Shoulder Special Tests

Question 1

6. NEUROLOGICAL TESTING

Answer 1

a. Possibilities for pain
i. Is there traction on nerve, on peripheral nerves
ii. Rediculopathy pain to shoulder
iii. Brachial plexus injury pain to shoulder and arm
iv. Sympathetic: reflex sympathethic dystrophy, complex regional pain syndrome
v. Viscera
b. Dermatomes C4-T5/6
c. If it is plexus or peripheral nerve, we need to know sensory distributions of all the peripheral nerves in the arms (ie small area on shoulder that doesn’t overlap other nerve roots and is specific to C5/6 axillary nerve)
d. Diaphragm, heart, spleen, liver, gallbladder, elbow, neck, thoracic spine (T4 syndrome) can refer to the shoulder and arm

Question 2

Actively Performed by Patient without resistance

Answer 2

Drop Arm Test (note, can add tap)

Yocum Test

Question 3

Actively Performed by Patient with resistance

Answer 3

Yergason Test
Speed’s Test (isometric)
Supraspinatus Test (isometric)
Empty and Full Can Tests (isomatric)
O’Brien Test
Biceps Load Test

Question 4

Passive, performed by therapist

Answer 4

Hawkins Impingement Test
Neer Test
Crank Test
Mimori New Pain Provocation Test

Question 5

TESTS FOR ANTERIOR INSTABILITY

5

Answer 5

1. anterior aprehension
2. anterior drawer
3. jobe relocation
4. rockwood
5. lachman

also part of the rowe test for multidirectional instability

Question 6

Anterior Apprehension:

Answer 6

1. Abduct and externally rotate the arm [be ready with other hand to put it back]
2. Therapist takes arm an brings it to a position where head of humerus will come anteriorly: External Rotation
3. Watch the patient.
4. if I think will have dislocation I can stabilize as I would in the PROM
5. Positive: patient pulls back, makes a face, says ouch, doesn’t want to be in this position, patient usually knows

Question 7

Anterior Drawer

Answer 7

1. Set up like supine anterior glide
2. Pick up scapula into a set position, put hands underneath humerus, bring humerus anterior to where it is in a lift to the ceiling
3. Positive: laxity, opens too much like a drawer

Question 8

Jobe Relocation Test

Answer 8

1. Put patient into position, as abduct and externally rotate the arm the humeral head comes anterior
2. If anterior drawer and it goes too far, I push it back (also can IR the humerus to help bring humeral head back posteriorly)
3. Positive: there is hypermobility and you can push it back into position
   - -note: if pain relief upon putting it back into position

Question 9

Rockwood

Answer 9

anterior instability: this test is used to evaluate the degree to which the humeral head can be anterioly subluxed from the glenoid cavity of the scapula.

1. Bring arm more into flexion and back so head of humerus comes forwards
2. Feel by palpation the back of capsule to see if humerus moves differently than normal
3. Person may not have instability in low range, it may show up in high range

Question 10

Lachman

Answer 10

reverse from anterior drawer test

Question 11

TESTS FOR POSTERIOR INSTABILITY (2)

Answer 11

1. posterior apprehension test

2. posterior drawer test

Question 12

Posterior Apprehension Test

Answer 12

1. My hand under scapula, have a finger and a hand to palpate the posterior glenoid area
2. Supine, bring arm up into 90 degrees of flexion and elbow flexed, push posteriorly through humerus towards floor
3. Positive: person stops you, indicate pain, apprehension

Question 13

Posterior Drawer Test

Answer 13

1. Supine, looks like posterior glide
2. Bring arm out to 50 degrees abduction, palpate back of joint with one hand and glide down towards the floor and come back up
3. Positive: excess glide

Question 14

INFERIOR INSTABILITY

3

Answer 14

1. sulcus sign
2. sulcus test
3. faegin test

Question 15

Sulcus Sign

Answer 15

(inferior instability)

1. Patient sit in relaxed position without forearm supported too much
2. Palpate acromion and drop off and see if too large a separation from humeral head
3. Measure by number of fingers of subluxation (finger sizes vary) [maybe look at resting position and a corrected posture]
4. Ie stretching of capsule when lost musculature, secondary support from deltoid and rotator cuff
5. Side note: then I may ask to raise arm to see if deltoid and rotator cuff activate and if humerus comes up

Question 16

Sulcus Test

Answer 16

1. Provide some upwards stabilization in the glenoid and scapulothoracic joint (maybe have hand cover from posterior to anterior near acromion?)
2. Jam hand up onto inferior glenoid, axillary border of scapula as stabilizer
3. Pull down on forearm (crook of elbow) with elbow bent to floor and palpate the separation
4. This adds mechanical force to gravity to find the laxity

Question 17

Faegin Test

Answer 17

1. Patient standing
2. Find acromion, find proximal humerus, put both hands on top
3. Feel the edge of acromion with my pinky fingers [feel joint- it goes down and recoil a little but not a major instability]
4. Patient abduct shoulder to the side (may be hard for patient to get into this position)
5. Come close to greater tuberosity, hands on humerus close to the joint, and push down to the floor (inferior glide to floor)

