Orthopedic Special Tests: Specificity Challenges

• Clinical examination helps to elicit signs that can supplement clinical symptoms gathered from the patient's history.
• Examination of any joint in orthopaedics follows a sequence of look/feel/move/special tests.
• The examiner inspects the patient, palpates the shoulder and scapular areas, and determines active and passive range of motion.
• Individual muscle strength is examined along with special tests to identify underlying conditions.
• The cervical spine, elbow, and other upper limb joints are also examined.
• A structured clinical approach ensures significant findings are not overlooked.

Look

• The patient is inspected overall for comfort at rest or in discomfort.
• The patient is asked to stand and take a few steps for assessing overall posture, balance and mobility of lower and upper limbs.
• Ability to walk with or without a walking aid is noted.
• The patient's upper trunk is exposed allowing the examiner to inspect the shoulders, scapulae, spine, clavicles, and chest wall.
• Look at the front, side, and back of the patient.
• Look for surgical or traumatic scars, lumps or bumps, abnormal posture or asymmetry, muscle wasting, and skin conditions.

Feel

• Palpation helps identify potential sources of pain:
• Cervical and thoracic spine with paraspinal muscles.
• Peri-scapular and shoulder muscles for tender spots.
• Sterno-clavicular joint.
• Acromio-clavicular joint.
• Anterior-lateral part of subacromial space.
• Bicipital groove.
• Anterior capsule.
• Coracoid.
• Posterior capsule.

Move

• Movement can be described as active when performed by the patient or passive when performed by the examiner.
• The patient performs a movement to the extent achievable.
• The examiner then tries to push the arm further in the specified direction.
• Under normal conditions most motion is achievable actively; the amount of passive motion may exceed active range only in certain disorders.
• When examining active motion, the examiner may instruct verbally and demonstrate using own arms.

Shoulder Movements Assessed

• Forward elevation.
• Abduction.
• External rotation with the elbow flexed 90° and apposed to the trunk.
• External rotation with the arm in 90° abduction and the elbow flexed 90°.
• Internal rotation.
• Motion can be described quantitatively as a range in degrees.
• Motion of internal rotation may be described by how far the extended thumb can reach on the back.
• Motion can be qualitatively described as smooth or interrupted.
• Shoulder motion can be described as total motion (combination of glenohumeral and scapulo-thoracic).
• Alternatively, motion maybe described in terms of the individual movements occurring at the glenohumeral and scapulo-thoracic articulations.
• Examiner may rest their hands on the scapula to stabilise it and palpate when scapular motion commences.

Cervical Spine Movements Assessed

• Flexion
• Extension
• Lateral rotation
• Lateral flexion

Special Tests in Shoulder Examination

• These are clinical examination maneuvers aiming to assess the presence of specific disorders or an individual's symptoms.
• Such tests may examine muscle strength, pain provocation, apprehension provocation, instability provocation, and other symptom provocation.
• Special tests aim to isolate and specifically test one structure or group of structures at a time.
• Focus maybe testing one muscle when assessing muscle strength.
• Focus maybe testing one pain source structure when assessing pain provocation.
• Focus maybe testing one process at a time when assessing apprehension.
• Focus maybe testing one group of structures when assessing instability.
• An ideal special test has high sensitivity, to correctly identify diseased states.
• An ideal special test has high specificity, to correctly identify non-diseased states.
• Qualities of commonly used special tests in orthopaedic examinations and shoulder examination specifically have been questioned.
• Tests are often not highly sensitive or specific.

Reasons for this include

• Close anatomical relationship makes it difficult to isolate and test a single structure.
• Multiple structures sharing a common origin of innervation can cause similar pain upon provocation.
• Multiple structures with similar functions can compensate for the loss of one structure.
• A test can identify the area of origin of symptoms but not the pathology, like subacromial pain.
• The anatomic basis for certain tests may not be scientifically proven yet.
• The amount of reported symptoms may vary greatly.
• Some tests may be unreliable or can't be performed in presence of concomitant pathology.

