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A user's guide to performance of the best

shoulder physical examination tests

Article in British Journal of Sports Medicine · January 2013

Impact Factor: 5.03 · DOI: 10.1136/bjsports-2012-091870 · Source: PubMed

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Cortney A Myer Eric J Hegedus

Akron Children's Hospital High Point University
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1
Center for Orthopedics and
Sports Medicine and Akron
Children’s Hospital, Akron,
Ohio, USA
2
Department of Physical
Therapy, High Point University,
School of Health Sciences,
High Point, North Carolina,
USA
3
Department of Exercise
Science, High Point University,
School of Health Sciences,
High Point, North Carolina,
USA
4
Fellow-Orthopaedic Sports
Medicine, Orthopedic Research
of Virginia, Richmond, VA and
Crystal Clinic Orthopedic
Center, Akron, Ohio, USA
Correspondence to
Daniel Thomas Tarara,
Department of Exercise
Science, High Point University,
School of Health Sciences,
High Point, NC 27262, USA;
dtarara@highpoint.edu
Received 27 October 2012
Revised 18 December 2012
Accepted 19 December 2012
Published Online First
15 January 2013
To cite: Myer CA,
Hegedus EJ, Tarara DT, et al.
Br J Sports Med
2013;47:903–907.
Myer CA, et al. Br J Sports Med 2013;47:903–907. doi:10.1136/bjsports-2012-091870
Downloaded from bjsm.bmj.com on August 23, 2013 - Published by group.bmj.com
A user’s guide to performance of the best shoulder
physical examination tests
Cortney A Myer,1 Eric J Hegedus,2 Daniel Thomas Tarara,3 Daniel M Myer4
ABSTRACT
Background This article provides clinicians with a
user’s guide on the performance of the shoulder physical
examination tests most supported by current evidence
from a recent systematic review published in the British
Journal of Sports Medicine.
Discussion A description of clinical shoulder tests is
provided with explanations on exact testing procedures
and complimentary photographs.
INTRODUCTION
The musculoskeletal clinical examination is an
important piece of any patient encounter. Yet, there
are multiple studies that show the medical commu-
nity, especially new practitioners, has a need to
improve their collective examination skills.1–3
An important component of the clinical examin-
ation is physical examination tests designed to
detect pathology. A challenge with these tests is the
sheer volume reported in the literature.4 One way
to solve this challenge for busy clinicians is to read
systematic reviews that summarise large quantities
of data from multiple articles in a concentrated
area of interest. One such systematic review was
published in 2008 and addressed physical examin-
ation tests of the shoulder.5 This study represented
the largest review of shoulder tests with
meta-analysis at that time. As a result of that
article, a group of authors published a pictorial
guide demonstrating how each test is performed.6
Recently, the 2008 systematic review was updated
along with recommendations for the use of newer
tests.7 While comprehensive in nature, the article
did not provide detailed descriptions of these new
tests and so, an updated pictorial guide may be in
order. The goal of this paper was to provide busy
clinicians with an additional user’s guide on the
performance of the most recently published shoul-
der physical examination tests most supported by
evidence.
CLINICAL SHOULDER TESTS
Impingement tests
No new tests.
Labral tear tests
Modified dynamic labral shear test.8
Patient position: standing with arm flexed 90° at
the elbow, abducted in the scapular plane >120°
and externally rotated to tightness.
▸ Test: examiner standing behind patient,
guiding involved upper extremity into
maximal horizontal abduction and applying a
shear load to the joint by maintaining external
Review
rotation and horizontal abduction and lower-
ing arm from 120° to 60° of abduction.
▸ Confirmatory findings: reproduction of pain
and/or painful click or catch in the posterior
joint line between 120° and 90° abduction.
▸ Test rationale: arm position and load applica-
tion are ideal for reproducing the peel-back
phenomenon and motion of the biceps, and
to reproduce the shearing mechanism of the
posterior rotator cuff against the posterosu-
perior labrum. The modified version of this
test did not place the arm into maximal hori-
zontal abduction until the arm was abducted
above 120°. This was intended to decrease
pain provocation throughout the entire ROM
(figure 1).
Summary from systematic review on labral tears.
The modified dynamic labral shear test may be
diagnostic of labral tears in general with both high
sensitivity and specificity.
Superior labrum anterior to posterior lesion
tests
Passive compression test9
▸ Patient position: lateral decubitus position
with affected side up.
▸ Test: examiner standing behind patient, stabi-
lising the affected shoulder by holding the
acromioclavicular (AC) joint with one hand
and the elbow with the other. The examiner
externally rotates the shoulder in 30° of
abduction and then pushes the arm proxim-
ally while extending the shoulder (figure 2).
▸ Confirmatory findings: pain or a painful click
in the glenohumeral joint.
▸ Test rationale: with glenohumeral external
rotation and extension (late cocking phase),
the long head of the biceps tendon is placed
under tensile forces while wrapping around
the lesser tuberosity and ultimately shifting the
superior labrum from the superior glenoid
rim. Proximal migration of the humerus aggra-
vates the displacement of the unstable labrum
and passively displaces the superior labrum.
Passive distraction test10
▸ Patient position: supine.
▸ Test: examiner standing on the affected side
of the patient and positions the extremity off
the edge of the table, into 150° elevation in
the coronal plane, the elbow extended, the
forearm supinated, and the upper arm stabi-
lised to prevent humeral rotation. The exam-
iner pronates the forearm while maintaining
steady position of the humerus (figure 3).
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Review

