LITERATURE REVIEW
Clinical Tests of the Shoulder
Accuracy and Extension Using Dynamic Ultrasound
Ke-Vin Chang, MD, PhD, Wei-Ting Wu, MD, Po-Cheng Hsu, MD, Henry L. Lew, MD, PhD, and Levent Özçakar, MD
Abstract: Shoulder pain is a common musculoskeletal disorder that
has a significant impact on the patient’s quality of life and functional
health. Because the shoulder joint is a complex structure, the relevant
symptoms of shoulder pain may not directly reflect the underlying pa-
thology. Hence, several shoulder tests have been developed to examine
shoulder problems, and their diagnostic accuracy varies. Familiariza-
tion with the performance of those physical tests and their strength
and limitation are of utmost importance for physicians dealing with
shoulder disorders. Therefore, the present narrative review focuses
on summarizing the most commonly used tests in physical examina-
tion and their diagnostic performance on several shoulder pathologies.
This article also discusses how ultrasound imaging can serve as an ex-
tension of those tests.
Key Words: Shoulder, Physical Examination, Rehabilitation, Ultrasound
(Am J Phys Med Rehabil 2020;99:161–169)
houlder pain is a common musculoskeletal disorder. Ac-
S cording to a previous systematic review, the point preva-
lence of shoulder pain ranged from 6.9% to 26%, whereas
the lifetime prevalence could be up to 66.7%.1 The patient’s
quality of life and functional health would be affected by
chronic painful shoulder conditions (eg, adhesive capsulitis),
and this leads to anxiety and depression.2 Furthermore, there
might be minimal influence of range of motion and muscle
strength in patients with painful shoulders, but the pain has al-
ready hindered their daily activities. The painful restricted activ-
ities that impair participation urge them to seek for physiatrists’
help. Because the shoulder joint has a complex anatomical struc-
ture, the relevant symptoms may not directly reflect the underly-
ing pathology. A systematic approach incorporating inspection,
palpation, range of motion examination, and muscle strength
testing is helpful for global assessment of shoulder function.
From the Department of Physical Medicine and Rehabilitation, National Taiwan
University Hospital, BeiHu Branch and National Taiwan University College of
Medicine, Taipei, Taiwan (K-VC, W-TW, P-CH); Department of Physical Med-
icine and Rehabilitation, School of Medicine, Virginia Commonwealth Univer-
sity, Richmond, Virginia (HLL); University of Hawaii School of Medicine,
Honolulu, Hawaii (HLL); and Department of Physical and Rehabilitation Med-
icine, Hacettepe University Medical School, Ankara, Turkey (LÖ).
All correspondence should be addressed to: Ke-Vin Chang, MD, PhD, Department
of Physical Medicine and Rehabilitation, National Taiwan University Hospital,
Bei-Hu Branch and National Taiwan University College of Medicine, No. 87
Neijiang St, Wanhua District, Taipei 108, Taiwan.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001311
American Journal of Physical Medicine & Rehabilitation • Volume 99, Number 2, February 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Several shoulder examinations have been developed to examine
shoulder problems and scrutinize specific lesions as well as their
diagnostic accuracy varies.3 Familiarization with the perfor-
mance of those physical tests and their strength and limitation
would be of paramount importance for physicians dealing with
shoulder disorders. Therefore, the present narrative review fo-
cuses on the commonly used shoulder physical tests and their
diagnostic performance on several pathologies. Moreover, this
article discusses how dynamic ultrasound (US) imaging can
serve as an extension of those clinical tests.
