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ABSTRACT
Examination of the shoulder complex has long been described as challenging. This is particularly true in
the examination of the overhead athlete who has structural differences when compared to a shoulder
patient who is a non-athlete. Complexity with the examination is due to unique biomechanical and struc-
tural changes, multiple joint articulations, multiple pain patterns, and the potential of injury to structures
both inside (intra-articular) and outside (extra-articular) the glenohumeral joint. Repetitive stresses placed
on the shoulders of overhead athletes may affect range of motion, strength, scapular position, and ulti-
mately, the integrity of soft tissue and bony structures in any of the joints that comprise the shoulder com-
plex. Furthermore, many shoulder examination tests thought to be unique to a single structure, joint, or
condition can be positive in multiple conditions. The examination of the overhead athletes shoulder, cou-
pled with a thorough medical history will provide a solid foundation to allow a functional physical therapy
diagnosis and provide clues as to the presence of the lesion (s) causing disability. The purpose of this clini-
cal commentary is to assist the reader to understand the unique physical characteristics of the overhead
athlete, which will lead to a more accurate and reproducible evaluation of athletes who sustain injuries
while participating in overhead sports.
Keywords: Overhead athlete, physical examination, shoulder
Level of Evidence: 5
CORRESPONDING AUTHOR
Robert Manske, PT, DPT, MEd, SCS, ATC, CSCS
Wichita State University – Department of
1
Physical Therapy
Wichita State University – Department of Physical Therapy,
Wichita, KS, USA Via Christi Health Sports and Orthopedic
2
Via Christi Health Sports and Orthopedic Physical Therapy, Physical Therapy
Wichita, KS, USA
3
Physiotherapy Associates Scottsdale AZ, USA Wichita, KS, USA
4
Medical Services – ATP World Tour Email: Robert.manske@wichita.edu
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 554
INTRODUCTION joints, rotator cuff or scapular strength and endur-
The overhead and throwing/serving athlete is a ance deficits, postural dysfunctions, and improper
very unique sports patient. In overhead athletes, training. Additionally when and athlete has a pain-
the kinetic energy and force created in the lower ful shoulder, this pain can be caused by numerous
extremities, pelvis and trunk is funneled through conditions. Anterior shoulder pain can be caused by
the shoulder complex including the glenohumeral, pathology such as tendinosis, partial thickness RC
scapulothoracic, acromioclavicular, and sternocla- tears, full thickness RC tears, calcific tendonitis, and
vicular joints ultimately resulting in maximal distal biceps tendon disorders, instability, superior labrum
upper extremity segmental velocity needed for opti- injuries, and coracoid impingement. To complicate
mal overhead performance. The arm, elbow, wrist, matters even further, some of these problems occur
and hand then add to that force and provide the fine from relatively uncommon pathologies rarely seen
tuning required in order to direct (or target) the cre- by the average clinician. These could include venous
ated energy into a specific action such as placing a occlusions, arterial lesions, nerve lesions (such as of
pitch or serve.1 Stresses placed upon the shoulder the long thoracic nerve or brachial plexus), or tho-
complex of the overhead athlete push the anatomi- racic outlet syndrome. Finally, note that it is not
cal limits of the shoulders physiological capacity. uncommon for the physical stresses endured by
During the throwing motion, angular velocity of the the overhead athlete to cause stress fractures of the
shoulder reaches over 7000 degrees per second.2,3 humerus or scapula.9,10
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 555
Table 1. History Questions for the Overhead Athlete Examination.
flexion and extension and lateral flexion and rota- progress the athlete may have pain with throwing
tion, as well as the quadrant or Spurling tests, are or may even be severe enough that they are now
commonly used to clear the cervical spine and rule unable to throw.
out radicular symptoms.11 Tong et al tested the Spurl-
For baseball and tennis athletes it is not simply
ing maneuver to determine it’s diagnostic accuracy.11
enough to ask if there are symptoms during throw-
The Spurling test had a sensitivity of 30% and speci-
ing or serving. The sports therapist must be more
ficity of 93%. Caution therefore must be used when
detailed and identify where within the throwing or
basing the clinical diagnosis solely on this examina-
serving motion does the symptom occur? Is it in the
tion maneuver. The test is not sensitive but is specific
cocking stages, the follow-through or somewhere in
for cervical radiculopathy and therefore can be used
between? Additionally, asking whether any equip-
to help confirm a cervical radiculopathy. This test is
ment changes have been made such as changes in
an excellent overall screening test that is applicable
string type or tension, racquet style/weight or grip
during examination of the overhead athlete.
changes can have enormous consequences on the
Determining the reactivity of shoulder injury is com- musculoskeletal system in the tennis player.
