Evidence-Based Shoulder Exam Shoulder Exam Goals What is ...

SummaryClinical Decision-Making(-) Ext. Rotation Lag Sign(-) Int. Rotation Lag Sign(-) Biceps Load I Test(-) Biceps Load II Test(-) Hornblower’s Sign(+) Active Compression (O’Brien)90+(-) Cross-body Adduction Stress Test(+) AC Resisted Extension Test•How?•ApplyingEBMDid you Rule IN a Dx.?Did you Rule OUT many?How did you decide the %?Clinical Decision-MakingLabralClinical Decision-MakingAC Sprain• Applying EBM to the use of orthopedictests1. What is my starting ‘probability’?2. How do I decide which tests to use?3. How much do I let each test’s (+) or (-)outcome affect my probability?1. What is my starting probability?Pt.• “My shoulder hurts”• 18 y/o freshman baseballoutfielder• Clinician understands• Prevalence of XX injury for thispopulation (rarely exact)• Prevalence based on ExperienceLabralHistoryAC SprainLabralHistoryAC Sprain• “where does it hurt?”• He points to his Rightshoulder – superior GH joint-line / AC joint• No history of significant shoulderinjury beyond typical soreness• No history of instability• MOI• “I don’t know; during final summer-ball game (1 month prior) I dove fora few balls and landed on my rightelbow at least once. I haven’tthrown since.”• c/o pain during throwing, lifting(military and bench press)5

Evaluation of Diagnostic TestsFalse positive rateLambda(Criterion dep.)False negative rateUncertainty Coefficient (Symmetric)Misclassification rateUncertainty Coeff. (Criterion dep.)PrevalencePearson Chi SquareTest levelwith Yate’s correctionQuality indexLikelihood Ratio Chi SquareYouden’s indexMinimum Expected FrequencyOdds ratio Cells with Expected Frequency < 5Odds ratio (Haldane’s estimator) Cells with Expected Frequency < 1Cohen’s KappaMcNemar’s TestObserved Agreementwith Yate’s correctionEvaluation of Diagnostic TestsSensitivityChance AgreementSpecificityPositive AgreementPositive Likelihood ratioNegative AgreementNegative Likelihood ratioByrt’s Bias IndexSensitivity of a random test Byrt’s Prevalence Asymmetry IndexQuality index of sensitivity Bias Adjusted KappaSpecificity of a random test Prevalence & Bias Adjusted dKappaQuality index of specificity Dice’s IndexEfficiency (Correct classification rate) Yule’s Q (Gamma)Efficiency of a random test PhiPredictive value of positive test Scott’s agreement indexPred. value of a positive random test Tetrachoric CorrelationPredictive value of negative test Goodman & Kruskal’s tau (Crit. dep.)Pred. value of a negative random test Lambda(Symmetric)How do I decide which tests to use?How do I decide which tests to use?• We’ll see how it can be done in 10 seconds, easilySensitivitySensitivity and Specificity• aka True Positive Rate• Ability to detect Pt.s whoactually have thecondition relative to thegold standard• Proportion of TruePositives• Formula:TRUE POSITIVETRUE POSITIVE + FALSENEGATIVESpecificity• aka True Negative Rate• Ability to detect Pt.s whodo not have the conditionrelative to the goldstandard• Proportion of TrueNegatives• Formula:TRUE NEGATIVETRUE NEGATIVE + FALSEPOSITIVESensitivity and Specificity• Sensitivity and Specificity individually canbe misleading…• Highly Sensitive tests may increase thenumber of false positives (low threshold todetection of condition)• Highly Specific tests may increase thefalse negatives (so focused, the testmisses some people with condition)7

