Table 17: Provocative tests performed in a neutral shoulder position, i.e. the arm is at the patient s side.

Transcription

1 Page 1 of 1 Table 17: Provocative tests performed in a neutral shoulder position, i.e. the arm is at the patient s side. Description Click Image Positive Indicator Study Painful Arc of Abduction Also reported as: Painful Arc Painful Arc Sign The patient is seated or standing with their shoulder adducted to their trunk in external rotation (i.e. arm relaxed by their side with their forearm supinated). The patient then actively abducts their shoulder to its end range of motion and then slowly lowers their arm back to the side of their body through the same arc. 2 pain or painful catching between 60 and 120 of elevation. Calis et al. (2000) Kelly and Brittle (2010) Michener et al. (2009) Nanda et al. (2008) Park et al. (2005) Paxinos Sign The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. The examiner places their hand over the patient s shoulder such that their thumb rests under the posterolateral aspect of the acromion and the index and long fingers of the examiner s same or other hand are placed superior to the midpart of the patient s ipsilateral clavicle. The examiner then applies an anterosuperior directed force to the clavicle with their thumb and an inferiorly directed force to the midpart of the clavicular shaft with their index and long fingers. 3 pain or an increase in pain in the region of the acromioclavicular joint. Walton et al. (2004) Yergason Also reported as: Supination Sign Typical The patient is seated or standing with their elbow flexed to 90, their shoulder adducted to their trunk in neutral rotation, and their forearm pronated. The patient is asked to actively supinate their forearm while the examiner holds the patient's wrist and resists the motion. 4 a recreation of their pain, or anterior pain in their biceps region/bicipital groove. Calis et al. (2000) Holtby and Razmjou (2004) Nanda et al. (2008) Oh et al. (2008) Ostor et al. (2004) Parentis et al. (2006) With Biceps Palpation The examiner performs a typical Yergason test with the patient s forearm in neutral rotation while palpating the biceps long head tendon 5 pain in their biceps region. Guanche and Jones (2003)

2 Page 1 of 1 Table 18: Provocative tests performed in a hand over hip position. Description Click Image Positive Indicator Study Anterior Slide Also reported as: Kibler The patient is seated or standing with their hand on their hip and their thumb pointing posteriorly. The examiner (standing behind the patient) places one hand placed across the top of the patient s shoulder, with the last segment of their index finger extending over the anterior aspect of the acromion at the glenohumeral joint, and stabilizes the scapula. Using their other hand, the examiner applies an anterosuperior directed axial force to the patient s humerus via the elbow and upper arm. The patient is asked to push back against this force. 6 pain localized deep or to the front of their shoulder under the examiner s hand, and/or a pop or click, and/or a reproduction of symptoms that occur during overhead activity. Kibler (1995) Oh et al. (2008) Parentis et al. (2006) Walsworth et al. (2008)

3 Page 1 of 5 Table 19: Provocative tests performed in shoulder abduction. Click Description Image Positive Indicator Study Anterior Drawer Held Between 60 to 80 of Shoulder Abduction The patient is supine with their shoulder just over the edge of the examination table. With one hand holding the patient's wrist and their other hand holding the patient s upper arm, the examiner passively abducts the patient s shoulder to 60 to 80 with 0 of rotation and the elbow flexed to 90. The examiner then applies a slight axial force to the arm, followed by an anteriorly directed force to translate the humeral head anterior over the glenoid rim. The patient is then asked if their symptoms of instability are reproduced. The amount of translation of the humeral head over the glenoid is measured to classify laxity. The examiner notes if the patient would not relax for the test because of muscle contraction or pain. 7 pain or a reproduction of instability symptoms. Farber et al. (2006) Held Between 80 to 120 of Shoulder Abduction The patient is supine with their hand placed over the examiner s axilla. With one hand over the patient s coracoid process, the examiner stabilizes the patient's scapula. The examiner's other hand holds the patient's humerus. The patient s shoulder is then abducted between 80 and 120 with 0 to 20 of forward flexion, and 0 to 30 of external rotation. The examiner then applies an anteriorly directed force to the patient's humerus to translate the humeral head anteriorly. The maneuver is repeated on the patient s other shoulder. 8 The patient experienced apprehension or increased translation of the humeral head compared with their other shoulder. van Kempen et al. (2013) Biceps Tension Also reported as: Full Can The patient is seated or standing with their arm abducted to 90 and externally rotated (i.e. their forearm supinated with their thumb pointing posterior). The examiner applies a downward force to the patient's arm while the patient resists. 9 pain, painful clicking, or demonstrates weakness. Field and Savoie (1993) Kelly and Brittle (2010) Kim, Ha, Han (1999)

