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- v.6(3); 2014 Jul
- PMC4935057
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Shoulder Elbow. 2014 Jul; 6(3): 215–221.
Published online 2014 Jun 17. doi:10.1177/1758573214535368
PMCID: PMC4935057
PMID: 27582939
Nick Phillips
Author information Copyright and License information PMC Disclaimer
Abstract
Clinical examination techniques need to allow the physician to determine the underlyingpathology of a patient’s condition with confidence. This review examines the evidence fortwo common conditions: impingement and rotator cuff disease
Keywords: Evidence, examination, shoulder; tests
Introduction
The purpose of any examination is to allow the clinician to establish the anatomical,pathological and functional conditions of a patient. The examination should be able todetermine the underlying causes of the presenting problem with confidence and assurity. Thetechniques used must give, where possible, a clarification of the suspected derangement, andthe examiner must be aware of the possibility that the tests employed may misdirect adiagnosis by giving a falsely positive finding. The purpose of the development of manyexamination tests has been to try to focus down on specific anatomical structures, and toimprove the reliability of the test in defining the structural integrity of the tissue, andits function. The present review aims to guide the examiner to utilize tests that provideboth confidence in their ability to determine the problem, and that are reproducible over aperiod of time, allowing comparison between one examination and another, thus giving anaccuracy of the progress of a condition. Clearly, there are subjective elements to anyexamination, with the most obvious being pain, although the objective findings still help indirecting diagnosis.
This review article aims to look at the examination techniques used to diagnose two commonconditions: subacromial impingement and rotator cuff disease.
The rotator cuff complex is defined as a group of tendons that envelope the humeral head,arising from four muscles that have their origin on the scapula. These muscles,subscapularis, supraspinatus, infraspinatus and teres minor, act in synergy as theglenohumeral joint is utilized to allow positioning of the hand in space for function. Theirprimary role appears to be stabilizing the humeral head on the glenoid surface, ensuringthat it remains centred as the head rotates in all the different planes of movementrequired. Pure internal and external rotation of the humeral head does not involve anycranial translational force, yet these movements are rarely needed in isolation. Thefunction of the more superiorly placed tendon fibres appears to both aid abductioninitiation of the humeral head and resist cranial translation of the head as the shouldercontinues to elevate the arm. Thus, any dysfunction of the tendon complex is likely to leadto an upward movement of the head as the arm is actively raised, which will inevitably causean increase contact pressure of both the upper surface of the tendon and the interposedsubacromial bursa upon the undersurface of the acromion and the coraco-acromialligament1.
Although this cause for pain is intrinsic to the tendon itself, regardless of whether it iscaused by inflammation (with or without calcification) or partial and full-thickness tears,there may also be extrinsic causes, such as an alteration in the dimensions of thesubacromial space (as is found with the differing morphological types of acromialdevelopment)2,hypertrophy of the coraco-acromial ligament3 or bursal anomalies such as aplica4 orthickening5 fromrepeated episodes of inflammation, or regional thickening of the tendons themselves, asfound in chronic calcinosis after episodes of acute calcific tendinitis6. Finally, the complexdynamic coordination of scapular movements as the arm is elevated can give rise to pain fromthe subacromial structures7. The diagnosis of impingement aims to isolate the pathological process tothe subacromial space; it does not, however, define the cause.
Subacromial impingement
Impingement syndrome is characterized by pain experienced through an arc of elevation asthe shoulder abducts. It should be appreciated that this is a condition that is associatedwith active movement of the shoulder (after all, the patient never functionally lifts thearm passively), so it occurs when the subacromial structures are actively brought intocontact with the acromion and coracoacromial ligament during the act of elevating thearm.
The two most commonly used tests for impingement are Neer's Sign and the Hawkins–Kennedytest8,9.
Neer’s sign
This test allows demonstration of a pain during passive abduction of the arm with thescapula stabilized, the examiner lifting the arm in the scapular plane with the arminternally rotated (Figure 1). Itwas described originally in 1977, and did not as such describe an ‘arc’ of pain. However,a painful arc through abduction is often associated with the eponym. As a supplementarypart to this manoeuvre, the effect on the pain following an injection of local anaestheticplaced into the subacromial space is called Neer's test. A significant reduction orabolition of the pain is seen as a positive test.
Figure 1.
Neer.
Hawkins–Kennedy test
Described in 1980, this test is again a passive test, with the examiner positioning thepatient's arm at 90° in the scapular plane, the elbow bent to 90°, and the arm takenpassively into internal rotation. Creation of pain during this maneuver is indicative of apositive test (Figure 2).
Figure2.
Hawkins–Kennedy.
The two tests differ in relation to the position of the humeral head below the acromion.Pappas etal. determined the invivo relationship of the insertion of thesupraspinatus tendon with magnetic resonance imaging using both tests, demonstrating thatthe Hawkins–Kennedy test caused both an increased incidence of, and a greater decrease in,the distance of the supraspinatus to the acromion than Neer’s sign10.
