Athletic Injury Examination Special/Stress Tests for the Shoulder

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TESTS

POSITION OF THE ARM

STRUCTURES INVOLVED

DESCRIPTION OF TEST BEING PERFORMED

MOUSE OVER PICTURE TO VIEW MOVIE

Apley Scratch Tests

Abduction and External Rotation

Internal Rotators & Adductors (Stretched)

Ask the patient to reach behind his or her head and touch the superior medial angle of the opposite scapula.

 

Adduction and Internal Rotation

External Rotators & Abductors (Stretched)

Instruct the patient to reach back and touch the inferior angle of the opposite scapula . You may also assess adduction and internal rotation by having the patient reach in front and touch the opposite acromion process. Check the level of Thoracic Vertebrae reached.

Apprehension Test

Position the patient supine in a relaxed position on the examination table. Support the patient's arm with the shoulder abducted 90 degrees and the elbow flexed 90 degrees.

Detects anterior shoulder subluxation or dislocation.

Inferior Glenohumeral Ligament

While supporting the humerus at the elbow with one hand, grasp the patient's forearm with your other hand. Gently and gradually externally rotate the shoulder. If the patient has had a recent anterior dislocation or subluxation of the glenohumeral joint, apprehension or discomfort will occur as the shoulder approaches 90 degrees of external rotation. Be careful not to cause an actual anterior dislocation when externally rotating the arm. You may modify this test to detect more subtle cases of anterior instability by placing the patient prone on the examination table. Place one hand on the forearm and the palm of your other hand on the posterior aspect of the proximal humerus. Abduct and externally rotate the shoulder 90 degrees as you push the humeral head anteriorly. When anterior instability is present, this position accentuates the anterior subluxation and elicits further apprehension and patient discomfort.

Relocation Test

With the patient supine, position the shoulder in 90 degrees abduction and zero degrees internal rotation.

Detects chronic anterior dislocation of the glenohumeral joint.

Inferior Glenohumeral Ligament

Keep the elbow flexed 90 degrees. Place one hand on the mid-forearm and your other hand on the anterior aspect of the proximal humerus. Externally rotate the shoulder while applying a posteriorly directed force to the proximal humerus. Application of posteriorly directed force should prevent anterior subluxation and reduce the patient's pain and apprehension. If anterior instability is present, removing the posteriorly directed force will cause the patient's apprehension and pain to return.

Anterior Instability Test

Position the patient supine with the glenohumeral joint slightly over the table edge.

Detects glenohumeral joint anterior instability.

Inferior Glenohumeral Ligament

Grasp the distal humerus at the elbow and support the arm with the shoulder abducted 90 degrees and externally rotated 60 to 80 degrees. The elbow should be flexed 90 degrees. Place the thumb of your other hand in the axilla on the anterior inferior humeral head with your fingers on the posterior aspect of the humeral head. While maintaining elbow flexion and neutral shoulder rotation, apply a posterior force to the humerus as the fingers of your other hand push the humeral head anteriorly. Utilize your thumb to appreciate the amount of anterior translation. Repeat the test as you increase the amount of glenohumeral abduction. As the humerus is abducted, you may feel varying amounts of anterior translation and laxity. If the capsular structures are intact you should note a firm end point at the end of each anterior levering maneuver. Also, compare bilaterally. Lack of a firm end point, patient apprehension and pain, and excessive anterior levering may indicate capsular structure injury.

Anterior/ Posterior Translation Test

The patient sits with arms relaxed at side.

Assesses anterior or posterior glenohumeral laxity.

Place one hand on the scapula superior aspect, stabilizing it against the thorax. Grasp the humeral head with your other hand. Use your fingers and thumb to push the humeral head anteriorly and then posteriorly. Note the amount of translation in both directions as compared to test application on the uninvolved shoulder.

 

Sulcus Test

Have the patient stand with the involved arm hanging relaxed at the side. Ask the patient to use the unaffected hand to grasp the wrist of the involved arm.

Assesses inferior glenohumeral laxity.

While the patient applies a downward directed, distractive force on the involved arm, you should palpate the space between the humeral head and the undersurface of the acromion. You may notice an indention or sulcus on the top of the middle deltoid as the humeral head subluxes inferiorly. You should also perform this test on the uninvolved shoulder, comparing bilaterally

Posterior Glenohumeral Instability Test

With the patient supine and relaxed, use one hand to hold the patient's arm in 90 degrees of abduction and 30 to 45 degrees of horizontal adduction.

Assesses humeral head posterior subluxation.

Place the thumb of your other hand on the anterior humeral head, using the fingers to locate the posterior glenohumeral joint. Apply a posteriorly directed force on the anterior humeral head while palpating posteriorly for any subluxation. Maintain the posterior displacement with your thumb, while using your other arm to slowly, horizontally abduct the arm to neutral. If the humeral head is actually subluxed, a sudden reduction may be felt as the arm is horizontally abducted. To fully appreciate the amount of posterior subluxation, repeat this maneuver a few times.

