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CLINICAL EXAMINATION OF THE SHOULDER IN DISORDERS OF THE ROTATOR CUFF
Ch. Dumontier, L. Doursounian
Article Summary

INTRODUCTION
SYMPTOMS
HISTORY TAKING INTERVIEW
DIFFERENTIAL DIAGNOSIS
PHYSICAL EXAMINATION - INSPECTION
PHYSICAL EXAMINATION - PALPATION
PASSIVE MOBILITY
ACTIVE MOBILITY
COMPARATIVE ACTIVE DIAGNOSTIC TESTING
MANOEUVRES FOR REVEALING SUBACROMIAL IMPINGEMENT
Hôpital Saint-Antoine- 75012  Paris

INTRODUCTION

Disorders of the rotator cuff are the main source of pain in the shoulder and despite recent progress in shoulder imaging, clinical examination remains a fundamental stage in evaluating pain in the region of the scapula. The rotator cuff of the shoulder consists of the tendons of insertion of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles in the humerus, combined with the intra articular portion along the biceps. In this article, we will deal with lesions which are part of the blurred notion of impingement syndrome between the cuff and the coracoacromial arch. There are in fact two types of impingement (Dumontier et al., 1999): anterointernal impingement and superoexternal impingement.

• Anterointernal impingement is rare and occurs in the coracohumeral space at the junction between the supraspinatus and subscapularis muscles, at the level of the coracohumeral ligament. The interval of the rotators rubs on the coracoid process and the fibrous band linking the external edge of the coracoacromial ligament with the tendon of the coracoid process and biceps (Fig. 1). Anthropometric studies have shown that the position of the coracoid process is the most important factor of variation in the anatomy of the coracoacromial arch (Renoux et al., 1986). Impingement is still not well understood and it situated at the limit of anterosuperior instabilities of the shoulder (Dumontier et al., 1999 - Jost et al., 2000). It is back in the limelight with publications in arthroscopy concerning impingement of the subscapularis with the coracoid process and the possibility of carrying out coracoidoplasty using arthroscopic procedures (Richards et al., 2005).

• Superoexternal impingement is by far the most frequent. The damage is predominantly on the supraspinatus and often extends towards the infraspinatus in zones of hypovascularisation. The impingement involves the coracoacromial arch formed by the anteroinferior edge of the acromion and the coracoacromial ligament (Apoil and Dautry, 1978 - Post et al., 1983) (Fig.2) as well as the acromioclavicular joint, in particular through its lower osteophytes (Fig. 3) (Petersson and Gentz, 1983). The hypothesis of vascular damage proposed in 1939 [Lindbolm] is also mentioned. Vascular incompetence can occur secondary to the effect of pressure on the cuff during movements which prevent the circulation of blood near the attachment to the humerus (Rathbun and Macnab, 1970). It may also be related to an increase in pressure in the subacromial region during lifting movements (the at-rest pressure of 8 mm Hg in the bursa increases to 56 mm Hg when the arm is bent at an angle of 45° and holds a weight of one kilo in the hand) (Sigholm et al., 1988). Although the term impingement, popularised by Neer and easy for patients to accept, is widely used, the exact pathological physiology of cuff lesions remains unclear (Fu et al., 1991). In addition to the studies mentioned above, current research shows a genetic predisposition (Harvie et al., 2004) as well as biochemical and histological abnormalities which will probably open the path to treatment in the future.

Amongst “impinging” subacromial lesions, there are tendinous inflammations and tears in the cuff, which are thought to be the outcome. The tears themselves are divided into small tears (able to be easily repaired and which do not destabilize the head of the humerus) and large tears (generally more than two tendons) accompanied by excentration of the head with a long-term result of degenerative osteoarthritis (Noel et al., 1989).

 

It is conventional to say that there is an anatomical dissonance and that all lesions will provide the same clinical picture because there are few or no specific symptoms (Litaker et al., 2000 - Murrell and Walton, 2001). This is partly true, and a clinical examination cannot reveal everything. The work of Yamaguchi et al. showed that the largest lesions are often the most symptomatic (Yamaguchi et al., 2006). However, when carried out carefully, a clinical examination will provide solid arguments for envisaging, with certainty, both the existence of an anatomical lesion and its extent. We would therefore insist strongly on the reliability of signs during examination which, when they are known, will provide sensitivity, specificity, positive and negative predictive value, and a precise diagnosis (Tables 1, 2 and 3).


Sensitivity and specificity do not, however, provide an answer to the following question: If the result of a test is a pathology, what is the probability that the patient has a lesion? On the other hand, if the test is negative, what are the chances that the patient has no lesion? Calculation of predictive values, or a posteriori probabilities, as developed by Bayes, will provide answers to these questions.

 

Figure 1: Anatomical view showing the relationship between coracoid process and rotator interval (open). There is a more or less developed sickle-shaped structure between the lateral fibres of the conjoint tendon (*) and the coracoacromial ligament (arrow).

