clearly deserves further evaluation.
  While doubt exists over its usefulness in evaluating shoulder instabilities ( Luime et al 2004 ), the test can be made more objective by the use of an approximate grading system where the distance between the inferior margin of the acromion and the upper part of the humeral head is measured as follows ( Mallon & Speer 1995):
  Grade
  | Distance between inferior margin of acromion and humeral head
  | ---|---|
  1
  | Less than 1 cm
  2
  | 1.0–1.5 cm
  3
  | More than 1.5 cm
  MDI can cause considerable pain and loss of function, resulting in an inability to use the arm usefully in positions of elevation or to carry loads with the shoulder. Associated neurological symptoms may also be reported as the nerve trunks become temporarily compressed during the abnormal shoulder movement patterns
  but any paraesthesiae (and in some cases weakness) are usually short-lived.
  In a review article, Tzannes & Murrell (2002) reported that the presence of a sulcus of 2 cm or more was highly predictive of MDI (specificity 97%). However, the associated sensitivity was low, meaning that a significant majority of patients with clinical instability would be missed if they did not exhibit this degree of sulcus. Sensitivity increased if a 1 cm sulcus was taken to indicate MDI but, unsuprisingly, specificity decreased.
  TABLE 2.18 SULCUS SIGN
  Author and year
  | LR +
  | LR —
  | Target condition
  Tzannes & Murrell 2002
  | 9
  
  | 0.74
  | MDI if sulcus 2 cm
  Tzannes & Murrell 2002
  | 4.8
  
  | 0.3
  
  | MDI if sulcus 1 cm
  MDI  multidirectional instability
• Clinical tip
  
  It is necessary to try to eliminate rotation of the humerus while performing this test as internal rotation tightens the posterior capsule and external rotation the anterior capsule – either of these positions will reduce the degree of sulcus attained. However, performing the test in about 20° of abduction and slight internal rotation allows maximum inferior movement of the humerus ( Helmig et al 1990).
  A positive sulcus test usefully directs the clinician to a likely diagnosis of MDI without triggering pain or significant apprehension and this induces trust from the patient and a willingness to permit further directional instability testing (apprehension/reloca-tion, p. 55; load and shift, p. 60; Norwood stress, p. 65, tests).
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Sulcus sign
  As a default assumption, patients under the age of 40 years presenting with impingement signs are assumed to have some kind of underlying instability until proven otherwise.
• Related tests
  
  A variation of the sulcus sign , Feagin’s test assesses the integrity of the inferior glenohumeral ligaments ( Ellenbecker 2004 ). With the patient sitting on an elevated couch or in standing, the arm rests on the clinician’s shoulder ensuring the arm is abducted to around 80°. The clinician interlocks both hands and positions them over the proximal humerus and applies a downward and slightly forwards force on the upper humerus ( Fig. 2.33). Again, apprehension is a tell-tale sign when performing this test.
  
  Fig. 2.33 ● Feagin’s test.
  The Rowe test for multidirectional instability aims to assess all planes of movement for the usual signs of apprehension, pain, evidence of the sulcus, excess movement and a possible clunk. In standing, the patient places the unaffected hand on an adjacent treatment couch or table for support as they flex forwards to about 45°. The clinician stands adjacent to the affected shoulder and, with one hand, fixes the humeral head so that the fingers are positioned anteriorly
  and the thumb is placed on the posterior aspect. The other hand holds the lower forearm. To test for:
  inferior
  instability
  | the arm is allowed to ‘dangle’ vertically and a downward force applied
  | ---|---|
  anterior
  instability
  | the arm is held in 20° of extension (from the starting position) and distraction added (in the line of the humerus) as the thumb of the other hand pushes the back of the humeral head anteriorly, encouraging a forward shift of the head in relation to the glenoid
  posterior
  instability
  | the arm is positioned in about 20° of flexion (from the starting position) and distraction added (along the line of the humerus) as the fingers of the other hand pull back on the anterior surface of the humeral head to
  engineer a posterior shift of the head against the glenoid.
  
