CHRONIC UNIDIRECTIONAL INSTABILITY PROVOCATIVE TESTS QUANTITATIVE TESTSto document the presence To quantitate the & direction of instability amount of laxity Anterior Instability •Drawer tests •Crank test •Load & shift test •Fulcrum test for both anterior and •Jobe’s relocation test posterior instability Posterior Instability •Jerk test •Circumduction test
ANTERIOR INSTABILITYProvocative testsApprehension test Crank test – Pt sitting; arm at 90° ABD. With increasing ER the examiner exerts an anterior translatory force with his thumb placed posteriorly on the humerus & watches for apprehension. Apprehension is diagnostic of instability. If only pain, subtle subluxation.
Fulcrum test –Pt supinewith the scapula supportedby the edge of the table.The arm is positioned in 90°ABD. With increasing ER theexaminer watches forapprehension.
Jobe’s Relocation testExaminer repeats apprehensiontest and notes the amount ofER before the onset ofapprehension.Then apply a posterior stressover the humeral head & repeatthe ER maneuver and againnote amount of ER at onset ofapprehension.Increase in the external rotationrange = +veRelease test- apprehensionreappears on release
POSTERIOR INSTABILITYProvocative testsJerk test Pt supine with 90° forward flexion of shoulder & elbow flexed to 90°, examinor applies posterior directed force by holding the forearm. Jerk/Jump = diagnostic of instability Pain/apprehension= subtle instability
Circumduction test Pt standing, examiner standing behind & holds the arm in extension & abduction; performs circumduction Visible subluxation/ apprehension in position of foreward flexion 160° & adduction (position of risk) = instability
Inferior laxitySulcus sign Patient in sitting or standing; the shoulder is in neutral position, muscles are relaxed. Downward traction applied + = dimpling of the skin below the acromion or widening of the subacromial space on palpation; >2cm translation MDI
Multidirectional instability Instability in more than one direction including inferior laxityVoluntary dislocation Abnormal generalized laxity Abnormal scapular mechanics Psychiatric illness
Painful arc syndrome In abduction arc of motion, patient feels pain in the range 60- 120°.
O’Brien test The patient flexes the arm to 90° with the elbow fully extended and then adducts the arm 10-15° medial to sagittal plane. The arm is then maximally internally rotated and the patient resists the examiners downward force.
Hawkins-Kennedy Test patient sitting with arm at 90° forward elevation and elbow flexed to 90°. Examiner then quickly moves the arm into internal rotation. +ve = Pain located to the sub-acromial space Subacromial impingement, rotator cuff tendinitis
Neer Impingement Sign Examiner performs maximal passive forward flexion with internal rotation whilst stabilizing the scapula. + = Pain located to the sub- acromial space or anterior edge of acromion Subacromial impingement of supraspinatius & anterior part of infraspinatus
Neer’s Impingement Test Examiner after eliciting impingement sign, injects local anesthetic soln. to subacromial space. Disappearance of pain is diagnostic
Inability to abduct or flex forewardAtrophy of supra & infraspinatusfossaeEmpty can test - for supraspinatusER at arm at side with elbowflexed- for infraspinatusLift off test/ abdominalcompression test – forsubscapularisDrop Arm signExternal rotation lag sign
Supraspinatus “Empty Can Test” Pt attempts to elevate the arms against resistance with arms at 90° abduction in a plane 30° anterior true coronal plane and full IR (thumb pointing downward) with elbows extended. Positive = supraspinatus tear
Infraspinatus & Teres minor Patient’s arms at the sides with elbows flexed to 90, attempts to do ER
Subscapularis1. “Lift off test/ Gerber’s test” Patient standing with hand behind back with the dorsum of the hand resting on the back. The hand is raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. Full passive internal rotation is prerequisite. Inability = subscapularis tear/ dysfunction
Subscapularis2. Abdominal compression test Patient attempts to press the hand down against abdomen with examiner preventing it. Useful when IR restricted. Inability = subscapularis tear/ dysfunction
Drop Arm signExaminer abducts patient’sshoulder to maximum. Afterwarning the patient, examinerreleases pt’s arm & asks him tolower the arm back to the side.Pt able to lower the arm partway & then suddenly losescontrol- arm drops suddenly tothe side.Indicates large rotator cuff tearAlso seen in axillary nerve palsy
External rotation lag sign Pt’s arm is externally rotated maximally and released- arm rotates internally spontaneously (passive ER>active ER). Seen when subscapularis is intact but infraspinatus & teres minor is torn.
Yergasson’s test The patients elbow is flexed and their forearm pronated. The examiner holds their arm at the wrist. Patient actively supinates against resistance. Pain located to bicipital groove = +ve
Speed’s test The patients elbow is extended, forearm supinated and the humerus elevated to 60°. The examiner resists humeral forward flexion. Pain located to bicipital groove = +ve
Cross chest adduction test Pt. elevates the affected arm to 90°, then actively adducts it.
Restriction of allrange of motion, esp- Abduction & ERPain on attemptedmovements
Note – ER restriction occurs in 2 conditions only1. Stiff shoulder2. Posterior dislocation Overhead athletes may have restriction of IR due to posterior capsular tightness
SUMMARYInstability Instability Provocative QuantitativeImpinge- Pain O’Brien, Hawkins-ment Kennedy, Neer’sCuff tear Pain Drop arm test, Test for loss of motion SS, IS & SSBiceps Pain Yergasson, Speed,tendinitis Instability Biceps instabilityAC jt injury Pain Tenderness, Cross chest abductionStiff Pain Passive motionshoulder stiffness restriction
Conclusion Clinical examination of shoulder should be guided according to patients age, chief complains and professional activities. All tests needn’t be performed to clinch the diagnosis. Merely knowledge of test is not enough, good practice is essential to perform the tests.
“It is more important to knowwhat patient the disease hasrather than what disease thepatient has” William Osler