SUOULO{R
The prerequisite to any treatment of a patient with pain
in the shoulder region is a predse and comprehensive
picture of the signs and symptoms as the y present dudng
the assessment and as they existed until that time . This
knowledge ensures that the techniques llsed will su it rhe
condition and that the degree of success will be estimated
against this background. Shoulder pain can be caused by
intrinsic djsease of the shoulder joints or pathology in
the periarticular structures, or it may originate from the
cervical spine ) chest, or visceral structures. Pathology is
commonly related to the level of activity, and age can
playa significant role . The shoulder complex is difficult
to assess because of its many structures (most of which
are located in a small area), its many movements, and the
many lesions that can occur either inside or olltside the
joints. Influences such as referred pain from the cervical
spine and the possibility of more than one lesion being
present at one time, as wdl as the difticulty in deciding
what weight to give to each response, make the examina-
tion even more difficult [0 understand . Assessment of the
sbo ulder region often necessitates an evaluation of the
cervical spine (see Chapter 3) to rule Out referred symp-
toms, a.nd the examiner must be prepared to include
the cervical spine and its scanning examination in any
shoulder assessment.
Applied Anatomy
The glenohumeral joint is a multiaxial, ball-and-socket,
synovial joint that depends primarily on the muscles and
ligaments rather than bones for its support, stability, and
integrity. I Thus, the assessment of the muscles and liga-
ments/capsule can playa major role in the assessment
of the shoulder. The labrum, which is the ring of fibro -
cartilage, surrounds and deepens the gle noid cavity of
the scapula about 50%.2 Only part of the humeral head
is in contact with the glenoid at anyone time. This joint
has three axes and three degrees of freedom . The resting
position of the glenohumeral joint is 55 of abduction
and 30 of horizontal adduction. The close packed posi -
tion of the joint is fuU abduction and lateral rotation.
When relaxed, the humerus sits centered in the glenoid
cavity; with contraction of the rotator cuff muscles, it
is pushed or translated anteriorly, posteriorly, inferiorly,
superiorly, or in any combination of these movements.
This movement is small , but if it does not occu r, full
movemcnt is impossible. The glenoid in the resting posi-
tion has a 5 superior tilt or inclination and a 7 retro-
version (slight medial rotation). The angle between the
humeral neck and shaft is about 130, and the humeral
head is retroverted 30 to 40 relative to the line joining
the epicondylc. 3
The rotator cuff muscles play an integral role in sho ul -
der movement. Their positioning on th e humerus may
be visualized by "cupping" d,e shoulder with d,C dlUmb
antcriorly, as shown in Fig ure 5-1. The biceps tendon
(Figure 5-2) runs between d,C thumb and index finger
just anterior to the index finger. The rotator cutf COl) -
troIs osteokinernatic and arthrokinematic motio n of the
humeral head in the glenoid and along with the biceps
depresses th e humeral head during movements into
elevation.
The primary ligaments of the glenohUllleral joint-the
superior, middle, and inferior glenohumeral ligaments-
play an important role in stabilizi ng the shoulder.3. .. The
superior glenohumeralligalllCnt'S primary role is limiting
231
232 CHAPTER 5 Shoulder
Figure 5-1
Positioning of the rotator cliff with thumb over subscapularis, index
finger ovcr slIpraspinanls , middle finger over infraspinatus , and ring
fUlger over teres minor.
inferior translation in adduction. It also restrains ante-
rior translation and lateral rotation lip to 45 abduction.
The middle glenohumeral ligament, which is absent in
30% of the population, limits lateral rotation between
45 and 90 abduction. The inferior glenohumeral liga-
ment is the most jmportant of the three ligaments. It has
an anterior and posterior band with a thin "polich" in
between so it acts much like a hammock or sling. It sup-
ports the humeral head above 90 abduction, limiting
inferior translation while the anterior band tightens on
lateral rotation and the posterior band tightens on medial
Acromion prc>Cess---------,L~~~
"cutout" for clarity
Transverse
humeralligamenl
rotation. s Excessive latera] rotation as seen in throwing
may lead to stretching of the anterior portion of the
ligament (and capsule), thereby increasing glenohumeral
laxity.' The coracohumeral ligament primarily limits infe-
rior translation and belps limit lateral rotation below 60
abduction. This ligament is found in the rotator interval
between the anterior border of the supraspinatlls tendon
and the superior border of the subscapularis tendon, thus
the ligament unites the two tendons anteriorly (Figure
5-3)-'8 Sec Table 5-1 for structures limiting movement
in different degrees of abduction. s,9 The coracoacromial
ligament forms an arch over the humeral head acting as
a block to superior translation. IO The transverse htUllerai
ligarnent forms a (oaf over the bicipital groove to hold
the long head of biceps tendon within the groove. The
capsular pattern of thc glenohumeral joint is latcral rota -
tion Illost limited , followed by abduction and medial
rotation. Branches of the posterior cord of the brachial
plexus and the suprascapular, axillary, and lateral pectoral
nerves innervate the joint.
Glenohumeral Joint
Resting position: 40-55 abduction, 30 horizontal
adduction (scapular plane)
Close packed position: Full abduction, lateral rotation
Capsular pattern: Lateral rotation, abduction, medial rotation
The acromioclavicular joint is a plane synovjal joint
that augments d,e range of motion (ROM ) ofd,e humerus
in d,e glenoid (Figure 5-4). The bones making up this
joint are the acromion process of the scapuJa and the lat-
eral end ofthc clavicle . The joint has three degrees offree-
donl. The capsule, which is fibrous, surrounds the joinr.
Coracoid
process
Short head
of biceps
Scapula Figure 5-2
Thc biceps apparatus.
 CHAPTER 5 Shoulder 233
Acromion proce,.. , ,SUDr'aSDiina!us tendon arc commonly th e first ligaments injured when the joint is
Coracohumeral stressed. The coracoclavicular ligament is the primary sup-
ligament
port of the acromioclavicular joint. It has two portions:
Rotator ilO"'rv'aI_~ ==___ Coracoid
process
the conoid and trapezoid parts, If a step deformity oenus,
Transverse this ligament has been torn. In the resti ng position of the
humeral joim, the arm rests by the side in the normal standing
ligmen! --+';'g.i~~~~?:l position, In the close packed position of the acromiocla-
vicular joint, the arm is abdu cted to 90. The indication
Biceps tendon _--'rT
of a capsular patte rn in the joint is pain at the extreme
ROM , especially in horizontal adduction (cross- flexion )
Long head of biceD" -'1, and full elevation. Tlus joint is innervated by branches of
the suprascapular and latcral pectoral nervc.
head of biceps

Figure 5-3 Acromioclavicular Joint

Rotator imcrval shov.ing thc relationship betwccn Ihe supraspinatus
tcndon, subscapuJ::aris tendon, and the coracohumeralligamcm.
Resting position: Arm by side

Close packed position: 90" abduction

An articular disc may be found within the joint. Rarely Capsular pattern: Pain at extremes of range of motion,
does the disc separate the acromion and clavicular articu.lar especially horizontal adduction and full
surfaces. This joint depends on liga ments for its strength. elevation
The acromioclavicular ligaments surround the joint and

Table 5-1
Structures Limiting Movement in Different Degrees of Abduction
Angle of Abduct ion Lateral Rotation Neuual Medial Rotation

0" S upe rior G-H ligament
Anterior capsu le
0-45 (nme 30-45 Coracohumeral iiga mcm
abd uction in scapular plane Superior G-H li game nt
[restin g position]- max.imum Amerior capsule
looseness of shoulder )
45"-60" Middle G -H ligament
Coracohumeral ligament
In ferior G -H ligame nt
(a nterior band)
Ante rior capsule
Infcrior G H ligamc nt
(anterior band )
Anterior capsu le
90"- 120" Inferior G -H ligament
(anterior band )
Anterior capsule
t20"- 180" Inferior G -H ligament
(anterior band)
Anterio r capsule
Coracohumera lljga m cnt Posterior capsule
S uperior G-H ligament
Capsule (anterior and
posterior)
S upraspinatlls
Mjddle G -H Iigamc nt Posterior capsule
Posterior capsulc
Subscapularis
Infraspin atus
Teres mJnor
Middle G -H ligament Inferior G-H ligame nt
Inferio r G-H lig ame nt (posterior band)
(especially anterior po rt io n ) Posterior capsu le
Subscapularis
Infraspinanls
Teres minor
In ferior G -H ligament Inferior G-H ligament
(especially JX)s[crior portion ) (posterior band)
Middle G-H li gament Posteri o r capsule
lnferior G-H ligament Inferior G-H ligame nt
(posterior band)
Posterior capsu Ie
Inferior G-H ligament Inferior G-H ligament
(posterior band)
Posterior capsule

Data from Curl LA, Warre n RF: GlenohumcT31 JOin t stabIlity: sc\ccuvc wtung studies O il thc sta ti C capsular restraints, elm Orthop Reine ReJ
330:54-65, 1996; and Peat M, Cu lham E: Functional anatomy of the shou lder complcx. Tn Andrcws JR., Wilk KE, cdilors: The athlete's fIJo14Jder,
New York, 1994, C hurchill LivingstOll e.
GH .. Gknohumeral.
234 CHAPTER 5 Shoulder
Acromioclavicular ,Inllra-articular disk
ligament cut"
Coracoacromial
II
Clavicle

Subacromial s~,aC<'~jt;~~~!
Coracohumeral
ligament
ligamenJ-
Transverse Coracoclavicular
ligament ligament
ligament
Figure 5-4
Anterior view of the right glenohumeral and
Coracoid process acromioclavicular joints. Note the subacromial
Biceps tendon
space or supraspinatus outlet located between
the tOp of the humeral head and the underside
of the acromion. (Modified [rom Neumann
DA: Ki,usioloBY of the muswJoskelurJ system:
Humerus Scapula foulldations for physical rthabilitatiml) p. 107.
(anterior) St. Louis, 2002 , Mosby. )

The ster noclavicular joint , along with the acromio-
clavicular joint, enables the humerus in the glenoid to
move through a full 180 0 of abduction (Figure 5-5).
It is a saddle-shaped synovial joint with three degrees of
freedom and is made up of the medial end of the clavicle,
the manubrium sternum, and th.e cartilage of the first
rib. It is the joint that joins the appendicular skeleton to
the axial skeleton. 11 There is a substantial disc between
the two bony joint surfaces, and the capsule is thicker
anteriorly than posteriorly. The disc separates the articu-
lar surfaces of the clavicle and sternum and adds signifi-
cant strength to the joint because of anachments, thereby
preventing medial displacement of the clavicle . Like
the acromioclavicular joint, the joint depends on Ligaments
for its strength. The ligaments of the sternoclavicular
joint include the anterior and posterior sternoclavicu.lar
ligaments, which support the joint anteriorly and posteri-
orly, the interclavicular ligament, and the costoclavicular

Left anterior IU(IUli" "Bin. Left common carotid artery

Costoclavicular Right vagus Left internal jugular vein
(rhomboid)
Interclavicular ligament Left external
ligament jugular vein
Clavicle

vein

Left vagus nerve

Right
brachiocephalic vein ~-Aortilr.arch
Anterior
Manubrium sternum sternoclavicular Pulmonary artery
ligament
Sternum
A B

Figure 5-5
A., Bony and ligamentous anatomy of the sternoclavicular joint. The major supporting strucmres include the
anterior capsule, the posterior capsule , the interclavicular Ligament, the costoclavicular (rhomboid ) ligament ,
and tlle intra-articular disk and ligament. B, Retrosternal anatomy. Note the prox-imiry of the sternoclavicular
joint ro the trachea, aortic arch, and brachiocephalic vein. ( Redrawn from Higginbotham TO , Kuhn JE:
Arraumatic disorders of the sternoclavicular joint, J Am Acad OrtlJo S,~rg 13: \39 , 2005. )

ligament rUllning from the clavicle to the first rib and
its costal cartilage. This is the main ligament maintain-
ing the integrity of the sternoclavicular joint. The move-
ments possible at [rus joint and at the acromioclavicular
joint arc elevation, depression, protrusion, retraction,
and rotation. The close packed position of the sternocla-
vicular joint is full or maximum rotation of the clavicle,
which occurs when the upper arm js in filll elevation.
The resting positjon and capsular pattern arc the same as
with the acromioclavicular joint. The joint is innervated
by branches of the anterior supraclavicular nerve and the
nerve to the subclavius r)1uscJe. Major vessels and the
trachea lie close behind the sternuUl and the sternocla-
vicular joint (sec Figure 5-5, B)."
Sternoclavicular Joint
Resting position: Arm at side
Close packed position: Full elevation and protraction
Capsular pattern: Pain at extremes of range of mction, especially
horizontal adduction and full elevation
Although the scapulothoracic joint is nor a true
joint, it functions as an integral part of the shoulder com-
plex and must be considered in any assessment because
a stable scapula enables the rest of the shou lder to function
correctly. Some texts call this strucnlre the scapulocostal
joint. This "joint" consists of the body of the scapula and
the muscles covering the posterior chest W3JI. The mus-
cles acting on the scapu la help to control its movements.
The medial borde( of the scapula is nor parallel with the
spinous processes but is angled about 30 away (top to
bottom), and the scapula lies 20' to 30' forward rela-
tive to the sagittal plane." Because it is not a true joint,
jt docs not have a capsular pattern nor a close packed
position. The resting position of this joint is the same as
for the acromioclavicular joint. The scapula extends frol11
the level ofT2 spinous process to T7 or T9 spinous pro-
cess, depending on the size of the scapula. Because the
scapula acts as a stable base for the rotator cuff muscles,
the muscles controlling its movements must be strong
and balanced because the joint funnels the forces of tl1e
trunk and legs into the arm.l !
Patient History
In addition to the questions listed under Patient History
in Chapter 1, the examiner should obtain the follow -
ing information from the patient. 13 Most commonly,
the patient complains of pain, especially on movement,
restricted motion, or shoulder instability.
CHAPTER 5 Shoulder 235
1. What is the patient's age? Many problems of the
shoulder can be age related. For example, rotator
cuff degeneration usually occurs in patients who arc
between 40 and 60 years of age. Rotator cuff tears,
though, can OCCllr at any age. 14 Primary impinge-
ment dut: to degeneration and weakness is lIsually
seen in patients older than 35, whereas secondary
impingement due to instability caused by weakness
in the scapular or humeraJ control muscles is more
common in people in their late teens or 20s espe-
ciall y those involved in vigorous overhead activities
such as swimmers or pitchers in basebal1. 1s Calcium
deposits may occur between the ages of 20 and 40. 16
Chondrosarcomas may be seen in those o lder than 30
years of age, whereas frozen shou lder is seen in per-
sons bct\\'cen the ages of 45 and 60 years if it results
from causes other than trauma (Tables 5-2 and 5-3).
Frozen shoulder due to trauma can occur at any age
but is more common \vith increased age.
2. Does the patient su.pport tlJe upper limb in a pro-
tected position (Figu.re 5-6) or hesitate to 1#01'e it?
This action could mean that one of the joints of the
shoulder complex is unstable or that tllcre is an acute
problem in the shoulder. In some cases, patients with
lax shoulders wiH ask, "What happens when I do
this?" In effect, the patient is subluxing the shoulder
(Figure 5-7). This mayor may nor be pathological ,
but it is a sign of vol untary instability in which the
patient uses his or her muscles to sublux the humerus
in the glenoid, stressing the labrum and inert tissues.
3. If there IVas nu. i1ljury) whnt exactly mas the mecha-
nism. of injury? Did the patient fall on an outstretched
hand (a "FOOSH" injury ), whieh could indicate
a fracture or dislocation of the glenohumeral joint~ Did
the patient faJ! on or receive a blow to the tip of tlle
shoulder, or did the patient land on the elbow, driving
the humerus up against the acromion? This finding
may indicate an acromioclavicular dislocation or sub-
luxation. 17 Docs the shoulder fcd unstable or feci I1ke
it is "corning out" during movement? Docs the arm
"go dead" when doing activity? "Going dead" implies
the patient cannot usc the ann functionaUy because
of pain and a subjective feeling of unease when using
the ann. IS Patients with instability may appear normal
on clinical examination, especially if shoulder muscles
are not fatigued. Many overuse injmies are J)1,ore evi-
dent immediately after the patient does repeated activ-
ity.19 This may indicate gross or anatomical instabiJity,
as in recurrent shoulder dislocation, subluxation, or
subtle translational instability. The spectrul1l of insta -
bility varies from gross or anatomical instability- the
TUBS type (Traumadc onset, Unidirectional anterior
with a Bankart lesion responding to Surgery) to a
more subtle translational instability- the AMBRJ type
(Atraumatic cause, Multidirectional with Bilateral
236 CHAPTER 5 Shoulder

Table 5-2
Differential Diagnosis of Rotator Cuff Degeneration, Frozen Shoulder, Atraumatic Instability, and Cervical Spondylosis
Atraumatic
Rotat01: Cuff Lesions Frozen Shoulder lustability Cervical Spondylosis

Hisrory Age 30- 50 yean; Age 45+ (in sidious Age 10- 35 yean; Age 50+ years
Pain and weakness after type) Pain and instability Acute or chronic
eccentric load Insidious Ollset or after with activity
trauma or surgery No history oftrallma
Functional restriction
of later:1l rotation,
abduction, and
medjal rotation
Observation Normal bon.e and soft Normal bone and soft- No(mal bone and soft- Minimal or no cervical
tisslle outlines tissue ouuines tissue outlines spine movement
Protective shoulder hike Torticollis may be
may be seen present
Active movement Weakness of abduction Restricted ROM Full or excessive ROM Lim.itcd ROM with
or rotation, or both Shoulder hiking pain
Crepitus may be present
Passive movement Pain if impingement Limited ROM, Normal or excessive Limited ROM
occurs especially in lateral ROM (symptoms may be
('Orat ion , abduction, exacerbated )
and medial rotation
(capsu lar panern )
Resisted isometric Pain and weakness on Normal, when arm by Normal Normal, except
movement abduction and lateral side jf nerve root
rotation compressed
Myotome may be
affected
Special tests Drop-arn1 test positive None Load and shift test Spurling's tcst positive
Empty can test positive positive Distraction test
Apprehension test positive
positive ULTT positive
Relocation test positive ShollJder abduction
Augmentation tests test positive
positive
Sensory function and Nor affected Not affecred Dermatomes affected
reflexes Reflexes affected
Palparion Tender ove r rotator cuff Nor painful unless Anterior or posterior Tender over
capsule is srretched pain appropriate vertebra
or facet
Diagnostic imaging R.1diograpby: upward Radiography: negative Negative Radiography:
displacement of Arthrography: narrowing
humeral head; decreased capsular osteophytcs
acromial spurring size
M IU diagnostic

M 1t.1 .. tnagneuc resonance ImaglJlg; ROM .. range 0 1 monon ; ULIT ,. upper limb fell Slon test.

shoulder findings with R ehabilitation as appropriate
rreatment and, rarely, Interior capsular shift surgery ) .
4. Are there any movements or positions that cause
the patient pain_or symptoms? If so, which ones? The
examiner must keep in mind that ce rvical sp ine move -
ments may cause pain in the shoulder. Persons who
have had recurrent dislocations of the shoulder may
find that any movement involving lateral rotation
bothers them, because this movement is involved
in anterior dislocations of the shoulder. Recurrent
dislocators may sometimes show pain at extreme of
n
medial rotation when the humeral head is "tightened

Table 5-3
Differential Diagnosis of Shoulder Pathology
Pathology
External primary impingement (stage J)
ExtcrnaJ primary impingement (stage II )
External pri.mary impingement (stage III )
Rotator cuff tears (full thickness )
Adhesive capsulitis (idiopathic frozen
shoulder )
Anterior instability (with or without external
secondary impingement)
Posterior instability
Multidirectional instabjlity
Modified from Maughon TS, Andrews JR: The subjective evaluation of the shoulder in the athlete . 111 Andrews JR.., Wilk KE, editOrs: The
nthlete)s YJolllder, p. 36, New York, 1994, Churchill -Livingstone.
Figure 5-6
Patient supports the uppe r limb in protected position .
CHAPTER 5 Shoulder 237
SYJl1ptoms
Intermittent mild pain with ove rhead activities
Over age 35
Mild to moderate pain with overhead activities or Strenuous activities
Pain at rest or with activities
Night pain may occur
Scapular or rotatOr cutIweakness is noted.
Classic night pain
Weakness noted predomu1<Ult1y in abduction and lateral ro tators
Loss of motion
Inability to perform activities of daily living owing to loss of motio n
Loss of motion may be perceived as weakness
Apprehension to mechanical shiftin g limits activities
Slipping, popping, o r slidin g may present as suitable instability
Apprehension usually associated with horizontal abduction and lateral rota tion
Anterior or posterior pain may be present
Weak scapular stabilizers
Slipping or popping of the humerus Ollt the back
This may be associated with forward tlexion and tllcdiat rotation while the
shoulder is under a compressive load
Looseness of shoulder in all directions
This may be mOSt pronounced while carrying lu ggage or turning over wh ile asleep
Pain mayor may not be present
Figure 5-7
Voluntary illSfabilil:)'. Notc how thc patient uses her muscles w sublux
the hum erus in the glenoid.
238 CHAPTER 5 Shoulder
against the anterior glenoid. Excessive abduction and
latcral rotation may lead to dead -arm syndrome in
which the patient feels a sudden paralyzing pain and
weakness in the shoulder. " This finding often indi-
cates altered shoulder Illcchanics cOlnmonly involv-
ing a tight posterior capsule, altered arthrokinematics
of the glenohumeral joint, and scapular dyskinesia."
In throwers, the condition may bt! referred to as
a SICK scapula (malposition of Scapula, prominence of
Inferior medial border of scapula, Coracoid pain and
malposition, and scapular dysKinesia ).20 Ifthc patient
complains of pain during specific phases of pitching
(for example, during the latc cocking and accelera-
tion phases ), anterior instability should be consid -
ered even in the presence of m.inlmal clinical signs. 2 1
Commonly, instability and secondary impingement
occlir together. Secondary impingement implies that
although impingement signs are present, they result
from a primary problem somewhere else, commonly in
the sca pular or humeral control or stabilizer muscles.
Stability of the shoulder depends on both dynamic
stabilizers (the muscles ) and static stabilizers (e.g.,
the capsule, labrum). S Night pain and resting pain are
often related to rotator cuff tears and, on occasion, to
tumors; activity-related pain usually signifies parateno-
nitis. Arthritis pain commonly shows, at least initially.
at the extremes of motion . Acromioclavicular pain is
especially evident at greater than 90 of abduction and
tends to be localized to the joint. Similarly, sternocla -
vicular pain is localized to the joint and increases on
horjzontal adduction .
5. What is the extmt alld behavior ofthe patieut's paill?
For example, deep, boring, tooduche-Like pain in the
neck, shoulder region, or both may indicate th oracic
outlet syndrom e (Figure 5 -8) or acute brachial
plexus neuropathy. Strains of dle rotator clitT usually
cause dull , toothache-like pain that is worse at night,
whereas acute calcific tendin.itis llsually causes a hot,
burning type of pain. Sprain of the first or second rib
from direct trauma or sudden contraction of rhe sca-
leni may mimic an acute impingement or rotator cuff
injury.22
6. Are there any activities that cause or increase the pain?
For example, bicipital paratenonitis or tendinosis 23 are
often seen in skiers and Olay result from holding on to
a ski tow; in cross-country skiing, it may result from
poling (using the pole for propulsion ). Paratenonitis
is inflamnlation of the paratenon of d1C tendon. The
paratenon is the outer covering of the tendon whed1er
or not it is lined with synovium. Tendinosis is actual
degeneration of the tendon itself. With chron ic over-
use, tcndinosis is more likely than paratenonitis23 ,24
(Table 5-4; see Table 1- 18). Elite swimmers may train
for more than 15 ,000 m daily, which can lead to stress
overload (repetitive microrrauma) of the strucnlres
of the shoulder. Docs d1fowing or reaching alter d1C
pain? If so, what positions cause pain or discomfort?
These questions may indicate which structures are
injured .
7. Do any positions relieve the pain ? Patients with
nerve root pain may find that elevating the arm ovcr
the head relieves symptoms. For a patient with insta-
bi~ry or inflammatory conditions, lifting the arm over
the head usually exacerbates shoulder problems.
8. What is the patimt ,,,,able to do functionally? [s the
patient able to talk or swallow? Is the patient hoarse?
These signs could indicatc an injury to the sternocla-
vicular joint (ifd1cre is swelling) or a posterior disloca-
tion of the joint because pressure is being applied to
the trachea.
9. HolV long has the problem bothered the patient? For
example, an idiopathic frozen shoulder goes tmough
three stages: the condition becomcs progressively
worse, plateaus, and thcn progressively improves, with
each stage lasting 3 to 5 months. 25 26
10. Is there any indication ofn,wsele spasm., deformity,
bruising, wasting) paresthesia) or n1tmblless?2 7 These
findings can help the examiner determine the acute-
ness of the condition and, potentially, d1C strucUlres
injured.
11. Does the patie'1'J.t complain ofn,eakness and hcal'i-
ness in the li11l,b after actil'it)'? Does the limb tire easily?
These findings may indicate vascular involvement. Are
there any venous symptoms, slIch as swelling or stiff-
ness, which may extend all the way to d1e fingers? Are
there any arterial symptoms, such as coolness or palJor
in the upper limb? These complaints may result from
pressure on an artery, a vein, or bot]1. An example is
dloracic outlet syndrome (see Figure 5-8), in which
pressure may be applied to d1e vascular or neurologi -
cal structures as they enter the upper limb in three
locations: at dle scalene triangle, at the costoclavicular
space, and under d1C pectoralis minor and the cora-
coid process. 28 ,29 Excessive repetitive demands placed
on the shoulder, such as thosc seen in pitcrung, may
lead to thoracic outlet syndrome, axillary artery occlu -
sion, effort d1rombosis, or pressure i.n the quadrHateral
space. (The quadrilateral space has as its boundaries
the medial border of the humerus laterally, the lateral
border of the long head of triceps medially, the infe-
rior border of teres minor) and the superior border of
teres major, )3
12. Is there any indication of nerve injury? The
examiner should evaluate the nerves and the muscles
supplied by the nerves to determine possible nerve
injury. Any history of weakness, numbness, or par-
esthesia may indicate nerve injury (Table 5-5). For
example, the suprascapular nerve may be injured
as it passes through the suprascapular notch under
the transverse scapular ligamcnt, leading to atrophy
 CHAPTER 5 Shoulder 239

Scaleni---------

Cervical r i b - - - - - ---j
'------f~:_---- Scalene muscles
Brachial DI.>xus -------7""
------".~-- Brachial plexus