Example (+) Test[Not So Helpful Test]Example (-) Test[Not So Helpful Test]• If we begin with 50% probability• Had a (+) result on this test(draw line through 1.1)Sens. Spec. +LR -LR QUADAS80 30 1.1 0.67 13• Post-test test probability = 53%• Changed only 3%!• If we begin with 50% probability• Had a (-) result on this test(draw line through .67)Sens. Spec. +LR -LR QUADAS80 30 1.1 0.67 13• Post-test test probability = 40%• Changed only 10%!Translation…(one of the main points)• The outcome of tests withpoor Likelihood Ratios arenot helpfulSupraspinatusHow does this affect ourclinical example?Rule OUT some easy onesInfraspinatus• Gives us 2 options:1. Don’t perform them!2. Perform them and don’t allowthe results to influence yourprobability!• Educators1. Don’t teach them?External Rotation Lag SignSupraspinatus or Infraspinatus Tear• Position: The examinerpassively flexes elbow to 90°,and holds shoulder at 20°elevation (in the scapular plane)and near maximal ER (i.e.,maximum ER -5° to avoid elasticrecoil in the shoulder)• Action: Ask the Pt. to activelymaintain the position as theexaminer releases the wrist whilemaintaining support of the limb atthe elbow• Positive Test: A lag, or angulardrop, occurs. For small ruptures,the movement may be subtle witha magnitude of as little as 5”(Tennent 2003)Supraspinatus or InfraspinatusSens. Spec. +LR -LR Reference98 98 49.0 0.02 Walch 199869 98 34.5 0.32 Hertel 1996(-) External Rotation Lag SignRules OUT Infraspinatus andSupraspinatus10

SubscapularisHow does this affect ourclinical example?Rule OUT some more easy onesTeres Minor(-) Internal Rotation Lag SignRule Out / In: Subscapularis Tear• Position: Examiner flexes elbow to90°, holds shoulder at 20° elevationand 20° extension, lifts the dorsum ofthe hand away from the spine untilalmost full IR is reached• Action: The Pt. is asked to maintainthis position as the examinerreleases the wrist while supportingthe elbow• Positive Test: A lag occurs; anobvious drop may occur with largetears; a slight lag indicates a partialtearSubscapularis(-) Internal Rotation Lag SignRules OUT Subscapularis Tear(-) Hornblower’s SignRule IN or OUT: Teres Minor Tear(+)• Action: The Pt. is asked tobring his hand to his mouthas eating or drinking• Positive Test: An inabilityto externally rotate the armforces the Pt. to abduct thearm and let it internallyrotate to reach the mouth (-)Post-TestProbTeres Minor(-) Hornblower’s SignRules OUT Teres Minor TearSLAPHow does this affect ourmore likely conditions?Dx.= SLAPProbability= 63%63%AC Sprain(same starting probability)Post-TestProb11

AC PathologyBest Application:Combination of Tests1. Active Compression (O’Brien’s) Test2. Cross-body Adduction Stress Test3. AC Resisted Extension TestAC Sprain(+) Active Compression(O’Brien’s) TestSens. Spec. +LR -LR QUADAS ReferenceAll 3 (+) 25 97 8.3 0.77≥ 2 (+) 81 89 7.4 0.21≥1 (+) 74 3.8(-) meansall 3 are (-)99 0.0110Chronopoulos 2004Sens. Spec. +LR -LR QUADAS Reference93 96 23.1 0.08 5 O’Brien 199841 95 8.2 0.62 10 Chronopoulos 200416 90 1.6 0.93 13 Walton 2004AC Sprain(-) Cross-body AdductionStress TestAC Sprain(+) AC Resisted ExtensionTestSens. Spec. +LR -LR QUADAS Reference77 79 3.6 0.29 10 Chronopoulos 2004Sens. Spec. +LR -LR QUADAS Reference72 85 4.8 0.33 10 Chronopoulos 2004AC SprainAC Pathology E-BOrthopedic Exam:Combination of TestsAC Sprain(+) 1-Finger Test(for AC Joint)• “Take 1 finger and point towhere it hurts”(+) Active Compression (O’Brien) Test(-) Cross-body Adduction Stress Test(+) AC Resisted Extension Test+LR -LR≥ 2 (+) 7.4All 3 are (-) 0.0193% prob.2% prob.Use the 93%result for pre-testSens. Spec. +LR -LR QUADAS Reference93 96 23 0.07 10 Chronopoulos 200413