  ● E ACROMIOCLAVICULAR JOINT (ACJ) TESTS

Active compression test

• Aka
  
  O’Brien’s test
• Purpose
  
  To identify a symptomatic acromioclavicular joint (ACJ) and/or a superior labral anterior posterior (SLAP) lesion.
• Technique
  
  Patient position
  Standing.
  Clinician position
  Standing adjacent to the affected arm and stabilizing the scapula with one hand.
  Action
  The patient adopts the starting position for this test by actively elevating the arm through flexion to 90° and adducting 10–15°,
  keeping the elbow fully extended throughout. In this position, the patient internally rotates the shoulder and fully pronates the forearm, so that the thumb points downwards. The examiner places one hand over the superior aspect of the patient’s distal forearm and exerts a uniform downward pressure, instructing the patient to resist this ( Fig. 2.34 ). The test is then repeated with the patient’s palm facing upwards ( Fig. 2.35).
  Positive test
• ** SLAP lesion : pain felt deep inside the shoulder, with or without a click, on testing with the thumb pointing down, relieved when repeated with the palm facing upwards.
  **
• ACJ disorder : pain felt on top of the shoulder, with or without a click, on testing with the thumb pointing down, relieved when repeated with the palm facing upwards.
  
  
  Fig. 2.34 ● Active compression test
  in internal rotation.
  
  Fig. 2.35 ● Active compression test
  in external rotation.
• Clinical context
  
  A patient with ACJ pain invented this test after noticing the position was provocative. O’Brien et al (1998) reportedly evaluated it on a number of other patients before noticing its efficacy in diagnosing labral lesions. In cadaveric studies, high pressure in the ACJ was reported in the pronated position (thumb down) which did not occur when the test was repeated in the supinated position (palm upwards). The mechanism proposed for this was speculative and less than clear. Arthroscopically, again in cadavers, O’Brien et al (1998) observed that the test position displaced the long head of biceps medially, causing it to pull on the upper glenoid labrum.
  Subsequent, more detailed, cadaveric work ( Parentis et al 2004) has shown that in the starting position for the test, the lesser tuberosity consistently contacts the superior labrum providing some
  TABLE 2.19 ACTIVE COMPRESSION TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  Chronopoulos et al 2004
  | 8.20
  
  | 0.62
  | ACJ pathology
  O’Brien et al 1998
  | 29.41
  
  | 0.00
  
  | ACJ pathology
  Walton et al 2004
  | 1.60
  | 0.93
  | ACJ pathology
  Guanche & Jones 2003
  | 1.02
  | 0.98
  | Any SLAP lesion
  McFarland et al 2002
  | 1.04
  | 0.96
  | Any SLAP lesions
  O’Brien et al 1998
  | 66.67
  
  | 0.00
  
  | Labral injury
  Parentis et al 2006
  | 1.25
  | 0.75
  | Any SLAP lesion
  Stetson & Templin 2002
  | 0.78
  | 1.48
  | Labral injury
  SLAP  superior labral anterior posterior ACJ  acromioclavicular joint
  basis for SLAP lesion provocation. The resistive component of the test could increase stress on the superior labrum via the long head of biceps. Because the lesser tuberosity has been shown not to contact the superior labrum in the second part of the test, a reduction in symptoms would be expected if labral in origin.
  As is often the case, the sensitivity and specificity reported by the test’s originators have not been reproduced by other researchers. Hegedus et al (2008) suggest that joint line tenderness is a sensitive initial screening test when considering the possibility of ACJ pathology, with the active compression test providing useful confirmation because of its high specificity. The addition of a positive scarf test (see p. 78) provides further confirmation of ACJ pathology ( Powell & Huijbregts 2006).
• Clinical tip
  
  On a technical note, the test’s originators emphasized that the patient should resist the clinician’s downward force, not vice versa; and that for the test to be considered positive, there must be reduction or elimination of pain in the test’s second phase.
  The starting position for the test has also been shown to force the supraspinatus tendon into contact with the lateral acromion ( Parentis et al 2004) and this mechanism is also likely to trigger primary impingement symptoms. Given that a positive test can indicate rotator cuff pathology, a labral or ACJ lesion, the findings need to be verified in the light of the patient’s history and overall clinical presentation.
  If a labral injury is suspected further evaluation is necessary (see crank and associated labral tests, p. 46).
  

Scarf test

• Aka
  
  Crossover impingement test Horizontal adduction impingement test Cross arm adduction test
  Cross arm adduction impingement test
• Purpose
  
  To test primarily for acromioclavicular joint (ACJ) lesions.
• Technique
  
  Patient position
  Sitting or standing.
  Clinician position
  Standing adjacent to the patient, one hand is placed on the upper scapula of the unaffected side to provide counter-pressure during the test. The other hand supports the flexed elbow of the affected arm and passively takes the shoulder into 90° of forward flexion, ensuring the shoulder is held in internal rotation and the palm of the hand faces the floor.
  Action
  From the starting position, the shoulder is horizontally adducted passively across the patient’s body to the end of available range.
  Positive test
  Localized pain over the joint line or the C4 (epaulette area) dermatome is a positive finding and indicates ACJ injury or pathology.
  
