Ryan J. Warth, Peter J. Millett Auth. Physical Examination of The Shoulder An Evidence-Based Approach

Ryan J.
Warth
Physical Peter J. Millett
Examination of
the Shoulder
An Evidence-Based
Approach
123
Physical Examination of the Shoulder
Ryan J. Warth • Peter J. Millett
Physical Examination
of the Shoulder
An Evidence-Based Approach
Ryan J. Warth, M.D. Peter J. Millett, M.D., M.Sc.
Steadman Philippon Research Institute The Steadman Clinic
Vail, CO, USA Steadman Philippon Research Institute
Vail, CO, USA
ISBN 978-1-4939-2592-6 ISBN 978-1-4939-2593-3 (eBook)

DOI 10.1007/978-1-4939-2593-3
Library of Congress Control Number: 2015934007
Springer New York Heidelberg Dordrecht London

© Springer Science+Business Media New York 2015
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Preface
Proper diagnosis and treatment of the various physical ailments with which
patients present to health care providers depends on accurate and efficient
history and physical examination. This is arguably never more important than
in the evaluation of symptoms relating to the shoulder, one of the most com-
plicated of all the bioengineering marvels of the human body, and one of the
most common sources of patient complaints.
The differential diagnosis of shoulder pain requires consideration of a very
long list of potential etiologies that can range anywhere from bursitis and
rotator cuff disease to cervical spine pathology in addition to any number of
coexisting conditions. Appropriate performance and interpretation of the
shoulder examination are essential skills that can answer many questions
regarding etiologies, potential diagnoses and treatment options including sur-
gical planning and postoperative management. This book provides an inte-
grated approach to the diagnosis of numerous shoulder pathologies by
combining discussions of pathoanatomy and the interpretation of physical
examination techniques and was written for any health care professional or
student who may be required to evaluate patients who present with shoulder
pain. This information will allow the clinician to make informed decisions
regarding further testing procedures, imaging and potential therapeutic
options. The primary goal of this book is to provide readers with the knowl-
edge and confidence required to perform an appropriate examination and to
generate a succinct list of differential diagnoses using an evidence-based
approach.
Vail, CO, USA Ryan J. Warth, M.D.

Peter J. Millett, M.D., M.Sc.
v
Contents
1 About This Book ........................................................................... 1

2 Range of Motion ............................................................................ 5
3 Strength Testing ............................................................................ 39
4 Rotator Cuff Disorders ................................................................. 77
5 Disorders of the Long Head of the Biceps Tendon ..................... 109
6 Glenohumeral Instability ............................................................. 139
7 The Acromioclavicular Joint ........................................................ 183
8 The Sternoclavicular Joint ........................................................... 209
9 Scapular Dyskinesis ...................................................................... 219
10 Neurovascular Disorders .............................................................. 241
Index ....................................................................................................... 271
vii
About This Book
1
The primary purpose of this book is to provide a Examination of the shoulder has historically
comprehensive guide for anyone who is required been stigmatized as being overly difficult or
to examine the shoulder. An online version of this intimidating, especially for the inexperienced
book is provided for easy accessibility. investigator who has yet to develop the necessary
While many books serve as an exhaustive list fund of knowledge to adequately evaluate shoul-
of all the available shoulder examination maneu- der function. As a result, imaging studies have
vers, few have undertaken the task of developing been relied upon to make diagnoses that should
a text that both simplifies and illustrates the most have been made during the initial physical exam-
important pathoanatomy, procedural elements, ination. There are numerous factors that may be
and clinical data involved with physical exami- involved with the perceived difficulty of the
nation of the shoulder. The goal of this book was shoulder exam:
to present the most relevant clinical data and 1. Factors in the patient’s history are often
examination maneuvers in a digestible, predict- nonspecific.
able manner such that the application and inte- The nonspecific nature of many historical
gration of the presented techniques can occur findings is particularly frustrating for the inex-
quickly and seamlessly. perienced clinician. This is especially true for
Although there have been numerous indi- physicians who are forced to care for patients
vidual studies evaluating the usefulness of the with musculoskeletal problems without the
various shoulder examination techniques, it is necessary training. As an example, a patient
nearly impossible to understand which maneu- with an anteroinferior labral tear (i.e., Bankart
vers are the most relevant without a complete lesion) may present with a sudden onset of
systematic review of each technique. This book sharp pain with movement, a gradually inten-
provides a literature review that iterates the sifying dull pain or even the absence of pain in
relative utility and efficacy of the various phys- some cases. This highlights the necessity to
ical examination maneuvers and provides guid- perform a complete examination in each
ance as to which techniques are most important patient with a shoulder condition such that
for each individual diagnosis or series of diag- notable and potentially problematic condi-
noses. In addition, we provide an evaluation of tions can be identified and properly treated.
current research surrounding the different 2. Physical examination findings commonly
examination techniques thereby identifying overlap across multiple pathologies.
knowledge gaps upon which improvements can There are many shoulder pathologies that
be sought. present in similar ways. For example, the
R.J. Warth and P.J. Millett, Physical Examination of the Shoulder: An Evidence-Based Approach, 1
DOI 10.1007/978-1-4939-2593-3_1, © Springer Science+Business Media New York 2015
2 1 About This Book
active compression test, initially developed tis, rotator cuff tears, labral lesions, acromio-
for the identification of labral pathology, is clavicular pathology, and/or various fractures
also sensitive for acromioclavicular joint among a long list of other potential
pathology in certain patients. The identifica- pathologies.
tion of biceps tendon pathology and SLAP 5. There may be multiple coexisting conditions
tears can also be difficult since there does not that present similarly.
exist an examination maneuver with adequate One of the most difficult aspects of the
sensitivity and/or specificity values. Although shoulder examination is discerning the find-
a positive test can be useful in many cases, it ings of different pathologies that may be pres-
is important to recognize the ability of each ent in the same patient. These findings may
test to detect various other pathologies. This overlap on many occasions, forcing the inex-
book will identify these discrepancies and perienced clinician to guess at the correct
provide strategies for the avoidance of diagnosis. This book will provide the reader
confusion. with the tools required to make these impor-
3. The utility of palpation is limited due to over- tant distinctions thus allowing for an accurate
lying muscle and fat. diagnosis and the development of a focused,
The deltoid is a large, thick muscle that structured treatment plan.
often precludes the ability to palpate normal 6. Significant pathologies may be asymptomatic.
or abnormal structures around the shoulder Sometimes the most important historical
complex. Even though palpation is difficult, findings are those that do not exist. This is
it is still a necessary portion of the physical especially important for shoulder conditions
examination process as there are certain that tend to progress over time—the devel-
clues that can be obtained with superficial or opment of symptoms often go unnoticed to
deep palpation. Another difficulty is that the patient for a significant period of time.
deep palpation may engender pain as a result However, it is still important to recognize
of the pressure from the examiner’s fingers how these pathologies affect the patient’s
rather than from the pathologic process. This shoulder function. Thus, it is always impor-
is especially important when evaluating tant to complete a full, structured examina-
anterior shoulder pain as a result of coracoid tion even if the patient denies symptoms.
impingement—deep palpation of the cora- One important example is that of rotator cuff
coid will generate pain in most patients who disease. While it is well recognized that the
are not extremely thin; however, this may or prevalence of rotator cuff disease increases
may not be the result of subscapularis with age [1–3], the development of symp-
impingement underneath the coracoid toms does not always follow this pattern of
process. progression [4]. However, studies have
4. Specific pain patterns are variable and have found that patients with asymptomatic rota-
not been fully defined for the shoulder. tor cuff tears develop changes in glenohu-
In most cases, the precise location, inten- meral range of motion, changes in shoulder
sity, onset, timing, and quality of shoulder strength [5, 6], and changes in radiographic
pain have not been firmly attached to any spe- parameters [7]. As the tear biology changes
cific diagnosis. Although certain pain patterns and progresses, symptoms may eventually
are helpful and may lead the clinician to per- become noticeable and potentially disabling.
form certain maneuvers, this information A study by Yamaguchi et al [4]. found that
should not be considered a reliable indicator patients with asymptomatic rotator cuff tears
for any one condition. As an example, anterior developed symptoms at an average of 2.8
shoulder pain can be the result of osteoarthri- years independent of whether an increase in
References 3
tear size occurred. Thus, a thorough clinical

evaluation beyond the patient history is 1.1 Conclusion
necessary to identify these previously
unidentified changes that may have a signifi- Evaluation of the shoulder can be a difficult and
cant effect on the treatment approach and confusing undertaking for the inexperienced exam-
the final outcome. iner. The purpose of this book is to provide the
7. Knowledge of both normal and pathologic reader with the pathoanatomic knowledge and
processes around the shoulder has not been examination skill to reliably and accurately evaluate
fully elucidated. the patient who presents with shoulder pain or dis-
Another major difficulty is that basic comfort. We do not aim to present an exhaustive list
knowledge of normal and pathologic proof all the physical examination tests ever to be men-
cesses is currently lacking; however, this is tioned in the literature, but rather to present and
not due to a lack of research in and around demonstrate the most relevant and useful maneu-
the shoulder joint. Many basic science and vers that can be directly integrated into clinical
biomechanical studies show inconsistent and practice through an evaluation of current evidence.
inconclusive results. This is especially true
for the dimensions of the rotator cuff inser-
References
tion, the biomechanical function of the long
head of the biceps tendon and the precise 1. Keener JD, Steger-May K, Stobbs G, Yamaguchi
function of various ligaments around the K. Asymptomatic rotator cuff tears: patient demo-
shoulder, such as that of the coracoacromial graphics and baseline shoulder function. J Shoulder
and coracohumeral ligaments. Elbow Surg. 2010;19(8):1191–8.
2. Mall NA, Kim HM, Keener JD, Steger-May K, Teefey
8. The current literature is full of studies that SA, Middleton WD, Stobbs G, Yamaguchi
may or may not provide actual evidence for or K. Symptomatic progression of asymptomatic rotator
against a specific maneuver. cuff tears: a prospective study of clinical and sonographic
The literature is riddled with substantially variables. J Bone Joint Surg Am. 2010;92(16):2623–33.
3. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt
flawed studies that make comparison, analy- CF, Galatz LM, Teefey SA. The demographic and
sis, and clinical integration extremely diffi- morphological features of rotator cuff disease. A com-
cult. A few recent meta-analyses attempted to parison of asymptomatic and symptomatic shoulders.
quantify the clinical utility and diagnostic J Bone Joint Surg Am. 2006;88(8):1699–704.
4. Yamaguchi K, Tetro AM, Blam O, Evanoff BA,
odds ratio of the many physical examination Teefey SA, Middleton WD. Natural history of
tests; however, the major limitation of this asymptomatic rotator cuff tears: a longitudinal analy-
study, as with many meta-analyses, is that the sis of asymptomatic tears detected sonographically.
limitations of each individual study cannot be J Shoulder Elbow Surg. 2001;10(3):199–203.
5. Yamaguchi K, Sher JS, Andersen WK, Garretson R,
accounted for in the data analysis [8–10]. Uribe JW, Hechtman K, Neviaser RJ. Glenohumeral
Some of these include selection bias, exam- motion in patients with rotator cuff tears: a compari-
iner bias, poor inter- and intra-rater reliability, son of asymptomatic and symptomatic shoulders.
publication bias, and, in some journals, the J Shoulder Elbow Surg. 2000;9(1):6–11.
6. Kim HM, Teefey SA, Zelig A, Galatz LM, Keener JD,
lack of an effective peer review process. Yamaguchi K. Shoulder strength in asymptomatic
With consideration of all of these confus- individuals with intact compared with torn rotator
ing factors, this book aims to provide the cuffs. J Bone Joint Surg Am. 2009;91(2):289–96.
means to efficiently navigate the shoulder 7. Keener JD, Wei AS, Kim HM, Steger-May K,
Yamaguchi K. Proximal humeral migration in shoul-
examination with confidence and accuracy. ders with symptomatic and asymptomatic rotator cuff
However, it is important to recognize that the tears. J Bone Joint Surg Am. 2009;91(6):1405–13.
examination is not always easy as there will 8. Hegedus EJ, Goode AP, Campbell S, Morin A,
often be challenging cases. Nevertheless, Tamaddoni M, Moorman 3rd CT, Cook C. Physical
examination tests of the shoulder: a systematic review
without this challenge, we would be less likely with meta-analysis of individual tests. Br J Sports
to love what we do every day. Med. 2008;42(2):80–92.
4 1 About This Book
9. Hegedus EJ, Goode AP, Cook CE, Michener L, 10. Wright AA, Wassinger CA, Frank M, Michener LA,
Myer CA, Myer DM, Wright AA. Which physical Hegedus EJ. Diagnostic accuracy of scapular physical
examination tests provide clinicians with the most examination tests for shoulder disorders: a systematic
value when examining the shoulder? Update of a sys- review. Br J Sports Med. 2013;47(14):886–92.
tematic review with meta-analysis of individual tests.
Br J Sports Med. 2012;46(14):964–78.
Range of Motion
2
shoulder motion. He described a “zero point” for

2.1 Introduction each joint from which various motions would be
measured. Cave and Roberts [2] followed in 1936
Range of motion evaluation is a critical compo- by suggesting that shoulder measurements should
nent of physical examination for any joint. be made with the humerus at the side and the
However, the shoulder is unique in that it pro- elbow flexed to 90°. Importantly, Cave and
vides a large arc of motion in three-dimensional Roberts [2] were also the first to recommend mea-
space which presents certain challenges for the surement of the joints above and below the affected
treating physician. Determining which motions joint with a goniometer (discussed below).
are clinically significant is perhaps the most Later in the century, further progress was
important aspect of the range of motion examina- made in the development of a standard nomen-
tion. The clinician must then use this information clature. Both the American Medical Association
to determine which static and dynamic factors are (AMA) [3] and the American Academy of
involved in the patient’s pathologic processes. An Orthopaedic Surgeons (AAOS) [4] created com-
understanding of the basic concepts and current mittees that would eventually come to an agree-
evidence surrounding shoulder range of motion ment regarding this language by the early 1960s.
testing is the cornerstone for an accurate and effi- The resulting publications defined the most
cient physical examination. important shoulder motions as flexion, abduc-
tion, adduction, extension, and internal and exter-
nal rotation both with the arm at the side and at
2.2 Glenohumeral Motion 90° of abduction.
When considering various shoulder positions,
Knowledge of a few basic concepts of glenohumeral it is most useful to first note the position of the
motion is required to understand, perform, and humerus alone rather than noting the position of
interpret many physical examination maneuvers. the rest of the extremity, such as the elbow and
As such, there exists an internationally standard- hand. For example, pronation of the forearm does
ized nomenclature through which basic glenohu- not constitute internal rotation of the shoulder in
meral motions are described to allow for reliable many cases. Similarly, supination of the forearm
and reproducible communication between clinicians, does not constitute external rotation of the shoul-
physical therapists, and anyone else involved in der. Thus, it is most important to examine the
the patient’s care. scapulohumeral relationship without regard to
In 1923, Silver [1] made the first attempt to cre- the rest of the extremity when evaluating shoul-
ate a standard language for the measurement of der motion.
6 2 Range of Motion
Fig. 2.1 Demonstration of

forward flexion in which
the humerus is elevated in
front of the body (curved
arrow).
2.2.1 Forward Flexion known as straight lateral abduction) (Fig. 2.2).

This position should be differentiated from
Forward flexion of the shoulder is defined as ele- abduction within the scapular plane which places
vation of the humerus in front of the body in the the humerus in approximately 20–30° of forward
sagittal plane (Fig. 2.1). This motion is typically angulation, also termed “scaption” (Fig. 2.3).
governed by contraction of the anterior fibers of This slight forward angulation facilitates exami-
the deltoid muscle and weakness is often a key nation such that surrounding soft tissues are simi-
indicator for several different pathologies. larly lax on both the anterior and posterior sides
Although the position of the elbow joint was of the joint. For example, examination of the
never specified by the AMA [3] or AAOS [4] patient with straight lateral abduction of the
back in the 1960s, most practitioners measure shoulder would place an increased stress on ante-
flexion range of motion with the elbow extended. rior structures relative to posterior structures
However, there are some other maneuvers that (Fig. 2.4). Thus, any evaluation of the capsular
can be used specifically to measure deltoid structures may produce inaccurate results when
strength. For example, having the patient make a the humerus is abducted in the coronal plane. For
fist and push anteriorly against the examiners this reason, appropriate glenohumeral and scapu-
hand would also activate the deltoid and simulate lothoracic resting positions should be utilized
a forward elevation motion without fully elevat- such that accurate assessment can be achieved
ing the shoulder overhead (see Chap. 3). This (the scapular plane and the glenohumeral resting
method is particularly useful when evaluating positions are discussed in more detail below).
deltoid strength either before or after an arthro-
plasty procedure where full elevation may not be
possible. 2.2.3 Extension
Extension of the shoulder typically refers to any

2.2.2 Abduction position in which the humerus rotates beyond
the scapular plane (Fig. 2.5). This can be
Abduction of the shoulder occurs when the achieved with the humerus at the side or ele-
humerus is elevated in the coronal plane such vated. With the arm at the side, the humerus can
that the extremity points directly laterally (also extend posteriorly in a limited capacity. Straight
2.2 Glenohumeral Motion 7

humeral abduction in
which the humerus is
elevated in the coronal
plane (curved arrows).
a
Sagittal plane
ne
r pla
ula
ap
Sc
~20° – 30°
Coronal plane
Supraspinatus
Fig. 2.3 (a) Illustration depicting the orientation of the the coronal plane. (b) Demonstration of humeral abduc-
scapular plane in which the humerus is elevated with tion within the scapular plane.
approximately 20–30° of forward angulation relative to
lateral abduction (also known as “horizontal 2.2.4 Internal Rotation

abduction”) as discussed above is also consid-
ered a position of extension since the humerus Internal rotation describes motion around a cen-
would be angulated posterior to the plane of the ter of rotation such that the angular motion vector
scapula. Similarly, the humerus can also extend points towards the midline. For example, when
posteriorly when the arm is overhead. For exam- viewing a right shoulder from the superior to
ple, throwing athletes require combined over- inferior direction, a counterclockwise rotation of
head extension and external rotation to achieve the humerus would be referred to as internal rota-
maximal torque and potential energy. Sometimes, tion (Fig. 2.6). Internal rotation with the arm in a
this motion sequence can lead to pathologic position of 90° of abduction or 90° of flexion
problems such as symptomatic internal impinge- uses the same concept. The humerus rotates in
ment, SLAP tears, and scapular dyskinesis. the same direction in each case, regardless of the
8 2 Range of Motion
Fig. 2.4 Illustrations depicting the change in capsular other hand, can be regarded as a position of extension in
tension when the humerus is elevated in the (a) scapular which anterior capsular structures become more tight
plane and (b) the coronal plane. Abduction in the scapular when compared to posterior capsular structures.
plane allows for accurate range of motion estimation Measuring range of motion or joint laxity in this position
because both the anterior and posterior capsular structures may produce inaccurate results.
are similarly lax. Abduction in the coronal plane, on the
position of the elbow, forearm, or hand. Internal humerus is abducted or flexed—it is only the
rotation can also be measured with the arm in the scapulohumeral angle that changes.
adducted position. In this case, the patient will
attempt to reach as far up the spinal column as
possible while the clinician determines the most 2.2.6 Adduction
superior spinal level that the patient can reach
(Fig. 2.7). This position maximizes internal rota- Shoulder adduction can also be described with
tion and has historically been a standard measure the arm at the side or elevated. The basic resting
for internal rotation capacity. However, this position with the arm at the side is often referred
method of measurement has recently been called to as “simple adduction.” When the humerus is
to question since the vertebral level to which one elevated to 90° followed by movement of the
reaches may be influenced by elbow, wrist, and humerus towards the opposite shoulder, this is
hand motion rather than isolated internal rotation most often referred to as “horizontal adduction”
of the humerus [5]. or “cross-body adduction” (Fig. 2.8). Conversely,
“horizontal extension” corresponds to the oppo-
site motion, where the humerus is extended pos-
2.2.5 External Rotation teriorly beyond the scapular plane.
When viewing a right shoulder from superiorly to

inferiorly, external rotation would be defined as 2.2.7 Scapular Plane
clockwise rotation of the humerus away from the
midline (see Fig. 2.6). Again, similar to internal The scapular plane is generally defined as a posi-
rotation, the rotational moment about the humeral tion of neutral scapulohumeral angulation which
anatomic axis does not change whether the optimizes glenohumeral joint congruity and
Fig. 2.5 (a) Extension

with the arms at the side
(arrow). (b) Extension
with the arms abducted
(arrow). (c) Extension with
the arms overhead (arrow).
a c
Neutral 90°
0° External
b
Internal External Neutral

External 0° Internal
60°
80°
Neutral
70° 0°
20°
Internal
90°
Fig. 2.6 Illustrations depicting glenohumeral internal and external rotation (a) with the arm at the side, (b) with the arm
in straight lateral abduction, and (c) with the arm flexed.
10 2 Range of Motion
C7
T3
T7
L4
Fig. 2.7 (a) Illustration demonstrating the measurement of internal rotation according to vertebral levels. (b)
Demonstration of the positioning for the measurement of internal rotation according to vertebral levels (curved arrow).
Fig. 2.8 (a) Demonstration of simple adduction with the humerus resting at the side. (b) Demonstration of horizontal
adduction in which the humerus is elevated and rotated towards the contralateral shoulder (arrow).
facilitates accurate and consistent evaluation of scapular malposition may display increased
the joint. This position of neutral scapulohumeral protraction and upward rotation in the resting
angulation is determined by the angle between a position (discussed below), thus altering the posi-
line drawn along the center axis of the scapula tion of the glenoid such that the plane of the scap-
and second line drawn at the same level that is ula occurs with greater forward angulation of the
perpendicular to the coronal plane (see Fig. 2.3). humerus. Therefore, performing physical exami-
This position, which most often occurs between nation tests within the “normal” scapular plane in
20° and 30° of forward angulation relative to the a patient with scapular malposition may produce
coronal plane with the humerus in various inaccurate results (specific examination maneu-
degrees of abduction, minimizes the potential for vers for evaluation of the scapulothoracic articu-
acromiohumeral contact while also allowing for lation are presented in Chap. 9).
the theoretical isolation of the rotator cuff muscu-
lature during various clinical examination tests.
In other words, some have theorized that abduc- 2.2.8 Glenohumeral Resting
tion of the humerus within the scapular plane Position
requires zero contribution from internal or exter-
nal rotators to achieve full abduction capacity [6]. Also known as the “loose pack position,” the rest-
Maximum capsuloligamentous laxity also occurs ing position of a joint is the position at which sur-
within the scapular plane (at the glenohumeral rounding soft tissues are under the least amount
resting position, discussed below) which facili- of tension, the joint capsule has its greatest laxity
tates examination of these structures (instability and the bony surfaces of the joint are minimally
and laxity testing are discussed in Chap. 6). congruent [7–9]. In other words, this position is
Although the scapular plane is generally considered to allow maximal glenohumeral
defined as 20–30° of humeral forward angulation mobility owing to an increase in joint laxity [8].
relative to the coronal plane in normal individu- The glenohumeral resting position in normal
als, it must be recognized that patients with scap- shoulders is thought to be between 55° and 70° of
ular malposition or dyskinesis, as which occurs abduction with the humerus in neutral rotation
commonly in overhead athletes, may have a within the plane of the scapula (Fig. 2.9) [10–12].
scapular plane that differs from the rest of the In this position, the amount of external force
population. For example, a throwing athlete with required to translate the humeral head is minimal

the approximate glenohu-
meral resting position with
the humerus abducted to
55–70° within scapular
plane and in neutral
rotation.
which is thought to facilitate examination accu- translational load and a 4 N-m (torque) rotational
racy. Although there is a general consensus load were applied. The greatest maximal rota-
regarding the location of the glenohumeral rest- tional range of motion occurred at approximately
ing position, validation studies have seldom been 49.8° of abduction in the scapular plane.
conducted. However, in contrast to Hsu et al. [14], the great-
In a cadaveric study, An et al. [13] evaluated est maximal anterior–posterior translation
arm elevation in positions of either internal or occurred at approximately 23.7° of abduction in
external rotation. In this study, maximum eleva- the scapular plane. These results suggested that
tion occurred with the arm externally rotated testing for anteroposterior joint laxity should be
within the plane of the scapula. They could not conducted at lower degrees of abduction than
achieve this maximal elevation with the arm when testing for rotational joint laxity.
internally rotated due to the acromiohumeral Considered together, these studies demon-
impingement that occurs in this position. In other strate the complexity and potential variability
words, there was bony contact between the acro- that the glenohumeral resting position can have
mion and the greater tuberosity, thus hindering across a population, between populations or even
the ability to further elevate the arm. When the between individuals (dominant versus non-
humerus was placed in a position of 30° of for- dominant shoulders). In general, it is important to
ward angulation, there was little contribution determine the maximal range of translational and
from the internal and external rotators during rotational range of motion for each patient. In
humeral abduction. general, the rotational resting position is thought
In 2002, Hsu et al. [14] used seven cadaveric to occur at a point near 45 % of the total abduc-
specimens to measure the translational and rotation arc [14] where half of this abduction angle is
tional range of motion at different angles of thought to represent the translational resting
humeral abduction within the scapular plane. The position [9].
glenohumeral resting position was calculated as
the mid-point of the confidence intervals where
maximal rotational and translational motion 2.2.9 Codman’s Paradox
occurred. Maximal anteroposterior translation
and maximal rotational range of motion occurred Codman’s paradox is the observation that as the
at approximately 39° of humeral abduction in the arm is flexed upward in the sagittal plane and let
scapular plane and corresponded to approxi- down in the coronal plane, the humerus appears
mately 45 % of the maximum available abduc- to rotate 180° as evidenced by the orientation of
tion range of motion. They also found that the the palm. In other words, when beginning the
glenohumeral resting position varied according motion, the palm faces posteriorly and, at the
to the maximal available range of motion, possi- end of the motion, the palm faces anteriorly
bly suggesting that patients with joint hypermo- (Fig. 2.10). Alternatively, an individual can
bility and hypomobility should be tested at place their hand at the top of the head through
greater and lesser degrees of humeral abduction, either (1) forward flexion and internal rotation or
respectively. Since this was a cadaveric study, the (2) abduction and external rotation. This obser-
effect of dynamic glenohumeral stabilization vation has traditionally been of academic inter-
(which also contributes to the resting position) est; however, many investigators have attempted
could not be evaluated. to mathematically solve the “paradox” using
More recently, Lin et al. [9] attempted to complex equations and algorithms [15, 16].
define the glenohumeral resting position in vivo Although the clinical relevance of Codman’s
in the dominant shoulders of 15 healthy patients. paradox is debatable, some authors have investi-
In that study, translational and rotational range gated an application of Codman’s paradox dur-
of motion capacities were determined using an ing manipulation of a stiff shoulder under
electromagnetic tracking device after an 80 N anesthesia [17]. In addition, the quadrant test
2.3 Scapulothoracic Motion 13
Fig. 2.10 Illustration of E

Codman’s paradox
demonstrating that the top
of the head can be reached
via forward flexion and D
internal rotation or
abduction and external
rotation. (Matsen FA 3rd,
Lippitt SB, Sidles JA,
Harryman DT II (eds) C
Practical evaluation and
management of the F
shoulder. W.B. Saunders
Company, Philadelphia,
1994) Chapter 2.
G A
Final Position Initial Position
180°
Induced Rotation
(discussed later in this chapter) is based on chain, into the shoulder and, finally, to the hand
Codman’s paradox and can be a useful measure thus allowing for functional overhead motion.
of global shoulder motion [18]. Changes in scapular positioning as a result of
alterations in the dynamic periscapular muscle
force couples leads to scapular dyskinesis.
2.3 Scapulothoracic Motion Evaluation of the scapular range of motion is
one of the most difficult aspects of the shoulder
The role of the scapula in the development and examination for several reasons. One reason is
progression of various pathologies has been stud- that scapular motion is very complex and
ied extensively over the most recent decade. requires the examiner to visualize motion in
Some authors have suggested that scapular mal- three dimensions. Another reason is that the rela-
position may be involved with both external and tive contributions of glenohumeral and scapulo-
internal impingement mechanisms, especially in thoracic motions are difficult to distinguish,
overhead athletes [19–24]. The scapula has four especially when abnormal motions are the result
basic functions with regard to shoulder motion. of muscle compensation for some other shoulder
The first function is to dynamically position the condition outside of the scapulothoracic articu-
glenoid in space to facilitate the generation of a lation. The scapula is also covered with large,
large arc of glenohumeral motion. Second, the thick muscles making it difficult to visualize or
scapula provides a stable fulcrum upon which gle- palpate the various scapular motions. In addi-
nohumeral motion can arise. Third, dynamic tion, there exists a change in nomenclature when
scapular positioning allows the rotator cuff ten- referring to scapular motion (discussed below).
dons to glide smoothly beneath the acromion with Specific examination maneuvers used to exam-
humeral elevation. Finally, the scapula functions ine the scapulothoracic articulation are presented
to transfer potential energy through the kinetic in Chap. 9.
To help the reader thoroughly understand This test was found to have high inter-rater
scapulothoracic motion, we have organized the reliability and accuracy when compared to
remainder of this section according to increasing post-measurement radiographs. Using similar
complexity, beginning with the scapular resting measurements, a cadaveric study by Fung et al.
position and two-dimensional motion planes fol- [26] found that the resting position of the scapula
lowed by the interpretation of three-dimensional was at approximately 3° of external rotation, 40°
motion. of internal rotation, and 2° of posterior tilt. Of
note, this nomenclature does not reflect the posi-
tion of the humerus. Rather, it represents the posi-
2.3.1 Scapular Resting Position tion of the scapular body relative to the coronal
plane (discussed below).
With the arm at rest, the scapula is predictably
positioned in a specific orientation that can be
used to detect scapular malposition before any 2.3.2 Two-Dimensional
motion measurements or evaluations are under- Scapular Motion
taken. There have only been a few studies that
quantified the precise location of the scapula on In order to evaluate three-dimensional scapulo-
the posterior thorax. Sobush et al. [25] quantified thoracic motion, it is perhaps most advantageous
the normal scapular resting position in cadavers to begin with an understanding of the basic two-
using the “Lennie test,” or a series of measure- dimensional scapular motions. In total, there are
ments taken from the superomedial and inferome- three rotational movements and two translational
dial angles of the scapula. The distance from the movements (Fig. 2.11). Although it is not possi-
superomedial angle to the midline, the distance ble to isolate these movements, they represent
from the inferomedial angle to the midline and the basic components that comprise three-
also the angle of scapular inclination were deter- dimensional scapular motion.
mined (i.e., the angle formed between a line con- Internal and external rotation occurs around
necting the spinous processes and a line drawn the vertical axis of the scapula—that is, internal
along the margin of the medial scapular border). rotation elevates the medial scapular border away
a b c
Superior view Posterior view Lateral view
Posterior Anterior
tilting tilting
External
rotation
Internal
rotation Downward Upward
rotation rotation
Fig. 2.11 Illustration depicting (a) scapular internal and external rotation, (b) scapular upward and downward rotation,
and (c) scapular anterior and posterior tilting.
2.3 Scapulothoracic Motion 15
from the posterior thorax (i.e., the glenoid faces The terms “protraction” and “retraction” are
more anteriorly) whereas external rotation refers most often used to describe scapular movement in
to the exact opposite motion (i.e., the glenoid three-dimensional space. To understand these
faces less anteriorly). terms, it is perhaps easiest to first recognize that
Upward and downward rotation occurs along scapular motion occurs along a rounded surface
the plane of the scapula. In other words, upward (i.e., the convexity of the posterior thorax). Using
rotation occurs when the inferior angle of the this approach, one could imagine that any lateral
scapula moves laterally and the glenoid faces translation of the scapular body would also require
more superiorly. Conversely, downward rotation scapular internal rotation. This movement also
refers to the opposite motion in which the inferior requires some anterior tilt and downward rotation.
scapular angle moves medially towards the mid- This combination of movements is generally
line and the glenoid faces more inferiorly. referred to as scapular “protraction” and can be
Anterior and posterior rotation (i.e., tilting) closely simulated by having the patient thrust their
occurs around the horizontal axis of the scapula. shoulders anteriorly (similar to a hunchback posi-
Anterior tilting of the scapula occurs when the tion). Conversely, any medial translation of the
inferior angle moves away from the thorax (and scapular body would also require scapular external
the superior border moves towards the thorax) rotation. This movement also requires some poste-
whereas posterior tilting refers to the exact oppo- rior tilt and upward rotation. This combination of
site motion in which the inferior angle moves movements is typically referred to as scapular
towards the thorax (and the superior border “retraction” which can be demonstrated by having
moves away from the thorax). the patient thrust their shoulders posteriorly (as in
The scapula can also translate in the medial– “squeezing” the scapulae together by extending
lateral direction (as in protraction and retraction, the humerus posteriorly below 90° of elevation)
described below) and the superior–inferior direc- (Fig. 2.12). Of course, neither protraction nor
tion (as in shrugging the shoulders). It is impor- retraction could be achieved without some amount
tant to recognize that these translational motions of upward and downward rotation along with ante-
also require intact AC and SC joints—upward rior and posterior tilt; however, the purpose of the
and downward translation of the scapula requires above example is to illustrate the fundamental
upward and downward angulation of the clavicle concept of scapular translation around the poste-
via the SC joint whereas medial–lateral transla- rior chest wall in three dimensions.
tion requires anterior–posterior motion of the This same concept also applies when the scap-
clavicle through the SC joint as the scapula ula translates superiorly or inferiorly along the
moves around the thorax. convex surface of the posterior thorax. In other
words, inferior translation of the scapula would
theoretically produce an increased posterior tilt
2.3.3 Three-Dimensional whereas superior translation of the scapula would
Scapular Motion produce an increased anterior tilt (as in shrugging
the shoulders). In reality, the shoulder shrug
Three-dimensional scapular motion, which is requires a combination of superior translation,
achieved by combining any of the above- anterior tilt, and internal rotation. Increased ante-
mentioned two-dimensional movements, is nec- rior or posterior scapular tilt is very subtle, is dif-
essary to optimize glenohumeral contact and ficult to recognize by direct visual or tactile
stability throughout the entire range of shoulder examination in the office setting, and generally
motion. However, during the evaluation of an cannot be isolated by any specific voluntary
actual patient, it is most useful to consider the movement. Biomechanical studies suggest that
observed three-dimensional scapular motion as a scapular tilting mostly occurs during extension-
summation of the individual rotational moments type maneuvers with the arm either overhead or
mentioned above. at the side.
Fig. 2.12 Illustration Protraction Retraction

demonstrating scapular
protraction and retraction.
Sagittal and posterior
views are shown.
Most clinicians agree that isolated glenohu- motion. It is with this foundational knowledge
meral motion occurs below approximately 90° of that one can begin to understand the complex dis-
elevation whereas combined glenohumeral and ease processes related to the shoulder.
scapulothoracic motion occurs above this level
(discussed below). In order to maximize gleno-
humeral contact and stability during this com- 2.3.4 Roles of the AC and SC Joints
bined motion, the scapular stabilizers must not in Scapular Motion
only contract in synchrony with each other, but
also with each of the muscles that cross the The clavicle acts as a strut which allows for the
glenohumeral joint along with the proprioceptive strategic positioning of the shoulder girdle along
feedback obtained from surrounding soft-tissue the side of the thorax. In order to maximize
structures (such as the glenohumeral joint cap- shoulder range of motion, the clavicle must be
sule [6]). Although a thorough discussion of each dynamically positioned according to scapular
possible scapular movement is beyond the scope motion via the AC and SC joints. Therefore, the
of this book, we aim to emphasize the extreme health of the clavicle and the AC and SC joints is
importance of understanding the fundamental extremely important to achieve normal scapu-
concepts related to three-dimensional scapular lar motion in three-dimensional space [26–28].
2.4 Differentiating Between Glenohumeral and Scapulothoracic Motion 17
For example, arm elevation requires the clavicle ness using a cross-body adduction technique
to retract, elevate, translate, and rotate posteriorly (described below), the clinician must first stabi-
along its long axis (i.e., the so-called “screw lize the scapula to minimize protraction.
axis”) where each of these movements is depen- Otherwise, the measured amount of total com-
dent on the function of intact, painless AC and bined adduction capacity will almost always be
SC joints [29, 30]. significantly greater than the true isolated gleno-
humeral adduction capacity as a result of the
additive effect of scapular protraction.
2.4 Differentiating Between Although complete isolation is probably not
Glenohumeral feasible in the clinical setting, clinicians can usu-
and Scapulothoracic Motion ally estimate the amount of isolated glenohu-
meral motion by detecting (or, in some cases,
The ability to elevate the arm overhead through stabilizing) scapular motion. In the case of
any plane relies on dynamic scapular positioning humeral elevation, the examiner can place one
which essentially places the glenoid in a position hand over the scapula (with the thumb over the
of maximum contact with the humeral head. Due scapular spine and the fingers wrapped anteriorly
to the three-dimensional complexity of scapular over the top of the shoulder) and ask the patient
motion, it may be difficult for an inexperienced to slowly flex or abduct the humerus. During this
examiner to differentiate between the glenohu- movement, the examiner uses their hand to deter-
meral and scapulothoracic components of shoul- mine the point at which the scapula begins to
der elevation. Many investigators have proposed translate or rotate. It is then assumed that any
methods of isolating each movement, thus allow- degree of elevation below this level would be
ing clinicians to more easily diagnose common composed of primarily glenohumeral motion
shoulder problems. For example, in order to whereas any motion above this level would
achieve normal cross-body adduction, the scap- involve a combination of glenohumeral and
ula must protract to maintain adequate glenohu- scapulothoracic motion (Fig. 2.13). The same
meral contact and stability (i.e., the scapula must concept can theoretically be applied to a variety
translate laterally and internally rotate to con- of other testing procedures where isolation of
form with the convexity of the posterior chest glenohumeral motion is desired. In contrast to
wall). While measuring posterior capsular tight- the method of detecting scapular motion, the
Fig. 2.13 Isolated

glenohumeral motion
versus combined glenohu-
meral and scapulothoracic
motion. In this subject, the
scapula began to rotate at
approximately 100° of
humeral abduction.
Therefore, motion above
this point is considered
combined glenohumeral
and scapulothoracic
motion whereas motion
below this point is
considered isolated
glenohumeral motion.
examiner can also stabilize the scapula by apply- The above discussion only considers the abil-
ing a downward force to the top of the shoulder ity of an examiner to isolate glenohumeral motion
during shoulder elevation. In many cases, the during arm elevation. No published studies have
same effect can be achieved by performing cer- examined the ability of an examiner to isolate
tain examination maneuvers with the patient glenohumeral rotation. However, the results of an
placed supine on the examination table (i.e., lay- unpublished cadaveric study by McFarland et al.
ing on a flat surface is thought to limit scapular [36] and Yap et al. [37] that were presented at the
motion during testing). 1998 annual meeting of the Orthopedic Research
The exact transition point between isolated Society in New Orleans, LA and the annual meet-
and combined motion has been debated. Clarke ing of the American College of Sports Medicine
et al. [31] found that passive isolated glenohu- in Orlando, FL in the same year suggested that
meral abduction in a series of young, healthy glenohumeral rotation may be isolated and,
patients occurred below 85.6° in females and potentially, accurately measured to within 2°
below 77.4° in males. Gagey and Gagey [32] prior to initiation of scapulothoracic motion.
found a similar result in which 95 % of their sub- Their methods have not been validated in the lit-
jects with normal shoulders transitioned to com- erature to date.
bined scapulothoracic motion between 85° and
90° of glenohumeral elevation. In contrast,
Sauers et al. [33] found that the transition 2.5 End Feel Classification
occurred at approximately 112° of glenohumeral
elevation and Lintner et al. [34] found that the Accurate range of motion testing requires that the
transition occurred at approximately 109° of gle- examiner utilizes both visual and tactile clues
nohumeral elevation. that ultimately aid in the entire physical examina-
Due to these conflicting results, the reliability tion process. While the visual clues are obvious
of this method in the measurement of isolated in many cases, tactile sensations that are trans-
glenohumeral motion came into question. A study mitted to the examiner’s hands or fingers as they
by Hoving et al. [35] determined that the intra- manipulate the upper extremity are equally
rater reliability for isolated glenohumeral motion important in directing future examination maneu-
was only 0.35; however, the study involved a vers and diagnostic studies. With range of motion
series of patients with varying degrees of shoul- testing, the concept of end feel is extremely
der pain which may have confounded their important on several levels. As the glenohumeral
results. In addition, the clinicians were somewhat joint nears its maximal range of motion, the qual-
unfamiliar with the digital inclinometers that ity of the end feel can give the clinician an idea of
were used in the study, potentially blurring the what is happening anatomically.
interpretability of their results. In 1947, Cyriax and Cyriax [38] described a
Several biomechanical studies have suggested basic classification system in which normal end
that although the majority of scapular motion feel was characterized as bony, capsular or soft-
occurs above 90° of glenohumeral elevation, tissue approximation and abnormal end feel was
there does exist some scapular motion below this characterized as spasm, springy block, and empty
level. This fact calls into question the ability of an (Table 2.1). These sensations occurred near the
examiner to completely isolate glenohumeral extremes of shoulder motion as a result of bony
elevation. Currently, it is thought that the scapula architecture, muscle contraction, and/or soft-
moves throughout the total arc of shoulder eleva- tissue stretching.
tion and that complete isolation of glenohumeral A bony end feel occurs when an abrupt end
motion is probably not realistic. However, when point is reached as two hard surfaces come into
the angle of glenohumeral elevation is less than contact (e.g., terminal extension of the elbow).
90°, the degree and quality of glenohumeral Capsular end feel occurs as the joint approaches an
motion can be reliably estimated. extreme motion plane—further motion becomes
2.6 Methods of Measurement 19
Table 2.1 Cyriax and Cyriax end feel classification abducted. The authors suggested that this
End-feel Description discrepancy was related to the fact that the scapu-
Capsular Motion ends gradually, as if a leather lae of the subjects were variably stabilized which
band were being stretched. may have produced differences in end feel in
Tissue Motion ends in a manner suggesting these patients. In addition to this variation, it is
approximation that motion would continue if not
prevented by another structure.
thought that the presence of pain may also have a
Springy block Motion ends with a noticeable rebound
significant effect on different end feel character-
sensation. istics [40].
Bony Motion ends immediately when two The clinical applicability or validity of the var-
hard surfaces come into contact. ious end feel characteristics has not been evalu-
Spasm Motion ends in a “vibrant twang,” or ated in the literature. The difficulty is that different
when motion is counteracted by muscle
end feel characteristics probably represent combi-
contraction.
Empty Motion does not end, but patient asks
nations of anatomic variables and pathologic
examiner to stop maneuver as a result lesions that likely cannot be differentiated by tac-
of pain. tile sensation alone. Therefore, despite its wide-
spread application in clinical practice, further
study is needed to validate this method of exami-
increasingly difficult to obtain as the capsule nation before it can be formally advocated.
stretches. Cyriax and Cyriax [38] suggested that
capsular feel was analogous to a thick leather band
being stretched. Soft-tissue approximation occurs 2.6 Methods of Measurement
when soft tissues prevent further motion, such as
in the instance of cross-body adduction or extreme Range of motion is defined as the magnitude of
elbow flexion. Muscle spasm can often have a motion capacity that exists across a joint. Because
hard end feel and was characterized as a “vibrant most major joints in the body achieve angular (or
twang” towards the extremes of motion. This can rotational) movements, range of motion is typi-
especially occur in the evaluation of a patient with cally measured in degrees relative to some nor-
instability who demonstrates a positive apprehen- mative plane. Range of motion measurement is a
sion sign (the apprehension sign is discussed in particularly important aspect of the physical
Chap. 6). A springy block is felt when an intra- examination that is often overlooked in clinical
articular block prevents motion, followed by an practice. These measurements can have signifi-
episode of rebound. An empty end feel occurs cant implications regarding treatment approaches
when the examiner cannot discern a palpable end and outcomes and should not be omitted when
point; however, significant pain often prevents fur- evaluating a new patient with a shoulder com-
ther motion. plaint. Shoulder range of motion is typically
In 2001, Hayes and Petersen [39] examined quantified using one of four basic techniques;
the inter- and intra-rater reliability of end feel in these include estimation via visual inspection,
patients with painful shoulders and knees. Two the use of an inclinometer, the use of a goniome-
physical therapists evaluated each patient twice, ter, the use of a gyroscope or, more recently, digi-
measuring two knee motions and five shoulder tal photography using a high resolution camera
motions. The examiners noted the character and or smart phone.
quality of the end feel at the extremes of range of
motion while patients vocalized the exact
moment of pain reproduction. The inter-rater κ 2.6.1 Visual Inspection
coefficients for end feel ranged from 0.65–1.00
to 0.59–0.87 for the pain/resistance sequence. Unfortunately, visual estimation is the most
However, their study also demonstrated large commonly used method for the measurement
variations in end feel when the shoulder was of shoulder range of motion. Although several
studies have found that experienced practitioners

can estimate range of motion with a similar accu-
racy to standardized measurement devices [41,
42], the lack of teaching regarding the fundamen-
tals of range of motion testing is disappointing.
This results in inaccurate measurement estima-
tions by the novice examiner who was never
properly taught to use goniometers or inclinom-
eters. Although formal measurement requires
more time to complete, it is suggested that inex-
perienced examiners use standard measurement
devices to aid in accurate patient assessment until
they become more knowledgeable and experi-
enced with the examination process. In a busy
clinical practice, however, the experienced clini-
cian can usually make rapid range of motion esti-
mations without sacrificing accuracy or precision.
Visual inspection and estimation of range of
motion is therefore a standard of practice in most
cases, but formal measurements are required
when a study involving range of motion data is
being conducted.
Fig. 2.14 Photograph of a mechanical inclinometer.
2.6.2 Inclinometers mechanical inclinometer. In an adjunct study