AC Joint – Other Special TestsNo Research Supporting / Refuting usefulness• Piano Key Sign (under anesthesia)Let’s just order Imaging AC Sprains!• X-raysSens. Spec. +LR -LR QUADAS Reference41 90 1.6 0.93 13 Walton 2004• MRISens. Spec. +LR -LR QUADAS Reference85 50 1.7 0.30 13 Walton 2004• Bone ScanSens. Spec. +LR -LR QUADAS Reference82 70 2.7 0.26 13 Walton 2004To Rule IN AC PathologyGetting to the point…1. Active Compression (O’Brien’s) Test2. Cross-body Adduction Stress Test3. AC Resisted Extension Test+LR -LR≥ 2 (+) 7.4All 3 are (-) 0.01Evidence-Based Shoulder ScreenRule Out Differential Dx.1-Finger Test+LR -LR23 0.07Evidence-Based Shoulder ScreenRule Out Differential Dx.• Ext. Rotation Lag Sign• Int. Rotation Lag Sign• Biceps Load I Test• Biceps Load II Test• Hornblower’s Sign• SLAP• Posterior Labral Lesion• Subacromial Impingement• Subscapularis TearInfraspinatus Tear• Supraspinatus Tear• Teres Minor Tear• Anterior Instability• Posterior InstabilitySign • Infraspinatus TearWhat if we can’t Rule OUT Conditions?14

SLAP Lesion ExamplePt.• “My shoulder hurts”• 18 y/o freshman baseballoutfielder, no Hx of seriousshoulder injury• Clinician understands• Prevalence of XX injury for thispopulation (rarely available)• Prevalence based on Experience• Active Compression (O’Brien)• Compression-Rotation Test• Clunk Test• Crank Test• Anterior Slide (Kibler) Test• Apprehension Test• Relocation Test• Biceps Load Test• Biceps Load II Test• Speed’s Test• Biceps Tenderness Test• Yergason’s Test• Neer’s TestSLAP Lesion:Rule OUT• Hawkins-Kennedy Test• Painful Arc Test• Sulcus Sign• Posterior Impingement Sign• New Pain Provocation Test• Forced Shoulder Abductionand Elbow Flexion Test• Passive Distraction Test• Passive Compression Test• Supine Flexion Resistance• Dynamic Labral Shear Test• Jerk (Painful Jerk) Test• Kim Test• Active Compression (O’Brien)• Compression-Rotation Test• Clunk Test• Crank Test• Anterior Slide (Kibler) Test• Apprehension Test• Relocation Test• Biceps Load Test• Biceps Load II Test• Speed’s Test• Biceps Tenderness Test• Yergason’s Test• Neer’s TestSLAP Lesion:Rule In• Hawkins-Kennedy Test• Painful Arc Test• Sulcus Sign• Posterior Impingement Sign• New Pain Provocation Test• Forced Shoulder Abductionand Elbow Flexion Test• Passive Distraction Test• Passive Compression Test• Supine Flexion Resistance• Dynamic Labral Shear Test• Jerk (Painful Jerk) Test• Kim TestSLAPActive Compression (O’Brien’s) TestPositive Test: Shoulder pain and/orpopping in superior GH joint with the armin IR (thumbs-down) that is relieved whenthe test is performed with the arm in ERSens. Spec. +LR -LR QUADAS Reference99 98 49.5 0.01 5 O’Brien OBrien 199885 41 1.4 0.37 10 Morgan 199854 31 0.7 1.50 11 Stetson 200247 55 1.0 0.96 11 McFarland 200278 11 0.8 2.00 8 Myers 200554 60 1.3 0.77 9 Nakagawa 200563 50 1.2 0.75 10 Parentis 200694 28 1.3 0.21 9 Ebinger 200863 53 1.3 0.70 9 Oh 200859 92 7.3 0.45 9 Schlechter 2009Labral SLAPCompression-Rotation TestLabral SLAPClunk Test• Position: :Pt’s shoulder in 90°abductionabduction,90° elbow flexion• Action: examiner applies an axial load tothe humerus followed by IR and ER• Positive Test: production of a catching orsnapping in the shoulderSens. Spec. +LR -LR QUADAS Reference24 76 1.0 1.00 11 McFarland 200226 98 13.0 0.76 9 Nakagawa 200563 53 1.3 0.70 9 Oh 2008Sens. Spec. +LR -LR QUADAS Reference44 68 1.3 0.84 9 Nakagawa 200515