 

Inferior Drawer Test Or Feagin Test

The patient sits on the examination table with shoulder abducted 90 degrees, elbow in full extension and arm resting on your shoulder.

Assesses humeral head inferior subluxation.

Inferior Glenohumeral Ligament

Place both hands along the proximal humerus over the deltoid and interlock your fingers. Apply an inferiorly directed force to the humerus and palpate for inferior movement, which is indicative of glenohumeral joint inferior instability. Also, watch for apprehension or discomfort displayed in the patient's face. You should also perform this test on the uninvolved shoulder, comparing bilaterally.

Rotator Cuff Impingement Tests (Full Flexion Test)

Have your patient sit on the examination table.

Assess the presence of rotator cuff inflammation or impingement syndrome.

Supraspinatus Tendon

Stand to the side of the patient's involved shoulder and place one hand on the posterior aspect of the scapula for stabilization. While maintaining neutral humeral rotation, use your other hand to fully flex the humerus to the maximal overhead position. As the humerus approaches full flexion, observe the patient's face for any signs of pain or apprehension indicating rotator cuff impingement. Perform this test on the uninvolved shoulder and compare bilaterally.

 

Rotator Cuff Impingement Tests (Flexion-Internal Rotation Test)

Have your patient sit on the examination table.

Assess the presence of rotator cuff inflammation or impingement syndrome.

Supraspinatus Tendon

Stand to the side of the patient's involved shoulder and grasp the patient's elbow with one hand and support the arm so that both the elbow and shoulder are flexed 90 degrees. Place your other hand on the patient's forearm and maximally, internally rotate the humerus. This passive movement drives the greater tuberosity under the coracoacromial arch and impinges the rotator cuff. This movement will elicit a painful response if rotator cuff inflammation or impingement syndrome is present. You should also perform this test on the uninvolved shoulder and compare bilaterally.

Supraspinatus Strength Test Or The Empty Can Test

The patient stands with both arms in 90 degrees of abduction, 30 degrees of horizontal adduction and full internal rotation.

Assesses the strength of the supraspinatus muscle.

Ask the patient to maintain this position. Place your hands on the superior aspect of the elbow and press downward. Compare the patient's ability to resist your downward pressure with both the involved and uninvolved shoulders. Decreased ability of the involved shoulder to resist your downward pressure as compared to the uninvolved shoulder is indicative of supraspinatus weakness. This test may also elicit pain, indicating inflammation and muscle weakness.

 

Internal Rotation Strength Test

The patient stands with arm at the side, the shoulder in 0 degrees of rotation, and the elbow flexed 90 degrees.

Assesses the strength of the subscapularis muscle.

You should place one hand on the lateral elbow and your other on the medial aspect of the distal forearm. Instruct the patient to internally rotate their shoulder while you provide resistance. Compare the strength of the involved shoulder with that of the uninvolved. This test may also cause pain indicating inflammation and weakness in the internal rotators.

 

External Rotation Strength Test

The patient stands with arm at the side, shoulder in 0 degrees of rotation, and elbow flexed 90 degrees.

Assesses the strength of the infraspinatus and teres minor muscles

You should place one hand on the medial elbow and the other on the lateral aspect of the distal forearm. Instruct the patient to externally rotate the shoulder while you provide resistance. It is important to stabilize the patient's elbow against their side to prevent them from substituting abduction for external rotation. Compare the strength of the involved shoulder with that of the uninvolved shoulder. This test may also elicit pain indicating inflammation and weakness in the external rotators.

 

Internal Derangement (Glenoid Labrum Clunk Test)

Position the patient supine with the glenohumeral joint slightly over the edge of the table.

Assesses the glenoid labrum's integrity and stability.

Place one of your hands on the elbow supporting the patient's arm with the shoulder maximally flexed and the elbow relaxed in approximately 60 degrees of flexion. Place the fingers of your other hand on the posterior aspect of the humeral head. Rotate the humerus and maneuver it between the end ranges of glenohumeral abduction and flexion. As you move the humerus through these extreme ranges of motion, a glenoid labrum tear, if present, may be trapped or caught. This trapping of the torn labrum will often cause a grinding or "clunking" sensation to be felt or heard. You should also perform this test on the uninvolved shoulder and compare bilaterally.

 

Acromioclavicular Joint Stability Test

The patient sits on the examination table with arm at the side.

Assesses integrity of the acromioclavicular and coracoclavicular ligaments.

Grasp the proximal forearm with one hand as you place your other hand on the mid-clavicle. Attempt to distract the acromion process from the clavicle by applying a downward force to the arm directed along the longitudinal axis of the humerus. Your fingers on the clavicle may be simultaneously used to palpate and grade the amount of separation at the acromioclavicular joint. Pain and increased movement elicited by this procedure as compared to the uninvolved shoulder may indicate a sprain to the acromioclavicular and/or coracoclavicular ligaments.

