Testes Clínicos para patologias ósseas - capítulo 2 - ombro

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69 
2 Shoulder 
Acute injuries and chronic complaints in the shoulder have beco1ne 
increasingly in1portant in recent years. Contributing factors include 
occupational, recreational, and sports activities. Years of occupational, 
recreational, or household activities involving overhead work lead to 
excessive stresses and n1uscle in1balance as does sitting at an unergo­
non1ic workplace like many secretaries. 
As in any clinical exa1nination, the first step in exan1ining the 
shoulder is to obtain a thorough history. The n1any different shoulder 
disorders may have their causes in acute traun1a, local processes due to 
chronic overuse, age-related degeneration, or systemic disease. In ado­
lescence and early adulthood, shoulder disorders are pri1narily attrib­
utable to trauma or congenital deforn1ities. The 1nost co1nmon of these 
shoulder disorders include dislocations and subluxations and their re­
sulting instabilities. Later in life, degenerative disorders beco1ne n1ore 
pro1ninent. These include impingen1ent syndrome, ruptures of the ro­
tator cuff, and degenerative acromioclavicular joint changes. 
Inquiring about occupational stresses and athletic activities provides 
important information. Jobs involving a lot of overhead work (painting) 
and sports with sin1ilar requirements (basketball, baseball, tennis, 
swin11ning, volleyball) often lead to early disorders in the subacro1nial 
space. These are accompanied by degenerative changes in the acro1nio­
clavicular joint. Obtaining a detailed history fro1n an athlete requires 
knowledge of the motion sequences specific to his or her respective 
sport. This is crucial to diagnosing patterns of injury specific to that 
sport. 
However, acute sy1nptoms are not always attributable to obvious 
trau1na fro1n an identifiable mechanis1n of injury. In the presence of 
preexisting tendon degeneration, a minor injury can lead to a supra­
spinatus tendon rupture. 
In addition to specific questions about shoulder disorders, the exan1-
iner 1nust always be alert to the possibility of diseases of other organ 
syste1ns. Pain fron1 angina pectoris often radiates into the shoulder and 
arn1, and this referred pain does not invariably occur on the left side. 
Gallbladder or liver disorders can also cause pain in the right shoulder. 
Rheumatic polyarthritis and hyperuricemia can n1anifest first in the 
shoulder. Patients with diabetes n1ellitus very often have an associated 
shoulder affliction that tends to restrict n1otion in the shoulder. One of 
70 2 Shoulder 
the 1nost co1nmon neoplastic causes of shoulder pain is a Pancoast 
tumor with a typical Horner syndro1ne. 
Observing the patient provides the exan1iner with an initial over-
view. Gait and any co1npensatory contralateral 1notion of the upper 
extren1ities are noted. A patient with a frozen shoulder avoids internal 
or external rotat ion and motion above horizontal when undressing. 
Patients with a ruptured rotator cuff will often ask for help undressing 
because they lack the strength to abduct the ar1n. Asy1nmetry and 
especially muscle atrophy is best revealed by con1parison with the 
contralateral side. In con1parative inspection of both acro1nioclavicular 
joints, the exan1iner looks for swelling or a step off resulting fro1n an 
acron1ioclavicular joint separation. Distal displace1nent of the n1uscle 
belly suggests a rupture of the long head of the biceps tendon. The sa1ne 
applies to n1any congenital disorders such as a Sprengel deforn1ity, 
l(lippel-Feil syndro1ne, congenital torticollis, or the clavicular fracture 
often seen in newborns and infants. Isolated supraspinatus atrophy 
suggests a rupture of this tendon. 
Distal con1pression neuropathies and thoracic outlet syndron1e also 
first 1nanifest then1selves as shoulder pain. 
AP and lateral radiographs and special shoulder views are indicated 
to supple1nent the clinical examination. These can differentiate bony 
changes from soft tissue pathology. Ultrasound, MRI, and CT 1nay also be 
useful in visualizing shoulder disorders. 
• Range of Motion of the Shoulder 
(Neutral-Zero Method) 
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2 Shoulder 
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a Forward flexion and extension. 
b Abduction and adduction. 
c Abduction exceeding 90° requires external rotation of the humerus in the 
glenohumeral joint and rotation of scapula. 
d Horizontal flexion and extension (forward and backward motion of the arm, 
abducted 90° from the body). 
e, f External and internal rotation: with the arm hanging down (e) and abducted 
go• (f). 
g Protraction and retraction of the shoulder. 
h Scapular elevation and depression. 
i Scapular rotation relative to the trunk 
72 2 Shoulder 
Shoulder tests-Assessment 
Function 
Orientation 
-
Rotator cuff 
Painful arc p. 91 
Neer impingement test p. 92 
Quick test of 
combined 
motion p. 74 
Cod man 
sign p. 74 
Hawkins and Kennedy impingement test p. 93 
Neer impingement injection test p. 94 
Palm sign and 
finger sign 
tests p. 76 
Differentiation: 
Impingement 
tests 
Rotator cuff tests 
Biceps tendon 
tests 
Bursitis 
sign p. 77 
Dawbarn 
sign p. 77 
Subacro-
mial 
bursitis 
Acromloclavicular 
joint tests 
Instability tests 
Fig. 2.2 Shoulder tests 
i 
Zero-
degree 
abduction 
test p. 81 
Jobe supra-
spinatus 
test p. 82 
Drop arm 
test p. 89 
i 
Lift-off 
test p. 84 
Napoleon 
sign p. 86 
Sub-
scapularis 
test p. 83 
Apley's scratch 
test p. 90 
Hornblower 
sign p. 90 
Supra-
splnatus 
lesion 
Subsca-
pularis 
lesion 
i 
Infra- Teres 
test p. 88 spinatus 
test p. 87 Horn-
Abduction blower 
external - sign p. 90 
rotation 
test p. 88 
lnfra-
splnatus 
lesion 
Teres 
major 
lesion 
Long head of the 
biceps tendon 
Acromloclavl-
cular joint 
• 
Nonspecific 
biceps tendon 
test p. 99 
Yergason 
test p. 102 
Huetersign 
p. 102 
Snap test p. 101 
Speed test 
p. 101 l 
-
O'Brien 
test p. 106 
Biceps load 
test 1 and 2 
p. 107,108 
Tendinitis SLAP 
Tendon lesion 
subluxa-
tlon 
Tendon 
rupture 
Painful arc 
p. 96 
Forced 
adduction 
test p. 97 
Dugas test 
p. 98 
Crossed 
body 
adduction 
stress test 
p.97 
Clavicle 
mobility 
test 
p. 98 
l 
Radiology 
1 
Acromlo-
clavlcular 
joint osteo-
arthritis 
Instability 
2 Shoulder 73 
Shoulder Joint 
(stability test) 
IL 
Anterior 
apprehen-sion test 
p. 110 
Anterior 
and 
posterior 
load and 
shift test 
p. 115 
Gerber-
Ganz 
anterior 
drawer 
test p. 115 
Anterior 
shoulder 
Instability 
Sulcus 
sign p. 119 
Inferior 
shoulder 
Instability 
Posterior 
apprehen-
sion test 
p. 116 
Gerber-
Ganz 
posterior 
drawer 
test p. 115 
Fukuda 
test p. 119 
Posterior 
shoulder 
Instability 
Multldlrectlonal instability 
74 2 Shoulder 
• Orientation Tests 
Quick Test of Combined Motion 
Procedure: A quick test of ,nobility in the shoulder is to ask the patient 
to place hand behind his or her head and touch the contralateral 
scapula. In a second moven1ent the patient places the hand behind his 
or her back, reaching upward fron1 the buttocks to touch the inferior 
1nargin of the scapula. 
Assessment: Mobility on one side that is restricted in con1parison with 
the contralateral side is a sign that a shoulder disorder exists. Other tests 
,nay then be used to diagnose this disorder in greater detail. Pain 
indicates degenerative tendinitis of one of the tendons of the rotator 
cuff, usually the supraspinatus tendon, or adhesive capsulitis. 
Codman Sign 
Tests passive n1otion in the shoulder. 
Procedure: The exa,niner stands behind the patient and places his or 
her hand on the patient's shoulder so that the thutnb in11nobilizes the 
patient's scapula slightly below the scapular spine, the index rests on 
Fig. 2.3a, b Quick test of 
combined motion: 
a touching the scapula from 
behind the neck, 
b touching the scapula from 
behind the back 
2 Shoulder 75 
Fig. 2.4 Cadman sign 
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the anterior 1nargin of the acromion toward the tip of the coracoid, and 
the retnaining fingers extend anteriorly past the acrotnion. 
The exan1iner then 1noves the patient's arm in every direction using 
the other hand. 
Assessment: The exan1iner notes any crepitation in the glenohutneral 
joint, snapping phenotnena (such as dislocations of the long head of the 
biceps tendon), or restricted motion. 
