Clinical Examination of Lower Limb Deformity

When a child is born, it has 10-15 degrees of physiological genu varum, 5 degree internal tibial torsion and external rotation contracture of the hip. It reaches the maximum by about 9-12 months. This usually gets corrected to neutral by the age of 18-24 months then the limb develops a valgus angulation, which reaches the maximum of about 12 degrees by the age of 3-4 years. This physiologic valgus usually gets corrected to the adult value of 7 degrees of valgus by the age of 8 years. Physiologic valgus is bilateral and symmetrical; less than 15 degrees and the inter-malleolar distance doesn’t exceed 8 centimetres.

Tibial torsion is the angle between the transverse axis of the knee and the transmalleolar axis. The tibia is internally rotated at birth. Internal tibial torsion is 5 degrees at birth and gets corrected to neutral by 4-5 years of age. The tibia then gradually becomes externally rotated and reach the adult value of 20-25 degrees of external rotation by the age of 8 years.

Femoral anteversion is the angle between the transcondylar axis and the longitudinal axis of the femoral neck in the horizontal plane. Femoral anteversion is 40 degrees at birth and reaches the adult value of less than 15 degrees by the age of 8 years. It produces intoeing gait which gradually increases during the first five years of life due to summation of deformities. It gets corrected by 8 years of age.

Deformity is defined as a deviation from normal structure or function which may be symptomatic or has the potential to produce symptoms.

Goals of deformity assessment

The goal of deformity assessment is to answer the following questions.

1. Is there a deformity?

One should be able to differentiate between physiological and pathologic malalignment.

2. What is the deformity?
Identify the name of the deformity.

3. Where is the deformity?
Identify the site of deformity whether it is at the joint level or in the bone. If in the bone, then it is in the epiphysis, metaphysis or diaphysis. Deformities due to tilting of the joint line becomes less when the joint is flexed. This is because the area of contact between the articular surfaces is altered during flexion.

4. Which is the plane of deformity?
Identify the alteration produced by the deformity in all three planes and any associated limb length discrepancy as well. Thus a deformity may have a component of flexion or extension in the sagittal plane, varus or valgus in the coronal plane, internal or external rotation in the axial plane; in addition there may be shortening or lengthening as well.

5. How severe is the deformity?
Identify the severity of deformity in each plane and also the severity of limb length discrepancy. Assess how much of passive correction of the deformity is possible.

6. Why there is a deformity?
Identify the cause of deformity. Identify whether it is a localised problem or part of a systemic disease. Try to detect whether it is due to soft tissue contracture, muscle paralysis or spasm or rupture, joint dislocation or subluxation or malformation and lastly bony malunion or nonunion or deformation.

7. Are there any consequences of the deformity?
Identify whether there are any compensatory malposition of neighbouring joints and secondary effects such as osteoarthritis on the concave side or laxity of ligaments on the convex side. Assess whether it is associated with any secondary joint instability such as patellofemoral instability in genu valgum. Identify how it is affecting the gait or joint function.

8. When does the deformity occur?
Identify whether it is a static or dynamic deformity.

History

From the history try to understand the relevant details about the deformity, look hints that help identify the cause and understand the secondary effects of the deformity and its impact on function. History should start with the following questions.

• How long the deformity is present?
• How did it start?
• How is it progressing?
• Any associated symptoms?
• Is there any history of trauma or infection?
In children get perinatal history
• Did the mother take any drugs during pregnancy especially in the first trimester?
• Did the mother have any infections especially in the first trimester?
• Did the mother have any history of substance abuse?
• Is there any maternal health problems?
• Did prenatal ultrasounds show any abnormality?
• Was there any abnormality in previous pregnancies?
Get a natal history in appropriate case.
• Was it a full term delivery?
• What was the type of delivery?
• What was the type of presentation at birth?
• What was the birth weight?
• Was there any delay in first cry?
• Were there any complications during delivery?
Get details of nutrition to assess the chance of nutritional deficiencies like rickets.
• Vegetarian or non-vegetarian
• Calorie intake
• Food fads
• Exposure to sunlight
• Whether diet is balanced or not
Family history
• H/o similar or other deformities

Developmental history
• When did social smile appear?
• When did the child achieve
• Neck steadiness
• Sitting
• Standing
• Crawling
• Walking
• Stair climbing and descending
• Hand to hand transfer

General Examination

In general examination look for features of generalised ligamentous laxity, general manifestations of rickets or known dysplasias.