 

Cross Chest Or Horizontal Adduction Test

With the patient supine or standing, grasp the distal humerus with one hand and position it in 90 degrees of abduction

Assesses acromioclavicular joint impingement.

Passively move the humerus across the chest. As the humerus approaches full horizontal adduction, question the patient regarding pain in the acromioclavicular joint. Lightly place the fingers of your other hand over the acromioclavicular joint to palpate for crepitus and separation. This procedure compresses or impinges the acromioclavicular joint and is painful if internal derangement or instability exist. Perform this test on the uninvolved shoulder and compare bilaterally.

Sternoclavicular Joint Integrity Test

The patient lies supine on the examination table.

Assesses the sternoclavicular and costoclavicular ligaments' integrity.

Sit on an examination stool at the head of the patient to allow visualization of the joints. Grasp the proximal clavicle between the thumb and fingers and attempt to move it superiorly and inferiorly.

Then move it anteriorly and posteriorly. Excessive joint play or laxity with associated pain as compared to the uninvolved side is indicative of a sternoclavicular sprain.

 

Speedís Test

(Biceps Test)

Arm is extended behind and the forearm supinated with elbow slightly flexed.

Biceps tendon

Examiner resists shoulder forward flexion by the patient while the patientís arm is supinated and the elbow is completely extended. Positive test elicits increased tenderness in the bicipital groove and indicates bicipital tendinitis.

 

Ludingtonís Test

Arm raised and hands clasped on top of head

Long Head of the Biceps Tendon

Patient clasps both hands on top of the head, allowing the interlocking fingers to support the weight of the upper limbs. This allows maximum relaxation of biceps tendon. Patient then alternately contracts and relaxes the biceps muscle. Examiner palpates the biceps tendon. If positive, tendon will not be felt and this indicates a rupture.

 

Transverse Humeral Ligament Test

Shoulder Abducted and Medially Rotated

Transverse Humeral Ligament

Patientís shoulder is abducted and medially rotated. Examinerís fingers are then placed along the bicipital groove and patientís shoulder is laterally rotated. Feel for the tendon popping out of its groove. This indicates a positive test.

 

Drop Arm or Supraspinatus Test

90 degrees abduction

30 degrees horizontal adduction and internal rotation

Supraspinatus tendon of rotator cuff

Have the athlete maintain this arm position as you press down on the forearm. If there is involvement of the supraspinatus tendon, the arm will drop because of weakness or pain.

 

Yergason Test

Elbow flexed to 90 degrees

Arm is in neutral

Tendon of the long head of the biceps.

Transverse humeral ligament

Have the athlete fully flex the elbow beyond 90 degrees. Grasp the elbow with one hand and grasp the athleteís wrist with the other hand. Instruct the athlete to maintain this position as you attempt to externally rotate the arm and extend the elbow. This places stress on the biceps tendon and will normally produce pain in the bicipital groove.

Winging Scapula Test

90 degrees Flexion/Flex elbow so that hand touches shoulder in wall push up position

Serratus Anterior Muscle

Have the patient start with trunk in against the wall and utilize his hands to push his body away from the wall against examiner applied manual resistance to the posterior spine. Check scapula for winging as patient pushes away from the wall.

Adson Maneuver

Neutral Adducted relaxed position

Radial Pulse

Thoracic Outlet Syndrome

Patientís head is rotated to face the tested shoulder. Patient then extends the head while the examiner laterally rotates and extends the patientís shoulder. Examiner locates radial pulse and the patient is instructed to take a deep breath and hold it. Disappearance of pulse is indicative of a positive test.

 

Shoulder Flexion

Shoulder flexed to 90 degrees with elbow relaxed

Deltoid muscle

Coracobrachialis muscle

Pectoralis major-upper

Patient flexes shoulder to 90 degrees without rotation of horizontal movement. Stabilize thorax. Resistance is given proximal to the elbow joint.

 

Shoulder Extension

Shoulder medially rotated and adducted

Latissimus dorsi muscle

Teres major muscle

Pectoralis major-lower

Patient is prone, shoulder medially rotated and adducted (palm up to prevent lateral rotation). Patient extends shoulder through range of motion.

 

Shoulder Abduction

Arm relaxed at side to 90 degrees abduction

Deltoid muscle

Supraspinatus muscle

Patient is sitting, with arm at side and elbow flexed a few degrees. Patient abducts shoulder 90 degrees. Resistance is given proximal to elbow joint.

 

Shoulder Horizontal Abduction

Prone, shoulder abducted to 90 degrees

Deltoid (posterior fibers)

Infraspinatus muscle

Teres minor muscle

Patient is prone with shoulder abducted to 90- degrees with forearm hanging vertically over edge of table. Patient horizontally abducts shoulder through range of motion.

 

Shoulder Horizontal Adduction

Supine, shoulder abducted to 90 degrees

Pectoralis major muscle

Patient is supine and horizontally adducts shoulder through range of motion. Resistance is given proximal to elbow joint.

 

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