Figure 1 Modified dynamic labral

shear (A) starting position and
(B) ending position. Access the article
online to view this figure in colour.

▸ Confirmatory findings: pain reported deep inside the gle-
nohumeral joint either anteriorly or posteriorly.
▸ Test rationale: peel-back phenomenon of the superior
labrum.
Summary from systematic review on superior labrum anterior
to posterior (SLAP) lesion tests.
The passive distraction test may be used for ruling in a SLAP
lesion while the passive compression test may be used for both
ruling in and ruling out a SLAP lesion.
Bony instability tests
Bony apprehension test11
▸ Patient position: patient sitting or standing with elbow
flexed to 90°.
▸ Test: examiner standing behind patient holding the lateral
forearm with one hand and placing the other hand on the
posterior aspect of the humeral head. The examiner moves
the affected arm into 45° abduction and 45° external rota-
tion (figure 4).
▸ Confirmatory findings: apprehension with or without
pain.
▸ Test rationale: authors arbitrarily chose positioning of the
glenohumeral joint to provoke instability from a bony
Bankart lesion and/or engaging Hill-Sachs bony lesion.
Summary from systematic review on bony instability tests.
The bony apprehension test may be used for both ruling in
and ruling out a diagnosis of bony instability.
Tendinopathy tests
Belly off sign12
▸ Patient position: seated or standing.
▸ Test: examiner standing in front of the patient while pas-
sively moving the affected upper extremity into flexion
and maximal internal rotation with the elbow flexed at

Figure 2 Passive compression

(A) starting position and (B) ending
position. Access the article online to
view this figure in colour.

Figure 3 Passive distraction

(A) starting position and (B) ending
position. Access the article online to
view this figure in colour.