ANATOMY AND COMMON PATHOLOGIES
The shoulder consists of the glenohumeral, acromioclavicular,
and sternoclavicular joints. The glenohumeral joint has a ball
(humeral head) -and-socket (glenoid fossa) configuration, con-
tributing to great mobility of the shoulder girdle.4 Several liga-
ments serve as important shoulder stabilizers, including the
coracoclavicular, acromioclavicular, coracoacromial, coracohumeral,
and superior, middle, and inferior glenohumeral ligaments. The
rotator cuff is a group of muscles and tendons (subscapularis,
supraspinatus, infraspinatus, and teres minor) encircling the
glenohumeral joint. The long head of the biceps tendon pierces
through the rotator cuff interval and has a direct connection
with the glenohumeral joint. The suprascapular nerve accounts
for 70% of the shoulder innervation,5 whereas the remaining
30% is innervated by the axillary nerve.6
There are several pathological conditions that physicians
wish to examine using physical examination. The long head
of the biceps tendon plays an important role in anterior shoul-
der pain, which may result from tenosynovitis or tendon tear.7
The superior labral tear from anterior to posterior (SLAP) le-
sion involves the superior glenoid labrum, inserted by the long
head of the biceps tendon.8 The acromioclavicular joint is an
important structure suspending the upper limb from the trunk,
and its pathology includes synovitis, osteoarthritis, and sprain/
separation of the overlying ligament.4 The rotator cuff tendon
disorder is the most common source of shoulder pain, and its
underlying pathology includes tendinopathy, calcification, and
tears.9 The subacromial impingement syndrome comprises a
spectrum of pathologies in the subacromial space, such as
subacromial spurs, subacromial bursitis, and rotator cuff tendon
disorders.10 Furthermore, dynamic instability can develop in
shoulders with glenohumeral capsular injury.11
GENERAL PRINCIPLES OF SHOULDER PHYSICAL
EXAMINATIONS
A comprehensive shoulder physical examination should start
from inspection. First, the physicians should check whether the
affected shoulder has swelling, scars, muscle atrophy, and asym-
metric postures in contrast to the unaffected site. Second, the
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Chang et al.
examiners can palpate common tender points, such as the
acromioclavicular joint, coracoid process, and greater and lesser
tubercles of the humeral head. Third, the active and passive
shoulder range of motion should be examined in all six direc-
tions (flexion, extension, abduction, adduction, internal rotation,
and external rotation). Fourth, the muscle power in flexion, ex-
tension, abduction, and adduction needs to be sequentially
tested. Finally, the examiner can proceed to the special shoul-
der physical tests for ruling out specific lesions.
SPECIFIC TESTS FOR SHOULDER EXAMINATION
Bicipital Groove Palpation
The examiner places his/her fingers on the participant’s
proximal lateral aspect of the arm and rolls over the humeral
head. The bicipital groove can be palpated between the greater
and lesser tubercles of the humerus (Fig. 1A). Tenderness orig-
inating from the bicipital groove may be attributed to the pa-
thologies of the long head of the biceps brachii tendon.12
Speed Test
The participant flexes his/her arm in 90 degrees, extends
the elbow, and supinates the forearm. The examiner gives a
downward force on the participants’ forearm (Fig. 1B). A pos-
itive test is considered in case of pain during resistive shoulder
flexion, which may be associated with disorders of the long
head of the biceps tendon or SLAP lesions.12
Yergason’s Test
The participant flexes his/her elbow in 90 degrees with the
forearm pronated. The examiner exerts resistive force on the
participant’s forearm, while the participant attempts to supinate
(Fig. 1C). A positive test is considered in case of pain over the
bicipital groove during resistive forearm supination, which might
be suggestive of biceps tendon pathology or SLAP lesions.12
FIGURE 1. Demonstration for the bicipital groove palpation (A), speed (B) and Yergason’s (C) tests. The arrows indicate the direction of the resistive
force exerted by the examiner (orange) or the participant (blue).