Figure 2: Lateral anatomical view of shoulder with coracoid process (*), the coracoacromial ligament (arrow) and acromion (A) which make up the elements of the coracoacromial arch. The acromioclavicular joint has been opened to push back the clavicula (C).
Figure 3: Scan view of acromioclavicular osteoarthritis showing an outline impression of lower osteophytes on the underlying supraspinatus muscle.
Tables 1, 2 and 3: Methods of calculation used to evaluate sensitivity, specificity and predictive value

SYMPTOMS

 

Pain is the most frequent symptom, often combined with functional impairment (Hawkins and Hobeika, 1983 - Post, 1987 - Brems, 1988). Pain tends to be isolated in tendinitis or small tears and a limit in movement appears when two tendons are affected. Pseudoparalysis is only met in extensive tears (more than 2 tendons) (Gschwend et al., 1988 - Norwood et al., 1989). However a large tear in the cuff can be totally asymptomatic and only come to light suddenly when a minor injury is on the mend, whereas simple tendinitis can be extremely painful and handicapping. The true frequency of asymptomatic tears has been very diversely evaluated. The earliest works, in particular those of Welfling and De Sèze, found up to 50 % or more of tears after the age of fifty. Neer only found 5 % of full tears on 500 cadavers, all aged over the age of 40 (Neer, 1972 - Post et al., 1983). There is a significant increase in frequency of tears with age, as shown by the work of Yamaguchi et al. who, in a series of 588 consecutive ultrasound images, found 212 intact cuffs, 199 unilateral and 177 bilateral lesions (Yamaguchi et al., 2006). In this latter series, the authors estimated at 50% the percentage of patients with a tear in the cuff after the age of 66. In one clinical series, the frequency of tears rose from 33% in forty-year old patients to 55% in fifty-year olds (Murrell and Walton, 2001). In another series, after the age of 70, more than 50% of patients presented a tear of the cuff, and this frequency rose to 80% in eighty-year olds (Milgrom et al., 1995). Only elderly patients with a fracture of the head of the humerus had a very low frequency (5%) of lesions associated with the cuff (Parsch and Wittner, 2000).


Clinical assessment must always be combined with standard x-rays so as to eliminate other possible disorders in the region.

 

 

HISTORY TAKING INTERVIEW

This is a very important moment in the consultation. Not only because it will often help orient the diagnosis, but also because it will enable the practitioner to gauge the patient’s ability, his true impairment, his functional requirement. It will also help to break the ice, and a patient who is at ease is always easier to examine. The patient’s complaint, his age, how the disorder started, how long it has been in existence and how it has developed will all help to orient the diagnosis. The profession, sport or leisure activities practised, whether they are left or right-handed and the side affected, treatment already initiated and its effectiveness, are all important additional indications. Tears of the cuff tend to occur more often on the dominant side in male patients towards the age of fifty (Szalay and Rockwood, 1984 - Rolf et al., 2006), working with the arm above the horizontal plane of the shoulder (removal men, delivery men, bricklayers and stone masons, etc.). Tendinopathies are often found in thirty-something sportsmen playing games in which throwing is involved, as well as in tennis players, swimmers (Jobe et Jobe, 1983 - Norwood et al., 1989), and those involved in heavy physical labour. In one series of adult males, the prevalence of tendinopathies was around 20%, higher in manual workers who engaged in static movement than those whose work involved more dynamic movement (Herberts et al., 1984). Risk of rotator cuff trauma was 9 times lower in office workers (Herberts et al., 1984).

Case history, in particular the pain and the circumstances which triggered it (overuse, a fall, sudden or progressive onset, etc.), is very evocative. The notion of a triggering injury is found essentially in extensive tears (2 or more tendons) (Norwood et al., 1989). However, because of increased longevity, cuff pain is frequently observed in sedentary women.

The feeling of a sudden tear when carrying a heavy load or during an unusual movement is particularly evocative of a degenerative cuff tear.

The pain then needs to be defined: the type, the seat, when it occurs. Pain is generally seated in the region of the anterior, lateral deltoid muscle and radiates in the arm but no lower than the elbow (Gerber et al., 1998). It is deep and hard to pinpoint. Pain in the region of the trapezius and rhomboid muscles is found more in spinal disorders and fibromyalgia, or is projected abdominal or thoracic pain. Pain in the upper part of the shoulder can be secondary to acromioclavicular damage, or to compression of the ulnar nerve (Shankwiler and Burkhead, 1996). Pain in the posterior scapulohumeral region is more often osteoarthrosic, or spinal, in origin.

Intensity of pain is very variable, from the hyperalgesic attack of certain types of calcific Tendinopathies, to pain caused during clinical examination. Its intensity can be evaluated using Huskinsson’s visual analog scale (or, more simply, verbally). It is generally a mechanical type of pain, diurnal, increased by movement, particularly raising the arm and relieved by rest. Nocturnal pain, during changes in position at the beginning, are also very evocative and very often the patient is unable to sleep on the affected side. The painful hyperalgesic attacks are met in calcific tendinopathies.

It is also during the history taking interview that the importance of functional impairment can be determined, both in professional and everyday activities. This impairment can also be quantified, either using an analog scale, or as a percentage. Evaluating the needs of the patient is essential to deciding on the type of treatment. For instance, the advantages and disadvantages of the surgical option need to be carefully weighed up in elderly patients with extensive cuff trauma.

DIFFERENTIAL DIAGNOSIS

The other principal types of shoulder pain which are not disorders of the cuff are acromioclavicular damage, compression of the suprascapular nerve, glenohumeral osteoarthritis, retractile capsulitis and spinal disorders. More rarely they will be related to pleuropulmonary, cardiac, abdominal or laryngeal disorders. Most of them will be detected by the clinical examination and/or simple additional tests. The main difficulty comes from the frequent confusion of pain in the cuff with pain originating in the spine. Approximately 500,000 cases of cervicobrachial neuralgia are diagnosed each year in the USA. In most cases, cervical pain projects into the inter-scapulovertebral region along the inner edge of the scapula. It generally radiates to the outer part of the shoulder and continues along the outer edge of the arm (C5-C6), along the outer part (C7) or to the inner edge of the arm (C8-T1). In typical forms, it is accompanied by paresthesia. Pain tends to be calmed by raising the arm, and increased by movement, effort, coughing and the supine position, which is conducive to obstruction of the deep cervical vein. Upon examination, the spine is painful when mobilized, but the shoulder painless. The most painful movement is active and passive retroflexion of the spine combined with lateroflexion. The Spurling manœuvre (prolonged axial pressure on the crown of the head) and that of Roger and Bilikas (Lasègue manoeuvre of upper arm associated with abduction, retropulsion and external rotation of the arm and supination of the forearm) are quite specific of CBN.

