11830 Westline Industrial Drive

St. Louis, Missouri 63146

CLINICAL EXAMINATION OF THE SHOULDER 0-7216-9807-7

Copyright © 2004, Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health
Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239,
e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier
Science homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining
Permissions’.

NOTICE

Physical Therapy is an ever-changing field. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current product information
provided by the manufacturer of each drug to be administered to verify the recommended dose, the
method and duration of administration, and contraindications. It is the responsibility of the licensed
prescriber, relying on experience and knowledge of the patient, to determine dosages and the best
treatment for each individual patient. Neither the publisher nor the editor assumes any liability for any
injury and/or damage to persons or property arising from this publication.
Publisher

Library of Congress Cataloging in Publication Data

Ellenbecker, Todd S., 1962–

Clinical examination of the shoulder / Todd
S. Ellenbecker.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7216-9807-7
1. Shoulder–Examination. 2. Shoulder–Wounds and injuries–Diagnosis. I. Title. [DNLM:
1. Shoulder Joint–injuries. 2. Shoulder Joint–physiopathology. 3. Diagnostic Techniques and
Procedures. 4. Shoulder–injuries. 5. Shoulder–physiopathology. WE 810 E45c 2004]
RC939.E45 2004
617.5¢72044–dc22 2004046718

Acquisitions Editor: Marion Waldman

Developmental Editor: Jacquelyn Merrell
Publishing Services Manager: Linda McKinley
Project Manager: Jennifer Furey
Designer: Amy Buxton

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my wife and best friend—Gail
FM.qxd 5/24/04 4:23 PM Page vii

PREFACE

dvances in basic science and clinical research of the tors can be used to better understand the seemingly com-
A shoulder have significantly increased the under-
standing of the anatomy, biomechanics, and pathophysiol-
plicated terms of specificity and sensitivity. These terms are
spin and snout, and the use of these terms may make it eas-
ogy of the human shoulder. With these advances has ier to apply the concepts of specificity and sensitivity using
come an influx of clinical tests and methods used to exam- these everyday terms. Spin, used for specificity, indicates
ine the patient with a musculoskeletal shoulder injury. that specificity refers to ruling “in” conditions, whereas
The primary purpose of this book is to provide the reader snout, representing sensitivity, assists in ruling conditions
with an overview of the available research substantiating “out.” While oversimplified, these simple descriptors can
or negating the use of many clinical tests for the patient be used while reading through the often detailed research
presenting with shoulder dysfunction. In addition to sim- on many clinical tests described in this text.
ply providing a detailed description of these tests, each Finally, it is hoped that the practical information
chapter provides an overview of the primary pathology for included in the latter portion of this text on strength test-
which these tests are used and summarizes the research ing, proprioception, and functional evaluation can be used
performed on these tests to provide a level of understand- to provide the most detailed clinical examination of the
ing regarding their effectiveness. high-functioning shoulder. Understanding the clustering
The inclusion of research is not meant to confuse the of signs and symptoms obtained during the clinical exam-
reader, but rather to allow for a more scientific approach ination processes inherent in the “master” clinician’s clini-
to the examination process. Repeated use of the terms cal behaviors is summarized in the final section of this
specificity and sensitivity can be at times intimidating. book in the form of case studies. It is hoped that this book
However, these statistical values can assist the clinician in will provide a valuable clinical reference tool for the prac-
identifying clinical tests that are the most effective for ticing clinician by consolidating practical and research-
patients with shoulder dysfunction. Two simple descrip- specific information in one place.

vii
FM.qxd 5/24/04 4:23 PM Page ix

ACKNOWLEDGMENTS

hile many individuals have provided guidance, I would also like to thank the physicians, therapists,
W both in this project and throughout my career, I
would like to acknowledge the following, whom this book
tennis teaching professionals, and coaches for the daily
opportunity to examine and treat their patients and
could not have been written without—George Davies, athletes and allow me the privilege to focus on clinical
Janet Sobel, Kevin Wilk, Dr. Ben Kibler, and Dr. Robert practice and research of the shoulder.
Nirschl—for their excellence and guidance in teaching me
shoulder examination and treatment.

ix
Ch01.qxd 5/24/04 4:25 PM Page 3

CHAP TER
Introduction to Clinical
1 Examination of the Shoulder

HOW TO USE THIS BOOK actually have the condition (Portney & Watkins, 1993).
This book is designed to present the integral parts of the The sensitivity of a test increases as the number of persons
examination process, combined with clinical research who are correctly identified as having the condition
identifying the effectiveness of the procedures and tech- increases. Another way of thinking of sensitivity is that it
niques used by clinicians, to evaluate the patient with increases when fewer persons with the disorder are
shoulder dysfunction. The research provided in this text missed. Obviously, it is advantageous for a clinician to use
provides crucially important information for the clinician tests that have high indexes of sensitivity.
and contains specific terms, such as specificity, sensitivity,
and predictive value. A discussion of these terms is war- Specificity
ranted to improve the application of this research to the Specificity is the ability of a test to obtain a negative result
clinical evaluation process. when the condition the clinician is testing for is truly
absent. Specificity is represented by the proportion of
Definition of Key Terms individuals who test negative for the condition out of
The use of terms such as specificity, sensitivity, and both all those who do not have the condition. According to
positive and negative predictive value are commonly applied Portney and Watkins (1993), a highly specific test will
in research reporting the accuracy and effectiveness of rarely test positive when a person does not have the
examination techniques on patients. In many studies, disease or condition for which he or she is being tested.
patients are examined clinically and results are compared
to determine the reliability of the clinical test both for one Combining Sensitivity and Specificity
examiner on numerous occasions of testing (intrarater Obviously, using tests with high sensitivity and specificity
reliability) and among several examiners (interrater relia- enhances a clinician’s ability to correctly identify patholo-
bility). Clinical tests contained in this book are also often gy and arrive at the best possible clinical impression and
compared with the results of other diagnostic tests such subsequent treatment plan. As with many clinical scenar-
as magnetic resonance imaging (MRI) or radiographs, ios, however, there are tradeoffs between the two charac-
as well as with intraoperative findings. The presence of teristics. Tests that are designed to be highly sensitive have
injury or pathology at time of surgery confirms or negates testing criteria that are typically less stringent; thus fewer
the result of clinical testing and is a common research cases are missed (Portney & Watkins, 1993). In this
design presented in this book. scenario, the chances of obtaining false-positive results
increase (decreased specificity) because less stringent qual-
Sensitivity ifying responses are used to render a test positive. Like-
The validity of a screening or evaluation test is measured wise, if the test criteria are made more stringent, such that
in terms of its ability to accurately assess the presence or only a narrow range of individuals with the criterion vari-
absence of the target condition (Portney & Watkins, able will test positive, a greater proportion of those who are
1993). Sensitivity can be defined as the ability of a test or normal will test negative (increasing specificity); however,
evaluation maneuver to obtain a “positive” result when the a larger number of the true cases (individuals who have the
condition the test is testing for is really present. In other condition) will be missed, which decreases sensitivity.
words, sensitivity is the ability of the test to produce a true Sensitivity is most important when the risk associated
positive result when the patient being tested actually has with missing a diagnosis is high, such as identifying can-
the disorder for which the examiner is testing. Sensitivity cer or other life-threatening disease. Using the muscu-
is represented by the percentage of individuals who test loskeletal tests mentioned in this book, including the
positive for the condition out of all those individuals who clinical elimination maneuvers for the glenoid labrum,

3
Ch01.qxd 5/24/04 4:25 PM Page 4

4 SECTION I General Overview

which may render a patient a candidate for a surgical pro- posture that does not allow further testing as a result of
cedure, would also carry a high risk, as an inaccurate diag- decreased relaxation. Therefore careful selection of the
nosis may subject a patient to an unnecessary surgical most important and clinically accurate tests is an impor-
procedure. Specificity is more important when either the tant responsibility of the clinician when performing a
costs or risks involved with further intervention are sub- clinical shoulder examination.
stantial (Portney & Watkins, 1993). This book includes
Prevalence
multiple tests in most areas to provide the clinician with a
variety of clinical tests, so that the results of several exam- The concept of prevalence must be considered when
inations can be combined to minimize the tradeoffs applying and interpreting clinical tests. The term preva-
between specificity and sensitivity. lence refers to the number of cases of a condition that exist
in a certain population at any given time (Portney &
Predictive Value Watkins, 1993). When the prevalence is high, the likeli-
To determine whether the performance of a clinical test or hood of identifying cases correctly using tests with a given
series of clinical tests is feasible and an efficient use of sensitivity and specificity increases. Also, when prevalence
both the examiner’s and patient’s time, the test’s predictive is high, a test will tend to have a higher PPV. When
value can be assessed. Positive predictive value (PPV) esti- prevalence is low, the chances of obtaining a false-positive
mates the likelihood that a person who tests positive will result are much higher than when the prevalence of a par-
actually have the condition for which he or she is being ticular condition is high. When using the empty or full
tested. PPV is the proportion of patients who test positive can test to detect a full-thickness rotator cuff tear, knowl-
and who truly have the condition. A clinical test with a edge regarding the prevalence of rotator cuff tears plays a
very high PPV provides a strong estimate of the number considerable part in applying the results of the test. For
of patients who actually have the condition. example, when testing an 11-year-old elite junior tennis
Likewise, negative predictive value (NPV) indicates player with anterior shoulder pain, a positive empty or full
the probability that a person who tests negative on a clin- can test is unlikely to indicate a full-thickness tear of the
ical test actually does not have the condition for which he supraspinatus tendon, as full-thickness rotator cuff tears
or she is being assessed. Research by Itoi et al (1999) illus- in that young population are less common and occur at a
trates the concept of predictive value. They studied the very low prevalence. In contrast, if the empty or full can
effectiveness of the empty and full can clinical tests in test resulted in significant muscular weakness in a 79-
identifying patients with full-thickness rotator cuff tears. year-old competitive tennis player with anterior shoulder
By using the criterion of muscular weakness, the full can pain, the likelihood that this finding would indicate a full-
clinical test had a PPV of 49%. This finding tells clini- thickness tear is much greater because of the greater
cians that approximately one of every two patients who prevalence of full-thickness tears in older individuals.
have substantial weakness during the performance of the Summary
full can rotator cuff test actually has a full-thickness rota- This book provides detailed descriptions of clinical tests
tor cuff tear. Likewise, one of every two patients who test along with research reporting their sensitivity and speci-
positive during the full can test is actually normal. ficity, as well as their positive and negative predictive
Applying positive and negative predictive values to the value. This information provides a better indication of the
clinical environment may at first seem overly scientific and actual effectiveness of a specific clinical test or group of
academic. However, consider the ramifications of using a clinical tests, as well as a better understanding of the role
clinical test with a very low PPV during the evaluation of that an examination maneuver or group of maneuvers can
a patient who presents with symptoms consistent with a play in the comprehensive evaluation of the patient with
labral tear. If an individual were to test positive for a labral shoulder pathology.
tear using a test with a very low PPV, considerable time
and additional resources would be required to further COMPARISON OF CLINICAL
determine whether that initial clinical test was actually EVALUATION FINDINGS WITH
correct. In some cases, the use of clinical tests with a very OTHER DIAGNOSTIC TESTS AND
low PPV or NPV is not worth the potential discomfort SURGICAL FINDINGS
and time required. Another potential problem with using One of the most common methods of determining the
tests with low predictive value is that alternative tests are effectiveness of a group of clinical examinations of the
often required to confirm the results of the first test. For shoulder is to compare the results with established diag-
example, use of a clunk test to identify labral pathology nostic tests. Naredo et al (2002) compared the results of
may place the patient in a more apprehensive clinical physical examination to ultrasound testing in 31 consecu-
Ch01.qxd 5/24/04 4:25 PM Page 5

CHAPTER 1 Introduction to Clinical Examination of the Shoulder 5

tive patients with a first episode of shoulder pain. Exami- tion 51% of the time and with the diagnostic categories
nations were performed by two rheumatologists, with a 80% of the time (Magarey et al, 1989). Further research
third rheumatologist blinded to the results of the clinical on the use of diagnostic categories as well as continued
examination performing the ultrasound. The clinical comparison of clinical test results with arthroscopic
examination consisted of active and passive range of evaluation will assist in determining accuracy and guide
motion and 10 special examination maneuvers. Results of therapists in both the performance and especially the
the comparison showed very low sensitivity in the clinical interpretation of clinical examination methods for the
diagnosis of nearly all shoulder lesions, especially rotator shoulder.
cuff tears; however, specificity was high for rotator cuff
tear, tendonitis of the subscapularis and infraspinatus, and
acromioclavicular joint injury. Specificity was very low for GENERAL CONCEPTS APPLIED
supraspinatus tears, biceps tendonitis, and rotator cuff DURING CLINICAL EXAMINATION
impingement. This study emphasized that pain elicited OF THE SHOULDER
during impingement testing by placing the rotator cuff Several general concepts are important when performing
beneath the acromial arch can be diagnostic for many clinical examination of the shoulder. These concepts are
types of rotator cuff lesions, and the induced pain cannot referred to throughout this book, but are described in
be clearly diagnostic for one particular condition. The detail here. They are essential to the successful examina-
authors concluded that clinical assessment by experienced tion of the patient with shoulder pathology.
physician examiners of the patient with a first-time
injured shoulder was often inaccurate and that ultra- Resting Position of the Glenohumeral Joint
sonography should be used whenever possible to improve The resting position of the human glenohumeral joint is
diagnostic accuracy. generally considered to be the position of maximum range
Research results comparing MRI with clinical evalua- of motion and laxity, as a result of minimal tension or
tion is also available. These studies are covered in greater stress in the supportive structures surrounding the joint
detail in Chapter 13. MRI has been reported to have a (Hsu et al, 2002). This position has been referred to as the
high sensitivity (100%) and specificity (95%) for the diag- loose-pack position of the joint. Kaltenborn (1989) and
nosis of rotator cuff tears (Ianotti et al, 1991) and can dif- Magee (1997) have both reported that the resting position
ferentiate normal rotator cuff tendons from tendons with of the glenohumeral joint ranges between 55 and 70
“tendonitis” (93% sensitivity, 87% specificity). degrees of abduction (trunk humeral angle) in the scapu-
Liu et al (1996a) introduced the crank test for clinical lar plane (see definition of scapular plane in this chapter).
identification of labral tears and reported a higher sensi- This loose-pack position is generally considered to be in
tivity of 90% compared with sensitivity of MRI (59%) and mid-range position, but only recently has been subjected
a specificity that equaled that of MRI (85%). This study to experimental testing.
found that a clinical test was more accurate than MRI in Hsu et al (2002) measured maximal anteroposterior
identifying labral tears in 62 patients who had an average displacements and total rotation range of motion in
of 3 months of shoulder symptoms that did not resolve cadaveric specimens, with different positions of gleno-
with physical therapy. humeral joint elevation in the plane of the scapula. They
Finally, comparison of clinical examination findings identified the loose-pack position, where maximal antero-
with arthroscopic shoulder surgery continues to be one of posterior humeral head excursion and maximal total rota-
the more common means to measure the validity of clini- tion range of motion occurred within the proposed range
cal tests. Itoi et al (1999) used this approach to study the of 55 to 70 degrees of humeral elevation in the scapular
effectiveness of the empty and full can clinical test to plane (trunk-humeral angle) at a mean trunk humeral
identify supraspinatus tears. Magarey et al (1989) com- angle of 39.33 degrees. This rate corresponded to 45% of
pared the results of a clinical examination of the shoulder the available range of motion of the cadaveric specimens.
by two physical therapists with findings obtained during Anteroposterior humeral head translations and maximal
arthroscopic surgery. The two therapists independently total rotation ranges of motion were significantly less, at 0
reached the same conclusion regarding the “tissue source” degrees of abduction and near 90 degrees of abduction
of the patient’s pain 100% of the time. There was 72% in the plane of the scapula, and were greatest near the
agreement in their ability to place the patient into one of experimentally measured resting position of the gleno-
four diagnostic categories: impingement, tendonitis, humeral joint. This study provides key objective evidence
tendon rupture, and instability. The use of arthroscopy for the clinician to obtain the maximal loose-pack posi-
to identify tissue source agreed with the clinical examina- tion of the glenohumeral joint by using the plane of the
Ch01.qxd 5/24/04 4:25 PM Page 6

6 SECTION I General Overview

Figure 1-1 Balance point position allowing clinician to support the patient’s extremity with one hand. Note the position of the hand
near the epicondyles of the elbow.

scapula and approximately 40 degrees of abduction. This retically required to allow for full overhead elevation in
information is important to clinicians who wish to evalu- the scapular plane (Inman et al, 1944). Throughout this
ate the glenohumeral joint in a position of maximal excur- book, the scapular plane position is used during specific
sion or translation to determine the underlying accessory evaluation techniques, including humeral head translation
mobility of the joint. tests and impingement tests.
This cadaveric research provides additional clinical
guidance for identifying relative or percent of abduction Balance Point Position of the Upper Extremity
range of motion where this position occurs. In patients The balance point position concept, used frequently in
with restrictions in humeral elevation resulting from clinical tests to evaluate the glenohumeral joint, is not
capsular tightness, the loose-pack position occurs in less technically based on a calculated or measured balancing
abduction than in individuals with full range of abduction point for the human upper extremity. Rather, this concept
range of motion. Clinicians should use this information refers to the position the clinician can use when grasping
during both evaluation and treatment of the human and supporting the patient’s extremity with only one
shoulder. hand, allowing use of the other hand for additional stabi-
lization or function.
Scapular Plane Position Figure 1-1 shows the approximate position and grip
According to Saha (1983), the scapular plane is defined that can be used to control or balance the patient’s upper
as being 30 degrees anterior to the coronal or frontal plane extremity. This position is referred to throughout this
of the body. Placement of the glenohumeral joint in the book as the balance point position. Note the location near
scapular plane optimizes the osseous congruity between the elbow and the use of the fingers and thumb to opti-
the humeral head and the glenoid and is widely recom- mize contact on a rather wide area at the elbow. This posi-
mended as an optimal position for performing both tion allows the clinician to influence humeral rotation, as
various evaluation techniques and many rehabilitation well as move the glenohumeral joint in flexion, abduction,
exercises (Saha, 1983; Ellenbecker, 1995). With the and circumduction. Care should be taken to avoid overly
glenohumeral joint placed in the scapular plane, bony aggressive grasping of the patient’s elbow, as this can lead
impingement of the greater tuberosity against the to an increase in patient apprehension and unwanted
acromion does not occur because of the alignment of the muscular activation. Repetitive practice with both the
tuberosity and acromion in this orientation (Saha, 1983). clinical tests and patient contact enables the clinician to
Also, no internal or external rotational movement is theo- use optimal patient contacts throughout the upper ex-
Ch01.qxd 5/24/04 4:25 PM Page 7

CHAPTER 1 Introduction to Clinical Examination of the Shoulder 7

tremity and ensures that an adequate amount of pres- that is widely recommended and followed closely is the
sure is used to stabilize and handle the patient’s extremity, ordering of the initial extremity to be evaluated. It is
while avoiding a painful or apprehensive response. recommended that the examiner perform clinical test pro-
cedures on the uninjured extremity first, followed by the
Extremity Examination Sequence involved extremity. Following this order promotes greater
The sequence of actual tests used in shoulder evaluation patient relaxation during examination of the involved
varies based on several factors. Although each clinician or extremity, which is often painful, and reduces the appre-
educator may prefer a specific sequence of elements when hension often encountered during the examination
performing the shoulder examination, few objectively process because the patient may be unsure of which move-
based criteria exist. One aspect of the examination process ments or maneuvers the examiner will be performing.
Ch02.qxd 5/24/04 4:26 PM Page 9

CHAP TER

2 Examination: Patient History

INTRODUCTION reader is referred to a summary of nonmusculoskeletal

A thorough, organized history of the patient with shoul- causes of shoulder region pain in Chapter 5. To perform
der dysfunction is required in the complete examination a complete and thorough patient examination, careful
process. It is important to include both general questions analysis of subjective information provided in the patient’s
with regard to shoulder pathology and specific questions history is required to alert the examiner to the possible
based on the patient’s sport or activity. Although there are presence of nonmusculoskeletal causes. This information
many approaches to history taking, one example of a thor- directs the clinician to a broader base of examination tech-
ough history applicable for a patient with shoulder dys- niques and possible referral to specialists to rule out non-
function is listed in Box 2-1. This chapter covers several musculoskeletal contribution of shoulder dysfunction.
areas of the patient history in greater detail.
PAST HISTORY
IMMEDIATE HISTORY A thorough understanding of the patient’s past history of
One of the initial areas of focus on the subjective evalua- shoulder injury and disability is essential to a successful
tion is the patient’s immediate history, which typically subjective evaluation. Using the example of a patient with
includes the chief complaint. Although many types of shoulder instability, it is important to delineate whether
questions can be asked, the following four questions sum- the patient has “one time” anterior dislocation from a
marize one approach to obtaining the immediate history: traumatic event (TUBS classification of Matsen [Trau-
1. What is the problematic area? matic, Unidirectional, Bankart, Surgery]) or a repeated,
2. How did the problem occur? chronic instability of the glenohumeral joint from repeti-
3. When did the problem develop? tive stresses and an acquired atraumatic onset of injury
4. Where did the problem occur? (AMBRI classification of Matsen [Atraumatic, Multi-
Although these questions may seem simplistic, they can directional, Bilateral Laxity, Rehabilitation, Inferior
effectively elicit the basic information required from the Capsular Shift]). Knowledge of the patient’s pertinent
patient (Maughon & Andrews, 1994). past shoulder history influences not only the sequence and
The description of the chief complaint or complaints inclusion of specific tests used in the evaluation but
typically involves pain, weakness, instability, sensory treatment procedures as well. Examination of a mature
changes, and crepitus. Attempts by the examiner to quan- athlete with a rotator cuff injury from overhead activity is
tify the degree, severity, and exact location of these factors another example of the importance of obtaining a thor-
via the patient’s subjective responses involve sequential, ough history relating to shoulder pathology. Complete
organized dialogue between the patient and examiner. questioning often can reveal a fall onto the lateral aspect
During the subjective evaluation of the shoulder, attempts of the shoulder as long ago as 20 to 30 years or a shoulder
should be directed toward delineating and localizing the separation in high school football that can shed light on
symptoms to the injured segment or segments. Identifica- the patient’s impingement-type symptoms. Encroach-
tion of radicular symptoms into the distal upper extrem- ment of the subacromial space as a result of degenerative
ity, constant pain without change or relief, and the changes in the acromioclavicular joint from previous
presence of headaches, low back or neck pain, and psy- injury has been reported as an etiologic factor in impinge-
chosocial stresses that may be influencing the patient’s ment lesions (Neer, 1983).
overall health provide rationales for further objective Specific questioning regarding previous treatment
evaluation outside the upper extremity kinetic chain. For to the injured shoulder is also of interest to the rehabilita-
a more detailed discussion of differential diagnosis, the tion specialist. Previous surgical procedures, steroid

9
Ch02.qxd 5/24/04 4:26 PM Page 10

10 SECTION I General Overview

Box 2-1 Examination: History

• Chief complaint
• Nature of symptoms
• Behavior of symptoms
• Location of symptoms
• Onset of symptoms A
• Course and duration of symptoms
• Effect of previous treatment
• Other related medical problems

Adapted from Saunders HD: Evaluation of a musculoskeletal disorder.

In Gould JA, Davies GJ: Orthopaedic and sports physical therapy, St Louis,
1985, Mosby.

injections, therapeutic modalities, and exercise programs

are relevant when formulating an evaluation-based treat-
ment program.

LOCATION OF SYMPTOMS
B
Determining the location of symptoms is an important
part of the subjective evaluation and is required to
enhance the objective portion of the evaluation process.
Isolating the area of discomfort is often difficult for the
patient with an overuse injury to the rotator cuff because
of the intimate association of the tendons of the rotator
cuff to one another near their humeral insertion (Clark & Figure 2-1 Pattern of pain presentation after localized injection
into A, the acromioclavicular joint, and B, the subacromial space.
Harryman, 1992). The splaying and interweaving of the (From Gerber C, Galantay RV, Hersche O: The pattern of pain
rotator cuff, as well as an ensheathed biceps tendon by the produced by irritation of the acromioclavicular joint and the sub-
subscapularis and supraspinatus tendon, may further com- acromial space, J Shoulder Elbow Surg 7(4):353, 1998.)
plicate the isolation of a direct point of injury in these
structures (Clark & Harryman, 1992). Identification of
referral symptoms into the lateral aspect of the shoulder,
or continuing into the elbow and distal upper extremity, Injection into the subacromial space produced a charac-
indicates the need for further objective testing and speci- teristic pain pattern, which included mainly the region
fic joint clearing tests to rule out involvement of the cer- overlying the lateral aspect of the deltoid in 100% of the
vical spine or elbow joints (Davies & DeCarlo, 1995). subjects injected (see Figure 2-1). All 10 subjects also had
Confirmation of the location of patient symptoms is often pain over the lateral border of the acromion. The acromio-
achieved through the use of a body chart. clavicular joint remained pain free in every case when
Gerber et al (1998) attempted to characterize pain injection was directed into the subacromial space.
patterns after an isolated injection of a hypertonic saline This important study provided evidence regarding the
solution directly into the subacromial space and acromio- typical pain patterns expected with irritation of either the
clavicular joint. Figure 2-1 shows the pain patterns subacromial space or acromioclavicular joint. It also char-
produced by the injections. Injection of the hypertonic acterized normal pain responses for irritation of these
saline into the acromioclavicular joint produced relatively structures and identified the lack of posterior scapular and
isolated symptoms directly over the joint in all subjects. neck symptoms from isolated irritation of either the sub-
Pain was also reported over the anterolateral neck region acromial space or acromioclavicular joint (Gerber et al,
and along the upper trapezius muscle, with extension dis- 1998). One of the most common patterns of radicular
tally to the anterolateral deltoid. This injection into the pain that can be confused with shoulder dysfunction is the
acromioclavicular joint produced palpable soreness over C6 radiculopathy. This pain is often referred to the shoul-
the joint, as well as tenderness over the coracoid in 87% of der, the anterosuperior aspect of the arm, the radial aspect
the subjects injected. Pain produced by cross-body abduc- of the forearm, and the thumb (Adams, 1977). This pat-
tion increased after injection in only 13% of the subjects. tern is similar to the one described by Gerber et al (1998)
Ch02.qxd 5/24/04 4:26 PM Page 11

CHAPTER 2 Examination: Patient History 11

for the acromioclavicular joint, except for the presence of because of the possibility of encroachment of the subacro-
posterior neck pain and exacerbation of the pain with mial space when the scapula is protracted.
movements of the cervical spine in cases of C6 radicu- An additional series of questions directed at the
lopathy. Weakness or abnormal C6 reflexes and a lack of patient’s sport or activity demands provides important
tenderness directly over the acromioclavicular joint inher- information for the clinician. For example, establishing
ent in cases of C6 radiculopathy further assist the clinician that a throwing or racquet sport athlete has pain when
in differentiating between acromioclavicular joint injury throwing or serving does not provide the appropriate level
and C6 radiculopathy. of information necessary to properly diagnose and formu-
C7 nerve root compression affects the pectoral region, late a treatment plan. Further questioning as to what
the medial axilla, the region of the scapula, and the tri- stages of the throwing or serving motion produce the
ceps, as well as the dorsal aspect of the forearm and elbow symptoms and after how many repetitions may provide
and middle finger (Gerber et al, 1998). Tenderness is insight into what structures are involved. Specific muscu-
often most noted over the vertebral border of the scapula lar activity patterns and joint kinematics inherent in each
opposite vertebral segments T3 and T4 (Adams, 1977). stage of the throwing motion and tennis serve can assist in
This pattern is uniquely different from the patterns identifying compressive disease or tensile-type injuries of
identified in the evidence-based research of Gerber et al the rotator cuff. The presence of instability of the gleno-
(1998). Their study showed the importance of the history humeral joint, however subtle, during the cocking phase
and physical examination in distinguishing pain arising in of overhead activities can produce impingement or com-
structures intimately associated with the glenohumeral pressive symptoms ( Jobe & Bradley, 1989; Walch et al,
joint versus more central pathology. 1992), whereas a feeling of instability or loss of control
during the follow-through phase during predominant
SEVERITY OF SYMPTOMS eccentric loading of the rotator cuff can indicate a tensile
The use of analog scales is typically recommended for rotator cuff injury (Andrews & Alexander, 1995). Addi-
quantification of the subjective response of pain severity. tional questions regarding a change in sport equipment,
The patient’s rating on a 10-point scale at rest and with ergonomic environment, and training history/habits pro-
activity or specific activities allows for comparison vide information that is imperative for understanding the
between visits and after treatment or activity trials. Using stresses leading to the injury. Examples of additional spe-
the analog scale involves asking the patient to rate the cific questions used during the examination of a baseball
pain, with “0” being no pain and “10” being the worst pain or tennis player are provided in Boxes 2-2 and 2-3.
ever encountered. Other scales are also used to quantify
the patient’s pain. These scales are generally used to eval-
uate the outcome of a specific surgical procedure or to
determine the effectiveness of a treatment process. Refer ACTIVITIES OF DAILY LIVING,
to Chapter 15 for a complete discussion of subjective VOCATIONAL, AND AVOCATIONAL
rating scales. The use of analog and subjective rating GOALS
scales provides additional information for the subjective The individual’s goals play an important part in the for-
evaluation to complement the patient’s report of pain. mulation of an evaluation-based treatment program.
Knowledge of the patient’s vocation and avocational activ-
GENERAL QUESTIONS ities and goals assists the clinician by allowing the use of
Additional questions specifically for the patient with more specific and functionally oriented evaluation and
shoulder pathology are recommended. One question treatment methods. Testing the shoulder in positions
involves the presence of night pain and sleeping position. required either in sport- or activity-specific movement
In a magnetic resonance imaging study (Solem-Bertoft et patterns is required for each shoulder to completely eval-
al, 1993), the subacromial space was narrower in a position uate the degree and level of injury and begin the formula-
of scapular protraction as compared with scapular retrac- tion of a treatment program. The patient’s symptoms can
tion. In a patient suffering from primary glenohumeral be more adequately elicited when specific positions, as
joint impingement, the side-lying position (i.e., lying on well as mode and force-specific muscular contractions, are
the involved side during sleeping) is not beneficial at rest used in the evaluation process.
Ch02.qxd 5/24/04 4:26 PM Page 12

12 SECTION I General Overview

Box 2-2 Examination: History of the Box 2-3 Examination: History in the
Throwing Shoulder Tennis Player
I. General Information I. Presence of Pain during Specific Stroke
A. Age A. Forehand
B. Dominant Arm (Throwing) 1. Preparation
C. Bats (Left, Right, Switch) 2. Acceleration
D. Years Throwing 3. Ball contact
1. Years pitching 4. Deceleration/follow-through
2. Years in other positions B. Backhand
E. Level of Competition 1. One-handed backhand
II. Medical Information 2. Two-handed backhand
A. Chronic or Acute Problem 3. Phase of pain development as in forehand
B. Review of Systems above (I–IV)
C. Preexisting or Recurrent Shoulder Problem C. Serve/Overhead
D. Other Musculoskeletal Problems 1. Cocking phase
1. Acute 2. Acceleration phase
2. Distant to shoulder (kinetic chain 3. Deceleration/follow-through phase
involvement) D. Volleys
III. Shoulder Complaints 1. Forehand
A. Symptoms (Specify Pitching Versus Throwing) 2. Backhand
1. Pain a. One-handed versus two-handed volley
2. Weakness or fatigue II. Specific Mechanism
a. Loss of velocity A. Single Stroke (Acute Onset)
b. Loss of accuracy B. Overtraining (Gradual Onset)
3. Instability/subluxation C. Able to Continue Playing
4. Stiffness (inability to get “loose”) 1. Without stroke modification
5. Catching/locking 2. With stroke modification
B. Injury Pattern III. Training History
1. Sudden onset or acute onset (pitching A. Change in Technique?
versus throwing) 1. Grip
2. Gradual or chronic onset (pitching versus 2. Stance
throwing) 3. Other
3. Traumatic onset—fall or blow to extremity B. Change in Coach
4. Recurrent pattern C. Change in Training Program
C. Symptom Characteristics 1. Surface
1. Location 2. On-court training
2. Character and severity 3. Off-court training
3. Provocation IV. Equipment
4. Duration A. Racquet
5. Paresthesias/referral pattern 1. Type
6. Phase of throwing or pitching 2. How long with current frame
a. Cocking phase 3. Modifications to current frame
b. Acceleration phase a. Weight
c. Deceleration phase 4. Previous frame
7. Related activities/disability B. String
D. Related Symptoms 1. Type
1. Cervical 2. Tension
2. Peripheral nerve 3. Change in tension/type?
3. Brachial plexus V. Ability to Play Presently
4. Entrapment A. Certain Strokes Pain-Free
B. Stroke Modification Required
Adapted from Gillogly S, Andrews JR: In Andrews JR, Zarins B, Wilk
KE, eds: Injuries in baseball, Philadelphia, 1998, Lippincott.
Ch03.qxd 5/24/04 4:27 PM Page 13

CHAP TER

3 Observation/Posture

INTRODUCTION combinations. Females should be evaluated while wearing

Evaluation of a patient’s posture has been regarded as a a gown or sports bra to preserve patient modesty. Clear
crucial part of the comprehensive examination of a patient visual inspection of the shoulder region and scapula is
with spinal dysfunction. Gould stated, “the static and essential for a complete postural evaluation.
dynamic posture of the client can add insight to muscu-
loskeletal problem solving,” and the importance of a com- SHOULDER HEIGHT ASSESSMENT
prehensive evaluation of posture is no less important in The relative height of the shoulders should be assessed
the patient with shoulder dysfunction. Gould also stated, because this can provide significant information about
“the clinician should attempt to gain awareness not only the patient’s muscular development, as well as the pres-
of gross alterations in posture such as shoulder heights or ence of any guarding through exaggerated use of the
iliac crest height, but also of subtle changes in muscle tone upper trapezius musculature. Typically, the dominant
or subtle disruptions in rhythm” (Gould, 1985). shoulder is lower than the nondominant shoulder in
Evaluation of sitting and standing posture begins neutral, nonstressed standing postures. Although the
before the patient is aware of it. Observing the patient’s exact reason for this phenomenon is unclear, increased
seated posture in the waiting area can serve as an impor- mass in the dominant arm may cause the dominant shoul-
tant initial finding. Common alterations in sitting are der to be lower secondary to the increased weight of
extreme variations in forward head posture, which include the arm, as well as elongation of the periscapular muscu-
increases in cervical lordosis and thoracic kyphosis, as well lature on the dominant or preferred side secondary to
as a protected posture that often includes shoulder girdle eccentric loading. In addition, stretching and elongation
elevation with scapular protraction and placement of the may occur from carrying heavy objects on the dominant
arm across the stomach held closely against the body. As side. Evaluation of the patient in the standing position
the patient ambulates to the evaluation room, careful should typically show the dominant shoulder to be
observation of how the affected extremity moves during slightly lower (no normative data currently exist in the
gait also provides valuable insight into the degree of pro- scientific literature), or at least the shoulders should be
tection the patient affords that extremity. The presence of level with each other.
this protective posture provides valuable insight into how
approachable the patient may be with objective clinical ALTERATIONS IN SHOULDER HEIGHT
tests. Approaching and handling the patient’s extremity Visual observation of the patient’s shoulders from the
with both greater care and a softer touch are required if posterior and anterior views can identify alterations from
protected posturing is initially observed. the normal relationship described previously.

STANDING POSTURE EVALUATION DOMINANT, INJURED

Evaluation of the patient in the standing position is indi- SHOULDER HIGHER
cated early in the evaluation process. A male patient Visual inspection of the dominant, injured shoulder often
should be evaluated with all shirts and undershirts identifies this shoulder as higher than the uninjured, non-
removed to allow for full visualization of the shoulders dominant shoulder. This finding often indicates muscular
and spine from the waist upward. When possible, observ- guarding and lends insight to the examiner as to any
ing the patient during removal of his shirt provides exaggerated upper trapezius muscular activation that may
valuable insight into active movement capabilities and require intervention (Figure 3-1). Objective data on the
degree of hesitancy to initiate movement in various magnitude of dominant injured shoulder elevation are not

13
Ch03.qxd 5/24/04 4:27 PM Page 14

14 SECTION I General Overview

Figure 3-2 Characteristic postural deviations with regard to

shoulder height of two elite level tennis players (player on left is
left-handed; player on right is right-handed). Note the lowered
dominant shoulder relative to the nondominant side.

in two elite level tennis players. Consequences of this

depression on the dominant side included thoracic outlet
syndrome, rotator cuff pathology from alteration of scapu-
Figure 3-1 Patient with guarded right shoulder position demon- lar positioning, and abutment of the rotator cuff on an
strating a higher dominant shoulder as seen after operative pro-
cedure.
altered acromial position, as well as spinal pathology
(Priest & Nagel, 1976). Of particular importance is the
finding of protraction and downward rotation of the dom-
available; however, it is recommended that this observa- inant scapula. Solem-Bertoft et al (1993) used magnetic
tional finding be noted. resonance imaging to demonstrate a narrowing of the
subacromial space when shoulders were experimentally
TENNIS SHOULDER
moved from positions of maximal retraction to protracted
“It is said that oarsman of ancient galleys developed a cor- positions. This narrowing of the subacromial space can
poreal deformity when rowing only on one side of the lead to glenohumeral joint impingement and alter normal
ship, and that a favor the slave master could bestow upon scapulothoracic and glenohumeral joint arthrokinematics.
an oarsman was to alternate him from one side of the ship Downward rotation of the scapula can also lead to a
to the other, allowing maintenance of symmetrical change in the resting posture/position of the glenoid
physique” (Priest & Nagel, 1976). The term tennis shoul- (Figure 3-3). Downward rotation secondary to postural
der has been described by Priest and Nagel (1976) to alteration can lead to a more vertical glenoid position and
describe a developmental characteristic in the dominant change the angle of inclination. Changes in the angle of
arm of tennis players, where the dominant shoulder inclination of the scapula have been reported in patients
droops inferiorly with an apparent scoliosis. The position with increases in inferior translation and multidirectional
of the shoulder girdle and scapula is one of depression, instability of the glenohumeral joint (Basmajian &
protraction, and often downward rotation. Tennis shoul- Bazant, 1959).
der exists in unilaterally dominant athletes such as tennis
players, baseball players, volleyball players, and individuals HANDS-ON-HIPS POSITION
who ergonomically use one extremity without heavy or In the standing position, the clinician can observe the
repeated exertion of the contralateral extremity (Priest & patient for symmetric muscle development and, more
Nagel, 1976; Kibler, 1991, 1998a). specifically, focal areas of muscle atrophy. One position
A total of 84 world class tennis players were initially that is recommended, in addition to observing the patient
examined by Priest and Nagel and found to have this with the arms at the sides in a comfortable standing pos-
drooping phenomenon of the dominant shoulder. ture, is the “hands-on-hips position” (Figure 3-4). This
Figure 3-2 shows this characteristic postural adaptation position places the patient’s shoulders in approximately 45
Ch03.qxd 5/24/04 4:27 PM Page 15

CHAPTER 3 Observation/Posture 15

Supraspinous fossa Crest of spine

Acromion

Dorsal surface
Infraspinous fossa (posterior)

Figure 3-3 Angle of inclination of the glenoid. Note the upward

tilt of the glenoid to prevent passive downward displacement of
the humeral head. (From Basmajian JV, Bazant FL: Factors pre- Figure 3-5 Scapular fossae and landmarks.
venting downward dislocation of the adductor shoulder joint, J
Bone Joint Surg 41A:1182, 1959.)
Transverse
Suprascapular scapular Suprascapular
nerve ligament
notch

Supraspinatus
muscle
Spinoglenoid
notch

Figure 3-6 Posterior view of the scapula outlining the course of

the suprascapular nerve.

observe focal pockets of atrophy along the scapular border,

as well as more commonly over the infraspinous fossa of
the scapula (Figure 3-5).
Thorough visual inspection using this position can
often identify excessive scalloping over the infraspinous
fossa present in patients with rotator cuff dysfunction, as
well as in patients with severe atrophy who may have
suprascapular nerve involvement. Impingement of the
suprascapular nerve can occur at the suprascapular notch
or spinoglenoid notch (Figure 3-6) and from paralabral
Figure 3-4 Hands-on-hips position in a right-handed patient.
cyst formation commonly found in patients with superior
labral lesions (Piatt et al, 2002). Figure 3-7 shows the iso-
to 50 degrees of abduction with slight internal rotation. lated atrophy present in the infraspinous fossa of a patient
The hands are placed on the iliac crests of the hips, with after arthroscopic labral repair. The patient stands in the
the thumbs pointed posteriorly. This position is also used hands-on-hips position, which exaggerates atrophy and
during the Kibler lateral scapular slide test (see pages assists the clinician in identifying this physical examina-
22–25). Placement of the hands on the hips allows the tion finding. Further examination of the patient with
patient to relax the arms and often enables the clinician to extreme wasting of the infraspinatus muscle is warranted
Ch03.qxd 5/24/04 4:27 PM Page 16

16 SECTION I General Overview

Table 3-1 Additional Postural Findings in

Patients with Shoulder Pathology
Typical Indication
Patient Presentation of Posture
Prominent acromion Glenohumeral joint
dislocation
Laterally depressed scapula
Slightly abducted humerus
“Stairstep” drop-off of the Acromioclavicular
lateral aspect of the separation
clavicle above the
acromion
“Popeye” biceps appearance Biceps long head
tendon rupture
Scapula grossly Scapular winging
disassociated from the from long thoracic
thoracic wall nerve involvement
Figure 3-7 Patient with significant atrophy in the infraspinous
fossa. Patient in hands-on-hips position after superior labral repair. Adapted from Halbach JW, Tank RT: The shoulder. In Gould JA, Davies
GJ, editors: Orthopaedic and sports physical therapy, St Louis, 1985,
Mosby.

to rule out suprascapular nerve involvement. The use of The incidence of scoliosis in unilaterally dominant ath-
nerve conduction tests, in addition to a detailed physical letes, even at very young developmental ages, has been
examination, can lead the clinician to the diagnosis of reported secondary to asymmetric muscular development
suprascapular nerve injury. and sport-specific upper body loading patterns (Priest &
Nagel, 1976). Methods of assessment for spinal curvature
ADDITIONAL POSTURAL TESTS include solely visual observation, as well as visual observa-
IN STANDING tion with the assistance of a plumb line or posture grid
Assessment of spinal position, in addition to shoulder (Davies & DeCarlo, 1995), in addition to radiographs.
height, is also important during this phase of the evalua- Evaluation of the patient using a maneuver known as the
tion process. The spine should be inspected from posterior Adam’s position (American Academy of Orthopaedic
and lateral views to assess for the presence of the charac- Surgeons, 1992; Grossman et al, 1995) involves placing
teristic curvature of the spine in the sagittal plane and lack the patient in a forward-flexed spinal posture between 45
of curvature in the frontal plane. Although posture is indi- and 60 degrees (approximate) to evaluate for the presence
vidualized, with a wide variation in what can be thought of a unilateral rib hump over the thoracic or lumbar spine.
of as “normal posture” among individuals, an “ideal” As a result of the rotation associated with lateral flexion of
posture in the sagittal plane has been described (Davies & the spine characteristic in scoliosis, asymmetric rib pro-
DeCarlo, 1995). This “ideal” lateral posture alignment has trusion exists and can be best identified by the clinician by
a plumb line traversing through the center or the external placing the patient in the Adam’s position and viewing the
auditory meatus (ear), mid-acromial bisection of the patient from a posterior position. Thorough evaluation of
scapula, greater trochanter of the femur, mid-lateral pelvic levels, as well as measurement of leg lengths, can
knee between the popliteal fossa and the patella, and just also assist in the postural evaluation of the patient with
anterior to the lateral malleolus. Significant deviations shoulder pathology presenting with associated postural
from this alignment should be noted and ultimately will conditions such as scoliosis. Table 3-1 lists additional pos-
affect the overall treatment of the patient with shoulder tural findings commonly encountered in patients with
pathology. shoulder pathology.
Ch04.qxd 5/24/04 4:28 PM Page 17

CHAP TER

4 Testing the Scapulothoracic Joint

INTRODUCTION which it may obtain in one of several ways:” (1) the scap-
The importance of the scapulothoracic joint and its rela- ula may remain fixed with motion occurring solely at the
tionship to shoulder function and dysfunction have been glenohumeral joint until a stable position is reached, (2)
extensively reported by Kibler (1991, 1998a). Although the scapula moves laterally or medially on the chest wall,
this important relationship is well understood and widely or (3) in rare instances the scapula oscillates until stabi-
accepted, there are limited clinical tests to evaluate scapu- lization is achieved. After 30 degrees of abduction and 60
lothoracic function. Also, scapular position and move- degrees of flexion have been reached, the relationship of
ment have been most effectively documented in scapulothoracic to glenohumeral joint motion remains
experimental research conditions and not in the clinical remarkably constant.
setting (Lukasiewicz et al, 1999). Research using three-dimensional analysis and other
laboratory-based methods has confirmed Inman’s early
DESCRIPTION OF NORMAL SCAPULAR descriptions of scapulohumeral rhythm (Doody et al,
RESTING POSITION 1970; Bagg and Forrest, 1988). These studies have also
Although there are many variations in normal scapular provided more detailed descriptions of the exact contribu-
positioning, Kibler (2003) described resting scapular ori- tion of the scapulothoracic and glenohumeral joint during
entation as being 30 degrees anteriorly rotated with arm elevation in the scapular plane. Doody et al (1970)
respect to the frontal plane, as viewed from above. Also, found the ratio of glenohumeral to scapulothoracic
the scapula is rotated approximately 3 degrees upward motion to change from 7.29 : 1 in the first 30 degrees of
(superiorly), as viewed from the posterior orientation used elevation to 0.78 : 1 between 90 and 150 degrees. Bagg
during most clinical observations/examinations. Finally, and Forrest (1988) found similar differences based on the
the scapula is tilted anteriorly approximately 20 degrees range of motion. In the early phase of elevation,
when viewed from the direct lateral aspect of the body. 4.29 degrees of glenohumeral joint motion occurred for
every 1 degree of scapular motion, with 0.71 degrees of
OVERVIEW OF glenohumeral motion occurring for every 1 degree of
SCAPULOTHORACIC MOTION scapular motion between the functional arc of 80 and 140
Scapulothoracic movement was initially described in clin- degrees.
ical terms as “scapulo-humeral rhythm” by both Codman Bagg and Forrest (1988) also identified the instanta-
(1934) and Inman (1944). Inman stated that “the total neous center of rotation (ICR) of the scapulothoracic
range of scapular motion is not more than 60 degrees” and joint at various points in the range of motion. Figure 4-1
that the total contribution from the glenohumeral joint is shows the ICR of the scapulothoracic joint at 20 degrees
not greater than 120 degrees. The scapulohumeral rhythm of elevation and Figure 4-2 at approximately 140 degrees
was described for the total arc of elevation of the shoulder of elevation. The ICR moves from the medial border of
joint to contain 2 degrees of glenohumeral motion for the spine of the scapula, with the shoulder at approxi-
every degree of scapulothoracic motion (Inman et al, mately 20 degrees of elevation near the side of the body,
1944). and migrates superolaterally to the region near the
In addition to this ratio of movement, Inman et al acromioclavicular joint at approximately 140 degrees.
(1944) identified a “setting phase,” which occurred during Bagg and Forrest also identified an increased muscular
the first 30 to 60 degrees of shoulder elevation. They stabilization role of the lower trapezius and serratus ante-
described this setting phase as when “the scapula seeks, in rior force couple at higher, more functional positions of
relationship to the humerus, a precise position of stability elevation. Figures 4-1 and 4-2 also show the line of pull of

17
Ch04.qxd 5/24/04 4:28 PM Page 18

18 SECTION I General Overview

Upper rhythm and identifying unilateral alterations in normal

trapezius scapular positioning are crucial in the complete evaluation
of the patient with shoulder pathology (Kibler, 1991,
1998a).
Middle
trapezius Deltoid
OVERVIEW AND DESCRIPTION OF
SCAPULAR MOTION
Typical movement of the scapula occurs in the coronal,
sagittal, and transverse planes. Brief descriptions here
20.8°
provide a framework for the classification of scapular
dysfunction and scapulothoracic joint testing sections pre-
sented later.
Lower
Lower serratus Upward/Downward Rotation
trapezius anterior
Movements of upward and downward rotation occur in
Figure 4-1 A biomechanical model of scapular rotation at 20.8 the coronal or frontal plane. The angle typically used to
degrees of abduction. Note the position of the instantaneous cen- describe the position of scapular rotation is formed
ter of rotation ICR and relative lengths of the lever arms of the between the spine and medial border of the scapula
scapular musculature. (Adapted from Bagg SD, Forrest WJ: A
(Figure 4-3). Poppen and Walker (1978) reported normal
biomechanical analysis of scapular rotation during arm abduction
in the scapular plane, Arch Phys Med Rehabil 67:243, 1988.) elevation of the acromion at approximately 36 degrees
from the neutral position to maximum abduction.
Upper Deltoid
trapezius
Anterior/Posterior Tilting
Sagittal plane motion of the scapula is referred to as ante-
rior/posterior tilting (see Figure 4-3). The angle of scapu-
lar tilting is formed by a vector passing via C7 and T7 and
Middle a vector passing via the inferior angle of the scapula
trapezius and the root of the spine of the scapula (Lukasiewicz
139.1° et al, 1999).

Internal/External Rotation
Transverse plane movement of the scapula is referred to as
internal and external rotation (see Figure 4-3). The angle
47.7°
used to describe internal/external rotation of the scapula is
formed by the coronal (frontal) plane of the body and a
Lower
Lower serratus vector passing via the transverse plane projection of the
trapezius anterior root of the spine of the scapula and the posterior angle of
the scapula (Lukasiewicz et al, 1999). Abnormal increases
Figure 4-2 A biomechanical model of scapular rotation at 139.1
degrees of abduction. Note the position of the instantaneous cen- in the internal rotation angle of the scapula lead to
ter of rotation ICR and relative lengths of the lever arms of the changes in the orientation of the glenoid. This altered
scapular musculature. (Adapted from Bagg SD, Forrest WJ: A position of the glenoid is referred to as “antetilting,” and it
biomechanical analysis of scapular rotation during arm abduction allows for an opening up of the anterior half of the gleno-
in the scapular plane, Arch Phys Med Rehabil 67:243, 1988.)
humeral articulation (Kibler, 1991). The antetilting of the
scapula has been shown by Saha (1983) to be a compo-
the serratus anterior and trapezius muscles and the relative nent of the subluxation/dislocation complex in patients
changes in the lever arm of each muscle in the two posi- with microtrauma-induced glenohumeral instability.
tions of glenohumeral joint elevation. This biomechanical
information on the scapulothoracic joint is presented in Protraction/Retraction
this text as a precursor to the important evaluation meth- The movement of retraction and protraction occurs liter-
ods and scapular dysfunction classification in the next ally around the curvature of the thoracic wall (Kibler,
section. Evaluating scapular position and scapulohumeral 1998a). Retraction typically occurs in a curvilinear fashion
Ch04.qxd 5/24/04 4:28 PM Page 19

CHAPTER 4 Testing the Scapulothoracic Joint 19

often identifies excessive early scapular elevation as a

compensatory movement to optimize humeral movement
C7 (Kibler, 1998a).

CLASSIFICATION OF
SCAPULAR DYSFUNCTION
Before discussing specific tests for the scapulothoracic
T7 joint, it is appropriate to describe types of scapulothoracic
pathology that can be identified by examination
maneuvers.
The most widely described and overused term pertain-
A ing to scapular pathology is that of scapular winging.
C7
Scapular winging is used to describe gross dissociation of
the scapula from the thoracic wall (Zeier, 1973). It is typi-
cally obvious to a trained observer when simply viewing a
patient from the posterior and lateral orientation and
becomes even more pronounced with active or resistive
X T7
movements to the upper extremities. True scapular wing-
B ing occurs secondary to involvement of the long thoracic
C nerve (Zeier, 1973). Isolated paralysis of the serratus ante-
rior muscle with resultant “winged scapula” was first
Figure 4-3 Definition of scapular position and orientation. described by Velpeau in 1837. The cause of winged scapu-
A, Upward rotation angle. The scapulothoracic angle is between
the medial border of the scapula (projected onto the frontal
la is peripheral in origin and is ultimately derived from
plane). Increasing values represent upward rotation. Total arm involvement of the fifth, sixth, and seventh spinal cord seg-
elevation is the angle between the spine and vector connecting ments (Zeier, 1973). Isolated serratus anterior muscle
the olecranon and a derived point 2 cm directly inferior to the pos- weakness as a result of nerve palsy creates a prominent
terior angle of the acromion. B, Scapular internal rotation angle. superior medial border of the scapula and depressed
The angle between the frontal plane and a vector passing through
the root of the spine of the scapula posterior angle of the
acromion, whereas isolated trapezius muscle weakness
acromion (projected onto the transverse lane). Increasing values resulting from nerve palsy creates a protracted inferior bor-
represent internal rotation. C, Scapular posterior tilt angle. The der of the scapula and elevated acromion (Kibler, 1998).
angle between a vector passing through C7 and T7 and a vector Although it is possible that some patients with shoul-
passing through the inferior angle and the spine of the scapula der pathology may present with true scapular winging,
(projected onto the sagittal plane). Increasing values represent
posterior tilting. C7, Seventh cervical process; T7, seventh tho-
most present with less obvious and less severe forms of
racic spinous process. (Adapted from Lukasiewicz AC et al: Com- scapular dysfunction. Clinicians have traditionally had
parison of 3-dimensional scapular position and orientation little nomenclature or objective descriptions for scapular
between subjects with and without shoulder impingement, J dysfunction, which has led to the use of numerous terms
Orthop Sports Phys Ther 29(10):578, 1999.) to describe nonoptimal or abnormal scapular positions
and movement patterns (Kibler, 1998a).
around the wall, whereas protraction may proceed in a
slightly upward or downward motion, depending on the Kibler Scapular Dysfunction Classification
position of the humerus relative to the scapula (Kibler, Rubin and Kibler (2002) classified scapular dysfunction
1998a). Depending on the size of the individual and the into two main types. When scapular dysfunction occurs
vigorousness of the activity, the translation of the human proximal and posterior to the glenohumeral joint, the
scapula during protraction and retraction can occur over observed scapular dyskinesis is considered proximally
distances of 15 to 18 cm (Kibler, 1993). derived and has been termed proximally derived scapular
dysfunction (PDSD). PDSD is commonly associated with
Elevation/Depression postural dysfunction such as forward head posture and
The scapula can move in the coronal plane along the lumbopelvic weakness, as well as injury to the long
thoracic wall superiorly and inferiorly in movements thoracic nerve or spinal accessory nerve, which leads to
typically called elevation and depression, respectively. weakness of the serratus anterior and upper trapezius,
Evaluation of the patient with rotator cuff weakness respectively. When any of these types of pathology exist or
Ch04.qxd 5/24/04 4:28 PM Page 20

20 SECTION I General Overview

combinations of pathology exist, they lead to a cascade of

events that can result in glenohumeral joint dysfunction
resulting from PDSD.
The second broad classification proposed by Rubin
and Kibler (2002) is distally derived scapular dysfunction
(DDSD). DDSD occurs from abnormality of the gleno-
humeral joint, such as glenoid labrum tears and sub-
acromial impingement. These abnormalities result in
altered upper extremity movement patterns that lead to
scapular muscle compensation and abnormal muscle
recruitment and firing patterns. DDSD can be thought of
as the result of a “recoil” or “kickback” from the gleno-
humeral joint or link in the kinetic chain distal to the
scapulothoracic joint. During the comprehensive evalua-
tion of the patient with a shoulder injury, it is imperative
to evaluate all factors relating to scapular dysfunction,
both PDSD and DDSD, not only to identify the presence
of scapular dysfunction, but also to better understand the Figure 4-4 Kibler type I: Inferior angle scapular dysfunction.
derivation of the scapular dysfunction. Note the prominence of the inferior angle of the scapula.
Kibler (1998a) and Kibler et al (2002) developed a
more specific scapular classification system for clinical use angle of the scapula (Figure 4-4). This pattern of dys-
that allows clinicians to categorize scapular dysfunction function involves anterior tilting of the scapula in the
based on common clinical findings obtained via visual sagittal plane, which produces the prominent inferior
observation of both static posture and dynamic goal- angle of the scapula. No other abnormality is typically
directed upper extremity movements. Kibler identified present with this dysfunction pattern; however, the
three specific scapular dysfunctions or patterns—inferior prominence of the inferior angle of the scapula often
or type I, medial or type II, and superior or type III—which increases in the hands-on-hips position, as well as during
are named for the area of the scapula that is visually active goal-directed movements of the upper extremities.
prominent during clinical evaluation (Table 4-1). In the According to Kibler et al (2002), inferior angle dysfunc-
Kibler classification system, normal symmetric scapular tion or prominence is most commonly found in patients
motion characterized by symmetric scapular upward rota- with rotator cuff dysfunction. The anterior tilting of the
tion “such that the inferior angles translate laterally away scapula places the acromion in a position closer to the
from the midline and the scapular medial border remains rotator cuff and humeral head compromising the sub-
flush against the thoracic wall with the reverse occurring acromial space.
during arm lowering” (Kibler et al, 2002).
Medial or Medial Border Dysfunction Type II
Inferior or Inferior Angle Dysfunction Type I In this classification of scapular dysfunction, the primary
In this classification of scapular dysfunction, the primary external visual feature is the prominence of the entire
external visual feature is the prominence of the inferior medial border of the scapula (Figure 4-5). This pattern or

Table 4-1 Summary of Kibler Scapular Dysfunction Characteristics

Dysfunction Dysfunction
Dysfunction Primary Visual Feature Pattern Plane
Inferior/Inferior
Angle Type I Prominence of inferior angle Anterior tilting Sagittal
Medial/Medial Border
Type II Prominence of medial border Internal rotation Transverse
Superior Type III Early, excessive superior Scapular elevation Coronal (frontal)
elevation of scapula
Ch04.qxd 5/24/04 4:28 PM Page 21

CHAPTER 4 Testing the Scapulothoracic Joint 21

Figure 4-5 Kibler type II: Medial border scapular dysfunction.

Note the prominence of the entire medial border of the scapula
as opposed to only the inferior angle prominence in Figure 4-4.

dysfunction involves internal rotation of the scapula in the

transverse plane. The internal rotation of the scapula pro-
duces a prominent medial border of the scapula. Similar to
the inferior or inferior angle dysfunction, the medial or
medial border dysfunction often increases in the hands-
on-hips position, as well as during active goal-directed
movements of the upper extremity. According to Kibler et
al (2002) and Saha (1983), the medial border scapular
dysfunction most often occurs in patients with instability
or rotator cuff dysfunction secondary to glenohumeral
joint instability. Earlier discussions in this chapter out- Figure 4-6 Kibler type III: Superior scapular dysfunction.
lined the opening up of the anterior aspect of the glenoid Note the exaggerated superior movement of this patient’s right
that occurs with scapular antetilting, which is a character- scapula compared with the contralateral extremity with arm
istic of this medial border scapular dysfunction. elevation.

Superior Dysfunction Type III clinician to determine the often subtle scapular dysfunc-
This type of scapular dysfunction is characterized by tion present in patients with shoulder pathology.
excessive and early elevation of the scapula during arm
elevation (Figure 4-6). This has been referred to as a Static
shoulder shrug or “hiking” of the shoulder girdle by clini- As mentioned previously, evaluation of the patient occurs
cians, and is most often present with rotator cuff dysfunc- in the standing position with arms held comfortably
tion and deltoid-rotator cuff force couple imbalances against the sides of the body. The clinician should note
(Inman, 1944). The superior movement of the scapula is the outline of the scapula and compare the scapulae bilat-
thought to occur as a compensatory movement pattern to erally. Although many variations exist in standing posture,
aid with arm elevation. the clinician should be particularly discriminating when
there are bilateral differences in scapular posture and,
EVALUATION SEQUENCE FOR KIBLER most notably, when greater prominence of the scapula is
SCAPULAR DYSFUNCTION present on the involved side. Bilateral symmetry, with
The specific sequence recommended for scapular evalua- respect to scapular position and scapular prominence in
tion includes both static and dynamic aspects. Both are the patient with unilateral shoulder dysfunction, is not
crucial for obtaining the clinical cues that allow the necessarily an indicator of scapular dysfunction.
Ch04.qxd 5/24/04 4:28 PM Page 22

22 SECTION I General Overview

After examination of the patient with the arms in com-

plete adduction at the sides of the body, the patient is then
examined in the hands-on-hips position. This position
creates slight internal rotation and abduction of the gleno-
humeral joint and often exaggerates the degree of promi-
nence of the scapula (see hands-on-hips position, pages
14–15 for more detailed description).

Dynamic
After the static examination, the patient is asked to ele-
vate the shoulders using a self-selected plane of elevation.
The clinician should be directly behind the patient to best
observe the movement of the scapula during concentric
elevation and especially during eccentric lowering. Exces-
sive superior movement of the scapula during concentric
arm elevation, as well as inferior angle and medial border
prominence during the eccentric phase are commonly
encountered in patients with scapular dysfunction.
Repeated arm elevation to confirm initial observations, as
well as to determine the presence and location of symp-
toms (location in/on the shoulder as well as the range of
motion where symptoms occur), is recommended. The
effect of repeated movements is also crucial to assess the Figure 4-7 Kibler lateral scapular slide position 1.
effects of fatigue on scapular stabilization.

TESTS FOR THE SCAPULOTHORACIC have a standard tape measure that is capable of measuring
JOINT: KIBLER LATERAL SCAPULAR in centimeters. The patient is measured in three positions
SLIDE TEST (LSST) (Figures 4-7 through 4-9):
Kibler Position 1: Standing position, with arms resting
Indication at the sides
The LSST is the primary clinical test to measure scapular Kibler Position 2: Hands-on-hips position, with hands
position. placed on the iliac crests, such that the thumbs are
pointing backward
About the Test Kibler Position 3: Ninety degrees of glenohumeral
The LSST was developed by Kibler as a semidynamic test joint abduction in the coronal plane with full inter-
to evaluate scapular position and scapular stabilizer nal rotation
strength on the injured and noninjured sides, in relation-
ship to a fixed point on the spine, as varying amounts or Action
loads and movement are superimposed on the supporting In each of the three positions listed previously, the exam-
musculature. The lateral scapular slide test is not a true iner measures between the inferior angle of each scapula
dynamic test and relies on static positions to assess scapu- to the corresponding vertebral spinous process. The corre-
lar muscle stabilization (Kibler, 1998a). sponding vertebral spinous process can be defined as the
spinous process in direct line (horizontally) with the infe-
Starting Position rior angle of the scapula. It should be noted that, in indi-
The patient is in a resting, standing position, with arms viduals with significant differences in shoulder heights or
placed comfortably at the sides. The examiner is posi- scoliosis, different vertebral spinous processes may be used
tioned behind the patient. To enhance the measurement for each side as a result of the discrepancy in shoulder/
and performance of this test, the patient should be tested scapular height. The examiner records the distance in cen-
without a shirt or undershirt (males) or in a gown timeters between the vertebral spinous process and the
(females) that allows for complete visualization of both inferior angle of the scapula bilaterally before moving to
scapulae and the thoracic spine. The examiner should the next testing position. Testing positions are typically
Ch04.qxd 5/24/04 4:28 PM Page 23

CHAPTER 4 Testing the Scapulothoracic Joint 23

started in Kibler position 1 and progress to Kibler posi-

tions 2 and 3.

What Constitutes a Positive Test?

In his original description of the Kibler LSST, Kibler
wrote that, even in asymptomatic athletes, the original
research with the LSST showed the function of the
scapular stabilizing muscles to be symmetric, with less
than 1 cm difference between sides in each of the three
positions. Symptomatic individuals had differences of
greater than 1 cm, and these differences were statistically
associated with the presence of pain and decreased shoul-
der function (Kibler, 1991).
Further research on the LSST by Kibler (1998a) iden-
tified the typical range of difference between sides
between 0.83 and 1.75 cm. For the purposes of clinical
evaluation, Kibler now considers a positive finding with
the LSST to be present when greater than a 1.5 cm dif-
ference between sides exists at any of the three testing
positions. This 1.5 cm difference is the “threshold of
abnormality,” with differences in long-standing cases of
shoulder and scapular pathology having a 2- to 3-cm dif-
ference between sides.
Kibler (1998a) also noted that subtle differences found
between injured and uninjured sides in the resting posi-
tions of testing (Kibler position 1 and 2) may often Figure 4-8 Kibler lateral scapular slide position 2.
decrease in Kibler position 3 as a result of the contraction
of the musculature in patients exhibiting some degree of
scapular muscle stabilization. This factor is important to
analyze with this test in addition to determining whether
the patient merely exceeds or does not exceed the 1.5 cm
bilateral difference “threshold of abnormality.”

Ramifications of a Positive Test

Patients with a positive Kibler LSST (bilateral difference
of greater than 1.5 cm) have deficits in either dynamic
scapular stabilization or have postural adaptations that
produce significant differences in scapular positioning
identified with this test. These patients are candidates for
rehabilitative exercise to promote scapular stabilization.

Objective Evidence Regarding This Test

Electromyographic evaluation of the three positions used
in the Kibler LSST shows that few muscles are working
in Kibler position 1. The serratus anterior and lower
trapezius muscles are working at low levels in position 2,
and in Kibler position 3, the upper and lower trapezius,
rhomboids, and serratus anterior are all working at about
Figure 4-9 Kibler lateral scapular slide position 3.
40% of maximal levels.
The ability of the examiner to accurately reproduce and
identify the inferior angle of the scapula has been tested
Ch04.qxd 5/24/04 4:28 PM Page 24

24 SECTION I General Overview

using radiography. When the accuracy of marking the Significant differences in scapular symmetry were found
inferior angle of the scapula was compared with a radio- between the subjects diagnosed with unilateral gleno-
graphic evaluation of the same point when marked using humeral joint impingement and normal subjects for
a lead shot or “BB,” there was a correlation of 0.91 with Kibler position 1. No difference was identified between
the three different positions (Kibler, 1998a). This finding groups in Kibler position 2. The authors concluded that
confirms that the position selected by the examiner is the Kibler LSST is a valid test to identify patients with
likely closely associated with the actual inferior angle of unilateral glenohumeral joint impingement.
the scapula during testing. Odem et al (2001) used a similar testing paradigm to
determine the sensitivity and specificity based on the cri-
Test-Retest Reliability terion of 1.5 cm bilateral difference in normal subjects and
Kibler (1998) performed a test-retest reliability investiga- in patients diagnosed with shoulder impairments. The
tion to assess both intratester and intertester reliability. authors reported sensitivity values of 28%, 53%, and 50%
Intraclass correlation coefficients (ICC) were between at Kibler positions 1, 2, and 3, respectively, with speci-
0.84 and 0.88 for intratester reliability, with similar co- ficity of 58%, 34%, and 52%, respectively at the three posi-
efficients reported in all three positions of testing. tions. In contrast to the findings of Litchfield et al (1998),
Intertester reliability coefficients ranged from 0.77 to Odem et al suggested the LSST should not be used to
0.85. These reliability coefficients indicate acceptable identify persons with shoulder pathology. Koslow et al
levels of reproducibility for the use of this clinical test (2003) measured the specificity of the LSST in asympto-
(Portney & Watkins, 1993). matic competitive athletes. In all, 38 females and 33 male
Additional studies have independently evaluated the athletes were tested using the Kibler LSST. These athletes
Kibler LSST. Gibson et al (1995) reported intratester were involved in what the author classified as “one-arm
reliability of 0.81 to 0.94 and intertester reliability of 0.18 dominant” sports: baseball, softball, tennis, volleyball, and
to 0.92. T’Jonck et al (1996) reported similar ICCs basketball. A total of 51 of the 71 subjects displayed a
for intratester reliability (0.69 to 0.96) and ICCs for difference of at least 1.5 cm or more in one of the three
intertester reliability ranging between 0.72 and 0.90. In Kibler testing positions. Overall specificity of the test was
addition to the reliability coefficients reported, Gibson et 26.8%, and the authors concluded that scapular posture
al (1995) and T’Jonck et al (1996) identified lower intra- was extremely variable in this athletic asymmetric testing
tester and intertester correlation coefficients with Kibler population. Specificity at each of the three Kibler testing
position 3. All of the researchers acknowledge the positions was reported as 54.9%, 57.7%, and 35.2% for
increased difficulty in palpating the inferior angle of the positions 1, 2, and 3, respectively. The authors concluded
scapula in position 3 because of the greater contraction of that these asymmetries do not necessarily identify or indi-
the muscles surrounding the scapula itself (Kibler, 1998a; cate dysfunction (Koslow et al, 2003). The low specificity
Gibson et al, 1995; T’Jonck et al, 1996). of the LSST in this population led to the authors’ recom-
Odem et al (2001) published a test-retest reliability mendation not to use the LSST to determine shoulder
study that conflicted with earlier studies of the Kibler dysfunction in one-arm dominant athletes. This finding
LSST. The reliability research by Kibler (1998a), Gibson agrees with the variable posture characteristics outlined in
et al (1995), and T’Jonck et al (1996) all tested the dis- Chapter 3. Further, it supports the use of a complete eval-
tances between the inferior angle of the scapula and the uation of the scapulothoracic joint, coupled with a general
vertebral spinous process. Odem et al (2001) tested the posture evaluation and specific glenohumeral special tests,
actual bilateral difference in subjects and found lower test- to more accurately identify shoulder pathology.
retest reliability coefficients ranging from 0.52 to 0.80 for The presence of multiple classifications and types of
intratester conditions and 0.43 to 0.79 for intertester con- scapular pathology identified by Kibler et al (2002) com-
ditions. They concluded that the Kibler test had com- plicates the identification of individuals with scapular
promised reliability and that caution should be used in pathology with one test. Odem et al (2001) showed that
interpretation of test results. This information is in con- although scapular pathology likely exists in their sample
trast to the other reliability studies on the LSST. of patients with shoulder impairment, the Kibler LSST
was not able to accurately identify those individuals based
Validity of the Kibler Lateral Scapular Slide Test solely on scapular position. Alterations in the distance
Litchfield et al (1998) tested 40 subjects, 20 of whom were between the vertebral spinous process and the inferior
diagnosed with unilateral glenohumeral joint impinge- angle of the scapula may be minimal in patients with
ment symptoms, using the Kibler LSST positions 1 and 2. internal rotation of the scapula (medial border
Ch04.qxd 5/24/04 4:28 PM Page 25

CHAPTER 4 Testing the Scapulothoracic Joint 25

prominence Kibler type II) or anterior tilting of the (T3) (A)

scapula (inferior angle prominence Kibler type I). Relying
solely on the results from the Kibler LSST to identify
scapular pathology is not recommended, and the results of
Odem et al (2001), Koslow et al (2003), and Kibler (2002) (B)
supported the use of a complete scapular evaluation in
addition to a glenohumeral and upper body musculoskele-
tal evaluation for patients with shoulder pathology.

ADDITIONAL TESTS TO ASSESS

SCAPULAR POSITION
Lennie Test
Additional tests have been reported to assess static scapu-
lar position. A detailed scapular evaluation test called the
Lennie test was published by Sobush et al (1996). This test
consists of an extensive series of measurements of the Figure 4-10 DiVeta scapular measurement technique. Mea-
scapula in standing, using a scoliometer and caliper. surement of scapular abduction was attained by measuring the
The examiner palpates and marks 12 landmarks along the distance A, from the spinous process of the third thoracic verte-
brae (T3) to the inferior angle of the acromion. B, This measure-
medial aspect of the scapula and spinal midline, with
ment was normalized to scapular length, which was defined as
the patient in the standing position with back exposed. the distance from the root of the spine of the scapula to the infe-
The examiner then uses a caliper to measure the distance rior angle of the acromion. (Adapted from DiVeta J, Walker ML,
between the spinal midline and the scapular landmarks. Skibinski B: Relationship between performance of selected
Sobush et al (1996) tested the reliability and validity of scapular muscles and scapular abduction in standing subjects,
Phys Ther 70(8):472, 1990.)
the Lennie test using three examiners and the scoliometer
and caliper. Same-day radiographs were used to validate
the scapular position identified using surface measure-
ments. Results of the research by Sobush et al (1996) con-
firmed that the medial borders of the scapulae were sizes of scapulae and to present the data from their scapu-
parallel to the midline of the thoracic spine. The scapulae lar abduction measurement in a normalized format,
were, on average, 17.19 cm apart in the resting position at DiVeta et al (1990) also measured the width of the scap-
the level of the root of the scapular spine. The dominant ula from the base or root of the spine of the scapula at the
scapula was 0.49 cm lower than the nondominant scapula medial border to the posterolateral corner of the acromion
in this population of normal healthy female subjects. (see Figure 4-10). This value was then divided into the
ICCs for the surface measurements of scapular position initial measure from the T3 spinous process to the
ranged between 0.64 and 0.86. The authors concluded posterolateral corner of the acromion:
that the Lennie test can provide an accurate and reliable Distance T3
measurement of scapular position. thoracic vertebral
spinous process to
posterior lateral corner
DiVeta Test
of the acromion
DiVeta et al (1990) described another test involving fewer = DiVeta scapular abduction
Distance root of scapular
measurements than those used for the Lennie test to esti- spine to posterolateral
mate scapular position. The technique involves measuring measurement corner
the distance between the vertebral spinous process of the of the acromion
third thoracic vertebrae and the posterolateral corner of
the acromion. The posterolateral corner of the acromion The unit of measure for the DiVeta test is centimeters.
was referred to as the inferior angle of the acromion in their The authors believed that this test had greater relevance
initial research. The linear distance (Figure 4-10) between than other clinical measures of scapular position, as it was
the third thoracic vertebral spinous process and the pos- normalized to patient scapular size. For this reason their
terolateral corner of the acromion was used to measure the research used a scapular abduction measurement that was
amount of scapular abduction. To account for different normalized to scapular length. An additional benefit of
Ch04.qxd 5/24/04 4:28 PM Page 26

26 SECTION I General Overview

this technique is the use of the posterolateral corner of the available in most clinical centers. No other methods for
acromion as a scapular landmark, instead of the inferior clinically applicable measurement of scapular tipping or
angle of the acromion. The posterolateral corner of the posterior scapular displacement have been reported.
acromion is pointed and typically prominent, except in the
most obese individuals. Kibler Scapular Assistance Test
The intrarater test-retest reliability for the measure-
ment technique described by DiVeta et al (1990) was Indication
assessed using ICCs. The ICCs were 0.86 for scapular The Kibler scapular assistance test is used to determine
length and 0.94 for scapular distance from midline. Based the effects of scapular dysfunction on active shoulder
on results, this test can be used in a reliable clinical format range of motion and glenohumeral joint impingement.
with a tape measure to quickly assess scapular position.
About the Test
Further research regarding bilateral symmetry and nor-
malized scapular abduction ratios in different populations This test assesses the effect of superimposing increased
of athletes and in normal individuals is needed to assist in scapular upward rotation during arm elevation on both
the application of this test in clinical formats. active range of motion and pain diminution. As the name
implies, during this test the examiner assists the scapula in
Posterior Scapular Displacement Test—The Perry the movement pattern of upward rotation during arm ele-
Tool Test vation. This test simulates the function of the serratus
Although the tests reported by Kibler (1998a), Sobush et anterior and lower trapezius force couple during elevation
al (1996), and DiVeta et al (1990) all measure the position (Kibler, 1998a, 1998b).
of the scapula relative to the midline of the body, they do Start Position
not assess the degree of posterior scapular displacement The examiner stands behind the patient. The patient
such as those reported in both the Kibler scapular dys- starts from a resting posture, with arms comfortably at the
function classification (2002, 2003) and the description of side.
true scapular winging (Zeier, 1973). Plafcan et al (1997)
developed an instrument called the Perry tool, which was Action
used to quantify posterior scapular displacement in nor- The patient is asked to actively elevate the involved shoul-
mal subjects in both weighted and unweighted upper der and is instructed to inform the examiner at what point
extremity conditions. in the range of motion pain occurs. The examiner closely
The tool, which consists of a T-shaped frame and monitors both the quality of the active range of motion
measurement scales, was placed on the subject’s back over and the actual amount of excursion of active elevation.
the “most distal aspect palpable on the medial border,” The examiner should note at what point in the range of
often near the inferior angle of the scapula (Plafcan et al, motion pain occurs. The patient then is asked to lower the
1997). This allowed the examiner to quantify the amount involved extremity to the resting position.
of posterior scapular displacement near the inferior angle The examiner then places the left hand (if examining a
of the scapula. ICCs ranged between 0.97 and 0.98 for right scapula/shoulder) along the superior border of the
intrarater reliability and between 0.92 and 0.97 for inter- scapula while placing the thumb of the examiner’s right
rater reliability. The test provides reliable measurements hand (if examining a right scapula/shoulder) along the
but requires a specialized measurement device. medial border of the patient’s scapula, near the inferior
Warner et al (1992) described another method to third of the scapula (Figure 4-11). The patient is again
quantify scapular position—specifically the amount of asked to elevate the involved shoulder (Figure 4-12).
posterior scapular displacement. Moire topographic While the patient elevates the involved shoulder, the
analysis, which relies on stroboscopic evaluation of the examiner assists the scapula by upwardly rotating it as the
exact contours of the scapula and spine, was used to mea- patient continues toward the end range of elevation. The
sure the scapular contours in normal subjects, subjects patient then lowers the involved extremity to the resting
diagnosed with unilateral glenohumeral joint impinge- position at the side.
ment, and subjects with unilateral glenohumeral joint
instability. Significant bilateral differences in scapular What Constitutes a Positive Test?
positioning were noted in the subjects with both gleno- Two clinical findings indicate a positive Kibler scapular
humeral impingement and instability. The technique of assistance test. This first is with respect to pain diminu-
measurement used by the authors, however, is not tion or alleviation of pain. If the patient reported pain
Ch04.qxd 5/24/04 4:28 PM Page 27

CHAPTER 4 Testing the Scapulothoracic Joint 27

Figure 4-12 Wide-angle photo of the Kibler scapular assistance

test.

