DAVIES’ SHOULDER ALGORITHM
EXAMINATION – 2013
Guidelines:
1. Davies’ Rule of 3 for passive tests:
 1st – general idea
 2nd – implicate structure
 3rd – corroborate findings
2. Resisted tests: 1 time because so provocative
3. Hand placements
4. Hand transitions
5. Corroboration of multiple tests to implicate involved
structures
Hegedus, EJ, et.al.
Physical examination tests of the shoulder: a systematic
review with meta-analysis of individual tests
Br. J Sports Med. 42: 80-92, 2008
No one test is the best test !!!
INSTABILITIES
Test Category
(Algorithm)
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
All Patients
Sitting: GH-0
Sulcus sign
(~11 mm)
All Patients
Sitting: GH-90
Sulcus sign
Anterior
Instability
All Patients
Sitting: GH-0
Anterior Load
and Shift
(~8 mm)
Posterior
Instability
All Patients
Sitting: GH-0
Posterior Load
and Shift
(~9 mm)
MDI (L) @ 0°/
Position
Sulcus sign
MDI (L) @ 90º/
Special Tests
Sens/Spec
Sens=.28.72
Spec=.86.97
Sulcus Sign
Sens=.50.91
Spec=.85100.0
Sens=.50.91
Spec=.85100.0
References:
Sulcus Sign @ 0°
Tzannes A, Murrell GA. Clinical examination of the unstable shoulder. Sports Med.
2002; 32(7):447-457.
Sulcus Sign @ 90°
1
Tissues
Implicated
Superior
capsule,
SGHL,
ROT Interval
Inferior
capsule,
IGHL
Anterior
capsule and
ligaments
Posterior
capsule
The sensitivity and specificity have not been established in any studies.
Anterior Load and Shift
Liu S, Henry MH. A prospective evaluation of a new physical examination in predicting
glenoid labral tears. Am J Sports Med. 1996;24:721-725.(Ability to predict labral
tears when used in combination with apprehension, relocation, inferior sulcus sign
and crank tests).
Neer CS, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional
instability of the shoulder. J Bone Joint Surg Am. 1980:62:897-908. (Ability to
diagnose Bankart lesion).
Tzannes A, Murrell GA. Clinical examination of the unstable shoulder. Sports Med.
2002;32(7):447-457.
Posterior Load and Shift
Tzannes A, Murrell GA. Clinical examination of the unstable shoulder. Sports Med.
2002;32(7):447-457.
SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) LESIONS
AND LONG HEAD BICEPS
Test Category
(Algorithm)
SLAP Lesions &
LHB
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*MOI-macrotraumatic
injury
*MOI-eccentric
deceleration history of
activities
Position
Special Tests
Sens/Spec
Tissues
Implicated
Sitting: GH-45
Compressionrotation
SLAP
Sitting: GH-0
Anterior slide
test
Sens=.24.80
Spec=.19.76
Sens=.08.78
Spec=.70.92
Sitting: GH-0
Posterior slide
test
Sitting: GH90F
Speed’s test
(LHB)
Sitting: F, H.
Add, IR, ER
O’Brien’s Test
or Active
Compression
Test
*c/o pain “deep” or
“in” shoulder
*Sensations of
locking/pseudo-locking
*Repetitive
clicking/clunking
2
SLAP
(ant supecc. Dec.)
SLAP
(post suppeel back)
Sens=.09.90
Spec=.13.75
Sens=.54100.0
Spec=.11.99
Sens=
Spec=
SLAP (Deep
c/o P)
LHB (Ant c/o
P)
SLAP (Deep
c/o P)
___________
AC (Sup c/o
P)
References:
Meserve, BB, et.al. A meta-analysis examining clinical test utility for assessing
superior labral anterior posterior lesions. AJSM. 37:2252-2258, 2009
Compression Rotation
Holovacs T, Osbahar D. The sensitivity and specificity of the physical examination to
detecting glenoid labrum tears. Scientific program AAOS 67th Annual Meeting, 2000.
McFarland EG, Kim TKl, Savino RM. Clinical assessment of three common tests for
superior labral anterior-posterior lesions. Am J Sports Med. 2002; 30:810-815.