. r-::------".;-- Subclavian artery Subclavian artery ----;f--;~

~--- Subclavian vein

'v----- Brachial plexus
,-/<~y:;- Subclavian artery

~~~=~-- Subclavian artery

_"::,L"A- Pectoralis minor

c D
Figure 5-8
Location and causes ofthor:tdc o utlet syndrome . A, Scalenus anterior syndrome. B, Ce rvical rib syndrome.
C, Costoclavicular space syndrome . D, Hypcrabdllcrion syndrome (abduction , extension , and lateral rotation ).

and paralysis of the supraspinatus and infraspinatus
muscles. The examiner shou ld listen to the history
carefully, because this condition could mimic a third -
degree (rupture ) strain of the supraspinatus tendon.
Another potential nerve injury is one to the axillary
(circumflex ) nerve (Figure 5-9 ) or musculocutaneous
nerve (Figure 5 -J 0) after dislocation of the glenohu-
meral joint. With an axillary nerve injury, the deltoid
muscle and the teres minor muscle are atrophied and
weak or paralyzed. The radial nerve (see Figure 5-9 )
is sometimes injured as it winds around the posterior
aspect of the shaft of the humerus. The inj\lry
frequently occurs when the humeral shaft is fractured.
If the nerve is damaged in this location, the extensors
of the elbo""" wrist ) and fingers arc affected ) and an
altered sensation occurs in [he radjal nerve sensory
distribution.
13. Which hand is domintU'/,t? Often th e dominant
shoulder is lower than the nondominant shoulder and
the ROM may not be the same for both. Usually, the
dominant shoulder shows greater muscularity and
often less ROM.
240 CHAPTER 5 Shoulder
Table 5-4
Implications of the Diagnosis of Tendinosis Compared with Tendinitis
Trait Overuse Tcndinosis
PrevaJencc Common
Time for recovery, carly presentation 6-10 weeks
Time for fuU rccoverY1 chronic 3-6 months
presentation
Likelihood of full recovery to sport from -80%
chronic symptoms
Focus of conservative therapy Encouragement of collagen -synthesis
maturation and strength
Role of surgery Excise abnormal tissue
Prognosis for surgery 7{}-85%
Time for recovery from su.rgery 4-6 months
From Khan KM ct al: Overuse tcndinosis, not tendonitis. Part 1: a new par<ldigm for a difficult clinica l problem, Phys Sporum ed 28:43 , 2000.
Rcprodllccd widl pCrlnissioll of McGraw -Hill.
Observation
The patient must be suitably undressed so that the
examiner can observe the bony and soft-tissue con-
tours of both shoulders and determine whether they are
normal and sym metric. When observing the shou lder,
the examiner looks at the head, the cervical spi.ne, the
thorax (especially the posterior aspect), Clnd the enrj re
upper limb. The hand , for example, may show vasol)1o-
tor changes that resuJt from. problems in the shou lder,
including shiny skin, hair loss, swelling, and muscle
atrophy.
It is important to observe the patient as he or she
removes clothes from the upper body and later replaces
them. For example, does the patient undress the affected
arm last or dress it first? This pattern indicates that the
patient is limiting the movement of the arm as much
as possible, signi/)'ing possible pathology. The patient'S
actions give sorne indication of functional restriction,
pain , or weakness in the upper limb.
Anterior View
\Nhen looking at the patient from the antcrior view
(Figure 5-11, A), the exami ncr should begin by ensuring
that the head and neck are in the midline of the body
and observing their relation to the shoulders. A forward
head posture is often associated with rounded shoul-
dcrs, a medially rotated humerus and a protracted scap-
ula resulting in the humeral head translating anteriorly,
a tight posterior capsule, tightness of the pectoral, upper
trapezius, and levator scapulae muscles, and weakness
of the lower scapu lar stabili zers and deep neck flexors Y
While observing the shoulder, the examiner should look
for the possibility of a step deformity (Figure 5- 12, A ).
Such a deformity may be caused by an acrom.ioclavicular
Overuse Tendinitis
Rare
Sevcl.Il days to 2 weeks
4-6 weeks
99%
Anti -inflammatory modalities and drugs
Not known
95%
3-4 weeks
dislocation, with the distal end of the clavicle lying supe-
rior to tJle acromion process. Seen at rest, a step deformjry
indicates both the acromioclavicu lar and coracoclavicular
ligaments have been torn. The deformity may be accentu -
ated by asking the patient to hori zontally adduct the arm
or to mediolly rotate the shoulder and bring the hond
up the back as high as possible. Occasionally, swelling
is evident anterior to the acrolluoclavicular joint. This is
called the Fountain sjgn and indicates that degeneration
has caused communication between the acromioclavicu-
lar joint and swollen subacromial bursa undcrncath .32 If
a sulcus deformity appears when traction is applied to
the arm , it may be caused by multidirectional instability
or loss of muscle control due to nerve injury or a stroke,
leading to inferior subluxation of the gle nohumeral joint
(Figure 5- 12, C). This deformity is lateral to the acromion
and should not be confused with a step deformity. This is
also referred to as a sulcus sign because of the appearance
of a sulcus or groove below the acromion process (Figure
5- 12 , B). Flattening of the normally round deltoid mus-
cle area may indicate an anterior dislocarjon of the gl~no
humeral joint or paralysis of the deltoid muscle (Figure
5 13 ). With an anterior dislocation , note also how thc arm
v
is held abducted because of the ioeation of the hllmeral
head below the glenoid. If the examiner palpated in the
axilla , he or she would feel the head o f the humerus. The
examiner should note any abnormal bumps or malalign-
ment in the bones that may indicate past injury, such as
a healed fracture of the clavicle .
In most people, the dominant side is lower than the
nondominant sidc. This difference may be caused by
the extra use of the dominant side, \vhich stretches the
ligaments, joint capsules, and muscles, allowing the ann
to sag slightly. Tennis playcrs33 and others who stretch
their upper limbs in a rcaching action show even greater
 CHAPTER 5 Shoulder 241
Table 5-5
Peripheral Nerve Injuries (Neuropathy) about the Shoulder
Affected Nerve Reflexes
(Root) Muscle We."lkncss Sensory Alteration Affected Mechanism of Injury

Suprascapular nerve S1I praspi n<t tll S, Top of shoulder None Compression in suprascapular notch
(C5- C6) infraspinatus (a nn from clavicle to Stretch into scapular protraction pills
lateral rotation ) spine of scapula horizontal adduction
Pain in posterior Compression in spinoglenoid notch
shoulder radiatin g Direct blow
into arlll Space occupying lesion (e.g., ganglion)
Axillary (circumflex ) Delmid, teres minor Deltoid area None Anterior gle nohumeral dislocation or
ne rve {posterior (arm abduction ) Anterior shoulder fracture of surgical neck of humerus
cord ; C5-C6) pain Forced abduction
Surgery for instability
Radial nerve (CS- C8, Triceps, wrist extensors, Dorsum of hand TI;ceps Fracture humeral shaft
TI ) finger extensors Pressure (e.g., crutch palsy )
(shoulder, wrist , and
hand extension )
Long thoracic nerve Serratus anterior Direct blow
(C5- C6, [C7 l) (scapular control ) Traction
Compression against internal chest wall
(backpack injury )
Heavy effort above should er height
Repetitive strai n
Muscuioclitaneou s Coracobr:l.chialis, Lueral aspect of Biceps Compression
nerve (C5- C7 ) biceps, brachialis forearm Muscle hypertrophy
(elbow Aexion ) Direct blow
Fracmre (clavicle and humerus)
Dislocation (anterior)
Surgery ( PU[ti -Platt, Bank:ut )
Spinal accessory nerve Trapezius (shou lde r Brachial plexus None Direct blow
(craniaJ nerve Xl ~ elevation ) sympmlllS possible Tracrion (shoulder depression and neck
C3-C4) because of drooping rotation [0 opposite side )
of shoulder Biopsy
Shoulder aching
Subscapular nerve Subscapularis, teres None None Direct blow
(poste ri or cord; major (medial Traction
C5- C6) rotation )
Dorsal scap ul:u nerve Levator scapulae, None None Direct blow
(C5 ) rhomboid Illajor, Compress ion
rhomboid minor
(scapular rct(action
and elevation )
Lateral pcccoral ner ve Pectoralis major, None None Direct blow
(C5- C6) pectoralis minor
Thoracodorsal nerve L'uissimus dorsi None None Direct blow
(C6-C7, rCS]) Com pression
Supracla\~cular nerve - Mild clavicu lar pain None Comprcssioll
Sensory loss over
anterior shoulder

differences along with gross hypertrophy of the muscles
on the dominant side ( Figure 5-14 ). If the patient is pro-
tective of the shoulder) however, it may appear that the
injured shoulder, whether dominant or nondomi.nant, is
higher than the normal side (see Figure 5-6 ).
The. examiner notes whether the patient is able to
assume the normal fUllcrionaJ position for the shoulder,
\:vhich is in the scapular pla.ne with 60 of abduction and
the arm in nelltral or no rotation. In this position, or with
the arm abducted to 90, rupture or congenital absence
242 CHAPTER 5 Shoulder

.t
BrachIal
Lateral cord
Posterior cord
plexus Medial cord -\----Teres minor

Radial nerve -----',W\\

Long head of triceps 'r-- L,nerall head of triceps

Medial head of triceps - - - ' , -

~.......~-. E)Iterlsor carpi

radialis longus
Anconeus ---~~
~k-\---I,xt,ens,or carpi
radialis brevis
Extensor digitorum - - - +-'t1l'i11
Extensor digiti minimi _ _---.J~I
\--Al>jU(:tor pollicis
Extensor carpi ulnaris - - - - - ' longus
Extensor pollicis longus - - -+J t\--Extensor pollicis
Extensor indicis ------~ brevis

Figure 5-9
Motor distribution of the radial and axillary nerves.

hand into midline, the biceps tcndon is forced against the

Coracobrachialis
Musculocutaneous
nerve --+---,1-
Biceps brachij
Figure 5-10
Motor and sensory djstributiol\ of musculocutaneous nerve.
of the pectoralis major may be evident (Figure 5-15) 3'
Rupture of the pectoralis major is often accompanied by
a tearing sensation and pop along with weakness, painful
limitatioll of movement, and ecchymosis. 34 If the patient's
arm is medially rotated from this position to bring the
lesser tuberosiry of the medial wall of the bicipital (i nter-
tubercular) groove. If this position is maintained for long
periods, there may be increased wear of the biceps ten -
dOll, which can lead to bicipital tendinitis or paratenoni-
tis. If the arm is horizontally adducted while it is medially
rotated, anterior pain indicates impingement symptoms
( Hawkins-Kennedy test-see special tests). The width
and depth of the bicipital groove may vary (Figure 5-16),
possibly leading to problems if the shoulder is overused.
Especially wide or deep grooves lead to the greatest
problems. The wide grooves tend to allow the tendon
too mllch lateral movement, leading to inflammation of
the paratcnon (paratenonitis)23; the deep gruuves tend to
be too narrow) compressing the tendon, especially if it
becomes inflammed .35
Posterior View
When viewing the patient from behind (see Figure 5-1 1,
13) , the examiner again notes bony and soft-tissue con-
tours and body alignment. For example, atrophy of the
upper trapezius may indicate spinal accessory nerve palsy,
whereas atropby of supraspinatus or infraspinatus may
indicate supraspinous nerve palsy.36 The spines of the
 CHAPTER 5 Shoulder 243

Figure 5-11
Views of the shou lder. A, Anterior. B, Posterior. C, Side.

Figure 5-12
A, Step deformity resul ting from. ilcromioclavicuJar disloc.:arion. H, Sulcus sig n for shoulder instability.
C, Subluxation o f glenohumeral joinr followin g a stroke (paralysis of dclroid muscit:). (B from Warren RF :
Subluxation of the sho ulder in athletes, Clin Sports Med 2:339, 1983 .)

scap uJae, which begin medially at the level of the third
(T3 ) thoracic vertebra, should be at the same angle. The
scapula itself sho uld extend from the T2 o r T 3 spinolls
process to the T7 or T9 spino LIS process of the dloracic
vertebrae. Sobush and associates devel o ped a meth o d for
measuring the scapular position called the Lennie test. 37
In this test, they measured frol11 the spinolls processes
horizontally to t hree scapular positions: the medial aspect
of the most superior po int (superio r angle), the root of
the spine of the scapula, and the inferior angle (Figure
5 17) .37 If th e scapul a is sitting lower tha.n no rmal against
the chest wall, the superior media l border of the scapula
244 CHAPTER 5 Shoulder
Figure 5-13
Subcor.lcoid dislocation of the shoulder. Note the prominent
acromion, the arm held away fwm rill:: side , and the flat deltoid .
(From McLaughlin HL: Trauma , p. 246, Philadelphia, 1959, WE
Saunders.)
may "washboard" over the ribs, causing a snapping or
clunking sound (snapping scapula) during abduction
and adduction. 38-42 The inferior angles of the scapulae
should be equidistant from the spine.
Kibler et al. divided scapular dysnll1ction or dyskine-
sia into four patterns. 43 Type I shows the inferior medial
border being prominent at (cst and the inferior angle tilts
dorsally with movement (scap ular tilt), while the acro-
mion tilts anteriorly over the top of the thorax. It may be
seen J[ rest or during concentric or eccentric movement.
If the inferior border tilts away from the chest wall, it
may indicate the presence of weak muscles (c. g., lo\.ver
trapezius, latissimus dorsi, serratus anterior) or a tight
pectoralis minor or major pulling or tilting the scapula
forward from abovc. 20 Type II is the classic winging of
the scapula with the whole medial border of the scap-
ula being prominent and lifting away frol11 the posterior
chest wall both statically and dynamically (Figure 5-18).
It too may be seen at rest or during ccccnttic or concen -
tric movements. This deformity may indicate the pres-
ence of a SLAl") (Superior Labrum Anterior and Posterior
[to the biceps])lesion weakness of the scrrauls anterior,
rhomboids, lower, middle and upper trapezius, a long
thoracic nerve problem or tight humeral rotators .20 Type
11\ is illustrated by the superior border of the scapula
being elevated at rcst and during movement; a shoulder
shrug initiates the 1110vcment and there is m.inimal wing-
ing. This deformity is seen with active movement and
may result from ovcractivity of the levator scapula and
upper trapezius along with imbalance of the upper and
lower trapezius force couple (Figure 5- \9 ). It is associ-
ated with impingement and rotator cuff lesions. 20 In the
type TV pattern, both scapulae are symmetrical at rest and
during motion; they rotate syrnmetricaUy up"./ard with
the inferior angles rotating laterally away from midline
(rotary winging). It is seen during movement and may
indicate the scapular control muscles are not stabilizing
the scapula.
Dynalnk winging (i.e. , winging with movement)
may be caused by a lesion of the long tboracic nerve
affecting serratus anterior, trapezius palsy (spinal acces-
sory nerve ), rhomboid weakness, multidirectional insta-
bility, voluntary action, or a painful shoulder resulting in
splinting of the glenohumeral joint, which in turn causes
reverse scapulohumcral rhythm. 44 This splinting of the
glenohumeral joint leads to reverse origin-insertion
of the rotator cuff muscles so that instead of moving
the humerus as they normally would, they \""ork in
reverse fashion and move the scapula. Commonly, with
pathology, the scapular control muscles are weak and
cannot counteract this action, resulting in protraction
of the scapula and dynamic winging. The two other
common causes of dynamic winging-long thoracic
nerve palsy and spinal accessory nerve palsy-cause dif-
ferent scapula positioning and different winging pat-
terns. Spinal accessory nerve palsy causes the scapula
to depress and move laterally, with the inferior angle
rotated laterally. If the trapezius is weak or paralyzed ,
the winging of the scapula occurs before 90 abduc-
tion, and there is little winging on forward fl exion. 45
Long thoracic nerve palsy causes the scapula to elevate
and move medially, with the inferior angle rotating
medially ( Figure 5-20).'6.47 If the serratus anterior is
weak or paralyzed, the winging of the scapula occurs
on abduction and forward flexion (especially witl1
a "punch out" forward against resistance) (see Figure
5-18 ).'5." Radiculopathies at C3, C4 (trapezius), C5
( rhomboids ), and C7 (ser ratus anterior, rhomboids)
can also cause winging. 49 5o
Static winging (Le., winging occurring at rest) is
lIsually caused by a structural deformity of the scapula,
clavicle, spine, or ribs. ~1
Sprengel's deformity, which is a congenitally high or
undescended scapula (Figure 5-21), is the most common
congenital deformity of the shoulder complexY-54 With
this deformity, the scapular muscles are poorly developed
or arc replaced by a fibrou s band. The condition may
be unilateral or bilateral, and the range of the shoulder
abduction decreases, although functional disability may
be slight. Usually, the scapula is smaller than normal and
is medially rotated.
The shoulder muscles may be accentuated by having the
patient place the hands on the hips and contract the mus-
cles. The examiner shou1d check closely for wasting in the
 CHAPTER 5 Shoulder 245

Figur.5-14
Depressed right shoulder in a right-
dominant individual-in this case, a tenn is
player. A, H ypertrophy of playing shoulder
muscles. n, With muscles relaxed, the
distance between spinolls processes and
medial border of scap ula is widened on the
right. C, Depressed shoulder.
(From Pri est lD, Nagel DA : Tennis
shoulder, Am J Sports Med 4:33 , 1976. )

Angle of the wall of the biceps groove

c3c5dd00 Frequency of each

type of groove
15

'

10%

Figur.5-16

13%
6%
-2%

Different shapes of the bicipital groove. (Adapted from Hitchcock

Figur.5-15 HH , Bechtol CO: Painful shoulder: observation on the role of the
Congenital absence of sternal head of pectoralis major. Note fascial tendon of the long head ofthe biceps brachii ill its causation , ) Bone
cord ( arrow). Joint Sm;g Am 30:267, 1948 .)
246 CHAPTER5 Shoulder
Nondominant Dominant
Midline
Figure 5-17
Lennie test. Measurements are taken .n three positions on the scapula,
and dominant and nondominant sides arc compared .
supraspinatus and infraspinatus muscles (suprascapular
nerve palsy), in the scrranlS anterior muscle (long tho-
racic nerve palsy), and in the trapezius muscle (spinal
accessory nerve palsy), all of which can lead to winging
of the scapula.
Examination
Because asseSSlllent of the shoulder may include an
assessment of the cervical spine, the examination can
be an extensive one. If the examiner has any doubt as
to the location of the lesion, a cervical spine assessment
Figure 5-18
\Vinging of the scapula. A, The shoulders at rest. B, Winging apparent when the patient is pushing rorward .
C, Winging when attemptin g full abduction . (From Foo CL, Swann M: Isolated paralysis of the serratus
.mterior: a rt:porl of 20 cases, ) Rone Joint Sm;g Br 65:554 , 1983. )
(see Chapter 3) should be performed. In addition, the
examiner must remember that the arm, of which the
shoulder is an integral part, may act as an open !cinctic
chain whcn the hand is free to move or as a closed !cioetic
chain when the hand is fixed to some relatively immov-
able object. For example, scapular instability may be evi -
dent in closed kinetic chain when the arm is fixed and
the rotator cuff muscles work in reverse order (reverse
origin -insertion; for example, the insertion of the mus-
cles into the humerus becomes the stable part because
the arm is fixed whereas the scapula becomes the mobile
part and is more likely to move) (Figure 5-22 ). It may
also be evident in open kinetic chain, especially durjng
high-speed movements when the scapula needs to be
stabili zed (e.g., when hitting a ball) or when the scapu -
lar muscles should be working eccentrically to slow or
stop a movement (i.e., they are unable to do so because
of weakness). In open kinetic chain, the scapula acts as
the base or origin of the muscles, whereas the insertion
into the hUlllcrlls is more 1l1Obile. Kno\vledge of muscle
bala.nce and muscle force couples becomes imperative in
detcrmin.ing a diagnosis. For example, the legs, pelvis,
and trunk act as force generators, whereas tJle shoulder
acts as a funnel and force regulator with the arm act-
ing as the force delivery system. 20 These kinetic chains
and the intricate and complex interplay of the compo-
nents of the kjnetic chain have different effects on the
shoulder. Eating, reaching, and dressing are considered
open kinetic chain activities, whereas crutch walking and
pushing lip fiom a chair are considered closed kinetic
chain movements.
As with any assessment, the examiner is comparing
one side of the body with the other. This comparison
is necessary because of individual differences among
normal people.
 CHAPTER 5 Shoulder 247

Figure 5-20
Scapular mo\'cmcm rcsu lting in scapula r winging caused by trapezius
palsy (A) and serratus anterior palsy ( B).

An understanding of the force couples acting o n the

shoulder complex and the necessity of balancing the mus-
cle strength and endurance of these muscles is especjal\y
important when assessing the sho ulder. 55 Force couples
are groups of counteracting muscles that show obvious
action when a movement is loaded or done quickly.56
With a particular movement, one group of muscles (the
agonists ) acts concentrically whereas the other group (the
antagonists) acts eccentrically in a controlled, harmoni zed
fas hion to produce smooth movement. In addition, these
muscles nlay work by cocontractio n or coactivation to
provide a stabilizing effect and joint control. Table 5-6
gives examples of some of the force couples acting about
the shoulder.
Active elevation throug h abduction is normally 170
to 180. The extreme of the ROM occurs when the arm
is abducted and lies against the car on the same side of

Figure 5-19
Imbalance pattern of the upper and lowe r trapez.ius. Note
ovcrdcvclopmcllt of upper trapezius Olnd lower trapezius working lO
prevent rotary winging. Active Movements of the Shoulder Complex
Elevation through abduction (170 to 180)
Elevation through forward flexion (160 to 180)
Elevation through the plane of the scapula (170 to 180)
Active Movements Lateral (external) rotation (80 to 90)
Medial (internal) rotation (60 to 100)
The first lDOVcmcl1[S to be examined arc the active move- Extension (50 to 60)
ments. These movements are usually done in such a way Adduction (50 to 75)
that the painful movements arc performed last so pain HOIizontal adduction/abduction (cross-flexion/cross-exlension; 130)
does not carryover to the next movement. It is also Circumduction (200)
essential to be able to di ffere ntiate between scapular Scapular protraction
movement and glenohumeral movements when watch- Scapular retraction
ing active movements because scapular movement often Combined movements (if necessary)
compensates for restricted glenohumeral movem.cnt Repetitive movements (if necessary)
leading to weak and often lengthened scapular control Sustained positions Of necessary)
muscles.
248 CHAPTER 5 Shoulder

Figure 5-21
Diagram (A) and pholograph (B) of child with
Sprcngcl's deformity. Note dcvatcd shoulder and
poorJy developed scapula on the lefr. (A modified
from Gartland JJ: FWldnmwrnlso!ortlJopadits,
p. 73, Philadelphia , 1979, WB S.unders. B counesy
A of Dr. Roshcl1 Irani. )

Figure 5-22
The patholllechanics o f "cbssic wingins" of th e scapul:l . A, Winging o f the ri ght scapula causcd by marked
weakness of the righ.r serratus amerior. The winging is cx-aggeratcd when resistance is applied against a
sho ulder ::abduction cnort. Note how rhe stabili zation occurs where the cX<lminer's hand is o lTering resistAnce.
Instc:ld of the: arm moving, the scapuJa moves beca use its stabili zing Illusde's are weak. B, Kinesiologic ana lysis
of the wingi ng scapul,l . Wirbom an adequate upward rout-ion force from the serratus anterior (fadiIV/ aYI()JI') .
the scapula becomes unstable and cannot resist Ule pull ofthc deltoid . Subseq uently, the force o f the I.klwitl
(bidiyu.riolla/ arrolv) causes the scapula to downwardly rotate and the glenohumeral joinr to partially abduct
(rc,crsc origin insertion ). (From Nellmann DA: Kinesi%gy o[lb( ,,"mll/oske/etal sYfteln:[o lmdatiolJS [or
pbysica/ rdJtJbi/italioll p. 107, St. Louis, 2002, Mosby.)
j

the head (Figure 5-23 ). As the patient devates the upper
extrcmity by abducting the shoulder, the cxaminer should
no tc whether a painful arc is present (Figure 5-24)'7
A painful arc may be caused by subacromial bursitis, cal-
cium deposits, or a peritenonitis or tcndinosis 23 24 of the
rotator cuff muscles. The pain results from pinching of
inflamed or tender structU(CS under the acromion pro-
cess and the coracoacromial Jig:ltllcnt. Initially, the struc-
tuxes are not pinched under the acromion process, so the
patient is able to abduct the arm 45 to 60 with little dif-
ficulty. As the patient abducts further (60 to 120), the
structures (e.g., subacromial bursa, rotator cuff tendon
 CHAPTER 5 Shoulder 249
Table 5-6 abduction movement. This painful arc (sec Figure 5-24)
Force Couples aboullhe Shoulder occurs toward tlle end of abductjon, in the last 100 to
20 0 of elevation, and is caused by pathology in the acro ~
Agonist/ Antagonist/
Movement Stabilizer Stabilizer mioclavicular joint or by a positive impingement test.
fn the case of the acromiocJavicular joint lesion, rJlC pain
Protr:lction (seaplIla) Se rratus anteri or'" Trapezius tends to be localized to the joint. With the impingement
Pectoralis major! Rhomboids syndrome, the pain is usually found in tlle anterior shou l ~
and minor t der region. Table 5-7 presents the signs and symptoms
Retraction (scapula ) Trapezius Serratus anterior of three types of painful arc in the shou lder, with the
RllOmboids Pectoralis major t superior type being the most common. The arc of pain
and minor t
may be present also during elevation tllrough torward
Elevarion (scapula ) Upper trapezius t Serratus amcrior*
flexion and scaption , although the pain is usually Jess
Levator scapulae t Lower trapezius'"
severe on these movements. The interconnection of the
Depression (scapuJa) Serratus anterior'" Upper trapezius t
Lower trapezius Levawc scapulae t
subacromial, subcoracoid, and subscapularis bursae with
Lacral rotation Trapez ius (upper! Levator scapulae t each other and with the glenohumeral joint capsule often
( upward rotation and lower'" Rhomboids produces a broad area of signs and symptoms, which may
of inferior angle of fibers) PcctQ(alis minor! result in a pajnful arc.
scapula ) Serr3tus a.nterior* When exam1l1111g the movement of elevation
Medial rOl.ltion Levator scapulae l Trape zius (uppert th.rough abduction, the examiner must take time to
(downward roration Rhomboids and lower* observe scapulohunleral rhythm of the shoulder com ~
ofinicnor angle of Pectoralis minor' fibers) plcx (Figure 5-25), both anteriorly and posteriorly." 60
scapula) Serratus anterior That is, during 1800 of abduction, thne is roughly
Scapu lar stabilization Upper trapezius' Serratus anterior
a 2: 1 ratio of movement of the humerus to the scapu la ,
Lower trapezius
with 120 0 of movement occurrin g at the gleno humeral
IUlOrnboids
Abduction (hlmlcrtls) Deltoid Supraspinatus
joint and 60 0 at the scapulothoracic joint; one should
Medial rotation Subscaplilarist Infraspinatus be aware, however, that there is a great deal of vari ~
(humerus) Pectoralis major' Teres minor ability among individuals and may depend on the speed
Latissimus dorsi Posterior deltoid of movement,<'1 and authors do not totally agree on
Anterior deltoid the exact amounts of each movement. 59 .60 .(.2 A.ltho ugh
Lateral rotation Infraspinatus Subscapularist all autho rs concede that there is more move ment in
( hum erus) Teres minor Pectoralis major' the glenohumeral joint than in the scapulothoracic
Posterior deltoid Latissimus dorsi joint, Davies Jnd Dickoff Hoffman believe the ratio is
Anterior deltoid greater, at least ro 120 0 of abduction ,63 whereas Poppen
and Walker"" and others 7 65 believe the ratio is less (5:4
Muscles p(one to weakness.
or 3:2 ) afte r 30 0 of abduction. During this total simul
'Muscks prone to rightness.
taneous movement at rhe four joints, there are three
phases; the reader should understand that others will
give values of the amount of each movement that vary
from those noted here.

insertions especially sllpraspinanls) become. pinched

and the patient is often unable to abduct fully because
of pain. If full abduction is possible, however, the pain
Scapulohumeral Rhythm
diminishes aner approximately 1200 because the pinched
soft tissues have passed under the acromion process and Phase 1: Humerus 30 abduction
arc no longer being pi.nched. Often , the pain is greater Scapula minimal movement (setting phase)
going up (against gravity) than coming down , and there Clavicle 0_50 elevation
is more pain on active abduction than on passive abduc~
rion. 1f the movement is very painful, the patient often Phase 2: Humerus 40 abduction
Scapula 20 rotation, minimal protraction or elevation
elevates the arm through forward flexion or hikes the
Clavicle 15 elevation
shoulder using upper trapezius and levator scapulae in
an attempt to decrease the pain. In some cases, retracting Phase 3: Humerus 60 abduction, 90 lateral rotation
the scapula so that the space under the coracoacromial Scapula 30 rotation
space is slightly enlarged may decrease pai n. A second Clavicle 30-50" posterior rotation, up to 15 elevation
painfuJ arc in the shoulder may be seen during the same
 180
I

Abduction
Forward
flexion

t !
Horizontal
0 flexion
I

60
Extension , Neutralplane
of the scapula

~
("Scaption ")

External
rotation
____ 900
'" I

A
Y Horizontal
extension
B

Figure 5"23
Movement in dlC shoulder complex . A, Range of motion of the shoulder. B, Axes of arm elevatioll. (Adapted
from Perry J: Anatomy and biomechanics of the shou lder in throwing, swimmin g, gymnastics, and tennis, Gin
Sports M ed 2:255, 1983.)

180"

Acromioclavicular
painful arc

Glenohumeral
painlul arc

B
Figure 5"24
Painful arc in the sho ulder. A, Painful arc of the glenohumeral joint. III the case of acromiocl::l.\'icular joint
problems only, the fange of 1700 to 180 0 would elicit pai n . B, Non.: the impingement ca usi ng pain on the
right al approximately 85. (A modified from Hawkins R.I , Hobeika PE: Impin gement syndrome in the
athletic shoulder, G in Sports Med 2:39 1, 1983. )
 CHAPTER 5 Shoulder 251
Table 5-7
Classification of Glenohumeral Painful Arcs
Anterior Posterior Superior

Night pain Yes Yes Maybe

Age 50+ 50+ 40+
Sex ratio F > M F>M M >F
Aggrav:m::d by Lateral roration and Medial rotation and Abduction
abduction abduction
Tenderness Lesser tuberosity Posterior aspect of greater Greater tuberosity
tuberosity
Acromioclavi cular joint involvement No No Often
Calcification (if present) Supraspinatus, infraspinatus, Supraspinatus and/or Supraspinatus and/or
and/ or slIbs(apularis infraspinatus subscapulari s
Third -dcgl:'"cc s[rf~in biceps bnchji No No O ccasio nal
(long hc.1d )
Prog nosis Good Vcry good Poor (without surge ry)

From Kessell ., Watson M: The painful arc syndrome, J &me / oill t SIIt'g Br 59: 166, 1977.

Figure 5-25
Movement of the scapll.l:l, h1l11lCru:" .1Il0 clavicle during
scapulohumeral rhythm .

1. In the first phase of 30 of elevation through abduc-
tion, the scapula is said to be "setting." This setting
phase means that tJ1C scapub may rotate slightly in rotate
slighrJy out, or not move at all.",8 Thus, there is no 2: 1
ratio of movement during this phase. The angle between
rJle scapu lar spine and the clavicle may also increase up
to 5 by elevating at the sternoclavicula r and acromiocla-
vicular joints,S!! bur this depends on whether the scapula
moves during this phase. The clavicle rotates minimally
during this stage.
2. During the next 60 of elevation (second phase), the
scapu la rotates about 20, alld the humerus elevates 40
with minimal protraction or elevation of the scapuJ a. S8
Thus there js a 2:1 ratio of scapulohumeralmovcmcnt.
l nohumeraL joint, so dlC examiner must be SUfe to check
During phase 2, rhe clavicle elevates because of the scap-
ular rotation /_58 but the clavicle still does not rotate or
does so minimally. During the second and third phase)
the rotation of the scapula (total: 60) is possible because
there is 20 of motion at the acromioclavicuLar joint and
40 0 at the sternoclavicular joint.
3. During the linal 90 of motion (third phase), the 2: I
ratio of scapulohumeral movement continues, and the
angle between the scapular spi ne and the clavicle increases
an additional 100. Thus, the scapula continues to rotate
l and now begins to elevate. The amount of protraction
conti nues to be minimal when the abduction movement
is performed. It is in this stage that the clavicle rotates
posteriorly 30 to 50 on a long axis and elevates lip to
a further 15.7 Also, during this final stage, the humerus
laterally rotates 90, so that the greater tuberosity OfrJ1C
humer us avoids the aCfo mion proce.ss.
In dlC unstable shoulder, scapulohumeral rhythm is
commonJy aJtered becallse ofincorrect dynamic function-
ing of the scapular o r humeral stabi lizers or both .66 This
may be related to incorrect arthrokincOlatics at the gle-
for nOfmal joint play and the presence of hypomobilc
structures that could lead to these abnormal motions. 66
Kibler pointed out that it is important to watch the
movement especially of the scapula in both the ascend-
ing and descending phases of abduction .67 Commonly,
weakness of the scapular control muscles is morc evident
during descent, and an instability jog, hitch, or jump Illay
occur when the patient loses control of tJ1C scapula.
252 CHAPTER 5 Shoulder
The speed of abduction may also have an effect on the
ratio. 68 Therefore, it is mOTC important to look for asym -
metry between the injured and the good sides than to be
concerned with the acnlai degrees of movement occur-
ring at each joint. That being said, jfthe clavicle does not
rotate and elevate, elevation through abduction at the
glenohumerAl joint is limited to 120.58 If the glenohu -
meral joint does not move, elevation through abduction
is limited to 60) which occurs totally in the scapulotho-
racie joint. If there is no lateral rotation of the humerus
during abduction, the total movement available is 120 0 )
60 of which occurs at the glenohumeral joint and 60
of which occurs at the scapuJorhoracic articulation ? The
normal end of ROM is reached when there is contact
of a surgical neck of humerus with the acromion pro-
cess. Reverse scapulohu meral r hythm (Figure 5 -26 )
means that the scapula moves more than the humerus.
This occurs in co nditions such as frozen shoulder. The
patient appears to "luke" tht: entire shoulder complex
rather than produce a smooth coordinated abduction
movement.
Active elevation dlfOlIgh forward flexion is normally
160 to 180, and at the extreme of the ROM , the arm
is in the sa IDe position as for active elevation through
abduction. Active elevation (170 to 180) through the
plane of the scapula (30 to 45 of forward flexion ),
termed scaption, is the most nanlrai and functional
motion of elevation (see Figure 5-23). ElevatiOI\ in this
position is sometimes caBed neutral elevation. The exact
angle is determined by the contour of the chest wall on
which dle scapula rests. Often , movement into eleva-
tion is less painful in this positioll than elevation through
abduction in which the glenohumeral joint is actually in
extension, or elevation in forward flexion. Movement in
the plane of the scapula puts less stress on the capsule and
surrounding musculature and is the position in which
most of the functions of daily activity are commonly per-
formed. Strength testing in this plane also gives higher
values. Patients with weakness spontaneously choose this
plane when elevating the arm. 69 ,70 During scaption eleva-
tion, scapulohumeral rhythm is similar to that of abduc
tion although there is greater individual variability. The
three phases arc similar, but there are differences. For
example, in scapaoo elevation, there is lirtle or no lateral
rotation of the head of the humerus in the third phase. 65
Also, the total elevation in scaption is about] 70, with
scapu lar rotation being about 65 and humeral abduc-
tion abollt 105; although there is slightly more scapu
lar rotation in scaption, this difterence again may result
from individual variation. 65 More scapular protraction is
likely to occur in scaption elevation, especially in eleva-
tion through forward flexion.
Figure 5-26
Reverse scapulohumcral rhYlhm ( notice shoulder
hiking) and excessive scapular mo\'cmcnt.
Examples include frozen shoulder (A) or [e:.\T of
rorator culT (B). ( B from Benham WP, Policy
HF , SlOclllll CH et al: Pb.ysical examination
of the joimsJ p. 41 , PhiJ:ldeiphia , 1965, WB
Saunders.)

Active lateral rotation is nonnally 80 to 90 but may
be greater in some athletes such as gymnasts and baseball
pitchers. Care must be taken when applying overpressure
with this movement, because it could lead to anterior
dislocation of the glenohumeral joint, especially in those
with recurrent dislocation problems. If glenohumeral
lateral rotation is limited, the patient will compensate by
retracting the scapula.
Active medial rotation is normally 60 to 100. This is
usually assessed by measuring the height of the "hitchhik-
ing" thumb (thumb in extension ) reaching up the patient's
back. Common reference points include the greater tro-
chanter, buttock, waist. and spinous processes, with T5 to
T IO representing the normal degree ofmedia1 rotation ? l
When doing the test in this fashion, the examjner must
be aware that, in rea li ty, the range measured is not that of
the glenohumeral joint alone. lo fact, much of the range
is gained by winging the scapu.la. In the presence of tight
medial glenohumeral motion) greater winging and pro-
traction of the scapula occurs. Doing the rotation testing
in 90 abduction) if the patient can achieve this position,
will give a clearer indication of true glenohumeral joint
medial and lateral rotation. Rotation is measured when
the scapula startS to move. I f rotation is tested in 90
abduction and crepitus is present on rotation, it indicates
abrasion of torn tendon margins against the coracoacro-
mial arch and js called the " abrasion sign. " 38
I t is important to compare medial and latera1 rotation,
especially in active people who use their dominant arm at
extremes of motion and under high load situations. It is
important to note any glenohumeral internal (medial)
rotation deficit (GIRD)," which is the difference in
nledial rotation between the patient's two shoulders.
Normally, the difference should be within 20 0 . l8 This
may also be compared with the glenohumeral external
(lateral) rotation gain (GERG) . lf the GIRD/ GERG
ratio is greater than I, the patient will probably develop
shoulder problems."
Active extension is normally 50 to 60. The examiner
must ensure that the movement is in the shoulder and
not in the spine because some patients may flex the spine
or bend forward , giving the appearance of increased
shoulder extension. Simi.larly, retraction of the scapula
increases the appearance of glenohumeral extension.
Weakness of full extension commonly implies weakness
of the posterior deltoid in onc ann and is sometimes
called the swallow tail sign as both arms do not extend
the same amount either because of injury to the muscle
itself o( to the axillary nerve.72
Adduction is normally 50 to 75 if the arm is brought
tn fn.mt of the body. Horizontal adduction, or cross-
flcxion , is normally 130. To accomplish this movement,