Figure 4-11 Close-up photo of the Kibler scapular assistance

test. active elevation. Superimposing scapular upward rotation
raises the overlying acromion from the path of the elevat-
ing humerus (Kibler, 1991, 1998a, 1998b). This superim-
during the initial independent arm elevation, the super- position by the examiner removes the acromion and may
imposed upward rotation performed by the examiner dur- be the mechanism by which pain is diminished.
ing the scapular assistance test often alleviates the pain Upward rotation of the scapula also improves the
because of a more optimal scapular component to arm length-tension relationship of the muscular force couples
elevation. Increased active range of motion with scapular that control glenohumeral and scapulothoracic move-
upward rotation is the second component that renders the ment, and may consequently improve the arc and quality
scapular assistance maneuver positive. Patients often have of the active range of motion against gravity (Kibler,
greater active range of motion and greater ease of eleva- 1998). Patients presenting with a positive Kibler scapular
tion when scapular upward rotation is superimposed by assistance test are candidates for scapular strengthening
the examiner. “Impingement symptoms are diminished or and stabilization programs in rehabilitation (Kibler,
abolished in cases of muscle inhibition” (Kibler, 1998a, 1998a).
1998b).
Kibler Scapular Retraction Test
Ramification of a Positive Test
One advantage of a clinical test like the scapular assistance Indication
test is that it directs the examiner to a treatment plan or The Kibler scapular retraction test is used to determine
intervention. With a positive Kibler scapular assistance the effect of a more retracted scapula on rotator
test, the implied ramification is the important component cuff strength indirectly assessed through changes in
scapular upward rotation plays in the improvement of shoulder elevation and reduction of symptoms with arm
either active range of motion, or diminution of pain with movement.
Ch04.qxd 5/24/04 4:28 PM Page 28

28 SECTION I General Overview

About the Test What Constitutes a Positive Test?

This test involves the use of manually imposed scapular A positive scapular retraction test occurs when either an
retraction by the examiner. This position “confers a stable increase in active range of motion in the patient’s involved
base of origin for the rotator cuff ” and often improves shoulder occurs during manually imposed scapular retrac-
clinical signs and symptoms. The manual support pro- tion or pain is abated or disappears. Use of the pretest
vided by the examiner mimics the function of the stabiliz- active motion serves as a benchmark or baseline to which
ing perimusculature and can help determine the effect of range of motion and pain levels are compared against
improved scapular positioning on shoulder range of during manual stabilization.
motion and patient self-reported pain levels.
Ramifications of a Positive Test
Start Position
Similar to the ramifications of a positive scapular assis-
The patient is typically examined in a standing position, tance test, a positive scapular retraction test implies that
with the examiner positioned directly behind the patient. inadequate scapular stabilization, in this case scapular
The patient is asked to actively elevate the arm in the retraction, is present, so that abnormal scapulohumeral
scapular plane against gravity or externally rotate the biomechanics produce an effect on the patient’s shoulder
shoulder from the neutral position with 90 degrees of movement and pain presentation. A positive finding
glenohumeral abduction in either the scapular or coronal directs the clinician to perform interventions to enhance
plane (Kibler & McMullen, 2003). The examiner notes scapular stabilization and to focus particularly on scapular
the amount and quality of the self-directed shoulder retraction, the major superimposed manual correction
motion, specifically where pain is encountered in the applied during this testing maneuver. Kibler reported
range of motion. improvement in symptoms and arm movement in patients
with internal impingement as the manually applied
Action
retraction removes the posterior glenoid impingement
The examiner then stabilizes the medial border of the from the excessively protracted impingement position
scapula (Figure 4-13) using both hands along the medial during testing (Kibler & McMahon, 2003).
border to maintain a greater amount of scapular retraction
during arm movement. The patient is again asked to ele- Scapulothoracic “Conductor’s” Test
vate the shoulder in the scapular plane or externally rotate
the shoulder from neutral with 90 degrees of abduction. Indication
The examiner notes the amount and quality of motion The scapulothoracic “conductor’s” test is a simple ma-
and asks the patient whether pain is present. neuver to monitor the relative movement of bilateral
upper extremities to movement of the scapulothoracic
articulation.

About the Test

Based on the scapulohumeral rhythm and, most specifi-
cally, research by Bagg and Forrest (1988) and Doody et al
(1970), who have reported movement ratios just under
1 : 1 in the movement arc between 80 and 120 degrees,
this test merely compares upward rotation movement of
both scapulae during elevation of the glenohumeral joint
in the scapular plane.

Start Position
The examiner stands directly in front of the patient, who
is examined in a standing position. The patient actively
elevates the arms in the scapular plane to approximately
70 to 80 degrees. The examiner reaches under the arms of
the patient to palpate the lateral border of the scapula near
Figure 4-13 Kibler scapular retraction test. the lower third of the scapulae bilaterally.
Ch04.qxd 5/24/04 4:28 PM Page 29

CHAPTER 4 Testing the Scapulothoracic Joint 29

Figure 4-14 Scapular conductor’s test.

Action scapulothoracic joint. In the case of the patient with exag-

The patient is instructed to actively elevate both extremi- gerated scapular motion resulting from restricted gleno-
ties between approximately 80 and 150 degrees in the humeral joint motion, this test directs the clinician to
scapular plane repeatedly while the examiner palpates the strategies to enhance capsular mobility and improve
motion of the scapula, making a visual note of the move- glenohumeral joint motion.
ment of the extremities (Figure 4-14). The repeated wav-
ing of the arms is similar to that of a conductor of an Flip Sign
orchestra, for which this maneuver is named.
Indication
What Constitutes a Positive Test? The flip sign is a test or sign noted during manual muscle
There is technically no positive or negative aspect to this testing of the glenohumeral joint to indicate scapu-
maneuver; it simply provides the clinician with an esti- lothoracic stabilization.
mate of how well the patient’s scapulothoracic joints are
moving relative to humeral elevation. According to About the Test
research outlined earlier, the arc of 80 to 120 degrees of This test or sign identifies the position of the scapula dur-
scapular plane elevation should produce close to a 1 : 1 ing routine manual muscle testing of the infraspinatus
pattern of scapulothoracic and glenohumeral joint (external rotation), which is performed during clinical
motion. This is easily palpated and assessed using this evaluation of the patient with shoulder dysfunction.
maneuver.
Patients with capsular hypomobility, such as those Starting Position
diagnosed with adhesive capsulitis, demonstrate early and The position of manual muscle testing, as recommended
excessive scapular motion relative to the movement of the by Kelly et al (1996) for the infraspinatus, is used. This
humerus, whereas other patients may exhibit unilateral test position is described on page 133 and consists of test-
humeral motion without concomitant upward rotation of ing the patient with the arm at the side and in a position
the scapula. Patients with glenohumeral joint instability of 45 degrees of internal rotation.
and impingement often have abnormal scapular upward
rotation because of abnormal muscular recruitment pat- Action
terns (McMahon et al, 1996). During traditional manual muscle testing, the examiner is
positioned so that the medial border of the scapula is vis-
Ramifications of a Positive Test ible during testing. Standard manual muscle testing over-
Unilateral abnormalities in this maneuver direct the clini- pressure is exerted on the distal aspect of the forearm
cian to focus on treatment strategies that promote more while the scapula is observed and the performance of the
optimal dynamic stabilization and movement of the infraspinatus muscle is graded.
Ch04.qxd 5/24/04 4:28 PM Page 30

30 SECTION I General Overview

What Constitutes a Positive Test?

A positive flip sign occurs when the medial border of the
scapula protrudes away from the thoracic spine during the
overpressure phase of the manual muscle test (Figure
4-15). The extent of the movement away from the thorax
is noted and compared with the condition of the scapula
on the contralateral side.

Ramifications of a Positive Test

A positive flip sign indicates that the patient is unable to
stabilize the scapula during a resisted movement requiring
rotator cuff activation. This sign alerts the clinician to a
deficiency in the stabilization of the scapula and directs
him or her to further test the scapulothoracic joint, as well
as integrate treatment strategies to improve the strength
and muscular endurance of the scapular musculature.

Figure 4-15 Scapular flip sign.

Ch05.qxd 5/24/04 4:30 PM Page 31

CHAP TER

5 Related Referral Joint Testing

INTRODUCTION vomiting, and reflex pain called Kehr’s sign, which radiates
Before the clinician can ultimately focus on a particular to the left shoulder and approximately one third of the
joint or complex, the joints and adjoining segments, both arm (Klafs & Arnheim, 1981). This pattern of pain radi-
proximal and distal to the area being examined, must be ation is particularly applicable during the evaluation of an
cleared to rule out the referral of symptoms from those athlete involved in a contact sport who presents with left
joints. This chapter describes the important steps that shoulder pain after a traumatic event or contact with
should be taken before evaluating the shoulder joint to either the ground or another player/participant.
ensure that adjoining segments are not involved in the Careful questioning regarding the aggravation of
patient’s symptom presentation and to rule out pathology symptoms can help to differentiate the common clusters
in the adjoining structures. typical in musculoskeletal shoulder pain from visceral
causes. One example is shoulder pain caused by pleural
GENERAL SCREENING irritation. Pleural irritation and other pulmonary diseases
In addition to the musculoskeletal screening process, create sharp localized pain in the shoulder. Aggravating
which includes testing the joint or joints below the injured factors of pleural irritation include respiratory movements
area and the joint or joints proximal to the injured area, that typically do not affect most musculoskeletal shoulder
general screening to rule out or screen the patient for conditions, as well as alleviation of symptoms by lying on
nonmusculoskeletal causes of shoulder-specific pain syn- the involved shoulder (Goodman & Snyder, 2000). Most
dromes is a crucial part of the comprehensive examination musculoskeletal shoulder conditions are aggravated by
process. This process, termed differential diagnosis, can be lying on the involved shoulder. This occurrence is nor-
difficult in the patient with shoulder pain, because pain mally attributed to compression, and placement of the
that is felt in the shoulder often affects the joint as though scapula in a protracted position, which narrows the sub-
the pain were originating in the joint (Mennell, 1964). acromial space, can exacerbate many shoulder conditions
Figure 5-1 outlines the musculoskeletal and systemic (Solem-Bertoft et al, 1993). Box 5-1 and Table 5-1 out-
structures that can refer pain to the shoulder. A brief line the additional systemic causes of shoulder pain. Table
overview of some specific referral patterns for the shoul- 5-2 lists the systemic origin of thoracic and scapular pain
der and scapula is provided in this chapter; for a more based on the specific location of symptoms.
complete overview, the reader is referred to Boissonnault Specific screening for rheumatic disease is also impor-
(1995) and Goodman and Snyder (2000). tant when performing a comprehensive examination of
The use of an extensive medical history and screening the patient with shoulder pain. The most fundamental aid
process is important for all patients. The patient present- to recognizing rheumatic disease in people presenting
ing with shoulder pain is no exception. Many visceral dis- with shoulder pain is a search for systemic components
eases are known to appear as unilateral shoulder pain. (Caldron, 1995). Systemic components include new-onset
Esophageal, pericardial, or myocardial diseases, as well as fatigue, fever, weight change, and mucocutaneous signs
diaphragmatic irritation from thoracic or abdominal dis- such as rash, mouth sores, hair loss, skin thickening or
ease, can all appear as unilateral shoulder pain (Goodman tightening, or nodules (Caldron, 1995). Although many
& Snyder, 2000). systemic symptoms occur with rheumatic diseases, the
Another common referral of shoulder pain occurs after clustering of these symptoms along with joint pain should
acute injury to the spleen. The typical history and symp- lead the clinician to suspect rheumatic disorders, and
toms inherent in a splenic rupture include a history referral should be made to the appropriate source for
of abdominal trauma, abdominal rigidity, nausea and further testing. The distinction between inflammatory

31
Ch05.qxd 5/24/04 4:30 PM Page 32

32 SECTION I General Overview

Cervical
Box 5-1 Systemic Causes of Shoulder Pain spine
Shoulder pain may be referred from the neck, chest
(thorax or thoracic spine), and abdomen and from sys-
temic disease. The following have been diagnosed as
having the onset or origin of presenting symptoms in
the shoulder.
Neck Bone tumors
Metastases Lungs Heart
Tuberculosis
Nodes in the neck (from metastases,
leukemia, and Hodgkin’s disease)
Cervical cord tumors Diaphragm
Chest Angina/myocardial infarct
Postcoronary artery bypass graft Elbow
Bacterial endocarditis
Pericarditis
Kidney Kidney
Aortic aneurysm
Empyema and lung abscess Gallbladder Spleen
Pulmonary tuberculosis
Pancoast’s tumor Figure 5-1 Musculoskeletal and systemic structures referring
Lung cancer (bronchogenic carcinoma) pain to the shoulder. (Adapted from Goodman CC, Snyder TE: Dif-
Spontaneous pneumothorax ferential diagnosis in physical therapy, ed 3, Philadelphia, 2000,
Nodes in mediastinum/axilla WB Saunders, p. 485.)
Metastases in thoracic spine
Breast disease:
Primary or secondary cancer
Mastodynia and degenerative arthritic conditions is rarely difficult to
Hiatal hernia make if the examiner focuses on the historical information
Abdomen Liver disease
Ruptured spleen
listed previously and notes the typical distribution of
Spinal metastases involved joints (Caldron, 1995).
Dissecting aortic aneurysm Finally, one additional area to be discussed in this sec-
Diaphragmatic irritation: tion is the presence and screening for nonorganic signs.
Peptic ulcer Waddell et al (1980) described five nonorganic signs, each
Gallbladder disease
Subphrenic abscess
identifiable with one or two simple testing maneuvers that
Hiatal hernia assess a patient’s pain behavior. A patient with three or
Pyelonephritis more of the five nonorganic signs is believed to have a
Diaphragmatic hernia clinical pattern of nonmechanical, pain-focused behavior
Ectopic pregnancy (rupture) (Waddell et al, 1980; Goodman & Snyder, 2000). Exam-
Upper urinary tract infection
Systemic Collagen vascular disease
ples of Waddell’s signs include deep tenderness felt over a
Disease Gout wide nonspecific pattern rather than isolated to a particu-
Syphilis/gonorrhea lar region or structure, and diminished sensation follow-
Sickle cell anemia ing a “stocking-type” pattern rather than dermatomal
Hemophilia patterns. Overreaction or disproportionate verbalization,
Rheumatic disease
Metastatic cancer:
facial expression, or muscle tension during examination
Breast maneuvers should also alert the examiner to the presence
Prostate of nonorganic sources of the patient’s pain.
Kidney
Lung CERVICAL SPINE CLEARING TESTS
Thyroid
Testicle
The cervical spine can be the source of pain in patients
Diabetes mellitus (adhesive capsulitis) presenting with primary complaints of shoulder and arm
pain and disability. Use of the overpressure and Spurling’s
Modified from Zohn DA: Musculoskeletal pain: diagnosis and physical tests provide valuable insight into the condition of the
treatment, ed 2, Boston, 1998, Little Brown.
cervical spine and its related structures (Grimsby & Gray,
1997). Cervical spine overpressure tests are completed
Ch05.qxd 5/24/04 4:30 PM Page 33

CHAPTER 5 Related Referral Joint Testing 33

Table 5-1 Shoulder Pain

Right Shoulder Left Shoulder
Systemic Origin Location Systemic Origin Location
Peptic ulcer Lateral border, right scapula Ruptured spleen Left shoulder (Kehr’s sign)
Myocardial ischemia Right shoulder, down arm Myocardial ischemia Left pectoral/left shoulder
Hepatic/biliary: Pancreas Left shoulder
Acute cholecystitis Right shoulder; between Ectopic pregnancy Left shoulder (Kehr’s sign)
scapulae; right (rupture)
subscapular area
Liver abscess Right shoulder
Gallbladder Right upper trapezius
Liver disease (hepatitis, Right shoulder, right
cirrhosis, metastatic subscapula
tumors)
Pulmonary: Ipsilateral shoulder; Pulmonary: Ipsilateral shoulder;
upper trapezius upper trapezius
Pleurisy Pleurisy
Pneumothorax Pneumothorax
Pancoast’s tumor Pancoast’s tumor
Kidney Ipsilateral shoulder Kidney Ipsilateral shoulder
Postoperative laparoscopy Left shoulder (Kehr’s sign)

From Goodman C, Snyder T: Differential diagnosis in physical therapy, ed 3, Philadelphia, 2000, WB Saunders.

after the patient has moved the cervical spine via the der to prevent compensatory shoulder girdle elevation. I
cardinal movements of flexion, extension, lateral flexion, perform the Spurling’s maneuver to both sides to thor-
and rotation. In the event that active range of motion of oughly stress the cervical structures. Local cervical spine
the aforementioned movements is within normal limits discomfort is often noted, particularly in older patients
and does not elicit or reproduce symptoms, passive over- with glenohumeral joint dysfunction; however, the most
pressure is applied at the end of each range of motion. significant indication of this test occurs when a patient’s
Although the presence of any symptom with these move- shoulder or arm symptoms are reproduced. Ramifications
ments and overpressures is important, the reproduction of of a positive cervical spine clearing test are for the com-
the patient’s symptoms in the shoulder or scapular region pletion of a more detailed and directed cervical spine
is of particular concern because this will ultimately lead examination, because these tests may indicate that the
the clinician to suspect that the patient’s symptoms arise source of the patient’s shoulder complaint is centrally
from the cervical spine. Isometrically applied resistance derived.
in mid-ranges of cervical spine motion can be applied
to stress the contractile elements, with end-range over- STERNOCLAVICULAR JOINT
pressure exerted to stress the noncontractile elements Evaluation of the sternoclavicular (SC) joint is an impor-
(Davies et al, 1981). tant part of the clearing process in the comprehensive
examination of the patient with shoulder dysfunction.
SPURLING’S MANEUVER This joint undergoes 30 degrees of axial rotation during
Another test recommended for cervical spine clearing is humeral elevation and receives stabilization from the bony
Spurling’s test, which is comprised of cervical spine exten- configuration of the joint, as well as both intrinsic and
sion with ipsilateral lateral flexion and rotation (Grimsby extrinsic ligamentous structures (Kapandji, 1985). Davies
& Gray, 1997). The position (Figure 5-2) stresses the et al (1981) recommended clearing the SC joint via active
intervertebral foramen and applies a compressive stress and passive movements of the shoulder girdle. Bilateral
and strain to the facet joints of the cervical spine comparison of the movement of the SC joint during
(Grimsby & Gray, 1997). The patient’s shoulder or arm shoulder girdle elevation/depression, protraction/retrac-
pain may be reproduced from the intervertebral disk via tion, and circumduction is recommended. Palpation of the
posterolateral compression and an inflamed nerve root, or SC joint during these motions can reveal crepitace and
facet joint. A slight overpressure can be applied as shown grating, as well as either hypermobility or restricted
in the figure, with stabilization of the contralateral shoul- motion. Anterior or posterior subluxation is often noted
Ch05.qxd 5/24/04 4:30 PM Page 34

34 SECTION I General Overview

Table 5-2 Location of Systemic

Thoracic/Scapular Pain
Systemic Origin Location
CARDIAC
Myocardial infarct Midthoracic spine
PULMONARY
Basilar pneumonia Right upper back
Empyema Scapula
Pleurisy Scapula
Pneumothorax Ipsilateral scapula
RENAL
Acute pyelonephritis Costovertebral angle
(posteriorly)
GASTROINTESTINAL
Esophagitis Mid-back between
scapulae
Peptic ulcer: stomach/ Sixth through tenth
duodenal thoracic vertebrae
Gallbladder disease Mid-back between
scapulae; right upper
scapula or subscapular
area
Biliary colic Right upper back; mid-back
between scapulae; right
interscapular or
subscapular areas
Pancreatic carcinoma Midthoracic or lumbar
spine
OTHER
Acromegaly Midthoracic or lumbar
spine

Adapted from Goodman CC, Snyder TE: Differential diagnosis in Figure 5-2 Spurling’s maneuver, consisting of passive exten-
physical therapy, ed 3, Philadelphia, 2000, WB Saunders, p. 487. sion, ipsilateral lateral flexion, and rotation of the cervical spine.

via either a prominent proximal clavicle or a sulcus, source of shoulder pain secondary to injury or separation,
respectively, as compared with the contralateral unin- which jeopardizes the intrinsic or extrinsic ligamentous
volved side. Passive mobility testing of the SC can be dif- structures that stabilize the joint. Hypermobility of the
ficult and uncomfortable for the patient because of the AC joint can lead to osteophyte production and hyper-
difficulty in grasping the clavicle itself. Bilateral compari- trophic bone formation, which can encroach on the
son of anterior posterior glide and superior inferior glide rotator cuff during arm elevation, leading to primary
can also assist the clinician in identifying either hypermo- glenohumeral joint impingement (Neer, 1983). Evalua-
bility or hypomobility of this joint. Research on the relia- tion of the AC joint consists of initially evaluating the
bility of accessory mobility assessment of this joint is not external appearance of the joint and comparing it with the
available. Davies et al (1981) reported that, in cases of contralateral uninjured side. The external appearance of a
anterior SC joint subluxation, a posterior relocation force unilateral step-down or piano-key sign, where the distal
can be maintained during reexamination of active or clavicle is higher than the acromion, can indicate a past
passive movements. An assessment of that relocation history of injury to the AC joint (Figure 5-3). In addition
force’s effect on the patient’s symptoms has diagnostic to visual inspection and palpation of the AC joint itself,
implications. three special examination maneuvers can be used to clear
the AC joint. One of these maneuvers is recommended as
ACROMIOCLAVICULAR JOINT a clearing test (AC joint passive mobility test, also called
The joint immediately proximal to the glenohumeral joint the AC joint shear test), and the other two (cross-arm
is the acromioclavicular (AC) joint. This joint can be a adduction impingement test and O’Brien’s test) are
Ch05.qxd 5/24/04 4:30 PM Page 35

CHAPTER 5 Related Referral Joint Testing 35

Figure 5-3 Patient with typical step-down sign on the left shoul-
der from complete acromioclavicular joint separation.

component parts of the examination of other structures of

the glenohumeral joint complex.

ACROMIOCLAVICULAR JOINT PASSIVE

Figure 5-4 Acromioclavicular joint shearing test; lateral view.
MOBILITY TEST (AC JOINT SHEAR TEST)
The AC joint passive mobility or shear test can be used to
provoke the AC joint by producing a shear force across the test is considered positive when the patient’s superiorly
joint. The AC joint passive mobility test can also be used directed pain is reproduced unilaterally with the shearing
to compare the actual motion of the AC joint with the movement. Normal responses to this test are for bilaterally
contralateral extremity to determine whether movement symmetric anterior posterior shear motions of the AC
of that joint reproduces the patient’s pain. One significant joint without symptoms.
advantage to this test maneuver is that actual hand con-
tacts are not placed close to the AC joint itself. Unlike CROSS-ARM ADDUCTION
other AC joint direct examination techniques, this tech- IMPINGEMENT TEST
nique produces movement of the clavicle and scapula This examination maneuver is discussed in detail with the
using proximal hand placements, thereby reducing the other impingement tests (see page 92). The reproduction
chance of producing pain simply by palpating and of superior shoulder discomfort over the AC joint with
attempting to grasp the clavicle and acromion near the the cross-arm adduction test is thought to indicate AC
AC joint. joint pathology as a result of compression of the distal
This test is performed with the patient in either the clavicle toward the acromion.
seated or standing position. The patient’s arm is positioned
at the side or in the lap if seated. The examiner stands on O’BRIEN’S TEST (ACTIVE
the same side of the patient’s shoulder being examined. COMPRESSION TEST)
Using clasped hands (Figure 5-4), the heels of the hands This test is described in detail in the labral testing section
are located near the midpoint of the clavicle anteriorly and of this text. The O’Brien’s test can be used to identify both
on the spine of the scapula posteriorly. With a compress- AC joint pathology and superior labral pathology. A posi-
ing-type action, the anterior hand presses posteriorly on tive O’Brien’s test, with specific pain being reproduced
the clavicle, while the posteriorly placed hand presses ante- and identified, indicates AC joint pathology.
riorly on the spine of the scapula in an oscillating-type pat-
tern. Several oscillations of movement are performed, with ELBOW JOINT
particular attention paid to both the amount and quality of Additional clearing of the extremity is indicated for the
the motion with bilateral comparison carried out. Repro- patient with shoulder dysfunction, including the joint
duction of pain is also an important factor in this test. The distal to the shoulder complex. Radiation of symptoms
Ch05.qxd 5/24/04 4:30 PM Page 36

36 SECTION I General Overview

distally often produces complex pain patterning in the

region of the elbow joint. Examination maneuvers to
screen the ulnohumeral and radiohumeral joints are part
of the patient’s comprehensive evaluation. Tests listed in
this section can be used to screen the structures that can
produce medial, lateral, and posterior elbow joint pain.

VALGUS STRESS TEST

The valgus stress test is used to evaluate the integrity of
the ulnar collateral ligament. The position used for testing
the anterior band of the ulnar collateral ligament is char-
acterized by 15 to 25 degrees of elbow flexion and forearm
supination. The elbow flexion position is used to unlock
the olecranon from the olecranon fossa and decreases the
stability provided by the osseous congruity of the joint.
Figure 5-5 Valgus stress test performed with 15 to 25 degrees
This places a greater relative stress on the medial ulnar of elbow flexion, with the shoulder placed in the coronal plane to
collateral ligament (Morrey & An, 1983). Reproduction minimize compensatory humeral rotation during testing.
of medial elbow pain, in addition to unilateral increases in
ulnohumeral joint laxity, indicates a positive test. Grading
the test is typically performed using the American Acad-
emy of Orthopaedic Surgeons (AAOS) guidelines of 0 to
5 mm grade I, 5 to 10 mm grade II, and greater than
10 mm grade III (Ellenbecker et al, 1998).
Use of greater than 25 degrees of elbow flexion in-
creases the amount of humeral rotation during perform-
ance of the valgus stress test and provides misleading
information to the clinician’s hands. Lateral movement by
the clinician’s distal hand grasping the patient’s distal fore-
arm is countered by the blocking of the clinician’s proximal
hand on the lateral aspect of the joint. This produces a lev-
ering effect, with opening of the medial aspect of the joint
to stress the medial ulnar collateral ligament. The test is
typically performed with the shoulder in the scapular
plane, but it can also be performed with the shoulder in the
coronal plane to minimize compensatory movements at
the shoulder during testing (Figure 5-5).

VARUS STRESS TEST

The varus stress test is performed using similar degrees of
elbow flexion and shoulder and forearm positioning. This
test assesses the integrity of the lateral ulnar collateral Figure 5-6 Varus stress test.
ligament and should be performed along with the valgus
stress test to completely evaluate the medial/lateral stabil-
ity of the ulnohumeral joint. Hand placements are VALGUS EXTENSION
reversed, such that the proximal blocking by the clinician’s OVERPRESSURE TEST
hand is now situated on the medial side of the elbow, The valgus extension overpressure test has been reported
while the clinician’s distal hand makes a medially directed by Andrews et al (1993) to determine whether posterior
motion of the distal forearm (Figure 5-6). The varus test elbow pain is caused by a posteromedial osteophyte abut-
is positive if lateral elbow pain is reproduced with unilat- ment with the medial margin of the trochlea and the ole-
eral increases in joint laxity. This test is graded using the cranon fossa. This test is performed by passively extending
same criteria as those for the valgus stress test. the elbow while maintaining a valgus stress to the elbow
Ch05.qxd 5/24/04 4:30 PM Page 37

CHAPTER 5 Related Referral Joint Testing 37

Figure 5-8 Tinel’s test demonstrating percussion over the

cubital tunnel retinaculum.

(Ellenbecker, 1995). These tests can be used to provoke

the muscle tendon unit at the lateral or medial epicondyle.
B Testing of the elbow at or near full extension can often
re-create localized lateral or medial elbow pain secondary
to tendon degeneration (Kraushaar & Nirschl, 1999).
Reproduction of lateral or medial elbow pain with resis-
tive muscle testing (provocation testing) may indicate
concomitant tendon injury at the elbow and directs the
clinician to perform a more complete elbow examination.
The presence of overuse injuries in the elbow occurring
with proximal injury to the shoulder complex or with
Figure 5-7 Valgus extension overpressure test. A, Valgus stress
exerted with elbow in flexion, B, with maintained valgus stress as scapulothoracic dysfunction has been widely reported
elbow is extended. (Ellenbecker & Mattalino, 1996; Ellenbecker, 1995;
Morrey, 1993; Nirschl, 1988a, 1988b).

TINEL’S TEST
(Figure 5-7). The valgus test is meant to simulate the This test involves tapping the ulnar nerve in the medial
stresses imparted to the posterior medial part of the elbow region of the elbow over the cubital tunnel retinaculum
during the acceleration phase of the throwing or serving (Figure 5-8). Reproduction of paresthesias or tingling
motion. Reproduction of pain in the posteromedial aspect along the distal course of the ulnar nerve indicates irri-
of the elbow indicates a positive test. The examiner’s tability of the ulnar nerve (Morrey, 1993) and can help
finger can be placed across the posterior part of the explain the distal radiation of symptoms in a patient with
olecranon tip to palpate during the valgus extension over- upper extremity pathology.
pressure force to feel for grating and crepitace.
LOWER EXTREMITY SCREENING
PROVOCATION TESTS One test that has been advocated by Kibler (1998b) as a
Provocation tests can be used when screening the muscle screening test for patients with glenohumeral and scapu-
tendon units of the elbow. These tests consist of manual lothoracic dysfunction is the one-leg stability test. This
muscle tests to determine pain reproduction. Specific tests test assesses the ability of the patient to perform a unilat-
used to screen the elbow joint of a patient with suspected eral squat while maintaining proper alignment of the
shoulder pathology include wrist and finger flexion and spine and lower extremities. The test is initiated with
extension, as well as forearm pronation and supination the subject in a standing position on one leg, with the
Ch05.qxd 5/24/04 4:30 PM Page 38

A B

Figure 5-9 One leg stability test. A, Start position. B, End position.

A
B

Figure 5-10 Common compensations during the one-leg stability test. A, Increased valgus angulation at the knee. B, Trende-
lenburg sign. C, Increased trunk flexion.
Ch05.qxd 5/24/04 4:30 PM Page 39

CHAPTER 5 Related Referral Joint Testing 39

contralateral limb flexed to 90 degrees (Figure 5-9, A). of the lower extremity and trunk in the overall function of
The arms are resting at the patient’s sides. The examiner the shoulder is best illustrated by the discussion of the
asks the patient to perform a squat on the weightbearing kinetic link principle in Chapter 17.
limb, bending that limb’s knee to 30 to 45 degrees (Figure
5-9, B). During the performance of the squat, the patient’s
overall alignment is noted. Presence of a Trendelenburg SUMMARY
pattern (dropping of the contralateral hip and pelvis), Although many tests can ultimately be used to clear the
corkscrew (twisting accompanying the squat maneuver), segments and joints both proximal and distal to the
or excessive trunk flexion all indicate weakness of the hip injured shoulder, the combination of these specific related
and pelvic musculature and would lead the clinician to referral tests with a detailed subjective evaluation can
include a broader exercise base in the patient’s rehabilita- ensure that the clinician has adequately screened for
tion program, including stabilization training of the trunk pathology in the adjoining segments and joints, thereby
and lower extremities (Figure 5-10). The important role enabling identification of a specific shoulder pathology.
Ch06.qxd 5/24/04 4:31 PM Page 41

CHAP TER

6 Neurovascular Testing

INTRODUCTION muscle tests helps the clinician to establish distal motor

Complete patient evaluation must include specific tech- function in the upper extremity before proceeding with
niques to establish the neurovascular integrity of the specific special tests and strength tests for the proximal
extremity being examined. These techniques are most muscle groups.
often used when the initial patient evaluation does not One example of a sequence for manual muscle testing
produce typical musculoskeletal pain patterns. that encompasses the cervical and upper thoracic nerve
roots is listed in Table 6-1. Although many sequences can
SENSATION be used, following a standardized sequence that includes
In most musculoskeletal evaluations, light touch sensation each level is recommended.
can be examined in a cursory fashion following the der-
matomal patterns (Figure 6-1). Figure 6-1 also shows the THORACIC OUTLET TESTING
cutaneous sensory distribution of the upper extremity. Although it is beyond the scope of this text to completely
Specific notation of locations of sensory loss or depriva- review the complex pathophysiology and diagnostic test-
tion should be followed. Focused areas of sensory loss may ing of thoracic outlet syndrome (TOS), its common
be present during the postoperative evaluation of a patient symptoms and clinical tests must be described. The use of
after open surgical exposure of the shoulder. The use of a clinical screening tests to rule out TOS is a crucial part of
Semmes Weinstein Monofilament Test Kit is recom- the complete evaluation of the patient who presents with
mended to better quantify the sensory pattern in the atypical musculoskeletal pain patterning in the upper
patient with identified sensory involvement. This test kit extremity. These patients are often referred with the diag-
consists of a series of monofilaments with different diam- nosis of shoulder pain or arm pain, and a systematic and
eters that can be used to test the patient’s sensation, there- detailed examination by the clinician is required to iden-
by providing an objective method to evaluate patient tify and/or rule out TOS.
sensation. Bilateral comparison forms the basis for most TOS is a controversial topic in clinical medicine, and
sensory measurement during musculoskeletal shoulder skeptics doubt its existence (Rayan, 1998). TOS can be
evaluations. defined as neurovascular compression of the thoracic inlet.
The thoracic inlet, also called the superior outlet, is a
REFLEXES pyramidal-shaped space containing the subclavian artery
The biceps (C5, C6), brachioradialis (C5, C6), and triceps and vein, and the lower trunk of the brachial plexus.
(C7, C8) reflexes should be checked, not only for their Numerous muscular structures insert onto the first rib,
presence but also for hyperactivity or bilateral differences. including the scalenus anticus, scalenus medius, scalenus
If these reflexes are difficult to obtain, Davies et al (1981) minimus, intercostals, serratus anterior, and subclavius. In
recommended having the patient clench the jaw and look addition to the structures originating and inserting in this
to the side opposite that being tested; this is termed the area, the space between the first rib and clavicle narrows
Jendrassik’s maneuver and facilitates the reflex response. with arm elevation (Telford & Mottershead, 1948).
TOS is typically classified into three categories: proxi-
STRENGTH mal, middle, and distal. Proximal TOS results from neu-
Specific manual muscle tests have been covered elsewhere rovascular entrapment at the interscalene triangle between
in this text; Chapter 14 contains detailed descriptions of the anterior and middle scalene muscles (Rayan, 1998).
isokinetic testing and interpretation. From a neurologic Middle TOS occurs at the interval between the first rib
standpoint, however, using simple but sequenced manual and the clavicle, and the less common distal TOS occurs

41
Ch06.qxd 5/24/04 4:31 PM Page 42

42 SECTION I General Overview

C3
C4
T2
C5 C5
T3
T4
T2 T2
T5
Lateral T6
supraclavicular T7
Lateral supraclavicular T8
Axillary
T1 T9 T1
Axillary T10 C6
C6
T11
Medial cutaneous of T12
Medial cutaneous L1
arm and S
of arm and
intercostobrachial L2 2–4 L2
intercostobrachial C8
C8 B
C7
Posterior cutaneous C7
Lower lateral of arm (radial)
A cutaneous of arm L3 L3
Lower lateral cutaneous
of arm (radial) L4 L4
Lateral cutaneous
Lateral cutaneous
of forearm (musculo-
of forearm (musculo-
cutaneous)
cutaneous)
Medial L5
cutaneous L5
Radial Medial Posterior cutaneous
of forearm
cutaneous of forearm (radial)
of forearm
Median Radial
Ulnar Ulnar
S1 S1
Median
Anterior Posterior

Figure 6-1 Cutaneous sensation distribution of the A, upper extremity, and B, dermatomes of the upper extremity. (A from Ellenbecker
TS, Mattalino AJ: Anatomy and biomechanics of the elbow. In The elbow in sport: injury treatment and rehabilitation, Champaign, IL,
1996, Human Kinetics Publishers. B from Jenkins DB: Hollinshead’s Functional anatomy of the limbs and back, ed 8, Philadelphia, 2002,
WB Saunders.)

Table 6-1 Upper Extremity Motor Screening Manual Muscle Test Sequence
Muscle Test Action Nerve/Level
Deltoid Resisted abduction (coronal plane) Axillary nerve (C5, 6)
Biceps Resisted elbow flexion (supinated forearm position) Musculocutaneous nerve (C5, 6)
Triceps Resisted elbow extension Radial nerve (C7, 8)
Extensor carpi radialis
Extensor carpi ulnaris
Resisted wrist extension Radial and deep radial nerve (C6, 7, 8)
Interossei dorsales Resisted finger abduction Ulnar nerve (C8, T1)

Adapted from Hislop HJ, Montgomery J: Daniels and Worthingham’s Muscle testing: techniques of manual examination, ed 7, Philadelphia, 2002,
WB Saunders.
Ch06.qxd 5/24/04 4:31 PM Page 43

CHAPTER 6 Neurovascular Testing 43

at the level of the coracoid process and pectoralis minor

muscle. The age of onset of TOS, although variable,
occurs most frequently between 20 and 40 years (Rayan,
1998).
TOS can be further classified into neurologic TOS and
the much less common vascular TOS. Neurologic TOS
is characterized by symptoms that are purely neurologic
without vascular symptoms, whereas vascular TOS has
arterial and venous symptoms without neurologic symp-
toms. Neurologic symptoms can be either motor or
sensory (Rayan, 1998).

PROVOCATION TESTS FOR THORACIC

OUTLET SYNDROME
Clinically, physical therapists use provocation tests to
screen for TOS. These tests have serious limitations, but
no other clinical testing methods are currently recom-
mended to more effectively screen or examine the patient
with suspected TOS. Most of the provocation tests use Figure 6-2 Adson’s test for screening for TOS.
certain positional maneuvers, with the clinician closely
monitoring the patient’s neurologic and vascular res-
ponses to these positions. Although there are many varia- The costoclavicular maneuver is performed by simulat-
tions of these tests to screen for TOS, four of the most ing an exaggerated military-type posture (Rayan, 1998).
commonly used provocation tests—Adson’s, Allen’s, cos- The patient is in a seated position, with the arms toward
toclavicular, and hyperabduction maneuvers—are covered the side in the coronal plane (Figure 6-3). The patient is
in more detail here. asked to retract and depress the scapulae, protrude the
In 1927, Adson and Coffey reported that cervical rib chest outward, and tuck the chin, holding this position for
symptoms could be provoked by head position. This led 1 minute. Changes in radial pulse are noted and the pres-
to the development of Adson’s maneuver, which is per- ence of paresthesias is recorded.
formed with the patient in a seated position, with the arm Finally, the hyperabduction or Wright’s maneuver is
held by the examiner in approximately 15 degrees of performed by palpating the radial pulse, initially with the
abduction in the coronal plane. The patient is then asked arms at the side and repeated with the arms in a hyperab-
to inhale deeply and hold the breath, with the head tilted duction position. Hyperabduction is typically performed
backward and the head and neck rotated to the ipsilateral with external rotation of the shoulder and elbow extension
side, so that the chin is elevated and pointing toward the without head movement. Changes in radial pulse and/or
examiner, who should be immediately beside and slightly the presence of paresthesias are recorded, with sampling
behind the patient being examined (Figure 6-2). The for 1 minute. Several modifications of this maneuver are
examiner palpates the radial pulse volume at the patient’s recommended. The first is to verify that the elbow is
wrist. The radial pulse (vascular response) is recorded as extended beyond 45 degrees to ensure that compression of
no change, diminished, or occluded. The patient is then the ulnar nerve does not unfairly bias or influence the
allowed to breathe normally, keeping the head in the result of the distal paresthesias (Rayan, 1998). Also, the
testing position for approximately 1 minute. If present, effects of gravity may influence the radial pulse diminu-
paresthesias (neurologic response) are recorded as mild, tion; therefore performing the test with the patient in the
moderate, or severe, and their distribution is noted supine position neutralizes the effects of gravity in the
(Rayan, 1998). overhead position. The use of this test is specific with
Allen’s test, another provocation maneuver, is per- regard to position for many industrial and athletic patients
formed exactly as described by Adson; however, the who report symptoms only with overhead positions.
patient looks to the contralateral side (away from the Rayan and Jensen (1995) tested the prevalence of pos-
examiner) during testing. Similar recording and proce- itive responses with TOS provocation tests in a normal
dures are used in this examination maneuver. population to determine the incidence of false-positive
Ch06.qxd 5/24/04 4:31 PM Page 44

44 SECTION I General Overview

maneuver, and 57% of the extremities for the hyperabduc-

tion maneuver. The neurologic response was present in 2%
of extremities for the Adson’s maneuver, 10% of the
extremities for the costoclavicular maneuver, and 16.5% of
the extremities for the hyperabduction maneuver. The
authors concluded that the vascular response was far more
common than the neurologic response in the normal
population. Caution must be taken when interpreting the
results of the vascular portion of these clinical TOS
maneuvers as a result of the high incidence of positive
findings in a normal population. The neurologic response,
consisting of replication of paresthesias in the distal upper
extremity with positional provocation, is far more dis-
criminating and less commonly occurs in the normal
population. Further research is needed to better define the
validity and reliability of these clinical TOS tests.
One final test has been reported in the literature for
TOS. As reported by Roos (1966), in this test the patient
opens and closes the hands quite rapidly for 3 minutes,
with the arms in an overhead position. A positive response
to this test consists of a neurologic response such as pares-
thesias, fatigue, heaviness, and a sudden drop of the limb.
This test can also be performed with the patient in the
“surrender” position, which places the elbows in 90
degrees of flexion. No reliability and typical response
Figure 6-3 Costoclavicular test used for screening for TOS.
pattern or incidence have been reported in the normal
population with this test.

SUMMARY
results. Provocation examination maneuvers were per- These neurovascular clinical evaluation tests are essential
formed in 200 upper extremities of 100 volunteers. Provo- to determine the integrity of the neurovascular structures
cation tests were assessed for both the vascular response before specific musculoskeletal tests for the shoulder
(diminution of the radial pulse) or neurologic response complex are performed. Ruling out involvement of the
(paresthesias). The vascular response was present in 13.5% neurovascular structures that supply the upper extremity is
of the normal volunteer extremities for the Adson’s essential for performing both an efficient and accurate
maneuver, 47% of the extremities for the costoclavicular musculoskeletal examination of the shoulder.
Ch07.qxd 5/24/04 4:32 PM Page 45

CHAP TER

7 Palpation

INTRODUCTION and several positions have been recommended for palpa-

Palpation is a widely used technique among physical ther- tion. Cyriax and Cyriax (1993) and Magee (1997) both
apists to identify structures and determine the presence recommended using a position where the patient is prone
and location of patient-described pain patterns. Various on elbows, with the affected shoulder in slight flexion,
positions have been advocated to place the shoulder in an adduction, and lateral rotation. In this position, the infra-
advantageous position to optimally palpate the tendons of spinatus is located just off the posterolateral corner of the
the rotator cuff and surrounding structures (Mattingly & acromion, with the teres minor immediately below the
Mackarey, 1996). The optimal shoulder position for pal- infraspinatus (Tomberlin, 2001). A limiting characteristic
pation and the typical location of specific structures in of this position is that it requires both a prone position
that position are reviewed to assist the clinician in obtain- by the patient and slight weightbearing through the
ing the most accurate information during this portion of humerus. Mattingly and Mackarey (1996) recommended
the clinical examination. maximal exposure for the infraspinatus and teres minor
tendons, which is similar to the position of the statue
ROTATOR CUFF TENDONS “The Thinker” by Rodin. The shoulder is placed in 90
The four rotator cuff tendons are not directly palpable degrees of flexion, 10 degrees of shoulder adduction, and
because of the overlying deltoid and acromion. The 20 degrees of lateral rotation (Figure 7-2). The patient can
recommended shoulder position to best palpate the place the ulnar side of the hand against the side of the face
supraspinatus tendon was originally described by Cyriax to achieve this position. The infraspinatus and teres minor
and Cyriax (1993) and included shoulder adduction, full can be palpated just inferior to the posterolateral corner of
internal rotation, and slight extension, such that the the acromion (Mattingly & Mackarey, 1996).
patient’s forearm and hand are placed behind the body in The subscapularis tendon does not require extensive
the lower back region. In this position, the supraspinatus positioning for palpation. Mattingly and Mackarey (1996)
is palpable just off the anterior medial aspect of the found the optimal position of the shoulder to be in
acromion and “passes near vertical, lateral and parallel to adduction against the side of the body, with neutral flex-
the bicipital groove” (Cyriax & Cyriax, 1993; Mattingly & ion/extension and internal/external rotation. In this posi-
Mackarey, 1996). One limitation of this position for many tion, the subscapularis can be palpated in the middle of
patients with shoulder pain is the lack of the available the deltopectoral triangle. Landmarks for the subscapu-
range of internal rotation to achieve the position behind laris tendon are inferior to the clavicle, lateral to the cora-
the back, similar to the Gerber lift-off test position (pages coid and bicep short-head tendon, and medial to the bicep
99–100). For these patients, Hawkins and Bokor (1990) long-head tendon in the intertubercular groove of the
recommended a modified position that includes shoulder humerus. Use of this shoulder position and palpation
adduction, medial rotation, and less extension, such that location allow the examiner to palpate the subscapularis
the patient’s forearm is placed against the stomach. This with the intervening presence of the deltoid (Mattingly &
position places the supraspinatus tendon just off the Mackarey, 1996).
anterolateral aspect of the acromion and allows the
patient’s extremity to be examined in a position of greater ADDITIONAL PALPATION CONCEPT
comfort that nearly all patients can achieve, even after a FOR THE ROTATOR CUFF
surgical procedure (Figure 7-1) (Hawkins & Bokor, Codman (1934) described palpation of full-thickness tears
1990). of the supraspinatus. This transdeltoid palpation has
The infraspinatus and teres minor tendons insert on become known as the rent test. This defect or “sulcus”
the lower facets of the greater tuberosity of the humerus, produced a rent in the supraspinatus tendon, which was

45
Ch07.qxd 5/24/04 4:32 PM Page 46

46 SECTION I General Overview

Figure 7-1 Position for palpation of the supraspinatus tendon. Figure 7-2 Position for tendon palpation for the infraspinatus
tendon (thinker’s position).

palpable through the deltoid (Wolf & Agrawal, 2001). The Lyons and Tomlinson (1993) correlated clinical palpa-
technique of transdeltoid palpation requires a relaxed tion using the rent test with the size of the tear at time of
patient, with palpation performed just anterior to the ante- surgery. They reported sensitivity of 91% and a specificity
rior margin of the acromion through the deltoid. The of 75% in a population of 42 patients. Wolf and Agrawal
patient is evaluated in the seated position, with the arm (2001) prospectively studied 109 consecutive patients
dangling next to the side to promote relaxation. With one using the rent test. Results of the transdeltoid palpation
hand, the examiner grasps the forearm, with the patient’s were compared with arthroscopic findings at the time of
elbow in 90 degrees of flexion. The examiner’s grasp on the surgery. A sensitivity of 95.7% and specificity of 96.8% for
forearm is meant to allow for rotational control of the diagnosis of a full-thickness tear of the supraspinatus
the extremity while the examiner’s other hand performs tendon were reported. The authors concluded that in the
the palpation. The arm is brought into extension while the trained examiner, transdeltoid palpation is highly accu-
patient’s extremity is rotated internally and externally. rate. Although the ability of each clinician to palpate the
According to Wolf and Agrawal (2001), both an eminence torn rotator cuff via the deltoid and determine the pres-
and a rent are palpated as the arm is brought from extension ence of a full-thickness rotator cuff tear remain in ques-
to slight flexion and internally and externally rotated. The tion, this information is relevant based on the specific
eminence represents the greater tuberosity that is more description of both the technique used and the exact loca-
prominent because of a full-thickness tear of the rotator tion of palpation and positioning of the patient. Deter-
cuff tendon.The rent is a soft tissue defect (Figure 7-3) cre- mining specific diagnostic conclusions from the palpation
ated by the rotator cuff that avulsed from the tuberosity. of the rotator cuff may not be indicated in the physical
The examination should be performed bilaterally to appre- therapy evaluation of the patient with shoulder pathology;
ciate the anatomy of the uninvolved shoulder and compare however, use of this technique can be recommended based
it with the symptomatic side (Wolf & Agrawal, 2001). on its success in the literature.
Ch07.qxd 5/24/04 4:32 PM Page 47

CHAPTER 7 Palpation 47

A B

Figure 7-3 A, Position of the hands for the rent test with B, demonstration of the
tip of the finger palpating the eminence and rent. (From Codman EA: The shoulder:
rupture of the supraspinatus tendon and other lesions in or about the subacromial
bursa, Boston, 1934, Thomas Todd; Reprint edition. Melbourne, FL, 1984, Krieger.)

BICEPS LONG-HEAD TENDON

Mattingly and Mackarey (1996) also reported maximal
exposure of the biceps long-head tendon. This tendon was
most exposed with the glenohumeral joint in adduction
and 20 degrees of internal rotation, placing the biceps
long-head tendon in the deltopectoral triangle (Figure
7-4). The tendon is less accessible with either neutral
rotation or lateral rotation because it is under the deltoid
muscle. To assist with palpation of the long head of the
biceps, the examiner can rotate the humerus back and
forth while gently palpating for the biceps long-head ten-
don as it slides back and forth with humeral rotation.

ADDITIONAL CONCEPTS FOR

SHOULDER PALPATION
Davies and DeCarlo (1995) reported that palpation used
during the examination of the shoulder provides informa-
tion regarding changes in skin temperature that might
suggest an inflammatory process, locate areas of sensation
loss or deficiency, identify specific sites of swelling, check
circulatory status via distal pulses, and identify point ten-
derness. Davies teaches palpation using similar sequences
on each patient to ensure that related areas are checked
Figure 7-4 Position for tendon palpation of the biceps long-head
consistently during the comprehensive evaluation process.
tendon in the deltopectoral triangle with 20 degrees of internal
The following sequence has been recommended: Starting rotation.
at the sternoclavicular joint anteriorly, the examiner pro-
Ch07.qxd 5/24/04 4:32 PM Page 48

48 SECTION I General Overview

gresses laterally along the margin of the clavicle to the Box 7-1 Shoulder Complex Compartments
acromioclavicular joint. After palpating the acromioclav-
for Palpation
icular joint, the examiner drops inferiorly to palpate the
coracoid process, lesser tubercle, and subscapularis inser- 1. Anterior Compartment
tion. By taking hold of the arm at the patient’s elbow, the Bicipital tendinitis
examiner palpates the biceps tendon in the intertubercu- Subscapularis tendinitis
Coracoacromial ligament pain secondary to rotator
lar groove and, with internal rotation of the humerus,
cuff impingement
palpates the greater tuberosity and the supraspinatus Anterior capsule pain secondary to chronic
insertion while the arm is being slightly extended, as men- subluxations, status post macrotraumatic
tioned earlier in this chapter. Rotation of the humerus dislocation
from internal to external rotation allows the examiner to Sternoclavicular joint sprain
Clavicular fracture
move from the lesser tuberosity to the intertubercular
2. Superior Compartment
groove, and finally to the greater tuberosity while palpat- Acromioclavicular joint sprain
ing. The lateral aspect of the acromion is then palpated Supraspinatus tendinitis
and, after slight flexion and lateral rotation, the infra- Subacromial/subdeltoid bursitis
spinatus and teres minor are encountered just inferior to Upper trapezius strain
Levator scapula strain/spasm
the posterolateral corner of the acromion with poste-
3. Lateral Compartment
rior palpation. Continuation of the palpation sequence Supraspinatus tendinitis
involves the margins of the scapula posteriorly. Systemat- Subacromial/subdeltoid bursitis
ically following this sequence allows the examiner to Sulcus sign indicating a multidirectional instability
palpate nearly all of the palpable structures around the 4. Posterior Compartment
Infraspinatus tendonitis/strain
shoulder girdle. This systematic approach helps to avoid
Teres minor tendonitis/strain
skipping or forgetting less common areas of involvement Posterior capsule pain secondary to chronic
that can occur when the areas that are most obvious or subluxation
subjectively directed by the patient are palpated first. Box Posterior impingement
7-1 lists commonly associated pathology with the com-
Modified from Davies GJ, DeCarlo MS: Examination of the shoulder
partment of palpation from Davies and DeCarlo (1995). complex: current concepts in rehabilitation of the shoulder, LaCrosse, WI,
This list is not meant to imply a direct relationship 1995, Sports Physical Therapy Association Home Study Course.
between the location of tenderness or pain reproduction
with palpation, but it is included here as a guide for the
examining clinician.
Ch08.qxd 5/24/04 4:33 PM Page 49

CHAP TER

8 Range of Motion Testing

INTRODUCTION movement performed with documented endpoint, but

One of the unique characteristics of the evaluation process also the quality of the motion and rhythm between the
used by physical therapists and other medical profession- glenohumeral and scapulothoracic joints.
als in physical rehabilitative medicine is the careful assess- Measurement of isolated glenohumeral joint elevation
ment of range of motion. Historically, joint motion during in the sagittal, frontal, or scapular planes is not clinically
clinical examination was evaluation via visual observation applicable above the first 30 degrees of glenohumeral joint
(Berryman-Reese & Bandy, 2002). Early editions of the elevation (Inman et al, 1944), and it is recommended that
Joint Range of Motion Guide published by the American measurement be performed to assess the combined move-
Academy of Orthopaedic Surgeons suggested that visual ment of these articulations when assessing humeral eleva-
observation of joint range of motion was equal or superi- tion in those three planes (Berryman-Reese & Bandy,
or to goniometric evaluation. As early as 1949, Moore 2002). Measurement of the patient in a supine position
supported the use of the universal goniometer but out- can assist with scapular stabilization to some degree dur-
lined its inherent errors, including lack of standardized ing humeral elevation measurements; however, complete
technique, patient positioning, and numerical expression. isolation of humeral motion is unlikely except in con-
Later research has shown both the effectiveness and reli- trolled laboratory conditions. Typical range of motion
ability of goniometric assessment of joint range of motion measures can be classified as combined or isolated.
in human subjects, and the universal goniometer initially
described by Clark in 1920 is used worldwide to objec- COMBINED SHOULDER ACTIVE RANGE
tively document joint range of motion during clinical OF MOTION TESTS
examination (Berryman-Reese & Bandy, 2002). The most popular combined motion tests used in clinical
This chapter highlights important concepts needed to examination are the Apley’s scratch tests (Hoppenfeld,
objectively measure active and passive range of motion 1976; Magee, 1997). These tests combine the motions of
during clinical evaluation of a patient with shoulder abduction with external rotation (top arm [dominant left
pathology. The reader is referred to three sources that arm], Figure 8-1) and adduction and internal rotation
provide detailed descriptions and copious references on with slight extension (bottom arm [nondominant right
joint range of motion assessment and normal values arm], see Figure 8-1). Additional positions include the
(Berryman-Reese & Bandy, 2002; American Academy of movement of cross-arm adduction and internal rotation
Orthopaedic Surgeons, 1994; Norkin & White, 1985). where the patient should reach across to touch the outer
aspect of the acromion of the contralateral shoulder.
RANGE OF MOTION ASSESSMENT Hoppenfeld (1976) suggested that these movements be
Measurement of both active and passive range of motion observed for symmetry and for any break in normal
is indicated during the complete evaluation of the patient rhythm. As a quick assessment, these movements can pro-
with shoulder pathology. It is important to understand the vide a visual marker for combined range of motion restric-
relationship between scapulothoracic and glenohumeral tions that can assist the clinician in coupling these range
motion when evaluating shoulder joint range of motion. of motion restrictions with the patient’s subjectively
The reader is referred to pages 17–18 for a discussion of reported functional limitations in activities of daily living.
scapulohumeral rhythm. It is imperative that the clinician Another use of the combined movement tests lies in the
observe and document the patient’s ability to elevate the visual demonstration of bilateral range of motion dif-
shoulder in flexion, abduction, and scapular plane eleva- ferences in overhead athletes. Loss of internal rotation
tion, with particular emphasis to not only the actual range of motion in the dominant shoulder of elite tennis

49
Ch08.qxd 5/24/04 4:33 PM Page 50

50 SECTION I General Overview

Figure 8-2 Combined glenohumeral joint measurement tech-

nique using hand placement behind the back to assess highest
maximal vertebral level contact.

(Figure 8-2) is particularly popular among clinicians for

Figure 8-1 Posterior view of Apley’s scratch test with combined
glenohumeral joint abduction/external rotation in the left domi- assessing glenohumeral joint internal rotation. Edwards et
nant arm, and adduction/internal rotation with the right nondomi- al (2002) evaluated the intraobserver and interobserver
nant arm in a senior tennis player. reliability of this measurement technique using three male
subjects, with 11 orthopaedic surgeons and 2 physical
therapists as examiners. All examiners measured internal
and baseball players has been widely documented rotation based on maximal vertebral level achieved
(Ellenbecker, 1992; Ellenbecker et al, 2002b). The vast between T4 and L5 with an extended thumb. Radio-
difference between the top and bottom arm (see Figure graphs were used to establish the true level the thumb was
8-1) observed when the dominant arm is performing the placed over. Results showed poor interobserver reliability
lower movement (adduction, internal rotation, and exten- (intraclass correlation coefficients [ICC] 0.12 to 0.27),
sion) can clearly identify to the patient and coaches the with an average error of 1 vertebral level. Intraobserver
degree of range of motion adaptation or loss (Roetert & reliability ranged between ICC 0.18 and 0.82, with a
Ellenbecker, 1998). mean of 0.44; the average error was 1 level. Even within a
In addition to the observation of the combined move- single examiner, repeated bouts of testing using
ments suggested by Hoppenfeld (1976), many clinicians this combined method to document internal rotation via
document which spinous process the patient can touch an extended thumb are prone to error on an average of
during each of the combined motions bilaterally. Docu- 1 vertebral level.
mentation using the combined movement of adduction Additional research testing the validity of the com-
and internal rotation (hand behind the back) movement bined method to assess maximal internal rotation active
Ch08.qxd 5/24/04 4:33 PM Page 51

CHAPTER 8 Range of Motion Testing 51

range of motion via vertebral level was performed by Analysis of Table 8-1 shows relatively consistent read-
Mallon et al (1996) during radiographic analysis. Pos- ings for some motions, such as flexion and abduction, and
teroanterior radiographs were used to determine actual a wide variation of normal responses in others. One area
movement of the scapulothoracic and glenohumeral with a particularly wide variation is glenohumeral joint
joints. The movement of maximal internal rotation internal and external rotation. This range of motion is
behind the back occurs at a ratio of 2 : 1, with 2 degrees of often measured in 0 or 45 degrees of abduction in the
glenohumeral joint motion occurring with 1 degree of initial evaluation after surgery or injury, and more fre-
scapulothoracic motion. The scapulothoracic motion was quently measured in 90 degrees of abduction as patients
more important in actually placing the hand behind the progress in rehabilitation (Ellenbecker & Mattalino,
back, with essentially all internal rotation range of motion 1999b). Also, the contribution of the scapulothoracic joint
occurring with the hand in front of the body (Mallon et to glenohumeral motion has been widely documented
al, 1996). The actual act of reaching toward the maximal (Inman et al, 1944; Mallon et al, 1996) and is one of the
vertebral level is achieved by elbow flexion and thumb variables that can lead to extensive variation of rotational
hyperextension, not continued internal rotation. Mallon et measurement in the human shoulder.
al (1996) concluded “that measuring shoulder internal Active rotational range of motion measures were taken
rotation by the maximal vertebral level reached by the bilaterally in 399 elite junior tennis players using two dif-
patient’s thumb greatly oversimplifies the concept of fering measurement techniques and a universal goniome-
internal rotation and that limitations in this motion may ter (Ellenbecker et al, 1993). A total of 252 subjects were
not be strictly due to a loss of internal rotation at the measured in the supine position for internal and external
glenohumeral joint.” Use of this combined pattern may rotation with 90 degrees of glenohumeral joint abduction,
give the clinician an indication of the combined move- with no attempt to stabilize the scapula (Figure 8-3); 147
ment of the glenohumeral and scapulothoracic joints, but elite junior tennis players were measured for internal and
should not be substituted for measurement of isolated external rotation active range of motion in 90 degrees of
internal rotation of the glenohumeral joint. glenohumeral joint abduction using scapular stabilization.
Stabilization was provided by a posteriorly directed force
ISOLATED GLENOHUMERAL JOINT applied by the examiner’s hand placed on the anterior
RANGE OF MOTION TECHNIQUES aspect of the shoulder over the anterior acromion and
As mentioned earlier, it is beyond the scope of this coracoid process (Figure 8-4). Results of the two groups
chapter to provide the detailed review of every isolated showed significantly less internal rotation range of motion
measurement technique for the shoulder girdle. However, when using the measurement technique with scapular
several important concepts, particularly regarding mea- stabilization (18% to 28% reduction in range of mo-
surement of rotational range of motion, are pertinent. tion). Changes in external rotation range of motion were
Table 8-1 provides descriptive data on normal range of
motion for the human shoulder. Riddle et al (1987) exam-
ined intratester and intertester reliability of measuring
the shoulder with a universal goniometer in 50 subjects
with shoulder pathology. Passive range of motion mea-
surements for flexion, abduction, and external rotation
ranged from 0.87 to 0.99 for intertester reliability,
with values of 0.26 to 0.55 for horizontal abduction/
adduction and internal rotation. They concluded that
the reliability of shoulder range of motion measurement
using a goniometer was motion specific. Norkin and
White (1995) summarized the intrarater reliability for
goniometric assessment of shoulder range of motion using
a large universal goniometer. They reported ICCs ranging
from 0.84 to 0.98 for shoulder flexion, extension, and
abduction, and ICCs ranging between 0.87 and 0.99 for
internal and external rotation. By comparison, Norkin and Figure 8-3 Glenohumeral joint internal rotation range of motion
White (1995) reported ICCs for elbow extension/flexion measurement technique without scapular stabilization in 90
range of motion at greater than 0.90. degrees of abduction.
 Ch08.qxd
5/24/04
4:33 PM
Page 52

Table 8-1 Normal Range of Motion Values for the Shoulder*

Daniels & Kendall Weichec
Boone Worthing- Dorinson Ewsch & Gerhardt Hoppen- & &
Joint AAOS & Azen Clark CMA ham & Wagner Lepley & Russe feld JAMA Kapandji McCreary Krusen

Flexion 180 167 130 170 — 180 170 170 — 150 180 180 180

Extension 60 62 80 30 50 45 60 50 45 40 50 45 45

Abduction 180 184 180 170 — 180 170 170 180 150 180 180 180

Internal 70 69 90* 60* 90 90 80 80 55 40 95 70 90

rotation

External 90 104 40* 80* 90 90 90 90 45 90* 80 90 90

rotation

Adapted from American Physical Therapy Association promotional material, Fairfax, VA.
*Measurements obtained with the shoulder in 0 degrees of abduction. Normal range of motion (in degrees) according to various authors.
Ch08.qxd 5/24/04 4:33 PM Page 53

CHAPTER 8 Range of Motion Testing 53

Table 8-2 Glenohumeral Joint Internal

Rotation Values from 138 Patients
with Glenohumeral Joint Instability
and Impingement
Internal rotation with scapular 38.8 degrees
stabilization
Internal rotation without 67.4 degrees
scapular stabilization
Maximal vertebral level T7

From Ellenbecker & Davies, 1997.

Figure 8-4 Glenohumeral joint internal rotation range of motion

measurement technique with scapular stabilization provided by a TOTAL ROTATION RANGE OF
posteriorly directed force on the anterior aspect of the shoulder. MOTION CONCEPT
The concept of total rotation range of motion combines
the glenohumeral joint internal and external rotation
range of motion measure by adding the two numbers to
smaller between groups, with 2% to 6% reduction in obtain a numerical representation of the total rotation
active range of motion. range of motion available at the glenohumeral joint
One common finding confirmed by this research is sig- (Figure 8-5). Kibler et al (1996) and Roetert et al (2000)
nificantly less (approximately 10 to 15 degrees) dominant found that decreases in the total rotation range of motion
arm glenohumeral joint internal rotation in elite junior arc in the dominant extremity of elite tennis players cor-
tennis players (Ellenbecker, 1992; Ellenbecker et al, related with increasing age and number of competitive
1996). In this study, however, this difference between years of play. Ellenbecker et al (2002b) measured bilateral
extremities in internal rotation range of motion was iden- total rotation range of motion in professional baseball
tified only when the scapula was stabilized. Failure to sta- pitchers and elite junior tennis players. The professional
bilize the scapula did not produce glenohumeral joint baseball pitchers had greater dominant arm external rota-
internal rotation range of motion measurements that tion and significantly less dominant arm internal rotation
identified a deficit. This study clearly demonstrates the compared with the contralateral nondominant side. The
importance of using consistent measurement techniques total rotation range of motion, however, did not differ
when documenting range of motion of glenohumeral joint significantly between extremities (145 degrees dominant
rotation. Based on the results of this study, I highly rec- arm, 146 degrees nondominant arm) (Figure 8-6). This
ommend the use of scapular stabilization during measure- research shows that, despite bilateral differences in the
ment of humeral rotation to obtain more isolated and actual internal and/or external rotation range of motion in
representative values of shoulder rotation. the glenohumeral joints of baseball pitchers, the total arc
Ellenbecker and Davies (1997) studied 138 patients of rotational motion should remain the same.
undergoing rehabilitation for rotator cuff impingement In contrast, Ellenbecker et al (2002b) tested 117 elite
and glenohumeral joint instability. Patients were mea- male junior tennis players and found significantly less
sured for internal glenohumeral joint rotation using three internal rotation range of motion on the dominant arm
methods: isolated supine glenohumeral joint internal rota- (45 degrees versus 56 degrees), as well as significantly less
tion in 90 degrees of abduction without scapular stabiliza- total rotation range of motion on the dominant arm (149
tion, isolated glenohumeral joint internal rotation with 90 degrees versus 158 degrees). The total rotation range of
degrees of glenohumeral joint abduction with sca- motion did differ between extremities (Table 8-3, see
pular stabilization, and determination of maximal verte- Figure 8-6); approximately 10 degrees less total rotation
bral level reached behind the back. Internal rotation range range of motion can be expected in the dominant arm
of motion was almost twice as large without scapular sta- compared with the nondominant arm of the uninjured
bilization, as compared with the condition when the elite junior tennis player.
scapula was stabilized. The average vertebral level Use of normative data from population-specific
achieved by these patients was T7 (Table 8-2). research can assist clinicians in interpreting normal range
Ch08.qxd 5/24/04 4:33 PM Page 54

54 SECTION I General Overview

of motion patterns and identify when sport-specific adap- degrees of external rotation and only 30 degrees of inter-
tations or clinically significant maladaptions are present nal rotation, there may be some uncertainty as to whether
(see Table 8-3) (Ellenbecker et al, 2002b). Further that represents a range of motion deficit in internal rota-
research on additional subject populations is needed to tion that requires rehabilitative intervention via stretching
outline the total rotation range of motion concept. and specific mobilization. If measurement of that patient’s
Clinical application of the total rotation range of nondominant extremity rotation reveals 90 degrees of
motion concept is best demonstrated by a case presenta- external rotation and 60 degrees of internal rotation, how-
tion of a unilaterally dominant upper extremity athlete. ever, the current recommendation is to avoid extensive
During initial evaluation of a high level baseball pitcher, mobilization and passive stretching of the dominant
if the clinician finds a range of motion pattern of 120 extremity, because the total rotation range of motion in
both extremities is 150 degrees (120 ER + 30 IR = 150
IR dominant arm/90 ER and 60 IR = 150 total rotation non-
dominant arm). In elite level tennis players, total active
rotation range of motion can be expected to be up to 10
degrees less on the dominant arm before a clinical treat-
ment to address internal rotation range of motion restric-
tion would be implemented. This total rotation range of
motion concept can be used to guide the clinician during
rehabilitation, specifically in the application of stretching
and mobilization. Careful measurement of range of
ER
motion can best determine what glenohumeral joint
Figure 8-5 Total rotation range of motion concept. requires additional mobility and which extremity should

6 degrees degrees
= 14 = 158
rc Nondominant a rc Nondominant
la tal
ta arm To arm
To

es egrees
d e g re 14 9 d
1 45 Dominant a rc = Dominant
c= tal
l ar arm To arm
ta
To

Baseball players Tennis players

Figure 8-6 Summary of total rotation range of motion research.