Nakagawa, S, et.al. Forced shoulder abduction and elbow flexion test: a new simple
clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy. 21:
1290-1295, 2005
Anterior Slide
Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes
with superior glenoid labral tears. Arthroscopy. 1995; 11: 296-300.
McFarland EG, Kim TKl, Savino RM. Clinical assessment of three common tests for
superior labral anterior-posterior lesions. Am J Sports Med. 2002; 30:810-815.
Nakagawa, S, et.al. Forced shoulder abduction and elbow flexion test: a new simple
clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy. 21:
1290-1295, 2005
Parentis, MA, et.al. An evaluation of the provocative tests for SLAP lesions. Am J
Sports Med. 34:265-268, 2006
Posterior Slide
The sensitivity and specificity have not been established in any studies.
Speed’s Test
Bennett WF. Specificity of the Speed’s Test: arthroscopic technique for evaluating the
biceps tendon at the level of the bicipital groove. Arthroscopy. 1998;14(8):789-796.
Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial
impingement syndrome. Ann Rheum Dis 2000;59: 44-47.
Gaunche CA, Jones DC Clinical testing for tears of the glenoid labrum. Arthroscopy.
2003; 19: 517-523.
Holtby R, Razmjou H. Accuracty of the Speed’s and Yeargason’s test in detecting
biceps pathology and SLAP lesions: Comparisons with arthroscopic findings.
Arthroscopy. 2004;20:231-236.
3
O’Brien’s Test – Active Compression Test
Gaunche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy.
2003; 19: 517-523.
Holovacs T, Osbahar D. The sensitivity and specificity of the physical examination to
detecting glenoid labrum tears. Scientific program AAOS 67th Annual Meeting, 2000.
McFarland EG, Kim TKl, Savino RM. Clinical assessment of three common tests for
superior labral anterior-posterior lesions. Am J Sports Med. 2002; 30:810-815.
Myers TH, Zemanovic JR, Andrews JR. The resisted supination external rotation test:
a new test for the diagnosis of SLAP lesions. Am J Sports Med. 33:1315-1320, 2005.
Nakagawa, S, et.al. Forced shoulder abduction and elbow flexion test: a new simple
clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy. 21:
1290-1295, 2005
Parentis, MA, et.al. An evaluation of the provocative tests for SLAP lesions. Am J
Sports Med. 34:265-268, 2006
OBrien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test:
a new and effective test for diagnosing labral tears and acromioclavicular joint
abnormality. Am J Sports Med. 1998; 26: 610-613.
Stetson WB, Templin K. The crank test, the O’Brien test, and routine magnetic
resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002; 30:
806-809.
Reviews/Systematic Reviews-SLAPS:
Oh, JH, et.al. The evaluation of various physical examinations for the diagnosis of
type II SLAP lesion. Am J Sports Med., 36:353-359, 2008
Pandya, NK, et.al. Physical examination and MRI in the diagnosis of SLAP lesions of
the shoulder: a sensitivity analysis. Arthroscopy. 24: 311-317, 2008
Powell, JW, et.al. Diagnostic utility of clinical tests for SLAP lesions: a systematic
literature review. J of Manual Manip Ther. 16:58-79, 2008
Walsworth, MK, et.al. Reliability and diagnostic accuracy of history and physical
examination for diagnosing glenoid labrum tears. Am J Sports med. 36: 162-168,
2008
Wilk, KE, et.al. Current concepts in the recognition and treatment of SLAP lesions. J
Orthop Sports Phys Ther. 35: 273-291, 2005
LONG HEAD BICEPS
Test Category
(Algorithm)
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
Position
4
Special Tests
Sens/Spec
Tissues
Implicated
Long Head
Biceps
*MOI-eccentric
deceleration history
*Pain to palpation
*C/o pain-anterior
shoulder
Sitting: GH-0
ER
Yergason’s Test
Sens=.37
Spec=.86
LHB,
THL
Reference:
Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial
impingement syndrome. Ann Rheum Dis 2000;59: 44-47.
