Orthopaedic
special tests for the
shoulder
Kate Harman
3rd year Physiotherapy
BSc undergraduate
University of Essex February 2014
Basic Shoulder
Anatomy
The Rotator
Cuff
Supraspinatus - Abducts
Origin - Supraspinatus fossa of the
scap
Insertion Greater tubercle of the
humerus
Infraspinatus - Lat rotates
Origin - Infraspinatus fossa of the
scap
Insertion - Greater tubercle of the
humerus
Teres Minor - Lat rotates
Origin - Upper 2/3 of lat border of
scap
Insertion - Greater tubercle of the
humerus
Subscapularis - Med rotates
Origin - Sub scap fossa
Insertion - Lesser tubercle of the
humerus
Sensitivity and Specificity in
Special Tests
Sensitivity is how well the test can identify a
patient as having a specific pathology (true +ve)
Specificity is how well the test can identify a
patient as NOT having a pathology (true -ve)
These are scored out of 1 (which can converted
into a %) The higher the score the more reliable
the test)
5 Categories of tests
1. Rotator cuff integrity
2. Impingement of the rotator cuff
3. Labral tears and biceps pathology
4. Instability of the GH joint
5. ACJ
Rotator Cuff integrity
Tests
Supraspinatus - External Rotation Lag Sign
(ERLS) and or Empty Can
Infraspinatus - ERLS, Infraspinatus muscle
strength test
Teres minor - Hornblowers (deterioration of
the tendon)
Subscapularis - Belly Press (more reliable that
lift off test)
External Rotation Lag Sign
Patient positioned in sitting or
standing.
The shoulder is positioned into
full lat rot, assisted by the PT,
elbows at 90 degrees flexion.
Pt is asked to hold this
position, the PT then releases
the arms.
A +ve test is an inability for the
pt to maintain this position
meaning the arms drop back
to neutral.
Complete lag = complete tear,
slight lag or loss of position =
partial tear.
Empty Can
The patient elevates the arms
to 90 degrees and
horizontally adducts 30
degrees to the scapular plane
with thumbs down to the
empty can position.
The physiotherapist provides
downward pressure to test
the patient’s strength in this
position.
A +ve test for rotator cuff tear
is weakness, pain or both.
Infraspinatus Muscle
Strength Test
The patient stands with the arms at
the side with the elbow at 90 degrees
and the humerus medially rotated to
45 degrees.
The physiotherapist applies a medial
rotation force that the patient resists.
Pain or the inability to resist medial
rotation indicates a +ve test for an
infraspinatus strain.
Hornblower’s
The physiotherapist
elevates the patient’s arm
to 90 degrees in the
scapular plane.
The physiotherapist then
flexes the elbow to 90
degrees, and the patient is
asked to laterally rotate
the shoulder.
A +ve test occurs with
weakness and/or pain.
Belly Press
The physiotherapist places a hand on
the abdomen so that the he or she can
feel how much pressure the patient is
applying to the abdomen.
The patient places his or her hand of
the shoulder being tested on the
physiotherapist’s hand and pushes as
hard as he or she can into the stomach.
The patient also attempts to bring the
elbow forward in the scapular plane
causing greater medial shoulder
rotation. It is a +ve test if the patient is
unable to maintain the pressure on the
physiotherapist’s hand while moving the
elbow forward or if the patient extends
the shoulder.
Impingement of the
Rotator Cuff
Primary (outlet)
Intrinsic and extrinsic
Secondary (outlet)
Internal (non - outlet)
Primary (outlet) intrinsic e.g degeneration of the cuff
Extrinsic e.g shape of acromion negatively
impacts on the ability of the greater tuberous
it 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 thus leading to
abnormal movement patterns
Internal (non-outlet) - resulting from injury to
the rotator cuff or the glenoid labrum caused
by impingement of Supra and Infra between
the posterosuperior aspect of the glenoid rim
and the humeral head. The impingement
occurs posteriorly.
Rotator Cuff Tests
Neer’s Sign
HawkinsKennedy
Test
Neer’s Impingement test: Patient in
standing, shoulder flexed to 20
degrees and fully med rotated.
The physiotherapist (standing in
front of patient) then takes arm
passively through flexion. +ve test =
pain anterolateral between 80-140
degrees
Hawkins - Kennedy:
The patient stands while the
examiner forward flexes the arm
to 90 degrees and then forcibly
medially rotates the shoulder.
The test may be performed in
different degrees of forward
flexion or horizontal adduction.
+ve test = pain
Both are testing for: Subacromial impingement of rotator cuff, subacromial bursa and long head of biceps
Labral Tears and
Biceps Pathology
O’Briens Test (Active Compression
test)
Speeds test - long head biceps or
SLAP
Yergasons - long head of biceps
O’Briens Test
This test is conducted with the physiotherapist standing
behind the patient.
The patient is asked to forward flex the affected arm 90° with
the elbow in full extension.
The patient then adducts the arm 10° to 15°. The arm is
internally rotated so that the thumb pointed downward.
The physiotherapist then applies a downward force to the arm.
With the arm in the same position, the palm is then fully
supinated and the movement repeated.
The test is considered +ve if pain is felt with the first
manoeuvre and was reduced or eliminated with the second
manoeuvre.
Pain localised to the acromio-clavicular joint or on top of the
shoulder can be diagnostic as acromio-clavicular joint
abnormality.
Pain or painful clicking within the glen-ohumeral joint itself is
indicative of labral abnormality.