Ch08.qxd 5/24/04 4:33 PM Page 55

CHAPTER 8 Range of Motion Testing 55

Table 8-3 Bilateral Comparison of Isolated and Total Rotation Range of Motion from Professional
Baseball Pitchers and Elite Junior Tennis Players
Subjects Dominant Arm Nondominant Arm
BASEBALL PITCHERS
External rotation 103.2 ± 9.1 (1.34) 94.5 ± 8.1 (1.19)
Internal rotation 42.4 ± 15.8 (2.33) 52.4 ± 16.4 (2.42)
Total rotation 145.7 ± 18.0 (2.66) 146.9 ± 17.5 (2.59)
ELITE JUNIOR TENNIS PLAYERS
External rotation 103.7 ± 10.9 (1.02) 101.8 ± 10.8 (1.01)
Internal rotation 45.4 ± 13.6 (1.28) 56.3 ± 11.5 (1.08)
Total rotation 149.1 ± 18.4 (1.73) 158.2 ± 15.9 (1.50)

All measurements are expressed in degrees. Standard error of the mean in parentheses.
From Ellenbecker TS, Roetert EP, Bailie DS, et al: Glenohumeral joint total rotation range of motion in elite tennis players and baseball pitchers, Med
Sci Sports Exerc 34(12):2052-2056, 2002b.

not have additional mobility because of the obvious harm head shear in the abducted externally rotated position
induced by increases in capsular mobility, which can lead with tightness of the posterior band of the inferior gleno-
to an increase in humeral head translation during aggres- humeral ligament (See Chapter 17 for a more complete
sive upper extremity exertion. description relative to the throwing athlete.)
Loss of internal rotation range of motion is significant The Tyler posterior shoulder tightness test is another
for several reasons. The relationship between internal test that can be used to measure cross-arm adduction
rotation range of motion loss (tightness in the posterior range of motion to assess posterior shoulder tightness
capsule of the shoulder) and increased anterior humeral (Tyler et al, 1999). This test assesses the limitation in
head translation has been scientifically identified (Tyler shoulder cross-arm adduction and is thought to measure
et al, 1999; Gerber et al, 2003). The increase in anterior tightness in the posterior capsule and the muscle tendon
humeral shear force reported by Harryman et al (1990) units of the posterior shoulder muscles. The patient is
was manifested by a horizontal adduction cross-body placed in a side-lying position on a plinth, approximately
maneuver, similar to that incurred during the follow- half the length of the humerus away from the edge of the
through of the throwing motion or tennis serve. Tightness plinth. The hips are flexed to approximately 45 degrees,
of the posterior capsule has also been linked to increased with 90 degrees of knee flexion to stabilize the patient.
superior migration of the humeral head during shoulder Males are measured with no shirt and females in a sports
elevation (Matsen and Artnz, 1990). bra or gown to expose the scapular area. The acromion is
Koffler et al (2001) studied the effects of posterior cap- aligned perpendicular to the plinth, with the nontested
sular tightness in a functional position of 90 degrees of extremity placed under the patient’s head. The tester
abduction and 90 degrees or more of external rotation in stands facing the patient (Figure 8-7) and grasps the
cadaveric specimens. Imbrication of either the inferior extremity to be measured at the elbow near both epi-
aspect of the posterior capsule or the entire posterior cap- condyles, and passively moves the patient’s shoulder to 90
sule altered the humeral head kinematics. In the presence degrees abduction in neutral rotation. The scapula is then
of posterior capsular tightness, the humeral head shifts in stabilized in a position of retraction by using the examin-
an anterosuperior direction, compared with a normal er’s other hand along the lateral border of the scapula (see
shoulder with normal capsular relationships. With more Figure 8-7). With the position of the scapula maintained,
extensive amounts of posterior capsular tightness, the the patient’s shoulder is lowered passively and gently into
humeral head shifted in a posterosuperior fashion. These horizontal adduction in neutral rotation. The humerus is
effects of altered posterior capsular tensions experimental- lowered with the patient relaxed, until motion has ceased
ly representing in vivo posterior glenohumeral joint cap- or rotation of the humerus occurs, indicating end range of
sular tightness highlight the clinical importance of using motion. At the end of the achieved range of motion, the
a reliable and effective measurement methodology to examiner takes a carpenter square (60 cm) and measures
assess internal rotation range of motion during examina- the distance from the top of the plinth to the patient’s
tion of the shoulder. Burkhart et al (2003) clinically medial epicondyle and records that value. Testing is
demonstrated the concept of posterior superior humeral repeated for the contralateral shoulder. A greater distance
Ch08.qxd 5/24/04 4:33 PM Page 56

56 SECTION I General Overview

A B

Figure 8-7 Tyler posterior shoulder tightness test demonstrating starting position with A, scapular stabilization, and B, end position.

represents decreased posterior shoulder flexibility, and a and soft tissue approximation. Abnormal end feels are
smaller distance between the top of the plinth and the spasm, springy block, and empty end feels (Cyriax &
medial epicondyle indicates greater flexibility of the pos- Cyriax, 1983). End feels for human joint movements have
terior shoulder structures (Tyler et al, 1999). been established, with normal expected end feels for
Tyler et al (1999) reported intratester reliability using glenohumeral joint motions being listed as capsular. One
ICCs ranging between 0.92 and 0.95 and intertester reli- exception is the movement of cross-arm adduction. On
ability of 0.80. They also reported a significant correlation some individuals with substantial muscular development
between the Tyler posterior shoulder tightness test and of the pectorals and biceps, the end feel for cross-arm
isolated glenohumeral joint internal rotation range of adduction can be interpreted as soft tissue approximation
motion, with 90 degrees of abduction and scapula stabi- as the muscles become superimposed against one another
lized (r = 0.61), as well as significant differences (P < at or before end range of motion.
0.001) between the dominant and nondominant extremi- An example of a common situation in which abnormal
ties in posterior shoulder tightness in NCAA division I end feels may be present during passive range of motion
college baseball pitchers. Greater posterior shoulder tight- assessment in the clinical examination of the patient with
ness was identified in the dominant arm. In addition to shoulder dysfunction is the empty end feel felt in patients
testing on nonimpaired subjects and athletes, Tyler et al with an acute onset of shoulder pain, where no measurable
(2000) tested shoulders in patients diagnosed with shoul- resistance is encountered during the patient’s range of
der impingement. The Tyler posterior shoulder tightness motion before pain is encountered. The spasm end feel is
test was positive in the involved shoulder in patients with also often encountered during apprehension testing of the
subacromial impingement when the impairment was in patient with glenohumeral joint instability as the arm is
the dominant or nondominant extremity. The authors brought toward abduction and external rotation. Finally, a
recommended this test for measuring posterior shoulder heavy capsular end feel at early ranges of motion is often
tightness in clinical applications. encountered during passive range of motion assessment of
the patient with adhesive capsulitis (Magee, 1997). Inter-
END FEEL CLASSIFICATION pretation of end feel can provide the clinician with valu-
An additional concept important in the determination able information with which to formulate a treatment
and measurement of both physiologic and accessory range program. For example, a patient with an empty, painful
of motion testing is end feel. Cyriax and Cyriax (1983) end feel is not a candidate for early aggressive strengthen-
described end feel as the feeling transmitted to the exam- ing. In general the concept of “pain before resistance”
iner’s hands at the extreme range of passive motion (Table indicates an acute condition whereby the clinician uses
8-4). Normal end feels are considered as bony, capsular, caution regarding range of motion and strengthening
Ch08.qxd 5/24/04 4:33 PM Page 57

CHAPTER 8 Range of Motion Testing 57

Table 8-4 Classification and Description of subjects with painful shoulders and knees. Two physical
End Feels therapists performed examinations to assess end-feel and
pain-resistance sequences in two knee motions and five
Classification Description
shoulder motions. Intrarater reliability for end-feel and
Bony Two hard surfaces meeting, pain-resistance sequences was “generally good,” with
bone to bone (i.e., elbow kappa coefficients ranging from 0.65 to 1.00 for end-feel
extension)
and 0.59 to 0.87 for pain-resistance sequence. Interrater
Capsular Leathery feel, further motion
available (shoulder external reliability coefficients were not acceptable for end-feel
rotation) classification or pain-resistance sequence. With reference
Soft tissue Soft tissue contact limits to the shoulder, Hayes and Peterson (2001) found more
approximation further motion (elbow discrepancy in the end-feel classification of shoulder
flexion, shoulder cross-arm
abduction. They attributed this discrepancy to the lack of
adduction)
Spasm Muscular spasm limits motion standardized stabilization of the scapula, which could lead
(vibrant twang) to confusing interpretations of end feel based on the
Springy block Intraarticular block prohibits amount and technique of scapular stabilization used by
motion (rebound is felt) the examiner. This finding again points to the importance
Empty Movement causes pain, pain
of scapular stabilization and the use of examination meth-
limits movement
ods that are standardized to enhance reliability and effec-
From Ellenbecker TS, Mattalino AJ: Comparison of open and closed tiveness (Ellenbecker et al, 1996; Hayes & Peterson,
kinetic chain upper extremity tests in patients with rotator cuff 2001).
pathology and glenohumeral joint instability, J Orthop Sports Phys
Ther 25:84, 1997.
SUMMARY
This chapter has provided important concepts for assess-
(Cyriax & Cyriax, 1983). Pain encountered with resis- ing the physiologic mobility of the glenohumeral and
tance indicates a subacute condition requiring light and scapulothoracic joints. The combination of the informa-
gentle range of motion and strengthening; resistance tion obtained during measurement and analysis of this
before pain indicates a more chronic condition where physiologic movement of the shoulder, coupled with the
vigorous interventions would be indicated to restore range accessory mobility assessment covered in the section on
of motion and strength to the injured segment or seg- glenohumeral joint instability testing, gives the clinician
ments (Cyriax & Cyriax, 1983). vital information for formulation of an evidence-based
Hayes and Petersen (2001) studied the reliability of treatment program to address hypermobility or hypo-
end-feel assessment and the pain-resistance sequence in mobility of the glenohumeral joint.
Ch09.qxd 5/24/04 5:50 PM Page 61

CHAP TER
Glenohumeral Joint
9 Instability Testing

INTRODUCTION TUBS refers to a patient with traumatic unidirectional

Historically, one of the primary methods to test for instability with a Bankart lesion, which usually requires
glenohumeral joint instability was the apprehension test surgery to correct. The classic example of a TUBS patient
(Hoppenfeld, 1976). Although the apprehension test is is a football quarterback who is tackled with the shoulder
still used in today’s clinical evaluation of the shoulder, in a position of abduction and external rotation while
many additional tests are now available to more accur- preparing to throw. The forceful movements into greater
ately identify and classify glenohumeral joint instability. degrees of external rotation, horizontal abduction, and
The close association between glenohumeral joint insta- abduction in this example often lead to an anterior unidi-
bility and rotator cuff pathology requires the use of these rectional dislocation of the shoulder that requires surgery
tests in virtually all clinical evaluations of the shoulder to repair the Bankart lesion (detachment of the anterior
( Jobe & Bradley, 1989; Ellenbecker, 1995). inferior labrum from the glenoid) in order to restore
In addition to identifying the presence of apprehension glenohumeral joint stability. The TUBS patient is also
with shoulder movement in patients with glenohumeral commonly referred to as the “torn loose” patient, based on
joint instability, the clinician must be able to assess the the traumatic incident that produced the unidirectional
amount and degree of humeral head translation in three dislocation.
directions, as well as the effects of humeral head transla- The AMBRI type of instability has an atraumatic
tion on pain reproduction in the individual with sus- onset and is most often multidirectional in nature, occur-
pected instability. This chapter describes tests to diagnose ring in patients with bilateral glenohumeral joint laxity
glenohumeral joint instability based on three primary and generalized joint laxity. These patients typically
factors—pain provocation, apprehension, and humeral respond best to rehabilitation and, if surgery is required,
head translation. an inferior capsular shift is most often performed. The
AMBRI patient is also commonly referred to as the “born
CLASSIFICATION OF GLENOHUMERAL loose” patient. A classic example of an AMBRI patient is
JOINT INSTABILITY a young female volleyball player with anterior shoulder
Many classification schemes and terms can be used to pain and inability to perform overhead movements.
describe glenohumeral joint instability including acute
versus chronic, first-time versus recurrent, traumatic ver- DIRECTIONS OF GLENOHUMERAL
sus atraumatic, voluntary versus involuntary, and subluxa- JOINT INSTABILITY
tion versus dislocation (Hawkins & Mohtadi, 1991). Each As a precursor to the discussion of specific tests to
of these descriptions can be addressed during both subjec- identify glenohumeral joint instability, it is imperative to
tive questioning of the patient and objective testing. It describe the actual directions of glenohumeral joint insta-
is important that instability of the glenohumeral joint bility. Three typical directions are discussed in the litera-
be thought of as a spectrum of disease or pathology ture: anterior, posterior, and multidirectional (Hawkins &
(Hawkins & Mohtadi, 1991). Table 9-1 presents one way Mohtadi, 1991; Jobe & Bradley, 1989). They are named
of classifying many of the components of glenohumeral according to the direction of movement of the humeral
joint instability. head relative to the glenoid.
By incorporating many of the components in Table 9- Anterior glenohumeral joint instability results when
1, Matsen et al (1991) described two acronyms, TUBS and the humeral head traverses excessively in an anterior
AMBRI, to classify shoulder instability. These represent direction relative to the glenoid, producing symptoms of
both ends of the instability spectrum. pain, apprehension, or loss of function. Dislocations of the

61
Ch09.qxd 5/24/04 5:50 PM Page 62

62 SECTION II Special Tests

Table 9-1 Classification of Glenohumeral humeral head relative to the glenoid when stress is applied
Joint Instability Using Five (Matsen, 1992). When defining laxity, reference should
Main Components be made to both humeral position and the direction of
the force applied (Borsa et al, 1999). A minimal amount
Components
of humeral head translation or laxity is required for nor-
Timing/frequency Acute versus chronic mal glenohumeral joint rotation to occur (McFarland et
First time versus al, 1996). Glenohumeral translation associated with
recurrent humeral rotation has been called coupled or obligate motion
Direction Anterior
Posterior
(Harryman et al, 1990; Hawkins et al, 1996).
Multidirectional (inferior) Instability can be defined as excessive symptomatic
Onset Traumatic translation of the humeral head relative to the glenoid
Atraumatic when stress is applied. According to Matsen (1992), this
Overuse excessive or “unwanted” translation compromises shoulder
Volition Voluntary
Involuntary
function and produces clinical symptoms. It is important
Degree Dislocation to use these terms in proper context when evaluating
Subluxation the patient with glenohumeral joint pathology, because
individuals possess varying amounts of glenohumeral
Adapted from Hawkins RJ, Mohtadi NGH: Clinical evaluation of
shoulder instability, Clin J Sports Med 1:59-64, 1991. joint laxity but only those with clinical symptoms
and functional limitations can be described as having
instability.
shoulder account for approximately 45% of the disloca-
tions in the human body (Kazar & Relovszky, 1969); of TESTS TO EVALUATE FOR
those, 85% are anterior glenohumeral joint dislocations GLENOHUMERAL JOINT INSTABILITY
(Cave et al, 1974). Subcoracoid dislocation is the most As mentioned previously, glenohumeral joint instability
common type of anterior glenohumeral joint dislocation tests rely on three primary factors: apprehension, humeral
(Matsen et al, 1998). The usual mechanism of subcoracoid head translation, and pain provocation/replication.
dislocation is a combination of glenohumeral joint abduc-
tion, extension, and external rotation forces that produces Apprehension Test
a challenge to the anterior capsule and capsular ligaments,
glenoid rim, and rotator cuff mechanism (Matsen et al, Indication
1998). The apprehension test is a test used to determine gleno-
Posterior glenohumeral joint instability occurs when humeral joint instability.
there is excessive movement of the humeral head in a pos-
terior direction relative to the glenoid, producing symp- About the Test
toms. The most common posterior glenohumeral joint This test uses the common instability movement pattern
dislocation is the subacromial dislocation. Posterior dislo- of abduction, external rotation, and horizontal abduc-
cations are frequently locked (Hawkins et al, 1987). They tion/extension to provoke the patient’s shoulder.
are reported to occur only 2% of the time; however, they
are also the most frequently missed diagnosis with respect Start Position
to shoulder instability (Matsen et al, 1998). The patient is typically examined in a seated position to
Carter Rowe (1962) was the first to report that atrau- minimize compensatory movements during examination,
matic instability could occur in more than one direction. but the patient can be evaluated in the standing, supine,
Neer and Foster (1980) called the combined type of insta- or even prone position (Rowe & Zarins, 1981; Andrews
bility multidirectional. Multidirectional instability consists & Wilk, 1994). The examiner should be positioned so
primarily of an inferior instability with excessive inferior that careful monitoring of the intended patient response
movement of the humeral head relative to the glenoid, can occur. Figure 9-1 shows the clinician positioned
with concomitant anterior and/or posterior excessive behind the patient. This clinician-patient alignment is
symptomatic mobility. particularly effective when a mirror or reflection allows
the clinician to clearly see the patient’s facial response. In
ADDITIONAL TERMINOLOGY an alternative position, the clinician stands to the lateral
It is important to note the difference between instability side of the involved extremity or directly in front of the
and laxity. Laxity can be defined as translation of the patient.
Ch09.qxd 5/24/04 5:50 PM Page 63

CHAPTER 9 Glenohumeral Joint Instability Testing 63

used during initial evaluation of a patient with a clinical

history consistent with anterior glenohumeral joint insta-
bility, as well as a criterion test in returning the athletic or
industrial patient back to function after rehabilitation.
Unlike other tests that attempt to quantify the amount of
humeral head translation, this test indicates the patient’s
willingness and confidence in the 90/90 position inherent
in many functional activities in both sport and industry.

Modifications of the Apprehension Test

Indication
Variations of the classic apprehension test can be used to
further provoke the patient with glenohumeral joint insta-
bility. These variations use alternative patient positions
and forces applied to the proximal humerus.

Figure 9-1 Apprehension test. (Modified from Hoppenfeld S, About the Tests
Hutton R: Physical examination of the shoulder. In Hoppenfeld S:
Magee (1997) described the apprehension crank test for
Physical examination of the spine and extremities, Norwalk, CT,
1976, Appleton-Century-Crofts.) patients with anterior glenohumeral joint instability. The
test is performed with the patient in the supine position
with 90 degrees of glenohumeral joint abduction. The
Action examiner externally rotates the shoulder slowly, monitor-
The clinician passively brings the patient’s affected arm ing the patient’s expression and muscle guarding. A posi-
into 90 degrees of abduction and full external rotation, tive test is indicated by a look or feeling of apprehension
while slightly horizontally abducting/extending the on the patient’s face. Resistance to further motion and
extremity just posterior to the coronal plane of the patient reporting that the shoulder feels like it did on prior
patient’s body. One of the examiner’s hands is placed just episodes of instability also characterize a positive test.
proximal to the wrist on the distal aspect of the patient’s The Rowe test (Rowe, 1988) for anterior instability is
involved extremity, and the other hand is placed on the also performed with the patient in the supine position.
posterior aspect of the humerus (see Figure 9-1). If the The patient places a hand behind the head, such that the
patient’s initial movement is well tolerated, pressure may glenohumeral joint is placed in abduction and external
then be applied to the posterior aspect of the shoulder, rotation. The examiner places one hand (clenched fist)
pushing the humeral head in an anterior direction to fur- under the proximal aspect of the posterior humeral head
ther provoke the patient’s extremity (Davies et al, 1981). and pushes gently in an anterior direction, while the
examiner’s other hand flexes the shoulder via a downward-
What Constitutes a Positive Test? directed force at the patient’s elbow (Figure 9-2). A look
The apprehension test does not actually measure the of apprehension or reproduction of the patient’s pain is
translation of the head of the humerus in any way. It uses considered a positive indicator for anterior glenohumeral
solely the position of instability (90 degrees of gleno- joint instability.
humeral abduction with external rotation) as a provoca-
tion to induce apprehension by the patient. The patient’s Objective Evidence Regarding These Tests
response is the only criterion evaluated during this No formal research has been reported on any of the
maneuver. The test is similar to the patellar apprehension apprehension tests for diagnosing glenohumeral joint
test, which is used to diagnose dislocation of the patella instability.
(Hoppenfeld, 1976).
Humeral Head Translation Tests
Ramifications of a Positive Test
A positive apprehension test indicates anterior gleno- Introduction
humeral instability and informs the clinician that the The most important tests that identify shoulder joint
patient cannot tolerate this position because of a lack of instability are humeral head translation tests (McFarland
stability in the glenohumeral articulation. This test can be et al, 1996a, 1996b; Gerber & Ganz, 1984). These tests
Ch09.qxd 5/24/04 5:50 PM Page 64

64 SECTION II Special Tests

(dominant/nondominant). Mean anterior humeral head

translation was 8.0 mm, with mean posterior translation
of 6.0 mm. Although a wide variation existed in anterior
and posterior humeral head translation in this study, most
subjects had less than 10 mm of anterior or posterior
translation.
Results of these studies (Harryman et al, 1992; Borsa
et al, 1996) support the theory reported by Speer (1995),
that a wide spectrum of laxity with a normal distribution
exists among healthy shoulders.
By using an ultrasonic measurement technique, Krarup
et al (1999) documented anterior humeral head transla-
tion bilaterally in asymptomatic subjects and patients
diagnosed with anterior glenohumeral joint instability.
Bilateral differences of only 1.9 mm in healthy shoulders
and 4.9 mm in unstable shoulders were reliably docu-
Figure 9-2 Rowe test for anterior instability. mented with patients in a seated position. Ellenbecker et
al (2000a) used a stress radiography technique to measure
anterior humeral head translation in asymptomatic,
healthy professional baseball pitchers (Figure 9-3). The
attempt to document the amount of movement of the glenohumeral joint was assessed with 90 degrees of
humeral head relative to the glenoid through the use of glenohumeral joint abduction in both neutral rotation
carefully applied directional stresses to the proximal and 60 degrees of external rotation. No significant differ-
humerus. ence in anterior humeral head translation was reliably
Harryman et al (1992) measured the amount of measured between extremities in either position of
humeral head translation in vivo in healthy, uninjured humeral rotation.
subjects using a three-dimensional spatial tracking These studies have identified relative symmetry
system. This device was pinned percutaneously to the between paired extremities (dominant/nondominant)
humerus and scapula of eight normal subjects. They found in both normal subjects and overhead athletes. Both
a mean of 7.8 mm of anterior translation and 7.9 mm Harryman et al (1992) and Borsa et al (1999) reported
of posterior translation using an anterior and posterior similar values for average anterior and posterior humeral
drawer test (see pages 74–78). Translation of the human head translation between 6 and 8 mm. These objective
shoulder in an inferior direction was evaluated using a studies can guide the clinician during the use of manual
multidirectional instability (MDI) sulcus test (see pages humeral head translation tests.
68–70 for description of this test). During the in vivo test-
ing of inferior humeral head translation, an average of Grading Anteroposterior Humeral Head Translation
10 mm of inferior displacement was measured. Results During Manual Clinical Tests
from this detailed laboratory-based research study indi- Before discussing the specific humeral head translation
cate that approximately a 1 : 1 ratio of anterior to poste- tests used in the clinical examination, it is imperative to
rior humeral head translation can be expected in normal review the grading methods that can be used to interpret
shoulders with manual humeral head translation tests. the results of these tests. Assessment of glenohumeral
The research did not provide a definitive interpretation of joint mobility during the clinical examination includes
bilateral symmetry in humeral head translation. both physiologic and accessory range of motion. Physio-
In vivo assessment of human glenohumeral joint trans- logic mobility assessment is typically performed using
lation was also reported by Borsa et al (1999), in normal both active and passive range of motion measurement,
healthy shoulders using a laboratory-based, instrumented quantified with a goniometer or other clinically applicable
arthrometer. Results of their testing, which examined the recording system (see Active and Passive Range of
shoulder in 20 degrees of scapular plane elevation and Motion). Physiologic movements of the glenohumeral
neutral rotation (a position similar to that used during joint include those motions that are under the patient’s
clinical testing with the load and shift test [pages 71–74]) control (Gould, 1985). Examples of these movements
showed no significant difference between extremities include flexion/extension, abduction/adduction, and
Ch09.qxd 5/24/04 5:50 PM Page 65

CHAPTER 9 Glenohumeral Joint Instability Testing 65

Figure 9-3 Shoulder stress radiography procedure with the shoulder in A, neutral rotation, and B, 60 degrees of
external rotation. (Adapted from Ellenbecker TS, et al: Anterior translation of the humeral head in the throwing shoulder,
Am J Sports Med 28(2):163, 2000, with permission.)

internal/external rotation. Accessory mobility testing For anterior/posterior tests of humeral head transla-
involves measuring the movements that are not under the tion, grade 0 translation denotes no translation, grade I
control of the patient. These motions include anterior, translation represents mild translation (0 to 1 cm) up the
posterior, and inferior gliding, also known as humeral head glenoid face, and grade II represents moderate translation
translation. It is these accessory movements of the human of 1 to 2 cm up to the glenoid rim. Grade III transla-
shoulder that are tested and graded to facilitate a determi- tion is termed severe translation and consists of anterior or
nation of the underlying accessory mobility status. posterior translation greater than 2 cm and over the
Grading humeral head translation has been reported glenoid rim.
using primarily three systems. These systems use mea- The American Shoulder Elbow Surgeons guidelines
surement in millimeters of translation (Harryman et al, for grading inferior translation include grade 0 (no trans-
1990; Richards et al, 1994), relationship of translation to lation); grade I, mild translation (0 to 1 cm); grade II,
the glenoid rim (Altchek & Dines, 1993), and percentage moderate translation (1 to 2 cm); and grade III, severe
of humeral head translated across the glenoid (Hawkins & inferior translation (>2 cm).
Mohtadi, 1991). Some authors believe that estimating humeral head
translation in millimeters is inexact and problematic
American Shoulder Elbow Surgeons Grading System (McFarland et al, 1996a). No study has examined the
Guidelines established by the American Shoulder Elbow intraobserver and interobserver error and reliability using
Surgeons (Richards et al, 1994) use techniques to grade or this technique. The technique is most applicable when
provide an estimation of the amount of humeral head using laboratory-based methods of measuring humeral
translation. Specific guidelines have been established for head excursion such as stress radiography and instru-
anterior/posterior translation testing, as well as inferior mented arthrometers (Ellenbecker et al, 2000a; Ellen-
humeral head translation testing. becker et al, 2002a; Borsa et al, 1999).
Ch09.qxd 5/24/04 5:50 PM Page 66

66 SECTION II Special Tests

Table 9-2 Altchek Humeral Head Translation

Grading System
Glenohumeral Joint
Grade Translation
I Humeral head rides up the glenoid
slope but not over the glenoid rim
II Humeral head rides up and over the
glenoid rim but spontaneously
reduces when stress is removed
III Humeral head rides up and over the
glenoid rim and remains dislocated
on removal of stress

Figure 9-5 Grade II humeral head translation using the Altchek

classification. (From Altchek DW, Warren RF, Wickiewicz TL, et al:
Arthroscopic labral debridement: a three-year follow-up study,
Am J Sports Med 20(6):703, 1992.)

Figure 9-4 Grade I humeral head translation using the Altchek

classification. (From Altchek DW, Warren RF, Wickiewicz TL, et al:
Arthroscopic labral debridement: a three-year follow-up study,
Am J Sports Med 20(6):703, 1992.)

Altchek Humeral Head Translation Grading Method

(Author’s Preferred Method) Figure 9-6 Grade III humeral head translation using the Altchek
Altchek et al (1992) proposed a system for grading classification. (From Altchek DW, Warren RF, Wickiewicz TL, et al:
Arthroscopic labral debridement: a three-year follow-up study,
anterior and posterior humeral head translation during Am J Sports Med 20(6):703, 1992.)
examination under anesthesia. This system has been
widely used and adapted for clinical interpretation of
humeral head translation tests (Ellenbecker et al, 2002a)
and grades humeral head translation relative to the Objective Testing of Altchek Grading System
glenoid. Table 9-2 and Figures 9-4 through 9-6 outline Ellenbecker et al (2002a) studied the intrarater and inter-
the characteristics of each of the three grades outlined in rater reliability of the Altchek grading system for anterior
Altchek’s grading system. humeral head translation in human subjects. Fifteen
In addition to the three grades of humeral head trans- asymptomatic subjects with varying degrees of anterior
lation listed in Table 9-2, a plus (+) sign can also be used glenohumeral joint laxity were clinically tested using ante-
to designate a softer, more compliant end feel during test- rior humeral head translation tests by two orthopedic sur-
ing and can allow the clinician to further describe humer- geons, three physical therapists, and two nonorthopedic
al head translation (Ellenbecker et al, 2002a). End feel has physicians. Subjects’ identities were shielded from the
been defined as the feeling transmitted to the examiner’s examiners to prevent bias during testing and retesting the
hands at the extreme range of passive motion (Cyriax & subjects. Examiners were asked to perform the anterior
Cyriax, 1983) (see End Feels). humeral head translation test with 90 degrees of gleno-
Ch09.qxd 5/24/04 5:50 PM Page 67

CHAPTER 9 Glenohumeral Joint Instability Testing 67

humeral joint abduction and to grade the tests using the

Altchek grading system, using the addition of a (+) to des-
ignate end feel. Examiners had four possible humeral 25%-50%
head translation conditions (I, I+, II, and II+) during A
bilateral testing and retesting of the 15 subjects. Statisti-
cal analysis included the use of a kappa coefficient and
coefficient of agreement for the translation conditions,
including end feel, and were 0.342 and 54%, respectively,
increasing to 0.529 and 81.4%, respectively, when statisti-
cal analyses were conducted using only the distinction >50%
between grades I and II with no reference to end feel.
B
Results of this study do not support the use of the addi-
tional mobility designation for end feel during anterior
humeral head translation tests because of the low kappa
coefficient and coefficient of agreement.
Interrater reliability with all four possible grades (I, I+,
II, II+) resulted in a coefficient of agreement of 37.3% and
kappa coefficient of 0.091. When end feel was not con-
sidered, the coefficient of agreement increased to 70.4%,
with a kappa coefficient of 0.208. Results of this study
indicate that both intrarater and interrater reliability of a C
manual anterior humeral head translation test is improved
when only the relationship of the humeral head to the gle-
noid rim is considered. The addition of an end feel desig-
nation to the Altchek grading system results in a decrease
in reliability both within and among examiners.
Levy et al (1999) conducted a test-retest reliability Figure 9-7 Hawkins’ humeral head translation grading system.
A, Grade I. The humeral head is translated in an anterior or pos-
study of anterior and posterior humeral head translation
terior position up to 50% of the humeral head diameter. B, Grade
tests, as well as the MDI sulcus sign. Asymptomatic II. The humeral head is translated greater than 50% of the humer-
NCAA division I athletes served as subjects and were al head diameter. C, Grade III. The humeral head is dislocated
tested initially and again after 3 months. Humeral head beyond the confines of the glenoid fossa. (From Hawkins RJ,
translation was graded from 0 to 3+ by four physicians. Mohtadi NG: Clinical evaluation of shoulder instability, Clin J
Sports Med 1(1):62, 1991.)
With the four possible grading conditions (0 [trace], 1+,
2+, and 3+) overall intraobserver reproducibility was 46%,
with interobserver reliability of 47%. Improved intraob-
server and interobserver reliability was reported when
grades 0 and 1+ were combined. These results are similar feeling of the humeral head riding up the glenoid face to
to the improved reliability coefficients reported by the glenoid rim is designated as grade I translation and is
Ellenbecker et al (2002a) with the elimination of the (+) typically estimated from 25% to 50% of the humeral head
designation for end feel. diameter (Figure 9-7, A). A feeling of the humeral head
riding over the glenoid rim, but spontaneously reducing
Additional Grading Systems to Interpret Anterior and with release of the stress, is grade II translation and is esti-
Posterior Humeral Head Translation mated as greater than 50% translation (Figure 9-7, B). A
Hawkins and Mohtadi (1991) and Hawkins et al (1996) feeling of the humeral head riding over the glenoid rim,
proposed an alternative method to communicate the but on release remaining dislocated, is designated grade
amount of humeral head translation during manual clini- III translation and is considered a dislocation (Figure 9-7,
cal tests. This method also grades the movement of the C). This grading system is traditionally applied for
humeral head relative to the glenoid but it uses an estima- anterior and posterior translation only. No study has
tion of the percent width of the humeral head diameter. A examined the intraobserver and interobserver error and
mild amount of humeral head translation is considered reliability of this estimation method to describe humeral
normal (approximately <25% humeral head diameter). A head translation.
Ch09.qxd 5/24/04 5:50 PM Page 68

68 SECTION II Special Tests

Objective Quantification of Optimal Force Application load as compared with 60 N. The authors concluded
during Clinical Translation Tests that when evaluating the integrity of the anterior talo-
Borsa et al (2001) measured the loads required to obtain a fibular ligament in cases of acute ankle injury, a low-
capsular end point in vivo using an instrumented device. magnitude load should be used to identify increases in
The directions of anterior, posterior, and inferior humeral translation.
head translation were studied in asymptomatic subjects in This research did not provide conclusive guidance with
a seated position with the arm in adduction. Loads rang- regard to the amount of load to use during examination of
ing between 40 and 45 pounds were required to obtain the patient with shoulder instability. Further research is
capsular end points, with significantly more force required needed to better define the exact magnitudes of load
to obtain the anterior capsular end point as compared needed to identify glenohumeral joint instability without
with the inferior direction. Borsa et al (2001) found mean necessarily taking the humeral head to the capsular limit
translations using the instrumented arthrometer of 14.5, using the high forces reported in the literature. Obtaining
14, and 13.9 mm for anterior, posterior, and inferior trans- the maximum translation with the lowest magnitude of
lations, respectively. The objective finding of directional force is desired to attempt to overcome the patient’s pro-
symmetry is in agreement with other authors and sup- tective response that is often elicited with larger loads.
ports the circle concept of glenohumeral joint stability It is important to follow the specific guidelines contained
(Borsa et al, 2001; Harryman et al, 1992; Sauers et al, in this text regarding hand placements and give careful
2001a, 2001b). attention to the amount of force and grasp placed on the
Application of forces of this magnitude to the shoulder extremity to accurately assess and interpret glenohumeral
in patients with glenohumeral joint pathology may not be joint translation.
clinically feasible. Further research has involved using
smaller amounts of force application during translation MDI Sulcus Sign (Neutral)
testing. McQuade et al (1999) reported that a minimum The MDI sulcus sign is also known as the sulcus test and
of 100 newtons (22.4 pounds) was required to reach cap- the inferior humeral head translation test.
sular end points using an electromagnetic tracking system
to quantify anterior and posterior translations. Borsa et al Indication
(1999, 2000) and Sauers et al (2001a,b) used displacement This test is used to diagnose multidirectional instability of
forces ranging from 0 to 134 newtons (30 pounds) and the glenohumeral joint.
reported that most nonimpaired shoulders demonstrated
force-displacement curves that were still on the rise using About the Test
the 30-pound force for anterior and posterior humeral This test is the primary method to identify the patient
head translation. with MDI of the glenohumeral joint. Excessive transla-
Comparing results of this research to clinical transla- tion in the inferior direction during this test most often
tion testing in other joints provides perspective when indicates a forthcoming pattern of excessive translation
performing glenohumeral translation tests. The KT-1000 in either the anterior or posterior direction or both.
(Medmetric Corp., San Diego CA), a clinical device to When performed in the neutral adducted position, the
test knee ligament laxity, uses anterior forces of 10, 20, test directly assesses the integrity of the superior gleno-
and 30 pounds. In addition the clinician attempts to humeral ligament and the coracohumeral ligament
translate the tibia anteriorly relative to the femur using (Pagnani & Warren, 1994). These ligaments are the pri-
their maximal anterior manual force to clinically evaluate mary stabilizing structures against inferior humeral head
and measure knee ligament laxity in vivo. Tohyama et al translation in the adducted glenohumeral position
(2003) reported the magnitude required to measure ante- (O’Brien et al, 1990).
rior laxity in the human ankle after injury to the anterior
talofibular ligament. In the cadaveric portion of the Start Position
research, the authors found greater anterior translation The patient should be examined in the seated position,
after sectioning of the anterior talofibular ligament at 10, with the arms in neutral adduction, resting gently in the
20, 30, and 40 newtons (N) of anterior load. This transla- patient’s lap. The elbows are flexed 60 to 90 degrees, with
tion or displacement was significantly greater than the the forearms in a neutral position. This position is used to
displacement measured with 60 N of anterior force. In foster greater muscular relaxation and to place the shoul-
vivo examination in the subjects with ankle injury pro- der in the position of maximal inferior excursion. Helmig
duced greater anterior displacement with 30 N of anterior et al (1990) reported that maximal inferior excursion of
Ch09.qxd 5/24/04 5:50 PM Page 69

CHAPTER 9 Glenohumeral Joint Instability Testing 69

the glenohumeral joint occurs in 20 degrees of abduction tethering of the skin between the lateral acromion and
and slight internal rotation. The test can be performed humerus from the increase in inferior translation of the
with the patient in a standing position; however, control humeral head and widening subacromial space in patients
over the exact position of the shoulder is limited, and with MDI.
increased muscle guarding can be encountered with test- Mallon & Speer (1995) recommended grading the sul-
ing in this position (McFarland et al, 1996a). In one cus sign as grade I, less than 1 cm of inferior translation;
modification of this test reported by Rowe (1988), the grade II, 1.0 to 1.5 cm of inferior translation; and grade
patient is in a standing position, with 45 degrees of trunk III, 1.5 cm of translation. No formal reliability research is
flexion, which places the shoulder in a flexed position. available using this grading system for inferior translation.
This modified version has been called the Rowe multidi-
rectional instability test (Magee, 1997). Ramifications of a Positive Test
A positive test indicates that the patient has increased
Action physiologic laxity of the glenohumeral joint capsule and
The examiner grasps the distal aspect of the humerus will possess increased humeral head translation in addi-
using a firm but unassuming grip with one hand, while tional directions during clinical testing and functional use
placing the thumb and index finger on the anterior and or activities. Increases in inferior humeral head translation
posterior lateral corners of the acromion for reference in the symptomatic glenohumeral joint have been identi-
(Figure 9-8). Several brief, relatively rapid downward fied in patients diagnosed with multidirectional gleno-
pulls are exerted to the humerus in an inferior (vertical) humeral joint instability (Hawkins et al, 1996; Warner et
direction. al, 1990).
The MDI test should be the initial examination in the
What Constitutes a Positive Test? clinical evaluation to identify the presence of increased
A visible sulcus sign is usually present in patients with physiologic laxity. If the test is positive, the clinician
MDI (Hawkins & Mohtadi, 1991). Figure 9-9 shows a should expect greater translation of the humeral head
patient with a positive sulcus sign as demonstrated by during anteroposterior translation tests and other instabil-

Figure 9-8 MDI sulcus test.

Ch09.qxd 5/24/04 5:50 PM Page 70

70 SECTION II Special Tests

found to have grade III translation in any direction,

including inferior humeral head translation using an MDI
sulcus sign. Also, humeral head translation up to II+ was
found in asymptomatic athletes, with as much as 32% of
the asymptomatic athletes tested having a bilateral differ-
ence in humeral head translation of up to one grade.
Emery and Mullaji (1991) tested 75 British school-
children with no history of shoulder pathology; 11% had
positive sulcus signs and 26% had asymmetric laxity with
respect to bilateral comparison. In another study evaluat-
ing 356 high school and college athletes without a
history of shoulder symptoms, McFarland et al (1991)
reported a grade II sulcus sign in 52%, with 5% of the
asymptomatic athletes having a grade III sulcus sign.
Bigliani et al (1997) measured glenohumeral joint
range of motion and laxity in 148 asymptomatic profes-
sional baseball players; 61% (44 of 72) of the pitchers and
47% (36 of 76) of the position players had a positive
sulcus sign on their dominant arm. Of the players with
positive sulcus signs, 89% of the pitchers and 100%
of the position players had bilateral signs.
These studies provide important descriptive informa-
tion for the interpretation of manual humeral head
Figure 9-9 Positive MDI sulcus sign in a patient’s left shoulder. translation tests. Unilateral increases in humeral head
translation alone, without symptoms, do not necessarily
indicate instability. Instability by definition is the exces-
ity tests performed during a thorough evaluation process. sive symptomatic, unwanted translation of the humeral
Extensive rehabilitation is indicated for patients with pos- head that leads to decrements in shoulder function
itive MDI sulcus signs to improve the dynamic stabilizers (McFarland et al, 1996a). No additional objective research
of the glenohumeral joint to compensate for the increased on the validity of this test has been reported.
capsular mobility identified with this clinical test.
MDI Sulcus Sign (90 Degrees Abduction)
Objective Evidence Regarding the Test This test is also known as the Feagin test (Rockwood,
Tzannes and Murrell (2002) found the sulcus sign to have 1984).
a specificity of 97% for MDI when the sulcus is estimated
manually at 2 cm or more. At this level, the sensitivity is Indication
relatively poor (28%) (Tzannes & Murrell, 2002). Thus, The MDI sulcus sign in 90 degrees of abduction is used
using the criterion of 2 cm or more of inferior translation to identify MDI of the shoulder in the functional position
during the sulcus test to indicate MDI, 72% of patients of 90 degrees of glenohumeral joint abduction.
would not be diagnosed if only this test were performed.
Using a criterion of MDI of a sulcus sign greater than 1 About the Test
cm, Tzannes and Murrell (2002) reported a sensitivity of This clinical maneuver tests the integrity of the inferior
72% and specificity of 85%. A much greater sensitivity glenohumeral ligament complex and is used in combina-
using this criterion was reported, but, as often occurs, the tion with the traditional MDI sulcus sign to provide a
specificity decreased from 97% to 85%. Tzannes and Mur- complete assessment of inferior stability of the gleno-
rell (2002) also reported substantial interobserver error humeral joint.
using the sulcus sign with intraclass correlation coefficient
values of 0.66 between experienced examiners. Start Position
Lintner et al (1996) tested 76 asymptomatic division I The test is typically performed with the patient in a
athletes using anterior, posterior, and inferior humeral seated position, but it can also be done with the patient
head translation tests. During testing, no athlete was standing, with particular care taken to prevent compensa-
Ch09.qxd 5/24/04 5:50 PM Page 71

CHAPTER 9 Glenohumeral Joint Instability Testing 71

sulcus sign in neutral adduction. This recommended grad-

ing system, as described by Mallon and Speer (1995), is as
follows: grade I, less than 1 cm of inferior translation;
grade II, 1.0 to 1.5 cm of inferior translation; and grade
III, greater than 1.5 cm of translation. A visible sulcus
sign is less prominent and often visible only when sub-
stantial inferior translation is present. The MDI test at 90
degrees of abduction requires greater use of estimation
and actually feeling the amount of movement by the
examiner’s hands than the MDI sulcus sign in neutral
adduction, which includes the added visual cue of the
tethering response in the skin at the lateral border of the
acromion.

Ramifications of a Positive Test

A positive MDI sulcus sign indicates increased physio-
logic laxity of the glenohumeral joint capsule. The spe-
cific portion of the capsule being tested is the inferior
glenohumeral ligament complex because of its role in pro-
viding inferior stability for the humeral head in 90 degrees
of glenohumeral joint abduction (O’Brien et al, 1990).
Increases in inferior translation identified using the MDI
Figure 9-10 MDI sulcus test performed with 90 degrees of sulcus test at 90 degrees of abduction should also alert the
glenohumeral joint abduction. examiner to the likely increase in anterior and posterior
translation that will be encountered during anterior and
tions from adjoining segments. The examiner sits or posterior humeral head translation tests. Attenuation of
stands next to the patient on the involved side of the the inferior glenohumeral ligament complex has serious
shoulder to be tested. The glenohumeral joint is abducted consequences for glenohumeral joint function at 90
90 degrees in the coronal plane in neutral rotation (Figure degrees of abduction (O’Brien et al, 1990).
9-10). The patient’s elbow can be placed over the examin-
er’s shoulder to provide stability during testing and to Objective Evidence Regarding the Test
allow both hands of the examiner to be free to directly No research is available for the MDI sulcus test at 90
perform the next action. degrees of glenohumeral joint abduction.

Action Load and Shift Test

The examiner’s hands are placed such that the fingers are This test is also known as the push-pull test.
interlocked together, with the ulnar side of the fifth digits
placed just lateral to the acromion over the proximal Indication
humerus (see Figure 9-10). The examiner then exerts a The load and shift test is used to assess anteroposterior
downward (vertical) force with the glenohumeral joint in humeral head translation.
90 degrees of coronal plane abduction. The examiner feels
the amount of translation inferiorly and compares that About the Test
amount with the contralateral extremity. This test measures anterior and posterior humeral head
excursion with the glenohumeral joint in a neutral
What Constitutes a Positive Test? adducted position. In this position the anterior capsule,
A positive test includes increased inferior humeral head specifically the superior glenohumeral joint ligament, is
translation in a symptomatic shoulder, a hallmark sign of stressed with anterior humeral head excursion, and the
multidirectional glenohumeral joint instability (Hawkins posterior capsule is stressed with posterior humeral head
et al, 1996). The inferior excursion of the humeral head translation (Pagnani & Warren, 1994). The test is done
relative to the glenoid is estimated using grading guide- with the patient in a seated position, which may be advan-
lines similar to those proposed for the traditional MDI tageous in clinical situations where performing humeral
Ch09.qxd 5/24/04 5:50 PM Page 72

72 SECTION II Special Tests

Figure 9-11 Load and shift test. Clinical testing technique depicting underlying shoulder anatomic struc-
tures. (From Hawkins RJ, Mohtadi NG: Clinical evaluation of shoulder instability, Clin J Sports Med 1(1):63,
1991.)

head translation tests in the supine position is nonoptimal forearm (flexor surface) can provide further stabilization
because of transfers or secondary orthopedic and/or gen- to the scapula. The examiner’s right hand grasps the
eral medical complications. Only an adducted gleno- humerus just distal to the humeral head (Figure 9-11). A
humeral joint position can be used because of this seated wide enough grip must be used to contain the humerus
position. and not simply the deltoid and overlying skin, which is a
common error when the test is done by inexperienced
Starting Position examiners.
The patient is examined in a seated position, such that the
examiner can either stand or sit directly to the side of the Action
shoulder being examined. Care should be taken to use an With hands placed on the patient’s scapula and humerus,
upright, erect posture during examination of both extrem- a gentle direct load is placed medially by the hand on the
ities, as Kebaetse et al (1999) reported changes in scapu- proximal humerus, approximating the humeral head into
lar and glenohumeral kinematics with altered thoracic the glenoid. This maneuver centers the humeral head into
postures. The patient’s hands can be placed in the lap to the glenoid and provides a neutral, “centered” starting
promote muscular relaxation and bilaterally symmetric position; this is the “load” portion of the load and shift
glenohumeral positions. To test the right shoulder, the test. After gently providing the load, the examiner
examiner’s left hand is placed over the patient’s shoulder attempts to translate the humeral head in an anteromedial
such that the index, second, and third fingers can palpate direction, using the thumb posteriorly as the primary
and rest against the coracoid process and clavicle to stabi- point of pressure. It is extremely important to note that
lize the scapula. The thumb is placed over the posterior the direction of force applied by the examiner to produce
lateral aspect of the acromion and oriented nearly hori- translation should be parallel along the line of the glenoid
zontally along the spine of the scapula. Flexion of the fossa (Figure 9-12). This anteromedial direction of trans-
examiner’s wrist is recommended, so that the examiner’s lation displaces the humeral head within the glenoid and
Ch09.qxd 5/24/04 5:50 PM Page 73

CHAPTER 9 Glenohumeral Joint Instability Testing 73

Left What Constitutes a Positive Test?

A unilateral increase in humeral head translation in the
direction of either anterior or posterior or in both direc-
Direction of tions in the symptomatic shoulder leads to the diagnosis
force application of either anterior or posterior instability, based on the
direction of increased humeral head translation relative to
the contralateral, asymptomatic extremity (Hawkins et al,
1996). A unilateral increase in anterior, posterior, or both
Back Front anterior and posterior, coupled with increased inferior
translation during the MDI sulcus test (see pages 68–70)
indicates the presence of MDI in the patient’s involved
glenohumeral joint (Hawkins et al, 1996).

Ramifications of a Positive Test

A positive load and shift test indicates capsular insuffi-
Right
ciency of the superior capsular structures because of the
adducted position inherent in this test. Unidirectional
Figure 9-12 Load and shift test overhead view with arrow increases in anterior humeral head translation are indica-
showing direction of translation along the lines of the tive of injury to the superior glenohumeral ligament
glenohumeral joint for both anterior and posterior humeral head
(SGHL) (Pagnani & Warren, 1994) and lead to the diag-
translation.
nosis of unidirectional anterior glenohumeral joint insta-
bility. Identification of increased anterior humeral head
translation requires the use of rehabilitative exercise to
enhance the dynamic stabilization of the posterior rotator
cuff in order to attenuate anterior humeral head transla-
is oriented at approximately 30 degrees relative to the tion and strain on the anterior capsular structures (Cain
sagittal plane of the body. Performing translation in the et al, 1987). A positive load and shift test in the poste-
sagittal plane in a straight plane anteriorly and posterior- rior direction indicates posterior capsular redundancy
ly results in nonoptimal translation and compression of and leads to the diagnosis of unidirectional posterior
the humeral head into the posterior glenoid during the instability.
posterior part of this test.
The examiner notes the amount of translation, using Objective Evidence Regarding the Test
the criterion reported by Altchek and Dines (1993). Instrumented laxity testing of the glenohumeral joint,
Translation within the glenoid without traversing the performed by Borsa et al (1999) using the load and shift
glenoid rim is considered grade I translation; translation test, resulted in humeral head translations of 8.0 mm for
up over the glenoid rim with spontaneous reduction on anterior translation and 6.0 mm for posterior translation.
removal of the anteromedial load is considered grade II. Manual laxity tests are thought to be performed with
After the anteromedial translation is assessed, a poste- approximately 67 to 89 N of force. Borsa et al (1999) used
rior lateral direction of translation is performed along the similar loads in their instrumented study of normal
line of the joint (Figure 9-11, posterior arrow). Similar to subjects to produce these translation values. They showed
the anterior portion of this test, the posterior direction of slightly greater anterior humeral head translation with the
translation is actually posterolateral, following the line load and shift test position than posterior humeral head
of the glenoid fossa. Careful monitoring of the direction translation. This is in slight contrast to values also
of translation ensures optimal amounts of translation with measured in vivo by Harryman et al (1990), who found
the applied force. Posterior translation is graded using essentially the same amount of anterior humeral head
identical criteria as outlined for anterior translation. translation as posterior humeral head translation in
Anteromedial and posterolateral translation is typically normal healthy volunteers.
repeated to optimally assess the amount of humeral head Hawkins et al (1996) tested normal subjects, patients
translation. This relatively rapid succession of the antero- diagnosed with anterior glenohumeral joint instability,
posterior translations has led many clinicians to refer to and patients with MDI, with all subjects under general
this test as the push-pull test. anesthesia, using the load and shift tests to measure ante-
Ch09.qxd 5/24/04 5:50 PM Page 74

74 SECTION II Special Tests

Table 9-3 Humeral Head Translation of Normal and Unstable Shoulders

Subject Type Anterior Posterior Inferior
Normal 17% 26% 29%
Anterior instability 29% 21% 40%
Multidirectional instability 28% 52% 46%

Values expressed as percentage of the width of humeral head translated over the glenoid, with 100% being complete dislocation and 0% being no
humeral head translation.
From Hawkins RJ, Schulte JP, Janda DH, et al: Translation of the glenohumeral joint with the patient under anesthesia, J Shoulder Elbow Surg
5:286-292, 1996.

rior and posterior humeral head translation, as well as the Anterior Drawer Test
sulcus sign for inferior translation. They used an estima-
tion of the percent width of the humeral head that could Indication
be translated out of the glenoid to report humeral head The anterior drawer test is a primary test to measure
translation. Results of their research are summarized in anterior humeral head translation in multiple positions of
Table 9-3. glenohumeral joint abduction.
Normal subjects had slightly greater posterior than
anterior humeral head translation with the load and shift About the Test
test. Patients with the diagnosis of anterior glenohumeral Gerber and Ganz (1984) and McFarland et al (1996a)
joint instability had greater anterior translation than con- believe testing for anterior and posterior shoulder laxity is
trol or normal subjects (almost twice as much), with less best performed with the patient in the supine position
posterior translation. Patients diagnosed with MDI had because of greater inherent relaxation of the patient. This
increased anterior, posterior, and inferior translation of the test allows the patient’s extremity to be tested in multiple
humeral head compared with control subjects, and positions of glenohumeral joint abduction, thus selectively
increased posterior and inferior humeral head translation stressing specific portions of the glenohumeral joint ante-
than the subjects with anterior instability. This study rior capsule and capsular ligaments. All three portions of
showed how these manual humeral head translation tests the glenohumeral joint capsular ligament complex (supe-
can be used to quantify and classify patients into diagnos- rior, middle, and inferior glenohumeral ligaments) can be
tic categories such as normal, unidirectional, and multi- assessed using this test.
directional instability.
Lintner et al (1996) used manual anterior, posterior, Start Position
and inferior humeral head translation tests and found that The patient is tested in a supine position. The examiner’s
laxity of up to grade II (Altchek classification) can be left hand is placed on the inside of the patient’s left elbow
expected in any direction in normal healthy shoulders of (to assess the left shoulder of a patient), while grasping
NCAA division I athletes. The authors reported asym- circumferentially just above the antecubital fossa. The
metric humeral head translation in 32% of the athletes hand grasping the patient’s elbow is responsible for main-
tested, including those from overhead sports. These taining the position of the scapular plane (30 degrees
findings help the examiner interpret clinical findings of anterior to the coronal or frontal plane) while testing all
anterior and posterior humeral head translation tests. ranges of abduction. A position of neutral rotation is rec-
Unilateral increases in translation by one grade (Altchek ommended for all anterior drawer tests to allow the ante-
classification), as well as translations of up to grade rior capsule to consistently be measured in a resting
II, can be expected in normal healthy subjects. Translation position. Examination of the glenohumeral joint in varied
in an extremity without symptoms or functional loss is positions of humeral rotation can decrease anterior
not considered a positive finding for glenohumeral joint humeral head translation (Ellenbecker et al, 2001).
instability. The examiner’s right hand is placed just distal to the
Tzannes and Murrell (2002) reported the validity of patient’s left humeral head. The actions listed next should
the load and shift test for anterior and posterior direc- be repeated in three positions of glenohumeral joint
tions. They found 50% sensitivity and 100% specificity for abduction to selectively assess the three glenohumeral
the anterior direction, and 14% sensitivity and 100% joint capsular ligaments. Ranges of abduction used in
specificity for the posterior direction. No additional speci- testing as start positions are 0 to 30 degrees, 45 to 60
ficity and sensitivity information is available. degrees, and 90 degrees.
Ch09.qxd 5/24/04 5:50 PM Page 75

CHAPTER 9 Glenohumeral Joint Instability Testing 75

Figure 9-14 Anterior drawer test at 30 degrees of glenohumer-

al joint abduction using alternative stabilized hand position.

An alternative hand placement and translation strategy

Figure 9-13 Anterior drawer test at 30 degrees of glenohu- can be used for clinicians who wish to minimize the
meral joint abduction. movement and contribution of the shoulder girdle during
the anterior loading phase of this test. Figure 9-14 shows
alternative hand placements that can be used to decrease
shoulder girdle movement. This technique requires the
examiner to support the patient’s extremity under the
upper arm and side to allow both hands to be free. To test
Action the left upper extremity of a patient, the patient’s arm
With the glenohumeral joint in the scapular plane, and in should be placed under the examiner’s left arm. The
the abduction range between 0 and 30 degrees, the exam- examiner’s left hand grasps just distal to the humeral head
iner’s right hand (left shoulder being tested) pushes in an from the medial side of the patient arm (axilla), and the
anteromedial direction, translating the humeral head examiner’s right hand is placed so that the thumb can
along the face of the glenoid fossa (Figure 9-13). The exert a downward restraining force on the coracoid
examiner then removes the stress from the humerus and process of the scapula being tested. The fingers of the sup-
allows the humeral head to return to the resting position. porting hand wrap up over the top of the shoulder to lend
The translation encountered during testing can be graded greater stabilization. Translation of the proximal humerus
using the systems described on pages 66–67. I recommend is performed in an identical direction and with identical
the use of the Altchek grading system (Altchek et al, force used during the unstabilized testing method
1992), with grade I translation being used to describe described previously.
translation of the humeral head within the glenoid, and Translation is repeated in an anteromedial direction
grade II describing translation of the humeral head up with the glenohumeral joint now placed in 45 to 60
over the glenoid rim, with immediate relocation of the degrees of abduction (Figure 9-15). Finally, a third series
head on release of the anteromedial stress. of loads in an anteromedial direction is transmitted with
During the anteromedial loading of the humeral head, the glenohumeral joint abducted 90 degrees (Figure 9-
some shoulder girdle anterior motion will occur simulta- 16). The clinician grades the movement of the humeral
neously. Differentiating shoulder girdle movement from head in all three positions of abduction and compares the
true glenohumeral joint translation can be difficult in translations with the contralateral extremity.
inexperienced examiners and requires practice. Use of a
fairly rapid and vigorous anteromedial translation force What Constitutes a Positive Test?
can help minimize movement of the shoulder as a unit Unilateral increases in anterior humeral head translation
and attempts to accelerate the humeral head ahead of the in the symptomatic glenohumeral joint indicate anterior
glenoid to produce translation. glenohumeral joint instability. Movement of the humeral
Ch09.qxd 5/24/04 5:50 PM Page 76

76 SECTION II Special Tests

anterior direction with the shoulder between 0 and

30 degrees of abduction indicates laxity or injury to
the superior glenohumeral ligament. Increased humeral
head translation in an anterior direction, with the
shoulder between 45 and 60 degrees of abduction,
indicates laxity or injury to the middle glenohumeral
ligament. Increased humeral head translation with
90 degrees of glenohumeral joint abduction indicates
laxity or pathology to the inferior glenohumeral ligament
complex. Labral injury, such as detachment of the
anterior inferior portion (Bankart lesion) or superior
portion (superior labrum anterior posterior [SLAP]
lesion), can also lead to selective increases in anterior
humeral head translation with this test (Pagnani &
Warren, 1994).

Objective Evidence Regarding the Test

Ellenbecker et al (2002a) studied the intrarater and inter-
rater reliability of the anterior drawer test in healthy, unin-
Figure 9-15 Anterior drawer test at 45 to 60 degrees of gleno- jured subjects. Using the Altchek system of grading
humeral joint abduction. humeral head translation, examiners produced coefficients
of agreement of 81.4% when distinguishing between
grade I and grade II translation between sessions. This
measure of intrarater test-retest reliability decreased to
54% when examiners were asked to further differentiate
and identify patients with loose compliant end feels with-
in each of the two Altchek humeral head translation
grades (four possible choices: grades I, I+, II, II+). This
lower, unacceptable level of reliability among experienced
examiners reinforces the recommendation of using the
Altchek grading system, recording mainly the relationship
of the humeral head to the glenoid rim. Ellenbecker et al
(2002a) used the 90-degree abducted position of testing
in the scapular plane; however, similar challenges with
respect to test-retest accuracy would be expected in the
other positions of abduction inherent in the anterior
drawer test.
Ellenbecker et al (2000b) tested professional baseball
Figure 9-16 Anterior drawer test at 90 degrees of glenohumer- pitchers using a technique of anterior humeral head
al joint abduction.
translation at 90 degrees of abduction with stress radi-
ography. No unilateral difference was noted using
head may be accompanied by a click, apprehension, or radiographs of humeral head translation between the
both (Magee, 1997). The click may indicate a labral tear dominant and nondominant extremity. Clinical ramifica-
or, most likely, translation of the humeral head over the tions of this research lie in the interpretation of clinical
glenoid rim (Magee, 1997). humeral head translation tests in athletes from this
population. Unilateral increases in anterior humeral
Ramifications of a Positive Test head translation in the symptomatic glenohumeral joint
The use of three positions of glenohumeral joint abduc- are indicative of abnormal static capsular stability and
tion can better isolate specific portions of the gleno- hence lead to the diagnosis of anterior glenohumeral joint
humeral capsule. Increased humeral head translation in an instability.
Ch09.qxd 5/24/04 5:50 PM Page 77

CHAPTER 9 Glenohumeral Joint Instability Testing 77

Posterior Drawer Test

Indication
The posterior drawer test is used to assess posterior
humeral head translation.

About the Test

This test is similar to the anterior drawer test; the supine
position is used to enhance patient relaxation and varied
positions of glenohumeral joint abduction are used. This
test stresses the posterior capsule and, when applied in 90
degrees of abduction, the posterior band of the inferior
glenohumeral ligament complex (Pagnani & Warren,
1994).

Start Position
The patient lies in the supine position. The examiner Figure 9-17 Posterior drawer test at 90 degrees of gleno-
humeral joint abduction. Arrow shows posterior lateral direction
grasps the patient’s elbow circumferentially just proximal of translation.
to the antecubital fossa with the left hand (for testing the
left shoulder of a patient). The humerus is controlled
primarily by the distal hand and should be placed in the
scapular plane by raising the elbow approximately 30
degrees anterior to the supportive surface on which the
patient is lying (30 degrees anterior to the coronal plane)
(Saha, 1983). The glenohumeral joint is abducted during
the performance of this test, unlike the testing position of
glenohumeral joint adduction used during the assessment
of posterior humeral head translation in the load and
shift test. Some authors recommend testing in 45 degrees
of abduction (McFarland et al, 1996a) or in 90 degrees of
glenohumeral joint abduction to place selective stress on
the posterior band of the inferior glenohumeral ligament
complex (Gerber & Ganz, 1984). The examiner’s proxi-
mal hand (right hand for examination of patient’s left
shoulder) is placed just distal to the humeral head center, Figure 9-18 Alternative posterior drawer hand placement used
with the thumb placed anteriorly and fingers wrapped to increase surface area of contact on the anterior aspect of the
posteriorly around the proximal humerus (Figure 9-17). proximal humerus.
An alternative technique (Figure 9-18) involves a crossed-
hand technique that allows the examiner to place the firm translations in the posterolateral direction are used.
entire heel and palmar surface of the proximal hand over Alternative hand placements to further stabilize the
the proximal humerus to increase the surface area of con- scapula are not necessary with the posterior drawer test
tact with the patient and minimize sensitivity with the because the supporting surface on which the patient is
posteriorly directed pressure on the anterior structures lying provides stabilization against posterior scapular
such as the biceps tendon. Pain elicited during testing will movement with the posterior lateral loading by the
significantly affect the resultant translation during the examiner.
test. In some accounts of this test (Magee, 1997), the exam-
iner’s distal hand moves in an anterior and medial direc-
Action tion, while the proximal hand pushes the humeral head in
From the starting position, the examiner presses the the posterior lateral direction. This creates a “pistoning”
humeral head in a posterior and lateral direction along the effect and may further provoke the humeral head in a
line of the joint (see Figure 9-17). Several rather rapid, posterior direction during testing.
Ch09.qxd 5/24/04 5:50 PM Page 78

78 SECTION II Special Tests

What Constitutes a Positive Test? functional loss, does not constitute glenohumeral joint
A positive posterior drawer test identifies unilateral instability.
increases in posterior humeral head translation in a symp-
tomatic shoulder. During testing, the examiner carefully Posterior Glide—90 Degrees Flexion Test
perceives the amount of translation of the humeral head in Indication
a posterior direction and records the grade of movement
This test assesses the integrity of the posterior capsule
accordingly. According to the grading system proposed by
with the shoulder in an elevated position and posterior
Altchek and Dines (1993), posterior translation within
capsule in a more elongated or tensed position.
the glenoid is graded as grade I. Grade II translation
entails movement of the humeral head posteriorly up over About the Test
the posterior glenoid rim, with spontaneous reduction on This test is a modification of the test described by Gerber
removal of the posterior lateral force. and Ganz (1984) and uses an elevated position of 90
Ramifications of a Positive Test degrees of shoulder flexion. It provides the examiner with
an alternative position to examine posterior shoulder sta-
A positive posterior drawer test indicates increased laxity
bility that approximates the position of many athletic and
or pathology in the posterior capsule of the glenohumeral
industrial shoulder stresses such as the posterior pressure
joint. Unlike the specific ligamentous structures found in
imparted to the glenohumeral joint during blocking in
the anterior capsule of the glenohumeral joint, the poste-
football and during an anteriorly directed fall. This test is
rior capsule is devoid of specific thickenings or ligamen-
similar in position and technique to the Norwood stress
tous structures other than the posterior band of the
test for posterior instability (Norwood & Terry, 1984).
inferior glenohumeral ligament (Pagnani & Warren,
1994). A positive posterior drawer test in isolation indi- Start Position
cates unidirectional posterior glenohumeral joint instabil- The patient lies in a supine position and the shoulder is
ity. A positive drawer test coupled with a positive MDI flexed 90 degrees in the sagittal plane. The examiner’s left
sulcus test indicates the presence of MDI (Neer & Foster, hand (left shoulder examination) is placed at the elbow so
1980). that the olecranon process is centered in the palm of the
examiner’s hand. The examiner’s right hand is placed
Objective Evidence Regarding the Test
behind the patient’s shoulder so that some fingers of the
Levy et al (1999) tested 43 asymptomatic division I hand are placed on the lateral aspect of the scapula for
collegiate athletes using the posterior drawer test. reference and some fingers are placed on the posterior
Intraobserver reproducibility was 52% for the posterior aspect of the humeral head (Figure 9-19).
drawer and 73% for the anterior drawer. Significantly
greater difficulty was encountered by four experienced Action
surgeons performing and interpreting the translation The examiner exerts an axial compressive force through
obtained during the posterior drawer test, as compared the humerus in a posterior and lateral direction using the
with the anterior drawer. Care must be used when per- hand placed at the elbow. The humerus can be brought
forming and interpreting translation during this test. Use into slight horizontal adduction beyond neutral, which
of this method with a posterior lateral direction of trans- further tightens the posterior capsule but allows the
lation is recommended to ensure that translation follows examiner to place the axially compressed load in a poste-
the angulation of the glenoid so as to prevent compression rior and lateral direction rather than a straight posterior
of the glenohumeral joint surfaces when a force is direct- direction (see Figure 9-19). The examiner’s other hand
ed in a straight sagittal posterior plane. palpates and monitors the movement of the humeral head
McFarland et al (1991) tested 356 shoulders in high relative to the scapular reference.
school and college athletes with no history of shoulder
pathology; 55% of the athletes had grade II translation What Constitutes a Positive Test?
using the Hawkins percent humeral head width transla- A positive test occurs when pain, apprehension, and often
tion grading system. This finding is consistent with the feeling of a click occur as the humeral head is pushed
anterior humeral head translation findings reported over the rim of the posterior glenoid. Replication of the
by Ellenbecker et al (2002a) and Lintner et al (1996), patient’s reported episodes of instability or “slipping” also
who found that the presence of increased humeral head indicates posterior glenohumeral joint instability (Davies
translation alone, without the presence of symptoms or & DeCarlo, 1995).
Ch09.qxd 5/24/04 5:50 PM Page 79

CHAPTER 9 Glenohumeral Joint Instability Testing 79

Figure 9-20 Subluxation relocation test (Start). Place the patient

supine with the arm off the table at 90 degrees of abduction and
external rotation. The examiner gently pushes anteriorly as his fin-
gers grasp the humeral head. No anterior subluxation or appre-
hension should be evident. Apprehension denotes a previous
dislocation. Pain indicates anterior subluxation. (Adapted from
Figure 9-19 Posterior glide with 90 degrees glenohumeral joint Jobe FW, Bradley JP: The diagnosis and nonoperative treatment
flexion and slight horizontal adduction. of shoulder injuries in athletes, Clin Sports Med 8(3):427, 1989,
with permission.)

Ramifications of a Positive Test About the Test

Posterior movement of the humeral head indicates Originally described by Jobe and Bradley (1989), the
substantial capsular or capsulolabral injury because the subluxation/relocation test is designed to identify subtle
posterior capsule in the position of testing (flexion, slight anterior instability of the glenohumeral joint. Credit for
internal rotation, and horizontal adduction) should the development and application of this test is also given
be tensed or tightened, making it able to resist posterior to Dr. Peter Fowler (Speer et al, 1994a), who described the
translation of the humeral head. Excessive posterior move- diagnostic quandary of microinstability (subtle anterior
ment by the humeral head or reproduction of the patient’s instability) versus rotator cuff injury or both in swimmers.
apprehension or subluxation in this position also leads the Fowler also advocated the use of this important test to
examiner to the diagnosis of posterior instability. assist in the diagnosis. This test has been advocated to dif-
ferentiate between occult and subtle anterior instability
Objective Evidence Regarding the Test
(Speer et al, 1994a). The subluxation/relocation test uses
There is no objective evidence with regard to this test. the position where most patients have symptoms of
Pain Provocation Tests anterior instability (abduction and external rotation).
Glenohumeral joint instability tests inherently assess three
Start Position
primary aspects: apprehension, humeral head translation,
and provocation or replication of the patient’s pain The patient is positioned supine on a plinth with 90
response. This final group of tests uses positions of stress to degrees of abduction of the glenohumeral joint and 90
induce humeral head translation to provoke the pain that degrees of external rotation. The examiner stands at the
patients have primarily with overhead activities such as patient’s side, facing the patient’s head (Figure 9-20). To
sport-specific movement patterns or repetitive industrial test the right shoulder, the examiner places the left hand
positions. on the patient’s right elbow to maintain the position of
abduction and external rotation. The examiner’s right
Subluxation/Relocation Test hand is placed on the proximal aspect of the humerus,
near the level of the humeral head. As a landmark, the
Indication posterior lateral corner of the acromion can easily be pal-
The subluxation/relocation test is used to identify subtle pated, with hand placement being just distal to the poste-
anterior glenohumeral joint instability and detect poste- rior lateral corner of the acromion. Placement of the right
rior impingement. hand over the posterior lateral corner of the acromion, or
Ch09.qxd 5/24/04 5:50 PM Page 80

80 SECTION II Special Tests

diminution or disappearance of anterior or posterior

shoulder pain with the relocation maneuver, constitutes a
positive test.

Ramifications of a Positive Test

A positive subluxation/relocation test detects subtle ante-
rior glenohumeral joint instability. Positive replication of
anterior-based symptoms are most likely caused by con-
tact of the rotator cuff superior or bursal surface on the
undersurface of the anterior acromion (Figure 9-22).
Pressure on the anterior capsule of the glenohumeral joint
and bicep long-head tendon could also be a source of pain
( Jobe & Bradley, 1989). Morgan et al (1998) reported that
a positive subluxation/relocation test can be used to iden-
Figure 9-21 Subluxation relocation test (End). After the exam- tify a posterior-based type II SLAP lesion.
iner pushes the humeral head anteriorly and demonstrates ante- Development of significant apprehension with this test
rior pain, the humeral head should be pushed posteriorly.
Immediate relief of pain is considered a positive test. (Adapted
indicates occult anterior instability and should be differ-
from Jobe FW, Bradley JP: The diagnosis and nonoperative treat- entiated from the pain provoking responses, which indi-
ment of shoulder injuries in athletes, Clin Sports Med 8(3):427, cate milder or more subtle forms of instability.
1989, with permission.) A positive subluxation relocation test provoking
posterior shoulder pain indicates posterior or internal
impingement. This relatively new concept involves
proximal to it, results in inappropriate subluxation because impingement of the undersurface or articular side of the
the hand is over the scapular portion of the glenohumeral supraspinatus tendon against the posterosuperior glenoid
joint, not the humeral head. (Figure 9-23). As the humeral head is translated ante-
riorly, contact against the posterosuperior glenoid is
Action increased. Halbrecht et al (1999) confirmed via magnetic
With proper right hand placement mentioned previously, resonance imaging, performed in the position of 90
the examiner gently subluxes the humeral head anteriorly, degrees of abduction and 90 degrees of external rotation,
while maintaining the position of abduction and 90 contact of the undersurface of the supraspinatus tendon
degrees of external rotation (see Figure 9-20). During this against the posterosuperior glenoid in baseball pitchers
maneuver, the examiner asks the patient if the mild sub- with arm placed in 90 degrees of external rotation and 90
luxation movement re-creates the patient’s symptoms degrees of abduction (the same initial position used in the
anteriorly or posteriorly. subluxation/relocation test). Ten collegiate baseball pitch-
If no pain is encountered during this portion of the ers were examined and, in all ten, physical contact was
test, see the Modified Subluxation/Relocation Test (page encountered in this position.
82). If pain or symptom replication occurs, the examiner
reverses the right hand placement from behind or under
Effectiveness of the Subluxation/Relocation Test
the humeral head to a position on top of the humeral head
(Figure 9-21). With a soft, cupped hand position to Speer et al (1994a) tested the diagnostic value of the sub-
minimize discomfort from the hand interface on the ante- luxation/relocation test as it was originally described by
rior aspect of the shoulder, force is applied in a posterior Jobe and Bradley (1989) and Fowler (Speer, 1994a). They
direction. The posterior force should be directed both tested 100 patients undergoing shoulder surgery, using the
posteriorly and slightly laterally, with the examiner realiz- subluxation relocation test, and assessed patient response
ing that the face of the glenoid is anteverted 30 degrees to the 90/90 position alone. During testing, specific atten-
relative to the frontal or coronal plane (Saha, 1983). The tion was given to whether the patient reported replication
patient is then asked, “Does this decrease the pain in your of shoulder pain or a response of apprehension or slipping
shoulder?” of the shoulder.
Speer et al (1994a) found that 63 of 100 patients had
What Constitutes a Positive Test? pain with the 90/90 position alone, with the number
Reproduction of anterior or posterior shoulder pain with reporting pain increasing to 74 of 100 when the anterior
the subluxation portion of this test, with subsequent subluxation force was applied. Of the patients with pain
Ch09.qxd 5/24/04 5:50 PM Page 81

CHAPTER 9 Glenohumeral Joint Instability Testing 81

Impingement Anterior subluxation

External
rotation

Posterior Posterior humeral head lesion

labral erosion
Anterior labral tear

Figure 9-22 Anatomic diagram showing secondary impingement. (Adapted from Jobe FW, Bradley JP: The diagnosis and nonopera-
tive treatment of shoulder injuries in athletes, Clin Sports Med 8(3):430, 1989, with permission.)

anterior instability) was 45%, increasing to 100% when

apprehension was used as the primary criterion. The
negative predictive value (NPV) of the test, which indi-
cated the percentage of patients with negative subluxation
relocation tests and those who did not have anterior
instability, was 53%. This value increased to 78% for
apprehension.
Results indicate lower specificity and sensitivity, as well
as lower positive and negative predictive values, when pain
was used as the diagnostic feature of the test with 90
degrees of glenohumeral joint abduction and 90 degrees of
external rotation. Some improvement was noted in the
diagnostic value of the test when apprehension was used
Figure 9-23 Anatomic diagram showing undersurface or inter-
nal impingement. (Adapted from Walch G, et al: Impingement of as the distinguishing diagnostic feature. Also, the anterior
the deep surface of the synospinatus tendon on the posterior subluxation force should be used as a provocation, as both
superior glenoid rim, J Shoulder Elbow Surg 1(5):243, 1992, with Fowler and Jobe and Bradley (1989) have recommended,
permission.) as higher specificity, sensitivity, and both PPVs and NPVs
are reported when the anterior force is used in the diag-
provocation with the 90/90 position, 59% experienced nostic sequence. Speer et al (1994a) concluded that the
diminished pain when the relocation force was applied. test as originally described by Jobe and Bradley (1989)
Patients with pain with anterior loading reported a may have limited effectiveness. Speer et al (1994a) also
diminution of pain and symptoms 73% of the time. suggested a modification of the subluxation/relocation
Sensitivity of the relocation test reveals the percentage test, with increased amounts of external rotation (as much
of patients with anterior instability who also had a posi- as end range external rotation for each patient) in the 90-
tive subluxation relocation test. The sensitivity of the test degree abducted position. No other research investiga-
for reproduction of pain with anterior force and diminu- tions are currently available (see Modified Subluxation/
tion of pain with relocation was 54%. Test sensitivity for Relocation Test).
apprehension was 68%. Finally, the Jobe subluxation/relocation test has been
Specificity of the relocation test revealed the percent- used to identify labral pathology. Guanche and Jones
age of patients who had neither anterior instability nor a (2003) tested 60 shoulders in 59 patients before patients
positive subluxation relocation test. Specificity of the test underwent arthroscopic surgery. Sensitivity and specifi-
using pain reproduction as a criterion was 44% for the city values were 44% and 87%, respectively, for the detec-
subluxation relocation test, and specificity using appre- tion of any labral lesion (PPV = 91%, NPV = 34%), and
hension as the primary criterion was 100%. This test’s 36% and 63% sensitivity and specificity, respectively, for
PPV (percentage of patients who had a positive test and the identification of SLAP lesions (PPV = 55%, NPV =
Ch09.qxd 5/24/04 5:50 PM Page 82

82 SECTION II Special Tests

45%). Morgan et al (1998) reported the Jobe subluxation

relocation test as the primary test used to identify type II
posterior SLAP lesions (see pages 115–116). Multiple
indications of this test can create confusion regarding the
diagnostic interpretation of a positive Jobe subluxation
relocation test; however, when this test is used in combi-
nation with other instability and labral tests, it can be
extremely valuable, particularly in the overhead athlete or
individual who functions in the 90/90 position.

Modified Subluxation/Relocation Test

120°
Indication
A modification of the subluxation/relocation test using 110°
altered positions of abduction and external rotation to
90°
assess subtle anterior glenohumeral joint instability and
posterior or internal impingement, particularly in the
overhead athlete or industrial patient. Figure 9-24 Modified subluxation relocation test showing
About the Test range of glenohumeral joint abduction used during testing.
(Adapted from Hamner DL, Pink MM, Jobe FW: A modification of
Based on the report by Speer et al (1994a), demonstrating the relocation test: arthroscopic findings associated with a posi-
limited effectiveness and accuracy of the originally de- tive test, J Shoulder Elbow Surg 9(4):264, 2000, with permission.)
scribed subluxation relocation test, this modification uses
greater amounts of external rotation and abduction to fur-
ther provoke patients who primarily have pain in this phase
of overhead motion (abduction with external rotation).
Start Position
The starting position for this test is nearly identical to the
original subluxation/relocation test described previously.
Modifications in this test are that testing now occurs in
the patient’s passive end range of external rotation and at
varying positions of glenohumeral joint abduction (Figure
9-24). For many high-level baseball and tennis players
(Ellenbecker, 1992; Ellenbecker et al, 2002a), this entails
often greater than 100 degrees of external rotation (Figure
9-25).
Action
With the patient’s shoulder held and stabilized in the end
range of external rotation at 90 degrees of abduction,
anterior subluxation is introduced as described for the Figure 9-25 Modified subluxation relocation test. Note the use
original subluxation/relocation test (see Figure 9-25). The of greater than 90 degrees of external rotation and use of sub-
patient is again asked if this subluxation reproduces the luxation and relocation forces (arrows). (Adapted from Hamner
DL, Pink MM, Jobe FW: A modification of the relocation test:
patient’s symptoms. Reproduction of patient symptoms of arthroscopic findings associated with a positive test, J Shoulder
either anterior or posterior shoulder pain with subluxation Elbow Surg 9(4):264, 2000, with permission.)
leads the examiner to reposition a hand on the anterior
aspect of the patient’s shoulder and perform a postero- range external rotation and 90 degrees of abduction leads
lateral directed force using a soft, cupped hand to mini- the examiner to reattempt the subluxation maneuver with
mize anterior shoulder pain from the hand/shoulder 110 and 120 degrees of abduction (see Figure 9-24). This
(examiner/patient) interface. modification has been proposed by Hamner et al (2000)
Failure to reproduce the patient’s symptoms with end to increase the potential for contact between the under-
Ch09.qxd 5/24/04 5:50 PM Page 83

CHAPTER 9 Glenohumeral Joint Instability Testing 83

surface of the supraspinatus tendon and the posterior patients at 90 degrees of abduction, 69% of patients in 110
superior glenoid. In each position of abduction (90, 110, degrees of abduction, and 100% of patients with 120
and 120 degrees of abduction), the same sequence of ini- degrees of abduction. No attempt was made to report
tial subluxation and subsequent relocation is performed as specificity, sensitivity, or predictive value because no con-
previously described. trol group was studied. No further research is available
using this test.
What Constitutes a Positive Test? Paley et al (2000) evaluated the dominant shoulder of
Reproduction of anterior or posterior shoulder pain with 41 professional throwing athletes. With the arthroscope
the subluxation portion of this test, with subsequent inserted in the glenohumeral joint, all 41 shoulders had
diminution or disappearance of anterior or posterior posterior undersurface impingement between the rotator
shoulder pain with the relocation maneuver, constitutes a cuff and posterior superior glenoid. In these athletes, 93%
positive test. Production of apprehension with any position had undersurface fraying of the rotator cuff tendons and
of abduction during the anteriorly directed subluxation 88% showed fraying of the posterosuperior glenoid. These
force phase of testing indicates occult anterior instability. findings help to explain the type of lesions/pathology
found in the dominant glenohumeral joint of overhead
Ramifications of a Positive Test athletes and aid in the explanation of the mechanism of
Ramifications of a positive test are the same as described pain provocation during specific tests such as the sublux-
for the traditional subluxation relocation test. The modi- ation relocation test described here.
fied test has been advocated as a diagnostic tool in the
treatment of shoulder pain in young overhand throwing Anterior Release Test
athletes. In a normal shoulder, the position of arm
cocking during throwing occurs in the scapular plane; Indication
however, if there has been stretching of the anterior The anterior release test was developed to physically diag-
capsular structures, the humerus may be hyperabducted or nose occult anterior shoulder instability.
hyperangulated (Davidson et al, 1995) into the coronal
plane (see Chapter 17). As this process of hyperangulation About the Test
continues and anterior humeral head translation occurs This test was originally described by Gross and Distefano
with external rotation of the humerus, the rotator cuff (1997) and is a modification of the basic apprehension
impinges on the posterosuperior labrum. This creates test. It uses the position of most frequent complaints of
undersurface rotator cuff tears and posterosuperior labral glenohumeral joint instability (90 degrees of abduction
fraying (Hamner et al, 2000). with external rotation) to provoke/reproduce shoulder
pain and apprehension.
Objective Evidence Regarding the Test
Hamner et al (2000) performed research using the modi- Start Position
fied subluxation relocation test in 13 overhand-throwing The patient is examined in a supine position with the
athletes who failed 3 months of traditional physical ther- involved shoulder hanging just slightly off the edge of
apy and were still unable to perform overhand throwing. the plinth or supporting surface. The patient’s arm is
The shoulder was evaluated arthroscopically during the abducted 90 degrees. One hand of the examiner holds the
subluxation relocation test at 90, 110, and 120 degrees of patient’s involved extremity near the elbow (at the balance
glenohumeral joint abduction. At 90 degrees of abduc- point) (see page 6 for description).
tion, 8 of 13 patients had physical contact between the
undersurface of the rotator cuff and the posterosuperior Action
glenoid; at 110 degrees of abduction, all 13 patients had The examiner’s other hand is placed over the anterior
contact between the undersurface of the rotator cuff and portion of the humeral head, using a soft, cupped
the posterosuperior glenoid; and at 120 degrees of abduc- hand-patient interface to minimize discomfort from the
tion, 12 of 13 patients had similar contact. Six of 13 posterior pressure itself. Keeping the posterior pressure
patients had a positive modified subluxation relocation maintained through the humeral head, the examiner
test in all three positions of glenohumeral joint abduction. externally rotates the shoulder to the extreme end range of
In the study by Hamner et al (2000), posterior external rotation motion (Figure 9-26, A). As soon as the
impingement of the rotator cuff was associated with a end range of external rotation is achieved, the humeral
positive modified subluxation relocation test in 63% of head is released (Figure 9-26, B).
Ch09.qxd 5/24/04 5:50 PM Page 84

84 SECTION II Special Tests

A B

Figure 9-26 Anterior release test. A, The humeral head is held in a reduced position while the arm is abducted and
brought into maximal external rotation. B, Anterior release test drawing showing the release of the humeral head
while the external rotation position is maintained. (Adapted from Gross ML, Distefano MC: Anterior release test. A
new test for occult shoulder instability, Clin Orthop 339:106, 1997, with permission.)

What Constitutes a Positive Test? reproduction of pain often indicates underlying insta-
The test result is considered positive when the patient bility of the glenohumeral joint. It also recognizes that
experiences a sudden pain on release of the posteriorly patients who do not have apprehension with the 90-
directed stress on the humeral head, notes a distinct degree abducted externally rotated position may indeed
increase in pain, or states that symptoms have been have instability as an underlying cause of their shoulder
reproduced. dysfunction (Gross & Distefano, 1997).