monly done through several mechanisms. The use of
a pain diagram or analog pain scale will help deter-
Observation and Posture
mine the patient’s perception of amount of pain in
The actual clinical examination begins by assessing
shoulder. Trying to determine the reactivity or irrita-
and observing the shoulder and arm and viewing
bility of a shoulder and surrounding structures helps
posture. A relaxed standing position is a good place
guide how the remainder of the examination should
to determine the posture of the head on the tho-
be organized. In an athlete with a highly reactive
rax. Forward head posture places significant strain
shoulder there is probably considerable pain, prob-
on cervical spine and upper thoracic musculature.
able limitations of motion and strength. In an ath-
The authors typically subjectively grade the amount
lete with a mildly reactive shoulder the pain may
of forward head as normal, minimal, moderate or
be minimal or only present with overhead activity.
severe pending the distance of the external auditory
Their symptoms may be minimal to absent when
meatus from the lateral tip of the acromion. Slight
they are not doing overhead activities, but signifi-
forward head position is not uncommon in overhead
cantly limited when throwing or serving.
athletes. The clinician should then note any abnor-
The symptoms experienced by overhead athletes malities seen in or around the shoulder initially
are generally of insidious onset, and as such they with the athlete’s arms at rest by their sides. Abnor-
may be subtle and initially may not alter an athlete’s malities could include bruising or discolorations,
performance. Symptoms can be vague and described unusual bumps, protrusions, or decreased contour
as inability to “loosen up” or “warm-up”, or they may of muscle that could be caused by swelling, thicken-
complain that they cannot find their normal velocity ing, or muscle atrophy. In most cases the dominant
or they have trouble with control. As they symptoms extremity is positioned slightly lower than the non
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 556
-dominant side, and is associated with and known coupled motions include superior and inferior trans-
as handedness.12 This is especially true of unilater- lations and protraction and retraction translations.
ally dominant sports such as baseball and tennis. During any overhead shoulder motion in the healthy
Theories for handedness include increased laxity, person the scapula must upwardly rotate, tilt posteri-
increased muscle mass, increased weight, and elon- orly, and externally rotate.13
gated soft tissue due to repetitive eccentric loading
When muscle performance is impaired by loss of
during sporting activities. Further examination can
motor control, strength, or endurance, scapular
be done in the hands-on-hips position (Figure 1)
dyskinesis will be produced with overhead shoul-
in which shoulders are abducted about 45 degrees.
der motions. To better examine the dyskinesis, the
Hands are also placed on the hips so that the thumbs
athlete can be asked to repetitively lift the extremi-
point posteriorly on the iliac crest creating shoulder
ties overhead or an axial load can be applied. Special
internal rotation. In this position it is easy for the
tests for scapular dysfunction will be described in
clinician to note asymmetries of rotator cuff or pos-
the special testing portion of this commentary.
terior scapular muscles, or abnormal postures such
as scapular internal rotation (winging) or anterior
Range of Motion
tilting (tipping). Muscular atrophy in areas such as
One of the unique abilities of being a rehabilitation
infraspinatus or supraspinatus fossa could indicate
clinician is our clear understanding of assessment of
rotator cuff tears or suprascapular nerve involve-
shoulder range of motion. One cannot discount the
ment. This can occur in the face of minimal symp-
crucial information that is gained from a detailed,
toms or discomfort.
isolated assessment of glenohumeral motion in evalu-
Evaluation of the scapulthoracic joint must be per- ation of the athlete with shoulder complex dysfunc-
formed as an integral component of any complete tion. Although historically some have described visual
shoulder complex examination. Although it is beyond observation of motion during the clinical examina-
the scope of this commentary a clear understanding tion the authors of this commentary recommend
of scapulohumeral mechanics is extremely useful. use of a universal goniometer of some fashion. The
Coupled scapular motions include both rotations and overhead athlete has several distinguishing charac-
translational movements. Rotations include upward teristics related to glenohumeral motion. Most over-
and downward rotation, internal and external rota- head athletes exhibit an excessive amount of external
tions, and anterior and posterior tilting. Translational rotation (ER) and a decrease in internal rotation (IR)
when measured from 90⬚ of abduction.14,15 This physi-
ological adaptation to the throwing shoulder occurs in
those that play baseball, softball, and tennis.16-21 Fur-
thermore this increase in shoulder ER and decrease
in shoulder IR is seen in both active and passive
motions.17,22,23
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 557
process for scapular motion (Figure 2). When scapular
motion is initially detected the arm is held in place and
the measurement is taken with a handheld goniome-
ter. For completeness shoulder rotation should also be
measured with the arm at 0 degrees of abduction at the
side (Figure 3). Measurements taken using goniometers
consistently show good intra-observer reliability and
modest inter-observer reliability with most measure-
ments demonstrating accuracy only up to 5 degrees.25-26
McFarland suggests that clinically relevant differences
in shoulder range of motion measurements for activi-
ties of daily living may be as high as 15 degrees.4
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 558
these may actually create too much mobility which It is important to consider the relationship of both pain
would increase stress to surrounding soft tissues and and posture on results of the performance of MMTs. It
capsular restraints. Therefore a loss of GIRD by itself is very common for pain or apprehension to invali-
may be considered a normal shoulder variant in the date an athlete’s true strength measurements due to
overhead athlete. Manske et al31 has proposed adopting a reflexive inhibition of motor units in an inflamed or
two forms of GIRD, one which is a normal loss of IR irritated muscle. Likewise poor posture can place rota-
with a concomitant equal or near equal gain in ER and tor cuff and scapular muscles into a state of length-
symmetrical TROM, and another which would be con- ened or shortened positions creating alterations of
sidered pathologic in which a concomitant increased normal length tension relationships that theoretically
ER has not occurred or there is a significant loss of could alter the ability to produce force during standard
TROM on the involved side. Anatomical GIRD (aGIRD) MMT procedures. Kibler et al35 have shown significant
is a normal loss of IR alone with adequate ER gain and differences in rotator cuff strength when measured in
TROM within 5 degrees of the uninvolved sides. Patho- either protracted or retracted postures of the scapula.