Question 18

MULTIDIRECTIONAL INSTABILITY

Answer 18

Rowe Test

Question 19

Rowe Test

Answer 19

can be a quick screen for instability seen in passive testing

1. Patient inclined forward at waist, arm hanging vertically (this drives humerus a bit forward)
2. Physical therapist GH joint proximal humerus to protect
3. Be sure to not rotate the patient
4. In a lax patient you will feel the mobility
5. Anteriorly: (stand in behind patient)
   a. Glide humerus anteriorly
6. Posteriorly:
   a. Glide humerus posteriorly (stand in front of patient)
7. Inferiorly: (stand in front of patient)
   a. Glide humerus inferiorly
8. If all three, even two positive then we have positive. Use this test to document if there are stability improvements.

Question 20

BICEPS TENDON (2)
There is a risk of the biceps tendon long head getting caught under the subachromial arch

Answer 20

1. Yergason

2. Speeds Classic/ Speeds shoulder extension

Question 21

Yergason

Answer 21

see if biceps tendon remains in the groove

1. Patient seated, arm at the side, elbow flexed 90 degrees, forearm pronated. PT passively abduct arm 10-20 degrees.
2. PT: Palpate/stabilize the bicipital groove. Say: “turn your palm up and hold—go like you are hitchhiking”
3. Three Dimensional Resistance:
4. Forearm supination—biceps
5. Elbow flexion—biceps
6. GH external rotation—humerus out into ER to expose tendon, stress the tendon
7. Positive: pain, or snap of longhead of biceps tendon (if superior intertubecular ligament isn’t holding the biceps tendon down you will feel it snap up out of the groove)

Question 22

Speeds Classic

Answer 22

1. Patient seated with 90 degrees of shoulder flexion, shoulder ER, elbow straight, forearm supinated
2. Test: PT resist isometric hold of shoulder flexion
3. Using biceps tendon as secondary shoulder flexor
4. Positive sign: pain in bicipital groove area (biceps tendon)

Question 23

Speeds in Shoulder Extension

Answer 23

1. Patient seated with shoulder extended, shoulder ER, elbow straight
2. Test: PT resists isometric hold of shoulder flexion (this puts more stretch on the tendon by putting into extension)
3. Positive sign: pain in bicipital groove area

Question 24

ROTATOR CUFF INVOLVEMENT (2)

Answer 24

1. Drop Arm Test

2. Supraspinatus Test

Question 25

Drop Arm Test

Answer 25

can the rotator cuff be a dynamic stabilizer

1. Patient lifts arm into abduction and then lowers it slowly to the side
2. If rotator cuff is not being a dynamic stabilizer it will start to drop (muscle strain, muscle tear)—deltoid and rotator cuff synergy
3. Phase 2: If patient can perform, give gentle tap as patient lowers
4. Positive sign: lack of eccentric control
5. ***be ready to catch the arm as it falls to the side
6. example can grade negative without resistance and positive with light tap

Question 26

Supraspinatus Test

Answer 26

commonly torn
1. can perform bilaterally

2. patient holds arm in abduction in the scapular plane (scaption) plus internal rotation
   - -But within the range where the supraspinatus functions in a more isolated fashion
   a. this position puts the supraspinatus in line with the humerus and is under the acromion lower than the impingement, we only want to test the ability of supraspinatus and not the area where you impinge (lower than 90 degrees)
   b. EMG: first part of arch of motion is supraspinatus, keep arm low to be more specific to supraspinatus
3. Therapist resists distal forearm (push down)
4. Positive: see if it provokes pain or cardinal sign (or if it drops?)

Question 27

ROTATOR CUFF TEARS

Answer 27

Full can test

Empty Can test

Question 28

Full Can, Empty Can Test

Answer 28

1. Position: arm elevated to 90 degrees in plane of scapula (scaption)
   - Empty can test: thumb down
   - Full can Test: thumb up
2. Test: Therapist resists (down? at distal humerus) as patient attempts an isometric contraction
3. Positive signs: pain and weakness

-Empty can test, 90 degrees and IR causes grinding whatever attach to proximal humerus under acromial arch—so does this test rotator cuff or more test the grinding and the impingement –by resisting and contracting muscles create more impinge. This is why the full can is beneficial because it gives the same data with the arm in a position of neutral or ER that doesn’t create an impingement.