4 Page 2 of 5 Compression Rotation Supine Crank The patient is supine with their arm abducted to 90 and their elbow flexed to 90. The examiner then applies an axial force to the patient s humerus via the elbow as the examiner repeatedly internally and externally rotates the patient's shoulder. The patient is supine with their shoulder maximally abducted to 160 and their elbow flexed to 90. The examiner applies an axial load to the patient s glenohumeral joint with one hand (via the elbow) as their other hand internally and externally rotates the patient s humerus (via the wrist or forearm). 10 a click or pain with compression. McFarland, Kim and Savino (2002) Oh et al. (2008) 11 Guanche and Jones (2003) Liu et al. (1996) Myers, Zemanovic and Andrews (2005) Stetson and Templin (2002) Walsworth et al. (2008) Cadogan et al. (2011) Liu, Henry and Nuccion (1996) Minori et al. (1999) Myers, Zemanovic and Andrews (2005) Stetson and Templin (2002) Walsworth et al. (2008) Upright (Held in 160 of Shoulder Abduction) The patient is seated or standing with their shoulder maximally abducted to 160 and their elbow flexed to 90. The examiner applies an axial load to the patient s glenohumeral joint with one hand (via the elbow) as their other hand internally and externally rotates the patient s humerus (via the wrist or forearm). 12 Upright (Held in 160 of Shoulder Flexion) The patient is seated or standing with their shoulder maximally flexed to 160 and their elbow flexed to 90. The examiner applies an axial load to the patient s glenohumeral joint with one hand (via the elbow) as their other hand internally and externally rotates the humerus (via the wrist or forearm). 13 pain, mechanical clicking, catching, or a reproduction of their activity-related symptoms. Parentis et al. (2006)

5 Page 3 of 5 Dynamic Labral Shear Also reported as: O Driscoll s The patient is seated, standing or supine with their elbow flexed to 90 and their shoulder adducted to their trunk in neutral rotation. The examiner holds the patient's elbow with one hand and the acromion with their other hand. The examiner then externally rotates the patient's shoulder to 90 and then abducts the patient's shoulder 90 (If supine, the patient s arm should be off the side of the table, allowing gravity to act on it). The examiner then further abducts the patient's shoulder from 90 to pain (deep, and/or posterior), and/or painful clicking in the 90 to 120 abduction range. Cook et al. (2012) Jerk The patient is seated with their elbow flexed to approximately 80. The examiner holds the patient's scapula with one hand and the patient's elbow with their other hand. The examiner then places the patient's shoulder in 90 of abduction. The examiner then applies a simultaneous axial and shoulder flexion force (in the transverse plane) to the patient's humerus via the elbow. 15 a sharp pain with or without posterior clunk or click. Kim et al. (2005) Jobe Also reported as: Jobe Supraspinatus Jobe Sign Supraspinatus Supraspinatus Muscle Strength Typical The patient is seated or standing with their arm abducted to 90 and internally rotated (i.e. their thumb pointing down). The examiner applies a downward force to the patient's arm while the patient resists. Some authors perform the maneuver on both shoulders for comparison. 16 pain, a reproduction of symptoms, or demonstrates weakness with a shoulder that gives way to the examiner s downward force application or compared to their opposite shoulder. Fowler, Horsley and Rolf (2010) Gerber and Krushell (1991) Hertel et al. (1996) Jobe and Jobe (1983) Johannsson and Ivarson (2009) Kelly and Brittle (2010) Nanda et al. (2008) Park et al. (2005)

6 Page 4 of 5 Empty Can Empty Can For Supraspinatus Held Between 30 to 40 of Shoulder Flexion The examiner performs a typical Jobe test with the patient s shoulder flexed between 30 and Jobe and Moynes (1982) Michener et al. (2009) Ostor et al. (2004) Held Between 60 to 80 of Shoulder Abduction The examiner performs a typical Jobe test with the patient s shoulder abducted between 60 and Nanda et al. (2008) Gilcreest Also reported as: Palm-Up The patient is seated or standing with a 5lbs weight (dumbbell) held in each hand. The patient maximally abducts their shoulder with their elbows extended. The patient then maximally externally rotates their shoulders. The examiner places their fingers over the long head of the biceps. The patient is then asked to lower their shoulders through 90 and 100 of abduction. 19 pain (localized to the shoulder and bicipital groove) and a click. Fowler, Horsley and Rolf (2010) Gilcreest (1936) Kim The patient is seated against the back of a chair with their elbow flexed to 90. The examiner holds the patient s upper arm with one hand and the elbow/proximal forearm with their other hand. The examiner then places the patient's shoulder in 90 of abduction. The examiner then applies an axial force to the humerus via the elbow while using combined shoulder flexion and abduction to elevate the arm (to approximately 135 ). The examiner also applies an additional simultaneous inferior and posterior force to the upper arm with their other hand. 20 a sudden onset of posterior shoulder pain. Cadogan et al. (2011) Kim et al. (2005)

7 Page 5 of 5 Labral Tension The patient is supine with their shoulder placed in 120 of abduction, their elbow flexed approximately 80, and their forearm in neutral rotation. The examiner then places the shoulder in maximal external rotation. In this position, the patient is asked to supinate their forearm while the examiner holds their hand and resists the motion. 21 increased pain with resisted supination. Cook et al. (2012) Pain Provocation The patient is seated or standing with their elbow flexed to 90, and their shoulder abducted between 90 to 100. The patient s forearm is then maximally pronated. The examiner then holds the patient's wrist with one hand and places their other hand over the acromion. The examiner then externally rotates the shoulder to 90. The maneuver is repeated with the patient s forearm maximally supinated. The patient is then asked which forearm position produced more severe pain (pronation or supination?). 22 pain only when the forearm is in the pronated position or when pain is more severe in the pronated position when compared to the supinated position. Mimori et al. (1999) Parentis et al. (2006) Resisted Isometric Abduction The patient is seated or standing with their arm abducted to 90, and in neutral rotation (i.e. their thumb pointing forward with their elbow extended). The examiner applies an internal rotary force to the patient's arm while the patient resists. 23 pain or demonstrates weakness. Kelly and Brittle (2010) Resisted Supination External Rotation The patient is supine with their scapula near the edge of the examination table. The examiner stands at the patient s side and holds the patient's elbow and hand to support their arm. The patient s shoulder is then abducted to 90 with the elbow flexed between 65 and 70, and their forearm in neutral or slight pronation. The patient is asked to supinate their forearm with a maximal effort while the examiner resists the motion as they simultaneously externally rotate the patient s shoulder to its end range of motion. 24 anterior or deep shoulder pain, clicking or catching in their shoulder, or a reproduction of symptoms that occur during overhead activities (i.e. throwing) while their shoulder is at maximum external rotation. Myers, Zemanovic and Andrews (2005)