[47], the same group found that the ability of the
An inclinometer is essentially a leveling device, inclinometer to detect changes in joint proprio-
similar to that which is used by a carpenter to ception was also pronounced. In that study, they
measure the degree of inclination of a surface calculated inter- and intra-observer reliabilities
relative to the horizontal plane, that is occasion- ranging from 0.978 to 0.984.
ally used in clinical practice to quantify shoulder Currently, digital inclinometers are more com-
range of motion or, in some cases, the degree of monly used to assess shoulder range of motion
spinal deformity such as kyphosis or scoliosis [48–57] and function by calculating the angle of
[43–45]. Both mechanical and digital inclinome- inclination relative to the horizontal plane using
ters have been described as reliable and valid an implanted gravity sensor. Kolber et al. [51]
tools for the measurement of shoulder range of determined that the inter- and intra-observer reli-
motion. abilities of digital inclinometry was greater than
Mechanical inclinometers, or hygrometers, 0.95 and found that this method was interchange-
use gravity and a fluid-level indicator to measure able with goniometry (intra-class correlation
the inclination of the humerus relative to the hori- [ICC] coefficients for goniometry were >0.94)
zontal plane in degrees (Fig. 2.14). The first [51]. Scibek and Carcia [54] studied 13 healthy
reported use of a mechanical inclinometer to collegiate subjects in an attempt to quantify
measure range of motion was in 1975 by Clarke scapulohumeral rhythm using a digital inclinom-
et al. [31]. In their study, the inter-observer reli- eter. In that study, the investigators found that the
ability was approximately 0.93. Similarly, Dover scapula contributed to 2.5 % of shoulder motion
et al. [46] calculated inter- and intra-rater reli- in the first 30° of shoulder abduction. This pro-
ability values of approximately 0.99 in the mea- portion dramatically increased to between 20.9
surement of shoulder range of motion using a and 37.5 % when measured between 30° and 90°
2.6 Methods of Measurement 21
of humeral abduction, respectively. Johnson et al. range of motion. The degree of angulation between
[58] calculated the reliability and validity of a the two arms of the device represents the total
digital inclinometer to measure scapular upward range of motion achieved by the joint. It is impor-
rotation during humeral abduction in the scapular tant to maintain stabilization of the limb proximal
plane. They found that the digital inclinometer to the center of rotation of the joint to avoid mea-
had excellent reliability and validity in the assess- surement errors. In addition, it is best practice to
ment of scapular motion with inter- and intra- read the goniometer measurement before remov-
observer ICCs ranging from 0.89 to 0.96. A ing the device from the joint. Goniometric mastery
similar study by Tucker and Ingram [56] calcu- requires extensive practice and anatomic knowl-
lated ICCs of >0.89 after using a digital incli- edge which will eventually result in measurement
nometer to quantify scapular upward rotation consistency and reproducibility. It is therefore rec-
with static humeral elevation. ommended for the novice examiner to learn the
More recently, studies by Shin et al. [59] and proper range of motion measurement techniques
Mitchell et al. [60] demonstrated the ability of early in their orthopaedic career.
smart phone inclinometers (and goniometers) to
accurately measure range of motion with excellent
inter- and intra-observer reliability (ICC >0.9). 2.6.4 Gyroscopes
One other study [61] demonstrated the capability
of smart phones to measure cervical range of A gyroscope is essentially a spinning wheel that
motion. This method of measurement eliminates changes in three-dimensional orientation with
the cost of standard digital inclinometers, a factor changes in angular momentum. Gyroscopes have
that has limited their widespread use. Nevertheless, numerous potential applications such as inertial
these studies demonstrate the utility and practical- navigation systems (e.g., orbiting satellites) and
ity of digital inclinometers in the accurate mea- various types of flying vehicles (e.g., helicop-
surement of scapulohumeral rhythm in addition to ters). With regard to the shoulder, gyroscopes can
glenohumeral range of motion capacity. also be used to precisely measure range of motion
as shown in a few preliminary studies [63, 64].
El-Zayat et al. [63, 64] reported good reproduc-
2.6.3 Goniometers ibility and reliability with regard to range of
motion measurements in two separate studies.
The use of a standard handheld goniometer is still Penning et al. [65] evaluated 58 patients with
the most commonly used device for the measure- either subacromial impingement (27) or glenohu-
ment of shoulder range of motion, especially since meral osteoarthritis (31) and determined the repro-
it produces results comparable to more expensive ducibility of a three-dimensional gyroscope to
devices that measure the same variables [51, 52, measure shoulder abduction. They also found that
62]. Goniometers come in various shapes and use of the gyroscope was a reproducible method to
sizes; however, the general setup has two movable measure shoulder range of motion; however, they
arms where one arm is place in line within a nor- recommended repeating the measurements for
malized vertical or horizontal plane (or the “zero improved accuracy. Further studies are needed to
position” as defined by Clarke et al. [31]) and the define how and when gyroscopes should be used
other arm is used to measure the degrees of devia- for accurate range of motion assessment.
tion from the chosen plane of reference. To use a
goniometer, the fulcrum of the device is aligned
over the center of rotation of the joint to be mea- 2.6.5 Digital Photography
sured. The stationary arm of the goniometer is
aligned with the limb being measured, generally Digital photography has been shown on multiple
over proximal muscle origins. The goniometer is occasions to be an accurate method of making
held in place while the joint is moved through its range of motion measurements [66–70]. Although
Fig. 2.15 Clinical photographs demonstrating maximal forward flexion in a patient both before (a) and after (b) an
interposition arthroplasty procedure. (Courtesy of J.P. Warner, MD).
Fig. 2.16 Clinical photographs demonstrating maximal forward flexion in a patient both before (a) and after (b) sub-
acromial injection with local anesthetic. (Courtesy of Christian Gerber, MD).
standardized photographic methods that place the advantages that should be recognized. The first
patient and the camera in the correct position to advantage centers around documentation as
allow for accurate and reproducible two- the photograph becomes part of the patient’s
dimensional measurements have yet to be estab- medical record which can be referred to at a
lished, digital photography offers several patient later date (Figs. 2.15 and 2.16). Second, digital
2.7 Measuring Active and Passive Shoulder Elevation 23
photographs can be sent through the internet to It is most prudent to measure abduction
distant clinics, especially when there is a geo- capacity within the plane of the scapula; that is,
graphic constraint to proper medical care. Third, abduction with approximately 20–30° of forward
standardized range of motion photographs of angulation. It is nearly physiologically impossi-
any given patient can be compared and reviewed ble to achieve maximal abduction with the
over a period of time to determine the progress humerus in the coronal plane. It is also best to
of rehabilitation or physical therapy. In addition perform this movement with the humerus exter-
to these patient advantages, taking digital pho- nally rotated to avoid acromiohumeral impinge-
tographs or video allows for the routine document, thus allowing the patient to maximally
mentation of uncommon pathologies which may elevate the humerus within the scapular plane.
facilitate inter-clinician communication and Attempting to abduct the humerus while inter-
education. nally rotated will result in an inaccurate measure-
ment of abduction capacity.
With the humerus abducted, the goniometer
2.7 Measuring Active is centered over the glenohumeral joint with
and Passive Shoulder one arm of the device perpendicular to the
Elevation floor and the other arm aligned according to
the angulation of the proximal humerus.
Shoulder elevation is an umbrella term used to Sometimes, the patient may experience pain
describe either flexion or abduction depending on during this maneuver. In these cases, an assis-
the scapulohumeral angle, whether in the coronal tant can hold the arm in abduction while the
plane (i.e., horizontal abduction), the sagittal measurement is made. After measurement, the
plane (i.e., forward flexion), the scapular plane examiner can passively assist the arm to deter-
(i.e., scaption) or somewhere in between these mine whether additional motion is available. If
reference points. Shoulder elevation includes the there is a considerable remaining proportion of
most important shoulder motions that are neces- motion available with passive assistance, it is
sary for activities of daily living, occupations, possible that the shoulder is weak in this posi-
sports, and recreational activities. tion. On the contrary, if abduction capacity is
limited both actively and passively, it is possi-
ble that either the shoulder is stiff or the patient
2.7.1 Measuring Shoulder is guarding from potential discomfort. It is best
Abduction to measure the degree of stiffness during an
examination under anesthesia, especially when
Shoulder abduction can be measured with the stiffness comprises a large proportion of the
patient either standing or, less commonly, lying patient’s total range of motion.
supine on the examination table. Sabari et al. [71]
found changes in abduction capacity with the
patient sitting due to compensatory contralateral 2.7.2 Measuring Shoulder Flexion
muscle activation. It is important to note that
although the patient may be able to abduct their Forward flexion of the humerus typically does
shoulders to an overhead position, they may also not require a completely intact rotator cuff to
utilize compensatory scapulothoracic motions to achieve sufficient motion, especially when the
achieve this position. Thus, it is vitally important deltoid muscle is intact. Thus, patients with
to evaluate the scapula in conjunction with any rotator cuff deficiency may have full flexion
shoulder motion. Assessment of scapular motion capability with poor abduction capacity.
and scapular dyskinesis is presented later in this Forward flexion of the humerus is typically
chapter and in Chap. 9. measured with the humerus and the forearm in
neutral rotation. The patient is then asked to 2.8.1 Measuring External Rotation
actively and maximally forward flex the shoul-
der. Once full, maximal forward flexion has 2.8.1.1 Supine Position
been achieved, the goniometer is centered over Numerous studies have examined the reliability
the glenohumeral joint with one arm perpendic- of isolated glenohumeral or combined glenohu-
ular to the floor and the other arm in-line with meral and scapulothoracic rotational measured in
the angulation of the proximal humerus. Once the supine position. However, variability in scap-
this measurement has been made, the arm can ular stabilization across these studies makes
be passively flexed further to measure any addi- comparison difficult since it has been shown that
tional motion that may be available. The inabil- scapular stabilization affects range of motion
ity of the patient to achieve satisfactory active measurements along with inter- and intra-rater
or passive forward flexion may be the result of a reliability [48, 72, 73]. When the examiner seeks
stiff shoulder and may require an examination information regarding glenohumeral range of
and manipulation under anesthesia. motion alone, it is necessary to determine the
point at which scapular motion begins. As men-
tioned above, the examiner places the palm of
2.8 Measuring Active their hand over the anterior shoulder, thus stabi-
and Passive Shoulder lizing the scapula while the humerus is rotated
Rotation externally at the side of the body (Fig. 2.17). The
end point for glenohumeral motion occurs when
Shoulder rotation has traditionally been mea- the shoulder begins to lift off the table as scapular
sured in the supine position; however, there are motion is initiated. The patient’s position is held
several variations in patient positioning that can while the goniometric measurement is made. In
be used to answer specific clinical questions or to the second technique, the examiner places their
facilitate patient comfort. In addition to the hand underneath the patient’s scapula and simul-
supine position, shoulder rotation can be mea- taneously externally rotates the humerus. When
sured with the patient standing, sitting or in the the scapula begins to move, the end point
lateral decubitus position. has been reached and the measurement is made.
Fig. 2.17 Demonstration

of the position used to
measure passive external
rotation in the supine
position.
2.8 Measuring Active and Passive Shoulder Rotation 25
A third way to measure isolated glenohumeral the body to increase this measurement. When the
external rotation in the supine position is to sim- humerus is abducted to 90°, the examiner pas-
ply visualize the point at which the shoulder sively externally rotates the humerus as far as the
complex begins to move in response to the rota- patient will allow while also preventing a hyper-
tional moment. This is done while simultane- lordotic posture. The examiner then asks the
ously feeling for an endpoint as the examiner patient to hold this position while the measure-
externally rotates the humerus. ment is made. In some cases, an assistant exam-
iner may be required to assist the patient in
2.8.1.2 Sitting or Standing Position holding this position, especially in those with
In the sitting or standing position, measure- joint hyperlaxity who display a large external
ments are made with the elbows flexed to 90° rotation arc.
with the humerus either at the side or abducted Although less commonly performed, com-
to 90° depending on the information sought by bined scapulothoracic and glenohumeral range
the examiner. It is often useful to obtain multi- of motion can also be measured actively. With
ple measurements such that a complete evalua- the arm at the side, the patient attempts to exter-
tion can be achieved. In addition, distinguishing nally rotate the humerus maximally without
between glenohumeral and scapulothoracic extending the shoulder or increasing lordosis.
contributions to shoulder motion can also pro- A similar maneuver is performed with the arm
vide powerful evidence for or against a specific abducted to 90°, taking care to prevent ancillary
pathology. muscular contraction. An assistant can help hold
Passive glenohumeral external rotation can be the final position while a goniometric measure-
isolated when the arm is either at the side or ment is made.
abducted to 90°. When the arm is at the side, the
examiner stabilizes the flexed elbow and pas- 2.8.1.3 Lateral Decubitus Position
sively externally rotates the humerus until the With the patient in the lateral decubitus position
glenohumeral joint reaches its first end point. and lying on the affected arm, passive external
This generally occurs when shoulder tightness rotation capacity can be measured. The arm is
develops and the patient begins compensatory first abducted to 90° and then passive external
rotation of the torso. The examiner then asks the rotation is measured with a goniometer once the
patient to hold their position at the end point so first end point has been reached (scapula begins
that measurements can be made with a goniome- to move or resistance is felt).
ter. An assistant can also hold the arm in place
while measurements are made.
When the shoulder is abducted to 90°, isolated 2.8.2 Measuring Internal Rotation
glenohumeral external rotation capacity is mea-
sured by passively externally rotating the Internal rotation of the shoulder can also be quan-
humerus until the first end point is detected. The tified using methods similar to that of external
end point is usually reached when the patient rotation, differentiating between glenohumeral
begins to bend backwards at the waist to compen- and scapulothoracic contributions. The various
sate for the force being placed on the arm. The techniques for measuring active and passive
examiner can also simultaneously inspect the internal rotation are described below.
scapula to determine the point of external rota-
tion at which the scapula begins to retract. 2.8.2.1 Supine Position
Passive combined glenohumeral and scapulo- Isolated glenohumeral or combined glenohu-
thoracic range of motion can be assessed by sim- meral and scapulothoracic internal rotation in the
ply externally rotating the humerus until its final supine position can be performed exactly as
end point is reached. It is important to prevent the described for external rotation above (Fig. 2.18).
patient from extending the shoulder or turning This method is especially helpful for the
stabilizes the elbow and rotates the humerus

internally as far as possible without compensa-
tory movements. The patient holds the arm in this
position and a goniometer (or similar device) is
used to make the measurement. Some patients
with internal rotation deficits, rotator cuff dis-
ease, and/or osteoarthritis may develop pain with
internal rotation. In these cases, the end point
occurs at the degree of internal rotation in which
the patient begins to experience pain.
A similar maneuver is performed to measure
active internal rotation with the arm abducted to
90°. In this case, the patient uses his or her mus-
cles to generate the internal rotation force until a
maximum angle is reached. The patient (or an
assistant) holds the arm in the maximally inter-
Fig. 2.18 Demonstration of the measurement of passive
internal rotation in the supine position with the arm nally rotated position until the measurement is
abducted to 90°. (Courtesy of Craig Morgan, MD.). documented.
In clinical practice, measuring active internal
rotation with the patient reaching the thumb
examination of overhead athletes who may have along the dorsal aspect of the thoracic spine was
developed hyperexternal rotation with a glenohu- originally advocated since this motion was
meral internal rotation deficit (GIRD) resulting in thought to require maximal internal rotation (see
a pathologically diminished total arc of rotation Fig. 2.7). The measurement took into account the
compared to the contralateral shoulder. vertebral level to which the thumb could reach up
the spinal column. For example, a patient may
2.8.2.2 Sitting or Standing Position reach to a level of T7 or L4 with their thumb as
With the patient sitting or standing, passive gle- they reach upwards—this system of reporting is
nohumeral internal rotation capacity is generally still occasionally used. However, researchers
measured with the arm abducted to 90° and the have refuted its usefulness as a measure of inter-
elbow flexed to 90°. From this position, the nal rotation for several reasons [5]. First, the
humerus is passively and gently internally rotated maneuver requires motion beyond the glenohu-
until the examiner notes compensatory scapular meral and scapulothoracic articulations.
or bodily movements. The patient is then asked to Adequate finger, wrist and elbow motion is also
hold this position while a measurement is required to perform this maneuver. A study by
recorded with a goniometer. If necessary, an Mallon et al. [5] found that this type of motion
assistant can hold the patient’s arm in place while required glenohumeral, scapulothoracic, elbow,
the measurement is being made. The zero posi- wrist, hand, and finger movements. Elbow flex-
tion is defined as the plane in which the forearm ion contributed significantly to the final internal
is perpendicular to the floor—if the patient can- rotation measurements in their study as the
not internally rotate to the zero position, the patient moved the hand from the sacrum upwards
goniometric measurement is recorded as a towards the thoracic spine. Thus, patients with
negative number. elbow pathology may not reach the same spinal
Internal rotation involving combined glenohu- level as someone with a normal elbow; however,
meral and scapulothoracic components can be both of their shoulders may have normal active
measured either actively or passively with the and passive internal rotation capacities. Second,
humerus abducted to 90° and the elbow flexed to Mallon et al. [5] also found that the relative
90°. In the passive form of the test, the examiner contributions of the scapulothoracic and
2.9 Factors That Affect the Accuracy of Range of Motion Measurements 27
glenohumeral articulations was approximately the authors concluded that the loss of forward
2:1 with this movement, suggesting that this test flexion in patients under 40 years of age should
may be more appropriate in the evaluation of not be attributed to the aging process.
global shoulder function rather than glenohu-
meral or scapulothoracic motion. Third, a recent
study by Hall et al. [74] found that when com- 2.9.2 Gender
pared to the estimation of vertebral levels, inter-
nal rotation measurements using a goniometer Gender appears to be another factor that may
with the arm abducted was more reliable and influence shoulder range of motion measure-
accurate. ments since several studies have demonstrated
the ability of women to achieve a greater range of
2.8.2.3 Lateral Decubitus Position active and passive motion when compared to men
Measuring passive isolated internal rotation in of the same age [31, 75, 77–80]. Clarke et al. [31]
the lateral decubitus position is performed exactly and Schwartz et al. [80] found similar results,
as described above for external rotation. however, neither study found a difference in
internal rotation capacity between genders.
2.9 Factors That Affect

the Accuracy of Range 2.9.3 Patient Positioning
of Motion Measurements
Several studies have found that the position of the
Measuring range of motion can sometimes be a torso may have a significant effect on range of
difficult task, especially when challenged with motion measurements [62, 71, 72, 81]. The pri-
various confounding variables. As such, there are mary concern revolves around the potential dif-
many factors that can potentially influence range ferences in measurements when the patient is
of motion measurements. Some of these include sitting versus standing versus supine. The sitting
age [31, 75–77], gender [31, 75, 77–80], patient position removes the effect of gravity when test-
positioning [62, 71, 72, 81], arm dominance [31, ing internal and external rotation with the arm at
76, 82, 83], posture [84, 85], participation in the side. The effect of gravity on abduction can
overhead sports, and the experience of the exam- also be eliminated by having the patient lie in the
iner [42, 86]. supine position, thus potentially allowing the
patient to obtain a larger arc of active shoulder
abduction. In addition, scapulothoracic motion
2.9.1 Increasing Age may be affected when a patient lies supine on a
flat surface, thus inhibiting the ability of the scap-
Several authors have reported a decrease in ula to move in conjunction with glenohumeral
shoulder range of motion with advancing age elevation.
[31, 75–77]. Barnes et al. [75] measured shoulder Sabari et al. [71] studied the effect patient
motion in 280 volunteers with 40 subjects in each position on range of motion in a series of 30
of 7 groups ranging in age from 0–10, 10–20, healthy volunteers, specifically noting whether a
20–30, 40–50, 50–60, and 60–70 years. Not sitting or supine position affects the ability of the
unexpectedly, the investigators found a gradual patient to flex or abduct the shoulder. The inves-
decline in active and passive range of motion tigators found significant differences in range of
with respect to increasing age; however, this was motion measurements depending on whether the
not true for internal rotation, which appeared to subject was in the sitting or supine position. In
increase as age increased. This paradox may be the sitting position, subjects were found to use
attributed to external rotation weakness which compensatory thoracopelvic movements to aid in
was also found to increase over time. In addition, shoulder motion. Although both methods can be
used to measure range of motion, it is important posture (e.g., those with kyphoscoliosis) may
to note the position of the subject during the underestimate the true anatomic restraints to
examination to help with interpretation of the shoulder motion.
collected data.
2.10 Specific Tests for General

2.9.4 Arm Dominance Shoulder Mobility
Range of motion measurements of the dominant There are many physical examination maneuvers
shoulder compared to those of the non-dominant that can be used to measure general shoulder
shoulder can vary considerably [75, 80], espe- mobility and flexibility. Compared to other
cially with regard to rotational measurements in maneuvers that measure specific components of
throwing athletes. Several studies have found no shoulder motion, these tests have the specific
differences in range of motion between shoul- advantage of determining the overall functional-
ders; [31, 76, 82, 83] however, Barnes et al. [75] ity of the upper extremity with regard to the per-
found that the non-dominant shoulder had sig- formance of activities of daily living. Of course,
nificantly increased active and passive internal there exists a ceiling effect when performing
rotation along with increased active and passive these tests on athletes who require a greater
extension compared to the dominant shoulder in degree of performance relative to the general
non-throwing athletes. Interestingly, the investi- population. Nevertheless, these tests can be use-
gators also found that the dominant shoulder had ful to determine if range of motion loss has an
significantly increased external rotation capacity effect on the patient’s normal activities since they
compared to the non-dominant shoulder. The require combinations of basic shoulder move-
authors concluded that comparing rotational ments in different planes. Some authors have
range of motion between dominant and non- called into question the clinical relevance of
dominant shoulders may not be as clinically use- many of these tests while also suggesting other
ful as once thought. types of tests that more closely simulate activities
of daily living [11, 12, 87, 88]. Patients who pres-
ent with shoulder complaints are often ques-
2.9.5 Posture tioned regarding these basic movements in
outcomes questionnaires (such as the American
The degree of thoracic curvature may also play a Shoulder and Elbow Surgeons’ [ASES] score
role in range of motion and strength measure- [89] and Disabilities of the Arm, Shoulder and
ments [80, 84, 85]. Kebaetse et al. [85] compared Hand [DASH] score [90]); however, these spe-
shoulder range of motion, strength, and scapulo- cific motions are infrequently tested directly by
thoracic kinematics in a series of 34 healthy par- the treating physician.
ticipants who were placed in either the erect or Description and discussion of a few general
slouched position. When in the slouched posture, shoulder mobility tests are described below. Note
the investigators noted increased scapular eleva- many more of these types of general motion tests
tion between 0° and 90° of humeral abduction exist; however, the tests described below were
and decreased posterior scapular tilt when the chosen because they are more likely to be taught
abduction angle was greater than 90°. In addi- and/or practiced.
tion, active glenohumeral range of motion was
significantly decreased in those with slouched
postures. Bullock et al. [84] also noted a signifi- 2.10.1 Apley Scratch Test
cantly decreased flexion range of motion after
measurement of those positioned in a slouched The Apley scratch test is one of the more fre-
posture. Therefore, range of motion measure- quently taught maneuvers for the evaluation of
ments in patients who present with a slouched general shoulder motion and overall function.
2.10 Specific Tests for General Shoulder Mobility 29
Fig. 2.19 Apley scratch test. (a) The subject reaches downward along the thoracic spine. (b) The subject reaches
upwards along the lumbar spine.
The patient is first asked to place one hand on the horizontal adduction towards the opposite
ipsilateral shoulder and to reach as far inferiorly shoulder. Measuring tape can be used to mea-
along the thoracic spine as possible. This motion sure the distance from the lateral epicondyle to
is useful for evaluating combined abduction, the AC joint at the top of the shoulder (Fig. 2.20).
flexion, and external rotation of the shoulder. Once this has been completed and a measure-
Next, the patient is then asked to place the arms ment has been recorded, the test is repeated on
at the side and then to reach up the lumbar and the contralateral side for measurement compari-
thoracic spine as far as possible. This motion is son. Patients with pain related to AC joint
useful for evaluating the combination of adduc- pathology may experience pain at the top of the
tion, extension, and internal rotation of the shoul- shoulder with this movement and, therefore,
der (Fig. 2.19). Although the clinical utility of range of motion measurements may be affected
this test has yet to be defined, it is generally (physical examination of the AC joint is dis-
thought to be a quick and effective modality for cussed in Chap. 7).
the evaluation of global shoulder function.
2.10.3 Combined Abduction Test

2.10.2 Cross-Body Adduction Test
The combined abduction test was first described
The cross-body adduction test is another mea- by Pappas et al. [91] in 1985. The patient is asked
sure of general shoulder motion that can be used to assume a supine position on the examination
more specifically to measure flexibility of the table. The examiner then places his or her hand
shoulder, especially with regard to the posterior behind the scapula to detect scapular motion
capsule. In this test, the arm is forward flexed to while the arm is simultaneously elevated in using
approximately 90° of elevation followed by a combination of flexion and abduction until the

of the measurement of
cross-body adduction. The
arm is passively adducted
across the chest until
resistance is felt. The
distance from the lateral
epicondyle to the
acromioclavicular (AC)
joint is then determined
using measuring tape.
arm is fully elevated, taking care to avoid an that this maneuver may only be clinically useful
increase in lordosis or any other compensatory when the examiner has performed the exam on
movement that may increase arm elevation. If many patients with normal shoulders such that
the arm cannot reach an angle that is parallel subtle changes in motion can be detected. The
with the examination table, inflexibility is likely test has not been formally evaluated in the
present and may indicate muscle or capsuloliga- literature.
mentous tightness. The structures involved have
not been specifically evaluated, although tight-
ness of the pectoralis major, latissimus dorsi, and 2.10.5 Posterior Tightness Test
teres major muscles has been implicated on one
occasion [92]. Tyler et al. [93, 94] described the posterior tight-
ness test which specifically examines the flexi-
bility of posterior shoulder structures. In this
2.10.4 Quadrant Test test, the patient is placed in the lateral decubitus
position with the untested arm placed beneath
The quadrant test, first described by Mullen et al. the head with the knees and hips flexed for com-
[18] in 1989, was designed to detect a subtle fort. The arm to be tested is then passively flexed
change in Codman’s paradox as a result of shoul- to 90° of forward elevation and the ipsilateral
der discomfort or pathology (Codman’s paradox scapula is stabilized with the examiner’s oppo-
is discussed earlier in this chapter). The test is site hand. The arm is then adducted across the
performed with the patient in the supine position. body, taking care to prevent any rotational
The examiner places his or her hand over the motion of the humerus (Fig. 2.22). When resis-
spine of the scapula and the distal clavicle and tance is felt, a tape measure can be used to deter-
applies a gentle inferiorly directed pressure to mine the distance from the lateral epicondyle to
prevent shoulder shrugging during the test. The the surface of the examination table. This
arm is first abducted to 90° of straight lateral maneuver is typically performed with an assis-
abduction and 90° of external rotation. From this tant who makes the final measurement. The test
position, the arm is adducted until the humerus is then repeated on the contralateral shoulder for
begins to internally rotate. The moment the arm comparison. The original investigators calcu-
begins to internally rotate is known as the quad- lated an inter-rater reliability of approximately
rant position (Fig. 2.21). It should be emphasized 0.80 and an intra-rater reliability of greater than
2.10 Specific Tests for General Shoulder Mobility 31
Fig. 2.21 Quadrant test.

(a) With the patient supine,
the scapula is stabilized
and the humerus is
abducted to 90° and
externally rotated to 90°.
The humerus is the
adducted (curved arrow)
until (b) the humerus
begins to internally rotate.
This is known as the
quadrant position.
0.90 for both the dominant and non-dominant and validity of the test in overhead athletes while
shoulders of asymptomatic subjects. also suggesting that performing the test in the
This test was subsequently used by the same supine position may actually be more accurate
group to evaluate a series of collegiate baseball [97, 98].
players and a cohort of patients with subacro-
mial impingement syndrome. In addition, other
authors have found that the test may be useful 2.10.6 Horizontal Flexion Test
for comparing posterior shoulder tightness
between the dominant and non-dominant shoul- The horizontal flexion test was also designed to
ders of baseball players [95] along with differ- detect posterior shoulder tightness and was first
ences in shoulder tightness among different described by Pappas et al. [91] in 1985. In this
baseball positions [96]. Although the test has not test, the patient is positioned supine and the tested
been formally validated for routine practice, arm is flexed to 90° of elevation. Without bending
several authors have confirmed the reliability the elbow, the arm is slowly adducted until
resistance is felt. The position is held and the

angle formed between the vertical axis and the
arm is measured with a goniometer (Fig. 2.23). In
general, when the adduction angle is less than
45°, posterior shoulder tightness should be con-
sidered. No studies have evaluated the validity of
this method to diagnose posterior shoulder tight-
ness; however, it can give the clinician a clue as to
the underlying pathologic process. It is important
to remember that the measured amount of adduc-
tion relative to any reference point should be cor-
rected in patients with scapular malposition.
2.10.7 Pectoralis Minor

Tightness Test
Tightness or shortening of the pectoralis minor

muscle-tendon complex can have significant clin-
ical implications and has been described a poten-
tial indirect pain generator and a cause for
scapular dyskinesis with specific alterations in
upward rotation, external rotation, and posterior
tilt [99, 100]. As a result, the inferiorly malposi-
Fig. 2.22 Posterior capsular tightness. With the patient in tioned scapula decreases the space available for
the lateral decubitus position, the untested arm is placed the rotator cuff tendons to travel beneath the
under the head and the knees are bent. This positioning acromion, potentially leading to subacromial
helps prevent the torso from rotating during the test. The impingement and subsequent rotator cuff disease
humerus is placed in 90° of forward flexion. The examiner
stabilizes the scapula and passively adducts the humerus [23, 101, 102].
until resistance is felt. A tape measure is sometimes used Kendall et al. [92] described a method of
to measure the distance from the lateral epicondyle to the determining whether pectoralis minor muscle
surface of the examination table. tightness was present. In this test, the patient is
Fig. 2.23 Horizontal

flexion test. With the
patient supine, the humerus
is flexed to 90° and slowly
adducted until resistance is
felt (curved arrow). The
angle of adduction is then
determined using a
goniometer, using a
vertical line as a reference
point.
2.11 The Stiff Shoulder and the Frozen Shoulder 33
placed supine on the examination table and the syndrome in which shoulder pain gradually
examiner places one hand on the anterior shoul- develops followed by a loss of shoulder motion.
der. The shoulder is then pushed posteriorly The condition is more common in women and
towards the surface of the examination table has been associated with increased levels of cyto-
using a gentle to moderate force. An inability to kines and inflammatory markers within the gle-
push the anterior shoulder such that the posterior nohumeral synovial fluid and subacromial bursa
shoulder lies flat on the table indicated pectoralis without an identifiable cause [123–127]. Soft tis-
minor tightness. Another way of testing for pec- sue contractures and scarring may result, leading
toralis minor tightness is to simply visualize the to significant range of motion loss. While some
asymmetric height of one scapula versus the con- authors have suggested an autoimmune origin
tralateral scapula. In the patient with pectoralis and an association with thyroid disorders, sys-
minor tightness, the affected scapula will sit far- temic lupus erythematosus, and diabetes melli-
ther away from the surface of the examination tus, these connections have yet to be fully
table than that of the contralateral shoulder. substantiated [124–126, 128–131].
Borstad [103] validated a direct measurement Clinical evaluation of the stiff shoulder thus
technique in a series of cadavers that would later requires a thorough history prior to initiation of
be used clinically to determine the actual length the physical examination process. Patients with
of the pectoralis minor muscle-tendon unit in a a history of autoimmune conditions are more
series of swimmers [104]. This method involves likely to have a frozen shoulder whereas patients
simply measuring the distance from the inferior who recently had surgery on the joint are most
aspect of the fourth rib to the coracoid process likely to have adhesion formation and symptom-
using a tape measure. When compared to an elec- atic scar tissue resulting in their loss of motion.
tromagnetic tracking system, this method resulted There are a host of reasons for a stiff shoulder
in inter- and intra-observer ICCs between 0.82 and most of the causes can be determined by a
and 0.87 [103]. thorough history.
Physical examination of patients with range
of motion loss should focus on the differences
2.11 The Stiff Shoulder between active and passive shoulder motion.
and the Frozen Shoulder When the total arc of motion is the same for
both active and passive motion, the patient is
Skillful evaluation of the stiff shoulder is one of said to have either a stiff shoulder or a frozen
the most valuable skill sets that a clinician can shoulder, depending on the etiology. In contrast,
possess. Due to the inherent complexity of the when passive range of motion exceeds that of
shoulder girdle, limited passive motion can have active range of motion, the patient is said to pri-
multiple potential etiologies and are typically marily have weakness rather than stiffness.
grouped according to whether the shoulder is Range of motion testing using a variety of tech-
“stiff” or “frozen” [105–111]. These categories niques (such as those listed above) can localize
are independent and effort must be made to the stiffness to a particular anatomic region
differentiate between the two categories since within the shoulder. For example, a patient with
their treatment options vary considerably [105– identical, yet decreased, active and passive
107, 112–122]. In general, a “stiff shoulder” internal rotation of the shoulder with the arm at
refers to any loss of joint motion from any identi- the side is likely to have stiffness of the poste-
fiable cause including arthritis, capsule contrac- rior capsulolabral structures, a common finding
ture, adhesion formation after surgery, or any in patients with glenohumeral osteoarthritis.
other joint abnormality that effectively decreases Similar examinations can be performed for
the total arc of shoulder motion. A “frozen external rotation, abduction, forward flexion,
shoulder” (also known as adhesive capsulitis), on and so on until the precise location of stiffness
the other hand, refers to the largely idiopathic or scarring is surmised.
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2.12 Conclusion Philadelphia: WB Saunders; 1997.
13. An KN, Browne AO, Korinek S, Tanaka S, Morrey
BF. Three-dimensional kinematics of glenohumeral
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essary before the clinician can implement many ing position of the glenohumeral joint: a cadaver
study. J Orthop Sports Phys Ther. 2002;32(12):
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Strength Testing
3
even if the muscle was passively stretched prior

3.1 Introduction to initiating contraction (Fig. 3.1). Therefore,
suboptimal limb positioning can have a profound
The evaluation of strength is an important aspect effect on muscular contraction strength and, as a
of the shoulder examination that, when con- result, may lead to inaccurate measurements dur-
ducted properly, can provide substantial evidence ing the strength evaluation. In other words, maxi-
for or against a suspected pathology within the mum contraction strength cannot be achieved
differential diagnosis. To perform an adequate when a muscle is placed in a position outside of
strength assessment, the clinician must have a its native resting length.
basic working knowledge of anatomy and func- Therefore, the reliability of muscular strength
tion of the skeletal muscles around the shoulder. testing depends on the clinician’s knowledge of
In addition, it is important to understand the cur- correct testing positions that are designed to opti-
rent state of research regarding shoulder strength mize the length–force relationship of the particu-
testing to aid in the interpretation and treatment lar muscle being tested. A few important clinical
of various shoulder conditions. examples include strength testing of the infraspi-
natus, subscapularis, and deltoid muscles as
described by Hertel et al. [6, 7]. In these maneu-
3.2 General Concepts vers, the extremity is passively placed such that
the muscle to be tested is in a relatively shortened
3.2.1 Length–Force Relationship position and the opposing muscle is in a relatively
lengthened position (i.e. increased tension). The
The length–force relationship of the sarcomere patient is then asked to hold the position. If the
was originally described by Blix in the late muscle being tested is weak, its contraction
1800s—a concept that was expanded upon by strength cannot overcome the passive tensile
numerous other investigators [1–5]. In his origi- force that is applied to the opposing muscle when
nal experiments, muscle tension during contrac- the arm is released by the examiner. For example,
tion was found to vary as a function of its overall when testing for infraspinatus weakness, the
length. After plotting his results, he found that humerus is passively positioned in approximately
this relationship took the form of a bell curve, the 20–30° of external rotation (also with the elbow
peak of which represented the active tension (i.e., flexed to 90°). This position decreases the passive
contraction force) produced by a muscle at its tension across the infraspinatus muscle since its
resting length. As the length of the muscle was overall length has been shortened relative to its
varied, the strength of contraction decreased, resting length. On the other hand, this position
40 3 Strength Testing
Muscle
Bundle of
muscle fibers
Single
muscle fiber
Myofibril Light Dark