ACROMIOCLAVICULAR JOINT
Test Category
(Algorithm)
A-C Joint
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*Age:>40
*MOI-macrotrauma to
superior shoulder
*MOI: CKC position
*c/o pain “on top” of
shoulder
*c/o pain to AC
palpation
c/o pain with crossover or overhead
activities
*Asymmetrical
deformities of AC
Position
Special Tests
Sitting: GH-0
AC AnteriorPosterior Shear
Sens/Spec
Tissues
Implicated
AC Joint,
capsule
References:
AC Anterior-Posterior Shear
Davies, GJ, etal. Examination of the Shoulder Girdle. Phys Sports Med, 1981
The sensitivity and specificity have not been established in any studies.
ROTATOR CUFF IMPINGEMENT TESTS
Test Category
(Algorithm)
RTC
Impingements
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*Age:>40
Position
Special Tests
Sens/Spec
Tissues
Implicated
Sitting: F-180
Neer Test
Sens=.75.89
Spec=.09.48
Supraspinat
us, LHB
*Repetitive overhead
activities
5
*Overuse of arm in
unaccustomed
activities
*c/o pain lateral aspect
of shoulder
*c/o night pain
*c/o painful arc
syndrome
*Painful arc during
AROM
*Compensatory
shoulder shrug sign
Sitting:
Scaption to
90, IR
HawkinsKennedy Test
Sitting: F to
90, IR
Coracoid
Impingement
Sitting: 90 F,
Horizontal ADD
Cross-over Test
Sens=.87.92
Spec=.25.44
ANT. MED:
LHB,
subscap
LAT:
Supraspinat
us
Sens=.92
Spec=.25
References:
Neer Test
Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial
impingement syndrome. Ann Rheum Dis 2000;59: 44-47.
Leroux JL, Thomas E, Bonnel F, Blotman F. Diagnostic value of clinical tests for
shoulder impingement syndrome. Rev Rhum Engl Ed. 1995;62:423-428.
Litaker D, Pioro M, El Bilbeisi H, Brems J. Returning to the bedside: using the history
and physical examination to identify rotator cuff tears. J Am Geriatr Soc.
2000;48:1633-1637.
MacDonald P, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the
Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg.
2000;9:299-301.
Hawkins-Kennedy
Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial
impingement syndrome. Ann Rheum Dis 2000;59: 44-47.
6
Supraspinat
us
MED: LHB,
Subscap
LAT:
Supraspinat
us
SUP: AC
Joint
POST:
Inf/Teres
Minor or
Post.
Capsule, INT
IMP
Leroux JL, Thomas E, Bonnel F, Blotman F. Diagnostic value of clinical tests for
shoulder impingement syndrome. Rev Rhum Engl Ed. 1995;62:423-428.
MacDonald P, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the
Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg.
2000;9:299-301.
Coracoid Impingement
The sensitivity and specificity have not been established in any studies.
Cross-Over Test
Calis M, et al. Diagnostic values of clinical diagnostic tests in subacromial
impingement syndrome. Ann Rheum Dis 2000;59: 44-47.
ROTATOR CUFF TEAR TESTS
Test
Category
(Algorithm)
RTC Tears
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*Age:>40
*Macrotraumatic injury
with functional disability
Position
Special Tests
Sens/Spe
c
Tissues
Implicated
*Idiopathic onset of
functional disability of
shoulder
20 Scaption,
ER
ERLS (External
Rotation Lag
Sign) I
Sens=.701.0
Spec =
1.0
Infraspinatu
s
20 Scaption,
ER
ERLS II
Supraspinat
us
*c/o dull constant ache in
shoulder
Not
Determin
ed
GH-90, ER-90
90/90 Lag Sign
*c/o night pain; often
wakes pt.
Infraspinatu
s
Same
90/90 Lag Sign
II
Not
Determin
ed
Not
Determin
ed
E, ADD, IR
IRLS (Internal
Rotation Lag
Sign)
Sens=.97
Spec=.96
Subscap
*c/o pain lateral aspect of
arm
*Compensatory shoulder
shrug sign
*Functional disability
RULES FOR INTERPRETATION:
1.
2.
3.
4.
AAROM to predetermined position
Isometric hold at position – normal Muscle-tendon unit
<5-10 ° lag – partial RTC tear
> 10 ° lag – full thickness RTC tear
7
Supraspinat
us
References:
Drop Arm Test I
Bryant L, Shnier R, Bryant C, Murrel GA. A comparison of clinical estimation,
ultrasonography, magnetic resonance imaging, and arthroscopy in determining the
size of rotator cuff tears. J Shoulder Elbow Surg. 2002;11:219-224.