8 Page 1 of 4 Table 20: Provocative tests performed in shoulder flexion. Description Click Image Positive Indicator Study Active Compression Also reported as: O'Brien O'Brien Sign Flexion-Adduction The patient is seated or standing with their shoulder flexed to 90 and their elbow in full extension. The patient then adducted their arm between 10 and 15. The patient s shoulder is then internally rotated (i.e. their thumb pointing down). The examiner (standing behind the patient) then applies a uniform downward force to the patient s arm while the patient resists. Any pain elicited by this maneuver is noted (Pain on top or "inside" of the shoulder). The patient s arm is then placed in the same position but this time the shoulder is externally rotated (i.e. their thumb pointing up), and the maneuver was repeated. 25 pain with the first maneuver (internal rotation) which is reduced or eliminated with the second maneuver (external rotation). Pain localized to the acromioclavicular joint or "on top" of the patient s shoulder is an indicator of acromioclavicular joint pathology. Pain/Clicking localized to the patient s glenohumeral joint, deep, or inside" their shoulder is an indicator of glenoid labral pathology (i.e. superior labral from anterior to posterior or SLAP lesions). Cadogan et al. (2011) Cook et al. (2012) Fowler, Horsley and Rolf (2010) Guanche and Jones (2003) McFarland, Kim and Savino (2002) Myers, Zemanovic and Andrews (2005) O'Brien et al. (1998) Oh et al. (2008) Parentis et al. (2006) Stetson and Templin (2002) Walsworth et al. (2008) Walton et al. (2004)

9 Page 2 of 4 Hawkins and Kennedy Impingement Also reported as: Hawkins and Kennedy Hawkins Hawkins Impingement Sign Hawkins and Kennedy Impingement Sign Typical Held in 45 of Transverse Shoulder Extension The patient is seated or standing with their elbow and shoulder flexed to 90. The examiner then rotates the patient's shoulder internally with one hand while supporting the elbow with their other hand. The examiner performs a typical Hawkins and Kennedy Impingement test with the patient s shoulder extended 45 in the transverse plane. 26 pain or a reproduction of their symptoms. Cadogan et al. (2011) Calis et al. (2000) Fowler, Horsley and Rolf (2010) Hawkins and Kennedy (1980) Johannsson and Ivarson (2009) Kelly and Brittle (2010) MacDonald, Clark and Sutherland (2000) Michener et al. (2009) Nanda et al. (2008) Parentis et al (2006) Park et al. (2005) Toprak et al. (2013) 27 Ostor et al. (2004) Neer Impingement Sign Also reported as: Neer Sign Neer Typical With Internal Rotation The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. The examiner applies a downward force to the patient s acromion to fixate and prevent thoracoscapular movements with one hand and lifts the patient s arm in shoulder flexion with their other hand until the patient reports pain or until full elevation is reached. The examiner performs a typical Neer impingement sign with internal rotation of the shoulder during shoulder flexion pain in the anterior, superior or lateral part of their shoulder, or a reproduction of their symptoms. MacDonald, Clark and Sutherland (2000) Michener et al. (2009) Neer (1983) Parentis et al. (2006) Park et al. (2005) Johannsson and Ivarson (2009) Toprak et al. (2013)

10 Page 3 of 4 Using Abduction The examiner performs a typical Neer impingement sign, but uses shoulder abduction to elevate the patient s arm instead of shoulder flexion. 30 Kelly and Brittle (2010) Using Flexion/Abd uction The examiner performs a typical Neer impingement sign, but uses combined shoulder flexion and abduction to elevate the patient s arm instead of pure shoulder flexion. 31 Calis et al. (2000) Nanda et al. (2008) Patte Maneuver Typical The patient is seated or standing with their elbow and shoulder flexed to 90. The patient s shoulder is then internally rotated 90. The examiner applies a downward force to the patient s acromion to fixate and prevent thoracoscapular movements. The patient is then asked to actively externally rotate the shoulder while the examiner resists the motion. 32 pain or a reproduction of their symptoms. Johannsson and Ivarson (2009) Speed Typical Held in 60 of Shoulder Flexion The patient is seated or standing with their elbow fully extended and their forearm supinated. The patient then flexes their shoulder to 90. The examiner then applies a downward force to the patient s arm and the patient is asked to resist. The examiner performs a typical Speed test with the patient s shoulder flexed to pain (localized in their anterior shoulder/bicipital groove region). Bennett (1998) Guanche and Jones (2003) Holtby and Razmjou (2004) Oh et al. (2008) Parentis et al. (2006) Park et al. (2005) Calis et al. (2000) Nanda et al. (2008) Held in 30 of Shoulder Flexion The examiner performs a typical Speed test with the patient s shoulder flexed to Ostor et al. (2004)

11 Page 4 of 4 Moving through 0 to 60 of Shoulder Flexion The patient is seated or standing with their elbow fully extended and their forearm supinated. The patient then flexes their shoulder from 0 to 60 while the examiner resists the motion. 36 Cook et al. (2012)