Nuclei
band band
Sarcomere
b
resting length
total
tension
Tension
active
tension passive
tension
Length
Length-Tension Curve of a Muscle
Fig. 3.1 (a) Skeletal muscle structure hierarchy includ- (Blix curve). Note that active and passive tension are addi-
ing a scanning electron micrograph (SEM) of a typical tive as the muscle length increases.
sarcomere. (b) Length-tension curve of skeletal muscle
also increases the passive tension across the (Fig. 3.2). This finding is referred to as a positive
opposing subscapularis muscle. When the clini- external rotation lag sign and the degrees of inter-
cian releases the arm, the patient will attempt to nal rotation lag (or the amount of internal rota-
hold the position by contracting the infraspinatus tion that occurs after the arm is released) is
muscle. When this force of contraction cannot typically documented as a measure of infraspina-
overcome the passive tensile force that is applied tus weakness. The internal rotation lag sign [6],
to the opposing subscapularis, the arm will inter- the deltoid lag sign [7], and the teres minor lag
nally rotate despite the patient’s best efforts sign (also referred to as “Hornblower’s sign” [8]
3.3 Quantifying Muscle Strength 41
the purpose of strength testing is a nearly impos-

sible task. In addition, weakness of one muscle
can be substituted by another similarly positioned
muscle, masking the underlying weakness during
physical examination. This is especially true in
cases where subtle weakness is present, such as
in small rotator cuff tears where, in many cases,
the overlying deltoid may substitute for the defi-
cient cuff. In fact, the ability of the deltoid to sub-
stitute for a deficient rotator cuff is the underlying
principle of reverse total shoulder arthroplasty in
patients with massive, irreparable rotator cuff
tears with associated superior migration of the
humeral head. Another example includes the
levator scapulae and the superior fibers of the tra-
pezius which have similar functions; however,
the neural supply to each muscle is different.
Thus, a patient with an isolated injury to the dor-
sal scapular nerve may still demonstrate rela-
tively normal scapulothoracic kinematics despite
levator scapulae weakness.
It is typically more advantageous to isolate the
overall function of specific groups of muscles
Fig. 3.2 Clinical photograph demonstrating the external
rather than attempting to isolate each muscle
rotation lag sign. When the humerus is released from a
position of approximately 20–30° of external rotation, individually. Alternatively, the clinician can also
patients with infraspinatus cuff pathology may be incapa- perform tests that conceptually and theoretically
ble of holding the position. As a result, the humerus isolate specific muscles with the understanding
undergoes compensatory internal rotation by the resting
that complete isolation is probably not attainable.
tension and tone generated by the stretched subscapularis
muscle. (From Hertel et al. [6]; with permission). Regardless of the method used, it is necessary to
develop a consistent, repeatable examination pro-
tocol which can improve individual diagnostic
or “drop sign” [6]) use the same length–force efficiency and accuracy.
relationship concepts and are discussed both later
in this chapter and in Chap. 4.
3.3 Quantifying Muscle Strength
3.2.2 Muscle Isolation 3.3.1 Manual Muscle Testing
There are numerous muscles that cross or act Manual muscle testing (MMT) is the most com-
upon the glenohumeral joint; however, several of mon method by which clinicians evaluate muscle
these muscles produce similar force vectors strength. MMT utilizes a standardized grading
which can complicate the assessment of muscu- system that is determined by the ability of the
lar strength. As a result, shoulder motion within tested muscle act against gravity or against resis-
any plane likely involves contributions from sev- tance applied by the examiner. In 1916, Lovett and
eral different muscles to produce the observed Martin [9] first described the method of manual
movement. While it would be ideal to isolate and muscle testing in newborns with infantile paraly-
test each individual muscle around the shoulder sis. Since then, abundant research has been con-
girdle, complete isolation of a single muscle for ducted regarding its various applications, including
Table 3.1 Manual muscle testing grading system (levels 0–5) 3.3.2 Dynamometry
0 No visible or palpable contraction
1 Visible or palpable contraction without motion A dynamometer is a device used to determine the
2 Full range of motion, gravity eliminated mechanical force generated by a contracting
3 Full range of motion against gravity muscle. While these measurements of force are
4 Full range of motion against gravity, moderate resistance generally given in Newtons or kilograms, torque
5 Full range of motion against gravity, maximal resistance can be calculated by simply multiplying Newtons
or kilograms by the distance (in meters) between
modifications of the original grading scale used to the dynamometer and the center of rotation of the
describe muscular strength. Despite these modifi- involved joint.
cations, the scale that is most widely accepted is Dynamometers first appeared in 1763 [32]
very similar to the original proposal by Lovett and and, since then, numerous modifications have
Martin [9] and was devised by the Medical been made. Currently, dynamometers come in a
Research Council (MRC) [10] in 1943. The scale large variety of shapes, sizes, and functional
has six levels (0–5) and is presented in Table 3.1. mechanisms that produce the desired force mea-
The inter- and intra-observer reliabilities of surements. Isokinetic dynamometers are large
MMT in the evaluation of various pathologies machines capable of generating numerous values
resulting in muscle weakness range from 0.82 to including peak muscular force, power, and endur-
0.97 and 0.96 to 0.98, respectively, according to ance among numerous other measurements
reports dating back to 1954 [11–22]. However, (Fig. 3.3) [33]. Isokinetic testing has been used as
only a few studies have specifically examined the a standard method of muscle strength measure-
reliability of manual muscle testing for the evalu- ment over the past 40 years since it has been
ation of patients with various shoulder patholo-
gies [23–25].
Although the MMT scale is still widely used in
clinical practice due to its low cost and rapidity,
there are several limitations that must be noted.
The first limitation is that the MMT scale is sub-
jective in nature and the score depends on the cli-
nician’s judgment [26–28]. The second limitation
of MMT is the inability of the scale to detect
small, between-level differences in strength. This
is largely due to the stepwise design of the scale
and has spurred the development of other scales
that have more diagnostic levels [10]. Third, the
MMT scale has been criticized for not being capa-
ble of detecting clinically relevant differences in
muscle strength. MMT was originally developed
to measure strength improvements in patients
treated with paralytic disorders and muscular dys-
trophies [29, 30]. Thus, the application of MMT
to a variety of clinical settings is probably due to
tradition rather than sound scientific rationale. As
a result of the subjectivity and reported inaccu-
racy of MMT, many clinicians (and insurers) pre-
Fig. 3.3 Example of an isokinetic dynamometer which
fer to measure strength with more objective
has been set up to measure shoulder internal and external
means that are more sensitive, such as with hand- rotation strength at 90° of abduction. (From Ribeiro and
held dynamometers [31]. Oliveira [161]).
3.3 Quantifying Muscle Strength 43
found to be reliable, reproducible, and valid on

numerous occasions [34–38]. As a result, iso-
kinetic devices have also been used as reference
standards for the evaluation of newer devices that
test muscle strength [39–42].
A large number of studies have evaluated the
inter- and intra-rater reliability using handheld
dynamometers to assess muscular strength. A
systematic review by Stark et al. [43] identified
19 studies in which the authors compared hand-
held dynamometry to isokinetic muscle strength
testing. In that review, all but two studies demon-
strated either good to excellent correlation with
isokinetic testing or good to excellent intra-class
correlation coefficient (ICCs). The study by
Burnham et al. [39] found a low correlation of
handheld dynamometry with isokinetic testing
when measuring shoulder abduction strength in a
series of football players (r = 0.28–0.43); how- Fig. 3.4 Example of a typical strain gauge dynamometer.
ever, the scapulae of the tested athletes in that
study were not stabilized by the examiner, insulator by an outside force (e.g., the force of
introducing potential confounding factors in their muscle contraction) (Fig. 3.4).
measurements. Reinking et al. [44] also found a In 1989, Bohannon and Andrews [45] studied
poor correlation between handheld dynamometry the accuracy of two handheld spring scale and
and isokinetic testing when measuring knee two strain gauge dynamometers using a series of
extension (r = 0.43–0.45); however, testing this certified weights ranging from 5 to 55 pounds.
group of muscles requires a sufficiently strong The dynamometers were tested by gradually
examiner to prevent movement of the dynamom- increasing the applied weight by 5-pound incre-
eter while the subject is tested. ments and comparing the readout measurement
In general, clinical dynamometry is performed generated by each device to the actual weight
with handheld devices due to their portability, applied. In their study, the spring scale dyna-
simplicity, low cost, and reported excellent reli- mometers measured forces significantly different
ability and validity when compared to isokinetic from the force that was actually applied. The
dynamometry [27, 43]. Although there are authors also noted that the accuracy of the spring
numerous such devices that have been reported as scale dynamometers diminished after extensive
both accurate and reliable for the measurement of use, suggesting that spring fatigue or permanent
muscular force, most handheld dynamometers deformation have been responsible for inaccurate
fall into one of two categories depending on the measurements. In contrast, the strain gauge dyna-
mechanism of measurement. These include mometers measured forces that were much closer
spring scale and strain gauge dynamometers. to the actual applied force.
Spring scale dynamometers work simply by mea- Hayes and Zehr [46] evaluated the reliability
suring the deformation (lengthening) of a spring of MMT, a manual spring scale dynamometer
as a force is applied—this deformation distance and a digital strain gauge dynamometer to
is converted to kilograms and is based on the measure rotator cuff strength using a random
stiffness (spring constant) of the inserted spring. effects statistical model. In this group of patients
Strain gauge dynamometers are more complex with symptomatic rotator cuff disease, they found
and work by detecting changes in electrical sig- that the digital strain gauge dynamometer was
nals caused by the deformation of an electrical the most reliable method of measuring rotator
Fig. 3.5 (a) Typical electromyograph to which (b) thin wire (left) or surface electrodes (right) can be attached.
cuff strength. Hosking et al. [47] examined the 3.3.3 Electromyography

test-retest reliability of handheld dynamometers
in children with and without muscular disease Electromyography (EMG) has been used exten-
and found that repeated testing did not cause sively over the past century to evaluate the utility
measurement variability of more than 15 %. of various manual muscle tests. An electromyo-
However, another study by Bohannon [28] found gram is obtained by placing an electrode on the
the test-retest reliability to be much higher in skin over the muscle being tested (i.e., surface
healthy patients compared to those who had mus- EMG) or, alternatively, a thin wire can be placed
cle weakness, potentially suggesting that muscle directly into the muscle of interest (i.e., intramus-
fatigue may play a role in the ability to obtain an cular EMG) (Fig. 3.5). When the muscle is stimu-
accurate measurement of peak muscle force after lated, the electrical potential that is produced by
multiple testing sessions. the muscle travels through the electrode and
There are several other potential limitations of towards the connected electromyograph which
digital handheld dynamometry. The first is that interprets and displays the signal through an oscil-
these handheld devices are of minimal use when loscope. It is important to remember that EMG
testing large muscle groups that can produce a readouts with higher amplitude do not necessarily
much larger force than the examiner can resist. indicate that the muscle is generating greater force.
This is particularly true for large, high-output As an example, an eccentrically contracting mus-
lower extremity muscles that may overcome the cle produces similar amplitude as a concentrically
strength of the examiner’s upper extremity [28, contracting muscle; however, the force produced
48–51]. A second limitation is that an inability to by the eccentric contraction may be much less than
adequately stabilize the device while the subject that produced by the concentric contraction.
applies maximal force is quite difficult to achieve. EMG is an important tool for the evaluation of
As a result, handheld dynamometers placed in a skeletal muscle activity; however, its interpreta-
fixed apparatus have gained popularity to elimi- tion can be influenced by several factors that
nate the effect of examiner strength and stabiliza- must be taken into account. Features of the sur-
tion on the reliability of strength measurements face electrode such as width, diameter, and elec-
[52–55]. trical properties can influence the signal output.
3.4 Strength Screening of Specific Muscles 45
In the case of surface EMG, increased distance or electrical measurements are compared to a refer-
increased soft-tissue interposition between the ence standard generated from a maximal volun-
surface electrode and the muscle being tested can tary contraction (MVC) of the muscle in question.
also significantly influence signal interpretation The ratio of the two measurements is recorded
[56, 57]. The primary drawback of thin-wire and compared between different subjects [58].
EMG is that the sample size is limited to the sur- Other methods of obtaining EMGs involve sub-
face area of the small electrode whereas surface maximal voluntary contractions and isometric
EMG can obtain measurements over an expanded measurements; however, these methods have
area of muscle tissue and is also easier to imple- been less reliable to date [57, 59].
ment; however, this can also introduce unwanted
noise due to soft-tissue interposition and contri-
butions from surrounding musculature. In addi- 3.4 Strength Screening
tion, the amplitude or morphology of the EMG of Specific Muscles
readout may be affected by the type of muscle
being tested (fast-twitch versus slow-twitch). Anatomic characteristics of the scapular muscu-
Many studies have utilized a normalization lature are presented in Table 3.2 [60] to help
technique to study muscle activity—that is, the guide the reader through this section.
Table 3.2 Anatomic characteristics of the periscapular musculature [8]

Muscle Origin Insertion Nerve supply Vascular supply Action
Supraspinatus Supraspinous Superior facet Suprascapular Suprascapular artery Abduction of the
fossa of greater tuberosity nerve humerus
Infraspinatus Infraspinous Posterior facet of Suprascapular Suprascapular artery External rotation of
fossa greater tuberosity nerve the humerus
Teres minor Inferolateral Inferior facet Axillary Posterior circumflex External rotation of
aspect of of greater tuberosity nerve humeral artery, humerus in
posterior circumflex scapular abduction
scapular body artery
Subscapularis Subscapular Lesser tuberosity Upper and Transverse cervical Internal rotation of
fossa lower artery, subscapular humerus
subscapular artery
nerves
Trapezius Spinous Superior aspect Spinal Superficial branch of Scapular rotation
processes of scapular spine accessory transverse cervical and elevation
of C7-T12 nerve artery
Serratus Upper Anterior aspect Long thoracic Thoracodorsal artery, Scapular
Anterior nine ribs of medial scapular nerve lateral thoracic arteryprotraction and
border upward rotation
Levator Transverse Medial border of Dorsal Dorsal scapular artery Scapular elevation
Scapulae processes scapula superior to scapular
of C1-C4 medial base of the nerve
scapular spine
Rhomboid Spinous Medial border of Dorsal Dorsal scapular artery Scapular retraction
Minor processes scapula at the level of scapular and rotation
of C7-T1 the medial base of the nerve
scapular spine
Rhomboid Spinous Medial border of Dorsal Dorsal scapular artery Scapular retraction
Major processes scapula inferior to scapular and rotation
of T2-T5 medial base of scapular nerve
spine
3.4.1 Periscapular Muscles In the early 1990s, Lindman et al. [61, 62]
performed immunohistochemical analysis on
3.4.1.1 Trapezius human trapezius muscles and found significant dif-
Innervated by the spinal accessory nerve, the tra- ferences in mitochondrial ATPase activity in vari-
pezius muscle is a large, flat, triangular muscle ous portions of the muscle. Specifically, the lower
that makes up the majority of the superficial poste- third of the superior region, the middle region, and
rior cervical and thoracic musculature. The muscle the inferior region all had low concentrations of
is thought to have three anatomic regions— mitochondrial ATPase activity. On the other hand,
namely, the superior, middle, and inferior the uppermost aspect of the superior region had the
regions—that are thought to have specific func- highest mitochondrial ATPase activity. With this
tional attributes (Fig. 3.6). The superior fibers information, the authors suggested that the upper
originate medially between the occiput and the C7 aspect of the superior region was best suited for
spinous processes and extend laterally to insert high-demand, short duration functionality (e.g.,
upon the posterior aspect of the distal clavicle, the heavy lifting) whereas the rest of the muscle was
superomedial acromion and the most distal portion best suited for low-demand, long duration function-
of the scapular spine. The middle fibers arise ality (e.g., posture and dynamic scapular stability).
medially between the C7 and T3 spinous processes The authors concluded that the differences in
and extend laterally to insert primarily along the ATPase activity and fiber type are likely due to both
scapular spine. The inferior fibers originate genetic factors and functional demands.
between the T4 and T12 spinous processes and The functions of the superior, middle, and
extend superolaterally to insert as an aponeurosis inferior fibers of the trapezius were first described
on the medial confluence of the scapular spine. by Inman et al. [63] in 1944. However, the exact
function of each muscle division has been debated
for many years. Based on fiber orientation,
Johnson et al. [64] suggested that the trapezius
largely functions as a scapular stabilizer. More
specifically, it was proposed that the upper fibers
draw the scapula superomedially while the mid-
dle and lower fibers antagonize the function of
the serratus anterior, preventing lateral excursion
of the scapula. Although others have confirmed
the functions of the middle and lower trapezius
with various motions (including scapular internal
and external rotation [87]) [66–69], the precise
role of the upper trapezius remains controversial.
A study by Ruwe et al. [70] found a decrease in
upper trapezius muscle activity in a series of
swimmers with shoulder pain. Another study [69]
found increased muscle activity of the middle and
lower fibers in a series of patients with signs and
symptoms of impingement. Although we under-
stand that contraction of the upper trapezius
causes upward rotation of the scapula, its precise
role in the development of shoulder discomfort
has not been clearly defined. However, it is widely
reported that unbalanced periscapular strength
Fig. 3.6 Illustration depicting the superior, middle, and and altered muscle firing patterns lead to scapular
lower fibers of the trapezius muscle. malposition and dyskinesis, both of which can
Fig. 3.7 (a) Subtle left-sided scapular winging due to trapezius muscle weakness. (b) Right-sided scapular winging
due to serratus anterior muscle weakness. (Courtesy of J.P. Warner, MD).
cause and exacerbate subacromial impingement

(scapular dyskinesis is discussed in further detail
in Chap. 9).
Clinically, atrophy of the trapezius muscle with
alteration in scapular resting position can be quite
subtle and thus requires close examination (the
scapular resting position is discussed in Chap. 2).
Patients with trapezius muscle atrophy, most com-
monly due to spinal accessory nerve palsy, gener-
ally present with “scalloping” of the ipsilateral
neck (due to loss of trapezius muscle mass) and
superomedial displacement of the inferomedial
border of the scapula (so-called “lateral” scapular
winging; Fig. 3.7). Patients with trapezius weak-
ness may also have difficulty elevating the humerus
above the horizontal plane due to the inability to
initiate upward rotation of the scapula [71]. This
pattern of winging must be discerned from that
which is produced by serratus anterior weakness as
a result of long thoracic nerve palsy, which most
commonly results in elevation of the medial scapu-
lar border away from the chest wall with superolat-
eral displacement of the inferomedial angle.
The upper fibers of the trapezius muscle are
tested by simply asking the patient to shrug their
Fig. 3.8 Strength of superior trapezius. The examiner asks
shoulders against resistance (Fig. 3.8). At least the patient to shrug their shoulders against resistance.
one study has confirmed this test as being effec-
tive for activating the uppermost fibers of the tra-
pezius muscle using surface EMGs [72, 73]. muscle; however, this type of movement also
A study by Moseley et al. [74] found that rowing recruits ancillary muscles and is difficult to per-
exercises maximally activate the upper trapezius form in the clinic setting.
Rhomboids
The rhomboid musculature consists of both the
rhomboid major and minor which, on some occa-
sions, exist as a single muscle-tendon unit [75].
The rhomboid major originates from the spinous
processes between T2 and T5 and inserts along
the posterior aspect of the medial border of the
scapula just inferior to the medial confluence of
the scapular spine and spans inferiorly towards
the inferomedial angle. The rhomboid minor
originates between the C7 and T1 spinous pro-
cesses and inserts just superiorly to the rhomboid
major at the level of the scapular spine on the
posterior aspect of the medial scapular border.
The dorsal scapular nerve is derived from the C5
nerve root and provides the motor innervation for
both of these muscles (Fig. 3.11).
The primary functions of the rhomboid
musculature are to induce superomedial migra-
tion and downward rotation of the scapula such
that the glenoid surface is angled inferiorly and
posteriorly (i.e., scapular retraction). To test the
rhomboids, the patient is asked to place the hands
on the iliac crests with the thumbs pointed poste-
Fig. 3.9 Strength of middle trapezius. With the patient riorly and with the elbows in neutral position.
prone and the arm hanging over the edge of the table, the The patient is then asked to resist an anteriorly
examiner grasps the distal arm and applies a downward directed force applied to the medial epicondyles
force while the patient resists. such that the elbows are pushed anteriorly into a
flared position. It is advised to observe and/or
The middle trapezius is most easily tested palpate the medial scapular border while the test
with the patient in the prone position with the is being performed (Fig. 3.12).
arm hanging over the side of the table in 90° of Smith et al. [76] suggested that the above
forward flexion. The examiner then places their maneuver (sometimes referred to as the modified
hand distally and applies a moderate downward Kendall test) does not separately activate the
force while the patient resists (Fig. 3.9). While rhomboid muscles from synergistic muscles such
this test is effective at testing the middle fibers of as the levator scapulae, middle trapezius, and latis-
the trapezius, care must be taken to rule out ante- simus dorsi muscles. The authors found that man-
rior instability before performing this test in ual testing of the posterior deltoid elicited greater
order to avoid glenohumeral dislocation. electromyographic activity of the rhomboids com-
To test the lower fibers of the trapezius, the pared to that of any of the other MMT maneuvers
patient is placed in the prone position with the that were tested (e.g., the Hislop–Montgomery
arm abducted to approximately 120° within the test for rhomboid strength). According to Smith
scapular plane. This position aligns the upper et al. [76], the posterior deltoid test (which is used
extremity with the superolaterally directed fibers to test rhomboid strength) is performed with the
of the lower trapezius. From this position, the patient in a sitting position, facing away from the
subject then attempts to extend the arm upward examiner. The humerus is slightly internally
while the examiner both applies resistance and rotated and abducted within the plane of the body
simultaneously examines the scapula for any evi- to approximately 90°. The examiner then places
dence of winging (Fig. 3.10). one hand on the posterolateral aspect of the upper
Fig. 3.10 Strength of

lower trapezius. With the
patient prone, the humerus
is abducted to approxi-
mately 120° within the
scapular plane. The patient
then attempts to extend the
humerus upward while
resistance is applied by the
examiner.
Fig. 3.11 Illustration

highlighting the anatomy
of the rhomboid
musculature.
arm and applies an anteromedially directed force evaluated 64 patients with traumatic medial scap-
while the patient resists (Fig. 3.13). ular muscle detachments. All patients that were
There are no clinical studies that have specifi- included in that study demonstrated abnormal
cally evaluated the effects of isolated rhomboid resting scapular positions (i.e., winging) and
or levator scapulae weakness on shoulder func- scapular dyskinesis with arm motion.
tion. However, a case report by Hayes and Zehr
[46] in 1981 described a patient with interscapu- Serratus Anterior
lar pain and scapular winging who was ultimately The serratus anterior muscle is anatomically
found to have a rhomboid muscle avulsion frac- divided into three divisions. The first division,
ture after a traumatic injury. The patient was suc- arising from ribs 1 and 2, inserts along the ante-
cessfully treated by surgically reattaching the rior aspect of the superomedial scapular angle.
avulsed segment. More recently, Kibler et al. [66] The second division arises from ribs 2 through 4
and inserts along the anterior surface of the

medial border of the scapula. The third division
originates from ribs 5 through 9 and inserts on
the anterior aspect of the inferomedial scapular
angle. Although these distinct divisions are ana-
tomically convenient, the muscle generally func-
tions as a single unit. The muscle is innervated by
the long thoracic nerve which is derived from the
C5, C6, and C7 nerve roots (Fig. 3.14).
Contraction of the serratus anterior muscle
results in upward rotation and protraction of the
scapula. Weakness of this muscle is most com-
monly due to long thoracic nerve palsy and
results in scapular winging with an increased dis-
tance between the medial scapular border and the
posterior chest wall. This form of scapular wing-
ing must be differentiated from the scapular
winging produced by spinal accessory nerve
palsy with subsequent weakness of the trapezius
muscle (see Fig. 3.7).
Scapular winging due to global weakness of
the serratus anterior can be elicited by simply
Fig. 3.12 Strength of rhomboids (modified Kendall). The
having the patient actively forward flex both arms
patient is asked to place their hands on the “hips” or iliac to 90° of elevation while simultaneously observ-
crests with the elbows in a neutral position. An anteriorly ing the dynamic motion of both scapulae. The
directed force is applied to the medial epicondyle while examiner can also provide resistance to forward
the patient attempts to resist. The medial scapular border
is simultaneously palpated, if possible.
flexion; however, using this method places the

rhomboids (posterior
deltoid test). With the
patient sitting facing away
from the examiner, the
humerus is slightly
internally rotated and
abducted to approximately
90° of elevation. The
examiner places one hand
on the posterolateral aspect
of the upper arm and
applies an anteromedially
directed force while the
patient provides resistance.
a b
Serratus Serratus anterior muscle

anterior muscle unable to contract
Pectoralis Front
Scapula
major
muscle Scapula
Long
thoracic
nerve
Rib cage
Normal Back
Scapular
winging
Normal Shoulder and Rib Cage Shoulders and Rib Cage

Viewed from the Right Side Viewed from Above
Fig. 3.14 (a) Illustration highlighting the three divisions serratus anterior relative to the scapulae in both a nor-
of the serratus anterior muscle and the associated long mal shoulder and a shoulder with scapular winging
thoracic nerve (lateral view). (b) Orientation of the (axial view).
examiner in an awkward position to visualize the with shoulder pain had significantly decreased
scapula during arm motion. We prefer to have the serratus anterior activity via EMG when com-
patient perform a wall push-up as this maneuver pared to throwing athletes without shoulder pain.
is more sensitive for the detection of both mild As many others have suggested, the authors con-
and severe serratus anterior weakness in a busy cluded that scapular malposition and dyskinesis
clinic setting. To perform the wall push-up, the was a significant contributor to the development
patient’s hands are placed flat on a nearby wall at of shoulder pain in overhead athletes. Burkhart
approximately shoulder height and shoulder et al. [84] later described a series of pathologic
width apart. The patient then performs a normal findings related to scapular motion in overhead
push-up as if they were in the prone position athletes for which the term “SICK scapula syn-
while the clinician simultaneously observes both drome” was coined.
scapulae (Fig. 3.15). Of note, this method of
strength testing activates the entire serratus ante- Latissimus Dorsi
rior muscle and does not differentiate between the The latissimus dorsi, which receives its motor
three divisions [77]. innervation from the thoracodorsal nerve, origi-
A study by Celik et al. [78] found that several nates from the iliac crest, sacrum, and T7 through
periscapular muscles, including the serratus ante- L5 spinous processes as an aponeurotic attach-
rior, were markedly weaker in shoulders with ment. The fibers of this large, flat muscle travel
signs of subacromial impingement compared to superolaterally over the teres major muscle and
healthy shoulders. This finding suggests that insert just inferior to the lesser tuberosity of the
evaluation of periscapular musculature is neces- humerus on the medial aspect of the bicipital
sary even in patients without perceived scapular groove (Fig. 3.16). This orientation has led some
dyskinesis. Periscapular muscle weakness can to infer its potential role as a humeral head stabi-
also result from fatigue, especially in those who lizer acting in synergy with the rotator cuff, espe-
participate in repetitive overhead activities [79– cially in the rare situation of humeral avulsion of
82]. Glousman [83] found that throwing athletes the glenohumeral ligament (HAGL) lesions [85].
Fig. 3.15 Wall push-up

for the assessment of
serratus anterior strength.
Weakness of the serratus
anterior would induce
scapular winging during
this maneuver.
The primary functions of the latissimus dorsi

muscle are to adduct, extend, and internally rotate
the humerus. A classic EMG study by Scheving
and Pauly [87] determined that the latissimus dorsi
is a more important internal rotator of the humerus
than the pectoralis major in several planes.
Clinically, the latissimus dorsi is tested with
the patient in the prone position and the arms at
the side. The patient is then asked to simultane-
ously extend and internally rotate the humerus
while the examiner applies resistance (Fig. 3.17).
It is important to note the position of the scapulae
during this movement since latissimus dorsi dys-
function has been associated with scapular dyski-
nesis [88]. The efficacy of this test has been
confirmed in a study by Park and Yoo [89] who
compared latissimus dorsi activation between six
different isometric exercises using surface
EMG. The authors found that extension of the
humerus in the prone position activated the mus-
cle with greater intensity than any other tested
exercise, including the common “lat pull-down”
exercise in the seated position.
Several authors have documented potential
Fig. 3.16 Illustration depicting the normal anatomy and
pathologic processes involving the latissimus
functional orientation of the latissimus dorsi muscle. dorsi muscle as it relates to the throwing shoulder
[65, 90–92]. Nobuhara [91] described a “latissi-
mus dorsi syndrome” in overhead athletes which
The muscle also variably attaches to the inferome- is characterized by insertional tenderness or mus-
dial angle of the scapula as it travels over the teres cle tightness. The syndrome is thought to result
major with or without an intervening bursa [86]. from repetitive throwing as the latissimus dorsi
Fig. 3.17 Strength testing

of latissimus dorsi. With
the patient prone and the
arm at the side, the patient
is asked to extend and
internally rotate the
humerus against resistance
applied by the examiner.
Supraspinatus
muscle
Infraspinatus
muscle Subscapularis
muscle
Teres minor
muscle
Posterior view Anterior view
Fig. 3.18 Illustration of the rotator cuff musculature viewing from both posteriorly and anteriorly.
tendon counteracts the significant external rota- At approximately the level of the glenohumeral
tion torque produced by overhead athletes result- joint, its tendon fibers become confluent with
ing in a type of insertional tendinitis. Although those of the infraspinatus to form a thick, wide
uncommon, tears of the latissimus dorsi and/or tendinous insertion that envelops the humeral
teres major have also been reported in throwing head (Fig. 3.19). Due to the intermingling of
athletes [90, 93]. fibers from each tendon, data regarding the indi-
vidual insertional dimensions of the supraspina-
3.4.1.2 Rotator Cuff tus tendon footprint have been inconsistent to
Supraspinatus date (Table 3.3) [94–100]. Further biomechanical
Innervated by the suprascapular nerve, the supra- and anatomical considerations as they relate to
spinatus takes origin from the supraspinous supraspinatus pathology are discussed in Chap. 4.
fossa of the scapula and its fibers travel laterally The isolated primary functions of the supra-
to insert on the greater tuberosity (Fig. 3.18). spinatus muscle are to abduct the humerus and to
Fig. 3.19 Cadaveric photograph showing the confluence natus and teres minor tendons and their insertion sites.
of (a) the supraspinatus and infraspinatus tendons and (From Dugas et al. [95]; with permission).
their insertion sites and (b) the confluence of the infraspi-
Table 3.3 Reported dimensions of the posterosuperior The assumption that the supraspinatus is iso-
cuff insertion lated using the “empty can” test has been chal-
Footprint dimensions Mean lenged on several occasions. Of note, Blackburn
M-L × A-P Length in mm) et al. [102] studied the electrical activation of the
References Supraspinatus Infraspinatus supraspinatus muscle in various arm positions
Minagawa et al. [96] NR × 22.5 NR × 14.1 with and without the application of resistance
Roh et al. [98] NR × 21.2 NR using surface EMG. Although the investigators
Volk and Vangsness 27.9 × NR NR did find relative isolation of the supraspinatus
Jr [100]
with the arm abducted to 90° within the scapular
Dugas et al. [95] 12.7 × 16.3 13.4 × 16.4
Ruotolo et al. [99] NR × 25 NR
plane in neutral rotation, their EMG results sug-
Curtis et al. [94] 23 × 16 29 × 19 gested that the “empty can” position did not max-
Mochizuki et al. [97] 6.9 × 12.6 10.2 × 32.7 imally activate the supraspinatus. Rather,
M–L medial–lateral, A–P anterior–posterior, NR not reported
maximal electrical activity occurred with the
patient prone and the humerus abducted to
approximately 100° in maximal external rotation;
act as a physical barrier to prevent superior however, they also found EMG activity within
migration of the humeral head. There are numer- the teres minor and infraspinatus muscles in this
ous methods by which supraspinatus strength position. A later EMG study found that neither
can be tested. Perhaps the most popular methods the “empty can” position nor the Blackburn posi-
were proposed by Jobe [101]. According to the tion fully isolated the supraspinatus muscle and
results of previous EMG studies [97], he recom- that other muscles, particularly the anterior and
mended testing the supraspinatus with the middle portions of the deltoid muscle, contribute
humerus in 90° of abduction within the scapular significantly to strength in these positions [103].
plane and in maximal internal rotation such that The fact that the deltoid and the supraspinatus
the thumb pointed towards the floor (the “empty work synergistically to abduct the humerus has
can” position). The patient then attempted to also been suggested by others [104, 105]. Colachis
abduct the humerus further against resistance Jr and Strohm [105] selectively injected the
applied by the examiner (Fig. 3.20). Weakness in suprascapular nerve with local anesthetic, thus
this position was thought to be the result of iso- paralyzing the supraspinatus and infraspinatus
lated supraspinatus weakness with minimal con- muscles. Although subjects were mildly weak
tributions from other muscles. with abduction, they were still able to achieve full
Fig. 3.20 Jobe’s “empty

can” position for supraspi-
natus strength. With both
arms at approximately 90°
of abduction in the
scapular plane and the
thumbs pointed downward,
the patient attempts to
further abduct the humerus
against resistance applied
by the examiner. The
relative strength of each
arm is compared.
Fig. 3.21 Drop arm sign.

The examiner passively
places the humerus in 90°
of abduction and asks the
patient to hold the position.
The drop arm sign occurs
when (a) the shoulder
appears to “shrug” as the
humerus is displaced
superiorly and (b) the arm
falls back towards the side
of the body despite the
patient’s best efforts.
(Courtesy of Christian
Gerber, MD).
humeral abduction. The investigators found a cuff force couples [106]). Patients with massive
similar result after selective injection into the rotator cuff tears involving more than one tendon
axillary nerve (paralyzing the deltoid muscle)— often display a positive “drop arm sign” in which
patients were still able to fully abduct the they are unable to hold the humerus in an abducted
humerus despite mild weakness [104]. These position against gravity. In these cases, the arm
studies suggested that patients with a full-thick- “drops” back to the patient’s side (Fig. 3.21).
ness supraspinatus tear or deltoid dysfunction Patients with supraspinatus weakness are likely
may still be able to achieve full active humeral to have a range of other symptoms, including sub-
abduction, especially when the supraspinatus tear acromial pain, with humeral abduction and inter-
does not extend anteriorly or posteriorly resulting nal rotation. Thus, the ability to achieve an “empty
in a derangement of dynamic rotator cuff force can” position may be difficult for some patients
couples (see Chap. 4 for more details on rotator due to guarding or pain, making it difficult to
Fig. 3.22 Jobe’s “full

can” position for supraspi-
natus strength. With both
arms at approximately 90°
of abduction in the
scapular plane and the
thumbs pointed upward,
the patient attempts to
further abduct the humerus
against resistance applied
by the examiner. The
relative strength of each
arm is compared.
assess supraspinatus strength using this maneuver. The infraspinatus is innervated by the infra-
In addition, internal rotation of the humerus places spinatus branch of the suprascapular nerve after
the greater tuberosity in a position that may exac- passing through the spinoglenoid notch. Isolated
erbate symptoms related to rotator cuff impinge- atrophy of the infraspinatus muscle is most often
ment on the undersurface of the acromion. This due to a synovial or glenolabral cyst that impinges
impingement-type of pain can be reduced by sim- upon the nerve as it courses nearby. Other causes
ply having the patient abduct the humerus to 90° include traction injuries [107, 108], rotator cuff
in the plane of the scapula in either neutral rota- tears [109], and/or postoperative scarring. In con-
tion or external rotation (i.e., the “full can” posi- trast, impingement that occurs more proximally
tion; Fig. 3.22). A study by Kelly et al. [24] found along the suprascapular nerve will cause weak-
no difference in EMG activity between the “empty ness and/or atrophy of both the supraspinatus and
can,” “full can” or neutral positions, indicating the infraspinatus muscles (Fig. 3.23). Atrophy of
that supraspinatus testing can probably be esti- the supraspinatus and/or infraspinatus can often
mated using in any of these positions. Because be detected on physical examination by
internal rotation in 90° of abduction also recruits comparing the posterior contour of both scapu-
the teres minor and subscapularis muscles, we lae, particularly noting the relative prominence of
prefer to test the supraspinatus in neutral rotation the scapular spine with the arms in a neutral posi-
as a means of decreasing the potential for ancil- tion and in 90° of forward flexion (Fig. 3.24)
lary muscle contraction. [107, 110].
Isolated atrophy of the infraspinatus muscle is
Infraspinatus a common occurrence in overhead athletes, espe-
The infraspinatus muscle, one of the primary cially in volleyball players [107, 111–114] and
external rotators of the humerus, originates from baseball players [108, 115, 116], as a result of
the infraspinous fossa and inserts as a tendon traction injury to the portion of the suprascapular
sheet posterior and inferior to the insertion of the nerve distal to the spinoglenoid notch. Lajtai
supraspinatus tendon (see Fig. 3.19). As men- et al. [107] evaluated 35 male beach volleyball
tioned above, because the tendinous fibers of the players and noted that 12 players (34 %) had vis-
supraspinatus and infraspinatus intermingle, it is ible isolated infraspinatus atrophy. External rota-
difficult to determine the exact location and/or tion and elevation strength was also decreased in
dimensions of the infraspinatus insertional foot- the dominant shoulder of all players. After cor-
print (see Table 3.3). relation of these clinical findings with EMG, the
a Suprascapular Nerve Entrapment b Suprascapular Nerve Entrapment

(via superior transverse scapular ligament) (via spinoglenoid cyst)
Superior transverse
scapular ligament Spinoglenoid cyst
compressing the compressing the
suprascapular nerve suprascapular nerve
Fig. 3.23 Posterior view of the shoulder depicting (a) proximal suprascapular nerve entrapment beneath the transverse
scapular ligament and (b) distal suprascapular nerve entrapment due to a spinoglenoid cyst.
position for testing infraspinatus strength is with

the humerus at the side in neutral rotation with
the elbow flexed to 90°. While the patient pro-
vides resistance, the examiner then applies a
medially directed force on the forearm to inter-
nally rotate the humerus (Fig. 3.25). The patient’s
inability to hold the humerus in neutral rotation
signifies potential infraspinatus weakness. Others
prefer to also test the infraspinatus in positions of
internal rotation [24] and/or external rotation
[71]. According to their rationale, internally
rotating the humerus would force the infraspina-
tus to assume a stretched position thus placing
the muscle at a mechanical advantage—weak-
ness of the infraspinatus in this position may
Fig. 3.24 Clinical photograph demonstrating a promi- indicate significant pathology. On the other hand,
nence of the left scapular spine with the arms in a neutral externally rotating the humerus would force the
position which is indicative of supraspinatus and infraspi- infraspinatus to assume a less-stretched position
natus atrophy. (Courtesy of J.P. Warner, MD).
thereby placing the muscle at a mechanical
disadvantage—weakness in this position may
investigators found that nerve conduction veloci- therefore indicate a more subtle pathology.
ties were significantly decreased and amplitudes Testing the infraspinatus in either the internally
were much lower in those shoulders with or externally rotated positions as a method to
decreased volume of the infraspinatus muscle, determine the subtlety of infraspinatus weakness
suggesting a possible stretching mechanism dur- has not been validated or substantiated in the lit-
ing the deceleration phase of overhead motion erature to date. This description also contradicts
resulting in suprascapular neuropathy in this pop- the length–force relationship since increasing or
ulation [107, 113]. decreasing the passive tension within a muscle
Although challenged by several authors [24, away from its resting position would each result
71], it is generally accepted that the optimal in a decrease in muscle contraction force.

infraspinatus. With the
arms at the side and in
neutral rotation, the elbows
are flexed to 90°. The
examiner then provides
resistance as the patient
attempts to externally
rotate.