PHYSICAL EXAMINATION - INSPECTION

 

The patient should remove clothes to the waist, and examination of the shoulders must be symmetrical and comparative (Hawkins and Hobeika, 1983) (Fig. 4). The patient needs to be observed undressing and dressing in order to evaluate functional impairment (Yocum, 1983). Patients are often unable to remove clothing over their heads and need to slide it down the affected arm. Examination should be carried out face on, and from the back, with the patient at ease and standing.

Inspection will enable appraisal of the spontaneous attitude of the patient, appearance of the muscles, whether there are any deformations, an œdema, or changes in appearance of the skin (Clarnette and Miniaci, 1998 - Hawkins and Bokor, 1998). Overall appearance of the patient needs to be studied carefully, how the arms swing when walking (if surroundings permit). A pain-relieving attitude is sometimes very evocative: an attitude with arms hanging, trying to free up subacromial space suggests a superoexternal impingement as was noted by Codman (Shankwiler and Burkhead, 1996). An antalgic posture of the cervical vertebra is what you are looking for. The distance between the acromion and the base of the neck will be reduced in muscle splinting of the trapezium, or increased where there is muscle atrophy, or the accessory nerve (a nerve in the trapezius) is affected (Brems, 1988).

The patient should first of all be examined from the back, looking for any atrophy of the supraspinatus and/or supraspinatus and infraspinatus muscles very evocative of an extensive and old rupture of the cuff.

The atrophy is all the more marked when the rupture involves the infraspinatus (Shimizu et al., 2002). This atrophy is easier to see in oblique light, and more evident for the infraspinatus where the atrophy causes the spine to jut out from the scapula (Hawkins and Bokor, 1998) (Fig. 5). For the supraspinatus, the atrophy is often masked by the relief of the trapezius and it is particularly perceptible in comparison with the opposite side. Atrophy of the deltoid muscle should also be sought, more easily visible when standing face on to the patient (Fig. 6).

Prior scarring should also be sought, the existence of an effusion encountered in rheumatoid arthritis, or in massive tears of the cuff (senile haemorrhagic shoulder) (Fig. 7).

However, in most cases, apart from noting the atrophy in extensive lesions, inspection will not contribute much.

 

Figure 4: Examination of the shoulder is carried out on a patient naked to the waist and will begin with an inspection of general appearance and a comparison of both shoulders from the back.
Figure 5: Atrophy of cuff muscles.
5A: Atrophy of infraspinatus in a well-padded patient exposed in an oblique light.
5B: Marked atrophy of infra and supraspinous fossae. In most cases atrophy of the supraspinatus muscle will be felt more easily than seen.
Figure 6: Atrophy of the anterior head of the deltoid muscle visible from the front (6A) and from above (6B)
Figure 7: Senile haemorrhagic shoulder over massive cuff tear with spread of ecchymosis.

 

PHYSICAL EXAMINATION - PALPATION

 

The object here is to find any painful points on the greater tuberosity of the humerus, the tip of the acromion, the coracoid process, the coracoacromial ligament and acromioclavicular joint (Post, 1987 - Brems, 1988). We usually stand behind the patient and palpate while comparing the sternoclavicular joints, then the clavicle, arriving at the acromioclavicular joint (Fig. 8). The acromioclavicular joint is often masked by subcutaneous fat and is only really visible in thinner patients. Palpation will enable points sensitive to pressure to be found, the sign of damage. In corpulent patients, the joint is sometimes difficult to palpate and Neviaser’s technique needs to be used. The acromioclavicular joint is immediately anterior to the palpable depression between the clavicle to the front, the acromion on the outside, the spine of the scapula to the back (Fig. 9). Acromioclavicular pain radiates laterally in the neck, in the region of the trapezius muscle and in the region of the deltoid process (Gerber et al., 1998). It is increased when the arm is passively adducted horizontally, i.e. when the arms are crossed horizontally in front of the chest (the cross-body adduction test) (fig. 10). The Paxinos sign is a good clinical orientation towards acromioclavicular disorder (Walton et al., 2004). It is to be found by placing the thumb on the back of the acromion, index finger on the clavicle in front and giving a posteroanterior push which will revive the pain in the case of an acromioclavicular disorder.

Palpation of the coracoid process is not particularly informative because it is often very sensitive, even in healthy people. The greater tuberosity of the humerus is easier to palpate in extension and in external rotation which will release the insertion of the supraspinatus muscle. The search for an impingement pain during palpation of the coracoacromial ligament is heightened by associating rotation movements of the arm with palpation of the ligament. The subscapularis muscle should be palpated in external rotation, just outside the coracoid process. The supraspinatus muscle should be palpated in extension of the shoulder, just opposite the anteroexternal edge of the acromion. The infraspinatus should be palpated at the posteroexternal edge of the acromion when the arm is in slight flexion and internal rotation (Clarnette and Miniaci, 1998).

