NMS I - Final Exam Part 1: Shoulder Orthopedic Test

How do you perform Apley's Test?

1) Patient seated or standing

2) Place hand behind head and touch opposite superior angle of scapula (asymptomatic first, then symptomatic) while examiner observes for asymmetry side to side

3) Patient places hand behind back and attempts to touch opposite inferior angle of scapula (asymptomatic side first, then symptomatic side) while examiner observes for asymmetry side to side

4) Any pain?

What is a positive Apley's test?

Asymmetry or pain w/ ROM

What would asymmetry or pain w/ ROM in Apley's test indicate?

Exacerbation of pain indicates tendinitis of one of the tendons of rotator cuff, usually supraspinatus tendon

How do you perform the Apprehension Test for Anterior Shoulder Dislocation?

1) Patient seated

2) Examiner applies slight P-A pressure on shoulder while abducting externally rotated the patient's shoulder

3) Observe or pain or looks of apprehension

4) Repeat on opposite side and observe patient for pain/apprehension

5) Any pain?

How do you perform the Apprehension Test for Posterior Shoulder Dislocation?

1) Patient supine

2) Examiner applies an A-P force on the patients elbow with the patient's shoulder flexed and internally rotated

3) Observe for pain/apprehension

4) Repeat on opposite side and observe for pain/apprehension

5) Any pain?

What motion of the shoulder could lead to anterior shoulder dislocation apprehension? How about posterior shoulder dislocation?

Anterior Shoulder Dislocation:

Abduct & Externally rotate

Posterior Shoulder Dislocation:

Flex & Internally rotate

What is a positive result for Apprehension test? What could this indicate?

Anterior shoulder test apprehension --> PROPENSITY for an anterior shoulder test

Posterior shoulder test apprehension --> PROPENSITY for a posterior shoulder dislocation

How do you perform Codman's Sign?

1) Patient seated

2) Patient arm is passively abducted just above 90

3) Examiner lets go of arm and patient has to maintain its position

4) Any pain?

5) Repeat on symptomatic side

What could a positive Codman's sign indicate?

Tear of rotator cuff complex, specifically supraspinatus tendon

How do you perform Dawbarn's Sign?

1) Patient seated w/ arm at side

2) Palpate patients shoulder in subacromial area to elicit well-localized tender area

3) Finger remains on painful spot and paitnents arm passively abducted to examiner

4) Any change in pain?

5) Repeat w/ other arm

What is a positive Dawbarn's Sign?

Pain disappears

What would a disappearance of pain with the Dawbarn's sign indicate?

Significant subacromial bursitis

How do you perform the Dugas' Test?

1) patient seated

2) patient places hand on opposite shoulder and attempts to touch chest w/ elbow

3) Any pain?

4) Repeat w/ asymptomatic side

What is a positive test for Dugas' Test?

Cannot touch chest wall w/ elbow

If the patient cannot touch the chest wall w/ their elbow in Dugas' Test, what could this indicate?

PROPENSITY for an anterior shoulder dislocation

How do you perform Impingement Sign?

1) Patient seated w/ arms at side

2) Stabilize scapula (depress)

3) Patients arm passively slightly abducted and moved through forward flexion

4) Any pain? If so where?

5) Repeat w/ symptomatic side

What is a positive result for impingement sign?

Pain in the shoulder due to jamming of greater tuberosity against the anteroinferior acromial surface

If there is Pain in the shoulder due to jamming of greater tuberosity against the anteroinferior acromial surface during impingement sign, what could this indicate?

Overuse injury of supraspinatus or biceps tendon

How do you perform the Speed's Test?

1) Patient seated

2) Patient flexes shoulder as examiner applies resistance

3) While flexing shoulder, patient supinates forearm and extends elbow

4) Any pain?

5) Repeat w/ symptomatic side

What would a positive test be for Speed's Test?

Tenderness in bicipital groove

If there is tenderness in the bicipital groove during Speed's test, what does this indicate?

Bicipital tendinitis

How do you perform the Supraspinatus Press Test?

1) Patient seated

2) Patient abducts shoulders to 90 (arms in neutral rotation)

3) Shoulder medially rotated and angled 30 degrees forward

4) Examiner resists abduction

5) Any pain? Where?

6) Repeat on symptomatic side

What is a positive test result for the supraspinatus press test?

Weakness or pain

If there is weakness or pain with the supraspinatus press test, what does this indicate?

Tear of supraspinatus tendon/muscle

What is a positive Yergason's test?

A click of bicipital tendon during motion, pain, or weakness

How do you perform Yergason's Test?