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Volume 99, Number 2, February 2020
Lift-off Test
It is also known as Gerber’s test, which is used for the ex-
amination of subscapularis tendon disorders. The participant
stands with his/her arm internally rotated and his/her hand placed
on the low back or buttock. The palm should face against the
body. While the participant attempts to lift the hand off the
body, the examiner exerts resistive force to hinder this move-
ment (Fig. 2A). The test is considered positive if the participant
feels pain or weakness when he/she is moving his/her hand
away from the trunk.13
Cross-body Adduction Test
The participant flexes his/her arm forward to 90 degrees
and then adducts it in the horizontal plane to cross the chest
at the maximal effort (Fig. 2B). A positive test is considered
when there is reproducible pain over the acromioclavicular joint,
suggesting acromioclavicular joint dysfunction or subacromial
impingement.14
Compression-Rotation Test
The participant lies in side-lying position with his/her un-
affected shoulder against the bed. The examiner flexes the par-
ticipant’s elbow to 90 degrees and abducts the participant’s arm
in 90 degrees. A compressive force is applied through the elbow
to be exerted on the glenohumeral joint followed by internal and
external rotation of the participant’s arm (Fig. 2C). A positive
test is considered in case of pain during rotation movements,
suggesting a SLAP lesion.15
Crank Test
The participant remains seated during the examination while
his/her arm is abducted greater than 90 degrees in the scapular
plane and the elbow is flexed. An axial load is applied on the
glenohumeral joint. The examiner internally and externally ro-
tates the humerus (Fig. 3A). A positive test is considered when
there is pain during dynamic examination, indicating potential
labrum lesions.16
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Volume 99, Number 2, February 2020
FIGURE 2. Demonstration of the lift-off (A), cross-body adduction (B), and compression-rotation (C) tests. The orange arrows indicate the direction of
the resistive force exerted by the examiner.
O’Brien Test
The participant fully extends his/her elbow and forward
flexes his/her arm to 90 degrees and then internally rotates it.
The examiner applies a downward force on the forearm and asks
the participant to resist against it. Subsequently, the participant ex-
ternally rotates his/her arm, and the resistive force is exerted again
(Fig. 3B). If the participant complains of pain during the first
but not the second test position, a SLAP lesion is suspected.16
Empty Can Test
The empty can test is also known as Jobe’s or supraspinatus
test. The participant abducts his/her arm to 90 degrees in the
scapular plane with his/her elbow extended. Subsequently,
maximal internal rotation of the participant’s arm is performed
with his/her thumb pointing toward the ground. The participant
resists the downward force given by the examiner on the tested
arm (Fig. 4A). A positive test is considered in case of pain dur-
ing resistive arm abduction, implying possible pathology over
the supraspinatus tendon/muscle.17
Painful Arc Test
The participant keeps his/her upper limb in a neutral posi-
tion and fully abducts his/her arm in the scapular plane. In the
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Clinical Tests of the Shoulder
presence of pain between 60 and 120 degrees of abduction, the
test is considered to be positive for subacromial impingement
(Fig. 4B). However, if the participant continues to report pain
at the end of shoulder abduction, acromioclavicular joint dys-
function should be taken into account.14
Patte’s Test
The participant flexes his/her elbow, pronates his/her fore-
arm, abducts his/her arm to 90 degrees, and externally rotates
it. The participant resists against an internal rotation force applied
by the examiner on the participant’s dorsal forearm (Fig. 4C).
A positive test is considered when there is shoulder girdle pain
during the examination or in case of inability to the main arm
in external rotation, indicating potential pathology over the
infraspinatus or teres minor tendon.18
Neer’s Impingement Test
The participant internally rotates his/her arm and extends
his/her elbow. The examiner holds the participant’s posterior
aspect of the scapula to prevent scapular rotation. The participant
forward flexes his/her arm to the maximal extent (Fig. 4D). A
positive test is considered in case of pain during arm elevation,
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Chang et al. Volume 99, Number 2, February 2020

FIGURE 3. Demonstration of the Crank (A) and O’Brien (B) tests. The O’Brien test is started by applying a downward force while internally rotating the
arm (left) and followed by externally rotating the arm (right). The arrows indicate the direction of the resistive force exerted by the examiner (orange)
or the participant (blue).

FIGURE 4. Demonstration of the empty can (A), painful arc (B), Patte’s (C), and Neer’s impingement (D) tests. The arrows indicate the direction of the
resistive force exerted by the examiner (orange) or the participant (blue).