The 1nost important bony pressure points, such as the greater and 
lesser tubercles of the hun1erus, coracoid process, and sternoclavicular 
and acron1ioclavicular joints, are assessed for tenderness to palpation. 
Joint stability is also assessed, and pain in the tendons of the rotator cuff 
is evaluated by palpation. 
The range of ,notion is determined using the neutral-zero 1nethod. 
The active and passive ranges of ,notion are determined, as are the 
region of occurrence and specific localization of sy1npton1s. Restricted 
,notion in every direction indicates the presence of a "frozen shoulder." 
In the early stages of a rotator cuff tear, only active n1otion is re-
stricted; passive n1otion retnains nor1nal. A chronic tear or advanced 
impinge1nent syndrome will exhibit the universally restricted n1otion of 
a frozen shoulder. 
76 2 Shoulder 
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a b 
Fig, 2,Sa, b Palm sign test and finger sign test: 
a palm sign, 
b finger sign 
Palm Sign Test and Finger Sign Test 
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Typically, shoulder pain begins in the shoulder and radiates into the 
upper ar1n, Patients usually describe this pain in two ways, The "paln1 
sign" is typical of glenohu1neral and subacromial pain; the patient 
places the pah11 of the nor1nal contralateral hand directly under the 
acron11on, 
The "paln1 sign" is typical of pain in the acro1nioclavicular joint; in 
this case, the patient places the finger of the nor1nal contralateral hand 
directly on the affected acron1ioclavicular joint. 
• Bursitis Tests 
Bursae 
The shoulder contains a series of bursae. Com1nunicating structures 
include the subscapular and subcoracoid bursae, and the subdeltoid 
bursa with its subacro1nial extension, They ensure s1nooth n1otion 
between the rotator cuff and acromion and acron1ioclavicular joint 
that lie superficial to it, They usually cause significant pain in shoulder 
pathology, These bursae often combine to fom1 a synovial bursa. 
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Bursitis Sign 
2 Shoulder 
Fig, 2,6 Subacromial bursitis sign 
Diagnosis of shoulder pains of uncertain etiology, 
77 
Procedure: The exa1niner palpates the anterolateral subacro1nial re-
gion with his or her index and 1niddle fingers, 
The exan1iner can expand the subacron1ial space by passively ex-
tending or hyperextending the patient's ar1n with the other hand and 
pressing the hu1neral head forward with the thu1nb, This also allows 
palpation of the superior portions of the rotator cuff and its insertions 
into the greater tubercle of the hun1erus. 
Assessment: Localized tenderness to palpation in the subacro1nial 
space suggests irritation of the subacromial bursa but can also be a 
sign of a rotator cuff disorder. 
Dawbarn Test 
Sign of subacro1nial bursitis, 
Procedure: While further abducting the patient's n1oderately ab-
ducted ar1n with one hand, the exa1niner palpates the anterolateral 
subacro1nial space with the other hand, 
The examiner exerts additional focal subacron1ial pressure while 
passively abducting the patient's ar1n up to 90°. 
78 2 Shoulder 
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Assessment: Subacron1ial pain that decreases with abduction suggests 
bursitis, also a rotator cuff lesion. In abduction, the deltoid glides over 
the n1argin of the subacrotnial bursa, reducing the pain. 
• Rotator Cuff (Impingement Symptoms) 
Pain and varying degrees of functional impairn1ent are typically the 
don1inant features in the clinical picture of a rotator cuff lesion. 
In the phase of acute pain, it will usually be difficult to obtain 
sufficient infom1ation frotn the exan1ination to deter1nine whether 
the shoulder is due to calcification, tendinitis, subscapularis syndrotne, 
or a rotator cuff tear. It is even 1nore difficult to distinguish a rotator cuff 
tear fron1 disorders caused by degenerative tendon changes without 
rupture. Clinical classification of shoulder pain and 1nuscle weakness 
only becotnes easier once the pain of the acute phase has abated. 
Active ,notion is nearly normal, but reduced overall, in supraspinatus 
tears involving the anterior superior portion. The loss of active 111otion is 
1nore pronounced in injuries to the posterior portion and n1ost extren1e 
2 Shoulder 79 
in cotnplete tears. However, this is only an indication; the range of 
,notion does not allow conclusions about the type of the lesion. 
Pseudo-stiffening of the shoulder n1ust be distinguished from "fro-
zen shoulder." Pseudo-stiffening is often caused advanced but n1ini-
1nally painful osteoarthritis in the sternoclavicular joint. If this change 
is not considered, one risks n1istakenly attributing the decreased range 
of motion to changes in the glenohun1eral joint. A good test to distin-
guish these two is to watch the patient shrug (elevate the shoulders); a 
lin1ited range of motion may only be attributed to glenohutneral joint 
pathology where elevation of the shoulders is norn1al. 
Scapular and thoracic pathology n1ust be excluded in the satne 
1nanner. A "creaking" shoulder due to a bony projection such as scapular 
or costal osteophytes is less serious than the scapula that becon1es fixed 
in a posterior thoracic defect, such as can occur secondary to thoraco-
plasty or n1ultiple fractures of adjacent ribs. It is equally i1npo1tant to 
exclude dysfunction of the shoulder 1nusculature, whether the scapular 
and thoracic or the glenohutneral musculature. The exan1iner should beparticularly alert to the possibility of a serratus muscle palsy, which is 
tested for by verifying whether the scapula lifts off when pushing away 
the patient with his or her arn1s in forward extension. Paralysis of the 
trapezius must also be excluded. This paralysis litnits ,nobility in the 
shoulder because the scapula can no longer be in11nobilized. The ability 
to elevate the scapula rules out this paralysis, as does the ability to 
elevate the shoulders ( in shrugging). 
Even under normal circu,nstances, there is little space available for 
the structures that lie beneath the coracoacron1ial arch. This space is 
further din1inished when the greater tubercle of the hutnerus moves 
beneath the acrotnion in elevation. The supraspinatus is particularly 
affected by this confinen1ent. The space available for its ,notion is 
lin1ited on all sides by the anterior acromion, the coracoacromial liga-
tnent, the acromioclavicular joint, and the coracoid process (the supra-
spinatus outlet). 
lmpinge1nent syndron1e is a painful functional i1npair1nent of the 
shoulder that occurs when the rotator tendons impinge on the anterior 
1nargin of the coracoacrotnial arch and/or the acrotnioclavicular joint. 
The rotator cuff and the bursa beneath it can be locally compressed on 
the anterior 1nargin of the acron1ion in elevation, and against the cora-
coid process in internal rotation. A subacromial or subcoracoid in1pinge-
1nent syndrome can occur. lmpingen1ent lesions can also involve struc-
tures other than the rotator cuff that lie in the in1pinge1nent zone, such 
as the biceps tendon and the subacron1ial bursa. 
According to Neer, a distinction is 1nade between primary in1pinge-
1nent (outlet impinge1nent) and secondary in1pingement (nonoutlet 
80 2 Shoulder 
in1pinge1nent). Prin1ary i1npingen1ent involves irritation of the supra-
spinatus as a result of mechanical constriction (in the supraspinatus 
outlet). Contributing factors 1nay include congenital changes in the 
shape of the acron1ion, acquired bone spurs on the anterior n1argin of 
the acromion, inferior osteophytes on the acro1nioclavicular joint, and 
posttraun1atic deforn1ities of the coracoid process, acron1ion, and 
greater tubercle of the humerus. Secondary i1npingement (subacro1nial 
syndron1e) involves relative constriction of the subacro1nial space due 
to the increase in volun1e of the structures that pass beneath the 
coracoacromial arch. Thickening of the rotator cuff and bursa ( due to 
calcifications or chronic bursitis) and posttraumatic superior displace-
1nent of the greater tubercle of the hu1nerus are the 1nost co1n1non 
causes. 
The failure of the depressor 1nuscles of the hun1eral head that occurs 
in a tear of the rotator cuff or biceps tendon as the principal cause of 
secondary impingen1ent. Where a defective rotator cuff is no longer able 
to counterbalance the superior pull of the deltoid, elevating the 
shoulder will cause the hu1neral head to shift upwards and produce 
in1pinge1nent. The sa1ne also applies to shoulder instability, where, 
especially in multidirectional displace1nent, the humeral head is pulled 
against the roof of the joint capsule, producing i1npingement. Functional 
constriction can also result where muscular paralysis and weakness 
prevent involven1ent of the scapula in the overall elevation of the 
arn1, or where separation of the acron1ioclavicular joint has eliminated 
its supporting structures. Finally, one should also re1ne1nber the patho-
genetic significance of a shrunken posterior capsule. If the hun1eral head 
cannot glide far enough posteriorly in flexion, it will be increasingly 
pressed against the anterior n1argin of the acron1ion, resulting in in1-
pinge1nent. 