subscapularis. With the
arms at the side and in
neutral rotation, the elbows
are flexed to 90°. The
examiner then provides
attempts to internally
rotate.
There are several other provocative maneuvers posterior cord of the brachial plexus. Unlike the
that can be utilized to test for infraspinatus supraspinatus and infraspinatus, isolated atrophy
strength; however, these are more sensitive for of the subscapularis is very rare and cannot be
detecting specific rotator cuff pathologies and are seen by simple observation.
discussed further in Chap. 4. The subscapularis is one of several internal
rotators of the humerus. Similar to infraspinatus
Subscapularis testing, the best position for determining subscap-
The subscapularis is a large, thick muscle that ularis strength is with the arm at the side in neutral
originates from the subscapular fossa and inserts rotation and the elbow flexed to 90°. The subject
on the lesser tuberosity while also contributing to then resists a laterally directed force applied to
the structure and function of the bicipital sheath the forearm by the examiner. In the case of
(see Fig. 3.18) (relevant anatomy of the bicipital subscapularis weakness, the patient will not
sheath is discussed in Chap. 5). The muscle is be able to hold the neutral position and the
innervated by the upper and lower subscapular humerus will externally rotate as a result of
nerves which are derived primarily from the the force applied by the examiner (Fig. 3.26).
Although there are other muscles that provide according to the MMT scale (see Table 6.1). In the
internal rotation of the humerus (such as the pec- same study, the authors proposed a new “lift-off”
toralis major, teres major, and latissimus dorsi) test and reported that it was both highly sensitive
[117], the subscapularis has been identified as the and specific for subscapularis tears. This test,
primary internal rotator of the humerus in a bio- along with the bear-hug test and the belly-press
mechanical study by Chang et al. [118] An EMG test, is discussed in detail in Chap. 4.
study by Suenaga et al. [119] also found that
resisted internal rotation in the neutral position Teres Minor
(arm at the side in neutral rotation with the elbow The teres minor muscle, which also functions as
flexed to 90°) electrically activated the subscapu- an external rotator, originates from the posterior
laris more than any other muscle at each tested aspect of the scapular body, just inferior to the
position (81.7 %); however, the muscle is infraspinatus muscle, and inserts on the posterior
probably best isolated when the humerus is aspect of the proximal humerus (see Fig. 3.18).
abducted to 90° within the scapular plane in neu- The tendon fibers of the teres minor blend with
tral rotation [120, 121]. those of the infraspinatus, making them indistin-
Gerber and Krushell [122] reported on 16 cases guishable in most cases. The teres minor is inner-
of isolated subscapularis tendon rupture where 15 vated by the axillary nerve as the nerve passes
of the patients were manually tested for internal through the quadrilateral (or quadrangular) space
rotation strength with the arm at the side and the towards the undersurface of the deltoid muscle
elbows flexed to 90°. Fourteen of the fifteen (Fig. 3.27). Fatty infiltration and atrophy of
patients (93.3 %) had at least grade 4 weakness the teres minor muscle from axillary nerve
Clavicle
Acromion
Suprascapular
artery and nerve
Supraspinatus
Capsule of
Scapular spine shoulder joint
Deltoid
Teres minor
Infraspinatus
Posterior circumflex
Medial border humeral artery and
axillary nerve
Circumflex
scapular artery Quadrangular space
Profunda brachii artery
and radial nerve in
triceps hiatus
Teres major
Long head
Triceps brachii
Lateral head
Triangular space
Fig. 3.27 Illustration showing the borders and contents head of the triceps defines the medial border and the supe-
of the quadrilateral space. The inferior margin of the teres rior margin of the teres major defines the inferior border.
minor defines the superior border, the humeral shaft The posterior circumflex humeral artery and the axillary
defines the lateral border, the lateral margin of the long nerve pass through this space.
Fig. 3.28 (a) Coronal-oblique MRI slice showing a normal oblique MRI slice showing a humeral head with a large
humeral head with the distance from the axillary neurovas- inferior osteophyte in close proximity to axillary neurovas-
cular bundle depicted by the yellow arrow. (b) Coronal- cular bundle. (From Millett et al. [123]; with permission).
impingement can occur in patients with large of the teres minor muscle and are discussed
inferior humeral head osteophytes as a result of further in Chap. 4.
glenohumeral osteoarthritis [123]. The inferior
osteophyte can generate a mass effect or make 3.4.1.3 Other Scapulohumeral Muscles
direct contact with the axillary nerve as it passes Teres Major
between the superior aspect of the lateral scapu- Innervated by the lower subscapular nerve, the
lar border and the humeral head before reaching teres major originates from the posterior aspect
the teres minor and deltoid muscles (Fig. 3.28). of the inferomedial angle of the scapula and
In contrast to atrophy involving the supraspinatus inserts on the proximal humerus just posterior to
and infraspinatus muscles, atrophy of the teres the latissimus dorsi tendon, oftentimes with an
minor is rarely detected by inspection or palpa- intervening bursa (Fig. 3.30). In some cases, the
tion of the posterior scapulae. teres major may insert directly into the latissimus
The teres minor is primarily an external rotator dorsi tendon [124]. Similar to the latissimus
with the humerus at 90° of abduction within the dorsi, the primary function of the teres major
scapular plane. Screening for teres minor weak- muscle is to adduct, extend, and internally rotate
ness can be performed by simply having the the humerus. Pearl et al. [125] found that both the
patient abduct the humerus to 90° in neutral rota- latissimus dorsi and the teres major muscles fire
tion with the elbow flexed to 90° and resisting maximally when moving the arm “obliquely
external rotation from this position (Fig. 3.29). downward away from the midline.” Because of
Blackburn et al. [102] suggested that isolation of their identical force vectors, each muscle can be
the teres minor is best obtained when the patient successfully transferred to the greater tuberosity
is in the prone position with the arm in maximal as a salvage procedure in patients with massive,
external rotation; however, this maneuver is not irreparable posterosuperior rotator cuff tears
quickly or easily performed in clinical practice (Fig. 3.31) [126–129].
and has not been formally validated in the litera- Although there have been several reports of
ture. There are a few other maneuvers, such as the isolated tears of the teres major muscle in high-
Patte test and the “Hornblower’s sign,” that can level athletes, this injury is uncommon in the
be used to specifically identify pathologic lesions general population [93, 130, 131]. In these cases,
Fig. 3.29 Strength

screening of teres minor.
(a) The humerus is
abducted to 90° in the
scapular plane in neutral
rotation and the elbow is
flexed to 90°. The
examiner then applies
attempts to externally
rotate the humerus. (b) The
same test, except that the
patient will start at 90° of
external rotation.
the diagnosis is most often made via imaging spine. All three divisions of the deltoid muscle
studies or direct visualization during surgery insert on the deltoid tubercle of the humerus and
since physical examination maneuvers designed function to elevate the arm in several different
to specifically detect weakness of the teres major planes (Fig. 3.32).
have not been developed. The axillary nerve branches from the posterior
cord of the brachial plexus, travels through the
Deltoid quadrangular space, around the proximal
The deltoid is the largest muscle of the shoulder humerus and towards the undersurface of the del-
girdle and consists of three separate divisions: toid muscle. The nerve first gives off a branch to
anterior, middle, and posterior. The anterior the teres minor muscle as it passes through the
portion of the deltoid originates from the superior quadrilateral space and then to the posterior, mid-
aspect of the distal third of the clavicle, the dle and, finally, the anterior deltoid while also
middle division originates from the superior providing sensory innervation to the skin overly-
aspect of the acromion and the posterior division ing the middle deltoid (i.e. the superior lateral
originates from the inferior aspect of the scapular cutaneous nerve).
glenohumeral joint during abduction within the

scapular plane; however, this function was less
effective and, in fact, decreased glenohumeral
stability during abduction in the coronal plane.
The authors also proposed that rehabilitation in
patients with anterior instability should focus on
strengthening the middle and posterior divisions
of the deltoid muscle to enhance glenohumeral
stability. More recently in 2008, Yanagawa et al.
[133] used a three-dimensional model to calculate
the relative contributions of the deltoid and rota-
tor cuff to glenohumeral stability. They found that
of all the muscles tested, the middle deltoid
produced the greatest amount of compression
between the humeral head and the glenoid; how-
ever, because of the significant shear forces pro-
duced, the middle deltoid was actually less able to
Fig. 3.30 Illustration of a posterior right scapula high- maintain glenohumeral stability than the rotator
lighting the teres major muscle. cuff musculature. This study suggested that the
rotator cuff is probably more effective at main-
The function of the deltoid muscle is to elevate taining glenohumeral stability than the deltoid
the humerus. It is usually taught that the plane of muscle which has significant implications for
elevation depends on which of the three muscle physical therapy and postoperative rehabilitation
divisions are activated. For example, forward in patients with instability.
flexion of the humerus requires activation from Testing the individual components of the del-
the anterior fibers and abduction requires activa- toid muscle is probably not routinely necessary
tion from the middle fibers. Thus, the key to test- unless one suspects axillary nerve dysfunction. In
ing the strength of the individual components of these cases, the examiner can also examine the
the deltoid muscle is to position the humerus in shoulder for any signs of deltoid atrophy that
line with the muscle fibers to be tested. may localize the site of axillary involvement. The
This model suggests that the muscle fibers not “scaphoid sign” or “scallop sign” can be observed
in-line with plane of elevation are relatively inac- in patients with deltoid atrophy since the loss
tive. However, in reality, all three divisions of the of muscle allows the acromion, acromioclavicu-
muscle are active with nearly any movement of lar joint and anterior structures to become more
the arm in any direction [92]. In 1959, Scheving prominent when compared to the contralateral
and Pauly [92] conducted an electromyographic side (Fig. 3.33). In addition, the muscle mass
study of several upper extremity muscles in vari- over the lateral aspect of the proximal humerus
ous movement planes. With respect to the deltoid, diminishes, thus giving a concave appearance of
it was found that although the entire deltoid mus- the upper arm compared to the contralateral side.
cle was active during humeral elevation in any In some patients with deltoid atrophy, promi-
plane, the anterior deltoid was most active during nence of the scapular spine may also be evi-
forward flexion, the middle deltoid was most dent—this becomes problematic in patients who
active in abduction, and the posterior deltoid was have undergone shoulder arthrodesis since the
most active during extension. It was postulated resulting deltoid atrophy allows the plate over the
that the less active portions of the deltoid actually scapular spine to irritate the overlying skin.
function to prevent humeral head translation with There are several methods that can be used to
arm elevation. In 2002, Lee and An [132] found test the anterior division of the deltoid muscle.
that the deltoid was effective at stabilizing the As a screening exam, we tend to place the patient
Fig. 3.31 Illustrations demonstrating the positions of the latissimus dorsi and teres major muscles both before and after
muscle transfer procedures for the treatment of massive rotator cuff tears.
in the sitting position with the humerus at the side has not been proven in any clinical or biomechan-
and the elbow flexed to 90°. We then ask the ical study. As discussed above, an EMG study by
patient to make a fist and to push forward against Colachis Jr et al. [104] found that both the rotator
resistance applied by the examiner (Fig. 3.34). cuff and the deltoid function synergistically to
Another way to test the anterior deltoid, as sug- achieve glenohumeral abduction. This test can
gested by McFarland [71], is to place the humerus therefore be performed with the elbow flexed or
in approximately 70° of abduction within the extended, depending on the subtlety of the sus-
scapular plane and to resist flexion and adduction pected pathology. For example, applying resis-
(Fig. 3.35). Placing the arm in 70° of abduction is tance to the wrist with the elbow extended
thought to more adequately isolate the deltoid increases the contraction force necessary to flex
muscle from the rotator cuff; however, this theory and adduct the humerus due to lengthening of the
Middle will result in abduction weakness. Bertelli and

Ghizoni [134] described an abduction-internal
rotation test to identify patients with axillary
nerve lesions. In this test, the patient actively
internally rotates and maximally abducts the
affected shoulder. If the patient could not reach
Posterior Anterior the abduction level of the contralateral shoulder,
the patient was asked to hold abducted and inter-
nally rotated position. If the patient could not
hold the position and the arm slowly fell back to
the side, axillary nerve palsy was diagnosed.
Fujihara et al. [135] devised the “akimbo test”
which was designed to detect abduction weak-
ness as a result of deltoid dysfunction; however,
none of the patients with axillary neuropathy
could consistently demonstrate the sign.
Fig. 3.32 Illustration of a right shoulder showing the
relative positions of the anterior, middle, and posterior
divisions of the deltoid muscle. Biceps Brachii
The biceps muscle spans two joints and is com-
posed of two origins (long head and short head)
lever arm. This method is likely to detect more from the scapula with a single insertion site at the
subtle forms of weakness as a result of axillary bicipital tuberosity of the proximal radius
neuropathy or primary deltoid weakness. (Fig. 3.37). The distal biceps insertion may be
The middle division of the deltoid can be bifurcated into their corresponding short and
tested using the same starting position—that is, long head segments [136]. The distal biceps also
70° of straight lateral abduction. However, rather forms an aponeurotic attachment to the muscles
than resisting flexion and adduction, the patient is of the medial forearm (the “lacertus fibrosus”).
asked to further abduct the humerus against resis- The long head of the biceps travels within the
tance. Similar to testing of the anterior deltoid, bicipital groove of the proximal humerus and
this test can be performed with the elbow flexed courses through the glenohumeral joint before
or extended, depending on the severity of the variably attaching to the superior labrum and
suspected pathology. supraglenoid tubercle. Further details regarding
There are a few different ways to test the pos- the long head of the biceps tendon are discussed
terior division of the deltoid, both of which extensively in Chap. 5. The short head of the
require the patient to be standing. One method is biceps converges with the coracobrachialis mus-
to position the humerus at the patient’s side in cle proximally (i.e., the “conjoined tendon”) and
neutral rotation and to resist active extension of originates from the anteroinferior aspect of the
the humerus from this position (sometimes called coracoid process. The musculocutaneous nerve
the “swallowtail test”) (Fig. 3.36). Another pierces the conjoined tendon approximately 8 cm
method, called the “deltoid lag sign” [7], is per- distal to the coracoid tip and runs deep to the
formed by passively extending the humerus and main belly of the biceps muscle and superficial to
asking the patient to hold the position once the the brachialis muscle of the forearm. There have
examiner releases the arm. If the arm falls back been reports of anomalous biceps musculature,
to the side, the patient has a positive deltoid lag such as those with three or four muscle heads;
sign which is indicative of posterior deltoid however, these cases are uncommon [137–139].
weakness. This test is specifically designed to The musculocutaneous nerve (C5 and C6)
distinguish between axillary neuropathy and a provides the motor innervation to the biceps,
massive rotator cuff tear since both pathologies brachialis and coracobrachialis muscles. Injury
Fig. 3.33 (a) Clinical photograph demonstrating atrophy structures. This patient also had significant atrophy of the
of the deltoid muscle. The implant from a previous hemi- supraspinatus and infraspinatus muscles (arrow), possibly
arthroplasty can be seen across the atrophic anterior del- indicating the presence of a concurrent injury to the supra-
toid (arrow). (b) Clinical photograph also showing scapular nerve. (Part B courtesy of J.P. Warner, MD, and
atrophy of the deltoid muscle as evidenced by prominence Christian Gerber, MD).
of the acromioclavicular joint and anterior shoulder
to the musculocutaneous nerve often occurs as a

traction injury due to overzealous surgical retrac-
tion of the coracobrachialis while approaching
the glenohumeral joint using a deltopectoral
approach. This injury results in weakness of the
entire biceps muscle (short and long heads), the
coracobrachialis and the medial half of the bra-
chialis muscle.
The biceps muscle functions primarily to
supinate the forearm and to flex the elbow. The
function of the long head of the biceps tendon as
it courses through the glenohumeral joint is con-
troversial and will be discussed in detail in Chap.
5. Rupture of the long head of the biceps tendon
typically results in a classic “Popeye deformity”
in which the muscle belly retracts distally, form-
ing a ball of muscle just proximal to the elbow
joint. In contrast, partial or complete rupture of
the distal biceps tendon causes muscle retraction
that appears more proximally (Fig. 3.38). Despite
the commonality of proximal and distal biceps
ruptures, it is important to rule out other causes of
deformity, such as tumors, that may have a simi-
lar appearance [140, 141].
Fig. 3.34 Anterior deltoid strength. With the patient in

Triceps Brachii
the sitting position, the arms at the side and the elbows
flexed to 90°, the patient is asked to make a fist and to Although the triceps muscle contributes little to
push anteriorly against the examiner’s hand. shoulder motion, it is considered here since it
Fig. 3.35 Anterior deltoid strength. (a) The arms are elevate the arms against resistance provided by the exam-
abducted to 70° in scapular plane with the elbows flexed iner. (b) The test can also be performed with the elbows
to approximately 90°. The patient then attempts to further extended.
Biceps Long head

brachii Short head
Aponeurosis of
biceps brachii
Fig. 3.37 Illustration highlighting the basic anatomy of

the biceps muscle.
attaches to the scapula and may contribute to

Fig. 3.36 Posterior deltoid strength. With the patient
shoulder pain in overhead athletes. The triceps
standing, the arms at the side and the elbows extended, the
patient attempts to extend the humerus against resistance has three heads: a long head, a medial head, and
provided by the examiner. a lateral head. The long head primarily takes ori-
Fig. 3.38 (a) “Popeye” deformity due to rupture of the proximal LHB tendon (distal retraction). (b) “Popeye” defor-
mity due to rupture of the distal LHB tendon (proximal retraction).
gin from the infraglenoid tubercle of the scapula;

however, it can also have an attachment to the
inferior capsulolabral complex of the glenohu-
meral joint. The lateral head originates from the
posterior aspect of the proximal humerus and the
medial head originates from the posterior aspect
of the distal 1/3 of the humerus inferior to the
radial groove. All three heads of the triceps insert
posteriorly on the olecranon process of the ulna Long head Lateral head
as a wide, flat tendon (Fig. 3.39). Motor innerva-
tion to the triceps is mostly provided by the radial
nerve (C6 through T1) which spirals around the
proximal humerus in the radial groove. The Medial head
medial head of the triceps has a dual nerve sup-
ply—the medial half of the medial head is sup-
plied by the ulnar nerve and the lateral half of the
medial head is supplied by the radial nerve which
forms an interneural plane that is used to facili-
tate deep surgical dissection.
The main function of the triceps muscle is to
extend the elbow joint and to prevent hyperflex- Fig. 3.39 Illustration depicting the general anatomy of
ion of the elbow as a counter-regulatory mecha- the triceps muscle. The medial, lateral, and long heads of
nism. Although its role in the shoulder has not the triceps muscle are shown.
been clearly defined, several investigators have
found that the triceps muscle may be involved in author to suggest that the deceleration phase of
the development of shoulder pain in overhead the throwing motion produced traction on the
athletes. Bennett [142] was perhaps the first inferior capsule from the pull of the triceps, thus
cle functions as a powerful adductor and internal

rotator of the humerus.
There have been no known cases of isolated
pectoralis major atrophy as a result of a nerve
lesion. Poland first described a condition in which
unilateral absence of the pectoral muscles was
evident along with other myocutaneous mani-
festations occurring on the ipsilateral side of
the body, including hand size discrepancies
(“Poland’s syndrome”). The cause of the disorder
is unknown; however, the most common theory
involves a disruption of subclavian artery circu-
Fig. 3.40 Anteroposterior (AP) radiograph demonstrat-
lation during pregnancy. Patients with unilateral
ing an inferior glenoid enthesophyte (Bennett lesion) in an
overhead athlete with posterior shoulder pain. (From absence of the pectoralis major rarely have func-
Spiegl et al. [162]; with permission). tional deficits and their concerns are usually cos-
metic in nature [143–145].
Rupture of the pectoralis major tendon is a
resulting in a traction spur at the inferior aspect common occurrence in clinical practice, espe-
of the glenoid. Although this theory has since cially in those who participate in heavy bench
been refuted, this so-called Bennett lesion is pressing activities [145–147]. The patient will
often an indicator of posterosuperior glenoid generally experience a “popping” sensation fol-
impingement in throwing athletes (Fig. 3.40). lowed by pain, swelling, and ecchymosis in the
Nobuhara [91] later suggested that repeated trac- axilla. The swelling rapidly subsides within a few
tion of the triceps during the deceleration phase days, leaving a classic “web” deformity in the
of the throwing motion may cause an overuse- axilla which can be detected by simple observa-
type of tendinitis thereby resulting in posterome- tion of the anterior chest.
dial pain in the upper arm. To date, no clinical or Strength testing of the pectoralis major is typi-
biomechanical studies have evaluated the effects cally indicated after re-attachment of the ruptured
of triceps muscle function on shoulder motion tendon; however, perceived weakness is more
and thus there are no clinical examination tests likely to be due to pain and guarding rather than
of the triceps muscle that are relevant to the true muscular weakness. The muscle is tested by
shoulder. first having the patient forward flex both arms to
90° of elevation with each humerus internally
3.4.1.4 Pectoral Muscles rotated. Alternatively, the test can also be per-
Pectoralis Major formed with the arms abducted to 90° within the
The pectoralis major has two heads that originate scapular plane. The patient then actively adducts
from the thorax—the clavicular head and the the arms against resistance applied by the exam-
sternal head. The clavicular head arises from the iner (Fig. 3.42). It has been suggested that the
inferior aspect of the medial clavicle along the upper and lower portion of the muscle can be
pectoralis ridge and the first few ribs. The sternal separately tested by varying the degree of for-
head arises from the ribs and the lateral portion of ward elevation [71]; however, this has not been
the sternum. The two heads converge into a sin- substantiated by any clinical, biomechanical, or
gle tendon sheet that inserts over the lateral lip of electromyographic study to date.
the bicipital groove (Fig. 3.41). The medial and
lateral pectoral nerves branch from the medial Pectoralis Minor
and lateral cords of the brachial plexus, respec- The pectoralis minor takes origin from the sec-
tively, to innervate the pectoralis major. The mus- ond through the fifth ribs on the anterior chest
wall and inserts along the anteromedial aspect of
Pectoralis major:
Pectoralis
Clavicular head minor
Sternal head
Fig. 3.41 Illustrations showing the general anatomy of the pectoralis major (sternal and clavicular heads) and pectora-
lis minor muscles.
Fig. 3.42 Pectoralis major

strength testing. With the
patient sitting or standing,
both arms can either be
flexed to 90° or abducted
to 90° in the scapular plane
with maximal internal
rotation. The patient then
adducts the arms against
resistance provided by the
examiner. (From Dodson
and Williams III [163];
with permission).
the coracoid process (see Fig. 3.41). The medial and the resting position of the scapula, although
pectoral nerve provides motor innervation to the the investigators did not evaluate muscle length
muscle and is derived from the C8 and T1 spinal nor did they perform EMG testing to prove that
nerve roots. Reflection of the muscle anteriorly the pectoralis minor muscle was actually firing
would reveal the brachial plexus and the middle during their testing maneuvers. Many researchers
portion of the axillary artery. believe that the pectoralis minor plays a relatively
Based on the orientation of its fibers, the pec- small role in normal scapular kinematics. This is
toralis minor has been theorized to primarily supported by several case reports in which con-
cause scapular protraction and internal rotation. genital absence or isolated tearing of the pectora-
However, Diveta et al. [148] found no relation- lis minor did not result in significantly disability
ship between the strength of the pectoralis minor [149–151]. In addition, pectoralis minor tendon
Fig. 3.43 Pectoralis minor

strength testing. With the
patient supine, the
examiner places their hand
on the anterior shoulder
and asks the patient to
thrust the shoulder forward
against resistance. The
patient’s hands should be
raised off the table during
the test to prevent
increased leverage.
transfers have been performed for irreparable To prevent the patient from obtaining leverage,
anterosuperior rotator cuff tears [152] and tenot- the patient’s ipsilateral hand can be raised away
omies have been performed to decompress the from the table during testing. As with many other
thoracic outlet [153, 154] without any apparent examination maneuvers, this test likely does not
effects on scapular motion. On the other hand, isolate the pectoralis minor and is probably best
tightness of the pectoralis minor has been found used as a screening tool in high-functioning
to cause scapular malposition and may also be patients with shoulder discomfort.
involved with altered scapular motion [155, 156]
and subacromial impingement [157–159].
Although isolated lesions of the pectoralis 3.5 Conclusion
minor are rarely reported, they are probably
underdiagnosed as a result of their relatively The mechanisms involved with shoulder motion
benign course. In one small case series, Bhatia are complex and weakness of any of the individ-
et al. [160] described an overuse insertional ual components can result in pain and dysfunc-
tendinitis of the pectoralis minor in five weight- tion. Although only a few important strength tests
lifters; however, the diagnosis was subjectively should be selected for any given patient to sup-
assumed after injection near the medial border of port a diagnosis, these maneuvers can provide
the coracoid resulted in symptomatic relief. Other important clues to the underlying diagnosis
than a case report by Mehallo [150] in 2004, we which can help guide the use of provocative tests.
are unaware of any other cases of isolated pecto-
ralis minor weakness as a result of tearing or neu-
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Rotator Cuff Disorders
4
4.1 Introduction 4.2 Anatomy and Biomechanics
Rotator cuff disease ranks among the most The rotator cuff is often conceptualized as being
common musculoskeletal disorders to be composed of four separate muscles, tendons, and
encountered in clinical practice. As a result, we insertion sites that each has its designated func-
have witnessed a rapid evolution in diagnostic tions. However, in reality, although each muscle
methods and treatment options for the entire belly arises from different areas of the scapular
spectrum of rotator cuff disorders over the past body, their tendons converge and coalesce to
few decades. form a single, continuous tendon sheet that
The derangement of normal anatomy and sub- inserts upon the greater and lesser tuberosities of
sequent rotator cuff impingement is often cited as the proximal humerus (Fig. 4.1). This structural
the primary cause for rotator cuff disease. configuration suggests that the individual mus-
However, the undersurface of the coracoacromial cles of the rotator cuff work simultaneously and
arch may not always be the culprit in this com- in synchrony to achieve its primary function—to
plex array of syndromes. Traumatic events, repet- dynamically stabilize and compress the humeral
itive microtrauma, and glenohumeral instability head within the glenoid fossa [2].
may also be causative in a large proportion of Maintenance of a stable fulcrum requires bal-
patients. These factors, among others, are impor- anced axial and coronal plane force couples
tant to consider when evaluating the patient with (Fig. 4.2) [3, 4]. This concept, initially developed
a suspected rotator cuff lesion. by Burkhart [4] in 1991, is produced by the stra-
Therefore, proficiency in the physical diagno- tegic anatomic positioning of the muscles around
sis of various rotator cuff lesions requires a solid the shoulder. Specifically, the combined actions
differential diagnosis, an appreciation of normal of the anterior cuff (i.e., the subscapularis) and
anatomy and biomechanics and the awareness the posterior cuff (i.e., the infraspinatus) work to
that surrounding structures involved with normal compress the humeral head within the glenoid
function may also contribute to pathologic condi- fossa due to their parallel force vectors in the
tions. This is important not only for the initial axial plane. In the coronal plane, contraction of
examination by the treating physician, but also each rotator cuff muscle and the deltoid muscle
for the teams of individuals who care for these also generates a net force vector that drives the
patients. humeral head medially against the glenoid.
78 4 Rotator Cuff Disorders
Fig. 4.1 Cadaveric dissection photographs demonstrat- interval between the supraspinatus (SS) and the infraspi-
ing the coalescence of the rotator cuff tendons as they natus (IS). (b) View from posteriorly showing the approx-
approach their respective insertion sites on the humerus. imately interval between the infraspinatus (IS) and teres
(a) View from posterosuperiorly showing the approximate minor (TM). (From Dugas et al. [1]; with permission).
Fig. 4.2 Illustration highlighting the important force head medially towards the glenoid fossa. (b) The com-
couples that help maintain concavity compression and bined actions of the subscapularis (S) and the infraspina-
overall glenohumeral stability. (a) The combined actions tus (I) make up the axial plane force couple and also work
of the deltoid muscle (D) and the rotator cuff (C) make up to drive the humeral head medially towards the glenoid
the transverse plane force couple and pull the humeral fossa.
Disruption of any of these force couples, as in the addition to providing a stable fulcrum for motion,
case of a rotator cuff tear or deltoid weakness, balanced force couples (with resulting concavity
can produce disordered shoulder function through compression) improve glenohumeral stability by
a variety of mechanisms. This concept led to the increasing the force and degree of humeral angu-
biomechanical principle of concavity compres- lation required for the humeral head to translate
sion, described by Lippitt and Matsen [5] in over the glenoid rim in any direction (i.e., an
1993, in which the balanced, parallel force cou- increased balance stability angle, as discussed in
ples generated by the rotator cuff and deltoid Chap. 6). It is easy to imagine that disruption of
compress the convex humeral head into the con- axial or coronal plane force couples would result
cave glenoid fossa thereby enhancing glenohu- in dysfunction of the concavity compression
meral stability in the mid-ranges of motion. In mechanism leading to scapular dyskinesis and
4.2 Anatomy and Biomechanics 79
a b
Rotator Supraspinatus
crescent Rotator
Rotator crescent
cable
Infraspinatus
Supraspinatus Rotator
cable
Teres minor
Biceps
tendon
Fig. 4.3 (a) Superior and (b) posterior view illustrating force dispersion which helps to prevent tension overload
the position of the rotator cable. The rotator cable is a within the rotator crescent (the area of tendon surrounded
thickened area of the rotator cuff that provides a path for by the rotator cable).
subsequent shoulder discomfort (see Chap. 9 for margins of the cuff tear increases exponentially
more information on scapular dyskinesis and its as the size of the tear increases.
relationship with rotator cuff tears). Anterior or posterior extension of a rotator
The rotator cable, described by Burkhart [3] in cuff tear can also occur as a result of the disrup-
1993 as a part of the “suspension bridge model,” tion of balanced force couples. A study by
is a thickened area of tendon that extends across Hughes and An [8] found that normal supraspi-
the supraspinatus and infraspinatus tendons natus tendons exerted a maximum force of
which biomechanically allows their respective approximately 175 N whereas normal infraspi-
forces of contraction to disperse along the length natus tendons exerted a maximum force of
of the cable, eventually concentrating at its ante- greater than 900 N. This has important implica-
rior and posterior insertion sites (Fig. 4.3). The tions for the development and progression of
rotator cable surrounds a crescent-shaped area of rotator cuff tears—posterior extension of a tear
tendon (i.e., the rotator crescent) that is some- into the infraspinatus tendon dramatically
what protected from the strong forces produced increases the force applied to the remaining
by the supraspinatus and infraspinatus tendons as intact tendon sheet which can accelerate tear
a result of the function of the rotator cable. The progression. Because the force exerted by the
force couple principle in combination with the infraspinatus must be similar to that of the sub-
function of the rotator cable may provide an scapularis to maintain balanced force couples,
explanation as to why some patients are able to this concept of tear extension can also be applied
maintain adequate shoulder function despite the anteriorly into the subscapularis muscle. Thus,
presence of a large full-thickness supraspinatus anterior or posterior extension of a rotator cuff
tear. However, recent evidence suggests that the tear into the subscapularis and/or the infraspina-
load-sharing capability of the rotator cuff is tus tendons, respectively, disrupts the balance of
diminished in the presence of a partial- or full- native force couples which also accelerates tear
thickness tear which subsequently promotes tear progression. Longitudinal (or medial) tear
extension [6, 7]. In other words, the defect in the extension of the supraspinatus with or without
cuff tendon decreases the available area required retraction can also disrupt glenohumeral kine-
to disperse normal tensile forces produced by matics; however, the pathomechanism typically
muscle contraction. Because these normal con- involves proximal humeral head migration,
traction forces must be transmitted (and re- highlighting the importance of the rotator cuff
directed) through a smaller area of intact tendon, as a dynamic depressor of the humeral head
the magnitude of stress concentration along the (Fig. 4.4).
Fig. 4.4 (a) Anteroposterior (AP) radiograph demon- a patient with a massive rotator cuff tear. Proximal migra-
strating a normal acromiohumeral distance (red arrow) in tion of the humerus and a subsequent decrease in the acro-
a patient with an intact rotator cuff. (b) AP radiograph of miohumeral distance (red arrow) can be seen.
acromion and coracoacromial ligament (Figs. 4.5

4.3 Subacromial Impingement and 4.6). He hypothesized that this repetitive
mechanical impingement led to the development
Subacromial impingement is one of the most of proliferative anterolateral acromial spurs.
common causes of shoulder pain encountered in He subsequently dissected 100 cadaveric shoul-
clinical practice. In the past, some authors ders and again revealed these traction spurs on
believed impingement was the result of extrinsic the anterolateral acromion. With this finding, he
factors, citing various potential sources of exter- proposed that anterior acromioplasty should be
nal cuff compression [9–11]. Others believed the performed to prevent impingement and subse-
disorder was related to intrinsic cuff degenera- quent bursitis and rotator cuff disease. Later, real-
tion, leading to cuff weakness and proximal izing that subacromial impingement likely
humeral migration followed by cuff abrasion involves a continuum of disease processes, Neer
under the acromion [12]. However, recent think- [10] described three basic stages in the develop-
ing suggests that subacromial impingement is ment of impingement syndrome. Stage I of
likely multifactorial involving a combination of impingement, occurring asymptomatically in
both intrinsic and extrinsic factors that ultimately patients younger than 25 years of age, involves
lead to rotator cuff disease. subacromial edema, hemorrhage, and bursitis.
Between the ages of 25 and 40, continued
impingement results in rotator cuff fibrosis and
4.3.1 Pathogenesis Involving tendinitis, eliminating the normal lubricating
Extrinsic Factors effect of the subacromial bursa. Beyond the age
of 40 years, continued impingement becomes
Neer [10] originally described subacromial more symptomatic with the development of acro-
impingement as the repeated contact between the mial spurs along with partial- and full-thickness
greater tuberosity and the undersurface of the rotator cuff tears.
4.3 Subacromial Impingement 81
a Coracoacromial b Coracoacromial
ligament Acromion ligament Coracoid
Supraspinatus
Coracoacromial arch
Labrum LHB tendon
SGHL
Infraspinatus Joint capsule
MGHL
Teres minor
IGHL (Anterior band)
IGHL (Posterior band) Axillary pouch
Fig. 4.5 (a) Anterior view of the coracoacromial liga- romial ligament, and the posterior aspect of the coracoid.
ment with the rotator cuff musculature passing closely With the humeral head removed, the rotator cuff muscula-
beneath. (b) Sagittal view of the coracoacromial arch ture can be seen traveling closely beneath the coracoacro-
which is made up of the anterolateral acromion, coracoac- mial arch.
Subacromial Impingement
Neutral Abduction
Acromion Bursal inflammation

Supraspinatus:
Muscle
Tendon
Subacromial
bursa
Greater
tuberosity
a b
Fig. 4.6 (a) Anteroposterior (AP) cross-section view of resting position. (b) When the humerus is elevated, the
the shoulder illustrating the position of the supraspinatus supraspinatus and subacromial bursa can make contact
muscle-tendon unit and the subacromial bursa relative to with the undersurface of the acromion, often resulting in
the inferior acromion when the humerus is in a neutral rotator cuff pathology with impingement-like symptoms.
Neer’s description of the stages of impinge- While there are several studies that support this
ment syndrome is one of the most popular mechanism [11, 13, 14], the precise etiology
pathomechanistic explanations behind the and location of subacromial impingement is
development of chronic rotator cuff disease. debatable.
Fig. 4.7 Axillary

radiograph demonstrating
os acromiale (yellow
arrow). This patient
presented to our clinic with
impingement-like
symptoms.
4.3.1.1 Coracoacromial Ligament during range of motion testing in a series of nor-

The coracoacromial ligament originates from the mal, healthy shoulders. This finding may provide at
distal-lateral extension of the coracoid process and least one possible explanation behind the develop-
travels posterosuperiorly to insert upon the antero- ment of traction-type spurs on the anterolateral
lateral margin of the acromion [15, 16]. As part of acromion with advancing age, potentially leading
the coracoacromial arch, this ligament is com- to extrinsic compression of the superior cuff ten-
monly described as being involved with rotator dons. However, whether or not the thickness of the
cuff impingement lesions due to the proximity of anterolateral band is a cause or effect of rotator cuff
the cuff tendons that pass closely beneath, espe- disease has not been elucidated.
cially as the arm is elevated. The coracoacromial
ligament has a number of anatomic variations [17– 4.3.1.2 Os Acromiale
19]; however, only those variations that involve a The acromion is also subject to developmental
distinct anterolateral and posteromedial bundle are abnormalities as a result of failed fusion of sec-
likely to be related to rotator cuff impingement and ondary ossification centers. This failed fusion
subsequent tearing. In a cadaveric study, Fremery results in a defect known as an “os acromiale” and
et al. [20] found that shoulders with rotator cuff occurs in approximately 8 % of the population
tears and clinical evidence of impingement had where 1/3 of these individuals are affected bilater-
stronger, thicker anterolateral bands compared to ally [24]. Os acromiale is a mobile accessory
shoulders with unrelated issues. Evidence of trac- ossicle that, when unstable and pulled inferiorly
tion spur formation within the anterolateral band by contraction of the deltoid with arm elevation,
has also been found which further implicates its has been associated with the development of iden-
involvement with the development of impinge- tifiable impingement lesions and pain at the top of
ment [21]. Chambler et al. [22] suggested that arm the shoulder (Fig. 4.7). However, this relationship
abduction results in increased tension of the cora- has been refuted on several occasions [25–29]. In
coacromial ligament which may provide an expla- addition, surgical treatment strategies for os acro-
nation for the development of traction spurs in miale that involve increasing the volume of the
these patients. A more recent cadaveric study by subacromial space has not resulted in an improve-
Yamamoto et al. [23] found that the superior cuff ment in clinical outcomes [26]. Further study is
made contact with and, in fact, generated increased therefore needed to clarify the effects of os acro-
tension through the coracoacromial ligament miale on normal rotator cuff tendons.
Fig. 4.8 Illustration of the Type I Type II Type III

three types of acromial
morphologies as described
by Bigliani et al. [30].
Type I: Flat acromion.
Type II: Curved acromion.
Type III: Hooked
acromion. Patients with a
type III hooked acromion
may have an increased Joint
propensity to develop capsule
subacromial impingement
and rotator cuff disease.
4.3.1.3 Acromial Morphology rotator cuff pathology using multivariate logistic

and Glenoid Version regression analysis. Additionally, Natsis et al.
The anterior aspect of the acromion may, in itself, [32] found a statistically significant increase in
be a potential site of rotator cuff abrasion and the rate of anterolateral acromial spur formation
subsequent tearing regardless of the presence or in those with a type III acromion. They concluded
absence of space-occupying traction spurs asso- that a type III acromion with anterolateral spur
ciated with the coracoacromial ligament. In 1991, formation was contributing factor associated
Bigliani et al. [30] described the three most com- with the development of rotator cuff impinge-
mon acromial morphologies as flat (type I), ment and tearing. In 2012, Hamid et al. [33]
curved (type II), and hooked (type III), citing the arrived at similar conclusions. However, despite
hooked acromion as most relevant to the devel- these results, there are also a number of studies
opment of subacromial impingement (Fig. 4.8). that refute the oft-cited correlation between the
In a cadaveric study, Flatow et al. [13] demon- type III acromion and the development or pro-
strated that the type III acromion has an increased gression of rotator cuff tears [17, 31, 34–38]. As
propensity to make contact with the rotator cuff a result of this conflicting data, further study is
tendons when compared to the other acromial needed to determine if acromial morphology, as
morphologies that were previously described by described by Bigliani et al [30], is truly associ-
Bigliani et al. [30]. Wang et al. [31] found that ated with the development of symptomatic sub-
acromial morphology influenced the success of acromial impingement and rotator cuff tears.
conservative management for rotator cuff tears. More recently, other acromial morphologies
In their study, the majority of patients with either have been also been described—namely, the con-
a type I or II acromion responded favorably to vex acromion (type IV; as described by Vanarthos
conservative management. In contrast, more than and Monu [39] as an addendum to the original
half of those patients with a type III acromion classification system developed by Bigliani et al.
failed nonoperative treatment and required sub- [30] Fig. 4.9) and the keeled acromion (originally
sequent surgical intervention. Unfortunately, described by Tucker and Snyder [41] Fig. 4.10).
these authors did not report their findings at the While the type IV acromion has not been impli-
time of surgery. In another study, Gill et al. [14] cated as an anatomic factor associated with rota-
found that acromial morphology was an indepen- tor cuff disease, the keeled acromion may be
dent factor associated with the development of involved to some extent. The keeled acromion,
Fig. 4.11 True anteroposterior (AP) radiograph demon-

Fig. 4.9 Magnetic resonance image (MRI) demonstrat- strating measurement of the acromial index. A first line is
ing a type IV convex acromion as described by Vanarthos drawn connecting the superior and inferior rims of the
and Monu [39]. Although a common variant, this acromial glenoid and extended superiorly such that the line com-
morphology has not been associated with rotator cuff dis- pletely crosses the acromion. A second line is drawn verti-
ease in the literature. (From Sanders and Miller [40]; with cally that corresponds with the most lateral extent of the
permission). acromion. The distance between the first line and the sec-
ond line is labeled “A.” A third line is drawn vertically
that corresponds with the most lateral extent of the greater
tuberosity. The distance between this third line and
the first line is labeled “B.” The ratio of A/B is equal to the
acromial index. Theories exist that rationalize both
increased and decreased acromial indices with rotator cuff
disease; however, further study is needed to elucidate the
precise role of the acromion in the development of rotator
cuff disease.
slope may be another factor associated with the

development of impingement lesions [34, 42–
44]; however, further study needs to be conducted
to substantiate these claims.
Fig. 4.10 Anteroposterior (AP) radiograph demonstrat- Excessive lateral extension of the acromion,
ing a keeled acromion as described by Tucker and Snyder
[41]. This acromial morphology may have some involve-
which is best quantified through calculation of
ment in the development of subacromial impingement, the acromial index (Fig. 4.11), has also been
although further study is needed to substantiate this claim reported as a potential contributor to the develop-
(From Tucker and Snyder [41]; with permission). ment of rotator cuff impingement and tearing.
Some investigators report that decreased cover-
which was described as a central spur (or convex- age of the humeral head by the acromion (i.e., a
ity) located on the undersurface of the acromion, decreased acromial index) may allow the humeral
was significantly associated with the presence of head to utilize the anterolateral acromion as a ful-
both partial- (bursal-sided) and full-thickness crum or lever to aid in glenohumeral elevation,
rotator cuff tears in the original study published possibly causing abrasion of the cuff tendons and
by Tucker and Snyder [41]. Several recent stud- subsequent rotator cuff tearing [45, 46]. Nyffeler
ies have also suggested that a steep acromial et al. [47] suggested that a large acromial index
may result in a more superiorly directed force

vector produced by the middle fibers of the del-
toid, potentially leading to superior migration of
the humeral head which, in turn, decreases the
available space for the cuff tendons to pass
beneath the acromion. This theory has been par-
tially validated since other more recent studies
have found statistically significant associations
between increased acromial indices and the pres-
ence of rotator cuff tears [31, 33, 34, 47–50].
Although the acromial index appears to play
some role in the development of rotator cuff dis-
ease, additional studies are needed to fully eluci-
date the exact pathomechanisms behind this
phenomenon.
Inclination of the glenoid in the coronal plane
has also been associated with the development of Fig. 4.12 True anteroposterior (AP) radiograph demon-
rotator cuff tears on several occasions [51–53]. strating measurement of the critical shoulder angle. Line
Tétrault et al. [52] performed measurements “AB” is first drawn, which connects the most lateral
points of the superior and inferior glenoid rim. Line “AC”
using magnetic resonance imaging (MRI) to is then drawn, which connects the previously drawn point
determine the orientation of the supraspinatus “A” to the most lateral point of the acromion (designated
muscle fibers relative to the glenoid surface. In as point “C”). The angle formed between lines “AB” and
that study, the mean angle formed between the “AC” represents the critical shoulder angle. According to
Moor et al. [57] an angle of less than 30° increases the risk
supraspinatus tendon and the glenoid surface was for osteoarthritis whereas an angle of greater than 35°
approximately 80° in the coronal plane. The increases the risk for degenerative rotator cuff tears.
authors suggested that a decrease in this angle
(i.e., increased upward tilt of the glenoid) may
result in a more vertically oriented force vector The critical shoulder angle (CSA) (recently
produced by the supraspinatus, thus preferen- described by Gerber et al. [56] and Moor et al.
tially pulling the humeral head superiorly [52]. If [57, 58]) is another radiographic measurement
this theoretical mechanism is factually correct, purported to have an association with rotator
the supraspinatus tendon could then make con- cuff tears or osteoarthritis. The CSA is obtained
tact with the acromion, possibly leading to the from true anteroposterior (AP) radiographs and
cascade of events commonly associated with takes into account both the acromial index and
rotator cuff disease. A similar mechanism may the degree of glenoid inclination in the scapu-
occur when considering glenoid anteversion and lar plane (Fig. 4.12). The original developers
retroversion in which tearing of the subscapularis of this measurement have suggested that the
and infraspinatus is observed, respectively [52]. CSA may have an ability to predict the future
Although at least one study found that surgically development of degenerative rotator cuff tears
decreasing the glenoid inclination angle may (when the CSA > 35°) and glenohumeral osteo-
decrease the measured amount of superior arthritis (when the CSA < 30°). However, a
humeral head translation with passive abduction well-designed prospective study would be
[49], none of the more recent imaging studies needed to confirm these claims given the cur-
have shown significant associations between any rent lack of conclusive clinical data suggesting
type or degree of glenoid version and the pres- any association between either the acromial
ence of rotator cuff lesions, regardless of location index or glenoid inclination and any shoulder
of the tear or the tendon involved [54, 55]. pathology.
4.3.2 Pathogenesis Involving using scanning electron microscopy. They