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Volume 99, Number 2, February 2020
suggesting possible subacromial impingement or supraspinatus
tendon pathology.14
Hawkins-Kennedy Impingement Test
The participant flexes his/her elbow to 90 degrees and for-
ward flexes his/her arm in the horizontal plane. The examiner
internally rotates the participant’s arm (Fig. 5A). A positive test
is considered when pain is present at the superior lateral aspect
of the shoulder, indicating possible subacromial impingement
or supraspinatus tendon pathology.14
Anterior Apprehension Test
The participant lies in supine position with his/her arm
and elbow flexed to 90 degrees. The examiner externally ro-
tates the participant’s arm to the maximal extent (Fig. 5B). A
positive test is considered in case of pain or apprehension (be-
ing afraid of shoulder anterior dislocation) during arm external
rotation, indicating possible anterior shoulder instability.19
Posterior Apprehension Test
The participant lies in supine position with his/her elbow
flexed and his/her arm forward flexed and adducted. The
FIGURE 5. Demonstration of the Hawkins-Kennedy impingement (A), anterior apprehension (B), and posterior apprehension (C) tests. The orange
arrows indicate the direction of the resistive force exerted by the examiner.
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Clinical Tests of the Shoulder
examiner exerts an axial load over the participant’s elbow and at-
tempts to push the participant’s arm posteriorly (Fig. 5C). The
test is considered positive when there is pain or apprehension
(being afraid of shoulder posterior dislocation) during the exam-
ination, indicating possible posterior shoulder instability.20
COMPARISON OF THE DIAGNOSTIC ACCURACY
Regarding diagnostic accuracy, some parameters in addition
to well-known sensitivity and specificity should be introduced.
Positive likelihood ratio (LR+) is calculated by “sensitivity/
(1 − specificity)” and it refers to the probability of a person
with the disorder testing positive divided by the probability
of a person without the disorder testing positive.21 Negative
LR (LR−) is calculated by “(1 − sensitivity)/specificity” and it
refers to the probability of a person with the disorder testing
negative divided by the probability of a person without the dis-
order testing negative.21 The diagnostic odds ratio (DOR) is cal-
culated by LR+/LR−. The DOR ranges from zero to infinity,
and a higher value is suggestive of a better diagnostic perfor-
mance.21 The benefit of using the DOR as an indicator of diag-
nostic performance is its independence of prevalence.22 A test
with LR+ less than 3 or LR− larger than 0.33 has little value for
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Chang et al.
improving diagnostic accuracy. A test with a DOR larger than
20 is considered excellent.23 In the following part, the diagnostic
accuracy of clinical tests for several shoulder disorders will be
discussed using the data from published meta-analyses (where
available). For searching relevant systematic reviews and meta-
analyses, we used the combination of “shoulder” and “physical
examination” as the key words for literature search in PubMed
from the earliest record to August 2019 without language re-
striction. The article type was focused on reviews.
In terms of biceps long head tendinitis, Chen et al.12 used US
to validate the findings of several physical tests. In their target
population, 39.1% had biceps tendinitis, and 55.3% experienced
concomitant rotator cuff tendon disorders. The sensitivity values
for Speed and Yergason’s tests were 63% and 32%, respec-
tively. The specificity values for Speed and Yergason’s tests
were 58% and 78%, respectively. They concluded that physical ex-
amination had limited values in the diagnosis of biceps long head
disorders because the finding might be confounded by rotator cuff
tendon injury, which has a significant anatomic relationship with
the biceps long head tendon (Supplementary Table 1, Supple-
mental Digital Content 1, http://links.lww.com/PHM/A881).
With regard to the SLAP lesion, Gismervik et al.24 con-
ducted a meta-analysis in 2017, where they evaluated the diagnos-
tic accuracy of bicipital groove palpation, Speed, Yergason’s,
compression-rotation, Crank, anterior apprehension, and O’Brien
tests. The anterior apprehension test had the highest sensitivity
(0.74) among all tests, whereas Yergason’s test had the highest
specificity (0.92) among all tests. However, the compression-
rotation test had the highest DOR (6.36), followed by Yergason’s
test (2.91), among all tests. The previously mentioned findings
were consistent with the observation from an earlier meta-
analysis performed by Hegedus et al.,25 revealing that Yergason’s
test had the best specificity (0.95) and the compression-rotation
test had the best positive LR (2.81) among all tests (Supplemen-
tary Table 1, Supplemental Digital Content 1, http://links.lww.
com/PHM/A881).