The chronic stage of in1pinge1nent syndro1ne can involve clinically 
conspicuous deltoid atrophy as well as supraspinatus and infraspinatus 
atrophy. The tendon insertions on the greater and lesser tubercles of the 
hu1nerus are often tender to palpation, and 1nobility in the glenohu-
1neral joint is often li1nited toward the end of its range of n1otion. Active 
elevation is 1nore painful than passive elevation. 
Where the patient is able to abduct his or her ar1n against resistance 
in spite of pain, this suggests degenerative tendon changes rather than a 
tear. The Neer impingen1ent injection test allows one to clinically 
distinguish between weakness in abduction due to a rupture and that 
due to pain. In the presence of a tendon rupture, the weakness in 
abducting the arn1 1nay be expected to re1nain even after infiltration 
of the subacro1nial space with anesthetic has reduced or eliminated 
. pain. 
2 Shoulder 81 
A patient with "pseudo-paralysis" is unable to lift the affected ar1n. 
This global sign suggests a rotator cuff disorder. Further exan1inations 
are then required to identify the da1naged tendon. Provocative tests can 
be very helpful in this regard. External and internal rotation against 
resistance is evaluated with the shoulder in various positions. Weakness 
is 1nore probably due to a functional deficit (such as a rupture), whereas 
pain is n1ore probably attributable to inflan11nation of the tendon in-
sertions or the adjacent bursae. 
Zero-Degree Abduction Test 
Procedure: The patient is standing with his or her arn1s hanging 
relaxed. The exan1iner grasps the distal third of each forearm. The 
patient atte1npts to abduct the arms against the exan1iner's resistance. 
Assessment: Abduction of the ar1n is initiated by the supraspinatus 
and deltoid. Pain and, especially, weakness in abducting and holding the 
arm strongly suggest a rotator cuff tear. 
Eccentricity of the humeral head in the forn1 of superior displace-
1nent of the htuneral head in a rotator cuff tear causes relative insuffi-
ciency of the outer 1nuscles of the shoulder. S1nall tears that can be 
functionally co1npensated for will cause minor loss of function with the 
san1e a1nount of pain. Larger tears are invariably characterized by weak-
ness and loss of function. 
Fig. 2.8 Zero-Degree abduction test 
82 2 Shoulder 
Jobe Supraspinatus Test 
Procedure: This test n1ay be performed with the patient standing or 
seated. 
With the elbow extended, the patient's ar1n is held at go0 of abduc-
tion, 30° of horizontal flexion, and in internal-neutral and external 
rotation. The exa1niner exerts pressure on the upper arm during the 
abduction and horizontal flexion motion. The supraspinatus can be 
tested largely in isolation after electromyography. It is in1portant to 
apply pressure gently at first and increase the pressure if the patient 
does not have pain. 
Assessment: When this test elicits severe pain and the patient is 
unable to hold his or her ar1n abducted go0 against gravity, this is called 
a positive drop arn1 sign. 
The superior portions of the rotator cuff (supraspinatus) are partic-
ularly assessed in internal rotation (with the thu1nb down as when 
e1nptying a can), and the anterior portions in external rotation. 
The test may be repeated at only 45° abduction to differentiate 
findings. Where the impinge1nent component predon1inates, there 
will be less pain and more strength where the tendon is still intact. 
The test can yield false-positive results where pathology of the long 
head of the biceps tendon is present. 
Where the test elicits pain and the patient is unable to abduct the 
arn1 go 0 and hold it against gravity, this indicates a tear of the supra-
spinatus tendon, or 1nuscle, or neuropathy of the suprascapular nerve. 
Strength in the supraspinatus 1nuscle 1nay not be diminished until 
over two-thirds of the tendon is torn. 
Injection studies into the suprascapular and axillary nerves substan-
tiate that both the supraspinatus and deltoid 1nuscle function in eleva-
tion of the arm. 
Therefore, the supraspinatus tendon can be co1npletelytorn and the 
shoulder can have full range of n1otion. The only deficit will be weakness 
using the ar1n for lifting above shoulder level and with the arm away 
from the body. 
EMG tests show no difference in the EMG activity with the arm in full 
internal rotation ( classic Jobe empty can position) with the thtunb 
parallel to the floor and with the arn1 in 1naximum external rotation 
(full can position). 
The strength of the supraspinatus 1nuscle can also be tested with the 
elbows flexed rather than extended to decrease the stress. It is less 
painful for patients. 
2 Shoulder 83 
a b 
Fig. 2.9a, b 
a Jobe supraspinatus test, 
b Jobe supraspinatus test with elbow flexed. Abduction of the arm to 90°, the 
elbow is flexed 
Subscapularis Test 
Procedure: This test has the opposite effect with respect to the infra-
spinatus. With the patient's elbow alongside but not quite touching the 
trunk, the examiner con1paratively assesses passive external rotation in 
both arn1s and active internal rotation of the shoulder against resist-
ance. 
Assessment: Increased painless passive external rotation in con1par-
ison with the contralateral side and weakness of the active internal 
rotation suggests an isolated tear of the subscapularis. 
A tear of the subscapularis 1nanifests itself as pain and weakness in 
internal rotation. Where pain is slight, this reduced strength suggests a 
tear. Where pain is n1ore severe, it is not usually possible to distinguish 
between a tear and tendinopathy. 
84 
a 
2 Shoulder 
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a passive external rotation, 
b 
b active internal rotation behind the back 
Gerber Lift-Off Test 
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Procedure: The patient places the dorsun1 of the hand on his or her 
back with the arn1 in internal rotation. The patient then lifts the hand 
away fron1 the back. If the patient is able to take the hand away fron1 the 
back, the exa1niner should apply a load, pushing the hand toward the 
back to test the strength of the subscapularis and to test how the scapula 
acts under dyna1nic loading. 
Assessment: Where a tendon rupture or insufficiency of the subsca-
pularis is present, the patient will be unable to lift the hand off the back 
against the examiner's resistance. Where pain renders maxi1nu1n inter-
nal rotation impossible, the belly press test 1nay be perforn1ed. 
With a torn subscapularis tendon, passive (and active) lateral rota-
tion will increase. If the patient's hand is passively n1edially rotated as 
far as possible and the patient is asked to hold the position, the exan1-
iner will note that the hand 1noves toward the back (subscapularis or 
2 Shoulder 85 
Fig. 2.11 Lift-off test 
~.' 
... j ', 
1nedial rotation spring back or leg test) as the subscapularis cannot hold 
the position due to weakness or pain. This test is also called the modified 
lift-off-test. 
A short lag between 1naxin1un1 passive n1edial rotation and active 
1nedial rotation suggests a partial tear of the subscapularis. This modi-
fied test is reported to be n1ore accurate in diagnosing rotator cuff tear. 
The test may also be used to test the rho1nboids. Medial border winging 
of the scapula during the test may indicate that the rhon1boids are 
affected. 
Because 1nany patients with biceps subluxations have partial or full-
thickness tears of the subscapularis, a positive test may indicate not only 
subscapularis, but also biceps tendon pathology. Where pain renders 
1naximun1 internal rotation i1npossible, the Napoleon sign n1ay be per-
formed. 
Belly Press-Abdominal Compression Test 
Procedure: The patient is standing. The patient's forearn1 lies along the 
abdo1nen with the elbow flexed. The patient attempts to continue 
forcefully pressing arm against abdo1nen. 
Assessment: A tear in the supraspinatus tendon results in loss of the 
internal rotation co1nponent. The elbow deviates laterally and posteri-
orly under the influence of the latissi1nus dorsi and teres n1ajor. Flexion 
also occurs in the wrist. 
86 2 Shoulder 
~ - --· 
-
-~-
:.. 
a b 
Fig. 2.12a, b Belly press test-abdominal compression test: 
a the forearm lies along the abdomen with the elbow flexed, 
b the arm deviates laterally and posteriorly while the wrist is flexed 
Napoleon Sign 
The active and passive lift-off test is only allowed where free active and 
passive internal rotation is possible in the injured shoulder. 
Procedure: The patient is instructed to press the palm of his or her 
hand against the abdon1en. 
Assessment: Nor1nally these 1notions produce anterior n1otion in the 
elbow due to the tension in the subscapularis musculature. In patients 
with a rupture in the subscapularis tendon, the position of the arn1 
remains unchanged. Some patients also exhibit increased passive ex-
ternal rotation. 
• 
,01 ,, 
' ~ 
-. . . 
Fig. 2.13 Napoleon sign: both hands 
are pressed against the abdomen 
lnfraspinatus Test 
2 Shoulder 
0 I \ 
I ~. 
I 
I 
' 
i 
I 
l 
LY 
. 
I 
Fig. 2.14 lnfraspinatus test 
87 
Procedure: This test 1nay be perfor1ned with the patient seated or 
standing. 
Comparative testing of both sides is best. The patient's arn1s should 
hang relaxed with the elbows flexed go0 but not quite touching the 
trunk. The exa1niner places his or her paln1s on the dorsu1n of each of 
the patient's hands and then asks the patient to externally rotate both 
forearn1s against the resistance of the examiner's hands. 