Drop Arm Test II
The sensitivity and specificity have not been established in any studies.
ERLS I
Castoldi, F, et.al. External rotation lag sign revisited: accuracy for diagnosis of full
thickness supraspinatus tear. JSES. 18:529-534, 2009.
Hertel R, Ballmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis of rotator cuff
rupture. J Shoulder Elbow Surg. 1996;5:307-313.
Walch G, et al. The “dropping” and “Hornblower’s” sign in evaluation of rotator-cuff
tears. J Bone Joint Surg Br. 1998;80(4):625.
ERLS II
The sensitivity and specificity have not been established in any studies.
90/90 Lag Sign I
The sensitivity and specificity have not been established in any studies.
90/90 Lag Sign II
The sensitivity and specificity have not been established in any studies.
IRLS
Hertel R, Ballmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis of rotator cuff
rupture. J Shoulder Elbow Surg. 1996; 5:307-313.
ANTERIOR INSTABILITY MACROTRAUMATIC
Test Category
(Algorithm)
Anterior
Instability
(Macrotrauma)
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*Macrotraumatic with
ant/inf injury
*hx of recurrent
subluxations
*c/o “dead arm
Position
Special Tests
Sens/Spec
Tissues
Implicated
Supine: 90
ABD/90ER
Apprehension
Test
Sens=.40.53
Spec=.87.99
Anterior
Capsule
and
IGHL
8
syndrome”
*Positive-apprehension
test
References:
Apprehension Test
Lo IK, Nonweiler B, Woolfry M, Litchfield R, Kirkley A. An evaluation of the
apprehension, relocation, and surprise tests for anterior instability. Am J Sports Med.
2004;32:301-307.
Mimori K, Muneta T, Nakagawa T, Shinomiya K. A new pain provacation test for
superior labral tears of the shoulder. Am J Sports Med. 1999;27:137-152.
ANTERIOR INSTABILITY MICROTRAUMA
Test Category
(Algorithm)
Anterior
Instability
(Microtraumati
c)
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*Age:<30
*Repetitive overhead
activities
*c/o pain with
overhead activities
*No overt signs of
instability
*c/o click/clunk in
shoulder
*Sensations of
shoulder weakness
Position
Special Tests
Sens/Spec
Tissues
Implicated
Supine: 90
ABD/90ER
Jobe
Subluxation/re
location test
Sens=.30.46
Spec=.54.87
Anterior
synovial
lining, ant.
capsule
and IGHL
(ant. c/o pain)
JOBE’S
RELOCATION
TEST: Sen76%
References:
Jobe Subluxation/Relocation for Instability
Lo IK, Nonweiler B, Woolfry M, Litchfield R, Kirkley A. An evaluation of the
apprehension, relocation, and surprise tests for anterior instability. Am J Sports Med.
2004;32:301-307.
Mimori K, Muneta T, Nakagawa T, Shinomiya K. A new pain provacation test for
superior labral tears of the shoulder. Am J Sports Med. 1999;27:137-152.
Speer KP, Hannafin JA, Altchek DW, Warren RF. An evaluation of the shoulder
relocation test. Am J Sports Med. 1994;22:177-183.
Jobe Subluxation/Relocation (for labral pathology)
Gaunche CA, Jones DC Clinical testing for tears of the glenoid labrum. Arthroscopy.
2003; 19: 517-523.
9
Hamner, DL, et.al. A modification of the relocation test: arthroscopic findings
associated with a positive test. JSES. 9:263-267, 2000
INTERNAL IMPINGEMENT SYNDROME
Test Category
(Algorithm)
Internal
Impingement
Syndrome
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*Specific c/o pain in
the post shoulder inf.
To the postero-lat.