Intrinsic Factors described a hypovascular zone on the surface of
the supraspinatus tendon, confirming the findings
While extrinsic factors probably have some role that had been reported by others (Fig. 4.13) [62,
in the development of subacromial impingement, 64, 65]. More recently, Brooks et al. [35] found
many authors believe that the initiation and pro- that both the supraspinatus and infraspinatus ten-
gression of rotator cuff disease primarily occurs dons were hypovascular in the most distal 15 mm
as a result of intrinsic cuff degeneration. They of their respective insertion sites on the greater
argue that degenerative changes and/or traumatic tuberosity. This area of the insertional footprint,
injuries weaken the contractile strength of supra- termed the “critical zone” by Moseley and Goldie
spinatus muscle which predictably leads to supe- [64] in 1963, may have an increased propensity to
rior humeral head migration and cuff impingement develop partial- or full-thickness rotator cuff tears
beneath the acromion with humeral elevation. as a result of poor tendon nutrition and a limited
Spurring of the anterolateral acromion and ero- capacity for spontaneous healing. Although sev-
sion of the greater tuberosity are then observed eral studies have revealed evidence of apoptosis
(due to repeated reciprocal contact) along with and hypoxia in rotator cuff tendons with visible
rotator cuff degeneration. tears and impingement lesions [18, 66–68], some
The deterioration of tendon quality due to authors believe these findings are the result of cuff
advanced age is often implicated as one of the degeneration rather than the cause of cuff degen-
primary causes of rotator cuff weakness, poten- eration [69].
tially resulting in proximal humeral head migra-
tion, subsequent bursal irritation and cuff
tendinopathy. While the incidence and severity of 4.3.3 Physical Examination
rotator cuff disease has been found to increase
with age on several occasions, Ogata and Uhthoff Numerous studies have evaluated the utility of
[59] found that acromial osteophytes were not physical examination tests to reliably identify
always present in older patients. Further, those subacromial impingement. The Neer impinge-
who did have acromial osteophytes actually had ment sign [10], Hawkins–Kennedy test [70], and
articular-sided partial-thickness rotator cuff tears the painful arc sign [71] are the most useful and
(as opposed to bursal-sided tears). However, a most widely utilized tests for the detection of
more recent study identified the presence of subacromial impingement. Tenderness to palpa-
anterolateral acromial spurs as an independent tion at the location of Codman’s point (described
risk factor for the development of rotator cuff below) may also suggest rotator cuff impinge-
disease [33]. Further research is needed to iden- ment. Because pathologies other than impinge-
tify and elucidate the roles of mechanical com- ment can produce impingement-like signs and
pression and intrinsic tendon degeneration on the symptoms during the physical examination, sen-
progression of rotator cuff disease. sitivity and specificity data for these tests are
The tenuous microvascular blood supply to the variable [72–78]. Therefore, consideration of all
supraspinatus and infraspinatus tendons has also available information, including other clinical
been suggested as a possible intrinsic factor related tests and historical features, is necessary to syn-
to the development and progression of certain thesize an accurate physical diagnosis in every
rotator cuff tears [12, 35, 60–65]. Lohr and Uhthoff patient. When the diagnosis is in question, it is
[12] identified an area along the edges of supraspi- often useful to inject a local anesthetic into the
natus tears in which no vessels were present, sug- subacromial space before repeating each test.
gesting that spontaneous healing of a torn rotator This method is typically used to identify whether
cuff tendon is probably not feasible without surgi- the patient’s subjective weakness is primarily due
cal intervention. Ling et al. [63] studied the vascu- to guarding or due to actual muscle weakness.
lar supply of the supraspinatus tendon in 22 adults The relief of impingement-like signs and symptoms
Fig. 4.13 (a) Axial slide showing the microvascular pat- Arrows correspond to the region of avascularity and aster-
tern of the supraspinatus tendon. (b) Coronal slide show- isks indicate the location of the supraspinatus footprint on
ing the microvascular pattern of the supraspinatus tendon. the greater tuberosity. (From [65] with permission).
that were present before the injection usually Both Fodor et al. [73] and Kelly et al. [79] used
confirms the diagnosis. This technique is usually ultrasonic evaluation to determine the sensitivity
referred to as the Neer impingement test which and specificity of the Neer sign in the diagnosis of
should not be confused with the Neer impinge- subacromial impingement. Interestingly, although
ment sign (described below). each study reported similar sensitivity values,
their specificity values were divergent (95 % and
4.3.3.1 Neer Impingement Sign 10 %, respectively). These results highlight the
The Neer impingement sign, first described by significant variability that may exist in the perfor-
Neer [10] in 1972, is elicited by passive and max- mance and interpretation of physical examination
imal forward elevation of the humerus and stabi- findings, specifically with regard to subacromial
lization of the scapula with the examiner’s impingement syndrome. Nevertheless, Hegedus
contralateral hand (Fig. 4.14). Stabilization of the et al. [81] attempted to account for various con-
scapula is essential to maximize the utility of the founding factors and study quality in a recent
test since upward rotation of the scapula (and meta-analysis. In that study, the overall calculated
therefore the acromion) with forward elevation sensitivity of the Neer impingement sign was
will decrease the likelihood of reproducing cuff 72 % while its overall specificity was approxi-
impingement under the acromion. Reproduction mately 60 %. Clearly, this maneuver is not ade-
of the patient’s symptoms is indicative of a posi- quate to diagnose subacromial impingement in
tive test. Several investigators have evaluated the isolation; however, combination of its results with
clinical efficacy of the Neer impingement sign in those obtained from the Hawkins–Kennedy test
its ability to accurately diagnose subacromial and the painful arc sign (described below) are
impingement (Table 4.1) [72, 73, 75, 76, 78, 80]. likely to improve diagnostic accuracy.
4.3.3.2 Hawkins–Kennedy Test

The Hawkins–Kennedy test [70] was first
described in 1980; however, it was not originally
thought to be as reliable or reproducible as the
Neer impingement sign. A positive Hawkins–
Kennedy test is the result of greater tuberosity
contact on the undersurface of the coracoacromial
ligament that is thought to reproduce symptoms
related to subacromial impingement. To perform
this test, the shoulder is brought to 90° of abduc-
tion in the scapular plane with the elbow also
flexed 90°. From this position, the humerus is
slowly and maximally internally rotated
(Fig. 4.15). Reproduction of the patient’s symp-
toms (typically pain over the anterior shoulder) is
deemed a positive test and may be indicative of
superior cuff impingement. Numerous studies
have evaluated the efficacy of the Hawkins–
Kennedy test in its ability to diagnose subacro-
mial impingement with variable results (Table 4.2)
[72–76, 78, 80, 82]. The meta-analysis by
Hegedus et al. [81] reported similar overall sensi-
tivities and specificities for both the Neer impinge-
ment sign and the Hawkins–Kennedy tests.
Fig. 4.14 Neer impingement sign. The examiner stabi-
lizes the scapula with one hand and uses the other hand to 4.3.3.3 Painful Arc Sign
passively forward-flex the humerus to a point of maximal The painful arc sign [71] is elicited with resisted
elevation. Reproduction of the patient’s symptoms with abduction of the shoulder in the scapular plane
this maneuver may suggest the presence of subacromial
impingement. (20–30° of forward angulation) with the elbow
Table 4.1 Diagnostic efficacy of the Neer impingement sign in isolation

Diagnostic efficacy of the Neer impingement sign in isolation
Investigators Maneuver Pathology Standard LR+ LR− Sensitivity (%) Specificity (%)
Silva Neer SIS MRI 0.98 1.1 68 30
et al. [78]
Fodor Neer SIS Ultrasound 10.8 0.48 54 95
et al. [73]
Michener Neer SIS Arthroscopy 1.76 0.35 81 54
et al. [76]
Kelly Neer SIS Ultrasound 0.62 3.80 62 10
et al. [79]
Chew Neer SIS Ultrasound 1.60 0.60 64 61
et al. [72]
Toprak Neer SIS Ultrasound 1.67 0.38 80 52
et al. [80]
SIS subacromial impingement syndrome, LR likelihood ratio
4.4 Subcoracoid Impingement 89
Fig. 4.15 Hawkins–

Kennedy test. The
examiner passively abducts
the humerus in the scapular
plane to approximately 90°
with the elbow also flexed
to 90°. The examiner then
internally rotates the
humerus which is thought
to induce impingement
between the greater
tuberosity and the
undersurface of the
acromion. Reproduction of
the patient’s symptoms
with this test may be
suggestive of subacromial
impingement.
Table 4.2 Diagnostic efficacy of the Hawkins–Kennedy test in isolation

Diagnostic efficacy of the Hawkins–Kennedy test in isolation
Silva et al. [78] H–K SIS MRI 1.23 0.65 74 40
Fodor et al. [73] H–K SIS Ultrasound 6.50 0.31 72 89
Michener et al. [76] H–K SIS Arthroscopy 1.63 0.61 63 62
Kelly et al. [79] H–K SIS Ultrasound 1.48 0.52 74 50
Chew et al. [72] H–K SIS Ultrasound 1.30 0.40 87 32
Salaffi et al. [77] H–K SIS Ultrasound 2.50 0.51 64 71
Fowler et al. [74] H–K SIS Arthroscopy 2.10 1.60 58 72
Toprak et al. [80] H–K SIS Ultrasound 1.26 0.70 67 47
SIS subacromial impingement syndrome, H–K Hawkins–Kennedy, LR likelihood ratio
in full extension (Fig. 4.16). Pain with this

maneuver is another possible indicator of sub- 4.4 Subcoracoid Impingement
acromial impingement, especially when used in
combination with the tests described above. Subcoracoid impingement is a potential cause
Although this test is not very sensitive in isola- for anterior shoulder pain as a result of compres-
tion, it does boast a modest specificity as reported sion of the subscapularis between the posterolat-
by Hegedus et al. [81] (Table 4.3). Therefore, eral edge of the coracoid process and the lesser
since both the Neer impingement sign and the tuberosity of the humerus [83–86]. In contrast to
Hawkins–Kennedy test each has low specificity subacromial impingement which likely involves
values, addition of the painful arc sign (which a multitude of intrinsic and extrinsic factors,
has a higher reported specificity) may improve most authors agree that many subscapularis tears
overall diagnostic accuracy when all three associated with a narrowed coracohumeral inter-
maneuvers are used in a composite exam to diag- val (i.e., the distance between the coracoid tip to
nose subacromial impingement. the crest of the lesser tuberosity measured by
Fig. 4.16 Painful arc sign.

In this test, the patient
attempts to abduct the
humerus within the
scapular plane against
examiner. Weakness or
pain with this maneuver
may indicate the presence
of subacromial impinge-
ment, although other tests
are needed to confirm this
finding. In this image, both
arms are tested simultane-
ously which may be more
sensitive for the detection
of more subtle pathology.
Table 4.3 Diagnostic efficacy of the painful arc sign in isolation

Diagnostic efficacy of the painful arc sign in isolation
Fodor et al. [73] Painful arc SIS Ultrasound 3.40 0.41 67 80
Michener et al. [76] Painful arc SIS Arthroscopy 2.25 0.38 75 67
Kelly et al. [79] Painful arc SIS Ultrasound 0.59 1.40 49 33
Chew et al. [72] Painful arc SIS Ultrasound 3.70 0.40 71 81
SIS subacromial impingement syndrome, LR likelihood ratio
axial MRI scans) are most likely caused by intrinsic and extrinsic factors that lead to a nar-
external tendon compression (Fig. 4.17) [86, rowed coracohumeral interval. There are numerous
88]. potential secondary causes for subcoracoid
impingement. Malunited fractures of the glenoid
neck, proximal humerus, glenoid or coracoid can
4.4.1 Pathogenesis impinge upon the subscapularis muscle, thus
resulting in anterior shoulder pain [85]. Importantly,
In 1909, Goldthwait [89] first described the con- patients with anterior glenohumeral instability (dis-
cept of subcoracoid impingement as it related to cussed in Chap. 6) may also present with subcora-
anterior shoulder pain. Many years later, Gerber coid impingement due to increased anterior
et al. [85] first described the surgical manage- translation of the humerus which subsequently nar-
ment of coracoid impingement and noted that the rows the coracohumeral interval. Iatrogenic causes
coracoid process was potentially involved with can include any type of anterior shoulder surgery,
pathology of the anterosuperior cuff tendons potentially causing the formation of subcoracoid
(subscapularis tendon and the anterior portion of adhesions and a functionally narrowed coracohu-
the supraspinatus tendon), subcoracoid bursa, meral interval. Idiopathic causes may include gan-
and the long head of the biceps tendon. glion cysts, congenitally malformed coracoid
Subcoracoid impingement can have primary, processes or subscapularis calcifications.
secondary, or idiopathic causes. Although primary Recently, several studies have described the
subcoracoid impingement has been relatively various morphologic characteristics of the cora-
understudied, it probably involves multiple coid and their potential roles in the development
4.4 Subcoracoid Impingement 91
Fig. 4.17 (a) Axial MRI slice demonstrating measure- aspect of the coracoid process. The distanced traveled by
ment of the coracoid index and the coracohumeral interval the white arrow represents the coracohumeral interval. (b)
with the humerus internally rotated. The white line con- Illustration depicting the mechanism of impingement
nects the anterior and posterior glenoid rim. The double- between the lesser tuberosity and the posterior aspect of
headed red arrow lies perpendicular to the white line and the coracoid. When the humerus is internally rotated, the
travels to the most lateral tip of the coracoid process. The coracoid induces a “roller wringer” effect on the subscap-
distance traveled by the red arrow represents the coracoid ularis tendon which induces stretching and tearing of the
index. The double-headed white arrow represents the dis- tendon when the coracohumeral interval is narrowed [87].
tance between the lesser tuberosity and the most posterior
of subscapularis impingement and anterior shoul- 4.4.2 Physical Examination

der pain [28, 90–93]. Bhatia et al. [90] found that
the posterolateral edge of the coracoid was Patients with subcoracoid impingement typically
involved with anterosuperior cuff impingement. complain of dull pain (rarely, a sharp pain) over
Richards et al. [88] found that a narrowed coraco- the anterior aspect of the shoulder. This pain may
humeral interval was significantly associated with radiate distally along the brachium if the long
subscapularis pathology. More specifically, those head of the biceps tendon is involved. Although
patients without subscapularis pathology had a patients typically present with a full range of
coracohumeral interval of 10 ± 1.3 mm while motion, they typically present with pain over the
those with subscapularis pathology had a coraco- coracoid that is exacerbated by forward flexion,
humeral interval of 5 ± 1.7 mm (p < 0.0001). internal rotation, and cross-body adduction.
Similarly, a sonographic study by Tracy et al. [94] Because this entity has not been studied exten-
found that asymptomatic patients had an interval sively, it remains a diagnosis of exclusion when
of 12.2 ± 2.5 mm while patients with clinical evi- all other causes of anterior shoulder pain have
dence of subcoracoid impingement had an inter- been ruled out. Despite the lack of literature on
val of 7.9 ± 1.4 mm. Ferreira Neto et al. [95] found the subject, it is important to remember that sub-
that women have a smaller coracohumeral inter- coracoid impingement may be the result of disor-
val compared to men when the arm was internally dered scapular mechanics. Thus, it is critically
rotated, suggesting that subcoracoid impingement important to evaluate the scapula in patients sus-
of the subscapularis may be more likely in female pected of having subcoracoid impingement
patients. Despite this evidence, the instigating (physical evaluation of the scapula is discussed
factor involved in the development of anterosupe- in Chap. 9). In the setting of a normal scapular
rior cuff pathology in patients with a narrowed exam, the subcoracoid impingement test may be
coracohumeral interval has yet to be completely an important tool in the diagnosis of subcoracoid
elucidated. impingement.
4.4.2.1 Subcoracoid Impingement Test is similar to the cross-body adduction test for
The subcoracoid impingement test, which is a acromioclavicular (AC) joint pathology, it is
modified version of the Hawkins–Kennedy test, important to note the precise location and quality
is useful to perform in any patient with shoulder of the pain that is generated by the test (i.e., pain
discomfort, especially anteriorly. The test is per- at the top of the shoulder is more likely associ-
formed by placing the patient’s arm in 90° of for- ated with AC joint pathology; see Chap. 7 for fur-
ward flexion, submaximal internal rotation and ther details). Although this test has not been fully
90° of elbow flexion. From this position, the evaluated in the literature, we have found the test
patient’s arm is progressively adducted and inter- useful to identify patients with chronic lesions
nally rotated. As the arm is adducted and inter- involving the subscapularis tendon. Because the
nally rotated, the patient with subcoracoid subscapularis muscle makes a significant contri-
impingement will complain of a dull anterior bution to the bicipital sheath, testing for pathol-
shoulder pain (Fig. 4.18). Because this maneuver ogy of the long head of the biceps tendon is also
indicated when subcoracoid impingement is sus-
pected (physical examination of the long head of
the biceps tendon is discussed in Chap. 5).
4.5 Symptomatic Internal

Impingement
The term “internal impingement” refers to a nor-

mal physiologic occurrence where the greater
tuberosity makes contact with the posterosupe-
rior glenoid labrum when the humerus is abducted
and externally rotated. Although its primary
function may involve the prevention of hyperex-
ternal rotation and maintenance of stability,
repeated episodes of this impingement (which
often occurs with repeated overhead activities
such as throwing) may lead to posterosuperior
labral tears and posterosuperior rotator cuff tears
which eventually become symptomatic. In
essence, the posterosuperior labrum and rotator
cuff become pinched between the greater tuber-
osity and the bony glenoid rim leading to poste-
rior shoulder pain (due to pathology of the
posterosuperior labrum and rotator cuff) espe-
cially when the humerus is abducted and exter-
Fig. 4.18 Subcoracoid impingement test. The examiner nally rotated (Fig. 4.19) [96–100].
passively abducts to humerus to 90°, maximally internally
rotates the humerus and flexes the elbow to 90°. From this
position, the examiner passively adducts the shoulder
across the chest. When resistance is felt, it is sometimes
4.6 Rotator Cuff Tears
useful to gently force the humerus into a greater degree of
adduction, especially in cases where the test is inconclu- Accurate physical evaluation of the patient with a
sive. The test is positive for subcoracoid impingement rotator cuff tear depends on the ability of the cli-
when a dull anterior shoulder pain is elicited. Note that
nician to decipher the primary cause of the tear
pain over the acromioclavicular (AC) joint with this test is
not considered a positive test, but may indicate the pres- which is most often obtained from the patient his-
ence of AC joint pathology. tory and initial strength examination.
4.6 Rotator Cuff Tears 93
Fig. 4.19 Illustration of

the pathomechanism
behind symptomatic
internal impingement.
Hyperabduction and
external rotation may pinch
the posterosuperior cuff
between the greater
tuberosity and the glenoid,
possibly leading to
articular-sided posterosu-
perior rotator cuff tears and
tearing of the posterosupe-
rior glenoid labrum.
4.6.1 Pathogenesis (e.g., abrasion of tendons beneath the

coracoacromial arch [10, 14, 20, 30, 32, 33]) that
The different etiologies of rotator cuff tears are lead to the insidious onset of pain especially at
most often multifactorial, ranging from acute night and/or with overhead activities. As the cuff
traumatic injuries to the three main types of tear develops and increases in size, pain and
mechanical impingement, namely the “classic” weakness become the predominant features. Pain
subacromial impingement, subcoracoid impinge- and weakness become worse as the tear extends
ment, and internal impingement in throwing ath- to involve other tendons, such as those of the
letes that can each progress rotator cuff tearing. infraspinatus (posterosuperior tear) or subscapu-
In acute injuries, patients will typically recall the laris (anterosuperior tear). Left untreated, pain
specific events leading to their shoulder pain, will often diminish and the patient will complain
weakness, and dysfunction. Other, more chronic of weakness as the primary symptom [104].
lesions, however, may be more difficult to Subcoracoid impingement (also discussed
recognize. Although each type of impingement above) is thought to result from a narrowed cora-
involves a chronic process, many patients are cohumeral interval and presents with an insidi-
asymptomatic until the tear has reached sufficient ous onset of dull pain over the anterior aspect of
size and/or has resulted in altered glenohumeral the shoulder in positions of adduction and inter-
kinematics. As such, it is thought that previously nal rotation [83–86]. Similar to subacromial
asymptomatic rotator cuff lesions may progress impingement, the progression of small, struc-
to larger, full-thickness tears especially in patients tural lesions of the subscapularis can lead to
with altered tendon biology [12, 101]. Without large, full-thickness tears resulting in progres-
treatment, small tears with intact glenohumeral sive pain, dysfunction and, in some cases, ante-
mechanics can progress to larger tears, leading to rior instability [10].
weakness and unbalanced force couples and, sub- Symptomatic internal impingement occurs as
sequently, increased shoulder pain and dysfunc- a result of repetitive hyperabduction and external
tion [102, 103]. rotation which leads to posterosuperior articular-
As discussed above, subacromial impinge- sided rotator cuff tears and labral lesions (see
ment involves a combination of intrinsic factors Fig. 4.19) [86, 99, 100]. These patients may also
(e.g., poor microvascularity [12, 35, 60–65] and report a gradual decrease in throwing perfor-
tendon quality [59]) and extrinsic factors mance such as a decline in throwing accuracy and
velocity. Scapular dyskinesis and the SICK scap-

ula syndrome is another predominant feature in
throwing athletes who may progress to symptom-
atic internal impingement [60].
4.6.2 Physical Examination
The possibility of a rotator cuff tear should be

strongly suspected in patients older than 60 years
of age, those with night pain and those with clini-
cal weakness as detected by the general strength
survey. Specifically, strength deficits in internal
or external rotation (with the arm both at the side
and at 90° of abduction) and/or abduction should
direct the clinician to specifically evaluate rotator
cuff strength. Although the presence of pain can
lead to guarding and the impression of weakness,
the sources of pain and weakness must be ascer-
tained to arrive at the correct diagnosis. Fig. 4.20 Illustration depicting the “sulcus” [101] which
may be palpated while performing the rent test.
4.6.2.1 Supraspinatus
Supraspinatus tendon tears are initially sus- [101]) could be felt between the edges of the torn
pected during the initial survey as a result of spe- tendon as the humerus was internally and exter-
cific historical findings and the presence of pain nally rotated during palpation. To perform this
and/or weakness with glenohumeral abduction. test, the examiner stands to the side of the seated
Furthermore, since painful impingement of the patient. With the arms initially at the side, the
rotator cuff may progress to partial- or full- examiner palpates the area just beneath the antero-
thickness tears, positive impingement signs may lateral acromion and lateral to the coracoacromial
also be present in patients with weakness associ- ligament which also corresponds to an anatomi-
ated with a rotator cuff tear. Further, since cally thin area of the deltoid, possibly facilitating
patients with suspected impingement in the the detection of a tendon defect [106]. When the
absence of a rotator cuff tear are managed differ- arm is at the side, this location is referred to as
ently from those with a concomitant tear, it is “Codman’s point” where the anterior supraspina-
essential to rule out the presence of a tear in tus tendon inserts on the greater tuberosity. During
those with positive impingement signs to avoid palpation, the patient’s arm is simultaneously
unnecessary surgery. moved through a range of motion, generally
involving a combination of slight abduction and
Rent Test extension along with internal and external rota-
The rent test is a method of trans-deltoid palpation (Fig. 4.21). At approximately 10° of internal
tion first described by Codman [105] in 1934 that rotation, the examiner can identify the bicipital
may have some utility in the detection of supra- sheath and the lesser tuberosity, thus providing
spinatus tendon defects. When performed cor- information regarding spatial orientation [17,
rectly, Codman suggested that clinicians could 106]. Extension of the shoulder may allow addi-
locate a point of tenderness and detect a sensation tional palpation of the anterior infraspinatus.
“crepitus” underneath their fingers which would Although many years have passed since its
therefore suggest the presence of a rotator cuff original description, only a few studies have
tear (Fig. 4.20). Specifically, a gap (or “sulcus” evaluated the diagnostic utility of this test for the
appeared to increase with increasing patient age:

sensitivities were >75 % and specificities
approached 100 % for patients older than 55
years of age whereas the test was less predictive
in younger patients (sensitivity of 43 % and spec-
ificity of 70 %).
Jobe Test
The Jobe test [19] is often performed to elicit
weakness as a result of supraspinatus tearing. To
perform the test, the arms are passively placed in
90° of abduction in the scapular plane with the
thumbs pointed downward (i.e., the “empty can”
position; Fig. 4.22). From this position, the exam-
iner places their hands on the top of the patient’s
forearms and applies a downward pressure while
the patient resists. A positive test occurs when
asymmetric weakness occurs in the affected
shoulder. Although this test isolates the supraspi-
natus muscle-tendon unit, clinical weakness can
be simulated by the presence of significant pain.
To alleviate some of this pain and to more directly
evaluate supraspinatus strength, the test can be
repeated with the thumbs pointed upward (i.e.,
Fig. 4.21 Rent test. While holding the patient’s forearm the “full can” position [108]; Fig. 4.23). This
with one hand, the examiner palpates the region just infe- maneuver is thought to position the greater tuber-
rior to the anterolateral aspect of the acromion (i.e., osity away from the coracoacromial arch and
Codman’s point). With the humerus slightly abducted and may therefore decrease the pain associated with
extended, the patient’s arm is internally and externally
rotated while the examiner simultaneously palpates the mechanical cuff impingement.
supraspinatus. A positive test occurs when a sulcus is felt
by the examiner regardless of the presence of pain. Drop Arm Sign
In some patients with massive supraspinatus
detection of rotator cuff tears. Lyons and tears, the patient may be unable to hold the arm
Tomlinson [107] calculated a sensitivity of 91 % abducted against the force of gravity as the arm
and a specificity of 75 % after performing the test drops back to the patient’s side. This is called
during strength testing in a series of 45 patients. “drop arm sign” (not to be confused with the
Wolf and Agrawal [101] calculated a sensitivity “drop sign,” as discussed below) and is indicative
of 96 and 97 % when test results were compared of a large supraspinatus/infraspinatus tear
with MRI and surgical findings; however, all 109 (Fig. 4.24). Although sensitivity and specificity
patients in this study had a previous diagnosis of data for the Jobe test and drop arm sign are mod-
subacromial impingement. Ponce et al. [106] per- est, the combination of both maneuvers is thought
formed the examination in 63 patients who pre- to improve diagnostic accuracy (Table 4.4).
sented with shoulder pain and compared the
results to a standardized MRI sequence. Their 4.6.2.2 Infraspinatus
results suggest that the rent test was more valu- The identification of an external rotation deficit
able in the detection of full-thickness tears when (infraspinatus/teres minor tear) is initially found
compared to any of the partial-thickness tears. during the general strength survey with the
In addition, sensitivity and specificity values resisted external rotation maneuvers. However,
Fig. 4.22 Jobe test in the

“empty can” position. In
this test, both arms are
placed in approximately
90° of abduction within the
scapular plane and
maximally internally
rotated (thumbs pointed
downward). The patient
then attempts to further
abduct the humerus against
resistance applied by the
examiner. A positive test
occurs when asymmetric
weakness occurs involving
the affected shoulder.
Fig. 4.23 Jobe test in the “full can” position. Both arms A positive test occurs when asymmetric weakness occurs
are placed in approximately 90° of abduction within the involving the affected shoulder. This variation of the Jobe
scapular plane and externally rotated (thumbs pointed test is thought to reduce the pain associated with supraspi-
upward). The patient then attempts to further abduct natus impingement and may be more sensitive to actual
the humerus against resistance applied by the examiner. weakness rather than guarding due to impingement.
this finding is often subtle or masked by placed in 20–30° of external rotation. A positive
significant pain. The external rotation lag sign is external rotation lag sign occurs when the patient
an effective alternative that eliminates the effect is unable to hold this externally rotated position
of pain on external rotation function. (estimate the amount of internal rotation that
occurs, corresponding to degrees of lag;
External Rotation Lag Sign Fig. 4.25). Given recent evidence that the supra-
To elicit the external rotation lag sign, the arm is spinatus may contribute up to 20 % of the total
kept at the patient’s side and the elbow is flexed contraction strength detected when this test is
90°. From this position, the humerus is passively performed in normal shoulders [114], this clinical
Fig. 4.24 (a) Clinical photograph demonstrating the drop tor cuff tear and coracoacromial ligament rupture. This
arm sign in which the patient is unable to hold the humerus image highlights the stabilizing effect of the supraspinatus
in an abducted position. Notice that the shoulder also which, in normal individuals, prevents superior humeral
“shrugs” in an attempt to compensate for rotator cuff head migration. Source: Defranco MJ, Walch G. Current
weakness. (b) Clinical photograph demonstrating antero- issues in reverse total shoulder arthroplasty. J Musculoskel
superior escape of the humeral head due to a massive rota- Med 2011;28:85–94.
Table 4.4 Diagnostic efficacies of the Jobe test and the drop arm sign in the detection of supraspinatus tears
Diagnostic efficacy of the Jobe test and drop arm sign
Itoi et al. [109] Empty can FTT Arthroscopy 1.75 0.30 87 43
Kim et al. [110] Empty can FTT/PTT MRI/arthroscopy 2.62 0.34 76 71
Itoi et al. [109] Full can FT Arthroscopy 1.77 0.32 83 53
Kim et al. [110] Full can FTT/PTT MRI/arthroscopy 2.41 0.34 77 32
Bak et al. [111] Drop arm FT Ultrasound 2.41 0.71 41 83
Miller et al. [112] Drop arm FTPST Ultrasound 3.20 0.30 73 77
FTT full-thickness tear, PTT partial-thickness tear, FTPST full-thickness posterosuperior tear (tear propagation to
involve both supraspinatus and infraspinatus tendons), LR likelihood ratio
finding may help identify patients with a postero- subscapularis tear with moderate to good
superior cuff tear (i.e., involving the supraspina- sensitivity and specificity (Table 4.6). According
tus and infraspinatus) since most studies report to a recent retrospective analysis in 52 shoulders
good sensitivity and specificity values (Table 4.5). with subscapularis tears, the overall sensitivity
The test is less useful for isolated supraspinatus was found to be 81 % when at least one of these
tears due to conflicting clinical data [111, 115]. three tests were positive [121].
4.6.2.3 Subscapularis Belly-Press Test

Suspicion of internal rotation weakness involv- The belly-press test is performed by placing both
ing the subscapularis muscle is typically gener- of the patient’s hands on the lower abdomen with
ated during the initial strength survey via resisted flat wrists, the elbows pointed laterally and
internal rotation stress tests at both 0° and 90° of without finger overlap. The patient presses poste-
glenohumeral abduction. In addition, patients riorly with their hands while keeping the elbows
may also exhibit increased external rotation anterior to the plane of the abdomen (Fig. 4.27).
capacity due to the decreased resting tension of A positive test occurs when the affected elbow
the subscapularis muscle (Fig. 4.26). The belly- falls posteriorly due to the recruitment of ancil-
press, lift-off, and bear-hug tests are provocative lary muscles to compensate for the weakened
maneuvers designed to detect the presence of a subscapularis (Fig. 4.28).
Fig. 4.25 External rotation lag sign. (a) With the arm at the amount of subsequent internal rotation indicates the
the side and the elbow flexed to 90°, the examiner pas- degrees of lag. (b) Clinical photographs demonstrating a
sively places the humerus between 20° and 30° of external positive external rotation lag sign in a patient with a mas-
rotation. The examiner then removes their hand and asks sive posterosuperior cuff tear. (Part B from Hertel et al.
the patient to hold this position. Inability to hold this posi- [113]; with permission).
tion indicates a positive external rotation lag sign where
Table 4.5 Diagnostic efficacy of the external rotation lag sign in the detection of posterosuperior cuff tears
Diagnostic efficacy of the external rotation lag sign
Bak et al. [111] ERLS FTT—Supraspinatus Ultrasound 5.00 0.60 77 26
Castoldi et al. [115] ERLS FTT—Supraspinatus Arthroscopy 28.0 0.45 56 98
Castoldi et al. [115] ERLS FTT—Supra & infra Arthroscopy 13.9 0.03 97 93
Miller et al. [112] ERLS FTT—Supra/infra Ultrasound 7.20 0.60 46 94
Castoldi et al. [115] ERLS FTT—Teres minor Arthroscopy 14.3 0.00 100 93
ERLS external rotation lag sign, FTT full-thickness tear, RCT rotator cuff tear, LR likelihood ratio
Fig. 4.26 Clinical photographs demonstrating increased passive external rotation capacity in a patient with a subscapu-
laris tear involving the right shoulder. (a) Anterior view. (b) Sagittal view.
Table 4.6 Diagnostic efficacies of the belly-press, lift-off and bear-hug tests for the detection of subscapularis tears
Diagnostic efficacy of the subscapularis strength tests
Bartsch et al. [116] Belly press Subscap tear Arthroscopy 9.67 0.14 86 91
Yoon et al. [117] Belly press Subscap tear Arthroscopy 28.0 0.73 28 99
Bartsch et al. [116] Lift-off Subscap tendinopathy Arthroscopy 1.90 0.76 40 79
Naredo et al. [118] Lift-off Subscap tendinopathy Ultrasound 7.20 0.67 50 84
Kim et al. [119] Lift-off Subscap tendinopathy Ultrasound 1.30 0.70 69 48
Salaffi et al. [77] Lift-off Subscap tendinopathy Ultrasound 1.45 0.85 35 75
Itoi et al. [109] Lift-off Subscap tear Arthroscopy 1.90 0.4 46 69
Yoon et al. [117] Lift-off Subscap tear Arthroscopy – 0.88 12 100
Bartsch et al. [116] Lift-off Subscap tendinopathy Arthroscopy 1.30 0.64 71 60
Millar et al. [68] Lift-off Subscap tear Ultrasound 6.20 0.00 100 84
Yoon et al. [117] Lift-off Subscap tear Arthroscopy 6.70 0.82 20 97
Barth et al. [120] Bear-hug Subscap tear Arthroscopy 7.50 0.43 60 92
LR likelihood ratio
Fig. 4.27 Belly-press test.

With the hand of the
affected extremity placed
over the abdomen with the
elbow pointed laterally, the
patient attempts to press
posteriorly against the
abdomen. A positive test
occurs when the patient is
unable to hold the elbows
within the plane of the
body during the applica-
tion of the posteriorly
directed force. In this
image, the test is per-
formed comparing both
arms to detect subtle
weakness.
Fig. 4.28 Clinical photographs demonstrating a positive patient is attempting to pull his right hand towards the
belly-press test in a patient with a subscapularis tear abdomen. Notice that the elbow falls posteriorly in both
involving the right shoulder. In both images (a and b), the images when compared to the patient in Fig. 4.27.
Lift-Off Test spine) indicates subscapularis weakness

The lift-off test [56] is also designed to demon- (Fig. 4.30). The term “internal rotation lag
strate weakness of the subscapularis muscle. sign” has been used on occasion to describe this
The test is begun by having the patient place test in accordance with the original terminol-
the dorsal aspect of the hand on the lumbar ogy coined by its developer [113]; however, in
spine. The examiner then passively lifts the contrast to the external rotation lag sign
hand away from the lumbar spine and asks the (described above for the evaluation of infraspi-
patient to hold this position (Fig. 4.29). Inability natus integrity), it is not often feasible to pre-
to hold the position (the hand falls back to the cisely measure the amount of external rotation
suggest less involvement whereas a stronger

applied force would suggest greater involve-
ment. Although the modified lift-off test is a
clinically useful examination technique, we
caution the reader that a few select patients who
have subscapularis tears may actually be capa-
ble of achieving a “negative” test result since
the latissimus dorsi is also highly active during
this maneuver [123]. In other words, the
strength of the latissimus dorsi (which primar-
ily functions to extend and internally rotate the
humerus) may overpower that of a torn sub-
scapularis, possibly allowing some patients to
demonstrate adequate strength with this test.
Bear-Hug Test
The bear-hug test is thought to cause near maxi-
mal activation of the subscapularis muscle; how-
ever, it has not been extensively studied with
regard to sensitivity or specificity. We have found
this test to be useful on some occasions when
other subscapularis tests are inconclusive. In the
most common version of the test, the patient first
Fig. 4.29 The lift-off test. In this test, the dorsum of the places the palm of the ipsilateral hand over the
patient’s hand is placed over the lumbar spine. The exam- contralateral AC joint. With the tip of the elbow
iner lifts the hand away from the spine and asks the patient
pointed directly forward, the patient is then
to hold this position. A positive test occurs when the arm
falls back towards the spine. instructed to push down onto the top of the shoul-
der without allowing the elbow to fall inferiorly
(Fig. 4.31). A positive test occurs when the
patient is unable to maintain the elbow in a hori-
lag (defined as the number of degrees of invol- zontal plane [120, 124]. Alternatively, the exam-
untary external rotation that occurs following iner may also attempt to pull the arm away from
release of the patient’s hand) using this test the shoulder while simultaneously applying an
given the awkward patient-clinician position- external rotation force—a positive test occurs
ing that is required. Using the same testing when the patient is unable to keep their hand on
position, a positive modified lift-off test refers top of the shoulder. To obtain the most reliable
to a patient’s inability to actively lift the hand results, it is important to confirm that the patient’s
away from the lumbar spine against resistance fingers are extended (i.e., not wrapped over the
(without extending the elbow via the triceps top of the shoulder) to prevent them from gener-
muscle). Based on our interpretation of the ating increased resistance by grabbing the shoul-
results presented by Hertel et al. [113], it may der [120]. Using this method, Barth et al. [120]
be possible for an experienced examiner to esti- calculated a sensitivity of 60 % and a sensitivity
mate the extent of subscapularis involvement of 91.7 % in a series of 68 patients who under-
by judging the amount of applied force neces- went subsequent diagnostic arthroscopy to con-
sary to cause the humerus to externally rotate. firm (or reject) the presence (or absence) of a
Theoretically, a smaller applied force would subscapularis tear.
Fig. 4.30 Two sequential

clinical photographs
demonstrating a positive
lift-off test. (a) The
patient’s hand is placed
posterior to the lumbar
spine and the examiner
asks the patient to hold this
position. The examiner
may also stabilize the
elbow when a massive tear
is suspected. (b) After the
examiner removed their
hand, the patient’s hand
fell back towards the spine
as the shoulder spontane-
ously externally rotated
due to the unopposed
resting tension of the
infraspinatus. This patient
had a massive subscapu-
laris tear as evidenced by
subsequent imaging
studies. (From Costouros
et al. [122]).
Several studies report that the upper and lower 0°, 45°, or 90° of shoulder flexion. Therefore,
portions of the subscapularis are differentially tests for subscapularis strength should currently
activated with the belly-press and lift-off tests, be viewed as an evaluation of the entire
potentially providing ancillary diagnostic utility muscle-tendon unit rather than individual regions
for these tests [75, 124–127]. Although Pennock of the muscle.
et al. [128] showed that the subscapularis muscle
was electromyographically activated dispropor- 4.6.2.4 Teres Minor
tionately more than any other rotator cuff muscle Hornblower’s Sign
during the belly-press and lift-off tests, their Weakness of the teres minor muscle is rarely
results indicated that the upper and lower por- isolated and is usually caused by inferior
tions of the subscapularis were not activated at extension of a posterosuperior rotator cuff tear.
different magnitudes depending on the clinical Hornblower’s sign (or “drop sign” [113]) is
test. Chao et al. [124] arrived at similar results another type of lag sign which is primarily used
regardless of whether the test was performed at to detect posterosuperior tears with inferior
4.7 Summary 103
of these patients will have demonstrated concom-

itant posterosuperior cuff weakness during both
the initial strength survey (see Chap. 3 for details
regarding strength testing) and subsequent pro-
vocative testing. In these cases, the hornblower’s
sign is performed as described above except that
the examiner must help the patient maintain an
abduction angle of approximately 90° by provid-
ing support beneath the elbow. This additional
support is required to optimize the strength and
direction of teres minor contraction in patients
who would not otherwise be capable of maintain-
ing this level humeral abduction.
Walch et al. [129] found that the sensitivity
and specificity of hornblower’s sign in its ability
to detect teres minor tears were 100 % and 93 %,
respectively. In addition, Castoldi et al. [115]
found that the external rotation lag sign (described
above for infraspinatus tears) was also highly
sensitive and specific for the detection of teres
minor tears (see Table 4.5). However, this finding
should be expected since patients with massive
posterior cuff tears are likely to demonstrate
Fig. 4.31 Bear-hug test. In this test, the hand of the
patient’s affected extremity is placed over the contralat- weakness of both the infraspinatus and teres
eral shoulder with the fingers extended. The patient is minor muscles.
instructed to use their hand to push downward onto their
contralateral shoulder. A positive test occurs when the
elbow of the affected extremity falls inferiorly below the
horizontal plane as they attempt to apply a downward 4.7 Summary
pressure onto the contralateral shoulder.
Knowledge of the pathogenesis of rotator cuff
disease is critical to the interpretation of various
extension. In this test, the humerus is passively physical examination maneuvers that test rotator
abducted to 90° in the scapular plane and cuff function. This information can be used to
maximally externally rotated with the elbow generate solid differential diagnoses based on the
flexed 90°. The patient is then instructed to hold details obtained from the history and initial sur-
this position of maximal external rotation. A pos- vey which guides the use of appropriate tests.
itive test occurs when the humerus involuntarily Although having knowledge of each provocative
falls back to internal rotation due to teres minor test is useful for the clinician, performing every
weakness, thus assuming a position of “horn test on every patient is not fruitful since sensitiv-
blowing” (Fig. 4.32). ity and specificity data for each maneuver are
As mentioned, the vast majority of patients widely variable. Therefore, the purpose of pro-
with tears involving the teres minor tendon had vocative testing is to rule in or out specific diag-
pre-existing full-thickness posterosuperior tears noses within the focused differential that was
that propagated inferiorly as a result of acute obtained from the history and general survey
trauma (e.g., an acute-on-chronic injury) or rather than completing the full gamut of provoca-
chronic tendon degeneration. As a result, many tive maneuvers on every patient.
Fig. 4.32 Hornblower’s

sign. (a) The examiner
passively elevates the
humerus to 90° of
abduction with the
humerus externally rotated
and the elbow flexed to
90°. The patient is asked to
hold this position as the
examiner releases their
hand. A positive test
occurs when the humerus
internally rotates after the
examiner releases their
hand. (b) Clinical
photograph demonstrating
a positive hornblower’s
sign. Note that the humerus
internally rotates as the
arm assumes a position of
“hornblowing” in this
patient with a massive
posterosuperior cuff tear.
(From Costouros et al.
[122]).
4. Burkhart SS. Arthroscopic treatment of massive

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Disorders of the Long Head
of the Biceps Tendon 5
bicipital groove which lies between the greater and