logic GIRD (pGIRD) occurs when the shoulder has Standardizing scapular positioning during testing is
GIRD and a concomitant loss of TROM > 5 degrees, or an important consideration to ensure accuracy with
an increase in external rotation deficiency. MMT in the overhead athlete.35 This is an area of con-
troversy as Smith et al and Smith et al, have found that
Wilk et al32 recently have introduced a concept
MMT around the shoulder produce the most force
referred to as external rotation deficiency (ERD).
with the scapula in a neutral position rather than in
External rotation deficiency is defined as the differ-
either retracted or protracted positions.36,37
ence between ER of the throwing shoulder and the
non-throwing shoulder of less than 5 degrees. When A “break test” in which the examiner applies the force to
evaluating a throwers shoulder one would expect to the limb or a “make” test in which the examiner allows
see an ER difference of greater than 5 degrees which the patient to exert the force against their limb can both
would indicate that the gain in ER on the throwing be used. Because the examiner is not in control of the
side is enough to tolerate the stress of throwing. force given during the “make” test it may be more dif-
ficult to grade accurately. In instances where the clini-
Other important shoulder motions measurements used
cian feels that pain may be involved either starting the
to exam an overhead athlete include shoulder elevation
“break” test with light resistance or allowing the patient
(forward flexion and abduction), and both horizontal
to exert during the “make” test may be useful to not cre-
abduction and adduction. Each of these motions should
ate an exaggerated pain response during testing.
be easily achieveable both actively and passively to
allow enough mobility to achieve the extremes of phys- Another commonly overlooked element of MMT is
iologic motions required for pitching, serving, etc. the use of palpation to ensure you are testing the
appropriate musculature. Especially in instance of
Strength Assessment weakness in the muscles which could be caused by
When performing a comprehensive examination of overuse, trauma or neurological issues, palpation is
the athletes shoulder a clinically relevant method critical to ensure that testing is eliciting the appro-
of strength assessment must be used. With over 100 priate response or not. This is especially true in the
years of utilization, manual muscle testing (MMT) is rare instances of extremely weak muscles due to
the method of choice for most practicing clinicians. neurologic issues such as long thoracic nerve palsy,
Complete coverage of all manual muscle tests used thoracic outlet, or suprascapular nerve involvement,
in the upper extremity is beyond the scope of this all of which can occur in overhead athletes.
article. However there are several excellent texts Table 2 describes easy methods to clinically assess
that describe in detail MMT of the entire body.33,34 strength of various shoulder muscles during the
Although the importance of examining the entire clinical evaluation. Although some of these positions
kinetic chain is recognized, this commentary will may be different than standard MMT as described in
focus upon the importance of the axioscapular, scapu- published textbooks, they are recommended by the
lohumeral, and scapulothoracic muscle groups. authors of this commentary.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 559
Table 2. Manual Muscle Testing Technique and Position.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 560
weakness, inhibition, or loss of motor control this
smooth and coordinated movement becomes dys-
functional. Pathologies such as instability or labral
pathology are common in shoulder patients with dys-
function.38 Furthermore scapular stabilizer muscles
such as the lower trapezius and serratus anterior
are highly susceptible to inhibition in early stages
of shoulder dysfunction resulting in dyskinesis.39,40
Scapular dyskinesis has been defined as “an observ-
able alteration of the position and motion of the scap-
ula relative to the thoracic cage.”41,42 This inhibition
may be demonstrated by a lack of scapular control
and disorganization of normal firing patterns or a loss
of strength and ability to exert torque and stabilize the Figure 4. Kibler type I scapular dyskinesis with inferior angle
scapular during normal movement patterns. protruding dorsally.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 561
with the assessment of scapular position to try to
further implicate scapular pathology as being part of
the pathological process in a dysfunctional overhead
athletes shoulder. These tests include the Kibler
lateral scapular slide test, scapular assistance test,
scapular retraction test, and the flip sign.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 562
test. Additionally, a positive SAT occurs when greater
ROM or decreased pain (negation of impingement
type symptoms) occurs during the examiners assis-
tance of the scapular upward rotation. Inter-rater
reliability of the SAT and found coefficient of agree-
ments ranging between 77% and 91% (kappa range
0.53-0.62) for flexion and scapular plane movements
concluding that this test is acceptable for clinical
use.50 The scapular assistance test can also be per-
formed with the athletes shoulder in abduction and
external rotation in a more provocative position
commonly seen during the cocking and acceleration
phase of the throwing motion or tennis serve (Fig-
ure 8). Kibler et al have also shown an increase in
the posterior tilt of the scapula by 7⬚ as well as move- Figure 9. Scapular retraction test performed in scapular plane
ment improvement with a decrease in pain ratings elevation.