While palpating the greater tuberosity of the humerus, it is sometimes possible to feel a crackling noise, showing a thickening of the subacromial-deltoid synovial bursa. Palpation of a rotator cuff tear was first described by Codman in 1911 in the form of a depression perceived in the deltoid muscle (Codman, 1990) (fig. 11). The deltoid should be palpated, forwards of the acromion, with one hand, while the other hand holds the patient’s bent elbow to rotate the shoulder while the arm is extended. The examiner should be able to palpate a protuberance which corresponds to the upper part of the greater tuberosity of the humerus in the case of a full tear, and a depression which corresponds to the tear. In Wolf’s series of 109 patients, the sensitivity of such a test was 95.7%, specificity 96.8%, positive predictive value 95.7%, negative predictive value 96.8% and diagnostic precision 96.3%. For other authors, upwards of 42 patients, the sensitivity (91%), specificity (75%), PPV (94%), NPV (66%) and diagnostic precision (88%) were somewhat similar (Lyons and Tomlinson, 1992). However, as Wolf remarked, examination is more difficult in more corpulent patients (fat or muscle), and he insists on the need to palpate the anterior edge of the acromion in a well-relaxed patient. Although we sometimes palpate cuff tears (or have the impression that we feel them), we do not pretend to be able to identify the inner edge of the cuff in a reliable manner, or to differentiate by palpation a full tear, a partial tear or a calcifying tendonitis as Wolf does !

The bicipital groove of the humerus should be palpated approximately 3 to 5 cm below the acromion; it is anterior when the arm is in a 10° internal rotation. It is easier to feel it roll under the fingers by making small rotation movements, being careful not to confuse the contour felt with the anterior edge of the deltoid muscle. De Anquin’s test consists in reviving the pain when the biceps passes under the examiner’s fingers while the patient’s arm is rotated. Lippman revived the pain by hooking the fingers and pulling on the tendon of the biceps.

Given the anatomical difficulty of palpating the tendon, this test is probably not of any great value (Shankwiler and Burkhead, 1996).

Lastly, palpation of the subclavicular fossa at the same time should not be forgotten, seeking ganglia in particular.

In all, what palpation will show in most cases of cuff disorders is pain when the anterior part of the acromion or coracoacromial ligament is pressed.

 

Figure 8: Principles for palpation of the shoulder. Bilaterally and comparatively, the examiner should palpate the bony contours and elements which might be involved in the impingement syndrome.

Figure 9: Neviaser’s technique is used in arthroscopy. The point of introduction is located in the depression on the medial edge of the acromion and forwards of the spine. This depression corresponds exactly to the posterior part of the acromioclavicular joint which is sometimes difficult to palpate.

Figure 10: Cross-body adduction test (arm crossed). This test is positive when it revives the acromioclavicular pain which the patient complains of.

Figure 11: Principle for palpation for cuff tears. Palpation is carried out on the anterior edge of the acromion. The presence of the bursa between the deltoid and the cuff should be noted.

PASSIVE MOBILITY

 

This is the stage which must precede any active mobilisation test or any provocative test. To begin with, mobility of the glenohumeral joint in abduction and in external rotation needs to be determined. This examination must be comparative because, although there are no absolute references for shoulder mobility, the mobility for a given individual will be symmetrical. It is easier to carry out the examination from behind the patient.

External rotation should be determined by maintaining the elbow bent along the patient’s body and by turning his forearms (Fig. 12). An increase in passive external rotation will suggest a tear in the subscapularis. For Hertel, the appearance of pain in forced passive external rotation was indicative of partial damage to the rotator interval.

Passive scapulohumeral abduction is determined by placing the arm in abduction and maintaining the point of the scapula with the other hand (Fig. 13). For patients in great pain, muscle splinting (the false antalgic stiffness) needs to be distinguished from the stiffness caused by soft tissue contraction. Passive mobility can be determined by asking the patient to bend forward, arms hanging loose, as Codman suggested. When the patient’s trunk is bent to an angle of 90° and the hanging arm is vertical, this means a passive antepulsion of at least 90°. In this case, if the examiner wishes to show the absence of stiffness, he should support the hanging arm and ask the patient to sit up. The ability to bring the arm up confirms that the capsule is free.

The existence of a real limitation to passive mobility is a sign of retractile capsulitis (in the absence of osteoarticular defects) that will need to be treated before any damage to the cuff (Dumontier, 1992). In practice, in the case of stiffness, clinical examination of the cuff will stop here, whatever the origin of the capsulitis; on the one hand because the other tests will be skewed by the stiffness; on the other because a mobile shoulder is a prerequisite for any treatment, with the exception of rehabilitation.

If the shoulder is passively flexible, the arm then needs to be placed in abduction and the passive internal rotation tested by comparing it with the other side. Posterior capsular retraction is rare, it tends to be seen more in sport activists and the pain is generally posterior, in the interarticular space.

After examination of passive mobility, you need to be able to form an opinion as to the existence of stiffness, or not, and its sector.

 

Figure 12: Examination of passive external rotation, elbow to body, looking for asymmetry. Loss of rotation suggests capsule stiffness if x-rays are normal.
Figure 13: Examining possibilities of passive abduction of the glenohumeral joint in the frontal plane. Normally, it is possible to raise the arm to 90° while maintaining the scapula fixed. Stiffness is determined in degrees and will correspond to the abduction value obtained just before the scapula pivots under the examiners fingers.

ACTIVE MOBILITY

 

Mobility in anterior and lateral elevation in the plane of the scapula is then measured, standing and (ideally) lying down. The existence of a painful zone (painful arc sign) needs to be determined for each movement, both ascending and descending, as well as the possibility of slowing the descent. In abduction, a painful arc between 60 and 120° is suggestive of a cuff disorder, whereas an arc above 120° is more suggestive of a disorder of the acromioclavicular joint (Fig. 14). However, this “painful arc sign” has no localizing value (Kessel and Watson, 1977). If the patient is limited by pain in abduction, he needs to be asked to do the movement again in external rotation; if mobility is improved, or less painful, this sign is very suggestive that the rotator cuff is affected. With experience, the use of a goniometer becomes optional, the literature showing that visual determination of mobility, in a trained examiner, is well correlated to measurement with the goniometer (Marx et al., 1999).