Ramifications of a Positive Test Objective Evidence Regarding the Test

Reproduction of pain with the anterior release test identi- Gross and Distefano (1997) performed the anterior
fies instability as playing a role in the patient’s pain and release test before induction of anesthesia in 82 patients
functional limitation. Rowe and Zarins (1981) initially scheduled to undergo shoulder surgery. The anterior
described occult anterior instability in patients who had release test was positive in 39 patients and negative in 43.
a positive apprehension test that reproduced both pain There were five false-positive and three false-negative
and apprehension with the 90-degree abducted, externally results, produced a sensitivity of 91.9% and a specificity
rotated position. Rowe and Zarins (1981) stated that, in of 88.9%. The PPV was 87.1% and the NPV was 93%.
the absence of a positive apprehension test, the examiner One of the most significant findings was that in 12 of 14
should suspect some other cause of shoulder disability. patients with occult subluxation, the anterior release test
The anterior release test was designed to assist in the correctly identified the instability. No other research has
evaluation of patients with instability and recognizes that been published using the anterior release test.
Ch10.qxd 5/24/04 4:43 PM Page 85

CHAP TER
Glenohumeral Joint (Rotator
10 Cuff ) Impingement

INTRODUCTION structures (Fleisig et al, 1995). These data provide scien-

Before an accurate diagnosis of impingement can be tific rationale for the concept of primary impingement
made, baseline knowledge of both the types of gleno- or compressive disease as an etiology of rotator cuff
humeral joint impingement and the underlying pathology.
mechanism behind impingement must be under-
stood. Significant advancement in the anatomy and bio- NEER’S STAGES OF IMPINGEMENT
mechanics of the shoulder has led to identification of Neer (1972, 1983) outlined three stages of primary
numerous types of impingement with several underlying impingement as it relates to rotator cuff pathology. Stage
pathomechanical causes. I, edema and hemorrhage, results from the mechanical irri-
tation of the tendon from the impingement incurred with
PRIMARY IMPINGEMENT OR overhead activity. Stage I is characteristically observed in
COMPRESSIVE DISEASE younger patients who are more athletic and is described as
Primary impingement, also known as compressive disease or a reversible condition with conservative physical therapy.
outlet impingement, is a direct result of compression of the Primary symptoms and physical signs are similar to the
rotator cuff tendons between the humeral head and the other two stages—a positive impingement sign, painful
overlying anterior third of the acromion, coracoacromial arc of movement, and varying degrees of muscular weak-
ligament, coracoid, or acromioclavicular joint (Neer, 1972, ness (Neer, 1983). The second stage of compressive
1983). The physiologic space between the inferior disease is termed fibrosis and tendonitis. This stage occurs
acromion and superior surface of the rotator cuff tendons from repeated episodes of mechanical inflammation and
is termed the subacromial space. It has been measured to be can include thickening or fibrosis of the subacromial
7 to 13 mm using anteroposterior radiographs in patients bursae. The typical age range for this stage of injury is 25
with shoulder pain (Golding, 1962) and 6 to 14 mm in to 40 years. Neer’s stage III impingement lesion is termed
normal shoulders (Cotton & Rideout, 1964). bone spurs and tendon rupture, and is the result of contin-
Biomechanical analysis of the shoulder has produced ued mechanical compression of the rotator cuff tendons.
theoretical estimates of the compressive forces against the Full-thickness tears of the rotator cuff, partial-thickness
acromion with elevation of the shoulder. Poppen and tears of the rotator cuff, biceps tendon lesions, and bony
Walker (1978) calculated this force at 0.42 times body alteration of the acromion and acromioclavicular joint
weight. Lucas (1973) estimated this force at 10.2 times may be associated with this stage (Neer 1972, 1983).
the weight of the arm. Peak forces against the acromion In addition to bony alterations that are acquired with
were measured in a range of motion between 85 and 136 repetitive stress to the shoulder, the native shape of the
degrees of elevation (Wuelker et al, 1994). This position acromion is of relevance.
is functionally important for activities of daily living, is The specific shape of the overlying acromion process is
inherent in sport-specific movement patterns (Fleisig et termed acromial architecture and has been studied in rela-
al, 1995; Elliott et al, 1986), and is commonly noted in tion to full-thickness tears of the rotator cuff (Bigliani
ergonomic activities. The position of the shoulder in for- et al, 1991; Zuckerman et al, 1992). Bigliani et al (1991)
ward flexion, horizontal adduction, and internal rotation described three types of acromions: type I (flat), type II
during the acceleration and follow-through phases of (curved), and type III (hooked). A type III or hooked
the throwing motion is likely to produce subacromial acromion was found in 70% of cadaveric shoulders with a
impingement as a result of abrasion of the supraspinatus, full-thickness rotator cuff tear, and type I acromions were
infraspinatus, or biceps tendon against the overlying associated with only 3% (Bigliani et al, 1991). Also, in a

85
Ch10.qxd 5/24/04 4:43 PM Page 86

86 SECTION II Special Tests

series of 200 clinically evaluated patients, 80% with a pos- posterior or undersurface impingement is the articular
itive arthrogram confirming a full-thickness rotator cuff side of the rotator cuff tendon. Traditional impingement
tear had a Type III acromion (Zuckerman et al, 1992). involves the superior or bursal surface of the rotator cuff
tendon or tendons. Individuals presenting with posterior
SECONDARY IMPINGEMENT shoulder pain brought on by positioning of the arm in 90
Impingement or compressive symptoms may be second- degrees of abduction and 90 degrees or more of external
ary to underlying instability of the glenohumeral joint rotation, typically from overhead positions in sport or
( Jobe & Kivitne, 1989; Andrews & Alexander, 1995). industrial situations, may be considered as potential can-
Although this concept is relatively common knowledge didates for undersurface impingement.
today, it was not well understood or recognized in the The presence of anterior translation of the humeral
medical community even through the late 1980s. The head with maximal external rotation and 90 degrees of
concept that impingement could occur secondary to abduction, which has been confirmed by arthroscopy dur-
instability, rather than as a primary cause, has had ing the subluxation/relocation test, can produce mechani-
significant ramifications, altering evaluation methods cal rubbing and fraying on the undersurface of the rotator
and treatment/rehabilitation (Wilk & Arrigo, 1993; cuff tendons. Additional harm can be caused by the pos-
Ellenbecker, 1995). terior deltoid if the rotator cuff is not functioning pro-
Attenuation of the static stabilizers of the glenohumer- perly. The posterior deltoid’s angle of pull compresses the
al joint, such as the capsular ligaments and labrum from humeral head against the glenoid, accentuating the skele-
the excessive demands incurred in throwing or overhead tal, tendinous, and labral lesions ( Jobe & Pink, 1994).
activities, can lead to anterior instability of the gleno- Walch et al (1992) performed arthroscopic evaluation on
humeral joint. Because of the increased humeral head 17 throwing athletes with shoulder pain during throwing
translation, the biceps tendon and rotator cuff can become and found undersurface impingement that resulted in 8
impinged secondary to the ensuing instability ( Jobe & partial-thickness rotator cuff tears and 12 lesions in the
Kivitne, 1989; Andrews & Alexander, 1995). A progres- posterosuperior labrum. Impingement of the undersurface
sive loss of glenohumeral joint stability is created when of the rotator cuff on the posterosuperior glenoid labrum
the dynamic stabilizing functions of the rotator cuff are may be a cause of painful structural disease in the over-
diminished from fatigue and tendon injury (Andrews & head athlete.
Alexander, 1995; Nirschl, 1988b). The effects of second- With the use of magnetic resonance imaging,
ary impingement can lead to rotator cuff tears as the Halbrecht et al (1999) confirmed contact of the under-
instability and impingement continue ( Jobe & Kivitne, surface of the supraspinatus tendon against the postero-
1989; Andrews & Alexander, 1995). superior glenoid in 10 of 10 college baseball pitchers with
arms placed in 90 degrees of external rotation and 90
POSTERIOR, INTERNAL, OR degrees of abduction. Paley et al (2000) found, on arthro-
“UNDERSURFACE” IMPINGEMENT scopic evaluation of the glenohumeral joint, that 41 of
An additional type of impingement more recently dis- 41 dominant shoulders of professional throwing athletes
cussed as an etiology for rotator cuff pathology that can had posterior undersurface impingement between the
often progress to an undersurface tear of the rotator cuff rotator cuff and posterior superior glenoid. In these
in the young athletic shoulder is termed posterior, internal athletes, 93% had undersurface fraying of the rotator cuff
(or inside), or undersurface impingement ( Jobe & Pink, tendons and 88% showed fraying of the posterosuperior
1994; Walch et al, 1992). This phenomenon was origin- glenoid.
ally identified by Walch during shoulder arthroscopy, with
the shoulder placed in the 90/90 position. This shoulder ANTERIOR INTERNAL IMPINGEMENT
placement causes the supraspinatus and infraspinatus ten- Anterior internal impingement has recently been
dons to rotate posteriorly. This more posterior orientation described as a source of pain in patients with a stable
aligns the tendons such that the undersurface of the ten- shoulder and positive traditional impingement signs.
dons rub on the posterosuperior glenoid lip and become Struhl (2002) reported this phenomenon during arthro-
pinched or compressed between the humeral head and scopic evaluation of patients who had clinical signs of
the posterosuperior glenoid rim (Walch et al, 1992). In traditional outlet impingement and anterior pain. Direct
contrast to the position involved in patients with tradi- visualization during arthroscopy revealed undersurface
tional outlet impingement (either primary or secondary), tears of the rotator cuff resulting from contact between
the area of the rotator cuff tendon that is involved in the anterosuperior labrum and undersurface of the rotator
Ch10.qxd 5/24/04 4:43 PM Page 87

CHAPTER 10 Glenohumeral Joint (Rotator Cuff ) Impingement 87

cuff, similar to that described by Walch et al (1992) in

posterior impingement.
In a series of 10 patients with traditional impingement
signs and anterior-based pain presentations, Struhl (2002)
reported arthroscopic confirmation of contact between
the fragmented undersurface of the rotator cuff tendons
and the anterosuperior labrum during the Hawkins
impingement test (pages 89–90), viewed from a posterior
arthroscopic portal. Understanding this new clinical enti-
ty is essential for both diagnosing and treating patients
with the clinical appearance of outlet impingement and
anterior pain. Jobe hypothesized that shoulder pain seen
in swimmers may be the result of anterior internal
impingement because pain is frequently reported at hand
entry into the water, and, in this position, the humeral
position is similar to that of the Neer and Hawkins tests
(Struhl, 2002).

NEER IMPINGEMENT TEST

This test is also called the forward flexion impingement test.
Figure 10-1 Neer impingement test. (From Jobe FW, Bradley
Indication JP: The diagnosis and nonoperative treatment of shoulder injuries
The Neer impingement test is used to identify impinge- in athletes, Clin Sports Med 8(3):425, 1989.)
ment of the rotator cuff against the coracoacromial arch.

About the Test facing forward as the arm is elevated (Figure 10-1). Place-
Originally described by Neer and Welsh (1977), this ment of the arm in external rotation would theoretically
impingement test places or jams the rotator cuff tendons rotate the greater tuberosity of the humerus away from the
of the forward flexed shoulder against the undersurface of overlying acromion and compromise test results because
the anterior acromion. The test is used to identify primary of a lack or decrease in contact of the acromion with the
glenohumeral joint impingement. greater tuberosity with external humeral rotation (Inman
et al, 1944).
Start Position The arm is moved into end range forward flexion in
The test is typically described (Neer & Welsh, 1977; Neer, the sagittal plane. At end range, several small movements
1972, 1983; Jobe & Kvitne, 1989) with the patient in a into and out of terminal end range forward flexion can be
standing position. The examiner grasps the patient’s performed with careful monitoring of both end feel (see
elbow near the balance point with one hand (see page 6 discussion of end feels of the human shoulder, pages
for discussion of upper extremity balance point), while the 56–57) and patient response.
examiner’s other hand is stabilizing the mid-thoracic
region. This stabilization is important to prevent the What Constitutes a Positive Test?
patient from arching backward as the arm is elevated Reproduction of the patient’s pain in the subacromial
toward end range forward flexion. Using a seated position region with the forward flexed position is indicative of a
for patient examination during this impingement test is positive test.
also indicated and helps to minimize the number of pos-
sible compensations during arm elevation from the trunk Ramifications of a Positive Test
and lower extremity kinetic chain. A positive Neer impingement test indicates rotator cuff
impingement. Irritability of the rotator cuff tendons, most
Action specifically the supraspinatus tendon, leads to reproduc-
The position of the arm to be tested is in slight internal tion of pain with compression of the tendon between the
rotation during elevation, so that the hand is placed in a greater tuberosity and the undersurface of the coracoacro-
position where the ulnar border of the hand or palm is mial arch ( Jobe & Bradley, 1989).
Ch10.qxd 5/24/04 4:43 PM Page 88

88 SECTION II Special Tests

Objective Evidence Regarding the Test Leroux et al (1995) tested the Neer, Hawkins, and
Valadie et al (2000) used cadaveric specimens to anatom- Yocum impingement tests in 55 consecutive patients.
ically study the relationship of the rotator cuff and biceps Sensitivity was satisfactory for all three impingement tests
tendons to the coracoacromial arch during the Neer (78% to 89%); the Neer test’s sensitivity was 89%. Despite
impingement test. Their results showed contact between overall acceptable levels of both sensitivity and specificity
the bursal side of the rotator cuff tendons (see discussion in the literature, it is recommended that several impinge-
of articular versus bursal side rotator cuff tears, page 86) ment tests be used to increase the clinician’s ability to
and the lateral aspect of the tendon in 60% of the speci- identify patients with subacromial impingement.
mens tested, and contact with the medial aspect of the Calis et al (2000) compared the Neer, Hawkins, and
acromion in 100% (Figure 10-2). Also, the biceps long- cross-arm impingement tests in patients with and without
head tendon was located beneath the acromion in 60% of a positive subacromial injection test. They reported 92%
the specimens tested. There was no evidence of impinge- sensitivity and 25% specificity for the Hawkins test, 89%
ment of the rotator cuff tendons against the coracoid. sensitivity and 31% specificity for the Neer impingement
These findings support the use of the Neer impingement test, and 82% sensitivity and 27% specificity for the cross-
test to produce contact between the undersurface of the arm adduction impingement test. These findings are
acromion and the bursal side of the rotator cuff tendons. similar to those reported by Leroux et al (1995) and Bak
Because Valadie et al (2000) reported compression of the and Fauno (1997).
biceps long-head tendon below the acromion in many of Finally, MacDonald et al (2000) assessed the diagnos-
the samples, caution is warranted regarding interpretation tic accuracy of the Neer and Hawkins impingement tests
of this test to involve solely the rotator cuff tendons. for the diagnosis of subacromial bursitis and rotator cuff
Post and Cohen (1986) reported the Neer impinge- pathology. A total of 85 consecutive patients were tested
ment test to have a sensitivity of 93% in the confirmation before and after shoulder arthroscopy. The Neer impinge-
of subacromial impingement. Bak and Fauno (1997) test- ment test had a sensitivity of only 75% for the appearance
ed 36 competitive swimmers and found the Neer suggestive of subacromial bursitis. The Hawkins test (see
impingement test to have no positive results in asympto- later) had a sensitivity of 92%.
matic swimmers. They reported a specificity of 100% and For rotator cuff tearing, the Neer test has a sensitivity
a sensitivity of 39%. of 85%, and the Hawkins test had a comparable sensiti-

Greater tuberosity

Acromion

AC joint

Figure 10-2 MRI showing contact during the Neer impingement test. (From
Valadie AL III et al: Anatomy of provocative tests for impingement syndrome of
the shoulder, J Shoulder Elbow Surg 9(1):40, 2000.)
Ch10.qxd 5/24/04 4:43 PM Page 89

CHAPTER 10 Glenohumeral Joint (Rotator Cuff ) Impingement 89

vity of 88%. The two tests had a high negative predictive

value (NPV) (96% for bursitis, and 90% for rotator cuff
tearing) when combined. Results of this study indicated
that these tests are sensitive for the appearance of sub-
acromial bursitis and both partial and complete rotator
cuff tearing. Both the Neer and Hawkins impingement
tests are used to formulate a more complete clinical eval-
uation for the patient with shoulder pathology.

HAWKINS IMPINGEMENT TEST

This test is also known as the Hawkins-Kennedy impinge-
ment test.

Indication
The Hawkins impingement test is used to test for
impingement of the rotator cuff against the coracoacro-
mial arch.
Figure 10-3 Hawkins impingement test. (From Jobe FW,
Bradley JP: The diagnosis and nonoperative treatment of shoul-
About the Test der injuries in athletes, Clin Sports Med 8(3):426, 1989.)
Originally described by Hawkins and Kennedy (1980),
this test forces the rotator cuff tendons under the cora-
coacromial arch and against the coracoid process to create of movement from the neutral rotation (starting position)
mechanical compression or impingement (Leroux et al, to end range (internal rotation).
1995).
Ramifications of a Positive Test
Start Position A positive Hawkins impingement test indicates irritabili-
The Hawkins impingement test is typically described ty of the rotator cuff tendons as they are encroached on
with 90 degrees of forward flexion in texts; however, the the coracoacromial arch.
photos and line art accompanying this clinical test show
the arm technically in 90 degrees of elevation in the Objective Evidence Regarding the Test
scapular plane (see scapular plane inset, page 6). The test In a cadaveric study, Valadie et al (2000) found contact
shows one examiner’s hand on the patient’s elbow, with between the medial surface of the acromion and the
the other hand placed at the wrist to provide the internal bursal surface of the rotator cuff tendons in 50% of the
rotation overpressure (Figure 10-3). My preferred starting specimens tested, with contact between the rotator cuff
technique is shown in Figure 10-4. One of the examiner’s tendons and biceps and the coracoacromial ligament in
hands is placed just distal to the elbow in the extremity 100% of the specimens (Figure 10-5). The authors also
balance point position (see page 6) to support the found contact in all specimens between the articular sur-
upper extremity with just one hand. The examiner’s other face of the rotator cuff tendons and the anterosuperior
hand is placed on top of the shoulder being tested to glenoid rim. In only one specimen tested, the subscapu-
stabilize the scapular and glenohumeral articulation laris tendon was deformed against the coracoid process.
during the upcoming internal rotation movement. The Contrary to common belief, the Hawkins test did produce
shoulder being tested is placed near neutral rotation (0 contact between the biceps long-head tendon and the
degrees). coracoacromial ligament in 50% of the specimens tested.
Penny and Welsh (1981) reported that internal rotation of
Action the forward flexed shoulder moved the biceps tendon into
Using the hand placements mentioned previously, the a position medial to the coracoacromial arch, making the
patient’s shoulder is internally rotated to end range. Hawkins test more specific for rotator cuff impingement.
The research by Valadie et al (2000) questions the selec-
What Constitutes a Positive Test? tive impingement of the rotator cuff by identifying the
A positive test is characterized by reproduction of the close association between the biceps tendon to the cora-
patient’s anterosuperior pain in the subacromial space, coacromial ligament during the Hawkins impingement
either at end range of internal rotation or along the course maneuver.
Ch10.qxd 5/24/04 4:43 PM Page 90

90 SECTION II Special Tests

A B

Figure 10-4 Author’s preferred technique for the Hawkins impingement test. Note the hand placements, which allow for greater
stabilization of the shoulder complex during testing. A, Starting position. B, Ending position.

Several clinical studies have been performed on the About the Test
Hawkins impingement test. Bak and Fauno (1997) A modification of the original test described by Hawkins
reported a sensitivity of 80% and specificity of 76% during and Kennedy (1980), this test also forces the rotator
the examination of 36 elite-level swimmers. Rupp et al cuff tendons under the coracoacromial arch and against
(1995) also studied the effectiveness of the Hawkins the coracoid process, to create mechanical compression
impingement test in elite-level swimmers. They reported or impingement (Davies & DeCarlo, 1995; Ianotti,
a sensitivity of 44% in a population of 44 shoulders. 1991).
Leroux et al (1995) reported sensitivity of 87% with
the Hawkins impingement test, making it similar to Start Position
the Neer impingement test, which was 89%. Calis et al
The coracoid impingement test is initiated with 90
(2000) reported 92% sensitivity and 25% specificity,
degrees of forward flexion in the sagittal plane. The pre-
as well as 75.2% positive predictive value (PPV) and
ferred starting technique is shown in Figure 10-6, A. One
56.2% NPV for the Hawkins test. As mentioned in
of the examiner’s hands is placed just distal to the elbow
the previous impingement test discussion, the use of mul-
in the extremity balance point position (see page 6) to
tiple impingement tests is recommended because of the
support the upper extremity with just one hand. The
differing locations of contact in the subacromial region
examiner’s other hand is placed on top of the shoulder
and the slightly different levels of both sensitivity and
being tested to stabilize the scapular and glenohumeral
specificity.
articulation during the upcoming internal rotation move-
CORACOID IMPINGEMENT TEST ment. The shoulder being tested is placed in external
rotation.
This test is a modification of the Hawkins-Kennedy
impingement test.
Action
Indication Using the hand placements mentioned previously, the
The coracoid impingement test is used to identify patient’s shoulder is internally rotated to end range as
impingement of the rotator cuff against the coracoacro- shown (Figure 10-6, B), while the shoulder remains in the
mial arch, more specifically the coracoid process. sagittal plane.
Ch10.qxd 5/24/04 4:43 PM Page 91

CHAPTER 10 Glenohumeral Joint (Rotator Cuff ) Impingement 91

AC joint
Distal clavicle
Acromion

Calcified
tendinitis in
supraspinatus
tendon

Figure 10-5 MRI showing contact during the Hawkins impingement test. (From
Valadie AL III et al: Anatomy of provocative tests for impingement syndrome of the
shoulder, J Shoulder Elbow Surg 9(1):43, 2000.)

A B

Figure 10-6 Coracoid impingement test. A, Starting position. B, Ending position.

What Constitutes a Positive Test? Ramifications of a Positive Test

A positive test is characterized by reproduction of the A positive coracoid impingement test indicates irritability
patient’s anterior pain in the subacromial space, either at of the rotator cuff tendons as they are encroached on the
end range of internal rotation or along the course of coracoacromial arch. The more medial position of the
movement from the neutral rotation (starting position) to humerus during testing (sagittal plane) is theorized to
end range (internal rotation). produce greater contact against the coracoid process
Ch10.qxd 5/24/04 4:43 PM Page 92

92 SECTION II Special Tests

(hence the test’s name), and involves impingement of the

subscapularis, supraspinatus, and biceps long-head tendon
(Davies & DeCarlo, 1995).

Objective Evidence Regarding the Test

No objective research is available regarding confirmed
anatomic contact with this test or either sensitivity or
specificity values on human subjects.

CROSS-ARM ADDUCTION TEST

This test is also known as the crossover impingement test or
horizontal adduction impingement test.

Indication
The cross-arm adduction test is used to identify impinge-
ment of the rotator cuff against the coracoacromial arch.

About the Test

This test uses the position of cross-arm or horizontal
adduction to produce contact between the rotator cuff and Figure 10-7 Cross-arm adduction impingement test.
biceps long-head tendon and the coracoacromial arch.
This test is often used because of the prevalence of this
movement pattern in many functional movement pat-
terns, as well as its ability to replicate the position of the What Constitutes a Positive Test?
glenohumeral joint during the follow-through of the golf Reproduction of the patient’s anterior shoulder pain at the
swing (right shoulder of a right-handed golfer) and tennis end range of horizontal adduction or in the process of per-
forehand and the preparation position of the tennis back- forming the horizontal adduction movement pattern indi-
hand (Roetert & Groppel, 2001). cates primary impingement of the rotator cuff against the
coracoacromial arch (Davies & DeCarlo, 1995). The test
Starting Position may also produce pain in the superior aspect of the shoul-
The patient is examined in the seated position (preferred der near the acromioclavicular joint. This is one of the
to avoid compensatory movements during testing) or primary tests used to identify acromioclavicular joint
while standing. The examiner grasps the patient’s arm pathology because of the compression of the distal aspect
with one arm near the balance point near the elbow and of the clavicle against the acromion (Davies & DeCarlo,
places the other hand on the back of the patient’s 1995). Finally, pain produced in the posterior aspect of the
contralateral shoulder to prevent trunk rotation. The shoulder during the cross-arm adduction maneuver may
hand placed on the posterior aspect of the shoulder and be indicative of posterior capsular tightness (Davies &
scapula is important for stabilizing the patient during DeCarlo, 1995).
testing.
Ramifications of a Positive Test
Action A positive cross-arm adduction impingement test indi-
The patient’s extremity to be tested is flexed to 90 degrees cates irritability of the rotator cuff tendons with compres-
with slight internal rotation so that the forearm is pronat- sion of the tendons against the coracoacromial arch. A
ed and the hand is in the palm-down position. The shoul- positive test can confirm impingement when it is used
der is then cross-arm or horizontally adducted to end with other impingement tests (Neer, Hawkins, coracoid,
range across the patient’s body (Figure 10-7). Several and Yocum). Results of this test can also be used to guide
small oscillations at end range of motion are performed both resistive exercise programs and the return to func-
before returning the patient’s arm to the resting position tional activity during rehabilitation, as the patient’s inabil-
at the side. ity to tolerate this movement pattern suggests that this
Ch10.qxd 5/24/04 4:43 PM Page 93

CHAPTER 10 Glenohumeral Joint (Rotator Cuff ) Impingement 93

position should be avoided during exercise and functional A B

activity.

Objective Evidence Regarding the Test

Calis et al (2000) tested the cross-arm impingement test
in patients with and without a positive subacromial injec-
tion test. The test had a sensitivity of 82% and specificity
of 27%, with a PPV of 73% and an NPV of 38%. Despite
these values, the authors reported that this test, by com-
pressing forces on the rotator cuff under the acromio-
clavicular joint, is more likely to be used to investigate
acromioclavicular joint osteoarthritis (Calis et al, 2000).

YOCUM TEST
Indication
The Yocum test is used to identify impingement of the
rotator cuff against the coracoacromial arch. Figure 10-8 Yocum impingement test. A, Starting position.
B, Ending position.
About the Test
Initially described by Yocum (1983), the Yocum test
is an active impingement test to diagnose subacromial
impingement by using the combination of humeral eleva- subacromial contact with an active, goal-directed move-
tion with internal rotation. ment by the patient.

Starting Position Objective Evidence Regarding the Test

The patient places the hand of the involved shoulder on Leroux et al (1995) performed preoperative clinical
top of the contralateral shoulder (Figure 10-8, A). This impingement tests on 55 consecutive patients undergoing
results in a position of cross-arm (horizontal) adduction surgery for Neer’s syndrome. Sensitivity of the Yocum test
and internal rotation. The examiner is not actively was 78%. This is somewhat comparable to the sensitivities
involved during administration of this test. of the Neer and Hawkins impingement tests, which had
sensitivities of 89% and 87%, respectively. No formal
Action anatomic study has been performed that outlines the exact
The patient is asked to raise or lift the elbow without rais- region of subacromial contact or any further analysis with
ing or elevating the shoulder girdle (Figure 10-8, B). The the Yocum test.
patient’s hand is to remain on top of the contralateral
shoulder. INTERNAL ROTATION RESISTANCE
STRENGTH TEST
What Constitutes a Positive Test?
Reproduction of anterior shoulder pain with elevation of Indication
the humerus and compression of the rotator cuff tendons The internal rotation resistance strength test distin-
against the coracoacromial arch constitutes a positive test. guishes between Neer outlet impingement and nonoutlet
or intraarticular causes of shoulder pain.
Ramifications of a Positive Test
Irritability of the rotator cuff tendons is implied with a About the Test
positive Yocum test during compression of the tendons This test was first reported by Zaslav (2001) as a test to
against the overlying coracoacromial arch. This test is the differentiate between classic Neer-type outlet impinge-
only impingement test reported in the literature using an ment and other types of intraarticular shoulder pathology.
active motion. The others (Neer, Hawkins, coracoid, and The use of a manual muscle test in a specific position and
cross-arm adduction) use a passive movement provided by the subsequent response of the patient to this manual
the examiner. This test confirms the presence of painful muscle test form the basis for this test.
Ch10.qxd 5/24/04 4:43 PM Page 94

94 SECTION II Special Tests

A B

Figure 10-9 Internal rotation resistance strength test. A, External rotation resistance. B, Internal rotation
resistance.

Starting Position relative weakness in the pathologic shoulder, strength

The internal rotation resistance strength test is performed between the injured and noninjured shoulder is not
with the patient in a seated position, with the examiner compared.
standing directly behind the patient oriented toward the
side being tested. The patient’s arm is positioned in 90 Ramifications of a Positive Test
degrees of abduction in the coronal plane and in approxi- A positive internal rotation resistance strength test (rela-
mately 80 degrees of external rotation (Figure 10-9). One tive weakness in internal rotation) in a patient with a
of the examiner’s hands is placed under the elbow of the positive Neer impingement sign is predictive of internal
patient’s extremity to provide support during testing, with (nonoutlet) impingement. A positive Neer impingement
the other hand placed at approximately the level of the sign and greater weakness in external rotation in the 90-
wrist to perform the manual isometric test. degree abducted and 80-degree externally rotated position
is suggestive of classic Neer outlet impingement.
Action
A manual isometric muscle test is performed for external Objective Evidence Regarding the Test
rotation (examiner’s distal hand placed on the extensor or Zaslav (2001) examined 115 consecutive patients who had
dorsal surface of the patient’s wrist) (see Figure 10-9, A) a positive Neer impingement test and were scheduled to
followed by a manual muscle test for internal rotation undergo arthroscopic evaluation of the injured shoulder.
(examiner’s distal hand placed on the flexor or palmar sur- All patients were tested using the internal rotation resis-
face of the patient’s wrist) (see Figure 10-9, B). tance strength test, and the presence or absence of the
index test was compared with intraoperative findings. The
What Constitutes a Positive Test? sensitivity of the test, defined as the percentage of patients
A positive Neer impingement sign and good strength in with diagnostic findings of internal impingement and a
external rotation and apparent weakness in internal rota- positive internal rotation resistance strength test, was
tion constitute a positive test. Because this is a test of 88%. Specificity, defined as the percentage of patients
Ch10.qxd 5/24/04 4:43 PM Page 95

CHAPTER 10 Glenohumeral Joint (Rotator Cuff ) Impingement 95

with arthroscopic findings of outlet or Neer-type primary cause of their symptoms) was 96%. Results indi-
impingement who exhibited a negative internal rotation cate that this clinical test can be used with confidence
resistance strength test, was 96%. The PPV (the percent- by clinicians trying to differentiate between outlet and
age of patients with a positive internal rotation resistance nonoutlet impingement. Further research, including
strength test who actually had internal impingement as interrater reliability, will result in further application of
the cause of their pain) was 88% and the NPV (patients this test in the clinical evaluation of patients with shoul-
with a negative test and outlet/Neer impingement as the der impingement symptoms.
Ch11.qxd 5/24/04 4:44 PM Page 97

CHAP TER

11 Rotator Cuff Tests

EMPTY CAN TEST

apply contact just proximal to the elbow ( Jobe & Bradley,
Indication 1989) or by using two fingers of pressure just proximal to
The empty can test is a manual resistive test to assess the the ulnar styloid process (see Figure 11-1). It is imperative
integrity of the supraspinatus muscle-tendon unit. that consistency be used with regard to the location and
intensity of the downward pressure to ensure accurate
About the Test interpretation of the test.
This test position was originally described by Jobe and
What Constitutes a Positive Test?
Moynes (1982) as a position to isolate the supraspinatus
muscle-tendon unit for both diagnostic testing and as an Interpretation of this test is somewhat controversial and
exercise position/movement pattern during glenohumeral deserves further clarification. Several authors consider the
joint rehabilitation. The test has been called the test to be positive when there is either muscular weakness
supraspinatus test, scaption, and empty can position because or reproduction of pain (Itoi et al, 1999; Jobe & Bradley,
of the position’s resemblance to a person holding a can 1989; Magee, 1997). Some authors consider the test to be
and emptying out its contents. purely a manual muscle test (Kelly et al, 1996). Itoi et al,
(1999) published a detailed example of the combined
interpretation of this test, noting whether pain was repro-
Start Position
duced during the maneuver. They used traditional grading
The patient can be examined in either the seated or stand- from manual muscle testing (Daniels and Worthingham,
ing position. The examiner is typically in front of the 1980) to determine whether there was muscular weakness.
patient in order to observe facial expression or compensa- Grading of the empty can test was classified from 0 to 5
tion by other parts of the kinetic chain. The patient’s (Table 11-1).
extremity is elevated to 90 degrees in the scapular plane Using the classification system from Daniels and Wor-
(30 degrees anterior to the coronal plane), with full inter- thingham (1980), Itoi et al, (1999) determined that mus-
nal rotation of the shoulder so that the patient’s thumb is cle weakness was present when the strength grade was less
pointing directly toward the ground (Figure 11-1). Care than 4. Although this classification is somewhat contro-
should be taken to ensure that the patient’s thoracic pos- versial and open to interpretation, I recommend its use,
ture is erect and consistent with positioning used during with both pain and muscular weakness being considered
testing of the contralateral side. Alterations in muscular positive reactions. Noting whether pain, weakness, or both
strength resulting from the length-tension relationship of are present during testing is recommended based on the
the muscle-tendon unit have been reported in the upper results of the research discussed in the next section.
extremity (Kebaetse et al, 1999) based on scapulothoracic
positioning. Care should be taken to note significant ele- Ramifications of a Positive Test
vation of the shoulder girdle as a compensation by the Itoi et al (1999) studied the empty can test and the full
patient, both during the set-up positioning and resistive can test (scapular plane elevation resistance with the upper
portion of the test. extremity in an externally rotated position such that the
thumb is pointing upward, similar to the position of
Action someone holding a full can of soda) (Figure 11-2) in
The examiner applies downward pressure to the patient’s patients with suspected rotator cuff pathology. The empty
extremity, with instruction to resist the pressure and and full can tests were performed in 143 shoulders of
maintain the initial starting position. The examiner can 136 consecutive patients, and results of the tests were

97
Ch11.qxd 5/24/04 4:44 PM Page 98

98 SECTION II Special Tests

Figure 11-2 Full can test position.

Figure 11-1 Empty can test position.

Table 11-1 Grading of the Empty Can Test The accuracy of the test was greater when muscular
Grade Description
weakness rather than pain was the determining feature for
both the empty and full can tests. No significant differ-
5 Normal amount of resistance to applied ence existed, however, between the two tests as far as
force accuracy was concerned in identifying patients with full-
4 Lesser amount of resistance than grade
5 but greater than grade 3
thickness rotator cuff tears. There was also no significant
3 Ability to move the segment through the difference between the two tests when pain was used as
range of motion against gravity the determining feature. Table 11-2 outlines the specific
2 Ability to move the segment through the statistical results of the study by Itoi et al (1999).
range of motion with gravity eliminated Ultimately, both of these tests can be used with varying
1 Presence of a muscular contraction
without joint motion
levels of statistical and clinical confidence when examin-
0 No muscular contraction ing the patient with suspected rotator cuff disease. Pain
and weakness are important variables when interpreting
From Itoi E et al: Which is more useful, the “full can test” or the “empty
this test. Table 11-2 shows the difference between these
can test” in detecting the torn supraspinatus tendon? Am J Sports
Med 27(1):65-68, 1999. important determinants during the clinical evaluation of
the patient with a suspected rotator cuff tear.
compared with results of high-resolution magnetic reso-
nance imaging (MRI), with 95% proven accuracy for full- Additional Evidence Regarding the Test
thickness rotator cuff tears (Itoi et al, 1999). The empty Leroux et al (1995) tested 55 consecutive patients using
can and full can tests were considered positive if there was the Jobe empty can test. A positive empty can test
pain, muscular weakness, or both. producing pain indicated supraspinatus tendonitis, and a
Ch11.qxd 5/24/04 4:44 PM Page 99

CHAPTER 11 Rotator Cuff Tests 99

Table 11-2 Statistical Results of the Empty Can and Full Can Tests for Supraspinatus Tears
Test/Condition Sensitivity Specificity PPV NPV Accuracy
FULL CAN TEST
Pain 66% 64% 37% 85% 64%
Weakness 77% 74% 49% 91% 75%
Pain, weakness, or both 86% 57% 39% 93% 64%
EMPTY CAN TEST
Pain 63% 55% 34% 82% 57%
Weakness 77% 68% 44% 90% 70%
Pain, weakness, or both 89% 50% 36% 93% 59%

PPV, Positive predictive value; NPV, negative predictive value.

positive empty can test with muscular weakness indicated from the lumbar spine; this is called a pathologic lift-off test
tendon rupture (full-thickness tear of the supraspinatus (Gerber & Krushell, 1991).
tendon). Sensitivity was 86% and specificity was 50% for
the identification of supraspinatus tendonitis; sensitivity Ramifications of a Positive Test
was 79% and specificity was 67% for rotator cuff tears.
An inability to move the dorsal surface of the hand from
These findings are similar to those reported by Itoi et al
the lumbar spine indicates extreme weakness of the sub-
(1999) using the empty can test.
scapularis muscle tendon unit and is thought to represent
a full-thickness tear of that tendon. It must be verified,
GERBER LIFT-OFF TEST however, that the patient has that range of motion and
does not simply lack internal rotation range of motion
Indication
that, when combined with the shoulder extension and
The Gerber lift-off test, designed by Christian Gerber, an adduction positioning of this test, prevents the patient
orthopedic surgeon from Switzerland, is used to identify from any further active motion. Failure to identify this
full-thickness tears of the subscapularis tendon. important range of motion restriction before doing this
test can lead to inaccurate diagnosis and misinterpretation.
About the Test
Traumatic rupture of the subscapularis tendon occurs
from a forced hyperextension or external rotation of the Modifications of the Traditional Gerber Lift-Off Test
adducted arm (Gerber & Krushell, 1991). Common Stefko et al (1997) performed an electromyogram (EMG)
clinical symptoms are increased external rotation range of and nerve block analysis of the Gerber lift-off test. Fifteen
motion and anterior shoulder pain with internal rotation subjects were tested in varying positions of shoulder
weakness. adduction, extension, and internal rotation while
indwelling electromyography was performed of several
Starting Position shoulder girdle muscles. Stefko et al (1997) reported that
The patient is examined in a standing position. The none of the experimental modifications of the Gerber lift-
patient is asked to place one hand behind the back such off test isolated either the upper or lower subscapularis
that the dorsal surface of the hand is resting against the from the latissimus dorsi, posterior deltoid, or rhomboid
patient’s lumbar spine (Figure 11-3, A). This position muscles. This finding revealed that this test maneuver did
places the shoulder in extension and internal rotation. not completely isolate the function of the subscapularis
muscle-tendon unit, thus questioning the ability of the
Action test to identify isolated pathology of the subscapularis
The patient is asked to lift the dorsum of the hand off the muscle-tendon unit.
lumbar spine and away from the body (Figure 11-3, B). In the second part of this investigation, the subscapu-
lar nerve was paralyzed in five human subjects. Patients
What Constitutes a Positive Test? with a nonfunctional subscapularis were able to perform
A patient with a full-thickness rupture/tear of the sub- the lift-off test in its original form as described pre-
scapularis tendon will be unable to lift the hand away viously (Gerber & Krushell, 1991), as well as during
Ch11.qxd 5/24/04 4:44 PM Page 100

100 SECTION II Special Tests

A B

Figure 11-3 Traditional Gerber lift-off test position. A, Starting position. B, Normal ending
position.

several other test modifications. However, one position of the subscapularis among those tested, eight had
of testing, the maximal internal rotation lift-off test pathologic lift-off tests, and one had a normal test, result-
(Figure 11-4), which consisted of the subject starting ing in a sensitivity of 80% and a specificity of 100%.
from a maximally internally rotated position with the dor- Leroux et al (1995) did not find the lift-off test to be
sum of the hand near the inferior border of the ipsilateral as accurate clinically. They found a specificity of 61% and
scapula, was not possible with a nonfunctioning sub- a sensitivity of 0% for the lift-off test in their evaluation
scapularis. The position was subsequently recommended of 55 consecutive patients. Kelly et al (1996) reported the
for better use in isolating subscapularis function or lift-off test position (dorsum of hand initially placed
pathology during clinical examination. This maneuver is against the lumbar spine with extension of the hand away
limited by its need for greater amounts of internal rotation from the lumbar spine) to be the optimal position to test
with the shoulder in an extended and adducted position. the integrity of the subscapularis muscle-tendon unit.
The range of motion requirement must be checked by the Greis et al (1996) used EMG to determine muscle
examiner before successful administration of this test. activity of the rotator cuff, pectoralis major, teres major,
latissimus dorsi, and serratus anterior during performance
Objective Evidence Regarding the Test of the lift-off test. Activity in the upper and lower sub-
In their original article, Gerber and Krushell (1991) test- scapularis muscle was 70% of maximal voluntary contrac-
ed 162 subjects, some with and some without pathology tion during the lift-off test when the hand was placed in
of the rotator cuff. Although they did not report specific the mid-lumbar region. The level of activity of the sub-
statistics on their initial research, 100 subjects with no scapularis was statistically higher than for all the other
pathology of the rotator cuff had 100 normal lift-off tests muscles tested during this maneuver. In addition, in
and 27 patients with confirmed rotator cuff tears but with agreement with other studies, Greis et al (1996) found
normal subscapularis muscle tendon units had 27 normal approximately 33% more muscle activity when the test
lift-off tests. Of nine patients with full-thickness tears was performed with the hand in the mid-lumbar region as
Ch11.qxd 5/24/04 4:44 PM Page 101

CHAPTER 11 Rotator Cuff Tests 101

About the Test

This test was initially described by Imhoff as a variation
of the Gerber belly press test (Burkhart & Tehrany, 2002);
it is named for Napoleon’s hand position as seen in por-
traits. The test is an alternative to the Gerber lift-off test
when glenohumeral joint internal rotation is too restricted
to allow for placement of the hand behind the back in
order to detect tears of the subscapularis.

Starting Position
The patient is typically examined in the standing position.
The hand is placed directly over the stomach, which
places the shoulder in slight forward flexion, abduction,
and internal rotation (Figure 11-5, A).

Action
The patient is asked to press the hand of the involved
extremity against the stomach while the examiner pays
particular attention to the position of the patient’s
involved wrist as the patient presses the hand into the
stomach (see later).

What Constitutes a Positive Test?

According to Burkhart and Tehrany (2002), the Napoleon
test is graded as negative (normal) when the patient can
push the hand against the stomach with the wrist straight.
Figure 11-4 Modified Gerber lift-off test position (starting A positive Napoleon sign exists if the wrist must flex 90
position).
degrees while pushing against the stomach (Figure 11-5,
B). An intermediate grade is given when the wrist flexes
compared with the buttock region. Adding resistance to 30 to 60 degrees when the patient pushes against the
the lift-off maneuver increased activity in all the muscles stomach.
except for the pectoralis major. Greater levels of muscular
activation are required in the scapular stabilizers during Ramifications of a Positive Test
resistance application in this maneuver (Greis et al, 1996). In a patient with a subscapularis tear, the wrist flexes as
This study further validates the Gerber lift-off test and the patient attempts to press against the stomach because
provides clinically specific information regarding arm/ this maneuver allows the patient to harness the power
hand placement during testing. of the posterior deltoid. With a subscapularis-deficient
Gerber and Krushell (1991) concluded that the lift-off shoulder, the patient cannot rotate the arm internally to
test is valid when tested in patients with full passive inter- full range actively in this position and must flex the wrist
nal rotation range of motion and when active range of to orient the arm so that the posterior deltoid can extend
motion is not severely limited by pain. In these condi- the shoulder back to produce this belly-pressing result.
tions, a pathologic lift-off test, coupled with increased This test can be used in patients with limited function,
external rotation range of motion and decreased internal making the Gerber lift-off test diagnostically inaccurate.
rotation strength, is indicative of a full-thickness tear of
the subscapularis tendon. Objective Evidence Regarding the Test
Burkhart and Tehrany (2002) performed the Napoleon
NAPOLEON TEST test in 25 patients before surgery; 9 had positive tests and
8 of the 9 had tears of the entire subscapularis tendon.
Indication The Napoleon test tended to correlate to the size and
The Napoleon test is used to identify a tear of the sub- location of the tear in the subscapularis. Positive
scapularis tendon. Napoleon tests involved full-thickness tears of the
Ch11.qxd 5/24/04 4:44 PM Page 102

102 SECTION II Special Tests

A B

Figure 11-5 Napoleon test. A, Positive Napoleon test, characterized by increased

shoulder extension and wrist flexion (B).

subscapularis in both the upper and lower halves. Nega- tral position and the arm placed against the side in adduc-
tive Napoleon tests were found in patients with only the tion. The shoulder is externally rotated 45 degrees to the
upper half of the subscapularis torn. Intermediate start position by supporting under the patient’s elbow and
Napoleon tests were found in patients with more than the the patient’s wrist (Figure 11-6, A).
upper half of the subscapularis tendon torn, but not a
complete tear of both the upper and lower portion. No Action
further objective testing or statistical information is avail- The examiner then performs a manual muscle test by ask-
able for the Napoleon test. ing the patient to press outward into external rotation. If
the patient cannot perform active external rotation and
DROPPING SIGN TEST the examiner essentially meets no external resistance, the
Indication dropping sign is commenced. The examiner then releases
the patient’s arm by releasing the patient’s wrist (Figure
The dropping sign test is used to assess the integrity of the
11-6, B and C).
infraspinatus muscle-tendon unit.

About the Test What Constitutes a Positive Test?

This test was designed to evaluate the integrity of the A positive test occurs when the patient’s arm drops into a
infraspinatus muscle-tendon unit based on its ability to more neutral rotated position as a result of an inability
perform and support the distal aspect of the upper to support even the weight of the arm in the externally
extremity against gravity. Neer (1990) described this rotated starting position (see Figure 11-6, C).
version of the dropping sign.
Ramifications of a Positive Test
Start Position A positive dropping sign has been correlated with a
The patient is typically examined in a seated position. The complete tear of the infraspinatus muscle (Walch et al,
elbow is flexed to 90 degrees, with the forearm in a neu- 1998).
Ch11.qxd 5/24/04 4:44 PM Page 103

CHAPTER 11 Rotator Cuff Tests 103

A B C
Figure 11-6 Dropping sign. A, The examiner places the forearm at 45 degrees of external rotation. The patient then
pushes against his hand. B, With the patient seated, the shoulder is placed in 0 degrees of abduction and 45 degrees of exter-
nal rotation with the elbow flexed 90 degrees. The examiner holds the patient’s forearm in this position and instructs the
patient to maintain it when the examiner releases the forearm. C, On releasing the forearm, a positive test is recorded when
the patient’s forearm drops back to 0 degrees of external rotation, despite efforts to maintain external rotation. (From Walch
G et al: The “dropping” and “Hornblower’s” sign in evaluation of rotator-cuff tears, J Bone Joint Surg Br 80(4):625, 1998.)

Objective Evidence for this Test

Walch et al (1998) tested 54 patients operated on for
combined supraspinatus and infraspinatus/teres minor
rotator cuff tears. They reported 100% specificity and
100% sensitivity for the dropping sign to identify patients
with irreparable degeneration of the infraspinatus
muscle-tendon unit. This clinical sign of impaired
external rotation (dropping sign) was correlated with fatty
degeneration (Goutallier stage 3 or 4) of the infraspinatus.
Results indicate severe weakness and impairment of the
infraspinatus.

HORNBLOWER’S SIGN

Indication
Hornblower’s sign is used to identify severe weakness and
degeneration of the teres minor muscle-tendon unit.
Figure 11-7 Hornblower’s sign.
About the Test Action
This test was originally reported in obstetric brachial The patient is asked to bring both hands up toward the
plexus palsy (Arthuis, 1972). The teres minor is responsi- mouth simultaneously.
ble for producing up to 45% of the power in external rota-
tion ( Jenp et al, 1996). What Constitutes a Positive Test?
A positive Hornblower’s sign is present when the patient
Start Position is unable to bring the hand toward the mouth in the same
The patient can be examined in either a standing or manner as the contralateral side and can only do so in the
seated position, with arms resting against the sides. characteristic compensatory pattern (Figure 11-7), which
Ch11.qxd 5/24/04 4:44 PM Page 104

104 SECTION II Special Tests

B
A

Figure 11-8 Drop-arm test. (Modified from Hoppenfeld S, Hutton R: Physical examination of the shoulder. In Physi-
cal examination of the spine and extremities, Norwalk, CT, 1976, Appleton-Century-Crofts.)

consists of shoulder abduction in the absence of external Starting Position

rotation. The patient is typically examined in the standing position
(Figure 11-8).
Ramifications of a Positive Test
A positive Hornblower’s sign has been linked to complete Action
full-thickness tears of the teres minor (Walch et al, 1998). The patient is instructed to abduct the shoulder in the
coronal plane fully, with the arm placed in slight internal
Objective Evidence Regarding the Test rotation, such that the palm is oriented toward the ground
Walch et al (1998) studied 54 patients operated on for (see Figure 11-8, A). The patient is then asked to slowly
rotator cuff pathology. The Hornblower’s sign had 100% lower the arm from the abducted position. If there are
sensitivity and 93% specificity for irreparable tears of the tears in the supraspinatus muscle-tendon unit, the arm
teres minor. This movement can be used to identify will drop rapidly to the side as the patient lowers the arm
patients with severe teres minor involvement, represented from a position of about 90 degrees of abduction. If the
by the characteristic compensatory pattern used with the arm is able to be held in 90 degrees of abduction, the
functional activity of movement of the hands toward the examiner may gently tap the distal aspect of the patient’s
face. No additional research has been conducted on this arm, which will cause the patient’s arm to fall to the side
test. (see Figure 11-8, B). It is recommended that the examin-
er place a hand or hands under the patient’s lowering
DROP-ARM TEST extremity, or one hand under the extremity when tapping,
to support and actually catch the weight of the arm after
Indication the dropping-type movement begins. This maneuver can
The drop-arm test is used to detect tears of the rotator help minimize pain.
cuff.
What Constitutes a Positive Test?
About the Test Inability to eccentrically lower the arm in adduction from
This nonspecific test was originally described by an abducted position in the coronal plane without drop-
Hoppenfeld (1976) and is based on the important role of ping as well as dropping of the arm after a light tap on the
the rotator cuff in the deltoid rotator cuff force couple distal aspect of the extremity are both considered positive
applied in humeral elevation (Inman et al, 1944). drop-arm tests.
Ch11.qxd 5/24/04 4:44 PM Page 105

CHAPTER 11 Rotator Cuff Tests 105

Ramifications of a Positive Test Calis et al (2000) studied the accuracy of the drop-arm
A positive drop-arm test is thought to indicate a full- test in a group of patients with and without a positive sub-
thickness tear of the supraspinatus muscle-tendon unit. acromial injection test. They reported a low sensitivity of
Inability to control the weight of the arm during con- 7.8% but a specificity of 97%. The drop-arm test is typi-
trolled adduction indicates significant weakness of the cally used to clarify whether a complete tear or rupture of
rotator cuff secondary to the tear. the rotator cuff has occurred. The high specificity may
have resulted from detection of a rotator cuff tear in
Objective Evidence Regarding the Test patients who tested positive for the subacromial impinge-
Sher et al (1995) conducted MRI evaluations of 96 ment test and perhaps had Neer stage III subacromial
asymptomatic individuals to determine the presence and impingement (Calis et al, 2000). Further research is nec-
prevalence of rotator cuff tears. The overall prevalence of essary, including comparison of the finding to actual sur-
rotator cuff tears was 34%, with 15% being full-thickness gical findings or MRI reports to better understand the
tears. The drop-arm test was performed to determine the effectiveness of the test. Based on the results of the study
presence of a substantial rotator cuff tear. All 96 patients by Sher et al, (1995), caution should be used when inter-
had negative drop-arm tests despite a 15% prevalence preting results of this test.
of full-thickness tears and 20% prevalence of partial-
thickness tears.
Ch12.qxd 5/24/04 4:53 PM Page 107

CHAP TER

12 Biceps Tests

INTRODUCTION complex were decreased during simulated contraction of

Injury to the biceps tendon can occur as an isolated the biceps in experimental studies (Rodosky et al, 1994).
entity; however, in most cases problems with this structure Detachment of the biceps anchor at the superior labrum
occur in conjunction with glenohumeral joint impinge- increased the strain on the inferior glenohumeral ligament
ment or instability (Eakin et al, 1999). A short discussion complex up to 120% (Cheng & Karzel, 1997). These
of biceps tendon pathology is presented to better under- studies show the important role the biceps and superior
stand the role specific tests play in the identification of labrum play in the stabilization of the human gleno-
biceps tendon disorders, as well as to emphasize the role humeral joint.
of a comprehensive evaluation to determine the underly- Dynamic muscular activity of the biceps has been
ing cause of biceps pathology. The close relationship of measured using electromyography (EMG) during both
the biceps long-head tendon to the superior labrum, sub- planar motions and functional activities (Glousmann et al,
scapularis, rotator interval, and coracohumeral ligament 1988; Yamaguchi et al, 1997). Yamaguchi et al (1997)
has increased interest in its functional anatomy, biome- studied the EMG activity of the biceps in 40 subjects who
chanics, and evaluation methods (Eakin et al, 1999). had their elbow locked in a brace to prohibit elbow move-
The biceps long-head tendon originates within the ment and isolate shoulder function. Planar shoulder
glenohumeral joint. After coursing through the bicipital motions were performed, including internal and external
groove between the greater and lesser tuberosities, the rotation and scapular elevation. EMG activity of the
tendon joins the short head of the biceps at the level of the biceps ranged from 1.7% to 3.6% of maximal activation
deltoid tubercle. Habermeyer et al (1987), in an anatomic levels. No difference was found between subjects with
study, found that the biceps long head tendon originated full-thickness rotator cuff tears and normal subjects. The
from the posterior superior labrum in 48% of specimens authors concluded that given the EMG results of their
examined, from the supraglenoid tubercle in 20%, and investigation, the function of the biceps during isolated
from both sites in 28%. Within the glenohumeral joint, glenohumeral motion does not include active contraction
the tendon is intraarticular but extrasynovial, ensheathed of the biceps. Using similar methodology, Levy et al
by a continuation of the synovial lining of the articular (2001) also found limited EMG activity of the biceps
capsule (Curtis & Snyder, 1993). long-head tendon during shoulder motion. They con-
The function of the biceps long-head tendon is con- cluded “any hypothesis on biceps function at the shoulder
troversial. Kumar et al (1989) reported upward migration must be a passive role of the tendon or tension in associ-
of the humeral head in 15 cadavers with intraarticular ation with elbow and forearm activity.”
release of the biceps long-head tendon. Dynamic depres- Glousmann et al (1988) compared the EMG activity
sion of the humeral head was demonstrated by Warner in throwing athletes diagnosed with glenohumeral joint
and McMahon (1995) who also showed superior migra- instability and in normal throwing athletes. Increases in
tion of the humeral head relative to the contralateral or biceps EMG activity were found during the acceleration
control shoulder in seven patients with loss of the biceps phase of the throwing motion in the group of athletes
long-head tendon. Several studies (Rodosky et al, 1994; with glenohumeral joint instability. This increased activity
Pagnani et al, 1996; Itoi et al, 1993) have identified the in the biceps was thought to improve glenohumeral joint
function of the biceps long-head tendon as a stabilizer stabilization.
against anterior humeral head translation. The torsional The specific pathomechanics that lead to injury in the
rigidity of the anterior capsule was increased and forces biceps long-head tendon typically focuses around im-
transmitted to the inferior glenohumeral ligament pingement or compression of the tendon in the supra-

107
Ch12.qxd 5/24/04 4:53 PM Page 108

108 SECTION II Special Tests

humeral space. According to Neer (1972), in most 1983). Walch et al (1994) have highlighted the
patients with biceps long-head tendon pathology, the pri- importance of the rotator interval lesion and the crucial
mary source of the pain is glenohumeral impingement, function of the coracohumeral ligament and superior
with biceps tendonitis being second. “Both Charles Neer glenohumeral ligament as stabilizers of the biceps
and Charles Rockwood have stressed the fact that 95% to long-head tendon.
98% of patients with the diagnosis of biceps tendonitis Table 12-1 lists the classification of biceps tendon
have in reality a primary diagnosis of impingement syn- pathology at the glenohumeral joint based on the descrip-
drome” (Burkhead, 1990). tions of Curtis and Snyder (1993). The close association
In addition to impingement as the primary pathome- of other glenohumeral joint abnormalities such as rotator
chanical factor in biceps tendonitis, Eakin et al (1999) cuff impingement and glenohumeral joint instability
have described the close association between gleno- emphasize the importance of performing a comprehensive
humeral joint instability and biceps involvement. Forces examination in the patient with suspected biceps long-
generated, particularly during overhead shoulder motions head tendon involvement.
in sports on a repetitive basis, eventually exceed the capa-
bility of the anterior static restraints of the shoulder. SPEED’S TEST
Eventually, progressive attenuation of these restraints can
cause a traction injury to both the rotator cuff and biceps Indication
tendon. This attenuation can lead to secondary impinge- Speed’s test is used primarily to identify biceps tendon
ment against the coracoacromial arch by the biceps pathology.
tendon and create further injury (Eakin et al, 1999).
Primary tendinosis has been described as a pathogene- About the Test
sis in biceps long-head tendon injury. Factors leading to J. Spencer Speed of the Campbell Clinic originally
the degenerative tendinosis include hypovascularity described the Speed’s test. The test was invented by Dr.
(Rathburn & MacNab, 1970), fiber failure, and mechani- Speed through the frequent use of his own shoulder in an
cal irritation within the intertubercular groove (Eakin elbow extended, forearm supinated position, elevating the
et al, 1999). Kraushaar and Nirschl (1999) described the leg of his patients doing a straight leg test for lumbar
degenerative response of tendon injury and highlighted pathology (Bennett, 1998; Van Moppes et al, 1995). He
the lack of inflammatory cells and high concentration of was subsequently diagnosed with bicipital tendonitis. His
fibroblasts and vascular hyperplasia in a histologic study test is used to evaluate for biceps tendon pathology as well
of injured tendons. This tendon degeneration can lead to as SLAP (superior labrum anterior posterior) lesions (see
failure and tendon rupture. labral injury section pages 115–117).
Finally, biceps long-head tendon instability has been
described as another form of biceps pathology at the Start Position
glenohumeral joint. Although rare, this condition was The patient is preferably in a seated position to minimize
thought to be primarily caused by tearing of the transverse compensatory movements; however, the standing position
ligament, which overlies the bicipital groove of the can be used, with feet placed shoulder-width apart. The
humerus (Eakin et al, 1999). Cadaveric study, however, shoulder is placed in 90 degrees of flexion in the sagittal
has shown that even with transection of the transverse plane, with the forearm in a supinated position such that
humeral ligament over the groove, the biceps long-head the hand is facing directly upward (Figure 12-1). Stabi-
tendon did not subluxate medially (Paavolainen et al, lization by the examiner is recommended by placing a

Table 12-1 Classification of Biceps Pathology

Pathology Description
Secondary biceps tendonitis Occurs secondary to either rotator cuff impingement or glenohumeral joint instability
Primary biceps tendonitis Caused by eccentric overload, hypovascularity, and abnormalities within the bicipital
groove, leading to attrition of the tendon
Biceps tendon instability Occurs infrequently, but may occur with rotator interval lesions or rotator cuff tears
Biceps tendon rupture Can be acute or chronic; actual tendon rupture can be the end stage of any of the
disorders listed in this table
Ch12.qxd 5/24/04 4:53 PM Page 109

CHAPTER 12 Biceps Tests 109

anterior shoulder pain. The clinical evaluation showed

that the Speed’s test was positive in 40 of 46 shoulders.
Arthroscopic evaluation after clinical testing was per-
formed with the use of a neuroprobe that pulled the biceps
long-head tendon into the articular portion of the gleno-
humeral joint. This allowed for direct visualization of the
tendon during surgery. Biceps and labral pathology was
found only at the time of surgery in 10 of 40 patients with
a positive Speed’s test. A specificity of 13.8% and a sensi-
tivity of 90% was reported, with a positive predictive value
(PPV) of 23% and negative predictive value (NPV) of
83%. This research indicates that the Speed’s test is posi-
tive for a variety of pathologic shoulder conditions, and
the test is nonspecific but sensitive for biceps/labral
pathology. Caution should be used when interpreting the
results of this lone test for biceps and labral pathology.
Clinical reproduction of localized anterior shoulder pain
over the bicipital groove has been recognized as the
primary positive result with this test; however, objec-
tive research findings question the accuracy of this
clinical test.
Figure 12-1 Speed’s test. Calis et al (2000) used the Speed’s test in patients with
and without a positive subacromial injection test. They
hand on the posterosuperior aspect of the shoulder reported 67% sensitivity and 55% specificity for the
(Bennett, 1998). Speed’s test, with a PPV of 79% and NPV of 41%. The
Speed’s test was more sensitive but less specific than the
Action Yergason test in patients testing positive for subacromial
A downward pressure is applied with the shoulder in 90 impingement syndrome via an injection test. Use of this
degrees of shoulder flexion in the sagittal plane. The test can play a part in understanding what structure or
extremity remains in a position of forearm supination structures are affected by impingement or compressive
during the test. disease; however, further research is needed to better out-
line this test’s diagnostic efficiency in identifying bicipital
What Constitutes a Positive Test? pathology.
Reproduction of pain in the anterior aspect of the shoul-
der over the bicipital groove indicates pathology of the YERGASON’S TEST
biceps long-head tendon (Bennett, 1998).
Indication
Ramifications of a Positive Test Yergason’s test is performed to evaluate for biceps long-
A positive Speed’s test indicates primarily bicipital tendon head tendon pathology. This test uses a more neutral
pathology. Because of the intimate blending of the biceps glenohumeral joint position, unlike the 90-degree posi-
long-head tendon with the superior labrum, reproduction tion of shoulder flexion used during the Speed’s test.
of anterior shoulder pain with this test has been reported
to indicate SLAP injury (Bennett, 1998). Detachment About the Test
of the superior labrum is provoked with the contraction The test was originally reported by Yergason (1931) as a
or tensing of the bicipital tendon that occurs with the test to identify biceps pathology.
Speed’s test and thus can re-create the patient’s anterior
shoulder pain during this maneuver. Starting Position
The patient is seated with the glenohumeral joint in 10
Objective Evidence Regarding the Test to 20 degrees of passive abduction; the examiner stands
The specificity of the Speed’s test was reported by Bennett directly to the patient’s side (same side as shoulder being
et al (1998) by evaluating 46 shoulders in 45 patients with tested) (Figure 12-2). For examination of the right
Ch12.qxd 5/24/04 4:53 PM Page 110

110 SECTION II Special Tests

subluxation of the long head of the biceps tendon as a

result of a second- or third-degree sprain of the transverse
humeral ligament (Davies et al, 1981).
Ramifications of a Positive Test
Although objective cadaveric studies that verify the tensile
loading of the biceps tendon with the maneuver have not
been published, this test is used to assess the irritability
of the biceps long-head tendon with the glenohumeral
joint placed in a more neutral nonimpingement position.
Provocation of anterior pain with biceps contraction in
this position would theoretically be less likely to be pro-
duced by compression of the rotator cuff or biceps tendon
against the coracoacromial arch as a result of the low
levels of abduction used during testing. Further research
evaluation of this test is needed to determine its efficacy.
This test should be used in combination with other biceps
and biceps/labral tests.
Objective Evidence Regarding the Test
Calis et al (2000) tested the validity of the Yergason test
in a group of patients with and without a positive sub-
Figure 12-2 Yergason’s test. acromial injection test, indicating subacromial impinge-
ment syndrome. They reported sensitivity values of 37%
shoulder, the examiner places his or her left arm under the and specificity of 86%, in addition to a PPV of 86% and
patient’s shoulder, producing 10 to 20 degrees of abduc- an NPV of 36%. By comparison, the Speed and Yergason
tion of the patient’s shoulder. The left hand of the exam- tests had higher specificity than the traditional impinge-
iner grasps the distal aspect of the patient’s forearm and ment tests of Neer, Hawkins, and cross-arm adduction,
wrist (for testing a right shoulder). The right hand of the leading the authors to speculate that bicipital involvement
examiner (again for testing the patient’s right shoulder) is may play a larger part than expected in patients testing
placed on the anterosuperior aspect of the right shoulder positive for subacromial impingement syndrome via the
to stabilize the arm during testing. No significant pressure subacromial injection test. Clearly, additional research is
or compression is performed by the hand stabilizing the needed regarding the effectiveness of this test.
proximal aspect of the patient’s shoulder.
LUDINGTON’S TEST
Action
Indication
While keeping the patient’s shoulder stationary, the
examiner provides resistance on the distal aspect of the Ludington’s test was originally used to diagnose rupture
patient’s forearm and wrist while the patient supinates of the long head of the biceps; it is also used to test for
against that resistance (Davies & DeCarlo, 1995) (see bicipital tendonitis.
Figure 12-2). Another variation of this test involves About the Test
simultaneous resistance of external rotation (lateral
Originally described by Ludington (1923) as a test to
rotation) during the resistance to forearm supination
identify a rupture of the long head of the biceps tendon,
(Yergason, 1931; Magee, 1997). Additional provocation
this test uses a functional position of abduction with
to the biceps can be obtained by also resisting elbow
external rotation to test the integrity of the biceps long-
flexion during the supinatory resistance phase of the
head tendon.
Yergason’s test (Reider, 1999).
Start Position
What Constitutes a Positive Test? The patient is preferably in a seated position, although a
Reproduction of the patient’s proximal anterior shoulder standing position is equally effective. The examiner asks
pain in the bicipital groove indicates a positive test. A the patient to interlock the fingers of both hands behind
painful snap along the bicipital groove may be caused by the head, placing the shoulders in approximately 120
Ch12.qxd 5/24/04 4:53 PM Page 111

CHAPTER 12 Biceps Tests 111

Figure 12-4 Patient with biceps long-head tendon rupture and

“Popeye” deformity.

Ramifications of a Positive Test

A positive Ludington’s test can be interpreted as indicat-
ing pathology of the biceps long-head tendon. Complete
rupture of the tendon typically leads to a retraction of the
biceps muscle-tendon unit and the appearance of a “Pop-
eye” deformity, resulting in a compacted and enlarged
biceps muscle mass (Osbahr et al, 2002) (Figure 12-4).
Clinical testing to confirm the ruptured biceps long-head
tendon is usually not necessary because of the often obvi-
ous muscular adaptation. Reproduction of anterior shoul-
der pain in the region of the bicipital groove, however, is
Figure 12-3 Ludington’s test.
indicative of biceps long-head tendonitis. The position of
the arm in this test (abduction and external rotation) sim-
ulates the cocking phase of both the throwing motion
(Fleisig et al, 1995) and tennis serve (Elliot et al, 1986)
degrees of abduction and 90 degrees of external rotation and tests the integrity of the biceps tendon in both a func-
(Figure 12-3). This position creates a relaxation of the tional position and a position of encroachment by the
biceps muscle-tendon unit by using the interlocking of coracoacromial arch (Valadie et al, 2000).
the hands to support the weight of the extremities
(Magee, 1997). Objective Evidence Regarding the Test
There is no objective evidence regarding this test in the
Action literature.
The patient alternately contracts the biceps muscles on
each extremity (uninvolved then involved) to produce a GILCHREST’S SIGN
forceful contraction of the biceps and tension in the biceps
long-head tendon. The biceps long-head tendon can be Indication
palpated at the level of the bicipital groove on the proxi- Gilchrest’s sign is a test to determine the presence of
mal humerus to determine whether the tendon has rup- biceps long-head tendonitis.
tured (Ludington, 1923).
About the Test
What Constitutes a Positive Test? This test uses a weight to load the biceps muscle-tendon
As originally described by Ludington (1923), failure to unit from an overhead position.
palpate the biceps long-head tendon on the involved
extremity indicates a rupture of the long head of the Start Position
biceps tendon. Davies and DeCarlo (1995) reported In a standing position, the patient holds a 2- to 3-kg
reproduction of anterior shoulder pain in the bicipital weight (approximately 5 to 7 pounds) and raises it
groove as indicative of biceps tendonitis. directly overhead.
Ch12.qxd 5/24/04 4:53 PM Page 112

112 SECTION II Special Tests

Action LIPPMAN’S TEST

The patient then lowers the arm in the coronal plane from
Indication
the overhead position in lateral rotation (Figure 12-5).
Lippman’s test is used to identify biceps tendon
What Constitutes a Positive Test? pathology.
Reproduction of pain in the bicipital groove on lowering
the weight in the coronal plane is indicative of biceps About the Test
tendonitis. An audible click or snapping sensation, most This test was described by Lippman (1943) for the diag-
commonly occurring around 90 to 100 degrees of eleva- nosis of biceps tendonitis.
tion (Magee, 1997), indicates biceps tendon pathology,
including instability of the biceps long-head tendon, Starting Position
resulting from interruption of the transverse humeral The patient sits or stands with the involved extremity held
ligament (Davies et al, 1981). in 90 degrees of elbow flexion with one hand by the exam-
iner. The arm is supported by the examiner such that the
Ramifications of a Positive Test
extremity is relaxed and minimal resting muscle activation
Loading of the biceps muscle-tendon unit with the use of is encountered.
an external load indicates pathology of the biceps long-
head muscle-tendon unit. This test is most indicated for Action
use in patients who report symptoms only with loads or in The examiner’s other hand palpates the biceps tendon in
overhead reaching applications. Caution is suggested in the bicipital groove, moving it from side to side.
using this test in patients with easily provoked symptoms
or with subjective histories that include microtraumatic What Constitutes a Positive Test?
mechanisms of overuse because of the presence of the 2- Lippman’s test is considered positive if reproduction of
to 3-kg external load. the patient’s anterior pain over the biceps tendon at the
Objective Evidence Regarding the Test level of the bicipital groove is produced.
There is no objective evidence regarding this test in the
Ramifications of a Positive Test
literature.
As with all tests, it is imperative that this test be per-
formed bilaterally. This region (the biceps long-head ten-
don at the level of the bicipital groove) is often sensitive
in patients with rotator cuff and other shoulder patholo-
gies, as well as in the uninvolved extremity. A positive test
is often encountered in both extremities.

Objective Evidence Regarding the Test

There is no objective evidence regarding this test in the
literature.

TESTS FOR BICEPS TENDON

INSTABILITY
Indication
The first reported case of biceps long-head tendon sub-
luxation occurred in 1694 in a woman who was wringing
clothes and felt something displace in her shoulder (Burk-
head et al, 1998). In patients who have complaints of
anteriorly based snapping and popping in addition to
symptoms of pain and tenderness, several tests or modifi-
cations of tests have been described in the clinical litera-
ture as being indicated to test for instability of the biceps
Figure 12-5 Gilchrest’s sign. long-head tendon.
Ch12.qxd 5/24/04 4:53 PM Page 113

CHAPTER 12 Biceps Tests 113

Figure 12-6 Biceps instability test. (From Rockwood CA, Matsen FA III, editors: The
shoulder, Philadelphia, 1990, WB Saunders.)

About the Tests Additional tests to evaluate the stability of the biceps
These tests use both positional provocation of the tendon long-head tendon are described in full detail in the pre-
and contraction of the tendon in an attempt to dislodge vious section (biceps tests). These tests include Yergason’s
or dislocate the tendon from the intertubercular groove. test and Gilchrist’s sign.
They are presented in this section as a group because
several of the tests also assess the integrity of the tendon Ramifications of a Positive Test
itself and are discussed in the previous section. The biceps long-head tendon originates at the supra-
glenoid tubercle and the glenoid labrum at the most
Tests Used for Biceps Tendon Instability superior aspect of the glenoid. The tendon is 9 mm long
The primary test used and reported for biceps tendon on average. The biceps tendon is intraarticular, but
pathology is the transverse humeral ligament test (Davies extrasynovial. It is stabilized not only by the transverse
& DeCarlo, 1995). This test is performed with the arm humeral ligament, but also proximally by the gleno-
at the side in neutral rotation. The patient is asked to humeral joint capsule. Several capsuloligamentous struc-
actively contract the biceps against the examiner’s hand, tures play a key role in stabilizing the biceps long-head
which is placed on the distal forearm. As the patient is tendon in the bicipital groove. The supraspinatus, infra-
contracting the biceps, the examiner passively rotates the spinatus, subscapularis, and coracohumeral and superior
humerus internally and externally in an attempt to sublux glenohumeral joint capsular ligaments all play a vital role.
the tendon from the groove. A positive test result is pres- Paavolainen et al (1983) reported that subluxation of the
ent when the tendon subluxates, as well as when the biceps long-head tendon is nearly impossible, even with
patient’s anterior symptoms are reproduced (Davies & complete transection of the transverse humeral ligament.
DeCarlo, 1995). Reproduction of the patient’s perception The tendon remained in the intertubercular groove as
of subluxation is also considered a positive result. long as the rotator cuff was intact. These studies inform
The second test described in the literature is the biceps the examiner of other possible pathology present when
instability test. This test was originally described by biceps long-head tendon instability is encountered during
Abbott and Saunders in 1939. It tests the biceps tendon clinical examination. A thorough and complete evaluation
with the shoulder in abduction. The examiner grasps the of the glenohumeral joint capsular structures is an integral
arm near 90 degrees of abduction and passively moves the part of the evaluation of biceps instability because of
glenohumeral joint from a position of external rotation to the important role other structures, beyond the transverse
a position of internal rotation during palpation of the humeral ligament, play in stabilizing this important
biceps tendon (Figure 12-6). A positive test occurs when structure.
the biceps long-head tendon is forced against the lesser
tuberosity with a palpable or audible click.
Ch13.qxd 5/24/04 4:54 PM Page 115

CHAP TER

13 Labral Testing

INTRODUCTION the underlying instability of the shoulder that led to labral

The glenoid labrum serves several important functions, injury in these overhead athletes must be addressed to
including deepening the glenoid fossa to enhance con- effectively return long-term function and symptomatic
cavity and serving as the attachment for the gleno- relief to the patient.
humeral capsular ligaments. Injury to the labrum can
compromise the concavity compression phenomenon by LABRAL DETACHMENT
as much as 50% (Matsen et al, 1991). Individuals with In addition to the tearing that can occur in the labrum,
increased capsular laxity and generalized joint hyper- actual detachment of the labrum from the glenoid rim
mobility have increased humeral head translation that can occur. The two most common labral detachments en-
can subject the labrum to increased shear forces (Kvitne countered clinically are the Bankart and SLAP (superior
et al, 1995). In the throwing athlete, large anterior trans- labrum anterior posterior) lesions. Perthes (1906) was the
lational forces are present at levels up to 50% of body first to describe the presence of a detachment of the ante-
weight during arm acceleration of the throwing motion rior labrum in patients with recurrent anterior instability.
with the arm in 90 degrees of abduction and external rota- Bankart (1923, 1938) initially described a method for sur-
tion (Fleisig et al, 1995). This repeated translation of the gically repairing the lesion that now bears his name.
humeral head against and over the glenoid labrum can A Bankart lesion is found in as many as 85% of dislo-
lead to labral injury. Labral injury can occur either as cations (Gill et al, 1997) and is described as a labral
tearing or as actual detachment from the glenoid. detachment occurring between the 2 and 6 o’clock posi-
tions on a right shoulder and between the 6 and 10 o’clock
LABRAL TEARS positions on a left shoulder (Figure 13-1). This anteroin-
Terry et al (1994) reported on arthroscopic evaluation of ferior detachment decreases glenohumeral joint stability
tears of the glenoid labrum in 83 patients. They classified by interrupting the continuity of the glenoid labrum and
labral tears into several types, including transverse tears, compromising the glenohumeral capsular ligaments
longitudinal tears, flap tears, horizontal cleavage tears, and (Speer et al, 1994b). Detachment of the anterior inferior
fibrillated tears. They also reported the distribution of glenoid labrum creates increases in anterior and inferior
the location of these tears. Primary tears of the glenoid humeral head translation.
labrum occurred most commonly in the anterosuperior In addition to labral detachment in the anteroinferior
(60%) or posterosuperior part of the shoulder (18%). Only aspect of the glenohumeral joint, similar labral detach-
1% of tears occurred in the anteroinferior shoulder. Tears ment can occur in the superior aspect of the labrum (see
were located in more than one location in 22% of cases. Figure 13-1). Snyder et al (1990) classified SLAP into
Altchek et al (1992) clinically studied the role of the four main types. Type I shows labral degenerative changes
labrum in the hypermobile shoulder. In a 3-year follow-up and fraying at the edges, but no distinct avulsion. Type II
evaluation of 40 overhead athletes who underwent arthro- is the most commonly reported superior labral injury
scopic labral débridement, 72% initially reported relief (Morgan et al, 1998) and has been described as complete
of symptoms in the first year after surgery. At the 2-year labral detachment from anterosuperior to posterosuperior
follow-up evaluation, only 7% of patients reported glenoid rim, with instability of the biceps long-head
symptom relief, with a consistent generalized deteriora- tendon. The authors further subclassified the type II
tion occurring over time. These authors concluded that superior labral lesion into type II anterior, type II pos-
arthroscopic labral débridement is not an effective terior, and type II anterior and posterior. Of significance
long-term solution for labral tears. They postulated that is the increased (threefold) likelihood of type II posterior

115
Ch13.qxd 5/24/04 4:54 PM Page 116

116 SECTION II Special Tests

Biceps tendon

SGHL
Biceps
tendon A
PC
P A
MGHL

PB Slap
AB lesion
AP
IGHLC

Bankart
lesion

Figure 13-1 Glenoid labrum and depiction of location of Bankart Figure 13-2 A, Superior view of resting position of the biceps-
and SLAP lesions. (Adapted from Speer KP et al: Biomechanical labral complex. B, Superior view of the biceps-labral complex in
evaluation of a simulated Bankart lesion, J Bone Joint Surg Am the abducted, externally rotated position, showing peel-back
76(12):1821, 1994.) mechanism as the biceps vector rotates posteriorly. (Adapted
from Burkhart SS, Morgan CD: The peel-back mechanism: its role
in producing and extending posterior type II SLAP lesions and
SLAP lesions in throwing athletes, as well as the finding its effect on SLAP repair rehabilitation, Arthroscopy 14(6):639,
of the Jobe subluxation relocation test as the most accu- 1998.)
rate and valuable test to identify the type II posterior
lesion (Morgan et al, 1998). Type II anterior SLAP
lesions are most commonly associated with trauma and glenohumeral ligament. This demonstrates a significant
are less likely to be found in overhead athletes. A type III increase in the load on the capsular ligaments in the
labral injury involves the displacement of the free margin presence of superior labral injury.
of the labrum into the joint in a bucket-handle type fash- Identifying the mechanism of injury for superior labral
ion with no instability of the biceps long-head tendon injury helps the clinician understand the positions used
noted. A type IV labral lesion is similar to a type III lesion and maneuvers recommended to test for superior labral
with a bucket handle displacement of the glenoid labrum. injury. Andrews and Gillogly (1985) first described labral
In contrast, though, a type IV lesion involves a partial injuries in throwers and postulated tensile failure at the
rupture in the direction of its fibers of the biceps long- biceps insertion as the primary mechanism of failure.
head tendon (Snyder et al, 1990). The Andrews theory was based on the important role the
One of the consequences of a superior labral injury is biceps plays in decelerating the extending elbow during
involvement of the biceps long-head tendon and the the follow-through phase of pitching, coupled with the
biceps anchor in the superior aspect of the glenoid. This large distractional forces present during this violent phase
compromise of both the integrity of the superior labrum of the throwing motion. Recent hypotheses have devel-
and loss of the biceps anchor leads to significant losses in oped based on the finding by Morgan et al (1998) of a
the static stability of the human shoulder. Cheng and more commonly located posterior type II SLAP lesion in
Karzel (1997) showed the important role the superior the throwing or overhead athlete. This posterior-based
labrum and biceps anchor play in glenohumeral joint sta- lesion can best be explained by the “peel back mechanism”
bility by experimentally creating a SLAP lesion between described by Burkhart and Morgan (1998) (Figure 13-2).
the 10 and 2 o’clock positions. They found 11% to 19% The torsional force created when the abducted arm is
decreases in the ability of the glenohumeral joint to brought into external rotation is thought to “peel back” the
withstand rotational force, as well as 100% to 120% biceps and posterior labrum. Thus several of the tests to
increases in strain on the anterior band of the inferior identify the patient with a superior labral injury use the
Ch13.qxd 5/24/04 4:54 PM Page 117

CHAPTER 13 Labral Testing 117

position of abduction and external rotation similar to the

position Burkhart and Morgan (1998) describe for the
“peel back mechanism.”