Labral SLAPCrank TestSens. Spec. +LR -LR QUADAS Reference91 93 13 0.10 11 Liu 199646 56 1.1 0.95 11 Stetson 200239 67 1.2 0.91 12 Guanche 200381 88 6.8 0.22 7 Mimori 200435 70 1.1 0.93 8 Myers 200558 72 2.1 0.58 9 Nakagawa 200513 83 0.8 1.05 10 Parentis 2006Labral SLAPAnterior Slide (KiblerKibler) TestAction: Examinerprovides an ant-sup force, Pt.resistsPositive Test:Pain or a pop inthe ant-supshoulderSens. Spec. +LR -LR QUADAS Reference78 91 8.3 0.24 7 Kibler 19958 84 0.5 1.10 11 McFarland 20025 93 0.7 1.02 9 Nakagawa 200510 82 0.5 1.10 10 Parentis 200621 98 10.5 0.81 9 Schlechter 2009Labral SLAP(+) Apprehension TestLabral SLAP(-) Relocation TestNo ChangeSens. Spec. +LR -LR QUADAS Reference30 60 0.8 1.11 12 Guanche 200383 40 1.4 0.43 9 Nakagawa 200562 42 1.1 0.90 9 Oh 2008Sens. Spec. +LR -LR QUADAS Reference59 54 1.3 0.76 10 Morgan 199836 63 0.9 1.02 12 Guanche 200375 40 1.2 0.63 9 Nakagawa 200550 53 1.1 0.94 10 Parentis 200644 54 0.9 1.04 9 Oh 2008SLAP(+) Biceps Load TestMay be a helpful test…• Action: Examiner performsan Apprehension TestAt end range of ER,examiner asks the Pt. to flexthe elbow; examiner resiststhe movementExaminer asks the Pt. if andhow the apprehension haschanged after elbow flexion• Positive Test: Either nochange in apprehension orpain that is worsened withresisted elbow flexion(+) Biceps Load TestSens. Spec. +LR -LR QUADAS Reference91 97 30.3 0.09 9 Kim 1999Sens. Spec. +LR -LR QUADAS Reference91 97 30.3 0.09 9 Kim 199916

