Examination of the Shoulder

Special Tests

Impingement / Rotator Cuff

  • Findings
    • Tenderness of subacromial bursa
    • Painful arc of abduction
      • Pain on abduction between 60-100°, maximal at 90°
      • Pain ↑ with resistance at 90°
      • Patients sometimes ER to clear GT under acromion (diminishing pain & allowing greater elevation in the coronal plane)
    • Abnormal scapulohumeral rhythm during abduction
    • Weak suprspinatus muscle-tendon unit
    • Weak infraspinatus muscle-tendon unit
  • Already performed
    • Neer’s
    • Drop arm
  • To Perform
    • Hawkin’s
    • Impingement

Hawkins Impingement Reinforcement Test

  • FF shoulder to 90°
  • Elbow at 90° (thus pt’s forearm is in front of body)
  • Passively IR shoulder
    • Drives GT & R/C into acromion & CA ligament

Neer’s Impingement Sign

  • FF flex shoulder whilst examiner’s hand on pt’s shoulder (scapula stabilized)
  • Look for reproduction of pt’s symptoms at maximum FF
    • It brings the AL acromion into contact with the affected R/C & GT

Neer’s impingement test

  • Inject LA (10 cc of 1% xylocaine)

Rotator Cuff

  • Test pain & grade power
  • Feel muscle belly & comment on
  • Presence of contraction
  • Stength 1-5
  • 1. Supraspinatus: Jobe
  • 2. Infraspinatus & Teres Minor: Resisted ER
  • 3. Subscapularis: Belly press test & lift off test
Supraspinatus (Suprascapula nerve)
1. Supraspinatus isolation test (Jobe test)
  • Abducted 90°
  • 30° anterior to coronal plane
  • elbows fully extended
  • thumb pointing downwards
    • patient pushes up towards ceiling against resistance
  • Differential Diagnosis
    • 50% of power at this position is from supraspinatus
    • Deltoid dysfunction
    • OA
2. Drop-arm Test
    • If pt’s passive ROM is much greater than active ROM – perform this test
    • Passively abduct arm to maximum amount
    • Warn the patient that you are about the let go
    • Ask patient to slowly lower arm
      • Positive Sign if
        • At 100°, the patient is unable to control arm & arm drops to side
          • Caused by pain of R/C tear & axillary nerve palsy
        • Inject with LA
          • If it improves, more likely due to pain
    • Cause
      1. Massive cuff tear
      2. Axillary nerve palsy
      3. Neuromuscular impairment
Infraspinatus (Suprascapula nerve) / Teres Minor (axillary nerve)
1. Resisted external rotation
    • elbows flexed to 90°
    • arm by the side
  • Feel for muscle
    • Teres minor is tested with infraspinatus
      • Teres minor is only involved in massive rotator cuff tears
  • If weak, perform
    • Dropping sign
      • Irreparable degeneration of infraspinatus
    • Hornblower’s sign
      • irreparable tear of infraspinatus & teres minor
2. Dropping sign
  • 0° of abduction, forearm is placed in 45 deg of external rotation
  • Pt asked to externally rotate against examiner's hand
  • If the patients arm falls back to 0° of ER, than +ve test
  • 100% sensitivity & 100% specificity for irreparable degeneration of the infraspinatus
3. Hornblower's sign
  • Power of external rotation in 90° of abduction in the scapular plane
  • Examiner places the patients elbow at 90 deg flexion with maximal ER
  • Examiner’s other hand is used to judge external rotation force
  • When the examiner's hand is released a positive test is recorded if the patient is unable to externally rotate
  • 100% sensitivity & 93% specificity for irreparable tear of infraspinatus & teres minor
  • "dropping" & "hornblower's" signs in evaluation of rotator cuff tears. G. Walch et al.
Subscapularis (Upper & Lower subscapular nerves)
1. Belly Press Test
  • Described in Gerber’s 1996 article
  • Patients with R/C pathology usually cannot do lift off test because of ROM
  • Resisted Internal Rotation with hand on belly
  • Must keep elbow forward

I’m going to hold onto your elbow

Could you now try to “Press your wrist into your belly”

  • Negative
    • Elbow forward
    • Pt uses subscap to internally rotate arm to press belly
  • Positive
    • Pt compensates for lack of subscapularis
      • Extending shoulder
2. Gerber subscapularis lift off test
  • Christian Gerber in JBJS(B) 1991
  • “Pathological lift off test – patient is unable to lift the dorsum of his hand off his back”
    • Put dorsum of patients hand on buttock then lift it off buttock & let go
    • Gerber’s test is normal if patient can hold hand off buttock
    • Pt must have full IR & not be limited by pain to use this test
  • other feature that Gerber described was ↑ passive ER with indistinct endpoint

 

Webpage Last Modified: 28 January, 2010
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