Assessment: Pain or weakness in external rotation indicates a disorder 
of the infraspinatus ( external rotator). As infraspinatus tears are usually 
painless, weakness in rotation strongly suggests a tear in this n1uscle. 
This test can also be perforn1ed with the arm abducted go0 and flexed 
30° to elin1inate involven1ent of the deltoid in this n1otion. The 1nost 
co1nn1on etiology for the atrophy of the infraspinatus is tendon tears or 
datnage to the infraspinatus branch of the suprascapular nerve by 
cotnpressive lesions ( synovial cyst) or by traction injuries ( overhead 
athletes, volleyball players). 
The infraspinatus fills the infraspinatus fossa of the scapula. The best 
way to detnonstrate infraspinatus atrophy is to ask the patient to un-
dress. Compression toward the contralateral side is helpful in detertnin-
ing if changes are unilateral or bilateral. 
88 2 Shoulder 
~
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a 
Fig. 2.1 Sa, b Teres test: 
a normal position, 
b contracture in the right arm 
Teres Test 
Procedure: The patient is standing and relaxed. The exa1niner assesses 
the position of the patient's hands from behind. 
Assessment: The teres 1najor is an internal rotator. Where a contrac-
ture is present, the pahn of the affected hand will face backward 
co1npared with the contralateral hand. With the patient standing in a 
relaxed position, such a finding suggests a contracture of the teres 
1naJor. 
Weakness of the rotator cuff or a brachial plexus lesion can also 
producean asy1nmetrical hand position. 
Abduction External Rotation Test 
Procedure: The arn1 is abducted go0 and flexed 30°. This neutralizes 
the effect of the deltoid in external rotation. The patient atte1npts to 
continue to externally rotate the ar1n against the resistance of the 
exa1niner's hand. 
Assessment: The lack of active external rotation in the abducted arn1 
suggests a clinically significant rupture of the infraspinatus tendon. 
Perfor1ning the test at over 45 ° of external rotation pri1narily tests the 
teres 1ninor. 
: · 
. 
l 
,I 
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Nonspecific Supraspinatus Test 
,, I 
I 
2 Shoulder 
Fig. 2.16 Abduction 
external rotation test 
89 
Procedure: The patient is seated with the arn1 abducted go0 with the 
exa1niner's hand resting on the patient's forearn1. The examiner then 
asks the patient to further abduct the ar1n against the exan1iner's 
resistance. 
Assessment: Weakness in further abduction and/or pain indicate pa-
thology of the supraspinatus tendon. 
Note: Painful arc syndron1e is son1etimes confused with arthritis of the 
acron1ioclavicular joint, which also causes pain during a certain phase of 
the abduction arc. 
Drop Arm Test 
Procedure: The patient is seated and the extended arn1 passively ab-
ducted go0 • The patient is instructed to hold the ar1n in this position 
without support and then slowly lower it. 
Assessment: Weakness in maintaining the position of the arn1, with or 
without pain, or sudden dropping of the ar1n suggests a rotator cuff 
lesion. Most often this is due to a defect in the supraspinatus. In pseudo-
paralysis, the patient will be unable to lift the affected an11. This global 
sign suggests a rotator cuff disorder. 
A painless drop ar1n sign can also be seen in neurologic diseases. 
Therefore patients with a positive drop ar1n sign should be exan1ined 
carefully for such findings. 
90 2 Shoulder 
' 
Fig. 2.17 Drop arm test Fig. 2.18 Hornblower sign 
Walch Hornblower Sign 
Procedure: The patient is requested to touch his or her n1outh with the 
affected hand. 
Assessment: Where there is con1plete insufficiency of both external 
rotators (infraspinatus and teres n1inor), the am1 will deviate into 
internal rotation and the patient will have to lift the elbow higher 
than the hand. To reach their n1outh, they 1nust first elevate the ar1n 
to about 90°. This allows the weak arn1 to fall into internal rotation, so 
that the ar1n assun1es a position resembling a person blowing a horn. 
The sensitivity and specificity of this sign is very high. 
Apley's Scratch Test 
Procedure: The seated patient is asked to touch the contralateral 
superior 1nedial corner of the scapula with the index finger. 
Assessment: Pain elicited in the rotator cuff and failure to reach the 
scapula because of restricted 1nobility in external rotation and abduc-
tion indicate rotator cuff pathology (n1ost probably involving the supra-
spinatus). A differential diagnosis should consider osteoarthritis in the 
glenohun1eral and acro1nioclavicular joints as well as capsular fibrosis. 
---¥-
·7 
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Painful Arc 
2 Shoulder 91 
Fig. 2.19 Apley's scratch test 
Procedure: The ar1n is passively and actively abducted fro1n the rest 
position alongside the trunk. 
Assessment: Pain occurring in abduction between 70° and 120° (Fig. 
2.20a) is a sign of a lesion of the supraspinatus tendon, which becon1es 
impinged between the greater tubercle of the hun1erus and the aero-
inion in this phase of the 1notion (subacro1nial in1pingement). (Contrast 
this with the painful arc in acron1ioclavicular joint disorders, where the 
pain only occurs only at 140° - 180° of abduction, Fig. 2.20c; see also Fig. 
2.24). Patients are usually free of pain above 120°. 
In the evaluation of the active and passive ranges of 1notion, the 
patient can often avoid the painful arc by externally rotating the ar1n 
while abducting it. This increases the clearance between the acro1nion 
and the diseased tendinous portion of the rotator cuff, avoiding in1-
pinge1nent in the range between 70° and 120°. 
In addition to complete or inco1nplete rotator cuff tears, swelling and 
inflamn1ation as a result of bursitis and abnormality of the 1nargin of the 
acron1ion occasionally lead to i1npingen1ent with a painful arc, as does 
osteoarthritis in the acromioclavicular joint. 
92 
/ 
.I 
I 
· . . 
a 
2 Shoulder 
) l J c 
. 
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\ 
, ; ·. 
' 
b 
Fig. 2.20a-c Painful arc: 
a starting position, 
30° 
i 
b painful motion between 30° and 120°, 
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c pain at the end of the range of motion, a sign of acromioclavicular joint 
pathology 
Neer Impingement Sign 
Procedure: The exan1iner in11nobilizes the scapula with one hand 
while the other hand jerks the patient's ar1n forward, upward, and 
sideways (1nedially) into the scapular plane. 
Assessment: If an impinge1nent syndrome is present, subacro1nial 
constriction or in1pingement of the diseased area against the anterior 
inferior n1argin of the acromion will produce severe pain with 1notion. 
The in1pinge1nent sign is nonspecific and can produce pain from a 
variety of conditions (bursitis, stiffness, anterior instability, arthritis, 
calcific tendonitis, bone lesions, rotator cuff tears). If the test is positive 
when done with the arm laterally rotated, the exa1niner should check 
the acromioclavicular joint (acro1nioclavicular differentiation test). 
I 
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Fig. 2.21 a, b Neer impingement sign: 
a starting position, 
2 Shoulder 
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b forcible forward flexion and adduction of the extended arm 
Hawkins and Kennedy Impingement Test 
93 
Procedure: The exan1iner in11nobilizes the scapula with one hand 
while the other hand adducts the patient's 90°-forward-flexed and 
internally rotated am1 (1noving it toward the contralateral side of the 
body). 
Assessment: Pain indicates a positive test for supraspinatus peritendi-
nitis, tendinitis, or secondary in1pingement. 
In a positive in1pingement syndron1e, impingement of the greater 
tubercle or co1npression of the supraspinatus tendon occurs, causing 
severe pain on n1otion. Coracoid in1pinge1nent is revealed by the ad-
duction 1notion, in which the supraspinatus tendon also impinges 
against the coracoid process. 
In the Jobe i1npingen1ent test, the forward flexed and slightly ad-
ducted arm is forcibly internally rotated. This will provoke typical 
impinge1nent pain. 
94 2 Shoulder 
\ 
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--
\. 
'· 
~· 
' ' 
a b 
Fig. 2.22a, b Hawkins impingement sign: 
a starting position 
b forcible internal rotation Uobe) 
Neer Impingement Injection Test 
·-
,_ 
·-
_ ... 
.. 
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--- --=-
--
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.. 
Procedure: The region beneath the anterior acro1nion or the subacro-
1nial space is infiltrated with an anesthetic. To open the subacro1nial 
space, the patient is asked to sit on the side of the table with the arn1 
hanging down unsupported. The weight of the ar1n will open the sub-
acron1ial space only if the patient is relaxed. The injection should be 
done with sterile technique. 