Use the 60%result for pre-test(+) Biceps Load II Test98%or90%May be a helpful test…Sens. Spec. +LR -LR QUADAS Reference90 97 30.0 0.10 11 Kim 200136 92 4.5 0.70 9 Oh 2008• Action: Examiner performsan apprehension test with120° of abduction;At end range of ER, thePt. is asked to flex theelbow while examinerresists the movement• Positive Test:Reproduction of painduring resisted elbowflexion(+) Biceps Load II TestSens. Spec. +LR -LR QUADAS Reference90 97 30.0 0.10 11 Kim 200136 92 4.5 0.70 9 Oh 2008Speed’s TestPositive Test:Tenderness in thebicipital groove maysuggest labral pathologySens. Spec. +LR -LR QUADAS Reference78 37 1.2 0.59 10 Morgan 19989 74 0.3 1.23 12 Guanche 200332 75 1.3 0.91 11 Holtby 20046 98 3.0 0.96 9 Nakagawa 2005Use the 90% 48 67 1.4 0.77 10 Parentis 2006result for pre-test60 38 0.9 1.05 9 Ebinger 200832 66 0.9 1.03 9 Oh 2008Biceps Tenderness TestAction: The involvedshoulder’s bicepsgroove is deeplypalpated; then theuninvolved bicepsgroove is deeplypypalpatedPositive Test: Pain in biceps tendonwith no pain on the uninjured sideSens. Spec. +LR -LR QUADAS Reference74 35 1.1 0.74 10 Morgan 199848 52 1.0 1.00 12 Guanche 200325 80 1.3 0.90 9 Nakagawa 200527 66 0.8 1.11 9 Oh 2008Yergason’s TestNeer’s TestSens. Spec. +LR -LR QUADAS Reference12 96 3.0 0.92 12 Guanche 200343 79 2.1 0.72 11 Holtby 200412 98 6.0 0.90 9 Nakagawa 200513 94 1.9 0.94 10 Parentis 200618 99 36.0 0.82 9 Oh 2008Sens. Spec. +LR -LR QUADAS Reference33 60 0.8 1.12 9 Nakagawa 200550 52 1.1 0.96 10 Parentis 200617

Hawkins-Kennedy TestPainful Arc TestSens. Spec. +LR -LR QUADAS Reference50 67 1.5 0.77 9 Nakagawa 200568 31 0.9 1.07 10 Parentis 2006Sens. Spec. +LR -LR QUADAS Reference21 73 0.78 1.08 9 Nakagawa 2005Sulcus SignPosterior Impingement Sign• Positive Test: Reproduction ofposterior joint-line painSens. Spec. +LR -LR QUADAS Reference17 93 2.4 0.89 9 Nakagawa 2005Sens. Spec. +LR -LR QUADAS Reference76 85 5.0 0.29 7 Meister 2004New Pain Provocation TestForced Shoulder Abductionand Elbow Flexion Test• Positive Test: Pain in pronatedpositionSens. Spec. +LR -LR QUADAS Reference98 86 7.0 0.02 7 Mimori 200415 90 1.5 0.94 10 Parentis 2006*17 89 1.7 0.92 10 Parentis 2006*** SLAP Type I ; ** SLAP Type IIPositive Test: Posterior-superior superior painon forced maximal abduction that isrelieved or diminished by elbow flexionSens. Spec. +LR -LR QUADAS Reference67 67 2.0 0.49 9 Nakagawa 200518

(-) Passive Distraction Test• Position: Pt’s arm abducted 150° in fullelevation, forearm supinated (A)• Action: Examiner pronates forearmwhile stabilizing arm (B)• Positive Test: Pain deep inside the GHjoint either anteriorly or posteriorly(-) Passive Compression Test• Position: Pt. side-lying, elbow flexed,arm at 30° of abduction• Action: Examiner ER humerus, appliesaxial load while extending humerus;compressing labrum into glenoid• Positive Test: Pain or a painful clickSens. Spec. +LR -LR QUADAS Reference53 94 8.8 0.50 9 Schlechter 2009Sens. Spec. +LR -LR QUADAS Reference82 86 5.7 0.21 10 Kim 2007Supine FlexionResistance Test• Position: Pt. supine, full flexion, palm-up• Action: Examiner provides resistance tothe proximal forearm and asks Pt. toforward flex the arm as if simulating athrowing motion (B)• Positive Test: Only if pain is eliciteddeep inside the joint or at the dorsalaspectBAImaging for Labral Lesions• MRISens. Spec. +LR -LR Reference83 99 83 0.17 Magee 2009• MRASens. Spec. +LR -LR Reference98 99 98.0 0.02 Magee 200989 91 9.9 0.12 Bencardinao 200082 98 41.0 0.18 Waldt 2004Sens. Spec. +LR -LR QUADAS Reference80 69 2.6 0.29 9 Ebinger 2008SLAP Lesion:Rule OUT• Biceps Load Test• Biceps Load II Test• MRI• MRASLAP Lesion:Rule IN• Biceps Load Test• Biceps Load II Test• MRI• MRAMay be helpful• Passive Distraction Test• Passive Compression Test19