5.1 Introduction lesser tuberosities of the proximal humerus.
Travelling distally, the muscle bellies of each head
Although its precise function remains relatively coalesce, cross the cubital fossa and spiral towards
unknown, the long head of the biceps (LHB) ten- their primary insertion on the bicipital tuberosity
don is likely a significant pain generator in a vari- on the proximal radius (Fig. 5.2). This chapter will
ety of shoulder conditions. Therefore, pathology focus on the intra-articular portion of the LHB ten-
related to the LHB tendon should be assessed in don since it is often implicated in the development
any patient with a condition related to the gleno- of acute and chronic shoulder pain.
humeral joint. Unfortunately, physical examina- The supraglenoid tubercle of the scapula has
tion is often difficult due to confounding results historically been described as the origin of the
and the lack of definitive research. However, an LHB tendon. However, several cadaveric studies
in-depth knowledge of relevant anatomy, biome- have found that the superior labrum contributes
chanics, and pathoanatomy can typically over- significantly to the LHB origin [1–5]. In a series
come these confounders and is instrumental in of 105 cadaveric shoulders, Vangsness Jr et al.
making any diagnosis or formulating a treatment [5] found that 40–60 % of the LHB tendon origi-
plan related to the LHB tendon. nated from the supraglenoid tubercle while the
remaining fibers originated from the superior
labrum (Fig. 5.3). Tuoheti et al. [4] dissected 101
5.2 Anatomy and Biomechanics cadaveric shoulders and found that the LHB ten-
don originated from both the supraglenoid tuber-
5.2.1 Anatomy cle and the glenoid in every case. In addition,
Gigis et al. [2] noted that the LHB not only arises
The biceps brachii, innervated by the musculocu- from both the supraglenoid tubercle and the
taneous nerve, has two heads that originate from labrum, but it also forms a portion of the postero-
different points on the scapula. The short head superior labrum itself. An anatomic study of 16
arises from the coracoid process as a single tendon cadaveric shoulders by Arai et al. [1] found that
combined with the coracobrachialis muscle (the the fibers of the labrum became stiffer and stron-
conjoined tendon) and the long head arises from ger as the LHB tendon origin was approached.
within the glenohumeral joint from both the supra- These studies support other claims that the tor-
glenoid tubercle and the adjacent glenoid labrum sional strain placed upon the superior labrum by
(Fig. 5.1). The tendon travels anterolaterally in the the LHB tendon in positions of hyperabduction
rotator interval and exits the joint through the and external rotation is at least one factor
110 5 Disorders of the Long Head of the Biceps Tendon
Fig. 5.1 Illustration depicting the basic anatomy of the

long and short heads of the proximal biceps muscle. Fig. 5.3 Cadaveric photograph showing the insertion of
the proximal biceps tendon on both the superior glenoid
labrum and the supraglenoid tubercle.
ing studies, is the significant anatomic variability

of the biceps anchor-superior labrum complex.
According to Rao et al. [7], there are three
predominant variations in superior labral anat-
omy that may be present in up to 10 % of the
general population: the sublabral recess, the sub-
labral foramen, and the Buford complex
(Figs. 5.4 and 5.5). The sublabral recess repre-
sents a potential space beneath the biceps anchor
and the anterosuperior aspect of the glenoid
labrum. The sublabral foramen is a small orifice
located between the anterosuperior labrum and
the articular cartilage of the anterior glenoid. The
Buford complex is characterized by an absence
of the anterosuperior labrum with a cord-like
middle glenohumeral ligament that attaches
directly to the superior labrum. It is crucial for
the clinician to identify these findings as normal
anatomic variants rather than pathologic lesions
since inappropriate “repair” may lead to signifi-
Fig. 5.2 Illustration demonstrating the rotation of the dis- cant pain and external rotation loss as a result of
tal biceps tendon just before its insertion on the bicipital stiffness [8, 9].
tuberosity. As the LHB tendon travels obliquely through
the joint in an anterolateral direction, the tendon
involved in the development of superior labral is encased in an outward-facing synovial mem-
anterior to posterior (SLAP) tears in throwing brane that is continuous with the joint capsule
athletes (discussed later in this chapter) [6]. and renders the tendon extra-synovial [10]. As
One of the difficulties inherent to the diagno- the tendon travels distally towards the bicipital
sis of SLAP tears, especially with regard to imag- groove of the proximal humerus, its position is

depicting the normal
anatomy of the glenohu-
meral capsuloligamentous
structures. Supraspinatus
LHB tendon
Labrum
SGHL
MGHL
Teres minor

BT
BT BT
SGHL SGHL
HH G
G G
MGHL MGHL
IGHLC IGHLC
Sublabral recess Sublabral foramen Buford complex
Fig. 5.5 Illustrations showing the most common glenolabral anatomic variations. The sublabral recess, sublabral fora-
men, and Buford complex are shown.
maintained by the capsuloligamentous restraints bicipital groove and contributes to the bicipital
within the rotator interval. The rotator interval is sheath (discussed below). The contents of the
a triangular area in the anterosuperior aspect of interval include the LHB tendon, the superior
the glenohumeral joint (Fig. 5.6). The medial glenohumeral ligament (SGHL), the coracohu-
base of the triangle is located at the coracoid pro- meral ligament (CHL), and the glenohumeral
cess. The anterior margin of the supraspinatus joint capsule [11]. A more detailed description of
and the superior margin of the subscapularis the structure, function, and pathologies associ-
make up the superior and inferior borders of the ated with the rotator interval can be found in
rotator interval triangle, respectively. The lateral Chap. 6.
apex of the rotator interval is composed of the As the LHB tendon courses towards the bicip-
transverse humeral ligament which covers the ital groove, the SGHL and the CHL form a sling

highlighting the compo-
nents of the rotator interval.
around the LHB tendon, primarily preventing its The bicipital sheath is another complex structure
medial subluxation. This sling extends to the through which the LHB tendon traverses as it
most anterior portion of the rotator cable and the passes through the bicipital groove (see Fig. 5.7).
biceps reflection pulley (BRP) at the proximal The floor of this sheath is formed from the coales-
end of the bicipital groove [12]. The BRP, derived cence of the SGHL and the subscapularis tendons
from the coalition of the SGHL, CHL, and the at the superior aspect of the lesser tuberosity.
upper 1/3 of the subscapularis tendon, redirects These fibers then travel laterally, forming the
the anterolateral course of the LHB tendon such floor of the bicipital sheath. The roof of the sheath
that the tendon travels directly inferiorly along is mostly composed of fibers from both the supra-
the anterior humeral shaft (Fig. 5.7). Habermeyer spinatus and CHL ligaments. All of these fibers
et al. [14] described a 30–40° inferior turn of the (the floor and the roof of the sheath) combine to
LHB tendon as it exited the joint via the form a continuous ring around the LHB tendon as
BRP. Tearing of the subscapularis in this region, it passes through the bicipital groove thus provid-
often known as a “pulley lesion,” can allow ing tendon stability (Fig. 5.9). A recent biome-
medial subluxation of the LHB tendon producing chanical study by Kwon et al. [17] found that the
a painful “popping” or “snapping” sensation as subscapularis tendon was the most important sta-
the arm is moved (Fig. 5.8). In addition, a biome- bilizer of the LHB tendon within the bicipital
chanical study by Braun et al. [16] found that the groove since tears of the subscapularis in this
LHB tendon slides up to 18 mm in and out of the area almost always resulted in medial sublux-
joint with forward flexion and internal rotation, ation of the LHB tendon.
respectively. Therefore, the LHB tendon itself is The bony structure of the bicipital groove can
subjected to significant mechanical stresses in the also play a role in pathologies of the LHB tendon.
area of the BRP which can lead to tendonitis, In a radiographic study by Pfahler et al. [18], the
tearing or rupture of the LHB. opening angle of the groove in patients without
a
Supraspinatus CHL
Biceps
Biceps
reflection
pulley
Subscapularis
Fig. 5.7 (a) Illustration showing the structure of the (b) Arthroscopic image showing anteromedial (AM) and
bicipital sheath and biceps reflection pulley as the posterolateral (PL) BRPs. (From Elser et al. [13]; with
LHB tendon travels away from the glenohumeral joint. permission).
Fig. 5.8 Classification of pulley lesions as proposed by Bennett [15]. Note that medial subluxation of the LHB tendon
is much more common than lateral subluxation.
LHB tendon pathology was between 101° and studies demonstrate that sympathetic innervation
120° with the medial wall having a greater height of the proximal LHB tendon may play a role in
than the lateral wall. Patients with a shallow the pathogenesis of shoulder pain.
groove or a lower medial wall may also be sus-
ceptible to subluxation of the LHB tendon.
The vascular supply to the LHB tendon near 5.2.2 Biomechanics
the biceps-labral complex is variably derived
from the suprascapular, circumflex scapular and Although the anatomy of the proximal LHB ten-
posterior circumflex humeral arteries [10]. don has been well described, its precise function
Vascularity of the tendon is richest near its origin has been debated for many years. Most studies
and dissipates prior to entering the bicipital that have aimed to describe its function are based
groove where the tendon is avascular and fibro- on cadaveric models that focus on glenohumeral
cartilaginous. This infrastructure helps prevent stability.
tendon injury from the sliding action of the LHB Pagnani et al. [21] used ten cadaveric shoul-
within the sheath of the groove. Similarly, inner- ders to show that decreased anterior, superior, and
vation of the LHB tendon is concentrated near its inferior humeral head translation occurred when a
anchor and dissipates as the tendon travels dis- simulated load of 55 N was applied to the LHB
tally [19]. This arrangement was described as a tendon in lower angles of elevation. Rodosky
“net-like” pattern of sympathetic fibers by et al. [22] used a dynamic cadaveric shoulder
Alpantaki et al. [19] in a cadaveric study using model to simulate the forces typically applied to
neurofilament antibodies (Fig. 5.10). In addition, both the rotator cuff and the LHB tendons. They
Tosounidis et al. [20] demonstrated the presence found that the LHB tendon contributed to gleno-
of sympathetic α1-adrenergic receptors along the humeral stability by resisting torsional forces in
LHB tendon in cadaveric specimens with known the abducted and externally rotated position. The
acute and chronic shoulder conditions. These authors also noted a significantly increased strain
applied to the anterior band of the inferior gleno-
humeral ligament (IGHL) when the biceps-labral
complex was detached from its anchor at the
superior aspect of the glenoid. This study pro-
vides some evidence that SLAP tears may con-
tribute to increased anterior humeral head
translation that is often found during physical
examination (see Chap. 6 for more details
regarding glenohumeral laxity and instability).
More recently, Youm et al. [23] showed that the
LHB tendon contributed significantly to anterior,
Fig. 5.9 Illustration highlighting the structures involved posterior, superior, and inferior translation of the
with a normal bicipital sheath [101]. humeral head when a 22 N load was applied.
Fig. 5.10 Photomicrograph

showing the attachment of
neurofilament antibodies to
the proximal LHB tendon in
a “net-like” pattern (from
Alpantaki et al. [19]; with
permission).
Rotational range of motion and scapulohumeral don dynamically stabilized the humeral head,
kinematics were also affected when a load was regardless of elbow activity. Other studies on
applied to the LHB tendon. Alexander et al. [102] pitching biomechanics found that the biceps may
also noted a decrease in humeral head translation primarily function as a stabilizer of the elbow
in all directions when a 20 N load was applied to during flexion and supination with little effect on
the LHB tendon. Su et al. [24] studied the effects shoulder stability [29, 30]. Thus, the effect of the
of the LHB tendon in cadaveric shoulders with LHB tendon on glenohumeral kinematics remains
variably sized rotator cuff tears. In their study, a controversial with respect to the most current
significant decrease in anterosuperior and supe- EMG literature.
rior humeral head translation occurred when a Both cadaveric and EMG studies have pro-
55 N load was applied to the LHB tendon. duced an incomplete picture of how the LHB ten-
Itoi et al. [25] contested that both the LHB and don actually functions with regard to
the short head of the biceps contribute signifi- glenohumeral kinematics. Therefore, in vivo
cantly to glenohumeral joint stability, particu- studies have also been conducted to help solve
larly in positions of abduction and external the mystery. Warner and MacMahon [31] studied
rotation when a simulated load of 1.5 and 3.0 kg a group of seven patients with rupture of the
were applied. This contribution to stability was proximal LHB tendon and compared humeral
particularly robust after attenuation of anterior head translation to their unaffected shoulders by
stabilizing structures had occurred. In another true anteroposterior radiographs. In their study,
biomechanical study, Kumar et al. [26] showed radiographs were obtained in 0°, 45°, 90°, and
that loading of the short head of the biceps alone 120° of abduction in the scapular plane. They
caused superior migration of the humeral head found that superior migration of the humeral
whereas tensioning of both the short head and the head was significantly increased in the shoulders
LHB simultaneously did not result in humeral with a ruptured LHB tendon compared to their
head translation in any direction. contralateral, unaffected shoulders at all angles
Although these studies suggest the role of the of abduction. Another radiographic study by
LHB tendon may be associated with glenohumeral Kido et al. [32] found similar results, noting that
stability, interpretation of dynamic shoulder mod- the humeral head was depressed as the LHB ten-
els is difficult since replication of the in vivo envi- don was stimulated. However, the accuracy of
ronment, including complex force couples and radiographic studies has been called into ques-
resting tension, is quite difficult to achieve. In addition. Therefore, three-dimensional biplane fluo-
tion, the variability of simulated loads (11–55 N) roscopy, a modality which has sub-millimeter
makes their results difficult to compare, especially accuracy, has been used to study in vivo kinemat-
when the precise physiologic loads applied to the ics with improved accuracy during full muscle
LHB tendon in different angles of abduction and activation. A study by Giphart et al. [33] found
rotation are currently unknown. Thus, it is possible that, in five patients who underwent unilateral
that some studies may have obtained statistically open subpectoral biceps tenodesis, humeral head
significant results due to the application of non- translations of approximately 3 mm occurred in
physiologically high loads, making the results of both the affected and unaffected shoulders during
these studies difficult to interpret. active elevation. The authors also studied various
To help answer these questions, electromyo- loading conditions such as forward flexion with
graphic (EMG) studies have been performed to maximal biceps activity on EMG, abduction to
evaluate the effect of the LHB tendon on gleno- assess superior translation and a simulated throw
humeral kinematics. However, their findings (hyperabduction and external rotation) to evalu-
have been inconsistent to date. Levy et al. [27] ate anterior translation. Despite these loading
found that the LHB tendon aided in glenohu- conditions, the differences in translation between
meral stability both passively and in association tenodesed and normal shoulders was always
with forearm supination or flexion. In contrast, less than 1.0 mm, suggesting that the proximal
Sakurai et al. [28] determined that the LHB ten- LHB tendon may actually play a minimal role in
Fig. 5.11 Depiction of humeral head translation with (a) foward flexion, (b) abduction and (c) a simulated throwing
motion. For each testing condition, biceps tenodesis resulted in minimal differences in humeral head translation when
compared to the contralateral shoulder with various loading conditions.
glenohumeral kinematics in a shoulder that oth- 5.3.1 Pathogenesis

erwise has an intact rotator cuff (Fig. 5.11).
The inconsistent and often contradictory find- Inflammation of the LHB tendon most often occurs
ings of cadaveric, EMG, and in vivo studies have secondarily as a result of surrounding pathologies
made it difficult to define the precise function of such as impingement syndrome, pulley lesions,
the proximal LHB tendon. While most of these and/or degenerative rotator cuff tears (Fig. 5.12).
studies have found that the LHB tendon may be Primary LHB tendonitis, in which there is isolated
involved with glenohumeral stability, further inflammation with no apparent cause, is not uncom-
in vivo kinematic studies are necessary to common in clinical practice. Although isolated inflam-
pletely elucidate the biomechanical role of the mation of the proximal LHB tendon can occur in
LHB tendon in shoulder motion and stability. overhead athletes, this may be the result of repeti-
tive microtrauma as the tendon glides back and
forth in a “sawing” motion within the bicipital
5.3 LHB Tendonitis, Tearing groove and across the BRP. It is important to
and Rupture remember that because the LHB tendon is encased
with synovium, inflammation within the shoulder
LHB tendonitis can occur as a result of impinge- may track proximally into the biceps-labral com-
ment under the coracoacromial arch, subluxation plex or distally into the bicipital groove.
out of the bicipital groove, or attrition as a result Subacromial impingement is the most com-
of degeneration [34]. Due to the many concurrent mon mechanism by which LHB tendonitis
pathologies that are typically present in patients occurs, especially in older patients. Subcoracoid
with LHB tendonitis, physical diagnosis is often impingement can also lead to injury involving the
difficult. However, a precise knowledge of the LHB tendon and the BRP [35]. Weak rotator cuff
pathogenesis of LHB tendonitis will help the cli- and periscapular musculature potentially allow
nician synthesize a complete and accurate differ- increased translation of the humeral head, nar-
ential diagnosis with an understanding that rowing the space available for the subacromial or
overlapping conditions are often present. subcoracoid contents to pass thus allowing
5.3 LHB Tendonitis, Tearing and Rupture 117
Fig. 5.12 Arthroscopic images demonstrating (a) a healthy LHB tendon and (b) an inflamed LHB tendon.
impingement of these structures between the 5.3.2 Physical Examination

greater tuberosity and the undersurface of the
acromion or between the lesser tuberosity and the Evaluation of patients with bicipital tendonitis
coracoid (further details on subacromial impinge- is often difficult due to vague symptoms and
ment and subcoracoid impingement are provided inconsistent physical examination findings. It is
in Chap. 4). In patients with subacromial therefore critically important to obtain a
impingement, LHB tendonitis almost always detailed history to help guide the use of appro-
occurs simultaneously since the LHB is subject priate provocative testing. Some patients may
to the same mechanical wear from the coracoac- describe a “popping” or “snapping” sensation,
romial arch. In addition, because the LHB tendon especially when internally and externally rotat-
is encased in an outward-facing synovial mem- ing the humerus in 90° of abduction. Although
brane extending from the glenohumeral joint, any the most common finding in patients with
inflammatory process within the joint can thus bicipital tendonitis is bicipital groove tender-
involve the LHB tendon, producing painful ness, this type of pain is difficult to differenti-
inflammation and tenosynovitis (Fig. 5.12). ate from pain related to the anterosuperior cuff
The acute stage of LHB tendonitis is charac- which inserts in the area of the bicipital sheath.
terized by significant anterior shoulder pain Patients who describe a history of anterior
localized within the bicipital groove. The LHB shoulder pain that suddenly resolved after a
tendon will swell and sometimes develop partial- specific incident likely had spontaneous rupture
thickness tearing at points of maximal wear. of their LHB tendon.
Later, the tendon further degenerates and may Both upper extremities of every patient should
form adhesions with surrounding structures such be inspected for any evidence of asymmetry.
as the bicipital sheath and rotator interval struc- Spontaneous rupture of the proximal LHB ten-
tures. In this stage, microscopic examination don can result in the classic “Popeye” deformity
reveals fibrinoid necrosis and atrophy of collagen in which the muscle belly is distally retracted,
fibers [36]. As the tendon degenerates, it can appearing as distinct bulge in the distal aspect of
either become hypertrophic or atrophic with a the humerus just above the elbow (Fig. 5.13).
deterioration of its organization and infrastruc- Strength and range of motion should also be
ture. If, or when, rupture occurs, symptoms will recorded for each extremity, particularly noting
often resolve immediately with the formation of a any discrepancies. Range of motion loss in
“Popeye” deformity (discussed later). On the patients with bicipital groove tenderness is most
contrary, attritional tendon degeneration may often associated with concomitant rotator cuff
occur asymptomatically and painless rupture disease (see Chap. 4 for information regarding
may occur. physical examination of the rotator cuff). Because
Fig. 5.13 Clinical photograph of Popeye deformity in results in distal retraction of the muscle belly whereas
(a) proximal LHB tendon rupture and (b) distal biceps distal biceps tendon rupture results in proximal retrac-
tendon rupture. Note that proximal LHB tendon rupture tion of the muscle belly.
some biomechanical data suggests that the LHB

tendon functions to promote glenohumeral stabil-
ity, it may also important to perform stability
testing in these patients (see Chap. 6). The most
important provocative tests traditionally used for
the detection of bicipital tendonitis and tearing
are presented below.
5.3.2.1 Palpation
There are several physical examination tests that
involve palpation of the LHB tendon on the ante-
rior aspect of the shoulder to detect peri-tendonitis
or tearing. However, rather than delving into each
individual palpation technique, it is most impor-
tant to realize that the bicipital groove faces
directly anteriorly when the humerus is slightly
internally rotated and tenderness with palpation
Fig. 5.14 Bicipital groove palpation. The LHB tendon is
of the groove will typically move laterally as the most easily palpated when the humerus is slightly inter-
humerus is externally rotated (Fig. 5.14). nally rotated. The examiner can also simultaneously inter-
Although testing for bicipital tenderness is non- nally and externally rotate the humerus to detect any
specific and examiner dependent, when present, evidence of subluxation.
it is sometimes helpful to rule out other patholo-
gies within the differential diagnosis. A recent groove tenderness to detect partial-thickness
study by Chen et al. [37] found that bicipital ten- tears of the LHB tendon; the authors calculated a
derness was 57 % sensitive and 74 % specific for sensitivity of only 53 % and a specificity of only
the presence of biceps tendonitis after confirma- 54 % using this diagnostic test. Thus, palpation
tion with ultrasonographic evaluation. Gill et al. of the bicipital groove should only be used to
[38] reported the diagnostic accuracy of bicipital document the presence or absence of bicipital
5.3 LHB Tendonitis, Tearing and Rupture 119
specificity for the Yergason test is higher than its

sensitivity thus requiring further information in
order to make the correct diagnosis (see Table 5.1).
5.3.2.4 Lift-Off Test

Testing for rotator cuff function, especially that
of the subscapularis, can also provide clues
regarding the status of the proximal LHB tendon
as it passes through the bicipital groove. Tearing
of the subscapularis may also involve tearing of
the bicipital sheath and the LHB tendon itself.
Gill et al. [38] noted that the lift-off test, which
tests the strength of the subscapularis, had a sen-
sitivity of 28 % and a specificity of 89 % for the
detection of partial-thickness tears of the LHB
tendon. The bear-hug test can also be used to
detect biceps tendinopathy with a reported sensi-
Fig. 5.15 Speed test. The patient is asked to forward flex tivity of 79 % and a specificity of 60 % [40]. See
the humerus to approximately 90° of elevation with the Chap. 4 for details regarding physical examina-
elbow extended and the forearm supinated (palm upward). tion for the detection of subscapularis pathology.
The examiner then applies a downward pressure to the
distal arm as the patient provides resistance.
5.3.2.5 Biceps Entrapment Sign
The hourglass biceps, first described by Boileau
groove tenderness since the test is not sensitive or et al. [54] in 2004, occurs when the LHB tendon in
specific for the detection of partial-thickness the proximity of the bicipital sheath becomes
tears. inflamed and swells to a diameter that exceed that
of the bicipital groove, thus preventing the LHB
5.3.2.2 Speed Test tendon from gliding within the sheath as shoulder
In the Speed test, the affected arm is placed in a motion is initiated (Fig. 5.17). Arthroscopically,
position of 90° forward flexion with the elbow the defect resembles an hourglass-shape that
extended and the palm supinated. From this posi- becomes entrapped proximal to the bicipital sheath
tion, the examiner applies a downward force to which typically limits forward flexion capacity.
the forearm while the patient resists (Fig. 5.15). Boileau et al. [54] originally reported this
Pain localized to the area of the bicipital groove entity in a series of 21 patients with a “hypertro-
is a positive test and may indicate the presence of phic intra-articular portion of the LHB tendon,”
bicipital tendonitis or partial tearing. The speci- all of which were associated with rotator cuff
ficity for this test is much higher than its sensitiv- tearing. The authors noted that a 10–20° loss of
ity, thus requiring a combination of historical and passive forward flexion in the presence of bicipi-
other physical findings to make the correct diag- tal groove tenderness were the most common
nosis (Table 5.1). physical findings in this group of patients. Others
have suggested that both active and passive
5.3.2.3 Yergason Test motion should be restricted where an attempt to
In the Yergason test, the affected arm is placed at the increase the forward flexion angle results in
side with the elbow flexed 90°. In patients with increased shoulder pain [55]. Because this exam-
bicipital tendonitis or partial tearing, resisted supina- ination finding has not been formally validated,
tion of the forearm should produce pain over the imaging studies such as those including ultrasonic
anterior aspect of the shoulder localized to the bicipi- evaluation [56], remain important for identifica-
tal groove (Fig. 5.16). Similar to the Speed test, the tion of these lesions in the clinical setting.
Table 5.1 Reported diagnostic efficacies of clinical tests used for the detection of LHB tendonitis
Maneuver Author(s) Year Pathology Diagnostic standard Sensitivity (%) Specificity (%) LR+ LR−
Palpation Chen et al. [37] 2011 Tendonitis Ultrasound 57 74 2.2 0.58
Gill et al. [38] 2007 Partial tear Arthroscopy 53 54 1.15 0.87
Lift-off test Gill et al. [38] 2007 Partial tear Arthroscopy 28 89 2.5 0.81
Jia et al. [39] 2009 Tendonitis Arthroscopy 28 89 2.5 0.81
Speed test Gill et al. [38] 2007 Partial tear Arthroscopy 50 67 1.51 0.75
Kibler et al. [40] 2009 Tendonitis Arthroscopy 54 81 2.77 0.58
Jia et al. [39] 2009 Tendonitis Arthroscopy 50 67 1.52 0.75
Goyal et al. [41] 2010 Tendonitis Ultrasound 71 85 4.6 0.34
Salaffi et al. [42] 2010 Tendonitis Ultrasound 49 76 2.1 0.66
Chen et al. [37] 2011 Tendonitis Ultrasound 63 60 1.55 0.63
Yergason Oh et al. [43] 2007 Tendonitis Ultrasound 75 81 4.03 0.31
test Kibler et al. [40] 2009 Tendonitis Arthroscopy 41 79 1.94 0.74
Chen et al. [37] 2011 Tendonitis Ultrasound 32 78 1.47 0.87
LR likelihood ratio
Fig. 5.16 Yergason test.

With the arm at the side
and the elbow flexed to
90°, the patient attempts to
supinate the forearm
against resistance provided
by the examiner.
(1) subluxation out of the groove, (2) disloca-

5.4 LHB Tendon Instability tion out of the groove, and (3) intra-articular
dislocation. In general, most episodes of insta-
Instability of the LHB tendon is most often bility occur with the LHB translating medially
associated with tearing of the subscapularis over the lesser tuberosity. Lateral instability of
tendon, coracohumeral ligament, and the SGHL, the LHB tendon is rare.
all of which are components of the BRP
(Fig. 5.18) [15, 57, 58]. Although several
authors have proposed different classification 5.4.1 Pathogenesis
systems to describe LHB instability [14, 57,
59], most clinicians still categorize this pathol- The pathogenesis of pulley lesions that lead to
ogy into one of two types primarily based on the medial subluxation or dislocation of the LHB
system developed by Walch et al. [59] in 1998: tendon has not been completely elucidated.
5.4 LHB Tendon Instability 121
Fig. 5.18 Illustration showing medial biceps subluxation

as a result of tearing of the subscapularis tendon and the
SGHL. Tearing of the coracohumeral ligament can also be
seen. Source: Stadnick ME. Pathology of the long head of
the biceps tendon. Radsource Web Clinics. February
2014. http://radsource.us/pathology-of-the-long-head-of-
the-biceps-tendon/.
groove indicates a high probability of concomi-

Fig. 5.17 Illustration depicting an hourglass biceps
tant full- or partial-thickness tearing of the upper
which cannot slide efficiently into and out of the bicipital
sheath with arm elevation. 1/3 of the subscapularis tendon and/or the ante-
rior aspect of the supraspinatus tendon [59, 61].
Therefore, full examination of the anterosuperior
Some have suggested that asymmetric loading rotator cuff is necessary in cases where instability
of the LHB in positions of abduction and of the LHB is suspected (see Chap. 4).
external rotation may be responsible for
lesions of the BRP. However, in a biplane flu- 5.4.2.1 Arm Wrestle Test
oroscopic study in cadavers performed by Recently, we have begun using an arm wrestle test
Braun et al. [16], the investigators demon- to detect medial or lateral subluxation of the LHB
strated high shear-force vectors across the tendon. In this test, the clinician first grasps the
BRP in both the neutral and in internal rota- patient’s hand in a standard “arm wrestle grip.”
tion positions with or without forward flexion. With the elbow flexed approximately 90° and the
Currently, there is insufficient data to suggest shoulder in neutral rotation, the patient is asked to
a specific pathomechanism responsible for the flex the elbow and supinate the forearm against
development of pulley lesions. resistance with perturbations (Fig. 5.19). A positive
test occurs when pain or other mechanical symp-
toms are reproduced as the LHB tendon subluxates
5.4.2 Physical Examination out of the bicipital groove. Although we are unaware
of any other previous studies that utilize this test, we
While there are some physical examination have anecdotally found it quite useful for the detec-
maneuvers that can be used to evaluate instability tion of medial or lateral biceps subluxation.
of the LHB tendon [25, 60, 61], none of these
methods have been formally validated. Typically,
the clinician will palpate the bicipital groove 5.5 SLAP Tears
while simultaneously internally and externally
rotating the humerus (see Fig. 5.14). Painful In 1985, Andrews et al. [62] were the first investi-
“clicking” or “popping” occurs as the LHB ten- gators to describe lesions to the proximal biceps
don translates over the lesser tuberosity. Complete tendon with involvement of the superior aspect of
dislocation of the LHB tendon out of the bicipital the glenoid labrum. Later, Snyder et al. [63] coined
Fig. 5.19 Arm wrestle

test. With the elbow flexed
to 90° in neutral rotation,
the examiner grasps the
hand of the patient in an
“arm wrestle grip.” The
patient then attempts to
flex and supinate the
forearm against resistance
(perturbations) provided by
the examiner.
the term “SLAP” tear due to the anterior to poste-

rior direction of labral tearing (Superior Labral
Anterior to Posterior; Fig. 5.20). Snyder et al. [63]
also classified SLAP tears into four groups which
were later supplemented by three additional
groups (types I–VII) (Fig. 5.21). The incidence of
non-type I SLAP (non-degenerative) tears ranges
from 3.4 to 26 % in patients who present with
shoulder pain [47, 63–68]; however, these figures
may be increased in high-level throwing athletes.
SLAP tears can occur in isolation or in conjunc-
tion with other shoulder pathologies such as rota-
tor cuff tears, biceps tendon pathology, and/or
glenohumeral instability [64, 67, 69].
5.5.1 Pathogenesis
The precise pathomechanism behind the develop-

ment of SLAP tears has been debated since its Fig. 5.20 Cadaveric photograph depicting a SLAP tear.
first description in 1985. Investigators most com- Note that the biceps-labral complex is elevated away from
the glenoid both anteriorly and posteriorly.
monly cite forceful traction loads, forceful com-
pression loads, and overhead sporting activities as
the most common causes of SLAP tears. A force- labrum complex between the humeral head and
ful traction load to the biceps tendon may create a the superior glenoid rim which may produce a
defect at the superior labrum resulting in pain and mechanical shearing effect (or “grinding,” as sug-
dysfunction [10, 70]. Clavert et al. [70] and Bey gested by Snyder et al. [63, 67]) resulting in a tear
et al. [71] found that forward flexion and inferior of the superior labrum. Repetitive traction from
traction, respectively, facilitated the development participation in overhead throwing sports such as
of SLAP lesions in separate cadaveric models. A baseball and softball also commonly result in
forceful compression load may trap the biceps- tearing of the superior labrum.
5.5 SLAP Tears 123
Fig. 5.21 SLAP tear classification system developed by biceps; Type IV = bucket-handle tear with biceps exten-
Snyder et al. [63] and later modified by Maffett et al. [64] sion; Type V = SLAP tear combined with Bankart lesion;
Type 1 = degenerative fraying; Type II = extension into Type VI = unstable flap tear Type VII = extension into
biceps tendon; Type III = bucket-handle tear with intact middle glenohumeral ligament (MGHL).
5.5.2 Physical Examination recognized that sudden compression (e.g., a fall

onto an outstretched arm) or traction loads (e.g.,
The physical diagnosis of SLAP tears is one of shoulder dislocation or sudden inferiorly directed
the most challenging aspects of the shoulder traction) are probably the most common etiolo-
examination for several reasons. First, there is gies of SLAP tears in the general population [63].
little evidence to support any single function of Third, SLAP tears are rarely isolated and typi-
the biceps anchor-superior labrum complex. cally occur concomitantly with other painful
Some clinicians have suggested that the glenoid shoulder conditions. Thus, the pain from a con-
labrum may have a similar function to that of the comitant pathologic lesion, such as a partial-
meniscus in the knee. They extrapolate that inju- thickness rotator cuff tear, could mask, enhance,
ries to the labrum may produce similar symptoms or mimic the pain produced by a possible SLAP
to that of injuries to the meniscus such as clicking tear, potentially confusing the clinical picture.
and/or locking with range of motion testing. Fourth, the location, quality, and intensity of pain
While this is a convenient analogy, several stud- related to a SLAP tear may differ across a popu-
ies have shown that these mechanical symptoms lation. In addition to making the clinical diagno-
are not sensitive or specific for superior labral sis of a SLAP tear difficult, this factor also
pathology, especially for type I SLAP lesions hinders the ability to study and interpret various
[45, 66, 72, 73]. Second, there are no proven his- physical examination maneuvers designed to
torical features that are associated with the pres- elicit symptoms associated with tearing of the
ence of a SLAP tear given the numerous potential biceps-labrum complex. Fifth, there are numer-
mechanisms of injury. However, it is now well ous physical examination maneuvers that are
purported to elicit symptoms related to SLAP (Fig. 5.22). Reproduction of the patient’s symp-
tears—deciding which techniques are most use- toms is regarded as a positive test.
ful is one of the more daunting aspects of the In Kibler’s original study of five groups of ath-
shoulder examination. The most common physi- letes [44], the sensitivity and specificity of the
cal examination maneuvers used to detect SLAP anterior slide test was calculated to be 78.4 and
tears are described below. Reported sensitivity, 91.5 %; however, this study did not involve a diag-
specificity, positive and negative likelihood ratio nostic gold standard. Later, Burkhart et al. [6] cal-
data for the detection of types II–IV SLAP tears culated a sensitivity of 100 % and a specificity of
are presented in Table 5.2. 47 % for the diagnosis of type II SLAP tears using
the anterior slide test. The investigators also found
5.5.2.1 Anterior Slide Test that the anterior slide test was more accurate in the
First described by Kibler [44] in 1995, the ante- detection of anterior lesions when compared to
rior slide test utilizes the rationale that a combined posterior or combined anterior–posterior SLAP
compression and shear force applied to the torn lesions. A more recent study by Schlecter et al.
superior labrum will produce pain and/or mechan- [47] evaluated 254 patients using the anterior slide
ical symptoms such as clicking. To perform this test and correlated the results with arthroscopic
test, the patient is asked to place each hand on the findings. The investigators calculated a sensitivity
iliac crests with the thumb pointed posteriorly. of 21 % and a specificity of 98 % for the detection
The examiner stabilizes the scapula by placing of type II–IV SLAP tears using the anterior slide
one hand on the top of the affected shoulder and test. When the anterior slide test was performed in
the other hand across the epicondyles of the combination with the so-called passive distraction
affected arm. The examiner then applies an anter- test described by Rubin [28] (passive forearm pro-
osuperior axial load through the humerus directed nation with the humerus in 150° of abduction in
towards the anterosuperior aspect of the glenoid the scapular plane), the sensitivity was 70 % and
Table 5.2 Reported diagnostic efficacies of clinical tests used for the detection of SLAP tears
Diagnostic Sensitivity Specificity
Maneuver Author(s) Year Pathology standard (%) (%) LR+ LR−
Anterior slide Kibler [44] 1995 SLAP tear Arthroscopy 78 92 2.63 0.64
test McFarland et al. [45] 2002 SLAP tear Arthroscopy 8 84 0.50 2.0
Parentis et al. [46] 2002 SLAP tear Arthroscopy 10 82 0.55 1.10
Oh et al. [43] 2008 SLAP tear Arthroscopy 21 70 0.70 1.13
Schlecter et al. [47] 2009 SLAP tear Arthroscopy 21 98 10.5 0.81
Crank test Parentis et al. [46] 2002 SLAP tear Arthroscopy 13 83 0.76 1.05
Guanche and Jones [48] 2003 SLAP tear Arthroscopy 39 67 1.18 0.91
Active McFarland et al. [45] 2002 SLAP tear Arthroscopy 47 55 1.04 0.96
compression Parentis et al. [46] 2002 SLAP tear Arthroscopy 63 50 1.26 0.74
test Guanche and Jones [48] 2003 SLAP tear Arthroscopy 54 47 1.02 0.98
Myers et al. [49] 2005 SLAP tear Arthroscopy 78 11 0.88 2.00
Oh et al. [43] 2008 SLAP tear Arthroscopy 63 53 1.34 0.70
Ebinger et al. [50] 2008 SLAP tear Arthroscopy 94 28 1.31 0.21
Schlecter et al. [47] 2009 SLAP tear Arthroscopy 59 92 7.38 0.45
Jia et al. [39] 2009 SLAP tear Arthroscopy 53 58 1.26 0.81
Fowler et al. [51] 2010 SLAP tear Arthroscopy 64 43 1.12 0.84
Cook et al. [52] 2012 SLAP tear Arthroscopy 91 14 1.06 0.64
Biceps load Kim et al. [53] 2001 SLAP tear Arthroscopy 90 97 30.0 0.10
test II Oh et al. [43] 2008 SLAP tear Arthroscopy 30 78 1.36 0.90
Cook et al. [52] 2012 SLAP tear Arthroscopy 67 51 1.4 0.66
LR likelihood ratio
5.5 SLAP Tears 125
the specificity was 90 % for the detection of type [45, 74]; however, the clinical relevance of the
II–IV SLAP tears. The utility of the anterior slide type I SLAP lesion has been questioned.
test to detect type I SLAP lesions is less reliable
5.5.2.2 Crank Test
The crank test was first described by Liu et al.
[75] in 1996 as a means to detect various types of
labral tears. This test can be performed with the
patient either standing or supine. The humerus is
maximally elevated with the elbow in approxi-
mately 20° of flexion. The examiner uses one
hand to hold the subject’s wrist while the other
hand is used to apply an axial force through the
humerus towards the glenoid. The humerus is
then rotated internally and externally against the
glenoid, producing mechanical shear across the
labrum (Fig. 5.23). Reproduction of the patient’s
symptoms is considered a positive test.
Liu et al. [75, 76] performed two studies eval-
uating the ability of the crank test to diagnose any
labral tear. However, the investigators were
unable to evaluate the difference between SLAP
tears and other labral tears (such as anterior or
posterior Bankart lesions) using this test. Mimori
et al. [77] performed the test on 15 baseball
players with shoulder pain and calculated a sensi-
tivity of 83 % and a specificity of 100 % for the
detection of SLAP tears using magnetic reso-
Fig. 5.22 Anterior slide test. In this test, the patient places nance arthrography (MRA) as the diagnostic
their hands over the iliac crests with the thumbs pointed poste- gold standard. However, Stetson and Templin
riorly. The examiner stabilizes the scapula with one hand and
applies an anterosuperiorly directed axial load through the [78] calculated a sensitivity of 46 % and a speci-
humerus towards the anterosuperior aspect of the glenoid. ficity of 56 % for the crank test in the diagnosis of
Fig. 5.23 Crank test. With

the patient standing or
supine, the humerus is
elevated above the
horizontal plane with the
elbow flexed to approxi-
mately 20°. The examiner
uses one hand to hold the
patient’s wrist while the
other hand applies an axial
load through the humerus
towards the glenoid. The
humerus is simultaneously
internally and externally
rotated while an axial force
is applied.
SLAP tears in a prospective series of 65 patients was relieved by the second maneuver (palm
over 45 years of age with shoulder pain. In their upward) indicated a positive test. O’Brien et al.
study, diagnosis was made via direct arthroscopic [79] calculated a sensitivity of 100 %, a specificity
visualization. In light of this evidence, we sug- of 99 %, a positive predictive value (PPV) of 95 %,
gest using the crank test in combination with and a negative predictive value of 100 % for the
other more sensitive and specific tests to aid in ability of the active compression test to diagnose
the physical diagnosis of SLAP tears. SLAP tears. However, these outstanding results
have never been reproduced despite numerous
5.5.2.3 O’Brien Test (Active published attempts [39, 43, 45, 47–52, 74, 80, 81].
Compression Test) The active compression test has several impor-
The active compression test, first devised by tant limitations that warrant discussion. First, in
O’Brien et al. [79] in 1998, is a two-part test that the original study published by O’Brien et al.
was originally designed to aid in the diagnosis of [79], the investigators noted that this maneuver
SLAP tears. With the patient standing, the humerus also had some efficacy in the diagnosis of pathol-
is placed in 90° of forward flexion and approxi- ogy involving the acromioclavicular (AC) joint
mately 10° of horizontal adduction. From this (discussed further in Chap. 7). For these reasons,
position, the humerus is internally rotated such the authors recommended that clinicians deter-
that the thumb points towards the floor and the mine the location and quality of the pain that was
palm faces laterally. The patient is then asked to produced during the first portion of the test. Pain
resist a downward force applied to the forearm or that occurred “deep” in the shoulder was thought
wrist by the examiner. The arm is then positioned to be related to superior labral pathology whereas
with the palm facing upward and an identical pain that occurred at the top of the shoulder (i.e.,
downward force is applied to the distal arm near the AC joint) was thought to be related to
(Fig. 5.24). According to the original description, pathology involving the AC joint. Second,
the presence of deep-seated pain and/or clicking because the perception of pain related to different
with the first maneuver (thumb downward) that shoulder pathologies can vary significantly
Fig. 5.24 Active compression test. (a) With the patient ward force to the distal arm while the patient provides
standing, the humerus is forward flexed to 90° with resistance. (b) The test is repeated with the palm facing
approximately 10° of horizontal adduction and the thumb upward. Characteristic pain with the first maneuver that is
pointed downward. The examiner then applies a down- relieved by the second maneuver indicates a positive test.
5.5 SLAP Tears 127
between individuals [6], patients may misinterpret which may also generate pain in the shoulder.
the location, quality, and/or intensity of the pain Therefore, it was thought both the entrapment of
which may lead to an inaccurate clinical diagno- the superior labrum and the increased tension
sis. For example, some patients may complain of could be relieved by humeral external rotation and
pain in areas that would not normally be indica- forearm supination which effectively moved the
tive of a SLAP tear whereas others may complain greater tuberosity away from the superior glenoid
of pain during both portions of the test. In addi- and diminished the tension applied to the biceps-
tion, some patients who do not have pain with labral complex, respectively.
this test demonstrate significant superior labral Several years later, the same investigators
pathology on subsequent imaging studies. Third, published the results of a study in which 66
although contrary to the original description, the patients with arthroscopically confirmed SLAP
presence of “clicking” within the shoulder during tears (types I–IV according to the classification
the first portion of the test should probably not be system developed by Snyder et al. [63]; see
considered a positive result since several studies Fig. 5.21) were evaluated retrospectively to
have demonstrated its lack of diagnostic utility determine whether a positive SLAPrehension
[45, 73]. It should be noted that audible clicking test was documented prior to surgical interven-
with this maneuver can also be caused by various tion. According to their results, the sensitivity of
pathologies involving the AC joint and, therefore, this test was found to be 87.5 % for the diagnosis
the clinician should exercise caution when inter- of types II–IV SLAP tears and 50 % for the diag-
preting this finding. nosis of type I SLAP tears. However, we could
In light of these limitations and the lack of not confirm these calculations since all patients
convincing clinical data, we prefer to perform in that study had an arthroscopically confirmed
this test in combination with other tests to SLAP tear (i.e., there were no true negatives or
improve the overall accuracy and reliability of false negatives for the overall prevalence of
the physical diagnosis. SLAP tears in their study, regardless of classifi-
cation). In addition, the ability of a patient to
5.5.2.4 SLAPrehension Test localize pain precisely to the bicipital groove is
This test, originally described by Berg and Ciullo notoriously poor and may influence the results of
[82] in 1995, is similar to O’Brien’s active com- both this study and future studies. No other stud-
pression test described above. With the patient ies have evaluated the clinical utility of the
standing, the patient actively flexes the arm to 90° SLAPrehension test in the diagnosis of SLAP
of forward elevation, adducts the arm by an tears. For these reasons, this test remains primar-
unspecified amount (presumably 10–20°), and ily of academic interest and probably should not
pronates the forearm such that the thumb points be utilized in clinical practice.
inferiorly. The clinician then applies an inferiorly
directed force on the distal arm while the patient 5.5.2.5 Biceps Load Test I
resists. The test was repeated with the forearm The biceps load test was developed by Kim et al.
supinated and the palm facing upward (see [83] as a method to detect SLAP tears in the pres-
Fig. 5.24). A positive test occurred when pain was ence of anterior instability with an associated
reproduced in the area of the bicipital groove with osseous or soft-tissue Bankart lesion. With the
the forearm supinated and subsequently relieved patient supine on the examination table, the
when the same resistance was applied with the affected arm was placed in neutral rotation and
forearm pronated. The authors hypothesized that abducted to approximately 90°. The elbow was
(1) the superior labrum became entrapped between flexed to 90° and the forearm was supinated. From
the greater tuberosity and the glenoid when the this position, the humerus was slowly externally
humerus was internally rotated and (2) forearm rotated until the patient experienced pain or
pronation increased the traction forces applied to became apprehensive (see Chap. 6 for details
the superior labrum through the LHB tendon regarding the apprehension sign). At this point,
Fig. 5.25 Biceps load test