Subacromial impingement syndrome is another important
shoulder disorder. Based on the meta-analysis of Gismervik
et al.,24 the sensitivity and specificity of Hawkins-Kennedy im-
pingement test were 0.58 and 0.67, respectively. Similarly, Neer’s
impingement test had a sensitivity of 0.59 and a specificity of
0.60. Overall, Hawkins-Kennedy impingement test had a slightly
higher DOR (2.86) than Neer’s impingement test (2.17). The or-
der of the DOR values pertaining to the two previously mentioned
tests was in accordance with the meta-analysis of Hegedus et al.25
in which the diagnostic power of the painful arc test was also
evaluated. They found that the DOR of the painful arc test
was not better than that of Hawkins-Kennedy and Neer’s im-
pingement tests (Supplementary Table 1, Supplemental Digital
Content 1, http://links.lww.com/PHM/A881).25
Considering any kind of rotator cuff tendon full-thickness
tears, the empty can test had a high DOR (9.24) with sensitivity
of 0.74 and specificity of 0.77 according to the meta-analysis
of Gismervik et al.24 If the pathology was restricted to
supraspinatus full-thickness tear only, the DOR of the empty
can test decreased to 3.50, with a sensitivity of 0.60 and a spec-
ificity of 0.70 (Supplementary Table 1, Supplemental Digital
Content 1, http://links.lww.com/PHM/A881).
Concerning anterior shoulder instability, the DOR of the
anterior apprehension test could reach as high as 53.60 with
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Volume 99, Number 2, February 2020
a sensitivity of 0.65 and a specificity of 0.95 based on the
meta-analysis of Hegedus et al.25 The high DOR indicated ad-
equate discriminative power of the anterior apprehension test.
Furthermore, its good specificity also reflected the capability of
the anterior apprehension test to exclude anterior shoulder insta-
bility in case of a negative finding (Supplementary Table 1, Sup-
plemental Digital Content 1, http://links.lww.com/PHM/A881).
Another issue that needs to be investigated is the reliability
of physical tests for shoulder disorders. Lange et al.26 conducted a
meta-analysis of 18 eligible studies in 2017. The intrarater reliabil-
ity was only reported in one study evaluating Neer’s impinge-
ment, Hawkins-Kennedy impingement, Patte’s, and empty can
tests. The κ coefficients reached 1 in almost every included test,
demonstrating excellent intrarater agreement. The meta-analysis
showed that interrater κ coefficients ranged from 0.47 to 0.71
for Hawkins-Kennedy impingement, Neer’s impingement,
empty can, and painful arc tests, indicating moderate-to-
substantial agreement.
LIMITATIONS AND PRACTICABILITY OF
SPECIFIC SHOULDER TESTS
In some patients with shoulder pain, the underlying pa-
thology may disappear but the pain persists because of altered
motion biomechanics and central pain modulation. The shoul-
der physical stress/function tests may yield a negative finding
in the chronic painful stage. Therefore, instead of targeting a
specific lesion to explain the patient’s symptoms, the examiner
should look for evidence of faulty postures and muscle activat-
ing patterns. A global and comprehensive evaluation of shoulder
kinematics may prevent patients from unnecessary surgeries.
The previously mentioned rule is also suitable for patents after
shoulder surgeries, where biotensegrity and regional anatomy
have been changed. Furthermore, shoulder pain may also pres-
ent with neck disorders and vice versa. A recent US study has
shown that in patients with shoulder or neck pain, the findings
of rotator cuff tendon tears are independent from cervical fo-
raminal stenosis.27 Therefore, if applicable, the physicians are
suggested to conduct physical examinations and imaging studies
of both the neck and shoulder regions in participants with un-
differentiated shoulder and neck pain.