Caution: After the injection it is necessary to observe the patient for 
vasovagal sympton1s. Patients are warned about potential side effects 
including pain and Joss of 1notion briefly after the injection and that the 
shoulder may be sore for a few days ( especially after co1nbined anes-
thetic and corticosteroid injection).Assessment: This test allows the exan1iner to deter1nine whether 
subacro1nial impinge1nent is the cause of the painful arc. A painful arc 
that disappears or in1proves after the injection is caused by changes in 
the subacromial space, such as bursitis or an activated rotator cuff 
defect. 
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2 Shoulder 
Fig. 2.23 Neer impingement injection 
test 
• Acromioclavicular Joint 
95 
The acron1ial end of the clavicle articulates with the acron1ion. The 
acron1ioclavicular ligan1ent reinforces the capsule of this joint. Func-
tionally, the articulation is a ball-and-socket joint whose range of n10-
tion is Jess than that of the sternoclavicular joint. Another strong liga-
1nent joins the scapula and clavicle, the coracoclavicular liga1nent. It 
arises fro1n the coracoid process and inserts into the inferior aspect of 
the clavicle. One of the most helpful signs of the presence of acro1nio-
clavicular joint problems is to co1npare the two shoulders for asymn1e-
try of the acron1ioclavicular joints (e.g., asy1nptomatic arthritis, trau1na, 
tumors, infections, synovial cysts). 
Osteoarthritis of the acro1nioclavicular joint can cause pain and 
further constrict the subacron1ial space. In addition to pain with motion 
and tenderness to palpation over the shoulder, palpation will often 
reveal thickening of the bony joint margins. 
The vast 1najority of degenerative acro1nioclavicular joints are not 
symptomatic and do not warrant treatJnent. 
Acron1ioclavicular joint disease can also n1i1nic cervical spine disease 
(which frequently radiates down the trapezius into the superior 
shoulder), a superior Jabrum anterior and posterior (SLAP) lesion, and 
a rotator cuff disease. 
96 2 Shoulder 
Acrotnioclavicular capsular ligan1ent injures are con11non. Rockwood 
classified acro1nioclavicular joint injuries in six grades. 
Grade 1: Acron1ioclavicular joint sprain 
Grade 2: Partial rupture of the acro1nioclavicular and coracoclavicular 
liga1nents and subluxation in the acron1ioclavicular joint 
Grade 3: Cotnplete rupture of the acro1nioclavicular and coracoclavic-
ular ligaments, dislocation of the acro1nioclavicular joint 
Grade 4: Dislocation of the acro1nioclavicular joint, the clavicle is 
posteriorly displaced into the trapezius 
Grade 5: Dislocation of the acron1ioclavicular joint, the clavicle is 
superiorly displaced by at least twice the width of the clavicle 
Grade 6: Dislocation of the acron1ioclavicular joint, the clavicle is in-
feriorly displaced beneath the coracoid process 
Painful Arc 
Procedure: The patient's arn1 is passively and actively abducted fron1 
the rest position alongside the trunk. 
Assessment: Pain in the acron1ioclavicular joint occurs between 140° 
and 180° of abduction. Increasing abduction leads to increasing con1-
I' 1, l 
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·1 ~ I 
\·. I J;I ,: 
a j 
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Fig. 2.24a-c Painful arc: 
a starting position, 
140' -1 80' 
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C 
b pain between 30° and 120°(sign of a supraspinatus syndrome). 
c pain between 140° and 180° (sign of osteoarthritis in the acromioclavicular 
joint) 
2 Shoulder 97 
pression and contortion in the joint. (In an impinge1nent syndron1e or a 
rotator cuff tear, by comparison, pain syn1pto1ns will occur between 70° 
and 120°; see Fig. 2.20). 
Crossed Body Adduction Stress Test 
Procedure: The 90° -abducted an11 on the affected side is forcibly 
adducted across the chest toward the nor1nal side. 
Assessment: Pain in the acromioclavicular joint suggests joint pathol-
ogy or anterior impinge1nent. (Absence of pain after injection of an 
anesthetic is a sign of joint disease.) 
Forced Adduction Test on Hanging Arm 
Procedure: The exan1iner grasps the upper ar1n of the affected side 
with one hand while the other hand rests on the contralateral shoulder 
and in11nobilizes the shoulder girdle. Then the exa1niner forcibly ad-
ducts the hanging affected artn behind the patient's back against the 
patient's resistance. 
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stress test 
; 
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Fig. 2.26 Forced adduction test on 
hanging arm 
98 2 Shoulder 
Assessment: Pain across the anterior aspect of the shoulder suggests 
acron1ioclavicular joint disease or subacro1nial impingen1ent. (Sy1np-
to1ns that disappear or in1prove following injection of an anesthetic 
indicate that the acron1ioclavicular joint is causing the pain.) 
Clavicle Mobility Test 
Procedure: The exan1iner grasps the lateral end of the clavicle be-
tween two fingers and moves it in every direction. 
Assessment: Increased 1nobility of the lateral clavicle with or without 
pain is a sign of instability in the acron1ioclavicular joint. In isolated 
osteoarthritis there will be circumscribed tenderness to palpation and 
pain with n1otion. Acromioclavicular joint separation with rupture of 
the coracoclavicular ligan1ents will be accon1panied by a positive "piano 
key" sign: the subluxated lateral end of the clavicle displaces proximally 
with the pull of the cervical 1nusculature and can be pressed inferiorly 
against elastic resistance. 
Dugas Test 
Procedure: The patient is seated or standing and touches the contra-
lateral shoulder with the hand of the go0 -flexed arn1 of the affected side. 
I 
. \ 
/' 
\ . 
-
- ' -' 
' ·· 
I 
1. 
Fig. 2.27 Clavicle mobility test 
I 
'· 
Fig. 2.28 Dugas test 
2 Shoulder 99 
Assessment: Acron1ioclavicular joint pain suggests joint disease ( os-
teoarthritis, instability, disk injury, or infection). A differential diagnosis 
1nust exclude anterior subacro1nial in1pingen1ent, due to the topo-
graphic proxilnity of that region. 
Acromioclavicular Injection Test 
Procedure: Inject the acron1ioclavicular joint with an anesthetic such 
as lidocaine (with a corticosteroid where indicated). A sterile prepara-
tion of the area is applied prior to the injection and the injection is done 
with sterile technique. Large osteophytes, arthritic joints, and an in1-
pinged n1eniscus render injection difficult. 
Assessment: Where injection relieves local pain, isolated acromiocla-
vicular pathology is present. To confir1n the diagnosis it is recon1-
1nended to atte1npt to reproduce the pain with whatever exa1nination 
produced the n1ost pain prior to injection, such as a cross ar1n adduction 
test or painful arc. 
• Long Head of the Biceps Tendon 
A rupture of the long head of the biceps tendon will appear as a distally 
displaced protrusion of the muscle belly of the biceps. The close ana-
tomic proxin1ity of the intraarticular portion of the tendon to the 
coracoacromial arch predisposes it to involve1nent in degenerative 
processes in the subacromial space. A rotator cuff tear is often accon1-
panied by a rupture of the long head of the biceps tendon. 
Isolated inflamn1ation of the long head of the biceps tendon (bicipital 
tenosynovitis) is accordingly rare. In younger patients, this n1ay occur as 
a tennis or throwing injury. Subluxations of the long head of the biceps 
tendon in the bicipital groove are usually difficult to detect. However, a 
series of specific tests can be used to diagnose biceps tendon injuries; 
the typical sign of these injuries is not the distally displaced musclebelly but incon1plete contraction and/or "snapping" of the tendon. 
Nonspecific Biceps Tendon Test 
Procedure: The patient holds the ar1n abducted in neutral rotation 
with the elbow flexed go0 • The exan1iner iIT~,j'ffibilizes the patient's 
elbow with one hand and places the heel of'\ k other hand on the 
patient's distal forear1n. The patient is then asked to externally rotate his 
or her ar1n against the resistance of the examiner's hand. 
100 
( 
. \ 
2 Shoulder 
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r:<".. ( 
..,,,_ t,,, ~ .-:f' 
,/ """''."""''"' 
' / . ' " \ 
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r 
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Fig. 2.29 Nonspecific biceps tendon test 
Assessment: Pain in the bicipital groove or at the insertion of the 
biceps suggests a tendon disorder. 
Pain in the anterolateral aspect of the shoulder is often a sign of a 
disorder of the rotator cuff, especially the infraspinatus tendon. 
Abbott-Saunders Test 
Den1onstrates subluxation of the long head of the biceps tendon in the 
bicipital groove. 
Procedure: The patient's arm is externally rotated and abducted about 
120° with progressive internal rotation. The exa1niner slowly lowers the 
arn1 from this position. The exa1niner guides this n1otion of the patient's 
arn1 with one hand while resting the other on the patient's shoulder and 
palpating the bicipital groove with the index and middle fingers. 
Assessment: Pain in the region of the bicipital groove or a palpable or 
audible snap suggest a disorder of the biceps tendon (subluxation sign). 
An infla1ned bursa (subcoracoid or subscapular bursa) can also occa-
sionally cause snapping. 