1) patient seated

2) patient attempts to flex elbow & supinate hand against resistance (arm wrestle position)

3) examiner resists patients attempt to supinate and flex the elbow while palpating bicipital tendon to feel for a "click"

4) Pain? Where?

5) Repeat w/ asymptomatic side

What does a positive sign of Yergason's indicate? How about specifically a click of the bicipital tendon during motion indicate? How about specifically pain?

Tenosynovitis or involvement of transverse humeral ligament

Click indicates torn transverse humeral ligament

Pain indicates bicipital tendonitis

How do you perform the Load and Shift test?

1) Patient seated

2) Patients arm in neutral position w/ hand resting on thigh

3) Examiner w/ one hand stabilizes shoulder over clavicle and scapula, and other hand grabs humerus to apply slight I-S pressure (forcing humeral head in glenoid fossa). Pain?

4) Push humeral head anteriorly. Pain?

5) Push humeral head posteriorly. Pain?

6) Pull S-I checking integrity of inferior capsule. Pain/instability?

7) Repeat with symptomatic side

What sign should you check for during the load and shift test?

Visible sulcus sign

-- looking at instability & laxity of shoulder

How do you perform O'Briens test?

1) Patient seated

2) Patient forward flexes arm to 90 with elbow extended and adducted 15 medial to midline of body w/ thumb pointed up

3) Examiner applies downward force to arm that patient resists (stresses AC joint)

4) Pain?

5) Patient forward flexes arm to 90 with elbow extended and adducted 15 medial to midline of the body and with thumb pointed down

6) Examiner applies downward force on arm that patient resists

7) Pain?

8) Repeat w/ symptomatic side

If the pain is worse with thumb down during O'Briens test, what could this indicate?

SLAP lesion

(Superior Labrum A-P tear)

How do you perform the Lift Off Test (Gerber Test)?

1) Patient seated or standing

2) Patient places dorsum of hand on the low back

3) Patient attempts to lift hand away from back

4) If able, how far does it go? Then examiner may apply resistance to test strength

5) Pain?

6) Repeat on symptomatic side

What is the Lift Off Test (Gerber Test) evaluating for?

Evaluates capsular ligament for laxity & subscapularis muscle

How do you perform Lift Off Lag sign?

1) patient standing or sitting

2) patient places dorsum of hand on low back

3) examiner passively medially rotates patients arm/hand and ask patients to hold the arm away for the low back

4) Examiner observes patients ability to maintain it in that position

5) Pain?

6) Repeat w/ symptomatic side

What is a positive sign for Lift Off Lag sign?

Inability to hold arm away form low back region

With an inability to hold the arm away from the low back region during Lift Off Lag sign, what would this indicate?

Weakness and possible tear of subscapularis tendon

How do you perform Kaplan's Test?

1) Patient seated w/ elbow fixed 90

2) Patient's grip strength assessed w/ dynamometer

3) Examiner places Tennis elbow braced on patient 3 cm below elbow joint line

4) Patients grip strength reassessed w/ dynamometer w/ tennis elbow brace on

5) Pain?

6) Repeat w/ symptomatic side

With Kaplan's test, if you had increased grip strength or decreased pain in the presence of a tennis elbow brace, what could this indicate?

Lateral epicondylitis

Why is the result of Kaplan's test clinically significant?

Suggestive of treatment parameters to assist patient (such as application of elbow brace)

How do you perform Hawkins-Kennedy Test?

1) patient standing or seated

2) Examiner forward flexes arm to 90

3) bend elbow to 90

4) Forcibly medially rotate shoulder

5) Pain?

6) Repeat on symptomatic side

What would be a positive sign for Hawkins-Kennedy test?

Pain in the anterolateral shoulder

What would pain in the anterolateral shoulder during Hawkins-Kennedy test indicate?

Supraspinatus impingement

What else does Hawkins-Kennedy test compress the supraspinatus tendon against?

Also compresses supraspinatus tendon against coracoclavicular ligaments and coracoid process

How do you perform Painful Arc Sign?

1) Patient seated

2) Examiner passively moves shoulder throughout abduction

3) Pain?

4) Repeat on symptomatic sign

What is a positive Painful Arc Sign?

Patient has increased shoulder pain from 60-120 degrees of abduction w/ less pain or no pain above/below this range

How do you perform the Belly Press Test?

1) Patient standing

2) Examiner places one hand on patients abdomen

3) Patient places their hand on top of examiner's hand and pushes as hard as they can into the stomach (medial shoulder rotation)

4) Pain? Note amount of pressure patient pressing into your hand

5) Repeat with symptomatic side

What is a positive Belly Press Test?