Inspection

Inspect the patient in standing, sitting, walking and in the supine position. Inspect from the front, back and both sides. Look for any asymmetry in size, shape and function.
Look at
• Head tilt and rotation
• Level of shoulders, scapula and iliac crests
• Look for spinal deformity such as scoliosis or kyphosis
• Look for lumbar lordosis suggestive of flexion deformity of hip when the patient is supine on a hard surface
• Look for knee deformity in all three planes
• Look for ankle equinus or calcaneus deformity from the side
• Look for any hindfoot varus or valgus from the back
• Look for any forefoot or toe deformity

Palpation

Palpate the bone, soft tissues and joint. Look for change in temperature; limb with post-polio residual contracture is cold. Look for any tenderness and note the site of tenderness. When palpating bony and soft tissues; look for any asymmetry, thickening, swelling or defect.

Movements

Assess the active and passive movements of spine, hip, knee and the foot and ankle. Record the range of movement. Look for restriction of range of movement, pain during joint movement, ligamentous laxity, joint instability and any abnormal sounds during joint movement. While moving the joint passively, watch out for muscle spasm. Movement should be assessed in all three planes depending on the normal movement for that particular joint.

Measurements

Measurement is done to detect any limb length discrepancy, to assess degree of muscle wasting. Limb length discrepancy may be true or functional. True LLD is due to real shortening or lengthening. Functional LLD is due to abnormal joint positioning such as adduction contracture of hip. Girth of the thigh is measured 15 cm above the knee joint line and girth of the calf is measured at the bulkiest area.

In addition measure intercondylar distance between medial femoral condyles in the standing position for genu varum. In cases of genu valgum measure the intermalleolar distance in the standing position.

Torsional profile of the lower limb

Torsional abnormalities may be in the femur, tibia or foot. Torsional abnormalities lead to either in-toeing or out-toeing. Intoeing is more common. Commonest cause of intoeing in children below one year is metatarsus adductus, commonest cause from 1-3 years is internal tibial torsion; and after 3 years of age excessive femoral anteversion is the commonest cause. It is identified by assessment of foot progression angle. Foot progression angle is the angular difference between the direction of walking and the long axis of the foot. If the foot is externally rotated then the angle is positive and if internally rotated then the angle is negative. Normal value for children and adolescents is 10 degrees.

Femoral anteversion is assessed by doing the Craig’s test. It is done in the following method.

Patient position – Prone
Joint position – Knee flexed to 90 degrees.
Procedure- One hand of the examiner is placed flat on the greater trochanter. Hold the leg and gently rotate the hip in both directions till the greater trochanter is maximally prominent. The amount of internal rotation needed to make the greater trochanter maximally prominent is the degree of anteversion.

In addition the range of rotational movement of the hip is also recorded. The patient is made prone and the pelvis is made level. Then rotate the hip internally and externally to the maximum point to which it is maintained by gravity alone. In patients with excessive femoral anteversion, the range of internal rotation is increased and external rotation is diminished. In femoral retroversion, the external rotation is increased and internal rotation diminished.

Tibial torsion is assessed by the thigh foot angle or angle of the transmalleolar axis.

Thigh foot angle is assessed by the following method.

Patient position – Prone
Joint position – Knee flexed to 90 degrees, ankle in neutral position.
Procedure – Measure the angle between the thigh axis and the foot axis. Angle is negative if internally rotated and positive if externally rotated. Normally the angle is 10 degrees in adults. In the newborn, there is 5 degrees internal tibial torsion normally.

If the foot is not normal, then measure the angle of the transmalleolar axis.

Patient position – The patient is asked lie prone on a couch with the knee flexed to 90 degrees.
Procedure – The centre of each malleoli are marked. Connect these points by a line across the plantar surface of the sole. Draw a line perpendicular to it.
Interpretation – The angle between the thigh axis and a line perpendicular to the transmalleolar axis is measured, which is equal to the tibial torsion.