Analysis of the scapulohumeral rhythm during elevation is an important moment, which Codman has already stressed (Codman, 1990) (fig. 15). Broadly, full abduction depends for one third on the scapulothoracic joint and for the other two-thirds on the scapulohumeral joint and the most important muscles are the trapezius, the serratus anterior, the deltoid and the supraspinatus. Abduction above 100° also requires external rotation. If the trapezius is weakened, the scapula, not held properly, will slide forward, its internal edge jutting out and the distance between scapula and spinous processes will increase. If it is the serratus which is defective, the internal border of the scapula will lift up and slide towards the spinous processes (scapula alata) (Fig. 16). Damage to rhomboid minor muscles can also be responsible for postural disorders of the scapula (Dumontier et al., 2004).

External rotation is determined on the one hand elbow to body (in degrees), and active external rotation needs to be compared with passive external rotation. Functional external rotation, as suggested by Constant, also needs to be measured. Internal rotation is measured according to the region affected by the thumb in extension (fig. 17). It is the first sector of mobility affected in disorders of the shoulder and the last to recuperate.

Two recent studies criticize the measurement of internal rotation by the position of the hand in the back. Ginn et al. (2006) note that with painful shoulders this method is not at all precise enough. Wakabayashi et al. (2006) conclude that 66% of internal rotation is obtained when the hand is on the sacrum; that above this it is the flexion of the elbow which is called upon in particular, and that above D12 internal rotation does not vary significantly.

.

Figure 14: Painful arc. It will appear during movements of anterior or lateral elevation. In lesions of the cuff it will appear between 60 and 90°.
Figure 15: Analysis of scapulohumeral rhythm. In this patient the scapula pivots before glenohumeral abduction takes place giving this aspect of raising of the shoulder
Figure 16: Two causes of scapula alata.

16A: Iatrogenic paresis of the trapezium with shift forward and inward of the right scapula. Elevation of the arm is reduced and/or painful, in particular in the frontal plane because the scapula does not pivot.

16B: scapula alata through paresis of serratus anterior muscle. The scapula, which is no longer retained, shifts upwards and inwards. Anterior elevation of the arm is made difficult, the scapula no longer fulfilling its support role.

Figure 17: Measuring the functional internal rotation according to Constant. The level reached is determined by the thumb, the lower angle of the scapula being projected on the 7th thoracic or 7th intercostal space.

COMPARATIVE ACTIVE DIAGNOSTIC TESTING

After studying active mobility, the strength of each of the cuff muscles needs to be looked at, beginning with the least painful. Since it was internal rotation which was last determined, it is naturally the subscapularis muscle that comes first.

Subscapularis

Damage to the subscapularis can be determined by:

 

      An increase in passive external rotation, elbow to body (ER1), in relation to the opposite side in case of full, or incomplete, tear in the subscapular muscle.
      A decrease in the strength of internal rotation tested elbow to body in relation to the opposite side, less specific to tear: indicative in particular of subscapular damage. For some, the subscapularis is better tested in maximum internal rotation (Kelly et al., 1996); for others its strength is better determined by testing internal rotation from a position of abduction of 90° in the plane of the scapula (Jenp et al., 1996).
 
      A positive Gerber lift-off test (Gerber and Krushell, 1991). This test can only be carried out when the patient is able to develop an internal rotation sufficient to place the hand in the back (Fig. 18). It is in this position that the subscapularis muscle is best tested, and that synkinesic movements are the weakest (Kelly et al., 1996). Normally, the patient can move the hand away from the back; in the case of a tear, the hand will remain “stuck” to the lumbar region. Sensitivity and specificity are said to be 100% in the case of full tears, but this test does not enable detection of a partial tear (Gerber and Krushell, 1991).
 
      This test was modified by Hertel et al (1996) using the name “internal rotation lag sign”. It is carried out by placing the patient’s hand at a distance from the lumbar region, elbow bent, and asking the patient to hold this position. Full return of the hand is a sign of full tear, a limited return of the hand indicating a tear in the upper portion of the subscapularis. Thus modified, this test is thought to be more sensitive and its diagnostic precision greater, but its specificity identical (Hertel et al., 1996). If the positive predictive value of these two tests is close to 100%, the negative predictive value is 96% for the modified test and 69% for the initial lift off test (Hertel et al., 1996). This modification would enable better detection of partial tears.
 
      The belly-press test (also called Napoleon’s test by many authors) was suggested by Gerber to test the subscapularis in patients with limited internal rotation. The patient, whose hand is placed on the stomach, wrist straight and elbow detached from the chest, is asked to press strongly on the stomach with the hand while keeping the forearm in line with the hand and the detached elbow. The test is positive and means a tear in the subscapularis when the patient who tries to press on his stomach cannot maintain his elbow forward and can only exercise abdominal pressure by a retropulsion of the arm and by bending the wrist (Fig. 19). Laurent Lafosse (Lafosse et al., 2007) provides an interesting modification to the belly-press test by asking the patient to carry out the manœuvre on both sides at the same time and by the examiner pressing on the elbows (Fig. 20). This way the evaluation is comparative and enables the weakness of the muscle to be “quantified”.
 