A recent pooled data analysis from Hegedus etal. has shown the sensitivity (a truepositive) of each of the tests varies (79% for Hawkins–Kennedy; 72% for Neer’s test) but,importantly, specificity (the statistical ability of a test to be negative when a definedpathological condition is not present) is lower, calculated at 59% and 60%,respectively11.Hegedus etal. also used a similar meta-analysis including a number of studies todemonstrate that, although neither test had sufficient sensitivity to diagnoseimpingement, there was evidence to conclude that a negative Hawkins–Kennedy test wassufficiently powerful to rule it out. Conditions such as acromioclavicular arthrosis,superior labral tears, internal impingement and even Bankart lesions may also yieldpositive tests12.
Lim etal. investigated the prognostic use of a subacromial injection when a diagnosis ofimpingement had been made, and a subacromial decompression was considered as a surgicaloption. They found that there was a significant correlation between the positive effect ofthe injection of the local anaesthetic and a good surgical outcome, considering bothsymptom improvement and the length of the postoperative recovery13.
Rotator cuff disease
The tests that aim to diagnose rotator cuff disease are numerous. The examiner shouldattempt to separate out the individual tendons that comprise the cuff to determine theintegrity of the tendon. True isolation of the individual tendons is almost impossiblebecause of the coupling effects across the rotator cuff complex. This is especially so whenthe superior cuff (the supraspinatus and infraspinatus) in conjunction with the long head ofbiceps tendon are being considered14. The exception appears to be the ability to isolate subscapularis.
Pain elicited from these tests may be a result of either tendinitis/tear or subacromialimpingement. Differentiation between tendinitis and a small tear (partialthickness or full thickness) is often difficult. Tears that involve a significant proportionof a tendon will tend to show signs of weakness, although the clinician must be aware that,even in the presence of a large or massive rotator cuff defect, the patient may still onlydemonstrate mild or subtle signs15. This is a result of the ability of the shoulder to compensate for theabsence of part of the rotator cuff with residual intact cuff and surrounding intactmuscles.
In the determination of an accurate assessment from each test, two basic requirements areadequate pain relief (else pain inhibition may mimic true weakness) and a sufficient rangeof passive movement to allow appropriate positioning of the arm in which to perform thetest.
Supraspinatus
Jobe’s empty can test was first described in 1983. This sets out to preferentially testsupraspinatus (complete isolation of supraspinatus from the deltoid is difficult), themost commonly affected tendon when considering degenerative cuff disease. It positions thearm such that the supraspinatus tendon is placed under maximal stress as the arm is pusheddown, attempting to invoke pain, weakness, or both, from the examination. It does not,however, completely isolate supraspinatus, and some fibres from the anterior part ofinfraspinatus are also tested.
The arm is flexed to 90°in the scapular plane and the forearm maximally pronated, sointernally rotating the shoulder joint (the classical ‘thumbs down’ position). Thisposition of internal rotation disadvantages the action of deltoid, so improving theaccuracy of testing supraspinatus. Pressure is applied to the arm and any pain or weaknessrecorded (Figure 3). The examinershould note where the pain is because it is not uncommon for this test to produce pain inthe common extensor origin at the elbow, especially if pressure is applied distal to theelbow joint. Some examiners therefore exert pressure above the elbow, aiming to minimizethe effect of triceps extending the elbow and compensating for an absent supraspinatus.This can be performed unilaterally or with both arms tested at the same time forcomparison. Some examiners prefer to have less flexion at the shoulder when performing thetest. This maybe to reduce the possibility of causing an inadvertent impingement position,and thus a falsely positive outcome if pain appears to be the main feature.
Figure3.
Jobe.
Park etal. calculated the sensitivity of the empty can test to be 44% but with aspecificity of 90%16. This gives the test significant validity but it should be noted that,although the review stated a positive predictive value (PPV) of 88%, it was almost 50%when the negative predictive value was calculated16. This may reflect the anatomical abilityof the rotator cuff complex to ‘balance’ a tear, as was suggested by Burkhart17, and may help explainwhy a significant number of patients remain asymptomatic despite a supraspinatus tearbeing confirmed on a shoulder scan.
An additional examination is the lateral Jobe test which has a reported 81% sensitivityand 89% specificity, with a PPV of 91%, and should considered a useful addition to theexamination18.
Infraspinatus
Hertel in 1996 described the ‘external rotation lag sign’ to diagnose an infraspinatustear. This test sets out to examine the posterosuperior and posterior cuff elements. Itwas originally described to evaluate infraspinatus19. The arm is held in 20° of flexion withthe elbow bent to 90°. The forearm is passively externally rotated to its maximal rangeand released. If the arm drops back towards its starting position, even by a few degrees,it is said to have a lag (‘the lag sign’) (Figure 4). The ability of the patient to maintain thearm fully externally rotated implies the effectiveness of the cuff structures, mostlyinfraspinatus, but, with the element of forward flexion, there is also an element ofsupraspinatus activity with the test, and so pain may be present even if no lag isrecorded.
Figure4.
External rotation lag.