Acromion
*Horizontal extension
motion
Position
Special Tests
Supine: 90
ABD/90ER
Jobe
Subluxation/re
location test
Tissues
Implicated
Sens/Spec
Articular
sides of
supraspin. &
infraspin.
hit against
post. sup.
labrum
(post. c/o
pain)
Walch, G, et.al. Impingement of the deep surface of the supraspinatus tendon on the
posterior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg. 1:238-245, 1992
OTHERS-SLAP
SLAP LESION
Same as SLAP table
Supine: 90°
Abd/90° ER
Combo Test:
Biceps Load
Test,
Pain
provocation
test,
ER/Sup test
Biceps
Load:
Sens: .30
Spec: .78
SLAP
Pain
provocation
test:
Sens: 1.00
Spec: .90
ER/Sup
Test:
Sens: .83
Spec: .82
References:
Biceps Load Test:
Kim, SH, et.al. Biceps load test: a clinical test for SLAP lesions in shoulders with
recurrent anterior dislocations. Am J Sports Med. 27:300-303, 1992
Kim, SH, et.al. Biceps load test II: a clinical test for SLAP lesions of the shoulder.
Arthroscopy. 17:160-164, 2001
POSTERIOR INSTABILITY TESTS
Test Category
Critical Pathways/
Clusters of Signs &
Position
10
Special Tests
Sens/Spec
Tissues
(Algorithm)
Posterior In
Posterior
Instability
Implicated
Symptoms/Clinical
decision making
*MOI: macrotrauma to
cause post. Trauma
Supine: GH-F90, IR-MAX
*Hx of volitional
subluxation
Supine: GH-F90, Horiz. ADD
*c/o posterior shoulder
pain
*Patient can
volitionally sublux
shoulder
*c/o click/clunk
Supine: GH
ABD 90,
Neutral for
Horiz. F/E
Posterior Glide
(Capsule tight)
Jerk Test
Posterior Glide
II
Not
Determined
Post.
Capsule
Not
Determined
Post.
Capsule
Not
Determined
Post.
Capsule
(Capsule lax)
References:
Jerk Test
Kim, et.al. Painful jerk test – a predictor of success in non-operative treatment of
postero-infeerior instability of the shoulder. Am J Sports Med. 32:849-855, 2005
Cuelkr, R, et.al. Exploration of glenohumeral instability under anesthesia: the
shoulder jerk test. Arthroscopy. 21: 672-679, 2005
Gerber, C, et.al. Clinical assessment of instability of the shoulder with special
reference to anterior and posterior drawer tests. J Bone Joint Surg-A. 87:824-831,
2005
The sensitivity and specificity have not been established in any studies.
BANKART LESIONS
Test Category
(Algorithm)
Bankart/SLAP
Lesions
Critical Pathways/
Clusters of Signs &
Symptoms/Clinical
decision making
*Hx of macrotrauma
*Hx of recurrent
subluxations
*c/o pain anterior or
“deep” in shoulder
*c/o click/clunk
*Sensation of pseudolocking
Position
Special Tests
Sens/Spec
Tissues
Implicated
Supine: GH –
Max scaption,
caudal glide
Clunk Test I
Not
Determined
Ant/Inf
Labrum
Supine: GH
ABD 90 to
180
Supine: GH
150 Scaption,
IR/ER
Clunk Test II
Not
Determined
Ant/Inf
Labrum
Crank Test
Sens=.35.91
Spec=.561.0
Ant/Inf
Labrum and
SLAP
11
References:
Clunk Test I
The sensitivity and specificity have not been established in any studies.
Clunk Test II
The sensitivity and specificity have not been established in any studies.
Crank Test
Gaunche CA, Jones DC Clinical testing for tears of the glenoid labrum. Arthroscopy.
2003; 19: 517-523.
Liu SH, Henry MH, Nuccions S, Shapiro MS, Dorey F. Diagnosis of glenoid labral tears:
a comparison between magnetic resonance imaging and clinical examinations. Am J
Sports Med. 1996;24:149-154.
Liu SH, Henry MH. A prospective evaluation of a new physical examination in
predicting glenoid labral tears. Am J Sports Med. 1996;24:721-725.
Mimori K, Muneta T, Nakagawa T, Shinomiya K. A new pain provacation test for
superior labral tears of the shoulder. Am J Sports Med. 1999;27:137-152.
Myers TH, Zemanovic JR, Andrews JR. The resisted supination external rotation test:
a new test for the diagnosis of SLAP lesions. Am J Sports Med. 33:1315-1320, 2005
Stetson WB, Templin K. The crank test, the O’Brien test, and routine magnetic
resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002; 30:
806-809.
12