Comprehensive Examination of the Athlete's Shoulder

Abstract

Context: Shoulder pain and dysfunction are common, with patients presenting complaints to both primary and orthopaedic physicians. History and physical examination remain essential to creating a differential diagnosis, even as noninvasive imaging has improved.

Evidence acquisition: Literature was obtained through keyword searches based on the pathology in question (eg, rotator cuff) and the keywords physical examination using PubMed from January 1, 1980, through September 20, 2017. Additional evidence was obtained through screening references from articles identified through the PubMed searches.

Study design: Clinical review.

Level of evidence: Level 3.

Results: A total of 7817 articles were screened for relevance. Several physical examination maneuvers have been described for each specific pathology. The Neer sign has a 75% sensitivity for subacromial impingement (SAI), while the Hawkins-Kennedy test has an 80% sensitivity. The painful arc test has an 80% specificity for SAI. The apprehension test has a hazard ratio of 2.96 for anterior shoulder instability. The Jobe test has a sensitivity of 52.6% and a specificity of 82.4% for full-thickness supraspinatus tears, confirmed on arthroscopy. The lag sign is highly sensitive and specific for combined full-thickness supraspinatus and infraspinatus tears at 97% and 93%, respectively. The Speed test has a sensitivity of 54% and specificity of 81% for biceps pathology. The anterior slide test and O'Brien active compression test have been described for superior labrum anterior posterior tears with inconsistent reliability. The cross-body adduction test has a sensitivity of 77% and a specificity of 79% for acromioclavicular joint pathology.

Conclusion: Several physical examination maneuvers can isolate specific pathology of the shoulder, with widely ranging sensitivity and specificity.

Keywords: acromioclavicular joint; biceps; glenoid labrum; physical examination; rotator cuff; shoulder.

Figure 1.

The Hawkins-Kennedy test performed on a right shoulder. The examiner stabilizes the posterior shoulder with 1 hand, and with the patient’s shoulder flexed to 90° and the elbow flexed to 90°, a downward-directed force is applied to the wrist to evaluate for elicitation of pain.

Figure 2.

The Jobe test performed on a right shoulder. The patient first abducts the arm to 90º then adducts 30º and internally rotates the shoulder so that the thumb is pointing down. The examiner then stabilizes the shoulder with 1 hand and applies a downward-directed force on the patient’s wrist with the other hand.

Figure 3.

Apprehension test. The patient is supine on the examination table and the examiner applies a downward force on the left wrist while stabilizing the elbow to evaluate for anterior shoulder laxity.

Figure 4.

(a) The load and shift test performed on a right shoulder. The examiner places 1 hand over the acromion and the other firmly around the humeral head. In this image, the shoulder is resting in its neutral anatomic position. (b) Anteriorly directed force being applied by the examiner to the right shoulder as part of the load and shift test. The examiner is evaluating for excessive translation of the humeral head in relation to the glenoid.

Figure 5.

Evaluation of a sulcus sign on the right arm. The examiner applies a downward-directed force to the right arm and is indicating the location where a sulcus sign, an indentation due to excessive laxity of the humeral head in relation to the glenoid, would be. This patient does not have a sulcus sign.

Figure 6.

Belly press test performed on a right shoulder. The patient presses the hand into the abdomen with the elbow in the coronal plane. The examiner is evaluating for the elbow dropping posteriorly.

Figure 7.

Positive belly press test performed on a right shoulder. The patient presses the hand into the abdomen with the elbow but is unable to maintain the elbow in the coronal plane and the wrist flexes as a result.

Figure 8.

Lift-off test performed on a right shoulder. The patient reaches to the small of the back with the palm facing posteriorly and then attempts to move the hand away from the spine.

Figure 9.

Speed test. The examiner stabilizes the posterior shoulder with 1 hand and applies a downward-directed force to the distal forearm while the patient has the shoulder flexed to 90° and the elbow fully extended. Elicitation of pain in the anterior aspect of the shoulder is considered a positive test.

Figure 10.

(a) The O’Brien active compression test. The examiner stabilizes the posterior shoulder with 1 hand and, with the patient flexing the right arm to 90° and adducting it approximately 30° with a pronated wrist, will ask the patient to supinate against resistance. (b) The patient has supinated against resistance of the examiner at the forearm. Elicitation of pain is considered a positive test.