the patient first abducts the arm to 90 and then moves the
arm across the front of the body. Horizontal abduction,
o( cross-extension, is approximately 45. After abduct-
CHAPTER 5 Shoulder 253
ing the arm to 90, the patient moves the straight arm in
a backward direction. In both cases, the examiner should
watch dle relative amOllnt of scapular movement between
the normal and pathological sides. If movement is limited
in the glenohumeral joint, greater scapular movement
occurs. Circumduction is normally approximately 200
and involves taking the arm in a circle in the verticaJ pi<UlC.
In adctition to rhe above movements, several of which
involve movement of the humerus and scapula, the
patient shou ld actively perform two distinct movements
of the scapulae: scapular retraction and scapular protrac-
tion (Figure 5-27 ). For scapular retraction, the examiner
asks the pat.ient to squeeze the shoulder blades (scapu la)
together. Normally, the medial borders of the scapula
remain parallel to the spine but Ill0VC toward the spine
with the soft tissue bunching up between the scapula (see
Figure 5-27, B). Ideally, the patient should be able to
do this movement without excessive contraction of the
upper trapezius muscles. For scapular protraction, the
patient tries to bring the shoulders together anteriorly
so the scapula move away from midline with the inferior
angle of the scapula coml11only moving laterally more
than the superior angle so some lateral rotation of the
inferior angle occurs (see Figure 5-27, C). This protrac-
tion/retraction cycle may cause a clicking or snapping
near the inferior angle or supramedial corner, which is
sometimes callcd a snapping scapula, caused by the
scapula rubbing over the underlying ribs. 4 1
Injury to the individual muscles can affect scveral move-
ments. For example, if the serratlls anterior muscle is weak.
or paralyzed, the scapula "wings" away from the dlora,x on
Figure 5-27
A, Resting position .
COl1til1ltcd
254 CHAPTER 5 Shoulder
mcnts are bothersorne. For example, Apley's scratch
test combines mediaJ rotation wjth adduction, and lat-
eral rotation with abduction (Figure 5-28 ). Tlus method
may decrease the time required to do the assessment. Tn
addition, by having the patient do the combined move-
ments, the examiner gains somc idea of the functional
capacity of the patient. For cX:,1rnple, abduction com -
bined with flexion and lateral rotation or adduction
combined with extension and medial rotation is needed
to comb the hair, to zip a back zipper~ or to reac h for
a wallet in a back pocket. However, the examiner must
take care to notice which movements are restricted and
wh.ich ones arc not, because several movements arc per-
fOfmed at thc same time . Some examiners prder doing
the same motion in both arms at the same time: neck
reach (abducrion, flex.ion , and lateral rotation at the gle-
noh umeral joint) and back reach (adduction, extension ,
and medial rotation at the glenohumeral joint). Some
believe this method makes comparison easier ( Figure
5_29). 32 Often, the dominant shoulder shows greater

Figure 5-27 conl'd

B, Scapular retraction. C, Scapular prot~ction.

its medial border. It also assists upper rotation of the scap-

ula during abduction. Injury to the muscle o r its nerve may
therefore limi t abd uction. In fact, loss or weakness of serra-
niS anterior affects all shoulder movements because scapu-
lar stabilization is IOSt. ~6 Similarly, weakness of the lower
trapezius muscle can alter scapular mechanics resulting in
anterior secondary impingement. ~1ally of the tests for
these muscles are described in the Special Tests section.
Figure 5-28
\'Vhen observing these movements, the examiner may Aplcy's scratch test. A, Tht: ri ght arm is in i:l.tcral rotation , fle xion
ask the patient to perform them in combination, espe- and abduction , and the kft arm is in medial rotatio n, extension , and
cially if the history has indicated that combined move - .l.dductio n.
 CHAPTER 5 Shoulder 255

Figure 5-28 co"I'd

B, The left arm is in lateral rotation, I1cxion and abduction , and the
right arm is in medial roeation, extension and adduction. Note the
difference in medial rotation and scapu lar winging in lhe right arm
compared to the left arm in A.

restriction than rJle nondominant shoulder, even in nor-

mal people. An exception would be patients who COI1 -
tinually use their arms at the extremes of motion (c.g.)
baseball pitchers}. Because of the extra range of motion
developed over time doing the activity, the dominant
arm may show greater range of motion. However, rhe
examiner must always be aware that shoulder move -
ments include movements of the scapula and clavicle
as well as rhe glenohumeral joint and that many of the
perceived glenohumeral joint problems arc, in reality,
scapular muscle control problems, which may second-
arily lead to glenohumeral joint problems, especially
in people lmder 40 years of age. If, in the history, the
patient has complained that shoulder movements in cer-
tain postures are painful or that sustained or repetitive
movements increase sy mptoms, the examiner should Figure 5-29
consider having the patient hold a sustained arm position A, Neck reach. B, Back reach.
(10 to 60 seconds ) or do the movements repetitively ( 10
to 20 repetitions). Ideally, these rcpeated movements
256 CHAPTER 5 Shoulder
should be performed at the speed and with the load that
the patient was using when the symptoms were elicited.
Thus, the volleyball player should do the spiking motion
in which he or she jumps up to hit the imaginary ball.
Capsular tightness, although commonly tested during
passive movement, call affect active movement by I.imit-
ing some or all movements in the glenohumeral joint with
compensating excessive movement of th e scapula. Just
as a frozen shoulder can affect all movements, selected
ti ghtness due to particular pathologies may affect only
part of the capsule. For example, with anterior shoulder
instability, posterior capsular tightness is a coml11on find
ing combined with weak lower trape zius and serratus
anterior muscles. Table 5-8 shows common selected cap-
sular ti g htness and states their effect 00 movement.
Likewise, Illuscle tightness can affect both active and
passive movement. For example, with anterior shoulder
instability, the following muscles may be found
tight: subscapularis, pectoralis minor and major, latis~
simus dorsi , upper trapezius, levator scapulae, sterno
c1eidomastoid. scalenes, and rectus capitlls. Weak muscles
include serratus anterior, middle and lower trapezius,
infraspinatus, teres minor, posterior deltoid, rhomboids,
longus colli , and longus capinls.'Il
The biceps tendon does not move in the bicipital
groove during movement~ rather, the humerus moves
over the fi.:'\cd tend o n. From adducti o n to full elevation
of abduction , a given point in th e groove moves along
the tendon at least 4 cm. If the examiner wants to keep
excursion of the bicipital groove along the biceps ten ~
don to a minimum , d1e arm should be elevated \vith the
humerus in medial rotation; elevating the arm with the
humerus laterally rotated causes maximuill excursion of
the bicipital groove along the biceps tendon . Patients
who have deltoid Of supraspinatus pathology sometimes
usc this laterally rotated position because lateral ro tation
allows th e biceps tendon to be used as a shoulder abduc ~
tor in a " cheating" movement.
Humeral Movement Faults
Superior humeral translation: Scapular downward rotators are
predominating
Anterior humeral translation: Weak subscapularis and teres major;
tight infraspinatus, teres minor
As the patient does the various movements, dle
examiner watches to sec wheth er d1C components of the
shouJdcr complex move in normal, coordinated sequence
and whether the patient exhibits any apprehension when
doing a movement. With anterior instability of dlC
shoulder, the shoulder girdle orren droops, and excessive
scapulothoracic movement may OCCUf on abduction. With
posterior instability, horizontal adduction (cross-Aex-
ion) may cause excessive scapulothoracic movem.ent. An y
apprehensio n on movement suggests the possibiljty of
instability. The examiner should also watch for winging of
the scapula on active movements. Wjnging of the medial
border of the scapula indicates injury to the serratus ante ~
rior muscle or the long d10racic nerve; rotary winging
of the scapula or scapular tilt indicates upper trapezius
pathology o r injury to the spinal accessory nerve (cranial
nerve XI ; Table 5_9 )36.71 ,,, Scapular tilt (interior angle of
to be scapula moves away from rib cage) may also be caused by
weak lower trapezius or a tight pectoralis minor. In some
cases, it may be necessary to load the appropriate muscle
isometrically (hold d1C contraction for 10 to 15 seconds)
to demonstrate abnormal scapular stability. It has been
reported that application of a resistance to adduction at
30 and at 60 of shoulder abduction is the best way to
show scapular winging ?l Eccentric loading of the shoul-
der in different positions, especially into hOl;zontal adduc-
tion , may also demonstrate winging or loss of scapular
contro l. 'eakness of the scapular control muscles often
leads to overactivity of the rotator cuff and biceps muscle
leading to overuse pathology in those structures.
Causes of Scapular Imbalance Patterns
Increased protraction: Tight pectoraliS minor
Weakllengthened lower trapezius
Weakllengthened serratus anterior
Increased depression: Weak upper trapezius
Loss of scapular stabilization: Early/excessive protraction
Early/excessive lateral rotation of
scapula
Early/excessive elevation of scapula
Tight lateral rotators
Secondary impingement

Inferior humeral translation:
Decreased lateral rotation:
Excessive scapular retraction
during lateral rotation:
Weak upward scapular rotators;
poor glenohumeral rotation timing
Short pectoralis major and/or
latissimus dorsi
Tight anterior capsule; tight medial
rotators; poor scapulothoracic
muscle control
Indications of Loss of Scapular Control
Scapula protracting along chest wall, espeCially under load
Early contraction of upper trapezius on abduction, especially under
load
Increased work of rotator cuff and biceps, especially with closed
chain activity (reverse origin-insertion)
Altered scapulohumeral rhythm
 CHAPTER 5 Shoulder 257

Table 58
Capsular Tightness: Its Effect and Resulting Humeral Head Translation
Where Effect (Signs and Symptoms) Resulting Translation

Posterio r Cross flexion decreased Anterior (with medical rotation)

Medidl rotation decreased
Flexion (e nd range ) decreased
Decreased posterior glide
Im pingement signs in medial roration
Weak external rotato rs
'Weak scapular stabili zers
Pos[c roinferior Elevation anteriorly Superior
Medial comtion of elevated arm decreased Amerosupcrior
Horizonta l add uctio n decreased Anterosupcrior
Posterosuperio r Medial rot:l. tion limited Anterosuperior
Anterosllpcrior Flexion (e nd ran ge) dec reased Posterior (wit h latem l rotation )
Extension (end range) decreased
Lateral rota tion decreased
Horizontal eX le nsion decreased
Abdu ction. (e nd range) decreased
Decreased posreroinferior glide
Impingement in medial [marion and cross flexion
In creased nigh t pain
Weak rotator cuff
May have positive U LTT
Bi ce ps tests may be positive
Antcroinfcrior Abduction decreased Poste rior (with lateral rotatio n of
Extension decreased elevated ann)
Lateral rotation decreased
H o ri zontal extension decreased
Increased posterior gl ide

Darn from Matsen FA ct al: PractICe eJ'lf/mrtt(m and ma1/lJgemmt of the sboulder, Philadelphia, 1994 , \VB Saunders.

Table 59
Scapular Winging Faults
Winging of the Scapula: Dynamic Causes and Effects
On concentric elevation: Long/weak serratus anterior Cause Effect (Signs and Sym.ptoms)
On eccentric forward flexion: Overactive rotator cuff; underactive
Trapezius o r spinal Inabilhy ro shrug shoulder
scapular control muscles
accessory nerve lesion
Tilting of inferior angle: Tight pectoralis minor; weak lower Serratus anterior or long Difficul lY elevating arm above 1200
trapezius t.horacic nerve lesion
Strain of rho m boids Difficulty pushing elbow back. against
resistance (widl hand on hip)
Muscle imbalance or Winging of upper margin of
contractu res scapula o n adduction and lateral
If the scapula appea rs to wing, the examiner asks the
rotation
patient to forward tlex the shoulder to 90. The examiner
then pushes the straight arm toward the patient's body
while the patient resists. If there is weakness of th e upper
or lower trapezius muscle) the serrams anterior mlLscle, or
the nerves s uppl)~ n g these muscles, their inability to con ~ asking the patient to do a floor pushup may dcmo nstrate
tract will cause the scapula to wing. Another way to test this winging (Fig ure 5 30 , B). T he patient should be
winging of the scapula is to have the patient stand and lcan tested in a rel axed starting position and be asked to do
against the wall. The examiner then asks the patient to do the pushup . Sometimes th e winging is visible at rest o nly
a pushup away from the wall while the examiner watc hes (static winging), sometimes during rest and activity) and
for winging (see Figure 5-18; Figure 5 30 , A). Similarly, sometimes o nly with the activity (dynamic wi nging).
258 CHAPTER 5 Shoulder
only the infraspi.natus, depending on where the pathology
lies (see Figure 5- \36), whereas injury to the musculocu-
taneous nerve can lead to paraJysis of the coracobrachja v

lis, biceps, and brachialis muscles. These changes affect

elbow flexion and supination and forward flexion of the
shoulder. There is also a loss of the biceps reflex. Injury
to the axillary (circumflex) nerve leads to paralysis of the
deltoid and teres minor muscles, affecting abduction and
lateral rotation of the shoulder. There is also a sensory
loss over the deltoid insertion area. Damage to the radial
nerve affects aU of the extensor muscles ofrhe upper limb,
including the triceps. Triceps paralysis Olay be overlooked
when examining the shoulder unless arm extension is
attempted along with elbow extension against gravity.
Both of these movements are affected in high radial nerve
palsy, although some uiceps function may remain ( e.g.~ in
radial nerve palsy after a humeral shaft fracture ).

Figure 530
Scapular winging is demonstrated by having (he patient push against
a wall (unilateral weakness) (A) or the floor ( bilatt"I<11 weakness)
(B) with bocll arms forward flexed to 90, (A from McClusky e M :
Classification and diagnosis of glcnohulllt'(al instability in athletes,
Sports Med A rtbro Rel' 8:163,2000.)
Passive Movements
If the ROM is not full during the active movements a.nd
the examiner is unable to test the end fcel , the examiner
should perform all passive movements of the shoulder
to determjne the end feel , and any restriction should
be noted. Such testing would show the presence of a
capsular pattern.

Passive Movements of the Shoulder Complex and

Injury to other nerves in the shoulder region must not
be overlooked (Table 5- 10). As previously mentioned,
damage to the suprascapular nerve may affect both the
supraspinatus and infraspinatlls muscles or it may affect
Table 510
Signs and Symptoms of Possible Peripheral Nerve
Involvement
Spinal accessory nerve Inability to abduct ann beyond 90
Pain in shoulder on abduction
Long thoracic nerve Pain on flexing fully extended arm
lnabjljty to flex fully extended arm
Winging startS at 90 forward
flexion
Suprascapular nerve Increased pain on forward shoulder
flexion
Shoulder weakness (partial Joss of
humeral control )
Pain increases with scapular abduction
Pain increases with cervical rotation
to opposite side
Axillary (circumflex) Inabilityto abductarm with neutral
nerve rotation
Musculocutaneous Weak elbow flexion wirh forearm
nerve supinated
Normal End Feel
Elevation through forward flexion of the arm (tissue stretch)
Elevation through abduction of the arm (bone-to-bone or tissue
stretch)
Elevation through abduction of the glenohumeral joint only (bone-
to-bone or tissue stretch)
Lateral rotation of the arm (tissue stretch)
Medial rotation of the arm (tissue stretch)
Extension of the arm (tissue stretch)
Adduction of the arm (tissue approximation)
Horizontal adduction (tissue stretch or approximation) and abduc-
tion of the arm (tissue stretch)
Quadrant test
The end feel of capsular tightness is different from
the tissue stretch end feel oflllllscle tightness. 74 Capsular
tightness has a more hard elastic feel to it, and it UStl v
ally occurs earlier in the ROM. If one is unsure of the
end feei , the examiner can ask the patient to contract the
muscles acting in the opposite direction 10% to 20% of
lnaxil1111rn voluntary contraction (MVC) and then relax.
The examiner then attempts to move the limb further
into range. If the range increases, the problem was mu s~
cular not capsular.

If the problem is capsular, capsula r tightness should
be measured. To measure postedor capsular tightness,
the patient, suitably undressed (no shirt for males; bra
for females), is placed in the side lying position with
the tcst arm uppermost (the normal side is tested first)
abour 6 inches ( 15 Cln) from the edge of the examining
table." The patient's hips and knees are Hexed for sta-
bility. Both acromion processes should be perpendicular
to the examining table, with the spine in neutral. The
examiner stands in front of the patient and holds the
patient's arm above rhe epicondyles of the elbow. The
patient's ar m is abducted to 90 with one hand while
maintaining tht! shoulder in nelltral rotation. With the
other hand , the examiner stabilizes the lateral border
of the scapu la in the retracred position (Figure 5-31 ).
\.rVhilc the scapula r position is maintained , the examiner
carefully horizontally adducts the arm until the move-
ment ceases, the scapula begins to move, or rotation of
the humerus occurs. The angle from the vertical to the
arm indicates the passive ROM avai lable . If the patho-
logical side has less ROM and the end teel is capsular,
capsular tightness is present. This capsular tightness
should correlate well with decreased medial rotation
provided the scapula is not allowed to move in COJ1l -
pensation. 75 ,76
Figure 5-31
Testing for posterior capsular tiglnllCS>. A, Starting position for rhe posterior shoulder flcxibility measurcment
with the subject positioned correnly on his side. B, Maximum passive ROM of the pOSTerior shoulder tissuc:t.
Note the scapular stabilization with the ton.o pt'fpcndicular to the examining table. As soon as the scapula
begins to move , the cx.uniner stops .
CHAPTER 5 Shoulder 259
Particular attention must be paid to passive medial and
lateral rotation if the exanlincr suspects a problem with the
glenohumeral joint capsule, Excessive scapular movement
may be seen as compensation for a tight gle nohumeral
joint. Subcoracoid bursitis may li mit fuU lateral rota-
tion, and subacromial bursitis may limit fu JI abduction
because of compression or pinching of these structu res.
If lateral rotation of the shoulder is limited, the examiner
should check forearm supination with the arm forward
flexed to 90. Patients who have a posterior dislocation at
the glenohumeral joint exhibit restricted lateral rotation
of the shoulder and limited supination in forward flex -
ion (Rowe sigo).n Even if overpressu re has been applied
on active movement, it is still necessary for the exami ner
to perform elevation through abduction of the glenohu-
meral joint only (Figure 5-32) and the quadrant test.
The examiner performs passive elevation through
abduction or scaption of the glenohumeral joint with
the clavicle and scapu la fixed to determine the amount
of abduction in the glenohumeral joint alone. This can
gjve an indication of capsubr tightness or subacromial
space pathology.32 Normally, this movement should bc
up to 120, although Gagey and Gagey7S have stated that
anything greater than 105 indicates laxity in the inferior
glenohumeral ligament.
260 CHAPTER 5 Shoulder

Figure 5-32
Passive abd uction of the glenohurl1eral joint.

The rotation of the humerus in the quadrant posi -

tion demonstrates Cod ma n's "pivotal paradox,,70.79
and MacConaiU's80 conjunct rotation (rotati o n th at
automatically or subconsciously occurs with movement)
in diadochal movement (a sllccession of two or morc
disti nct movements). For example, if the arm, with the
elbow flexed , is laterally rotated when the arm is at the
side and then abducted in the coronal plane to 180 0 , the
sho ulder will be in 90 of medial rotation even though no
apparent rotation has occurred. The path traced by the
humerus during the quadrant test, in which the humerus
moves forward at appro.xjmarely 120 0 of abduction, is
the unconsciolls (o tation occurring at the glenohumeral
jo int. Thus, the quadrant test is desi g ned to demonstrate
whether the automatic or subconscious rotation is occur-
ring during movement. The examiner sho uld not only Figure 5-33
Quadrant position . A, Adduction tcst. B, Abduction test (locked
feel the movement bur also deter mine the quality of the
quadrant ).
move ment and the amount of anterior humeral move-
men t. This test and the following locked quadrant test
assess one arca or quadraJlt of the 200 0 of circumduc-
rjOI1. It is d1e quadrant of the circumduction movement the position , the uppa limb is elevated to rest alongside
in which the humerus must rotate to allow nlll pain-free the patient's head with the shoulder laterally rotated. The
movement. Althoug h both of these tests sho uld normally patient's shoulder is then adducted. Because adduction
be pain free , the examiner should be aware that they place occ urs on the coro nal pla.ne) a point (the quadrant posi-
a high level of stress on the soft [issues of the glenohu- tion) is reached at which the arm moves forward slightly
meral joint, and discomfort should nOt be misinterpreted from the coronal plane. At approximately 60 0 of adduc-
as pathological pain. Ifmovement is painful and restricted, tion (frolll the ann beside the head ), this position of
th e tests indicate early stages of shoulder pathology." maximum forward movement occurs (i.e. ) at about 120 0
To test the q uadran t position,1:I 2.83 the examiner stabi- of abduction ) eve n if a backward press ure is applied. As
lizes the scapula and clavicle by placing the forearm under the shoulder is fi..lrther adducted, the ann falls back to the
the patient's scapula o n the side to be tested and extending previous coro nal plane. The quadrant positio n indicates
dlC hand ovcr the shoulder to ho ld the trapezius muscle the position at which the arm has med.ially rotated during
and prevent shoulder shrugging (Fig ure 5-33 ). To test its descent to the pa tient's side.
262 CHAPTER 5 Shoulder
Table 5-11
Muscles about the Shoulder: Their Actions, Nerve Supply, and Nerve Root Derivation
Nerve Root Derivation
Action Muscles Acting Nerve Supply Retraction

Forward flexion l. Deltoid (a nterior fibers ) Axillary (circumflex) CS-C6 (posterior cord)
2. Pector:tlis majo r (clavicular fibers ) Lateral pectoral C5-C6 (lateral cord )
3. Coracobrachialis Musculocutaneous C5-C7 (lateral cord )
4. Biceps (when strong contraction M uscuioclitaneous C5-C7 (lateral cord)
requi red)
Extension l. Deltoid (posterior fibers ) Axillar), (circumflex ) C5-C6 (posterior co rd )
2. Teres major Subscapular C5-C6 (posterior cord)
3. Teres minor A.xiUary (circumflex ) C5-C6 (posterior cord)
4. Latissimus dorsi Thoracodorsal C6-CS (posterior cord)
S. Pectoralis major (sternocostal fibers ) Lateral pectoral C5-C6 (lateral cord)
Medial pectoral C8 , Tl (medial cord)
6. Triceps (long head ) Radial C5-C8, Tl (posterior cord)
Horizontal adduction I. Pectoralis major L.1reral pectoral C5- C6 (lateral cord )
2. Deltoid (anterior tibers) Axillary (circumflex) C5- C6 (postctior cord )
Horizontal abduction J. Deltoid (poste rior fibers ) Axillary (circumflex ) CS- C6 (poste rior cord)
2. Teres major Subsca pular C5- C6 (posterior cord )
3. Teres minor Axillary (circumflex) CS- C6 (brachial plexus trunk)
4. Infraspinatu s Suprascapu lar CS- C6 ( brachial pkxus trunk )
Abduction J. Deltoid Axillary (circumt1ex ) CS- C6 (posterior cord )
2. Supraspinatus Suprascapular C5-C6 ( brachial plexus t runk )
3. In rraspinatus Suprascapular CS-C6 (brachial plexus trunk )
4. Subscapularis Subscapular CS- C6 ( posterior cord)
S. Teres minor Axillary (circumtlex ) CS-C6 (posterior cord)
6. Long head of biceps (if ann laterally Musc uloclItaneous C5- C7 (lateral cord )
rotated tirst, trick movement )
Adduction J. Pec toralis major Lateral pectoral C5-C6 (lateral cord )
2. L.Dssimlis dorsi Thoracodorsal C6-C8 (posterior cord )
3. Teres major Subscap ul ar CS- C6 ( posterior cord )
4. Subscapuktris Subscap ular CS-C6 (posterior cord)
Medial roratio n I. Pectoralis major Latera l pectoral C5-C6 (lateral cord )
2. Deltoid (anterior fibers ) Axi llar y (c ircumflex ) C5-C6 (postelior cord)
3. Latissimus dorsi Thor-.1codorsai C6-C8 (posterior cord)
4. Teres major Subscap ular CS-C6 (posterior cord)
5. Subscapularis (when arm is by side ) Subscap ular C5-C6 (postelior cord )
Lateral rotation I. Infraspinatus Suprascapular C5-C6 (brachial plexus trunk )
2. Deltoid (posterior fibers ) Axillary (c ircumflex ) CS- C6 ( posterior cord )
3. Teres minor A-..:illary (ci rcumflex ) CS- C6 (posterior cord )
Elevation of scapula I. Trapezius ( upper fibers ) Accessory C ranial nerve XI
C3-C4 nerve roots C3-C4
2. Levator scapulae C3-C4 nerve roots C3-C4
Dorsal scapu lar C5
3. Rhomboid major Dorsal scapular (C4), C5
4. Rhomboid minor Dorsal scapular (C4 ),CS
Depression of scapu la I. Serratus anterior LOllg thoracic C5-C6, (C7)
2. PectOralis major Lateral pectoral C5-C6 (late ral cord )
3. Pectoralis minor Medial pectoral C8, 1'1 ( medial cord)
4. Latissimus dorsi Thoracodorsal C6-C8 (posterior cord)
5. Trapezius (lower fibers) Accessory Cranial nerve Xl
C3- C4 nerve roots C3- C4
Protraction (forw;l rd 1. Serratus anterior Long rhoracic CS-C6, (C7)
movement ) of scapula 2. Pectoralis major Larentl pectoral CS-C6 (lateral co rd )
3. Pectoralis minor Medial pectoral C8 , T1 ( medial cord)
4. Latissimus dorsi ~1hOf<\codorsal C6-C8 (poste,rior cord)
 CHAPTER 5 Shoulder 263

Table 5-11-Cont'd
Nerve Root Derivation
Action Muscles Acting Nerve Supply Retraction

Retraction (backward 1. Trapezius Accessory Cranial nerve XI

move ment ) o f scapula 2. Rh omboid major Dorsal scapu lar (C4 ), C5
3. Rhomboid minor Dorsa l scapu lar (C4), CS
Lateral (upwatd) ]. Trapezius (upper and lower fibers ) Accessory Cranial ne rve XI
rotation of inferior C3-C4 nerve roots C3-C4
angle of scapula 2. Serratus anterior Long thoracic CS- C6, (C7)
Media] (downward) 1. Levator scapulae C 3-C4 nerve roots C3--C4
rotation of infe rior 2. Rhomboid major Dorsal scapu lar CS
angle of scapula 3. Rhomboid minor Dorsal scapubr (C4 ), CS
4. Pectoralis minor Dorsal scapular (C4 ), C5
Medial pectoral C8, TI (media l cord )
Flexion of elbow I. Brachialis Mlt sculocutancoll s C5--C6, (C7)
2. Bi ceps brachij Mu sculocutaneous C5--C5
3. Brachiorad iali s Radial CS- C6, (C7 )
4. Pro nator teres M edian C6-C7
5. Flexor carpi ulnaris Ulnar C7- C8
Extension of elbow I. Triceps R.1diaJ C6-C8
2. An conells Radial C7-C8, (TI )

kinetic chain. Assessment of function plays an important

Relative Isometric Muscle Strengths
Abduction should be 50% to 70% of adduction
Forward flexion should be 50% to 60% of adduction
Medial rotation should be 45% to 50% of adduction
Lateral rotation should be 65% to 70% of medial rotation
Forward flexion should be 50% to 60% of extension
Horizontal adduction should be 70% to 80% of horizontal abduction
Functional Assessment
The shoulder complex plays an integral role in the activi ~
ties of daily living, sometimes acting as part of an open
kinetic chain and sometimes acting as part of a closed
part of the shoulder evaluation. 84 Limitation of function
can g reatly affect the patient. For example, placing the
hand behind the bead (e.g., to comb the hair ) requires full
lateral rotation, whereas placing the hand in the smaJi of
the back (e.g., to get a wallet out of a back pocket or undo
a bra) requires fiJllmcdial rotation. Matsen and colleagues
have listed tllC nmctional R01\1 necessary to do some of
the fu nctional activities of dail y livin g" (Table 5-12 ).
The functionaJ assessmcn t may be based on activities
of daiJy living, work, or recreatio n , because these activi -
ties arc of most concern to the patient ( Figure 5_3685,86
or it may be based o n numerical scoring charts ( Figures
5 -37 to 5-40 arc exampics), which are derived from clinical
measures as we ll as functional measures. Sorne numerical

Figure 5-35
Rupture of the long head of the biceps brachii ,,\Used
by the patient 's awkward carch of pan ncr in gymnastics.
Bun ching of muscle is artended by comple te loss of
fllnction of the long ht:ad. (From O ' Donoghue DH :
Treatmtmt ojinjlfrics to atbletes, ed 4, p 53, Philaddph ia,
1984, WB Saunders.)
 Table 512
Range of Motion Necessary at the Shoulder to Do Certain Activities of Daily Living
Activity Range of Motion Activity Range of Motion

Eating 70 0 _ 100 0 ho ri zontal adducrion Hand behind head 100_ 15 hori zon tal add uction*
45-60 :tbd uctio n 110_ 125 torward flexion
Combing hair 30_70 ho ri zonta l adduction * 90 lateral rotation
105_ 120 abduction Put someth ing on shelf 70 0 - 80 0 hori zontal adduction
90 lateral roration 70_80 forward tlexio n
Reach perineum 75-90 horizontal abduction 45 lateral rotation
30-45 abduction ,"Vash o pposire shoulder 60-90 forward flexion
90+ medial rotation 60-120 horizontal addllction *
Tuck in shirt 50-60 horizontal abduction
55_65 abduction
90 medial rotation

Adapted from Matsen FA ct al : Pmcttcn! el'a'lfnttol~ a1ut IIIrl1lngemem oltl)e shoulder, pp. 2 0, 24, Phibddphla, 1994, \VB Saunders.
-Horizontal adduction is from 0 to 90 ofabducrion.

Please indicate with an "X" how otten you performed each activity in your healthiest
and most active state, in the past year.

Never or less than Once a I Once a More than

Daily
once a month month week once a week
Carrying objects 8 pounds or
heavier by hand (such as a bag
of groceries)

Handling objects overhead

Weight lifting or weight training

with arms

Swinging motion (as in hitting a

tennis ball, golf ball, baseball,
or similar object)

lifting objects 25 pounds or

heavier (such as 3 gallons of
waler) NOT INCLUDING
WEIGHT LIFTING

For each of the following questions, please circle the letter that best describes your
participation in that particular activity.

1) Do you participate in contact sports (such as , but not limited to, American football ,
rugby, soccer, basketball, wrestling, boxing , lacrosse, martial arts, etc)?

A No
8 Yes, without organized officiating
C Yes, with organized officiating
o Yes, at a professional level (i.e. , paid to play)

2) 00 you participate in sports that involve hard overhand throwing (such as baseball,
cricket , or quarterback in American football), overhead serving (such as tennis or
Figure 5-36
volleyball), or lap/distance swimming?
Shoulder activi ty scak. Ir includes
A No five numerically scored items and two
alpha scored items. (From Brophy
8 Yes, without organized officiating RH er al : Measurement of shoulder
C Yes, with organized officiating activity level, C/j" Orthop R dat Res
o Yes, at a professional level (I.e., paid to play) 439,]05,2005. )
 Athletic Shoulder Outcome Rating Scale
Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Age _ _ _ _ _ _ Sex _ _ _ _ __

Dominant Hand (R) _ _ (L) _ _ (Ambidextrous) _ _

Date of Exam ination _ _ _ _ _ _ _ _ _ _ _ _ __ Position Played _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Su~eon------------------ Years Played _ _ _ _ _ _ _ _ _ _ _ _ _ __

Type of Sport _ _ _ _ _ _ _ _ _ __ _ _ __ Prior Injury _ _ _ _ _ _ _ _ _ _ _ _ _ __ __

Activity Level Diagnosis

1) Professional (major league) 1) Anterior instability 7) Acromioclavicular arthrosis
2) Professional (minor league) 2) Posterior instability 8) Rotator cuff repair (partial)
3) College 3) Multidirectional instability 9) Rotator cuff tear (complete)
4) High school 4) Recurrent dislocations 10) Biceps tendon rupture
5) Recreational (full lime) 5) Impingement syndrome 11) Calcific tendinitis
6) Recreational (occasionally) 6) Acromioclavicular separation 12) Fracture

Subjective (90 Points)

I. Pain Points IV. Intensity Points
No pain with competition 10 Preinjury versus postinjury hours of 10
Pain after competing only 8 competition (100%)
Pain while competing 6 Preinjury versus postinjury hours of 8
Pain preventing competing 4 competition (less than 75%)
Pain with ADLs 2 Preinjury versus postinjury hours of 6
Pain at rest 0 competition (less than 50%)
II. St rength/Endurance Preinjury versus postinjury hours of 4
competition (less than 25%)
No weakness, normal competition fatigue 10 Preinjury and postinjury hours of ADLs 2
Weakness after competition, early 8 (100%)
competition fatigue Preinjury and postinjury hours of ADLs o
Weakness during competition , abnormal 6 (less than 50%)
competition fatigue
Weakness or fatigue preventing 4 V. Performance
competition At the same level, same proficiency 50
Weakness or fatigue with ADLs 2 At the same level , decreased proficiency 40
Weakness or fatigue preventing ADLs 0 At the same level , decreased proficiency , 30
tit. Stability not acceptable to athlete
Decreased level with acceptable 20
No looseness during competition 10 proficiency at that level
Recurrent subluxations while competing 8 Decreased level, unacceptable 10
Dead-arm syndrome while competing 6 proficiency
Recurrent subluxations prevent competition 4 Cannot compete, had to switch sport o
Recurrent subluxations during ADLs 2
Dislocation 0

Objective (1 0 Points)
Range of Motion Points
Normal external rotation at 90 - 90 position ; normal elevation
0 0
10
Less than 50 loss of external rotation; normal elevation 8
Less than 100 loss of external rotation ; normal elevation 6
Less than 150 loss of external rotation ; normal elevation 4
Less than 20 0 loss of external rotalion; normal elevation 2
Greater than 20 0 loss of external rotation , or any loss of elevation 0

Overall Results
Excellent: 90-'00 points
Good: 70-89 points
Fair: 50- 69 points
Poor: Less than 50 points

Figure 5-37
Arhletic shoulder ourcome rarin g selic. (From Tibone JE, Bradley JP: EV31uation ofrreatl1lellt OlllCOmes for
the athlete's shoulder. In Matsen j=A, Fu FH , H;\wkins RJ. edirors: 17Je sh01tldcr: fl bala1lce oImobility and
stability, pp. 526-527, Rose mont, tIl , 1993, American Academy of Orthopedic Surgeons. )
266 CHAPTER5 Shoulder
evaluation scales are designed for specific populations,
such as athletes (see Figure 5-37), or specific injuries, such
as instability (see Figures 5 -38 and 5-40). Other shoulder
rating scales are also available. 87-95 When lLsing numerical
scoring charts, the examiner should not place total reli -
ance on the scores, because most of these charts are based
primarily on the examiner's clinical measures and not
the patient's subjective functional, hoped-for outcome,
which is the patient's primary concern. 96 ,97 Probably the
most functional numerical shoulder tests from a patient's
perspective are the simple sh o ulder test (Figure 5-41)
developed by Lippitt, Matsen, and associates/8 ,98 the
Disabilities o f the Arm , Sho ulder and Hand (D ASH)
Test by Hudak et a1 99 (Figure 5 -42), and the Penn
Shoulder Scor e by Leggin et al. 'oo ,101 Table 5-13 provides
the exam.iner with a method of determining the patient's
functional shoulder strength and endurance. This table
is based on the general population and would not indi-
cate a true functional reading of athletes or persons ,vho
do heavy work involving the shoulders. For athletes or
those applying significant load to their shoulders while
forward flexed, the one-arnl hop test has been developed
(Figure 5-43 ). To do this test, the patient assumes the
pushup position, balancing on one arm. The patient then
hops up onto aID-cOl (4 -inch) step and then back to the
floor. The hop is repeated five times and the time noted.
The patient starts with the good arm and then uses the
injured arm, and the two times are compared. Provided
the patient is trained, completing th is action in less than
10 seconds is considered normal. 102
Burkhart et a1. felt it was important to test core stability
(i.e., testing kinetic chain function ) and flexibility when
assessing the shoulder to ensure the proper transfer of
forces fiom the legs to the trunk and the shoulder as part

Walch-Duplay Rating Sheet for Anteri or Instability of the Shoulder

Family Name: _ _ _ _ _ _ _ _ _ _ _ First name: _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ _ _ _ __ _

Sport
(1) Type of Sport Practiced
C = competition
L = leisure (spare time)
N = not practicing a sport

(2) Type of Sport

o= no sport

1 = risk free athletics, rowing, fencing, swimming, breaststroke, underwater diving, voluntary gymnastics,
cross-country skiing, shooting, sailing.

2 = with contact martial arts, cycting, motorcycling or biking, scrambling , soccer, rugby, waterskiing, downhill
skiing, parachute jumping, horse riding.

3 = with cocking climbing, weight lifting, shot-putting, swimming overarm and buttertly, pole vaulting, figure
of the arm skating, canoeing, golf, hockey, tennis, baseball.

4 = with blocked basketball, handball, volleyball , hang gliding, kayaking, water polo , javelin throwing, judo, karate,
cocking or wrestling, sky diving, wind surfing, diving, ice hockey, acrobatics, gymnastics (floor, using
"high risk" apparatus).

(3) Side

D = dominant
d = nondominant

(4) FunctIonal Score of the Shoulder (100 points) with respect to

resuming sport 25 points

stability 25 points
pain 25 points
mobility 25 points

Figure 5-38
Walch-Duplay rating sheet for anterior instability of the shoulder. (From Walch G: Dire~tionsfor the lise of.the
quotation of anterior instabilities of the shoulder, Abstracts of the First Open Congress ot the European Socl\~ty
of Surgery of the Shoulder and Elbow, pp. 51-55, 1987, Paris. )
 CHAPTER 5 Shoulder 267

Walch.Duplay Rating Sheet for Anterior Instability of the Shoulder

Daily Activity

Return to the same level in the same sport + 25 points

No discomfort
Decrease of level in the same sport practiced + 15 points
Slight discomfort in forceful movements
Change in sport + 10 points
Slight discomfort during simple movements
Decrease of level and change, or stop sport a points
Severe discomfort

Stability

No apprehension + 25 points
Persistent apprehension +15 points
Feeling of instability o points
True recurrence - 25 points

Pa in

No pain or pain during certain climatic conditions + 25 points

Pain during forceful movements or when tired + 15 points
Pain during daily life o points
Mobility

Pure frontal abduction against a walt: symmetric + 25 points

Internal rotation (IR) limited to less than three vertebrae
External rotation (ER) at 90 0 abduction limited to less than
10% of the opposite side

Pure fron tal abduction against a wall < 1500 + 15 points

IR: limited to less than three vertebrae
ER: limited to less than 30% of the opposite side

Pure frontal abduction against a wall < 1200 +5 points

IR: limited to less than six vertebrae
ER : limited to less than 50% of the opposite side

Pure frontal abduction against a wall < 90" o points

IR: limited to more than six vertebrae
ER : limited to more than 50% of the opposite side