Summary
Understanding the primary types and mechanisms of
labral injury when these tests are performed helps the
clinician determine whether a labral tear or detachment
is present. It is recommended that each clinician have
confidence in their ability to perform several of the labral
tests outlined in this chapter to optimize the ability to
correctly identify injury to this important structure. It is
also important to understand the high incidence of addi-
tional pathology found at the time of arthroscopic surgery
in patients with glenoid labrum injury. Kim et al (2003) Figure 13-3 Labral clunk test showing set-up and examiner/
evaluated the findings from 544 shoulder arthroscopies. patient positioning.
Superior labral lesions were found in 26% of the 544
cases, with 21% being classified as a type II labral lesion.
Of clinical importance was the common finding of grasp the humerus far enough proximally will result in
Bankart lesions in patients less than 40 years old who had difficulty with the primary action described next.
a superior labral injury and the high incidence of rotator
cuff tears in patients more than 40 years old with a supe- Action
rior labral injury. This study clearly demonstrates the The examiner compresses the humeral head and initially
importance of performing a comprehensive examination glides it caudally. A continuation of a circumduction
in any patient with suspected superior labral pathology. pattern is performed both clockwise and/or anticlockwise
while the gentle compression of the humeral head into the
CLUNK TEST glenoid is maintained.

Indication What Constitutes a Positive Test?

The clunk test is used to detect the presence of a labral A “clunk” that reproduces the patient’s symptoms, pain
tear or detachment. reproduction, and pseudolocking constitute a positive test.
Grating and crepitace are often encountered, with no
About the Test symptom reproduction. This finding of grating and crepi-
This test was originally described by Andrews (Andrews tace does not constitute a positive test and is frequently
and Gillogly, 1985) to detect labral tears in overhead ath- misinterpreted as a labral tear by both informed patients
letes. The test attempts to trap the torn labrum between and less experienced examiners. Another common find-
the humeral head and glenoid by using compression and ing in hypermobile shoulders is the movement of the
rotation of the humeral head. humeral head over the glenoid rim. This finding does not
indicate labral dysfunction per se, but should alert
Start Position the examiner to the hypermobile nature of the patient’s
The patient is placed in the supine position, with the arm shoulder.
elevated 150 to 160 degrees in the scapular plane. The
examiner should face the patient’s feet, such that the Ramifications of a Positive Test
patient’s involved extremity can be placed under the A positive clunk test indicates either labral tearing or
axilla of the examiner to facilitate the use of both hands labral detachment. Davies and DeCarlo (1995) inter-
on the proximal humerus (Figure 13-3). For example, to preted the findings of the clunk test. A positive “clunk” or
examine the patient’s right shoulder, the patient’s right reproduction of symptoms with the humeral head in the
arm is placed under the examiner’s left axilla. position between the 3 and 6 o’clock positions (right
The examiner grasps the proximal humerus just distal shoulder) or the 9 and 6 o’clock positions (left shoulder)
to the humeral head with both hands. A firm yet relaxed implicates a possible Bankart lesion. Positive findings
grip must be used to facilitate patient relaxation. Failure to occurring with the humeral head between the 10 and 12
Ch13.qxd 5/24/04 4:54 PM Page 118

118 SECTION II Special Tests

o’clock positions in either the left or right shoulder indi-

cate a SLAP lesion.

Objective Evidence Regarding the Test

In a retrospective review of 100 shoulders in 96 patients,
Hurley and Anderson (1990) diagnosed 15 patients with
labral pathology using the clunk test before patients
underwent shoulder arthroscopy. At the time of surgery,
72 of the 100 shoulders examined had a tear of the
glenoid labrum. This finding calls into question the
sensitivity (15%) of the clunk test and suggests that the
examiner use the test in combination with other evaluative
procedures to more accurately identify labral pathology.
Other data pertaining to the clunk test have not been
published.

CIRCUMDUCTION TEST Figure 13-4 Circumduction labral test, set-up position.

Indication
The circumduction test is used to identify labral patho-
logy in multiple glenohumeral joint positions.

About the Test

This test uses principles similar to those previously listed
for the clunk test. Compression with rotation of the
humeral head is meant to trap the labrum between the
humeral head and glenoid. The advantage of this test is
that it uses many different positions and can even incor-
porate humeral rotation in the evaluation process, which
is functionally specific for many patients with labral
pathology.

Start Position
The patient is in a supine position on a plinth. Initially,
the arm is abducted to 90 degrees in the scapular plane.
The examiner faces the patient below the patient’s Figure 13-5 Abduction external rotation position of the circum-
duction test.
abducted humerus. The examiner’s right hand (for exam-
ining the patient’s left shoulder) is positioned at the elbow
in the balance point position (see page 6 for description) starting position (see Figure 13-4), a circumduction or
to allow one-arm support of the patient’s extremity by the rotating movement is performed by the examiner, so that
examiner. The patient’s elbow remains flexed approxi- the patient’s glenohumeral joint undergoes a large cir-
mately 90 degrees during the test. The examiner’s hand is cumduction pattern (Figure 13-5). In addition to the cir-
placed over the superoanterior aspect of the patient’s cumduction pattern, the examiner, via hand placement at
shoulder to palpate and provide support. No pressure or the elbow using the balance point position, can provide
movement is performed by the examiner’s proximal hand internal and external rotation as the patient’s arm is being
(Figure 13-4). moved through the circumduction pattern. This provides
a scouring type of motion to entrap the torn labrum and
Action enable manual detection.
The examiner provides a long axis compression of the One additional cue that can be helpful to a less experi-
humeral head into the glenoid with the shoulder at 90 enced examiner is to ensure that a large enough circum-
degrees of abduction in the scapular plane. From that duction motion is performed during testing. As a guide,
Ch13.qxd 5/24/04 4:54 PM Page 119

CHAPTER 13 Labral Testing 119

the back of the patient’s hand and forearm should liter- CRANK TEST
ally brush the forehead, so that if a baseball cap were being
worn by the athlete or patient, it would be knocked off. Indication
Coming that far medially with internal rotation of the The crank test is used to identify labral pathology with the
humerus, followed by a full circle into abduction and arm in an overhead position.
external rotation (see Figure 13-5), ensures that the
humeral head is traversing the glenoid rim. About the Test
What Constitutes a Positive Test? This test was originally described by Liu et al (1996b)
as a sensitive and specific test for the evaluation of glenoid
Reproduction of pain, a “clunk,” or pseudocatching may
labrum tears. The test can be performed in both
implicate labral pathology.
the supine and seated positions, using similar combina-
Ramifications of a Positive Test tions of compression and rotation to determine labral
status.
A positive circumduction test indicates the presence of
labral pathology. This finding can have implications
similar to those discussed for the clunk test. Both labral Starting Position
tears and labral detachment may produce pain and The test can be performed with the patient in either a
catching during the performance of these maneuvers. seated or supine position. In both positions, the gleno-
The use of this test, in combination with other labral tests, humeral joint is elevated 160 degrees in the scapular
can increase the likelihood of making a definitive plane. One of the examiner’s hands is placed at the elbow
diagnosis. at the balance point position (page 6) to allow the exam-
iner to control the patient’s extremity. The examiner’s
Objective Evidence Regarding the Test other hand is placed on the superior aspect of the shoul-
There is no evidence regarding this test in the literature. der for support and to palpate (Figure 13-6, A).

A B

Figure 13-6 Crank test. A, Starting position, and B, superimposed humeral rotation in the seated position.
Ch13.qxd 5/24/04 4:54 PM Page 120

120 SECTION II Special Tests

Action of the glenoid labrum seen during arthroscopic evalua-

The hand placed on the patient’s elbow applies a long axis tion. The crank test in this study had a specificity of 56%,
compressive force while the humerus is internally and sensitivity of 46%, PPV of 41%, and NPV of 61%. These
externally rotated (Figure 13-6, B). The combination of values obtained are significantly lower than reports from
compression and rotation is the same whether the patient the originators of the test.
is seated or supine. Guanche and Jones (2003) tested 60 shoulders before
undergoing arthroscopy using a series of labral tests. The
What Constitutes a Positive Test? crank test had a sensitivity of 40%, specificity of 73%,
A positive test is determined either by pain elicited pri- PPV of 82%, and NPV of 29% for the diagnosis of any
marily during external rotation with or without a click or type of labral lesion. These findings are slightly higher
by reproduction of the pain or catching felt by the patient than those reported by Stetson and Templin (2002).
during athletic or work-related activities. According to When Guanche and Jones (2003) analyzed their results
the originators of the test, the supine position promotes for only diagnosis of SLAP lesions, however, sensitivity
greater patient relaxation, and frequently a positive crank and specificity values were 39% and 67%, respectively,
test in the supine position is also positive in the seated with a PPV of 59% and an NPV of 47%, which are much
position. closer to the findings of Stetson and Templin (2002).
Results from these research studies suggest that cau-
Ramifications of a Positive Test tion be applied when interpreting a positive crank test.
A positive crank test indicates a tear in the labrum. The The test should be used in conjunction with other labral
originators of this examination claim that this test is par- tests and a thorough clinical examination to determine the
ticularly useful in patients who have stable joints. The underlying pathology in patients presenting with shoulder
presence of labral tears in patients with stable gleno- pain.
humeral joints include bucket-handle, transverse, flap,
longitudinal, horizontal cleavage, fibrillated, and SLAP- COMPRESSION ROTATION TEST
type tears (Liu et al, 1996b).
Indication
Objective Evidence for This Test The compression rotation test is used to identify the pres-
Liu et al (1996b) evaluated 62 patients using the crank ence of superior labral pathology (SLAP lesions).
test before arthroscopic evaluation of the shoulder; 31
patients (50%) had a positive preoperative crank test. At About the Test
time of arthroscopy, 32 patients had evidence of labral This test uses a position of 90 degrees of glenohumeral
tears. Two patients who had positive crank tests but no joint abduction to combine the movements of internal and
labral tears on arthroscopic examination had partial- external rotation and compression to determine the status
thickness undersurface rotator cuff tears. The crank test of the superior labrum.
had a sensitivity of 91% and a specificity of 93%. The pos-
itive predictive value (PPV) of the crank test was 94% and Start Position
the negative predictive value (NPV) was 90%. The patient is examined in a supine position. The exam-
In a related work, the same authors (Liu et al, 1996b) iner grasps near the elbow of the patient’s involved
compared the accuracy of physical examination in patients extremity using the balance point (see page 6 for descrip-
with suspected labral injury with the results of magnetic tion) with the patient’s elbow flexed 90 degrees. The
resonance imaging (MRI) (conventional and arthrogram). examiner stands below the patient’s extremity being eval-
Results of the physical examination maneuver (crank test) uated and faces directly toward the patient (Figure 13-7,
were far superior to the MRI, which had a sensitivity of A). To examine the patient’s left shoulder, the examiner’s
59% and a specificity of 85%. right hand is near the elbow and the examiner’s left hand
Research by Stetson and Templin (2002) evaluated the is cupped over the superior aspect of the shoulder to pal-
effectiveness of the crank test in identifying patients with pate and feel for any “clunk” or abnormal catching during
suspected labral pathology. A complete prospective clini- the maneuver described next.
cal evaluation was performed by one examiner on 65
patients whose shoulder pain had been present for a mean Action
time of 12 months. The crank test was positive in 29 of 62 The examiner exerts a compressive force via the elbow
patients, 12 of whom (41%) actually had evidence of tears toward the glenoid to approximate the humeral head into
Ch13.qxd 5/24/04 4:54 PM Page 121

CHAPTER 13 Labral Testing 121

B
A

Figure 13-7 Compression rotation test. A, Starting position. B, Humeral rotation action.

the glenoid while internally and externally rotating the patients who were correctly identified using the compres-
humerus (Davies & DeCarlo, 1995; McFarland et al, sion rotation test, six had pain reproduction and one had
2002) (Figure 13-7, B). Magee (1997) described a pain reproduction and a click.
modification of this test in which the test is performed in Based on these finding, the sensitivity of the compres-
only 20 degrees of abduction, rather than 90 degrees sion rotation test was 24%, specificity was 76%, and the
as used by Snyder et al (1995), Davies and DeCarlo NPV and PPV were 90% and 9%, respectively. This study
(1995), and McFarland et al (2002). This lower level of clearly showed the difficulty in detecting labral lesions
abduction results in a greater superior shear of the using manual tests in patients who present with shoulder
humeral head. pain. An additional finding that has clinical significance
is that most SLAP lesions do not occur in isolation
What Constitutes a Positive Test? (McFarland et al, 2002); 77% of the patients who had a
Reproduction of the patient’s pain, a “clunk,” or pseudo- SLAP lesion at time of arthroscopic examination had an
catching may implicate a SLAP lesion. associated intraarticular lesion. This finding is supported
by other diagnostic series in the literature, specifically
Ramifications of a Positive Test Morgan et al (1998), who found 31% of patients with
The use of glenohumeral joint compression with super- type II SLAP lesions to have rotator cuff lesions.
imposed rotation is meant to catch the labral fragment, In summary, the compression rotation test cannot be
much like the McMurray test of the knee (McFarland used in isolation to accurately identify patients with
et al, 2002). Detachment of the superior labrum from the SLAP lesions. The test is recommended in combination
glenoid may result in instability of the biceps anchor and with other manual clinical tests, as well as thorough clin-
lead to glenohumeral joint instability (Cheng & Karzel, ical evaluation and history. Research does not support the
1997). need to produce a “clunk” or “click” for the test to be con-
sidered positive. Pain reproduction alone, or in addition to
Objective Evidence Regarding the Test a possible clunk or click, is a more appropriate indicator of
McFarland et al (2002) used the compression rotation test superior labral pathology.
on 426 patients who subsequently underwent shoulder
arthroscopy. The compression rotation test was positive in ANTERIOR SLIDE TEST
67 of 274 (25%) control patients (those who did not have
a SLAP lesion identified at time of shoulder arthroscopy) Indication
and in 7 of 29 patients who did have a type II, III, or IV The anterior slide test is used to identify patients with
SLAP lesion at the time of arthroscopy. Of the seven superior labral pathology.
Ch13.qxd 5/24/04 4:54 PM Page 122

122 SECTION II Special Tests

About the Test

This test, initially developed and reported by Kibler
(1995), was devised to clinically detect lesions of the supe-
rior glenoid labrum with or without a movable free frag-
ment. The test is based on creating an anteriorly and
superiorly directed force vector on the humerus relative to
the glenoid, which normally is resisted by an intact supe-
rior labrum biceps complex (Rodosky et al, 1994).

Start Position
The patient can be examined in either the standing or sit-
ting position. The patient places hands on hips, with the
thumbs pointed in a posterior direction. The examiner
stands directly behind the patient and places one hand on
top of the shoulder from the posterior direction, so that
the last segment of the index finger extends over the ante-
rior aspect of the acromion at the glenohumeral joint.
Typically this would be the examiner’s left hand when
examining the patient’s right shoulder. The examiner’s
other hand is placed behind the patient’s flexed elbow
(Figure 13-8).

Action
Using the hand placed behind the patient’s elbow, the
examiner exerts a forward and slightly superiorly directed Figure 13-8 Lateral view of the Kibler anterior slide test.
force to the elbow and upper arm. The patient is asked
to gently push back against the anterosuperior-directed
force.
and biceps complex, which normally resists this anterior
What Constitutes a Positive Test? translation.
Pain localized to the front of the shoulder under the
examiner’s hand that is placed in an anterosuperior posi- Objective Evidence Regarding the Test
tion, and/or a pop or click in the same region, is consid- In his original article, Kibler (1995) used the anterior slide
ered a positive test. Kibler (1995) also interpreted the test test in 226 patients/subjects to determine the efficacy of
as positive if the testing maneuver reproduces the symp- the test. Five groups of individuals were tested by Kibler:
toms that occur during overhead throwing or other func- 46 athletes with arthroscopic confirmation of superior
tional activities. labral tears, 52 patients with arthroscopic confirmation of
partial rotator cuff tears (36 of which also had superior
Ramifications of a Positive Test labral injury as well), 28 patients undergoing anterior sta-
A positive Kibler anterior slide test indicates superior bilization procedures, 54 asymptomatic overhead throw-
labral pathology. The superoanterior-directed force moves ing athletes, and 46 lower extremity athletes who were
the shoulder into internal rotation. Patients who are over- also asymptomatic. These groups were chosen to test the
head athletes often have reduced internal rotation active anterior slide test in conditions of both isolated and non-
and passive range of motion on their dominant side isolated superior labral injury, as well as in individuals
(Ellenbecker et al, 2002b; Ellenbecker, 1992). Movement without superior labral pathology. The anterior slide test
produced from internal rotation in the presence of an was positive 69 times in 88 total superior labral lesions in
internal rotation deficit causes increased anterior transla- the testing populations, or a sensitivity rate of 78.4%. The
tion of the humeral head. In the presence of superior anterior slide test was correct 125 out of 138 times, or a
labral pathology, the anterior translation of the humeral specificity rate of 91.5%. Kibler concluded that the ante-
head can create stress on the superior glenoid labrum rior slide test can be added to the evaluation process to aid
Ch13.qxd 5/24/04 4:54 PM Page 123

CHAPTER 13 Labral Testing 123

in diagnosing superior labral lesions because it has a high active muscle force to provoke the biceps/labral complex
specificity for superior labral lesions. and also load the acromioclavicular joint (O’Brien et al,
McFarland et al (2002) used the anterior slide test to 1998). Both superior labral pathology and acromioclavic-
evaluate 426 patients undergoing arthroscopic shoulder ular joint degenerative lesions can be identified based
surgery. The anterior slide test was positive in 62 of 381 on the location of pain produced during the O’Brien
control patients who did not have types II, III, or IV supe- provocative maneuver.
rior labral pathology. The test was also positive in 3 of 38
patients with superior labral pathology. In actual patients Start Position
with superior labral pathology, the anterior slide test pro- The test is performed with the examiner standing
duced pain in only two patients and a click in only one directly behind the patient. The patient is asked to flex the
patient. An overall sensitivity was only 8%, specificity was shoulder forward to 90 degrees in the sagittal plane, with
84%, and PPV and NPV were 5% and 90%, respectively. the elbow completely extended. The patient is then asked
to adduct the arm horizontally 10 to 15 degrees medial
ACTIVE COMPRESSION TEST to the sagittal plane of the body, with the arm rotated
This test is also known as O’Brien’s test. internally so that the thumb is pointing downward
(Figure 13-9, A).
Indication
The active compression test is a clinical test to identify Action
superior labral pathology and acromioclavicular joint The examiner then places a downward force distal to the
involvement. patient’s elbow, with the patient resisting this downward
force as in a manual muscle test. The patient is asked
About the Test whether pain is produced during this maneuver and, if so,
This test, originally developed by Dr. Stephen O’Brien to identify its exact location.
from the Hospital for Special Surgery in New York, uses The test is repeated using the same position (90
a combination of glenohumeral joint positioning and degrees of sagittal plane shoulder flexion, full elbow

Maximum Maximum
internal external
rotation rotation

A B
10°
10° Adduction
Adduction

90° 90°
Flexion Flexion

Figure 13-9 O’Brien’s test. A, Starting position, and B, second position. (Adapted from O’Brien SJ et al: The active compression test:
a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality, Am J Sports Med 26(5):611, 1998.)
Ch13.qxd 5/24/04 4:54 PM Page 124

124 SECTION II Special Tests

A B C
Figure 13-10 O’Brien’s test, anatomic drawing for acromioclavicular (AC) joint. A, To demon-
strate the anatomic basis of the active compression test, selective cutting was performed to
create AC joint instability after testing in the intact situation. B, In the unstable AC joint, the
highest pressure generated was with the arm forward flexed 90 degrees with approximate-
ly 10 to 15 degrees of adduction and maximal internal rotation. C, In this position, the greater
tuberosity comes over and, by positioning, elevates the relatively depressed acromion and
“locks and loads” the AC joint. (Adapted from O’Brien SJ, et al: The active compression test:
a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality,
Am J Sports Med 26(5):611, 1998.)

extension, and 10 to 15 degrees of horizontal adduction Ramifications of a Positive Test

medial to the sagittal plane), except that the palm is now Cadaveric studies were performed with the active com-
placed in the “up” position, with a supinated forearm posi- pression test to determine the anatomic basis of the test
tion and external rotation of the humerus (Figure 13-9, maneuvers. The largest pressure between the acromiocla-
B). The uniform downward force is again applied and the vicular joint surfaces occurred with 90 degrees of shoulder
patient is asked whether this maneuver produces pain and, flexion in the sagittal plane, with 10 to 15 degrees of hor-
if so, its exact location. This test is most effective when the izontal adduction and internal rotation. Maneuvers that
patient is asked to resist the examiner’s downward force used more than 10 to 15 degrees of horizontal adduction
rather than when the examiner resists the patient’s upward produced a “bayoneting” effect, whereby the unstable
force. acromioclavicular joint was free from pressure as a result
of an override effect. This may explain the variable results
What Constitutes a Positive Test? seen with the cross-arm adduction test for acromioclavic-
O’Brien’s active compression test is considered positive ular joint pathology (O’Brien et al, 1998). Abduction
when the first maneuver (downward pressure with the arm of the arm away from the midline of the body produced
in the internally rotated position) elicits pain and when a relaxation of the acromioclavicular joint. The effect
that pain is eliminated with testing using the second of O’Brien’s test for acromioclavicular pathology is further
maneuver (downward pressure with the arm in the enhanced by the addition of active muscular contraction
externally rotated position). Pain indicates a positive test of the deltoid with anatomic attachment to both the
when it occurs in the following locations. For superior acromion and clavicle, with increased compressive
labral pathology, the pain must occur deep in the anterior force being measured during simulated contraction
aspect of the shoulder. Pain reproduction with this (Figure 13-10).
maneuver or painful clicking is also considered positive The mechanism for the provocation produced by the
for labral pathology. For acromioclavicular joint patho- active compression test on the superior labrum was iden-
logy, the pain must be localized and occur in the superior tified by arthroscopic evaluation (O’Brien et al, 1998).
or top of the shoulder directly over the acromioclavicular The position of shoulder flexion and horizontal adduction
joint. Pain in other locations besides the superior aspect causes the biceps long-head tendon to displace both
(acromioclavicular joint) or deep in the anterior aspect medially and inferiorly, tensioning the biceps-labral com-
(superior labral pathology) is not considered positive for plex (Figure 13-11). This position may also produce
this test. anterosuperior shear forces.
Ch13.qxd 5/24/04 4:54 PM Page 125

CHAPTER 13 Labral Testing 125

A B C
Figure 13-11 O’Brien’s test, anatomic drawing for SLAP. A, Anatomic drawing of the
shoulder in neutral position without force applied. B, When the arm is positioned in 90
degrees standard flexion, 10 to 15 degrees of adduction, and maximum internal rota-
tion, the biceps tendon displaces medially and inferiorly, extending the bicipital-labral
complex. C, Joint load increases because of the wind-up effect of the capsuloligament
and musculotendon units. (Adapted from O’Brien SJ, et al: The active compression test:
a new and effective test for diagnosing labral tears and acromioclavicular joint abnor-
mality, Am J Sports Med 26(5):613, 1998.)

Objective Evidence Regarding the Test those reported by O’Brien et al (1998). Compared with
In their original report, O’Brien et al (1998) included a the anterior slide test and the compression rotation test,
prospective study of 318 patients to measure the effective- which were also used in the population of 426 patients,
ness of their test. In all, 53 of 56 patients whose preoper- the active compression test had the highest sensitivity,
ative examinations indicated a superior labral tear had highest PPV, and lowest overall accuracy. It is important
confirmed labral tears during follow-up arthroscopic to note that the presence of a click and the location of
surgery; 55 of 62 patients with acromioclavicular joint pain were not particularly reliable diagnostic indicators.
pain during preoperative testing with O’Brien’s test had Stetson and Templin (2002) compared the results of
confirmed pathology and abnormalities at follow-up the active compression test with the crank test (pages
evaluation. 119–120) and routine MRI in the diagnosis of superior
For labral pathology, the O’Brien active compression labral pathology. They reported the active compression
test had a sensitivity of 100%, specificity of 98.5%, and test to have a sensitivity of 54%, specificity of 31%, PPV
PPV and NPV of 94% and 100%, respectively. For of 41%, and NPV of 61%. They concluded that the active
acromioclavicular joint pathology or abnormality, the test compression and crank tests are not sensitive clinical indi-
had a sensitivity of 100%, specificity of 96.6%, and PPV cators for detecting glenoid labrum pathology, and they
and NPV of 88.7% and 100%, respectively. found false-positive clinical tests in patients who had
McFarland et al (2002) used the active compression rotator cuff tears and impingement. Caution should be
test in 426 patients who subsequently underwent diag- used when interpreting the results of these individual clin-
nostic shoulder arthroscopy. The active compression test ical tests to detect glenoid labrum pathology.
was positive in 168 of 371 control patients (those with no Finally, Guanche and Jones (2003) used the active
arthroscopic evidence of labral pathology). A total of 18 of compression test during examination of 60 shoulders in
38 patients with verified superior labral pathology at time 59 patients before shoulder arthroscopy for shoulder pain.
of surgery also had a positive active compression test; Sensitivity values of 63% and specificity of 73% were
none of these 18 patients had a click with the actual test, reported, with PPV of 87% and NPV of 40% for the diag-
only pain reproduction. McFarland (2002) reported an nosis of any labral pathology. Values specifically for SLAP
overall sensitivity of 47%, a specificity of 55%, a PPV of lesions were lower, with sensitivity of 54%, specificity of
10%, and NPV of 91%. These values are far lower than 47%, PPV of 57%, and NPV of 45%.
Ch13.qxd 5/24/04 4:54 PM Page 126

126 SECTION II Special Tests

BICEPS LOAD TEST et al (1999) recommend that the movement be isolated to

include only elbow flexion, and that no other direction of
Indication resistance be performed simultaneously. Resistance should
The biceps load test is used to detect superior labral be strictly in line with the biceps tendon force vector,
pathology in individuals who have suffered recurrent which is in line with the long axis of the humerus.
anterior glenohumeral dislocations.
What Constitutes a Positive Test?
About the Test A positive biceps load test is present when the feeling of
This test was developed by Kim et al (1999) to test for apprehension does not change during contraction of the
SLAP lesions in shoulders of patients who have multiple biceps or actually becomes more apprehensive or painful
dislocations. The test was called the biceps load test to during inducement of the biceps contraction. A negative
represent the dynamic contribution of the biceps ten- biceps load test is present when the patient’s feeling of
don–superior labral complex. apprehension is lessened during contraction of the biceps.

Start Position Ramifications of a Positive Test

The test is performed with the patient in a supine posi- The biceps load test is positive when the feeling of appre-
tion. The examiner is seated next to the patient on the hension is not abated or improved by the contraction
same side as the extremity being tested. The examiner of the biceps/labral complex. Normally, the biceps and
grasps the patient’s elbow and wrist. The shoulder is superior labrum provide extensive stability to the gleno-
abducted 90 degrees in neutral rotation, and the forearm humeral joint (Rodosky et al, 1994), and failure of the
is placed in a supinated position (Figure 13-12, A). The biceps contraction to improve the apprehensive feeling in
patient is allowed to relax in this resting position. the abducted, externally rotated position indicates that
these superior structures are not functioning (Kim et al,
Action 1999).
An anterior apprehension test is performed with the
examiner taking the shoulder back into external rotation Objective Evidence Regarding the Test
while maintaining 90 degrees of abduction. When the Kim et al (1999) compared the effectiveness of the biceps
patient becomes apprehensive, the external rotation is load test, including the apprehension test, biceps tension
stopped and the position is maintained. The patient is test, and compression rotation test. Tests were performed
then asked to flex the elbow while the examiner resists the on 75 consecutive patients with unilateral glenohumeral
movement with the hand placed near the patient’s wrist joint dislocations with a Bankart lesion. The biceps load
(Figure 13-12, B). The patient is asked how this affects test was negative in 63 patients and positive in 12. Of the
the feeling of apprehension. To optimize test results, Kim 63 patients with a negative test, 62 showed no evidence of

A B

Figure 13-12 Biceps load test. A, Starting position. B, Ending position.

Ch13.qxd 5/24/04 4:54 PM Page 127

CHAPTER 13 Labral Testing 127

superior labral injury; one patient had a type II superior

labral lesion. Ten of the 12 patients with positive biceps
load tests had arthroscopic evidence of superior labral
injury. Sensitivity of the biceps load test was 90.9%, speci-
ficity was 96.9%, PNV was 83%, and NPV was 98%. The
kappa coefficient representing the intraobserver reliability
of the test was 0.846. Among the other tests performed by
these examiners, the compression rotation test detected
only three SLAP lesions.

BICEPS LOAD TEST II

Indication
The biceps load test II is a clinical test to detect isolated
superior labral injuries of the shoulder.
Figure 13-13 Biceps load test II.
About the Test
This test was developed by Kim et al (2001) as a counter-
part to the biceps load test (see pages 126–127) to assist in
the detection of isolated superior labral lesions. It uses the
dynamic contraction of the biceps as an integral part of contraction of the biceps against the resistance in the
the test. abducted and externally rotated position eliminates
the standard apprehension of patients with unstable
Start Position shoulders who have intact biceps-labral complexes as a
The test is conducted with the patient in a supine posi- result of compression of the humeral head into the gle-
tion. The examiner sits directly beside the patient, on the noid and the concavity compression mechanism. Second,
same side as the extremity being tested. The examiner active contraction of the biceps against resistance further
grasps the patient’s extremity at the elbow and wrist. The stresses the attachment of the biceps superior labral com-
shoulder is abducted 90 degrees in the coronal plane and plex, by which pain is elicited in the shoulder with a type
externally rotated to its maximal point. The elbow remains II SLAP lesion. Finally, based on the results of a cadaver-
in 90 degrees of flexion throughout the test, and the fore- ic study by Kuhn et al (1999), the biceps labral complex
arm is in a supinated position, so that the patient’s palm fails under significantly less force for the cocking position
faces directly toward their head. of throwing (60 degrees abduction with maximal 125
degrees of external rotation in the scapular plane) than in
Action a position with less external rotation and abduction. This
The patient is asked to flex the elbow while the examiner study suggests the importance of the ultimate position
resists elbow flexion, so that an isometric contraction of used in testing during the biceps load test II (Figure 13-
the biceps muscle occurs (Figure 13-13). Care must be 14). This concept is supported by Burkhart & Morgan
taken to isolate the resistance to the elbow flexion compo- (1998), who reported the peel-back mechanism that
nent to avoid additional loads placed on the shoulder. occurs in the superior labrum with the glenohumeral joint
in positions of abduction and external rotation with
What Constitutes a Positive Test? humeral head translation.
The test is considered positive if the patient complains Kim et al (2001), concluded that the reproduction
of pain during resisted elbow flexion and negative if no of pain in the abducted externally rotated position used
pain is elicited, if the pretesting pain level is diminished during the biceps load test II is elicited by the forceful
during the elbow flexion resistance, or if the pain level is traction of the displaced biceps superior labral complex
unchanged. during resistance to the biceps muscle.

Ramifications of a Positive Test Objective Evidence Regarding the Test

The biceps load test II is a dynamic test to assess the Kim et al (2001) reported a prospective biceps load test II
integrity of the superior labrum and is based on three in 127 patients undergoing shoulder arthroscopy. A posi-
principles, according to Kim et al (2001). First, the tive biceps load test II was found in 38 patients, which
Ch13.qxd 5/24/04 4:54 PM Page 128

128 SECTION II Special Tests

A B

Figure 13-14 Biceps load test II. A, In the neutral rotation position of the shoulder, the
biceps tendon is parallel to the posterosuperior labrum. B, The abduction and external rota-
tion of the shoulder during the biceps load test II changes the relative direction of the biceps
fiber in a position that is of an oblique angle to the posterosuperior labrum. This change in
the vector of the biceps force increases the pain generated on the superior labrum that is
peeled off the glenoid margin during the resisted contraction of the biceps in the abducted
and externally rotated position. (From Kim SH, et al: Biceps load test II for SLAP lesions of
the shoulder, Arthroscopy 17(2):163, 2001.)

correlated positively with 35 superior labral lesions found extremity of the patient). An abduction angle of 90 to 100
during subsequent surgical procedures, resulting in a sen- degrees in the coronal plane is used throughout the test.
sitivity of 89.7%, a specificity of 96.9%, a PPV of 92.1% The elbow is placed in 90 degrees of flexion, where it
and an NPV of 95.5%. Intraobserver reliability was mea- remains during the test. The examiner’s other hand is
sured using a kappa coefficient (0.815), which indicates placed over the top of the shoulder to stabilize the arm
a high level of intraobserver reliability. during the movement described next.
No additional research has been reported using the
biceps load test II. Action
The examiner rotates the shoulder externally, keeping the
MIMORI PAIN PROVOCATION TEST glenohumeral joint abduction angle in a position of 90 to
100 degrees. This portion of the maneuver is similar to the
Indication anterior apprehension test. The Mimori pain provocation
The Mimori pain provocation test is used to detect supe- test is performed with the forearm in two positions, once
rior labral pathology. in a fully pronated position (Figure 13-15, A) and once in
a fully supinated position (Figure 13-15, B). In each posi-
About the Test tion the shoulder is brought back into end-range external
This test was developed by Mimori et al (1999) to evalu- rotation. The patient is asked which of the two forearm
ate the integrity of the superior labrum. This test uses the positions provoked the most pain.
tension imparted to the biceps long-head tendon to pro-
voke pain and reproduce symptoms in an overhead posi- What Constitutes a Positive Test?
tion inherent in many sport-specific movement patterns The test is positive for a superior labral tear when pain
and functional activities. is provoked only when the forearm is placed in the
pronated position, or when pain provoked in the pronated
Start Position position is greater than pain provoked in the supinated
The patient is examined in a seated position. The exam- position. The test is negative when there is either no
iner stands behind the patient and grasps the distal aspect difference in pain between the two forearm conditions, or
of the forearm (examiner’s right hand to examine the right when the forearm is less painful in the pronated position.
Ch13.qxd 5/24/04 4:54 PM Page 129

CHAPTER 13 Labral Testing 129

A B

Figure 13-15 Pain provocation test. A, Pronated position. B, Supinated position.

Ramifications of a Positive Test arthroscopy to determine the efficacy of the pain provoca-
Tension in the long head of the biceps is greater when the tion test. In 22 patients, detachment of the superior
Mimori pain provocation test is performed with the fore- labrum was confirmed with an arthrogram, and all of
arm in a pronated position than in a supinated position. these patients had a positive pain provocation test; 11
The greater length of the biceps tendon in the pronated of 15 patients had type II SLAP lesions at the time of
forearm position is thought to create more stress on the arthroscopy and all of them had a positive Mimori pain
superior labrum. provocation test; sensitivity was 100% and specificity was
90%. No additional research is available for this test. In
Objective Evidence Regarding the Test the same study, the crank test (pages 119–120) detected
Mimori et al (1999) reported results of a prospective detachment of the superior labrum, with a sensitivity of
analysis of the Mimori pain provocation test in 32 83% and a specificity of 100%. This study supports the use
patients who, after testing, had MRI evaluation of the of both the pain provocation and crank test in patients
shoulder; 15 of these patients were also evaluated with with suspected SLAP lesions.
Ch14.qxd 5/24/04 4:55 PM Page 133

CHAP TER

14 Muscular Strength Testing

INTRODUCTION glenohumeral joint (Ellenbecker & Mattalino, 1996;

The most clinically relevant method used to assess Davies & Ellenbecker, 1993).
strength of the shoulder girdle is manual muscle testing
(MMT). Since its development in the early 1900s during MANUAL MUSCLE TESTING OF
the study of muscle function in patients with THE ROTATOR CUFF
poliomyelitis, MMT has become a standard practice Kelly et al (1996) used electromyography (EMG)
during the physical evaluation of patients with both to determine the optimal position for testing the muscles
neurologic and orthopedic injuries (Daniels & of the rotator cuff in human subjects. Four criteria were
Worthingham, 1980). Although beneficial in nearly all used to establish which position was optimal for each
aspects of rehabilitative evaluation, MMT has some rotator cuff muscle: maximal activation of the muscle,
limitations in reliability. The technique of MMT has minimal contribution from shoulder synergists, minimal
been found to be reliable within one grade between two provocation of pain, and good test-retest reliability.
examiners (Aitkens et al, 1989; Lilienfeld et al, 1954);
however, Frese et al (1987) reported low intertester relia- Supraspinatus
bility in 110 patients for the middle trapezius and gluteus
Kelly et al (1996) found the optimal muscle testing posi-
medius musculature. They concluded that caution must be
tion for the supraspinatus to be at 90 degrees of elevation,
used when interpreting the results of MMT between two
with the patient seated. The scapular plane position was
or more examiners. It is beyond the scope of this text to
used (in this research this represented 45 degrees of hori-
completely review all aspects of MMT. This chapter
zontal adduction from the coronal plane) with external
describes several studies that have objectively identified
rotation of the humerus such that the forearm was placed
positions for testing muscles in the shoulder complex,
in neutral position and the thumb was pointing upward
with particular emphasis on the rotator cuff (Kelly et al,
(Figure 14-1). This position was termed the full can test-
1996). The reader is referred to more detailed texts dedi-
ing position. Another position used to assess the strength
cated to MMT (Daniels and Worthington, 1980; Kendall
of the supraspinatus muscle-tendon unit is the empty can
and McCreary, 1983) for comprehensive descriptions and
test (Figure 14-2). This test position has been advocated
theories on the technique itself. Table 14-1 lists specific
by Jobe and Bradley (1989), and indwelling EMG has
muscles and their respective neural derivations and
documented high levels of supraspinatus muscular activa-
actions.
tion (Malanga et al, 1997). See the discussion by Itoi et al
During a comprehensive musculoskeletal evaluation,
(1999) comparing the empty can and full can tests on
MMT of the axioscapular, scapulohumeral, and scapu-
pages 97–99 in this text.
lothoracic muscles is indicated, with specific reference to
the muscles of the rotator cuff. Testing the muscles in the
distal portion of the upper extremity and trunk is also Infraspinatus
indicated, as a result of the kinetic chain function of the According to Kelly et al (1996), the optimal position to
body and the importance of the transfer of muscle force test for infraspinatus strength is with the patient in a
from the lower extremity and trunk during functional seated position, with 0 degrees of glenohumeral joint
activities (Marshall & Elliott, 2000). Use of concepts such elevation and in 45 degrees of internal rotation from
as total arm strength and kinetic chain during rehabilita- neutral (Figure 14-3). This position is similar to that used
tion requires knowledge of muscular strength and the in the Neer drop test (pages 102–103) to evaluate for
endurance of the segments proximal and distal to the severe functional loss of the infraspinatus muscle. Jenp

133
Ch14.qxd 5/24/04 4:55 PM Page 134

134 SECTION III Additional Shoulder Evaluation Techniques

Table 14-1 Muscles About the Shoulder: Actions and Neural Derivation
Nerve Root
Action Muscles Acting Nerve Supply Derivation
Forward flexion 1. Deltoid (anterior fibers) Axillary (circumflex) C5-C6 (posterior cord)
2. Pectoralis major (clavicular Lateral pectoral C5-C6 (lateral cord)
fibers)
3. Coracobrachialis Musculocutaneous C5-C7 (lateral cord)
4. Biceps (when strong Musculocutaneous C5-C7 (lateral cord)
contraction required)
Extension 1. Deltoid (posterior fibers) Axillary (circumflex) C5-C6 (posterior cord)
2. Teres major Subscapular C5-C6 (posterior cord)
3. Teres minor Axillary (circumflex) C5-C6 (posterior cord)
4. Latissimus dorsi Thoracodorsal C6-C8 (posterior cord)
5. Pectoralis major Lateral pectoral C5-C6 (posterior cord)
(sternocostal fibers) Medial pectoral C8, T1 (medial cord)
6. Triceps (long head) Radial C5-C8, T1 (posterior cord)
Horizontal adduction 1. Pectoralis major Lateral pectoral C5-C6 (lateral cord)
2. Deltoid (anterior fibers) Axillary (circumflex) C5-C6 (posterior cord)
Horizontal abduction 1. Deltoid (posterior fibers) Axillary (circumflex) C5-C6 (posterior cord)
2. Teres major Subscapular C5-C6 (posterior cord)
3. Teres minor Axillary (circumflex) C5-C6 (brachial plexus trunk)
4. Infraspinatus Suprascapular C5-C6 (brachial plexus trunk)
Abduction 1. Deltoid (posterior fibers) Axillary (circumflex) C5-C6 (posterior cord)
2. Supraspinatus Suprascapular C5-C6 (brachial plexus trunk)
3. Infraspinatus Suprascapular C5-C6 (brachial plexus trunk)
4. Subscapularis Subscapular C5-C6 (posterior cord)
5. Teres minor Axillary (circumflex) C5-C6 (posterior cord)
6. Long head of biceps Musculocutaneous C5-C7 (lateral cord)
(if arm laterally rotated
first, trick movement)
Adduction 1. Pectoralis major Lateral pectoral C5-C6 (lateral cord)
2. Latissimus dorsi Thoracodorsal C6-C8 (posterior cord)
3. Teres major Subscapular C5-C6 (posterior cord)
4. Subscapularis Subscapular C5-C6 (posterior cord)
Medial rotation 1. Pectoralis major Lateral pectoral C5-C6 (lateral cord)
2. Deltoid (anterior fibers) Axillary (circumflex) C5-C6 (posterior cord)
3. Latissimus dorsi Thoracodorsal C6-C8 (posterior cord)
4. Teres major Subscapular C5-C6 (posterior cord)
5. Subscapularis Subscapular C5-C6 (posterior cord)
(when arm is by side)
Lateral rotation 1. Infraspinatus Suprascapular C5-C6 (brachial plexus trunk)
2. Deltoid (posterior fibers) Axillary (circumflex) C5-C6 (posterior cord)
3. Teres minor Axillary (circumflex) C5-C6 (posterior cord)
Elevation of scapula 1. Trapezius (upper fibers) Accessory Cranial nerve XI
C3-C4 nerve roots C3-C4
2. Levator scapulae C3-C4 nerve roots C3-C4
Dorsal scapular C5
3. Rhomboid major Dorsal scapular (C4), C5
4. Rhomboid minor Dorsal scapular (C4), C5
Depression of scapula 1. Serratus anterior Long thoracic C5-C6, (C7)
2. Pectoralis major Lateral pectoral C5-C6 (lateral cord)
3. Pectoralis minor Medial pectoral C8, T1 (medial cord)
4. Latissimus dorsi Thoracodorsal C6-C8 (posterior cord)
5. Trapezius (lower fibers) Accessory Cranial nerve XI
C3-C4 nerve roots C3-C4

From Magee DJ: Orthopedic physical assessment, ed 4, Philadelphia, 2002, WB Saunders.

Ch14.qxd 5/24/04 4:55 PM Page 135

CHAPTER 14 Muscular Strength Testing 135

Table 14-1 Muscles About the Shoulder: Actions and Neural Derivation—cont’d
Nerve Root
Action Muscles Acting Nerve Supply Derivation

Protraction (forward 1. Serratus anterior Long thoracic C5-C6, (C7)

movement) of 2. Pectoralis major Lateral pectoral C5-C6 (lateral cord)
scapula 3. Pectoralis minor Medial pectoral C8, T1 (medial cord)
4. Latissimus dorsi Thoracodorsal C6-C8 (posterior cord)
Retraction (backward 1. Trapezius Accessory Cranial nerve XI
movement) of 2. Rhomboid major Dorsal scapular (C4), C5
scapula 3. Rhomboid minor Dorsal scapular (C4), C5
Lateral (upward) 1. Trapezius (upper and Accessory Cranial nerve XI
rotation of inferior lower fibers) C3-C4 nerve roots C3-C4
angle of scapula 2. Serratus anterior Long thoracic C5-C6, (C7)
Medial (downward) 1. Levator scapulae C3-C4 nerve roots C3-C4
rotation of inferior 2. Rhomboid major Dorsal scapular (C4), C5
angle of scapula 3. Rhomboid minor Dorsal scapular (C4), C5
4. Pectoralis minor Dorsal scapular (C4), C5
Medial pectoral C8, T1 (medial cord)
Flexion of elbow 1. Brachialis Musculocutaneous C5-C6, (C7)
2. Biceps brachii Musculocutaneous C5-C5
3. Brachioradialis Radial C5-C6, (C7)
4. Pronator teres Median C6-C7
5. Flexor carpi ulnaris Ulnar C7-C8
Extension of elbow 1. Triceps Radial C6-C8
2. Anconeus Radial C7-C8, (T1)

30°

Figure 14-1 Full can test. (Adapted from Kelly BT, Kadrmas WR, Figure 14-2 Empty can test. (Adapted from Jobe FW, Bradley
Speer KP: The manual muscle examination for rotator cuff JP: The diagnosis and nonoperative treatment of shoulder injuries
strength. An electromyographic investigation, Am J Sports Med in athletes, Clin Sports Med 8(3):424, 1989.)
24(5):585, 1996.)
Ch14.qxd 5/24/04 4:55 PM Page 136

136 SECTION III Additional Shoulder Evaluation Techniques

Figure 14-3 Infraspinatus MMT position. Figure 14-4 Patte test: MMT in 90 degrees of external rotation
with 90 degrees of scapular plane elevation.

et al (1996) recommended an alternative position for test- pages 99–101 for additional discussion of the Gerber
ing infraspinatus strength in which the shoulder is in 90 lift-off test).
degrees of elevation in the sagittal plane, with the arm in
half maximal external rotation. ALTERNATIVE FORMS OF STRENGTH
EVALUATION FOR THE SHOULDER
Teres Minor Because of the limitations of MMT, particularly in the
evaluation of muscular strength in individuals with only
Kelly et al (1996) did not report on the teres minor mus-
subtle muscular weakness or muscular imbalance, clini-
cle; however, both Walch et al (1998) and Leroux et al
cians often use alternative forms of muscular strength test-
(1995) have recommended the use of the Patte test (Patte
ing. These alternatives can include augmentation of MMT
et al, 1988) to isolate the teres minor. In this test, the
positions with hand-held dynamometers to assess isomet-
glenohumeral joint is abducted 90 degrees in the scapular
ric muscular performance, as well as the use of isokinetic
plane with 90 degrees of external rotation (Figure 14-4).
dynamometers to evaluate dynamic muscular performance
characteristics. A review of the basic theory, rationale for
Subscapularis use, and interpretation of isokinetics is indicated to facili-
Kelly et al (1996) reported the optimal position for tate optimal dynamic evaluation of the shoulder complex.
subscapularis muscular activation to be in the Gerber
lift-off position (Figure 14-5). This position is consistent Rationale for Use of Isokinetics in Upper Extremity
with Gerber and Krushell (1991) but in contrast to Stefko Strength Assessment
et al (1997), who found the highest isolated muscular Unlike the lower extremity, where most functional and
activity with the dorsal aspect of the hand placed up sport-specific movements occur in a closed kinetic chain
near the inferior border of the ipsilateral scapula (see environment, the upper extremity almost exclusively func-
Ch14.qxd 5/24/04 4:55 PM Page 137

CHAPTER 14 Muscular Strength Testing 137

methodology for the upper extremity. MMT provides a

static alternative for the assessment of muscular strength,
using well-developed patient positions and stabilization
(Daniels & Worthingham, 1980; Kendall & McCreary,
1983). Despite the detailed description of manual assess-
ment techniques, the reliability of MMT is compromised
as a result of clinician size/strength differences and the
subjective nature of the grading system (Frese et al, 1987).
Ellenbecker (1996) compared isokinetic testing of the
shoulder internal and external rotators with MMT in 114
subjects exhibiting manually assessed, symmetric normal
grade (5/5) strength. Isokinetic testing found 13% to 15%
bilateral differences in external rotation and 15% to 28%
bilateral differences in internal rotation. Of particular
significance was the large variability in the size of this
mean difference between extremities, despite bilaterally
symmetric MMT. The use of MMT is an integral part of
a musculoskeletal evaluation. MMT provides a time-
efficient, gross screening of muscular strength of multiple
muscles using a static, isometric muscular contraction,
particularly in situations of neuromuscular disease or in
patients with large muscular strength deficits. Limitations
of MMT appear to be most evident where only minor
impairment of strength is present, as well as in the identi-
fication of subtle, isolated strength deficits. Differentiation
Figure 14-5 Gerber lift-off MMT.
of agonist/antagonist muscular strength balance is also
complicated when using manual techniques, as opposed to
using isokinetic instrumentation (Ellenbecker, 1996).
tions in an open kinetic chain format (Ellenbecker &
Davies, 2001). The throwing motion, volleyball spike, Use of Isokinetic Testing for the Shoulder Complex
tennis serve, and tennis groundstrokes are all examples of Initial testing and training using isokinetics for rehabilita-
open kinetic chain activities for the upper extremity. The tion and testing of the shoulder typically involve the
use of open kinetic chain muscular strength, power, and modified-base position, which is obtained by tilting the
endurance assessment methodology allows for isolation of dynamometer approximately 30 degrees from the hori-
particular muscle groups, as opposed to closed-chain zontal base position (Davies, 1992). The patient’s gleno-
methods, which use multiple joint axes, planes, and joint humeral joint is placed in 30 degrees abduction and 30
and muscle segments. Traditional isokinetic upper degrees forward flexion into the plane of the scapula or
extremity test patterns are open chain with respect to the scaption, and with a 30-degree diagonal tilt of the
shoulder. The velocity spectrum (1 degree per second to dynamometer head from the transverse plane (Figure
approximately 600 degrees per second) currently available 14-6). This position has also been termed the 30/30/30
on commercial isokinetic dynamometers provides speci- internal/external rotation position by Davies (1992). The
ficity with regard to testing the upper extremity by allow- modified base position places the shoulder in the scapular
ing the clinician to assess muscular strength, power, and plane 30 degrees anterior to the coronal plane (Saha,
endurance at faster, more functional speeds. Admittedly, 1983). The scapular plane is characterized by enhanced
most functional activities have angular velocities far bony congruity and a neutral glenohumeral position,
exceeding the capabilities of isokinetic dynamometers; which results in a mid-range position for the anterior cap-
however, the velocities in the upper extremity are a sum- sular ligaments and enhances the length-tension relation-
mation of numerous joint movements and muscular forces ship of the scapulohumeral musculature (Saha, 1983).
(Marshall & Elliott, 2000). The modified base position does not place the supra-
The dynamic nature of upper extremity movements is humeral structures in an impingement situation and is
a crucial factor in directing the clinician to optimal testing well tolerated by patients (Davies, 1992).
Ch14.qxd 5/24/04 4:55 PM Page 138

138 SECTION III Additional Shoulder Evaluation Techniques

Figure 14-7 The Cybex isokinetic dynamometer position used

for testing the glenohumeral joint in 90 degrees of abduction in
the coronal plane.

with intraclass correlation coefficients (ICCs) applied to

determine the degree of test-retest reliability. There was
high test-retest reliability, with ICCs ranging between
0.91 and 0.96. This is one of the first studies to demon-
strate reliability of this frequently used position in the
clinical setting.
Internal and external rotation strength is also fre-
quently assessed using isokinetic testing with 90
degrees of glenohumeral joint abduction (Figure 14-7).
Specific advantages of this test position include greater
Figure 14-6 Modified base isokinetic dynamometer position stabilization in either a seated or supine test position on
used for testing and training glenohumeral joint internal and exter-
nal rotation.
most dynamometers and placement of the shoulder in an
abduction angle corresponding to the overhead throwing
position used in many sport activities (Elliott et al, 1986).
Isokinetic testing using the modified base position Initial tolerance of the patient to the modified base
requires consistent application of the patient to the position (30/30/30) is required as a precursor to use of the
dynamometer. Studies have demonstrated significant dif- 90-degree abducted position. Ninety-degree abducted
ferences in internal and external rotation strength, with isokinetic testing can be performed in either the coronal
varying degrees of abduction, flexion, and horizontal or scapular plane. Benefits of the scapular plane are simi-
abduction/adduction of the glenohumeral joint lar to those discussed in the modified position and include
(Hageman et al, 1989; Soderberg & Blaschak, 1987; protection of the anterior capsular glenohumeral liga-
Walmsley & Szybbo, 1987). The modified base position ments and a theoretical length-tension enhancement of
uses a standing patient position on many dynamometer the posterior rotator cuff (Greenfield et al, 1990).
systems, which can lead to compromises in both gleno- Changes in length-tension relationships and the line
humeral joint isolation and test-retest reliability. Despite of action of scapulohumeral and axiohumeral musculature
these limitations, valuable data can be obtained early in are reported in 90 degrees of glenohumeral joint
the rehabilitative process using this neutral modified base abduction compared with a more neutral adducted gleno-
position, which is a safe, comfortable position for most humeral joint position (Davies, 1992). Use of the 90-
patients with most pathologies and postsurgical consider- degree abducted position of isokinetic strength assessment
ations (Davies, 1992; Ellenbecker & Davies, 2001). addresses more specifically muscular function required for
Knops et al (1999) conducted a test-retest reliability overhead activities (Bassett et al, 1994).
study of the modified neutral position for internal/exter- Primary emphasis is placed on assessment of internal
nal rotation of the glenohumeral joint. This position and external rotation strength of the shoulder during
places the arm in a 30/30/30 position. Velocity spectrum rehabilitation. Rationale for this apparently narrow focus
testing at 60/180/300 degrees per second was performed, is provided by an isokinetic training study by Quincy et al
Ch14.qxd 5/24/04 4:55 PM Page 139

CHAPTER 14 Muscular Strength Testing 139

(2000). Six weeks of isokinetic training of the internal as in elite level junior (Chandler et al, 1992;
and external rotators produced statistically significant Ellenbecker, 1991) and adult (Ellenbecker, 1991) tennis
improvements in not only internal and external rotation players. No difference between extremities was demon-
strength but also in flexion/extension and abduction/ strated in concentric external rotation in professional
adduction strength. Isokinetic training of shoulder (Ellenbecker & Mattalino, 1999a; Wilk et al, 1993) and
flexion/extension and abduction/adduction produced collegiate (Cook et al, 1987) baseball pitchers, as well as in
improvements only in the position of training with no elite junior (Chandler et al, 1992; Ellenbecker, 1992) and
overflows. The overflow of strength caused by training the adult (Ellenbecker, 1991) tennis players. This selective
internal and external rotators provides the rationale for strength development in the internal rotators produces sig-
the primary emphasis on strength development and nificant changes in agonist/antagonist muscular balance.
assessment in rehabilitation. Additional research has iden- In all the aforementioned activities, the internal rotators
tified the internal/external rotation movement pattern as are the primary muscle group used during the acceleration
the preferable testing pattern in patients with rotator cuff phase of the throwing or overhead activity, thereby demon-
tendinosis (Holm et al, 1996). strating specificity of muscular adaptation. Identification
of this muscular imbalance using isokinetic testing has
Interpretation of Glenohumeral Joint Internal and implications for rehabilitation and injury prevention.
External Rotation Testing
Unilateral Strength Ratios (Agonist/Antagonist)
Bilateral Comparisons Assessment of muscular strength balance of the internal
Similar to isokinetic testing of the lower extremity, assess- and external rotators is of vital importance when interpret-
ment of an extremity’s strength, power, and endurance rel- ing upper extremity strength tests. Alteration of this exter-
ative to the contralateral side forms the basis for standard nal/internal ratio (ER/IR) has been reported in patients
data interpretation. This practice is more complicated with glenohumeral joint instability and impingement
in the upper extremity because of limb dominance, par- (Leroux et al, 1994; Warner et al, 1990). The initial descrip-
ticularly in the unilaterally dominant sport athlete. In tion of the ER/IR ratio on normal subjects was published
addition to the complexities added by limb dominance, by Ivey et al (1985) and Davies (1992) for both males and
isokinetic descriptive studies demonstrate disparities in females. An ER/IR ratio of approximately 66% is targeted
the degree of limb dominance, as well as the presence of in normal subjects. One unique aspect of the ER/IR ratio is
strength dominance only in specified muscle groups that it appears to remain approximately 66% throughout
(Alderink & Kluck, 1986; Chandler et al, 1992; Cook the velocity spectrum. The ER/IR ratio is one of the few
et al, 1987; Ellenbecker, 1991, 1992; Ellenbecker & unilateral strength ratios in the body to demonstrate this
Mattalino, 1999a; Hinton, 1988). unique, consistent relationship at all velocities.
In general, a maximum limb dominance of the internal There have been widespread reports of alteration of the
and external rotators of 5% to 10% is assumed in non- ER/IR ratio resulting from selective muscular develop-
athletic and recreational level upper extremity sport ath- ment of the internal rotators without concomitant exter-
letes (Davies, 1992). Ellenbecker and Bleacher (1999) nal rotation strength (Alderink & Kluck, 1986; Chandler
measured 38 active adult females between the ages of 18 et al, 1992; Cook et al, 1987; Ellenbecker, 1991, 1992;
and 45 and found significantly greater internal rotation Ellenbecker & Mattalino, 1999a; Hinton, 1988). This
strength (P < 0.01), with no significant difference in alteration has provided clinicians objective rationale for
external rotation strength. Testing was performed using the global recommendation of preventive posterior rotator
the NORM isokinetic dynamometer (Cybex, Inc., cuff external rotation (ER) strengthening programs for
Ronkonkoma, NY ), with subjects seated with stabiliza- athletes in high-level overhead activities (Wilk & Arrigo,
tion straps and the shoulder in the scapular plane and at 1993). Clinicians have advocated biasing this ratio in
45 degrees of glenohumeral joint abduction. favor of the external rotators for both prevention of injury
Several studies have been performed to determine the in throwing and racquet sport athletes, as well as after
degree of unilateral strength dominance in unilaterally insult or surgery to the glenohumeral joint (Davies, 1992;
dominant upper extremity sport athletes. Significantly Wilk & Arrigo, 1993; Ellenbecker & Davies, 2001).
greater internal rotation strength has been identified in the Examples of ER/IR ratios are presented with respect to
dominant arm in professional (Ellenbecker & Mattalino, population and apparatus specificity in Tables 14-2
1999a; Brown et al, 1988), collegiate (Cook et al, 1987), through 14-4 (Ellenbecker & Roetert, 2003; Ellenbecker
and high school (Hinton, 1988) baseball players, as well & Mattalino, 1999a; Wilk).
Ch14.qxd 5/24/04 4:55 PM Page 140

140 SECTION III Additional Shoulder Evaluation Techniques

Table 14-2 Isokinetic External Rotation/Internal Rotation Ratios in Elite Junior Tennis Players*
Dominant Arm Nondominant Arm
Peak Torque (%) Work (%) Peak Torque (%) Work (%)
Male, 210°/sec 69 64 81 81
Male, 300°/sec 69 65 82 83
Female, 210°/sec 69 63 81 82
Female, 300°/sec 67 61 81 77

From Ellenbecker & Roetert: J Science & Medicine in Sport, 2003.

*A Cybex 6000 series Isokinetic Dynamometer and 90° of glenohumeral joint abduction were used. Data are expressed as ER/IR ratios representing
the relative muscular balance between the external and internal rotators.

Table 14-3 Unilateral External Table 14-4 Unilateral External

Rotation/Internal Rotation Ratios Rotation/Internal Rotation Ratios
in Professional Baseball Pitchers in Professional Baseball Pitchers
Dominant Nondominant Dominant Nondominant
Speed Arm Arm Speed Arm Arm
210°/sec 180°/sec
Torque 64 74 Torque 65 64
Work 61 66 300°/sec
300°/sec Torque 61 70
Torque 65 72
Work 62 70 Data from Wilk KE, Andrews JR, Arrigo CA, et al: The strength
characteristics of internal and external rotator muscles in
Data from Ellenbecker TS, Mattalino AJ: Concentric isokinetic shoulder professional baseball pitchers, Am J Sports Med 21:61-66, 1993.
internal and external rotation strength in professional baseball
pitchers, J Orthop Sports Phys Ther 25:323-328, 1997.

Normative Data Utilization Inman force couple (Inman et al, 1944) and the func-
Use of normative or descriptive data can help clinicians tional relationship of the adductors to throwing velocity
further analyze isokinetic test data. Care must be taken to (Bartlett et al, 1989; Pedegana et al, 1982). Specific factors
use normative data that are both population and appara- important in this testing pattern are the limitation of
tus specific (Davies, 1992). Tables 14-5 through 14-7 range of motion to approximately 120 degrees to avoid
present data from large samples of specific athletic popu- glenohumeral joint impingement and consistent use of
lations on two dynamometer systems. Data are presented gravity correction (Davies, 1992). No formal research
using body weight as the normalizing factor. specifically addressing the test-retest reliability of the
Another application for normative data is to normalize shoulder abduction/adduction isokinetic testing pattern
the isokinetic parameters to the patient’s body weight has been published.
when bilateral injury is present. Bilateral comparisons and Interpretation of abduction/adduction isokinetic tests
unilateral strength ratios may often be within normal follows traditional bilateral comparison, normative data
limits; however, if the patient has torque- and work-to- comparison, and unilateral strength ratios. Ivey et al
body-weight ratios that are lower than normative data, (1985) reported abduction/adduction (AB/ADD) ratios
this may indicate that the patient may not be fully reha- of 50% bilaterally in normal adult females. Similar find-
bilitated from a muscular standpoint. ings were reported by Alderink & Kluck (1986) in high
school and collegiate baseball pitchers. Wilk et al (1991,
Additional Glenohumeral Joint Testing Positions 1992) reported dominant arm AB/ADD ratios of 85%
to 95% using a Biodex dynamometer. Their analysis used
Adduction/Abduction a windowing technique, which removed impact artifact
Isokinetic evaluation of shoulder abduction/adduction after free limb acceleration and end stop impact from the
strength is an additional pattern frequently evaluated data. Upper extremity testing, using long input adapters
because of the key role played by the abductors in the and fast isokinetic testing velocities, can produce torque
Ch14.qxd 5/24/04 4:55 PM Page 141

CHAPTER 14 Muscular Strength Testing 141

Table 14-5 Isokinetic Peak Torque–to–Body Weight Ratios and Single Repetition Work–to–Body
Weight Ratios in Elite Junior Tennis Players*
Dominant Arm Nondominant Arm
Peak Torque (%) Work (%) Peak Torque (%) Work (%)
EXTERNAL ROTATION (ER)
Male, 210°/sec 12 20 11 19
Male, 300°/sec 10 18 10 17
Female, 210°/sec 8 14 8 15
Female, 300°/sec 8 11 7 12
INTERNAL ROTATION (IR)
Male, 210°/sec 17 32 14 27
Male, 300°/sec 15 28 13 23
Female, 210°/sec 12 23 11 19
Female, 300°/sec 11 15 10 13

*A Cybex 6000 series Isokinetic Dynamometer and 90° of glenohumeral joint abduction were used. Data are expressed in foot-pounds per unit of
body weight for ER and IR.
From Ellenbecker & Roetert: J Science and Medicine in Sport, 2003.

Table 14-6 Isokinetic Peak Torque–to–Body Weight Ratios from 150 Professional Baseball Pitchers*
Internal Rotation External Rotation
Speed Dominant Arm Nondominant Arm Dominant Arm Nondominant Arm
180°/sec 27% 17% 18% 19%
300°/sec 25% 24% 15% 15%

From Wilk KE, Andrews JR, Arrigo CA, et al: The strength characteristics of internal and external rotator muscles in professional baseball pitchers,
Am J Sports Med 21:61-66, 1993.
*Data were obtained on a Biodex Isokinetic Dynamometer.