Patient unable to maintain pressure on examiner's hand while moving elbow forward or if patient extends the shoulder

What would an inability to maintain pressure on the examiners hand while moving the elbow forward or if the patient extends the shoulder during the Belly Press Test?

Subscapularis lesion

(especially for patients who cannot medially rotate the shoulder enough to take it behind back)

How do you perform Horn Blowers Part A Test?

1) Patient standing

2) Examiner elevates patients arm (asymp) to 90 in scapular plane and elbow to 90

3) Patient laterally rotates shulder against resistance

4) Any pain/instability? Note strength & repeat w/ symp side

How do you perform Horn Blowers Part B Test?

1) Patient standing w/ arms by side

2) Patient brings hands to mouth

3) Any pain/symptoms?

What is a positive Horn blowers Part A Test? Part B?

Part A: Unable to laterally rotate arm or weak compared to other side

Part B: Unable to lift hands to mouth w/o abducting arm first

What does a positive Horn Blower Part A or Part B test indicate?

Teres minor tear

How do you perform the External Rotation Lag Sign?

1) Patient seated/standing

2) Examiner takes asymp arm and passively flexes elbow to 90, shoulder to 90, and held 5 off maximal external rotation

3) Patient asked to maintain position actively while examiner releases wrist (but maintains elbow support)

4) Note any inability of patient to maintain position, and magnitude of lag recorded in degrees to nearest 5 degree

5) Any pain?

6) Repeat w/ symptomatic side

What is a positive test for External Rotation Lag Sign?

Arm medially rotate and springs back anteriorly (w/ signs of instability)

What does a positive external rotation lag sign indicate?

Supraspinatus and/or infraspinatus tendon TEAR

For the External Rotation Lag Sign, testing and interpretation can be complicated by pathologic changes in passive range of motion in the _____________. When PROM is ___________ because of capsular contracture or _________ because of a subscapularis rupture, for instance, false-negative and false-positive results can be expected.

Glenohumeral joint

Reduced

Increased

How do you perform the Biceps Load Test 1?

1) Patient supine

2) Examiner abducts patients shoulder to 90 and passively externally rotates shoulder until patient becomes apprehensive and then supinates forearm

3) Examiner then resists elbow flexion

4) Pain? Repeat w/ symptomatic arm

How do you perform the Biceps Load Test II?

1) Patient supine

2) Examiner abducts patients shoulder to 120 and passively externally rotates the shoulder until the patient becomes apprehensive and then supinates the forearm

3) Examiner resists elbow flexion while in this position

4) Pain? Repeat w/ symptomatic side

What is a positive for Biceps Load Test I and II?

Pain stays the same or worsens & apprehension remains

NOTE: a negative is if the apprehension decreases or patient feels more comfortable

If during the Biceps Load Test I & II, the patient has pain that stays the same or worsens & apprehension remains, what could this indicate?

SLAP lesion

How do you perform the Upper Limb Tension Test for Median Nerve Bias?

1) Patient supine

2) Depress shoulder/scapula

3) Abduct shoulder

4) Supinate forearm w/ wrist and finger extension

5) Abducts shoulder

6) Extend elbow

7) Patient laterally flexes cervical to contralateral & ipsilateral side

8) Pain? Repeat w/ symptomatic side

How do you perform the Upper Limb Tension Test for Radial Nerve Bias?

1) Patient supine

2) Depress shoulder/scapula

3) Abduct shoulder

4) Pronate forearm w/ wrist & finger flexion

5) Abduct shoulder

6) Extend elbow

7) Patient laterally flex cervical to contralateral & ipsilateral side

8) Pain? Repeat w/ symptomatic side

What is a positive Upper Limb Tension Test for Median or Radial Nerve Bias?

Positive if one or more occurs:

- symptoms reproduced

- side to side difference in elbow extension greater than 10 degrees

- contralateral bend increases symptoms or ipsilateral bend decreases symptoms

What does a positive upper limb tension test for Median Nerve Bias? How about Radial Nerve Bias?

Median Nerve Bias = Cervical radiculopathy, mainly median nerve lesion

Radial Nerve Bias = Cervical radiculopathy, mainly radial nerve lesion

If there was pain on the dorsum of the hand and the lateral forearm, what is affected?

Radial Nerve

If there was pain on the dorsum and palmar aspects of the hand and lateral forearm, what is affected?

C6 dermatome

If there was pain on the palmar surface of the hand and the lateral forearm, what is affected?

Median nerve