Assessing Muscle Strength in Shoulder Examination

• Assessing muscle strength is challenging.
• It is essential to distinguish between true and apparent weakness.
• Several muscles may contribute to a motion; hence an attempt is made to isolate the action of the muscle in question during examination.
• Medical Research Council grading system grades muscle strength from 0-5.
• Grade 0 is no muscle contraction.
• Grade 1 is flicker or trace of muscle contraction.
• Grade 2 is contraction allowing movement with gravity eliminated.
• Grade 3 is contraction allowing movement against gravity.
• Grade 4 is active movement against gravity and resistance.
• Grade 5 is normal motor function.
• A simplified grading system describes three grades of muscle strength such as:
• Strong can but can maintain preposition.
• Weak but can maintain preposition
• Severely weak – cannot maintain preposition.
• Ask the patient to perform the motion actively to gauge the severity of weakness.
• Passively place the arm in the expected position.
• Ask the patient to maintain it there, and be ready to catch the arm if it's forward elevation.
• Inability to maintain position indicates a lag sign and severe weakness.
• If position retained, examine the strength, comparing to the opposite healthy shoulder where applicable.
• Achieve this by asking the patient to maintain position while applying an opposing force.

Testing Muscle Strength: Individual Muscles

Supraspinatus

Drop-Arm Sign

• Elevate the patient's arm to 90° in the scapular plane.
• Warn the patient and release the arm, staying close to catch it if needed.
• Inability to maintain the arm position suggests substantial supraspinatus weakness.

Supraspinatus Resistance Strength Test

• Patient stands with arm elevated to 90° in the scapular plane and internally rotated (thumb pointing down).
• The patient has to maintain that arm position by resisting a downward force applied by the examiner.
• An alternative is with the arm in external rotation (thumb pointing upwards).
• It is preferable for the examiner to use one or two fingers to apply force proximally to the elbow to minimize the moment arm effect.
• Test with arm in 30° of forward elevation since greater elevation may cause pain.
• With a massive supraspinatus tendon rupture (whereby arm forward elevation or abduction cannot be initiated), passively assist the arm for the first 15-30° of motion.
• The deltoid may then complete the movement where the pt may assist with the opposite arm or use their upper body to throw the arm forwards.

Infraspinatus and Teres Minor

Infraspinatus External Rotation Lag Sign

• With elbow flexed at 90° and kept by the trunk ( or elevated 20° in the scapular plane), passively externally rotate the arm to the maximum level and ask the patient to hold this position once the examiner lets go.
• The test is +ve if the patient is unable to hold the arm in the position and the arm internally rotates back towards the trunk.

Hornblower's Sign

• The patient will attempt to bring their hand to their mouth.
• Positive sign = In order to achieve this motion, the patient abducts the affected arm to raise the elbow to the same or higher than the hand level (due to lack of active external rotation of the shoulder).
• An external rotation deficit may prevent them from eating and drinking.

Infraspinatus Resistance Strength Test

• The arm position is elbow flexed at 90 degrees, with the shoulder externally rotated to 45 degrees.
• The patient will try to maintain that position, whilst the examiner applies an internal rotation force to the distal forearm.

External Rotation Strength at 90° of Abduction

• The arm position is that the patient's arm is passively elevated to 90° of abduction in the scapular plane, then the elbow is flexed to 90°.
• The patient will try to maintain the arm's external rotation, resisting an internal rotation force applied by the examiner.
• The infraspinatus and teres minor are the main external rotators of the shoulder; the teres minor may be responsible for up to 45% of the power of external rotation.
• The extent of external rotators dysfunction is determined by the external rotation lag sign and Hornblower's sign.
• External rotation lag sign positive indicates a substantial infraspinatus tear.
• Hornblower's sign positive - indicates substantial tear of infraspinatus and teres minor.