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Figure 4 Bony apprehension. Access the article online to view this
figure in colour.
90°. The examiner supports the patient’s elbow while the
other hand brings the arm into maximal internal rotation
placing the palm of the hand on the abdomen. The patient
is asked to keep the wrist straight and actively maintain
this position of internal rotation as the examiner releases
the wrist (maintaining elbow support; figure 5).
▸ Confirmatory findings: the patient is unable to maintain
the position, the wrist flexes or lag occurs and the hand is
lifted off the abdomen.
▸ Test rationale: the subscapularis muscle acts as a strong
internal rotator and this test evaluates the integrity of the
musculotendinous unit.
Belly press test modified12
▸ Patient position: seated or standing with the affected hand
flat on the abdomen and elbow close to the body.
▸ Test: examiner stands on the affected side of the patient
and instructs the patient to bring the elbow forward and
straighten the wrist. The examiner measures the final belly-
press angle of the wrist with a goniometer (figure 6).
▸ Confirmatory findings: belly-press angle difference of 10°
between affected and unaffected side.
▸ Test rationale: the subscapularis muscle acts as a strong
internal rotator and this test evaluates the integrity of the
musculotendinous unit. The modified version of this test
measures between side differences in the belly-press angle
unlike the original belly press test.13
Lateral Jobe14
▸ Patient position: seated or standing.
▸ Test: the examiner instructs the patient to abduct their
affected shoulder to 90° in the coronal plane with the elbow
Figure 5 Belly off sign (A) starting
position and (B) ending position.
Access the article online to view this
figure in colour.
Myer CA, et al. Br J Sports Med 2013;47:903–907. doi:10.1136/bjsports-2012-091870
Review
flexed to 90° and the shoulder internally rotated so that the
fingers point inferiorly and the thumbs medially. The exam-
iner then applies an inferior force to the distal arm (figure 7).
▸ Confirmatory findings: pain or weakness or inability to
perform the test.
▸ Test rationale: the author’s did not provide an explanation
as to why this test mechanically differs from the original
Jobe test.
Summary from systematic review on tendinopathy tests.
The three previously mentioned tests may be used for both
ruling in and ruling out subscapularis and rotator cuff tendino-
pathy, respectively.
Other tests
Olecranon-manubrium percussion test15
▸ Patient position: seated or standing with elbows flexed at
90°.
▸ Test: the examiner places the stethoscope bell over the manu-
brium and percusses each olecranon process (figure 8).
▸ Confirmatory findings: a decrease in pitch or the intensity
of the affected side.
▸ Test rationale: if there are any bony abnormalities, the
affected side should have a duller sound than the normal
side.
▸ Shrug sign.16
▸ Patient position: standing.
▸ Test: the examiner instructs the patient to abduct both
arms in the coronal plane (figure 9).
▸ Confirmatory findings: elevation of the scapula or shoul-
der girdle in order to achieve 90° of abduction. Measured
with a goniometer, the magnitude of the shoulder shrug
was defined as the angle between the arm and the horizon-
tal point at which the shrug moment began.
▸ Test rationale: the authors conclude the shrug sign can detect
shoulder abnormalities, especially those associated with loss
of range of motion or weakness on manual muscle testing.
Summary from systematic review on other tests.
The olecranon-manubrium test may be used to rule in or rule
out bony abnormalities. The shrug sign may be used to rule out
stiffness-related disorders as well as rotator cuff tendinopathy.
DISCUSSION
There are an inordinate amount of physical examination tests
pertaining to the shoulder complex,4 and it was not the inten-
tion of this paper to provide an exhaustive list. The purpose of
this paper was to take the best tests from a recent update7 of a
systematic review5 and create a user-friendly guide for clinicians
on how to perform these tests. Since Moen et al6 produced a
pictorial summary of the best tests from the original review, an
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Review

Figure 8 Olecranon-manubrium percussion. Access the article online

to view this figure in colour.

