Orthopaedic special tests for the shoulder - PowerPoint PPT Presentation

Title: Orthopaedic special tests for the shoulder


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Orthopaedic special tests for the shoulder
Kate Harman 3rd year Physiotherapy BSc
undergraduate University of Essex February 2014
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Basic Shoulder Anatomy
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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
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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)
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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

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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)

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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.
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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 patients strength in this
position. A ve test for rotator cuff tear is
weakness, pain or both.
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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.
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Hornblowers
The physiotherapist elevates the patients 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.
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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 physiotherapists 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 physiotherapists hand while
moving the elbow forward or if the patient
extends the shoulder.
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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.
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Rotator Cuff Tests
Neers 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

• Neers Sign
• Hawkins-Kennedy Test

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
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Labral Tears and Biceps Pathology

• OBriens Test (Active Compression test)
• Speeds test - long head biceps or SLAP
• Yergasons - long head of biceps

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OBriens 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.
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Speeds 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 patients
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.
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Yergasons Test
Resisted supination Looking at the biceps
instability in the bicipital groove Patient sits
while physiotherapist stands in front. The
patients 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 Speeds tests
were found to have high specificity (0.830.86)
and low sensitivity (0.230.36), indicating that
these manoeuvres would be better at ruling out
biceps disease than detecting it.
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Instability of the GH Joint

• Apprehension Relocation Test (also known as
  Fowlers 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
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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 patients with
recurrent dislocations. Patients with anterior
subluxation will experience pain but not
apprehension with this test, and patients with
normal shoulders will be asymptomatic. The
Relocation Test is then performed by
administering a posteriorly directed force on the
humeral head. Patients with primary impingement
will have no change in their pain, whereas
patients 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.
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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.
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ACJ Pathologies
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.

• Horizontal adduction test (scarf test)
• Palpation
• OBriens can also be used

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Stats
Test Sensitivity Specificity
ERLS 0.98 0.98
Empty Can 0.86 0.50
Infraspinatus muscle strength test 0.42 0.90
Hornblowers 1 0.93
Belly Press 0.40 1
Neers sign 0.68 0.69
Hawkins-Kennedy 0.92 0.25
OBriens Test 0.47 0.55
Speeds 0.90 0.14
Yergasons 0.37 0.86
Apprehension Relocation Test 0.81 0.92
Posterior Subluxation Test 0.73 0.98
Horizontal Adduction Test 0.23 0.82
Hattam Smeatham (2010)
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Summary

• Rotator cuff integrity
• External Rotation Lag Sign
• Empty Can
• Infraspinatus muscle strength test
• Hornblowers
• Belly Press
• Impingement of the rotator cuff
• Neers Sign
• Hawkins-Kennedy
• Labral tears and biceps pathology
• OBriens Test
• Speeds test
• Yergasons
• Instability

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References

• Biederwolf NE (2013) A Proposed Eveidence-Based
  Shoulder Special Testing Examination Algorithm
  Clinical utility based on a systemic review of
  the literature International Journal of Sports
  Physical Therapy 8 (4) 427-440 Online at
  http//www.ncbi.nlm.nih.gov/pmc/articles/PMC381283
  7/!po48.0769 Accessed 2 February 2014
• Day R, Fox J and Paul-Taylor G (2009)
  Neuro-Muscularskeletal 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.pdfhtml 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.pdfh
  tml Accessed 3 February 2014
• Therapy Haven (2014) Special Tests Online at
  http//www.pthaven.com/page/show/102937-special-te
  sts Accessed 2 February 2014