Question 29

IMPINGEMENT (4)

Under achromial arch, if I stress the tissue under arch, when I mechanically get into the position, do I recreate cardinal sign: suprapinatus tendon, subachromial bursa, AC joint, pectoralis minor, coracobrachialis is nearby, biceps tendon

Answer 29

1. Hawkins-Kennedy Impingement Test
2. Yocum Test
3. Neer Test
4. Posterior Impingement Test
   .

Question 30

Hawkins-Kennedy Impingement Test

Answer 30

for subacromial impingement

a. bring supraspinatus tendon against the anterior portion of the coracoacromial ligament—pain if the patient has supraspinatus tendinitis (rosen)
2. Arm at 90 degrees of shoulder flexion or in the plane of the scapula, Elbow at 90 degrees of flexion
3. Therapist: overpressure the arm into IR
4. Positive: Pain
5. Pain secondary to compression of structures under coracoacromial ligament and acromion

Question 31

Yocum Test

Answer 31

for subacromial impingement

1. Affected hand is placed on opposite shoulder
2. Patient lifts elbow
3. Positive: pain
4. Pain secondary to compression of structures under coracoacromial ligament and acromion

Question 32

Neer Test

Answer 32

for subacromial impingement

1. Stabilize the trunk
2. Therapist: IR arm and lift arm to flexion to ear
3. Positive: Pain
4. Pain secondary to compression of structures under coracoacromial ligament and acromion

Question 33

If all 3 positive: Hawkins, Yocum, Neer: this indicates ____?

Whenever patient says painful, you ask where –is it subacromial, is it ____

Answer 33

Some articles say if all 3 positive: Hawkins, Yocum, Neer: this indicates impingement

Coracoachrimial ligament
Whenever patient says painful, you ask where –is it subacromial, is it AC joint,

Question 34

Posterior impingement test

Answer 34

: put stretch on capsule as bring arm up—like neer to the ear but do it in the supine position

1. Supine, arm in flexion, elbow bent, rotate
2. (see Dutton page 523)

Question 35

LABRAL TEARS

Answer 35

1. Crank Test
2. O’brien’s Test
3. Mimori New Pain Provocation
4. Biceps Load Test
5. Modified Dynamic Labral Shear Test

Question 36

Crank Test

Answer 36

labral pathology

1. Patient seated or supine
2. Arm in 160 degrees shoulder abduction in the scapular plane (scaption), elbow flexed 90 degrees
3. Therapist stabilizes the patient’s posterior shoulder
4. Test: therapist pushes toward the joint through the patients elbow while gently rotating the arm IR and then ER—cranking
5. Positive sign: pain with ER or reproduction of the cardinal sign during overhead activities

Question 37

O’Brien’s Test

Answer 37

superior labral problem vs. AC joint –an active compression test to provoke labral symptoms (superior labrum is close to the attachment of the biceps tendon)
1. Patient standing (in picture)

2. Part 1: (IR) flex shoulder 90 degrees, shoulder IR, (elbow straight) then does horizontal adduction. Therapist resists by pushing down: for an isometric hold of the position
3. Part 2: (ER) flex shoulder 90 degrees, shoulder ER, (elbow straight) then does horizontal adduction patient turn palm up, then therapist resists by pushing down: for an isometric hold of the position
4. Positive sign: pain with part 1 and no pain with part 2: rule in Labrum
   • IR: In a stressful place and push down so muscles will be compressing and by resisting provoke pain in the labrum in part 1, IR,
   • ER: Turning palm up puts biceps on slack and less stress there in part two, changing the compression should change symptoms if it is the labrum
5. If pain for both part 1 and part 2—the problem may be at the AC joint
   • IR: In a stressful place and push down so muscles will be compressing and by resisting provoke pain in the labrum in part 1, IR,
   • ER: Turning palm up puts biceps on slack and less stress there in part two, changing the compression did not change symptoms and we suspect the AC joint

Question 38

Mimori New Pain Provocation

Answer 38

superior labral problem
1. Patient seated, therapist stabilizes the shoulder and holds the distal forearm

2. Test Phase 1: therapist lifts arm to 90 degrees abduction and fully ER with elbow flexed to 90 degrees and forearm pronated.
   • Bicep on slack one joint, but stretching a little as a pronator—is it painful?
3. Test Phase 2: allow patient to rest a second with arm at side, then therapist lifts arm again but with forearm supinated
   • Bring arm down, shake it out, then supinate it so slack on biceps both proximally and distally—is it painful?
4. Positive sign: pain provoked with pronation or pain greater in pronation than in supination
   • By creating some compression by stretching biceps tendon over the GH joint, does that pinpoint pain for patient compared to when less compression
   • If in pronated, think labrum
   • This is a passive compression test.

Question 39

Biceps Load Test

Answer 39

superior labral pathology in patients with recurrent dislocation [same position as anterior apprehension test]
1. Patient supine

2. Test: same as anterior apprehension test, only add resistance to isometric biceps elbow flexion at 90 degrees—cause biceps to cause compression
3. Positive sign: feeling of apprehension increases when resist elbow flexion (weakness, pain)
4. Negative sign: no pain, no change
5. Of note: symptoms relieved when resist elbow flexion (bicep contraction)—maybe taking out impingement or setting humerus into a better position

• Side note: Create compression and have patient pronate and then resist to put stretch on bicep and see if that provokes the symptoms

Question 40

Modified Dynamic Labral Shear Test

Answer 40

test for SLAP lesions: superior labrum anterior to posterior (see Rosen page 185)

1. Finding a painful arc, cranking in the arc, and getting a click
   https: //www.youtube.com/watch?v=5bkPXavhKU8