Orthopedic Special Tests for the Shoulder

1. Orthopedic Special Tests for the Shoulder James H. Lynch, MD, MS Military Sports Medicine Fellowship Modified from lecture by Keith Scorza, MD, MBA

2. History and Physical Exam • Cornerstone of the diagnostic process • Determine Treatment Path • Avoid unnecessary procedures

3. History Observation Inspection Palpation Range of motion Strength Neurovascular exam Imaging Orthopedic Special Tests (OST’s) Limited number of studies Questionable reliability and accuracy Orthopedic Encounter

4. What is the best evidence we have to date? • Comprehensive systematic review published in 2008 • Hegedus et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med 2008;42:80-92. • Critiqued 45 studies • Only half were deemed well designed • Only two had adequate samples sizes • Close to 100 shoulder OST’s evaluated • Only three tests had adequate studies for meta-analysis

5. Five Categories of Tests • Impingement • Rotator Cuff Pathology • Labral Tears and Biceps Pathology • AC joint pathology • Instability

6. Five Categories of Tests • Impingement • Rotator Cuff Pathology • Labral Tears and Biceps Pathology • AC joint pathology • Instability

7. Impingement • Hawkins-Kennedy • Neer’s sign • Supraspinatus Test • Infraspinatus Test

8. Hawkins-Kennedy Test and Neer’s Sign

9. Supraspinatus (‘empty can’*) and Infraspinatus Tests *Recent study with EMG data suggests that the Supraspinatus may be better isolated with a “full can” position

10. Evidence Based Considerationsfor impingement • Hawkins-Kennedy test and Neer’s sign • May serve as a screening test • Infraspinatus and Supraspinatus tests • May serve as a confirmation test

11. Five Categories of Tests • Impingement • Rotator Cuff Pathology • Labral Tears and Biceps Pathology • AC joint pathology • Instability

12. Supine Impingement Sign External Rotation Lag Sign (ERLS) Drop Arm Test Bear Hug Test Belly Press Test Hornblower’s Test Sensitive, any injury Specific, any injury Specific-subscapularis Specific-teres minor Rotator Cuff Integrity

13. Supine Impingement Sign

14. External Rotation Lag SignDrop Arm Test

15. Bear Hug and Belly Press Tests

16. Hornblower’s Sign

17. Evidence Based RecommendationsRotator Cuff Integrity • Supine Impingement Tests • May be a useful screening test for any rotator cuff tear. • ERLS and Drop Arm Tests • May have value to “rule in” any rotator cuff tear when positive • Bear-Hug and Belly Press tests • May have value to “rule in” a subscapularis tear • Hornblower’s • May be a sign of severe degeneration of the teres minor muscle

18. Five Categories of Tests • Impingement • Rotator Cuff Pathology • Labral Tears and Biceps Pathology • AC joint pathology • Instability

19. Labrum and Biceps Pathology

20. Kim Test Jerk Test Biceps Load I Biceps Load II Posterior Labral lesions SLAP lesions Labrum integrity and biceps tendon pathology

21. Other Labral Tests • Active Compression test • Anterior slide test • Crank test • Rotation-compression test • Systematic Reviews in 2007 and 2009 showed limited utility due to considerable variation between independent evaluations • Jones, GL, Galluch DB. Clinical assessment of superior glenoid labral lesions. Clin Ortho and Rel Rsrch 2007;455:45-51. • Calvert E et al. Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review. J Clin Epidem 2009;62:558-563.

22. Kim Test and Jerk Test

23. Biceps Load I and II Tests

24. Evidence Based RecommendationsLabrum and Biceps Pathology • Biceps Load II test • May be diagnostic for SLAP • Biceps load I can be considered with caution • Kim and Jerk Tests • May be diagnostic for posterior labrum pathology • Needs more studies • Biceps tendon tests • Have not fared well in current literature

25. Five Categories of Tests • Impingement • Rotator Cuff Pathology • Labral Tears and Biceps Pathology • AC joint pathology • Instability

26. A-C Joint Pathology • Palpation • Active Compression Test

27. Palpation and Active Compression Test

28. Evidence Based RecommendationA-C Joint Pathology • Palpation • May be a good screening test • Limited formal investigation • Active Compression Test • Likely a good “specific” test to “rule in” pathology

29. Five Categories of Tests • Impingement • Rotator Cuff Pathology • Labral Tears and Biceps Pathology • AC joint pathology • Instability

30. Instability • Apprehension Test • Relocation Test • Anterior Release Test • Diagnostic value increases if “apprehension” is used as a positive finding rather than “pain”

31. Apprehension, Relocation, and Anterior Release Tests

32. Evidence Based RecommendationsAnterior Instability • Apprehension, Relocation, and Anterior Release Tests • All appear to be diagnostic for anterior instability • Use “apprehension” not pain as a positive finding

33. Summary • Impingement • Kennedy-Hawkins or Neer as a screening test • Supraspinatus and Infraspinatus for confirmation • Rotator cuff integrity • Supine Impingement Sign for screening • ERLS or Drop arm for confirmation of any tear • Bear Hug or Belly press for confirmation of subscapularis tear • Hornblower’s for degeneration of teres minor • Labrum and Biceps Injury • Kim or Jerk tests for SLAP (not sensitive) • Biceps load I or II for posterior labrum (fairly sensitive, very specific) • AC Joint Pathology • Palpation for screening • AC compression test for confirmation • Instability • Apprehension, relocation, and release tests all fairly diagnostic • Use apprehension rather than pain to improve diagnostic ability

34. Caveats… • These tests were evaluated as a “single” evaluation… • Diagnostic Values may increase when combining with: • Other OST’s • Historical data (Patient’s age) • Evolution of rehabilitative progress • Diagnostic injections • Experience • OST’s are not performed in a “vacuum”. They are part of a comprehensive diagnostic process

35. References • Barth JR, Burkhart SS, De Beer JF. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy 2006;22:1076-84 • Calvert E et al. Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review. J Clin Epidem 2009;62:558-563 • Hegedus EJ, Goode A, Campbell S et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med 2008;42:80-92 • Jones, GL, Galluch DB. Clinical assessment of superior glenoid labral lesions. Clin Ortho and Rel Rsrch 2007;455:45-51. • Kim SH, Ha KI, Ahn JH et al. Biceps load test II: A clinical test for SLAP lesions of the shoulder. Arthroscopy 2001;17:160-4 • Kim SH, Ha KI, Han KY. Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. Am J Sports Med 1999;27:300-3 • Kim SH, Park JS, Jeong WK et al. The Kim test: a novel test for posteroinferior labral lesion of the shoulder – a comparison to the jerk test. Am J Sports Med 2005;33:1188-92 • Litaker D, Pioro M, El Bilbeisi H et al. Returning to the bedside: using the history and physical exam to identify rotator cuff tears. J Am Geriatr Soc 2000;48:1633-7 • Park HB, Yokota A, gill HS et al. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am 2005;87:1446-55 • Reinold MM, Macrina LC, Wilk KE et al. Electromyographic analysis of the Supraspinatus and deltoid muscles during three common rehabilitation exercises. J Athletic Training 7007;42(4):464-469 • Tennent DT, Beach WR, Meyers JF. A review of the special tests associated with shoulder examination. Part II: laxity, instability, and superior labral anterior and posterior (SLAP) lesions. Am J Sports Med 2003;31:301-7. • Tennent TD, Beach WR, Meyers JF. A review of the special tests associated with shoulder examination. Part I: the rotator cuff tests. Am J Sports Med 2003;31:154-60

36. Thank You Questions???