Speed’s Test
Biceps tendon
Origin
Long head supra-glenoid
tubercle of the scapula
Short head - Coracoid process
Insertion - tuberosity of the radial
and aponeurosis of the biceps
brachii
The patient’s arm is fully
extended and into slight
extension, wrist is in supination.
The patient is asked to resist an
eccentric movement into
extension.
A +ve test elicits increased
tenderness in the bicipital
groove.
Yergason’s Test
Resisted supination
Looking at the biceps instability in the bicipital groove
Patient sits while physiotherapist stands in front. The patient’s
elbow is flexed to 90 degrees and the forearm is in a pronated
position while maintaining the upper arm at the side. Pt is
instructed to supinate arm while examiner concurrently resists
forearm supination at the wrist.
Localised pain at the bicipital groove indicates a +ve test
Yergasons and Speed’s tests were found to have high specificity
(0.83–0.86) and low sensitivity (0.23–0.36), indicating that these
manoeuvres would be better at ruling out biceps disease than
detecting it.
Instability of the GH
Joint
Apprehension
Relocation Test (also
known as Fowler’s
test)
Posterior Subluxation
Test (also known as
the Jerk test)
Apprehension Relocation
Test - Anterior instability of
the GHJ
Posterior Sub lux Test - Post
instability of the GHJ
Most instability is anterior.
Anterior tests have the
most validity
Apprehension
Relocation Test
Apprehension Relocation Test
These tests are performed with the patient supine and the
arm in abduction and external rotation.
During the Apprehension Test, the physiotherapist pushes
anteriorly on the posterior aspect of the humeral head. This
movement will produce apprehension sometimes coupled with
pain in patient’s with recurrent dislocations.
Patient’s with anterior subluxation will experience pain but not
apprehension with this test, and patient’s with normal
shoulders will be asymptomatic.
The Relocation Test is then performed by administering a
posteriorly directed force on the humeral head. Patient’s with
primary impingement will have no change in their pain,
whereas patient’s with instability (subluxation) and secondary
impingement will have pain relief and will tolerate maximal
external rotation with the humeral head maintained in a
reduced position.
Posterior Subluxation
Test
Jerk Test - Patient is positioned in supine, shoulder at 90 degrees with slight adduction and
medial rot. The physiotherapist places one hand on the distal humerus and one hand on the
post aspect of the joint line. The physiotherapist then applies a downward force to the
humerus.
A +ve test is indicated by sharp pain in the shoulder with or without a clicking sound.
ACJ Pathologies
Horizontal
adduction test
(scarf test)
Palpation
O’Briens can
also be used
No single test has been found to
accurately diagnose ACJ pathology
but they should be used in
combination. Pain for the ACJ can
spread to the C4 dermatome
(epaulette area, clavicle area).
Adduction Test (good to rule out):
With the patient in a sitting position
the physiotherapist stands with one
hand on the posterior aspect of the
shoulder to stabilise the trunk and
the other hand holding the subjects
elbow of the arm being tested.
With the trunk stabilised the
physiotherapist passively moves
the
shoulder
into
maximum
horizontal adduction. +ve test is
when pain is felt over the ACJ.
Stats…
Test Sensitivity Specificity
ERLS
Empty Can
Infraspinatus muscle strength test
Hornblowers
Belly Press
Neer’s sign
Hawkins-Kennedy
O’Briens Test
Speeds
Yergasons
Apprehension Relocation Test
Posterior Subluxation Test
Horizontal Adduction Test
0.98
0.86
0.42
1
0.40
0.68
0.92
0.47
0.90
0.37
0.81
0.73
0.23
0.98
0.50
0.90
0.93
1
0.69
0.25
0.55
0.14
0.86
0.92
0.98
0.82
Hattam & Smeatham (2010)
Summary
Rotator cuff integrity
External Rotation Lag Sign
Empty Can
Infraspinatus muscle strength test
Hornblowers
Belly Press
Impingement of the rotator cuff
Neer’s Sign
Hawkins-Kennedy
Labral tears and biceps pathology
O’Briens Test
Speeds test
Yergasons
Instability
Apprehension Relocation Test
Posterior Subluxation Test
ACJ
Horizontal Adduction Test (scarf)
Palpation
References
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Biederwolf NE (2013) A Proposed Evidence-Based Shoulder Special Testing Examination Algorithm: Clinical
utility based on a systemic review of the literature International Journal of Sports Physical Therapy 8 (4): 427440 Online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812837/#!po=48.0769 [Accessed 2 February
2014]
Day R, Fox J and Paul-Taylor G (2009) Neuro-Musculo-skeletal Clinical Tests Edinburgh: Churchill Livingstone
Elsevier
Hattam P and Smeatham A (2010) Special Tests in Musculoskeletal Examination: An Evidence-Based Guide for
Clinicians Edinburgh: Churchill Livingstone Elsevier
Tennent DT, Beach WR and Meyers JF (2003) A Review of the Special Tests Associated with Shoulder
Examination Part I: The Rotator Cuff Tests American Journal of Sports Medicine 31 (1): 154-160 Online
at: http://ajs.sagepub.com/content/31/1/154.full.pdf+html [Accessed on 2 February 2014]
Tennent DT, Beach WR and Meyers JF (2003) ‘A Review of the Special Tests Associated with Shoulder
Examination Part II: Laxity, Instability, and Superior Labral Anterior and Posterior (SLAP) Lesions’ The American
Journal of Sports Medicine 31 (2): 301-307 Online at: http://ajs.sagepub.com/content/31/2/301.full.pdf+html
[Accessed 3 February 2014]
Therapy Haven (2014) Special Tests Online at: http://www.pthaven.com/page/show/102937-special-tests
[Accessed 2 February 2014]