Special Tests for the Shoulder Exam
The physical examination of the shoulder should include a standardized exam approach as well as a series of special tests to help diagnose the cause of the patients pain. In general, a thorough physical examination will include inspection, palpation, active and passive range of motion, strength, neurovascular and special tests. The purpose of today’s post is to review some of the special tests for the shoulder exam that all members of the sports medicine team should be familiar with. We will review some of the more commonly used exam techniques but it is worth mentioning there are dozens of others that are not covered here. It is also worth noting that some of these examination techniques may overlap with more than one disease process.
Hawkins Test. Place the patient’s arm shoulder in 90 degrees of shoulder flexion. The elbow is flexed to 90 degrees and then internally rotates the arm.
The test is positive if the patient experiences pain.
Neer’s Test. The patient is seated or standing. The patients arm is brought into flexion at 90°, internal rotation with thumb pointed towards the floor. Examiner stabilizes patients scapula with one hand and applies resistance to the arm. The patient is asked to flex the arm upward against the examiners resistance. Positive test is pain
Lift off test. The patient is seated or standing. The arm is internally rotated with hand behind the small of the back on the lumbar spine. The dorsum of the hand is facing the back. The examiner places their hand on the patients and asks them to push off against their resistance. A positive test is pain or weakness pushing off the back.
Belly Press Test. Patient is seated or standing. Patient presses abdomen with palm of hand, maintaining shoulder in internal rotation. Positive test:
Pain suggests tendinopathy. Elbow drops back (does not remain in front of trunk) suggests complete tear.
Empty Can Test. Patient can be seated or standing. Arm raised/ or abducted to 90 degrees and arms 30-45 degrees from midline. Shoulder internally rotated, thumbs pointed to floor. Physician applies downward force at the wrist/forearm while the patient resists. A positive test is pain or weakness.
Drop Arm Test. The patient is either seated or standing. The examiner passively raises the arm to 90°. The patient slowly lowers the arm towards their side in the same plane with palm down. A positive test is pain, sudden drop of arm or inability to smoothly control the descent.
Hornblower’s Sign. The patient is seated or standing. The examiner passively flexes elbow to 90°, abducts arm to 90°. The patient is asked to hold the arm in this position. A positive test is the arm falls into internal rotation and patient unable to maintain position.
Resisted External Rotation Test. The patient is seated or standing. Arms at side, elbows flexed 90°. Important to keep elbow tucked against chest wall. The patient externally rotates shoulders against resistance. A positive test is pain or weakness.
Yergason’s Test. The patient is seated, examiner stands in front of patient. The elbow is flexed to 90°, forearm is pronated. Patient is instructed to supinate forearm while examiner resists. A positive test is pain localizing to bicipital groove.
Speed’s Test. The patient is standing or seated. Arms are flexed forward to 90°, arms supinated. The patient is asked to bring the arm into further flexion above 90° against examiners resistance. The arm is then switched to pronation and the resisted flexion is repeated. A positive test is pain with flexion especially in pronation suggests biceps etiology. Vague shoulder pain may suggest SLAP tear
Resisted AC Joint Extension Test. The patient is seated, examiner behind patient. Shoulder flexed to 90°, internally rotated, elbow flexed to 90°. The examiner then places hand on lateral elbow and asks patient to abduct against resistance. A positive test is pain at the AC joint.
Crossover Test. The patient is seated. Place one hand on the posterior aspect of the patient’s shoulder, the other hand on the patient’s elbow. Stabilize the patient’s trunk and then passively and maximally horizontally adducts the test shoulder. Positive test is anterior, superior or posterior shoulder pain
Crank Test. The patient is seated with the examiner behind the patient. Examiner places distal hand on subjects elbow and proximal hand on subjects humerus. Examiner passively abducts shoulder to 160°. The hand on the elbow now places an axial load on the humerus. The proximal hand internally and externally rotates the humerus. A positive test is reproduction of symptoms ± clicking
Obrien’s Test. The patient is seated or standing, shoulder flexed to 90°. Patient internally rotates the shoulder and pronates the forearm. The instructor then asks the patient to apply an upward force against instructor resistance. The patient then externally rotates the shoulder and supinates the forearm. The instructor then applies an upward force again against resistance. A positive test is pain or clicking when in pronated position that improves in supination position
Wright’s Test. The patient is seated. Examiner passively brings affected limb into abduction and external rotation to 90°. Elbow flexed no more than 45°, arm held in this position for 1 minute. The patient can be asked to take a deep breath. Monitor radial pulse and patients symptoms. Now the examiner repeats the same test with the arm in hyperabduction over the patients head. A positive Test is a decrease in radial pulse or reproduction of patients symptoms
Passive Compression Test. The patient is in the lateral decubitus position, laying on the unaffected side. The examiner places the arm in 30 degrees of abduction and then passively externally rotates the arm. At the same time, they apply an axial load into the joint and slowly extend the shoulder. A positive test is pain. Additionally, injecting local anesthetic into the joint and repeating the exam can increase diagnostic accuracy
|↑1||Image courtesy of uptodate.com, “Hawkins Kennedy test for shoulder impingement”|
|↑2||Image courtesy of stanfordmedicine25.stanford.edu, “Hawkins Kennedy test for shoulder impingement”|
|↑3||Clark, Russell J., et al. “Isolated traumatic rupture of the subscapularis tendon.” The Journal of the American Board of Family Practice 15.4 (2002): 304-308.|
|↑4||Lee, Julia, Dave R. Shukla, and Joaquín Sánchez-Sotelo. “Subscapularis tears: hidden and forgotten no more.” JSES Open Access 2.1 (2018): 74-83.|
|↑5||Image courtesy of mobilephysiotherapyclinic.in. “Empty can test of shoulder”|
|↑6||Bak, Klaus, et al. “The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 26.6 (2010): 734-742.|
|↑7||Itoi, Eiji. “Rotator cuff tear: physical examination and conservative treatment.” Journal of Orthopaedic Science 18.2 (2013): 197-204.|
|↑8||Image courtesy of geekymedics.com, “shoulder examination”|
|↑9||Image courtesy of healthjade.net, “Yergason’s Test”|
|↑10||Image courtesy of uptodate.com, “Speeds test for biceps tendon”|
|↑11||Image courtesy of youtube.com, “AC Resisted Extension Test”|
|↑12||Sports Medicine for the Emergency Physician A Practical Handbook , pp. 2 – 56 DOI: https://doi.org/10.1017/CBO97813 6084328.002[Opens in a new window]. Publisher: Cambridge University Press. Print publication year: 2016|
|↑13||Image courtesy of uptodate.com, “Crank test for SLAP lesion”|
|↑14||Owen, J. Matthew, et al. “Reinterpretation of O’Brien test in posterior labral tears of the shoulder.” International Journal of Shoulder Surgery 9.1 (2015): 6.|
|↑15||Kim YS, Kim JM, Ha KY, Choy S, Joo MW, Chung YG. The passive compression test: a new clinical test for superior labral tears of the shoulder. Am J Sports Med. 2007 Sep;35(9):1489-94. doi: 10.1177/0363546507301884. Epub 2007 May 3. PMID: 17478654.|
|↑16||Panagiotopoulos, Andreas Christos, and Ian Martyn Crowther. “Scapular dyskinesia, the forgotten culprit of shoulder pain and how to rehabilitate.” SICOT-J 5 (2019).|