12 Page 1 of 2 Table 21: Provocative tests performed in shoulder adduction. Description Extended Elbow Cross-Body Adduction Also reported as: Horizontal Adduction Acromioclavicular Joint Flexed Elbow Also reported as: Elevation Front Adduction SLAPrehension Typical The patient is seated or standing with their shoulder flexed 90. The examiner holds the patient's arm and adducts the patient's shoulder to bring the patient's arm across their body. The patient is seated or standing with their shoulder flexed to 90. The examiner then forces the patient s shoulder into horizontal adduction (adducting the shoulder across the patient s chest to their opposite shoulder in the transvers plane) while the patient's elbow is flexed. The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. The examiner then forces the patient s shoulder into adduction (across the patient s body towards their opposite hip in the frontal plane). The patient is seated or standing with their elbow extended. The patient s shoulder is internally rotated (i.e. their forearm is pronated) and then horizontally adducted and flexed across their chest. The horizontal shoulder adduction/flexion across the patient s chest is repeated but this time the patient s forearm is supinated. Click Image Positive Indicator Study 37 pain in their shoulder. Park et al. (2005) Calis et al. (2000) Ostor et al. (2004) 38 pain (at the acromioclavicular joint). Ostor et al. (2004) pain referable to their bicipital groove or "SLAPrehension" with their pronated hand (an audible or palpable click may be observed) and relief of pain when the test is repeated with a supinated hand. Berg and Ciullo (1998)

13 Page 2 of 2 Whipple Typical The patient is seated or standing with their shoulder flexed to 90. The patient then adducts their shoulder until their hand is opposite their other shoulder. The examiner then applies a downward force to the patient's arm while the patient resists. 41 pain in their shoulder or down their arm. Oh et al. (2008)

14 Page 1 of 4 Table 22: Provocative tests performed in an apprehension position. Description Click Image Positive Indicator Study Apprehension Also reported as: Crank Fulcrum Feagin Maneuver Anterior Apprehension Maneuver Typical Anterior Apprehens ion (Supine) Also reported as: Augmentat ion The patient is supine with their glenohumeral joint at the edge of the examination table with their scapula supported by the table. The examiner holds the patient's wrist with one hand while the examiner s other hand is placed over the patient s humeral head. The patient s shoulder is then placed in 90 of abduction and maximal external rotation with their elbow flexed to 90. The examiner uses their knee to support the patient's elbow (preventing extension of the shoulder). The patient s shoulder is progressively externally rotated until the patient can no longer tolerate further rotation (point of apprehension). The degree of external rotation is recorded. If the response is pain, the patient is asked to localize the pain to the posterior, superior, anterior, or lateral aspect of their shoulder. The examiner performs a typical apprehension test with an anterior and external rotation force to the shoulder until the patient can no longer tolerate further rotation (point of apprehension) The patient experiences pain, apprehension (that their shoulder will dislocate), or instability. Guanche and Jones (2003) Lo et al. (2004) Tzannes et al. (2004) Oh et al. (2008) Tzannes et al. (2004) van Kempen et al. (2013)

15 Page 2 of 4 Anterior Apprehens ion (Upright) Modified Apprehens ion The patient is seated or standing. The examiner stands behind the patient and holds the patient's wrist with on hand while their other hand is placed over the patient s humeral head. The patient s shoulder is then placed in 90 of abduction and maximal external rotation with their elbow flexed to 90. The examiner then applies an anterior force to the patient s humeral head until the patient can no longer tolerate further rotation (point of apprehension). The patient is standing with both of their shoulders concurrently placed in approximately 90 of abduction, 90 of elbow flexion and 90 of external rotation. 44 Liu et al. (1996) 45 Farber et al. (2006) Biceps Load Also reported as: Biceps Load of Kim Typical Biceps Load II Also reported as: Kim II The examiner performs a typical apprehension test to place the patient's shoulder in a position of apprehension (or maximal external rotation) with the examiner supporting the patient's elbow with their hand, and the patient's forearm is supinated. The patient is then asked to flex their elbow while the examiner resists the flexion with their other hand. The direction of the examiner s resistive force should be in the same plane of motion as the patient s elbow flexion so as not to change the degree of abduction and rotation of the patient s shoulder. The patient is then asked if and/or how their apprehension has changed. The examiner performs a typical biceps load test with the patient's shoulder abducted to The patient experiences no change in apprehension or an increase in pain. The patient experiences pain during the resisted elbow flexion or an increase in pain with resisted elbow flexion regardless of the degree of pain before the elbow flexion maneuver. Kim, Ha and Han (1999) Cook et al. (2012) Kim et al. (2001) Oh et al. (2008)