Regarding the diagnostic scheme of shoulder disorders, US
imaging can in theory be used as the first line because the US
machine is more accessible nowadays. Given this case, the
shoulder physical tests may be served as assistance to rule out
hidden pathologies. However, the proposed diagnostic algorism
has not been supported by available guidelines yet, which needs
more prospective studies to prove. Furthermore, the physician
should be aware of the limitation of US in detecting certain
shoulder pathologies, such as SLAP lesion. When the physical
findings are not consistent with the US presentations, the in-
vestigators should be alerted that the lesion may be outside
of the shoulder joints. If the shoulders have been treated by sur-
geries or other invasive nonsurgical interventions (eg, radiofre-
quency ablation), the physical or imaging findings might not
be consistent with symptom improvement. Overdiagnosis with
sonographic imaging in painful shoulder disorders is not un-
common.28 There are still several clinical scenarios that US im-
aging might not be representative of the severity of underlying
pathologies.29 Furthermore, the examiner should be aware that
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Volume 99, Number 2, February 2020 Clinical Tests of the Shoulder

FIGURE 6. Demonstration of the US-guided biceps palpation test (A) and corresponding US imaging before (B) and after (C) palpation by the thumb.
Demonstration of the dynamic US cross-body adduction test (D) and corresponding US imaging before (E) and after (F) adduction of the examiner’s
arm. *Biceps long-head tendon. The yellow dashed line indicates superficial fascia; white dashed line, capsule of the acromioclavicular joint. ACR,
acromion; CLA, clavicle; DEL, deltoid muscle; GT, greater tubercle; LG, lesser tubercle.

there are still several blind spots for shoulder US, such as the
superior labrum. In those cases, the findings on the specific
shoulder physical tests would provide useful information for
physicians to decide whether advanced imaging examinations
(eg, computed tomography and magnetic resonance imaging)
should be prescribed.

EXTENSION OF TRADITIONAL SHOULDER TESTS

Ultrasound imaging has been considered as one of the
most useful tools for the management of shoulder problems.30–32
The possibility of dynamic assessment renders US an extension
of the physical examination. In patients with bicipital groove ten-
derness, it can help verify whether the painful area is on top of
the biceps long head tendon (Figs. 6A–C and Supplementary
Video 1, Supplemental Digital Content 2, http://links.lww.
com/PHM/A882). When the cross-chest test was performed to
examine the acromioclavicular joint, the transducer can
be put over the joint while the participant adducts his/her arm
(Figs. 6D–F and Supplementary Video 2, Supplemental Digital
Content 3, http://links.lww.com/PHM/A883). Bulging of the
joint capsule, narrowing of the joint space, and protruding intra-
articular disc can be easily visualized in relevant cases. In patients
with positive Hawkins-Kennedy and Neer’s impingement
tests, the examiner can perform a dynamic subacromial
impingement test.10,33 The transducer is positioned along the
scapular plane lateral to the acromion. The participant gradually
raises his/her arm, and the examiner simultaneously observes
whether there is bulging of the subacromial bursa and FIGURE 7. Demonstration of the dynamic US subacromial
abnormal elevation/movement of the humeral head (Fig. 7 and impingement test (A) and corresponding US imaging at rest (B) and
during shoulder abduction along the scapular plane (C). The blue arrow
Supplementary Video 3, Supplemental Digital Content 4, indicates the direction of movement of the participant’s arm. ACR,
http://links.lww.com/PHM/A884). Normally, the supraspinatus acromion; CLA, clavicle; DEL, deltoid muscle; GT, greater tubercle; SS,
tendon (“bird’s beak”) fully disappears beneath the acromion. supraspinatus muscle.

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Chang et al.
FIGURE 8. Demonstration of the dynamic US posterior glenohumeral joint impingement test (A) and corresponding US imaging at rest (B) and during
extension and external rotation of the arm at 90 degrees of shoulder abduction (C). The blue arrow indicates the direction of movement of the
participant’s arm. *Labrum. CLA, clavicle; DEL, deltoid muscle; HH, humeral head; IS, infraspinatus muscle.