  Fig. 2.36 ● Scarf test.
• Clinical context
  
  The scarf test is used primarily as a test for the ACJ although other anterior structures, notably the lower fibres of the subscapularis tendon and its bursa, the subacromial bursa and the sternoclavic-ular joint, are also vulnerable to compression in the test position ( Atkins et al 2010). Any tightness of the posterior capsule of the glenohumeral joint will be distinguishable by poorly localized discomfort over the posterior aspect of the shoulder, rather than the more specific localized pain arising from an ACJ lesion.
  In a small study of patients with chronic ACJ pathology the accuracy of the scarf test was found to have a greater sensitivity when compared with the active compression test (see p. 75), but the latter was the more specific. Using the tests in combination leads to increased diagnostic accuracy ( Chronopoulos et al 2004).
  TABLE 2.20 SCARF TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  Chronopoulos et al 2004
  | 3.67
  
  | 0.29
  
  | ACJ pathology
  ACJ  acromioclavicular joint
• Clinical tip
  
  The addition of palpation for joint line tenderness is a further useful physical test for diagnosing lesions of the joint. A cohort of patients with pain over the upper arm and superior aspect of the shoulder underwent a selection of ACJ tests prior to diagnostic joint injection. ACJ tenderness was the most sensitive measure but it lacked specificity ( Walton et al 2004).
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Scarf test
  Useful as a non-specific test. The position adopted may also induce pain and/or apprehension in the presence of posterior instability.
  

Shear test

• Aka
  
  Acromioclavicular passive mobility test
• Purpose
  
  To test for acromioclavicular joint (ACJ) pathology or injury.
• Technique
  
  Patient position
  Sitting or standing with the arm dependent or in a neutral position on the lap.
  Clinician position
  Standing adjacent to the patient. The heel of one hand is placed posteriorly over the spine of the scapula with the fingers pointing upwards; the other hand is positioned in a similar fashion anteriorly over the mid section of the clavicle. The fingers of both hands are then interlocked over the upper trapezius area of the shoulder.
  Action
  The hands are gradually squeezed together, imparting a shear stress through the ACJ created by the approximation of the clavicle and scapula.
  Positive test
  Localized pain over the ACJ or increased joint excursion are considered to be positive findings and are indicative of ACJ pathology or injury.
  
  Fig. 2.37 ● AC shear test.
• Clinical context
  
  Pain from the ACJ is characteristically well localized to the region of the joint but can spread across the C4 dermatome – over the epau-lette area of the shoulder. A fall on the hand or a direct blow of the
  kind commonly sustained in contact sports can cause ACJ injury which can be classified as follows:
  Type I
  | ACJ ligaments are partially torn but remain intact
  | ---|---|
  Type II
  | Minor subluxation due to more significant tearing of the ACJ ligaments but the coracoclavicular ligament remains intact
  Type III
  | Complete dislocation of the ACJ
  The degenerative process commonly afflicts the ACJ, with changes noted in the fibrocartilaginous disc as early as the second decade of life. X-rays are accurate in diagnosing ACJ osteoarthrosis (OA) but should always be interpreted in the light of the patient’s clinical history and findings, as false positives have been reported in asymptomatic patients with radiologically confirmed OA ( Walton et al 2004).
• Clinical tip
  
  No single test has been found to accurately diagnose ACJ pathology but a combination of tests (see active compression, p.76 and scarf tests, p. 79) increases the diagnostic certainty ( Hegedus et al 2008).
  EXPERT OPINION
  | COMMENTS
  | ---|---|
  
  | Shear test
  Useful as a screening test
• Variations
  
  The Paxinos test ( Fig. 2.38A and B ) is a further shear type test for the ACJ. The clinician’s hand rests over the top of the shoulder with the thumb under the posterolateral aspect of the acromion and the index and middle fingers resting on top of the lateral third of the clavicle. The thumb applies an anterior and superior pressure to the acromion, and the fingers push the clavicle inferiorally. A positive test for ACJ pathology or injury is indicated by an increase in ACJ pain. This test was evaluated by its originator and only shown to have moderate to low sensitivity and specificity which, given the propensity for these figures to be high in such circumstances, suggests that other tests should be used in preference ( Walton et al 2004).
  A
  B
  
  
  
  
  Fig. 2.38 ● (A,B) Paxinos test showing the position of the thumb on the posterior angle of the acromion and fingers over the outer clavicle.
  TABLE 2.21 PAXINOS TEST
  Author and year
  | LR +
  | LR —
  | Target condition
  Walton et al 2004
  | 1.58
  | 0.42
  
  | ACJ pathology
  ACJ  acromioclavicular joint