I. With the patient supine,
the humerus is elevated to
90° of straight lateral
abduction in neutral
rotation. The elbow is
flexed to 90° and the
forearm is supinated. The
examiner then passively
externally rotates the
humerus until pain or
apprehension is felt by the
patient. At this point, the
patient is asked to flex the
elbow against resistance
provided by the examiner.
external rotation was stopped and the patient was similar test (biceps load test II) which was
asked to further flex the elbow while the examiner thought to reproduce symptoms related to SLAP
applied resistance (Fig. 5.25). When resisted tears independent of glenohumeral stability. In
elbow flexion did not relieve the patient’s symp- this test, the arm was abducted to 120° and maxi-
toms, the investigators suspected the presence of a mally externally rotated. With the forearm supi-
Bankart lesion with a concomitant SLAP tear. nated and the elbow flexed to approximately 90°,
When resisted elbow flexion did relieve the the patient was asked to flex the elbow against
patient’s symptoms, the presence of a concomi- resistance. A positive test occurred when the
tant SLAP tear was deemed less likely. Although patient experienced an increase in shoulder pain
several studies have confirmed that the LHB ten- with resisted elbow flexion (Fig. 5.26). The
don is most active during this test [84, 85], no authors hypothesized that this maneuver
other studies have specifically evaluated the ten- increased the tension placed on the biceps anchor
sion placed on the proximal biceps anchor and, and, when torn, would produce an increase in
therefore, the exact cause of the increased pain shoulder pain.
with this maneuver is still largely theoretical. Kim et al. [53] also evaluated the diagnostic
Kim et al. [83] also evaluated the clinical util- utility of this test in a series of 127 patients with
ity of the biceps load test in the diagnosis of SLAP shoulder pain who all underwent subsequent
tears with an associated Bankart lesion. According arthroscopic evaluation. Their results indicated
to their statistical analyses, the biceps load test that the biceps load test II was 90 % sensitive
had a sensitivity of 91 %, a specificity of 97 %, a and 97 % specific for the diagnosis of SLAP
PPV of 83 %, and an NPV of 98 % for the above- tears with a PPV of 92 % and an NPV of 96 %.
mentioned diagnosis. This study included only However, no other studies have been able to con-
patients with recurrent anterior instability without firm the diagnostic accuracy of this test (see
a control group and, unfortunately, no other stud- Table 5.2) [43, 52].
ies have evaluated the diagnostic efficacy of this
test. For these reasons, we cannot recommend the 5.5.2.7 Pain Provocation Test
use of this test in clinical practice. The pain provocation test was developed by
Mimori et al. [77] in 1999. Similar to the biceps
5.5.2.6 Biceps Load Test II load tests described above, it was hypothesized
A few years after their original description of the that this test would specifically activate the LHB
biceps load test, Kim et al. [53] devised another tendon, thus generating increased tension over the
5.5 SLAP Tears 129
Fig. 5.26 Biceps load test

II. This test is performed in
the same manner as the
Biceps load test I, except
that the humerus is first
elevated to approximately
abduction. The humerus is
maximally externally
rotated until pain or
apprehension is felt by the
patient. The patient then
flexes the elbow against
examiner.
proximal biceps anchor and producing pain in a Unfortunately, no other clinical studies have
patient with a lesion involving the biceps-labral evaluated the efficacy of this test in the diagnosis
complex. With the patient sitting, the arm was of SLAP tears and, therefore, we cannot currently
abducted to 90° of elevation and the elbow was recommend its use in clinical practice.
flexed to 90°. The clinician stood behind the
patient, using one hand to stabilize the scapula 5.5.2.8 Relocation Test
while the other hand was placed on the distal arm/ The relocation test was originally developed by
wrist to control humeral rotation along with fore- Jobe et al. [29] in 1989 as a method to assess
arm supination and pronation. The humerus was shoulder pain in overhead athletes. With the
then externally rotated first with the forearm pro- patient supine, the humerus was abducted to 90°
nated and then with the forearm supinated. The and externally rotated into the position of appre-
patient was then asked to report which of these two hension that is commonly used to test for anterior
positions (forearm pronated or supinated) pro- instability (see Chap. 6 for more information
duced the greatest amount of pain (Fig. 5.27). The regarding the apprehension sign). The authors
test was considered positive when the intensity of hypothesized that overhead athletes, many of
pain was greatest with the forearm pronated. This whom demonstrate anterior microinstability as a
description of a positive test is in contrast to the result of capsular laxity, would have an increased
biceps load test where a positive test occurred propensity for subacromial impingement as a
when shoulder pain was produced by resisted result of anterior humeral head translation.
elbow flexion with the forearm supinated. It is also Therefore, pain over the deltoid with the shoulder
not clear whether similar pain in both positions in this position was thought to represent rotator
was considered a positive or negative test. cuff impingement beneath the acromion. The
In the original study conducted by Mimori shoulder was then “relocated” by applying a pos-
et al. [77], the pain provocation test was used to teriorly directed pressure to the anterior aspect of
evaluate 32 overhead athletes with shoulder pain the humeral head (Fig. 5.28). If this relocation
in the absence of instability. All patients had a maneuver resulted in pain relief, the patient was
negative relocation test (discussed below and in thought to have anterior microinstability with
Chap. 6). Because only 15 patients underwent secondary subacromial impingement.
diagnostic arthroscopy, MRA was used to make Several years later, both Jobe [86] and Walch
the final diagnoses. The investigators calculated a et al. [87] concluded that overhead athletes were
sensitivity of 100 % and a specificity of 90 %. more likely to experience pain with this test as a
Fig. 5.27 Pain provoca-

tion test. With the patient
sitting with the affected
arm either at the side or
elevated to 90° of straight
lateral abduction and the
elbow flexed to 90°, the
examiner uses one hand to
stabilize the scapula while
the other hand is used to
control humeral rotation.
The humerus is then
passively and maximally
externally rotated, first
with the forearm pronated
(a) and then with the
forearm supinated (b).
When the patient reports
greater pain with the
forearm pronated, the test
is considered positive.
Fig. 5.28 Relocation test. With the patient supine, the (b) The examiner then applies an anteriorly directed pres-
humerus is laterally abducted to 90° with the elbow flexed sure on the proximal humerus to relocate the humeral
to 90°. (a) The examiner slowly externally rotates head which should relieve the apprehension.
the humerus until the patient becomes apprehensive.
5.5 SLAP Tears 131

showing the mechanism of
symptomatic internal
impingement. As the
humerus becomes more
capable of extreme
amounts of external
rotation, the posterosupe-
rior cuff and posterosupe-
rior labrum can become
pinched between the
greater tuberosity and the
glenoid rim, producing
a partial-thickness
rotator cuff tear and/or
a labral tear.
result of superior labral pathology. Under direct have a control group which eliminated the ability
arthroscopic visualization, Walch et al. [87] noted to calculate true sensitivity and specificity data
that the posterosuperior labrum became pinched regarding the ability of the relocation test to detect
between the greater tuberosity and the posterosu- either the presence or absence of a SLAP tear.
perior glenoid rim when the arm was abducted Oh et al. [43] studied the diagnostic efficacy of
and externally rotated (Fig. 5.29). This so-called the relocation test in 297 patients with shoulder
internal impingement was subsequently relieved pain who underwent diagnostic arthroscopy. After
when the joint was relocated. While many investi- retrospective review, 146 patients with type II
gators believed this condition was secondary to SLAP lesions were identified along with an age-
anterior glenohumeral laxity [86, 89–92], more matched control group of 151 patients without
recent studies have suggested a more complex labral pathology. Their results showed that the
mechanism involving anatomic and physiologic relocation test was 44 % sensitive and 54 % spe-
remodeling of the shoulder that occurs throughout cific for the diagnosis of SLAP tears with a PPV
the sporting careers of overhead athletes [93–96]. of 52 % and an NPV of 47 %. In contrast to these
Burkhart et al. [80] performed a retrospective results, a more recent study by van Kampen et al.
study of the relocation test in a series of patients [97] evaluated the relocation test in 175 patients
who were all diagnosed with type II SLAP tears who presented with shoulder pain. Of these, 60
(anterior extension, posterior extension or com- patients were diagnosed with anterior instability
bined) by direct arthroscopic visualization. and 109 patients were diagnosed with other
According to their results, the relocation test was conditions following MRA interpretation. The
most sensitive for the diagnosis of SLAP tears relocation test was found to be 96.7 % sensitive
with posterior extension (85 %). The sensitivity and 78.0 % specific for the diagnosis of SLAP
of the test for SLAP tears with combined anterior tears with a PPV of 71.1 % and an NPV of 97.7 %.
and posterior extension was 59 % and, for SLAP Given these conflicting results and the lack of
tears with anterior extension, the sensitivity was consensus regarding the actual meaning of a posi-
only 4 %. However, approximately one-third of tive test, we conclude that the test may have some
the patients included in this study had concomi- diagnostic utility in some situations; however,
tant rotator cuff tears which may have altered the determining when this test is most efficacious has
statistical analyses. In addition, this study did not been challenging topic of discussion thus far.
5.5.2.9 Resisted Supination External symptoms for which they sought medical
Rotation Test treatment. The test was considered negative when
The resisted supination external rotation test, first the patient experienced pain posteriorly, no pain
described by Myers et al. [49] in 2005, was or apprehension.
designed to detect SLAP lesions in overhead ath- In their study, 40 overhead athletes with
letes that resulted from a “peel-back” mechanism shoulder pain were subjected to the above-
that was previously described by Burkhart et al. described maneuver. At diagnostic arthroscopy,
(Fig. 5.30) [6]. Briefly, the peel-back mechanism
for the development of SLAP tears occurs when
the biceps-labral complex (particularly the poste-
rior aspect) experiences extraphysiologic tor-
sional strain as a result of repeated bouts of
glenohumeral abduction and hyperexternal
rotation as which occurs in throwing athletes.
With the patient lying supine, the humerus was
abducted to 90°, the elbow was flexed to 65–70°
and the forearm was placed in either neutral rota-
tion or pronation. The examiner supported the
elbow and asked the patient to supinate the fore-
arm against resistance. While resistance was
being applied, the humerus was slowly and maxi-
mally externally rotated. The patient was then
asked to describe their symptoms at the point of
maximal external rotation (Fig. 5.31). The test
Fig. 5.30 Illustration showing the peel-back mechanism.
was deemed positive if they experienced pain
Increasing degrees of external rotation increases the tor-
anteriorly or deep within the shoulder, clicking sional strain across the biceps anchor which can lead to
within the shoulder or the reproduction of similar SLAP tears.
Fig. 5.31 Resisted

supination external rotation
test. With the patient
supine, the humerus is
laterally abducted to 90°
and the elbow is flexed to
65–70° with the arm in
neutral rotation. While
supporting the elbow, the
patient then attempts to
supinate the forearm
against resistance provided
by the examiner. While this
resistance is applied, the
humerus is slowly
externally rotated.
5.5 SLAP Tears 133
Fig. 5.32 Dynamic labral

shear test. With the patient
sitting or standing, the
patient’s arm is placed at
the side and the humerus is
passively abducted and
externally rotated while the
examiner stabilizes the
scapula. The humerus is
then moved upward and
downward in the coronal
plane between 60° and
abduction.
29 athletes (72.5 %) were found to have a 5.5.2.10 Dynamic Labral Shear Test
SLAP tear. This resulted in a sensitivity of Information regarding the dynamic labral shear
82.8 %, a specificity of 81.8 %, a PPV of test was apparently communicated to Pandya
92.3 %, and an NPV of 64.3 % for the ability of et al. [99] in late 2004 through personal commu-
the resisted supination external rotation test to nications with Dr. O’Driscoll; however,
diagnose SLAP tears in overhead athletes. The McFarland [72] suggested that the test was
authors also noted that 79 % of the shoulders described as early as 2000 at various professional
with a SLAP tear also had concomitant lesions meetings. Because each source reported different
such as rotator cuff tears and chondral defects aspects of the procedure, we combined the infor-
among other various injuries. Almost every mation obtained from both sources to describe
patient in the control group also had other the full procedure. Given the verbal nature of the
intra-articular injuries. communication and the potential for recall bias,
In at least two EMG studies [85, 98], the we caution the reader that small variations in this
resisted supination external rotation test was maneuver may exist. The test can be performed
found to selectively activate the LHB tendon with the patient sitting or standing with the clini-
which, in turn, was thought to increase the cian standing behind the affected shoulder.
applied tension to the biceps-labral complex, Beginning with the arm at the side in neutral rota-
especially when the humerus was maximally tion, the examiner passively externally rotates
externally rotated. However, no study has quanti- and abducts the humerus within the coronal plane
fied the amount of tension that this test (or any using one hand while the other hand is used to
other test designed to detect SLAP tears) pro- stabilize the scapula. The humerus is then moved
duces at the biceps-labral complex relative to upwards and downwards between 60° and 120°
normal physiologic loads. This information of abduction (Fig. 5.32). McFarland [72] reported
would be important to help clinicians and that an anteriorly directed force should also be
researchers understand the precise mechanism applied to the posterior aspect of the humeral
behind the development of SLAP tears in overhead in conjunction with this motion. A positive
head athletes. Although this testing procedure test occurred when the patient experienced poste-
requires further study, it appears to have some rior shoulder pain with or without a clicking sen-
potential and may become an important diagnos- sation as the humerus was moved between
tic tool in the future. abduction angles.
Pandya et al. [99] performed a study that eval- high rate of false positives that were found in a
uated the efficacy of the dynamic labral shear test pilot study when the humerus was initially
in its ability to detect symptomatic SLAP tears. abducted in the coronal plane. In their study, six
In that study, 51 consecutive patients with clinical tests were used to make the diagnosis in
arthroscopically confirmed SLAP tears under- 101 patients who underwent subsequent diag-
went both preoperative physical examination and nostic arthroscopy. With specific regard to the
magnetic resonance imaging (MRI) or MRA modified dynamic labral shear test, the sensitiv-
evaluation. Physical examination findings were ity was 72 %, the specificity was 98 %, the PPV
compared to the findings on imaging studies and was 97 %, and the NPV was 77 %. This test was
diagnostic arthroscopy for sensitivity analyses. more accurate than any of the other tests for the
The sensitivity of the dynamic labral shear test diagnosis of SLAP tears performed in this study.
was found to be 80 %. The authors also calcu- Future studies are needed to confirm these
lated a sensitivity of 100 % when any one of the results before we can recommend its routine use
following three SLAP tests were positive: the in clinical practice.
active compression test, the dynamic labral shear
test, or the relocation test. 5.5.2.11 SLAC Test
Kibler et al. [40] performed a slightly modi- In 2001, Savoie et al. [100] used the term “SLAC
fied version of this test and compared its diag- lesion” to represent a frequently observed com-
nostic efficacy with other clinical tests designed bination of pathologies involving the superior
to detect SLAP tears. The modified version of labrum and the anterior cuff that were thought to
the test was performed as described above result in anterosuperior glenohumeral instability
except that the humerus was first abducted (i.e., labral tearing, articular-sided anterosupe-
>120° within the scapular plane and then moved rior cuff tears and/or glenoid chondromalacia).
directly horizontally such that the position of The same investigators also designed a physical
abduction was in the coronal plane. When the examination test to detect these so-called SLAC
humerus was moved between 60° and 120° of lesions. In this test, the humerus was abducted to
elevation, a positive test occurred only when 90° within the scapular plane with the palm fac-
posterior shoulder pain and/or clicking was ing upward. The clinician then applied a down-
present in the interval between 90° and 120° of ward force to the wrist (Fig. 5.33). A positive test
abduction. According to the authors, this proce- occurred when the humeral head “shifted” anter-
dural change was performed to eliminate the osuperiorly or when the patient experienced pain
Fig. 5.33 SLAC test. The

humerus is abducted to
approximately 90° in the
scapular plane with the
palm facing upward. The
examiner then stabilizes
the scapula and applies a
downward force to the
wrist while the patient
provides resistance.
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Glenohumeral Instability
6
6.1 Introduction 6.2 Anatomy and Biomechanics
The structure of the glenohumeral joint allows for a 6.2.1 Basic Structure
large arc of shoulder motion. Since approximately and Function
one-fourth of the humeral head articular surface
remains in contact with the glenoid throughout the The balance between mobility and stability of the
range of shoulder motion [1], instability can result glenohumeral joint is achieved through the coor-
when static and/or dynamic stabilizers are dis- dinated, complex interactions between multiple
rupted. Static stabilizers include bony articular con- static and dynamic stabilizers that function to
gruency, the glenohumeral ligaments, the glenoid center the humeral head within the glenoid fossa
labrum, the rotator interval, and the negative intra- throughout the full range of shoulder motion.
articular pressure whereas dynamic stabilizers Static constraints include articular congruency,
include the rotator cuff and periscapular muscula- glenoid version, the coracoacromial arch, the gle-
ture. The long head of the biceps (LHB) tendon is noid labrum, capsuloligamentous structures, the
probably not significantly involved with glenohu- rotator interval, and the inherent negative intra-
meral stability since Walch et al. [2], Boileau et al. articular pressure. Dynamic constraints include
[3], and Giphart et al. [4] all demonstrated that nei- the rotator cuff and periscapular musculature
ther proximal humeral head migration nor glenohu- which both contribute to the well-described con-
meral instability occurred after biceps tenodesis. cavity compression mechanism. The LHB ten-
As a result of the numerous structures involved don should not be considered a dynamic
with the maintenance of glenohumeral stability, constraint since a recent biplane fluoroscopic
physical examination of the patient with instability study found no difference in humeral head trans-
can be particularly challenging. However, an effec- lation in any plane after biceps tenodesis when
tive examination most often reveals a characteris- compared to the contralateral, unoperated shoul-
tic pattern of signs and symptoms that typically der [4]. These findings have also been noted by
lead the clinician towards the correct diagnosis. others [2, 3].
140 6 Glenohumeral Instability
Fig. 6.1 Illustrations of

(a) a normal glenoid, (b)
a fractured anteroinferior
glenoid (bony Bankart
lesion), and (c) an
“inverted pear” glenoid.
6.2.1.1 Static Constraints

Articular Congruency
The glenoid takes the shape of a teardrop or a
pear—that is, the diameter of the superior aspect
of the glenoid is approximately 20 % less than
that of the inferior glenoid [5, 6]. The inferior
aspect of the glenoid is more circular and its sym-
metry is often used to measure the amount of
acute or attritional bone loss in cases of recurrent
instability (e.g., “inverted pear glenoid”) via pre-
operative imaging or direct visualization at
arthroscopy (Fig. 6.1) [7, 8]. Approximately one-
fourth of the humeral head makes contact with
the glenoid at any point throughout the entire
range of shoulder motion, thus highlighting the
importance of strong soft-tissue stabilizers that
serve to maintain the constant balance between
motion and stability (Fig. 6.2) [9]. Geometrically,
the glenohumeral ratio (maximum glenoid
diameter divided by the maximum diameter of Fig. 6.2 Illustration showing the articular congruency of
the glenohumeral joint. Note that only approximately
the humeral head) is approximately 0.75 in the 25 % of the humeral head articular cartilage makes con-
sagittal plane and 0.60 in the transverse plane tact with the glenoid throughout the entire arc of motion.
[10]. Biomechanically, glenohumeral stability is
determined by the balance stability angle (maxi-
mum angle of the axial force vector applied by are affected by the morphology of the articular
the humeral head to the glenoid center line) and cartilage, labrum, and osseous anatomy of both
the effective glenoid arc (radius of curvature of the humeral head and the glenoid (Fig. 6.4).
the glenoid able to support the joint reaction
force produced by the humeral head), a parame- Glenoid Version
ter which includes the increased depth produced Churchill et al. [12] reported that the normal gle-
by an intact labrum (Fig. 6.3) [11]. Both the bal- noid is retroverted a mean of 1.2°. Their study
ance stability angle and the effective glenoid arc reported a range between 9.5° of anteversion to
Fig. 6.3 Illustrations

demonstrating (a) the
effective glenoid arc and
(b) the balance stability
angle. The effective
glenoid arc refers to the
radius of curvature of the
glenoid able to support
joint reaction forces across
the joint that would
otherwise lead to humeral
head translation. The
balance stability angle is
the maximum scapulo-
humeral angle at which
humeral head translation
can be prevented by the
effective glenoid arc when
an axial load is applied
through the humerus.
structures. This arch is known to prevent exces-

Depth Labrum sive anterosuperior migration of the humeral
Cartilage head (Fig. 6.6). However, contact of the humeral
head with the undersurface of the acromion can
Glenoid bone be both a cause and effect of significant rotator
cuff disease (see Chap. 4). In general, clinical
instability as a result of superior humeral head
migration in the absence of a large rotator cuff
tear is an extremely rare entity.
Fig. 6.4 Axial cut-away view showing the structure of Glenoid Labrum
the glenoid, articular cartilage, and labrum. The glenoid labrum is a triangular, fibrocartilagi-
nous structure that adheres to the circumference
of the glenoid rim (see Fig. 6.1). Its primary func-
10.5° of retroversion in 344 human scapulae with tion is to provide an extension of the bony gle-
a mean age of 25.6 years, indicating that a high noid by increasing both its depth and surface area
degree of anatomic variability exists across the (Fig. 6.7)—factors that have been shown to con-
general population. Although it is unknown tribute to approximately 10 % of glenohumeral
whether these shoulders were afflicted with stability [19, 20]. Recently, Park et al. [21] stud-
recurrent instability, most evidence suggests that ied the effect of labral height on subjective out-
excessive glenoid version (anterior, posterior, comes in 40 patients who underwent arthroscopic
superior, or inferior) or humeral torsion may be repair of soft-tissue lesions of the anteroinferior
associated with decreased glenohumeral stability glenoid (i.e., Bankart lesions). Patients with
[12–17] and rotator cuff tears (Fig. 6.5) [18]. decreased labral height after repair demonstrated
inferior clinical outcomes 1 year postoperatively
Coracoacromial Arch (via Rowe scores) when compared to those with
The coracoacromial arch is situated anterosuperi- higher labral height. In addition to improving
orly above the humeral head and is composed of glenoid depth and contact surface area, the gle-
the anterior acromion and the coracoid with the noid labrum also serves as an attachment site for
coracoacromial ligament spanning between these the joint capsule and the glenohumeral ligaments.
a b
Retroversion
Transepicondylar line
Torsion
Abnormal
glenoid version
Anatomic neck
Fig. 6.5 (a) Increased glenoid retroversion can lead to the subscapularis tendon. (b) Increased humeral retrotor-
recurrent instability due to absence of the effective gle- sion can lead to recurrent instability by overcoming the
noid arc. Severe anterior instability may cause tearing of native balance stability angle of the glenohumeral joint.
Fig. 6.6 (a) Normal

coracoacromial arch. (b)
Surgical release of the
coracoacromial ligament
and removal of the anterior
acromion can result in
anterosuperior instability.
This is extremely
uncommon when the
rotator cuff is intact.
a Normal labrum b Labral tear
Effective depth of Effective depth of

glenoid concavity glenoid concavity
Fig. 6.7 (a) Effective glenoid depth with an intact labrum. (b) Effective glenoid depth with a labral tear.
Fig. 6.8 Cadaveric photograph showing the origin of the

LHB tendon from both the superior labrum and the supra-
glenoid tubercle.
Approximately 40–60 % of the LHB substance

originates from the superior labrum (the remain-
ing percentage originates from the supraglenoid Fig. 6.9 (a) Loose pack position. Note that in the scapu-
tubercle) (Fig. 6.8) [22]. lar plane, the humerus and glenoid are in neutral align-
ment and the anterior and posterior capsule are in a normal
resting position. (b) Increased tension of anterior struc-
Capsuloligamentous Structures
tures occurs when the humerus is externally rotated. The
With the humerus in a neutral position (such as posterior structures become taut when the humerus is
the “loose pack position” described in Chap. 2), internally rotated.
stability is achieved through dynamic muscle
contraction since the glenohumeral joint capsule
and associated ligamentous structures are some- important for the maintenance of glenohumeral
what lax in this position [23]. However, these stability in any plane of shoulder motion. These
structures become variably taught with both structures become variably taught with both
active and passive shoulder motion which both active and passive motion, thus maximizing artic-
maximizes articular surface contact and prevents ular surface contact and preventing abnormal
abnormal humeral head translation (Fig. 6.9). humeral head translation. The shape and function
The joint capsule itself, the coracohumeral liga- of each individual ligament is determined by the
ment (CHL) and the superior, middle, and infe- position of the humerus in space.
rior glenohumeral ligaments (SGHL, MGHL, The CHL has two distinct bands (anterior and
and IGHL, respectively) make up this important posterior) that originate from the lateral base of the
capsuloligamentous complex (Fig. 6.10). coracoid and travel between the supraspinatus and
The glenohumeral joint capsule is one of the subscapularis tendons. The anterior band merges
primary static restraints involved in maintaining with the insertional fibers of the subscapularis ten-
shoulder stability. It is primarily composed of don and the joint capsule near the lesser tuberosity
collagen fiber bundles with varying degrees of whereas the posterior band inserts over the ante-
thickness and fiber orientation [24, 25]. The rior aspect of the greater tuberosity. With the arm
CHL, SGHL, MGHL and IGHL make up distinct at the side, the anterior band primarily resists
bands or areas of capsular thickening that are excessive external rotation and the posterior band

showing the major
labroligamentous
structures surrounding the
glenoid. The rotator cuff Supraspinatus
musculature is also shown.
LHB tendon
Labrum
SGHL
MGHL
Teres minor

primarily functions to prevent excessive internal Biomechanical ligament sectioning studies have
rotation. Both the anterior and posterior bands of shown that the MGHL primarily functions as a
the CHL also provide resistance to inferior humeral restraint to anterior translation when the humerus
head translation with the arm at the side and poste- is between 0° and 45° of abduction and exter-
rior humeral head translation when the arm is hori- nally rotated [23]. In addition, the MGHL may
zontally adducted [26–29]. also be important in limiting external rotation
The SGHL originates from the superior rim of when the humerus is abducted greater than 60°.
the glenoid near the biceps-labral complex, trav- The IGHL complex circumferentially attaches
els parallel to the much larger CHL, and inserts to the inferior aspect of the glenoid labrum ante-
on the lesser tuberosity, blending with the fibers riorly, inferiorly, and posteriorly and runs later-
of the subscapularis tendon. Its usual functions ally to widely insert over an area extending
are similar to that of the CHL, preventing exces- between the lesser tuberosity anteriorly and the
sive external rotation [30] and inferior translation triceps tendon posteriorly. The IGHL is com-
[31] when the arm is at the side and preventing posed of thick anterior and posterior bands with
posterior translation when the arm is horizontally an interposed “hammock-like” pouch that loosely
adducted. However, its diameter, strength, and cradles the inferior aspect of the humeral head
relative contribution to shoulder stability are (see Fig. 6.10). Its function is to resist both
highly variable across the population. anterior and posterior humeral head translation
The anatomy of the MGHL is also highly vari- when the humerus is abducted more than 60°
able. It can originate from the scapular neck, the [30]. Specifically, as the humerus is abducted
anterosuperior glenoid rim or the supraglenoid and externally rotated, the anterior band of the
tubercle with the biceps-labral complex. Similar IGHL complex along with the anteroinferior cap-
to the CHL and the SGHL, the distal insertion of sule becomes taut and prevents anterior humeral
the MGHL blends with the fibers of the subscap- head translation. When the humerus is flexed,
ularis tendon. The morphologic phenotype of the adducted, and internally rotated, the posterior
MGHL can also range in appearance from a band of the IGHL complex and the posterior cap-
round, cord-like ligament to a flat, sheet-like sule become taut and prevent posterior humeral
structure that blends with the IGHL inferiorly. head translation (see Fig. 6.9).

highlighting the compo-
nents of the rotator interval.
Rotator Interval Medial–lateral imbrication of the same structures

The rotator interval is a triangular space over the resulted in the opposite effect, thus decreasing
anterosuperior aspect of the joint capsule. The these motions. The authors concluded that the
supraspinatus forms the superior border, the sub- rotator interval provided resistance against exces-
scapularis forms the inferior border, and the cora- sive motion while also functioning to limit pos-
coid process forms the medial base (Fig. 6.11). The teroinferior glenohumeral translation. Nobuhara
CHL, the SGHL, the MGHL, the LHB tendon and and Ikeda [39] also showed that tightening of the
the anterosuperior joint capsule all reside within rotator interval decreased the propensity for
this triangular space. Jost et al. [32] performed one humeral head translation in the posteroinferior
of the more detailed cadaveric studies in which the direction. As a result of these studies, most
rotator interval was described as being composed surgeons believe that the rotator interval does
of several layers. However, the precise anatomy of provide some degree of stability, especially
the rotator interval is still under investigation and inferiorly when the humerus is externally rotated.
is beyond the scope of this chapter. As mentioned in Chap. 5, the rotator interval
The exact function of the rotator interval is also contributes to stability of the LHB tendon as
also the subject of numerous biomechanical stud- it travels through the bicipital groove towards the
ies [26, 32–39]. However, many of their reported superior labrum and supraglenoid tubercle.
results have been conflicting. Harryman et al. Specifically, the SGHL, CHL, and subscapularis
[36] performed one of the first comprehensive tendon together form a structure known as the
and descriptive studies that examined the func- biceps reflection pulley which supports the ten-
tion of the structures within the rotator interval. don as it enters the glenohumeral joint (Fig. 6.12)
After dividing the capsule and ligamentous struc- [2, 26, 27, 40].
tures within the rotator interval in a series of 80
cadaveric shoulders, the investigators noted an Negative Intra-Articular Pressure
increase in passive glenohumeral flexion, exten- Within the closed joint, a negative intra-articular
sion, external rotation, and adduction capacity. pressure is produced by either a “piston-in-valve”
a Supraspinatus CHL
Biceps
Biceps
reflection
pulley
Subscapularis
Fig. 6.12 (a) Illustration showing the structure of the bicip- BRPs. (Part B from Elser F, Braun S, Dewing CB, Giphart
ital sheath and biceps reflection pulley (BRP) as the LHB JE, Millett PJ. Anatomy, function, injuries, and treatment of
tendon travels into the glenohumeral joint. (b) Arthroscopic the long head of the biceps brachii tendon. Arthroscopy.
image showing anteromedial (AM) and posterolateral (PL) 2011;27(4):581–92; with permission).
mechanism, an adhesion-cohesion effect of the Table 6.1 Mean intra-articular pressures with the neutral
viscous synovial fluid, or both, which exist to and abduction/axial traction positionsa
provide some degree of stability to the glenohu- Neutral position Abduction/axial
meral joint [41]. Any perforation of the joint (mm Hg) traction (mm Hg)
capsule can “vent” the joint, eliminating this Cadaveric −34 −111
shoulders (n = 18)
nascent pressure gradient (Table 6.1) [41–43].
Stable shoulders −32 −133
However, although this mechanism may provide (n = 15)
some joint stability, capsular venting alone is not Unstable shoulders 0 −2
an apparent cause of clinical instability. (n = 17)
Table adapted from Habermeyer et al. [41]; with
6.2.1.2 Dynamic Constraints permission
a
Rotator Cuff The values given are the mean intra-articular pressures
with each position in each population sample
The rotator cuff contributes to glenohumeral sta-
bility through several different mechanisms.
First, contraction of the rotator cuff muscles
serves to compress the humeral head within the and the subscapularis helps to stabilize the joint
glenoid concavity, thus maximizing contact anteriorly. Third, the rotator cuff forms direct
between the articular surfaces during active attachments with the joint capsule and contrib-
motion (the “concavity compression” mecha- utes to stability by increasing capsular tension
nism is discussed below). Second, the physical during active motion. Finally, the glenohumeral
presence of the rotator cuff musculature prevents joint capsule has proprioceptors that are activated
humeral head migration. Specifically, the supra- by capsular stretching [44]. Afferent nerve
spinatus (along with the coracoacromial arch) impulses travel through the dorsal root ganglia
helps prevent superior translation, the infraspina- and return via efferent fibers to produce contrac-
tus and teres minor resist posterior translation tion of the rotator cuff and deltoid muscles which
Posterior view
Levator scapulae muscle

Rhomboid minor muscle
Rhomboid major muscle
Supraspinatus muscle
Trapezius muscle
Acromion
Spine of scapula
Deltoid muscle
Infraspinatus muscle
Teres minor muscle
Triangle of Teres major muscle
auscultation
Long head Triceps brachii
Lateral head muscle
Latissimus dorsi muscle
Spinous process
of T12 vertebrae
Fig. 6.13 Illustration highlighting the anatomy of the periscapular musculature.
effectively counteracts the initial stimulus (i.e., parallel muscles on opposite sides of the joint
capsular stretching). (e.g., the subscapularis anteriorly and the infra-
spinatus posteriorly) compresses the humeral
Periscapular Musculature head into the glenoid while contraction of mus-
The periscapular muscles, including the trape- cles on the same side of the joint (e.g., the supra-
zius, rhomboids, levator scapulae, serratus ante- spinatus and the deltoid superiorly) produces
rior, latissimus dorsi, and pectoralis minor, humeral head rotation (e.g., abduction). In addi-
function in synchrony to optimize the position of tion, the relative strength of contraction of each
the scapula during rotation, elevation, and hori- muscle determines the plane of elevation or rota-
zontal adduction of the humerus, thus maintain- tion. For example, if the concentric contraction
ing the humeral head in a centered position within strength of the subscapularis was 1.0 units and the
the glenoid fossa in any motion plane (Fig. 6.13). eccentric contraction strength of the infraspinatus
See Chaps. 2, 3 and 9 for more information was 0.5 units, the net rotational moment would
regarding basic scapulohumeral kinematics and favor subscapularis and, thus, internal rotation
related physical examination techniques. with simultaneous glenohumeral compression
would result. This dynamic mechanism favors
Concavity Compression both motion and stability and can be applied to
Contraction of the rotator cuff and deltoid mus- other muscles and joints throughout the body.
cles compresses the humeral head against the
glenoid fossa during active motion (also known as
“concavity compression”; Fig. 6.14). As discussed 6.2.2 Anatomic Variations
in Chap. 4, the rotator cuff and deltoid muscles
produce parallel force vectors that act against Many of the structures described above have
the glenoid surface. Simultaneous contraction of several anatomic variations that are important
Fig. 6.14 Illustration highlighting the important force head medially towards the glenoid fossa. (b) The com-
couples that help maintain concavity compression and bined actions of the subscapularis (S) and the infraspina-
overall glenohumeral stability. (a) The combined actions tus (I) make up the axial plane force couple and also work
of the deltoid muscle (D) and the rotator cuff (C) make up to drive the humeral head medially towards the glenoid
the transverse plane force couple and pull the humeral fossa.
BT
BT BT
SGHL SGHL
HH G
G G
MGHL MGHL
IGHLC IGHLC
Sublabral recess Sublabral foramen Buford complex
Fig. 6.15 Illustrations showing the most common glenolabral anatomic variations. The sublabral recess, sublabral
foramen, and Buford complex are shown.
to recognize from a management perspective

(Fig. 6.15). However, because these variations are 6.3 Classification of Instability
not discernible by physical examination, an in-
depth discussion of each variation would not be Instability is typically described according to
helpful in the context of this chapter. Rather, we severity (microinstability, subluxation, or dislo-
have provided a summary of this information with cation), direction (anterior, posterior, inferior, or
their corresponding references in Table 6.2 in an multidirectional), and chronicity (acute, chronic,
effort to direct the reader towards the most rele- or acute on chronic). In other cases, instability
vant published evidence related to these anatomic can also be described as being voluntary or invol-
variations. In addition, we recommend reviewing untary [54] and hereditary or acquired [55].
the article published by Tischer et al. [53] which Although several classification systems have
provides a detailed discussion of the relevance of been proposed, none of these have been compre-
each anatomic variation as they relate to the hensive nor have they been proven to adequately
arthroscopic management of instability. facilitate communication between physicians,
6.3 Classification of Instability 149
Table 6.2 Anatomic variations of the glenoid and glenoid labrum

Structure Anatomic variation Prevalence References
Glenoid Teardrop glenoid with notch 59 % Anetzberger and Putz [5]
Teardrop glenoid without notch 29 % Anetzberger and Putz [5]
Oval glenoid 12 % Anetzberger and Putz [5]
Glenoid labrum Any anterosuperior variation 13.4–25 % Cooper and Brems [45] and Kanatli et al. [46]
Sublabral recess Highly variable Kanatli et al. [46] and Smith et al. [47]
Sublabral foramen 12–18.5 % Ilahi et al. [48], Pfahler et al. [49], and
Williams et al. [50]
Buford complex 1–6.5 % Williams et al. [50], Ilahi et al. [48], and Ide
et al. [51]
Fig. 6.16 Stanmore Polar type 1

classification [58]. See text Traumatic/structural
for explanation and Increasing
interpretation. (From trauma
Lewis et al. [58]; with
permission).
Polar type III Polar type II

Muscle patterning/non- Atraumatic/structural
structural
Reducing trauma/increasing
muscle patterning
guide treatment decisions or predict outcomes. In between the TUBS and AMBRI groups. For
1989, Thomas and Matsen [56] categorically example, many patients with generalized hyper-
divided those with instability into two distinct laxity present with uni- or bi-directional instabil-
groups according to the distinctive characteristics ity [57] whereas up to one-fourth of patients with
of their condition. In one group, the acronym traumatic instability display evidence of contra-
TUBS was used to describe individuals with lateral involvement and increased capsular elas-
Traumatic, Unilateral instability with a Bankart tin content which suggests the possibility of
lesion that generally requires Surgical repair. The familial inheritance [55]. This overlap indicates
other group was described using the acronym that the term “instability” most likely encom-
AMBRI which included patients with Atraumatic, passes a continuous spectrum of pathologic fea-
Multidirectional instability which was typically tures where the TUBS and AMBRI groups
Bilateral, Responded to physical therapy and represent the terminal ends.
sometimes required Inferior capsular plication to As a result, other classification systems were
prevent recurrence. In this group, many individu- proposed to account for this continuum of pathol-
als are afflicted with underlying multiligamen- ogies associated with glenohumeral instability.
tous laxity who gradually develop instability as Particularly noteworthy is the Stanmore classifi-
they age. However, although this classification cation developed by Lewis et al. [58] in 2004 in
system has some academic merit, its usefulness which the three points of a triangle represent the
in clinical practice is very limited since most polar pathologic characteristics associated with
patients present with pathologic traits that overlap instability (Fig. 6.16). Type I represented traumatic
instability, type II represented atraumatic instabil-

ity, and type III represented neurologic dysfunc- 6.4 Pathoanatomic Features
tion and muscle patterning (i.e., voluntary of Traumatic Instability
instability). The line between types I and II cor-
responded with the spectrum of disease between 6.4.1 Soft-Tissue Defects
traumatic (TUBS) and atraumatic (AMBRI) eti-
ologies. The line connecting types II and III cor- 6.4.1.1 Capsular Distention
responded with the spectrum of disease in those As mentioned above, the IGHL complex is the
with atraumatic instability and neurologic dys- most important static restraint that prevents
function. As one moves towards the apex of the abnormal anterior–posterior humeral head trans-
triangle (i.e., towards the polar type I pathology), lations. In the normal shoulder, anterior (or poste-
the involved pathology increasingly resembles rior) dislocation occurs when a force is applied to
the clinical picture of traumatic instability. The the humeral head that exceeds the peak load
opposite is true when one moves towards the base required to displace the humeral head from the
of the triangle. While this system adequately rep- glenoid fossa, to stretch and deform the anterior
resents the variability in clinical presentation, it (or posterior) band of the IGHL complex and, in
fails to guide the clinician towards a specific treat- most cases of acute dislocation, detachment of
ment option for individual clinical scenarios. the glenoid labrum (i.e., Bankart Lesions—
In 2008, Kuhn et al. [59] systematically discussed below). Once the microstructure of the
reviewed the literature to determine the frequency ligament has been damaged via plastic deforma-
of various criteria that have been used to classify tion, a return to its previous shape and function is
glenohumeral instability. The authors observed unlikely in most cases [61]. This is particularly
that four of these criteria were used in more than true for the mid-substance of the ligament where
50 % of the proposed classification systems. They strain to failure has been found to be less than that
also noted that a survey conducted by the of the other portions of the ligament substance
American Shoulder and Elbow Surgeons (ASES) (e.g., the bony insertion sites) [62]. Bigliani et al.
echoed these same results. As a result, a classifi- [62] noted that failure of the anterior band
cation system that accounts for Frequency, occurred either at its glenoid insertion (40 %), in
Etiology, Direction and Severity of instability its mid-substance (35 %) or at its humeral inser-
(FEDS system) was developed since these tion (25 %). However, significant elongation of
features were found to be the most important the ligament occurred regardless of the mode of
factors involved in treatment decision-making. failure in this study. After reduction of the joint,
Subsequent analysis revealed that the FEDS clas- the anterior (or posterior) band of the IGHL com-
sification had high inter- and intra-rater agree- plex remains irrecoverably elongated and patulous,
ment [60]. However, the major drawback of the thus substantially increasing the risk for future dis-
FEDS system is its inability to categorize all locations (Fig. 6.17). Rowe et al. [63] found that up
patients who present with instability. Therefore, to 28 % of patients with recurrent instability had
further studies that correlate this classification some degree of capsular redundancy. Further-
system with treatment outcomes are needed. With more, recurrent episodes of instability increase
this information, clinical results could be pre- the severity of capsular distention which can lead
dicted at the time of initial clinical evaluation. to significant disability through a variety of other
Due to the lack of a single validated classifica- mechanisms [13, 64].
tion system for glenohumeral instability, the cli-
nician must utilize the concepts derived from 6.4.1.2 Bankart Lesions
several different classification schemes and pub- Detachment of the anteroinferior glenoid labrum
lished literature to make individual treatment (also known as a Bankart lesion) is thought to
decisions based on the etiology and underlying occur in up to 90 % of cases of traumatic anterior
pathologic lesions associated with the injury. instability and has traditionally been referred to
6.4 Pathoanatomic Features of Traumatic Instability 151
as the “essential lesion” of traumatic shoulder

dislocation (Figs. 6.18 and 6.19b). When the soft-
tissue defect is associated with periosteal strip-
ping of the glenoid neck without medial
displacement of the labral tissue, it is typically
referred to as a “Perthes lesion” (Fig. 6.19c) [65].
Despite its near-universal presence in cases of
traumatic instability [66, 67], soft-tissue Bankart
lesions alone are not a frequent cause recurrent
instability. Rather, the underlying cause is most
often multifactorial with particular focus on
redundancy and plastic deformation of the IGHL
complex [68].
6.4.1.3 ALPSA Lesions