Total points _ _

Overall Functional Result

Excellent: 91 to 100 points

Good: 76 to 90 points
Medium: 51 to 75 points
Poor: 50 points or less

* Criterion If the patient did not participate in sports before the operation

Figure 5-38 cont'd

268 CHAPTER 5 Shoulder

American Shoulder and Elbow Surgeons' Shoulder Evaluation Form

Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Hosp # _ _ _ _ _ _ Date _ _ _ _ _ _ Shou lder: R I L

I. Pai n : (5 = none , 4 = slight, 3 = after unusual activity, 2 = moderate, 1 = marked, 0 = complete disability, NA = not
available) _ _

II. Motion:

A. Patient Sitting
1. Active lotal elevation of arm: ___ degrees
2. Passive internal rotation :
(Circle segment of posterior anatomy reached by thumb)
(Note if reach restricted by limited elbow flexion)

1 = Less than trochanter 5 ~ L5 9 ~ 11 13 = T9 17 = T5

2 = Trochanter 6 ~ L4 to ~ T12 14 = T8 18 = T4
3 = Gluteal 7 ~ L3 11 ~ T11 15 = T7 19 = T3
4 = Sacrum 8 ~ l2 12 ~ T10 16 = T6 20 = T2
21 = T1

3. Active external rotation with arm at side: ___ degrees

4. Active external rotation at 90" abduction : ___ degrees

(Enter " NA" if cannot achieve 90 of abduction)

B. Patient Supine
1. Passive total elevation of arm: _ _ degrees
2 . Passive external rotation with arm at side: ___ degrees

* Total elevation of arm measured by viewing patient from side and using goniometer to determine angle between arm
and thorax.

111. Stren gth : (5 = normal , 4 = good , 3 = fair, 2 =- poor, , = trace , 0 = paralysis)

A. Anterior deltoid _ __ C. External rotation _ __

B. Middle deltoid __ O. Internal rotation _ __

IV. Stability: (5 = normal , 4 = apprehension , 3 = rare subluxation , 2 = recurrent subluxation , 1 = recurrent dislocation,
o
= fixed dislocation , NA = not available)

A. Anterior _ _ _ 8 . Posterior _ _ _ C . Inferior _ _

V. Function : (4 = normal , 3 = mild compromise, 2 = difficulty , 1 = with aid, 0 = unable , NA = not ava ilable)

A. Use back pocket I. Sleep on affected side

B. Perineal care J. Pulling
c. Wash opposite axilla K. Use hand overhead
D. Eat with utensil L. Throwing

E. Comb hair M. Lifting

F. Use hand with arm al shoulder level N. Do usual work (specify _ _ )

G. Carry 10-15 Ib with arm al side o. Do usual sport (specify _ _ )

H. Dress

VI. Patient Res ponse: (3 = much better, 2 = better, , = same , 0 = worse , NA = nol available/applicable) _ __

Figure 5-39
American Shouldc: r and Elbow Surgeons' shoulder cvalua.tion fo rm . (Cou rtcsy of the Anu:rican ShouJder and
Elbow Surgeons.)
 CHAPTER 5 Shoulder 269

12~ltem Shoulder Instability Questionnaire

Itam Scoring Categories

1. During the last six months, how many times has your 1 Not al all in 6 months
shoulder slipped out of joint (or dislocated?) 2 1 or 2 times in 6 months
3 1 or 2 times per month
4 1 or 2 times per week
5 More often than 1 or 2 timeslweek

2. During the last three months, have you had any trouble (or 1 No trouble at all
worry) dressing because of your shoulder? 2 Slight trouble or worry
3 Moderate trouble or worry
4 Extreme difficulty
5 Imposs ible to do

3. During the last three months, how would you describe the 1 None
worst pain you have had from your shoulder? 2 Mild ache
3 Moderate
4 Severe
5 Unbearable

4. During the last three months. how much has the problem with 1 Not at all
your shou lder interfered with you r usual work (inctuding 2 Alit1lebit
school or college work, or housework)? 3 Moderately
4 Greatly
5 Totally

5. During the last three months, have you avoided any activities 1 Not at atl
due to worry about your shoulder - feared that it might slip 2 Very occasionally
out of joint? 3 Some days
4 Most days or more than one activity
5 Every day or many activities

6. During the last three months, has the problem with your 1 No, not at all
shoulder prevented you from doing things that are important 2 Very occasionally
to you? 3 Some days
4 Most days or more than one activity
5 Every day or many activities
7. During the last three months , how much has the problem with 1 Not at all
your shoulder intenered with your social life (including sexual 2 Occasionally
activity - if applicable)? 3 Some days
4 Most days
5 Every day

8. During the last four weeks, how much has the problem with 1 Not at aU
your shoulde r intene red with your sporting activities or 2 A little/occasionally
hobbies? 3 Some of the time
4 Most of the time
5 All of the time

Figure 5-40
The 12-itcm sho ulder instability qu estionnaire. (Modi fie d from Dawson J. Fitzpatrick It, Carr A: T he
assessment of shoulder im tability: the development and validation or a qll cstionna i(c, J Bone Joint SIIt:g B,.
8L422, 1999.)
Continued
Z70 CHAPTER 5 Shoulder

Item Scoring Categories

9. During the last four weeks. how often has your shoulder been 1 Never, or only if someone asks
'on your mind' - how often have you thought about it? 2 Occasionally
3 Some days
4 Most days
5 Every day

10. During the last four weeks, how much has the problem with 1 Not a! all
your shoulder interiered with your ability or willingness to lift 2 Occasionally
heavy objects? 3 Some days
4 Most days
5 Every day

11 . During the last four weeks, how would you describe the pain 1 None
which you usually had from your shoulder? 2 Very mild
3 Mitd
4 Moderate
5 Severe

12. During the last four weeks, have you avoided lying in certain 1 No nights
positions in bed at night, because of your shoulder? 2 Only 1 or 2 nights
3 Some nights
4 Most nights
5 Every night

TOTAL SCORE: - - - Maximum score: 60 Minimum score: 12

Figure 5-40 conl'd

of the kinetic chain. 20 They advocated testing o ne-legged
stance (no Trcndelenburg), one-legged sq uat (stable pel-
vis), one-legged step up and step down (stable pelvis),
normal hip medial rotation bilaterally, and stren gth of
hip abductors, trllnk flexors, and abdominal muscles.
Special Tests
SpeciaJ tests arc often lIsed in sho ulder examin ations to
confirm findings o r a tentative diagnosis. The examiner
must be proficient in those tests that he or she decides
to usc . Proficiency increases the reliability of the find-
ings) although the reliability of some of the tests has
been qucsrioncd. 103 The reliability, validity, speciticity,
and sensiti vity of some diagnostic/special rests used in
the sho ulder are Olalined in Appendix 5-1. Depending
on the history, some tests are compulsory) and others
may be llsed as confirming or excluding tests. As with
all passive tests, results are more likely to be positive in
the presence of pathology when the muscles are relaxed ,
the p<ltient is supported, and there is minimal or no
Illuscle spasm.
Instability and Pseudolaxity Impingement
Anterior shoulder pain is commonly seen in patjents
young and old complaining of shoulder pain and dysfunc-
tion . In the older patient (40-plus years old ), mechani-
cal impingement occurs because of degenerative changes
to the rotator cuff, the acro mion process, the coracoid
process, and the anterior tissues from stress overload
resulting in impingement. In this case, impingement is
the prima ry problem (thus the term primary impinge-
ment). It Illay be intrinsic because of rotator cuff degen-
eration or extrinsic because of the shape of the acromion
and degeneration of the coracoacromial ligament. 104
In the young patient ( 15 to 35 years old ), anterior
shoulder pain is primarily caused by problems with muscle
dynamics wid, an upset in th e normal force couple action
leadin g to muscle imbalance and abnormal movement
patterns at both the gle no humeral joint and the scapu-
lothoracic articulation. These altered muscle dynamics
lead to symptoms of anterior impingement (thus the
te rm secondary unpingcment). The irnpingemcnt signs
arc a second ary result of altered muscle dyn3mics in the
scapul a or gleno hllmeral joint. 104
 CHAPTER 5 Shoulder 271

Last First M.1.

Name: Date: Age:

SlreeVApt # City Stale Zip Code

Address: Occupation:
Hom, Business Relative

Phone:
Circle one Circle one

Dominant Hand: Right / Left I Ambidextrous Shoulder Evaluated: Right / Left

Answer Each Question Below by Checking "Yes" or " No" Response

Yes No

1. Is your shoulder comfortable with your arm at rest by your side?

2. Does your shoulder allow you to sleep comfortably?

3. Can you reach the small of your back to tuck in your shirt with your hand?

4. Can you place your hand behind your head with the elbow straight out to the side?

5. Can you place a coin on a shelf at the level of your shoulder without bending your elbow?

6. Can you lift one pound (a full pint container) to the level of your shoulder without bending your
elbow?

7. Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your
elbow?

8. Can you carry twenty pounds at your side with the affected extremity? o OB
9. Do you think you can toss a softball underhand ten yards with the affected extremity? o 0'
10. Do you think you can toss a softball overhand twenty yards with the affected extremity? o 010
11. Can you wash the back of your opposite shoulder with the affected extremity? o 0"
12. Would your shoulder allow you to work full-time at your regular job? o 0 12

Office Use On ly
Diagnosis: DJD RA AVN IMP RCT FS TUBS AMBRII Other: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Dx Confirmed? _ _ _ _ __ _ _ __ Pt# _ _ _ _ _ _ _ __ Physician _ _ _ _ _ _ _ _ __

SST: Initial! Pre-op J Follow-up: 6 mon 1 yr 18 mon 2 yr 3 yr 4 yr 5 yr Other: _ _ _ _ _ _ _ _ _ __

Initial SST Date: --.1--.1__ Rx: Surgery Date: --.1----.-1 __

Figur.5-41
Simple shoulder test questionnaire form. (From Lippitt S8 et al : A practical tool for evaluating function:
the simple shoulder test. In Matsen FA Ct ai, editors: The sh()ulder: a balallcc ofmobilit:y alld sta,bility, p 514,
Rosemont , Ill, 1993 , American Academy ofOnhopedic Surgeons.)
Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.
No Mild Moderate Severe
Difficulty Difficulty Difficulty Difficulty Unable
1. Open a tight or new jar. 2 3 4 5
2. Write. 2 3 4 5
3. Turn a key. 2 3 4 5
4. Prepare a meaL 2 3 4 5
5. Push open a heavy door. 2 3 4 5
6. Place an object on a shelf above your head. 2 3 4 5
7. Do heavy household chores (e.g., wash walls, wash floors). 2 3 4 5
8 . Garden or do yard work. 2 3 4 5
9. Make a bed. 1 2 3 4 5
10. Carry a shopping bag or briefcase. 1 2 3 4 5
11 . Carry a heavy object (over 10 Ibs). 2 3 4 5
12. Change a light bulb overhead. 2 3 4 5
13. Wash or blow dry your hair. 2 3 4 5
14. Wash your back. 2 3 4 5
15. Put on a pullover sweater. 2 3 4 5
16. Use a knife 10 cut food. 2 3 4 5
17. Recreational activities which require little effort (e.g ., 2 3 4 5
cardplaying, knitting , etc.).
18. Recreational activities in which you take some force or 2 3 4 5
impact through your arm , shoulder or hand (e.g ., golf,
hammering, tennis, etc.).
19. Recreational activities in which you move your arm 2 3 4 5
freely (e.g., playing frisbee, badminton, etc.).
20. Manage transportation needs (getting from one place 2 3 4 5
to another).
21 . Sexual activities. 2 3 4 5

DISABILITIES OF THE ARM, SHOULDER, AND HAND

Not at All Slightly Moderately Quite a Bit Extremely

22. During the past week, to what extent has your arm , 2 3 4 5
shoulder, or hand problem interfered with your normal
social activities with family, friend s, neighbors or
groups? (circle numben

Nol
Limited At Slightly Moderately Very
All Limited Limited Limited Unable
23. During the past week, were you limited in your work or 2 3 4 5
other regular daily activities as a result of your arm,
shoulder or hand problem? (circle number)

Please rate the severity of the following symptoms in the last week. (circle number)

None Mild Moderate Severe Extreme

24. Arm , shoulder, or hand pain. 2 3 4 5
25. Arm , shoulder, or hand pain when you performed any 2 3 4 5
specific activity.
26. Tingling (pins and needles) in your arm , shoulder, or hand. 2 3 4 5
27. Weakness in your arm, shoulder, or hand. 2 3 4 5
28. Stiffness in your arm , shoulder, or hand . 2 3 4 5

Figure 5-42
The DASH Quesri ol1l1:l ire . (From Dunon M : OJthopedi c exami1JatiolJ, evalu(ftion (fud inten't:ntiotl,
pp. 449-4 50, N ew York , 2004 , M cGraw-Hili .)
Continued
 CHAPTER 5 Shoulder 273

DISABILITIES OF THE ARM , SHOULDER , AND HAND

So Much
Difficulty
No Mild Moderate Severe That I
Difficulty Difficulty Difficulty Difficulty Can 'I Sleep

29. During the past week, how much difficulty have you 2 3 4 5
had sleeping because of the pain in you r arm , shoulder
or hand? (circle number)

Neither
Strongly Agree nor Strongly
Disagree Disagree Disagree Agree Agree
30. I feerless capable, less confident or less useful because 2 3 4 5
01 my arm, shoulder, or hand problem. (circle number)

Scoring DASH function/symptoms: Add up c ircled responses (item 1- 30); s ubtract 30 ; divide by 1.20 = DASH score.
SPORTS/PERFORMING ARTS MODULE (Optional)

The following questions relale to the impact of you r arm, shoulder, or hand problem on playing your musical instrument or sport. If you
play more than one sport or instrument (or play both) , please answer with respeclto that activity which is most important.

Please indicate the sport or instrument which is most important to you ; _ _ _ _ __ __ __

I do not playa sport or an instrument. (You may skip this section.)

Please circle the number that best describes your physical ability in the past week . Did you have any difficulty:

No Mild Moderate Severe

Difficulty Difficulty Difficulty Difficulty Unable

1. Using your usual technique for playing your instrument 2 3 4 5

or sport?
2. Playing your musical instrument or sport because of arm, 2 3 4 5
shoulder, or hand pain?
3. Playing your musical instrument or sport as well as you 2 3 4 5
would [ike?
4. Spending your usual amount of time practicing or playing 2 3 4 5
your instrument or sport?

WORK MODULE (Optional)

The following questions ask about the impact of your arm, shoulder, or hand problem on your ability to work
(including homemakers if that is your main work role)

I do not work. (You may skip this section.)

Please circle the number that best describes your physical ability in the past week. Did you have any difficulty:

No Mild Moderate Severe

Difficulty Difficulty Difficulty Difficulty Unable

1. Using your usual technique for your work? 2 3 4 5

2. Doing your usual work because of arm, shoulder, 2 3 4 5
or hand pain?
3. Doing your work as well as you would like? 2 3 4 5
4. Spending your usual amount of time doing your work? 2 3 4 5

Figure 5-42 cont'd

274 CHAPTER 5 Shoulder

Table 5-13
Functional Testing of the Shoulder
Starting Position Action FWlction Test*

Sitting Forward flex arm to 90 Lift 4 to Sib weight: Functional

Lift 1 to 31b weight: Functionally fair
Lift arm weight: Functionally poor
Cannot lift arm: Nonfunctional
Sitting Shoulder extension Lift 4 to Sib weight: Functional
Lift 1 to 31b weight: Functionally fair
Lift arm weight: Functionally poor
Cannot lift arm: Nonfunctional
Side lying (may be done in sitting Shoulder medial rotation Lift 4 to Sib weight: Functional
with pulley ) Lift J to 3tb weigbt: Functionally fair
Lift arm weight: Functionally poor
Cannot lift arm: Nonfimcrionai
Side lying (may be done in sitting Shoulder lateral rotation Lift 4 to Sib weight: Functional
with pulley) Lift 1 to 31b weight: Functionally fair
Lift arm weight: Functionally poor
Cannot lift arm: Nonfunctional
Sitting Shoulder abduction Lift 4 to Sib weight: Functional
Lift 1 to 31b weight: Functionally fair
Lift arm weight: Functionally poor
Cannot lift arm: Nonfunctional
Sitting Shoulder adduction (using wall pulley ) Lift 4 to Sib weight: Functional
Lift I to 3 Ib weight: Functionally fair
Lift arm weight: Functionally poor
Cannot lift arm: Nonfunctional
Sitting Shoulder elevation (shoulder shrug ) Five to six repetitions: Functional
Three to four repetitions: Functionally fair
One to two repetitions: Functionally poor
Zero repetition s: Nonfllllct,ional
Sitting Sitting pushup (shoulder dysfunction) Five to six repetitions: Functional
Three to four repetitions: Functionally t:1ir
One to nvo repetitions: Functionally poor
Zero repetitions: Nonfunctional

Data from Palmer ML, Epler M: Clitlical assessment procedures m physIcal therapy, pp. 68-73, Philadelphia, 1990, JB LippiJlcott.
"'Younger, more fit paricms should casily be able to do morc than the values given for these tests. A comparison between the good side and the
injured sidc gives the examiner some idea about the patient's functional strength capacity.

Figure 5-43
One-arm hop test. A, Start position. B, End position.
 CHAPTER 5 Shoulder 275

i1llpi1Jgement) , As the areas of impingement arc in dle

Special Tests Commonly Performed on the Shoulder sup raspinatlls outlet area, they are also called o utlet
im p ingement syndromes. 31
Instabitity, anterior: Load and shift test Jobe and colleagues believed that impingement and
Crank (apprehension) and relocation test instabiliry often occur together in throwing athletes and,
Instability, posterior: Load and shift test based on that assumption, developed the following clas-
Posterior apprehension test sification: 2 l ,107
Norwood test Grade r. Pure impingement with no instabi liry (often
seen in older patients)
Instability, inferior Sulcus sign
Grade JI. Secondary impingement and instability caused
(multidirectional): Feagan test
by chronic capsular and labral microrraum3
Impingement tests: Neer test Grade II 1. Secondary impingement and instability caused
Hawkins-Kennedy test by generaij zed hypc rmobility or laxity
Posterior internal impingement test Grade IV. Primary instabili ty with no impingement
Labral tesions: Clunk test (Bankart) In this classification, secondary impingement implies the
Anterior slide test (Bankart/SlAP) impinge ment occurs secondari ly and that the main prob-
Active compression test of O'Brien (SLAP) lem is instability.
Biceps tension test (SlAP) A third type of impingemcnt is termed intern al
impingem ent or nonoutlct impingement. This type of
Scapular stability tests: Lateral scapular-slide tests
impingemcnt is found posteliorly rather than anteriorly,
Wall/floor pushup
Scapular relraction test mostly in overhead athletes. Jt involves contact of the
undersurface of the rotator cuff (primarily supraspina-
Muscle tendon pathology: Speed's test tus and infraspinatus ) with the posterosuperior glenoid
Vergason's test labrum when the arm is abducted to 90 and laterall y
Empty can test rotated fully. 104,108-112
Lift-off sign
If the history indicates instabili ty, then at least one test
Lag or "spring back" tests (subscapu-
each for ante rior, posterior, and multidirectional instabil-
laris Imedia Irotation Iand infraspi na-
tusiteres minor pateral rotationn ity sho uld be performed. Also, because of the interrela-
Trapezius weakness tion of impingement and instability, tests for both should
Serratus anterior weakness be applied jf the history indicates that either condition
Pectoralis major and minor tightness may be prcsent. 113
It is important when looking at shoulder instabi lity to
Neurological involvement: Upper limb tension tests reali ze that instability includes a spectrum of conditions
Thoracic outlet syndromes: Roes test (EAST) from gross or anatomjcal instability seen with dlC TU BS
lesion to translational instability (muscle weakness) seen
with AMBIU lesions" (Table 5- 14 ). Burkhart et al . also
included pseudolaxity; 8 which includes altered gleno-
humeral arthrokinematics because of the presence of a
As secondary impingement is primarily a problem with SLAl) lesion , a tight posteroinfcrior capsule , and often
muscle dynamics, it comrnon ly presents in conjunction scapu lar d yskinesia. They felt tlle apparent increased ante-
with instability, ei ther of the scap ula or at the glenohumeral rior laxity resulted from the decreased cam effect in the
joint. A hypermobile or lax joint does not imply instabil- glenohumeral joint combined with functional lengthen-
ity. to:; L1Xity implies that there is a certain amollnt of non ing of the anteroinferior capsule and glcnohumeralliga-
pathological " looseness" in a joint so that ROM is greate r ment. 18 A posterosuperior SLAl) lesio n allows laxity on
in one or more directions and the shouJder complex fill1c - the opposite side (circle concept of instability)." With
tions normally. It is usually found bilaterally. Instability the instability tests, tlle examiner is trying to duplicate
implies the patient is unable to control or stabili ze a joint the patient'S symptoms as well as feel for abnormal move-
during motion or in a static position either because static ment. Therefore, a response of "That's what my shoulder
restraints have been injured (as wou ld be noted in an ante- feels like when it bothers mt:" is much more significant
rior dislocation with tearin g of the capsule and labrum, than the degree oflaxity or translation found. 38
also called gross or anatomical instability) or because the
muscles controlling the joint arc weak or the force couples Tests for Anterior Shoulder Instability
are unbalanced (also called translational instability).I" Load and Shift Test1 J ,lI"'. T his test is designed to
Both primary and second impingements occur anteri- check primarily atraumatic instability problems of the gle-
orly (thus the term anterior pri1'nar.yor anterior secondary nohumeral joint. The patient sits with no back support
276 CHAPTER 5 Shoulder

Table 5-14
Differential Diagnosis of Shoulder Instability (AMBRI) versus Traumatic Anterior Dislocation (TUBS)
Shoulder Instability Traumatic Anterior Dislocation

History Feeling of shoulder slippage with pain Arm elevated and laterally rotated
Feeling of insecurity when doing specific acti\~tics relative to body
No history of injury Feeling of insecurity when in specific
position (of dislocation)
Rec urrent episodes of apprehension
Observation Normal Normal (ifreduced ) (if not, loss of
rounding of deltoid caused b)' anterior
dislocatio n )
Active movement Normal ROM Apprehension and decreased ROM in
May be abnormal or painful at activity speed abduction and lateral rotation
Passive movement Normal ROM Muscle gua rdin g and decreased ROM in
Pain at extre me of ROM possi bl e apprehension position
Resisted isometric move me nt Normal in test position Pai n into abduction and lateral rotation
May be weak ill provocative position
Special tests Load and shift test is positive Apprehension positive
Augmentation positive
Relocation positive
Reflexes and curancous distributi o n Normal reflexes and sensati o n Reflexes normal
Se nsation normal, unless axillary or
musculocutaneous nerve is injured
Palpati on Normal Anterior shoulder is tender
Diagnostic imaging Norm;!.1 Normal, unless still dislocated; defect
possible

ROM - range of motion .

and with the hand of the test arm resting on the thigh.
Ideally, the patient should be sitting in a properly aligned
posture (i.e., car lobe, tip of acromion, and high point of
iliac crest in a straight line). If the patient slouches for-
ward, the scapula protracts causing the humeral head to
translate anteriorly in the glenoid and narrows the sub-
acromial space. It S For best results, the muscles about the
shoulder should be as relaxed as possible. The examiner
stands or sits slightly behind the patient and stabilizes
the shoulder with one hand over the clavicle and scapula
(Figure 5-44, A ). With the other hand, the examiner
grasps the head of the humerus with the thumb over the
posterior humeral head and the fingers over the ante-
rior humeral head (Figure 5-44, B). The examiner runs
the fingers along the anterior humerus and the thumb
along the posterior humerus to feci where the humerus is
seated relative to the glenoid (Figure 5-45). If the fingers
"dip in" anteriorly as they move medially, but the thumb
does not , it indicates the humeral head is sitting anteri-
orly. Normally, the humeral head feels a bit more ante-
riorly (i.e., the " dip" is sligntly greater anteriorly) when
it is properly '~seated " in the glenoid. Protraction of the
scapula causes the glenoid head to shift anteriorly in the
glenoid. The exa miner must be careful with the finger
and thumb placement. In the presence of anterior or pos-
terior pathology, finger and thumb placement Illay cause
pain . The humerus is tim, gently pushed anteriorly or
posterio rl y (most common ) in the glenoid if necessary to
scat it pro perly in the glenoid fossa. l l l The seating places
the head of the humerus in its normal positio n relative to
the gicnoid ." This is the "load" portion of the test. If the
load is nor applied (as is the case in the anterior drawer
test), there is no " normal n or standard starting position
for the test. The examiner then pushes the humeral head
anteriorly (anterior instability ) or posteriorly (poste rior
instability), noting the amount of translation and end
feel. This is the "shift" portion of the test .
With anterior translation, if the head is not centered,
posterior translation will be greater tllan anterior transla-
tion, giving a false negative test. If the head is properly
centered first, however, with anterior instability present,
anterior translation wiJJ be possible but posterior transla-
tion will be virtually absent because of the tight posterior
capsule that accompanies a positive anterior instability.
Differences between affected and normal sides should
be compared in terms of the amount of translation and
the ease with which it occurs. This comparison, along
with reproduction of the patient's symptoms, is often

Figure 5-44
A, Load and shift test in sitting startin g positio n. Note that the hUl1)erus is loaded ur "ctntcrcd" in the
glenoid to begi.n . Examin er then shifts humerus anteriorly or posteriorly. B, Line dr;\wing showing position of
examiner's hands in relarion [0 bones ofparicnt's shoulder. Notice that cxamint't's left dlllmb holds the spine
of the scapula for stability.
Figure 5-45
Superior vi.ew of the shoulder showing palpation of rhe anterior and
posterior gknohumcral joint to ensure the humeral head is centered
in the glenoid .
considered more important than the amount of move-
ment obtained. If the patient has multidirectional insta-
bility, bodl anterior Jnd posterior translation may be
excessive on the affected side compared with the normal
side. The tcst may also be done with the patient in supine
lying position.
Translation of 25% or less, of the humeral head diam -
eter anteriorly, is considered normal, although results
vary among patients. 116.l17 Generally, anterior translation
is less than posterior translation, although some authors
disagree with this and say that anterior and posterior
CHAPTER 5 Shoulder 277
translation arc virtually cqual.II IUJ9 Sauers ct al. 119 and
Ellenbecker et aJ.l20 stated that hand dominance docs
not affect the amount of translation, but Lintner et all2l
disagreed saying that the nondominant shoulder shows
more translation. Hawkins and Mohtadi,"4 Silliman
and Hawkins,1l 3 and Altchek ct a1. 122 advocated a three-
grade system for anterior translation (Figure 5-46 ).
These allthors feel that the head normally translates 0%
to 25% ofthc djameter of the humeral head. Up to 50%
of humeral head translation, with the head riding up to
the glenoid rim and spontaneolls reduction , is consid-
ered grade I. For grade 11, the humeral head has more
tllan 50% translation; the head feels as though it is riding
over the glenoid rim but spontaneously reduces. Normal
hypermobilc shoulders may show grade II translation in
any direction. 12l Grade III implies that the humeral head
rides over the glenoid rim and does not spontaneously
reduce. For posterior translation, translation of 50% of
the diamete( of the hUllleral head is consjdered normal,
although results vary among patients. I 16 Thus, normally,
one would expect greater postcrior translation than antc-
rior translation when doing the test. However, all authors
do not suppOrt this view.
The load and shift test Illay also be done in supi.ne lying
position.1 23 To tcst anterior translation, the patient's arm
is taken to 45 to 60 scaption (abduction in the plane
of the scapula ) and in neutral rotation by tlle examiner
holding the forearm near the wrist (Figure 5-47) . The
278 CHAPTER 5 Shoulder

examiner then places the other hand around the patient's

Normal Laxity upper arm ncar the deltoid insertion with the rhumb
anterior and the fingers posterior feeling the movement
a mild amount of translation
(0-25%)
of the humeral head in the glenoid while applying an
anterior or antcroinfclior translation force (with the fUl-
gers) or a posterior translation force (with the thumb).
Grade I Ideally, the humerus should be "loaded" in the glenoid
before starting the test. With the hand holding the lore-
a feeling of the humeral head riding
upto the glenoid rim
arm, the examiner controls the arm position and applies
(25-50%) an axial load to the humerus. During the translation
movements with the thumb or fingers, the scapula should
Grade II not move. As the anterior or anteroinferior translation
force is applied, the exam.iner, using the other hand (the
a feeling of the humeral head over
riding the rim , but spontaneously reduces
one holding the forearm) incrementally, lateraHy rotates
(>50%) the humerus (sec Figure 5-47, B). This causes greater
involvement of the anterior ba.nd of the inferior gleno-
Grade ill humeral ligament, which, if intact, \vill limit movement
so the an10unt of anterior translation decreases as IateraJ
a feeling of the humeral head over
riding the rim, but remains dislocated
rotation increases. To test posterior translation (posterior
(50%) instability), the arm is placed in scaption with 45 to 60
of lateral rotation (Figurc 5-48 ). In tllis case, the thumb
Figure 546 pushes the humerus postcriorly.1 23.l24 Incrementally,
Grades of anterior glenohumera l translation. while applying the posterior translation, the examiner

Figure 547
A, Initi:ll position for IO:ld and shift rcst for anterior instability testing of the shoulder in supine lying posirion .
The examiner's hand grasps rhe patient's upper arm wirh the fingers posrerior. Tht: examiner's arm positions
thc patient's arm and comrols its roration . The arm is placed in the plane of the scapula , abducted 45 [0 60,
and maintained in 0 of rotation. The cX~lIniner's arm places an a..xialload to Ihe pariem's arm through the
humerus. The examiner's fingers then shift the humeral head anteriorly, and :l.Iltcroinfcriorly over rhe glenoid
rim. 8, The second position for the load and sh ift tesl for anterior stabili ty is as described in A for the ini6al
positi on, except that the arm is progressively laterally rot;ned in 100 to 20 increments while the anterior
dislociltion force is alrern:ltivdy applied and released.

Figure 5-47 conl'd
C, The examiner quantifies the degree oflareral rotation required to
reduce the tra nslation from grade 3 or 2 to gmde 1. The examiner
compares tbe normal and abnormal shoulders for {his difference in
translation with the humeral rotation. The degree of rotation requi red
to reduce the translation is an indic\tor of the functional Laxity of the
anterior inferior capsular ligaments.
Figure 5-48
Load and shift tcst for posrerior instability testing of the shoulder in
supine lying position . The patient is supine on the examining table.
The arm is brought into approximately 90 of forward elevation in
the plane of the scapu la. A posteriorly directed force is applied to the
humerus with the arm in varyi ng degrees oflateral rotation.
CHAPTER 5 Shoulder 279
medially rotates the arm. Medial rotation causes the pos-
terior band of the inferior glenohumeral ligament and
the posteroinferior capsule to become increasingly tight
so d1ar posterior translation decreases as medial rotation
increases.
Apprehension (Crank) Test for Anterior Shoulder
Dislocation. This test is primarily designed to check for
traumatic instability problems causing gross or anatomi-
cal instability of tbe shoulder, although the relocation
portion of the test is sometimes used to diffe rentiate
between instability and impinge ment. The examiner
abducts the arm to 90 and laterally rotates the patient'S
shoulder slowly (Figure 5-49 ). By placing a hand under
the glenohumeral joint to act as a fulcrum (Figu re
5-50 ), rhe apprehension test becomes the fulcrum
test.i25 Kvitne and Jobe recommended applying a mild
ante rio rl y directed force to the posterior humeral head
when in the test position to sec if appre hension or pain
increases (Figure 5-5 1 ).21 If posterior pain increases, this
indicates posterior internal impingement. 112 H amner
et al. suggested tha t ifposterior superior internal impinge-
ment is suspected, the relocation test should be done
in 110 0 and 1200 of abduction. 126 Translatio n of the
humeral head in the glenoid is less than with other tests,
provided the joint is normal, because the test is taking
the joint into the close packed position.11 6 A positive test
is indicated when the patient looks or feels apprehensive
or alarmed and resists fu rther motion. T hus, the patient's
apprehension is greater than the com plaint of pain (i.e. ,
apprehension predominates). The patient may also state
that the feeling resembles what it felt like when the shoul-
der was dislocated . It is imperative that this test be done
slowly. If the test is done too q uickl y, the humerus may
dislocate. H awkins and Bokor noted that the examiner
should observe the amount of lateral rotation that exists
when the parient becomes apprehensive and compare the
range with the uninjured side. 127
If the examine r then applies a posterior translation
stress to the head of the humerus or the arm (relocation
test), the patient will com monly lose the appre hen-
sion, any pain that is present cornmonly decreases, and
further lateral rotatio n is possible before the appre-
hension or pain returns (see Figures 5-5 1) A , and
5-51 , C). This relocatio n is sometimes referred to as the
Fowler sign or test or the Jobe relocation test. The
test is considered positive if pain decreases durin g the
maneuver, even jf there was no app rehension .I14.1 28 If
the patient'S symptoms decrease or are eliminated when
doing the relocatio n test, the diagnosis is glenohumeral
instability, subluxation , dislocation, o r impingement .
I f apprehension predominated when doin g the crank
test and disappears with the relocation test, the djagno-
sis is glenohumeral instability, sublu xation , or disloca-
tion. If pain predominated when doing the crank test
and disappears with the relocation test, the diagnosis
280 CHAPTER 5 Shoulder
Figure 5-49
Anterior apprehension (crank ) test.
is psc udolaxity or anterior instability either at the gle-
nohumeral joint or scapulothoracic joint with second -
ary irnpingc ment or a posterio r SLAP lesiol1 . 129 The
relocation test docs no t alter the pain for patients with
primary impingemcnt. 2l , J07 ,130 If, when doing the relo -
cation test posteriorly, posterior pain decreases, it is a
positive [cst for posterior internal impingemenr. 11 2 , ISI If
the arm is released (anterior release or "surprise" test
[see Fjgure 5-51, D] ) in the newly acquired ran ge, pain
and forward translation of the head arc noted in positive
tests.1\3,12H,132 The resulting pain from this release pro-
cedure may be caused by anterior shoulder instabili ty,
I.bral lesion (Bankart lesion or SLAP lesion- superior
labrum, anterior posterior), or bicipital peritenonitls
or tcndinosus. Most commonly, it is related to anterior
Figure 5-50
Fulcrum rcst with 1e:ft fist pushing head of hum crus anteriorly.
instability because the pain is temporarily produced by
the anterior rranslation. ' 32 It has also been reported to
cause pain in older patients with rotator cuff pathology
and no instability.1 3.:! This release mancuver should be
done with care because it often causes apprehension and
distrust on the part of the patient and it could cause a
dislocation, especially in patients who have had recurrent
dislocations. For most patients, therefore, when doin g
thc relocation test , lateral rotation should be released
before the posterior stress is released.
The crank test may be modified to test lateral rota-
tion at different degrees of abduction, depending on
the histor y and mechanism of injury.' 23 The Rockwood
test described next is simply a modificltion of the crank
[cst .

Rockwood Test for Anterior Instability"'. The
examiner stands behind the seated patient. With the
arm at the patient's side, the examiner laterally rotates
the shoulder. The arm is abducted to 45 , and pas
sive lateral rotation is repeated . The same procedure is
repeated at 90 and 120 (Figure 5 52 ). These different
positions are performed because the stabilizers of the
shoulder vary as the angle of abduction cbanges (see
Table 5 - 1). For the test to be positive , the patient must
show marked apprehension with posterior pain when
the arm is tested at 90, At 45 and 120, the patient
shows some uneasiness and some pain ; at 0) there is
rarel y apprehension.
Similarly, the Rowe and fulcrum tests stress the ante-
rior shou lder strucnlres. They arc morc likely to bring
Figure 5-51
Crank and relocation test . A, Abd uction and latnal rotarion (crank test ). B, Abduction and lateral roratio n
combined with anterior translation of humerus, which may cause anterior subluxatioll or posterior joinr pain .
CHAPTER 5 Shoulder 281
on apprehension sooner, because they stress the anterior
strllcnlres sooner (i.e., the examiner pushes the head of
the humerus forward ). In effect, they arc the opposite of
the relocation test; they are therefore called augm enta-
tion tests.
R owe Test for An terior In stabjlityl35. The
patient lies supine and places the hand behind the
head. The examiner places one hand (clenched fist )
against the posterior humeral head and pu shes up
while extending the arm slightly (Figure 5 53 ). This
pa rt is similar to the fulcrum test. A look of appre -
hens ion or pain indicates a positive test for anterior
instability. If a clunk or grinding sOllnd may indicate
a torll anterior labrum (sec clunk test under "Tests
for Labral Tears" ).
Continued
282 CHAPTER 5 Shoulder
Figure 5-51 conl'd
C, Abduction and hlreral rotation combined with posterior translation of the humerus (relocation test).
D , Surprise test.
The following anterior instability tests arc mod ifica-
tions of the anterior load and shift test in that dlCY are
designed to cause anterior translation of the head of the
humerus in the glenoid. As with the load and shift test,
the examiner can determine or grade the amount of
anterior translation. Therefore, these rests can be llsed as
substinltes for the load and shift test.
Prone Anterior Instability Test '36 The patient lies
prone. The examiner abducts the patient's arm to 90 0
and laterally rotates it 90. While holding this position
with one hand at the dbow, the examiner places the
other hand over the humeral head and pushes it forward
(Figure 5 54). A reproduction of the patient's symptoms
indicates a positive rcst for anterior instability.
Andrews' Anterior Instability Test l 36 The patient
lies supine with the shou lder abducted 130 and later
ally rotated 90. The examiner stabili zes the elbow and
distal humerus with o ne hand and uses the other hand to
grasp the humeral head and lift it forward (Figure 5-55).
A reproduction of the patient's symptoms gives a positive
test for anterior instability. If the examiner hears a clunk,
an anterior labral tear may be present.
Anterior Drawer Test of the Shoulder 137 The
patient lies supine. The examiner places the hand of