of 56 % (8 mm VAS) during application of stabiliza-
tion by the clinician.51 SRT showed an increase of 5⬚ of scapular retraction
during application of the clinician’s pressure created
Scapular Retraction Test (SRT) by moving the scapula into retraction during this
The SRT involves retraction of the scapula manu- maneuver. Additionally, mean increases of 12⬚ of
ally by the examiner while a movement that previ- posterior tilting, and a reduction of scapular IR by 8⬚
ously was either unable to be performed secondary occurred during the performance of the SRT. These
to weakness or loss of stability or a movement that favorable kinematic changes during the application
was painful.42,52 Manual retraction of the scapula is of the SRT place the GH joint in a biomechanically
performed by compression of the scapular medial favorable position for overhead function. Additional
border as the athlete repeats of the index movement applications of the SRT include stabilizing the scap-
that provoked symptoms without scapular retrac- ula in a retracted position during manual muscle
tion (Figure 9). Research by Kibler52 profiling the testing (MMT). Kibler et al have reported increases
kinematic and neuromuscular actions during the in muscular strength of the shoulder while perform-
ing the empty can maneuver during the SRT with
mean strength increases of 24% with scapular sta-
bilization.35 The use of this maneuver demonstrates
the important role proximal stabilization plays in
shoulder function and can educate the patient on
the need and result of improved scapular control
and stabilization.
Flip Sign
Kelley et al53 originally described this flip test which
performed by the examiner providing resistance to
ER with the arm at the side, with close visual moni-
toring of the medial border of the scapula during the
ER resistance application (Figure 10). A positive flip
sign is present when the medial border of the scap-
ula “flips” away from the thorax and becomes more
Figure 8. Scapular assist test performed in in abducted and prominent indicating a loss of scapular stability. This
externally rotated position. finding would indicate the need for further scapular
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 563
replication testing in which the extremity is placed
in a position and held for a short time then moved
back to an initial reference position. The athlete is
then asked to return to the position initially selected.
The examiner then measures the degree of accuracy
on repositioning of the extremity voluntarily by the
athlete. The score given is the difference between
the reference angle and the actual matched angles
by the athletes. In the seminal study on clinical use
of active joint angular reproduction, Davies and
Hoffman tested subjects seated with angles greater
than and less than 90 degrees of flexion, abduction,
followed by external rotation greater than and less
than 45 degrees of abduction and internal rotation.54
Figure 10. Scapular flip sign indicating dynamic scapular sta-
Normative data of 100 male subjects without shoul-
bilization weakness. der pathology using 7 different angular measures to
assess joint angular reproduction on each subject
resulted in an average error or of 2.7 degrees.
evaluation. It would additionally imply that inte-
grated exercise progressions aimed at the serratus Another method to test kinesthesia of the shoul-
anterior and trapezius force couple (important for der is through the threshold to detection of passive
scapular stabilization) may be warranted. Although motion (TTDPM). This testing is used to assess the
originally described for patients with spinal acces- athlete’s ability to detect a passive movement at very
sory nerve lesions, it is commonly used for those slow velocities. Because this form of testing requires
with apparent general scapular muscle weakness sophisticated equipment and more elaborate testing
where excessive scapular dysfunction is observed. devices the authors have chosen not to describe it
One added clinical sign to watch for is the appar- in detail but will refer the readers to literature that
ent downward rotation of the scapula during the pertain to this form of testing.55-58
flip sign maneuver in patients with spinal accessory Regardless of methods of testing numerous authors
nerve lesions, which results in massive trapezius have demonstrated that muscular fatigue has an
weakness and subsequent loss of function. effect on proprioception of the glenohumeral joint
and may indicate a need for proprioceptive chal-
Proprioceptive Testing lenges/exercises in the rehabilitation of the over-
Because of the extreme range of motion that most head athlete.58-62 Additionally this loss of kinesthetic
overhead athletes exhibit some degree of capsular awareness in the overhead athlete provides rationale
laxity also exists. Due to this laxity the glenohumeral for continued research and into how it may affect
joint has a reliance on joint proprioception and neu- the overhead athlete.