In athletes who participate in throwing activities, dynamic US
can be used to examine whether there is posterior instability
causing impingement between the humeral head and the
posterior labrum (Fig. 8 and Supplementary Video 4,
Supplemental Digital Content 5, http://links.lww.com/PHM/
A885). The examiner can always improvise and place the
transducer on the area (“sonopalpation”) where the pathology
may be observed during the physical examination or where
the participant describes the exact location of pain. In the
future, the examiners may consider using dynamic US to
verify the results obtained from traditional shoulder
examinations. Likewise, if the findings from the physical
examination seem equivocal, the physicians can take advantage
of dynamic US to augment the diagnostic accuracy of those
traditional tests.
CONCLUSIONS
Because the shoulder is a complex structure, concomitant
disorders of the shoulders are common. The physical tests are
helpful to detect the likely pathology of shoulder disorders,
but interpretation of findings may vary across the examiners.
Regarding diagnostic performance, most shoulder physical
tests have better specificity than sensitivity, making them more
suitable to rule out certain lesions in case of negative findings.
Lastly, US can be considered as an extension of physical exam-
ination where static/dynamic imaging can be a contributing
factor along with the previously mentioned tests.
REFERENCES
1. Luime JJ, Koes BW, Hendriksen IJ, et al: Prevalence and incidence of shoulder pain in the
general population; a systematic review. Scand J Rheumatol 2004;33:73–81
168 www.ajpmr.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Volume 99, Number 2, February 2020
2. Bagheri F, Ebrahimzadeh MH, Moradi A, et al: Factors associated with pain, disability
and quality of life in patients suffering from frozen shoulder. Arch Bone Jt Surg
2016;4:243–7
3. Hermans J, Luime JJ, Meuffels DE, et al: Does this patient with shoulder pain have
rotator cuff disease?: the rational clinical examination systematic review. JAMA
2013;310:837–47
4. Chang KV, Mezian K, Nanka O, et al: Ultrasound-guided interventions for painful shoulder:
from anatomy to evidence. J Pain Res 2018;11:2311–22
5. Wu WT, Chang KV, Mezian K, et al: Basis of shoulder nerve entrapment syndrome: an
ultrasonographic study exploring factors influencing cross-sectional area of the suprascapular
nerve. Front Neurol 2018;9:902
6. Chang KV, Lin CP, Lin CS, et al: A novel approach for ultrasound guided axillary nerve block:
the inferior axilla technique. Med Ultrason 2017;19:457–61
7. Chang KV, Chen WS, Wang TG, et al: Associations of sonographic abnormalities of the
shoulder with various grades of biceps peritendinous effusion (BPE). Ultrasound Med Biol
2014;40:313–21
8. Wu WT, Chang KV, Ozcakar L: Dynamic ultrasound imaging for the diagnosis of
superior labrum anterior to posterior (SLAP) lesion. Am J Phys Med Rehabil
2019;98:e130–1
9. Hung CY, Chang KV, Ozcakar L, et al: Can quantification of biceps peritendinous effusion
predict rotator cuff pathologies?: a retrospective analysis of 1352 shoulder ultrasound.
Am J Phys Med Rehabil 2016;95:161–8
10. Chang KV, Wu WT, Han DS, et al: Static and dynamic shoulder imaging to predict initial
effectiveness and recurrence after ultrasound-guided subacromial corticosteroid injections.