      The bear-hug test is the latest test for evaluating the subscapularis. The patient presses his hand (of the side to be tested) flat on his contralateral shoulder while maintaining the elbow raised. The examiner tries to lift the hand off the shoulder by pulling on the wrist (Fig. 21). The test is positive if the patient is unable to maintain his hand on his shoulder while the examiner tries to pull it off. According to J. Barth et al. (2006) this test is the most sensitive for detecting subscapular lesions. These authors evaluated the four tests - Bear-hug, Lift-off test, Belly-press test and Napoleon - in 68 patients, and monitored the subscapular damage arthroscopically. They noted that:
 
  • in 40% of cases, none of the tests detected subscapular damage,
  • the lift-off test tests the lower part of the subscapularis,
  • the belly-press and the bear-hug test the upper part of the muscle,
  • the lift-off test was only positive for damage to the subscapularis of more than 75 %,
  • the belly-press and the bear-hug tests were only positive for damage of at least 30%,
  • the 4 tests were specific, but the sensitivity was very variable, ranging from 17.6 % for the lift-off, to 60% for the bear-hug.

 

Figure 18: lift-off test.

18A: on the unaffected side, the patient is able to lift his hand from his lumbar region.

18B: on the affected side (full tear of the subscapularis), the patient is unable to lift his hand off the lumbar region. This test is only possible if there is sufficient internal rotation.

Figure 19: Press-belly (or Napoleon’s) test

This test is carried out by asking the patient to press hard on the stomach, the hand, the wrist and the forearm being straight, which means raising the elbow. If the subscapularis is intact, the patient can press and hold the position (19A), otherwise, he will move the elbow towards the back (19B).

Figure 20: Lafosse suggests that the press-belly test be carried out comparatively by pressing on the elbows to quantify the strength of the supraspinatus muscle.

Figure 21: Bear-Hug test

The patient places his hand on the opposite shoulder (21A) and the examiner tries to lift it up by moving it like the leaf of a door, where the elbow is the hinge, while asking the patient to resist. The test is positive if the patient cannot keep his hand on his shoulder. (21B)

Infraspinatus and teres minor

 

The quality of the external rotators, infraspinatus and teres minor muscles need to be determined next. In addition to the atrophy, very evocative of an extensive and old tear, one can determine:
 
      the strength in external rotation, elbow to body, always decreased in the case of tears. For Kelly, the muscle is tested "almost in isolation" from the elbow to body position, the arm being in internal rotation at 45° (Kelly et al., 1996). For Jenp, it is, on the contrary, from elevation at 90° in the plane of the scapula and from a moderate external rotation that isolated testing of the infraspinatus can be better carried out (Jenp et al., 1996).
Elbow to body, several tests will enable evaluation of the quality of the infraspinatus.
 
      Evaluating the strength of the infrasupinatus: elbow bent at a 90° angle, the arm in neutral rotation, the examiner applies internal pressure on the forearm and asks the patient to resist. The test is positive if the patient gives way through weakness or pain (Fig. 22).
 
      The automatic recall test in internal rotation or dropping-sign described by Neer (Neer, 1990) and called external rotation lag sign by Hertel (1996). After having passively placed the arm in external rotation at a maximum of 5°, the shoulder in slight abduction of 20°, the patient should be asked to hold this position. The test is positive when the patient cannot hold the position, and when the forearm comes heavily back to its initial position (Fig. 23). This test has a sensitivity and a specificity of 100% for infraspinatus muscle damage with fatty degeneration (Walch et al., 1998). This test is simple to carry out, non painful and very precise. However, it is positive only in the case of serious damage to the infraspinatus. Hertel maintains with insistence that the internal rotation lag sign also indicates damage to the suprasupinatus.

•        Bell-clapper or gate sign. Elbow to body, the forearm at 90°, the examiner asks the patient to make a forced internal rotation against resistance from a position of neutral rotation, then suddenly lets the resistance go. The sign is positive when the patient cannot slow the movement and his hand hits his stomach violently.

 

Figure 22: Examination of strength in external rotation, elbow to body.
Figure 23: Automatic recall in internal rotation. The examiner takes the arm passively to maximum external rotation (less than 5° to avoid the pain) and in 20° abduction (23A). The patient is asked to hold this position (23B). The test is positive because the patient is unable to hold the prior position.

The infraspinatus is then tested in elevation

 

      Patte’s test (1988) consists in examining in comparative fashion the strength of external rotation. The examiner supports the arm examined in a 90° abduction in the plane of the scapula, elbow bent at 90°, and opposes the external rotation the patient is asked to make (Fig. 24). The test is positive when it reveals a deficit in muscle strength.
 
      The bugle sign (Walch et al., 1998). The patient is asked to place his hand on his mouth. The sign is positive when the patient is obliged to lift his elbow higher than his hand or when the patient is unable to take his arm in external rotation from the raised position (Walch et al., 1998) (fig. 25). This sign has a sensitivity of 100% and a specificity of 93% for diagnosis of damage to teres minor with fatty degeneration of stage 3 or 4 according to the classification of Goutallier and Bernageau (1994). The role exact of teres minor is not well known, since Neer only attributes 10% of the strength of external rotation to it, while other authors attribute up to 45% of the strength of external rotation to it (Colachis and Strohm, 1971) (Neer, 1990).
 
      The drop sign is a variation of the bugle which consists in taking the arm in a 90° abduction and to maximum external rotation.  The patient is asked to hold the position. An impossibility to do so is a sign of tear in the infraspinatus (Hertel et al., 1996). This sign was also described by Patte (Patte and Goutallier, 1988).

 

Suprasupinatus

Damage to the supraspinatus is suspected in the case of atrophy of the supraspinous fossa and on loss of strength on testing the muscle. Electromyographic studies conflict somewhat with clinical practice, since the muscle is either not able to be individualized (Jenp et al., 1996), or tested preferentially in a 90° abduction at the level of the scapula and in external rotation (Kelly et al., 1996). Whatever the techniques used, there is always a participation of the mid-deltoid muscle during testing of the supraspinatus.
 