16 Page 3 of 4 Release Also reported as: Surprise Jobe Relocation Typical Anterior Release The examiner performs a typical relocation test (see below) to place the patient's shoulder in a position of apprehension relief. Once in this position, the examiner suddenly releases the force applied to the patient s humeral head (while maintaining the patient s arm in the position of apprehension). The examiner performs a typical anterior relocation test (see below) to place the patient's shoulder in a position of apprehension relief. Once in this position, the examiner suddenly releases the force applied to the patient s humeral head (while maintaining the patient s arm in the position of apprehension). 48 The patient experiences a sudden return of pain and/or apprehension (that their shoulder will dislocate) Guanche and Jones (2003) Lo et al. (2004) Tzannes et al. (2004) van Kempen et al. (2013) Relocation Also reported as: Apprehension- Relocation Jobe Relocation Typical Anterior Relocation (Supine) Anterior Relocation (Supine, 110 of Abduction) The examiner performs a typical apprehension test to place the patient's shoulder in a position of apprehension. The examiner then applies a posteriorly directed force to the anterior aspect of the patient s humeral head (depressing it) while the patient s shoulder is being externally rotated. The examiner performs a supine anterior apprehension test to place the patient's shoulder in a position of apprehension. The examiner then applies a posteriorly directed force to the anterior aspect of the patient s humeral head (depressing it) while the patient s shoulder is being externally rotated. The examiner performs a supine anterior apprehension test with the patient s shoulder abducted to 110 to place the patient's shoulder in a position of apprehension. The examiner then applies a posteriorly directed force to the anterior aspect of the patient s humeral head (depressing it) while the patient s shoulder is being externally rotated The patient experiences diminution of pain and/or apprehension with the posteriorly directed force. Farber et al. (2006) Fowler, Horsley and Rolf (2010) Lo et al. (2004) Speer et al. (1994) Tzannes et al. (2004) Oh et al. (2008) Parentis et al. (2006) Speer et al. (1994) van Kempen et al. (2013) 50 Parentis et al. (2006)

17 Page 4 of 4 Anterior Relocation (Supine, Held in 120 of Shoulder Abduction) Anterior Relocation (Upright) The examiner performs a supine anterior apprehension test with the patient s shoulder abducted to 120 to place the patient's shoulder in a position of apprehension. The examiner then applies a posteriorly directed force to the anterior aspect of the patient s humeral head (depressing it) while the patient s shoulder is being externally rotated. The examiner performs an upright anterior apprehension test to place the seated or standing patient's shoulder in a position of apprehension. The examiner then applies a posteriorly directed force to the anterior aspect of the patient s humeral head (depressing it) while the patient s shoulder is being externally rotated. 50 Parentis et al. (2006) 51 Liu et al. (1996)

18 Page 1 of 3 Table 23: Strength and lag tests performed in a neutral shoulder position, i.e. the arm is at the patient s side. Description Click Image Positive Indicator Study Abduction Initiation The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. The patient is asked to abduct their arm while the examiner applies a force to resist the motion. The procedure is conducted with both of the patient s arms and weakness in their injured arm as compared to their uninjured arm is noted. 52 The patient demonstrates weakness in their injured arm when compared to their uninjured arm. Nanda et al. (2008) Belly-Off Sign The patient is seated or standing with their elbow supported by the examiner. With their other hand, the examiner passively flexes the patient s elbow and brings the patient's shoulder into maximum internal rotation by placing the supinated palm of the patient's hand onto their abdomen. The patient is then asked to keep the wrist straight and actively maintain the position of internal rotation as the examiner releases the patient s wrist. 53 The patient demonstrates an inability to maintain the maximal internal rotation position and a lag occurs, lifting the patient's hand off their abdomen. Scheibel et al. (2005)

19 Page 2 of 3 Belly-Press Also reported as: Napoleon Napoleon Sign Typical Instrumented The patient is seated or standing with their elbow flexed to 90 and their shoulder adducted to their trunk in neutral rotation. The patient actively presses their palm into their abdomen (places their hand on their belly in the same position in which Napoleon Bonaparte held his hand for portraits) by internally rotating their shoulder. The examiner performs a typical belly press test with the active internal rotation force produced by the patient quantified (i.e. by means of a digital tensiometer attached to a padded sling held perpendicular to the patient s forearm or a hand-held dynamometer stabilized against the patient s abdomen). The patient is asked to maintain a maximal internal rotation force for 5-7 seconds to obtain a static measurement (in kg). The test is also performed on the patient s opposite (normal) side for a comparison The patient demonstrates and inability to push their hand against their stomach with their wrist straight, or their wrist is flexed between 60 and 90 with their shoulder extended (resulting in their elbow dropping behind their body). A wrist flexed between 30 and 60 is and intermediate test, which is also considered positive. The patient demonstrates weakness in resisted internal rotation compared with their opposite side (>30% force deficit, based on the mean or peak force from 3 trials interspersed with a 30s rest break) or the force was produced by means of elbow or shoulder extension and not active internal rotation. Barth, Burkhart and De Beer (2006) Scheibel et al. (2005) Barth, Burkhart and De Beer (2006) Cadogan et al. (2011)

20 Page 3 of 3 Dropping Sign Also reported as: External Rotation with the Arm by the Side The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand holding the patient's elbow and their other hand holding the patient s wrist, the examiner passively places the patient s elbow in 90 of flexion and the shoulder in 45 of external rotation. The patient is then asked to rotate externally against resistance. The patient s strength is then graded according to the Medical Research Council (MRC) scale. 56 The patient demonstrates an inability to maintain the externally rotated position and their arm drops back to the neutral position. Walch et al. (1998) Infraspinatus Muscle Strength Also reported as: Infraspinatus Resisted External Rotation for Infraspinatus Resisted External Rotation Resisted Isometric External Rotation External Rotation Resistance The patient is seated or standing with their elbow flexed to 90 and their shoulder adducted to their trunk in neutral rotation (between 0 and 20 of external rotation). The examiner then applies an internal rotation force to the patient s forearm while the patient resists. Some authors perform the maneuver on both shoulders for comparison. 57 The patient demonstrates and inability to maintain the neutral rotation position with a shoulder that gives way due to weakness or pain, weakness when compared to their other shoulder, or the patient experiences pain. Kelly and Brittle (2010) Michener et al. (2009) Nanda et al. (2008) Ostor et al. (2004) Park et al. (2005)