romuscular control. Assessment of proprioception
and neuromuscular control in the throwing shoul- Shoulder Special Tests
der will encompass both afferent and efferent neu- Discussion of several types of manual orthopedic
ral function. These can be assessed through systems tests is important as their inclusion in the compre-
of kinesthesia, joint position sense, and sensation to hensive examination sequence gives the clinician
resistance of movement. the ability to determine the underlying cause or
Joint position sense is the ability of the athlete causes of shoulder complex dysfunction. The tests
to determine where the extremity is oriented in to be covered in this commentary include impinge-
space. Joint position sense can be tested by use of ment, instability, and labral tests. It is beyond the
repositioning the shoulder in several patterns of scope of this chapter to completely discuss all clini-
movement. Clinically this is done via joint angular cal tests; however several excellent texts can be ref-
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 564
erenced by readers wishing for a more complete
discussion.12,63 Tests discussed in this commentary
will be specifically referenced relative to those tests
that are the most important for examination of the
overhead athlete.
Impingement tests
Tests to identify glenohumeral (GH) impingement
primarily involve the re-creation of subacromial
shoulder pain using maneuvers that are known
to reproduce and mimic functional positions in
which significant subacromial compression is pres-
ent. These motions involve forcible forward flexion
(Neer impingement sign),64 (Figure 11) forced IR in
the scapular plane (Hawkins-Kennedy impingement Figure 12. Hawkins-Kennedy impingement test.
sign),65 (Figure 12) forced IR in the sagittal plane (cor-
acoid impingement test),66 (Figure 13) and cross-arm
adduction impingement tests (Figure 14).12 These
tests all involve passive movement of the GH joint.
The Yocum impingement test involves the active
combination of elevation with IR and can provide a
valuable understanding of the patient’s ability to con-
trol superior humeral head translation during active
arm elevation in a compromised position67 (Figure
15). Valadie et al68 has provided objective evidence of
the degree of encroachment and compression of the
rotator cuff tendons against the coracoacromial arch
during several impingement tests. These tests can be
used effectively to reproduce a patient’s symptoms of
impingement and to give important insight into posi-
tions that should be avoided in the exercise progres-
sions used during treatment following evaluation. Figure 13. Coracoid impingement test.
Figure 11. Neer impingement test. Figure 14. Cross-arm adduction impingement test.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 565
Use of likelihood ratios can be best summarized or
interpreted whereby a clinical test with a likelihood
ratio of +2.0 or greater might result in an impor-
tant increase in the likelihood that the patient has
the condition being tested for by that clinical test.74
Similarly, a likelihood ratio of -0.50 or less results
in an important decrease in the likelihood that the
patient does not have the condition being tested for
by a negative response to that clinical test. The fact
that no one impingement test has very high metrics
indicates the value of combining the results from
multiple impingement tests to assist or increase the
diagnostic accuracy of the application of impinge-
Figure 15. Yocum impingement test. ment tests for the patient with suspected rotator cuff
disease from compression or impingement origins.
Interpretation of Clinical Tests (Diagnostic
Accuracy) Instability tests
The diagnostic accuracy of the impingement tests Another major type of clinical test that must be
have been studied and profiled in a systematic included during the examination of the shoulder of
review by Hegedus et al.69,70 They report the pooled the overhead athlete is instability testing. While there
specificity and sensitivity of the Neer test to be 53% may be gross instability from a traumatic incident such
and 79%, respectively, and for the Hawkins–Ken- as a collision with another player, or the ground dur-
nedy impingement test 59% and 79%. These tests ing diving, the main goal for the clinician during the
are important for the identification of rotator cuff examination of the overhead athlete with an overuse
impingement but must be used in combination with type of shoulder injury is to determine the presence of
a complete examination to allow the clinician to dis- subtle anterior instability.75 There are two main types
criminate between primary, secondary, and internal of instability tests that are used and recommended.
impingement for a more accurate and meaningful These are humeral head translation tests and provoca-
diagnosis.71 tion tests. Each type is presented in this section.
To further discuss the diagnostic accuracy of the
clinical tests presented in this section of the mono- Humeral Head Translation Tests
graph, several definitions should be discussed. Several authors believe that the most important
The specificity of a clinical test measures the abil- tests used to identify shoulder joint instability are
ity of the test to be positive when the patient actu- humeral head translation tests.76,77 These tests
ally has the condition being tested for .72 Often the attempt to document the amount of movement of
pneumonic (SPIN) is used which stands for Speci- the humeral head relative to the glenoid through
ficity, Positive rules the condition IN. Sensitivity the use of carefully applied directional stresses to
estimates the ability of a clinical test to be negative the proximal humerus. There are three main direc-
when the patient does not have that condition. The tions of humeral head translation testing, anterior,
pneumonic for sensitivity is (SNOUT) standing for posterior, and inferior. Inferior humeral head trans-
Sensitivity Negative rules the condition OUT. While lation testing is also referred to as multidirectional
commonly used, specificity and sensitivity they are instability or MDI.76 It is important to know some
less useful than likelihood ratios because they pro- reference values for the human glenohumeral joint
vide a less quantifiable estimate of the probability when doing humeral head translation tests. Harry-
of a diagnosis.73 Therefore when possible, this com- man et al78 measured the amount of humeral head
mentary has provided key tables including both (+) translation in vivo in healthy, uninjured subjects
and (-) likelihood ratios as well as (+) and (-) predic- using a three-dimensional spatial tracking system.