Torsional deformity of the foot is assessed by heel bisector line. Heel bisector line divides the heel into two equal halves in the longitudinal axis. In the normal foot it passes through the second toe. If it passes medial to the second toe, forefoot is abducted and if it passes lateral to the second toe, the forefoot is adducted. If it passes through the third metatarsal, adduction deformity is mild, through fourth metatarsal is considered moderate and through fifth metatarsal is considered to be severe metatarsus adductus.

In newborn feet, V- finger test is done to assess the forefoot adduction. The heel of the child is placed in the second interdigital cleft of the examiner. Normally the lateral border of foot is straight and will be in contact with the examiners finger. If the lateral border of the foot beyond the fifth metatarsal base is not in contact with the examiner’s finger due to medial deviation, then there is metatarsus adductus deformity.

Angular profile of the lower limb

Angular deformities may be physiological or pathological. It is more likely to be pathological if it is unilateral; asymmetrical; painful or if progressive.

Ask the patient to stand with his feet and knee touching each other while the patella is facing forwards. When inspected from the front, there will be a gap between the knees in patients with genu varum. In patients with genu valgum, the ankles will be kept apart. Inspect from the side, specifically looking for equinus or calcaneus deformity of ankle, flexion deformity or hyperextension deformity of knee.

Ask the patient to lie supine on a hard couch and look for any lumbar lordosis suggestive of fixed flexion contracture of hip. If present do the Thomas test to assess the severity of flexion deformity.

Thomas well leg raising test

Patient position- Supine
Examiner position – Stand on the right side of the patient with one hand under the lumbar spine of the patient. With the other hand hold the unaffected side.
Procedure- Flex the unaffected knee fully, then flex the unaffected hip till the excessive lumbar lordosis disappears. Measure the angle between the thigh of the affected side and the couch to assess the angle of fixed flexion deformity of the hip.

Intercondylar distance is measured to assess the severity of genu varum deformity. Ask the patient to stand with his medial malleoli touching each other and then measure the distance between the medial femoral condyles. Intermalleolar distance is measured in patients with genu valgum deformity. Ask the patient to stand with his medial femoral condyles touching each other and the foot should be in neutral rotation, measure the distance between the medial malleoli. Both these measurements have the disadvantage of being influenced by the size of the patient. In this situation, measurement of the tibiofemoral angle using a goniometer is essential. This is measured in the standing position. Lateral thigh leg angle is measured by keeping the arms of the goniometer on the lateral surface of thigh and leg and the hinge of the goniometer at the level of knee. Other method is by keeping the arms of goniometer on the anterior surface of the thigh and leg and the hinge of goniometer over the centre of patella.

In patients with genu valgum one should do the Ober’s test to rule out ITB contracture and assess the patient for patellofemoral instability. Measure the standing height, sitting height and arm span of the patient.

Assessment of lower limb length discrepancy

Limb length discrepancy(LLD) may be true or functional. True limb length discrepancy is due to shortening or lengthening of bone or joint dislocation. Functional LLD is due to abnormal joint positioning such as pelvic obliquity due to adduction contracture or flexion deformity of knee.

LLD may be due to abnormal pelvic height, femoral length, tibial length or foot height. LLD may lead to abnormal gait, cosmetic problem, osteoarthritis due to abnormal weight transmission or low backache. LLD up to 2 cm at skeletal maturity is considered physiological as only about 25-30% of normal population have equal limb length. Left lower limb is longer than the right in a ratio of 3.5:1.

When the patient is standing; assess whether the shoulder, iliac crest and the popliteal and the gluteal creases are at the same level. Look for compensatory scoliosis, which will disappear if the patient is made to sit. LLD may be masked by flexion of opposite knee and plantar flexion of ankle.

LLD is best measured using blocks of known height under the foot of the affected side; till the pelvis is level and the compensatory lordosis disappears. Lower limb length measurement includes measurement of the whole lower limb and measurement of length of individual limb segments. Whole length measurement is done either by placing blocks of known thickness under the shorter limb till the pelvis is level or by measuring using a measuring tape.