Arch Phys Med Rehabil 2017;98:1984–94
11. Ma R, Brimmo OA, Li X, et al: Current concepts in rehabilitation for traumatic anterior
shoulder instability. Curr Rev Musculoskelet Med 2017;10:499–506
12. Chen HS, Lin SH, Hsu YH, et al: A comparison of physical examinations with
musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis. Ultrasound Med
Biol 2011;37:1392–8
13. Greis PE, Kuhn JE, Schultheis J, et al: Validation of the lift-off test and analysis of
subscapularis activity during maximal internal rotation. Am J Sports Med 1996;24:589–93
14. Woodward TW, Best TM: The painful shoulder: part I. Clinical evaluation. Am Fam Physician
2000;61:3079–88
15. Somerville LE, Willits K, Johnson AM, et al: Clinical assessment of physical examination
maneuvers for superior labral anterior to posterior lesions. Surg J (N Y) 2017;3:e154–62
16. Stetson WB, Templin K: The crank test, the O'Brien test, and routine magnetic resonance
imaging scans in the diagnosis of labral tears. Am J Sports Med 2002;30:806–9
17. Gillooly JJ, Chidambaram R, Mok D: The lateral Jobe test: a more reliable method of
diagnosing rotator cuff tears. Int J Shoulder Surg 2010;4:41–3
18. Collin P, Treseder T, Denard PJ, et al: What is the best clinical test for assessment of the teres
minor in massive rotator cuff tears? Clin Orthop Relat Res 2015;473:2959–66
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Volume 99, Number 2, February 2020
19. Kumar K, Makandura M, Leong NJ, et al: Is the apprehension test sufficient for the
diagnosis of anterior shoulder instability in young patients without magnetic resonance
imaging (MRI)? Ann Acad Med Singapore 2015;44:178–84
20. Valencia Mora M, Iban MAR, Heredia JD, et al: Physical exam and evaluation of the unstable
shoulder. Open Orthop J 2017;11:946–56
21. Simundic AM: Measures of diagnostic accuracy: basic definitions. EJIFCC 2009;19:203–11
22. Glas AS, Lijmer JG, Prins MH, et al: The diagnostic odds ratio: a single indicator of test
performance. J Clin Epidemiol 2003;56:1129–35
23. Fischer JE, Bachmann LM, Jaeschke R: A readers' guide to the interpretation of diagnostic
test properties: clinical example of sepsis. Intensive Care Med 2003;29:1043–51
24. Gismervik SO, Drogset JO, Granviken F, et al: Physical examination tests of the shoulder:
a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskelet
Disord 2017;18:41
25. Hegedus EJ, Goode AP, Cook CE, et al: Which physical examination tests provide clinicians
with the most value when examining the shoulder? Update of a systematic review with
meta-analysis of individual tests. Br J Sports Med 2012;46:964–78
26. Lange T, Matthijs O, Jain NB, et al: Reliability of specific physical examination tests for the
diagnosis of shoulder pathologies: a systematic review and meta-analysis. Br J Sports Med
2017;51:511–8
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Clinical Tests of the Shoulder
27. Wu WT, Chang KV, Han DS, et al: Cross-talk between shoulder and neck pain: an imaging
study of association between rotator cuff tendon tears and cervical foraminal stenosis.
Medicine (Baltimore) 2018;97:e12247
28. Serafin-Krol M, Maliborski A: Diagnostic errors in musculoskeletal ultrasound imaging
and how to avoid them. J Ultrason 2017;17:188–96
29. Henderson RE, Walker BF, Young KJ: The accuracy of diagnostic ultrasound imaging for
musculoskeletal soft tissue pathology of the extremities: a comprehensive review of the
literature. Chiropr Man Therap 2015;23:31
30. Ozcakar L, Kara M, Chang KV, et al: EURO-MUSCULUS/USPRM Basic Scanning
Protocols for shoulder. Eur J Phys Rehabil Med 2015;51:491–6
31. Wang JC, Chang KV, Wu WT, et al: Ultrasound-guided standard versus dual-target
subacromial corticosteroid injections for shoulder impingement syndrome: a randomized
controlled trial. Arch Phys Med Rehabil 2019;100:2119–28
32. Lew HL, Chen CP, Wang TG, et al: Introduction to musculoskeletal diagnostic
ultrasound: examination of the upper limb. Am J Phys Med Rehabil
2007;86:310–21
33. Chang KV, Wu WT, Ozcakar L: Association of bicipital peritendinous effusion with
subacromial impingement: a dynamic ultrasonographic study of 337 shoulders. Sci Rep
2016;6:38943
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