21 Page 1 of 1 Table 24: Strength and lag tests performed in a hand over the lumbar region position. Description Click Image Positive Indicator Study Gerber Lift-Off Also reported as: Subscapularis Strength Lift-Off Sign Lift-Off Typical Resisted Internal Rotation The patient is seated or standing. The patient or examiner abducts and extends the patient s shoulder. The patient s elbow is then flexed to place their hand (with the palm facing posteriorly) behind their back at the level of the lumbar spine. The patient is then asked to actively lift their hand off the lower back. The examiner performs a typical lift-off test, but resists the internal rotation of the patient s shoulder The patient demonstrates and inability to internally rotate their shoulder, lifting their hand posteriorly off of their lower back, or they performed the lifting maneuver by extending their elbow or shoulder. pain or demonstrates weakness. Barth, Burkhart and De Beer (2006) Fowler, Horsley and Rolf (2010) Gerber and Krushell (1991) Hertel et al. (1996) Scheibel et al. (2005) Nanda et al. (2008) Ostor et al. (2004)

22 Page 1 of 3 Table 25: Strength and lag tests performed in in shoulder abduction. Description Click Image Positive Indicator Study Drop-Arm Also reported as: Drop-Arm Sign Typical Examiner Applies a Downward Force The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand holding the patient's elbow and their other hand holding the patient s wrist, the examiner passively abducts the patient s shoulder to 90 (or the patient actively abducts their shoulder). The patient is then asked to slowly lower (adduct) their arm to their side. The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand holding the patient's elbow and their other hand holding the patient s wrist, the examiner passively abducts the patient s shoulder to 90. The examiner then applies a downward force to adduct the shoulder while the patient resists The patient demonstrates and inability to slowly lower their arm (i.e. their arm drops), or experiences severe pain when slowly returning their arm to their side. The patient demonstrates an inability to maintain the abducted position. Calis et al. (2000) Nanda et al. (2008) Park et al. (2005) Cadogan et al. (2011) Ostor et al. (2004) Drop Sign The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand holding the patient's elbow and their other hand holding the patient s wrist, the examiner passively abducts the patient s shoulder to 90, flexes the elbow to 90, and externally rotates the shoulder to near maximal rotation. The patient is asked to actively maintain this position as the examiner releases the patient s wrist while supporting the patient s elbow. 62 The patient demonstrates an inability maintain the maximal externally rotated position (i.e. a lag of 5 or more) Hertel et al. (1996) Miller, Forrester and Lewis (2008)

23 Page 2 of 3 Typical The patient is seated or standing with their elbow flexed to 90, their shoulder flexed to 90 and internally rotated to 90. The patient is then asked to externally rotate their shoulder and touch their lips. 63 The patient demonstrates an inability to touch their lips without shoulder abduction. Horn Blower's Sign External Rotation at 90 of abduction The patient is seated or standing with their elbow flexed to 90, their shoulder abducted to 90 and maximally externally rotated. The examiner places one hand on the patient's elbow to support the arm and their other hand over the dorsum of the patient's hand. The patient is then asked to externally rotate their shoulder while the examiner resists the motion. 64 The patient demonstrates weakness or an inability to externally rotate their shoulder. Walch et al. (1998) External Rotation Lag Sign The patient is seated or standing. The examiner passively places the patient's shoulder in 20 of abduction with one hand holding the patient s elbow. Using their other hand to hold the patient's wrist, the examiner passively flexes the patient s elbow to 90, and externally rotates the shoulder to near maximal external rotation (i.e., maximum external rotation minus 5 to avoid elastic recoil in the shoulder). The patient is then asked to actively maintain the position of external rotation as the examiner releases the patient s wrist while maintaining support of the patient's elbow. Lags are recorded to the nearest The patient demonstrates an inability maintain the maximal externally rotated position (i.e. a lag of 5 or more) Hertel et al. (1996) Miller, Forrester and Lewis (2008) Park et al. (2005)

24 Page 3 of 3 Internal Rotation Lag Sign The patient is seated or standing. The examiner passively places the patient's shoulder in 20 of abduction and 20 of extension with one hand holding the patient s elbow. Using their other hand to hold the patient's wrist, the examiner passively flexes the patient's elbow to 90, placing the patient's hand behind their back at the level of the lumbar spine. The dorsum of the patient's hand is then passively lifted away from the lumbar region by the examiner until almost full internal rotation is reached. The patient is then asked to actively maintain this position as the examiner releases the patient's wrist while maintaining of the patient's elbow. Lags are recorded to the nearest The patient demonstrates a complete lag, or an intermediate response were a lag (i.e. 5 or more) occurred but the patient is able to keep their hand off the lumbar region. Hertel et al. (1996) Miller, Forrester and Lewis (2008) Scheibel et al. (2005) Internal Rotation Resistance Strength The patient is seated or standing with the examiner holding the patient's elbow with one and the patient's wrist with their other hand. The patient's arm is positioned in 90 of abduction and approximately 80 of external rotation and elbow flexion. The patient is asked to externally rotate their shoulder while the examiner resists with a force applied to the patient s wrist. The patient s arm is placed in the same position, but this time the patient is asked to to internally rotate the shoulder while the examiner resists. 67 The patient demonstrates weakness in external rotation when compared to internal rotation. Zaslav (2001)