With measuring tape; measure both the true length and apparent length. Apparent length is measured from the xiphisternum or umbilicus to the inferior tip of the medial malleolus when the limbs are kept parallel. To measure the true length, both the limbs should be kept in an identical position. Hence if there is a fixed adduction deformity of hip; first make the pelvis level by adducting the affected hip till both the anterior superior iliac spines (ASIS) are at the same level. Measure the true length if the affected limb from the inferior edge of ASIS to the inferior edge of medial malleolus. Now keep the opposite hip also in an identical degree of adduction and then measure the other side as well.

The lower limb has 4 segments; supratrochanteric (pelvic), infratrochanteric (femur), tibial and foot segments. Infratrochanteric segment is measured from the tip of greater trochanter to the lateral joint line of knee. Tibial segment is measured from the medial joint line of knee to the tip of medial malleolus.

Supratrochanteric segment is measured by drawing the Bryant’s triangle, Nelaton’s line or Shoemaker’s line. Bryant’s triangle is drawn by drawing three lines in the supine position. First line from the inferior edge ASIS vertically down towards the examination table. Second line is drawn from the ASIS to the tip of greater trochanter. Third line is from tip of trochanter to the first line. Measure each sides of the triangle and compare with the other lower limb. Difference in the length of third line suggests supratrochanteric shortening. Supratrochanteric shortening may be due to hip arthritis, hip dislocation, fracture neck of femur or coxa vara.

Galeazzi test or Allis test

Patient is supine on the table. Flex both the hip and knees and place both the feet together. Note the level of knee. In case of LLD the levels will be different. Now look from the side. If the shortening is in the femoral segment; the level of knee will be proximal to the other knee and if shortening is in the tibial segment, knee will be distal to other knee.

Cover-up test

Done between the ages of 1-3 years. The child is either standing or lying supine. The part of tibia distal to the proximal third is covered by a hand and observe the angular relationship between the thigh and proximal tibia. If in neutral or valgus, no need to observe for tibia vara. If in varus then observe to rule out tibia vara.

Suggested reading

1. Pauwels F. Biomechanics of the locomotor apparatus. New York: Springer Verlag, 1980.
2. Chao EYS, Neluheni EVD, Hsu RWW, Paley D. Biomechanics of malalignment. Orth Clin N.A. 25: 379-386, 1994.
3. Moreland JR, Bassett LW, Hanker GJ. Radiographic analysis of the axial alignment of the lower extremity. J. Bone Joint Surg, 69A: 745-749, 1987.
4. Andriacchi TP. Dynamics of knee malalignment. Orth Clin N.A., 25: 395 406, 1984.
5. Paley D, Tetsworth K. Malalignment and realignment of the lower extremity. Orth Clin N. A., 25:355-367, 1994.
6. Paley D,Herzenberg JE,Tetsworth K et al. Deformity planning for frontal and sagittal plane corrective osteotomies. Orthop Clin North Am. 1994;25:425-465
7. Salenius P, Vankka E. The development of the tibiofemoral angle in children. J Bone Joint Surg Am 1975;57:259-61
8. Bruce RW Jr. Torsional and angular deformities. Pediatric Clinics of North America 1996:43:867-81.
9. Staheli LT, Corbett M, Wyss G, King H. Lower extremity rotational problems in children. Normal values to guide management. J Bone Joint Surg Am 1985;67:39-47

 

Posted by Dr Rajesh Purushothaman, Associate Professor, Government Medical College, Kozhikode, Kerala, India

Examination of shoulder

Shoulder symptoms may be due intrinsic causes or referred causes due to spine, thorax or abdomen pathology. Hence it is important to rule out referred causes for shoulder pain.

History

Should include age, handedness, occupational and recreational activities and the shoulder symptoms. In patients with pain; ask for the exact site, duration, onset, progress, character, radiation, associated symptoms, aggravating factors and relieving factors. In case of left sided shoulder pain ask for cardiac symptoms. Patient should be asked to point out the site of pain with a single finger. If site is over the lateral arm especially during overhead activity, the cause is likely to be rotator cuff pathology or impingement. Superior pain especially on adduction is suggestive of acromioclavicular pathology. Anterior shoulder pain may be due to long head of biceps pathology. Deep shoulder pain is likely to be due to glenohumeral pathology or labral lesions.
In patients with instability; ask for the duration, onset, frequency, precipitating posture or activity, position of shoulder after the dislocation, and how it gets corrected after an episode. Also ask for history of epilepsy as posterior instability is more likely in such patients. Also look for history suggestive of voluntary dislocation.