Table 14-7 Isokinetic Peak Torque–to–Body Weight and Work–to–Body Weight Ratios from 147
Professional Baseball Pitchers*
Internal Rotation External Rotation
Speed Dominant Arm Nondominant Arm Dominant Arm Nondominant Arm
210°/sec
Torque 21% 19% 13% 14%
Work 41% 38% 25% 25%
300°/sec
Torque 20% 18% 13% 13%
Work 37% 33% 23% 23%

Data from Ellenbecker TS, Mattalino AJ: Concentric isokinetic shoulder internal and external rotation strength in professional baseball pitchers, J
Orthop Sports Phys Ther 25:323-328, 1997.
*Data were obtained on a Cybex 350 Isokinetic Dynamometer.

artifact that significantly changes the isokinetic test result. and horizontal AB/ADD. Both of these motions are gen-
Wilk recommends windowing the data by removing all erally tested in a less functional supine position to improve
data obtained at velocities outside 95% of the pre-set stabilization. Normative data related to these testing
angular testing velocity. positions are less prevalent in the literature. Test-retest
research is available for shoulder extension/flexion testing
Flexion/Extension and Horizontal Abduction/Adduction and demonstrates ICCs between 0.75 and 0.91 (Moffroid
Additional isokinetic patterns used to obtain more et al, 1969). No formal test-retest data are currently avail-
detailed profiles of shoulder function are flexion/extension able for shoulder horizontal AB/ADD.
Ch14.qxd 5/24/04 4:55 PM Page 142

142 SECTION III Additional Shoulder Evaluation Techniques

Flexion/extension ratios reported on normal subjects Basic characteristics of eccentric isokinetic testing,
by Ivey et al (1985) are 80% (4 :5). Ratios on athletes with such as greater force production compared with concen-
shoulder extension dominant activities are reported at tric contractions at the same velocity, are reported in
50% for baseball pitchers (Alderink & Kluck, 1986) and the internal and external rotators (Ellenbecker et al, 1988;
75% to 80% for highly skilled adult tennis players Davies & Ellenbecker, 1992). This enhanced force
(Ellenbecker, 1991). Further development of normative generation is generally explained by the contribution of
data is needed to more clearly define strength in these the series elastic (noncontractile) elements of the muscle-
upper extremity patterns. Body position and gravity tendon unit to force generation in eccentric conditions.
compensation are key factors affecting proper data An increase in postexercise muscle soreness, particularly
interpretation. of latent onset, is common after periods of eccentric
work. Therefore eccentric testing would not be the
Scapulothoracic Testing: Protraction/Retraction mode of choice during early inflammatory stages of an
In addition to the supraspinatus/deltoid force couple, the overuse injury (Davies & Ellenbecker, 1992). Many clini-
serratus anterior/trapezius force couple is crucial in a thor- cians recommend the use of dynamic concentric testing
ough evaluation of upper extremity strength. Gross MMT before performing an eccentric test. Both concentric and
and screening that attempt to identify scapular winging eccentric isokinetic training of the rotator cuff has
are commonly used in the clinical evaluation of the shoul- produced objective concentric and eccentric strength
der complex. Davies and Hoffman (1993) have published improvements in elite tennis players (Ellenbecker et al,
normative data on 250 shoulders, regarding isokinetic 1988).
protraction/retraction testing. A nearly 1 : 1 relationship
of protraction/retraction strength was reported. Testing Isokinetic Fatigue Testing
and training the serratus anterior, trapezius, and rhom- Isokinetic dynamometers have also been extensively used
boid musculature enhance scapular stabilization and in the measurement of muscular fatigue (Ellenbecker &
strengthen primary musculature involved in the scapulo- Roetert, 1999; Kannus et al, 1992). Isokinetic muscular
humeral rhythm. Nearly all disciplines of rehabilitative fatigue tests typically consist of measuring the number of
medicine emphasize promotion of proximal stability to repetitions of maximum effort that are required to reach a
enhance distal mobility. 50% reduction in torque, work, or power from the begin-
ning to the end of a certain time period or number of con-
Additional Isokinetic Testing Concepts tractions. Relative fatigue ratios consist of comparing the
work in the last half of a preset number of muscular
Concentric versus Eccentric Considerations contractions with the work performed in the first half
Dynamic strength assessment has had a significant effect, (Kannus et al, 1992; Davies, 1992).
primarily in research investigations. The extrapolation Relative fatigue ratios have been studied in elite tennis
of research-oriented isokinetic principles to patient players and have produced clinically applicable informa-
populations has been a gradual process. Use of eccentric tion. Ellenbecker and Roetert (1999) measured the rela-
testing in the upper extremity is clearly indicated based on tive fatigue response in the internal and external rotators
the prevalence of functionally specific eccentric work. of 72 elite junior tennis players using 20 maximal effort
Maximal eccentric functional contractions of the pos- concentric testing repetitions at 300 degrees per second in
terior rotator cuff during the follow-through phase of the the supine position, with 90 degrees of glenohumeral joint
throwing motion and tennis serve provide rationales abduction. The external rotators fatigued to a level of
for eccentric testing and training in rehabilitation and 69%, and the internal rotators fatigued only to a level of
preventative conditioning (Davies, 1992). Kennedy et al 83%. These percentages are significant because of the sub-
(1993) found mode-specific differences between the stantial contribution the external rotators play in humeral
concentric and eccentric strength characteristics of the deceleration during overhead throwing and serving activ-
rotator cuff. Ellenbecker et al (1988), Mont et al (1994), ities (Elliott et al, 1986), as well as dynamic stabilization
and Treiber et al (1998) demonstrated the applications of the humeral head in the glenoid (Bassett et al, 1994).
of eccentric training of the rotator cuff muscles, its effects That the external rotators appear to fatigue more quickly
on muscular strength, and its carryover to functional and to a greater extent than the internal rotators further
performance. Further research regarding eccentric muscu- supports the current concepts of preventive conditioning
lar training is necessary before widespread use of eccentric and balancing of the shoulder external rotators in unilat-
isokinetics can be applied to patient populations. erally dominant upper extremity athletes.
Ch14.qxd 5/24/04 4:55 PM Page 143

CHAPTER 14 Muscular Strength Testing 143

A similar study was performed on swimmers by Beach to documenting strength improvements with isokinetic
et al (1992). They tested collegiate swimmers at 240 testing, an increase in tennis serve velocity was measured
degrees per second using 50 repetitions. Relative fatigue in the experimental group.
ratios for external rotation were 80%, with internal rota- The complex biomechanical sequences of segmental
tion fatigue ratios of 105% in the collegiate swimmers. velocities and interrelationship between the kinetic chain
The authors also found a significant correlation between link with the lower extremities and trunk make it difficult
isokinetic fatigue ratios and shoulder pain among this to identify a direct relationship between an isolated struc-
swimming population. ture and a complex functional activity. Isokinetic testing
These studies demonstrate the important role fatigue can provide a reliable, dynamic measurement of isolated
testing plays, both in guiding and providing rationale for joint motions and muscular contributions that can assist
the high-repetition training programs used in rehabilita- the clinician in assessing underlying muscular strength
tion and in providing a clinically acceptable method for and strength balance.
assessing muscular fatigue.
Closed Kinetic Chain Upper Extremity Testing
Relationship of Isokinetic Testing to Functional Another method used to assess neuromuscular control of
Performance in the Upper Extremity the shoulder has been the use of closed chain upper
Dynamic muscular strength assessment is used to evaluate extremity tests. Although widespread use of closed chain
the underlying strength, power, endurance, and balance of training techniques has been reported in the physical
strength in specific muscle groups. This information is medicine and rehabilitation literature (Ellenbecker et al,
used to determine the specific anatomic structures that 2000b), limited evaluation methods for the upper extre-
require strengthening, as well as to demonstrate the effi- mity currently exist to properly assess closed-chain
cacy of treatment procedures. Isokinetic testing of the function.
shoulder internal and external rotators has been used as One of the gold standards in physical education for
one aspect in demonstrating functional outcome after gross assessment of upper extremity strength has been
rotator cuff repair on select patient populations (Gore the push-up. This test has been used to generate sport-
et al, 1986; Rabin & Post, 1990; Walker et al, 1987; specific normative data in normal populations (Ellen-
Walmsley & Hartsell, 1992; Kirschenbaum et al, 1993), becker et al, 2000b; Roetert & Ellenbecker, 1998), but it is
as well as after arthroscopic thermal capsulorraphy to not typically considered appropriate for use in patient pop-
treat unidirectional glenohumeral joint instability ulations with shoulder dysfunction. Positional demands
(Ellenbecker & Mattalino, 1999b). placed on the anterior capsule and increased joint loading
Isokinetic testing is also used to determine the rela- limit the effectiveness of this test in musculoskeletal
tionship of muscular strength to functional performance. rehabilitation. Modification of the push-up has been
Several studies have tested upper extremity muscle groups reported and used clinically as an acceptable alternative
and correlated their respective levels of strength to sport- to assess closed-chain function in the upper extremities.
specific functional tests. Pedegana et al (1982) found a Davies has developed the closed kinetic chain (CKC)
statistically significant correlation between elbow exten- upper extremity stability test in an attempt to assess more
sion, wrist flexion, shoulder extension, shoulder flexion, accurately the functional ability of the upper extremity
and shoulder external rotation strength measured isoki- (Ellenbecker & Davies, 2000; Ellenbecker et al, 2000b;
netically and throwing speed in professional pitchers. In a Goldbeck & Davies, 2000). The test is initiated in the
similar study, Bartlett et al (1989) found the shoulder starting position of a standard push-up for males and
adductors to correlate to throwing speed. modified (off knees) push-up for females. Two strips of
Ellenbecker et al (1988) found that 6 weeks of concen- tape are placed parallel to each other, 3 feet apart on the
tric isokinetic training of the rotator cuff resulted in a floor (Figure 14-8). The subject or patient then moves
statistically significant improvement in serving velocity both hands back and forth, touching each line alterna-
in collegiate tennis players. In a similar study, Mont et al tively as many times as possible in 15 seconds. Each touch
(1994) found serving velocity improvements after both of the line is counted and tallied to generate the CKC
concentric and eccentric internal and external rotation upper extremity stability test score. Normative data have
training. Treiber et al (1998) used isokinetic testing to been established, with men averaging 18.5 touches in
document strength changes before and after a 4-week 15 seconds, and females averaging 20.5 touches. The
training program using isotonic dumbbell or Thera-Band CKC upper extremity stability test has been subjected to
internal and external rotation strengthening. In addition a test-retest reliability test, with an ICC generated at
Ch14.qxd 5/24/04 4:55 PM Page 144

144 SECTION III Additional Shoulder Evaluation Techniques

extremity is placed in the lumbar spine to minimize com-

pensation. The subject is instructed to remain as still as
possible, with the eyes closed, during the 20-second test,
in which the amount of postural sway or movement is
measured (Ellenbecker & Roetert, 1996; Ellenbecker &
Mattalino, 1997).
Ellenbecker and Roetert (1996) used this test to
measure upper extremity closed-chain stance stability in
19 professional baseball players and 75 elite junior tennis
players. Results of the bilateral comparisons of these play-
ers showed no significant differences between extremities.
By contrast, previous open kinetic chain testing on ath-
letes in this population found significantly greater domi-
nant arm strength when compared with the nondominant
extremity (Ellenbecker, 1991, 1992; Wilk et al, 1993;
Ellenbecker & Mattalino, 1999a). Ellenbecker and
Mattalino (1997) tested patients undergoing rehabilita-
Figure 14-8 Davies closed kinetic chain test. tion for glenohumeral joint impingement and instability,
and compared bilateral CKC function using the unilat-
eral stance stability test and traditional open kinetic chain
0.927, indicating high clinical reliability between sessions isokinetic glenohumeral rotational testing. There was no
(Goldbeck & Davies, 2000). statistically significant correlation between results of the
Ellenbecker and Roetert (1996) and Ellenbecker and bilateral comparisons of the open and CKC tests. The
Mattalino (1997) have used other methods of CKC test- presence of a significant deficit in isokinetically measured
ing for the upper extremity. The unilateral CKC stance open kinetic chain external rotation did not necessarily
stability test consists of 20-second testing over a Fastex correlate to a deficit in CKC function. This research indi-
(Cybex International, Medway, MA) or Biodex Stability cates that CKC upper extremity testing may provide
System (Shirley, NY ) to measure postural sway or pertur- unique information on upper extremity function; how-
bation. The subject assumes a unilateral upper extremity ever, further research is needed to better understand its
stance with a standardized trunk-extremity angle of 80 role and relationship to other more traditional methods
degrees and feet placed 1 foot apart. The contralateral of upper extremity evaluation.
Ch15.qxd 5/24/04 4:56 PM Page 145

CHAP TER

15 Shoulder Rating Scales

INTRODUCTION status and perception of health status in patients under-

The use of rating scales that assess the glenohumeral joint going treatment for shoulder pathology.
and upper extremity in general is an important part of the
evaluation process. The use of such scales can vary from SHOULDER-SPECIFIC RATING SCALES
the multitude of developed rating systems or scales to the This chapter describes several joint- or shoulder-specific
simple application of the visual analog scale rating a rating scales that are commonly used and recommended
patient’s pain or symptoms from 0 to 10 or 0 to 100. This for patients after either injury or surgical procedures to the
chapter outlines some of the most common shoulder shoulder. Unlike the knee joint, where one or two joint-
rating scales and describes applicable research that has specific rating scales have become gold standards for
validated the instruments. evaluation, the shoulder has no single universally accepted
In general, health questionnaires such as rating scales scale or instrument. Given the wide variety in use, this
can be divided into two categories: generic and joint- or chapter discusses several popular instruments and
disease-specific. An example of a generic health status includes examples of each instrument to facilitate applica-
questionnaire is the Short Form–36 (SF-36) (Ware et al, tion by the reader.
1993). Generic questionnaires assess unexpected health
effects using a common instrument such as the SF-36 CONSTANT-MURLEY SCORING SYSTEM
across different patient groups. Beaton and Richards This system was originally described by Constant and
(1998) compared the sensitivity to change in five shoulder Murley (1987) as a simple clinical method of shoulder
joint–specific questionnaires and the SF-36 in a large functional assessment that combines individual parameter
sample of patients with shoulder pain. The shoulder- assessments with an overall rating on a 100-point scoring
specific questionnaires were more sensitive to change than system; 35% of the Constant-Murley system is subjective
the SF-36. Despite this finding, use of the SF-36 can pro- and 65% is objective. The subjective portions of the scor-
vide valuable insight about the general health effects that ing system include the degree of pain the patient is expe-
shoulder pain and disability caused by shoulder injury or riencing, as well as the patient’s ability to perform simple
surgery can have on patients undergoing rehabilitation. activities of daily living. The objective parameters include
Gartsman et al (1998) used the SF-36 on 544 patients actual measurements of active range of motion in flexion,
with glenohumeral joint instability (149), rotator cuff abduction, and combined internal and external rotation
tears (111), adhesive capsulitis (100), glenohumeral with a goniometer. Strength testing is carried out with the
osteoarthritis (67), and impingement (117) before and use of a spring balance to test shoulder power in 90
after treatment. Compared with the normative data in the degrees of abduction. In patients with less than 90 degrees
United States, these patients had significant decreases in of abduction, strength testing occurs at a point in the
health ratings for Physical Functioning, Role-Physical, range of motion near the maximum. The amount of
Bodily Pain, Social Functioning, Role-Emotional, and the weight or force that can be lifted in the scapular plane is
Physical Component Summary as measured by the SF-36 recorded with a value between 0 and 25 based on the
survey instrument. Patients with shoulder pathology per- amount lifted or pounds of force measured depending on
ceived their general health in the same category as pub- the method used.
lished standards for patients with congestive heart failure, Constant and Murley (1987) developed age- and
acute myocardial infarction, diabetes mellitus, and clinical gender-specific scoring ranges in 900 normal individuals.
depression. This finding supports the use of a generic- The Constant-Murley system is used extensively in
type scale to lend valuable insight into the general health Europe and is one of the most commonly used outcome

145
Ch15.qxd 5/24/04 4:56 PM Page 146

146 SECTION III Additional Shoulder Evaluation Techniques

measures in many short- and long-term follow-up studies UCLA RATING SCALE
evaluating the efficacy of various shoulder surgical proce- The UCLA rating scale is a similar instrument to the
dures. The European Shoulder and Elbow Society modified Rowe scale that combines the components of
requires that the results of clinical data be reported using pain, function, range of motion, manually assessed muscle
the Constant-Murley score. strength, and patient satisfaction (Ellman et al, 1986).
Ianotti et al (1996) used the Constant-Murley scoring Objective portions of this scale include active range of
system to determine the postoperative function of patients motion of forward flexion measured in degrees. This
after the repair of full-thickness rotator cuff tears. In measurement accounts for as much as 5 points if it is
their study, a preoperative Constant score of 35 points greater than or equal to 150 degrees; muscle strength in
was reported among the 40 patients with a rotator cuff forward flexion is assessed manually and accounts for 5
tear. The authors used the categories of excellent for points if it is normal. The patient provides a subjective
Constant scores of 90 to 100, good for scores of 80 to 89, assessment of pain, functional use, and overall satisfaction
fair for scores ranging between 70 and 79, and poor for with the surgical procedure that accounts for a total of 35
scores less than 70 points. They grouped the good and points. Box 15-1 shows the component parts of the
excellent scores together and characterized this group as UCLA rating scale, as well as the allotment of points for
satisfied or satisfactory outcomes (Constant score greater each section.
than 80 points) and unsatisfactory as scores less than 80 Roddey et al (2000) studied the self-report sections of
points. the UCLA, simple shoulder test (SST), and shoulder pain
Patients were evaluated 2 years after open repair of a and disability index (SPADI) in 192 patients with shoul-
full-thickness rotator cuff tear; 60% of shoulders had der dysfunction. All three scales demonstrated good inter-
excellent Constant scores, with 28% having good scores. nal consistency; however, the authors could not validate
The authors concluded that 88% of patients undergoing a or invalidate the use of the UCLA rating scale for
full-thickness rotator cuff tear had a satisfactory outcome. either group or individual comparison. Further research is
Many other studies have used the Constant-Murley needed to determine the validity and reliability of this
system; however, the study of Ianotti et al (1996) is scale in the clinical setting.
presented here as an example of the application of one Soldatis et al (1997) used the Rowe, American Shoul-
scoring system used in clinical and research follow-up der Elbow Surgeons (ASES), UCLA, Constant-Murley,
evaluation. and SST to determine the presence and severity of shoul-
der symptoms in healthy college athletes at mid-season.
MODIFIED ROWE SCALE Athletes were chosen from men’s baseball, basketball, and
The Rowe scale was originally developed as a tool to football; and women’s volleyball, basketball, swimming,
assess outcome after open anterior stabilization proce- and tennis. In general, shoulder pain was the most fre-
dures. The three main headings in the Rowe scale are Sta- quent symptom reported in 47% of all participants. The
bility, Motion, and Function. A total of 100 possible points UCLA rating system was deemed the most “sensitive” for
are allotted for this scale. The scale is heavily weighted evaluating healthy college athletes in this study. The
toward the Stability category. The allotment of 50 pos- authors concluded that the ideal scoring system for shoul-
sible points for a stable shoulder is a major component ders has yet to be developed, but these shoulder rating
of this shoulder rating scale. The presence of instability systems can be used as a reference in the evaluation
in virtually any form significantly detracts from the com- and treatment of athletes.
posite score, making the scale an excellent choice to use in
patients after glenohumeral joint stability procedures MODIFIED AMERICAN SHOULDER
(both open and arthroscopic), as well as in nonoperative ELBOW SURGEON RATING SCALE
rehabilitation of the unstable shoulder. The self-reported portion of the ASES rating scale con-
Table 15-1 lists the components of the modified Rowe sists of 15 questions that are answered using a score rang-
scale, which was developed to address slightly higher ing from normal (3), which indicates an ability to perform
demands that athletes and more active individuals have. that activity without any problem, to (0), which indicates
Ellenbecker et al (2003a, 2003b) used the modified Rowe an activity that cannot be performed at all. Figure 15-1
scale in a long-term follow-up study of patients after contains the self-reported questions from the modified
arthroscopic thermal capsulorrhaphy and in the baseline ASES rating scale (Barrett et al, 1987), which evolved
assessment of uninjured elite unilaterally dominant over- from the Neer rating scale. Beaton and Richards (1998)
head athletes. used the self-reported section of the modified ASES
Ch15.qxd 5/24/04 4:56 PM Page 147

CHAPTER 15 Shoulder Rating Scales 147

Table 15-1 Modified Rowe Scale

Scoring Excellent Good Fair Poor
System Units (100-90) (89-75) (74-51) (50 or Less)
STABILITY
No recurrence 50 No recurrences No recurrences No recurrences Recurrence of
or subluxation dislocation
Apprehension 30 No apprehension Mild Moderate Marked
when when placing apprehension apprehension apprehension
placing arm arm in complete when placing during elevation during elevation
in certain elevation and arm in elevation and ER or extension
positions ER and ER
Subluxation (not 10 No subluxation No subluxation No subluxation
requiring
reduction)
Recurrent 0
dislocation
MOTION
100% of 20 100% of normal 75% of normal 50% of normal No ER; 50%
normal ER, IR, ER, complete ER, complete ER, 75% of elevation
and elevation elevation and elevation and elevation and (can get
75% of normal 15 IR IR IR hand only
ER, normal to face);
elevation, and 50% IR
IR
50% of normal 5
ER, 75% of
normal
elevation and
IR
50% of normal 0
elevation and
IR, no ER
FUNCTION
No limitation in 30 Performs all Mild limitation Moderate Marked
work or sports; work and in work and limitation limitation;
little or no sports; no sports; doing unable to
discomfort limitation in shoulder overhead perform
overhead strong; work and overhead
activities; minimum heavy lifting; work and
Mild limitation 25 shoulder discomfort unable to lifting;
and minimum strong in throw, serve cannot
discomfort lifting, hard in throw, play
swimming, tennis, or tennis, or
Moderate 10 tennis, swim; swim;
limitation throwing; no moderate chronic
and discomfort discomfort disabling discomfort
pain
Marked 0
limitation
and pain

ER, External rotation; IR, internal rotation.

Total units possible: 100.
From Rowe CR, Patel D, Southmayd WW: The Bankart procedure: a long term end-result study, J Bone Joint Surg 60A:1-16, 1978.
Ch15.qxd 5/24/04 4:56 PM Page 148

148 SECTION III Additional Shoulder Evaluation Techniques

Box 15-1 UCLA Rating Scale: shoulder pain than the generic SF-36 questionnaire. The
modified ASES shoulder rating scale has also been used in
Functional/Reaction Measures
the follow-up evaluation of patients after arthroscopic
PAIN thermal capsulorrhaphy for treatment of unidirectional
Present all of the time and unbearable; strong instability, as well as in the baseline evaluation of unilater-
medication frequently 1 ally dominant elite upper extremity athletes (Ellenbecker,
Present all of the time but bearable; strong 2000b, 2003a).
mediation occasionally 2
None or little at rest, present during light
SIMPLE SHOULDER TEST
activities; salicylates frequently 4
Present during heavy or particular activities Matsen et al (1994) developed a brief questionnaire to facil-
only; salicylates occasionally 6 itate and standardize patient reporting of functional status
Occasional and slight 8 of their injured shoulder. The SST is comprised of a mini-
None 10
mal data set of 12 questions that were derived from the
FUNCTION basic complaints of patients entering the University of
Unable to use limb 1 Washington Shoulder Service for treatment (Figure 15-2).
Only light activities possible 2 Before developing the SST for patients, a pool of 60- and
Able to do light housework or most of activities 70-year-old healthy individuals were tested to ensure that
of daily living 4
healthy older individuals could perform these functions.
Most housework, shopping, and driving
possible; able to fix hair and dress and The 12 questions in the SST can be answered with a
undress, including fastening brassiere 6 yes or no response. It is important that the patient answer
Slight restriction only; able to work above the questions without assistance to ensure that the answer
shoulder level 8 reflects the patient’s assessment of function. The SST is
Normal activities 10
designed to represent the functional status of the shoulder
ACTIVE FORWARD FLEXION rather than degrees of motion or pounds of force that are
150 degrees or more 5 assessed with other more traditionally applied measures.
120 to 150 degrees 4 Matsen et al (1994) added questions to the SST for cer-
90 to 120 degrees 3 tain athletic patient populations (e.g., does your shoulder
45 to 90 degrees 2
allow you to serve with your usual speed and control?).
30 to 45 degrees 1
Less than 30 degrees 0 These questions can be added, but the initial data set
should be kept intact to facilitate administration of the
STRENGTH OF FORWARD FLEXION (MMT) SST in the clinical setting.
Grade 5 (normal) 5 Figure 15-3 lists the questions for the SST and the
Grade 4 (good) 4
normal responses from a group of 80 healthy subjects 60
Grade 3 (fair) 2
Grade 2 (poor) 2 to 70 years old without shoulder complaints during clini-
Grade 1 (muscle contraction) 1 cal examination of their shoulders and with normal ultra-
Grade 0 (nothing) 0 sound evaluation of the glenohumeral structures (Matsen
et al, 1994). The test-retest reliability of the SST has been
SATISFACTION OF THE PATIENT
measured by Matsen et al (1994), with 70 patients com-
Satisfied and better 5
Not satisfied and worse 0 pleting the test on two separate occasions. A total of 63%
of the patients had identical responses on retesting; 90%
MAXIMUM SCORE: 35 POINTS of the patients answered all but one of the questions
From Ellman H, Hander G, Bayer M: Repair of the rotator cuff: end-
identically between sessions. The simplicity of the SST
result study of factors influencing reconstruction, J Bone Joint Surg 68A: facilitates communication of results to patients and is rec-
1136-1144, 1986. ommended for both clinical and research applications
(Matsen et al, 1994).
rating scale in addition to four other joint-specific scales
and the SF-36 in 99 patients with shoulder dysfunction. THE SHOULDER PAIN AND
They found acceptable levels of reliability and responsive- DISABILITY INDEX
ness using the modified ASES rating scale; they also The SPADI is a self-administered questionnaire that
found the ASES scale and the other four joint-specific consists of two dimensions, pain and function or func-
scales to be more sensitive to change in patients with tional activities (Heald et al, 1997). Box 15-2 lists the five
Ch15.qxd 5/24/04 4:56 PM Page 149

CHAPTER 15 Shoulder Rating Scales 149

MODIFIED AMERICAN SHOULDER & ELBOW SURGEONS RATING SCALE

Please rate your ability to do the following daily activities using the following scale:

0 = unable 1 = very difficult 2 = somewhat difficult 3 = not difficult at all

Get dressed, including

putting on your coat

Wash back/do up bra

Manage toileting

Comb hair

Reach a high shelf

Lift heavy objects

Do usual work

Do usual sport

Sleep on your painful side

Throw a ball overhand

Open a jar of food

Cut with a knife

Use a phone

Do up buttons

Carry shopping bag

Figure 15-1 Modified American Shoulder Elbow Surgeons (ASES) rating scale.

questions from the pain dimension and the eight ques- scores and the pain and disability dimensions. Williams et
tions from the functional activity dimension. al (1995) also studied the SPADI and examined the con-
Heald et al (1997) administered the SPADI to 103 struct validity using a population of 102 patients with
patients undergoing outpatient rehabilitation for shoulder shoulder involvement. Their research supported the con-
pain. Scores of patients who completed the SPADI at struct validity of this instrument, suggesting that the
both the initial and final treatments were analyzed to SPADI is another valuable tool that can be used clini-
determine the responsiveness of the index. The SPADI cally during the examination and treatment of patients
was more responsive in this patient population than the with shoulder pathology.
sickness impact profile (SIP), which is a generic rating
instrument. Evidence to support the construct validity of ATHLETIC SHOULDER OUTCOME
the SPADI was moderately strong; however, it was sug- RATING SCALE
gested that the SPADI may not readily measure occupa- After reviewing the list of questions used in the SPADI
tional and recreational disability. and other rating scales, it is apparent that the level
Roach et al (1991) measured test-retest reliability of of questions in most scales is not applicable to the
the SPADI in a group of 23 subjects for both the total demands and intensities inherent in upper extremity sport
Ch15.qxd 5/24/04 4:56 PM Page 150

150 SECTION III Additional Shoulder Evaluation Techniques

UNIVERSITY OF WASHINGTON SHOULDER INFORMATION FORM

SIMPLE SHOULDER TEST

Please answer these questions about your shoulder. Date:

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 1 pound (a full pint container) to the level of your shoulder
without bending your elbow?

7. Can you lift 8 pounds (a full gallon container) to the level of the top
of your head without bending your elbow?

8. Can you carry 20 pounds (a bag of potatoes) at your side with the
affected extremity?

9. Do you think you can toss a softball underhand 10 yards with the
affected extremity?

10. Do you think you can thow a softball overhand 20 yards with the
affected extremity?

11. Can you wash the back of your opposite shoulder with the affected
extremity?

12. Would your shoulder allow you to work full time at your regular job?

Are there other important things you cannot do as a result of your shoulder problem?

Previous doctors you have seen about your shoulder problem:

Previous tests you have had concerning your shoulder problem:

Previous nonmedical treatment you have had for your shoulder problem:

How many cortisone, steroid, or other types of injections have you had in your shoulder?

Previous shoulder surgeries (please list which shoulder, procedure, and date):

Are there any other aspects of your shoulder problems that we should know about?

Any family history of shoulder problems?

Figure 15-2 Simple shoulder test. (Adapted from Matsen FA III, Lippitt SB, Sidles JA, et al: Practical evaluation and management of
the shoulder, Philadelphia, 1994, WB Saunders, p. 15, with permission.)
Ch15.qxd 5/24/04 4:56 PM Page 151

CHAPTER 15 Shoulder Rating Scales 151

Normal shoulders aged 60 to 70 Box 15-2 Shoulder Pain and Disability

Normals Index (SPADI)
Yes
0 20 40 60 80
No
PAIN DIMENSION—HOW SEVERE IS YOUR PAIN:
80 of 80 yes Comfort at side 1. At its worst?
2. When lying on the involved side?
80 of 80 yes Sleep comfortably 3. Reaching for something on a high shelf?
4. Touching the back of your neck?
80 of 80 yes Tuck in shirt 5. Pushing with the involved arm?

DISABILITY DIMENSION—HOW MUCH DIFFICULTY

80 of 80 yes Hand behind head DO YOU HAVE:
1. Washing your hair?
80 of 80 yes Place coin on shelf 2. Washing your back?
3. Putting on an underskirt or pullover sweater?
80 of 80 yes Lift pint to shoulder level 4. Putting on a shirt that buttons down the front?
5. Putting on your pants?
79 of 80 yes Lift gallon to head level 6. Placing an object on a high shelf?
7. Carrying a heavy object (e.g., 10 pounds)?
80 of 80 yes Carry 20 pounds 8. Removing something from your back pocket?

To answer each of the questions, patients place a mark on a 10-cm

80 of 80 yes Toss softball underhand
visual analog scale for each question. The ends of each line have the
verbal anchors of “no pain at all” and “worst pain imaginable” for the
77 of 80 yes Throw softball overhand pain dimension and for the functional disability dimension “no diffi-
culty” and “so difficult it required help.” The scores from both dimen-
80 of 80 yes Wash opposite shoulder sions are averaged to derive a total score.
Data from Heald SL, Riddle DL, Lamb RL: The shoulder pain and
Figure 15-3 Normal responses to the SST in persons 60 to 70 disability index: the construct validity and responsiveness of a region
years old. specific disability measure, Phys Ther 77(10):1079-1089, 1997.

participation. Tibone and Bradley (1993) stated: “to ade- adequately address both the demands and intensities
quately determine the overall results, a different set of required in the glenohumeral joint of the overhead ath-
parameters is required for evaluation of outcome in the lete. Further research using this instrument is needed to
athletic shoulder.” They formulated a rating system to establish its accuracy and effectiveness.
evaluate overall results in the athletic shoulder. Their out-
come instrument contains major subjective headings— SINGLE ASSESSMENT NUMERIC
pain, strength and endurance, stability, intensity, and EVALUATION METHOD
performance—with objective information, specifically One of the limiting factors of most subjective rating
regarding range of motion, also factored into the rating scores and rating systems is the amount of time it takes
system (Figure 15-4). Range of motion is measured with patients, clinicians, and researchers to perform the neces-
a goniometer to determine active external rotation in a sary functions involved in that particular scale or scoring
standing position with 90 degrees of abduction, as well as system. Williams et al (1999) developed the single assess-
total active elevation in the scapular plane. Internal rota- ment numeric evaluation (SANE) method. This method
tion is not measured because Tibone and Bradley (1993) uses a single question that is easily processed and applied:
believe that overhead athletes often have internal rotation “How would you rate your shoulder today as a percentage
range of motion losses, and including internal rotation of normal?” Patients are instructed to provide SANE rat-
active range of motion might lead to unfair loss of points ings in whole numbers. This method provides a rapid and
after injury or surgery. Overall results are graded such that easy method to obtain the patient’s perception of shoulder
an excellent score consists of 90 to 100 points, good scores function and overall status. This method is an excellent
range from 70 to 89, fair scores range from 50 to 69, and example of a self-administered, patient-based method for
a poor score is less than 50. Neither test-retest reliability evaluating patient outcome. It differs from the clinical
nor responsiveness or validity was measured in this study. data, which require a more objective process (Williams
The type of questions inherent in this questionnaire more et al, 1999).
Ch15.qxd 5/24/04 4:56 PM Page 152

152 SECTION III Additional Shoulder Evaluation Techniques

ATHLETIC SHOULDER OUTCOME RATING SCALE

Name________________________________________________ Age_________ Sex_________

Dominant hand (R)__________ (L)__________ (Ambidextrous)__________
Date of examination_____________________________
Surgeon______________________________________

Type of sport_____________________________________________
Position played____________________________________________
Years played______________________________________________
Prior injury_______________________________________________

Activity Level Diagnosis

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

SUBJECTIVE (90 points)

I Pain Points
• No pain with competition 10
• Pain after competing only 8
• Pain while competing 6
• Pain preventing competing 4
• Pain with ADLs 2
• Pain at rest 0
II Strength/Endurance
• No weakness, normal competition fatigue 10
• Weakness after competition, early competition fatigue 8
• Weakness during competition, abnormal competition fatigue 6
• Weakness or fatigue preventing competition 4
• Weakness or fatigue with ADLs 2
• Weakness or fatigue preventing ADLs 0
III Stability
• No looseness during competition 10
• Recurrent subluxations while competing 8
• Dead-arm syndrome while competing 6
• Recurrent subluxations prevent competition 4
• Recurrent subluxations during ADLs 2
• Dislocation 0
IV Intensity
• Preinjury versus postinjury hours of competition (100%) 10
• Preinjury versus postinjury hours of competition (less than 75%) 8
• Preinjury versus postinjury hours of competition (less than 50%) 6
• Preinjury versus postinjury hours of competition (less than 25%) 4
• Preinjury and postinjury hours of ADLs (100%) 2
• Preinjury and postinjury hours of ADLs (less than 50%) 0

Figure 15-4 Athletic shoulder outcome rating scale. (Adapted from Matsen FA, Fu FH, eds: The shoulder: a balance of mobility and
stability, Rosemont, IL, 1993, American Academy of Orthopaedic Surgery, pp. 526–527, with permission.)
Ch15.qxd 5/24/04 4:56 PM Page 153

CHAPTER 15 Shoulder Rating Scales 153

To test the effectiveness of the SANE method, the use of one or a series of shoulder rating scales specific
Williams et al (1999) used the SANE score during 209 to the individual patient (i.e., modified Rowe scale for
follow-up evaluations of 163 military cadets after surgical instability patients) based on the intended population,
procedures for glenohumeral joint dislocations, chronic both at initial patient examination and at the completion
subluxations, and acromioclavicular joint separations. The of physical therapy (i.e., discharge) to document patient
Rowe and ASES scales were used in addition to the progression. The postoperative use of shoulder rating
SANE method for all patients at various times during scales at predetermined periods can provide important
follow-up evaluations. Results showed statistically signifi- insight into the function and subjective level of pain and
cant (P < 0.001) correlations between the overall results of limitation that patients experience at various times after
the Rowe scale and SANE score (r = 0.77), as well as surgery (Ellenbecker et al, 2003a). The use of these scales
between the ASES and SANE scores (r = 0.69). The adds an additional variable to the traditional examination
authors recommend the use of the SANE method during of patients (range of motion and strength) with shoulder
follow-up evaluation to obtain patient-based information injury.
on perception of shoulder function. One obvious
weakness of this method noted by the authors is the SUMMARY
inability to determine “why” patients rate their shoulder at Additional shoulder-specific rating scales, such as the
a certain level. The authors did not recommend that this instruments used by the Hospital for Special Surgery in
rating method replace other rating scales, but they did New York (Altchek et al, 1990) and the rating scale
recommend its use as a convenient adjunct to clinical designed by Neer et al (1982), can also be used in specific
evaluation methods and other rating scales. Further patient populations after the surgical procedures for which
research on other subject populations is needed to better the instruments were initially intended and applied in
understand the global effectiveness of this subjective research. This chapter described some of the most com-
rating method. monly applied instruments, along with research demon-
strating either the effectiveness of the instrument or
APPLICATION OF SHOULDER RATING examples of applications of each instrument, to facilitate
SCALES TO CLINICAL PRACTICE their use and application in both clinical and research are-
The myriad of shoulder rating scales described in this nas. Further research will better identify the effectiveness
chapter demonstrates the variety of instruments currently of each rating system, as well as new and more sensitive
available to clinicians both when measuring the baseline shoulder rating scales that may produce a more “univer-
status and when documenting progress after a series or sally accepted” upper extremity rating system for both
completion of rehabilitative interventions. I recommend clinical and research application.
Ch16.qxd 5/24/04 4:57 PM Page 155

CHAP TER
Proprioceptive Testing of
16 the Glenohumeral Joint

INTRODUCTION AND DEFINITIONS this chapter. Proprioception can be defined as afferent

Review of the orthopedic and musculoskeletal rehabilita- information received, including joint position sense,
tion literature identifies many different versions of defini- kinesthesia, and sensation of resistance. Joint position sense
tions for the terms associated with joint proprioception and can be defined as the ability to appreciate and recognize
neuromuscular control. In Goetz’s Textbook of Clinical Neu- where a joint or limb is in space. Kinesthesia can be defined
rology, proprioception is defined as any postural, positional, as the ability to sense or recognize joint motion or move-
or kinetic information provided to the central nervous sys- ment. Sensation to resistance can be defined as the ability to
tem by sensory receptors in muscles, tendons, joints, or skin sense force or tension generated through a joint. The
(Goetz, 1999). Other texts define proprioception as appropriate efferent response to these afferent propriocep-
“awareness of the position and movements of our limbs, tive inputs has been termed neuromuscular control.
fingers, and toes derived from receptors in the muscles, ten-
dons, and joints” (Adams et al, 1997). Sherrington (1906) AFFERENT NEUROBIOLOGY OF
classically defined proprioception as afferent information THE GLENOHUMERAL JOINT
arising from the proprioceptive field and identified Afferent proprioceptive function of the human gleno-
mechanoreceptors or proprioceptors as being the source of humeral joint includes both the muscular-based afferent
the origination of this afferent information. receptors in human active and passive movement and joint
These original definitions of the term proprioception position detection (Roland and Ladegaard-Pedersen,
continue to be used today; however, a more advanced 1977). In 1898, Goldsheider proposed that sensation of
definition of the sensory involvement that encompasses passive movements was solely the product of joint-based
human proprioceptive function is clearly needed. In a receptors. This view is still widely accepted today with
classic monograph entitled Physiologie des Muskelsinnes, passive movements.
Goldsheider (1898) proposed that muscle sense be Until the 1970s it was thought that, regarding sensory
divided into four distinct and separate sensory functions: feedback of active human movements, after voluntary
sensation of passive movements, sensation of active move- movement was initiated by the cerebral cortex, only low-
ments, sensation of position, and appreciation or sensation level control was presented by the receptors in the muscles
of heaviness and resistance. These original classifications and tendons. Sensory information from the muscles and
have been expanded to decrease confusion. The sensation tendons was sent to the spinal cord and some subcortical
of passive movements is considered a product of sensa- extrapyramidal parts of the brain such as the cerebellum,
tions induced by external forces that results in a change in but it played no role as contributors to conscious sensa-
limb position with noncontracting muscles. The sensation tion, which remained in the province of the joint receptors
of active movement (or kinesthesia as it is now better (Roland and Ladegaard-Pedersen, 1977). In the early
known) encompasses the appreciation of change in posi- 1970s, however, Goodwin et al (1972) and Eklund (1972)
tion of a limb with contracting muscles. The appreciation independently showed the qualitative role that muscular
of a limb’s position in space has been termed stagnosia. In receptors play in sensations of active movement.
the presence of tension, the appreciation of force applied
during a voluntary contraction has been termed dyna- AFFERENT MECHANORECEPTOR
maesthesia (Roland and Ladegaard-Pedersen, 1977). CLASSIFICATION
Although these expanded definitions provide addi- Mechanoreceptors are sensory neurons or peripheral
tional information regarding human proprioception, afferents located within joint capsular tissues, ligaments,
adaptations of them have been suggested and are used in tendons, muscle, and skin (Grigg, 1994; Wyke, 1972).

155
Ch16.qxd 5/24/04 4:57 PM Page 156

156 SECTION III Additional Shoulder Evaluation Techniques

Deformation or stimulation of the tissues in which the similar in nature to the Golgi tendon organ. These recep-
mechanoreceptor’s lie produces a gated release of sodium, tors are completely inactive in immobile joints and
eliciting an action potential (Myers & Lephart, 2000). become active or stimulated toward the extreme ends of
Four primary types of afferent mechanoreceptors joint ranges of motion only where the ligamentous struc-
have been classified and are commonly present in non- tures become taut. Wyke (1967) also reported that the
contractile capsular and ligamentous structures in human type III receptors become activated with longitudinal
joints. traction to the limbs, activating the receptors centripet-
Type I articular receptors are traditionally globular or ally at a high velocity only if extreme joint displacement or
ovoid corpuscles with a very thin capsule. They are joint traction is maintained.
numerous in the capsular tissues in all the limb joints, as Unlike types I, II, and III receptors, type IV receptors
well as the apophyseal joints of the vertebral column. are noncorpuscular and are represented by plexuses of
Wyke (1972) reported that the population of type I recep- small unmyelinated nerve fibers or free nerve endings.
tors appears more dense in proximal joints than in distal These receptors are typically distributed throughout the
joints. Type I receptors are typically located in the super- fibrous joint capsule, adjacent periosteum, and articular fat
ficial layers of the joint capsule. pads. They represent the pain receptor system of articular
Physiologically, type I receptors are low-threshold, tissues and are entirely inactive in normal circumstances.
slowly adapting mechanoreceptors. A portion of the type Marked mechanical deformation or chemical irritation,
I receptors is always active in every joint position (Wyke, such as exposure of the nerve endings to agents including
1972). The resting discharge of the type I receptors allows histamine, bradykinin, and other inflammatory exudates
the body to know where the limb is placed and receives produced by damaged or necrotic tissues, can stimulate
constant output on limb position in virtually any joint activation of the type IV receptor (Wyke, 1967, 1972;
position. The type I receptor is categorized as both a Myers & Lephart, 2000).
static and dynamic mechanoreceptor (Wyke, 1972) whose
discharge pattern signals static joint position; intraarticu- AFFERENT JOINT RECEPTORS
lar pressure changes; and the direction, amplitude, and IN THE HUMAN GLENOHUMERAL JOINT
velocity of joint movements. The classification system for the four primary types of
Type II mechanoreceptors are elongated, conical mechanoreceptors found in human noncontractile capsu-
corpuscles with thick multilaminated connective tissue lar and ligamentous tissues provides generalized informa-
capsule. They are present in the fibrous capsules of all tion regarding the location of these receptors in the
joints but are reported to be more numerous in distal human body. Vangsness et al (1995) studied the neural
joints than in the proximal joints (Wyke, 1972). Type II histology of the human shoulder joint, including the
corpuscles are located in the deeper layers of the fibrous glenohumeral ligaments, labrum, and subacromial bursa.
joint capsule, particularly at the border between the They found two types of slowly adapting Ruffini end
fibrous capsule and the subsynovial fibroadipose tissue, organs and rapidly adapting pacinian corpuscles in the
often alongside articular blood vessels. Type II mechano- superior, middle, and inferior glenohumeral ligaments.
receptors are low-threshold, rapidly adapting receptors The Ruffini end organs were more common than the
and are entirely inactive in immobile joints (Wyke, 1972). pacinian corpuscles. Shimoda (1955) and Kikuchi (1968)
They become activated for brief moments (1 second or reported that the type II pacinian corpuscles were found
less) at the onset of joint movement. The type II receptor more commonly in the human glenohumeral joint capsu-
is considered a dynamic mechanoreceptor whose lar ligaments than in the human knee. Analysis of the
brief, high-velocity discharges signal joint acceleration coracoclavicular and acromioclavicular ligaments showed
and deceleration with both active and passive joint equal distribution of type I and II mechanoreceptors.
movements. Morisawa et al (1994) identified types I, II, III, and IV
Type I and II mechanoreceptors are the primary mechanoreceptors in human coracoacromial ligaments.
receptors located in the joint capsule. Type III receptors These reviews show how the glenohumeral joint capsular
are primarily confined to the joint intrinsic and extrinsic ligaments aid in providing afferent proprioceptive input
ligamentous structures (Wyke, 1972). The type III recep- by their inherent distributions of both type I Ruffini
tor is predominantly found in the superficial surfaces of mechanoreceptors and the more rapidly adapting pacinian
the joint ligaments, near their bony attachments. Research receptors. A rapidly adapting receptor like the pacinian
delineating the type III mechanoreceptor classifies this can identify changes in tension in the joint capsular liga-
receptor as a high-threshold, slowly adapting structure, ments, but quickly decreases its input after the tension
Ch16.qxd 5/24/04 4:57 PM Page 157

CHAPTER 16 Proprioceptive Testing of the Glenohumeral Joint 157

becomes constant (Vangsness et al, 1994). In this way, the the muscle tendon unit to remain sensitive over a wide
type II receptor has the ability to monitor acceleration and range of motion, during both reflex and voluntary
deceleration of a ligament’s tension. activation.
Several authors have studied the labrum and subacro- Muscle spindles provide much of the primary informa-
mial bursa. Vangsness et al (1994) found no evidence for tion for motor learning in terms of muscle length and
mechanoreceptors in the glenoid labrum; however, they joint position. Upper levels of the central nervous system
noted free nerve endings in the fibrocartilage tissue in the can bias the sensitivity of muscle spindle input and sam-
peripheral half. The subacromial bursa was found to have pling (Nyland et al, 1998). Muscle spindles do not occur
diffuse, yet copious, free nerve endings, with no evidence in similar densities in all muscles in the human body.
of larger more complex mechanoreceptors. Ide et al (1996) Spindle density most likely is related to muscle function,
also studied subacromial bursa taken from three cadavers with greater densities of muscle spindles being reported in
and found a copious supply of free nerve endings, most of muscles that initiate and control fine movements or main-
which were located on the roof side of the subacromial tain posture. Muscles that cross the front of the shoulder,
arch, which is exposed to impingement-type stresses. such as the pectoralis major and biceps, have a large num-
Unlike the study by Vangsness et al (1994), Ide et al ber of muscle spindles per unit of muscle weight (Voss,
(1996) did find evidence of both Ruffini and pacinian 1971). Muscles with attachment to the coracoid, such as
mechanoreceptors in the subacromial bursa. Their find- the biceps, pectoralis minor, and coracobrachialis, also
ings suggest that the subacromial bursa receives both have high spindle densities. Lower spindle densities have
nociceptive stimuli and proprioception and may play a been reported for the rotator cuff muscle tendon units,
role in regulating shoulder movement. More research into with the subscapularis and infraspinatus having greater
the exact distribution of these important structures in the densities than the supraspinatus and teres minor (Voss,
human shoulder is indicated to give clinicians additional 1971). This lower rotator cuff spindle density most likely
information and enhance understanding of proprioceptive suggests synergistic mechanoreceptor activation with the
function of the shoulder. scapulothoracic musculature, with glenohumeral joint
movement (Nyland, 1998; Inman, 1944). This coupled
AFFERENT RECEPTORS OF THE or shared mechanoreceptor activation is an example of
CONTRACTILE TISSUES OF THE HUMAN kinetic link or proximal-to-distal sequencing that occurs
GLENOHUMERAL JOINT with predictable or programmed movement patterns in
In addition to the afferent structures found in the non- the human body (Marshall & Elliott, 2000).
contractile tissues of the human shoulder (joint capsule, The second major aspect of musculotendinous afferent
subacromial bursa, and intrinsic and extrinsic ligaments), activity is the Golgi tendon organ. These tendinous
significant contributions to the regulation of human mechanoreceptors are present in the human shoulder and
movement and proprioceptive feedback are obtained from respond to tension generated with muscular contraction
receptors located in contractile structures. (Myers & Lephart, 2000; Nyland, 1998). Activation of
Two primary mechanisms for afferent feedback from the Golgi tendon organs relays afferent feedback regard-
the muscle tendon unit are the muscle spindle mechanism ing muscle tension and joint position. Activation of the
and the Golgi tendon organ (Myers & Lephart, 2000; tension-sensitive Golgi tendon organ produces a protec-
Nyland et al, 1998). Research classifying muscle spindles tive mechanism that causes relaxation of the agonist
has traditionally grouped intrafusal muscle fibers into two muscle that is undergoing tension, with simultaneous
groups based on the type of afferent projections (Nyland stimulation of antagonistic musculature.
et al, 1998; Barker et al, 1976). These groups consist of
nuclear bag and nuclear chain fibers. Nuclear chain fibers EFFECTS OF GLENOHUMERAL JOINT
project from large afferent axons. Nuclear bag fibers are INSTABILITY ON PROPRIOCEPTION
innervated by gamma 1 (dynamic) motor neurons and are Several studies have addressed the influence of gleno-
more sensitive to the rate of muscle length change, such as humeral joint instability on proprioception. One of the
occurs during a rapid stretch of a muscle during an eccen- most common clinical maladies addressed by clinicians is
tric contraction or passive stretch (Nyland et al, 1998). anterior glenohumeral joint instability. Speer et al (1994b)
Intrafusal nuclear chain fibers are innervated by gamma studied the effects of a simulated Bankart lesion in
2 (static) motor neurons and are more sensitive to static cadavers. Coupled anterior/posterior translations were
muscle length. The combination of the nuclear chain and assessed in the presence of sequentially applied loads of 50
nuclear bag fibers allows the afferent communication from Newtons in anterior, posterior, superior, and inferior
Ch16.qxd 5/24/04 4:57 PM Page 158

158 SECTION III Additional Shoulder Evaluation Techniques

directions. The effects of a simulated Bankart lesion thresholds to detection of passive motion, as well as
resulted in small (maximum of 3.4 mm) increases in ante- greater inaccuracy with joint angular replication testing
rior and inferior translations of the humeral head relative than they experienced with their contralateral uninjured
to the glenoid in all positions of elevation, and in poste- extremity. Lephart et al (1994) found no significant dif-
rior translation at 90 degrees of elevation only. Speer et al ferences among kinesthesia and joint position sense in the
(1994b) concluded that detachment of the anterior infe- subject’s operated extremity compared with the uninjured
rior labrum from the glenoid (Bankart lesion) alone does extremity after reconstructive surgery. These patients were
not create large enough increases in humeral head trans- examined at least 6 months after open or arthroscopic
lation to allow for anterior glenohumeral joint dislocation. repair of chronic, recurrent anterior instability. The
Permanent stretching or elongation of the inferior gleno- authors concluded that these results provide evidence,
humeral ligament may also occur and may be necessary to consistent with the previously mentioned studies, for
produce a full dislocation of the glenohumeral joint. This partial deafferentation leading to proprioceptive deficits
elongation or permanent stretching of the ligamentous when the capsuloligamentous structures are damaged.
structures may lead to alterations of the intrinsic tensile Reconstructive surgery in this experiment appears to
relationships of the glenohumeral joint capsule and capsu- restore normal joint proprioception 6 months or more
lar ligaments. The authors concluded that capsular elon- after the surgical procedure.
gation may be responsible for the high incidence of failed Lephart et al (2002) tested 20 subjects diagnosed with
anterior reconstructions to address anterior glenohumeral unilateral anterior, anteroinferior, or multidirectional
joint instability that do not fully restore normal capsular instability with no other concomitant pathologies. Sub-
tension of the anterior structures. jects underwent testing to assess “joint angular replica-
Blaiser et al (1994) compared the proprioceptive tion” and the “threshold to detect passive motion” 6 to 24
ability of subjects without known shoulder pathology with months after arthroscopic thermal capsulorraphy. Signifi-
individuals with clinically determined generalized joint cantly better proprioceptive function was found in the
laxity. Individuals with greater glenohumeral joint laxity involved shoulder compared with the uninvolved shoul-
had less sensitive proprioception compared with those der, with a mean of 11 months after arthroscopic surgery
with less glenohumeral joint laxity. They found enhanced using thermal energy to address glenohumeral joint insta-
proprioception at or near the end range of external rota- bility. This study provides important objective evidence
tion, when the anterior capsular structures have greater showing that no appreciable deleterious effects exist with
internal tension. The authors concluded that decreased respect to proprioceptive function of the shoulder after
joint angular reposition sense is one characteristic in indi- arthroscopic surgery with thermal capsulorraphy.
viduals with increased glenohumeral joint laxity. In a prospective study, Zuckerman et al (2003) evalu-
Smith and Brunolli (1989) examined kinesthesia after ated proprioceptive ability in patients with traumatic
glenohumeral joint dislocation in 8 subjects and compared anterior instability. A total of 30 consecutive patients with
their inherent joint position sense with 10 normal subjects recurrent bouts of anterior instability were evaluated for
using an instrumented modification of a shoulder wheel. passive position sense and detection of motion in flexion,
They reported a significant decrease in joint awareness abduction, and external rotation. A significant deficit in
in the involved shoulders after shoulder dislocation proprioceptive function was found in all directions in
compared with all uninvolved shoulders tested in the these subjects 1 week before surgical repair. All subjects
study. underwent a standard anterior capsulorraphy and labral
Lephart et al (1994) studied glenohumeral joint pro- detachment repair followed by a standardized postopera-
prioception in 90 subjects in three experimental groups. tive rehabilitation protocol. Subjects were tested 6 months
One group consisted of 40 college-aged subjects with nor- after surgery using identical testing procedures. The
mal shoulders, another group of 30 patients diagnosed authors reported approximately 50% improvement in pro-
with anterior instability, and a third group of 20 subjects prioceptive ability, but this ability was still significantly
who had undergone surgical reconstruction for shoulder deficient when compared with the contralateral side. One
instability. No significant difference was found be- year after surgery during final evaluation, the subjects
tween extremities (dominant versus nondominant) in the were again tested using identical procedures. No signifi-
normal subjects’ kinesthesia and joint position sense; cant difference in side-to-side proprioceptive function
however, subjects with anterior instability had significant was found. This study provides important evidence
differences between the normal and unstable shoulder. regarding the amount of time needed for the return of
Subjects with anterior instability had significantly longer normal proprioceptive function and alerts clinicians that a
Ch16.qxd 5/24/04 4:57 PM Page 159

CHAPTER 16 Proprioceptive Testing of the Glenohumeral Joint 159

full year may be required to attain normal values for both

position sense and detection of motion. This research sup-
ports the use of rehabilitative interventions that retrain
the proprioceptors of the shoulder after surgery to elimi-
nate glenohumeral joint instability.

PRIMARY MEASUREMENT METHODS

FOR ASSESSING PROPRIOCEPTION FOR
THE GLENOHUMERAL JOINT
Evaluation of proprioception and neuromuscular control
in the human shoulder encompasses both afferent and
efferent neural function, as well as the resulting muscular
activation patterns (Myers & Lephart, 2000). Propriocep-
tion consists of three major submodalities: kinesthesia,
joint position sense, and sensation of resistance. Separate
techniques can be used to assess each of these aspects of Figure 16-1 Proprioceptive testing device used for assessment
proprioception. of glenohumeral joint proprioception. (Reprinted with permission
from Allen AA: Neuromuscular contributions to normal shoulder
joint kinematics. In Lephart SM, Fu FH, eds: Proprioception and
neuromuscular control in joint stability, Champaign, IL, 2000,
MEASUREMENT OF KINESTHESIA Human Kinetics, p. 111.)
Glenohumeral joint kinesthesia has been assessed using
a test called the threshold to detection of passive motion enhanced (smaller amount of movement before detection)
(TTDPM). This test assesses the subject’s ability to detect at or near the end range of external rotation as compared
a passive movement occurring typically at very slow angu- with mid-range external rotation or internal rotation.
lar velocities (Lephart et al, 1994; Myers & Lephart, Warner et al (1996) reported normative data on 40
2000; Lephart & Fu, 2000). Elaborate testing devices healthy college-aged individuals using the TTDPM test
have been used in several studies of TTDPM such as from both neutral rotational starting positions and 30
an instrumented (motorized) shoulder wheel (Smith & degrees of humeral rotation at 90 degrees of glenohumeral
Brunolli, 1989) and other devices such as the one dia- joint abduction. They found an average of 1.5 to
grammed in Figure 16-1 from the University of 2.2 degrees for all testing conditions, with no significant
Pittsburgh (Lephart & Fu, 2000). Extensive research difference measured between the dominant or preferred
using the TTDPM test has resulted in the selection and hand relative to the nondominant extremity. Allegrucci et
recommendation of slow angular velocities (0.5 to 2 al (1995) measured shoulder kinesthesia in healthy unilat-
degrees/second) to enhance the reliability of data acquisi- eral athletes who performed upper extremity sports. The
tion. In addition to the device used, blindfolds, earphones, TTDPM test was performed with the shoulder in 90
and a pneumatic cuff are recommended to eliminate cues degrees of abduction at both 0 and 75 degrees of external
from the visual, auditory, and tactile realm (Lephart et al, rotation and compared bilaterally. There was greater diffi-
1994; Lephart & Fu, 2000). This ensures that only joint culty in detecting passive motion in the dominant extrem-
kinesthesia is being assessed and not simply visual or audi- ity than in the nondominant extremity. Consistent with
tory responses to perceived movement. earlier research (Blaiser et al, 1994), Allegrucci et al
Physiologically, the TTDPM test is designed to selec- (1995) measured greater sensitivity to passive movement
tively stimulate the Ruffini or Golgi-type mechanorecep- with the shoulder in 75 degrees of external rotation bilat-
tors in the articular structures being tested. Testing is erally, compared with the more neutral condition. These
typically applied for internal and external rotation of the findings suggest that unilaterally dominant upper extrem-
glenohumeral joint in varying positions of elevation in the ity athletes, such as those involved in baseball, tennis, or
scapular and coronal planes. Testing has been done at mid- volleyball, may have a proprioceptive deficit on the domi-
and end-range positions of glenohumeral rotation (Lep- nant arm that may interfere with optimal afferent feed-
hart et al, 1994; Lephart & Fu, 2000; Myers & back regarding joint position. This finding provides a
Lephart, 2000). As stated earlier, TTDPM in the human rationale for proprioceptive upper extremity training in
shoulder has been measured by Blaiser et al (1994) and was athletes from this population.
Ch16.qxd 5/24/04 4:57 PM Page 160

160 SECTION III Additional Shoulder Evaluation Techniques

MEASUREMENT OF JOINT
POSITION SENSE
Joint position sense measures the ability of the subject to
appreciate where the extremity is oriented in space. Test-
ing procedures to assess joint position sense are called
joint angular replication tests. The joint angular replication
tests typically place the extremity in a particular position
to allow the subject to appreciate the spatial orientation of
the extremity. After this period of joint positioning, the
subject’s extremity is returned to a starting position. The
subject then reapproximates the position initially selected
as closely as possible, without any visual, auditory, or tac-
tile cues. Researchers have used both active (Lephart et al,
1994; Lephart & Fu, 2000; Myers & Lephart, 2000;
Davies & Hoffman, 1993) and passive (Voight et al, 1996)
angular replication tests to assess the glenohumeral joint.
Various apparatuses have been used to facilitate the
accuracy of joint angular replication testing. Voight et al Figure 16-2 Clinical method of measuring active joint angular
(1996) used an isokinetic dynamometer with 90 degrees replication using a universal goniometer and standardized
technique.
of abduction and elbow flexion, with standard isokinetic
stabilization, to perform active angular joint replication
testing using a fatigue paradigm. They also used the
passive mode of the isokinetic dynamometer set at 2
degrees/second to perform passive joint angular replica-
tion testing. Various authors (Lephart & Fu, 2000;
Jerosch, 2000; Slobounov et al, 1999) have used complex
three-dimensional spatial tracking devices to quantify arm The clinically applicable method of measuring joint
position, using multiple positions of active joint angular angular replication described by Davies and Hoffman
replication testing. (1993) can best be replicated in most clinics using a
standard goniometer and standardized testing protocol
CLINICAL MEASUREMENT OF JOINT (Figure 16-2). Although limitations exist regarding the
POSITION SENSE reliability of goniometric measurement of the gleno-
In the most clinically applicable research study on active humeral joint (see Chapter 8 for a more detailed descrip-
joint angular reproduction, Davies and Hoffman (1993) tion of joint range of motion measurement), the clinical
tested subjects in a seated position using an electronic method of using a goniometer to determine differences
digital inclinometer (EDI, Cybex, Inc., Ronkonkoma, in joint angular replication can be performed using the
NY ). Reference angles were chosen in the following positions outlined by Davies and Hoffman (1993).
ranges and verified with the EDI, with subsequent active This method undoubtedly has limitations in regard to
angular replication by the patient and verification of accuracy, but it can provide some measure of joint angular
extremity position with the EDI. Angles chosen were replication ability by the patient and may be of particular
greater than and less than 90 degrees of flexion and interest in the patient with glenohumeral joint instability.
abduction, external rotation greater than 45 degrees, Further research using more clinically applicable methods
external rotation less than 45 degrees, and internal rota- of documenting joint angular replication and the thresh-
tion. Normative data developed by Davies and Hoffman old to detection of passive movement is needed before
on 100 male subjects without shoulder pathology showed more specific guidelines can be developed.
an average of the seven measurements to be 2.7 degrees Regardless of testing methodology, the active joint
(Davies & Hoffman, 1993). This represents the average angular position replication tests primarily involve the
difference between the seven reference angles and the stimulation of both joint and muscle receptors and pro-
actual matched angles by the subjects over the seven vide a thorough assessment of afferent pathways of the
measurements. human shoulder (Lephart & Fu, 2000).
Ch16.qxd 5/24/04 4:57 PM Page 161

CHAPTER 16 Proprioceptive Testing of the Glenohumeral Joint 161

EFFECTS OF MUSCULAR Finally, Myers et al (1999) used an active angular repli-

FATIGUE ON PROPRIOCEPTION cation test and neuromuscular control test to examine the
IN THE GLENOHUMERAL JOINT effects of muscle fatigue in normal shoulders. A concen-
Zuckerman et al (1999) injected lidocaine into the tric isokinetic internal and external rotation fatigue proto-
subacromial space and glenohumeral joint to assess col was used. Fatigue of the internal and external rotators
proprioception in young and old male subjects. They of the shoulder decreased subjects’ accuracy in detecting
found no adverse effects from the injection of lidocaine in both mid- and end-range absolute angular error, but not
either location, proposing compensatory extracapsular their neuromuscular control using a bilaterally assessed
feedback in order to ensure intact proprioception after unilateral closed-chain stability type test measuring pos-
injection. No differences in joint position sense and tural sway velocity.
TTDPM testing were noted between the dominant and The consistent finding of a proprioceptive decrement
nondominant extremity; however, a decline in proprio- after muscular fatigue in these studies has led researchers
ception with age was found between the younger (20 to 30 to emphasize the importance of the muscle-based recep-
years) and older (50 to 70 years) subjects. tors. Use of the active joint angular positioning tests
Several studies have investigated the effect of muscular has been reported to stimulate both joint and muscle
fatigue on various indices of joint proprioception and neu- mechanoreceptors and is considered to be a more func-
romuscular control. Carpenter et al (1998) tested subjects tional assessment of afferent pathways (Lephart & Fu,
using a TTDPM test, with the shoulder in 90 degrees of 2000; Myers et al, 1999). The exact mechanism by which
abduction and 90 degrees of external rotation. By follow- muscular-based proprioception is affected is not known.
ing an isokinetic fatigue protocol, subjects’ detection of Muscle fatigue is thought to desensitize the muscle spin-
passive motion was marred or decreased 171% for internal dle threshold, leading to decrements in both joint position
rotation and 179% for external rotation. In preexercise sense and neuromuscular control. Djupsjobacka et al
testing, the authors found increased sensitivity moving (1994, 1995a, 1995b) reported alterations of muscle spin-
into external rotation compared with internal rotation, but dle output in the presence of lactic acid, potassium chlo-
no difference between the dominant and nondominant ride, arachidonic acid, and bradykinin. Intramuscular
extremity. The authors concluded that the effect of mus- concentrations of these substances are altered during mus-
cular fatigue on joint proprioception may play a role in cular exertion and fatigue. This consistent relationship has
injury and decrease athletic performance. provided further rationale and support for the improve-
Voight et al (1996) tested subjects using an active ment of muscular endurance of the dynamic stabilizers of
and passive joint angular replication protocol after isoki- the glenohumeral joint.
netically induced muscular fatigue of the glenohumeral
joint internal and external rotators. No significant differ- SUMMARY
ence in shoulder joint angular replication was found The important role proprioception plays in normal func-
between the dominant and nondominant extremity. Sig- tion of the glenohumeral joint and the research docu-
nificant decreases in accuracy were noted after muscular menting decrements in proprioceptive function in cases of
fatigue in both the active and passive joint angular replica- glenohumeral joint instability and with muscular fatigue
tion tests. Petersen et al (1999) tested the ability of healthy clearly provide rationales for the clinician to perform test-
subjects to discriminate movement velocity of the gleno- ing to determine the level of function of the propriocep-
humeral joint in the transverse plane. Subjects had a tive system in the glenohumeral joint. Further research
decrement in the discrimination of movement velocity advancing clinical methods of measurement will continue
after a hard isokinetic horizontal flexion/extension exercise to enhance the clinician’s ability to measure and test for
fatigue protocol, compared with a light exercise condition. this important function.
Ch17.qxd 5/25/04 2:13 PM Page 163

CHAP TER
Analysis of Sport Technique:
17 Tennis and Overhead
Throwing Model
INTRODUCTION prised of conical links, including the lower extremities,
Although it is beyond the scope of this text to completely torso, and upper extremities. In reference to upper extrem-
review all aspects of sport technique, it is imperative to ity skill performance, work in these upper extremity seg-
review the basic mechanism and concepts surrounding the ments is transmitted to the trunk and spine via a large
overhead arm motion used in sport-specific activities as musculoskeletal surface. A change of forces across this
an essential part of the comprehensive evaluation of the musculoskeletal surface results in the generation of mas-
patient with shoulder injury. Failure to perform this por- sive amounts of energy.
tion of the evaluation can ultimately lead to reinjury and Davies (1992) described how the upper extremity can
an incomplete understanding of the injury mechanism. be viewed as a series of links that include the trunk, scapu-
Although baseline information in this area is important to lothoracic articulation, scapulohumeral or glenohumeral
all clinicians working with athletes and active individuals, joints, and distal arm regions. Each of these links can be
it is also essential to have adequate referral mechanisms considered independent anatomically and biomechani-
in place for more complete biomechanical evaluation of cally, but with reference to human function, they must be
sport-specific activity technique. Use of sport-specific, considered as a unit.
high-performance coaches and biomechanists is recom-
mended, as it is uncommon for rehabilitation profes- PROXIMAL-TO-DISTAL SEQUENCING
sionals to be proficient in activity evaluation and When analyzing human movement, Putnam (1993) dis-
biomechanical modification and intervention in more cussed the concept of proximal-to-distal sequencing. This
than one or two sports, if at all. principle states that to produce the largest possible speed
This chapter briefly reviews some of the common at the end of a linked chain of segments, movement must
mechanisms found in the overhead motion and provides initiate in more proximal segments and proceed to the
examples of common pathomechanics often identified in more distal segment. Also, the distal segment motion
individuals with shoulder injury. The overhead throw- should commence at the time of maximal speed in the
ing/serving motion is the model for this chapter. It is more proximal segment. This has been referred to by
recommended that the reader seek additional information many names such as the summation of speed principle
in the areas of swimming (Toussaint et al, 2000) and golf (Bunn, 1972), kinetic link principle (Kreighbaum and
(Farrally & Cochran, 1999) to more completely under- Barthels, 1985), and Palgenhoef ’s (1971) concept of
stand similar mechanisms inherent in these activities. acceleration-deceleration. This concept has been verified
and illustrated by measuring the linear speeds of segment
THE KINETIC LINK OR endpoints, joint angular velocities, and joint moments
KINETIC CHAIN PRINCIPLE (Marshall & Elliott, 2000).
The kinetic link principle describes how the human body Several investigators have reported proximal to distal
can be broken down into a series of links or segments that sequencing for kicking a ball, with the hip, knee, and
are interrelated and ultimately affect segments both prox- ankle joints reaching their peak speeds in a sequence and
imal and distal to that segment. Kibler (1998a, 1998b) each peak being greater than that of the proximal joint
referred to the kinetic link system as a series of sequen- (Putnam, 1993). Most researchers feel that the proximal
tially activated body segments. The kinetic link principle segment deceleration is caused by the acceleration of the
is predicated on a concept developed and described by distal segment (Putnam, 1993).
Hanavan (1964), who constructed a computerized form of Proximal to distal sequencing has been reported in the
the adult human body. This computerized form is com- upper extremity during throwing (Vaughan, 1985; Joris

163
Ch17.qxd 5/25/04 2:13 PM Page 164

164 SECTION III Additional Shoulder Evaluation Techniques

et al, 1985; Ishii et al, 1986), as well as in the tennis serve extremity sport activities, such as the throwing motion
(Elliott et al, 1986; VanGheluwe & Hebbelinck, 1985). and tennis serve, is clearly evident by analyzing this
However, more recent analysis suggests that aspects of model. It is important to note that initiation of movement
these upper extremity patterns (throwing, serving, and of the next segment in the kinetic chain occurs before
striking) have significant modifications in the traditional complete deceleration of the previous segment. The angu-
proximal to distal sequencing. Feltner and Dapena (1986) lar velocity of the segmental rotation in the body’s kinetic
reported peak internal rotation velocity of the humerus link system was originally thought to occur at increas-
after movements of the wrist and hand during overhead ingly faster velocities moving from the lower extremities
throwing. Sprigings et al (1994) showed that internal to the upper extremities during the tennis serve (Groppel,
rotation was the largest contributor to racquet head veloc- 1992). Further biomechanical analysis, however, has
ity at impact despite being one of the last components in demonstrated that although this sequential increase in
the modified sequence of proximal to distal sequencing. angular velocities does occur over many of the segments,
a perfect progression in angular velocity does not occur
APPLICATION OF THE KINETIC LINK (Elliot et al, 1986).
SYSTEM TO EVALUATION OF Kibler (1998b) provided an objective analysis of force
TECHNIQUE generation during a tennis serve (Table 17-1). A total of
Groppel (1992) applied the kinetic link system to the 54% of the force development during the tennis serve
analysis and description of optimal upper extremity sport comes from the legs and trunk, with only 25% coming
biomechanics. He stated that initiation of the sequential from the elbow and wrist. Nonoptimal performance and
activation of the kinetic link system starts at the ground as increased risk of injury occur in tennis and other sport
the lower extremities of the body create a ground reaction activities when an individual attempts to use the smaller
force. The sequential activation then proceeds from the muscles and distal arm segments as a primary source for
legs, through the hips and trunk, and is funneled via the power generation (Kibler, 1994; Groppel, 1992).
scapulothoracic and glenohumeral joints to the distal
aspect of the upper extremity. Figure 17-1 shows the EXAMPLES OF ALTERATIONS IN
kinetic link system described and applied by Groppel OPTIMAL KINETIC LINK PATTERNING
(1992). The important role of both linear and angular Use of the kinetic link principle is of paramount impor-
momentum in the production of force and power in upper tance when analyzing sport performance or exercise
movement patterns. Identification of movement patterns
that do not sequentially activate all portions of the
kinetic link system or omit a portion or link such as trunk
rotation can lead to injury and nonoptimal performance
Wrist (Kibler, 1994a, 1994b; Groppel, 1992). Examples of
nonoptimal use of the kinetic link principle are depicted
Elbow
in Figures 17-2 and 17-3, where a segment is deleted from
the sequential activation pattern or improper timing of
Shoulder
the sequential activation is encountered, respectively.

Trunk and back Table 17-1 Specific Segments’ Contribution

to Kinetic Energy and Force
Ground reaction force

Production in the Tennis Serve

Hips
Kinetic Force
Velocity Energy (Units
Legs Segment M/S (Units [%]) [%])
Leg/trunk 2.7 197.1 (51%) 729 (54%)
Ground Shoulder 2.2 49.1 (13%) 297 (21%)
Elbow 6.4 82 (21%) 212 (15%)
Wrist 7.8 61 (15%) 130 (10%)
Figure 17-1 Kinetic link principle. (Adapted from Groppel JL:
High tech tennis, ed 2, Champaign, IL, 1992, Human Kinetics From Kibler WB: Shoulder rehabilitation: principles and practice, Med
Publishers.) Sci Sports Exerc 30(4): S40-S50, 1998b.
Ch17.qxd 5/25/04 2:13 PM Page 165

CHAPTER 17 Analysis of Sport Technique: Tennis and Overhead Throwing Model 165

Wrist

Elbow

Shoulder

Trunk and back

Ground reaction force

Legs

Ground

Figure 17-2 Kinetic link principle: omitting a segment from the

kinetic link system. (Adapted from Groppel JL: High tech tennis,
ed 2, Champaign, IL, 1992, Human Kinetics Publishers.)

Wrist

Elbow

Shoulder

Trunk and back Figure 17-4 Example of a player using an excessively closed
stance, resulting in an inability to utilize hip and trunk rotation.
Ground reaction force

Hips
Applying these diagrams to a functional movement
pattern such as the tennis serve would involve hitting the
Legs
serve with no trunk rotation, or minimal trunk rotation,
because the hips are blocked from rotating by an im-
Ground
proper stance (Figure 17-4). This movement would pro-
duce greater loads and stresses to the shoulder and elbow
Figure 17-3 Kinetic link principle: mis-timing a link in the and possibly result in injury. If improper sequencing or
kinetic link system. (Adapted from Groppel JL: High tech tennis, timing of the rotation from the legs to the hip and trunk
ed 2, Champaign, IL, 1992, Human Kinetics Publishers.)
occurs, greater loads to the upper arm are again encoun-
tered. Figure 17-5 demonstrates how improperly timed
These two examples are common clinically when analyz- trunk rotation can lead to a “lagging behind” phenomenon
ing complex human movement patterns such as the tennis in tennis, increasing loads to the anterior aspect of the
serve and throwing motion. It is common to have an indi- shoulder and medial elbow, and Figure 17-6 demonstrates
vidual perform an activity without hip rotation either the same phenomenon in a baseball pitcher.
from improper foot positioning or inflexibility in the hip Marshall et al (1993) used three-dimensional cine-
region. Also, inappropriate timing of trunk rotation can matography to analyze the mechanics of a highly skilled
lead to disastrous consequences in segments proximal and tennis player and study the torques produced during
distal to the trunk (Marshall et al, 1993). the tennis serve. Using mathematical calculations, they
Ch17.qxd 5/25/04 2:13 PM Page 166

166 SECTION III Additional Shoulder Evaluation Techniques

Figure 17-6 Hyperangulation concept. Shoulder is placed pos-

teriorly or behind the scapular plane of the body.

44 radians/second (2521 degrees/second). On initial

analysis, researchers would assume that the triceps (elbow
extensor) musculature is contracting concentrically to pro-
duce this elbow extension velocity during the acceleration
phase of the tennis serve. Jorgensen (1976) delineated that
velocities beyond 20 radians/second (1146 degrees/
second) are beyond the contractile velocity range of
human skeletal muscle. This finding clearly confirms pre-
vious research by Quanbury et al (1975) and Robertson
and Winter (1980), who reported two sources of a limb’s
mechanical energy: (1) muscles that are attached directly
to the limb and (2) passive energy flow across a joint from
Figure 17-5 Result of early and improperly timed trunk rotation, an adjoining limb developed along the body’s kinetic
resulting in “arm-lag.”
chain. These studies help to demonstrate the important
role the kinetic link system plays in human movement
studied the effects of delaying shoulder internal rotation and the importance of training the entire limb or entire
(until late in the total movement) on the medial aspect kinetic link of the body when attempting to affect a spe-
of the elbow. The effects of delaying shoulder internal cific segment or link in the kinetic link system.
rotation highlight the underlying concept behind the
kinetic link principle. The amount of valgus stress to the CLINICAL ANALYSIS OF
medial elbow was increased 53% immediately before ball SPORT TECHNIQUE
impact when nonoptimal timing was used during the In many cases, the use of video analysis using a camcorder
serving motion. This study graphically displays the effects or digital photography can assist the clinician in both
of manipulation of the normal kinetic link interaction on identifying pathomechanics and conveying that informa-
the human body during stressful upper body sport move- tion to the patient, parent, and/or coach. High-tech digi-
ment and exertion. tizing systems found in any biomechanics laboratory and
Another important example of how the body’s kinetic some clinical centers provide the highest level of sophisti-
link system is applied during stressful musculoskeletal cation and allow for detailed analyses of human
exertion is shown by Buckley and Kerwin (1988), again movements. However, identification of common patho-
using the tennis serve. Elbow extension velocities during mechanical features in the throwing motion and tennis
the tennis serve measured in elite tennis players averaged strokes, as well as other sport movement patterns, can be
Ch17.qxd 5/25/04 2:13 PM Page 167

CHAPTER 17 Analysis of Sport Technique: Tennis and Overhead Throwing Model 167

achieved with the use of commonly available technology ing shoulder during this phase; therefore few injuries or
(Fleisig et al, 1989). episodes of pain provocation are typically described.
A description of the throwing motion and tennis serve One essential aspect to analyze during the end of the
and groundstrokes provides characteristic markers or wind-up phase is the presence of proper balance (Fleisig
patterns of performance in each specific sport activity. et al, 1989). The lead leg (left leg in a right-handed
Although there are many variations in throwing and ten- throwing athlete) is lifted and rotated around the plant leg
nis mechanics, certain characteristics are found in most (right leg in a right-handed throwing athlete). This rota-
individuals that lead to optimal levels of performance. It is tion must be achieved in a balanced fashion and should be
important to emphasize the difference between funda- evaluated in reference to the shoulder, as an unstable base
mentals and idiosyncrasies. Fundamentals can be defined during this phase of throwing may have drastic conse-
as specific biomechanical movements or patterns that are quences as the player moves into external rotation and
characteristic of complex movement patterns such as begins the sequential segmental rotation during accelera-
throwing a ball or hitting a serve. Idiosyncrasies consist of tion later in the throwing motion. The one-leg stability
individual variations from the normal fundamental pat- test (pages 37-39) is another key test to apply in the return
terns that are often recognizable and attributable to a par- to activity phase to ensure that the throwing or overhead
ticular player or performer. Examples of idiosyncrasies in athlete has ample levels of core stability to provide the sta-
baseball are relief pitcher Mike Fetters’ violent head jerk ble base needed for this particular phase of the activity. A
movement, pitcher Vida Blue’s high leg kick, and John digital photo or video pause near the end of the wind-up
McEnroe’s unique stance and wind-up during his serve. phase with the pitcher in the balance position is one of the
Examples of both normal biomechanics and common first checkpoints recommended (Figure 17-8).
pathomechanics are presented in these brief overviews of The cocking phase is often divided into two phases
the sport-specific movement mechanics. (Glousman et al, 1992; Fleisig et al, 1989). The early
cocking phase begins as the ball leaves the glove and con-
THROWING MOTION tinues until the lead foot contacts the ground. During the
For the purposes of evaluation, the throwing motion has early cocking phase the arm is brought backward away
been divided into four primary phases (Glousman et al, from the body coupled with a forward drive of the lead
1992): wind-up, cocking, acceleration, and follow- leg. As the lead leg is extended forward, it strikes the
through (Figure 17-7). The wind-up phase begins with mound; this is termed foot contact. At front foot or lead
the initial motion of the pitcher and ends when the ball foot contact, there is another crucial marker or evaluation
leaves the glove (Glousman et al, 1992; Fleisig et al, point. At the time the foot strikes the mound, the throw-
1989). Little muscular activation is required in the throw- ing elbow should be flexed 90 degrees and the throwing

Wind- Early Late Acceleration Follow-

up cocking cocking through

Figure 17-7 Phases of throwing. (From Glousman RE, Barron J, Jobe FW, et al: An electromyographic analysis of the
elbow in normal and injured pitchers with medial collateral ligament insufficiency, Am J Sports Med 20(3):312, 1992.)
Ch17.qxd 5/25/04 2:13 PM Page 168

168 SECTION III Additional Shoulder Evaluation Techniques

Figure 17-8 Wind-up phase: balance point position. Figure 17-9 Body position at foot contact. Note elbow flexion
angle and external rotation angle of the glenohumeral joint. The
open stride angle (foot angled toward first base side of
shoulder should be externally rotated to at least the neu- home plate) for a right-handed pitcher leads to an abnormal body
position.
tral position (Fleisig et al, 1989) (Figure 17-9). Failure of
the athlete to achieve this arm position at foot contact can
lead to a “lagging” behind of the arm as the hips rotate angles block rotation of the pelvis and decrease the con-
forward in preparation for ball release. This places the arm tribution from the lower extremity segments.
in a “catch-up” situation, as the rest of the body is too far The lead foot also should land directly in front of the
ahead of the arm at this point in the movement pattern rear foot or in a position with a few centimeters closed
(see Figure 17-6). Also, failure to flex the elbow provides stance (lead foot a few centimeters to the right of the rear
a longer lever arm and more strain on the shoulder during foot in a right-handed thrower). Again, if the lead foot
this early stage of the throwing motion (Figure 17-10). A lands in a position that is too closed, pelvic rotation is
static photo or video pause at this position allows the impeded, forcing the pitcher to throw across the body,
clinician to evaluate and provide crucial feedback. which minimizes contribution from the lower extremity
Additional information crucially important to the (Fleisig et al, 2000). Consequently, landing in a “too open”
glenohumeral joint is the stride characteristics of the position leads to early pelvic rotation and dissipation of
lower extremity during the foot contact portion of the ground reaction forces and lower extremity contribu-
the throwing motion. Fleisig et al (2000) outlined the tion, and leads to arm fatigue and throwing with “too
stride characteristics during baseball pitching. They much arm” (Fleisig et al, 2000). Careful documentation of
reported stride length (distance from ankle to ankle) to foot position using video or digital photography can pro-
range from 70% to 80% of the athlete’s height. At foot vide valuable insight into possible mechanisms of arm
contact the angle of the lead foot should be closed (angled injury stemming from lower extremity pathomechanics.
inward) between 5 and 25 degrees, rather than pointing Late cocking occurs after foot contact and continues
straight ahead toward home plate. An open stance or until maximal external rotation of the throwing shoulder
stride angle increases opening or early rotation of the occurs (Glousman et al, 1992). By the end of the cocking
pelvis and may lead to hyperangulation and arm lag, phase, the shoulder can obtain a nearly horizontal position
increasing stress on the medial elbow and shoulder (see of 180 degrees of external rotation. This amount of rota-
Figures 17-6, 17-9, and 17-10). Excessively closed stride tion, however, is combined with scapulothoracic and
Ch17.qxd 5/25/04 2:13 PM Page 169

CHAPTER 17 Analysis of Sport Technique: Tennis and Overhead Throwing Model 169

Anterior Posterior

AIGHL

PIGHL

Figure 17-10 Abnormal body position at foot contact: note the Figure 17-11 In abduction and external rotation (late cocking),
increased elbow extension and hyperangulation (excessive shoul- the posterior band of the inferior glenohumeral ligament (IGHL) is
der horizontal abduction), increasing stress to the shoulder. bowstrung beneath the humeral head, causing a posterosuperior
shift in the glenohumeral rotation point. Also in late cocking, the
biceps vector shifts in a posterior direction and twists at its base,
trunk articulation and gives the appearance of the artifi- maximizing peel-back forces. As a result of the tight posteroinfe-
cially high external rotation value at the shoulder joint rior capsule, this pitcher shows classic derangements of pitching
mechanics: hyperexternal rotation, hyperhorizontal abduction (out
(Fleisig et al, 1989).
of the scapular plane), dropped elbow, and premature trunk rota-
At the time of maximal external rotation in the throw- tion. (From Burkhart SS, Morgan CD, Kibler WB: The disabled
ing arm, it is important to note that the scapulothoracic throwing shoulder: spectrum of pathology. Part I. Pathoanatomy
joint must be in a retracted position (Kibler, 1998a, 1998b; and biomechanics, Arthroscopy 19(4):416, 2003.)
Burkhart et al, 2003). The scapula actually translates 15 to
18 cm during the throwing motion (Kibler, 1998a, 1998b).
Failure to retract the scapula leads to an increase in the rotator cuff impingement and labral injury derangement
antetilting of the glenoid as a result of a protracted scapu- (see Figures 17-6 and 17-11).
lar position and can exacerbate the instability continuum The acceleration phase begins after maximal external
and create anterior instability and suboptimal perfor- rotation and ends with ball release. During the delivery
mance leading to injury (Kibler, 1998; Burkhart et al, phase, the arm initially starts in -30 degrees of horizontal
2003). Research has shown that in late cocking, the abduction (30 degrees behind the coronal plane) (Dillman
abduction and external rotation position places the poste- et al, 1991). As acceleration of the arm continues, the
rior band of the inferior glenohumeral ligament in a glenohumeral joint is moved forward to a position of 10
“bowstrung” position under the humeral head such that degrees of horizontal adduction (anterior to the coronal
tightness in this structure can lead to a posterosuperior plane) (Dillman et al, 1991). During acceleration, the arm
shift in the humeral head, which can lead to rotator cuff moves from a position of 175 to 180 degrees of compos-
and labral pathology (Burkhart et al, 2003) (Figure 17- ite external rotation to a position of nearly vertical (105)
11). Improper scapular positioning coupled with increases degrees of external rotation at release. This is another
in horizontal abduction during late cocking and the tran- point at which the video can be paused or a digital image
sition into the acceleration phase has been termed hyper- generated for analysis. When viewed from the side, the
angulation and leads to aggravation of undersurface forearm is in an almost vertical position; however, the arm
Ch17.qxd 5/25/04 2:13 PM Page 170

170 SECTION III Additional Shoulder Evaluation Techniques

ward momentum is gradually dissipated by wrapping the

arm across the body with trunk rotation. Also, the rear leg
should come forward to assist in this process, leaving the
pitcher in a balanced finish position.
Failure at any one of these stages in the throwing
motion can have profound implications on the throwing
shoulder. As mentioned throughout this section, use of
digital still photography from multiple sides of the throw-
ing athlete, as well as the use of video, can enhance the
evaluation process and clearly improve biofeedback and
education with the injured athlete, parent, and coach.
Removal of the shirt when applicable for men and use of
a sports bra or sleeveless shirt for women will enhance the
ability to estimate arm-trunk relationships. Even with
careful clinical monitoring at this level, more extensive
biomechanical analysis may be needed to better identify
deviations from normal movement patterning. Referral
Figure 17-12 Ball release position. Note the vertical position of to a biomechanist who has access to three-dimensional
the forearm and the forward flexed position of the trunk. motion analysis programs is indicated in many cases.