tive value in addition to specificity and sensitivity. They found a mean of 7.8 mm of anterior translation
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 566
and 7.9 mm of posterior translation when an ante-
rior and posterior drawer test was used. Transla-
tion of the human shoulder in an inferior direction
was evaluated with a multidirectional instability
(MDI) sulcus test. During in vivo testing of inferior
humeral head translation, an average of 10 mm of
inferior displacement was measured. Results from
this detailed laboratory-based research study indicate
that approximately a 1:1 ratio of anterior-to-posterior
humeral head translation can be expected in normal
shoulders with manual humeral head translation
tests. No definitive interpretation of bilateral sym-
metry in humeral head translation is available from
this research. Important clinical recommendations
for utilizing humeral head translation tests include Figure 16. Multi-directional instability test at 0 degrees of
testing the uninjured shoulder first, using firm but abduction.
not overly aggressive holds to promote patient relax-
ation, using fairly rapid accelerative movements
with the humeral head as well as comparing both mion and the humerus from the increase in inferior
the amount of translation and end feel during the translation of the humeral head and the widening
translation test. Without patient relaxation during subacromial space) is usually present in patients
testing muscle guarding will likely create inaccuracy with MDI.76,80
during testing of passive humeral head translation.
Anterior & Posterior Translation (Drawer)
Multidirectional Instability Sulcus Tests Tests
(MDI) Sulcus Sign McFarland et al76 and Gerber and Ganz77 believe that
One key test used to evaluate the stability of the testing for anterior and posterior shoulder laxity is
shoulder is the MDI sulcus test (Figure 16). This best performed with the patient in the supine posi-
test is the primary test used to identify the patient tion because of greater inherent relaxation of the
with MDI of the GH joint. Excessive translation in patient. This test allows the patient’s extremity to be
the inferior direction during this test most often tested in multiple positions of GH joint abduction,
indicates a forthcoming pattern of excessive transla- thus selectively stressing specific portions of the
tion in an anterior or posterior direction, or in both GH joint anterior capsule and capsular ligaments.
anterior and posterior directions.76 This test, when Seated humeral head translation tests are typically
performed in the neutral adducted position, directly referred to as load and shift tests and involve test-
assesses the integrity of the superior GH ligament ing of the glenohumeral joint in neutral (0 degrees)
and the coracohumeral ligament.79 These ligaments of GH joint abduction. Figure 17 shows the supine
are the primary stabilizing structures against inferior translation technique for assessing and grading the
humeral head translation in the adducted GH posi- translation of the humeral head in both anterior and
tion.79 To perform this test, it is recommended that posterior directions. It is important to note that the
the patient be examined in the seated position with direction of translation must be along the line of
the arms in neutral adduction and resting gently the GH joint, with an anteromedial and posterolat-
in the patient’s lap. The examiner grasps the distal eral direction used because of the 30⬚ version of the
aspect of the humerus using a firm but unassuming glenoid. This is accomplished by ensuring that the
grip with one hand, while several brief, relatively examiner places the patient’s GH joint in the scap-
rapid downward pulls are exerted to the humerus ular plane as pictured. Testing for anterior transla-
in an inferior (vertical) direction. A visible “sulcus tion is performed in the range between 0⬚ and 30⬚ of
sign” (tethering of the skin between the lateral acro- abduction, between 30⬚ and 60⬚ of abduction, and at
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 567
Subluxation / Relocation Test
One final instability test to be discussed in this sec-
tion is the subluxation relocation test. This test may
be one of the most important tests used to identify
subtle anterior instability in the overhead-throwing
athlete or the individual with symptoms in overhead
positions. The original apprehension test, which
involves the combined movements of abduction
and external rotation while monitoring the patients
“apprehension” response is best suited to determine
the presence of gross or occult instability of the GH
joint. The subluxation relocation test is a subtle form
of provocation test that does not measure actual
Figure 17. Anterior and posterior load and shift performed in humeral head translation. Originally described by
supine. Jobe,75 the subluxation/relocation test is designed
to identify subtle anterior instability of the GH
90⬚ of abduction to test the integrity of the superior, joint. Credit for the development and application
middle, and inferior GH ligaments, respectively.79,80 of this test is also given to Dr Peter Fowler.75 Fowler
Posterior translation testing typically is performed at described the diagnostic quandary of microinstability
90⬚ of abduction because no distinct thickenings of (subtle anterior instability) versus rotator cuff injury
the capsule are noted, with the exception of the pos- or both in swimmers and advocated the use of this
terior band of the inferior GH ligament complex.79 important test to assist in the diagnosis. The sublux-
Grading (assessing the translation) for this test is ation/relocation test is performed with the patient’s
performed using the classification of Altchek and shoulder held and stabilized in the patient’s maximal
Dines.81 This classification system defines grade I end-range of ER at 90⬚ of abduction in the coronal