What about Posterior Labral Lesions?Posterior Labral Lesion:Rule OUT• Active Compression (O’Brien)• Compression-Rotation Test• Clunk Test• Crank Test• Anterior Slide (Kibler) Test• Apprehension Test• Relocation Test• Biceps Load Test• Biceps Load II Test• Speed’s Test• Biceps Tenderness Test• Yergason’s Test• Neer’s Test• Hawkins-Kennedy Test• Painful Arc Test• Sulcus Sign• Posterior Impingement Sign• New Pain Provocation Test• Forced Shoulder Abductionand Elbow Flexion Test• Passive Distraction Test• Passive Compression Test• Supine Flexion Resistance• Dynamic Labral Shear Test• Jerk (Painful Jerk) Test• Kim TestPosterior Labral Lesion:Rule In• Active Compression (O’Brien)• Compression-Rotation Test• Clunk Test• Crank Test• Anterior Slide (Kibler) Test• Apprehension Test• Relocation Test• Biceps Load Test• Biceps Load II Test• Speed’s Test• Biceps Tenderness Test• Yergason’s Test• Neer’s Test• Hawkins-Kennedy Test• Painful Arc Test• Sulcus Sign• Posterior Impingement Sign• New Pain Provocation Test• Forced Shoulder Abductionand Elbow Flexion Test• Passive Distraction Test• Passive Compression Test• Supine Flexion Resistance• Dynamic Labral Shear Test• Jerk (Painful Jerk) Test• Kim TestPosterior Impingement Sign• Positive Test: Reproduction ofposterior joint-line painSens. Spec. +LR -LR QUADAS Reference76 85 5.0 0.29 7 Meister 2004Dynamic Labral Shear• Position: Pt. standing, elbow flexedto 90°, arm abducted in scapularplane to above 120°, and ER ‘totightness’• Action: Clinician guides arm intomax horiz. abduction, then lowersthe arm from 120° to 60° ofabduction• Positive Test: Reproduction of painand/or a painful click or catch inthe posterior joint line between120° and 90° of abductionSens. Spec. +LR -LR QUADAS Reference72 98 36 0.29 9 Kibler 2009Jerk (Painful Jerk) Test• Action: An axial force is appliedto the arm in 90° of abductionand IR (A); the arm ishorizontally adducted while theaxial load is maintained (B)• Positive Test: A sharp painw/without t posterior clunk or clickmay indicate a posterior lesionSens. Spec. +LR -LR QUADAS Reference25 80 1.3 0.94 9 Nakagawa 200589 85 5.9 0.12 9 Kim 200473 98 36.5 0.26 11 Kim 200520

Kim Test• Position: Seated, arm in 90°abduction• Action: Examiner applies an axialforce and 45° of upward diagonalelevation to the humerus (A), thenapplies an inferior-posterior forceto the proximal arm (B)• Positive Test: A sudden onset ofposterior should pain, regardlessof posterior clunk may indicate aposterior lesionRule OUT• MRI• MRAPosterior Labral LesionRule IN• Posterior Impingement Sign• Dynamic Labral Shear Test• Jerk (Painful Jerk) Test• Kim Test• MRI• MRASens. Spec. +LR -LR QUADAS Reference80 94 13 0.21 11 Kim 2005What about Instability?Rule OUT Glenohumeral Instability• Anterior Apprehension Test• Apprehension• Pain• Apprehension and Pain• Apprehension or Pain• Relocation Test• Relief of Apprehension• Relief of Pain• Relief of Appreh. and Pain• Relief of Appreh. or Pain• Surprise Test• Apprehension• Pain• Appreh. and Pain• Appreh. or Pain• Post. Apprehension Test• Load and Shift Test• Anterior Drawer Test• Jerk (Painful Jerk) Test• Sulcus SignAnterior Glenohumeral Instability:Rule In• Anterior Apprehension Test• Apprehension• Pain• Apprehension and Pain• Apprehension or Pain• Relocation Test• Relief of Apprehension• Relief of Pain• Relief of Appreh. and Pain• Relief of Appreh. or Pain• Surprise Test• Apprehension• Pain• Appreh. and Pain• Appreh. or Pain• Post. Apprehension Test• Load and Shift Test• Anterior Drawer Test• Jerk (Painful Jerk) Test• Sulcus SignApprehension Test• Position: Examiner standing withone hand supporting elbow,other hand controlling ER atwrist• Action: Pt. relaxed, examinerpassively abducts humerus to90° and slowly moves humerusinto ER, monitoring Pt’s facialexpression/body language forsigns of apprehensionPerform test at least 3 differentangles of abduction• Positive Test: Apprehension.Posterior pain w/out significantinstability may represent internalimpingement21