the affected shoulder in the examiner's axilla, hold
ing the patient's hand with the ann so that the patient
remains relaxed. The shoulder to be tested is abducted
between 80 and 120 0 , forward flexed up to 20 0 ) and

Figure 5-52
Rockwood test for anterior instability. A, Arm at side. B, Arm
laterally rotated lip to 30, The examiner then stabilizes
the patient's scapu la with the opposite hand , pushing the
spine of th e scap ula forward with the index .md middle
fin gers. The exa miner's thumb exerts counterpressu re
on the patient's coracoid process. Using the arm that is
holdin g the patient's hand, the examiner places his or her
hand around the patient's relaxed upper ann and draws
the humerus forward. The movement may be accompa
nied by a click, by patient apprehension, or both . The
amount of movemen t available is com pared with that of
the normal side . A positive test indicates anterior insrabil
ity (Figu re 5-56), depending o n the amount of ante rior
translation. The click may indicate a labral tear or slip-
page of the humeral head ove r the glenoid rim .
CHAPTER 5 Shoulder 283
a( 45 , C, Arm at 90, D, Arm at 120,
Protzman Test for Anterior InstabiHty138. The
patient is sitting. The exa miner abducts the patient'S arm
to 90 0 and supports the ann against the examiner's hip
so that the patient's shoulder muscles are relaxed. The
examiner palpates the anterior aspect of the head of the
humerus with the fin gers of one hand deep in the patient's
axi lla while the fingers of th e other hand arc placed over
the posterior aspect of the humeral head . The examiner
then pllshes th e humeral head anteri o rly and inferiorly
(Figure 5 -57 ). If this move ment causes pain and if pal -
pation indicates abnormal anteroinferior movement, the
test is positive for anterior instability_ Normally, anterior
translation sho uld be no more than 25% of the diam-
ere r of the hurneral head. l39 A click may so me times be
284 CHAPTER 5 Shoulder
Figure 5-53
Rowe test for anterior instlbiljty.
Figure 5-54
Prone anterio r inst-.J.biliry rest. EX:lnuner sta bilizes the arm in 90
abduction and lateral rotation and then pushes anteriorly on the
humerus.
palpated as the humeral head slides over the glenoid rim.
The test may also be done with the patient in the supi ne
lying position with the dbow supported on a pillow.
Anterior Instability Test (Leffert's Test)I4O. The
examiner stands behind the shoulder being examined
while the patient sits. The examiner places his or her near
hand over the shoulder so that the index finger is over
the head of the humerus anteriorly and the middle finger
is over the coracoid process. The thumb is placed over
Figure 5-55
Andrews' anterio r instability test .
Figure 5-56
Anterior drawer rcsr of the shoulder.
the posterior humeral head . The exallliner's other hand
grasps the patient's wrist and carefully abducts and later-
ally rotates the arm (Figure 5-58 ). [f, on movement of
the arm , the finger palpating the anterior humeral head
moves forward, the test is said to be positive for anterior
instability. Normally, the two fingers remain ill the same
plane . With a positive test, when the arm is returned to
the starting position, the index finger returns to the start-
ing position as the humeral head glides backward.
Dugas' TestHI This test is used if an unreduced
anterior shoulder dislocation is suspected. The patient
is asked to place the hand on the opposite shoulder and
then attempt to lower the elbow to the chest. With an
anterior dislocation, this is not possible, and pain in
 CHAPTER 5 Shoulder 285

th e sho ulder resul ts. If the pain is o nly over the acro-
mioclavicular join t, pro blems in th at joint should be
suspected .

Tests for Posterior Shoulder Instability

Figure 5-57
Pro tzman test fo r anterior instability (posrerior view).
Load and Shift Test. T his test is d esc ribed under
anteri o r shoulder instabilit:y.
Posterior Apprehension or Stress Test 124 ,142. The
patie nt is in a supine lying or sitting position . T he exa m ~
iller eleva tes the patient's sho ulder in th e plane of th e
scapula ro 90 while sta bilizing the scapula with the
o ther hand (Figure 5-59 ). T he exa miner then applies a
posterio r force o n th e patient's elbow. VVhiIc applying
the axial load , th e exa miner ho ri zontally adducts aod
mediall y ro tates th e arm. A positi ve result is indicated
by J look of apprehensio n or alarm o n the patie nt'S face
and the patien r's resistance to further motion o r rhe
reprodu ctio n of the patient'S sympto ms. Pagnani and
Warren repo rted that pain production is mo re likel y t han

Figure 5-58
Anterior instabi lity tcst . A. Side view. B, Superior view. Wirh the patient'S
3rm by the side , the ex.aminer's fi n gers arc in rhe s.lme phUH:. C, 'With
a positivc test, o n abdllction and later.al rotation , the indcx and middlr.:
fin gers arc no lo nger in the same planc. (Adapted tTo m Lefferr RD,
Gumbery G: The relation ship hetween dead arm syndro me and thoracic
outlet syndrome , Gill Ort/Jop Relnt R es 223: 22 -23 , 1987.
c
286 CHAPTER 5 Shoulder

Figure 5-59
Posterior apprcht:nsion test. A, Supine. B, Sitting medially rotan:d and addllcted.

apprehension ill a positive test.I4~ They reported that

with arraumatic multidirectional (inferior) inst~lbility, the Glenoid
test is negative. If the test is done with the patient in the Humeral
sitting position, the scapula must be stabilized . A posi head
rive test indicates a posterior instability or dislocation of
Posterior ~ ..... Anterior
the humerus. The test should also be performed with
(3-20 mm) (2-13 mm)
the arm in 90 of abduction. The examiner palpates the Normal: Normal:
head of the humerus with one hand while the other hand 1/2 width 1/4 width
pushes the head of the humerus posteriorly. Translation of head of head
of 50% of the humeral head diameter or less is consid -
ered normal , aJrhough results vary among paticnts. 116
If the humeral hcad moves posteriorly more than 50%
of its diameter (Figure 5-60 ), posterior instability is evi -
dcnt. l.19 The movement may be accompanied by a clunk
as the humeral head passes over the glenoid rirn. Inferior
Norwood Stress Test for Posterior lnstability144. (5-15 mm)
The patient lics supine with the shoulder abducted 60
to 100 and laterall), rotated 90 and with the elbow
Figure 5-60
flexed to 90 so that the arm is horizontal. The exam-
Normal translatio n movement of hUmef:lJ head in gl ~ n o id.
iner stabilizes the scapula with one hand, palpating the ( Redrawn from Harryman DT cr al: Llxity o flhe normal
posterior humeral head with the fingers , and stabilizes gleno humeral jo int: A quantitative ;n \;vo assessmen t, J Shouldr:r
the upper limb by holding the forearm and elbow at the Elboll' $u rg l:73, 1992 .)

elbow or wrist. The examiner then brings the arm into
horizontal adduction to the forward flexed posjtion.
At the same time, the examiner feels the humeral head
slide posteriorly with the fingers (Figure 5-61 ). Cofield
and Irving recommend medially rotating the forearm
approximately 20' after the forward flexion then push-
ing the elbow posteriorly to enhance the effect of the
test. I" Similarly, the thumb may push the humeral
head posteriorly as horizontal adduction in forward
flexion is carried out to enhance the effect making the
test similar to the posterior apprehension test. A posi-
tive tcst is indicated if the humeral head slips posteriorly
relative to the glenoid. Care must be taken because the
test does not always cause apprehension before sub-
luxation or dislocation. The patient confirms that the
sensation felt is the same as that felt during activities.
The arm is returned to the starting position, and the
humeral head is felt to reduce. A clicking caused by the
passage of the head over the glenoid rirn may accompany
either subluxation or reduction.
Push- Pull Test 12 S The patient lies supine. The
examiner holds the patient's ann at the \vrist, abducts the
arm 90 0 , and forward flexes it 30 0 The examiner places
the other hand over the humerus close to the humeral
head. The examiner then pulls up on the arm at the wrist
while pushing down on the humerus with the other hand
(Figure 5-62 ). Normally, 50% posterior translation can
Figure 5-61
Norwood sness {est for posterior shoulder instability. A, Arm is abducted 90. B, Atm)s honzonraUy adducrc(
to the forwa rd fl exed position .
CHAPTER 5 Shoulder 287
be accomplished. If more than 50% posterior translation
occurs or if the patient becomes apprehensive or pain
results, the examiner should suspect posterior instabil-
ity.1 39
Posterior Drawer Test of the Shoulder 137, 146, The
patient lies supine. The examiner stands at the level of
the shoulder and grasps the patient's proximal forearm
with one hand, flexing the patient's elbow to 120' and
the shoulder to between 80' and 120' of abduction and
between 20' and 30' of forward flexion. With the other
hand, the examiner stabilizes the scapula by placing the
index and middle fingers on the spine of the scapula
and the thumb on the coracoid process (the examining
table partially stabilizes the scapula as well). The exam-
iner then rotates the upper arm medially and forward
flexes the shoulder to between 60' and 80' while taking
the thumb of the other hand off the coracoid process
and pushing the head of the humerus posteriorly. The
head of the humerus can be felt by the index fmger of
the same hand (Figure 5-63 ). The test is usually pain
free , but the patient may exhibit apprehension. A posi-
tivc test indicates posterior instability and demonstrates
significa.nt postcdor translation (>50% humeral head
diameter).
Miniaci Test for Posterior Subluxation 147 The
patient lies supine with the shoulder off the edge of the
examining table. The examiner uses one hand to flex
.. I
288 CHAPTER 5 Shoulder

(70' to 90' ), adduct, and medially rotate the arm while

pushing the humerus posteriorly. The patient may become
apprehensive during this maneuver, as these motions will
cause the humerus to sublux posteriorly. vVith the other
hand, the examiner palpates the anterior and posterior
shoulder. The examiner then abducts and laterally rotates
the arm, a clunk will be heard, and the humerus reduces
(relocates), indicating a positive test (Figure 5-64).
Jerk Test 125,148, 149. The patient sits with the arm
mediall y rotated and forward flexed to 90' . The exa!)l -
iner grasps the patient's elbow and axially loads the
humerus in a proximal direction. vVhile maintaining the
axial loading, the exa miner moves the arm ho ri zontally
(c ross- flexion / hori zontal adduction) across dle body
( Figure 5 -65 ). A positive test for recurrent posterior
instability is the production of a sudd en jerk or clunk
as the humeral head slides off (subluxes) the back of
the glenoid (Figure 5-66). When the arm is returned

Figure 5-62
Push -pull test.

Figure 5-63
Posterior drawer lest of the shOlllder. A, and B, The test.
C, and D, Superim posed view of bones uwoked in the
tCSI .
 CHAPTER 5 Shoulder 289

Figure 5-63 cont'd

E, and F, R.adiographic images of the tCSt. (From Gerber
C, GallZ R: Clinical assessment of instability of the
shoulder, J BOI/e Joint SlIrg Br 66:554, 1984 .)

Figure 5-64
Miniaci test for posterior subluxation. A, To st'u t, the examiner lIses o ne hand to flex, adduct, and mcdi<llly
rotate the ,mn while pushing the hUlllerus POStt:!riorly. B, The arm is then abducted and bterally rotated while
the examiner palpates for a dunk.

to t.he original 90 abduction position, a second jerk
may be felt as the head reduces. Kim et a1. reported
that the positive signs also indicate a positive test for a
posteroinferior labral tcaL H8
Circumduction Test 150 The patient is in the standing
position. The examiner stands behind the patient grasping
the patient's forcann with the hand. The examiner begins
circumduction by extending the patient's arm while main-
taining slight abduction. As the circumduction continues
into elevation , the arm is brought over the top and into the
flexed and adducted position. As the arm moves into for-
ward flexion and adduction from above, it is vulnerable to
postelior subluxation if the patient is unstabk posteriorly.
If the examiner palpates the posterior aspect of the patient's
shoulder as the ann moves downward in forward flexion
and adduction, the humeral head will be felt to sublux pos-
teriorly in a posirive tcst, and the patient will say, "That's
what it feels like when it bothers me" (Figure 5-67).
290 CHAPTER 5 Shoulder

Tests for Inferior and Multidirectional Shoulder

Instability
It is believed that if a patient demonstrates inferior
instability, multidirectional instability is also present.
Therefore, the patient with inferior instability will also
demonstrate anterior or posterior instability. The primary
complaint of these patients is pain rather than instability,
with symptoms most commonly in midrange. Transient
neurological symptoms may also be present. lSI
Test for Inferior Shoulder Instability (Sulcus
Sign)125,137, The patient stands with the arm by the side
and shoulder Illuscles relaxed . The examiner grasps the
patient's forearm below the elbow and pulls the arm dis-
tally (Fig ure 5-68). The presence of a sulcus sign (see
Figure 5-68, B) may indiGltc inferior instability or gleno-
humeral laxity.152 A bi lateral sulcus sign is not as clioicaUy
significant as unilateral laxity o n the affected side. 153 The
sulcus sign with a feeling of sublu xation is also clinically
significant . 153 The sulcus sign Illay be graded by Illeasuring
frolll the inferior margin of the acromion to the humeral
head. A + 1 sulcus implies a distance of less than 1 em; +2
sulcus, 1 to 2 em ; and +3 sulcus, more than 2 cm.
It has been reported that the best position to test
for inferior instability is at 20 0 to 50 0 of abduction vo/ith
neutral rotation . AJso, rotation will cause the capsule to
tighten aJltcrioriy (lateral rotation ) or posteriorly (medial
rotation ), and the sulcus distance decreases. 123 Thus, morc
than one position should be tcsred. 46 ,143,154 Depending on
the history, the examiner should test the patient in the
Figure 5-65 position in which the se nsation of instabili ty is reported .
Jerk test.

Figure 566
Positive jnk test. A, Normal
appearance of the shou lder before rhe
patient performs a jerk resr.
B, With axial loading and movement
of the arm horizontally across the
body, the humeral head slides oil the
back of the glenoid , as demonstr.m.:d
by the prominence in the an terior
aspect of rhe paticnr's shoulder. 111is
maneuver resulted in a sudden jerk and
some discomforr. (From Matsen FA
cr 011: Glenohumeral instabiJiry. In
Rockwood CA , Matsen FA , editors:
The siJmdder, p 551 , Philaddphia ,
1990 , WB Saunders. )
 CHAPTER 5 Shoulder 291

Figure 5-67
Circumduction test. A, Starting position. B, The fl exed adductcd position where rhe shoulder is vulnerable to posterior subluxation .

Figure 5-68
A, Test fi.Jf intCrior shoulder insrabiliry (sulcus test ). B, Pm itivc sulcus si gn (arran's).
I
292 CHAPTER 5 Shoulder

Feagin Test 134 The Feagin test is a modification of

the sulcus sign test with the arm abducted to 90 instead
of being at the side. Some authors consider it to be
the second part of the sulcus test. 153 The patient stands
with the arm abductcd to 90 and the elbow extended
and resting on the top of the examiner's shoulder. The
examiner's hands afC clasped together over the patient's
humerus, between the upper and middle thirds. The
examiner pushes the humerus down and fo rward (Figure
5-69 , A ). The test may also be done with the patient in
a sitting position. In this case, rhe examiner holds the
patient's arm at the elbow (elbow straight) abducted to
90 with one hand and arm holding the arm agai nst the
examiner's body. The other hand is placed just lateral
to the acromion over the humeral head. Ensuring the
shoulder musc ulature is relaxed, the examiner pushes
the head of the humerus down and forward (Figure
5-69 , B). Doing the test this way oftcn gives the
Figure 5-70
A 21 -year-old woman whose shoulder could be dislocated inferiorly
and anteriorly and subluxated posteriorly. Note sulcus (arrow)
anteriorly. She was unable to carry books, reach ove(head, or use the
arm for activities such as te nnis or swi mming. There were associated
episodes of numbness and weakness of we (;'[lfirt! upper extremity that
at times I.lslcd for I or 2 days. (From Neer CS, Foster CR: Interior
capsular shift for involuntary inferior and multidirectional instability of
the shou lder, J Bout Joint Surg Am 62 :900, 1980 .)

examiner greater control when doing the test. A sulcus

may also be seen above the coraco id process ( Figure
5-70 ). A look of apprehension on the patient's face
ind.icates a positive test and the prese nce of anre roinfe -
ri or instability. If both the sulcus sign and Feagin test
are positive, it is a greater indication of multidirectional
instability rather than just laxity. This test position
also places more stress on th e inferior glenohumeral
ligament.
Rowe Test for Multidirectional Instability l 35 . The
patient stands forward fl exed 45 at the waist with th e
arms relaxed and pointing at tbe floor. The examiner
places one hand o ve r the shoulder so that the index
and middle fingers sit over the anterior aspect of th e
humeral head and the thumb sits over the posterio r
aspect of the humeral head. The examiner then pulls
t he arm down slightly (Figure 5-71). To test for ante -
rior instability, the humeral head is pushed anteriorly
with the thumb while the ann is extended 20 to 30
from the vertical position . To test for posterior insta -
bility, the humeral head is pushed posteriorly with the
index and middle fingers while the arm is fle xed 20 to
30 from the ve rtical posi tion. For inferior instabi lity,
Figure 5-69 more traction is applied to the arl1l~ and th e sulc us sig n
Feagin test. A, In standing. B, In sitting. is evident.

Figure 5-71
Rowe: lest for mullidirccrion:l] instability. A, Testing fOr anterior instability. B, Testing for posterior instability.
C, Testing for inferior instability.
Tests for Impingement
Anterior shoulder impingem.ent, regardless of its calise (i.e.,
rotator cutY pathology, bicipital pararcnonirjs/ tendinosis,
scapular or hWlleral instability, labral pathology), results
from structtlrcs being compressed in the anterior aspect
of rhe humerus between the head of the humerus and the
coracoid process under the acromion process (FiSllrc 5-
72 ). 15; 158 Park et al. found that combining rests gave bet-
ter rcs'~ts . ' ;9 They found that the Hawkins-Kenncdy test,
the painfi.t1 arc sign, and a positive infraspinatus test gave
the best probability of impingement while the painful arc
sign, drop arm tcst, ;Hld the infraspinatus test were best for
full thickness rotator cuff tears.
Common Shoulder Impingement Tests
Neer impingement test
Hawkins-Kennedy impingement test
Posterior internal impingement test
Neer Impingement Testl60 The patient's ann is
passively and forcibly fully elevated in the scapular plane
with the arm medially rotated by the examiner. This pas~
sive stress causes = the greater tuberosity to jam against
the anteroinferior border of the acromion ( Figure
CHAPTER 5 Shoulder 293
5 -73 ).16J The patient's face shows pain, reflecting a posi-
tive test result (Figure 5-74, A ). The test indicates an
overuse injury to the supraspinatus muscle and some-
times to the biceps tendon. If the test is positive when
done with the arm larcraJly rotated, the examiner should
check the acromioclavicular joint (acromioclavicular
differentiation test). lb2
Hawkins-Kennedy Impingement Test'' . The
patient stands while the examiner forward flexes the arm
to 90 and then forcibly medially rOtates the shoulder
(Figure 5 -74, B). This movement pushes the sup raspi -
natus tcndon against the anterior surface l 6<l of the cora-
coacromial liga mcnt and coracoid proccss. 161 ,16S The test
filaY also be performed in different degrees of forwa rd
flexion (vertically ~"ci l'c1in g the shou lder" ) or horizontal
adduction (horizontally "circling the shoulder" ). Pain
indicates a positive test for supraspinatus pararcnonitis/
tendinosis or secondary in1pingemcnr.H ~1cFariand et
al. described the coracoid impingmcnt sign , l66 which
js the same as the Hawkins-Kennedy test but involves
horizontally adducting the arm across the body 10 to
20 before doing the medial rotation ( Figure 5 -75 ).
This is more likely to approximate ci1C lesser tuberosity
of the humerus and the coracoid process. The Yocum
tcst is a modification of this test in which the patient's
hand is placed on the opposite shoulder and the exam-
iner elevates the elbow.33 , 1!'>7
294 CHAPTER 5 Shoulder

Acromioclavicular
Area of I C."a,:oid process joint
impingement Supraspinatus

Acromion
process

Biceps Impingement
brachii area -\--1\\qll
tendon

A Coracoacromial
ligament
Coracoacromial Area of
ligament Subscapularis impingement Figure 5-73
tendon Greater The nlnctional arc of elevation of the proximal h\l11lCrUS is
Coracoid tuberosity forward , as proposed by Nccr. The greater tuberosity impinges
Process
against the anterior one third of the acromial surfucc. This critical
area comprises the sllpraspinarus and bicipital tendons and the
subacromial bursa.
I t'.#.\~r\\-- Supraspinatus
tendon
Infraspinatus
tendon
Teres minor

Impingement Test l68 The patient is seated. The

Acromion examiner takes the arm to 90 abduction and full lat
eral rotation. This is the same position as for the appre
h 'T# 7-ri---"--'?.<---- Supraspinatus
muscle hension test. However, if thcre is no histor y of possible
traumatic subluxation or dislocation, the movcment also
can cause anterior translation of the humerus, resulting
B in secondary impingement of the rotator cuff. Therefore,
a positive test indicates a grade II or III sho ulder lesion
Coracoacromial
based on lobe's classification (see the previous disclIs-
sion ).I 07 A positive test depends on production of the
li 9ament\ Acromion
process patient's symptoms, anterior or posterior shoulder pain,
Coracoid
process or both.
Branch et a1. advocated testing the anterior capsule
in a position of 30 to 40 abduction and 0 to 10
f1cxion. 169 Lateral rotation is then passively applied to
Glenoid stress the anterior capsule. To test the posterior cap-
sule, they advocated placing the humerus in 60 to 70
abduction and 20 to 30 flexion, followed by passive
Area of ~---H eadof medial rotation to stress the posterior capsule. By test-
impingement Humerus
ing below 70 ~lbd u c ti ol1, they felt impingement signs
would be less.
Reverse Itnpingement Sign (Illlpingement Relief
Test)133. This test is used if the patient has a positive
painful arc or pain on lateral rotation. The patient lies
supine . The examiner pushes the head of the humerus
Anterior Posterior inferiorly as the arm is abducted or laterally rotated.
c Corso advocated doing the test in the standing posi-
ti0I1.' 70 He also advocated an inferior glide of the
Figure 5-n
Impingement lone. A, Anterior vjcw. B. Supcnor vicw. C, L.ueral hUinerLLs during abduction but suggested llsing a pos-
vicw. teroioferior glide of the humeral head during forward
 CHAPTER 5 Shoulder 295

Figure 5-74
Impingement sign. A, A positive Nccr impingement sign is present ifrail) and irs resulting f.'lcial expression
arc produced when the exami ner forcibly fkxcs the arm forward , jamming the greater tuberosity against
the anteroinfcrior su rface of the acromion . B, An altcfll<ltivc method (Hawkins-Kennedy impingement [cst)
demonstrates Ihe impingement sign by forcibly mediall~' rotating the proximal humerus when the arm is
forward tlexed to 90.

flexion. He advocated applying the glide JUSt before the
ROM where pain occurred on active movement. If the
pain decreases or djsappcars when rcpeating the move -
ments with the humeral head depressed , it is considered
a positive [cst for mechanical impingement under the
acromion (Figure 5 76).
Posterior Interna.l Impingement Test39.131.1 7 1-
173 , This type of impingement is found primarily in over~
head athletes although it may be found i.n others who
hold their arm in the vulnerable position. The impinge-
ment occurs when the rotator cutI impinges against the
posterosuperior edge of the glenoid when the arm is
abducted, extended, and laterally rotated (Fib....lre 5-77).
The result is of a " kissing" labral lesion posteriorly. The
resulting impingement is between the rotator cuff and
greater tuberosity on the onc hand , and the posterior
glenoid and labrum on the othcr. It often accompanies
anterior instability or pseudo laxity, and the deltoid activ-
ity increases to compensate for weakened rotator cuff
muscles. The patient complains of pain posteriorly in late
cocking and early acceleration phase of throwing. To per-
form the test, the patient is placed in the supine lying
position. The examiner passively abducts the shoulder to
90) with 15 to 20 forward flexion and maximum lat-
eral rotation (Figure 5-78). The test is considered posi-
tive ifit elicits localized pain in the posterior shoulder.39
I nternal (Medial) Rotation Resistance Strength
Test (IRRST)'74. This test is a follow -up to a Neer
test. The patient stands with the arm abducted to 90
and laterally rotated 80 to 85 . The examiner then
applies an isometric resistance into lateral rotation
followed by isometric resistance into medial (inter-
nal ) rotation (Figure 5 -79). The test is considered
positive in a patient who has a positive impingement
296 CHAPTER 5 Shoulder
Figure 5-75
The coracoid impingement sign with the test performed \\lith the arm
tlexed 90, adducted 10, and internally rotated. The test is positive jf
it produces pain in the area of the coracoid.
test if the patient has good strength in lateral rota -
tion but not medial rotation and indicates an internal
impingement. If the patient exhibits more weakness
on lateral rotation, it indicates a classic external ante -
rior impingement.
Figure 5-76
Reverse impin gement sign (impingement rclicftest). A, In sllPine . B, In stand ing, doing test in abdllction. C, In standin g, doing test in forward
flexion.
Tests for Labral Tears
Injuries to the labrum are relatively common, especially
in throwing athletes where the labrum plays a key role
in glenohumeral stability. 20 In the YOllng, t.he tensile
strength of the labrum is less than the capsule, so it is
more prone to injury when anterior stress (e.g., anterior
dislocation ) is applied to the glenohumeral joint ,l75 The
tear may be a Bankart lesion, in which the anteroinferior
labrum is torn , or the superior labrum may have been
injured, causing a SLAP lesion (superior labrum, ante-
rior and posterior [to the biceps]) (Figure 5 _80), 176-178
These injuries are classic examples of the circle concept
of instability. This concept suggests that injury in one
direction of the joint results in injury to structures on
the other side of the joint. A Bankart lesion occurs most
commonly with a traumatic anterior dislocation leading
to anterior instability. In the right shoulder, for example,
this injury results in the labrum being detached any-
where from the 3 o'clock to the 7 o'clock position result-
ing in both anterior and posterior struculral injury (see
Figure 5-80, A) , Not only is the labrum torn, but the
stability of the inferior glenohumeral ligament is lost.1 79
The SLAP lesion has the labrum detaching (pulled
or peeled depending on the mechanism ) from the 10
o'clock to t11e 2 o'clock position (see Figure 5-80, B).
The injury often results from a FOOSH injury, occurs
during deceleration when throwing, or arises when sud -
den traction is applied to the biceps. IRQ,IS I If the biceps
tendon also detaches, the shoulder becomes unstable
and the support of the superior glenohumeral ligament
is lost. Snyder and colleagues have divided these SLAP
lesions into four types: 182
 CHAPTER 5 Shoulder 297

Acromion

Greater tuberosity

Rotator cuff lendon

Area of internal
impingement
Superior labrum

Posterosupe rior
edge of glenoid

Figure 5-n
Area of po!lterior internal impingement.

Figure 5-79
Internal roranoll resistance strength test. T he patient is asked LO
maximally resist first external rotation and then il}ternal ror:ltion with
the arm in 90 0 extern.!.1 rot.uion and 85 0 intanal rotation .

Type 1. Superior labrum markedly fra yed but attac h-

ments intact
Type 11. Superior labrum has small tear and there is insta
bility of the labral-bieeps complex (most col11l11on)
Type 1Il . Bucket-handle tear of labrul11 thar may displace
into joint; labral biceps attachment intact
T ype IV. Bucket-handle tear of labrum that extends to
biceps rendo n) allowing tcndon to sublux into joint
Parentis ct a1. felt that no single test could acc urately
diag nose a SLAP lesio n .H!3
Clunk Test. The patient lies supine. The cxarnincr
places one hand o n the posterio r aspect of the sho ul
der over the humeral head. The exa miner's other hand
holds the humerus above the elbow. The examiner full y
abdu cts the arm over the patient's head. The examiner
thell pushes anteriorly with the hand over the humeral
head (a fist may be lIsed to apply mo re anterior pres-
Figure 5-78
Posterior inrernal impingement tcst. sure) while the other hand rotates the humerus into
298 CHAPTER 5 Shoulder

:/~~)-/~!~~;:~~.~gl~'e~~:~o.~h~umeralligament
Posterior
glenohumeral ligament \...-_,,,oIJleglenohumeral ligament
(Posterior bundle)

Inferior glenohumeral
ligament (anterior bundle)
Teres minor
Pectoralis major

Sling" of inferior
glenohumeral ligament

Posterior Anterior
A

-:;:;:;~~/-I-~!~~;~~~~g~'e~~n,~o~h~umeralligament
Posterior
glenohumeral ligament Middle glenohumeral ligament
(Posterior bundle)

1~lnl'.';'" glenohumeral
ligament (anterior bundle)
Teres minor Pectoralis major

"Sling " of inferior

glenohumeral ligament

Figure 580
Posterior Anterior
Labrallcsions to the right shoulder. A, Bank:art lesion .
B B, SLAP lesion .

lateral rotation (Figure 5 -81 ). A dunk or grinding
sOllnd indicates both a positive test and a tear of the
labrum, IM The test may also calise apprehension if
anterior instability is present. Walsh indicated that if
the examiner follows these maneuvers with horizontal
adduction that relocates the humerus, he or she may
also hear a clunk or a click, indicating a tear of the
labrum. 18s
The examiner may also position the arm in different
amounts of abduction (vertically "circling the shoulder" )
and perform the test. This will stress different parts of
the labrum.
Anterior Slide Test 186, 187. The patient is sitting with
the hands on the waist, thumbs posterior. The examiner
stands behind the patient and stabilizes the scapula and
clavicle with one hand. With the other hand, the examiner
applies an anterosuperior force at the elbow (Figure 5-82).
If the labrum is torn (SLAP lesion ), the humeral head
slides over the labrum with a pop or crack, and the patient
complains of anterosuperior pain.
Active Compression Test of Q'Brien 39 ,H9,188, This
test is designed to detect SLAP (Type ll) or superior
labral lesions. The patient is placed in the standing posi -
tion with the arm forward flexed to 90 and the elbow
fully extended. The arm is then horizontally adducted
10 to 15 (starting position ) and medially rotated so
the thumb faces downward. The examiner stands behind
the patient and applies a downward eccentric force to the
arm (Figure 5-83). The arm is returned to the starting
position and the palm is supinated, and the downward
eccentric load is repeated. If pain or painful clicking is
produced inside the shoulder (not over the acromiocla-
vicular jOlnt) in the first part of the test and eliminated
or decreased in the second part, the test is considered
 CHAPTER 5 Shoulder 299

arm (Fig ure 5-84). A sudden onscr of posterior shoulder

pain and click jndicatcs a positive test for a posteroinfe -
rior labral lesion.
Biceps Tension Test. This test determines whether
a SLAP iesjo n is present. The patient, in standing,
abducts and laterally rotates the arm to 90 with the
elbow extended and forearm supinated. The examim:r
then app lies an eccentric adduction fo rce to the arm.
A reproduction of the patient's sympto ms is a positive
test (Figure 5-85). The examiner should also do Speed's
test (discussed la ter) to rule o ut biceps patholob'Y.
Biceps Load Test ' 89 This test is designed to check
Figure 5-81
Clunk rest.
the integri ty of t he superio r labrum . The patient is in
the supine position with the shoulder abducted to 90
and laterally rotated, with the elbow flexed to 90 and
the forearm supinated as it is for the apprehension or
positive tor Iabral abnormali ties. The tcst also "locks and cran.k. test. The examiner performs an apprehension test
loads" the acromioclavicub r joint in medial ro tatio n so
the exam iner must take care to differentiate between
labral and acrom ioclavicular pathology.
Kim Test l4 8 The patient sirs wi th the back supported.
The arm is abducted to 90 with the elbow supported in
90 fle xion. The examiner's hand, while suppo rtin g the
elbow and forearm, applies an axial compression force
to the gleno id through the hu merus. While maintai ning
the axial compressio n force, the af m is elevated dia go-
nally upward lIsing the same hand while th e other hand
ap plies a downward and backward force to the proximal

Figure 5-83
Active compression tcSt of O'Brien. A, Position 1: The paticnt
fo rward flexes the arm to 90 with the elbow extended and adducted
150 medjal to the midline. of the body .md with rhe thumb pointed
down . The examiner applies a downward force to the arm that the
Figure 5-82 patienl resists.
Anterior slide testing. Note the position of the examiner's hands and Continued
the patient's. arms.
300 CHAPTER 5 Shoulder

Figure 5-85
Biceps tension rest . Tbe p:ltient's arm is abducted to 90 and brerally
rotated. The examiner then applies an eccentric adduction force.

on the patient by taking the arm into fl.l1l1ateral rotation.

Figure 5-83 conl'd
B, Position 2: The test is performed with the arm in dle same
position, but the patient fuUy supinares the arm with the palm facing
the ceiling. The same maneuver is repeated. The test is positive for a
superior labral injury if pain is elicited in the first step and reduced or
eliminated in the second step of this maneuver.
If apprehension appears, the examiner stops lateral rota-
tion and holds the position. The patient is then asked
to flex the elbow against the examiner's resistance at
the wrist. If apprehension decreases or the patient fcels
more comfortable, dle test is negative for a SLAP lesion.
If the apprehension remains the same or the shoulder
becomes more painful, the test is considered positive
(Figure 5-86).
SLAP Prehension Test l90 The patient is in the sit-
ting or standing position. The arm is abducted to 90
with the elbow extended Jnd the forearm pronated
(thumb down and shoulder medially rotated ) . The
patient is then asked to horizontally adduct the arm.
The movement is repeated widl dlC forearm supinated

Figure 5-84 Figure 5-86

Kim test. Biceps load test.

(thumb up and shoulder laterally rotated). If the patient
feels pain in the bicipital groove in the first case (prona-
tion) but the pain lessens or absent in the second case
(su pination ), the test is considered positive for a SLAP
lesion (Figure 5-87).
Labral Cran k Test l9l , The patient is in the supine
lying or sitting position. The examiner elevates the arm to
160 0 in the scapular plane . In this position , an axial load
is applied to the humerus with one hand of the exam-
iner while the other ha.nd rotates the hUlI1CfllS medially
and laterally. A positive test is indicated by pain on rota-
tion, especially lateral rotation with or without a click or
reproduction of the patient's symptoms (Figure 5-88 ).
Pain Provocation Test l92 The patient is seated and
the arm is abducted to between 90 and 100) and the
examiner laterally rotates the arm by holding the wrist
Figure 5-87
SLAP prehension test. A, Starr position I: Arm abducted to 90 with
elbow extended and forearm pronated. The patient then horizontally
adducts the ann. B, Start position 2: Same: as position I , but the
forearm is supinated. The patient again horizontally ~dduc[~ the arm.
If position 1 is painful and position 2 is not, the tcst IS conSIdered
positive .
CHAPTER 5 Shoulder 301
(Figure 5-89 ). The forearm is taken into maximum supi-
nation and then maximum pronation. If pain is provoked
only in the pronated position or if the pain is more severe
in the pronated position , the tcst is considered positive
for a superior (SLAP) tear. As with other superior labral
tests, the biceps must be tested (Speed's test) to rule out
biceps pathology causing the pain.
Compression Rotation Test l 3 , The patient lies
relaxed in supine posjtion. The examiner grasps the arm
and flexes the elbow with the arm abducted to about 20.
The examiner then pushes or compresses the humerus
in the glenoid by pushing up on the elbow while the
examiner's other hand rotates the humerus medially and
laterally (Figure 5-90). If there is a snapping or catching
sensation when the humeral head is felt, the test is posi -
tive for a I.bral tear ( Bankart or SLAP lesion ).
Figure 5-88
Labral crank test. A, Crank [cst in sitting with 1;1tc(31 humeral
rotation. B, Crank lcst in sitti ng with medial humeral rotation .
302 CHAPTER 5 Shoulder
Resisted Supination External Rotation Test". This
test is designed to check for SLAP lesions and is thought
to re-create the peel-back mechanism of the superio r
labrum . The patient is placed in supine lying with the
scapula near the edge of the bed. The examiner stands
beside the patient holding the arm to be examined at
the elbow and hand . The patient's arm is placed with
the shoulder abducted to 90, the elbow fl exed to 65
to 70, and the forearm is neutral or slight pronation .
The patient is then asked to maximally supinate the hand
while th e examiner resists. While the patient continues
to supin ate against th e examiner' s resistan ce, the exam-
iner laterally rotates the shoulder to end ran ge (Figure
5-91 ). T he test is considered positive if the patient has
anteri o r o r deep sho uld er pain , clickin g o r catc hing in the
shou lde r, o r rep roductio n o f symptoms. It is considered
negative if there is posteri o r sho ulder pain , no pain, o r
apprehension.

Tests for Scapular Stability

For t he rl.)llscics of th e gleno humeral joint to work in
a normal coordinated fushion , the scapula must be sta-
bilj zed by its muscles to act as a fi rm base fo r the gle-
no hu meral 11'1lIscies. Thus, when doing these tests, the
examiner is wa tchin g fo r IllOvem ent patterns of th e scap-
ulo as well as scapular dyskinesia.

"SICK" Scapula Signs and Symptoms"

Figure 5-89
Pain provocation test. A, Test \\lith forearm pronated . B, Test with Insidious onset
forearm sLL pi rl<ltr.:d. Prominence of inferior medial border of scapula
o Protraction of scaputa
o Acromion less prominent
o Coracoid very tend er to palpation
o Tight pectoralis minor
o Lack full forward flexion
o Tight short head of biceps

Lateral Scapular SUde Test" ,3.l.' . T his test deter-

nunes the sta biljty of the scapuJa during glenohumeral
move men ts. T he patient sits or stands with th e arm rest -
ing at the side. T he cxanliner measures the distance fro m
the base o f the spine o f th e sca pula to the spino lls p rocess
of T 2 o r T3 (most common ), from the inferior angle o f
the scap ula to the spino LIS process ofT7-T9 , or from T 2