. 
' 
-
Fig. 2.30 Abbott-Saunders test 
. 
. 
( 
I 
2 Shoulder 
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.--.:"s.:..7/':-
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101 
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Fig. 2.31 Speed test 
Palm-Up Test (Speed Biceps or Straight Arm Test) 
Procedure: The patient's arn1 is extended in supination at 90° of 
abduction and 30° of horizontal flexion. The patient atten1pts to either 
1naintain this position or continue to abduct and pronate the ar1n 
against the downward pressure of the examiner's hand. 
Assessment: A positive test elicits increased tenderness in the bicipital 
groove especially with the arm supinated and is indicative of bicipital 
paratenonitis or tendinosis. 
Snap Test 
Tests for subluxation of the long head of the biceps tendon. 
Procedure: The exa1niner palpates the bicipital groove with the index 
and middle finger of one hand. With the other hand, the exa1niner 
grasps the wrist of the patient's arm ( abducted 80° -90° and flexed 
90° at the elbow) and passively rotates it at the shoulder, first in one 
direction and then the other. 
Assessment: Subluxation of the long head of the biceps tendon out of 
the bicipital groove will be detectable as a palpable snap. 
102 2 Shoulder 
) ___ _,, 
I 
I 
I 
a 
Fig. 2.32a, b Snap test: 
a external rotation, 
b internal rotation 
Yergason Test 
b 
Functional test of the long head of the biceps tendon. 
Procedure: The patient's ar1n is alongside the trunk and flexed go0 at 
the elbow. One of the exan1iner's hands rests on the patient's shoulder 
and palpates the bicipital groove with the index finger while the other 
hand grasps the patient's forearm. The patient is asked to supinate the 
forearm against the exa1niner's resistance. This places isolated tension 
on the long head of the biceps tendon. 
Assessment: Pain in the bicipital groove is a sign of a lesion of the 
biceps tendon, its tendon sheath, or its liga1nentous connection via the 
transverse ligament. The typical provoked pain can be increased by 
pressing on the tendon in the bicipital groove. 
Hueter Sign 
Procedure: The patient is seated with the arn1 extended at the elbow 
and the forearn1 in supination. The exan1iner grasps the posterior aspect 
of the patient's forean11. The patient is then asked to flex the elbow 
against the resistance of the exan1iner's hand. 
2 Shoulder 103 
·. 
i 
( 
r 
Fig. 2.33 Yergason test Fig. 2.34 Hueter sign 
Assessment: In a rupture of the long head of the biceps tendon, the 
distally displaced muscle belly can be observed as a "ball" directly 
proxin1al to the elbow. 
Transverse Humeral Ligament Test 
Procedure: The patient is seated with the ar1n abducted go0 , internally 
rotated, and extended at the elbow. From this position, the exa1niner 
externally rotates the arm while palpating the bicipital groove to verify 
whether the tendon snaps. 
Assessment: In the presence of liga1nentous insufficiency, this n1otion 
will cause the biceps tendon to spontaneously displace out of the 
bicipital groove. Pain reported without displacen1ent suggests biceps 
tendinitis. 
104 2 Shoulder 
\ '· 
I~ 
l 
' ' ; .t 
a 
\ 
' I 
Tl 
Fig. 2.35a, b Transverse humeral ligament test: 
a starting position, 
b palpating the biceps tendon in internal rotation 
Thompson and Kopell Horizontal Flexion Test 
(Cross-Body Action) 
Procedure: The patient is standing and n1oves the 90° -abducted arn1 
across the body into 1naxi1nu1n horizontal flexion. 
Assessment: Dull, deep-seated pain above the superior n1argin of the 
scapula in the supraspinatus fossa and on the posterolateral scapula 
radiating into the upper arn1 can be caused by compression of the 
suprascapular nerve beneath the transverse scapular liga1nent as a 
result of distal displacement of the scapula. 
Note: A differential diagnosis n1ust consider pain due to acromiocla-
vicular joint pathology. Such pain can also be elicited by this test 
1naneuver. 
Fig. 2.36 Thompson and Kopell horizontal flexion test 
Fig. 2.37 Ludington test: the pa-
tient places both hands behind the 
head, testing the biceps tendon 
Ludington Test 
2 Shoulder 105 
Fig. 2.38 Lippmann test: the arm is flexed 
to 90°; the examiner palpates the biceps 
tendon 
Procedure: The patient is standing and is asked to place both hands 
behind the head locking the fingers. This allows the ar1ns to be sup-
ported by the hands on the head and allows the biceps to relax. The 
patient then is asked to relax and contract the biceps tendon. The 
exa1niner stands behind the patient and palpates the proxin1al biceps 
tendon to see if tension is found in the tendon with muscle contraction. 
Assessment: If there is no tension in the tendon, then the proximal 
biceps tendon n1ay be torn. 
Lippman Test 
Procedure: The patient is sitting or standing, and the exa1niner is 
holding the arm of the patient flexed to 90 degrees. The exa1niner 
palpates the biceps tendon in the bicipital groove 6 to 8 cn1 below the 
glenohun1eral joint und atte1npts to move it back and forth. 
Assessment: If the patient feels a sharp pain in the biceps tendon when 
it is being flipped back and forth, then tendon pathology is present. 
106 2 Shoulder 
SLAP Lesions 
The intraarticular insertion of the long head of the biceps tendon for1ns 
an integral unit with the adjacent superior glenoid labrun1. A fall on the 
extended, slightly flexed, and abducted ar1n; trau1na in external rotation 
and abduction; and 1nicrotrau1na from repeated throwing 1notions can 
all lead to superior labral-anterior posterior (SLAP) lesions. Associated 
injuries are co1nn1on and may include tears of the rotator cuff and 
Bankart lesions. 
Snyder classifies SLAP lesions as follows: 
Type I: ( 11 %) Labral degeneration not affecting the 1nargin of the 
labrun1 or biceps anchor. 
Type II: ( 41 %) Avulsion of the biceps tendon fron1 the supraglenoidtubercle. Biceps and labru1n are avulsed together. Anterior, 
posterior, or con1bined lesion. 
Type III: (33%) Bucket-handle tears of the superior labrun1 with in-
tact biceps anchor. 
Type IV: (15%) Bucket handle tear of the superior labrum involving 
the biceps anchor. 
O'Brien Active Compression Test 
Assess1nent of a superior labral-anterior posterior (SLAP) lesion. Sepa-
ration of the glenoid labru1n fron1 the anterior superior and posterior 
superior 1nargins of the glenoid accon1panied by avulsion of the inser-
tion of the long head of the biceps tendon. 
Procedure: The patient stands with the elbow extended and 1noves his 
or her an11 into 90° flexion, 10° adduction, and 1naximun1 internal 
rotation (thun1bs pointing downward). The examiner atte1npts to press 
~
! I 
I 
' ' ., 
' 
a b 
Fig. 2.39a, b O'Brien active compression test 
2 Shoulder 107 
the ar1n downward against the patient's resistance (the test is then 
repeated in n1axi1nu1n external rotation). 
Assessment: The test is positive where the first phase elicits pain that 
then lessens or disappears in supination (1naximum external rotation). 
It is crucial to inquire about the location of the pain as the O'Brien test 
can also yield positive results in the presence of acro1nioclavicular joint 
disorders. Pain reported within the shoulder suggests a SLAP lesion, 
whereas pain over the acron1ioclavicular joint may also be due to osteo-
arthritis of the acro1nioclavicular joint. 
In addition to the O'Brien test, the internal rotation resistance 
strength test (IRRS test) is suitable for clinical evaluation of the biceps 
tendon insertion. In this test, the patient 1noves his or her arn1 with the 
elbow flexed into 90° abduction and 80° external rotation. The patient is 
then asked to rotate the arm externally and then internally against the 
exa1niner's resistance. The test is positive where the strength of internal 
rotation is significantly less than that of external rotation. 
The active con1pression test is a test for both acro1nioclavicular joint 
problen1s and SLAP lesions. When the test is perforn1ed, the patient is 
asked whether the pain provoked when his pahn is down (the first half 
of the test) is located on top of the shoulder near the acro1nioclavicular 
joint or if it is located deep in the joint. If the pain is superficial, this 
indicates an acromioclavicular joint problen1; if it is deep in the joint, it 
is suspicious for a SLAP lesion. The test is repeated with the paln1 up, and 
the pain should be din1inished regardless of the etiology. 
Biceps Load Test 1 
Diagnosis of superior labru1n tears in patients who had anterior 
shoulder instability associated with Bankart lesions. 
Procedure: The patient is placed supine and the extremity abducted to 
90 degrees. The elbow is flexed 90° and the arn1 is placed in a neutral 
rotation. The forearm is supinated and then an anterior apprehension 
1naneuver is perfor1ned. 