Relocation Test• Position: In apprehensionposition (supine), examinerstabilizing humerus at theelbow/wrist• Action: Examiner applies aninferior force at the humeralhead (stabilizing humeral headin glenoid fossa) whilemonitoring Pt’s facialexpression/body language forsigns of apprehension• Positive Test: Relief ofapprehension;relief ofposterior pain may representinternal impingementSurprise Test• Position: In relocation position(supine), examiner providinginferior force at the humeralhead (stabilizing humeral headin glenoid fossa)• Action: Release inferior force atthe humeral head whilemonitoring Pt’s facialexpression/body language forsigns of apprehension• Positive Test: ApprehensionReturn of posterior pain mayrepresent internal impingementPosterior Glenohumeral Instability:Rule In• Anterior Apprehension Test• Apprehension• Pain• Apprehension and Pain• Apprehension or Pain• Relocation Test• Relief of Apprehension• Relief of Pain• Relief of Appreh. and Pain• Relief of Appreh. or Pain• Surprise Test• Apprehension• Pain• Appreh. and Pain• Appreh. or Pain• Post. Apprehension Test• Load and Shift Test• Anterior Drawer Test• Jerk (Painful Jerk) Test• Sulcus SignPosterior Apprehension Test• Position: Supine or standing,shoulder with 90° of shoulderabduction, flexion, 90° elbow flexionand IR• Action: Examiner applies posteriorlongitudinal force, encouragingposterior translation of the humerusrelative to the scapula; should bedone at various angles of shoulderabduction, adduction and flexion (inand out of scapular plane)• Positive Test: Increased posteriortranslation of humerus may indicateposterior instability; Pt. may displayapprehensionWhat about Subacromial Impingement?Subacromial Impingement Syndrome:Rule InCombination of 3 Tests1. Painful Arc Sign2. Ext. Rotation Lag Sign3. Hawkins-Kennedy Test≥ 2 (+) Rules IN SAIS22

Painful Arc TestExternal Rotation Lag SignRule In: Supraspinatus and Infraspinatus Tear• Position: The examinerpassively flexes elbow to 90°,and holds shoulder at 20°elevation (in the scapular plane)and near maximal ER (i.e.,maximum ER -5° to avoid elasticrecoil in the shoulder)• Action: Ask the Pt. to activelymaintain the position as theexaminer releases the wrist whilemaintaining support of the limb atthe elbow• Positive Test: A lag, or angulardrop, occurs; for small ruptures,the movement may be subtle witha magnitude of as little as 5”(Tennent 2003)Hawkins-Kennedy TestWhat about Ruling IN aTeres Minor Tear?• Painful Arc Sign• Drop-arm Sign• Ext. Rotation Lag Sign• Int. Rotation Lag Sign• Hawkins-Kennedy Test• Drop Sign• Lift-off Test• Cross-body Adduction• Hornblower’s Sign• Bear-hug Test• Belly-press TestHornblower’s SignRule IN or OUT: Teres Minor Tear(+)• Action: The Pt. is asked tobring his hand to his mouthas eating or drinking• Positive Test: An inabilityto externally rotate the armforces the Pt. to abduct thearm and let it internallyrotate to reach the mouth(-)What about Ruling IN aSupraspinatus Tear?• Painful Arc Sign• Drop-arm Sign• Ext. Rotation Lag Sign• Int. Rotation Lag Sign• Hawkins-Kennedy Test• Drop Sign• Lift-off Test• Cross-body Adduction• Hornblower’s Sign• Bear-hug Test• Belly-press Test23