updated examination description of the most recent evidence-

Figure 6 Belly press test modified (A) starting position and (B)
ending position. Access the article online to view this figure in colour.
based shoulder tests was warranted.
Notably absent from this guide are tests for impingement.
The reasons for this absence were that meta-analysis showed no
diagnostic benefit of popular impingement tests, and the review
on which this paper is based questioned the value of the diag-
nostic label of impingement syndrome.7
While the label of impingement may be losing diagnostic favour,
a diagnostic category attracting greater interest is the area of bone-
related pathology. The olecranon-manubrium percussion test may
be helpful in acute conditions like a fracture, where a determination
of referral for x-ray may be required. Likewise, the bony apprehen-
sion test appears to have a high-enough sensitivity and positive like-
lihood ratio to serve as a screen for potential bony instability, such
as a bony Bankart lesion. This may increase the diagnostician’s
awareness of needing referral or ordering further imaging.
Diagnosing a labral tear in the shoulder remains difficult but
there is reason for optimism and some confusion- optimism
because either the passive compression or the passive distraction
test can be used to rule in a SLAP lesion. Some confusion sur-
rounds the dynamic labral shear test, reportedly specific for a
labral tear. This test was first reported by O’Driscoll in 200217
as a test for a specific type of labral tear, the SLAP lesion. The
first peer-reviewed publication of the dynamic labral shear test
was by Kibler et al8 but these authors called the test the modi-
fied dynamic labral shear test, assumedly because the original
test is performed in supine and Kibler et al8 performed the test
with the patient standing. Kibler et al8 also used the test in ref-
erence to all labral tears and not just SLAP tears. Finally, Cook
et al (2012)18 used this test for its original purpose (to detect
SLAP lesions) but modified the test yet again by performing the

Figure 7 Lateral Jobe (A) starting

position and (B) ending position.
Access the article online to view this
figure in colour.

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 Downloaded from bjsm.bmj.com on August 23, 2013 - Published by group.bmj.com
Figure 9 Shrug sign (A) starting
position and (B) ending position.
Access the article online to view this
figure in colour.
test in standing but externally rotating the arm to 90° instead of
to the natural limitation of gravity-assisted external rotation. As
authors have modified the original test, they have, in essence,
produced a new test so it could be argued that the value of the
original dynamic labral shear test is unknown. The modified
dynamic labral shear test as described by Kibler et al8 is what is
described in our paper. As evident by the continual emergence
of new tests aimed at diagnosing labral tears in general and
SLAP lesions specifically, the most efficient way to diagnose
these pathologies is far from certain. The value of these three
tests, the modified dynamic labral shear, the passive distraction
and the passive compression, need to be confirmed by more
than one study.
While we hope this guide eases the acceptance of the new
physical examination tests into practice, we also echo the
thoughts of the review and meta-analysis on which this paper is
based:7 these physical examination tests are probably best used
in the context of a comprehensive history and physical examin-
ation and few, if any, single tests have the sensitivity and specifi-
city to rule in a diagnosis when positive and rule out a diagnosis
when negative.
What this paper adds
▸ The study is an update on the most clinically useful shoulder
tests as found in the Hegedus et al 2012 systematic review
and meta-analysis of shoulder physical examination tests.
▸ It provides the busy clinicians with a user’s guide on the
performance of the shoulder physical examination with
detailed descriptions and photographs.
Contributors This manuscript has four contributing authors. Individual
contributions are as follows: (1) CAM, conceptual design; drafting and revision of
the article for important intellectual content; (2) EJH, conceptual design; drafting the
article or revising it critically for important intellectual content; final approval of the
version to be published; (3) DTT, revising it critically for important intellectual
content; final approval of the version to be published; (4) DMM, conceptual design;
drafting and revision of the article for important intellectual content.
Competing interests None.
Myer CA, et al. Br J Sports Med 2013;47:903–907. doi:10.1136/bjsports-2012-091870
Review
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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A user's guide to performance of the best

shoulder physical examination tests
Cortney A Myer, Eric J Hegedus, Daniel Thomas Tarara, et al.

Br J Sports Med 2013 47: 903-907 originally published online January

15, 2013
doi: 10.1136/bjsports-2012-091870

Updated information and services can be found at:

http://bjsm.bmj.com/content/47/14/903.full.html

These include:
References This article cites 16 articles, 5 of which can be accessed free at:
http://bjsm.bmj.com/content/47/14/903.full.html#ref-list-1

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