to t he superi or angle of t he scapula. T he patient is then
tested ho ld ing [W0 194 ( Figure 5-92) o r fo u r6 3 other posi-
tio ns: 45 0 abduction (hands o n wa ist, thumbs postcri -
0
orly )/,3.194 90 0 abduction wi t h medial r o t a ti o n ,63 .l 94 120
abdu ctio n,63 and 150 abdllctio n . 6~ D av ies and Dickoff-
0

Figure 5-90 Hoffman 63 and Kiblcr 194 stated t hat in eac h positio n, d1 C
Compression-rotation tcst . distance measured sho uld no t va ry mo re than 1 to 1.5 CI11
 CHAPTER 5 Shoulder 303

Figure 5-91
The resisted supination external rotarion tcst. A, The;:. examiner
supports the limb in the starting position. The p3ticnr attempt'S 10
supinate his hand as the examiner resists. B, The shoulder is then
gCllIly externally rorated to rhe maximal point.

(0.5 to 0.75 inch) from the original measure. However,
there may be increased distances above 90 as the scapula
rotates during scapulohumc(al rhythm. Mil1imal protrac-
tion of the scapula should occur, however, during full
elevation through abduction. it therefore is important [0
look for asynlmetry of movement bct\vcen left and right
sides, as well as the amount of movement, when deter-
mining scapular stability.
Figure 5-92
Lateral scapular slide lesl. The examiner measures from spinous
process to scapula at level ofbasc of spine ofscapul3 (sec arrows in A ).
A, Arms a.t side. B, Arms abducted , h3nds Oil waisl, thumbs back.
Continued
The test may also be perfon-ned by loading the arm
(providing resistance) at 45 and greater abduction
(scapular load test) to sec how the scapula stabilizes
under dynami c load. Tllis load may be applied anteri-
orly, posteriorly, inferiorly, or superiorly to the arm
,
304 CHAPTER 5 Shoulder
c excessive movement wiU be evident at that joint rela -
Figure 5-92 conl'd
C, Arms abducted to 90, thumbs down.
(Figure 5-93). Again, the scapula should not move more
than 1.5 cm (0.75 inch ). Odom and associates have stated
that the test has poor reliability for differentiating nor-
mal and pathological shoulders. 195 However, loading the
scapula, either by the weight of the arm or by applying
a load to the arm , indicates the stabilizing ability of the
scapular control muscles and whether abnormal winging
or abnormal movement patterns occur.
Figure 5-93
Scapular load test in 4 5 abduction.
In the different positions, the examiner may test for
scapular and humeral stability by performing an eccen-
tric movement at the shoulder by pushing the arm for-
ward (eccentric hold tcst). One arm is tested at a rime.
As the arm is pushed forward eccentrically, the exam-
iner should \varch the relative movement at the scapulo-
thoracic joint (protraction ) and the glenohumeral joint
(horizontal adduction ). Normally, slightly more move-
ment (relatively) occurs at the glenohumeral joint. If
instability due to muscle weakness exists at either joint,
tive to the other joint. In addition , the examiner should
watch for winging of the scapula, which indicates scapu-
lar instability.
Wall Pushup Test67 , 196 . The patient stands arms
length from a wall. The patient is then asked to do a
"wall pushup" 15 to 20 times (Figure 5-94). Any weak-
ness of the scapular muscles or winging usually shows
up with 5 to 10 pushups. For stronger or younger peo-
pic , a normal pushup on the floor shows similar scapu -
lar changes, usually with fewer repetitions. Goldbeck
and Davies have taken this test further in what they
describe as a closed kinetic chain upper extremity
stability test. 197 In this test, two markers (e.g., tape )
are placed 91cm ( 36 inches ) apart. Patients assume the
pushup position with one hand on each marker. When
the examiner says "go," the subject moves one hand to
touch the other and returns it to the original position
and then does the same with the other hand, repeating
the motions for 15 seconds. The examiner counts the
number of touches or crossovers made in the allotted
time. The test is repeated three times, and the average is
the test score . This test is designed primarily for young,
active patients.
Scap uJar Retraction Tesrt 2 ,67.196.198. The patient is in
the standing position. The examiner, standing behind the
patient, places the fingers of one hand over the clavicle
with the heel of the hand over the spine of the scapula to
stabilize the clavicle and scapula a.nd to hold the scapula
retracted. The examiner's other hand compresses the
scapula against the chest wall (Figure 5-95). Holding the
scapula in this position provides a firm stable base for
the rotator cuff muscles, and often rotator cuff strength
(if tested by a second exanuner) will improve. The test
may also be positive in patients with a positive relocation
test. [f scapular retraction decreases the pain, when the
relocation test is performed, it indicates that the weak
scapular stabilizers must be addressed in the treatment. 198
This test may also be done in supine. In patients with
a SICK scapula, if the scapula is repositioned, forward
flexion will improve. 2o
Scapular Isometric Pineh or Squeeze Test6 7 The
patient is in a standing position and is asked to actively
""pinch" or retract tht' scapulae together as hard as possible
 CHAPTER 5 Shoulder 305

Figure 5-95
Scapular relraction test. Examiner uses hands to s[abili7...c clavicle and
scapul:t.

and to hold the position for as long as possible (Fig ure

5 -96 ). Normally, an individual can hold the contractions
for 15 to 20 seconds with no burning pain or obviolls
muscle weakness. If burning pain occurs in less than 15
seconds, the scapular retractors are weak. When doin g
th e tcst, the examiner must wa tch th e patient ca refully.
Subconsciously, many patients wi U rel ax the contraction

A
Figure 5-94
Wall ( A) .mel t100r (B) pushup tests . C, Closed kinetic chain upper Figure 5-96
extremity stability tc:st touching opposite hand. Scapular isometric pinch tCSt. A, Start position .
Continllcd
306 CHAPTER 5 Shoulder

Figure 5-97
Scapular assistance test.

Figure 5-96 conl'd

B, Pinch posicion.
(Figure 5-98 ). Abnormal movement at the acromiocla-
vicular joint indicates a positive test as well as acroI11iocla-
vicular joint pathology.
Acromioclavicular Crossover, Crossbody, or Hori-
zontal Adduction Test. The patient stands and reaches
a slight amount, which is barely noticeable but allows the hand across to the opposite shoulder. The examiner
the patient to hold the contraction in a comfort zone tor may also passively perforrn the test. With the patient in
longer periods with no burning. a sitting position, the examiner passively forward flexes
Scapular Assistance Test+ 267, 196, 198. This test evalu -
ates scapular and acromial involvement in patients with
impingement symptoms. The patient is in a standing
position , and the examiner stands behind the patient. The
examiner places the fingers of one hand over the clavicle
with the heel of d,e hand over the spine of the scapula.
This stabilizes the clavicle and scapula and holds the scap-
ula retracted. The examiner's other hand holds the infe-
rior angle of the scapula. As the patient actively abducts
or forward flexes the arm, the examiner stabilizes and
pushes the inferior medial border of the scapula up and
laterally wh.ile keeping the scapula retracted. Decreased
pain would be a positive test and would indicate that the
scapular control muscles arc weak. as the assistance by the
examiner simulates the activity of serratus anterior and
lower trapezius during elevation (Figure 5-97) .

Other Shoulder Joint Tests

Acromioclavicular Shear Test 139 With the patient
in the sitting position, the examiner cups his or her
hands over the deltoid muscle, with one hand on the
clavicle and one hand on the spine of the scapula. The Figure 5-98
examiner then squeezes the heels of the hands together Acrom ioclavicu la r shcar tc;t .

the arm to 90 and then horizontally adducts the arm
as far as possible (Figure 5-99)-"162 If the patient feels
localized pain over the acromioclavicular joint, the test is
positive.199.201 Localized pain in the sternoclavicular joint
indicates that joint is at fault.
Elhnall 's Compression Rotation Tcst202.203. The
patient lies on the unaffected side . The examiner com-
presses the humeral head into the glenoid while the
patient rotates the shoulder medially and laterally. If the
patient's symptoms are reproduced , glenohumeral arthri-
tis is suspected (Figure 5-100).
Figure 5-99
Acromioclavicular crosso\'c r, cross body, or hori zontal :ldducrion [t::st.
~re~OO "
Ellman 's comprcssion-rotation lest for gknohumt:ral ann ntis.
CHAPTER 5 Shoulder 307
Tests for Ligament Pathology
Crank Test (Also see wlder Tests for Anterior
Shoulder Instability). The crank test may also be
used to evaluate tile different glenohumeral ligaments
( Figure 5-101 ). For example, when the crank test is done
with the arm by the side, primarily the superior glenohu-
meralligament and capsule are bdng tested. At 45 to 60
abduction, the middle glenohumeral ligament, the cora-
cohumeral ligamcnt, the inferior glenohumeral liga-
ment (anterior band ), and anterior capsule arc being
tested. Over 90 abduction, the inferior glenohumcral
Figure 5-101
Crank tcst uscd l O test glcnohumeral1i gamcms. A, Arm by the
side-superior gJenohull1cralli gament testcd . B, 45 to 60
abduction- middle g1cnohumemlligamcllt tested.
Contiuued
308 CHAPTER 5 Shoulder

Figure 5-101 co"I'd

C, Over 90 abduction- inferior g lenohulllcralligamcnr tested.
0

ligament and anterior capsule are being tested (see Table

5 -I ) 204,205
Posterior Inferior Glenohlffilcral Liganlcut Test186
Just as the crank test Illay be llsed to test the superior
glenohumeral ligament, middle glenohumeral ligament,
and the anterior portion of the inferior glenohumeral
ligament, the posrcrjor intcrjor glenohumeral test may
be used to test the posterior portion of the inferior gle-
nohumcralligamcnt. The patient sirs while the examiner
forward flexes the arm to between 80 and 90 and then
horizontally adducts the arm 40 with medial rotation
(Figure 5 -102 ), While doing the movement, the exam -
iner palpates the postcroinfcrior region of the glenoid.
If the humerus protrudes or pain is felt in the area, the
test is considered positive and indicates a lesion of the
posterior portion of the inferior glenohumeral ligament.
If movement (i.e., horizontal adduction) is restricted, it
may also indicate a tight posterior capsule.
Coracoclavicular Ligalnent Test. The integrity of
the conoid portion of the co racoclavicular ligament may
be tested by placing the patient in <1 side lying position
on the unaffected side with the hand resting against the
lower back. The examiner stabiljzes the clavicle while Figure 5-102
pulling the inferior angle of the scapula away from the Posterio r inferior Ijgament test. ~ Anterior view. S, llosterior view.
chest wall. The trapezoid portion of the ligament may be
tested from the same position. The examiner stabilizes the
clavicle and pulls the medial border of the scapula away Tests for Muscle or Tendon Pathology
from the chest waU (Figure 5-103 ). Pain in either case Speed's Test (Biceps or Straight-Arm Test). The
in the area of the ligament (anteriorly under the clavicle examiner resists shoulder forward flexion b y the
between the olltcr one-third and inner two-thirds ) con - patient while the patient' s forearm is first supinated,
stinltes a positive test. then pronated, and the elbow is completely extended.

Common Muscle and Tendon Pathology Tests
Speed's test (biceps)
Yergason's test (biceps)
Empty can test (supraspinatus)
Lift-off test (subscapularis)
Lag or "spring back" tests (subscapularis-medial rotation; infra-
spinatus-lateral rotation)
Trapezius weakness (three positions)
Serratus anterior weakness
Pectoralis major and minor tightness
The test may also be performed by forward flexing the
patient's arm [0 90 and then asking the patient to
resist an eccentric movement into extension first with
the arm supinated, th en pronated (Figure 5-104).
A positive tcst elicits increased tenderness in the bicip-
ital groove especially with the arm supinated and is
indicative of bicipital parateno nitis or tcndin osis. 23
Speed 's test is more effective than Ycrgason's test
because the bone moves ove r 1110re of the tendon dur-
in g the Speed's test. It has been reported that this
test may cause pain and will therefore be positi ve if a
SLAP (type II ) lesion is prescnr.'64 If profound weak-
ness is found on resisted supinatio n, a severe second ~
or third -degree ( ruprure ) strain of the distal biceps
should be suspccred. 206
Figure 5-' 03
Cor:l.coclavicuJar ligament test. A. Conoid portion . B, Tl.l.pczoid portion.
CHAPTER 5 Shoulder 309
Yergason's Test. This tcst is primarily designed to
check the ability of the transve rse humeral ligament to
hold the biceps tendon in the bicipital groove. With th e
patient's elbow flexed to 90 and sta bilized against the
thorax and with the forearm pronated , the examiner
resists supination while the patient also laterally rotates
the arm against resisrance (Figu re 5-105 )' 07 1fthe exam-
iner palpates the biceps tendon in the bicipital groove
during th e sllpjnation and lateral rotation movement,
the tendon will be felt to "pop o ut" of the groove if the
transverse humeral liga ment is torn. Tenderness in the
bicipital groove aJonc without the dislocation may indi -
cate bicipital paratenonitis/tendinosis. 23 This test is not as
effective as Speed's test when testing th e biceps tendon,
because the bicipital groove moves only slightly over the
tendon affecting o nly a small part of tile tendon during
the test and because biceps tendon pain tends to occur
with motion or palpation rather than with tension.
Ludington'S TestZO' , The patient clasps both hands
on top of or behind the head , allowing the interlock-
ing fingers to support the weight of the upper limbs
(Figure 5-106). Tlus action allows maximum relaxation
of the biceps tendon in its resting position. The patient
then alternately contracts and rela xes th e biceps muscles.
While the patient does the contractions and relaxations,
tile examiner palpates the biceps tendon , which will be
felt on the uninvolved side but not o n the affected side if
tile test result is positive. A positive result indicates that
the lon g head of biceps tendon has ruptured.
310 CHAPTER 5 Shoulder
Gilchrest's Sign",,20'. While standing, the patient lifts
a 2- to 3-kg (5 - to 7-lb) weight over the head. The arm is
laterally rotated fuJly and lowered to the side in the coronal
plane. A positive test is indicated by discomfort or pain in
the bicipiraJ groove. A positive [est indicates bicipital pal"a[c-
nonitis or tendinosis Y Jn some cases, an audible snap or
pain may be felt at between 90 and 100 abduction.
Lippman's Tcst 210 The patieot sits or stands while
the examiner holds the arm flexed to 90 with one hand .
With the other hand, the examiner palpates the biceps
tendon 7 to 8 em (2.5 to 3 inches) below the glenohu -
meral joint and moves the biceps tendon from side to
side in the bicipital groove. A sharp pain is a positive test
and indicates bicipital pararcnonitis Of tcndinosis. 23
Reuter's Sign209. NOfmally, ifelbow flexion is resisted
when the arm is pronated, some supination occurs as the
biceps attempts to help the brachia lis muscle flex the elbow,
This supination movement is called Heuter's sign. If it is
absent, the distal biceps tendon has been disrupted.
Supraspinatus ("Empty Can" or Jobe) Test1ll . The
patient's arm is abducted to 90 with neu tral (no ) rotation ,
and the examiner provides resistance to abduction. The
shoulder is then mediaI.ly rotated and angled torward 30
Figure 5-104 (cmpty can position ) so that thc patient's thumbs point
Speed's test (biceps or straight-arm test ). toward the floor (Figure 5-107) in the plane ofthe scapula.

Figure 5-105
Yergason's test. A, Start position. B, End position.

Figure 5-106
Ludingto n's lcst.
Figure 5-107
Supraspinarus u cmpry can" rest.
Others have said that testing the arm with the thumb up
("full can" ) is best for ma..xilllU01 contraction of supraspi-
natus. 212 Resistance to abduction is again given whiJc the
examiner looks for weakness or pain, reflecting a positive
test result. A positive test result indicates a tear of the
supraspinatus tendon or muscle, or neuropathy of the
suprascapular nerve.
Drop-Arm (Codman's) Test. The examiner abducts
the patient'S shoulder to 90 and then asks the patient
to slowly lower rhe arm to the side in the same arc of
movement (Figure 5-108 ). A positive test is indicated if
the patient is unable to returo the arm to the side slowly
o r has severe pain when attempting to do so. A positive
result indicates a tear in the rotator cuff complex. 213 A
complete tear (3 strai n) of the rotator cuff is more com-
CHAPTER 5 Shoulder 311
Figure 5-108
Drop-arm rest. A, The patient abducts the arm to 90. B. The patient
tries to lower the arm slowly and is wlablc: to do so; instead, the arm
drops to his side. Examiner's hand ilIustrntcs the start position .
mon in o lder patients (50+ years ). In younger people, a
partial tear (1 or 2 strain ) is more likely to occur when
the patient is abducting the arm and a strong downward,
eccentric load is applied to the ann.
Abrasion Sign38. The patient sits and abducts the
arm to 90 with the elbow flexed to 90. The patient
then medially and laterally rotates the arm at the shoul-
der. Normally, there are no signs and symptoms. If crepi-
tus occurs, it is a sign that the rotator cuff tendons are
frayed and are abrading against the under surfaces of the
acromion process and the coracoacromial ligament.
Lift-Off Sign212.214.217. The patient stands and
places the dorsum of the hand on the back pocket or
against the midlumbar spine. Great subscapu laris activ-
ity is shown with the second position (Figure 5_ 109 ).218
The patient then lifts the hand away from the back . An
inability to do so indicates a lesion of the subscapularis
muscle . Abnormal motion in the scapula during the test
may indicate scapular instability. If the patient is able to
312 CHAPTER 5 Shoulder
Figure 5-109
LiftotTsign. A, Start position. B, Lift offposirion. C, Resistance to lift off provided by exam iner. Examiner tests strength of subscapularis and
watches positioning of scapula.
take the hand away from the back, the examiner should
apply a load pushing the hand toward the back to test the
strength oftbe subscapularis and to test how the scapuJa
acts under dynam.ic loading. With a torn subscapularis
tendon , passive (and active) lateral rotation increasesY s
If the patient's hand is passively medially rotated as f.:"1f
as possible and the patient is asked to hold the position,
it will be found that the hand moves toward the back
(subscapularis or medial rotation "spring back" or lag
test) because subscapularis cannot hold the position due
to weakness or pain. This test is also called the modified
lift off test (Figure 5 _ll0). 215,1!9 A small lag between
maximum passive medial rotation and active medial rota -
tion implies a partial tear (1 0 ,2 ) of subscapularis. 214 This
modified test is reported to be more accurate in diag -
nosing rotator cuff tear.220 The test may also be used to
test the rhomboids. Medial border winging of the scap-
ula during the test may indicate that the rhomboids are
affected. Stefko et al. reported that maximum isolation
of the subscapularis was achieved by placing the hand
against the posteroinferior border of the scapula (maxi-
mwn medial rotation test) and then attempting the lift
off. 221 [n the other positions for lift off, teres major, latis-
simus dorsi, posterior deltoid, or rhomboids may com-
pensate for a weak subscapularis.
Abdominal Compression (Belly-Press) Test2!.,2!7,,,,.
This test checks the subscapularis muscle, especially if the
patient cannot medially rotate the shoulder enough to
take it behind the back. Tile patient is in a standing posi -
tion. The examiner places a hand on the abdomen so that
the examiner can feel how much pressure the patient is
applying to dle abdomen. The patient places his or her
hand of the shoulder being tested on the examiner's hand
and pushes the hand as hard as he or she can into the
stomach (medial shoulder rotation ). While pushing the
hand into the abdomen, the patient attempts to bring the
elbow forward to the scapular plane causing greater medi -
ally shoulder rotation. If the pati.ent is unable to maintain
the pressure on the examiner's hand whiJc moving the
elbow forward or extends the shoulder, the test is positive
for a tear of the subscapularis muscle (Figure 5- 111).
Lateral Rotation Lag Sign (Infraspinatus "Spring
Back" Test)106. The patient is seated or in standing
position with the arm by the side and the elbow flexed
to 90. The examiner passively abducts the arm to 90 in
the scapular plane, laterally rotatt.:s the shoulder to end
range (some authors say 45 ),223 and asks the patient to
hold it (Figure 5-112, A ). For a positive test, the patient
cannot hold the position and the hand springs back ante-
riorly toward midline, indicating infraspinatus and teres
minor cannot hold the position due to weakness or pain
(Fjgure 5-112 , B). 216,224 The examiner will also find pas-
sive medial rotation will have increased on the affected
side.
 CHAPTER 5 Shoulder 313

Figure 5-110
Subscapularis spring back o r lag test . A, Start position. B, Patienr is unable: to hold t.he start posiriotl and hand
springs back toward tht: lower bad..

If the tcst is performed with t he ann in 20 abduc-

tion or by the side in the scapu lar plane with the elbow
at 90 and the shoulder laterally rotated, the examiner
then takes the arm into maximum lateral rotation and
asks the patient to hold the position (Figure 5 -113, A ).
If the supraspinatus and infraspinatus are torn , the arm
will mcdiaJly rotate and spring back anteriorly indicat-
ing a positive test ( Figure 5-113, B). This test has also
been called the ERLS tcst (extcrn al [sic. lateral] rotation
lag sign ). Hertel ct al. described a drop sign in which
the patient is standing and abducts the arm to 90 with
the elbow flexed to 90,220 The examiner maxima.lly la t-
erally rotates the arm , and the patient is asked to hold
the position. If the arm falls or drops into media.l rotJ -
tion, the test is considered positive for tears to infra-
spinatus and supraspinatus and perhaps subscapu laris
( Figure 5 -11 4 ).'66 If the patient is able to hold the posi-
tion , the strength of infraspinatus can be graded as 3 or
greater depending on the resistance to the examiner's
medially rotated force. 223
Hornblower's (Signe de Clairon) Sign 106,219.223. This
test, also ca1Jed Patte Test, is designed to test the strength of
te res minor. The patient is in a standing position. The cxam-
iner elevates dlC patient'S arm to 90 in the scapular plane.
The examiner then flexes the elbow to 90 1 and the patient
Figure 5-111 is asked to laterally rotate dlC shoulder against resistance.
Abdominal compression test.
J
314 CHAPTER 5 Shoulder
Figure 5-112
Lateral rotation lag test to test the teres minor and infraspinatus. A, Arm is abducted 90. B, Note how hand
springs forward when released by examiner.
A positive test is inclicated when the patient is unable
to laterally rotate the arm and indicates a tear of teres
minor.225
McClusky offered a second way to do the test lO6 The
patient is standing with the arms by the side and then is
asked to bring the hands to the mouth (Figure 5 -115, A ).
\Vith a massive posterior rotator cuff tear, the patient
is unable to do this without abducting the arm first
(Figure 5-115, B). This abduction with hands to the
mouth is called hornblower's sign.
Infraspinatus Test. The patient stands with the arm
at the side with the dbow at 90 and the humerus medi-
ally rotated to 45. The examiner then applies a medial
rotation force that the patient resists. Pain or the inability
to resist medial rotation indicates a positive test for an
infraspinatus strain (Figure 5 -116 ).
Teres Minor Test. The patient lies prone and places
the hand 011 the opposite posterior iliac crest. The patient
is then asked to extend and adduct the medially rotated
arm against resistance. Pain or weakness indicates a posi-
tive test for teres minor strain (Figure 5- 117 ).
.
Trapezius Weakness 226 The patient sits down and
places the hands together over the head. The examiner
stands behind the patient and pushes the elbows forward.
Normally the three parts of the trapezius contract to sta-
bilize the scapula (Figure 5-]]8, A). The upper trape-
zius can be tested separately by elevating the shoulder
with the arm slightly abducted or to resisted shoulder
abduction and head side flexion (Figure 5 -U8, B) .'27,228
If the shoulder is elevated with the arm by the side,
levator scapulae and rhomboids are more likely to be
involved as well. The middle trapezius can be tested with
the patient in a prone position with the arm abducted to
90 0 and laterally rotated. The test involves the exarniner
resisting horizontal extension of the arm watching for
retraction of the scapula, which should normally occur
(Figure 5 -118, C).227,228 If scapular protraction occurs,
the middle fibers of trapezius are weak. To test the lower
trapezius, the patient is in prone lying with arm abducted
to 120 and the shoulder laterally rotated. The exam-
iner applies resistance to diagonal extension and watches
for scapular retraction that should normally occur
 CHAPTER 5 Shoulder 315

Figure 5-113
External rotation lag sign or drop rest. A, Start position. B, Position ill positive test.

Figure 5-114
The drop sign. A, The lcst is pcrlormcd by the oamincr placin.g the arlll in 90 ofabdllction and maximum
eXlernal rotation and asking rhe p:llknr to hold the position. B, Ifrhc patient cannot hold this position, and
the arm falls into imcrnal rotation, the {t:st is positive.
316 CHAPTER 5 Shoulder
Figure 5-115
Hornblower's (Signe de Ckliron) sign. A, Normal result. B, Positive test. Patient must abduct the arm
rhe hand to the mouth.
Figure 5-116
Infmspinatus [cst.
(Figure 5-118, D). If scapular protraction occurs, the
lower trapezius is weak. 227 If the scapula is elevated morc
d1an normal, it may indicate a tight trapezius or the pres-
ence of cervical torticollis.
Serratus Anterior Weakness 226 The patient is in
a standing position and forward flexes the arm to 90.
The examiner applies a backward force to the Jrm
(Figure 5-119). If serratus anterior is weak or paralyzed,
the medial border of the scapula will wing (classic wing-
ing). The patient will also have difficulty abducting or
forward flexing the arm above 90 with a weak serratus
anterior, but it still may be possible with lower trapezius
to bring
Figure 5-117
'len:s minor tcSt.
compensation. 45 A similar finding may be accomplished
by doing a wall or fioor pushup.
Rhomboid Weakness lO6,226. The patient is in a prone
lying position or sitting with the test arm behind the body
so the hand is on the opposite side (opposite back pocket).
The examiner places the index finger along and under the
medial border of the scapula while asking the patient to
push the shoulder forward slightly against resistance to
relax the trapezius (Figure 5-120, A). The patient then is
asked to raise the forearm and hand away ITom the body.
If the rhomboids are normal, the thumb is pushed away
from under the scapula (Figure 5-120, B).
 CHAPTER 5 Shoulder 317

Figure 5-118
Testing fo r trapezius weakness. A, All portions of triceps. B, Upper trapezius. C, Middle trapezius. D, Lower trapezius.
318 CHAPTER 5 Shoulder
Figure 5- 119
Testing lor serratus anrcrior weakness. Pu nch out test : examiner
applies a backward force .
Latissimus Dorsi Weakness iSO The patient is in a
standing position with the arms elevated in the plane of
the scapula to 160. Against resistance of the examiner,
the patient is asked to lllcdially rotate and extend the ann
downward as if climbing a ladder (Figure 5-121 ).
Figure 5-120
Testing for rhomboid we;)kness. A, Start position. B, Test position.
Biceps Tightness. The patient lies supine with the
shoulder in extension over the edge of the examining
table with the elbow fl exed and the forearm supinated.
The examiner thcn extends the elbow, which would
norrnally have a bone-to-bone end feel if the biceps is
normal. If the biceps is tight, fuU elbow flexion will not
occur and the end feci will be a IlHlscuiar tissue stretch
(Figure 5-122 )'"
Triceps Tightness. The patient is in a sitting posi-
tiOI1. The arm is fully elevated through forward flex -
ion and 1atera! rotation . While stabilizing the humerus,
tl,e examiner tlexes tl,e elbow (see Figure 6- 15, il).'"
Normally, the end feci would be soft tissue approxima-
tion. If the triceps is tight, elbow flexion will be limited
and the end feel will be musc ul ar tissue stretch.
Pectoralis Major Colltractul'c Test. The patient lies
supine and clasps the hands together behind the head.
The arIllS are then lowered until the elbows touch the
examining table (Figure 5- 123, A ). A positive test occurs
if the elbows do not rea ch the table Jnd indicates a tight
pectoralis major muscle .
Pectoralis Minor Tightness. Pecto ralis minor nlOc-
rions along with the rhombo ids and levator scapulae to
stabili ze the scapula during ann extension. T igh tness of
the pectoralis minor can lead to increased scapular prorrac-
tion and tilting of th e inferior angle of the scapula poste -
riorly. Tightness of the pectoralis minor can be tested by
havi ng the patient in a supine lying positio n. The exam -
iner places the heel of the hand Over the coracoid process
and pushes it toward the examining table (Figure 5-123,
B). NormaUy, the posterior movement occurs with no dis-
comfort to the patient, and the scapula lies flat against the
table. However, if there is tightness ( l11l1scJ e tissue stretch)
 CHAPTER 5 Shoulder 319

Figure 5121
Testing for latissimus dorsi weak.ness.

Figure 5123
Testing for tighUlcSS of (A) pectoralis major and (1\) pectoralis minor.
Examiner is tc:sting md fecI. Note pmirion of examiner's band 011 (A)
humerus and (8) coracoid pr:occss.

over the pectoralis minor muscle during the posterior

movement, the tcst would be considered positive.
Tightness ofL..'ltissimus D orsi, Pectoralis Majo r, and
Pectoralis Minor. The patient is placed in a supine lying
position and is asked to fully elevate the arms through for-
ward flexion. Jfthc three muscles have normal length , the
arms wil l extend to rest against the examining table. Ifthc
sca pula docs nor ije flat against the table, it indicates that
the pectoralis minor, pecrorahs major, Or latissimus dorsi is
tight (tll. scapula remains protracted ) (Figure 5-124)227

Tests for Neurological Function

Upper Limb Tension (Bradlial Plexus Tensioo)
Test''''. This test is tl,C upper limb equivalent of the
straight leg raising test of the lower limb. It is used when
the patient has presented with upper IilUb racticular signs
o r peripheral nerve synlptoms. The patient is positioned to
stress the neurological tissue entering the arm.. The patient
lies supine. The tcst may be performed by phlcing the joints
of the upper limb in different positions to stress each of the
neurological tissues ditTerently.231 There are, in effect, four
Figure 5122
Testing for biceps tig.htnc:~. upper limb tension tests (ULTI \ to 4 ) (see Table 3-\3 and
320 CHAPTER 5 Shoulder
Figure 5-124
Testing for tightnt'ss of latissimus dorsi, pectoralis major, and
pectoralis minor as A gruup.
Figure 3_36).232 The key to performing the tests correctly is
to ensure the shoulder is held in depression. Ifit is allO\vcd
to elevate, tension is taken off the neurological strucnlres.
Depending on the history, the examiner picks the ULTI
that will stress the appropriate neurological tissue. Pain in
the form of tingling or a stretch or ache in the cubital fossa
indicates stretching of the dura mater in the cervical spine.
The available range of passive m.ovement at the elbow, when
compared with dlC normal side, can indicate the restriction.
L1tcral or side flexion of the cervical spine to the opposite
side can enhance the effect. If full ROM is not available
in the shoulder, the test can still be perfotmed by taking
the should er to the point just shorr of pain in abduction
,md lateral rotation and performing the other maneuvers
of the arm or by passively side flexing the ce rvical spine.
The upper limb tension tests put tension on the upper limb
neurological tissues even in normal individuals. Therefore,
reproduction of the patient'S symptoms, rather than stretch-
ing, constitutes a positive sign. This flnding indicates the
neurological tisslle is being stressed but it does not tell the
examiner where or why it is being stressed.
Tine!'s Sign (at the Shoulder). The area ofrhe bra
dual plexus above tbe clavicle in the area of the scalene
triangle is tapped. A positive sign is indicated by a tin -
g ling sensation in one or more of the nerve roots.
Neurological Function Tests
Upper limb tension tests
Tests for Thoracic Outlet Syndrome
Thoracic outlet sy ndromes may combine neurological and
vascular signs, or the signs and symptOlns of neurological
deficit, restriction of arterial flow, or restriction of venous
flow may be seen individuaUy. For this reason , a diagnosis
of thoracic outlet syndrornc is usually one of exclusion in
which all other causes have been eliminated.233.136 In fact,
neurogenic signs are rare jn thoracic outlet syndrome,
and there is poor correlation betwcen tllC vascular signs
of the condition and neurological involvement. Thoracic
outlet tests must not only decrease the pulse, they must
also reproduce the patient's symptoms to be considered
positive.''' The tests do nor show hi gh reliability.
Common Tests for Thoracic Oullet Syndrome
Roos test
Wright test
Costoclavicular syndrome test
With thoracic oudet tests rJlat involve taking the pulse,
the examiner must find the pulse before positioning the
patient's arm or cervical spinc . Because the pulse may
be diminished even in a " norma l" individual, it is more
important to look for tlle reproduction of symptoms
than tor diminution of the pulse. Unless stated, the dura -
tion of these provocative tests sho uld be no mon:: tlun 1
to 2 minutes. H4
Roos Test (EAST)'38. The patient stands and abducts
the arms to 90, Jaterally rotates the sho ulder, and flexes
the elbows to 90 so that the elbows arc slig htly behind
the frontal plane. The patient thcn opcns and closes the
hands slowly for 3 minutes (Figure 5 125 ). [fthe patient
is unable to keep the arms in the starting position for 3
tninutcs or suffers ischemic pain, heaviness or profound
weakness of the arm, or numbness and tingling of the
hand during tllC 3 minutes, thc test is considered positive
Figure 5-125
Roo:. test.

for thoracic outlet syndrome on the affected side. Minor
fatigue and distress are considered negative tests. The test
is sometimes called the positive abduction and external
rotation (AER) position test, the "hands up" test, or
the elevated arm stress test (EAST).23Il-'"
Wright Test or Maneuver. Wright advocated
"hyperabducting" the ann so that the hand is brought
over the head with the elbow and arm in the coronal
plane with the shoulder laterally rotated (Figu re 5 126,
A ).242 H e advocated doing the test in the sitting and then
the supine positions. Having the patient take a breath or
rotating or extending the head and neck may have an
Figure 5-126
A, Wright test. B, Modified Wrighr test or ll1:lncuvn (Allen m:lncuvcr).
CHAPTER 5 Shoulder 321
additional dTeet. The pulse is palpated lor differences.
This test is used to detect compression in the costoclavic-
ular space and is si milar to rhe costoclavicular syndrome
test described ne xt.
Examiners have modified this test over time so that
it has come to be described as follows. The examiner
flexes the patient's elbow to 90 while the shoulder
is extended horizontally and rotated laterally (Figure
5126, B). The patient then rotates the head away from
the test side. The examiner palpates the radial pulse ,
which becomes absent (disappears) when the head is
ro tated away fron"} the test side. The test done in this
322 CHAPTER 5 Shoulder
fashion has also been called the AJlen maneuver. The
pulse disappearance indicates a positive rest result for
thoracic outlct syndrome.
Costoclavicular Syndrome (Military Brace) Test. The
exanuncr palpates the radial pulse and then draws the
patient's shoulder down and back (Figure 5-127 ). A positive
test is indicated by an absence of the pulse and implies pos-
sible thoracic outlet syndrome (costoclavicular syndrome).
Ths test is particularly eflective in patients who complain of
symptoms while wearing a backpack or heavy coat.
Provocative Elevation Test 12s The patient elevates
both arms above the horizontal and is asked to rapidly
open and close the hands 15 times. If fatigu e, cramping,
or tingling occurs during the test, the test is positive fo r
vascular insufikicncy and thoracic outlet syndrome. This
test is a modification of the RODS test.
Shoulder Girdle Passive Elevation l 33 . Tlus test is
lIsed on patients who already present with symptoms. The
patient sits and the examiner grasps the patient's arms
fro m behind and passively elevates the shoulder girdle up
and forward into fu ll elevation (a passive bilateral shoulder
shrug ), a.nd t1,e position is held for 30 or more seconds
(Figure 5-128 ). Arterial relief is evidenced by stronger
pulse, skin colo l" change (more pink), and increased hand
temperature. Venous relief is shown by decreased cya-
nosis and venous engorgement. Neurological signs go
from numbness to pins and needles or tingling as well as
Figure 5-127
Costodaviclilar syndrome rest.
some pain as the ischemia to the nerve is released . This is
referred to as a release phenomenon.
Adson Maneuver"'. This test is probably one of the
most common methods of testing for thoracic outlet syn-
drome reported in the literanlrc . The examiner locates
the rad ial pulse. The patient's head is rotated to face the
test sho ulder (Figure 5-129). The patient then extends
the head while the exam iner lateraU y rotates and extends
the patient's shoulder. The patient is instructed to take
a deep breath and hold it. A disappearance of the pulse
indicates a positive test.
H alstead Maneuver. The examiner finds the radial
pulse and app lies a downward traction on tlle test
extremity while the patient's neck is hyperextended and
the head is rotated to the opposite side (Figure 5- 130).
Absence or disappearance of a pulse indicates a positive
test for thoracic outlet syndrome.
Reflexes and Cutaneous Distribution
The reflexes in the shou lder region that are often assessed
include the pectoralis major, clavicular portio n (C5-
Figure 5-128
Shoulder girdl e passive elevation . A, Start position .
 CHAPTER 5 Shoulder 323

Figure 5-129
Adson 1ll3.11(U\'C r.

Figure 5-128 cont'd

fi , Relicf position .

C6 ), sternocostal portion (C7-C8 and T1 ), thc biceps

(C5-C6), and the triceps (C7-C8 ) (Figure 5-131 ).
The examiner must be 3wan; of the dermatome pat-
terns of the nerve roots (Figure 5-132) as well as the
cutaneous distribution of the peripheral nerves (Figure
5-133 ). DCflllatomcs vary from person to person , so tJ1C
diagrams arc estimations only. A scanning test for altered
sensation is performed by running the relaxed hands and
fingers over the neck, shoulders, and a.ntcrior and pos-
terior chest area. Any difference in sensation between
the two sides should be noted. These differences can be
mapped morc ex.actly using a pinwheel , a pin, a brush ,