Glenohumeral instability has been classified according to the cause and direction. Cause can be classified into traumatic and atraumatic. Atraumatic instability develops either due to laxity or overuse. Direction of instability can be classified into anterior, posterior, inferior and multidirectional. If history of trauma is not present then careful history of occupational and recreational activities must be made to identify overuse. Position of arm at the moment of instability is very helpful in the identification of the direction of instability. In anterior instability, the shoulder will be abducted, externally rotated and extended. In posterior instability, the shoulder is adducted, internally rotated and flexed. In inferior instability, the arm is abducted and the hand is supported over the head.
Anterior instability causes pain during late cocking phase of throwing due to anteroinferior capsule laxity. Posterior instability causes pain during follow through phase. Patients with anterior instability may present with dead arm syndrome; paralysing pain in the maximally externally rotated, abducted and extended position.

Different age groups have different causes for their presentation. Patients <25 years present due to traumatic dislocations, recurrent instability or acromioclavicular pathology. Adults below 40 years present due to impingement, frozen shoulder or ACJ arthritis; and those over 40 years present due to rotator cuff impingement or tear and osteoarthritis of glenohumeral or acromioclavicular joint. The steps of physical examination of shoulder is determined by patient's presenting complaints and history. The entire region from the cervical spine to the hand should be examined.

Inspection

Patient should be dressed in such a manner that shoulder can be assessed fully. Observe the posture and the bony and soft tissue contour of both shoulders and look for any asymmetry. Observe whether the pelvis is level and the spine is straight as their malalignment may cause secondary shoulder abnormality.

Drooping of shoulder may be caused by trapezius palsy. Winging of scapula is abnormal prominence of vertebral border of scapula. Winging can be produced by injury, dysfunction of muscles and nerve palsy. It may be dynamic or static. Dynamic winging may be due to trapezius palsy or serratus anterior palsy. True winging is due to serratus anterior palsy. Serratus anterior supplied by long thoracic nerve, and it’s action is protraction of the scapula. It’s function is tested by asking the patient to stand at an arm length from wall and push against it. Pseudowinging is produced by trapezius palsy, acromioclavicular dislocation and scapular dysrrhythmia. In trapezius palsy, winging is more during abduction of shoulder, the inferior angle of shoulder is rotated laterally and it is more obvious when the patient stoops forward so that the body so parallel to the floor and then tries to abduct the shoulder. In serratus anterior palsy, winging is more pronounced during forward flexion of the shoulder and the inferior angle of scapula is rotated medially. Winging may also occur due to scapular muscle dysrrhythmia due to shoulder instability or rotator cuff tear. It may also occur acromioclavicular joint dislocation with ruptured coracoclavicular ligaments or fracture of outer third of clavicle.

A step deformity may be seen at the ACJ in dislocations of the ACJ. Contour of clavicle may be altered in case of clavicle malunion or nonunion. Popeye sign of abnormal prominence of biceps is seen in patients with long head of biceps rupture. Abnormal contour of anterior auxiliary fold and pectoralis major is seen patients with pectoralis major tendon rupture and Poland syndrome. Wasting of supraspinatus and infraspinatus may be seen.

Palpation

Feel for local rise of temperature. Stand on the back of the patient and palpate the structures of the shoulder using the Kochers method of palpation starting at the sternoclavicular joint and moving laterally over the clavicle, ACJ, coracoid, spine of scapula and down the humerus. Look for tenderness, irregularity, thickening, defect, abnormal mobility etc. Biceps tendon should be palpated in its groove anteriorly.

The tenderness over the glenohumeral joint is elicited anteriorly over a point 1cm inferior and lateral to the coracoid process and posteriorly over the point 2cm medial and inferior to the angle of acromion. Diffuse tenderness over the trapezius and interscapular area may be seen in patients with shoulder instability and scapular dysrrhythmia due to abnormal shoulder biomechanics.