25 Page 1 of 1 Table 26: Strength and lag tests performed in shoulder adduction. Description Click Image Positive Indicator Study Bear-Hug The patient is seated or standing with their elbow flexed, their shoulder flexed to 90 and their shoulder adducted until their hand is placed on their opposite shoulder with their fingers extended (so that the patient could not resist by grabbing the shoulder). The examiner applies an external rotation force perpendicular to the forearm in an attempt to pull the patient's hand up from their shoulder while the patient resists. The active internal rotation force produced by the patient can be assessed and quantified by means of a digital tensiometer attached to a padded sling held perpendicular to the forearm. The patient is asked to maintain a maximal internal rotation force for 5 seconds to obtain a static measurement (in kg). The test is also performed on the patient s opposite (normal) side for a comparison. 68 The patient demonstrates an inability to hold their hand against their shoulder or showed weakness in resisted internal rotation of greater than 20% when compared with their opposite side. Barth, Burkhart and De Beer (2006)

26 Page 1 of 6 Table 27: Mobility and laxity tests performed in shoulder abduction. Description Click Image Positive Indicator Study Hyperabduction The patient is standing with their elbow flexed to 90, their shoulder in relaxed abduction and neutral rotation (i.e. their forearm is horizontal). The examiner stands behind the patient and applies a downward force to the patient s shoulder girdle with their forearm while their other hand applies a force to the patient s upper arm to abduct the shoulder. 69 The patient experienced apprehension or their arm could be hyperabducted above 105. van Kempen et al. (2013) Load and Shift Also reported as: Push-Pull Shoulder Laxity Exam Anterior (Upright, Arm at Side) The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand over the patient s shoulder (their fingers and thumb resting on the anterior and posterior joint line) to stabilize the scapula and feel any glenohumeral translation, and their other hand holding the patient's humeral head, the examiner center's the patient s humeral head on the glenoid by applying an medial force to the patient s humeral head. The examiner then attempts to shift the patient s humeral head off the glenoid in the anterior direction. 70 Grade 0 laxity is indicated by little to no movement of the humeral head. Grade I laxity is indicated by the humeral head shifting up onto the glenoid labrum. Grade II laxity is indicated by the humeral head shifting off the glenoid but spontaneously relocating (reducing) once the force Tzannes et al. (2004)

27 Page 2 of 6 Anterior (Upright, Held in 90 of Shoulder Abduction) The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand holding the patient's elbow and their other hand holding the patient s upper arm, the examiner passively positions the patient's shoulder in 90 of abduction with the patient s forearm in neutral rotation. The examiner then center's the patient s humeral head on the glenoid by applying an axial force to the patient s humerus via the elbow. The examiner then attempts to shift the patient s humeral head off the glenoid in the anterior direction. 71 application is removed. Grade III laxity is indicated by the humeral head shifting off the glenoid and remaining dislocated once the force application is removed. van Kempen et al. (2013) Anterior (Supine, Held in 20 of Shoulder Abduction) Anterior Drawer (Supine, Held Between 60 to 80 of Shoulder Abduction) The patient is supine with the center of their scapula on the edge of the examining table. With one hand holding the patient's elbow and their other hand holding the patient s upper arm, the examiner passively abducts the patient s shoulder to 20. The examiner then center's the patient s humeral head on the glenoid by applying an axial force to the patient s humerus via the elbow. The examiner then attempts to shift the patient s humeral head off the glenoid in the anterior direction. The patient is supine with their shoulder just over the edge of the examination table. With one hand holding the patient's wrist and their other hand holding the patient s upper arm, the examiner passively abducts the patient s shoulder between 60 and 80 with 0 of rotation and the elbow flexed to 90. The examiner then applies a slight axial force to the patient s arm, followed by an anteriorly directed force to translate the patient s humeral head anteriorly over the glenoid rim. The amount of translation of the humeral head over the glenoid is measured to classify laxity. The examiner notes if the patient would not relax for the test because of muscle contraction or pain. 72 Tzannes et al. (2004) 73 Farber et al. (2006)

28 Page 3 of 6 Anterior (Supine, Held in 90 of Shoulder Abduction) The patient is supine with the center of their scapula on the edge of the examining table. With one hand holding the patient's elbow and their other hand holding the patient s upper arm, the examiner passively abducts the patient s shoulder to 90. The examiner then center's the patient s humeral head on the glenoid by applying an axial force to the patient s humerus via the elbow. The examiner then attempts to shift the patient s humeral head off the glenoid in the anterior direction. 74 Tzannes et al. (2004) Anterior (Supine, Held in 90 of Shoulder Abduction and 20 of Flexion) The patient is supine with their shoulder held in 90 of abduction, 20 of flexion, and neutral rotation by the examiner. The examiner then center's the patient s humeral head on the glenoid by applying an axial force (approximately 10 pounds) to the patient's arm. The examiner then attempts to shift the patient s humeral head off the glenoid in the anterior direction. 75 Levy et al. (1999) Load and Shift Also reported as: Push-Pull Shoulder Laxity Exam Posterior (Upright, Arm at Side) The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand over the patient s shoulder (their fingers and thumb resting on the anterior and posterior joint line) to stabilize the scapula and feel any glenohumeral translation, and their other hand holding the patient's humeral head, the examiner center's the patient s humeral head on the glenoid by applying an medial force to the patient s humeral head. The examiner then attempts to shift the patient s humeral head off the glenoid in the posterior direction. 70 Grade 0 laxity is indicated by little to no movement of the humeral head. Grade I laxity is indicated by the humeral head shifting up onto the glenoid labrum. Grade II laxity is indicated by the humeral head shifting off the glenoid but spontaneously relocating Tzannes et al. (2004)