When the patient becomes apprehensive, external rotation is 
stopped. The patient is then asked to actively flex the forearn1 at the 
elbow by bringing the hand toward his face. Upon resistance by the 
exan1iner, the patient is asked if the feeling of instability is i1nproved, 
unchanged, or worsened. 
Assessment: If the pain is unin1proved or worsens, then there is suspi-
cion of a SLAP lesion. The exa1niner should note that the forearm should 
be supinated during the test. Also, the examiner should be at the sa1ne 
level as the patient, e.g., sitting on a chair. 
108 2 Shoulder 
·-.-I 
Biceps Load Test 2 
Fig. 2.40 Biceps load 1 test: the elbow is fl exed to go•; 
the arm is placed in neutral position 
Test for isolated SLAP lesions independent of shoulder instability 
Procedure: The rationale for the test is that resisted flexion of the ar1n 
with the forean11 in a supinated position places stress on the proxi1nal 
biceps anchor. 
The patient is supine, but the arn1 is abducted to 120° of elevation. 
The arm is then externally rotated to its n1axi1nal extent, and the elbow 
is flexed go• and the forearn1 supinated. The patient is asked to flex the 
elbow toward the head while the exa1niner resists that motion. 
Fig. 2.41 Biceps load 
2 test: the arm is ab-
ducted to 120° and 
rotated to its maximal 
extent. The elbow is 
flexed to go• 
2 Shoulder 109 
Assessment: A positive test is the presence of pain with the test or 
increased pain over baseline with the test. A negative test is the absence 
of pain or a lack of increase in the baseline pain. 
• Shoulder Instability 
The joint capsule of the shoulder may be too loose, leading to instability. 
Often this is attributable to congenital generalized laxity of the liga-
1nents (hyperlaxity) with increased bilateral 1nultidirectional instability. 
Chronic shoulder pain n1ay be attributable to an unstable shoulder. The 
clinical picture of subluxation in particular is often difficult to diagnose, 
and patients then1selves can usually give only a vague description of 
their sympto1ns. 
According to Neer, instability patients invariably have a history of a 
period of intensive shoulder use (such as co1npetitive sports), an episode 
of repeated minor traun1a (overhead use), or generalized ligament 
laxity. Both young athletes and inactive persons are affected, men and 
wo1nen alike. 
The transition between subluxation and dislocation is continuous. 
There is no clearly defined point before which a lesion is still a sublux-
ation and beyond which it is already a dislocation. Patients with volun-
tary instability are a separate issue. In such cases, consultation with a 
psychologist 1nay be helpfu l in addition to repeated clinical exan1ina-
tion. 
The differential diagnosis 1nust specifically consider an i1npingen1ent 
syndron1e, a rotator cuff tear, osteoarthritis in the acro1nioclavicular 
joint, and also a cervical spine syndro1ne. In cases of doubt, injection 
of a local anesthetic at the point of 1naximum pain 1nay be required. 
However, this treatment cannot permanently eli1ninate instability 
symptoms. Signs of generalized ligament laxity 1nay include increased 
1nobility in other joints and, especially, increased hyperextension in the 
elbow or retroflexion in the 1netacarpophalangeal joint of the thu1nb 
with the forear1n extended. The use of a variety of relatively specific 
tests will make it easier for the examiner to arrive at a diagnosis. 
Assess1nent of the range of motion is crucial in patients with sus-
pected shoulder instability. Rotation should be exa1nined in both ad-
duction and go• -abduction. Restricted external rotation in both adduc-
tion and abduction will often be the first sign of instability,1llpatients 
with anterior instability. Flexion and abduction in the scapula) 61ane are 
not norn1ally restricted. 
110 2 Shoulder 
Compression Test 
Procedure and assessment: Passive elevation of the an11 to the end of 
its range of n1otion with continued application of posterior pressure 
produces pain as a result of con1pression of the biceps tendon between 
the acromion and hun1eral head. 
Evaluation of the range of motion is crucial in patients with sus-
pected shoulder instability. Rotation should be exan1ined both in ad-
duction and go0 -abduction. Restricted external rotation in both adduc-
tion and abduction will often be the first sign of instability in patients 
with anterior instability. Flexion and abduction in the scapular plane are 
not norn1ally restricted. 
Anterior Apprehension Test 
Tests of shoulder stability. 
Fig. 2.42 Compression test 
Procedure: The exa1nination begins with the patient seated. The ex-
a1niner palpates the humeral head through the surrounding soft tissue 
with one hand and guides the patient's ar1n with the other hand. The 
exa1niner passively abducts the patient's shoulder withthe elbow flexed 
and then brings the shoulder into 1naxin1um external rotation, keeping 
the arm in this position. The test is performed at 60°, go0 , and 120° of 
abduction to evaluate the superior, 1nedial, and inferior glenohu1neral 
ligan1ents. With the guiding hand, the exan1iner presses the hu1neral 
head in an anterior and inferior direction. 
The exa1niner then applies a posterior translational stress to the head 
of the hu1nerus or the artn, and the patient will con11nonly lose the 
a 
Fig. 2.43a-e Anterior apprehension 
test: 
a starting position, 
b test position, 
c apprehension test (supine), 
d supine with posteriorly directed 
pressure applied to the humeral 
head, 
e after relieving the posteriorly 
directed pressure 
b 
d 
I 
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1 I\ 
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e 
2 Shoulder 111 
112 2 Shoulder 
apprehension. Any pain that is present co1n1nonly decreases and further 
lateral rotation is possible before the apprehension and/or pain returns. 
The test is considered positive if pain decreases during the n1aneuver 
even if there was no apprehension (Fowler sign or Jobe relocation test). 
Note: The test n1ust be performed slowly. If the test is done too quickly, 
there is a chance that the humeral head will dislocate. 
Assessment: Shoulder pain with reflexive n1uscle tensing is a sign of an 
anterior instability syndron1e. This 1nuscle tension is an attempt by the 
patient to prevent i1nminent subluxation or dislocation of the hu1neral 
head. Even without pain and with tension only in the anterior shoulder 
1nusculature (pectoralis), there may be signs of instability. 
Placing the patient supine in1proves the specificity of the apprehen-
sion test. By placing the left hand under the glenohu1neral joint to act as 
a fulcru1n the apprehension test beco1nes a fulcrum test. 
In a further stage of the apprehension test, releasing the posteriorly 
directed pressure causes a sudden increase in pain with the apprehen-
sion pheno1nenon (release test). 
In a 1nodification by Jobe, the apprehension phenomenon can also be 
specified in four grades of severity (impinge1nent and instability often 
occur together). 
Grade 1: Pure impinge1nent with no instability 
Grade 2: Secondary instability and instability caused by chronic 
capsular and Iabral 1nicrotrauma 
Grade 3: Secondary in1pinge1nent and instability caused by general-
ized hypen11obility or laxity 
Grade 4: Primary instability with no impinge1nent 
Applying increasing posterior pressure to the humeral head increases 
the pain and dislocation sensation in the sa1ne n1anner as increasing 
external rotation and abduction. 
Note: Hawkins describes a three-grade systen1 for anterior translation 
(Fig. 2.44). 
Note: When the patient con1plains of sudden stabbing pain with simul-
taneous or subsequent paralyzing weakness in the affected extren1ity, this 
is referred to as the "dead ar1n sign." It is attributable to the transient 
co1npression the subluxated hun1eral head exerts on the plexus. 
It is important to know that at 45° of abduction, the test prilnarily 
evaluates the medial glenohun1eral liga1nent and the subscapularis 
tendon. At or above 90° of abduction, the stabilizing effect of the sub-
scapularis is neutralized and the test primarily evaluates the inferior 
glenohun1eral ligan1ent. 
2 Shoulder 113 
The Hawkins classification of instability is based upon what is felt by 
the exa1niner. 
Grade O: nor1nal laxity (a1nount of translation) 
Grade 1: hun1eral head moves slightly up to the glenoid rim 
Grade 2: humeral head rides over the rin1, but spontaneously reduces 
Grade 3: humeral head rides up and over the glenoid rim, but re-
mains dislocated 
Fig. 2.44 Hawkins classification 
0 
1 
* 
" 
_ _/ 2 
,·· 
3 
114 2 Shoulder 
Throwing Test 
Procedure and assessment: In the throwing test, the patient executes 
a rapid throwing n1otion against the exan1iner's resistance. This test can 
reveal anterior subluxation that occurs during the throwing n1otion. 
Leffert Test 
Procedure and assessment: The Leffert test can be used to quantify a 
drawer phenon1enon. Looking downward at the shoulder of the seated 
patient (craniocaudal view), the examiner displaces the humeral head 
anteriorly. The anterior displacement of the exan1iner's index finger in 
relation to the middle finger shows the degree of anterior translation of 
the hun1eral head. 