It should be noted that this test can only be both sensitive and specific when a normalrange of external rotation is demonstrated by the patient. With a capsular contraction,the patient loses external rotation, and so they cannot achieve a position in which therotator cuff tendons can be induced to produce a lag through weakness. Similarly, if thereis excessive external rotation (as might be seen in a subscapularis rupture), the passiveexternal rotation of the shoulder will be greater than normal, and a falsely positive lagsign may be elicited.
An additional sign useful for the clinician (as it relates directly to the functionalcapacity of a patient in activities of daily living) is the drop-arm sign. The patient maybe able to elevate the arm to near full range, although often they require assistance todo this (either using their other arm to lift the affected side upward, or needing activehelp from the examiner) but, when asked to lower the arm slowly back to a restingposition, they lose control of the descent through a mid-arc range, and the speed of thelowering increases until it reaches a comfortable resting position again. This sign isoften but not always associated with pain as the arm is lowered. It is indicative of alarge superior cuff tear involving both supraspinatus and infraspinatus incombination.
Teres minor
The examination of the posterior cuff is the hornblower sign20. The arm is placed passively by theexaminer in 90° of abduction and maximal external rotation. The patient is instructed toattempt to maintain the hand in space when the examiner releases the hold on the wrist. Ifthe patient’s arm falls forwards, this is a positive test, and indicates significantweakness of infraspinatus and usually teres minor (Figure 5). If the patient can maintain the positionof the arm, gentle forward pressure on the forearm may cause pain, and indicate thepresence of a small tear involving infraspinatus.
Figure 5.
Hornblower.
Subscapularis
Testing subscapularis involves the evaluation of the patient’s ability to forciblyinternally rotate the humerus. This can be achieved either in front (the belly press testand bear-hug test) or behind (Gerber’s lift-off test) the body. It must be appreciatedthat, to achieve a satisfactory examination, the patient must be able to comfortablyposition their arm in the required place and, although this is rarely a problem with atest performed in front of the body, any loss of internal rotation and/or extension of theshoulder may prevent the patient being able to place the hand behind the back, and thusperform the test.
Belly press test (Napoleon sign)
This involves the hand (or hands if done bilaterally) being placed flat on the abdomen,and the patient is requested to press the hand onto the stomach. If the patient is unableto maintain the elbow forward, so extending the shoulder and flexing the wrist to achievethe desired pressure, this indicates a positive test21 (Figure 6).
Figure 6.
Belly-press. (a) One hand. (b)Bilaterally.
Bear-hug test
This test was described by Burkhart and De Beer, and involves the arm reaching across thebody to hold the opposite latissimus dorsi and, with the elbow held forward of the body,the strength of the resistance to the hand being pulled away from the body isevaluated22.Some examiners modify this slightly, asking the patient to simply place the hand on theopposite chest wall, with the examiner’s hand between the patient’s and their chest wall,and ask them to resist a pull off (Figure7).
Figure7.
Bear hug.
Gerber’s lift-off test
The dorsum of the hand is placed on the sacrum and the patient is asked to take the handoff the back, when the examiner maintains a fixed angle of elbow flexion23. If the elbow is allowedto extend, the test is false because there is recruitment of triceps to the manoeuvre andso any determination of the strength of the lift off is inaccurate (Figure 8). In addition to this test, a lag sign maybe looked for, with the arm held away from the sacrum by the examiner, so maximizing theinternal rotation of the humerus, and the patient is then asked to maintain that positionas the hand is released. If the hand falls back onto the sacrum, it indicates a weaknessof subscapularis.
Figure8.
Lift-off.
Electrophysiological validation of these tests has been performed, notably by separatingthe upper and lower parts of the subscapularis. The anterior tests are more sensitive inrecording weakness in the upper fibres of the tendon, and a positive lift-off testindicates a weakness in the lower elements of the tendon24,25. Yoon etal. explored the differenttests most commonly used for subscapularis pathology, and found the lift-off test to bethe most specific at differentiating between an intact and torn tendon (100% of patientsstudied), whereas the belly-press test was the most sensitive, although only recording avalue of 28%26.Similarly, to detect full-thickness from partial thickness tears, the lift-off test was97% specific, with the belly-press test being the most sensitive at 57%.
One important difference between testing subscapularis anteriorly or posteriorly is thefundamental ability of the patient to position their hand in the correct place. Althoughthis is rarely if ever a problem for the belly press or bear-hug positions, anysignificant degree of restriction of internal rotation of the shoulder, or a body shapewith big hips and buttocks, may prevent the patient being able to reach sufficiently fararound their back to allow comfortable positioning of the hand, meaning an accurate andconsistent assessment may be impossible to achieve.
The above description of tests is far from exhaustive when aiming to examine the shoulderfor any suspected rotator cuff pathology but, as with all musculoskeletal assessments, thefindings are to be considered against the background of a full and detailed clinicalhistory, especially noting the activity-related symptoms that a patient reports. Thisshould ultimately allow the examiner to focus on the likely causes of the ongoingcomplaint with increased accuracy, allowing greater specificity in the use of diagnosticsand a greater confidence in the prescription of appropriate forms of treatment for thepatient and their condition.
Declaration of conflicting interests
None declared.
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