29 Page 4 of 6 Posterior (Supine, Held in 20 of Shoulder Abduction) The patient is supine with the center of their scapula on the edge of the examining table. With one hand holding the patient's elbow and their other hand holding the patient s upper arm, the examiner passively abducts the patient s shoulder to 20. The examiner then center's the patient s humeral head on the glenoid by applying an axial force to the patient s humerus via the elbow. The examiner then attempts to shift the patient s humeral head off the glenoid in the posterior direction. 72 (reducing) once the force application is removed. Grade III laxity is indicated by the humeral head shifting off the glenoid and remaining dislocated once the force application is removed. Tzannes et al. (2004) Posterior (Held in 20 of Shoulder Abduction and 90 of Shoulder Flexion) Posterior (Supine, Held in 90 of Shoulder Abduction) The patient is seated, standing, or supine with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand stabilizing the patient's shoulder and their other hand holding the patient s upper arm, the examiner passively positions the patient's shoulder in 20 of abduction and 90 of flexion with the patient s forearm in neutral rotation. The examiner then center's the patient s humeral head on the glenoid by applying a medial force to the patient s humeral head. The examiner then attempts to shift the patient s humeral head off the glenoid in the posterior direction (performs anterior-to-posterior translation). The patient is supine with the center of their scapula on the edge of the examining table. With one hand holding the patient's elbow and their other hand holding their upper arm, the examiner passively abducts the patient s shoulder to 90. The examiner then center's the patient s humeral head on the glenoid by applying an axial force to the patient s humerus via the elbow. The examiner then attempts to shift the patient s humeral head off the glenoid in the posterior direction. 76 Liu et al. (1996) 74 Tzannes et al. (2004)

30 Page 5 of 6 Posterior (Supine, Held in 90 of Shoulder Abduction and 20 of Flexion) Inferior (Upright, Arm at Side) Inferior (Supine, Held in 20 of Shoulder Abduction) The patient is supine with their shoulder held in 90 of abduction, 20 of flexion, and neutral rotation by the examiner. The examiner then center's the patient s humeral head on the glenoid by applying an axial force (approximately 10 pounds) to the patient's arm. The examiner then attempts to shift the patient s humeral head off the glenoid in the posterior direction. The patient is seated or standing with their elbow extended and their shoulder adducted to their trunk in neutral rotation. With one hand over the patient s shoulder (their fingers and thumb resting on the anterior and posterior joint line) to stabilize the scapula and feel any glenohumeral translation, and their other hand holding the patient's humeral head, the examiner center's the patient s humeral head on the glenoid by applying an medial force to the patient s humeral head. The examiner then attempts to shift the patient s humeral head off the glenoid in the inferior direction. The patient is supine with the center of their scapula on the edge of the examining table. With one hand holding the patient's elbow and their other hand holding the patient s upper arm, the examiner passively abducts the patient s shoulder to 20. The examiner then center's the patient s humeral head on the glenoid by applying an axial force to the patient s humerus via the elbow. The examiner then attempts to shift the patient s humeral head off the glenoid in the inferior direction. 75 Levy et al. (1999) 70 Tzannes et al. (2004) 72 Tzannes et al. (2004)

31 Page 6 of 6 Inferior (Supine, Held in 90 of Shoulder Abduction) The patient is supine with the center of their scapula on the edge of the examining table. With one hand holding the patient's elbow and their other hand holding their upper arm, the examiner passively abducts the patient s shoulder to 90. The examiner then center's the patient s humeral head on the glenoid by applying an axial force to the patient s humerus via the elbow. The examiner then attempts to shift the patient s humeral head off the glenoid in the inferior direction. 74 Tzannes et al. (2004)

32 Page 1 of 1 Table 28: Sulcus tests performed in a neutral shoulder position, i.e. the arm is at the patient s side. Description Click Image Positive Indicator Study Sulcus Sign The patient is seated, standing, or supine with their elbow extended and their shoulder adducted to their trunk in neutral rotation. The examiner holds the patient s elbow and pulls down with an inferiorly directed force. 77 The patient demonstrates the appearance of a sulcus or dimple between the lateral acromion and the humeral head Levy et al. (1999) Liu et al. (1996) Tzannes et al. (2004)

33 Page 1 of 2 Table 29: Palpation tests performed in a neutral shoulder position, i.e. the arm is at the patient s side. Description Click Image Positive Indicator Study Biceps Long Head Tendon Palpation Also reported as: Biceps Groove Tenderness The patient with the shoulder relaxed or adducted 10 has their biceps long head tendon at the shoulder/intertubercal sulcus examined for tenderness by deep palpation with kg of thumb, index finger, and middle finger pressure. 78 pain or tenderness. A score of 0 3, corresponding to no tenderness, mild tenderness, moderate, or severe tenderness, respectively, can be determined based on the participants response and feedback during the palpation Guanche and Jones (2003) Mackarey and Mattingly (1996) Oh et al. (2008) Toprak et al. (2013) Infraspinatus Tendon Palpation The patient has their infraspinatus tendon at the shoulder examined for tenderness by deep palpation with kg of thumb, index finger, and middle finger pressure. The patient is seated or standing with their shoulder in maximal internal rotation, adduction and slight extension (i.e. their arm is behind their back). 79 tenderness. A score of 0 3, corresponding to no tenderness, mild tenderness, moderate, or severe tenderness, respectively, is determined based on the participants response and feedback during the palpation Mackarey and Mattingly (1996) Toprak et al. (2013)