Movements

Assess range of motion using the recommendations of the American Shoulder and Elbow Surgeons Research Committee 1. Abduction is tested in the scapular plane (30 degree- anteriorly)and not in the coronal axis of the body. Ideally patient should be stripped to the waist and examiner should stand behind the patient and both shoulders are abducted simultaneously. In the resting position the vertebral border of both scapula should be equidistant from the vertebral column. Both scapula should move symmetrically when the arm is abducted, asymmetrical movement is noted as scapular dyskinesis. Normally the ratio of glenohumeral to scapulothoracic movement on abduction is 2:1.

Shrug sign is seen in patients with supraspinatus dysfunction, the patient shrugs at the beginning of abduction to substitute glenohumeral abduction by supraspinatus with scapulothoracic motion. If there is abnormal prominence of vertebral border then there is dynamic scapular winging. Maximum achievable angle between the humerus and thorax is recorded as shoulder elevation. Internal and external rotation are measured in 90 flexion of elbow and with arm by the side of body and in 90 abduction of shoulder. Rotations are better tested in the supine position after applying pressure over the anterior shoulder to fix the scapula.

Strength testing

Strength of rotator cuff muscles are measured. Supraspinatus is assessed in the empty can position; 90 abduction of shoulder with elbow straight and shoulder in the fully internally rotated position with the thumb pointing downwards and the patient is asked to abduct further against resistance. Strength of infraspinatus is measured with the arm in 90º abduction, elbow at 90º flexion and the patient is asked to externally rotate against resistance.

Special tests

May be classified into
Tests for impingement
Tests for laxity
Tests for instability
Tests for rotator cuff disease
Tests for SLAP
Tests for biceps tendon
Tests for ACJ
Tests for cervical disc disease

1. Tests for impingement

Neer impingement sign- (Forced forward elevation test)

Examiner position- Stand next to the patient with one hand over the top of shoulder and other hand holding the patient’s arm.
Patient position- Standing.
Joint position- Arm by the side of body
Procedure- Stabilise the scapula with one hand, passively flex the shoulder fully and then push further.
Interpretation- Pain is due to rotator cuff impingement. Test is 79% sensitive and 53% specific.

Hawkins-Kennedy test(Forced internal rotation test)

Examiner position- Stand in front of the patient.
Patient position- Standing.
Procedure- Flex the arm and elbow to 90 degrees and then internally rotate the shoulder using the flexed forearm as a lever.
Interpretation- Test is positive if pain is reported. Test is 79% sensitive and 59% specific.

Neer impingement test

Inject 10 ml of 1% lidocaine into the subacromial space using a sterile technique. Then ask the patient to actively abduct. Relief of pain for the duration of the anesthetic effect is confirmatory of impingement.

2. Tests for laxity

Anterior drawer test

Described by Gerber and Ganz.
Examiner position- Stand on the affected side
Patient position- Supine. Patient’s hand is stabilised in the axilla of examiner.
Joint position- Shoulder in 80-120 abduction, 0-20 forward flexion, 0-30 external rotation.
Procedure- Stabilise the shoulder with one hand, grasp the proximal humerus with the other hand. Apply anterior translation force.
Interpretation – Click and abnormal laxity indicate anterior instability. Grade the degree of translation.
0- None or minimal when compared to contralateral shoulder.
1+ – Up to glenoid rim.
2+- Beyond glenoid rim and spontaneously relocates.
3+- Dislocates and doesn’t reduce spontaneously.

Posterior drawer test

Described by Gerber and Ganz.
Patient position- Supine.
Joint position- Shoulder in 80-120 abduction, 20 forward flexion, 60-80 internal rotation.
Procedure- Stabilise the shoulder, grasp the proximal humerus. Apply posterior translation force.
Interpretation- Click and abnormal laxity indicate posterior instability. Grade the degree of translation.

Load and shift test

Described by Silliman and Hawkins
Patient position- Sitting
Joint position- Arm by the side and hand resting in the lap of patient
Procedure- Stabilise the shoulder with one hand, grasp the proximal humerus with the other hand. Load the humeral head against the glenoid and then slide the head anteriorly and posteriorly
Interpretation- Look for abnormal anterior translation, which suggest anterior instability. Grade the translation.