External Rotation Lag SignRule In: Supraspinatus and Infraspinatus Tear• Position: The examinerpassively flexes elbow to 90°,and holds shoulder at 20°elevation (in the scapular plane)and near maximal ER (i.e.,maximum ER -5° to avoid elasticrecoil in the shoulder)• Action: Ask the Pt. to activelymaintain the position as theexaminer releases the wrist whilemaintaining support of the limb atthe elbow• Positive Test: A lag, or angulardrop, occurs. For small ruptures,the movement may be subtle witha magnitude of as little as 5”(Tennent 2003)What about Ruling IN aInfraspinatus Tear?• Painful Arc Sign• Drop-arm Sign• Ext. Rotation Lag Sign• Int. Rotation Lag Sign• Hawkins-Kennedy Test• Drop Sign• Lift-off Test• Cross-body Adduction• Hornblower’s Sign• Bear-hug Test• Belly-press TestDrop SignRule In: Infraspinatus Tear• Position: Examiner holds theaffected arm at 90° of elevation (inthe scapular plane) and at almostfull ER, with the elbow flexed to90°• Action: Ask the Pt. to activelymaintain this position as theclinician releases the wrist whilesupporting the elbow• Positive Test: A lag or "drop"occurs; the magnitude of the lag isrecorded to the nearest 5”(maintenance ER in this positionis a function mainly of theinfraspinatus)(Tennent 2003)(Tennent 2003)What about Ruling IN aSubscapularis Tear?• Painful Arc Sign• Drop-arm Sign• Ext. Rotation Lag Sign• Int. Rotation Lag Sign• Hawkins-Kennedy Test• Drop Sign• Lift-off Test• Cross-body Adduction• Hornblower’s Sign• Bear-hug Test• Belly-press TestInternal Rotation Lag SignRule In: Subscapularis TearLift-off Test• Position: Examiner flexes elbow to90°, holds shoulder at 20° elevationand 20° extension, lifts the dorsumof the hand away from the spineuntil almost full IR is reached• Action: The Pt. is asked to maintainthis position as the examinerreleases the wrist while supportingthe elbow• Positive Test: A lag occurs; anobvious drop may occur with largetears; a slight lag indicates a partialtear• Position: Examiner flexeselbow to 90°, holdsshoulder at 20° elevationand 20° extension; back ofinvolved-side hand onlumbar spine• Action: Pt is asked to lifthis/her hand off the back• Positive Test: Pt. cannotlift hand off the backwithout extending thehumerus24

Bear-hug TestBelly-Press Test• Position: Palm of involved side onopposite shoulder, fingers extended;elbow anterior to body• Action: Pt is asked to hold the positionExaminer applies an ER force at theforearm, trying to pull the Pt’s handaway from the shoulder• Positive Test: Pt cannot hold handagainst shoulder or weakness > 20%compared bilaterally (B) indicates asubscapularis tear (pain withoutweakness is negative)• Position: Involved hand onbelly, elbow off the trunk• Action: Pt is asked topress his/her hand into thebelly• Positive Test: Pt. cannotpress hand into bellywithout moving the elbowSummary• Identify a clinically-helpful orthopedic test in theliterature by looking at the Likelihood Ratios• To Rule INYou want a (+) result using a test that has: High+LR(>10) (5-10 moderate)• To Rule OUTYou want a (-) result using a test that has:Low -LR(