Subscapularis

Belly-Off Lag Sign

• The arm is passively brought into flexion and maximum internal rotation, with the elbow flexed 90°.
• The examiner supports the elbow elbow of the patient with one hand, presses their hand on abd, then asks the patient to maintain that position with the wrist straight as the examiner releases the hand whilst still supporting the elbow.
• The test is positive if the patient cannot maintain that position and the hand lifts off the abdomen.

Belly Press Test

• The arm is on the side of the body with the elbow flexed 90°.
• The patient will press their hand against the belly with a flexed elbow, and forearm at 90° with the trunk (internally rotating the GH joint).
• The patient will hold the arm in this position.
• The test is positive if the patient cannot maintain pressure with the wrist straight and elbow forwards.

Internal Rotation Lag Sign

• The patient puts their hand on their lower back with the back of the hand touching the lumbar region.
• The arm becomes internally rotated and extended.
• The hand is then passively lifted of the patient's back.
• The patient attempts to maintain this position.
• The sign is positive when this position can't be held and the hand drops back
• Subscapularis is the main internal rotator so helping to isolate its effects from latissimus doors and pectorals major.

Lift-Off Test

• The patient puts their hand on their lower back with the back of the hand touching the lumbar region.
• The arm is internally rotated and extended.
• The patient attempts to raise his hand off the back.
• The test is positive if the patient cannot raise the arm posteriorly off the back.
• If the patient can lift the hand, the examiner applies an anterior force to the hand, assessing muscle strength.
• The belly press test maybe easier to perform than the internal rotation lag sign and lift-off test because of pain on internal rotation of the arm or there is a restricted motion.

Rhomboids

Rhomboids Resistance Test

• Place the patient in a position facing away from the examiner.
• The patient's arms are placed in 90° abduction and slight internal rotation with the elbows in 90° flexion.
• The examiner presses on the patient's posterior aspect of the arm (just above the elbow) and gives an anterior/medial directed force, which requires by the patient is asked to resist against.

Trapezius

Shrug Test

• Have the patient shrug shoulders against examiner-applied downward force to test the upper trapezius.

Pain Provoking Tests

Subacromial Pain Provoking Tests

Painful Arc Sign

• This refers to a range of motion which brings on or worsens pain.
• The test is conducted with the patient standing, actively abduct their arm in the scapular plane until it's fully elevated and then brought back down
• A painful are felt on the lateral aspect of the upper arm (in the region of the deltoid muscle and its insertion) between 60° and 120° of elevation means a subacromial origin.
• A painful arc felt from 120° to 180° elevation, felt over the top of the shoulder means an ACJ origin.

Neer Impingement Sign

• Patient's arm is placed in the scapular plane with the thumb facing downwards (internal rotation).
• The examiner stabilises the patient's scapula and then passively elevates the patient's arm in the scapular plane until pain is reported or until full elevation is achieved.
• A positive test = pain over the anterior or lateral part of the shoulder between 60-120° of elevation.
• The same maneuver will be repeated with the patient's arm in external rotation (thumb facing upwards).

Hawkins-Kennedy Impingement Test

• The arm is passively elevated forwards to 90°, and with the elbow flexed 90°, the arm is placed into internal rotation.
• The test is positive if such internal rotation causes pain and may be repeated in various positions of the arm from 90° of pure abduction to 90° forward elevation.

ACJt Pain Provoking Tests

Cross-Body Adduction Test

• A patient is standing while the arm is passively elevated forwards to 90° and internally rotated so the forearm is parallel to the floor.
• The examiner passively adducts arm across patient's body.
• The test is positive if the patient feels pain over the ACJt.

Paxinos Sign

• The patient is sitting with the affected arm by the side.
• The examiner places one hand over the shoulder with the thumb on the posterolateral part of the acromion
• the opposite index finger is placed over the superior mid-part of the clavicle.
• The examiner applies pressure to the acromion (antero-superior direction) and to the clavicle (inferior direction).
• The test is positive if this causes or aggravates pain in the ACJt.