translation as humeral translation within the glenoid plane. The examiner then provides a mild anterior
without edge loading or translation of the humerus subluxation force (Figure 18-A) being sure to exert the
over the glenoid rim. Grade II represents transla- subluxation force to the proximal humerus to create
tion of the humeral head up over the glenoid rim anterior translational stress or loading. The patient is
with spontaneous return on removal of the stress. then asked if this subluxation force reproduces his or
The presence of grade II translation in an anterior or her symptoms. Reproduction of patient symptoms of
posterior direction without symptoms does not indi- anterior or posterior shoulder pain with subluxation
cate instability but instead merely represents laxity leads the examiner to reposition his hand on the
of the GH joint. Unilateral increases in GH transla- anterior aspect of the patient’s shoulder and perform
tion in the presence of shoulder pain and disabil- a posterior-lateral directed force, using a soft, cupped
ity can ultimately lead to the diagnosis of GH joint hand to minimize anterior shoulder pain from the
instability.82 Grade III translation, which is not seen hand-shoulder (e.g. examiner-patient) interface (see
clinically in orthopaedic and sports physical ther- Figure 18-B). Failure to reproduce the patient’s symp-
apy, involves translation of the humeral head over toms with end-range ER and 90⬚ of abduction leads
the glenoid rim without relocation upon removal of the examiner to reattempt the subluxation maneuver
stress. Ellenbecker et al83 tested the intrarater reli- with 110⬚ and 120⬚ of abduction. This modification
ability of humeral head translation tests and found has been proposed by Hamner et al84 to increase the
improved reliability when using the main criterion potential for contact between the undersurface of
of whether the humeral head traverses the glenoid the supraspinatus tendon and the posterior superior
rim. The use of end-feel classification and other esti- glenoid. In each position of abduction (90⬚, 110⬚, and
mators decreases intra-rater, and inter-rater reliabil- 120⬚ of abduction), the same sequence of initial sub-
ity and interferes with the interpretation of findings luxation and subsequent relocation is performed as
from GH translation testing.83 described previously.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 568
with a positive subluxation/relocation test.85 This
test can form a very important part of the return to
throw or return to serve evaluation. Reproduction of
pain during this maneuver often indicates that the
athlete is not able to return to aggressive overhead
function due to a decrease in shoulder stabilization
and can be used as a clinical test to determine readi-
ness to return to throw by the clinician.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 569
Empty Can Test
In addition to using the empty or full can test to
solely assess muscle strength of the rotator cuff,
Itoi et al90 tested the effectiveness of both the full
can and empty can test to predict the presence of a
rotator cuff tear. Their results showed that greater
predictive values were present when only weak-
ness was encountered during the use of both the full
can and empty can tests as compared to when pain
was encountered during testing. There was no sig-
nificant difference in the ability of these two tests
to predict a full thickness rotator cuff tear and the
author concluded that both test positions could be
used for supraspinatus testing.
Subscapularis Tests
Three tests are commonly used to assess the integ-
rity of the subscapularis muscle tendon unit. These
include the Gerber lift-off position (Figure 19),
Napoleon or Belly Press Test (Figure 20), and the
Bear Hugger Sign.91 (Figure 21) Recent research has
assessed the effects of subscapularis muscular acti-
vation in each of these three clinical tests as well as
slight variations (+/-) 10 degree positional changes
to the reference positions described in the literature.
This study concluded that all three tests (Gerber lift Figure 20. Should state: A) Napoleon or B) Belly press test
off / Napoleon & Bear Hugger) isolate the subscapu-
laris and are recommended for use to evaluate the
integrity of the subscapularis muscle tendon unit.
Yoon et al,92 recently published a study testing the
effectiveness of 4 tests to evaluate the integrity of the
subscapularis. These authors found the lift-off test to
be highly specific for identification of a full-thickness
Labral Testing
Glenoid labrum tears are among the most difficult
Figure 19. Gerber lift-off test. clinical diagnoses to make, solely using clinical special
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 570
tests This is evidenced by the wide variety and volumi- of the integrity of the superior labrum and loss of
nous number of tests reported in the literature. In the the biceps anchor lead to significant losses in the
throwing athlete, large anterior translational forces are static stability of the human shoulder.97 Cheng and
present at levels up to 50% of body weight during arm Karzel97 demonstrated the important role the supe-
acceleration of the throwing motion, with the arm in rior labrum and biceps anchor play in GH joint sta-
90⬚ of abduction and ER.2 This repeated translation of bility by experimentally creating a SLAP lesion at
the humeral head against and over the glenoid labrum between 10 and 2 o’clock positions. They found an
can lead to labral injury. Labral injury can occur as 11% to 19% decrease in the ability of the GH joint to
tearing or as actual detachment from the bony glenoid withstand rotational force, as well as a 100% to 120%
rim. increase in strain on the anterior band of the infe-
rior GH ligament. This demonstrates a significant
In addition to the tearing that can occur in the labrum, increase in the load on the capsular ligaments in the
actual detachment of the labrum from the glenoid presence of superior labral injury.