TENNIS SERVE
appears to be 10 to 15 degrees behind the trunk because The tennis serving motion can be classified into four pri-
the trunk is flexed forward at ball release (Figure 17-12). mary phases: wind-up, cocking, acceleration, and follow-
This internal rotation movement after maximal external through (Rhu et al, 1988) (Figure 17-13). These phases
rotation is difficult to capture on video and with digital are used to scientifically break down the movement and
images because it occurs at more than 7000 degrees per do not occur as separate individual stages or phases
second (Dillman et al, 1991; Fleisig et al, 1989). during actual performance.
Another important variable to monitor during arm The wind-up phase of the tennis serve is similarly quiet
cocking and acceleration is the abduction angle of the with respect to muscular activity, but it does require a
glenohumeral joint. Research has consistently shown that balanced position to provide a stable base for optimal per-
the abduction angle for the throwing motion ranges formance. Also, the stance should be aligned such that if a
between 90 and 110 degrees (Dillman et al, 1991; long board were placed along the tips of the feet, it would
Atwater, 1979). It is important to note that this angle is point in the direction the serve is intended. An excessively
relative to the trunk, with varying amounts of trunk later- closed stance leads to blocking the pelvis and would poten-
al flexion changing the actual release position while keep- tially keep the hips from rotating during later stages of the
ing the abduction angle remarkably consistent among serve, whereas an excessively open stance leads to early
individuals and major pitching styles (Dillman et al, 1991; opening of the hips and would likely produce nonoptimal
Fleisig et al, 1989; Atwater, 1979). Elevation of the gleno- transfer of energy from the lower extremities and trunk.
humeral abduction angle to more than 110 degrees can Arm cocking occurs as the hands separate and the ball
subject the rotator cuff to impingement stresses from the toss is initiated (Rhu et al, 1988). Initially, the racquet arm
overlying acromion. Careful monitoring of this abduction classically pursues a downward path followed by an
angle during the throwing motion is recommended using upward motion toward maximal external rotation similar
digital still images or video. to throwing. Dillman et al (1991) reported a composite
Follow-through is the stage after ball release and con- maximal external rotation angle of the dominant arm of
tains high levels of eccentric muscular activity in the pos- 154 degrees during serving in elite-level players. During
terior rotator cuff and scapular region (Fleisig et al, 2000). arm cocking, when the elbow is in a position of 90 degrees
Additional movements of the entire body are necessary to of elbow flexion, dominant arm abduction angles have
help dissipate the energy of the arm. Close monitoring been reported at 83 degrees in elite Australian players
during this stage of the throwing motion is also recom- (Elliott et al, 1986). A digital photo or video footage of
mended to ensure that an abrupt upright posture is not the tennis player from multiple angles at the stage of max-
assumed by the pitcher and that a continuation of the for- imal external rotation can be useful to identify significant
Ch17.qxd 5/25/04 2:13 PM Page 171

Figure 17-13 Phases of the tennis serve. A, Wind-up. B, Cocking. C, Acceleration. D, Follow-through.
Ch17.qxd 5/25/04 2:13 PM Page 172

172 SECTION III Additional Shoulder Evaluation Techniques

A B

Figure 17-15 Contact positions of the tennis serve. A, Improper.

B, Proper. (Adapted from Tennis Pro, Sept/Oct 13:2000.)

For the purpose of analysis, the acceleration phase ter-

minates at ball contact. This is another time point at
which a digital photo or “stop/pause” in video is recom-
mended. Specific analysis of the glenohumeral joint
abduction angle has considerable relevance for the patient
Figure 17-14 Arm cocking. Note the position of glenohumeral with glenohumeral joint dysfunction. The initial appear-
joint abduction during this phase.
ance of glenohumeral joint position during ball contact
often reveals a nearly vertical humeral position (Figure
alterations in elbow flexion angles, as well as glenohumer- 17-15, A). On closer analysis, however, the contribution
al joint abduction angles during maximal apparent com- from the trunk via lateral flexion allows the glenohumeral
posite external rotation (Figure 17-14). Inappropriate joint to be positioned between 90 and 100 degrees (Fig-
abduction angles greater than 90 degrees during arm ure 17-15, B). This position is crucial to allow for forceful
cocking and acceleration may lead to impingement of the rotational movements with the glenohumeral joint below
rotator cuff tendons under the coracoacromial arch. positions with inherent subacromial impingement or
After maximal external rotation, the dominant shoul- compression (Ellenbecker, 1995). Frequently, tennis
der undergoes rapid concentric internal rotation. This players with nonoptimal trunk control or stabilization or
movement is termed the acceleration phase and it occurs those who are unable to laterally flex their trunk to allow
between maximal external rotation and ball contact. for this important alignment use inappropriate amounts
Angular velocities of 1074 to 1514 degrees per second of glenohumeral abduction during their serve. Identifica-
have been measured during the acceleration phase of the tion of this important alignment using feedback for
tennis serve in elite players (Shapiro & Stine, 1992). Dur- the patient is another excellent example of how tech-
ing the acceleration phase, proper evaluation and moni- nique/sport analysis can provide a tremendous advantage
toring are indicated as the hips, trunk, and shoulders in the examination and rehabilitation process.
rotate segmentally. Premature opening of the hips and Another important facet in ball contact is the location
trunk can lead to “arm lag,” in which the shoulder is of the toss by the contralateral arm. Placement of the ball
placed in extremes of horizontal abduction. This has also in the 12 o’clock position (directly overhead) leads to ball
been termed hyperangulation (Burkart et al, 2003). (see contact positions with greater inherent abduction than a
Figures 17-6, 17-10, and 17-11), where the humerus lags ball toss that is placed to the side of the player. A common
behind the scapular plane of the body during internal biomechanical correction for players with pain during the
rotation of the glenohumeral joint. This hyperangulation acceleration and follow-through phases of the serving
can lead to rotator cuff and labral injury and has been motion is to toss the ball farther laterally to allow for a
implicated as a major factor in overuse injury in overhead contact point that reduces the amount of glenohumeral
athletes, including tennis players (Burkart et al, 2003). joint abduction and subacromial compression.
Ch17.qxd 5/25/04 2:13 PM Page 173

CHAPTER 17 Analysis of Sport Technique: Tennis and Overhead Throwing Model 173

After ball contact, the follow-through phase begins

and terminates at the end of the serving motion. This
phase is characterized by significant eccentric muscular
activity (Rhu et al, 1988; Ellenbecker, 1995). A common
biomechanical fault found in players with shoulder dys-
function is rapid abbreviation of the follow-through phase
after ball contact. Recommended technique includes a full
motion, including trunk flexion and rotation, shoulder
extension adduction, cross-arm adduction, and internal
rotation. Abnormally abbreviated follow-through move-
ment patterns require greater amounts of muscular work
(eccentric overload) and must occur over a shorter period
of time and motion. Also, reduced internal rotation range
of motion in the dominant shoulder of the elite tennis
player (Ellenbecker et al, 1996, 2002b; Kibler et al, 1996)
may lead to abbreviated patterns of movement and an
increase in scapular upward rotation and protraction. This
finding can be compared with the clinical examination
findings of total rotation range of motion to determine
whether abbreviated follow-through patterns are being
applied as a result of a true loss of glenohumeral joint
internal rotation.
Figure 17-16 Square stance forehand.
TENNIS GROUNDSTROKES
Tennis groundstrokes consist of the forehand and back-
hand and can be divided into three primary phases. These
phases are termed preparation, acceleration, and follow- of stance rely primarily on linear momentum to gain
through. The discrimination between the acceleration and power, which is initiated as the player steps forward
follow-through phases is based on ball contact. Most con- toward the oncoming ball (Roetert & Groppel, 2001).
sequences for the tennis playing shoulder occur during Although this classic stance has been used for a long time,
acceleration and follow-through, with the preparation one limitation occurs during follow-through when the
phase showing minimal muscular activity in the shoulder pelvis can block further rotation of the trunk and pelvis as
region (Rhu et al, 1988). One factor regarding the fore- a result of the square stance alignment. This blocking phe-
hand groundstroke preparation phase is the importance of nomenon is particularly prevalent when the player uses a
scapular retraction. Placement of the arm behind the body truly closed stance in which the front foot is placed in a
requires horizontal abduction with trunk rotation. Failure position where it crosses over the back foot. This stance is
to achieve this position with a scapular protracted position rarely used and is not recommended for forehand ground-
may lead to increased anterior shoulder stress, particularly strokes because it limits the effective transfer of kinetic
as forward trunk rotation is imposed on this pro- energy from the lower body and trunk to the upper body
tracted position with the glenohumeral joint horizontally for power generation.
abducted. In the modern game of tennis played today (2004),
An important concept for analysis of the forehand and nearly all top players use an open or partially open stance
backhand groundstroke is the position or stance that the on the forehand, with many top players using the open
player takes during execution. Three primary stances are stance for the two-handed backhand as well. The open
prevalent: square, closed, and open (Roetert & Groppel, stance involves placing the feet parallel to the net or base-
2001; Segal, 2002). The traditional position is the square line. What is crucially important and the most common
stance, whereby the player stands perpendicular to the net error regarding the open stance is that the upper body
(sideways), with the tips of one foot aligned with the tips (shoulders) must be rotated or closed so that they are
of the other foot (Figure 17-16). The shoulders are also placed perpendicular to the pelvis and lower body position
perpendicular to the net and baseline such that upper and perpendicular to the net or baseline (Figure 17-17).
body and trunk rotation can occur. Players using this type This positioning allows for greater generation and utiliza-
Ch17.qxd 5/25/04 2:13 PM Page 174

174 SECTION III Additional Shoulder Evaluation Techniques

where the lower body and trunk rotate too quickly ahead
of the arm. This improper sequential rotation leaves
power generation to the upper body, as the trunk and
pelvis rotate too early so that the optimal transfer of
power from the lower extremities and trunk cannot occur
(Figure 17-18). Also, this poorly timed rotation places the
glenohumeral joint in a position in the coronal plane dur-
ing ball contact, or in many cases ball contact occurs with
even greater amounts of horizontal abduction behind the
coronal plane of the body. This creates a position similar
to that described during the serving motion of hyper-
abduction, and when coupled with scapular protraction
and imbalanced muscle function can lead to injury
(Ellenbecker, 1995). The digital camera should be used to
show both an anterior and side view of the acceleration
phase of the forehand groundstroke to identify this sub-
optimal segmental rotation and convey this information
to the player, parent, and coach.
Figure 17-17 Open stance forehand. One final area of analysis on the forehand ground-
stroke is the follow-through. This occurs after ball impact
and should involve a continued pattern that ultimately
ends up with the racquet and racquet hand being placed
on the opposite side of the head. Some players use an
abbreviated follow-through pattern that leads to a greater
amount of eccentric muscular work, shorter follow-
through time, and movement arcs that can create injury.
Finally, most players generate tremendous topspin on the
forehand groundstroke by using a low to high racquet
path and grips that enable the generation of topspin
(Roetert & Groppel, 2001). However, some players use
excessive grips (extreme western grips) and excessive fore-
arm pronation during the acceleration and follow-through
phases of the forehand groundstroke. This distal prona-
tion leads to increased upper arm internal rotation and
requires greater eccentric deceleration by the posterior
rotator cuff (Rhu et al, 1988). This greater load placed on
the shoulder by a distal movement is another example of
Figure 17-18 Improper open stance forehand demonstrating the application of the kinetic link principle to upper
ball contact behind the body with shoulder in or behind the coro-
extremity sport movement patterns.
nal plane.

BACKHAND GROUNDSTROKE
tion of angular momentum as a result of the large angle of The backhand groundstroke can be executed both with
separation between the pelvis and shoulders. Also, the one and two hands. Research has shown that muscular
relationship of the lower extremities in the open stance activity during the one- and two-handed backhands are
does not “block” the pelvis and allows for a more optimal statistically similar (Giangarra et al, 1993); however, the
rotation pattern as the upper extremity is accelerated use of both hands on the racquet can allow for greater
toward the ball and continues through the follow-through facilitation of trunk rotation and more optimal transfer of
phase (Roetert & Groppel, 2001). energy via the kinetic chain theory. Stances used for the
A common error associated with the open stance fore- backhand are similar to those discussed for the forehand;
hand that can lead to anterior shoulder pain and rotator however, the closed stance is used with more frequency on
cuff dysfunction occurs during early rotation of the pelvis, the backhand side because of the tremendous shoulder
Ch17.qxd 5/25/04 2:13 PM Page 175

CHAPTER 17 Analysis of Sport Technique: Tennis and Overhead Throwing Model 175

rotation that is required for proper execution. Use of dig- cross-arm adduction during preparation. If the player does
ital photography or video should identify tremendous not rotate the pelvis and trunk and merely cross-arm
shoulder rotation whereby the player’s dominant arm adducts (horizontally adducts) the arm, pain may be
scapula should be pointing at the oncoming ball. Again, a reported over either the anterior or superior aspect of the
low to high motion should be used to generate topspin on shoulder from primary impingement or compression of
the ball regardless of whether one or two hands are used. the rotator cuff under the coracoacromial arch. Careful
Ball contact should occur slightly in front of the body to monitoring of body position and a reliance on rotation of
allow for forward progression of the momentum gener- the pelvis and trunk ensure a clear path for arm movement
ated. One common error inherent in many players who during this important stroke.
report pain during the backhand groundstroke is what is The mechanics developed in this chapter, as well as the
referred to as a late ball contact. This occurs when the ball simple, straightforward use of either a digital camera or
is contacted either in line with the body or actually behind video camcorder, can be clinically applied to allow the
the midline (umbilicus) of the body. This results in a clinician greater insight into the possible causes of shoul-
nonoptimal transfer of energy from the lower body and der dysfunction. The reader is urged to gain further
trunk and a reliance on concentric shoulder external rota- biomechanical information on sport-specific activities
tion for power generation. inherent in the patients commonly treated to allow for
During the one- and two-handed backhands, the the comprehensive evaluation and treatment of shoulder
dominant arm is initially brought into some degree of dysfunction.
Ch18.qxd 5/25/04 2:14 PM Page 177

CHAP TER
Putting It All Together: Using
Clinical Tests to Formulate
18 a Clinical Diagnosis for the Patient
with Shoulder Dysfunction

INTRODUCTION patients ( Jensen et al, 1992). Finally, the master clinician

In reviewing the previous chapters, clinicians will find no described the examination process as achieving a working
shortage of tests to assess the integrity of specific struc- diagnosis by performing a selective tissue examination to
tures around the shoulder. Methods to test muscular identify the structure or structures at fault (Davies, 1995;
strength and endurance, joint range of motion, and pro- Jensen et al, 1992).
prioception are also included. This chapter summarizes
the evaluation process by discussing several studies that DAVIES FUNCTIONAL TESTING
reviewed the differences between the way advanced mas- ALGORITHM
ter clinicians and novice clinicians perform and interpret
Davies (1995) developed a functional testing algorithm,
the evaluation process. A summary of common patterns or
using a combination of information gained in the exami-
clusters of signs and symptoms occurring with common
nation and in subjective reports and incorporating the
shoulder injuries is presented to provide examples of how
mechanism of injury data with clinical tests. The shoulder
the information in the previous chapters can be combined
examination algorithm is presented in this chapter to pro-
and formulated to achieve a clinical diagnosis.
vide an example of how clusters of signs and symptoms
Clinical evaluations in physical therapy are performed
can be used to formulate a diagnosis on which an objec-
for several reasons. They determine the involved struc-
tively based treatment program can be developed. Table
tures, assess the severity of the injury, develop and initiate
18-1 shows the Davies Functional Testing Algorithm,
a treatment program based on the examination data and
which includes the test category, critical pathways that
resultant database, and continually reassess the patient’s
represent the types of patients to be considered for the
progress based on the database from the initial examina-
condition being tested for, the special tests used, and
tion (Davies, 1995). Several differences in the perfor-
the tissues implicated. This table does not contain all of
mance and interpretation of the clinical examination have
the special tests contained in this text, nor does it include
been researched and reported and deserve mention here
an exhaustive list of possible shoulder injuries. It is meant
( Jensen et al, 1990, 1992).
to serve as a guide to assist the clinician in putting some
One of the first main areas identified by Jensen et al
of the contents of the previous chapters together in a clin-
(1990, 1992) was the master clinician’s recall of meaning-
ically referenced manner for some of the most common
ful relationships or patterns. Master clinicians performed
shoulder injuries typically presenting to clinicians work-
the examination with a strong tie between information
ing in orthopedics and sports medicine.
gathered and the clustering of signs and symptoms.
Master clinicians not only collected disease data (findings
that helped to validate or invalidate a diagnosis) but also APPLICATION OF CLINICAL
gathered illness data regarding the patient’s perception of TESTS TO CLASSIFY ROTATOR
how the disease affected their lives. The main emphasis by CUFF IMPINGEMENT
the novice clinician was to obtain enough information to Using a similar format to the Davies Functional Testing
complete the evaluation form ( Jensen et al, 1992). In Algorithm, the main types of rotator cuff impingement
addition, the master clinician showed an intense focus on can be identified and differentiated using a summary of
the patient to achieve a connection with the patient, the special tests and examination procedures presented in
whereas the novice clinician was focused on filling out the this book. Table 18-2 summarizes this information for
evaluation form, which dominated the interaction with rotator cuff impingement.

177
Ch18.qxd 5/25/04 2:14 PM Page 178

178 SECTION III Additional Shoulder Evaluation Techniques

Table 18-1 Davies Modified Functional Testing Algorithm

Test
Category Critical Pathways Special Tests Tissue(s) Implicated
MDI All patients Sulcus sign (neutral) SGHL, CHL, rotator interval
MDI All patients Sulcus sign (90 ABD) IGHL, anterior inferior capsule
Anterior instability All patients Anterior load and shift Anterior capsule, SGHL, MGHL,
Anterior drawer IGHL
Subluxation relocation test
Anterior release test
Macrotraumatic injury Apprehension test
Posterior instability All patients Posterior load and shift Posterior capsule
Posterior drawer
Long-head biceps MOI: eccentric deceleration Speeds test Long-head biceps
Pain on palpation Yergason’s test
C/O anterior shoulder pain Ludington’s test
AC joint Age >40 years AC joint shear test AC joint and intrinsic and
extrinsic ligaments
MOI: macrotraumatic Cross-arm adduction
injury (i.e., fall on lateral
side or blow to lateral
aspect of shoulder)
C/O pain top of shoulder
Pain with AC joint palpation Impingement test
C/O pain with crossover O’Brien’s active
activities compression test
Asymmetric deformity of AC
Labral injury MOI: macrotraumatic injury Compression rotation test SLAP
MOI: eccentric deceleration Anterior slide test SLAP
C/O pain “deep” in shoulder O’Brien’s active SLAP
compression test
Sensation of locking or Speed’s test SLAP
pseudolocking
Repetitive clicking/clunking Clunk test Labrum nonspecific
MOI: FOOSH Circumduction test Labrum nonspecific
Crank test Labrum nonspecific
Rotator cuff tears Age >40 years Drop arm test Supraspinatus
Macrotraumatic injury with Full can/empty Supraspinatus
functional disability can MMT
Idiopathic onset of Hornblower’s sign Teres minor
functional disability
C/O pain in lateral aspect Dropping sign Infraspinatus
of arm
C/O dull constant pain in Gerber lift-off test Subscapularis
shoulder
Compensatory shoulder Napoleon test Subscapularis
shrug sign

ADDITIONAL CONCEPTS shoulder instability before using other examination tech-

FOR CLINICAL EXAMINATION OF niques. For example, establishing whether a patient has a
THE SHOULDER positive sulcus sign early in the examination can guide or
As stated earlier, special tests are applied to the uninjured alert the clinician as to the expected outcome of other
shoulder first to enhance relaxation and gain patient con- examination maneuvers where humeral head translation is
fidence. The exact ordering of clinical testing for shoulder measured. A patient with a positive sulcus sign often has
examination, however, has not been clinically tested and at increases in anterior and/or posterior translation because
this time remains at the discretion of the examiner. I of the underlying hypermobility of the glenohumeral joint
recommend that special tests be applied first to rule out capsule. After the mobility status and presence of instabil-
Ch18.qxd 5/25/04 2:14 PM Page 179

CHAPTER 18 Putting It All Together 179

Table 18-2 Differentiation of Rotator Cuff Impingement Using Clinical Testing

Impingement Type Special Test/Clinical Measures Clinical Findings/Status
Primary impingement Anterior/anterolateral shoulder pain,
particularly with overhead
repetitive activities
Neer, Hawkins, cross-arm, Coracoid, and Positive traditional impingement
Yocum’s testing
MDI sulcus sign, A/P humeral head General joint hypomobility
translation testing Grade I translation (Altchek et al, 1992)
Reduced glenohumeral joint range of Loss of internal rotation (IR) common;
motion restricted elevation
Rotator cuff weakness Manual muscle testing (MMT) shows
<5/5 strength of rotator cuff (RTC)
and scapular stabilizers

Secondary impingement Anterior/anterolateral shoulder pain,

particularly with overhead repetitive
activities
Neer, Hawkins, cross-arm, coracoid, and Positive traditional impingement
Yocum’s testing
MDI sulcus sign, anterior/posterior (A/P) General joint hypermobility
humeral head translation testing Grade II or greater translation
(Altchek et al, 1992)
Subluxation relocation test Positive subluxation relocation test
with reproduction of anteriorly
based shoulder pain
Altered glenohumeral joint range of Loss of IR common; increased external
motion rotation (ER) common
Rotator cuff weakness MMT shows <5/5 strength of rotator
cuff (RTC) and scapular stabilizers

Internal or posterior Posterior shoulder pain most notable

impingement with shoulder in 90/90 position
(arm cocking)
Neer, Hawkins, cross-arm, coracoid, and Negative traditional impingement
Yocum’s testing
MDI sulcus sign, A/P humeral head General joint hypermobility
translation testing Grade II or greater translation
(Altchek et al, 1992)
Subluxation relocation test Positive subluxation relocation
test with reproduction of posteriorly
based shoulder pain
Altered glenohumeral joint range of motion Loss of IR; increased ER
Rotator cuff weakness MMT shows <5/5 strength of RTC and
scapular stabilizers

ity have been ruled out, additional testing to determine tests) has been shown to increase the effectiveness and
the status of additional structures in and around the likelihood that a positive test result will be found. For
glenohumeral joint can be carried out. example, the author of this text frequently uses a combi-
It is also important to point out that all clinical tests are nation of impingement signs such as the Neer, Hawkins,
not performed on every patient. Based on patient presen- coracoid, cross-arm, and Yocum’s to evaluate the patient’s
tation, subjective history, and clinical experience, an response to movement and possible encroachment of the
orderly flow of clinical tests is recommended. Every chap- rotator cuff and biceps long-head tendons against the
ter containing special tests reviews not only how to per- coracoacromial arch. Greater confidence can be gleaned
form the test but the research behind the test and its from the finding of a negative response to five impinge-
proven or unproven effectiveness. The use of several tests ment signs than from findings of a negative response
within a particular category (i.e., labral tests, impingement on just one maneuver. Repetitive practice with these
Ch18.qxd 5/25/04 2:14 PM Page 180

180 SECTION III Additional Shoulder Evaluation Techniques

examination maneuvers allows for the performance of a examination process can be performed. It is hoped that
core group of examination maneuvers in a clinically effi- the combination of the detailed and scientific description
cient time frame to optimize clinical interpretation and and discussion of these clinical tests and examination
minimize trauma or exacerbation of symptoms from the techniques will lead the clinician to successful identifica-
patient. tion of shoulder pathology and provide objective assis-
The final chapter of this text contains several case stud- tance for the development of evidence-based treatment
ies that demonstrate one manner in which the clinical plans.
Ch19.qxd 5/25/04 2:15 PM Page 183

CHAP TER
Three Cases: Putting Theory
19 Into Practice

Case Study 19-1

EXAMINATION: SUBJECTIVE HISTORY extremities in 90 degrees of shoulder flexion. In addi-

Meghan is a 16-year-old right-handed elite junior ten- tion, a medial type II Kibler scapula is evident during
nis player with a 3-week history of anterior shoulder active scapular plane elevation with loss of scapular
pain after increases in training and competitive tennis control noted at approximately 60 degrees of eleva-
play. She reports no pain at rest and 9/10 level pain tion during arm lowering. This is significantly more
during serving and forehands. The pain is localized to visually evident on the right side. Symmetric scapular
the right dominant shoulder, and she denies any neu- control is noted during concentric arm elevation in the
ral symptoms radiating down the arm or numbness or scapular plane bilaterally. Full pain-free active shoul-
tingling in the distal aspect of her right upper extre- der elevation in the scapular plane is present; therefore
mity. She does have pain at night (6/10) if she has scapular assistance and retraction tests are deferred.
trained earlier in the day, and she is unable to lie on Documentation of scapular position is assessed using
her affected arm while sleeping. She denies any sig- the Kibler lateral scapular slide test with results listed
nificant past medical history of right shoulder injury below.
and has no history of neck or back injury. She reports
a brief history of medial elbow pain 2 years ago that Position Left Uninjured Right Injured
was treated successfully with physical therapy, allow-
ing a full return to tennis activity. She has no signifi- 1 9 cm 11 cm
cant medical history and is not taking any medications. 2 8 cm 10.5 cm
She plays with a Prince Graphite midsize tennis rac- 3 8 cm 9.5 cm
quet strung with synthetic gut at 64 pounds, and
denies any change in technique or equipment. She RELATED REFERRAL JOINT TESTING
uses a semi-western forehand grip. Her goal is to
A negative Spurling’s maneuver was present to both
return to training and compete in tennis as soon as
sides, negative acromioclavicular (AC) joint shear
possible.
test, and bilaterally increased elbow valgus stress and
OBSERVATION/POSTURE valgus stress test physiologic laxity without pain
provocation.
Meghan stands with the right dominant shoulder
approximately 1 inch lower than the nondominant left
NEUROVASCULAR TESTING
extremity. Mild scoliosis is noted with a right thoracic
rib hump noted in the Adams position in 45 degrees of Meghan is intact to light touch sensation from C5 to T1
trunk forward flexion. Noted atrophy is present in the and has normal biceps, triceps, and brachioradialis
hands on hips position in the infraspinous fossa of the reflexes bilaterally; 40 kg of right distal grip strength is
right scapula, and a type II Kibler scapula is present, measured, with 28 kg on the left. Additional neurovas-
with increased prominence of the entire medial border cular testing is deferred at this time based on patient
of the right scapula as compared with the left. history and presentation.

SCAPULAR EXAMINATION RANGE OF MOTION MEASUREMENT

Scapular provocation tests increase the prominence of Active range of motion was measured in the standing
the entire medial border of the right scapula with position for forward flexion and abduction, and in the
waist-level pressure via the extremities against the supine position for internal and external rotation with
wall, and similarly with pressure exerted to the upper 90 degrees of glenohumeral joint abduction.

183
Ch19.qxd 5/25/04 2:15 PM Page 184

184 SECTION IV Case Studies

Active Range of Left Right SPECIAL TESTS

Motion Uninjured Injured A 2 degree multidirectional instability (MDI) sulcus
sign was noted on the right shoulder; 1 degree was
Forward flexion 0-170 0-170 noted on the left. Impingement testing revealed posi-
Abduction 0-175 0-175 tive traditional impingement tests of Neer, Hawkins,
External rotation with 0-95 0-100 and Yocum’s, with a negative coracoid and cross-arm
90 degrees abduction impingement test. The Speed’s, Yergason’s, O’Brien’s,
Internal rotation with 0-55 0-35 clunk, circumduction, and compression rotation tests
90 degrees abduction were all negative. Supine humeral head translation
Total rotation range 150 135 testing revealed 2 degree anterior translation at 60 and
of motion with 90 90 degrees of abduction in the right shoulder, with 1
degrees abduction degree translation on the left. One degree posterior
translation testing was noted bilaterally, tested at 90
degrees of abduction. A positive subluxation/reloca-
MUSCULAR STRENGTH TESTING tion test was present in the right shoulder, which
Manual muscle testing was performed bilaterally; 5/5 reproduced the patient’s anterior symptoms with sub-
strength was found in the left upper extremity for all luxation and abated the symptoms during posterior
tests, with 5/5 flexion/extension, abduction/adduction, humeral head relocation.
and horizontal abduction/adduction, and internal rota-
tion strength in the right shoulder, and 4/5 strength in CLINICAL IMPRESSION
external rotation tested in both neutral and 90 degrees Secondary impingement of the right shoulder with
of glenohumeral joint abduction, which reproduced underlying multidirectional instability and isolated
the patient’s pain. Supraspinatus strength of 4+/5 was rotator cuff muscular weakness and strength imbal-
measured using the empty can test position (scapular ance, scapular dysfunction, and loss of glenohumeral
plane elevation with internal rotation). joint internal rotation range of motion.

Case Study 19-2

EXAMINATION: SUBJECTIVE HISTORY gentle repetitive arm swinging irritates her condition.
Betty is a 78-year-old right-handed retired female who Betty completed a modified American Shoulder Elbow
reports falling on her left outstretched arm 6 months Surgeons (ASES) shoulder rating scale and scored
ago while walking her golden retriever. She reports 22/45 points on the self-report section.
having an immediate onset of anterior and posterior
shoulder pain that radiated down the lateral aspect of OBSERVATION/POSTURE
her left upper arm to a level just below the insertion of Betty stands holding her left injured shoulder in inter-
her deltoid. Initial pain levels were 10/10 with move- nal rotation and clutching her belt line in front of her.
ment and 4/10 at rest. She tried icing and not using her Her left nondominant shoulder is higher than the right
left arm, but the pain and weakness have worsened. dominant shoulder, with obvious guarding noted in
She now presents to the clinic with a primary complaint the left upper trapezius. Betty has a very forward head
of 6/10 pain at rest, and 8/10 pain at night. She also posture and significantly increased thoracic kyphosis.
reports extreme weakness in the left shoulder and an Bilateral scapular protraction is noted. Severe atrophy
inability to perform basic functions. Past medical histo- is present in the supraspinous fossa and infraspinous
ry includes right shoulder bursitis 45 years ago that fossa of the left scapula compared with muscular size
was treated with a cortisone shot and two right knee and resting tone over the right scapula. Betty is unable
surgeries. Medical history is unremarkable with the to achieve the hands-on-hips posture with her left
exception of high blood pressure and high cholesterol, shoulder, most likely because of loss of internal rota-
for which she is presently taking medications. No other tion range of motion.
medications are being used except for Tylenol at night
for pain and Advil during the day. She is seeking an SCAPULAR EVALUATION
evaluation today because her pain levels at night have No significant increase in either medial or inferior
prevented her from sleeping. Betty’s goals are scapular prominence is noted. Betty is unable to ele-
to continue to care for her home and backyard land- vate her left shoulder more than approximately 70
scaping, as well as to remain active and able to walk degrees against gravity. She shows extensive superior
her dog every day. Her pain and range of motion movement of the left scapula (“shrug sign”) and is
presently limit her from walking the dog because even classified as having a Kibler type III scapula. The
Ch19.qxd 5/25/04 2:15 PM Page 185

CHAPTER 19 Three Cases: Putting Theory Into Practice 185

scapular assistance test is positive and increases her MUSCULAR STRENGTH TESTING
left shoulder elevation to 95 degrees, but pain is elici- The right shoulder tested 5/5 for all movements, with
ted as she lowers her arm back to the neutral starting left shoulder 3-/5 for flexion and abduction, 4-/5 for
position, even with scapular assistance. The Kibler external rotation in neutral adduction, 5-/5 for internal
lateral scapular slide test shows relative symmetry rotation, and 4/5 adduction and extension; 2/5 strength
between sides, with testing in position 1 measuring 10 was measured in the empty can and full can testing
cm for both the involved left and uninjured right arm. positions. Betty has 5/5 biceps and triceps strength
Kibler positions 2 and 3 could not be assessed because bilaterally, with no evidence of a “Popeye” deformity
of the patient’s inability to assume those positions. in the left shoulder.

RELATED REFERRAL JOINT TESTING SPECIAL TESTS

Spurling’s maneuver is negative for shoulder symp- Betty has a trace left shoulder sulcus sign, with vir-
tom reproduction but is painful at the base of the cer- tually no motion available in the inferior direction. Pain
vical spine, with both left and right directional testing. is reproduced with impingement testing in both the
The AC shear test is negative, as are the elbow varus Neer and Hawkins tests, with the other tests deferred
and valgus stress tests. because of patient discomfort levels encountered with
testing. A positive drop arm test and empty and full
NEUROVASCULAR TESTING can test (positive for both pain reproduction and weak-
Betty is fully intact to light touch sensation between ness) are present in the left shoulder. A negative
levels C5 and T1, and has symmetric reflexes of the Napoleon sign is present in the left shoulder. Labral
biceps, triceps, and brachioradialis. Additional neuro- testing is deferred because of significant range of
vascular testing is deferred at this time. motion limitations and baseline pain levels. Trace ante-
rior/posterior humeral head translation is measured in
RANGE OF MOTION MEASUREMENT the left shoulder with 1 degree of translation on the
Active range of motion for forward flexion and abduc- right.
tion was measured in the standing position, with pas-
sive flexion and abduction and active glenohumeral CLINICAL IMPRESSION
joint internal and external rotation range of motion Full-thickness rotator cuff tear of the left shoulder with
measured in the supine position. secondary adhesive capsulitis and a classic capsular
pattern of limited range of motion.
Left Right
Range of Motion Involved Uninvolved

Active forward flexion 0-70 0-165

Active abduction 0-50 0-155
Passive forward flexion 0-135 0-155
Passive abduction 0-120 0-155
Active external rotation 0-40 with 45 0-80 with 90
degrees degrees
abduction abduction
Active internal rotation 0-40 with 45 0-45 with 90
degrees degrees
abduction abduction

Case Study 19-3

EXAMINATION: SUBJECTIVE HISTORY occurred. He denies feeling his shoulder dislocate and
Tony is a 55-year-old right-handed male who presents did not initially report to the emergency department or
for evaluation of his left shoulder 2 weeks after an industrial medicine center after the injury and was able
episode in which he felt his left shoulder “slip and to continue working. He reports the pain to be 3/10 at
pop” while unloading a large 4 ¥ 8 sheet of plywood rest and 5/10 after a shift at work. He believes he has
from an overhead position at a Home Depot store at lost some strength in his shoulder and that his arm
which he works. Tony manages the lumber depart- occasionally feels “heavy and out of place.” Tony
ment and loads and unloads new stock and assists reports some occasional tingling in the fourth and fifth
customers; he reports that his arm was in an abducted digit of his left hand, but this tingling is intermittent
and externally rotated position when the incident and does not appear to have a pattern. His past med-
Ch19.qxd 5/25/04 2:15 PM Page 186

186 SECTION IV Case Studies

ical history includes a left clavicle fracture and shoul- RANGE OF MOTION MEASUREMENT
der separation that he suffered playing high school Active range of motion was measured in the standing
football more than 30 years ago. He has no other med- position for forward flexion and abduction and in the
ical history and is not taking any medications. His goal supine position for internal and external rotation.
is to increase the strength and function of his left
shoulder to continue working in his physical environ- Motion Left Injured Right Uninjured
ment in the lumber department. Tony completed the
self-report section of the modified ASES rating scale Forward flexion 0-160 0-175
and scored 38 of 45 points. Abduction 0-150 0-175
External rotation with 0-65* 0-90
90 degrees abduction
OBSERVATION/POSTURE
Internal rotation with 0-45 0-45
Tony stands with level shoulders. He has excellent 90 degrees abduction
overall muscular development and no signs of visible
atrophy at rest or in the hands-on-hips position. He has MUSCULAR STRENGTH TESTING
a characteristic step-down sign over the left AC joint, The right upper extremity is 5/5 for all tests, with
and mild misalignment of the left clavicle with palpa- left shoulder manual muscle testing (MMT) revealing
ble bone formation along the inferior surface of the 4/5 external and internal rotation tests. Flexion, abduc-
distal third of the clavicle. Tony has a slightly forward tion, and supraspinatus testing were 5-/5 for the left
head posture and holds his left scapula in what shoulder.
appears to be greater protraction than his right.
SPECIAL TESTS
SCAPULAR EXAMINATION Tests revealed 1 degree sulcus sign bilaterally, a posi-
tive apprehension sign in approximately 70 degrees of
The borders of Tony’s scapulae are well concealed with
external rotation, and 90 degrees of abduction. Nega-
a normal (type IV) scapula and no evidence of a loss of
tive impingement signs (Neer, Hawkins, coracoid,
scapular control on bilateral arm elevation and lower-
cross-arm, and Yocum’s) and negative Speed’s and
ing in the scapular plane.
Yergason’s tests were also noted. Humeral head trans-
lation testing showed 2+ anterior humeral head trans-
RELATED REFERRAL JOINT TESTING lation at 30, 60, and 90 degrees of abduction and 1
Spurling’s maneuver is negative; AC joint shear test degree posterior translation left shoulder. The right
is positive with general hypomobility noted compared shoulder had 1 degree anterior and posterior transla-
with the other side and mild pain provocation directly tion. The seated load and shift test also showed 2+
over the AC joint of the left shoulder. Negative elbow anterior and 1 degree posterior translation of the left
varus and valgus stress tests are noted bilaterally; a shoulder and 1 degree translation anteriorly and pos-
negative Tinel’s test also occurred bilaterally. teriorly of the right shoulder. Labral testing produced a
positive circumduction and crank test with both catch-
ing in the shoulder and symptom reproduction. A neg-
NEUROVASCULAR TESTING ative O’Brien’s test and negative compression rotation
Tony is fully intact to light touch sensation from test were noted in both shoulders.
C5 to T1, shows normal vascular filling, and has
bilaterally symmetric upper extremity reflexes. A CLINICAL IMPRESSION
negative Adson’s and costoclavicular test were also Anterior instability of the left shoulder with possible
encountered. labral tear.
RE.qxd 5/25/04 2:11 PM Page 187

References

Abbott LC, Saunders LB de CM: Acute traumatic dislocation of the Bak K, Fauno P: Clinical findings in competitive swimmers with shoul-
tendon of the long head of the biceps brachii: report of 6 cases with der pain, Am J Sports Med 25:254-260, 1997.
operative findings, Surgery 6:817-840, 1939. Bankart ASB: Recurrent or habitual dislocation of the shoulder joint,
Adams RD: Pain in the back, neck and extremities. In Principles of BMJ 2:1132-1133, 1923.
neurology, New York, 1977, McGraw-Hill. Bankart ASB: The pathology and treatment of recurrent dislocation of
Adams RD, Victor M, Ropper AH: Principles of neurology, ed 6, New the shoulder joint, BMJ 26:23-29, 1938.
York, 1997, McGraw-Hill Health Professions Division. Barker D, Banks RW, Harker DW, et al: Studies of the histochemistry,
Aitkens S, Lord J, Bernauer E, et al: Relationship of manual muscle test- ultrastructure, motor innervation, and regeneration of mammalian
ing to objective strength measurements, Muscle Nerve 12:173-177, intrafusal muscle fibers, Exp Brain Res 44:67-88, 1976.
1989. Barrett WP, Franklin JL, Jackins SE, et al: Total shoulder arthroplasty,
Alderink GJ, Kluck DJ: Isokinetic shoulder strength of high school- and J Bone Joint Surg 69A:865-872, 1987.
college-aged pitchers, J Orthop Sports Phys Ther 7:163-172, 1986. Bartlett LR, Storey MD, Simons BD: Measurement of upper extremity
Allegrucci M, Whitney SL, Lephart SM, et al: Shoulder kinesthesia in torque production and its relationship to throwing speed in the com-
healthy unilateral athletes participating in upper extremity sports, petitive athlete, Am J Sports Med 17:89-91, 1989.
J Orthop Sports Phys Ther 21(4):220-226, 1995. Basmajian JV, Bazant FJ: Factors preventing downward dislocation of
Altchek DW, Dines DW: The surgical treatment of anterior instability: the adducted shoulder joint, J Bone Joint Surg 41A:1182, 1959.
selective capsular repair, Operative Techniques Sports Med 1:285-292, Bassett RW, Browne AO, Morrey BF, et al: Glenohumeral muscle force
1993. and moment mechanics in a position of shoulder instability, J
Altchek DW, Warren RF, Wickiewicz TL, et al: Arthroscopic acromio- Biomech 23:405-415, 1994.
plasty: technique and results, J Bone Joint Surg 72A:1198-1207, 1990. Beach ML, Whittney SL, Hoffman SA: Relationship of shoulder flexi-
Altchek DW, Warren RF, Wickiewicz TL, et al: Arthroscopic labral bility, strength and endurance to shoulder pain in competitive swim-
debridement: a three year follow-up study, Am J Sports Med mers, J Orthop Sports Phys Ther 16:262-268, 1992.
20(6):702-706, 1992. Beaton D, Richards RR: Assessing the reliability and responsiveness of
American Academy of Orthopaedic Surgeons: Clinical measures of joint 5 shoulder questionnaires, J Shoulder Elbow Surg 7:565-572, 1998.
motion, Rosemont, IL, 1994, American Academy of Orthopaedic Beighton P, Horan F: Orthopaedic aspects of the Ehlers-Danlos syn-
Surgeons. drome, J Bone Joint Surg 51(B)3:444-453, 1969.
American Academy of Orthopaedic Surgeons: School screening programs Bennett WF: Specificity of the speeds test: arthroscopic technique for
for the early detection of scoliosis: a position statement, Rosemont, IL, evaluating the biceps tendon at the level of the bicipital groove,
1992, American Academy of Orthopaedic Surgeons. Arthroscopy 14(8):789-796, 1998.
Andrews JA, Wilk KE: The athletes shoulder, New York, 1994, Churchill Berryman-Reese N, Bandy WD: Joint range of motion and muscle length
Livingstone. testing, Philadelphia, 2002, WB Saunders.
Andrews JR, Alexander EJ: Rotator cuff injury in throwing and racquet Bigliani LU, Codd TP, Connor PM, et al: Shoulder motion and laxity in
sports, Sports Med Arthrosc Rev 3:30, 1995. the professional baseball player, Am J Sports Med 25(6):609-613,
Andrews JR, Gillogly S: Physical examination of the shoulder in throw- 1997.
ing athletes. In Zarins B, Andrews JR, Carson WG, editors: Injuries Bigliani LU, Ticker JB, Flatow EL, et al: The relationship of acromial
to the throwing arm, Philadelphia, 1985, WB Saunders. architecture to rotator cuff disease, Clin Sports Med 10:823, 1991.
Andrews JR, Wilk KE, Satterwhite YE, Tedder JL: Physical examina- Blaiser RB, Carpenter JE, Huston LJ: Shoulder proprioception: effect of
tion of the throwers elbow, J Orthop Sports Phys Ther 6:296-304, joint laxity, joint position, and direction of motion, Orthop Rev
1993. 23:45-50, 1994.
Arthuis M: Obstetrical paralysis of the brachial plexus I. Diagnosis: clin- Boissonnault WG: Examination in physical therapy practice: screening for
ical study of the initial period, Rev Chir Orthop Reparatrice Appar medical disease, ed 2, Philadelphia, 1995, Churchill Livingstone.
Mot 58(suppl I):124-136, 1972. Borsa PA, Sauers EL, Herling DE: In vivo assessment of AP laxity in
Atwater AE: Biomechanics of overarm throwing movements and of healthy shoulders using an instrumented arthrometer, J Sports
throwing injuries, Exerc Sport Sci Rev 7:43-85, 1979. Rehabil 8:157-170, 1999.
Bagg SD, Forrest WJ: A biomechanical analysis of scapular rotation dur- Borsa PA, Sauers EL, Herling DE: Patterns of glenohumeral joint
ing arm abduction in the scapular plane, Arch Phys Med Rehabil 238- laxity and stiffness in healthy men and women, Med Sci Sports
245, 1988. Exerc 32:1685-1690, 2000.

187
RE.qxd 5/25/04 2:11 PM Page 188

188 References

Borsa PA, Sauers EL, Herling DE, et al: In vivo quantification of Cyriax JH, Cyriax PJ: Cyriax’s Illustrated manual of orthopaedic medicine,
capsular end-point in the nonimpaired glenohumeral joint using an ed 2, Oxford England, 1993, Butterworth Heinemann.
instrumented measurement system, J Orthop Sports Phys Ther Daniels L, Worthingham C: Muscle testing: techniques of manual exami-
31(8):419-431, 2001. nation, ed 4, Philadelphia, 1980, WB Saunders.
Brown LP, Neihues SL, Harrah A, et al: Upper extremity range of Davidson PA, El Attrache NA, Jobe CM, et al: Rotator cuff and poste-
motion and isokinetic strength of the internal and external shoulder rior superior glenoid labrum injury associated with increased gleno-
rotators in major league baseball players, Am J Sports Med 16:577- humeral motion: a new site of impingement, J Shoulder Elbow Surg
585, 1988. 4:384-390, 1995.
Buckley JP, Kerwin DG: The role of the biceps and triceps brachii Davies GJ: A compendium of isokinetics in clinical usage and rehabilitation
during tennis serving, Ergonomics 31(11):1621-1629, 1988. techniques, ed 4, Onalaska, WI, 1992, S&S Publishing.
Bunn J: Scientific principles of coaching, Englewood Cliffs, NJ, 1972, Davies GJ: The need for critical thinking in rehabilitation, J Sport
Prentice Hall. Rehabil 4:1-22, 1995.
Burkhart SS, Morgan CD: The peel-back mechanism: its role in pro- Davies GJ, DeCarlo MS: Examination of the shoulder complex: current
ducing and extending posterior type II SLAP lesions and its effect concepts in rehabilitation of the shoulder, LaCrosse, WI, 1995, Sports
on SLAP repair rehabilitation, Arthroscopy 14:637-640, 1998. Physical Therapy Association Home Study Course.
Burkhart SS, Morgan CD, Kibler WB: The disabled throwing shoulder: Davies GJ, Ellenbecker TS: Eccentric isokinetics, Orthop Phys Ther Clin
spectrum of pathology. Part I: pathoanatomy and biomechanics, North Am 1:297-336, 1992.
Arthroscopy 19(4):404-420, 2003. Davies GJ, Ellenbecker TS: Scientific and clinical rationale for utilization
Burkhart SS, Tehrany AM: Arthroscopic subscapularis tendon repair: of a total arm strength rehabilitation program for shoulder and elbow
technique and preliminary results, Arthroscopy 18(5):454-463, 2002. overuse injuries, LaCrosse, WI, 1993, APTA Orthopaedic Section
Burkhead WZ, Jr: The biceps tendon. In Rockwood CA, Jr, Matsen FA Home Study Course.
III, eds: The shoulder, Philadelphia, 1990, WB Saunders. Davies GJ, Gould JA, Larson RL: Functional examination of the shoul-
Burkhead WZ, Jr, Arcand MA, Zeman C, et al: The biceps tendon. der girdle, Physician Sports Med 9(6):82-104, 1981.
In Rockwood CA, Jr, Matsen FA III, eds: The shoulder, ed 2, Davies GJ, Hoffman SD: Neuromuscular testing and rehabilitation
Philadelphia, 1998, WB Saunders. of the shoulder complex, J Orthop Sports Phys Ther 18:449-458,
Cain PR, Mutschler TA, Fu F, et al: Anterior stability of the gleno- 1993.
humeral joint: a dynamic model, Am J Sports Med 15:144-148, 1987. Dillman CJ, Fleisig GS, Werner SL, et al: Biomechanics of the shoulder in
Caldron PH: Screening for rheumatic disease. In Boissonnault WG, ed: sports: throwing activities. Postgraduate studies in sports physical
Examination in physical therapy practice, ed 2, Philadelphia, 1995, therapy, Berryville, VA, 1991, Forum Medicum.
Churchill Livingstone. DiVeta J, Walker ML, Skibinski B: Relationship between performance
Calis M, Akgun K, Birtane M, et al: Diagnostic values of clinical diag- of selected scapular muscles and scapular abduction in standing sub-
nostic tests in subacromial impingement syndrome, Ann Rheum Dis jects, Phys Ther 70(8):470-476, 1990.
59:44-47, 2000. Djupsjobacka M, Johansson H, Bergenheim M: Influences on the
Carpenter JE, Blaiser RB, Pellizon GG: The effects of muscle fatigue gamma muscle spindle system from muscle afferents stimulated by
on shoulder joint position sense, Am J Sports Med 26(2):262-265, increased intramuscular concentrations of arachidonic acid, Brain
1998. Res 663:293-302, 1994.
Cave EF, Burke JF, Boyd RJ: Trauma management, Chicago, 1974, Year Djupsjobacka M, Johansson H, Berenheim M, et al: Influences on the
Book Medical Publishers. gamma muscle spindle system from muscle afferents stimulated by
Chandler TJ, Kibler WB, Stracener EC, et al: Shoulder strength, power, increased intramuscular concentrations of bradykinin and 5-HT,
and endurance in college tennis players, Am J Sports Med 20:455-458, Neurosci Res 22:325-333, 1995a.
1992. Djupsjobacka M, Johansson H, Bergenheim M, et al: Influences on
Cheng JC, Karzel RP: Superior labrum anterior posterior lesions of the the gamma muscle spindle system from contralateral muscle affer-
shoulder: operative techniques of management, Operative Techniques ents stimulated by KCl and lactic acid, Neurosci Res 21:301-309,
Sports Med 5(4):249-256, 1997. 1995b.
Clark JM, Harryman DT: Tendons, ligaments, and capsule of the rota- Doody SG, Freedman L, Waterland JC: Shoulder movements during
tor cuff, J Bone Joint Surg 74(A):713-725, 1992. abduction in the scapular plane, Arch Phys Med Rehabil 595-604, Oct
Clark WA: A protractor for measuring rotation of joints, J Orthop Surg 1970.
2:154-155, 1921. Eakin CL, Faber KJ, Hawkins RJ, et al: Biceps tendon disorders in
Codman EA: The shoulder, Boston, 1934, Author. athletes, J Am Acad Orthop Surg 7(5):300-310, 1999.
Constant CR, Murley AHG: A clinical method of functional assessment Edwards TB, Bostick RD, Greene CG, et al: Interobserver and intra-
of the shoulder, Clin Orthop Rel Res 214:160-164, 1987. observer reliability of the measurement of shoulder internal rotation
Cook EE, Gray VL, Savinor-Nogue E, et al: Shoulder antagonistic by vertebral level, J Shoulder Elbow Surg 11:40-42, 2002.
strength ratios: a comparison between college-level baseball pitchers, Eklund G: Position sense and state of contraction; the effects of vibra-
J Orthop Sports Phys Ther 8:451-461, 1987. tion, J Neurol Neurosurg Psychiatry 35:606-611, 1972.
Cotton RE, Rideout DF: Tears of the humeral rotator cuff: a radiologi- Ellenbecker TS: A total arm strength isokinetic profile of highly skilled
cal and pathological necropsy survey, J Bone Joint Surg 46B:314, tennis players, Isok Exerc Sci 1:9-21, 1991.
1964. Ellenbecker TS: Shoulder internal and external rotation strength and
Curtis AS, Snyder SJ: Evaluation and treatment of biceps tendon range of motion in highly skilled tennis players, Isok Exerc Sci 2:1-8,
pathology, Orthop Clin North Am 24(1):33-43, 1993. 1992.
Cyriax JH, Cyriax PJ: Illustrated manual of orthopaedic medicine, London, Ellenbecker TS: Rehabilitation of shoulder and elbow injuries in tennis
1983, Butterworth. players, Clin Sports Med 14(1):87-110, 1995.
RE.qxd 5/25/04 2:11 PM Page 189

References 189

Ellenbecker TS: Muscular strength relationship between normal grade Ellenbecker TS, Roetert EP, Bailie DS, et al: Glenohumeral joint total
manual muscle testing and isokinetic measurement of the shoulder rotation range of motion in elite tennis players and baseball pitchers,
internal and external rotators, Isok Exerc Sci 6:51-56, 1996. Med Sci Sports Exerc 34(12):2052-2056, 2002b.
Ellenbecker TS, Bailie DS, Andraka J: Subjective and objective follow- Ellenbecker TS, Roetert EP, Piorkowski PA: Shoulder internal and
up of patients following arthroscopic thermal capsulorrhaphy, 2004. external range of motion of elite junior tennis players: a comparison
Ellenbecker TS, Bailie DS, Mattalino AJ, et al: Intrarater and interrater of two protocols, J Orthop Sports Phys Ther (abstract) 17(1):65,
reliability of a manual technique to assess anterior humeral head 1993.
translation of the glenohumeral joint, J Shoulder Elbow Surg 11:470- Ellenbecker TS, Roetert EP, Piorkowski PA, et al: Glenohumeral joint
475, 2002a. internal and external rotation range of motion in elite junior tennis
Ellenbecker TS, Bleacher J: A descriptive profile of bilateral gleno- players, J Orthop Sports Phys Ther 24(6):336-341, 1996.
humeral joint internal and external rotation strength in uninjured Elliott B, Marsh T, Blanksby B: A three dimensional cinematographic
females using the Cybex NORM dynamometer, Phys Ther 79:S80, analysis of the tennis serve, Int J Sport Biomech 2:260-271, 1986.
1999. Ellman H, Hander G, Bayer M: Repair of the rotator cuff: end-result
Ellenbecker TS, Davies GJ: The application of isokinetics in testing and study of factors influencing reconstruction, J Bone Joint Surg
rehabilitation of the shoulder complex, J Athletic Training 35(3):338- 68A:1136-1144, 1986.
350, 2000. Elmore E, Ellenbecker TS, Bailie DS: Glenohumeral joint range of
Ellenbecker TS, Davies GJ: Closed kinetic chain exercise: a comprehen- motion and rotator cuff strength following arthroscopically assisted
sive guide to multiple joint exercises, Champaign, IL, 2001, Human rotator cuff repair, J Orthop Sports Phys Ther 34(Ab1):1, 2003b.
Kinetics Publishers. Emery R, Mullaji A: Glenohumeral joint instability in normal adoles-
Ellenbecker TS, Davies GJ: A comparison of three methods for measuring cents, J Bone Joint Surg 73B:406-408, 1991.
glenohumeral joint internal rotation, unpublished research, Farrally M, Cochran A: Science and golf III: Proceedings of the World
Physiotherapy Associates Scottsdale Sports Clinic Scottsdale Arizona, Scientific Congress of Golf, Champaign, IL, 1999, Human Kinetics
and Gunderson Lutheran Sports Medicine, LaCrosse, WI, 1997. Publishers.
Ellenbecker TS, Davies GJ, Rowinski MJ: Concentric versus eccentric Feltner ME, Depena J: Dynamics of the shoulder and elbow joints of the
isokinetic strengthening of the rotator cuff: objective data versus throwing arm during a baseball pitch, Int J Sport Biomechanics 2:235-
functional test, Am J Sports Med 16:64-69, 1988. 259, 1986.
Ellenbecker TS, Manske R, Davies GJ: Closed kinetic chain testing Fleisig GS, Andrews JR, Dillman CJ, et al: Kinetics of baseball pitching
techniques of the upper extremities, Orthop Phys Ther Clin North Am with implications about injury mechanisms, Am J Sports Med 23:233,
9(2):219-245, 2000b. 1995.
Ellenbecker TS, Mattalino AJ: Comparison of open and closed kinetic Fleisig GS, Dillman CJ, Andrews JR: Proper mechanics for baseball
chain upper extremity tests in patients with rotator cuff pathology pitching, Clin Sports Med 1:151-170, 1989.
and glenohumeral joint instability, J Orthop Sports Phys Ther 25:84, Fleisig GS, Jameson EG, Dillman CJ, et al: Biomechanics of overhead
1997. sports. In Garrett WE, Kirkendall DT, eds: Exercise and sport science,
Ellenbecker TS, Mattalino AJ: Concentric isokinetic shoulder internal Philadelphia, 2000, Lippincott Williams and Wilkins.
and external rotation strength in professional baseball pitchers, Frese E, Brown M, Norton J: Clinical reliability of manual muscle test-
J Orthop Sports Phys Ther 29:323-328, 1999a. ing: middle trapezius and gluteus medius muscles, Phys Ther
Ellenbecker TS, Mattalino AJ: The elbow in sport: injury treatment and 67(7):1072-1076, 1987.
rehabilitation, Champaign, IL, 1996, Human Kinetics Publishers. Gartsman GM, Brinker MR, Khan M, et al: Self-assessment of general
Ellenbecker TS, Mattalino AJ: Glenohumeral joint range of motion and health status in patients with five common shoulder conditions,
rotator cuff strength following arthroscopic anterior stabilization J Shoulder Elbow Surg 7:228-237, 1998.
with thermal capsulorrhaphy, J Orthop Sport Phys Ther 29(3):160- Gerber C, Galantay RV, Hersche O: The pattern of pain produced by
167, 1999b. irritation of the acromioclavicular joint and the subacromial space,
Ellenbecker TS, Mattalino, AJ, Elam EK, et al: Medial elbow joint J Shoulder Elbow Surg 7:352-355, 1998.
laxity in professional baseball pitchers: a bilateral comparison using Gerber C, Ganz R: Clinical assessment of instability of the shoulder
stress radiography, Am J Sports Med 26(3):420-424, 1998. with special reference to anterior and posterior drawer tests, J Bone
Ellenbecker TS, Mattalino AJ, Elam E, et al: Quantification of anterior Joint Surg 66B(4):551-556, 1984.
translation of the humeral head in the throwing shoulder: manual Gerber C, Krushell RJ: Isolated rupture of the tendon of the subscapu-
assessment versus stress radiography, Am J Sports Med 28:161-167, laris muscle: clinical features in 16 cases, J Bone Joint Surg 73B:389-
2000a. 394, 1991.
Ellenbecker TS, Nazal F, Bailie DS, et al: Subjective rating scales from Gerber C, Werner CML, Macy JC, et al: Effect of selective capsulor-
uninjured unilaterally dominant overhead athletes, 2003a. rhaphy on the passive range of motion of the glenohumeral joint,
Ellenbecker TS, Roetert EP: Age specific isokinetic glenohumeral inter- J Bone Joint Surg 85A(1):48-55, 2003.
nal and external rotation strength in elite junior tennis players, J Sci Giangarra R, Jobe FW, Tibone JE, et al: Electromyographic and cine-
Med Sport 6(1):63-70, 2003. matographic analysis of elbow function in tennis players using
Ellenbecker TS, Roetert EP: A bilateral comparison of upper extremity single- and double-handed backhand strokes, Am J Sports Med
unilateral closed chain stance stability in elite junior tennis players 21:394-399, 1993.
and professional baseball pitchers, Med Sci Sports Exerc 28:S105, Gibson MH, Goebel GV, Jordan TM, et al: A reliability study of meas-
1996. urement techniques to determine static scapular position, J Orthop
Ellenbecker TS, Roetert EP: Testing isokinetic muscular fatigue of Sports Phys Ther 21(2):100-106, 1995.
shoulder internal and external rotation in elite junior tennis players, Gill TJ, Micheli LJ, Gebhard F, et al: Bankart repair for anterior insta-
J Orthop Sports Phys Ther 29:275-281, 1999. bility of the shoulder, J Bone Joint Surg 79A:850-857, 1997.
RE.qxd 5/25/04 2:11 PM Page 190

190 References

Glousman RE, Barron J, Jobe FW, et al: An electromyographic analysis Hanavan EP: A mathematical model of the human body, Dayton, OH,
of the elbow in normal and injured pitchers with medial collateral 1964, Wright-Patterson Air Force Base, (AMRL-TR-64-102).
ligament insufficiency, Am J Sports Med 20(3):311-317, 1992. Harryman DT, Sidles JA, Clark MJ, et al: Translation of the humeral
Glousman RE, Jobe FW, Tibone JE, et al: Dynamic electromyographic head on the glenoid with passive glenohumeral motion, J Bone Joint
analysis of the throwing shoulder with glenohumeral joint instability, Surg 72A:1334-1343, 1990.
J Bone Joint Surg 70A:220-226, 1988. Harryman DT, Sidles JA, Harris SL, et al: Laxity of the normal gleno-
Goetz CG, Pappert EJ: Textbook of clinical neurology, ed 1, Philadelphia, humeral joint: in-vivo assessment, J Shoulder Elbow Surg 1:66-76,
1999, WB Saunders. 1992.
Goldbeck TG, Davies GJ: Test-retest reliability of the closed kinetic Hawkins RJ, Bokor DJ: Clinical evaluation of shoulder problems. In
chain upper extremity stability test: a clinical field test, J Sport Rockwood CA, Matsen FA III, eds: The shoulder, Philadelphia, 1990,
Rehabil 9:35-45, 2000. WB Saunders.
Golding FC: The shoulder: the forgotten joint, Br J Radiol 35:149, 1962. Hawkins RJ, Kennedy JC: Impingement syndrome in athletes, Am J
Goldscheider A: Gesammelte Abhandlungen. II. Physiologie des Sports Med 8:151-158, 1980.
Muskelsinnes, Leipzig, 1898, Barth. Hawkins RJ, Mohtadi NGH: Clinical evaluation of shoulder instability,
Goodman CC, Snyder TEK: Differential diagnosis in physical therapy, Clin J Sports Med 1:59-64, 1991.
ed 3, Philadelphia, 2000, WB Saunders. Hawkins RJ, Neer CS, Pianta R, et al: Locked posterior dislocation of
Goodwin GM, McCloskey DI, Matthews PBC: The contribution of the shoulder, J Bone Joint Surg 69A:9, 1987.
muscle afferents to kinaesthesia shown by vibration induced illusions Hawkins RJ, Schulte JP, Janda DH, et al: Translation of the gleno-
of movement and by the effects of paralysing joint afferents, Brain humeral joint with the patient under anesthesia, J Shoulder Elbow
95:705-748, 1972. Surg 5:286-292, 1996.
Gore DR, Murray MP, Sepic SB, et al: Shoulder muscle strength and Hayes KW, Petersen CM: Reliability of assessing end-feel and pain and
range of motion following surgical repair of full thickness rotator cuff resistance sequence in subjects with painful shoulders and knees,
tears, J Bone Joint Surg Am 68:266-272, 1986. J Orthop Sports Phys Ther 31(8):432-445, 2001.
Gould JA: The spine. In Gould JA, Davies GJ, eds: Orthopaedic and sports Heald SL, Riddle DL, Lamb RL: The shoulder pain and disability
physical therapy, St Louis, 1985, Mosby. index: the construct validity and responsiveness of a region specific
Greenfield BH, Donatelli R, Wooden MJ, et al: Isokinetic evaluation of disability measure, Phys Ther 77(10):1079-1089, 1997.
shoulder rotational strength between the plane of the scapula and the Helmig P, Sojbjerg JE, Kjaersgaaard-Anderson P, et al: Distal humeral
frontal plane, Am J Sports Med 18:124-128, 1990. migration as a component of multidirectional instability: an anatom-
Greis PE, Kuhn JE, Schultheis J, et al: Validation of the lift-off test and ical study in autopsy specimens, Clin Orthop 252:139-142, 1990.
analysis of subscapularis activity during maximal internal rotation, Hinton RY: Isokinetic evaluation of shoulder rotational strength in high
Am J Sports Med 24(5):589-593, 1996. school baseball pitchers, Am J Sports Med 16:274-279, 1988.
Grigg P: Peripheral mechanisms in proprioception, J Sport Rehabil 3:2- Holm I, Brox JI, Ludvigsen P, et al: External rotation-best isokinetic
17, 1994. movement pattern for evaluation of muscle function in rotator ten-
Grimsby O, Gray JC: Interrelationship of the spine to the shoulder donosis. A prospective study with a 2-year follow-up, Isok Exerc Sci
girdle. In Donatelli RA, ed: Physical therapy of the shoulder, ed 3, 5:121-125, 1996.
Philadelphia, 1997, Churchill Livingstone. Hoppenfeld S: Physical examination of the spine and extremities, Norwalk,
Groppel JL: High tech tennis, ed 2, Champaign, IL, 1992, Human CT, 1976, Appleton-Century-Crofts.
Kinetics Publishers. Hsu AT, Chang JH, Chang CH: Determining the resting position of
Gross ML, Distefano MC: Anterior release test: a new test for occult the glenohumeral joint: a cadaver study, J Orthop Sports Phys Ther
shoulder instability, Clin Orthop Rel Res 339:105-108, 1997. 32(12):605-612, 2002.
Grossman TW, Mazur JM, Cummings RJ: An evaluation of the Adams Hurley JA, Anderson TE: Shoulder arthroscopy: its role in evaluating
forward bend test and the scoliometer in a scoliosis school screening shoulder disorders in the athlete, Am J Sports Med 18:480-483, 1990.
setting, J Pediatr Orthop 15:535-538, 1995. Ianotti JP, editor: Rotator cuff disorders, Chicago, 1991, American
Guanche CA, Jones DC: Clinical testing for tears of the glenoid labrum, Academy of Orthopaedic Surgeons.
Arthroscopy 19(5):517-523, 2003. Ianotti JP, Bernot MP, Kuhlman JR, et al: Postoperative assessment of
Habermeyer P, Kaiser E, Knappe M, et al: Functional anatomy and bio- shoulder function: a prospective study of full-thickness tears, J
mechanics of the long biceps tendon, Unfallchirurg 90:319-329, Shoulder Elbow Surg 5:449-457, 1996.
1987. Ianotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging
Hageman PA, Mason DK, Rydlund KW, et al: Effects of position and of the shoulder: sensitivity specificity, and predictive value, J Bone
speed on eccentric and concentric isokinetic testing of the shoulder Joint Surg 73A:17-29, 1991.
rotators, J Orthop Sports Phys Ther 11:64-69, 1989. Ide K, Shirai Y, Ito H, et al: Sensory nerve supply in the human sub-
Halbach JW, Tank RT: The shoulder. In Gould JA, Davies GJ, acromial bursa, J Shoulder Elbow Surg 5:371-382, 1996.
eds: Orthopaedic and sports physical therapy, St Louis, 1985, Inman VT, Saunders JB, Abbott LC: Observations on the function of
Mosby. the shoulder joint, J Bone Joint Surg 26(1):1-30, 1944.
Halbrecht JL, Tirman P, Atkin D: Internal impingement of the shoul- Ishii K, Suzuki M, Saito Y, et al: Contribution factors to increase veloc-
der: comparison of findings between the throwing and nonthrowing ity of a distal end in human body: ball throwing. In Adrian M,
shoulders of college baseball players, Arthroscopy 15(3):253-258, Deutch H, editors: Biomechanics, the 1984 Olympic Scientific Congress
1999. Proceedings, Eugene, OR, 1986, Microform Publications.
Hamner DL, Pink MM, Jobe FW: A modification of the relocation test: Itoi E, Kido T, Sano A, et al: Which is more useful the “full can test” or
arthroscopic findings associated with a positive test, J Shoulder Elbow the “empty can test” in detecting the torn supraspinatus tendon? Am
Surg 9:263-267, 2000. J Sports Med 27(1):65-68, 1999.
RE.qxd 5/25/04 2:11 PM Page 191

References 191

Itoi E, Kuechle DK, Newman SR, et al: Stabilising function of the Kibler WB: Management of the scapula in glenohumeral instability, Tech
biceps in stable and unstable shoulders, J Bone Joint Surg 75B:546- Shoulder Elbow Surg 4(3):89-98, 2003.
550, 1993. Kibler WB: The role of the scapula in athletic shoulder function, Am J
Ivey FM, Calhoun JH, Rusche K, et al: Isokinetic testing of shoulder Sports Med 26(2):325-337, 1998a.
strength: normal values, Arch Phys Med Rehabil 66:384-386, Kibler WB: Role of the scapula in the overhead throwing motion,
1985. Contemp Orthop 22(5):525-532, 1991.
Jenp YN, Malanga BA, Gowney ES, et al: Activation of the rota`tor cuff Kibler WB: Shoulder rehabilitation: principles and practice, Med Sci
in generating isometric shoulder rotation torque, Am J Sports Med Sports Exerc 30(4):S40-S50, 1998b.
24:477-485, 1996. Kibler WB: Specificity and sensitivity of the anterior slide test in throw-
Jensen GM, Shepard KF, Gwyer J, et al: Attribute dimensions that dis- ing athletes with superior glenoid labral tears, Arthroscopy 11(3):296-
tinguish master and novice physical therapy clinicians in orthopaedic 300, 1995.
settings, Phys Ther 72:711-722, 1992. Kibler WB, Chandler TJ, Livingston BP, et al: Shoulder range of
Jensen GM, Shepard KF, Hack LM: The novice versus the experienced motion in elite tennis players, Am J Sports Med 24(3):279-285,
clinician: insights into the work of the physical therapist, Phys Ther 1996.
70:314-323, 1990. Kibler WB, Livingston B, Bruce R: Current concepts in shoulder reha-
Jerosch JG: Effects of shoulder instability on joint proprioception. bilitation, Adv Operative Orthop 3:249-297, 1995.
In Lephart SM, Fu FH, eds: Proprioception and neuromuscular Kibler WB, McMullen J: Scapular dyskinesis and its relation to shoulder
control in joint stability, Champaign, IL, 2000, Human Kinetics pain, J Am Acad Orthop Surg 11:142-151, 2003.
Publishers. Kibler WB, Uhl TL, Maddux JWQ, et al: Qualitative clinical evaluation
Jobe FW, Bradley JP: The diagnosis and nonoperative treatment of of scapular dysfunction: a reliability study, J Shoulder Elbow Surg
shoulder injuries in athletes, Clin Sports Med 8:419-437, 1989. 11:550-556, 2002.
Jobe FW, Kivitne RS: Shoulder pain in the overhand or throwing Kikuchi T: Histological studies on the sensory innervation of the shoul-
athlete, Orthop Rev 18:963-975, 1989. der joint, J Iwate Med Assoc 20(5):554-567, 1968.
Jobe FW, Moynes DR: Delineation and diagnostic criteria and a reha- Kim SH, Ha KI, Ahn JH, et al: Biceps load test II: a clinical test
bilitation program for rotator cuff injuries, Am J Sports Med 10:336- for SLAP lesions of the shoulder, Arthroscopy 17(2):160-164,
339, 1982. 2001.
Jobe FW, Pink M: The athlete’s shoulder, J Hand Ther 107, April-June Kim SH, Ha KI, Han KY: Biceps load test: a clinical test for superior
1994. labrum anterior and posterior lesions in shoulders with recurrent
Jorgensen K: Force velocity relationships in human elbow flexors and anterior dislocations, Am J Sports Med 27(3):300-303, 1999.
extensors. In Komi PV, ed: Biomechanics VA, Baltimore, 1976, Kim TK, Queale WS, Cosqarea AJ, et al: Clinical features of the differ-
University Park Press. ent types of slap lesions, J Bone Joint Surg 85A:66-71, 2003.
Joris HJJ, Edwards van Muyen AJ, Van Ingen Shenau GJ, et al: Force, Kirschenbaum D, Coyle MP, Leddy JP, et al: Shoulder strength with
velocity and energy flow during the overarm throw in female hand- rotator cuff tears: pre and post-operative analysis, Clin Orthop Rel Res
ball players, J Biomech 18:409-414, 1985. 288:174-178, 1993.
Kaltenborn FM: Manual mobilization of the extremity joints, Oslo, Klafs CE, Arnheim DD: Modern principles of athletic training, St Louis,
Norway, 1989, Olaf Norlis Bokhandel. 1981, Mosby.
Kannus P, Cook L, Alosa D: Absolute and relative endurance parame- Knops JE, Meiners TK, Davies GJ, et al: Isokinetic test retest reliability of
ters in isokinetic tests of muscular performance, J Sport Rehabil 1:2- the modified neutral shoulder test position, unpublished research,
12, 1992. LaCrosse, WI, 1998, University of LaCrosse.
Kapandji IA: The physiology of the joints, New York, 1985, Churchill Koffler KM, Bader D, Eager M, et al: The effect of posterior capsular
Livingstone. tightness on glenohumeral translation in the late-cocking phase of pitch-
Karup Al, Court-Payen M, Skjoldbye B, et al: Ultrasonic measurement ing: a cadaveric study, Abstract (SS-15) presented at Arthroscopy
of the anterior translation in the shoulder joint, J Shoulder Elbow Surg Association of North America Annual Meeting, Washington, DC,
8:136-141, 1999. 2001.
Kazar B, Relovszky E: Prognosis of primary dislocation of the shoulder, Koslow PA, Prosser LA, Strony GA, et al: Specificity of the lateral
Acta Orthop Scand 40:216, 1969. scapular slide test in asymptomatic competitive athletes, J Orthop
Kebaetse M, McClure P, Pratt NA: Thoracic position effect on shoulder Sports Phys Ther 33(6):331-336, 2003.
range of motion, strength, and three-dimensional scapular kine- Kraushaar BS, Nirschl RP: Tendonosis of the elbow (tennis elbow):
matics, Arch Phys Med Rehabil 80:945-950, 1999. clinical features and findings of histological, immunohistochemical,
Kelly BT, Kadrmas WH, Speer KP: The manual muscle examination for and electron microscopy studies, J Bone Joint Surg 81A(2):259-278,
rotator cuff strength: an electromyographic investigation, Am J Sports 1999.
Med 24:581-588, 1996. Kreighbaum E, Barthels KM: Biomechanics: a qualitative approach for
Kendall FD, McCreary EK: Muscle testing and function, ed 3, Baltimore, studying human movement, Minneapolis, MN, 1985, Burgess.
1983, Williams and Wilkins. Kuhn JE, Lindholm SR, Huston LJ, et al: Failure of biceps superior labral
Kennedy K, Altchek DW, Glick IV: Concentric and eccentric isokinetic complex in the throwing athlete: a biomechanical model comparing max-
rotator cuff ratios in skilled tennis players, Isok Exerc Sci 3:155-159, imal cocking to early deceleration, Presented at the Annual Meeting of
1993. the American Academy of Orthopaedic Surgeons, AANA Specialty
Kibler WB: Evaluation of sports demands as a diagnostic tool in shoul- Day, Anaheim, CA, February 1999.
der disorders. In Matsen FA, Fu F, Hawkins RJ, eds: The shoulder: a Kumar VP, Satku K, Balasubramaniam P: The role of the long head of
balance of mobility and stability, Rosemont, IL, 1993, American the biceps brachii in the stabilization of the head of the humerus,
Association of Orthopaedic Surgeons. Clin Orthop 244:172-175, 1989.
RE.qxd 5/25/04 2:11 PM Page 192