Sulcus sign

Described by Neer and Foster.
Patient position- Sitting
Joint position- Arm by the side and hand resting in the lap of patient
Procedure- Hold the elbow of the patient with one hand and then stabilise the shoulder with other hand and then apply longitudinal traction.
Interpretation- Appearance of a gap more than the other side below the acromion suggest inferior capsular laxity. It is indicative of multidirectional instability. Grading – 1+ -0-1cm, 2+- 1-2cm, 3+- >2cm.
Recent modification- Now externally rotate the shoulder, if the gap persists then rotator interval is likely to be defective.

Gagey hyperabduction test

Principle – Tests inferior glenohumeral ligament complex.
Patient position – Sitting
Examiner position – Behind seated patient
Joint position – Arm by the side of body.
Procedure – Place the forearm of examiner on the top of shoulder to stabilise the scapula. Abduct the shoulder of patient maximally and note the range of abduction till the scapula start moving.
Interpretation – Normal range of passive abduction is 105 degrees. If it is more then there is IGL laxity.

3. Tests for Instability

Glenohumeral laxity is the ability to translate the humeral head to glenoid rim and glenohumeral instability is the unwanted translation of humeral head on the glenoid that compromises patient comfort and shoulder function. Multidirectional instability is instability in two or more directions and the hallmark of inferior instability is positive sulcus sign.

Apprehension test

Patient position- Supine,
Joint position- Shoulder in 90 abduction, elbow in 90 flexion.
Procedure- Maximally externally rotate shoulder while applying anteriorly directed pressure.
Interpretation- Look for apprehension.

Jobe apprehension relocation test

If apprehension is present with previous test, repeat the test with posteriorly directed pressure. Absence of apprehension is confirmatory of anterior instability. This test is the gold standard for the diagnosis of anterior instability. With apprehension as the criteria for diagnosis; it shows 85% accuracy, 68% specificity, 100% sensitivity, 100% positive predictive value and 78% negative predictive value.

Jerk test
Patient position- Supine
Joint position- Shoulder abducted to 90, elbow flexed to 90.
Procedure- Grasp elbow. Axially load the shoulder. Adduct the shoulder horizontally across the body
Interpretation- Clunk and pain in presence of posterior instability. Return to abducted position may produce another jerk due to relocation of joint.
Reliability – 90% sensitivity, 85% specificity, 72% positive predictive value and 94% negative predictive value. 10

4. Tests for rotator cuff disease

Jobe empty can test

Ask the patient to actively abduct the shoulder in the scapular plane with the elbow in extension with the shoulder in full internal rotation and the thumb pointing down.4 Reinard identified by electrical studies that more fibres of supraspinatus are active if the test is done with the thumb pointing up (Full can test) and may be more useful.5. Jobs test has 75% accuracy in detection of supraspinatus tear. 6
Integrity of subscapularis is assessed separately for the upper fibres and lower fibres.

Lift off test

Lower fibres are tested by the lift-off test; ask the patient to place the dorsum of the hand against the small of back and then lift the hand posteriorly away from the body against resistance. Inability to lift the hand indicate subscapularis tear.

Belly press test

Upper fibres are tested by the belly press test; patient is asked to place his palm against the umbilicus and push against the abdomen. Inability to do this indicate subscapularis tear.

Drop sign

Done to detect infraspinatus tear. Patient is asked to lie in the lateral decubitus position with the affected side up. Flex the shoulder and elbow to 90 degrees. Hold the wrist and externally rotate to the maximum. Now release the wrist and ask the patient to hold the limb in external rotation. In presence of infraspinatus tear, he will not be able to do this.

5. Tests for Superior labrum Anterior Posterior (SLAP) lesion

Numerous tests are available, but they are of 2 types; active tests which try to recreate the torsional traction force that caused the injury or passive tests that exert compressive stress on the labrum. O’Brien test is an active test and crank test is a passive test.

