Orthopedic Special Tests
for the Shoulder
James H. Lynch, MD, MS
Military Sports Medicine Fellowship
Modified from lecture by Keith Scorza, MD, MBA
History and Physical Exam
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Cornerstone of the diagnostic process
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Determine Treatment Path
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Avoid unnecessary procedures
Orthopedic Encounter
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History
Observation
Inspection
Palpation
Range of motion
Strength
Neurovascular exam
Imaging
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Orthopedic Special
Tests (OST’s)
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Limited number of
studies
Questionable reliability
and accuracy
What is the best evidence we
have to date?
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Comprehensive systematic review published in
2008
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Critiqued 45 studies
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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.
Only half were deemed well designed
Only two had adequate samples sizes
Close to 100 shoulder OST’s evaluated
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Only three tests had adequate studies for metaanalysis
Five Categories of Tests
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Impingement
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Rotator Cuff Pathology
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Labral Tears and Biceps Pathology
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AC joint pathology
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Instability
Five Categories of Tests
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Impingement
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Rotator Cuff Pathology
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Labral Tears and Biceps Pathology
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AC joint pathology
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Instability
Impingement
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Hawkins-Kennedy
Neer’s sign
Supraspinatus Test
Infraspinatus Test
Hawkins-Kennedy Test and
Neer’s Sign
Supraspinatus (‘empty can’*) and
Infraspinatus Tests
*Recent study with EMG data
suggests that the Supraspinatus
may be better isolated with a
“full can” position
Evidence Based Considerations
for impingement
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Hawkins-Kennedy test and Neer’s sign
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May serve as a screening test
Infraspinatus and Supraspinatus tests
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May serve as a confirmation test
Five Categories of Tests
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Impingement
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Rotator Cuff Pathology
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Labral Tears and Biceps Pathology
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AC joint pathology
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Instability
Rotator Cuff Integrity
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Supine Impingement Sign
Sensitive, any injury
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External Rotation Lag
Sign (ERLS)
Drop Arm Test
Specific, any injury
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Bear Hug Test
Belly Press Test
Specific-subscapularis
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Hornblower’s Test
Specific-teres minor
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Supine Impingement Sign
External Rotation Lag Sign
Drop Arm Test
Bear Hug and Belly Press Tests
Hornblower’s Sign
Evidence Based Recommendations
Rotator Cuff Integrity
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Supine Impingement Tests
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ERLS and Drop Arm Tests
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May have value to “rule in” any rotator cuff tear when positive
Bear-Hug and Belly Press tests
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May be a useful screening test for any rotator cuff tear.
May have value to “rule in” a subscapularis tear
Hornblower’s
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May be a sign of severe degeneration of the teres minor muscle
Five Categories of Tests
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Impingement
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Rotator Cuff Pathology
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Labral Tears and Biceps Pathology
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AC joint pathology
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Instability
Labrum and Biceps Pathology
Labrum integrity and biceps
tendon pathology
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Kim Test
Jerk Test
Posterior Labral lesions
Biceps Load I
Biceps Load II
SLAP lesions
Other Labral Tests
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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
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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.
Kim Test and Jerk Test
Biceps Load I and II Tests
Evidence Based Recommendations
Labrum and Biceps Pathology
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Biceps Load II test
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Kim and Jerk Tests
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May be diagnostic for SLAP
Biceps load I can be considered with caution
May be diagnostic for posterior labrum pathology
Needs more studies
Biceps tendon tests
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Have not fared well in current literature
Five Categories of Tests
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Impingement
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Rotator Cuff Pathology
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Labral Tears and Biceps Pathology
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AC joint pathology
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Instability
A-C Joint Pathology
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Palpation
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Active
Compression Test
Palpation and Active
Compression Test
Evidence Based Recommendation
A-C Joint Pathology
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Palpation
May be a good screening test
 Limited formal investigation
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Active Compression Test
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Likely a good “specific” test to “rule in”
pathology
Five Categories of Tests
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Impingement
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Rotator Cuff Pathology
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Labral Tears and Biceps Pathology
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AC joint pathology
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Instability
Instability
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Apprehension Test
Relocation Test
Anterior Release Test
Diagnostic value increases if
“apprehension” is used as a positive finding
rather than “pain”
Apprehension, Relocation, and
Anterior Release Tests
Evidence Based Recommendations
Anterior Instability
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Apprehension, Relocation, and Anterior
Release Tests
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All appear to be diagnostic for anterior
instability
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Use “apprehension” not pain as a positive
finding
Summary
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Impingement
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Rotator cuff integrity
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Kim or Jerk tests for SLAP (not sensitive)
Biceps load I or II for posterior labrum (fairly sensitive, very
specific)
AC Joint Pathology
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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
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Kennedy-Hawkins or Neer as a screening test
Supraspinatus and Infraspinatus for confirmation
Palpation for screening
AC compression test for confirmation
Instability
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Apprehension, relocation, and release tests all fairly diagnostic
Use apprehension rather than pain to improve diagnostic ability
Caveats…
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These tests were evaluated as a “single” evaluation…
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Diagnostic Values may increase when combining with:
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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
References
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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;62:558563
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):464469
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
Thank You
Questions???