192 References

Kvitne KS, Jobe FW, Jobe CM: Shoulder instability in the overhead or Mallon WJ, Herring CL, Sallay PI, et al: Use of vertebral levels to meas-
throwing athlete, Clin Sports Med 14(4):917, 1995. ure presumed internal rotation at the shoulder: a radiographic analy-
Lephart SM, Fu FH: Proprioception and neuromuscular control in joint sis, J Shoulder Elbow Surg 5:299-306, 1996.
stability, Champaign, IL, 2000, Human Kinetics Publishers. Mallon W, Speer K: Multidirectional instability: current concepts,
Lephart SM, Myers JB, Bradley JP, et al: Shoulder proprioception and J Shoulder Elbow Surg 4:55-64, 1995.
function following thermal capsulorrhaphy, J Shoulder Elbow Surg Marshall RN, Elliott BC: Long-axis rotation: the missing link in proxi-
18(7):770-778, 2002. mal to distal sequencing, J Sports Sci 18:247-254, 2000.
Lephart SM, Warner JJP, Borsa PA, et al: Proprioception of the shoul- Marshall RN, Noffal GJ, Legnani G: Simulation of the tennis serve:
der joint in healthy, unstable, and surgically repaired shoulders, factors affecting elbow torques related to medial epicondylitis, Paris, 1993,
J Shoulder Elbow Surg 3:371-380, 1994. ISB.
Leroux JL, Codine P, Thomas E, et al: Isokinetic evaluation of rotational Matsen FA, Fu FH, Hawkins RJ: The shoulder: a balance of mobility and
strength in normal shoulders and shoulders with impingement syn- stability, Park Ridge, IL, 1992, American Academy of Orthopaedic
drome, Clin Orthop Rel Res 304:108-115, 1994. Surgeons.
Leroux JL, Thomas E, Bonnel F, et al: Diagnostic value of clinical tests for Matsen FA, Harryman DT, Sidles JA: Mechanics of glenohumeral
shoulder impingement syndrome, Rev Rheum 62(6):423-428, 1995. instability, Clin Sports Med 10:783, 1991.
Levy AS, Kelly BT, Lintner SA, et al: Function of the long head of the Matsen FA, Lippittt SB, Sidles JA, et al: Practical evaluation and man-
biceps at the shoulder: electromyographic analysis, J Shoulder Elbow agement of the shoulder, Philadelphia, 1994, WB Saunders.
Surg 10(3):250-255, 2001. Matsen FA, Thomas SC, Rockwood CA, et al: Glenohumeral instabi-
Levy AS, Lintner S, Kenter K, et al: Intra- and interobserver repro- lity. In Rockwood CA, Matsen FA, eds: The shoulder, Philadelphia,
ducibility of shoulder laxity examination, Am J Sports Med 27(4):460- 1998, WB Saunders.
463, 1999. Matsen FA III, Artnz CT: Subacromial impingement. In Rockwood
Lilienfeld AM, Jacobs M, Willis M: A study of the reproducibility of CA, Jr, Matsen FA III, eds: The shoulder, Philadelphia, 1990, WB
muscle testing and certain other aspects of muscle scoring, Phys Ther Saunders.
Rev 34:279-289, 1954. Mattingly GE, Mackarey PJ: Optimal methods for shoulder tendon
Lintner SA, Levy A, Kenter K, et al: Glenohumeral translation in palpation: a cadaver study, Phys Ther 76(2):166-174, 1996.
the asymptomatic athlete’s shoulder and its relationship to other Maughon TS, Andrews JR: The subjective evaluation of the shoulder in
clinically measurable anthropometric variables, Am J Sports Med the athlete. In Andrews JR, Wilk KE, eds: The athlete’s shoulder, New
24(6):716-720, 1996. York, 1994, Churchill Livingstone.
Lippman RK: Frozen shoulder: periarthritis, bicipital tenosynovitis, Arch McFarland E, Campbell G, McDowell J: Posterior shoulder laxity in
Surg 47:283-296, 1943. asymptomatic adolescent athletes, Am J Sports Med 24:460-471,
Litchfield DG, Jeno S, Mabey R: The lateral scapular slide test: is it valid 1991.
in detecting glenohumeral impingement syndrome? Phys Ther McFarland EG, Campbell G, McDowell J: Posterior shoulder laxity in
78(5):S29, 1998. asymptomatic athletes, Am J Sports Med 24(4):468-471, 1996a.
Liu SH, Henry MH, Nuccion S, et al: Diagnosis of glenoid labrum tears. McFarland EG, Kim TK, Savino RM: Clinical assessment of three com-
A comparison between magnetic resonance imaging and clinical mon tests for superior labral anterior-posterior lesions, Am J Sports
examinations, Am J Sports Med 24(2):149-154, 1996a. Med 30(6):810-815, 2002.
Liu SH, Henry MH, Nuccion S: A prospective evaluation of a new McFarland EG, Torpey BM, Carl LA: Evaluation of shoulder laxity,
physical examination in predicting glenoid labrum tears, Am J Sports Sports Med 22:264-272, 1996b.
Med 24(6):721-725, 1996b. McMahon PJ, Jobe FW, Pink MM, et al: Comparative electromyo-
Lucas DB: Biomechanics of the shoulder joint, Arch Surg 107:425, 1973. graphic analysis of shoulder muscles during planar motions: anterior
Ludington NA: Rupture of the long head of the biceps flexor cubiti glenohumeral joint instability versus normal, J Shoulder Elbow Surg
muscle, Ann Surg 77:358-363, 1923. 5:118, 1996.
Lukasiewicz AC, McClure P, Michener L, et al: Comparison of 3- McQuade JK, Shelley I, Cvitkovic J: Patterns of stiffness during clinical
dimensional scapular position and orientation between subjects with examination of the glenohumeral joint, Clin Biomech 14:620-627,
and without shoulder impingement, J Orthop Sports Phys Ther 1999.
29(10):574-586, 1999. Mennell JM: Joint pain: diagnosis and treatment using manipulative tech-
Lyons AR, Tomlinson JE: Clinical diagnosis of tears of the rotator cuff, niques, Boston 1964, Little, Brown.
J Bone Joint Surg (Br) 74:41-45, 1993. Mimori K, Muneta T, Nakagawa T, et al: A new pain provocation test
MacDonald PB, Clark P, Sutherland K: An analysis of the diagnostic for superior labral tears of the shoulder, Am J Sports Med 27(2):137-
accuracy of the Hawkins and Neer subacromial impingement signs, 142, 1999.
J Shoulder Elbow Surg 9(4):299-301, 2000. Moffroid M, Whipple R, Hofkosh J, et al: A study of isokinetic exercise,
Magarey ME, Hayes MG, Trott PH: The accuracy of manipulative Phys Ther 49:735-747, 1969.
physiotherapy diagnosis of shoulder complex dysfunction: a pilot Mont MA, Cohen DB, Campbell KR, et al: Isokinetic concentric versus
study. In Proceedings of the Sixth Biennial Conference, Adelaide, eccentric training of the shoulder rotators with functional evaluation
Australia, 1989, Manipulative Physiotherapists Association of of performance enhancement in elite tennis players, Am J Sports Med
Australia. 22:513-517, 1994.
Magee DJ: Orthopaedic physical assessment, ed 3, Philadelphia, 1997, WB Moore ML: The measurement of joint motion. Part I: Introductory
Saunders. review of the literature, Phys Ther 29:195-205, 1949.
Malanga GA, Jemp YN, Growney ES, et al: EMG analysis of shoulder Morgan CD, Burkhart SS, Palmeri M, et al: Type II SLAP lesions: three
positioning in testing and strengthening the supraspinatus, Med Sci subtypes and their relationships to superior instability and rotator
Sports Exerc 28(6): 661, 1996. cuff tears, Arthroscopy 14:553-565, 1998.
RE.qxd 5/25/04 2:11 PM Page 193

References 193

Morisawa Y, Kawakami T, Uermura H, et al: Mechanoreceptors in the Paley KJ, Jobe FW, Pink MM, et al: Arthroscopic findings in the over-
coraco-acromial ligament: a study of the aging process, J Shoulder hand throwing athlete: evidence for posterior internal impingement
Elbow Surg 3:S45, 1994. of the rotator cuff, Arthroscopy 16(1):35-40, 2000.
Morrey BF: The elbow and its disorders, ed 2, Philadelphia, 1993, WB Patte D, Goutallier D, Monpierre H, et al: Over-extension lesions, Rev
Saunders. Chir Orthop 74:314-318, 1988.
Morrey BF, An KN: Articular and ligamentous contributions to the Pedegana LR, Elsner RC, Roberts D, et al: The relationship of upper
stability of the elbow joint, Am J Sports Med 11:315, 1983. extremity strength to throwing speed, Am J Sports Med 10:352-354,
Myers JB, Guskiewicz KM, Schneider RA, et al: Proprioception and 1982.
neuromuscular control of the shoulder after muscle fatigue, J Pedersen J, Lönn J, Hellström F, et al: Localized muscle fatigue decreases
Athletic Training 34(4):362-367, 1999. the movement sense in the human shoulder, Med Sci Sports Exerc
Myers JB, Lephart SM: The role of the sensorimotor system in the 31:1047, 1999.
athletic shoulder, J Athletic Training 35(3):351-363, 2000. Penny JN, Welsh RP: Shoulder impingement syndrome in athletes and
Naredo E, Aguado P, DeMiguel E, et al: Painful shoulder: comparison their surgical management, Am J Sports Med 9:11-15, 1981.
of physical examination and ultrasonographic findings, Ann Rheum Perthes G: Ueber Operationen der habituellen Schulterluxation,
Dis 61:132-136, 2002. Deutsche Ztschr Chir 85:199, 1906.
Neer CS: Anterior acromioplasty for the chronic impingement syn- Piatt BE, Hawkins RJ, Fritz RC, et al: Clinical evaluation and treatment
drome in the shoulder, J Bone Joint Surg 54A:41-50, 1972. of spinoglenoid notch ganglion cysts, J Shoulder Elbow Surg 11:600-
Neer CS: Cuff tears, biceps lesions, and impingement. In Neer CS, ed: 604, 2002.
Shoulder reconstruction, Philadelphia, 1990, WB Saunders. Plafcan DM, Truczany PJ, Guenin BA, et al: An objective measurement
Neer CS: Impingement lesions, Clin Orthop 173:70-77, 1983. technique for posterior scapular displacement, J Orthop Sports Phys
Neer CS, Foster CR: Inferior capsular shift for involuntary inferior and Ther 25(5):336-341, 1997.
multidirectional instability of the shoulder: a preliminary report, Plagenhoef S: Patterns of human movement, Englewood Cliffs, NJ, 1971,
J Bone Joint Surg 62A:897, 1980. Prentice Hall.
Neer CS, Watson KC, Stanton FJ: Recent experience in total shoulder Poppen NK, Walker PS: Forces at the glenohumeral joint in abduction,
replacement, J Bone Joint Surg 64A:319-337, 1982. Clin Orthop 135:165, 1978.
Neer CS, Welsh RP: The shoulder in sports, Clin Orthop Rel Res 8:583, Portney LG, Watkins MP: Foundations of clinical research applications to
1977. practice, Stamford, CT, 1993, Appleton & Lange.
Nirschl RP: Prevention and treatment of elbow and shoulder injuries in Post M, Cohen J: Impingement syndrome: a review of late stage II and
the tennis player, Clin Sports Med 7:289-308, 1988a. early stage III lesions, Clin Orthop Rel Res 207:127-132, 1986.
Nirschl RP: Shoulder tendonitis. In Pettrone FP, ed: Upper extremity Priest JD, Nagel DA: Tennis shoulder, Am J Sports Med 4(1):28-42,
injuries in athletes, American Academy of Orthopaedic Surgeons 1976.
Symposium, Washington, DC, 1988b, Mosby. Putnam CA: Sequential motions of the body segments in striking and
Norkin CC, White DJ: Measurement of joint motion: a guide to goniome- throwing skills: descriptions and explanations, J Biomechan 26(suppl
try, ed 2, Philadelphia, 1995, FA Davis. 1):125-136, 1993.
Norwood LA, Terry GC: Shoulder posterior and subluxation, Am J Quanbury AO, Winter DA, Reimer GD: Instantaneous power and
Sports Med 12:25-30, 1984. power flow in body segments during walking, J Human Movement
Nyland JA, Caborn DNM, Johnson DL: The human glenohumeral Studies 1:59-67, 1975.
joint: a proprioceptive and stability alliance, Knee Surg Sports Quincy R, Davies GJ, Kolbeck K, et al: Isokinetic exercise: the effects of
Traumatol Arthrosc 6:50-61, 1998. training specificity on shoulder power, J Athletic Training 35:5,
O’Brien SJ, Beves MC, Arnoczky SJ, et al: The anatomy and histology 2000.
of the inferior glenohumeral ligament complex of the shoulder, Am J Rabin SJ, Post MP: A comparative study of clinical muscle testing and
Sports Med 18:449-456, 1990. Cybex evaluation after shoulder operations, Clin Orthop Rel Res
O’Brien SJ, Pagnani MJ, Fealy S, et al: The active compression 258:147-156, 1990.
test: a new and effective test for diagnosing labral tears and acromio- Rathburn JB, MacNab I: The microvascular pattern of the rotator cuff,
clavicular joint abnormality, Am J Sports Med 26(5):610-613, JBJJ (Br) 52-B:540, 1970.
1998. Rayan GM: Thoracic outlet syndrome, J Shoulder Elbow Surg 7(4):440-
Odem CJ, Taylor AB, Hurd CE, et al: Measurement of scapular asym- 451, 1998.
metry and assessment of shoulder dysfunction using the lateral Rayan GM, Jensen C: Thoracic outlet syndrome: provocative examina-
scapular slide test: a reliability and validity study, Phys Ther tion maneuvers in a typical population, J Shoulder Elbow Surg 4:113-
81(2):799-809, 2001. 117, 1995.
Osbahr DC, Diamond AB, Speer KP: The cosmetic appearance of the Reider B: The orthopaedic physical examination, Philadelphia, 1999, WB
biceps muscle after long-head tenotomy versus tenodesis, Arthroscopy Saunders.
18(5):483-487, 2002. Rhu KN, McCormick J, Jobe FW, et al: An electromyographic analysis
Paavolainen P, Bjorkenheim JM, Slatis P, et al: Operative treatment of of shoulder function in tennis players, Am J Sports Med 16:481-485,
severe proximal humeral fractures, Acta Orthop Scand 54:374-379, 1988.
1983. Richards RR, An KN, Bigliani LU, et al: A standardized method for the
Pagnani MJ, Deng XH, Warren RF, et al: Role of the long head of the assessment of shoulder function, J Shoulder Elbow Surg 3:347-352,
biceps brachii in glenohumeral stability. A biomechanical study in 1994.
cadavers, J Shoulder Elbow Surg 5:255-262, 1996. Riddle DL, Rothstein JM, Lamb RL: Goniometric reliability in a
Pagnani MJ, Warren RF: Stabilizers of the glenohumeral joint, J clinical setting: shoulder measurements, Phys Ther 67:668-673,
Shoulder Elbow Surg 3:73-90, 1994. 1987.
RE.qxd 5/25/04 2:11 PM Page 194

194 References

Roach KE, Budiman-Mak E, Songsiridez N, et al: Development of a Sherrington C: The integrative action of the nervous system, New York,
shoulder pain and disability index, Arthritis Care Res 4:143-149, 1906, Scribner’s Son.
1991. Shimoda F: Innervation, especially sensory innervation of the knee joint
Robertson DGE, Winter DA: Mechanical energy generation, absorp- and motor organs around it in early stage of human embryo, Arch
tion, and transfer amongst segments during walking, J Biomechanics Histol Japan 9:91-108, 1955.
13:845-854, 1980. Slobounov SM, Poole ST, Simon RF, et al: The efficacy of modern tech-
Rockwood CA: Subluxations and dislocations about the shoulder. In nology to improve healthy and injured shoulder joint position sense,
Rockwood CA, Green DP, eds: Fractures in adults, Philadelphia, J Sport Rehabil 8:10-23, 1999.
1984, JB Lippincott. Smith RL, Brunolli J: Shoulder kinesthesia after anterior glenohumeral
Roddey TS, Olson SL, Cook KF, et al: Comparison of the University of joint dislocation, Phys Ther 69(2):106-112, 1989.
California-Los Angeles shoulder scale and the Simple Shoulder Test Snyder SJ, Banas MP, Karzel RP: An analysis of 140 injuries to the supe-
with the Shoulder Pain and Disability Index: Single-Administration rior glenoid labrum, J Shoulder Elbow Surg 4:243-248, 1995.
reliability and validity, Phys Ther 80(8):759-768, 2000. Snyder SJ, Karzel RP, Del Pizzo W, et al: SLAP lesions of the shoulder,
Rodosky MW, Harner CD, Fu F: The role of the long head of the biceps Arthroscopy 6:274-279, 1990.
muscle and superior glenoid labrum in anterior stability of the Sobush DC, Simoneau GG, Dietz KE, et al: The Lennie test for
shoulder, Am J Sports Med 22:121-130, 1994. measuring scapular position in healthy young adult females: a
Roetert EP, Ellenbecker TS: Complete conditioning for tennis, Champaign reliability and validity study, J Orthop Sports Phys Ther 23(1):39-50,
IL, 1998, Human Kinetics. 1996.
Roetert EP, Ellenbecker TS, Brown SW: Shoulder internal and Soderberg GJ, Blaschak MJ: Shoulder internal and external rotation
external range of motion in nationally ranked junior tennis players: a peak torque production through a velocity spectrum in differing
longitudinal analysis, J Strength Conditioning Res 14(2):140-143, positions, J Orthop Sports Phys Ther 8:518-524, 1987.
2000. Soldatis JJ, Moseley JB, Etminan M: Shoulder symptoms in healthy ath-
Roetert EP, Groppel J: World class tennis technique, Champaign IL, 2001, letes: a comparison of outcome scoring systems, J Shoulder Elbow
Human Kinetics Publishers. Surg 6:265-271, 1997.
Roland PE, Ladegaard-Pedersen H: A quantitative analysis of sensa- Solem-Bertoft E, Thuomas K, Westerberg C: The influence of scapula
tions of tension and of kinaesthesia in man: evidence for a peripher- retraction and protraction on the width of the subacromial space,
ally originating muscular sense and for a sense of effort, Brain Clin Orthop 266:99-103, 1993.
100:671-692, 1977. Speer KP: Anatomy and pathomechanics of shoulder instability, Clin
Roos D: Transaxillary for first rib resection to relieve thoracic outlet syn- Sports Med 14(4):751-760, 1995.
drome, Ann Surg 163:354-358, 1966. Speer KP, Deng X, Borrero S, et al: Biomechanical evaluation of a
Rowe CR: Acute and recurrent dislocations of the shoulder, J Bone Joint simulated Bankart lesion, J Bone Joint Surg 76-A(12):1819-1826,
Surg 44A:998, 1962. 1994b.
Rowe CR: Dislocations of the shoulder. In Rowe CR, ed: The shoulder, Speer KP, Hannafin JA, Altchek DW, et al: An evaluation of the shoul-
Edinburgh, 1988, Churchill Livingstone. der relocation test, Am J Sports Med 22(2):177-183, 1994a.
Rowe CR, Patel D, Southmayd WW: The Bankart procedure: a long Sprigings E, Marshall R, Elliott B, et al: A three-dimensional kinematic
term end-result study, J Bone Joint Surg 60A:1-16, 1978. method for determining the effectiveness of arm segment rotations
Rowe CR, Zarins B: Recurrent transient subluxation of the shoulder, in producing racquet head speed, J Biomechan 27:245-254, 1994.
J Bone Joint Surg 63A:863-871, 1981. Stefko JM, Jobe FW, VanderWilde RS, et al: Electromyographic and
Rubin BD, Kibler WB: Fundamental principles of shoulder rehabilita- nerve block analysis of the subscapularis liftoff test, J Shoulder Elbow
tion: conservative to postoperative management, Arthroscopy Surg 6:347-355, 1997.
18(9)(suppl 2):29-39, 2002. Stetson WB, Templin K: The crank test, the O’Brien test, and routine
Rupp S, Berninger K, Hopf T: Shoulder problems in high level swim- magnetic resonance imaging scans in the diagnosis of labral tears,
mers: impingement, anterior instability, muscular imbalance? Int J Am J Sports Med 30(6):806-809, 2002.
Sports Med 16:557-562, 1995. Struhl S: Anterior internal impingement: an arthroscopic observation,
Saha AK: Mechanism of shoulder movements and a plea for the recog- Arthroscopy 18(1):2-7, 2002.
nition of “zero position” of glenohumeral joint, Clin Orthop 173:3- Telford E, Mottershead S: Pressure at the cervical brachial junction:
10, 1983. an operative and anatomical study, J Bone Joint Surg 30B:249-265,
Sauers EL, Borsa PA, Herling DE, et al: Instrumented measurement of 1948.
glenohumeral joint laxity and its relationship to passive range of Terry GC, Friedman SJ, Uhl TL: Arthroscopically treated tears of the
motion and generalized joint laxity, Am J Sports Med 29:143-150, glenoid labrum. Factors influencing outcome, Am J Sports Med
2001a. 22(4)504-512, 1994.
Sauers EL, Borsa PA, Herling DE, et al: Instrumented measurement of Tibone JE, Bradley JP: Evaluation of treatment outcomes for the ath-
glenohumeral joint laxity: reliability and normative data, Knee Surg letes shoulder. In Matsen FA, Fu FH, Hawkins RJ, eds: The shoulder:
Sports Traumatol Arthrosc 9:34-41, 2001b. a balance of mobility and stability, Rosemont, IL, 1993, American
Segal DK: Tennis sistema biodinamico, Buenos Aires, Argentina, 2002, Academy of Orthopaedic Surgeons.
Tenis Club Argentino. T’Jonck L, Lysens R, Gunther G: Measurement of scapular position and
Shapiro R, Stine RL: Shoulder rotation velocities, technical report sub- rotation: a reliability study, Physiother Res Int 1(3):148-158, 1996.
mitted to the Lexington Clinic, Lexington, KY, 1992. Tohyama H, Yasuda K, Ohkoshi Y, et al: Anterior drawer test for acute
Sher JS, Uribe J, Posada A, et al: Abnormal findings on magnetic reso- anterior talofibular ligament injuries in the ankle: how much load
nance images of asymptomatic shoulders, J Bone Joint Surg 77(1):10- should be applied during the test? Am J Sports Med 31(2):226-232,
15, 1995. 2003.
RE.qxd 5/25/04 2:11 PM Page 195

References 195

Tomberlin J: Physical diagnostic tests of the shoulder. An evidence based per- Ware JE, Jr, Snow KK, Kosinski M, et al: SF-36 health survey manual and
spective, LaCrosse, WI, 2001, Orthopaedic Section of the APTA, interpretation guide, Boston, 1993, The Health Institute.
Home Study Course 11.1.2. Warner JP, Micheli LJ, Arslanian LE, et al: Patterns of flexibility, laxity,
Toussaint HM, de Hollander P, van den Berg C, et al: Biomechanics and strength in normal shoulders and shoulders with instability and
of swimming. In Garrett WE, Kirkendall DT, eds: Exercise and sport impingement, Am J Sports Med 18:366-375, 1990.
science, Philadelphia, 2000, Lippincott Willians and Wilkins. Warner JP, Micheli LJ, Arslanian LE, et al: Scapulothoracic motion in
Treiber FA, Lott J, Duncan J, et al: Effects of Theraband and light normal shoulders and shoulders with glenohumeral instability and
weight dumbbell training on shoulder rotation torque and serve per- impingement syndrome: a study using Moiré topographic analysis,
formance in college tennis players, Am J Sports Med 26:510-515, Clin Orthop Rel Res 285:191-199, 1991.
1998. Warner JJP, Lephart S, Fu FH: Role of proprioception in pathoetiology
Tyler TF, Nicholas SJ, Roy T, et al: Quantification of posterior capsular of shoulder instability, Clin Orthop Rel Res 330:35-39, 1996.
tightness and motion loss in patients with shoulder impingement, Warner JJP, McMahon PJ: The role of the long head of the biceps
Am J Sports Med 28(5):668-673, 2000. brachii in superior stability of the glenohumeral joint, J Bone Joint
Tyler TF, Roy T, Nicholas SJ, et al: Reliability and validity of a new Surg 77a:366-373, 1995.
method of measuring posterior shoulder tightness, J Orthop Sports Wilk KE, Andrews JR, Arrigo CA, et al: The strength characteristics
Phys Ther 29(5):262-274, 1999. of internal and external rotator muscles in professional baseball
Tzannes A, Murrell GAC: Clinical examination of the unstable shoul- pitchers, Am J Sports Med 21:61-66, 1993.
der, Sports Med 32(7):447-457, 2002. Wilk KE, Arrigo CA: Current concepts in the rehabilitation of the
Valadie AL, Jobe CM, Pink MM, et al: Anatomy of provocative tests for athletic shoulder, J Orthop Sports Phys Ther 18:335, 1993.
impingement syndrome of the shoulder, J Shoulder Elbow Surg Wilk KE, Arrigo CA, Andrews JR: Isokinetic testing of the shoulder
9(1):36-46, 2000. abductors and adductors: windowed vs nonwindowed data collec-
VanGheluwe B, Hebbelinck M: The kinematics of the service movement tion, J Orthop Sports Phys Ther 15:107-112, 1992.
in tennis: a three dimensional cinematographical approach. In Wilk KE, Arrigo CA, Andrews JR: Standardized isokinetic testing pro-
Winter DA, Norman RW, Wells RP, et al, eds: Biomechanics tocol for the throwing shoulder: the throwers series, Isok Exerc Sci
IX-B, Champaign IL, 1985, Human Kinetics Publishers. 1:63-71, 1991.
Vangsness CT, Ennis M, Taylor JG, et al: Neural anatomy of the gleno- Williams GN, Gangel TJ, Arciero RA, et al: Comparison of the single
humeral ligaments, labrum, and subacromial bursa, Arthroscopy assessment numeric evaluation method and two shoulder rating
11(2):180-184, 1995. scales: outcomes measures after shoulder surgery, Am J Sports Med
Van Moppes FI, Veldkamp O, Roorda J: Role of ultrasonography in 27(2):214-221, 1999.
the evaluation of the painful shoulder, Eur J Radiol 19:142-146, Williams JW, Holleman DR, Simel DL: Measuring shoulder function
1995. with the shoulder pain and disability index, J Rheumatol 22:727-732,
Vaughan RE: An algorithm for determining arm action during overarm 1995.
baseball pitches. In Winter DA, Norman RW, Wells RP, et al, Wolf EM, Agrawal V: Trandeltoid palpation (the rent test) in the
eds: Biomechanics IX-B, Champaign, IL, 1985, Human Kinetics diagnosis of rotator cuff tears, J Shoulder Elbow Surg 10:470-473,
Publishers. 2001.
Voight ML, Hardin JA, Blackburn TA, et al: The effects of muscle Wuelker N, Plitz W, Roetman B: Biomechanical data concerning
fatigue on and the relationship of arm dominance to shoulder pro- the shoulder impingement syndrome, Clin Orthop 303:242, 1994.
prioception, J Orthop Sports Phys Ther 23(6):348-352, 1996. Wyke B: Articular neurology: a review, Physiotherapy 58:94-99, 1972.
Voss H: Tabelle der absoluten und relativen Muskel-spindelzahlen der Wyke BD: The neurology of joints, Ann R Coll Surg Engl 41:25, 1967.
menschlichen Skelettmuskulatur, Anat Anz 129:562-572, 1971. Yamaguchi K, Riew BK, Galatz LM, et al: Biceps activity during shoul-
Waddell G, McCulloch JA, Kummer E, et al: Nonorganic physical signs der motion: an electromyographic analysis, Clin Orthop 336:122-
in low back pain, Spine 5(2):117-125, 1980. 129, 1997.
Walch F, Boulahia A, Calderone S, et al: The “dropping” and Yergason RM: Supination sign, J Bone Joint Surg 13:160, 1931.
‘Hornblower’s signs in evaluation of rotator cuff tears, J Bone Joint Yocum LA: Assessing the shoulder, Clin Sports Med 2:281-289, 1983.
Surg 80B:(4):624-628, 1998. Zaslav KR: Internal rotation resistance strength test: a new diagnostic
Walch G, Boileau P, Noel E, et al: Impingement of the deep surface of test to differentiate intra-articular pathology from outlet (Neer)
the supraspinatus tendon on the posterosuperior glenoid rim: an impingement syndrome in the shoulder, J Shoulder Elbow Surg
arthroscopic study, J Shoulder Elbow Surg 1:238, 1992. 10:23-27, 2001.
Walch G, Nove-Josserand L, Levigne C, et al: Tears of the supraspina- Zeier FG: The treatment of winged scapula, Clin Orthop Rel Res 91:128-
tus tendon associated with “hidden” lesions of the rotator interval, 133, 1973.
J Shoulder Elbow Surg 3:353-360, 1994. Zemek MJ, Magee DJ: Comparison of glenohumeral joint laxity in elite
Walker SW, Couch WH, Boester GA, et al: Isokinetic strength of the and recreational swimmers, Clin J Sports Med 6:40-47, 1996.
shoulder after repair of a torn rotator cuff, J Bone Joint Surg Am Zuckerman JD, Gallagher MA, Cuomo F, et al: The effect of instability
69:1041-1044, 1987. and subsequent anterior shoulder repair on proprioceptive ability,
Walmsley RP, Hartsell H: Shoulder strength following surgical rotator J Shoulder Elbow Surg 12:105-109, 2003.
cuff repair: a comparative analysis using isokinetic testing, J Orthop Zuckerman JD, Gallagher MA, Lehman C, et al: Normal shoulder pro-
Sports Phys Ther 15:215-222, 1992. prioception and the effect of lidocaine injection, J Shoulder Elbow
Walmsley RP, Szybbo C: A comparative study of the torque generated Surg 8(1):11-16, 1999.
by the shoulder internal and external rotator muscles in different Zuckerman JD, Kummer FJ, Cuomo, et al: The influence of coracoacro-
positions and at varying speeds, J Orthop Sports Phys Ther 9:217-222, mial arch anatomy on rotator cuff tears, J Shoulder Elbow Surg 1:4,
1987. 1992.
INDEX.qxd 5/25/04 2:12 PM Page 197

Index*

A AMBRI. See Atraumatic multidirectional bilateral laxity,

AAOS. See American Academy of Orthopaedic Surgeons rehabilitation, inferior capsular shift
AB/ADD. See Abduction/adduction ratio American Academy of Orthopaedic Surgeons (AAOS), 36,
Abdominal trauma, joint testing for referred symptoms with, 49
31, 32b American Shoulder Elbow Surgeons (ASES)
Abduction humeral head translation tests and, 65-66
range of motion for, 52t, 55 severe translation in, 65
Tyler posterior shoulder tightness test with, 55-56, 56f rating scale, 146, 148, 149f
Abduction ratio, DiVeta test with, 25-26 Anatomy, cutaneous sensation distribution, 42f
Abduction/adduction ratio (AB/ADD), 140 Angina, joint testing for referred symptoms with, 32b
AC joint. See Acromioclavicular joint Anterior drawer test
Acromial architecture, 85 action in, 75
Acromioclavicular (AC) joint alternative hand position in, 75f
joint testing for referred symptoms in, 34-35 clinical diagnosis with, 178t
case study with, 185 description of, 74
clinical diagnosis with, 178t glenohumeral joint in, 74-76, 75f, 76f
passive mobility test for, 35, 35f objective evidence regarding, 76
O’Brien’s test anatomic drawing for, 124f positive result in, 75-76
Acromioclavicular joint ramifications of, 76
degenerative changes in, 9 start position for, 74
pain in, 10, 10f Anterior release test
Acromioclavicular joint sprain, palpation for, 48 action in, 83-84, 84f
Acromioclavicular separation, posture observed with, 16t clinical diagnosis with, 178t
Acromion. See also DiVeta test description of, 83
inferior angle in, 25 glenohumeral joint in, 83-84, 84f
Active compression test, 35 indication for, 83
action in, 123-124, 123f objective evidence regarding, 84
case studies with, 186 positive result in, 84
clinical diagnosis with, 178t ramifications of, 84
description of, 123 start position for, 83
indication for, 123 visual of, 84f
joint testing for referred symptoms with, 35 Anterior slide test, 121-123, 122f
labral in, 123-125, 123f, 124f, 125f action in, 122
objective evidence regarding, 125 clinical diagnosis with, 178t
positive result in, 124, 124f description of, 122
ramifications of, 124, 125f indication for, 121
start position for, 123, 123f objective evidence regarding, 122-123
Adam’s position, posture observed with, 16 positive result in, 122
Adson’s maneuver, neurovascular testing with, 43, 43f ramifications of, 122
Allen’s test, 43 start position for, 122, 122f
Altchek grading Anterior tilting
anterior drawer test with, 75, 76 inferior angle dysfunction with, 20t
humeral head translation tests with, 66-67, 66f scapular motion with, 18, 18f
grade I, 66f Anteroposterior displacement, glenohumeral joint with, 5
grade II, 66f, 74 Aortic aneurysm, joint testing for referred symptoms with,
grade III, 66f 32b
Apley’s scratch tests, range of motion in, 49, 50f
Apprehension test
action in, 63, 63f
*Page numbers followed by f indicate figures; t, tables; b, boxes. clinical diagnosis with, 178t

197
INDEX.qxd 5/25/04 2:12 PM Page 198

198 Index

Apprehension test—cont’d Biceps—cont’d

glenohumeral joint with, 62-63, 63f tendon instability tests for, 112-113, 113f
indication for, 62 description of, 113
modifications to, 63 indication for, 112
objective evidence regarding, 63 ramifications of, 113
positive result in, 63 transverse humeral ligament test for, 113
ramifications of, 63 Yergason’s test for, 109-110, 110f
start position for, 62 action in, 110
Arthroscopic shoulder surgery, clinical evaluation verified by, description of, 109
5 indication for, 109
ASES. See American Shoulder Elbow Surgeons objective evidence regarding, 110
Athletic shoulder outcome rating scale, 149, 151, 152f positive result in, 110
Atraumatic multidirectional bilateral laxity, rehabilitation, ramifications of, 110
inferior capsular shift (AMBRI), patient history with, 9 start position for, 109-110, 110f
Atraumatic multidirectional bilateral rehabilitation and Biceps load test
inferior (AMBRI), glenohumeral joint instability with, test I, 126-127, 126f
61 action in, 126
description of, 126
B indication for, 126
Balance point position objective evidence regarding, 126-127
clinical evaluation with, 6-7 positive result in, 126
definition of, 6-7 ramifications of, 126
Bankart lesions, labral detachment with, 115, 117 start position for, 126, 126f
Baseball. See also Throwing motion test II, 127-128, 127f, 128f
anterior drawer test for, 76 action in, 127, 127f
ER/IR with, 140t description of, 127
general information in, 12b indication for, 127
injury pattern in, 12b objective evidence regarding, 127-128
medical information in, 12b positive result in, 127
range of motion in, 53-56, 54f, 55f ramifications of, 127
dominant/nondominant arm in, 54f start position for, 127
external rotation, 55f Biceps long-head tendon, palpation of, 47, 47f
internal rotation, 55f Bicipital tendinitis, palpation for, 48
total rotation, 55f Bilateral symmetry
symptom characteristics in, 12b DiVeta test with, 26
Biceps, 107-113 sensation evaluated with, 41
Gilchrest’s sign for, 111-112, 112f Bone spurs, Neer’s stages of impingement with, 85
action in, 112 Bone tumors, joint testing for referred symptoms with, 32b
description of, 111 Breast disease, joint testing for referred symptoms with, 32b
indication for, 111
objective evidence regarding, 112 C
positive result in, 112 Capsule pain, palpation for, 48
ramifications of, 112 Capsulolabral injury, 79
start position for, 111-112, 112f Case studies, 183-186
instability test, 113, 113f Hawkins impingement test in, 186
introduction to, 107-108, 108t LSST in, 183, 185
Ludington’s test for, 110-111, 111f neurovascular testing in, 183, 185, 186
action in, 111 posture in, 183, 184, 186
description of, 110 range of motion in, 183-184, 185
indication for, 110 scapular examination in, 183, 184-185, 186
objective evidence regarding, 111 Spurling’s maneuver in, 183, 186
positive result in, 111 Cervical cord tumors, joint testing for referred symptoms
ramifications of, 111 with, 32b
start position for, 110-111, 111f Cervical lordosis, posture observed with, 13
pathology classification for, 108t Cervical spine
Popeye deformity, 111, 111f joint testing for referred symptoms for, 32-33
Speed’s test for, 108-109, 109f patient history with, 11
action in, 109 Circumduction test, 118-119, 118f
description of, 108 action in, 118-119, 118f
indication for, 108 clinical diagnosis with, 178t
objective evidence regarding, 109 description of, 118
positive result in, 109 indication for, 118
ramifications of, 109 objective evidence regarding, 119
start position for, 108-109, 109f positive result in, 119
INDEX.qxd 5/25/04 2:12 PM Page 199

Index 199

Circumduction test—cont’d Compression rotation test—cont’d

ramifications of, 119 ramifications of, 121
start position for, 118, 118f start position for, 120, 121f
CKC extremity testing. See Closed kinetic chain extremity Compressive disease, glenohumeral joint with, 85
testing Constant-Murley scoring system, 145-146
Clinical diagnosis, tests for, 177-180 Coracoacromial ligament pain, palpation for, 48
additional concepts in, 178-180 Coracoid impingement test
Davies functional testing algorithm, 177, 178t action in, 90, 91f
introduction to, 177 description of, 90
rotator cuff impingement in, 177, 179f glenohumeral joint in, 90-92, 91f
Clinical evaluation. See also Joint testing for referred indication for, 90
symptoms objective evidence regarding, 92
case study with, 183, 184, 185 positive result in, 91
general concepts applied during, 5-7 ramifications of, 91
balance point position in, 6-7 start position for, 90, 91f
extremity examination sequence in, 7 visual of, 91f
glenohumeral joint resting position in, 5-6 Costoclavicular maneuver, provocation tests with, 43, 44f
scapular plane position in, 6 Crank test, 119-120, 119f
humeral head translation tests for, 6 action in, 119f, 120
joint kinematics in, 11 clinical diagnosis with, 178t
other diagnostic tests v., 4-5 description of, 119
arthroscopic shoulder surgery as, 5 indication for, 119
MRI as, 5 objective evidence regarding, 120
ultrasound as, 4-5 positive result in, 120
patient history in, 9-12 ramifications of, 120
activities of daily living in, 11 start position for, 119, 119f
general questions for, 11 Cross-arm adduction, 49
goals in, 11 Cross-arm adduction test, 35
immediate, 9 action in, 92, 92f
introduction to, 9 clinical diagnosis with, 178t
joint testing for referred symptoms, 31 description of, 92
past, 9-10 glenohumeral joint, 92-93, 92f
symptoms’ location in, 10-11 indication for, 92
symptoms’ severity in, 11 objective evidence regarding, 93
tennis player, 12b positive result in, 92
throwing shoulder, 12b ramifications of, 92-93
TUBS in, 9 start position for, 92
posture in, 13-16 visual of, 92f
additional tests in, 16 Cross-arm impingement test. See Cross-arm adduction test
hands-on-hips, 14-16, 15f, 16f Cross-body maneuver, 55
introduction to, 13 Cubital tunnel retinaculum, Tinel’s test with, 37, 37f
standing, 13 Cutaneous sensation distribution, 42f
tennis shoulder and, 14 Cybex isokinetic dynamometer, 138f, 139
shoulder height in, 13-14
alterations in, 13 D
assessment of, 13 Davies functional testing algorithm, 177, 178t
dominant, 13-14 DDSD. See Distally derived scapular dysfunction
Closed kinetic chain (CKC) extremity testing, 143-144, Deltopectoral triangle, palpation of, 47f
144f Depression, scapular motion with, 19, 19f
Clunk test, 117-118, 117f Diagnosis. See Clinical diagnosis
action in, 117 Diagnostic tests
clinical diagnosis with, 178t arthroscopic shoulder surgery, 5
description of, 117 clinical evaluation v., 4-5
indication for, 117 MRI, 5
objective evidence regarding, 118 ultrasound, 4-5
positive result in, 117 Diaphragmatic irritation, joint testing for referred symptoms
ramifications of, 117-118 with, 32b
start position for, 117, 117f Differential diagnosis, joint testing for referred symptoms
Compression rotation test, 120-121, 121f with, 31
action in, 120-121, 121f Distally derived scapular dysfunction (DDSD), scapular
description of, 120 function classifications with, 20
indication for, 120 DiVeta test, scapular position tests for, 25-26, 25f
objective evidence regarding, 121 abduction ratio in, 25-26
positive result in, 121 acromion angle in, 25
INDEX.qxd 5/25/04 2:12 PM Page 200

200 Index

DiVeta test, scapular position tests for—cont’d Flexion, range of motion for, 52t
bilateral symmetry in, 26 Flip sign test, scapular position tests for, 29-30, 30f
test-retest reliability in, 26 action in, 29
Drop-arm test, 104-105, 104f indications for, 29
action in, 104, 104f positive test in, 30
clinical diagnosis with, 178t ramifications of, 30
description of, 104 start position of, 29
indication for, 104 Foot contact, 167, 168f, 169f
objective evidence regarding, 105 Football injury, patient history with, 9
positive result in, 104 Forward flexion impingement test. See Neer impingement
ramifications of, 105 test
start position for, 104, 104f Full can test. See also Empty can test
Dropping sign test, 102-103, 103f clinical diagnosis with, 178t
action in, 102, 103f MMT in, 133, 135f
clinical diagnosis with, 178t rotator cuff injury and, 89f, 99t
description of, 102
indication for, 102 G
objective evidence regarding, 101-102 Gerber lift-off test, 99-101, 100f, 101f
positive result in, 102, 103f action in, 99
ramifications of, 102 clinical diagnosis with, 178t
start position for, 102, 103f description of, 99
Dynamaesthesia, 155 indication for, 99
modifications in, 99-100, 101f
E muscular strength testing with, 136, 137f
Edema, Neer’s stages of impingement with, 85 objective evidence regarding, 100-101
EDI. See Electronic digital inclinometer palpation with, 45
Elbow joint positive result in, 99
biomechanics of, 42f, 42t ramifications of, 99
joint testing for referred symptoms with, 35-36 start position for, 99, 100f
Electromyogram (EMG), 99, 100, 133 visual of, 98f
Electronic digital inclinometer (EDI), 160 Gilchrest’s sign, 111-112, 112f
Elevation action in, 112
scapular motion with, 19, 19f description of, 111
superior dysfunction with, 20t indication for, 111
EMG. See Electromyogram objective evidence regarding, 112
Empty can test, 89f, 97-99, 98t, 99t positive result in, 112
action in, 97, 98f ramifications of, 112
additional evidence regarding, 98-99 start position for, 111-112, 112f
description of, 97 Glenohumeral joint
grading of, 98t afferent contractile tissue receptors of, 157
indication for, 97 afferent joint receptors in, 156-157
positive result in, 97 afferent mechanoreceptor classification and, 155-156
ramifications of, 97-98 afferent neurobiology of, 155
start position for, 97, 98f anterior drawer test with, 74-76, 75f, 76f
visual of, 98f action in, 75
Empyema, joint testing for referred symptoms with, 32b alternative hand position in, 75f
End feel classification description of, 74
bony, 57t indication for, 74
capsular, 57t objective evidence regarding, 76
empty, 57t positive result in, 75-76
range of motion in, 56-57, 57t ramifications of, 76
soft tissue approximation, 57t start position for, 74
spasm, 57t anterior release test with, 83-84, 84f
springy block, 57t action in, 83-84, 84f
ER/IR. See External /internal ratio description of, 83
Examination. See Clinical evaluation indication for, 83
Extension, range of motion for, 52t objective evidence regarding, 84
External /internal ratio (ER/IR), 139, 140t positive result in, 84
Extremity examination sequence ramifications of, 84
clinical evaluation with, 7 start position for, 83
definition of, 7 visual of, 84f
apprehension test in, 62-63, 63f
F action in, 63, 63f
Feagin test. See Multidirectional instability sulcus sign indication for, 62
Fibrosis, Neer’s stages of impingement with, 85 modifications to, 63
INDEX.qxd 5/25/04 2:12 PM Page 201

Index 201

Glenohumeral joint—cont’d Glenohumeral joint—cont’d

apprehension test in—cont’d instability testing for, 61-84
objective evidence regarding, 63 directions of, 61-62
positive result in, 63 introduction to, 61
ramifications of, 63 terminology in, 62
start position for, 62 internal rotation resistance strength test for, 93-95, 94f
Coracoid impingement test for, 90-92, 91f action in, 94, 94f
action in, 90, 91f description of, 93
description of, 90 indication for, 93
indication for, 90 objective evidence regarding, 94-95
objective evidence regarding, 92 positive result in, 94
positive result in, 91 ramifications of, 94
ramifications of, 91 start position for, 94, 94f
start position for, 90, 91f visual of, 94f
visual of, 91f load and shift test in, 71-74, 72f, 73f
cross-arm adduction test for, 92-93, 92f action in, 72-73
action in, 92, 92f description of, 71-72, 72f
description of, 92 indication for, 71
indication for, 92 overhead view of, 73f
objective evidence regarding, 93 positive result in, 73
positive result in, 92 ramifications of, 73
ramifications of, 92-93 starting position for, 72
start position for, 92 MDI sulcus sign (90º abduction) for, 70-71, 71f
visual of, 92f action in, 71
Hawkins impingement test for, 89-90, 89f, 90f, 91f indication for, 70
action in, 89 positive result in, 71
description of, 89 ramifications of, 71
indication for, 89 start position in, 70-71
MRI showing, 91f MDI sulcus sign (neutral) for, 68-70, 69f, 70f
objective evidence regarding, 89-90 action in, 69
positive result in, 89 indication for, 68
ramifications of, 89 objective evidence regarding, 70
start position for, 89, 89f, 90f positive result in, 69, 70f
visual of, 89f, 90f ramifications of, 69-70
humeral head translation tests for, 63-68 start position in, 68-69
additional grading in, 67, 67f modified subluxation/relocation test with, 82-83, 83f
Altchek grading in, 66-67, 66f action in, 82-83, 82f
American Shoulder Elbow Surgeons grading in, description of, 82
65-66 indication for, 82
grading of, 64-65 objective evidence regarding, 83
Hawkins’ system in, 67, 67f positive result in, 83
introduction to, 63-64 ramifications of, 83
manual clinical tests with, 64-65 start position for, 82, 82f
optimal force application during, 68 visual of, 82f
quantification of, 68 Neer impingement test for, 87-89, 87f, 88f
impingement in, 24, 85-95 action in, 87, 87f
anterior internal, 86-87 description of, 87
compressive disease, 85 indication for, 87
Neer’s stages of, 85-86 objective evidence regarding, 88-89
outlet, 85 positive result in, 87
posterior, internal, 86 ramifications of, 87
primary, 85 start position for, 87
secondary, 86 visual of, 87f
undersurface, 86 pain provocation tests with, 79
instability classification for, 61, 62t posterior drawer test with, 77-78, 77f
AMBRI, 61 action in, 77
coupled, 62 alternative position for, 77, 77f
degree as, 62t description of, 77
direction as, 62t indication for, 77
multidirectional, 62 objective evidence regarding, 78
obligate motion, 62 positive result in, 78
onset as, 62t ramifications of, 78
timing/frequency as, 62t start position for, 77, 77f
TUBS, 61 posterior glide 90 degree flexion test with, 78-79, 79f
volition as, 62t action in, 78
INDEX.qxd 5/25/04 2:12 PM Page 202

202 Index

Glenohumeral joint—cont’d Hands-on-hips position—cont’d

posterior glide 90 degree flexion test with—cont’d clinical evaluation with—cont’d
capsulolabral injury with, 79 rotator cuff dysfunction in, 15
description of, 78 scalloping in, 15
indication for, 78 inferior angle dysfunction in, 20t
objective evidence regarding, 79 Hawkins impingement test, 89-90, 89f, 90f, 91f
positive result in, 78-79 action in, 89
ramifications of, 79 case study with, 186
start position for, 78, 79f description of, 89
visual of, 79f indication for, 89
posture observed with, 15f, 16t MRI showing, 91f
proprioceptive testing of, 155-161 objective evidence regarding, 89-90
definitions in, 155 positive result in, 89
introduction to, 155 ramifications of, 89
joint angular replication test in, 160, 160f start position for, 89, 89f, 90f
joint instability with, 157-159 visual of, 89f, 90f
joint position sense measurement in, 160, 160f Hawkins’ system, humeral head translation tests with, 67, 67f
kinesthesia measurement in, 159 Hemorrhage, Neer’s stages of impingement with, 85
measurement methods in, 159, 159f History. See Patient history
muscular fatigue with, 161 Horizontal adduction impingement test. See Cross-arm
summary of, 161 adduction test
range of motion of Hornblower’s sign, 103-104, 103f
resting position in, 5 action in, 103
scapular stabilization with, 53t clinical diagnosis with, 178t
techniques for, 51, 51f, 52t, 53 description of, 103
recoil in, 20 indication for, 103
resting position of, clinical evaluation with, 5-6 objective evidence regarding, 104
rotation testing in, 139-142 positive result in, 103-104, 103f
adduction/abduction in, 140-141 ramifications of, 104
bilateral comparisons with, 139 start position for, 103
ER/IR with, 139, 140t Humeral head
flexion/extension in, 141-142 kinematics of, 54
horizontal adduction/abduction in, 141-142 translation, 65
normative data utilization with, 140, 141t Humeral head translation tests
protraction/retraction in, 142 additional grading in, 67, 67f
scapulothoracic testing with, 142 Altchek grading in, 66-67, 66f
torque/body weight ratio with, 141t American Shoulder Elbow Surgeons grading in, sever
unilateral strength ratios with, 139, 140t translation in, 65
scapulothoracic joint motion and, 17 grading of, 64-65
subluxation/relocation test with, 79-82, 79f Hawkins’ system in, 67, 67f
action in, 80, 80f introduction to, 63-64
anatomic diagram for, 81f manual clinical tests with, 64-65
description of, 79 optimal force application during, 68
effectiveness of, 80-82 quantification of, 68
indication for, 79 scapular plane position in, 6
positive result in, 80 Hyperabduction maneuver, 43
ramifications of, 80 Hyperangulation
start position for, 79-80, 79f tennis serve with, 172
visual of, 79f, 80f throwing motion with, 167f, 169, 169f
Yocum test for, 93, 93f
action in, 93 I
description of, 93 ICC. See Intraclass correlation coefficients
indication for, 93 ICR. See Instantaneous center of rotation
objective evidence regarding, 93 IGHL. See Inferior glenohumeral ligament
positive result in, 93 Impingement, 24, 85-95. See also Coracoid impingement
ramifications of, 93 test; Hawkins impingement test; Neer impingement
start position for, 93, 93f test
visual of, 93f anterior internal, 86-87
Goniometric evaluation, range of motion in, 49 clinical diagnosis with, 178t
compressive disease in, 85
H glenohumeral joint with, 85-95
Hands-on-hips position Neer’s stages of, 85-86
clinical evaluation with, 14-16 outlet, 85
LSST in, 15 posterior, internal, 86
INDEX.qxd 5/25/04 2:12 PM Page 203

Index 203

Impingement—cont’d Joint testing for referred symptoms—cont’d

primary, 85 introduction to, 31
secondary, 86 lower extremity screening in, 37-39, 38f
undersurface, 86 one-leg stability test, 37-39, 38f
Inferior angle dysfunction. See Kibler scapular dysfunction O’Brien’s test in, 35
classification provocation tests in, 37
Inferior glenohumeral ligament (IGHL), 169f SC joint in, 33-34
Inferior humeral head translation test. See Multidirectional Spurling’s maneuver in, 33, 34f
instability sulcus sign Tinel’s test in, 37, 37f
Infraspinatus, muscular strength testing with, 133, 134t, 136 Valgus extension overpressure test in, 36-37, 37f
Infraspinatus tendinitis, palpation for, 48 Valgus stress test in, 36, 36f
infraspinatus tendon, palpation of, 45, 46f Varus stress test in, 36, 36f
Infraspinous fossae, posture observed with, 15f, 16f
Instantaneous center of rotation (ICR), scapulothoracic joint K
motion in, 17, 18f Kehr’s sign, joint testing for referred symptoms with,
Internal rotation resistance strength test 31
action in, 94, 94f Kibler lateral scapular slide test (LSST)
description of, 93 action in, 22-23
glenohumeral joint in, 93-95, 94f case study with, 183, 185
indication for, 93 evidence regarding, 23-24
objective evidence regarding, 94-95 indication for, 22
positive result in, 94 position for, 22, 22f, 23f
ramifications of, 94 position 1, 22, 22f
start position for, 94, 94f position 2, 22, 23f
visual of, 94f position 3, 22, 23f
Intraclass correlation coefficients (ICC) starting, 22
isokinetics muscular strength testing and, 138 positive result in, 23
LSST reliability measured with, 24 pain and, 23
range of motion with, 50, 56 posture observed with, 15
Isokinetics muscular strength testing, 136-139, 141t, 142- ramifications of, 23
143 test-retest reliability with, 24
additional concepts in, 142 ICC measuring, 24
closed kinetic chain with, 114f, 143-144 validity of, 24-25
concentric v. eccentric as, 142 glenohumeral joint impingement and, 24
fatigue testing in, 142-143 Kibler scapular assistance test, scapular position tests for, 26-
functional performance related to, 143-144 27, 27f
neurovascular testing with, 41 action in, 26
rational for, 136-137 indications for, 26
shoulder complex with, 137-139 positive test in, 26-27
ramifications of, 27
J start position of, 26
Jendrassik’s maneuver, neurovascular testing with, 41 Kibler scapular dysfunction classification, 19-21
Jobe subluxation/relocation test. See Subluxation/relocation glenohumeral joint recoil in, 19-21
test inferior angle dysfunction in, 20, 20t
Joint angular replication test, 160, 160f anterior tilting in, 20t
Joint position sense medial border dysfunction in, 20-21, 20t, 21f
definition of, 155 internal rotation in, 20t
measurement of, 160, 160f superior dysfunction in, 20t, 21, 21f
Joint Range of Motion Guide, 49 scapular elevation in, 20t
Joint testing for referred symptoms, 31-39 shoulder shrug in, 21
AC joint in, 34-35 Kibler scapular retraction test, scapular position tests for, 27-
passive mobility test for, 35, 35f 28, 28f
active compression test in, 35 action in, 28
case studies with, 183, 185, 186 indications for, 27
cervical spine clearing, 32-33 positive test in, 28
cross-arm adduction impingement test in, 35 ramifications of, 28
elbow joint in, 35-36 start position of, 28
general screening in Kinematics
differential diagnosis, 31 clinical evaluation with, 11
Kehr’s sign in, 31 humeral head, 54
medical history and, 31 Kinesthesia
nonorganic signs in, 32 definition of, 159
rheumatic disease in, 31, 32b measurement of, 159
ruptured spleen in, 31, 32b TTDPM for, 159
INDEX.qxd 5/25/04 2:12 PM Page 204

204 Index

L Labral testing—cont’d
Labral testing, 115-129 crank test for—cont’d
active compression test for, 123-125, 123f, 124f, 125f, 178t positive result in, 120
action in, 123-124, 123f ramifications of, 120
description of, 123 start position for, 119, 119f
indication for, 123 detachment and, 115-117
objective evidence regarding, 125 Bankart lesions in, 115, 117
positive result in, 124, 124f SLAP lesions in, 115-117, 116f
ramifications of, 124, 125f introduction to, 115
start position for, 123, 123f Mimori pain provocation for, 128-129, 129f
anterior slide test for, 121-123, 122f action in, 128, 129f
action in, 122 description of, 128
description of, 122 indication for, 128
indication for, 121 objective evidence regarding, 129
objective evidence regarding, 122-123 positive result in, 128
positive result in, 122 ramifications of, 129
ramifications of, 122 start position for, 128
start position for, 122, 122f Late ball contact, 175
biceps load test for, 126-127, 126f Lennie test, scapular position tests for, 25
action in, 126 Liver disease, joint testing for referred symptoms with, 32b,
description of, 126 33t
indication for, 126 Load and shift test
objective evidence regarding, 126-127 action in, 72-73
positive result in, 126 clinical diagnosis with, 178t
ramifications of, 126 description of, 71-72, 72f
start position for, 126, 126f glenohumeral joint in, 71-74, 72f, 73f
biceps load test II for, 127-128, 127f, 128f indication for, 71
action in, 127, 127f objective evidence regarding, 73-74, 74f
description of, 127 overhead view of, 73f
indication for, 127 positive result in, 73
objective evidence regarding, 127-128 ramifications of, 73
positive result in, 127 starting position for, 72
ramifications of, 127 Loose-pack position. See Resting position
start position for, 127 LSST. See Kibler lateral scapular slide test
circumduction test for, 118-119, 118f Ludington’s test, 110-111, 111f
action in, 118-119, 118f action in, 111
description of, 118 clinical diagnosis with, 178t
indication for, 118 description of, 110
objective evidence regarding, 119 indication for, 110
positive result in, 119 objective evidence regarding, 111
ramifications of, 119 positive result in, 111
start position for, 118, 118f ramifications of, 111
clinical diagnosis with, 178t start position for, 110-111, 111f
Clunk test for, 117-118, 117f Lung cancer, joint testing for referred symptoms with, 32b
action in, 117 M
description of, 117
indication for, 117 Magnetic resonance imaging (MRI)
objective evidence regarding, 118 clinical evaluation verified by, 5
positive result in, 117 Hawkins impingement test in, 91f
ramifications of, 117-118 Neer impingement test in, 88f
start position for, 117, 117f Manual muscle testing (MMT), 133, 135f, 136, 137, 142
compression rotation test for, 120-121, 121f case study with, 186
action in, 120-121, 121f MDI sulcus sign. See Multidirectional instability sulcus sign
description of, 120 Medial border dysfunction. See Kibler scapular dysfunction
indication for, 120 classification
objective evidence regarding, 121 Metastases, joint testing for referred symptoms with, 32b
positive result in, 121 Mimori pain provocation, 128-129, 129f
ramifications of, 121 action in, 128, 129f
start position for, 120, 121f description of, 128
crank test for, 119-120, 119f indication for, 128
action in, 119f, 120 objective evidence regarding, 129
description of, 119 positive result in, 128
indication for, 119 ramifications of, 129
objective evidence regarding, 120 start position for, 128
INDEX.qxd 5/25/04 2:12 PM Page 205

Index 205

MMT. See Manual muscle testing Napoleon test—cont’d

Modified Rowe scale. See Rowe scale clinical diagnosis with, 178t
Modified subluxation/relocation test. See also Subluxation/ description of, 101
relocation test indication for, 101
action in, 82-83, 82f objective evidence regarding, 101-102
description of, 82 positive result in, 101
glenohumeral joint in, 82-83, 83f ramifications of, 101
indication for, 82 start position for, 101, 102f
objective evidence regarding, 83 Neer impingement test
positive result in, 83 action in, 87, 87f
ramifications of, 83 case studies with, 183
start position for, 82, 82f description of, 87
visual of, 82f glenohumeral joint in, 87-89, 87f, 88f
MRI. See Magnetic resonance imaging indication for, 87
Multidirectional instability (MDI) sulcus sign objective evidence regarding, 88-89
90 degrees abduction positive result in, 87
glenohumeral joint in, 70-71, 71f ramifications of, 87
indication for, 70 start position for, 87
positive result in, 71 visual of, 87f
ramifications of, 71 Neer’s stages of impingement, 85-86
start position in, 70-71 acromial architecture in, 85
case studies with, 185 bone spurs in, 85
clinical diagnosis with, 178t edema in, 85
glenohumeral joint with, 68-71, 69f, 70f, 71f fibrosis in, 85
neutral hemorrhage in, 85
action in, 69 tendon rupture in, 85
indication for, 68 tendonitis in, 85
objective evidence regarding, 70 Negative predictive value (NPV)
positive result in, 69, 70f anterior release test with, 84
ramifications of, 69-70 cross-arm adduction test with, 93
start position in, 68-69 definition of, 4
Muscular strength testing, 133-144 empty can test with, 99, 99t
case studies with, 184, 185, 186 full can test with, 99t
glenohumeral joint rotation testing in, 139-142 Hawkins impingement test with, 90
adduction/abduction in, 140-141 internal rotation resistance strength test with, 95
bilateral comparisons with, 139 Neer impingement test with, 89
ER/IR with, 139, 140t subluxation/relocation test with, 81-82
flexion/extension in, 141-142 Nerve root compression, patient history with, 11
horizontal adduction/abduction in, 141-142 Neuromuscular control, 155
normative data utilization with, 140, 141t Neurovascular testing, 41-44
protraction/retraction in, 142 case study with, 183, 185, 186
scapulothoracic testing with, 142 introduction to, 41
torque/body weight ratio with, 141t isokinetic testing in, 41
unilateral strength ratios with, 139, 140t Jendrassik’s maneuver in, 41
introduction to, 133 provocation tests with, 43-44
isokinetics in, 136-139, 141t, 142-143 Adson’s maneuver in, 43, 43f
additional concepts in, 142 Allen’s test, 43
closed kinetic chain with, 143-144, 144f costoclavicular maneuver, 43, 44f
concentric v. eccentric as, 142 hyperabduction maneuver, 43
fatigue testing in, 142-143 Wright’s maneuver, 43
functional performance related to, 143-144 reflexes examined in, 41
rational for, 136-137 Semmes Weinstein Monofilament test kit in, 41
shoulder complex with, 137-139 sensation examined in, 41
rotator cuff in, 133-136, 134t, 135f, 135t strength examined in, 41, 42t
infraspinatus with, 133, 134t, 136 summary of, 44
subscapularis with, 134t, 136 thoracic outlet tested in, 41, 43
supraspinatus with, 133, 134t NPV. See Negative predictive value
teres minor with, 134t, 136
Musculoskeletal disorder, patient history with, O
10b Obligate motion, glenohumeral joint instability with,
62
N O’Brien’s test. See Active compression test
Napoleon test, 101-102, 102f One-leg stability test, 37-39, 38f
action in, 101 Outlet impingement, glenohumeral joint with, 85
INDEX.qxd 5/25/04 2:12 PM Page 206

206 Index

P Posterior drawer test—cont’d

Pain, 10f. See also Joint testing for referred symptoms; indication for, 77
Shoulder pain and disability index objective evidence regarding, 78
LSST with, 23 positive result in, 78
radicular, 10 ramifications of, 78
referred, 10, 32b, 32f start position for, 77, 77f
subacromial space with, 10, 10f Posterior glide 90 degree flexion test
Pain provocation tests, glenohumeral joint in, 79 action in, 78
Palpation, 45-48 capsulolabral injury with, 79
biceps long-head tendon with, 47, 47f description of, 78
introduction to, 45 glenohumeral joint in, 78-79, 79f
rotator cuff tendons with, 45-46 indication for, 78
shoulder with, 47-48 objective evidence regarding, 79
Pancoast’s tumor, joint testing for referred symptoms with, positive result in, 78-79
32b, 33t ramifications of, 79
Paralabral cyst formation, posture observed with, 15 start position for, 78, 79f
Patient history visual of, 79f
activities of daily living in, 11 Posterior scapular displacement test, scapular position tests
case study with, 183, 184 for, 26
clinical evaluation with, 9-12 Posterior tilting, scapular motion with, 18, 18f
general questions for, 11 Posture
goals in, 11 additional tests in, 16
immediate, 9 acromioclavicular separation in, 16t
introduction to, 9 Adam’s position in, 16
past, 9-10 lateral view in, 16
AMBRI in, 9 plumb line for, 16
one time versus repeated event in, 9 Popeye biceps in, 16t
sports injury in, 9, 11 posterior view in, 16
TUBS in, 9 rib protrusion in, 16
symptoms’ location in, 10-11, 10b scapular wringing in, 16t
acromioclavicular joint, 10, 10f, 11 case study with, 183, 184, 186
cervical spine, 11 cervical lordosis in, 13
musculoskeletal disorder, 10b clinical evaluation of, 13-16
nerve root compression, 11 hands-on-hips, 14-16, 15f, 16f
rotator cuff, 11 LSST in, 15
subacromial space, 10, 10f rotator cuff dysfunction in, 15
symptoms’ severity in, 11 scalloping in, 15
PDSD. See Proximally derived scapular dysfunction introduction to, 13
Peptic ulcer, joint testing for referred symptoms with, 32b, scoliosis in, 14
33t shoulder height in, 13-14
Pericarditis, joint testing for referred symptoms with, 32b alterations in, 13
Perry tool test, scapular position tests for, 26 assessment of, 13
Physiologie des Muskelsinnes, 155 dominant, 13-14
Pleurisy, joint testing for referred symptoms with, 33t, standing, 13
34t tennis shoulder and, 14, 14f
Plumb line, posture observed with, 16 rotator cuff in, 14
Popeye biceps, 111, 111f scapula position in, 14
case studies with, 183 thoracic kyphosis in, 13
posture observed with, 16t PPV. See Positive predictive value
Positive predictive value (PPV) Predictive value, definition of, 4
anterior release test with, 84 Prevalence, definition of, 4
cross-arm adduction test with, 93 Primary impingement, glenohumeral joint with, 85
definition of, 4 Proprioceptive testing, glenohumeral joint with, 155-
empty can test with, 99, 99f 161
full can test with, 99f definitions in, 155
Hawkins impingement test with, 90 introduction to, 155
internal rotation resistance strength test with, 95 joint angular replication test in, 160, 160f
subluxation/relocation test with, 81-82 joint instability with, 157-159
Posterior drawer test joint position sense measurement in, 160, 160f
action in, 77 kinesthesia measurement in, 159
alternative position for, 77, 77f measurement methods in, 159, 159f
clinical diagnosis with, 178t muscular fatigue with, 161
description of, 77 summary of, 161
glenohumeral joint in, 77-78, 77f Protraction, scapular motion with, 18-19
INDEX.qxd 5/25/04 2:12 PM Page 207

Index 207

Provocation tests Rotator cuff injury

joint testing for referred symptoms with, 37 clinical diagnosis for, 177, 178t
neurovascular testing in, 43-44 drop-arm test for, 104-105, 104f
Proximally derived scapular dysfunction (PDSD), scapular action in, 104, 104f
function classifications with, 19-20 description of, 104
Pulmonary tuberculosis, joint testing for referred symptoms indication for, 104
with, 32b objective evidence regarding, 105
Push-pull test. See Load and shift test positive result in, 104
ramifications of, 105
R start position for, 104, 104f
Radiograph, shoulder stress procedure, 65f dropping sign test for, 102-103, 103f
Range of motion action in, 102, 103f
case study with, 183-184, 185 description of, 102
end feel classification for, 56-57, 57t indication for, 102
bony, 57t objective evidence regarding, 103
capsular, 57t positive result in, 102, 103f
empty, 57t ramifications of, 102
soft tissue approximation, 57t start position for, 102, 103f
spasm, 57t empty can test for, 89f, 97-99, 98t, 99t
springy block, 57t action in, 97, 98f
normal values for, 52t additional evidence regarding, 98-99
abduction, 52t description of, 97
extension, 52t grading of, 98t
external rotation, 52t indication for, 97
flexion, 52t positive result in, 97
internal rotation, 52t ramifications of, 97-98
scapulothoracic joint with, 17 start position for, 97, 98f
testing for, 49-57 visual of, 98f
active/passive, 49 Gerber lift-off test for, 99-101, 100f, 101f
Apley’s scratch tests, 49, 50f action in, 99
assessment for, 49 description of, 99
combined shoulder, 49-51, 50f indication for, 99
goniometric evaluation, 49 modifications in, 99-100, 101f
introduction to, 49 objective evidence regarding, 100-101
isolated glenohumeral joint, 51, 51f, 53 positive result in, 99
normal values in, 52t ramifications of, 99
scapulohumeral rhythm, 49 start position for, 99, 100f
summary of, 57 visual of, 98f
total concept of, 53-56 glenohumeral joint instability with, 62
Tyler posterior shoulder tightness test, 55-56, 56f Hawkins impingement test with, 89
Rating scales. See Shoulder rating scales Hornblower’s sign for, 103-104, 103f
Referred pain. See also Joint testing for referred symptoms action in, 103
causes for, 32b description of, 103
musculoskeletal structures with, 32f indication for, 103
symptom location and, 10 objective evidence regarding, 104
Reflexes, neurovascular testing with, 41 positive result in, 103-104, 103f
Rent test, palpation with, 45-46, 47f ramifications of, 104
Resting position start position for, 103
clinical evaluation with, 5-6 Napoleon test for, 101-102, 102f
definition of, 5 action in, 101
scapular, 17 description of, 101
Retraction, scapular motion with, 18-19 indication for, 101
Rheumatic disease, 31, 32b objective evidence regarding, 101-102
Rib protrusion, posture observed with, 16 positive result in, 101
Rotation ramifications of, 101
medial border dysfunction with, 20t start position for, 101, 102f
range of motion with, 49, 50, 52t Neer impingement test and, 88
external, 52t palpation of, 45-46
internal, 49, 50, 52t patient history with, 11
scapular motion with tennis shoulder with, 14
downward, 18, 18f, 19f tests for, 97-105
external, 18, 18f Rowe multidirectional instability test, 69.
internal, 18, 18f See also Multidirectional instability sulcus
upward, 18, 18f, 19f sign
INDEX.qxd 5/25/04 2:12 PM Page 208

208 Index

Rowe scale, 146, 147t Scapulothoracic joint—cont’d

Rowe test. See Apprehension test scapular position tests for, 25-30
DiVeta test, 25-26, 25f
S flip sign test, 29-30, 30f
SANE. See Single assessment numeric evaluation Kibler scapular assistance test, 26-27, 27f
method Kibler scapular retraction test, 27-28, 28f
SC joint. See Sternoclavicular joint Lennie test, 25
Scalloping, posture observed with, 15 Perry tool test, 26
Scaption position. See Empty can test posterior scapular displacement test, 26
Scapular examination, case studies with, 183, 184-185, scapulothoracic conductor’s test, 28-29, 29f
186 scapular resting position and, 17
Scapular fossae, posture observed with, 15f Scapulothoracic testing, 142
Scapular plane position Scoliosis, posture observed with, 14, 16
clinical evaluation with, 6 Secondary impingement, glenohumeral joint with, 86
definition of, 6 Semmes Weinstein Monofilament test kit, 41
humeral head translation tests for, 6 Sensitivity
Scapular resting position, scapulothoracic joint and, 17 cross-arm adduction test with, 93
Scapular wringing, 19 definition of, 3
posture observed with, 16t empty can test with, 99, 99t
Scapulohumeral rhythm full can test with, 99t
range of motion with, 49 Hawkins impingement test with, 90
scapulothoracic joint with, 17 Neer impingement test with, 88
Scapulothoracic conductor’s test, scapular position tests for, specificity and, 3-4
28-29, 29f subluxation/relocation test with, 81
action in, 29 transdeltoid palpation with, 46
indications for, 28 Setting phase, scapulothoracic joint motion with, 17
positive test in, 29 Severe translation, 65
ramifications of, 29 SF-36. See Short Form-36
start position of, 28 SGHL. See Superior glenohumeral ligament
Scapulothoracic joint, 17-30 Shear test. See Acromioclavicular joint
introduction to, 17 Short Form-36 (SF-36), 145
Kibler dysfunction evaluation sequence for, 21-22 Shoulder pain and disability index (SPADI), 148-149, 151b
dynamic, 22 Shoulder rating scales, 145-153
static, 21-22 ASES rating scale as, 146, 148, 149f
LSST for, 22-25 athletic shoulder outcome rating scale as, 149, 151, 152f
action in, 22-23 Constant-Murley scoring system as, 145-146
evidence regarding, 23-24 introduction to, 145
indication for, 22 Rowe scale as, 146, 147t
positive result in, 23 SANE as, 151, 153
ramifications of, 23 SPADI as, 148-149, 151b
starting position for, 22 SST as, 148, 150f, 151f
test-retest reliability with, 24 summary of, 153
validity of, 24-25 UCLA rating scale as, 146, 148b
motion of, 17-18, 18f Shoulder shrug, superior dysfunction with, 21
3D research on, 17 Shoulder stress radiograph procedure, 65f
glenohumeral joint in, 17 Simple shoulder test (SST), 146, 148, 150f, 151f
ICR in, 17, 18f Single assessment numeric evaluation method (SANE), 151,
range of motion in, 17 153
scapulohumeral rhythm in, 17 SLAP lesions. See Superior labrum anterior posterior
setting phase in, 17 lesions
scapular function classifications for, 19-21 SPADI. See Shoulder pain and disability index
DDSD, 20 Spasm, end feel classification of, 57t
inferior angle dysfunction, 20, 20t Specificity
Kibler scapular dysfunction classification, 19-21 cross-arm adduction test with, 93
medial border dysfunction, 20-21, 20t, 21f definition of, 3
PDSD, 19-20 empty can test with, 99, 99t
scapular winging, 19 full can test with, 99t
superior dysfunction, 20t, 21, 21f Hawkins impingement test with, 90
scapular motion and, 18-19, 18f, 19f internal rotation resistance strength test with, 94-95
anterior/posterior tilting, 18, 18f Neer impingement test with, 88
elevation/depression, 19, 19f sensitivity and, 3-4
internal/external rotation, 18, 18f subluxation/relocation test with, 81
protraction/retraction, 18-19 transdeltoid palpation with, 46
upward/downward rotation, 18, 18f, 19f Yocum test with, 93
INDEX.qxd 5/25/04 2:12 PM Page 209

Index 209

Speed’s test, 108-109, 109f Sulcus sign. See Multidirectional instability sulcus sign
action in, 109 Superior dysfunction. See Kibler scapular dysfunction
clinical diagnosis with, 178t classification
description of, 108 Superior glenohumeral ligament (SGHL), 73
indication for, 108 Superior labrum anterior posterior (SLAP) lesions
objective evidence regarding, 109 biceps load test for, 126, 127
positive result in, 109 clinical diagnosis for, 178t
ramifications of, 109 labral detachment with, 115-117, 116f
start position for, 108-109, 109f O’Brien’s test anatomic drawing for, 125f
Spinal metastases, joint testing for referred symptoms with, Superior outlet, 41
32b Suprascapular nerve, posture observed with, 15, 15f
Spinoglenoid notch, posture observed with, 15, 15f Suprascapular notch, posture observed with, 15, 15f
Spleen, ruptured, 31, 32b Supraspinatus, muscular strength testing with, 133, 134t
Sports Supraspinatus muscle, posture observed with, 15f
injury Supraspinatus tendinitis, palpation for, 48
cutaneous sensation distribution for, 42f Supraspinatus tendon, palpation of, 46f, 47f
patient history with, 11 Supraspinatus test. See Empty can test
kinetic link principle with, 163, 164-166, 164f
alterations in, 164-166 T
technique evaluation with, 164, 164f Tendon rupture, Neer’s stages of impingement with, 85
patient history with, 12b Tendonitis, Neer’s stages of impingement with, 85
football in, 9 Tennis
tennis in, 11, 12b case study with, 183
throwing in, 12b ER/IR with, 140t
range of motion in, 53-56, 54f groundstrokes, 173-175, 174f
baseball, 53-56, 54f backhand in, 174-175
tennis, 53-56, 54f forehand in, 173f
technique, 163-175 late ball contact in, 175
clinical analysis of, 166 phases in, 173
evaluation of, 164, 164f patient history with, 12b
introduction to, 163 different strokes in, 12b
proximal-to-distal sequencing with, 163-164 equipment in, 12b
tennis force production in, 164t, 165f, 166f specific mechanism in, 12b
tennis groundstrokes in, 173-175, 174f training history in, 12b
tennis serve in, 170-173, 171f, 172f posture in, 14
throwing motion in, 167-170, 167f, 168f, 169f, rotator cuff in, 14
170f scapula position in, 14
tennis shoulder in, 14 range of motion in, 53-56, 54f, 55f
Spurling’s maneuver, 33, 34f dominant/nondominant arm in, 54f
case study with, 183, 186 external rotation, 55f
SST. See Simple shoulder test internal rotation, 55f
Stagnosia, 155 total rotation, 55f
Sternoclavicular (SC) joint, joint testing for referred serve, 170-173, 171f, 172f
symptoms with, 33-34 arm cocking in, 172f
Strength, neurovascular testing and, 41, 42t hyperangulation in, 172
Subacromial bursa, palpation of, 47f phases of, 170, 171f
Subacromial bursitis, palpation for, 48 Tennis shoulder, clinical evaluation of, 14
Subacromial space, pain in, 10, 10f Teres minor, muscular strength testing with, 136
Subluxation/relocation test. See also Modified Teres minor tendinitis, palpation for, 48
subluxation/relocation test Teres minor tendon, palpation of, 45
action in, 80, 80f Textbook of Clinical Neurology, 155
anatomic diagram for, 81f thinker’s position, palpation with, 45, 46f
clinical diagnosis with, 178t 30/30/30 internal/external rotation position, 137-138
description of, 79 Thoracic kyphosis, posture observed with, 13
effectiveness of, 80-82 Thoracic outlet syndrome (TOS)
glenohumeral joint in, 79-82, 79f neurovascular testing with, 41, 43-44
indication for, 79 provocation tests for, 43-44, 43f, 44f
positive result in, 80 Adson’s maneuver, 43, 43f, 44
ramifications of, 80 Allen’s test, 43
start position for, 79-80, 79f costoclavicular maneuver, 43, 44f
visual of, 79f, 80f hyperabduction maneuver, 43
Subscapularis, muscular strength testing with, 134t, 136 Wright’s maneuver, 43
Subscapularis tendinitis, palpation for, 48 Threshold to detection of passive motion (TTDPM), 155,
Subscapularis tendon, palpation of, 45 161
INDEX.qxd 5/25/04 2:12 PM Page 210

210 Index

Throwing motion, 12b, 167-170, 167f, 168f, 169f, 170f V

foot contact, 167, 168f, 169f Valgus extension overpressure test, 36-37, 37f
hyperangulation in, 167f, 169, 169f Valgus stress test, 36, 36f
patient history with, 12b Varus stress test, 36, 36f
phases of, 167, 167f Vomiting, joint testing for referred symptoms with, 31
wind-up phase, 168f
Tilting, scapular motion with, 18, 18f W
anterior, 18, 18f Wright’s maneuver, 43
posterior, 18, 18f
Tinel’s test, 37, 37f Y
TOS. See Thoracic outlet syndrome Yergason’s test, 109-110, 110f
Transdeltoid, palpation of, 46 action in, 110
Transverse humeral ligament test, biceps in, 113 clinical diagnosis with, 178t
Transverse scapular ligament, posture observed with, 15f description of, 109
Traumatic, unidirectional Bankart surgery (TUBS), patient indication for, 109
history with, 9 objective evidence regarding, 110
Traumatic unidirectional instability (TUBS), glenohumeral positive result in, 110
joint instability with, 61 ramifications of, 110
TTDPM. See Threshold to detection of passive motion start position for, 109-110, 110f
Tuberculosis, joint testing for referred symptoms with, 32b Yocum test, 93, 93f
TUBS. See Traumatic, unidirectional Bankart surgery; action in, 93
Traumatic unidirectional instability case studies with, 183
Tyler posterior shoulder tightness test, range of motion in, description of, 93
55-56, 56f indication for, 93
U objective evidence regarding, 93
positive result in, 93
UCLA rating scale, 146, 148b ramifications of, 93
Ulnar nerve, Tinel’s test with, 37 start position for, 93, 93f
Ultrasound, clinical evaluation verified by, 4-5 visual of, 93f
Undersurface impingement, glenohumeral joint with, 86
Upper extremity Motor Screening Manual Muscle Test
Sequence, 42t