Labrum Tear Pain Provoking Tests

O'Brien's Test for Superior Labrum Anterior Posterior (SLAP) Tear

• The Patient is standing & has arm elevated forwards to 90° ,and placed 10–15° of adduction and full internal rotation (thumb pointing down).
• In the first maneuver, the examiner applies a downward force to the distal arm
• The patient will try to resist that force
• The test is repeated this time, the palm will face upwards in (full external rotation).
• A positive test is described as feeling/aggravating the pain during the 1st maneuver, but not feeling in the 2nd maneuver.
• Pain felt deeply in the glenohumeral joint is suggestive of labrum tear and pain felt over the ACJt is suggestive of ACJt arthropathy

Jerk Test for Posterior Labrum Tear

• Displaces humeral head posteriorly with the patient sitting, while the examiner stabilises the scapula with one hand.
• The examiner applies a posterior axial force and brings the arm into adduction.
• The test is positive for a posterior labrum lesion due to a sharp glenohumeral pain.

Kim's Test for Posterior-Inferior Labrum Tear

• The patient will sit up against the the of a chair, with their arm in : 90° of abduction and internal rotation with the elbow flexed to 90°.
• The examiner holds the patient's elbow and arm and then flexes the patients arm forwards by 45°
• The next position, also applying an axial posterior and inferior forces will move the proximal arm into adduction.
• The test is positive if this creates pain, shoulder pain clunk, or posterior slunk on the humeral head.

Long Head of Biceps Tendon Pain Provoking Tests

Speed's Test

• Elevate the arm forwards to 90° with the elbow fully extended and the forearm supinated (palm facing upwards).
• The examiner then applies is downward force to the forearm, which the patient will resist against. The test is positive if the patient experiences pain in the bicipital groove area

Yergason's Test

• The arm will be the patient's side, with the patients elbow will remain flexed at 90°
• The patient will want to maintain elbow in full supination
• Examiner will apply a pronating force. The test is positive if the patient feels pain in the bicipital groove area.

Laxity Assessment

• Hyper-laxity refers to excessive joint translation/motion.
• Glenohumeral joint: refers to movement of humeral head relative to glenoid.
• Generalised hyper-laxity: involves multiple joints.

Assessment of Shoulder Laxity

Load and Shift Testing

• Support arm at 20° abduction, 20° forward elevation, neutral rotation.
• Grasp humeral head, apply anterior stress, then posterior stress to assess translation.

Translation

• Translation may also be assessed with the arm in 90° of abduction and external rotation (tension of the intact ligaments limit.
• Humeral head translation may be described as: Moves forwards but does not sublux, Subluxes but does not dislocate, Dislocates but reduces upon removal of the distracting force, Dislocates but doesn't reduce upon removal of the distracting force.

Excessive or Increased External Rotation of the Arm

• Increased passive external rotation, opposite the normal side is suggestive of anterior laxity/ruptured subscapularis tendon occurs with the elbow flexed 90° and pressed to the patients truck.

Gageys Sign

• Test with stabilised scapula, takes arm into abduction while elbow flexed to 90 degrees and the forearm is in horizontal position.
• Abduction of the glenohumeral joint that is greater than 105° or greater by more than 20° compared to the opposite side is suggestive of inferior glenohumeral laxity

Inferior Sulcus Sign

• Arm by side in neutral position with elbow flexed at 90°, a longitudinal downwards pull is applied by the examiner on the arm. The shoulder is observed for the development of a sulcus on its lateral aspect between the acromion and humeral head.
• Inferior humeral head displacement greater than 1 cm from the acromion suggest inferiorly laxity.
• The test is done with the arm placed in 30° with external rotation to check for deficiency of the rotator interval or the superior glenohumeral ligament.