( 
' ', 
a b 
Fig. 2.45 Throwing test 
Fig. 2.46a, b Leffert test: 
a starting position, 
b index finger displaced 
anteriorly 
2 Shoulder 115 
Anterior and Posterior Load and Shift Test 
Procedure: The patient is seated. The examiner stands behind the 
patient. To evaluate the right shoulder, the exan1iner grasps the patient's 
shoulder with the left hand to stabilize the clavicle and superior 1nargin 
of the scapula while using the right hand to 1nove the humeral head 
anteriorly and posteriorly. 
Assessment: Significant anterior or posterior 1nobility of the hu1neral 
head suggests instability. 
( 
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1 
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I 
Fig. 2.47 
shift test 
Gerber-Ganz Anterior Drawer Test 
Anterior and posterior lead and 
Procedure: The patient is supine with the affected shoulder positioned 
such that it projects slightly past the edge of the exa1nining table. The 
affected shoulder is held in 80°-120° of abduction, 0°-20° of flexion, and 
0° -30° of external rotation as loosely and without pain as possible. The 
exa1niner im1nobilizes the scapula with the left hand (with the index 
and middle fingers on the scapular spine and the thumb on the cora-
coid). With the right hand, the exa1niner tightly grasps the patient's 
proxin1al upper arm and pulls it anteriorly in a n1anner sin1ilar to the 
Lachman test for anterior instability in the knee. 
Assessment: The relative 1notion between the i1nmobilized scapula 
and the anteriorly displaced humerus is a 1neasure of anterior instability 
and can be classified in degrees. 
Occasional audible clicking with or without pain can indicate an 
anterior labrum defect. 
116 2 Shoulder 
a b 
Fig. 2.48a, b Gerber-Ganz anterior drawer test: 
a starting position, 
b dislocation maneuver 
Posterior Apprehension Test (Posterior Shift and Load Test) 
Procedure: With the patient supine, the exan1iner places one hand 
under the patient's scapula and grasps the elbow with the other. By 
pressing the abducted, horizontally flexed, and internally rotated arn1 
posteriorly, the exan1iner atten1pts to provoke posterior subluxation of 
the hun1eral head. 
Assessment: Sufficient laxity in the capsular liga1nents will allow 
posterior subluxation or even dislocation of the hun1eral head with 
associated pain. 
Maintaining the axial pressure on the humeral head increasingly 
abducts and retracts the ar1n. The previously subluxated or dislocated 
hu1neral head can be reduced again with a readily palpable and audible 
click. (Caution: This test involves a ce1tain risk of acute dislocation.) 
Gerber-Ganz Posterior Drawer Test 
Procedure: The patient is supine. Guiding the htuneral head with one 
hand (with the thtunb on the anterior humeral head and the fingers on 
the scapular spine, posterior humeral head, and scapular spine and 
posterior glenoid if necessary), with the other hand the examiner holds 
the patient's am1 in 90° of flexion at about 20° - 30° of horizontal 
extension. 
b 
2 Shoulder 
Fig. 2.49a, b Posterior 
apprehension test: 
a starting position, 
b reduction maneuver 
117 
The exa1niner exerts pressure on the anterior humeral head with the 
thun1b while sin1ultaneously holding the arm in horizontal flexion and 
applying axial posterior compression in slight internal rotation. 
Assessment: Where there issufficient laxity in the capsular liga1nents, 
this test will provoke a posterior drawer (subluxation or dislocation of 
the hun1eral head). Horizontal extension, slight external rotation of the 
ar1n, and additional posteroanterior pressure applied by the finger to 
the posterior aspect of the hun1eral head will suffice to reduce the 
hun1eral head. The snap that accon1panies reduction n1ust be carefully 
distinguished fron1 anterior subluxation. The in1portant thing is to 
118 2 Shoulder 
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,~ 
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1----- -----; 
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a b 
I I 
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Fig. 2.50a, b Gerber-Ganz posterior drawer test: 
a starting position, 
b dislocation maneuver 
assess the 1notion of the hun1eral head relative to the glenoid fossa by 
placing the index finger posteriorly around the glenoid and pressing the 
hu1neral head in an anteroposterior direction with the thu1nb. 
The examination may also be perfor1ned with the patient seated. 
With the patient in a relaxed posture bending slightly forward with the 
arn1 hanging alongside the trunk, the exan1iner places his or her thu1nb 
on the patient's scapular spine or posterior glenoid and grasps the 
hu1neral head anteriorly. Applying rotation and pressure with the fin-
gers will provoke posterior subluxation of the head where there is 
sufficient laxity in the capsular liga1nents. 
In posterior instability, the hun1eral head can be posteriorly displaced 
by one-half its dian1eter. 
Posterior Apprehension Test with the Patient Standing 
Procedure: The patient is standing. The exan1iner abducts the affected 
arn1 between go0 and 110° at the shoulder and flexes it horizontally 
about 20° -30°. The examiner's other hand ilnmobilizes the scapula fron1 
above; the exa1niner's fingers grasp the scapular spine and the hu1neral 
head while the thun1b rests on the anterior aspect slightly lateral to the 
coracoid process. 
Assessment: With slowly increasing horizontal flexion, the posterior 
thrust along the longitudinal axis of the hu1nerus leads to posterior 
,· 
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.. 
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0 · _____ ... i 
I 
Fig. 2.51 Posterior apprehension test 
2 Shoulder 119 
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\ 
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Fig. 2.52 Fukuda test 
subluxation in the glenohu1neral joint. Both the thun1b lateral to the 
coracoid process and the fingers can detect the translation of the hu-
1neral head. Occasionally, the slightly pro1ninent hun1eral head will be 
visible beneath the acromion. Extending the arn1 by 20° -30° in the sa1ne 
horizontal plane will lead to palpable reduction of the humeral head. 
Fukuda Test 
Procedure and assessment: The Fukuda test elicits a passive posterior 
drawer sign. The patient is seated with the exa1niner's thumbs resting 
on both the patient's scapular spines. The exan1iner's other fingers rest 
anterior to the hu1neral head and exert posterior pressure to trigger a 
posterior drawer. This is usually done on both shoulders at the sa1ne 
time to con1pare the two sides. 
Sulcus Sign 
Tests for n1ultidirectional instability. 
Procedure: The patient is seated or standing. With one hand, the 
exa1niner stabilizes the patient's contralateral shoulder while exerting 
a distal pull on the patient's relaxed affected ar1n with tk other hand. 
This is best done by grasping the patient's a1n at the ~-·pw with the 
elbow slightly flexed. 
Assessment: Instability with distal displacement of the humeral head 
creates an obvious indentation (sulcus sign) inferior to the acro1nion. 
The test can also be performed so that the exa1niner supports the 
patient's go0 -abducted arn1. Applying pressure to the proxin1al third of 
120 
a 
2 Shoulder 
. 
C'- I : 
), 
J ' ,. 
Fig. 2.53a, b Sulcus sign: 
a starting position, 
', 
l 
t--
1! - --
' ' 
b 
b sulcus sign with distal distraction of the arm 
l .. 
--·-- ) --
/ 
' 
the upper am1 from above can then provoke distal subluxation of the 
hu1neral head. This will create a significant step-off beneath the acro-
1n1on. 
Aside fro1n testing for the sulcus sign in the neutral position, it is 
recon1n1ended to perform the test with the arn1 externally and inter-
nally rotated as well. Increased inferior translation in external rotation 
suggests elongation of the rotator interval. A positive sulcus sign that 
occurs with the am1 in internal rotation demonstrates laxity of the 
posterior capsular structures. Hyperlaxity in an inferior capsular liga-
1nent rupture can be demonstrated with the Gagey hyperabduction test. 
The exan1iner stands behind the patient and i1nmobilizes the scapula 
with one hand. Achieving purely glenohumeral abduction over 105° 
suggests hyper laxity of the inferior glenohun1eral ligament in particular. 
The sulcus sign may be graded by measuring fron1 the inferior 
1nargin of the acron1ion to the hun1eral head. The typical syste1n clas-
sifies a sulcus as grade I ( < 1.5 cn1), grade II (1.5-2.0 cm), or grade III 
(> 2 cm). A high-grade sulcus sign (grade III) is a sign of multidirectional 
instability. 
2 Shoulder 121 
Rowe Test 
Procedure: The patient stands and bends forward slightly with the 
arn1 relaxed. To examine the right shoulder, the exan1iner grasps the 
patient's shoulder with the left hand and with the right hand passively 
1noves the patient's ar1n slightly anteriorly and inferiorly. The exa1niner 
then pulls the arms down slightly. 
Assessment: To test for anterior instability the hu1neral head is pushed 
anteriorly with the thumb while the arn1 is extended 20° -30° fro1n the 
vertical position. To test for posterior instability the humeral head is 
pushed posteriorly with the index and n1iddle fingers while the am1 is 
flexed 20° -30° fro1n the vertical position. For inferior instability n1ore 
traction is applied to the am1 and the sulcus sign is evident. 
Fig. 2.54 Rowe test 
' ··~ " 
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