or cotton batting. In this way, the examiner can use sell -
sation to help differentiate between a peripheral nerve
lesion and 3 nerve root lesio n referred from the cervical
sptne .
True shoulder pain f3rely extends below the elbow.
Pain in the acromioclavicular or sternoclavicular joint
tends to be localized to the affected joint and usually Figure 5-130
docs no t spread or radiate . Pain can be referred to the Halst(ad maneuver.
324 CHAPTER 5 Shoulder

Figure 5-131
POSitioning to tcst the reflexes around the shoulder. A, Biceps.
B, Triceps. C, Pt'ctoralis major.

shoulder and slirrolmding tissues frolll Illany struc-
turcs,244 including the cervical spine, elbow, lungs) heart,
diaphragm, gallbladder, and spleen (Figure 5-134;
Table 5-15 ).
Peripheral Nerve Injuries About the Shoulder
Axillary (Circumflex) Nerve (C5-C6). The axil-
lary nerve is the most commonly injured nerve in the
shoulder. and the most common cause of injury is ante-
rior dislocation of the shoulder or fracture of the neck
of the hurnerusYS,246 The nerve injury may occur d ur-
ing tJle dislocation itself or d uring the reduction. Other
traumatic events (e.g., fracnlre, bullet, or stab wounds)
or brachial plexus injuries, compression (e.g.) crutches),
quadrilateral space entrapment (Figure 5-135 ) or shoul-
der surgery also may affect the axiJlary nervc .247
Motor loss (see Tables 5-5 and 5-10) includes an
inability to abduct the arm (deltoid ), although the patient
may attempt [0 laterally rotate the ann and USt:. the long
head of biceps to abduct the arm (trick movement ). In
sornc cases, a patient is asymptomatic, although he or she
may demonstrate early fatigue with strenuous activirics, H7
There is weakness of lateral rotation owing to the loss of
teres rninor.247 The patient may attempt to usc scapular
movement (i.e .) trapezius or se rratus anterior ) to COIll -
pensate for the muscle loss (trick movement). Atrophy of
the deltoid leads to loss of the lateral roundness (fla tten -
ing) of the shoulder. Sensory loss is over the deltoid, with
the main loss being a small, 2 - to 3-cm ( I -inch ) circular
area at the deltoid insertion (see Figure 5 -9 ).
Suprascapular Nerve (C5-C6). The suprascapular
nerve may be injured by a faIl on the posterior shoul-
der, stretching, repeated microtrauma, or fracture of the
scapula .247 Commonly, the nerve is injured as it passes
through the suprasca pular notch under the transverse
scapul ar (suprascapular ) ligament or as it winds around
 CHAPTER 5 Shoulder 325

Figure 5-134
Structures referring pain to the shou lder.

-- Table 5-15
Shoulder Muscles and Referral of Pain
Muscle Referral Pattern

Levator sca pulae Over muscle [0 poste rior shoulder and

along medial borde r of scap ul a
Lati ssimus dorsi Interior angle of scapula up (0 posterior
Figure 5-132 and anterior shOllld er into posterior
DcnnatOmt: pattern oflhc shoulder. Dermatomes on olle side only ann; may refer to area above iliac crest
Jre illustrated. Rhomboids J\1cdial border of scapu la
Su praspinatlls Ovn shou lder cap and above spine of
scapula; sometimes down lateral aspect
"""'"<::::--Supraclavicular nerve of arm to proximal fo rearm
[nfraspinatus Anterolateral shoulder ;u ld medial border
----'...---- Axillary nerve of scapu la; may refer down lateral aspect
(pa rtial loss) of arm
~K-:::=F:\---- Posterior brachial Teres minor Nea r deltoid insertion , up to shoulder
cutaneous nerve cap. and down lateral arm to elbow
Lower lateral brachial Subscapularis Posterior shoulder ro scap ula and down
cutaneous nerve postno mt:d iaJ :l1ld antt:ro mt:dial aspt:cts
+--~- Medial cutaneous of arm to elbow
Teres major Shoulder cap down lateral aspect of arm
to elbow
Del toid Over muscle and posterior glenoid area
of shoulder
Coracobrachialis Anterior shoulder and down posterior arm

+-+---\--Total sensory loss

01 axillary nerve the spine of the scapula under th e spinoglenoid ligament
(Figure 5_136):44.247-252 Often , it is hard to disting ui sh
from rotato r cu ff sy ndrome, so rhe history and mecha -
nism of injury becon. . e important fo r differential diagno-
sis. M ost commo nly, the co nditi o n is seen in people who
Figure 5-133 work with their ann s overhead or in activities involving
Cutaneous distribution of peripheral nerves arou nd [he shoulde r.
326 CHAPTER 5 Shoulder

Supraspinatus

, Po".,i,n'circumilex
humeral artery

Deltoid muscte

Axillary nerve

Triceps
A B

Figure 5-135
QU:ldrilatera! space entt'apmcnt , posterior \'i~w of (he shoulder. A, "Vit.h the arm in '.uiducriclIl or at the side,
then: js no compression of rill' ax illary nerve and posterior circumtlcx humeral arrery. B, A mechanism o f
intermittent compression of the :lxillary ncn'c and posterior circurn l1ex humer;'t) :lrtcry as a resuit ofshe;.uing
a.nd dosing down ofthc space by the teres major ,111d tncs minor. ( Rcdr:lwn from Safran MR: NerVI:: injury
about the sho uldn in atWcrcs. Part 1: suprascapular ncn'e .me! ax illary nen-c, Am J Sports Med 32:8J4 , 2004 .)

Transve rse shoulder. Wasting may also be evident in the Dluscies

Suprascapular nerve scapular ligament over the scapu la.
Musculocutaneous Nerve (C5-C6). This ner ve is

---,'-13~~~~~~~:~
not commonly injured, although it may be injured by
Supraspinatus trauma (e.g., humeral dislocation or fracture) or in con-
junction with injury to the brachial plexus or adjacent
Spinoglenoid
ligament
axillary artery. Injur y to this nerve (see Tables 5-5 and
5-10 ) results primarily in loss of elbow flexi o n (biceps and
brachialis), shoulder forward flexion (biceps and coraco-
brachialis), and decreased supination strength (biceps).
Infraspinatus - - In additjon, injury to its sensory branch, the antebrachial
cutaneous nerve, leads to altered sensation jn the antero-
latcral aspect of the forearm (see Figure 5-10). This sen-
sory branch is sometimes compressed as it passes under
the distal biceps tendon, resulting in musculocutaneous
nerve tunnel syndrome. The inj ur y results in sensory
Figure 5-136 loss in the forearm; it is usually the result of forced elbow
Suprascapular llC[\C . hyperex tension or rcpeated pronation (e.g., excessive
scrcwdriving, backhand tennis stro kes) and may be mis-
diagnosed as tennis elbow.
Long Thoracic Nerve (C5-C8). Injur y to the long
thoracic nervc, although not com mOil , may occur frolll
cocking and following through. (c.g., volleyball spiking, repetitive microtraullla with heavy effort above shoulder
pitching).3'JW}.2s3,254 height, pressure on the nerve frolll backpacking, vigor-
Signs and symptoms include persistent rear shoulder OliS upper limb acrivitics 236 (e.g., shoveling, chopping,

pain and paralysis of the supraspinatus (suprascapular stretching), or wounds (see Tables 5-5 and 5- 10 ). The
notch ) and infraspinatus (suprascapular notch and spine result is paralysis of the serratus anterior, callsing wing-
of scapula) , leading to decreased strength of abduction ing (med ial border) of the scapula and pain and weakness
(supraspinanlS) and lateral rotation (intraspinatus) o f the on forward tlexion of the extended arm.::I9,4:', 411.56,2-I5.2-I6,250
 CHAPTER 5 Shoulder 327

,255,256Abduction above 90 is difficult because of scapu-
lar winging. Stabilization of the scapula by the examiner
enables the patient to further abduct the arm. Recovery
time can be as long as 2 years.
Spinal Accessory Nerve (C3-C4). The spinal acces-
sory nerve is vulnerable to trauJllatic injury as it passes
the posterior triangle of the neck; injury spares the ster-
nocleidomastoid muscles but affects the trapezius muscle.
A common example would be abnormal pressure from a
poorly fining backpack (see Tables 5-5 and 5-10). Shoulder
drooping (scapula is translated laterally and rotates down -
ward) and scapular winging (medial superior portion)
with medial rotation of tbe inferior angle, especiaUy on
abduction, Jllay be evident, along with deepening of the
supraclavicular fossa (asymmetric neck linc ) as a result of
trapezius atrophy (Figure 5-137).")57);' The patient has
difficulty abducting the arm above 90. 245 Interestingly,
Safran reported that spinal accessory palsy results in scapu-
lar winging on abduction but not forward flexion. 236
Joint Play Movements
Joint play Illovements are llSUaily performed \vith the
patient lying supi.ne ,48.259 The examiner compares the
amount of available movement and end feel on the affected
side with the movement on the unaffected side and notes
whether the movements affect dle patient's symptoms.
To perform the backward joint play movement of the
humerus) the examiner grasps the patient's upper limb)
placing one hand over the anterior humeral head. The
other hand is placed around the humerus above and ncar
tile elbow while the patient's hand is held against the
examiner's thorax by the examiner's arm (Figure 5-138,
A ). The examiner then applies a backward force (sinlil.r
Joint Play Movements of the Shoulder Complex
Backward glide of the humerus
Forward glide of the humerus
Lateral distraction of the humerus
Caudal glide of the humerus (long arm traction)
Backward glide of the humerus in abduction
Lateral distraction of the humerus in abduction
Anteroposterior and cephalocaudal movements of the clavicle at
the acromioclavicular joint
Anteroposterior and cephalocaudal movements of the clavicle at
the stemoclavicular joint
General movement of the scapula to determine mobility

Figure 5-137 .' . . .

Spinal accessory nerve paby. A 17-year-old male pari~nr wit~ a I -ycar hIstory o f shou.lder pam . A) WlOglOg of
[he superior medial angle of UIC scapula with abductIon . A IlIle drawn alo~g the medial .border of Ule normal
left shoulder is to be compared with the symptomatic right shoulder. B, Forward elevatIon doe~ not result
. ' . pan" n, d ,' I"e-c"riaring spinal accessory nerve palsy winging from lo ng thoraCIC nerve palsy
III wmgmg III .L
ullS .... , I' , , . . I
. . (F Sal~'n MO . Nerve in)' U'y about the shouldcr in athletcs. Part 2: long thoraCIC nerve, spllla
wlllgmg. rom ,a I I..... 00 )
acccsson' ner\'e burners/stingers, thoracic ou tlet synd rome , Am) Spm'fJ M,d 32 : I 065 , 2 4.
. '
328 CHAPTER 5 Shoulder

Figure 5-138
Joint play movements ofthc shoulder cC)Jllplex. A, Backward glide of the humerus. B, Forward glide orthe
humerus. C, l~\fer.ll dis(!";lcrion of the humerus. D, Long arm tr:'lction applied below dbow. E, Long arm
tmetion applied abm'c elbow. P, Backward glide of tile humcrm. in abductioll .

Figure 5-138 conl'd
G, Joint play offhc acrOl1.1i(ldavi cul3f joint". H, Joint play oftht: stcrnodavi cu13r joinr. J, Gcncralmovcmem of
the scapula to dercrminc mobility
to a posterior shift ), keeping the patienr's arm parallel
to the body so thar no roration or torsion occurs at the
glenohumeral joint.
Forward joint play movement of the humerus is car-
ried out in a similar fashion , with the cX<lminer's hands
placed as shown in Figure 5- 138, B. The examiner applies
an anterior force (anterior drawer ), keeping the patient's
arm parallel to the body so that no rotation or torsion
occurs at the glenohumeral joint.
To apply a lateral distraction joint pJay movement to
the humerus, the examiner's hands are placed as shown
in Figure 5-138, C. A lateral distraction force is applied
to the glenohumeral joint, with the pat.ient's arm kept
parallel to the body so that no rotation or torsion occurs
at the glenohumeral joint. The examiner must be carc-
ful to apply the lateral distraction force with the flat of
the hand, as one sometimes has a tendency, when apply
CHAPTER 5 Shoulder 329
ing a force, to nlrll the hand so the distraction is applied
through the side of the index finger. This is uncomto rt-
able for the patient.
Caudal glide (long arm traction ) joint play movement
is performed with th e patient in the same supine posi-
tion . The examiner grasps above the patient's wrist with
one hand and palpates with the other hand , below the
distal spine of the scapula posterioriy and below the dis-
tal clavicle anteriorly over the glenohumeral joint line
( Figure 5 -138, D ). The examiner then applies a traction
force to the shoulder while palpating to see whether the
head of the humerus drops down ( moves distally ) in the
glenoid cavity as it normally should. IftJle patient COl)1-
plains of p3in in the elbow, the test may be don e with the
hands positiol1t::d as in Figure 5-138, E.
The examiner then abducts the patient'S arm to 90 0 ,
grasping abo\'e the patient's wrist with one hand while
330 CHAPTER 5 Shoulder
stabilizing the thorax with the other hand . The examiner
applies a long arm traction force to determine joint play
in this position.
Witl1 the patient's arm abducted to 90, the examiner
places olle hand over the anterior hurnerus while stabiliz
ing the patient's arm with the other hand and stabilizing
the patient's hand against the thorax with the same arm.
A backward force is then applied, keeping the patient's arm
parallel to the body. This is a backward joint play move-
ment of the humerus in abduction (Figure 5-138, F).
To assess the acromioclavicular and sternoclavicular
joints (Figures 5-138, G, and 5 -138, H, respectively ), the
examiner gently grasps the clavicle as close to the joint
to be tested as possible and moves it in and o ut or up
and down while palpating the joint with the other hand.
Because the bone lies just under the skin, these techniques
arc uncomfortable for the patient where th e exaJniner
grasps the clavicle . The examiner should warn the patient
befo re attempting rhis techn.ique. A comparison of the
amount of movemen t available is made between the two
sides. Care should be taken not to sq ueeze the clavicle, as
this roo may CJuse pain.
For a determination of mobili ty of the scapu la ) the
patient lies on o ne side to fixate the thorax with th e
arm relaxed and resting behind the low back (band by
opposite back poc ket). The uppermost scapula is tested
in this position. The examiner faces the patie nt, placing
the lower hand along th e medial border of the patient's
scapul a. The hand of the examiner's other arm holds
the upper (cranial ) dorsal surface of the patient's scap-
ula . To relax the: sca pula fu rth er, th e patient is asked to
relax against th e examiner an d t.he examiner uses his or
her body to push the patient's test sho ulder posteriorly,
retracting it to obtain a berter hold o n the scapula. By
holding the scapul a in this way, the exa miner is able to
move it medially, laterally, caudally, cranially, and away
f[mn the thorax (Figure 5-138 , J).
Palpation
When palpating the shoulder complex, th e examiner
should note any muscle spasm , tenderness, abnormal
bumps, o r other signs and symptoms that may indicate
rhe source of patho logy. The examiner should perform
palpation in a systcmatic manner, begin ning with the
anterior structures an d wo rkin g around to the posterior
structures. Findings on the injured side should be com-
pared with those o n the unaffected side. Any differences
between the two sides should be noted, because they
may indicate the cause of the patient's problems.
Anterior Structures
T he anterior structures of the shoulder may be palpated
with th e patient in the supine lying or sitting position
(Figure 5- 139, A ).
Clavicle. The clavicle should be palpated along its full
length for tenderness o r abnormal bumps, such as callus
formation after a fraculre, and to ensure that it is in its
resting position relative to the uninjured side. That is, it
may be rotated anteriorly or posteriorly more than the
unaffected side, o r one end may be higher than that of
the uninjured side, indicating a possible subluxation or
dislocation at the sternoclavicular or acromioclavicular
joint.
Sternoclavicular Joi.nt. The sternoclavicular joint
should be palpated for normal positioning in relation to
the sternum and first rib. Palpation should also include
the supportin g ligaments and sternocleidomastoid mus-
cle. Adjacent to the joint, th e supraste rnal notch may be
palpated. From the notch , the examiner moves the fin -
gers laterally and posteriorly to palpate the first rib . The
examiner should apply sLight caudal pressure to the first
rib on both sides and note any difterence . Spasm of thc
scalene muscles or pathology in the area may elevate the
first rib o n the affected side.
Acromioclavicular Joint. Like the sternoclavicular
joint, the acromioclavicular joint sho uld be palpated for
normal positioning and tenderness. Likewise, supporting
ligaments (acromioclavicular and coracoclavicular) and
the trapezi us, subclavius, and deltoid (anterio r, middle,
and posterior fibers) muscles should be palpated for ten-
derness and spasm.
Coracoid Process. The coracoid process may be
palpated approximately 2 .5cm (1 inch ) below th e junc-
tion of the Lateral o ne third and medial two thirds of the
clavicle. The short head of biceps and coracobrachialis
muscles originate from, and the pectoralis minor inserts
into, this process. With a SICK scapula syndrome, the
coracoid is often very tender.20
Sternum. In the midline of th e chest, the examiner
should palpate th e three portio ns of th e ste rnum (manu -
brium, body, and xiphoid process), noting any abnormal -
ity or tenderness.
Ribs and Costal Cartilage. Adjacent to the sternum,
the examiner should palpate the sternocostal and costochon-
dral articulations, noting any swelling, tenderness, or other
abnormality. These "articulations" are sometimes sprained
or subluxed, or a costochondritis (Tietze's syndrome) may
be evident. The examiner should palpate the ribs as they
extend around the chest wall, seeking any po tential pathol-
ogy and noting whether they arc aligned with each o ther,
or one protrudes more than the adjacent ones as sometimes
occurs with anterior shoulder pathology.
Humerus and Rotator Cuff Muscles. Moving lat-
erally from the chest and caudally from the acromion
process, the examiner should palpate the humerus and
its surrounding str uctures for potential pathology. The
examiner first palpates the lateral tip of the acromion
process and then moves inferio rly to the grea ter tuberos-
ity of the humerus. T he examiner shou ld then laterally
 CHAPTER 5 Shoulder 331

Clavicle
Spine of scapula
Sternoclavicular joint
Acromioclavicular joint

Acromion ------~c:5~~~;;:2:-<;;;:;
Coracoid process --1---,,;?';i;~J J~_--r-Manubrium of sternum

Rib
Greater tubercle

Lesser tubercle
~~=E~~-F--\It-
-f,,' ---+l-- Body of sternum
Bicipital groove

Humerus '~-'O."::7~:p._-+-I-_ Costal cartilage

Axilla
A Xiphisternum

2nd Rib Superior angle

of scapula
Spinous process Clavicle
>-,,_~ Acromion

Facet joint T---......:);fr~~ ~:::::::::::;~it:T~-Greater tubercle

Spine of scapula

7th Rib=t1==~,~.~_~ '"

Inferior angle
of scapula
'. Lateral border
Figure 5-139
of scapula
Bony 1.1l1dlmrks of the shouldcr region. A,
B Anterior vicw. H, Posterior view.

rotate the humerus. During palpation, the long head of
the biceps in the bicipital groove will sLip under the fin
gcrs, followed by the lesser tuberosity of the humerus
(Figure 5-140 ). As with all palpation, the testing should
be done gently and carcful1y to prevent causing the
patient undu e pain. By rotating the humerus alternately
laterally and mediaIJy, the smooth progression over ule
three structu res is normally noted (de Anquin test), and
the lesser tuberosity is tCit at the level of the coracoid
process. If the examiner then palpatcs along tilC lesser
ulbcrosity and rJ1C lip of U1C bicipital groove, tilC fin gas
will rest on the tendon of the subscapularis muscle. The
subscapularis may also be palpated in thc triangle made
up of the superior border of pectoralis major, the clavicle,
and the med ial bordcr of the delroid. 260 If the examiner
places the thumb over the lesser tuberosity and grips"
the shoulder between the second, third, and fOllrth fin -
gers as shown in Figure 5- l ) the fingers will be over the
insertion of the other three rotator cuff muscles: supra-
spinatus, infraspinauls, and teres minor. Moving laterally
over the bicipital groove to its other lip, the examiner
may palpate the insertion of the pectoralis major muscle.
The patient is then asked to furrher mcdjally rotate the
humerus so that the forearm rests behind the back, and
the examiner palpates 2 cm inferior to thl: anterior aspect
of the acromion process for the supraspinants tendon.
Any tenderness of the tendon should be noted. The
examiner tilen passively abducts ti1C patient's shoulder to
between 80 and 90 and palpates the notch formed by
thc acromion and spine of ti"le scapu la with the clavicle .
In the notch, the examiner is palpating U1C musculoten-
dinous junction of the supraspinatus muscle.
The examiner should then palpate the head of the
humerus and its relationship to tile glenoid cavity.
By placing the fingers over the anterior humeral head and
the thumb over the posterior humeral head, the examiner
then slides the fingers and thumbs mediall y (see Figure
5-45 ). As the humeral head is larger than the glenoid
witb only about 25% to 30% of the head in contact with
the glenoid at anyone time, the examiner's fingers and
thumb will '"'"dip in" as they approach the glenohumeral
joint. This '"'dipping in" should be slightly greater ante-
riorly. If there is no dipping anteriorly or posteriorly, it
means the humeral head is sitting further posteriorly or
332 CHAPTER 5 Shoulder
Figure 5-140
Palpation around the shoulder. A, Gre:nn tuberosity. H, Lesser tuberosity. The bicipital groove lies between
these two landmarks.
anteriorly than it should. Once th e examiner has found
the glenohumeral joint (at the point of hardness after tJle
"dip in"), he or she can palpate along the joint line supe ~
riorly and inferiorly 011 the anterior and posterior surface
feeli.ng for any pain or the presence of pathol0!ll' (torn
labrum , ligament, or capsule). The examiner can deter-
mine the joint line by mediaJly and laterally rotating the
humerus while palpating. The examiner should be able
to differentiate the glenoid (docs not move ) from the
humerus (rotates). As the technique is uncomfortable to
the patient, the patient should be warned abollt possible
discomfort, and the results should be compared with the
normal side. With care, the examiner can palpate all of
the g lenoid edge except superiorly where the proxilnity
of the acromion ro the humerus docs not aHow it.
Axilla. With the shoulder slightly abducted (20 0 to
30) , the examiner palpates the structures of the axilla,
latissimus dorsi muscle (posterior wall), pectoralis major
muscle (anterior waLl), serratus anterior muscle (medial
wall), lymph nodes (palpable only if swollen ), and bra-
chial artery. The inferior glenohumeral joint and glenoid
edge may also be palpated in the axilla. The patient is
then asked to lie prone on the elbows (sphinx position)
with the shoulders slightly laterally rotated and ti,e elbow
slightly adducted in rclation to the shoulder. The exam-
iner then palpates just inferior to the most lateral aspect
of the sca pula tor the insertion of the infraspinatus mus-
cle. Just distal to this insertion , the examiner may be able
to palpate the insertion of the teres minor.
Posterior Structures
To compkte the palpation, the patient may be either sit-
ting or lying prone with the upper limb by the trunk (see
Figure 5- 139, 8 ).
Spine of SCr.1.pula. Frail,} the acromion process the
examiner moves his or her haJlds alon g the spine of the
scapula, noting any tenderness or abnormaJity.
Scapula. The examiner follows thc spine of the sca p-
ula to thc medial border of thc scapula and th en follows
the outline of the scapula, which normally extends from
the spinolls process ofT2 to the spinalIS process of T9 ,
depending on the size of the scapula. The superio r angle
lies at the level of the T2 spina lIS process. The base or
root of the spine of the scapula lies between T3 and T4,

and the inferior angle lies between T7 and T9. Along the
medial border and spine of the scapula, the examiner can
palpate the trapezius muscle (upper, middle, and lower
parts) and the rhomboids. At the inferior aogle, the latis-
simus dorsi may be palpated. The examiner then moves
around the inferior angle of the scapula and along its lat-
eral border. Against the lateral border and along the ribs,
tJ1C serratus anterior can be palpated. Near the glcnojd,
long head of triceps, and teres minor may be palpated.
After the borders of the scapula have been palpated, d,e
posterior surface (supraspinatlls and infraspinatus mus-
cles ) may be palpated for tenderness, atrophy, or spasm.
By positi oni ng the arm in forward flexion (60), add uc-
tion and h\tcral rotation, infraspinatus and teres minor
may be palpated just under and slighdy inferior to the
posterior aspect of the acrolTIlon. 260
Spinolls Processes of Lower Cervical and Thoracic
Spine_ In the midline, the examiner may palpate the cer-
vica l and thoracic spinous processes for any abnormality
or tenderness. This is followed by palpation of the trape-
ziu s muscle.
Diagnostic Imaging
Diagnostic imaging is used in conjuncdon with a physical
examination to determine a diagnosis. It should never be
used in isolation, but any findings should be related to
clinical signs to rule out false positive indications or age-
related changes. 261 263
Posterior
glenoid rim m
Routine A-P shoulder
r) ~-. . . Anterior
~!~~~~
..nd ~-1',()..~O(.o;
glenoid rim glenoid rims
superimposed _ _
CHAPTER 5 Shoulder 333
Plain Film RadiographY-2S8
Anteroposterior View. This may be a true anterior-
posterior view or a tilt view (Figure 5- 141 ). A great deal
of information can be obt-uned fronl either view (Figure
5- 142 ).
I . The relation of the humerus to the glenoid cavity
should be examined. The "empty glenoid" sign may rec -
ognize posterior dislocations. Normally, the radiograph
shows overlapping shadows of the humerus and glenoid.
With a posterior dislocation, this shadow is reduced or
absent (Figure 5-143).267
2. The relation of the claviclc to the acromion process and
the humerus to the glenoid should also be observed.
3. The examiner shou ld determine whether the epiph-
yseal plate of the humeral head is present and , if so,
whether it is normal.
4. The examiner should note whedler there are any cal-
cifications in any of the tendon s ( Figure 5- 144), espe-
cially those of the supraspinatus or infraspinams muscles,
o r fractures. 268 .269
5. The examiner should note dlC configuration of the
undersurface of the acromion (see Figure 5 - 142 , D,
Figure 5- 145 )270.271 and the presence of any subacromial
spurs ( Figure 5- 146 ). The pOSliible configurations arc
type I (tlat [17%]), type II (c urved [43%J ), and type III
(hooked [39%]). Hooked acromion is not seen in young
people and is dlOught to be part of a degenerative pro-
cess.
~
~$
/ '\ ~...
Figure 5-141
J'ositiOllin g for the .lnrcropostcrior radiographic view.
334 CHAPTER 5 Shoulder

Figure 5-142
Normal radiographic examination . A, l ...1.1craJ rOlation. The greater tuberosity (GT ) is shown in profile .
The humeral head normally o\'c:r\aps rhe glenoid 011 this view. The Jnterior (bla ck arrows) and posterior
(arrowheads) gicnoid margins .ut': wed) shown and do not overt .. p because oft-he anrcrior tih of the glenoid.
The all:ll"omical (black A) .md surgical (.5) nt:cks oCthe hUlllerus arc indicated. Whitt: A - acromion prucess;
CP .. coracoid process . A vacuum phenomenon (lilh ile arrow) is present. B, !'vtedial rotarion. The overlap of
the gn::;Hn tuberosity and the humcr.d head produces a rounded appearance of the proximal humerus. LT
.. lesser ruberosity. A small CXQs[Osis is noted projening from r.he hurnnal metaphysis. C, Posterior oblique.
The gicnolulIlll:r:.11 cartilage SP;1CC is shown in profile with no overhlp of the humerus and g lenoid. D, Normal
scapular Y view. This true lateral vi~w of the scapul" (anterior oblique of the shoulder) shows the humeral head
centered over Ihe glenoid (arrows). A - acromion ; C = chwicle; CP '" coracoid process. E, Diagram of normal
scapular Y vicw.
 CHAPTER 5 Shoulder 335

CP

.....

Figure 5-142 co"I'd

F, Axillary view. A = acromion; ANT .. anterior; C .. clavicle; CP _ coracoid process. G, Normal transthoracic
view. The smooth arch formed by the inferior border of rhc scapu la and the posterior aspect of the humerus
is indicated (nrrowhends) . A lint view of the coracoid process (CP) is shown. Tbe margins of the glenoid arc
indicated (arrolJ'J). This vit:w is slightly oblique , allowing the glenoid to be shown more ell tace th:lil usual.
( from Weissman BNW, Sledge ell: Orthopedic radiology, p 219, Philadelphia , 1986, 'VB Saunders.)

6. Nledial rotation of the humerus with this view may
show a defect on the lateral aspe:ct of the humeral head
from recurrent dislocations. This defect is called a Hill-
Sachs lesion (Figure 5-147) and may be classed as
engaged or nonengaged. 272 Engaged implies the area of
the lesion articulates with the glenoid when the a.rm is in
abduction and lateral rotation.
7. The examiner should look at the acromiohum
era I interval (the space between the acromion and the
humerus ) and see whether it is normal. 273 The normal
interval is 7 to 14nun (Figure 5-148). If this distance
decreases, it may indicate rotator cuff (eaes Y" Likewise,
if the arm is medially rotated and the view shows the
coracohumcnu distance of less than 11 mm , this indicates
impingement and rotator cuff pathology.275
8. A stress anteroposterior radiograph may be used to gap
the injured acromioclavicular joint to see whether there
has been a third-degree sprain or to show an inferior laxity
at the glenohumeral joint (Figure 5- 149 ). Equal weights
of 9 kg (20 Ib) are tied to each of the patient's hands to
apply traction to the arms. If a third-degree acromiocla-
vicular sprain has occurred, the coracoclavicular distance
will increase and a step deformity wiJl be evident.
Axillary Lateral View. This view shows the relation
of the humeral head to th e g lenoid. It is used to diagnose
anterior and posterior dislocations at the glenohumeral

<q
f

Figure 5-143
"Empty glenoid" sign of posterior dislocat.ion on
anteroposterior radiogrnph . The head of the humerus
fills the glenoid in the normal radiograph (left)
With a posterior dislocation, the g.Icnoid is "empty."
especially in its anterior porrion (rigbt). ( From Magee
DJ. Reid DC: Shou lder injuries. In Zachnewski JE
ct ai, ediwrs: Arhlaic illjunes nnd r(/mbi/irnrion) p 523,
Normal Posterior Philadelphia , 1996, \VB Saunders.)
dislocation
336 CHAPTER 5 Shoulder

Figure 5-144
Calcitic tendinitis-supraspinatus and infraspinattls. A, L,ner,,] rotation view shows calcification projected over
the base of the greater tuberosity (whitt arrow) and above the greater tuberosity (open arrow). B, Medial
rotation view projects the iniTaspinatus calcificatiun (wbitt! arrow) in profile :lIld documents ils posterior
location. The supraspinatu s cakifk,uion (open flrrow) is rotated medially and mainrains its sllperior location .
(From Weissman B?\T\,y, Sledge CB: Orthopedic radiology, p. 227, PhUadclphia, 1986, WB Sau nders. )

joint (Figure 5-150) and to look for avulsion rr>cturcs

of the glenoid or a Hill-Sachs lesion. It docs, however,
rt:quirc the patient to be able to abduct the ann 70 to
90. This vicw is the best for observation of the acromio ~
clavicular joint. [0 addition, the examiner should note
the relations of the glenoid cavity, humerus, scapula, and
clavicle and any calcifications in the subscapularis, infra-
spinatus, or te.res minor fllusclcs.

Figure 5-146
ExternJ.1 subacrom ial impingement syndrome: route radiographic
abnormalities. Frontal radiograph of the shou lder shows a large
enthesophyre (arrQw) extending frolll the anteroinferitw portion of
the acromion and associated wilh os[cophyu::s at the acromioclavicular
joint and in the inferior portion OftJ1C humeral head. (hom Rcsokk
Figure 5-145 D, Kransdorf MJ : 801le (wd joint imagillg, p. 922, Philadelphia , 2005,
Acromion morphology. WE Saunders.)

Figure 5-147
Glenohumnal joint: Hill -Sachs lesion. J.11 a p:lticnr wiu) a previolls
anterior dislocation , an internal rot<ltio{l view reveals the ex tent of rhe
Hill -Sachs lesion (mTowheads). ( From Resnick D, KransdurfM): Borte
aJld joiut imagillgJ p. 833, Philo:1deJphia, WB 2005, Saunders.)
\ co mplere separation .
Figure 5-148
AcrOllliohumcraJ interval.
Transscapular (Y) Lateral View. This vicw (Figure
5 -151 ) shmvs the position of the humerus relati ve to the
glenoid and the ac ro mio n and coracoid processes. This
view is the trllC larcrru view of the scapula (see Figure
5-142 , D, an d 5-142, E).
CHAPTER 5 Shoulder 337
c
Figure 5-149
Stress r:"ldi()graph for third-degree acromioclavicular sprain.
A, No stress. B, Stress. Note the increase in [be distance between
th e cor;lcoid process and the clavicle. C, Lateral view showing the
Stryker Notch View. For this view, the patient lies
supine with the ar m forward fl exed and the hand on
top of the head. The radiograph centers on the coracoid
process. This view is lIsed to assess a Hil1-Sachs lesion
( Figure 5- 152) o r a Bankart Iesion. v6
West Point View. The patient is positio ned in a prone
position (Figure 5-153 ). This projectio n gives a good
view of the glenoid to delineate glenoid fracturcs. 277
338 CHAPTER 5 Shoulder

Arm
~ abduction

Figure 5-151
Posjtioning for transscapu]ar (Y) lateral view.

Figure 5-150
Axillary lateral view.

Photographic
plate

I
I
25
I
~"' I
I
Figure 5-153
Figure 5-152 Positioning parient for West Poi.nt ax.i IiJr)' view. The beam (bottom
A Stryker notch view demonstrates :1 notch in the posterolateral aspect left) is also angled downward to form an angle 0(25 0 fi"om the
of the hume ral head, representing:1 l::trgc Hill -Sachs It::sion . horizonral plane.
 CHAPTER 5 Shoulder 339

Arch View. Tllis lateral view is used to determine the

width and height of the subacromial arch. It helps the exam-
iner determine the type of acromial arch (Figure 5-154).

Arthrography
An arthrogram of the shoulder is useful for delineating
man y of the soft tissues and recesses around the gleno 4

humeral joint (Figures 5-155 and 5 _156 )."7)78280 The

joint ca n normaliy hold approxi mately 16 to 20 mL of
solution. With adhesive capsu litis (idiopathic frozen
shou lder), the amount the joi nt can ho ld may decrease
to 5 to lOmL. The arth rogram shows a decrease in
the capacity of the joint and obliteration of the axi llar y
fold . Also , there is an almost complete lack of fill ing of
the subscapu lar bursa with adhesive capsul itis (Figure
5 415 7 ). Tea ring of any structures, stich as the suprasp i4
natus tendon and rotator cuff, may result in ext ravaSJ. 4
rion of rhe radiopaque dye. 28 !

Figure 5-154
Arch vi!!\" of acromiocl:!vicular joint. Notice the separation of rhe
clavicle and acromion. The view also shows the relation ofthl'
humerus to the glenoid (Y view).

Figure 5-155
Normal slng1c -contrast ;'m hrogram . A, Lataal rotation. B, Medial rotation . A - axillary
recess, S _ subscapula ris recess, open IU70111S _ tendon of long head of biceps within
biceps sheath . The huml;r:) l articular can-ilage is coated wit.h contrast medium (white
arrOlvs). There is IlO contrast agent in the subacromial -sulxicltoid bursa . The defect
created by the glenoid labrum (blnck arrows) is shown. FiJlin g of thc subscapularis
rece ss is often poor o n l:lteral rotation views because of bursal compression by the
subscapularis muscl e. C, In the axillary vicw, the anterior (si'Jgle arrolV) and posterior
(double arrows) glenoid Iabral margins are shown . The biceps tendon (a rrowheads)
is surrounded by contrast medium in the biceps tendo n shea th. No contrast agent
o \'crlies the surgical neck o f the hume rus. (From Weissman Bj\,f\, Sled ge C B:
Orthopedic radiology, p. 222, Philadelphia, 1986, WB Saunders.)
c
340 CHAPTER 5 Shoulder

Figure 5-156
Normal double -contrast arthrogralll. Upright views of the patient with a sandba g suspended ITom the wrist,
and the humeru s in btcrai rotation (A) and medial rotation (B) show the: structu{CS noted on singlc-contr:1sr
examinadon and al low berter appn::ciariorJ of the anjeuiar carriiagro::s. (From Weissman fiNW, Sledge CS:
OrtIJoptdic radiology, p. 222 , Philadelphia, 1986, WB Saunders. )

Figure 5-157
Typical a.rthrographic picture in adhesive capsul itis. Note the absence
of a dcpcndclH axillary fold and poor filling of t.hc biceps. ( From
Ncviascr )S : Aruu-ography of the shoulder joint: study of the find ings
of adhesive c<lpsuliris of the shoulder,) Bone joi1lt Surg Am 44 :1328,
1962.)
Figure 5-158
Tomogram and. computed tomography scan of the glenoid labrum .
A, Normal glcnoid labrum on posterior oblique doublc-conlr.'lst
arthrotomography. Tomographic section through tht: an terior margin
of the glenoid in the poslcrior obliqut! position shows smooth
articular cartilage on the humcral head (black nrrml') and glenoid and
a smooth contour to the gknoid labrum (mhitt: arrow).
 CHAPTER 5 Shoulder 341

Figure 5158 con1'd

B, Abnormru glenoid labrum . Tomographic section shows ~l triangular defect
ill the labnun (lIIhite arrow). The bony margin of the glenoid is also irregular
(open arrolJ'). The patient had suffered a single anterior dislocation. C, Normal
glenoid labrum o n computed fOmography after do uble-contrast arthrography.
one sharpl)' pointed anterior ( arro1l's) and sligh tly rounder posterior margins of
the labru m an:: visible. D, Computed romoarthrogram shows an absence of the
anterior labrum and a loose body (arrOll'; pos(eriorl)'. (B courtesy of
Dr. Erhan Braunstein , Brigham and Women's H ospiral. Boston, Massachusetts;
C and 0 , Counesy of Dr. Arthur Newberg, BO!!toll , Massach usctts. From
WeiSSI1l3Jl BNW, Sledge CB: Orthopedic radi%m. p 257. Philadelphia, 1986,
\VB Saunders. )

Ultrasonography
Diagnosti c ultrasound is becoming 3 more frequently
used device in the shoulder. It Gill be used to measure
the acromiohumcral distancc,282 amount of laxity,283.284
and fo r rotator cuff tcars. 2115
Computed Tomography
Computed tomography, especially when combined with
radiopaqlle dye (computed to m oarthrogram, or eTA),
is effective in diagnosing bone: and soft-tissue anoma-
lies and injurit:s arou nd the shoulder, including tcars of
the labrum (Figures 5-J58 , 5- 159 , and 5- 160 ) and the
rOtator cuff. 274,28() This technique helps delineate cap-
sular redundancy, glenoid rim abnormalities, and loose
bodies.269.287-2K9
Magnetic Resonance Imaging
Magnetic resonance imaging ( MRI ) is proving to be lIse-
ful in diagnosing soft- tissue injuries to the sho ulder and
has, in f.1ct, become the method of cho icc for demon-
strating soft-tissue abnormalities ofthc sholi lder. 266 ,29Q-294
However, it is important that these abnormalities be cor-
related with clinical findin gs. 291 It is possible to differ-
entiate bursitis, peritcnonitis/ tcndinosis, muscle strains,
cspeciall y with injuries to the ro tator ( ll f f. 2Y5 .It is also use-
ful for difterentially diagnosing causes of impingement
and instability syndromes. Labral tc:.ars, Hill -Sachs lesions,
glenoid irregularities, and the state of bone marrow can
also be diagnosed in the sholi ide r wi th the lise of MIU
(Figllres 5-161 through 5_167).1<"66.,69.'96 301 Magnetic
resonance arthrography has been found to increase the
sensitivity to detecting partial thickness tears. 2,)5,JU2
Angiography
1n the casc of thoracic o utlct syndromes and other syn-
dromes involving arterial impingemcnt, angiograms are
sometimes used to demonstrate blockage of the subcla-