rim has been reported. The two most common labral
detachments encountered clinically are the Bankart A brief discussion of the proposed mechanisms of
lesion and the SLAP lesion. Perthes93 in 1906 was superior labral injury is indicated as it will assist
the first to describe the presence of a detachment the clinician in better understanding the underlying
of the anterior labrum in patients with recurrent mechanisms behind the present clinical tests that
anterior instability. Bankart94,95 initially described a are used to provide stress and provoke the superior
method for surgically repairing this lesion that now labrum. Andrews and Gillogly98 first described labral
bears his name. A Bankart lesion, which is found in injuries in throwers and postulated tensile failure at
as many as 85% of dislocations,82 is described as a the biceps insertion as the primary mechanism of
labral detachment that occurs at between 2 o’clock failure. The theory proposed by Andrews was based
and 6 o’clock on a right shoulder, and between the 6 on the important role the biceps plays in decelerat-
and 10 o’clock positions on a left shoulder. This ante- ing the extending elbow during the follow-through
rior-inferior detachment decreases GH joint stability phase of pitching, coupled with the large distraction
by interrupting the continuity of the glenoid labrum forces present during this violent phase of the throw-
and compromising the GH capsular ligaments.82 ing motion. Recent hypotheses have been developed
Detachment of the anterior-inferior glenoid labrum based on the finding by Burkhart and Morgan et al99
creates increases in anterior and inferior humeral of a more commonly located posterior type II SLAP
head translation—a pattern commonly seen in lesion in the throwing or overhead athlete. This pos-
patients with GH joint instability.82 teriorly based lesion can best be explained by the
“peel back mechanism” as described by Burkhart
In addition to labral detachment in the anterior-infe- and Morgan.99 The torsional force created when the
rior aspect of the GH joint, similar labral detach- abducted arm is brought into maximal ER is thought
ment can occur in the superior aspect of the labrum. to “peel back” the biceps and posterior labrum. Sev-
Superior labrum anterior posterior (SLAP) lesions eral of the tests discussed in this chapter that are
are defined as superior labrum anterior posterior. used to identify the patient with a superior labral
Snyder et al96 classified superior labral injuries into injury utilize the position of abduction. External rota-
4 main types with additional classifications being tion similar to this position is described by Burkhart
created as greater identification and study of the and Morgan99 for the peel back mechanism. Kuhn et
superior labrum has evolved. Snyder reported a al100 compared load vs failure of the superior labrum
type I labral tear as fraying with types II-IV tears after repair was performed cadaverically using both
involving actual detachment of the labrum away distraction and peel back simulation models in the
from the glenoid with or without involvement of throwing motion. They found significantly lower
the actual biceps tendon.96 One of the consequences load to failure for the peel back pathomechanical
of a superior labral injury is the involvement of the model than is seen with distraction, indicating the
biceps long head tendon and the biceps anchor in vulnerability of the superior labrum and of subse-
the superior aspect of the glenoid. This compromise quent labral repair to this type of loading.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 571
TESTS FOR LABRAL PATHOLOGY
General Labral Tests
Many general labral tests such as the clunk test
(Figure 22), circumduction test (Figure 23), and
compression rotation test (Figure 24), utilize a long
axis compression exerted through the humerus to
scour the glenoid and to attempt to trap the torn or
detached labral fragment between the humeral head
and the glenoid, much like a mortar and pestle type
mechanism.63,40,101 The circumduction and clunk
tests literally scour the perimeter of the glenoid try-
ing to trap the labral tear with the compression and
rotation performed by the examiner during the test.
Figure 24. Compression rotation test.
Due to the large ranges of motion in the throwing
motion, use of these types of test to scour the perim-
eter of the glenoid and glenoid labrum are indicated. frequent finding of crepitace and grating during the
One key clinical application with these tests is the movements as well as increases in humeral head
translation that can create “noise” from the joint.
These tests typically when positive will recreate the
pain experienced by the patient. Noise generation
or a feeling of traversing across the glenoid rim does
not indicate a torn labrum and can fool an inexpe-
rienced clinician during the interpretation of the
exam findings. It is important to note laxity, and the
type of crepitus and sensations encountered during
the test along with the patient’s report of pain associ-
ated with the test to fully interpret the results.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 572
Figure 27. Biceps load test.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 573
important variable in the interpretation of these
tests for clinical application is the ability of virtually
any examiner to reproduce the exceptional diagnos-
tic accuracy reported in these tests.
The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 574
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The International Journal of Sports Physical Therapy | Volume 8, Number 5 | October 2013 | Page 578