      Loss of strength of the supraspinatus, determined by holding an object in the hand, is evocative of a tear in the supraspinatus (75% diagnostic precision), pain alone being of little value (Itoi et al., 1999).
 
      The drop-arm sign consists of raising the arm to 90° and letting it drop suddenly, asking the patient to hold (Magee, 1987). The drop of the arm means damage to the infraspinatus muscle. The sensitivity of this test is high (98%) but its specificity is low (10%) (Murrell and Walton, 2001) (Calis et al., 2000).
 
      In clinical practice, the method described by Jobe (Jobe and Jobe, 1983) is readily used. From the raised position at 90° in the plane of the scapula, the arm in internal rotation, the strength of the muscle is tested by asking the patient to resist the pressure exerted by the examiner (Fig. 26). The test is uninterpretable if pain prevents the patient from resisting. The patient therefore needs to be warned that the test is painful, but that he must try and resist as hard as possible. If, during the test, the head subluxes upwards and forwards, a combined tear of the supraspinatus and subscapularis should be suspected.
 
      Jobe’s manœuvre is particularly reliable since after 227 cases of radioclinical confrontation (Noel et al., 1989), there were 14 % false positives and 15 % false negatives. In Hertel’s study, Jobe’s test was more sensitive than the external rotation lag sign, itself more sensitive than the drop sign for posterosuperior tears of the cuff (Hertel et al., 1996). On the other hand, the external rotation lag sign was as specific as the drop sign and more specific than Jobe’s test (Hertel et al., 1996). The positive predictive value of Jobe’s test was 84%, whereas the external rotation lag sign and drop sign had a positive predictive value of 100%. The negative predictive value was 58% for Jobe, 56% for the external rotation lag sign, and 32% for the drop sign.

 

Figure 24: Patte’s test. In position of 90° abduction, in the plane of the scapula, the patient is asked to carry out an external rotation which the examiner resists. The test is positive if there is loss of strength.
Figure 25: Bugle sign. The patient is asked to take the hand to the mouth. In the absence of external rotators (infraspinatus and teres minor), the patient will need to raise his elbow.

Figure 26: Jobe’s test. This is to test the muscle. The examiner places the arm in a 90° abduction in the plane of the scapula and in internal rotation. He will then ask the patient to resist the pressure and determine the muscular strength of the supraspinatus. Pain will often prevent this test from being carried out correctly.

MANOEUVRES FOR REVEALING SUBACROMIAL IMPINGEMENT

A great many tests, called specific tests, have been described. The aim of all of them is to revive pain by manoeuvres creating contact and friction between the arch and the cuff or by putting elective pressure on the tendon through active staggered mobilisation. Painful, they should be carried at the end of the examination and their only practical interest is to confirm the involvement of the rotator cuff in the patient’s symptomatology.

Impingement

 

      Neer and Welsh’s sign of and test for impingement of (1972) (Post, 1987): the examiner blocks the scapula to avoid its rotation while he suddenly raises the arm forward (fig. 27) in maximum internal rotation which will revive the pain. The sedation of pain during arm raising by injecting 10 cc of Xylocaïne® at 1% in the subacromial bursa will confirm the diagnosis. Anatomically, the greater tuberosity of the humerus traps the cuff under the external edge of the acromion and under its medial edge during this manœuvre, but also against the upper rim of the glenoid fossa (Valadie et al., 2000). Other works confirm that the cuff is compressed, in particular at the anterior edge of the acromion, as Neer suggested. The sensitivity of this test is very good: 88.7 % (Calis et al., 2000).
 
      Hawkins’ test (Hawkins and Kennedy, 1980): arm raised anteriorly to 90°, elbow bent. Placing in internal rotation will revive pain in the case of anterosuperior or anterointernal impingement (fig. 28). Anatomical studies show that the cuff is compressed under the coracoacromial ligament during this manœuvre, but also at the anterosuperior edge of the glenoid on its endoarticular side (Valadie et al., 2000). This test seems to be the most sensitive of the tests for evaluating impingement. Calis found a sensitivity of 92.1 % (Calis et al., 2000). These latter two tests being the most well known are often studied together, and several studies found approximately similar results (Tables 4 and 5). Other studies have found a lesser sensitivity (Neer, 46% and Hawkins, 62%) in stage 2 tendinitis in 45 patients monitored arthroscopically (Ure quoted by Calis).
 
      Jobe’s test (Jobe and Jobe, 1983). This is the manœuvre described above to test the strength of the suprasupinatus. The test is positive if the patient cannot resist, which means a very painful phenomenon of release.
 
      Yocum’s test (Yocum, 1983): hand is place on the non-affected shoulder. The examiner asks the patient to lift up the bent elbow and provokes pain by impingement, first of all between the greater tuberosity of the humerus and the coracoacromial ligament, then with the acromioclavicular joint by resisting the raising of the elbow. This test is very sensitive (82 %) (Calis et al., 2000). It was not named this by Yocum, who tended to call it Gerber’s test (see below).
 
      External rotation abduction test. The patient’s arm is placed in maximum external rotation and then mobilized in abduction between 90 and 150° (Walch et al., 1991). Pain then favours a cuff disorder, with an indication of instability. It is very often associated with other symptoms of instability and/or of the cuff. This test is only useful in for lesions in young patients, where either an instability, or a posterosuperior impingement as described by Walch is suspected (Walch et al., 1991).
 
      Gerber’s test: Pain caused by placing the arm in 90° abduction and internal rotation. It shows an anterointernal impingement.
 
      The cross-body adduction test, which has already been mentioned, is not very sensitive in subacromial impingement. It is a test of acromioclavicular damage.