O’Brien’s test (Active compression test)

Patient position- Standing.
Examiner position – By the side with one hand on shoulder and other hand on the distal forearm.
Joint position- Forward flexion of shoulder to 90, adduction of 10-15, fully internally rotated. Elbow straight. Thumb pointing down.
Procedure- Elevate against resistance. Repeat with shoulder in external rotation.
Interpretation – Pain in internal rotated position and absence of pain in external rotation suggestive of SLAP lesion. Ask about the location of pain, if it is over the acromioclavicular joint then the test is negative.
Sensitivity- 90%
Specificity- 98%

Crank test(Compression rotation test)

Patient position – Supine
Joint position- Shoulder in 160 abduction, 30 forward flexion. Elbow flexed
Procedure- Stabilise scapula with one hand, grasp the elbow with the other hand. Axially load and rotate externally and internally.
Interpretation- Pain and reproduction of patient’s symptoms indicate labral pathology
Reliability – 91% sensitive, 93% specific, 94% positive predictive value, 90% negative predictive value.

Resisted supination external rotation test

Patient position- Supine.
Joint position- Shoulder 90 abducted, elbow 70 flexed, forearm semipronated.
Procedure- Externally rotate the shoulder and ask the patient to supinate the forearm against resistance.
Interpretation- Pain indicative of SLAP lesion.

Anterior slide test

Patient position – Standing.
Joint position – Hand on hips with thumb pointing posteriorly.
Procedure – Apply forward and axial pressure over the elbow and ask the patient to resist.
Interpretation – Pain indicate superior labral pathology.
Reliability – 78% sensitive and 90% sensitive for type II SLAP lesion.

6. Test for Biceps long head

Pathology may be tendinitis, tear, instability of the long head of biceps or synovitis of its sheath.

Speed test

Patient position- Standing.
Examiner position- By the side of patient with one hand over shoulder and other hand over the anterior aspect of distal forearm.
Joint position – Shoulder forward flexed by 60. Elbow extended. Forearm supinated.
Procedure- Flex the shoulder against resistance with elbow kept straight.
Interpretation – Anterior shoulder pain indicate long head of biceps pathology.
Sensitivity- 90%
Specificity – 14%
Reference – Bennet WF. Arthroscopy. 1998 Nov‐Dec;14(8):789‐96

Yergason test

7. Tests for acromioclavicular joint

Horizontal adduction test- The shoulder is passively elevated to horizontal and the arm is adducted across the body beyond the full range. Ask the patient if there is pain and the site of pain. If pain is located over the ACJ then the test is positive for ACJ pathology. Test is 77% sensitive and 79% specific with an accuracy of 79%

8. Test for cervical spine

Spurling test
Patient position – Sitting
Joint position – Neck flexed forward and tilted laterally.
Procedure – Apply axial load over the head.
Interpretation- Reproduction of patient’s symptom of radiating pain indicate cervical root pathology.

Further Reading

Richards RR, An KN, Bigiliani LU et al: A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994; 3:347-52

Chronopoulos E, Kim TK, Park HB, et al. Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. Am J Sports Med . 2004;32(3):655-661

Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med . 2008;42(2):80-92

Jobe FW, Jobe CM. Painful athletic injuries of the shoulder. Clin Orthop Relat Res . 1983;(173): 117-124.

Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train . 2007;42(4):464-469.

Itoi E, Kido T, Sano A, et al. Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon? Am J Sports Med . 1999;27(1):65-68.

Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle: clinical features in 16 cases. J Bone Joint Surg Br . 1991;73(3):389-394.

Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am . 1992;74(1):53-66

Speer KP, Hannafi n JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test. Am J Sports Med . 1994;22(2):177-183

Kim SH, Park JC, Park JS, Oh I. Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med . 2004;32(8):1849-1855

O’Brien SJ, Pagnani MJ, Fealy S, et al: The active compression test: A new and effective test for diagnosing labral tears and acromio-clavicular joint abnormality. Am J Sports Med 26: 610–613, 1998

Parentis MA, Mohr KJ, ElAttrache NS: Disorders of the superior labrum: Review andtreatment guidelines. Clin Orthop 400: 77–87, 2002

Posted by Dr Rajesh Purushothaman, Associate Professor, Government Medical College, Kozhikode, Kerala, India

Copyright @Dr Rajesh Purushothaman, Associate Professor, Government Medical College, Kozhikode, Kerala, India