Generalised Joint Hyper

• laxity should be evaluated via Beighton Score

Presence of Beighton Score

• Passive dorsiflexion of the little finger beyond 90°
• Passive thumb opposition to the flexor aspect of the forearm
• Elbow/Knee hyperextension beyond 10° (Patient will attempt to push these as straight as possible)
• Trunk bend and touch the palms of the hands flat on the floor whilst keeping the knees straight

Assessing Shoulder Instability

Shoulder Instability Tests

• Shoulder Instability describes joint translation regardless of where it's from & their clinical symptoms.

Tests for Anterior Glenohumeral Instability

Anterior Apprehension Test

• Arm in abduction and then bring the patient into external rotation as far as possible.

Anterior Relocation/Release Test

• Arm in abduction and then externally rotated.
• The patient might experience apprehension here, posterior force on the humeral head/examiners hand will improve them
• The patient's symptoms will get aggravated by sudden release of the shoulder's posterior force.

Tests for Posterior Glenohumeral Instability

Posterior Apprehension Test

• The examiner elevates forwards their patient's arm to 90° and internally rotates the arm (using other hand to stabilise the scapula).

Jerk Test for Posterior Instability

• Stabilise the Scapula by with one hand.
• With your other, abduct the arm to 90 degrees, and internally rotate the arm to 90 degrees.
• Apply posterior axial loading and adduction to the arm
• Positive is this created palpable clunk, or click test to the humeral head.

Tests for Inferior Instability

Inferior Sulcus Test

• A longitudinal downward pull is applied to the patient's arm while the arm is in the neutral position and flex elbow flexed to 90°.
• The presence of a Sulcus created on the patient's lateral side of the acromion and humeral head means there is is an inferior instability.

Testing for abnormal motion-driven-glenohumeral instability

Test using arm motions while watching out for:

• Trunk, Neck or Spinal movements
• Scapula ( Dysrythmia (Abnormal rhythm or rotation while moving))
• Internal Rotation (Elbow extension)

Treating via correcting and/or controlling

• Opposing neck or thoracic motion
• Correcting the shoulders with the medial border
• Rotate the Scapula

Testing for abnormal muscle patterning. (Forward and backward elevating arm)

What to test for?

• Overactivity = Pectorals major/Latissimus dorsi for overactivity means a indication of muscle-based instability.
• Compensation = Patient attempts the internal/external rotation, while also pushing examiners hand with opposite force.

Hand Squeeze Test

• Used for testing muscle-based instability.
• Examiner holds and tests for posterior humeral displacement while asking to squeeze opposite arm to distract from this test.

Test by utilizing various components with the spine

• Spurling. Can be done via compression

Testing for Thoracic Outlet Syndrome

• Roos Test. Arms and hands in the position the patient flexes and opens the arm for 3 mins
• Pressure test

Adson's Test

• Inters calene entrapment.
• The patient is asked to sit with their arms straights resting on the knees. -Take a deep breath in and sustain the position, test for compression of the radial pulse.
• Elevate and turn towards to the affected side.

Wright's Test

Testing in the Pectoralis minor spaces. Perform this space by moving arm 90°/ abduction and full external rotation.

Test costoclavicular space

• Place the arm's elbow in abduction, straight while noting if the strength of the radial, and pulse is lost.

Performing Upper-limb and Tension Test

The Patient will perform these steps for the test

• The will put his arms out 90 abduction, straight elbows while their hands are faced palm down. Then they dorsiflex and then reach their ear towards the opposite shoulder, and state if they feel pain parathesia and report is there any type of indication.

Assessing Core Imbalances

• Single-leg Stance - Watch for stability and balance is maintained . Inability to do so signifies imbalances
• Single-leg Squats - Tests for weakness and or imbalances.
• Tri-planar Core - Testing sagittal, horizontal rotation from patient-driven momentum and the examiners states if there instability or imbalances are created