 

Figure 27: Neer’s sign and test: In standing position, the examiner blocks the patient’s scapula and suddenly raises the arm forwards which will revive the pain because the cuff will rub against the coracoacromial arch. If the pain disappears after injection it is a sign that the test is positive.
Figure 28: Hawkins’ test: Shoulder in anterior elevation, elbow bent, the examiner places the arm in internal rotation which will revive pain.

Figure 29: Speed’s (or Gilcrest’s) test. Anterior elevation in staggered supination revives pain, which is more related to damage to the long head of the biceps.
Table 4: Value of the Neer and Hawkins tests on 24 patients for diagnosis of bursitis without cuff tear (according to MacDonald et al., 2000)). Pre-test probability of 28.2%
Table 5: Value of the Neer and Hawkins tests on 24 patients for diagnosis of cuff damage (according to MacDonald et al., 2000)). Pre-test probability of 28.2%
Table 6: Overall diagnostic value of 8 clinical tests seeking subacromial impingement without judging extent of damage (according to Park et al., 2005).
Table 7: Analysis of clinical tests according to stage of disorder using the multiple logistic regression method ((Park et al., 2005))

Tendon of long head of biceps

 

Disorders of the intra-articular part of the tendon of the long head of the biceps (LPB) are in general associated with that of the rotator cuff. In sportsmen and women who predominantly use their arms, the functional overload (during the deceleration phase) causes repeated microtrauma of the tendon and can lead to tendinitis (Farron and Gerber, 1994) (Biasca and Gerber, 1996). In the most severe cases, partial wrenching of the insertion on the upper edge of the glenoid fossa and the adjacent anterior and posterior parts of the glenoid labrum will cause damage called SLAP (superior labral lesion anterior to posterior) (Snyder et al., 1990). However, intra-articular tears of the LPB are rare without associated disorders of the rotator cuff. Estimated to be 25% by Neer, they were only 2.2 % in a series of 74 patients monitored using arthroscopy (Gleyze and Habermeyer, 1996). Out of a series of 438 rotator cuff tears operated, the biceps was affected in 45% of cases. Dislocation or instability of the LPB cannot exist without damage to the bicipital pulley, or to the subscapularis muscle. It is estimated that 20% of rotator cuff tears show an instability in the long head of the biceps.
Pain will be anterior in the bicipital groove of the humerus and descend along the arm. It is revived by extension and internal rotation and during almost all manœuvres of impingement. Pain during palpation of the groove is the best clinical sign, easier to carry out in internal rotation of 10° (and particularly by turning the arm). This pain should be differentiated from the pain of bursitis which remains permanent in all rotation movements.
 
      The tendon of the long part of the biceps can be tested with a number of manœuvres, but few are both sensitive and specific; they are, above all, indicative of a probable participation of the biceps in the patient’s pain.
 
      Speed’s test was described by J. Spencer Speed who personally complained of a shoulder pain when he carried out the Lasègue manœuvre (arm in external rotation, elbow in extension and forearm in supination) cited by Crenshaw and Kilgore, 1966 - Magee, 1987. This test is also called Gilcrest’s test (1939). Flexion of the arm against resistance is carried out, elbow in extension and in supination, which will cause pain on the anterior face of the shoulder, at the level of the bicipital groove of the humerus (fig. 29). This test is thought to be the most efficient in examination of the biceps. Its sensitivity is high (90%) but its specificity is low (13.8%), its PPV is 23% and its NPV 83% (Bennett, 1998). That is to say that the test is positive in many disorders of the shoulder where the biceps is not affected. However, when it is negative, it is probable that the biceps is healthy.
 
      Yergason’s test (1931) (Magee, 1987 - Post, 1987): elbow bent at 90°, and steadied against the chest, the forearm in pronation. The patient carries out a supination against resistance. Pain will be a sign of tendinitis. This test has very good specificity (86.1 %) (Calis et al., 2000).
 
      Heuter’s test (Post, 1987 - Shankwiler and Burkhead, 1996): forced flexion of the elbow from a forearm in pronation will always lead to supination. In the case of a tear, the biceps will not contract, or there is no supination. In addition, flexion here is more powerful in pronation than in supination. Not very specific.
 
      O’Brien’s test consists of asking a patient whose arm, elbow in extension, is taken to anterior elevation at 90°, slightly in adduction (15°) and internal rotation (thumb down) then external rotation (thumb up) to resist a superoinferior pressure. The test is positive if pain appears in internal rotation and pronation, then disappears in external rotation and supination.
If pain is located high on the shoulder, it is more probably likely to be an acromioclavicular disorder, whereas if the pain is in the shoulder, it is more likely to be a disorder of the labrum.
 

 

Summary of manoeuvres

In 2005, HB Park et al., published a very rigorous study on the precision of the manœuvres for revealing a subacromial impingement on a population of almost one thousand patients. Eight manœuvres were evaluated: The Neer test, the Hawkins test, the painful arc, the Jobe test, the Speed test, horizontal adduction, the drop-arm test and the strength of the infraspinatus, elbow to body. The diagnoses of bursitis, of partial and of full tear have been established by arthroscopy. The diagnostic value of each of the tests is shown in Table 6. After a very detailed analysis, the authors conclude that to diagnose subacromial impingement, whatever the type, the greatest certitude lay in the combined positivity of three tests: Hawkins, painful arc and the infraspinatus test. For diagnosis of full tear of the cuff, the best combination of positive tests was the painful arc, the drop arm and the infraspinatus test (Table 7). These conclusions do not concern populations of athletes.

We would like to thank Abdou Sbihi for the initial preparation of the manuscript. 

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Maîtrise Orthopédique n° 168 - November 2007
 
 
 
 
 
 
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