vian arrery during certain moves (Figure 5- 168 ).
342 CHAPTER 5 Shoulder

C 0
Figure 5-159
Normal shoulder, computell arthrotOmography. Normal anatomy is demonstrated by l:omplltcd
arthrotomograpbk sections at the level of the bicipital tendon origin (A), the coracoid process (B), rhe
subscapularis tendon, (C) and the inferior joint level (D ). Bt '" bicipital tendon ; H _ hllllleral head;
Co,. coracoid process; G - glenoid process; GT '" greater rubcrosiry ; LT '" lesser tuberosity; SuST '"
Sl1bsclpularis tendon; AGL - amcrior gknoid labrum; PGL = posterior glenoid labrum . (From Dc Lee jC,
Drcz D, cdirors: Orthopedic spurts medicitIC: principles arid practice, p. 721, Philadelphia, 1994, WB Saunders. )
 CHAPTER 5 Shoulder 343

Figure 5-160
Computed wlllography scan oflabr;ll lear (arrow) .

Figure 5-161
Tl -wcightcd ax ial magnetic resonance images from cranial (A) to caudal
(C). D .. deltoid musck; SS .. supraspinatus Illuscle; C .. coriu.:oid ; H .. humerus;
SB .. subscapularis muscle; G .. glenoid of scapula; sdb .. subdeltoid-subacromial
bursa; IS ... il)fraspinams muscle ; sbt .. subscapularis te ndon; 31 .. anterior labrum ;
TM .. teres minor muscle ; pi '" posterior labrum . (From Meyer SJF, Dalinka MK:
Magnetic resonance imaging of the shoulder, Orthop eli" North Am 21 :499,
1990.)
344 CHAPTER 5 Shoulder

Figure 5-162
Shoulder impingcmt:'llr syndrome: subacromial cnthesophyte. Sagittal oblique Tl -weighted (TR/TE , 800/20 )
spin echo MR image shows the cl) thesophytc (open arrow)) which is intimate with tht: coracoacromial
ligamcTH (solid arrow) and slIpr.1spin3tus tendon (arrowhead). ( From Resnick D , Krallsdorf MJ: Bone (wdjoiul
imaging, p. 375 , Philadelphia, 2005 , WR Saunders .)

Figure 5-163
full -thickness ro tato r cuffll'ar: MRimaging . In the coronal oblique plane, intermediate -
wei ghted (TJ\/TE, 2000/20) ( A) and T2 -wci ghted (TRI TE , 2000/80 ) ( B) spin echo MR
images show Huid in a gap (so lid arrow) in the supraspinarus tendon; the fluid is of increased
signal intensity in B. Also in B, note the increased signal intensity rdatcd to fluid in the
g!t:nohumer;tl joim (o peu nrrolJl) and subdeltoid bursa (arrowhead). Osteoarthritis oftht:
acro miocJ :w1cular joint is evident. C , In the. S:lIne patient, s:lgitral oblique T2~weighted (TR,I
TE , 2000/60) spin echo Mit images show the site (nrrolV) of disruption of the supraspinatus
tcndon , which is of high signal i{1tc:nsity. ( From Resnick D, Kr.lllSdorf M J: Bl1ne fwd jl1int
imaging, p . 925, Phibdclphja, 2005 , WB Saunders.)
 CHAPTER 5 Shoulder 345

Figure 5-164
A, Tl -wcightcd coronal image dcmonsn:aring mild thickening of the supraspinatus tendon with in termediate
signal (arrorv) present within rhe substance of the tendo n. B, T2-weightcd coronal image at the sa me level
also demonstrating thickenin g of the tendon with intermediate signal (arrow) within the [endol) . The presence
ofinrcrmediatc signa l within the tendon is diagnostic oftcndinoparhy, whereas bright (l1uid ) signal. within the
tendo n is diagnostic ofa tear. C, A globular area of low signal abnormality (arrow) in dlC infraspinatus tendon
and mild surrounding edCIll:'1 consistenr wilh calcific bursitis . ( From Sanders TG, Miller MD : A systematic
approach to magnetic resonance imaging interpretation of sportS medicine: injuries o f the shoulder, Am J Sports
Md 33, 1094, 2005.)

Figure 5-165
Rotator cuff rear. Criteria for diagnosing
a rotator cuff tear on m.agnetic resonance:
(MR) imaging include the: presence of
fluid in the expected location of the
tendon or retraction of the tcndon .
A, MR 3.rt11(ogram of a partial-thickness
articular surface tear of the supraspinatus
tendon as contrast (arrow) extends into
the substance of the tendon but nor
completely through the thickness of the
tendon. B, Convem-ional
T2-weightcd coronal image. C, Sagittal
image. Both (B) and (C) demonstrate
tluid signal intensity (arrows) extending
partially through t.he thickncss of the
tendon im'o lvin g the bu rsal surfuct',
0 , An interstitial [car (arrow) of the
supraspinatus tendon . Fluid signal
intensity (arrow) is prl'scnt within
rhe substance of the tendon but d ocs
not cxtend to either the articu lar or
blll's;11 surt:lce of the tendon. E,A rlJll -
thickness tear with bright fluid sig nal
(nrrolP) ex tending aU the way through
the thickness oflhe tendon from top
to bon om . F, A compkte tear of the
supraspinams tendon ex tending from
front to back, wi th approximately 3 em
of re-traction of the musculotendinous
junction (arrow). ( hom Sanders TG ,
Miller M D: A systematic approach
to magnetic resonance imaging
interpretation of sports medicine injuries
of the shoulder, Am J Sports M cd
33,1094, 2005.)
346 CHAPTER 5 Shoulder

Figure 5-166
Bankart lesions. A, Cartilage undermining (arrows) the anterior and posterior labrum. The articular cartilage
is intt:rrnt'diate in signal intensity and smooth and tapering as it undermines the fibrocartilage of the glenoid
labrum. This image should 1l0l be confused with a tear, which will be irregular in appearance and usually
extends completely beneath the labrum. B, Marked irregularity and fraying (arrow) afthe antcroinfcrior
labrum. C, A displaced Bankarc lesion (arrom). D, T2-weightcd coronal image through the level of the
anterior labrum demonstrating an irregular fluid collection (arrow) located within a tear ofrbe anterior
labrum, between the labrum and the glenoid. This irregularity is referred to as the "double ax.illary pOlich"
sign and is very for an anterior labral tcar. E, A minimally displaced Bankart fracture (a rrows) through the
inferior glenoid. F, Axial image with intra-articular contrast. G, Abduction external rotation image with
intra -articular contrast. Both F and G demonstrate a small collection of contrJ.st (arrows) exn:nding partially
beneath the anterior labrum, representing a nondisplaced Bankan (Perthes) lesion. H, A mc.dialized Bankart
lesion (arrows). I, T2 -wcightcd axial image through the superior aspect of the humeral head demonstrating a
concavity (arrow) of the posterosuperior humeral head, representing a Hill-Sachs deformity. The humerJ.] head
should be round on the top three images, with no flattening or concavity. (From Sanders TG, Miller MD:
A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the
shoulder, Am J Sports Med 33:1097, 2005.)
 CHAPTER 5 Shoulder 347

Figure 5-167
Superior \.. bral ;ulrnior posterior (SLAP) tear. A, Fraying and irregularity (arrOlv) of the
undersurface of the superior labrun1, consistelll with a SLi\P rcar. B, A lincar area of high
signal (arrow) cucnding into the substance of the superior labrum. l1le presence orany hjgh
sign:ll within the substance of the superior labrum is diagnostic of a SLAP tear.
e, Displacement (arron,) ofthc superior labrum away from tht: glenoid. This image
represents a rypc II SLAP tcar. D, A bucket-h.mdlc tear (type III SLAP tear) of the superior
labrum, with lhe bucket-handle fragmen( (arrow) dangling in the superior joint. E, Axial
image demonstrating an irregular (ollcction of cOntrast extending imo the bict:ps ,mehor
consistt:nt with a type IV SLAI) tear, with involvement of the biceps anchor. (From Sanders
TG, Miller M D: A systematic approach [0 magnetic resonance imaging intcrprcr:ujon of
sports medicine injuries ofdlC s.houlder, Am] Spmts Med 33:1096, 2005. )
E
348 CHAPTER 5 Shoulder

Figure 5-168
Angiograms of the:: subclavi;ul <Irtery with the arm at rest (A) and <lbdllCtcd (B). Note complete obstruction of
rhe subclavian artery in B. ( From Brown C: Compn:ssivf:, invasive referred pain to the shoulder, Clin Orthop
InS9 , 1983. )

Precis of the Shoulder Assessment*

History (s itting) Active compression test of O'Brien (SLAP)

Observation (sitting or standing) Biceps tension test (SLAP)
Examination Scapular stability
Active movunmts (sittitlg or stfl.'tlditlg) Lateral scapular slide test
Elevation through forward flexion of the arm Wall (floor) push up
Elevation through abduction of the arm Muscle/tendon pathology
Elevation "U'ough the plane of the scapula (scaption) Speed's test (biceps )
Medial rotation of the arm Yergason's test (biceps )
Latcrnl rotation of the arm Empty can test (supraspinatus)
Adduction of the arm Lift-off sign (subscapularis)
Horizon~1 adduction and abduction ofrhe arm Medial rotation "spring back" or lag test (subscapu-
Circumduction of rhe arm laris)
Pmsivc movemellts (sitting) Lateral rotation "spring back" or lag test (infraspina-
Elevation through abduction of the arm nls/ teres minor)
Elevation through forward flexion of the arm Serratus anterior weakness
Elevation through abduction at tbe glenohumeral Thoracic outlet tests
joint only Roos test
L1teral rotation of the arm Reflexes and cuta1JCOUS distribution (sitting)
Medial rotation of the arm Reflexes
Extension of the arm Sensory scan
Addu ction of the arm Peripheral nerves
Horizontal adduction and abduction of the arm Axillary nerve
Special tests (sitting or strmding) Suprascapular nerve
lnstability tests Musculocutaneous nerve
Load and shift test (a nterior and posterior) Long thoracic nerve
Sulcus sign Spinal accessory nerve
Feagin test PatpatiMI (sitti ng)
Posterior apprehension test Resisted isometric m01'emwts (mpine tyi"g)
Impingement tests Forward flexion of the shoulder
Neer test Extension of the shoulder
Hawkins-Kennedy test Abduction of the shou lder
Posterior internal hnpingcmcnt test Adduction of the shoulder
L1bral tears Medial rotation of the shoulder
Clunk test (B ank.rt ) Lateral rotation of the shoulder
Anterior slide test ( Bankart) Flexion of the elbow
 CHAPTER 5 Shoulder 349

Precis of the Shoulder Assessment*-cont'd

Extension of the elbow Forward glide of the humerus

SpeciaL tests (supine lyi'l;g) Lateral distraction of the humerus
Instability rests Long arm traction
Crank (apprehension ) and relocation tests (anterior) Bad:ward glide of the humerus in abduction
Norwood tcst (posterior) Anteroposterior and cephalocaudal movements of the
Push-pull test (posterior) clavicle at the acromioclavicu lar joint
Labral tcars Anteroposterior and cephalocaudal movements of the
Clunk rest clavicle at the sternoclavicular joint
Muscle/ tendon pathology General movement of the scapula to determine mobility
Trapezius wcakocss-3 positions (prone lying ) Diagnostic imaging
Pecroralis minor tightness (supine lying)
Pccmralis major tightness (supine lying) "The precis is shown in an o rder that limits the amo unt of movement
Neurological tests that the patient has to do but ensures that all necessary stmctures
Upper limb tension tests are tested. Afh:r any examination, the patient sho uld be warned
Joint play movements (mpillc lying) of the possibility that symptoms may exacerbate as a result of the
Backward glide of rhe humerus assessment .

Case Studies
When doing these case studies, the examiner should list the appropriate questions to ask the patient and should specify why they
are being asked, what to look for and why, what things should be tested, and why. Depending on the patient's answers (and the
examiner should consider numerous responses), several possible causes of th e patient's problem may become evident (examples
are given in parentheses). The examiner should prepare a differential diagnosis chart. He or she can then decide how different
diagnoses may affect th e treatment plan . For example, a 23-year-old man comes to th e clinic complaining of shoulder pain. He
says that 2 days earlier he was playing touch football. When his fri end threw the ball, he reached for it, lost his balance, and fell
on the tip of his shoulder but managed to hang onto the ball. How would you differentiate between acromioclavicular sprain and
suprasp inatu s tendinitis? Table 5- 16 demonstrates a differential diagnosis chart for the two conditions.

1. A 47-year-old man comes to YOli complaining of
pain in the left shoulder. There is no history of over-
use acrjvity. The pain that occurs when he elevates
his sho ulder is referred to his neck and sometimes
down the arm to his wrist. Describe your assessment
plan fo r this patient (cervical spondylosis versus sub-
acromial bursitis) .
2 . An 18 -year-old woman reccntJ y had a Putti -
Platt procedure for a recurring dislocation of the
left sho ulder. When yo u sec her, her arm is still in a
sling, but th e surgeo n wants you to begin tre atment .
Describe your assessment fo r this patient.
3. A 68-year-old woman comes to you complaining
of pain and resrricred ROM in the right shoulder.
She teUs you that 3 months earlier she slipped on a
rug on a tile fl oor and landed o n her elbow. Both her
elbow and shoulder hurt at that time. Describe your
assessment plan for this patient (olecranon bursitis
versus adhesi ve capsulitis) .
4. Parents bring their 5 -year-old son in to see you .
They state that he was running around the recrc-
ation room chasing a friend when he tripped o ver a
stool and landed on his shoulder. He refuses to move
his arm and is crying because the accident occurred
onJy 2 hours earlier. Describe your assessment plan
for this patient (clavicular fracture versus humeral
epiphyseal injury).
5. A 35 -year-old female master swimmer comes to
you complaining of sbo ulder pain. She states she
has been swimming approximately 2000 m pcr day
in two training sessions; she recently increased her
swimming from 1500 m per da y to get ready fo r a
competition in 3 weeks. Describe your assessment
plan for this patient (subacromial bursitis versus
bice ps tendinitis ).
6. A 20 -year-old male tennis player comes to YOll
complaining that when he serves the ball , his arm
" goes dead. " He has had this problem for 3 weeks
but never before . He has increased his training dur-
ing the past 111onth . D escribe your assessment plan
for this patient (tho racic outlet syndrome versus bra -
chial plexus lesion ).
C ontinued
350 CHAPTER 5 Shoulder

Case Studies-cont'd
7. A IS -year-old female competitive swimmer comes
to you complaining of dilfuse shoulder pain. She
notices the problem most when she does tJ1C back-
stroke. She complains that her shoulder sometimes
feels unstable when doing this stroke. Describe your
assessment plan for this patient (anterior instability
versus supraspinatlls tendinitis).
8. A 48 -year-old man comes to YOll complaining of
neck and shoulder pain. He states that he has dilC
fieulty abducting his right arm. There is no history
of tfallma , but he remembers being in a car accident
10 years earlier. Describe your assessment plan for
this patient (cervical spondylosis versus adhesive cap-
sulitis ).

Table 5-16
Differential Diagnosis of Acromioclavicular Joint Sprain and Supraspinatus Paratenonitis
Acromioclavicular Joint Sprain Supraspinatus Paratcnonitis

Observation Step deformity (third-degree) Norma.!

Active movement Pain especially at extreme of motion Pain on active movement, especially of
(horizontal adduction and full elevation abduction
especially paintld)
Passive movement Pain on horizontal adduction and elevation No pain except jf impingement occurs
Muscle spasm end feel at end of ROM
possible
Resisted isometric movement May have some pain jfrest causes stress on Pain on abduction
joint (e.g.} abduction) May h~lve some pain on stabilizing for
other movements
Functional tests Pain on extremes of movement Pain on any abduction movement
Special tests Acromioclavicular shear test painful Empty can test positive
Impingement tests positive
Reflexes and cutaneous distribution Negative Negative
Joint play Acromioclavicular joint play movements Negative
painfi.t1
Palpation Acromioclavicular joint painful Supraspinatus tendon and insertion
tender or painful

ROM = r:l11gc ofmorjon.

References
To enhance this text and add value for the reader, all rderences
have been incorporated into a CD-ROM that is provided \v1th
this text. The reader can view the reference source and access
it online whenever possible. There are a total of 331 cited and
other general references for this chapter.
 CHAPTER 5 Shoulder 351

APPENDIX 5-1
< ~..c>'-"'. ,,~ . . . .~,.~ __

RUlA8IL1TY, VALIDITY, SPWflCITY, AND SfNSITIVITY Of SpWALlDIAGNOSTIC Tms US[D IN T"f

SHOULDfR
AC RESISTED EXTENSION TEST
Sensitivity Odds Ratio
Chronic acromjoclavicular Positive likelihood ratio 4 .8,
lesions 72%303 negative likelihood ratio 0.33

Specificity Sensitivity Odds Ratio

For SLAP 47%. for any labrallesion For SLAP 54%, for any labral Positive likelihood ratio for SlAP 1.02 ,
including SLAP 73%304 lesion including SLAP 63%3()<1 aoy labrallesion 2 .33; negative
For labral tear 31%305 For labral tear 54%305 likelihood ratio for SLAP 0 .98,
L1bral abnormality 98.5%, Labral abnormality 100%, any labrallcsion 0 .51
acromiod avicular joint acromioclavicular joint Positive likelihood ratio 0.78,
abnormality 96.6%187 abnormality 100%187 negative likelihood ratio 1.48
Unstable superior labral anterior Unstable superior labral anterio r Positive likel ihood ratio
posterior lesions 11. 1%HIO posterior lesion s 77.8%1 7'9 for labral abnofmality 66.66,
For labral tear 55%300 Fo r labral tear 47%106 acromioclavicular joint abnonnaUry 0
Chronic acromioclavicular C hronic acromioclavi cular Positive likelihood rati o 0 .87,
lesions 95 %303 les ions 7 2%303 negative Likelihood ratio 1.90
Positive likelihood ratio 1.04,
negative likelihood ratio 0.96
Positive likelihood ratio 14.4 ,
negative Hkclihood ratio 0.29

AMERICAN SHOULDER AND ELBOW SURGEONS STANDARDIZED ASSESSMENT FORM (ASES)

Reliability Validity Specificity Sensitivity Responsiveness Odds Ratio

Total ICC - 0.84, Internal consjstency 75%307 91%307 Total SRM - 1.54 Positive likelihood
pain lCC - 0.79 , cronbach's alpha 0.86, effect size :IE 1.39, ratio 3.64, negative
n..1l1ction convergent validity of pain SRM - 1.08 likelihood ratio 0.12
ICC _ 0.82'" ASES with ( Penn SCOfe etTect size - 1.07,
ICC - 0 .96" " r - 0 .78 , SF-36 physical function
Test-retest overaU function score r ... 0 .41, SRM - \. 34
ICC - 0.94"" SF-36 role physical score effi:.ct si7-c _ 1.24307
r - 0.33, SF-36 physical Shoulder instability
component su mmar y effective size - 0 .86,
r = 0.40) di\'ergent validity SRM - 0.93, rotator
SF-36 role emotional score cuff disease etTee[
r - 0 .24, SF-36 mental size - 1.33 ,
health score r - 0.05 , SRM 1.16,
SF-36 mental component gle nohumeral
r ~ 0.15 , discrim inant arthritis effect
validity higher SCOTes of the size ... 1.74,
ASES in patients with score SRM 1.11 " 9
"gotten much better" tha.n
those wh o had "gotte n
slightly better" p < 0.001
and between rating of the
physiotherapist of the
fi.mcrional limitati o n of
the patient p < 0.001107

COlltwued
352 CHAPTER 5 Shoulder

APPENDIX 5-1-cont'd
. ' L "' -~l--.ao:"..",, __..-

AMERICAN SHOULDER AND ELBOW SURGEONS STANDARDIZED ASSESSMENT FORM (ASES)-cont'd

Reliability Validity Specificity Sensitivity Responsiveness Odds Ratio

Croll bach alpha for

shoulder insrabiJicy 0.61,
rotator cuff disease 0.64)
glenohumeral arthrit.is
0.62309
Contellt validity
showc,d minimum floor
and ceiling cftcCtS 309
Criterion vaJidiry correlation
with physical fimctioning
r _ 0.57 (p <0 .001 ),
role physical activity
r = 0.32 (p - 0.002 ),
bodily pain r - 0.58
(p < 0.00 I ), role
emotional r - - 0.09
(p - 0.49), mcntal health
r - -0.08 (p - 0.67 ),
,itality r - 0.11 (p - 0.27),
social function r - 0.10
(p - 0.34)'"
Construct validity: 23
hypotheses were constr-
ucted by consensus and
showed co be true and
significant (p < 0.05 )3()<)

ANTERIOR APPREHENSION TEST

Specificity Sensitivity Odds R.1tio
For SLAP 63%, for any Iabral lesion For SLAP 30%, for any labeal lesion Positive likelihood ratio for
including SlAP 87%304 including SLAP 40%304 SLAP 0.81 , for any labral
lesion 3 .08; negative likelihood
ratio for SLAP 1.11 , for any
labral lesion 0.69

ANTERIOR RELEASE TEST

Reliability Validity Specificity Sensitivity Odds Ratio
Inrerratcr for pain Accuracy: 90.2%m 88.9%\11 91.9%31 1 Positive likelihood
ICC = 0.31 , apprehension ratio 8.28 , negati\'e
ICC - 0.63, pain or likelihood ratio 0.01
apprehension fCC _ 0.45 310

ANTERIOR SLIDE TEST

Specificity Senshivity Odds Ratio I
Supe Lior glenoid labral tear 9 1. 5%1 8~ Superior glenoid labral tcar 78.4 % 1 8~ Positive likelihood ratio 9.22,
Labr,,1 tear 84%306 L.,braJ tcar 8%.'106 negative likelihood ratio 0.24
Positive likelihood ratio 0.5,
negative likelihood ratio 1.09

APPREHENSION (CRANK) TEST
Reliability
Illtrararcr for amount of
external rotation ICC .. 0.95 3 12
Interratcr for: pain ICC = 0.31,
apprehension TCe 0.47 .
II<
pain or apprehension
ICC - 0.44'10
AUGMENTATION TEST
Reliability
Interrarcr for pain ICC 0.09 , apprehension ICC '"' 0.48, pain or apprehension ICC _ 0.33 3 10
BICEPS LOAD TEST II FOR SLAP LESIONS
96.6%313
Test
Jobe and O'Brien
lobe and Apprehension
O'Brien and Apprehension
Jobe and O'Brien and
Apprehension
Jobe or O'B ri en
lobe or Apprehension
O'Brien or Apprehension
Jobe or O'Bric n or
Apprehension
MRI and C ran k
MIU and O ' Brien
COMPRESSION ROTATION TEST
Specificity
For labral tear 76%306
Specificity Sensitivity
98.91%m 52.78%312
Reliability Specificity
For any labral lesion For any labral lesion
indudi ng SLAP 91 %3tH including SLAP 41 %304
For any labral lesion For any labral lesion
induding SLAP 93%304 including SLAP 38%ltH
For any labrallesion For any labrallcsion
including SlAP 82%304 indudjng SLAP 38%,04
For any labral lesion For any labraJ lesion
including SLAP 9 1%304 including SLAP 34%3{H
For any labral lesion For any labral lesion
including SLAP 73%304 including SLAP 72%304
For any labral lesion For any labral lesion
including SLA.P 80%104 including SLAP 47%""
For any labral lesion For any labral lesion
including SLAP 73%31).1 including SLAP 72%304
For any labral lesion For any labral lesion
including SLAP 73%304 including SLAl) 72%304
For any labral lesion For any labra llcsion
including SLAP 67%304 including SLAP 43%304
For any labrallesion For any labral lesion
including SLAP 82%304 including SLAP 50%30<1
Sensitivity
For bbral tcar 24%306
CHAPTER 5 Shoulder 353
Odds Ratio
Positive Ukelihood ratio 48.42,
negative likelihood ratio 0.48
Odds Ratio
Positive likelihood ratio 26.38 ,
negative likelihood ratio 0.11
Sensitivity
Positive likel ihood rario 4.55,
negarive likelihood ratio 0.65 304
Positive likelihood rario 5.43,
negative likelihood ratio O.673Oi
Positive likelihood ratio 2.1 1,
negative likelihood ratio 0.76304
Positive li kelihood ratio 3.78,
negative likelihood ratio 0.72 304
Positive likelihood ratio 2.67,
negative likelihood rario 0.383001
Positive likelihood rario 2.35,
negarive likelihood ratio 0.66304
Positive likelihood ratio 2.67,
ne gative Ilkdihood ratio 0.38 304
Posirive likelihood ratio 2.67,
negarive likelihood ratio 0.38 304
Positive lik.elihood ratio 1.30 ,
negative likelihood rario 0.85 3Q.4
Positive likelihood ratio 2.78,
negative likelihood ra.rio 0 .6 13Oi
Odds Ratio I
Positive likelihood ratio 1,
negarive likdihood rario 1
COllonllcd
354 CHAPTER 5 Shoulder

APPENDIX 5-1-cont'd

CRANK TEST
Specificity Sensitivity Odds Ratio
For labral tcar 100%192 For labral tear 83%1<)2 Positive likelihood ratio for SLAP
For SLAP 67%, for any labral lesion For SLAP 39%, for any labraJ lesion l.05, for any labrallesion 1.48;
including SLAP 73%300l including SLAJ) 40%304 negative likelihood ratio for SLAP
For labral tear 93%191 For labral tcar 9 1%19 0.91, for any bbraJ lesion 0.82
For labral tear 56%305 For labral tear 46%305 Positive likelihood ratio 13,
Unstable superior labral anrerior Unstable superior labral anterior negative likelihood ratio 0 . 10
posterior lesions 70%180 posterior lesions 34.6%180 Positive likelihood ratio 1.04,
negative likelihood ratio 0 .96
Positive likelihood ratio 1.15 ,
negative likelihood ratio 0 .93

CROSS BOOY AODUCTION TEST

Specificity Sensitivity Odds Ratio
Tendinitis and bursitis 79.7%, Tendinitis and bursitis 25.4%, Positive likelihood ratio for tendinitis
parrial tear 78.5%, full tcar 80.8%, partia l tear 16.7%, full tear 23.4%, and bursitis 1.25, partial tcar 0.78,
overall 82%159 overall 22 .5%159 full tear 1.22. overall 1.25; negative
Chronic acromioclavicular Chronic acromioclavicular likelihood ratio for tendiniti s and
lesions 79%303 lesions 77%303 bursitis 0.94, partial tcar 1.06, full
tear 0.95, overall 0 .95
Positive likelihood ratio 3.67,
negative likelihood ratio 0.29

DASH, DISABILITY OF THE ARM, SHOULDER, AND HEAD

Reliability Validity Responsiveness

Test-retest ICC - 0.96 Construct validity: people still For observed change SRM ". 0.78
SEM == 4.6 J1 4 wo rki ng had less disability effect size 0.59, rating problem as
p < 0.0001, less disability in better SRM - 1.06 effect size 0.75,
those who couJd do all they rating fun ction as better SRM = 1.20
wanted p < 0.000 1314 effect size 0.84314
Concurrent validity with shoulder
pain and disability index (pain )
r ~ 0.82, (nmction ) r ~ 0.88, Brigham
questionnai re (symptoms ) r - 0 .7 1,
(function ) r = 0.89, pain severity
r - 0.72 , overa ll rating ofproblcm
r = 0.71 , abi lity to function r = 0.79,
abi liry to work r = 0.76 314
Subjects with workers compens~l.tion
benefits scored worse p = 0.0047 m

DEPALMA'S CLASSIFICATION OF SHOULDER CALCIFIC TENDINITIS

Reliability
lnrerrater k _ 0.234, imrarater 0.332 < k < 0.57 316
 CHAPTER 5 Shoulder 355

DROP ARM TEST

Specificity Sensitivity Odds Ratio
97.2%317 7.8%317 Positive likelihood ratio 2.78,
Tendinitis and bursitis 77.3%, Tt:lldinitis and bursirjs l3.6%, negative likelihood ratio 0.95
partial tear 77.5%, full partial tear 14.3%, filII Positive likel ihood ratio for tendinitis
rear 87.5%,overaJl 26.9%1 59 tear 34.9%,ovcrall 88.4%159 and bursiris 0.60, partial tear 0.63 ,
Chronic acromioclavicular Chronjc acromiocl,\\~clliar full tcar 2.79, overall 1.21 ~ negative
lesions 72%303 lesions 35%303 likelihood ratio for tendinitis and
bursitis 1.12, panial tcar 1.10, tidl
tear 0.74, overall 0.43
Positive likelihood ratio 1.25 ,
negative likelihood (ario 0.90
END FEEL OF SHOULDER EXTERNAL ROTATION
Reliability
Intrarater k ., 0.90, inrerrater k "" 0.83 318
END FEEL OF SHOULDER FULL ABDUCTION
Reliability
Inrrarater k "" 0.86, interratcr k = O.44HII
END FEEL OF SHOULDER GLENOHUMERAL ABDUCTION
Reliability
Intraratcr k ." 0.63, interrater k = 0.1 318

END FEEL OF SHOULDER HORIZONTAL ABDUCTION

Reliability
lntraratcr k - 1, interratcr k =< 0.75.118
END FEEL OF SHOULDER INTERNAL ROTATION
Relia b ility
lntrararcr k '" 0.89, imcrr:ucr k '" 0.43 318
GROWER SIGN
Reliability
k ... 0319
HAWKINS TEST
Specificity Sensitivity Odds R..'ltio i

25%317 92%3 17 Positive like1il100d ratio 1.23,

Te ndinitis and bursitis 44.5%,
partial tear 44.4%, full tear 48.3%,
overall 66.3%158
Chronic acromioclavicular
lesions 45%197
Bursitis 44 .3%, rotawr cuff
pathosis 42 .6%, overall 60%320
Tendinitis and bursitis 75.5%.
partial tear 75.4%, full rcar 68.7%,
overall 7L.5%'511
Chronic acromioclavicular
lesions 47%297
Bursitis 91 .7%, rotator culT
pathosis 87.5%, overall 88 .9 %320
negative likelihood ratio 0.32
Positive likelihood ratio for tendinitis
and bursitis 1 .36, partial [car l.36 ,
full tear 1.33, overall 2.12j negative
Ukelihood ratio for tendinitis and
bursitis 0.55, partial tear 0.55 ,
full tcar 0.65, overall 0 .43
Positive likelihood ratio 0.85 ,
neg;)tive likelihood ratio 1.78
Positive likelihood ratio for bursitis
1.65, rot;)tor cuff pathosis 1.52,
overall 2.22; negative likelihood
ratio for bursitis 0 . 19, rotator cuff
pathosis 0.29, overall 0 . 18

Continued
356 CHAPTER 5 Shoulder

APPENDIX 5-1-cont'd
~~:;'P;;._ ""~-"'''''''--~ _'. ~ ..:l.":.. _ _ _

HORIZONTAL ABDUCTION
Specificity Sens itivity Odds Ratio
27.7%317 82%317 Positive likelihood ratio 1.13,
negative likelihood ratio 0.65
INFRASPINATUS MUSCLE TEST
Specificity Sensitivity Odds Ratio
Tendinitis and bursitis 68.9%, Tendinitis and bursitis 25%, Positive likelihood ratio for tend initis
partial tear 69. 1%, full tea r 84%, partial tear 19.4%, full tear 50.5%, and bursitis 0.80 , partial tea r 0.63,
overall 90.1 %159 overall 41.6%159 filii rea.r 3. 16, overall 4.20; negative
likelihood ratio for tendinitis and
bursitis J .09, partial tcar 1.17,
full tear 0.59, overall 0 .65

INSTABILITY CATCH
Reliability

k = 0.25 319
INTERNAL ROTATION RESISTANCE STRENGTH TEST/KIM TEST
Reliability Specificity Sensitivity Odds Ratio

k = 0.85 321 96%321 88%321 Positive likelihood r<ltio 22,

Interrater reliabil ity 0.91 148 Labral lesion 94%148 Labral lesion 80%1"8 negative Ijkd ihood ratio 0. 12
Positive likelihood ratio 13.33,
negative likeli hood ratio 0.2 1

JERK TEST
Specificity Sensitivity Odds Ratio
L1brallesion 98%1"8 Labrallesion 73%1"8 Posit.ive likelihood ratio 36.5,
negative likelihood ratio 0.27

LAG TEST
Validity Specificity Sensitivity
A lag of 10 to 15 degrees was Internal roration lag sign is as specific Internal roration lag sign more
observed in all patients with co mplete as lift off test p =- I , external rotation sensitive as Jjft off test p = 0 .002 ,
rupture of the supraspinatu s and lag sign is as specific as the drop test external rotation lag sign is morc
infraspinam s, and 15 of 16 patients and both arc more specific than sensitive as the drop test p < 0.001
with infra , supra , and subscapularis220 jobe test p = 0.002 220 and less sensitive as the jobc
test p = 0.05 220
 CHAPTER 5 Shoulder 357

LATERAL SCAPULAR SLIDE TEST

R eliability
Intrararer ICC .. 0.75
SEM - 0.61 for subjeers
without shou lder
impairmenrs, ICC = 0 .52
SEM ~ 0 .78 for subjects
with shoulder
impairmenrs l 9S
Specificity Sensitivity Odds Ratio
Bilateral difference Bilateral difference Positive likelihood ratio for bilateral
greater than J em greater than I el11 difference greater than 1 em
position 1 ,. 48%, position I "" 35%, position I = 67%, position 2 = 0.89,
position 2 .. 54%, position 2 - 41 %, position 3 - 0 .98; differences
position 3 "" 56%; position 3 - 43%; greater than 1.5cI11 position 1 ,., 0.59,
diHerenccs greater differences position 2 - 1.19, position 3 - 0.71;
than 1.5 em greatcr than 1.5 em negative likel ihood ratio for bilateral
position] .., 53%, position I - 28%, difference greater than 1 elll
position 2 - 58%, position 2 - 50%, position 1 = 1. 35, position 2 = 1.09,
position 3 _ 52%195 position 3 _ 34%195 position 3 = 1.02; differences
Equal or greatc r than 1.5cm position 1 _ 1. 36,
greater than 1.5 em position 2 - 0.86, position 3 - 1.27
difference bctween
right and left sid e
with arm beside the
boy 54.9%, with hand
on dlC waist 57.7%,
with arms abducted
90 degrees and
internally rotated
35.2%, overall 26.7%m

LENNIE TEST
Reliability Validity
Interrater distance from: midline ICC> 0.66, Correlation with landmarks and radiographic measurements
angular position ICC > 0.64, scap ular d istance from: midline r > 0.69, angular posjtion r > 0 .43,
symmetry ICC co 0.74 37 scapular symme try r _ 0.6237

LOAD AND SHIFT TEST

Reliability
[ntrarater betwee n grades o f commitment: all grades k - 0.342, between grades I and If+ k ... 0.529j imerrater for all grades k
= 0.09 1, between grades I and II k - 0.208 (when analyzing only grades I and II the end fed is excluded )
Intrarater anterior ICC - 0.72, posterio r ICC - 0.42, inferior ICC - 0.65 , sulcus ICC _ 0.60 310
Test-retest for dynamometer measurement r _ 0.996 m
Test-retest with KTIOOO, dominant side ICC - 0.67, nondominant ICC = 0.76324
MR ARTHROGRAPHY FOR SLAP LESIONS
Relia bility Specificity Sensitivity O dds Ratio
Intcfrater k _ 0.77 32S
Positive likelihood ratio 4 .04,
negative likelihood ratio 0.14

MRI FDR LABRAL TEAR

Specificity Odds Ratio
92%305 42%305 Positive likelihood ratio 5.25,
negative likelihood ratio 0.63

Specificity Sensitivity Odds Ratio

Complete and partial tear
togerher 67%, partia l rear 68%326
Complete and partial rear
together 100%, partial tear 100%326
Positive likelihood ratio for complete
and partial tear together 4.35,
parti al tcar 3.12; negative likelihood
ratio for complete and partial tcar
together 0, partial tear 0

Conttntlcd
358 CHAPTER 5 Shoulder

APPENDIX 5-1-cont'd
- ....--...-,,, .. , ... ,
-~",..,.-.,-"-<',"",,-~-.,,,.., - - "'- -~ > - - ,,) ,-~-""----.~ ,

NEER IMPINGEMENT TEST

Specificity Sensitivity Odds Ratio
30.5%317 88.7%m Positive likelihood ratio 1.27,
Tendinitis and bursitis 49.2%, Tcndjnitis and bursitis 85.7%, negative likelihood ratio 0.37
partial rear 47.5%, full tear 47.2%, partial rear 75.4%, full rear 59.32%, Positive likel ihood ratio for renctiniris
overall 68.7%159 overall 68%1 59 and bursitis 1.69, partial tear 1.44,
Chronic acromioclavicular Chronic acromioclavicubl,' full tear 1.12, overall 2 . 17;
lesions 41 %'>03 lesions 57%303 negative likelihood ratio for tendiniti s
Bursitis 47.5%, rotator cuff Bursitis 75%, rotator cufT and bursitis 0.29, partial tear 0.52 ,
pathosis 50.8%, overall 62.5%310 pathosis 83.3%, overall 77%'uO full tear 0.86, overall 0.46
Positive likelihood ratio 0 .96,
negative likelihood ratio 1.05
Positive likelihood ratio for
bursitis 1.43, rorator cuff
pathosis 1.69, overall 2.05;
negative likel ihood ratio for
bursitis 0.53, rotator cuff
pathosis 0.33, overall 0 .37

PAINFUL ARC TEST

Reliability Specificity Sensitivity Odds Ratio

In tlexion k - 0 .69, on return 80.5%317 32.5%::117 Positive likelihood ratio 1.67,

from flexion k _ O.6P19 9.9%327
Tendinitis and
bursitis 46.9%,
partial tear 47%,
nul tear 6 1.8%,
overall 81. 1%159
Chronic
acromioclavicular
lesions 47%303
97.5 %327 negative likelihood ratio 0.84
Tendinitis and Positive likelihood ratio l.08 ,
bursitis 70.6%, negative likelihood ratio 0.25
partia l tear 67.4%, Positive likelihood rario for tendinitis
full tear 75.8%, and bursitis 1.33, partia l tear 1.27,
overall 73.5%l s'} full tcar 1.98 , overa ll 3.98;
Chronic negative likelihood ratio for tendinitis
acrornioclavicular and bursi tis 0.63, partial tear 0.69,
lesions 50%303 full tcar 0.39, overall 0.33
Positive likelihood ratio 0.94,
negative likelihood ratio 1.06

PENN SHOULOER SCORE

Reliability Validity
Test-retest overa ll ICC - 0.94, Cronbach alpha = 0.93, correlation
pain subseale ICC - 0.88 SEM - 3.8 , with conStant shoulder
satisfaction subscalc ICC - 0.93 score r = 0.85 , American Shou lder
SEM .. 1.3, function subscale and Elbow Surgeons Shoulder
ICC- 0 .93 SEM _ 6 . 1"1 Score = 0.87, correlation of each
item with total score: pain r:: 0.80,
sa tisfaction r = 0.44 ,
function r = 0.95 101
Responsiveness
Eftect size for overalJ score 1.01
SRNt - 1.27, pain subscalc 0.85
SRM .. 0 .95, sa tisfaction 1. 19
SIU"t - LIS , function 0 .80
SRM _ 1.09 101

POSTERIOR SHEAR TEST

Reliability

k = 0.35 3 111
PRONE INSTABILITY TEST
Reliability
319
k = 0.87
 CHAPTER 5 Shoulder 359

RELOCATION, FOWLER, OR JOBE RELOCATION TEST

lkJiability
Intrarater fol' amount of
external ro tation IC C .. 0.89 3 12
Interrarer for: pain ICC - 0.31,
apprehension I CC,. 0.71, pain
or apprehension ICC = 0.44310
RESISTED SUPINATION EXTERNAL ROTATION TEST
Unstable superior labral anterior
posterior lesions 8l.8%ISO
Specificity Sensitivity Odds Ratio
54.35%'" 45.83%312 Positive likelihood ratio 1,
For SLAP 63%, Fo r SLAP 36%, negative likelihood ratio 0.99
fo r an y labral lesion for any labral lesion Positive likelihood ratio for
including SLA.P 87%304 including SLAP 44%100l SlAP 0.97, for any labral
lesion 3.38; negati ve likelihood
ratio SLAP 1.01, for any labral
lesion 0.64
Odds Ratio
Unstable superior labral anrerior Positive likelihood ratio 4.55,
posterior lesions 82.8%180 negative likelihood ratio 0.21

ICC ~ 0.9 1""

SHOULDER SEVERITY INDEX
Reliability
ICC - 0.97;<)8
SIMPLE SHOULDER TEST
Reliabili ty Validity

ICC ~ 0.99 308 Patients in work compensation performed worse

on the test p 0.0034 315
III

SPEED'S TEST (BICEPS OR STRAIGHT-ARM TEST)

Validity Specificity Sensitivity Odds Ratio

A ccuracy 56% 55.5%,17 68.5%317 Jlositive likelihood ratio 1.54,

(arthroscopy)328
75% (a rthroscopy as 44% (arthroscopy as negative likelihood ratio 0 .57
gold for biceps and gold for biceps and Positive likelihood ratio 1.76,
SLAP).l28 SLAP)'" negative likelihood ratio 0 .75
For SLAP 74%, For SLAP 9%, Positive likelihood ratio for
for any labral lesion fo r any labral lesion SLAP 0.35 , any labrallesion 1.38;
induding SLAP 87%304 including SlAP 18%30'1 negative likelihood rati o for
Tendinitis and Tendinitis and SlAP 1.23, any labrallesion 0.94
bursitis 69.8%, bursitis 33.3%, Positive likelihood ratio for tcndinitis
partial tcar 70.6%, partial tear 33 .3%, and bursitis 1.10, partial tcaf 1.13 ,
full tcar 75.3%, fuj i rcar 39.9%, full tear 1.61 , overall 2.29;
overall 83.3%1 59 overall 38.3%]59 negative likelihood ratio for tendinitis
Chronic Chronic and bursitis 0 .95, partial tear 0 .94,
acromioclavicular acromioclavicular full tear 0.80, ovcrall 0.74
lesio ns 7 1%.103 lesions 24%303 Positive likelihood ratio 0.83,
negative likelihood ratio 1.07

SUBJECTIVE SHOULDER RATING SCALE

Reliability
ICC_ 0.71"8
Con tinued
360 CHAPTER 5 Shoulder

APPENDIX 5-1-cont'd
_"-._.>-"w,r''''~' ,~,,, " _. ~_. ~ ~ _ '>.i" ~ __ ~~''-,",,<_ ~

SUPRASPINATUS (EMPTY CAN OR JOBE) TEST

Reliability Specificity
Measuring rotator cuff Partial thi ckness tcars Partial thickness tcars
pathology - interrater of the supraspinatus 54%)
k0.43'" full thickness tear 70%,
large and massive full
thickness tcars 70%329
Tendinitis and
bursitis 6 .9%,
partial tear 67.8%,
full tear 82.4%,
overall 89.5%I Sll
Sensitivity
Positive likelihood ratio for partial
of the supraspinatus 62%,
full thickness tear 41 %,
large and massive full
thickness tears 88%.129
Tendinitis and
bursitis 25%,
partial tcar 32.1 %,
fu ll [car 52.6%,
overall 44.1 % 159
Odds Ratio
thickness rears of the
supraspinatlls 1.35 , full thickness
tear 1.36, large and massive full
thickness tcars 2.93; negative
likelihood ratio for partial thickness
tears of the supraspinatlls 0.70,
full th ickness tear 0.84, large and
massive full thickness tears 0 .17
Positive likelihood ratio for
tendinitis and bursitis 0.27,
partial tear 1, full tear 2.99,
overall 4.2 ; negative likelihood
ratio for tendinitis and
bu rsitis 10.87, partial tear 1,
full tear 0.57, overall 0.62

SURPRISE TEST (ANTERIOR INSTABILITY)

Odds Ratio
98 .9 1%312 63.89%312 Positive likelihood ratio 58.61 ,
negative likelihood ratio 0.36

Specificity Sensitivity Odds Ratio

Complete and partial tear
together 67%, partial rcar 80%326
Complete and partial tear
together 97%, partial tcar 98 %,l26
Posirive likel ihood ratio for complete
and partial tear together 2.94,
partial tcar 4.9 ; negative likelihood
ratio for complctc and partial
tear together 0 .04, partial tcar 0.02

UPPER LIMB TENSION (BRACHIAL PLEXUS TENSION) TEST

Reliability
Medial nerve: inrra ratcr ICC > 0 .88 SEM < 2.41 , interrater ICC - 0.33 SEM ... 6.35 310

YERGASON'S TEST
Validity Specifici ty Sensitivity Odds Ratio
Accuracy 63%3l8 EMG showed 79% (arthroscopy for 37%317 Positive likelihood ratio 2.05 )
that d1C activity of thc upper biceps and SlAP)328 4 3% (a rthroscopy for negative likelihood ratio 0.72
and lowc r subscapularis was For SLAP 96%, labral biceps and Positive likelihood ratio
significandy hi gher than the for any labral lesion SLAP)"" for SLAP 3, any labral
other muscles (p > 0 .05 )m in cl uding For SLAP 12%, lesion 1.28 ; negative likelihood
EMG showed that the SLAP 93%"" for any labral lesion ratio for SLAP 0 .92,
SUbSc'1pularis had a mean including SLAP 9%304 any labrallcsion 0 .98
activation greater than 50%
lvlMT; using a dencrvation
ancsd1cric technique and a group
of patients wirh detached
subscapu laris, they had dlC
same EMG patter but were unable
to perform the maximum internal
rotation test (elevating the dorsum
of the hand from the posterior
~ infcrior border of the scapula)221