The anterior labral periosteal sleeve avulsion
Fig. 6.17 Magnetic resonance arthrogram (MRA) of the (ALPSA) lesion is an entity similar to that of the
right shoulder following an acute posterior glenohumeral Bankart lesion; however, in this case, the perios-
dislocation. Note the significant distention of the posterior teum along the anterior glenoid neck elevates
capsule (arrow).
from the underlying bone in a “sleeve-like” pat-
tern along with the IGHL-labrum complex which
typically appears in a medialized position
(Fig. 6.19d) [69].
6.4.1.4 SLAP Tears

Superior labral anterior to posterior (SLAP) tears
(discussed in Chap. 5) are more common in over-
head athletes probably as a result of the peel-back
mechanism as described by Burkhart and Morgan
[70] (Fig. 6.20). The deceleration phase of the
Fig. 6.18 Illustration depicting an anteroinferior labral
tear (Bankart lesion). throwing motion may also produce extraphysio-
Fig. 6.19 Axial cut-away view showing (a) a normal glenoid labrum, (b) a Bankart lesion, (c) a Perthes lesion, and (d)
an ALPSA lesion.
logic eccentric loads on the biceps anchor that the humeral head in overhead athletes as a result
can result in tearing or rupture. Complete tears of of posterior capsular contracture may produce a
the biceps anchor increased superior–inferior and greater degree of anterior translation that can eas-
anterior–posterior humeral head translation in a ily be perceived as clinical laxity (i.e., “pseudol-
cadaveric study [71]. However, more recent evi- axity”). This perceived laxity is more likely to be
dence suggests that posterosuperior migration of the result of posterior capsule contracture rather
than the presence of a SLAP lesion in these
patients; however, it should be noted that SLAP
tears that extend into the MGHL can also pro-
duce increased anterior humeral head translation.
Chapter 5 provides further details regarding
SLAP tears.
6.4.1.5 HAGL Lesions

The humeral avulsion of the glenohumeral liga-
ment (HAGL) lesion occurs when the insertion of
the IGHL complex avulses or otherwise separates
from the humeral neck (Fig. 6.21a). Although its
incidence is relatively low, this injury most com-
monly occurs after a first-time anterior shoulder
dislocation. When combined with a Bankart
lesion, the anterior band of the IGHL complex is
referred to as a “floating segment.” The same
Fig. 6.20 Illustration showing the peel-back mechanism
combination of injuries can also occur posteri-
described by Burkhart and Morgan [70]. Increasing
degrees of external rotation increases the torsional strain orly thus involving the posterior band of the
across the biceps anchor which can lead to SLAP tears. IGHL complex (Fig. 6.21b) [72, 73].
Fig. 6.21 (a) Axial image of HAGL lesion. (b) Axial MRI demonstrating a floating posterior HAGL lesion. (From
Martetschläger et al. [72]; with permission).
6.4 Pathoanatomic Features of Traumatic Instability 153
Fig. 6.22 (a) Illustration of an anteroinferior glenoid fracture (bony Bankart lesion). (b) Velpeau axillary radiograph of
a right shoulder showing a fracture of the anterior glenoid.
6.4.1.6 Rotator Interval Lesions shown that soft-tissue Bankart repair is not ade-
Due to the significant anatomic variability inher- quate for defects involving at least 20–25 % of
ent to the rotator interval, it is sometimes difficult the inferior glenoid diameter [7]. Although there
to determine whether a physical finding is normal are numerous methods for measuring anteroinfe-
or abnormal. However, in our experience, laxity rior glenoid bone loss, discussion of their signifi-
of the rotator interval can be detected on physical cance is beyond the scope of this chapter.
examination by inducing a sulcus sign of >2 cm
when the humerus is externally rotated (dis-
cussed below). 6.4.2.2 Attritional Glenoid Bone Loss
Erosion of the anteroinferior glenoid rim as a
result of repeated dislocations is another cause
6.4.2 Osseous Defects for glenoid bone loss (Fig. 6.23). These patients
must rely on soft-tissue constraints to maintain
6.4.2.1 Bony Bankart Lesions anterior stability; however, these restraints are
Anterior shoulder dislocations can also create insufficient due to the capsuloligamentous
fractures of the anteroinferior glenoid rim (i.e., stretching from previous anterior dislocations.
bony Bankart lesions; Fig. 6.22). These fractures Although these patients present similarly to those
can range in morphology and size depending on with other causes of instability, there are many
the direction of load transmission. Loss of bone fewer treatment options. For example, there is
from the anterior glenoid from any cause often no bony fragment that can be used for sur-
decreases glenoid concavity and increases the gical fixation and, in many cases, soft-tissue
potential for recurrent dislocations. In general, as repair would not be adequate to prevent recurrent
the size of the lesion increases, glenohumeral sta- instability [63]. Bony reconstruction of the ante-
bility decreases [74]. Several biomechanical rior glenoid is typically indicated which may
studies have shown that defects measuring more involve iliac crest bone grafting, the Latarjet
than one half of the glenoid length decrease joint procedure, or distal tibial osteochondral allograft
stability by up to 30 % [75, 76]. Others have (Figs. 6.24 and 6.25).
6.4.2.3 Hill–Sachs Lesions

The Hill–Sachs lesion is characterized by an
impression fracture of the posterosuperior aspect
of the humeral head. These fractures can occur
as a result of anterior dislocation when the soft
bone of the posterosuperior humeral head
impacts the much harder bone of the anteroinfe-
rior glenoid rim. Although most lesions are small
and generally do not affect glenohumeral stabil-
ity, other larger lesions can cause recurrent dis-
locations especially in positions of 90° of
abduction and 90° of external rotation (i.e., the
90/90 position) where the humeral head defect
can “engage” with the glenoid rim (Fig. 6.26)
[7, 77–79].
6.4.2.4 Glenoid Version

Glenoid version, especially retroversion, has
been cited as an uncommon, but potential con-
tributory factor involved in recurrent shoulder
instability due to the absence of an effective gle-
noid arc (see Fig. 6.5a) [12, 80]. Due to conflict-
ing data suggesting a possible link between mild
glenoid version and recurrent instability, this
entity is generally considered a diagnosis of
exclusion after all other causes of recurrent insta-
bility have been ruled out [14, 81, 82]. On the
Fig. 6.23 (a) Axillary radiograph of a right shoulder
demonstrating attritional bone loss involving the anterior other hand, more severe cases of glenoid version
glenoid. Note that the humeral head appears to be resting can result in debilitating instability (Fig. 6.27);
anterior to the axis of glenoid. (b) Axillary radiograph of most of these cases involve significant retrover-
a left shoulder demonstrating attritional bone loss involv-
sion that lead to posterior instability.
ing the anterior glenoid. The humeral head appears to be
positioned anterior to the glenoid axis.

depicting the Latarjet
procedure for the treatment
of recurrent anterior
instability in the setting of
glenoid bone loss.
6.5 Pathoanatomic Features of Atraumatic Instability 155
Fig. 6.25 Other bony

reconstruction options for
the treatment of glenoid
bone loss include iliac
crest bone grafting and
distal tibial osteochondral
allograft. (a) Surgical
photograph demonstrating
fixation of a bone graft to
the anterior glenoid in a
patient with recurrent
anterior instability. (b)
Example of an iliac crest
bone graft. (c) Example of
a distal tibial osteochon-
dral allograft.
tent in both the skin and capsular tissue of many

6.5 Pathoanatomic Features patients with MDI [84] in addition to increased
of Atraumatic Instability capsular volume [57, 85, 86] and, in some cases,
laxity of the rotator interval [87]. These findings
It is often difficult for clinicians to define which suggest that undiagnosed Ehlers–Danlos syn-
patients are afflicted with atraumatic instability drome or multiligamentous laxity may be a sub-
because the effects of activities of daily living stantial contributing factor involved in the
and/or sporting activities may lead to undetect- development of instability in many of these
able glenohumeral joint damage. The cumulative patients. It should be also noted that traumatic
effects of this damage may lead to unilateral or and atraumatic instability can occur simultane-
bilateral instability without an apparent cause. ously in the same patient and thus should not be
However, some degree of genetic predisposition considered entirely independent from one
is implied when patients present with atraumatic another. For example, a patient diagnosed with
bilateral shoulder instability [83]. For example, MDI can also present to the clinic after a trau-
multidirectional instability (MDI) is defined as matic dislocation, potentially resulting in any of
atraumatic anterior or posterior instability with a the pathologic lesions associated with traumatic
component of increased inferior translation. instability (i.e., bony Bankart lesion, Hill–Sachs
Studies have demonstrated increased elastin con- lesion, HAGL lesion, etc.).
Fig. 6.26 (a) Hill–Sachs

lesions can engage with the
anterior glenoid when the
humerus is externally
rotated. Bone loss or
fracture of the anterior
glenoid can exacerbate the
problem. Engagement of
the Hill–Sachs lesion with
the anterior glenoid can
deepen the humeral head
defect. (b) Axial computed
tomography (CT) scan
showing an engaging
Hill–Sachs lesion in a
patient with debilitating
instability.
6.6 Instability or Increased

Laxity?
The semantic relationship between laxity and

instability should be recognized and understood
by all clinicians who evaluate patients with vari-
ous shoulder pathologies. The term “laxity”
refers to the normal physiologic motion allowed
as a result of the position and tension of the liga-
ments that maintains stability of a joint [88–90].
Without this physiologic laxity, joint motion
would not be possible. Because the shoulder
requires a large range of motion, its physiologic
laxity has a greater magnitude than the other
joints within the body. Therefore, laxity testing in
the shoulder requires that the clinician under-
Fig. 6.27 Axial computed tomography (CT) scan dem-
onstrating severe glenoid retroversion. This patient pre- stands the difference between “normal” and
sented with recurrent posterior instability. “abnormal” joint motion as they relate to the
6.7 Quantifying Humeral Head Translation 157
entire clinical picture. Along the same lines, 6.7.2 Humeral Head Translation
the clinician should also understand that as a Percentage of Humeral
increased joint laxity does not necessarily Head Diameter
equate pathologic instability, even if this finding
occurs unilaterally. As mentioned above, these Measurement of humeral head translation can also
conditions lie along a spectrum of disease that is be estimated using the humeral head diameter as
most frequently and conveniently labeled as described by Cofield and Irving [96]. Specifically,
“instability.” the amount of translation as a percentage of the
humeral head diameter is used. This method
accounts for the size of the individual being tested
and may theoretically provide a more accurate
6.7 Quantifying Humeral Head estimate of glenohumeral translation. However,
Translation several studies have provided conflicting results
regarding the amount of translation that should be
Currently, there are three basic methods by which considered abnormal. Reported estimates for nor-
humeral head motion is quantified: (1) translation mal anterior and posterior translations have ranged
in millimeters, (2) translation as a percentage of from 0 to 50 % and from 26 to 50 %, respectively
the humeral head diameter, and (3) the sensations [79, 89, 93, 97–99]. In addition, humeral head
felt when the humeral head is translated. A fourth diameters vary widely across the population and
modality includes the use of instrumentation or its estimation may be difficult without some sort
imaging; however, these methods are currently of radiographic measurement. This method has
under development. not been formally validated for the measurement
of humeral head translation and, in at least one
case, has been reported as invalid [89].
6.7.1 Humeral Head Translation
in Millimeters
6.7.3 Tactile Sensation of Humeral
There are four grades of anterior and/or posterior Head Translation
translation of the humeral head [91].
• Grade 0 = minimal or no translation Another way to quantify humeral head transla-
• Grade 1 = <10 mm of translation tion is to report what is felt by the examiner when
• Grade 2 = 10–20 mm of translation the humeral head is translated anteriorly or poste-
• Grade 3 = >20 mm of translation or riorly. The primary advantage of the classifica-
subluxation tion scheme is that the measurement does not rely
A similar system exists for the measurement upon absolute numbers to define certain patholo-
of inferior translation [92–95]. The primary limi- gies. There are four grades of translation accord-
tation of this method of measurement is its sub- ing to Hawkins and Bokor [100]:
jectivity—that is, each measurement is an • Grade 0: Normal physiologic motion
approximation made by the examiner and exten- • Grade 1: Translation to the glenoid rim
sive practice is needed before one becomes profi- • Grade 2: Translation over the glenoid rim
cient and accurate. As of this writing, these • Grade 3: Humeral head remains out of joint
methods of measurement have not been biome- after examiner removes hands (i.e., “lock out”)
chanically or clinically validated; however, they Levy et al. [94] investigated the reliability and
are widely used in the setting of a busy clinical accuracy of the original Hawkins system to detect
practice due to their convenience and, when per- humeral head translations in a series of 43 athletes.
formed by the most experienced clinicians, suf- Two fellows in sports medicine, a senior orthope-
ficient accuracy. dic resident or an attending physician in orthopedic
Fig. 6.28 Illustration of the modified Hawkins classification of glenohumeral translation (grades 1, 2 and 3) [100].
surgery performed all of the physical examina- 6.7.4 Objective Instrumentation

tions. These researchers found an overall inter-rater
reliability of less than 50 %. However, they found In the shoulder, humeral head translation in any
that the inter-rater agreement increased to a mean direction is primarily measured by tactile sensa-
of 73 % when grades 0 and 1 were considered tion and requires a great deal of practice and
together. The intra-rater agreement also increased experience. When a clinician becomes proficient,
from 46 to 73 % when grades 0 and 1 were con- abnormal joint motions of <1 mm can reliably be
solidated. Using this modified Hawkins scale, detected, especially when the patient is under
McFarland et al. [101] demonstrated an intra-rater general anesthesia. Although this practice has
reliability of 100 % and 86 % for anterior and pos- some element of subjectivity, it is widely accepted
terior humeral head translations, respectively. As a since there are currently no validated devices that
result of these studies, the original Hawkins system can accurately and reproducibly detect small
was modified due to the difficulty in distinguishing amounts of joint motion. These types of instru-
between patients with grade 0 and grade 1 transla- ments for the shoulder are currently in develop-
tions. Currently, grade 1 represents humeral head ment and use a similar design to that of the
translation “not over the rim,” grade 2 represents KT-1000 [105–107] a device used to measure
“over the rim,” and grade 3 represents “lock out” tibial translation relative to the femur. However,
(Fig. 6.28). However, the clinical significance of measuring humeral head translation using these
the modified Hawkins system is still heavily new instruments is limited due to the effects of
debated. For example, using the anterior and poste- soft-tissue compliance and patient apprehension.
rior drawer tests (described below), several studies In addition, there is no single amount of humeral
have demonstrated grade 2 laxity in physiologi- head translation beyond which instability or
cally normal shoulders without clinical instability increased laxity can be diagnosed [36, 109, 110].
[102–104]. In addition, these studies also found Further research is necessary before these types
that glenohumeral joint laxity may be increased in of instruments can be recommended for clinical
the non-dominant shoulder, suggesting that asym- practice. The use of ultrasound and stress radio-
metric findings with laxity testing is most likely graphs have also been proposed as methods to
normal in the majority of cases. Additional research measure joint translation; however, these methods
is necessary to determine the applicability of the are unreliable and, again, further testing is needed
modified Hawkins classification as it relates to the before they can be recommended for use in the
diagnosis of shoulder instability. clinical setting.
6.8 Laxity Testing 159
maneuver. This is sometimes difficult in patients

6.8 Laxity Testing who present with overt instability where signifi-
cant guarding and/or apprehension may be pres-
Patient guarding or apprehension is one of the ent. As mentioned above, it may be helpful to
main challenges associated with laxity testing of place the patient in the supine position to promote
the shoulder in the office setting. With these patient relaxation. When the patient is supine, it is
maneuvers, it is required that the patient remains also important to confirm that the humeral head is
relaxed to allow the humeral head to translate not supported by the examination table beneath
appropriately during testing. While many of these as this will prevent posterior translation. On the
tests can be performed in the sitting or supine other hand, posterior support of the scapula is
position, several authors have noted that laxity advantageous since increased scapular rotation
testing with the patient in the supine position may (internal or external rotation) may produce inac-
produce the best results because the patient is curate results when attempting to manipulate the
generally more relaxed [111, 112]. Another chal- humeral head. Although the original developers
lenge associated with laxity testing is the inter- of this maneuver recommended that the arm be
pretation of the clinical findings. Although the placed between 80° and 120° of abduction, it is
end feel classification system derived by Cyriax preferred to place the humerus in the approximate
and Cyriax [113] in 1947 has been used in the “loose pack” position [102, 114, 115] to (1) mini-
past (see Chap. 2), defining the quality of the end mize the effects of proprioceptive muscle con-
point in shoulder laxity testing is not practical traction (generated by increased capsular tension
since none of these qualities can be associated [16]), (2) to prevent scapular motion during test-
with any specific pathology, treatment or out- ing, and (3) to more accurately assess true
come. However, in the clinical setting, the repro- humeral head translation (Fig. 6.29). The gleno-
duction of symptoms is often a strong indicator of humeral resting position (or the “loose pack”
the underlying diagnosis and may also direct the position, discussed in Chap. 2) is debated; how-
use of other provocative maneuvers. ever, it is generally thought to occur between 55°
and 70° of abduction within the scapular plane
and with neutral rotation [116, 117].
6.8.1 Drawer Signs The posterior drawer test is performed with the
patient supine and the shoulder in the “loose pack”
Drawer signs can be used to assess anterior or position as described above. The examiner holds
posterior humeral head translation as long as the the wrist to minimize patient-controlled contrac-
patient remains in a relaxed state throughout the tion of the deltoid in an effort to actively hold the

of the approximate
glenohumeral resting
position with the humerus
abducted to 55–70° within
scapular plane and in
neutral rotation.
Fig. 6.30 Posterior drawer test. With the patient supine, Fig. 6.31 Anterior drawer test. The patient is placed in an
the extremity is placed in the approximate “loose pack” identical position to that which is presented in Fig. 6.33.
position. The examiner holds the patient’s wrist to prevent In this case, the fingers are used to pull the humerus ante-
biceps contraction while the other hand is placed over the riorly. The amount of humeral head translation is then
shoulder such that the thumb is anterior and the fingers are estimated. It may be helpful to apply a gentle axial load
posterior. The examiner then applies a posteriorly directed during drawer testing to aid in the detection of translation
force with the thumb and the amount of translation is relative to the glenoid rim.
estimated.
arm in position. This also allows for passive flexion also control scapular motion which can affect
of the elbow and subsequent relaxation of the translation measurements. One method involves
biceps muscle which may have some effect on gle- placing one hand over the top of the shoulder to
nohumeral stability via the proximal LHB tendon. stabilize the scapula while the other hand is
The examiner’s other hand is placed over the shoul- wrapped around the upper arm near the humeral
der such that the thumb lies on the anterior aspect head. A posterior to anterior force is then
of the humeral head and the fingers span over the applied to the humeral head, producing anterior
top of the shoulder. From this position, the thumb is translation [112]. In most cases, it is preferred to
used to apply a posteriorly directed force on the hold the wrist with one hand and the proximal
humeral head to a point of subluxation which is felt humerus with the other hand while simultane-
by the examiner’s fingers. Pressure from the thumb ously applying a medially directed force on the
is then removed while the fingers continue to moni- humeral head towards the glenoid fossa
tor the subluxation status of the humeral head (Fig. 6.31). This method helps prevent scapular
(Fig. 6.30). At this point, the modified Hawkins motion and also helps the examiner detect the
classification is used to quantify the degree of gle- precise moment of joint subluxation [95, 118].
nohumeral laxity (discussed above). When the The results of this maneuver are classified using
humeral head does not subluxate posteriorly, the the modified Hawkins criteria as described above
patient has grade 1 laxity (a normal finding). If sub- for the posterior drawer test.
luxation does occur, grade 2 laxity is diagnosed
when the removal of thumb pressure allows the
humeral head to spontaneously reduce whereas 6.8.2 Load-and-Shift Test
grade 3 laxity is diagnosed when the humeral head
remains subluxated even after the removal of ante- The load-and-shift test was first described by
rior thumb pressure (i.e., “lock out”) (see Fig. 6.28). Silliman and Hawkins [95] in 1993 as a method
The anterior drawer test has a similar biome- to assess anterior and posterior laxity. With the
chanical premise; however, the examiner must patient sitting, the examiner places one hand over
6.8 Laxity Testing 161
the top of the shoulder to stabilize the scapula 6.8.3 Sulcus Signs
while the other hand is placed over the proximal
humerus. The examiner then applies gentle pres- First described by Neer and Foster [119] in 1980,
sure to the proximal humerus in the direction of sulcus signs have traditionally been utilized as a
the glenoid fossa, thus “loading” the joint as measure of inferior glenohumeral laxity. The test
described by its original developers [79, 95]. The is typically performed with the patient sitting
purpose of this initial joint loading is to ensure since this places the humerus in a relative resting
adequate joint reduction and to assist the exam- position, especially when the hands and forearms
iner in detecting joint subluxation. The humeral are placed on the patient’s lap. Each arm can be
head is then grasped with the examiner’s thumb tested individually; however, we recommend first
placed posteriorly and the fingers placed anteri- testing both extremities simultaneously in new
orly. An anteriorly directed force is applied to the patients since this method allows direct compari-
humeral head in an attempt to translate the son between extremities. If asymmetry is present,
humeral head over the anterior rim of the gle- then the affected shoulder can be evaluated in
noid. This is followed by a similar maneuver in more detail (Fig. 6.33). With the patient seated on
which a posteriorly directed force is applied to the examination table, the examiner grasps both
induce posterior subluxation (Fig. 6.32). arms just above the elbow and applies gentle
Although the original developers placed the inferior traction to the glenohumeral joint. Each
arm in 20° of abduction and 20° of forward flex- shoulder should also be tested individually with
ion before applying the translation force, we have the humerus in maximum external rotation to
not found this positioning to be helpful. This test evaluate laxity of the rotator interval structures
can also be performed with the patient supine. (Fig. 6.34) [31, 36, 120]. The patient should
Fig. 6.32 Load-and-shift test. With the patient sitting and then applies a medially directed force to the proximal
the arms at the side, the examiner places one hand over the humerus in the direction of the glenoid fossa while simul-
top of the shoulder to stabilize the scapula and the other taneously translating the humeral head (a) anteriorly and
hand is placed over the proximal humerus. The examiner then (b) posteriorly.
Fig. 6.33 Sulcus sign. (a) While the patient is seated with joint laxity. (b) Clinical photograph demonstrating a posi-
the hands resting on their lap, the examiner grasps each tive sulcus sign (>2 cm step-off between the lateral edge
arm just above the elbow and applies a distraction force to of the acromion and the top of the humeral head).
the glenohumeral joint bilaterally to detect asymmetric
always be asked if the maneuver reproduces their

symptoms. In most cases, sulcus signs are graded
according to the degree of inferior translation
that is produced: grade I indicates <1 cm infe-
rior translation, grade II indicates 1–2 cm inferior
translation, and grade III indicates >2 cm inferior
translation [92–95]. Of course, this grading
system is most useful when correlated with
other findings within the history and physical
examination.
6.8.4 Hyperabduction Test
The hyperabduction test was first described by

Gagey and Gagey [121] in 2001 as a method to
evaluate the patency of the IGHL complex. With
the patient sitting, the examiner stands behind the
affected shoulder. While a downward pressure is
applied to the top of the shoulder to stabilize the
scapula, the humerus is passively abducted until
the scapula begins to rotate (Fig. 6.35). The
degree of abduction at which scapular motion
Fig. 6.34 With the patient sitting and the arm at the side, begins was originally termed the maximum range
the humerus is placed at approximately 90° of external of passive abduction (RPA). When the RPA was
rotation. The examiner grasps the arm just above the exceeded 105°, the test was considered positive
elbow and applies an inferiorly directed distraction force for increased laxity of the IGHL complex. This
to the glenohumeral joint. A positive sulcus sign with this
maneuver is indicative of rotator interval pathology. cut-off point is derived from the original study
6.9 Testing for Anterior Instability 163
Fig. 6.35 Hyperabduction

sitting, the examiner
stabilizes the scapula and
passively abducts the
humerus in the coronal
plane until the scapula
begins to rotate upward.
When upward rotation of
the scapula begins at >105°
of humeral abduction, the
test is considered positive.
which involved performing the test on 100 cadav- 6.9 Testing for Anterior
ers (both before and after sequential sectioning of Instability
the IGHL complex; however, other soft tissues
were not left intact), 100 volunteers without 6.9.1 Drawer Signs
shoulder complaints and 90 volunteers with doc-
umented shoulder instability. In that study, 85 % Although the drawer signs are typically used to
of unstable shoulders demonstrated an RPA of assess glenohumeral laxity (discussed above),
>105° whereas stable shoulders demonstrated a there are specific scenarios in which these signs
mean RPA of approximately 90°. The authors may increase the clinical suspicion for instabil-
concluded that laxity of the IGHL complex could ity (see Figs. 6.30 and 6.31). For example, some
be suspected in patients with an RPA >105°. The clinicians consider the maneuver to be “posi-
intra-class correlation coefficients (ICCs) were tive” for instability when the patient experi-
found to be excellent in this study (inter-observer ences apprehension. In the study by van
ICC: 0.87–0.90; intra-observer ICC: 0.84–0.89). Kampen et al. (mentioned above) [122], the
More recently, van Kampen et al. [122] studied anterior drawer sign was also evaluated with
six clinical tests for instability in 169 consecutive regard to its diagnostic efficacy for clinical
patients at an orthopedic outpatient clinic (appre- instability. A “positive” test was defined as
hension, relocation, release, anterior drawer, either increased anterior humeral head transla-
load-and-shift and hyperabduction tests). tion as detected by the examiner when com-
Magnetic resonance arthrography was used as the pared to the contralateral shoulder or when the
diagnostic gold standard. Of the 169 patients, 60 patient experienced feelings of apprehension
patients were diagnosed with anterior instability during the maneuver. In this study, the sensitiv-
according to imaging studies. Overall, the diag- ity of the anterior drawer sign was calculated to
nostic accuracy of the clinical tests for increased be 58.3 % (high rate of false negatives) whereas
glenohumeral laxity ranged between 80.5 and the specificity was calculated to be 92.7 % (low
86.4 % where the hyperabduction test was found rate of false positives). It should be remem-
to be 81.1 % accurate with a sensitivity of 66.7 % bered that asymmetric laxity measurements do
and a specificity of 89.0 %. not always indicate instability.
during the maneuver. Other variations of the ante-

rior apprehension sign have been proposed, such
as performing the test at both lower and higher
levels of glenohumeral abduction [96, 125]; how-
ever, currently, there is no solid evidence to sup-
port their potential diagnostic utility.
Although the apprehension signs are relatively
simple to understand from a conceptual stand-
point, there are several caveats that should be
noted. First, given the nature of the test, a patient
who had been examined on multiple prior
occasions may either become accustomed to the
Fig. 6.36 Anterior apprehension. This test can be per- discomfort or they may adopt compensatory
formed with the patient sitting or standing. The humerus mechanisms to reduce the symptoms related to
is laterally abducted to 90° and externally rotated to 90°. subluxation or dislocation [126]. Both of these
The examiner then applies a gentle anteriorly directed factors may produce inaccurate results in patients
force to the posterior aspect of the humeral head.
who require frequent clinic visits for instability. As
a potential solution, McFarland [103] suggested
that the test may also be performed during range
6.9.2 Anterior Apprehension Sign of motion testing to surprise the patient, especially
during the evaluation of passive external rotation
The apprehension sign was initially described by capacity. With the patient sitting or standing, each
Rowe and Zarins [123] in 1981 as a method to arm is abducted to approximately 90°, the elbows
reproduce symptoms related to clinical instabil- are flexed to 90° and each arm is slowly and pas-
ity. With the patient sitting or standing, the sively externally rotated (similar to that which is
humerus is externally rotated and abducted to performed during range of motion testing). The
approximately 90° within the coronal plane. The patient is then asked to indicate the point at which
examiner then applies a gentle anteriorly directed pain or apprehension is felt. This technique elimi-
force to the posterior aspect of the humeral head nates the need to perform a separate maneuver and
(Fig. 6.36). A positive test occurs when the patient may decrease the patient’s ability to mentally pre-
initiates a sudden guarding reflex to prevent dis- pare for the apprehension test. Second, patients
location, sometimes in the presence of pain. The who experience pain during the apprehension test
anterior apprehension sign can also be elicited may have a tendency to become apprehensive at
with the patient lying supine on the examination smaller degrees of external rotation during future
table [95, 122–124]. In this variation of the test, examinations. Third, most patients with instability
the patient is asked to slide to the edge of the table will display apprehension at different levels of
such that the extremity to be tested must be held humeral abduction, external rotation, and/or
against gravity using voluntary muscle contrac- extension. Lo et al. [124] performed a study to
tion. The scapula must remain supported by determine the mean degrees of external rotation
the examination table to prevent erroneously required to produce apprehension in patients with
increased external rotation estimations as a result anterior instability, posterior instability, or MDI. In
of compensatory scapular motion. With the that study, mean external rotation of 83°, 100°, and
elbows flexed to 90°, the humerus is then exter- 131° was required to generate apprehension in
nally rotated using the edge of the table as a ful- patients with anterior instability, posterior instabil-
crum to generate an anteriorly directed force over ity, and MDI, respectively. These data suggest that
the posterior aspect of the humeral head. The test external rotation beyond the common 90° land-
is positive when the patient experiences appre- mark may be necessary to elicit anterior apprehen-
hension with or without the production of pain sion in some patients, especially in those who
6.9 Testing for Anterior Instability 165
display evidence of increased glenohumeral laxity to apprehension alone) was used to make the
during other clinical examination maneuvers. diagnosis of anterior instability.
Finally, although it has been suggested on numer-
ous occasions, a positive apprehension test follow-
ing a first-time traumatic dislocation does not 6.9.3 Relocation Sign
necessarily correspond to an increased risk of
future dislocations [1]. Although there is no clear consensus regarding
Several studies have evaluated the diagnostic who actually provided the first description of the
efficacy of the anterior apprehension sign as it relocation sign, Jobe et al. [129] is most often
relates to clinical instability. In most studies, both credited with its development and subsequent
the sensitivity and specificity of the anterior implementation into clinical practice. The authors
apprehension test in the diagnosis of anterior suggested that stretching of the IGHL complex
instability has ranged from 70 to 90 % with increased the propensity for mechanical impinge-
excellent intra-class correlation [110, 122, 124, ment of the rotator cuff tendons on the undersur-
127]. However, in one study, Speer et al. [128] face of the acromion as a result of hyperexternal
performed the test in a series of patients with rotation. Thus, increased glenohumeral translation
various shoulder pathologies to specifically and/or subluxation was thought to produce a “sec-
determine whether pain was needed to define a ondary impingement” of the rotator cuff. To per-
“positive” apprehension test. In those with ante- form this test, the patient should be in the supine
rior instability, 63 % of patients demonstrated position with the affected arm over the edge of the
apprehension during the test whereas 46 % expe- examination table. The humerus is abducted 90°
rienced pain during the test. In addition, many and externally rotated to approximately 90° (i.e.,
other patients with stable shoulders also experi- the 90/90 position). From this starting position,
enced pain during the maneuver. This study pro- the humerus is then slowly abducted and exter-
vides evidence that pain during the anterior nally rotated until the patient reports pain. Jobe
apprehension test may not be a necessary crite- et al. [129] indicated that patients most commonly
rion for the diagnosis of anterior instability. Both reported pain over the anterior aspect of the del-
Lo et al. [124] and Tzannes et al. [110] came to toid. The examiner then applies a posteriorly
similar conclusions when they noted precipitous directed pressure over the humeral head to reduce
decreases in their calculated specificity and ICCs, (or “relocate”) the subluxated joint (Fig. 6.37).
respectively, when pain alone (as opposed A positive test occurs when this posteriorly
Fig. 6.37 Relocation sign.

This test can also be
performed with the patient
sitting or standing. The
anterior apprehension test
is performed as described
in Fig. 6.36. The examiner
then applies a posteriorly
directed force to the
anterior aspect of the
humeral head to “relocate”
the joint and relieve the
patient’s pain and/or
apprehension.
directed pressure results in symptomatic relief, [128] calculated a sensitivity and specificity of
potentially indicating the relief of secondary 68 % and 100 %, respectively, when the relief of
impingement beneath the acromion. apprehension was considered a positive reloca-
However, even Jobe et al. [129] questioned the tion sign. In this study, the resolution of pain with
clinical efficacy of this test to diagnose instability the relocation test was not a reliable method to
in overhead athletes since the starting position diagnose clinical instability (sensitivity: 30 %;
can produce pain in athletes with rotator cuff dis- specificity: 58 %). Tzannes et al. [110] calculated
ease, instability or both. As a result, the authors the reliability of the relocation test in a series of
described a basic algorithm which was thought to 25 patients with overt instability (patients with
be useful in differentiating between athletes with occult instability or internal impingement were
and without rotator cuff disease. In this descrip- excluded). In that study, they found high inter-
tion, the test was performed using the same tech- observer agreement when the relief of apprehen-
nique; however, when the posteriorly directed sion was considered a positive test (ICC: 0.71)
pressure failed to relieve the patient’s symptoms, and low inter-observer agreement when the relief
the pain was assumed to be the result of rotator of pain was considered a positive test (ICC: 0.31).
cuff disease rather than occult instability. More
recent studies have suggested that the relief of
posterior pain with this maneuver may be an 6.9.4 Release Test
important clinical sign in the diagnosis of symp-
tomatic internal impingement and posterior SLAP The release test was originally described by
tears in overhead athletes [7, 70, 130–132]. Silliman and Hawkins [95] in 1993 as an exten-
The test can also be used as a method to detect sion of the relocation test. With the patient supine,
clinical instability in both athletes and non- the humerus is placed in 90° of abduction and 90°
athletes alike when the posteriorly directed pres- of external rotation. The arm is slowly externally
sure relieves the patient’s feeling of apprehension rotated until the patient becomes apprehensive.
in the abducted and externally rotated position. In A posteriorly directed forced is applied to the
fact, this is the most widely utilized version of the humeral head to relieve the patient’s symptoms.
relocation sign and has been heavily scrutinized At this point, the humerus is further exter-
in the literature. As a part of the study mentioned nally rotated and the examiner removes their
above for the apprehension sign, Speer et al. hand from the anterior shoulder (Fig. 6.38).
Fig. 6.38 Release test.

With the patient supine, the
arm is placed in the 90/90
position. The examiner
applies a gentle posteriorly
directed force on the
anterior aspect of the
humeral head. The
examiner then suddenly
removes, or “releases”
their hand from the
anterior shoulder. A
sudden increase in pain or
apprehension signifies a
positive test.
6.10 Testing for Posterior Instability 167
After releasing the shoulder, the patient should 6.9.5 Surprise Test
experience a sudden increase in pain and appre-
hension. It should be noted that the primary pur- Currently, many surgeons use the terms “sur-
pose of this test is to detect subtle anterior prise test” and “release test” interchangeably;
instability and should not be used in patients with however, there are subtle differences that should
more severe patterns of instability due to the pro- be noted. The surprise test was actually
duction of unnecessary discomfort and the high described by Lo et al. [124] in 2004 as a slight
risk of shoulder dislocation. modification to the original release test devel-
Gross and Distefano [133] evaluated the diag- oped by Silliman and Hawkins [95] a decade
nostic efficacy of a slightly modified version of earlier. In their version of the test, the investiga-
the release test in a series of 100 patients with tors first performed the relocation test as
various pathologies who were scheduled to described above. After stabilizing the proximal
undergo arthroscopic shoulder surgery. According humerus by applying a posteriorly directed
to their description, the patient was positioned force, the examiner simply removed their hand
supine and the humerus was abducted to 90°. A from the patient’s anterior shoulder without
posteriorly directed forced was applied to the increasing the degree of external rotation. The
anterior aspect of the humeral head to maintain reproduction of pain or apprehension defined a
the humerus within the glenoid fossa while the positive test. In their study, the investigators
humerus was simultaneously externally rotated. evaluated and compared the diagnostic efficacy
The examiner then suddenly removed their hand of the apprehension sign, relocation sign and
from the anterior shoulder. A positive test occurred the surprise test (as described above) in a series
when removal of the examiner’s hand resulted in of 46 shoulders with various diagnoses. They
a sudden increase in pain intensity or the repro- found that the surprise test had the highest posi-
duction of symptoms. According to their surgical tive predictive value (PPV) (98 %) and the
findings, the patients were divided into either an highest specificity (99 %) than any of the other
instability group or a non-instability group. After tests; however, the sensitivity was found to be
the exclusion of 18 patients with instability related 64 %. The authors suggested that a positive test
to another condition, 37 patients were placed in on all three clinical exams for instability was
the instability group and 45 patients were placed highly predictive of traumatic anterior instabil-
in the non-instability group. Following review of ity. In addition, they recommended performing
preoperative clinical examination findings, the the apprehension sign and the relocation test
investigators calculated a sensitivity of 92 % and before attempting the surprise test since this
a specificity of 89 % for the release test in its abil- maneuver can actually startle the patient and pro-
ity to accurately diagnose shoulder instability. duce abnormal measurements when performing
However, these results should be interpreted with subsequent examinations.
caution due to the retrospective study design, the
use of pain as an indicator for a positive test and
the incomplete description of the surgeons’ 6.10 Testing for Posterior
arthroscopic findings. Nevertheless, the sensitiv- Instability
ity and specificity values calculated by Van
Kampen et al. [22] for the release test were actu- Posterior instability most often results from an
ally quite similar: the sensitivity was calculated to acute traumatic injury, such as a fall onto an out-
be 91.7 % and the specificity was calculated to be stretched hand or, in some cases, following a sei-
83.5 %. Of note, the study by van Kampen et al. zure or an electric shock, that forces the humeral
[122] utilized MRA as the diagnostic gold stan- head to subluxate or dislocate posteriorly as result
dard and did not consider pain as an indicator of a of uncoordinated muscle contraction. Chronic
positive release test. posterior instability can then result through a series
of pathoanatomic changes similar to that which

occurs for anterior instability (discussed above).
Patients who present with either an acute or
chronic posterior dislocation typically hold the
arm internally rotated and slightly abducted since
this position produces the least amount of pain.
Examination under anesthesia usually reveals
adequate external rotation capacity due to the
elimination of pain. Inspection of the shoulder
with a chronic posterior dislocation often reveals
a prominence posteriorly (i.e., the humeral head),
especially in thin patients with minimal overly-
ing soft tissues. On the other hand, this promi-
nence may not be detectable after an acute
posterior dislocation due to significant swelling Fig. 6.39 Posterior apprehension sign. The patient’s arm
and/or spontaneous relocation. is placed at approximately 90° of forward flexion with
slight internal rotation and adduction. An axial load is
applied through the long axis of the humerus, thus forcing
the humeral head to translate posteriorly.
6.10.1 Posterior Apprehension Sign
First mention of the posterior apprehension sign bursa. If the injection resulted in significant pain
presumably occurred in a textbook published in relief, the pain was presumably caused by rotator
1982 by Kessel [134]. According to his original cuff pathology. If the injection did not result in
description, the posterior apprehension sign was pain relief, it was assumed that the pain was
performed by applying an axial load through the related to posterior instability.
humerus via the elbow with the humerus in 90° Although the posterior apprehension sign
of forward flexion, slight internal rotation, and (and its variations) is a commonly used test, its
slight adduction (Fig. 6.39). A positive test diagnostic efficacy and validity have been ques-
occurred when the patient initiated a guarding tioned. Hawkins et al. [93] reported the results of
reflex or complained of apprehension. an electromyographic and photographic analysis
Since its first description, the posterior appre- to determine the position at which the humerus
hension sign has been modified on several occa- was most likely to subluxate or dislocate posteri-
sions. For example, Rowe [135] performed the orly in a series of patients with voluntary poste-
test by applying a posteriorly directed force rior instability. They found that while each
through the long axis of the humerus with the arm patient demonstrated different patterns of insta-
in 90° of forward flexion and slight internal rota- bility, the position of the humerus most condu-
tion (no adduction). A positive test was declared cive to subluxation was actually near the
when the patient experienced apprehension or glenohumeral resting position (or the “loose pack
posterior shoulder pain. O’Driscoll and Evans position”; see Fig. 6.29) which occurs when the
[83] incorporated subacromial injection of local humerus is between 55° and 70° of abduction, in
anesthetic to help differentiate between pain neutral rotation and within the plane of the scap-
resulting from rotator cuff impingement and pain ula (discussed in Chap. 2) [102, 114, 115]. Until
resulting from posterior instability. In their ver- future studies address the clinical utility of the
sion of the test, the arm was flexed to 90°, inter- posterior apprehension sign for the diagnosis of
nally rotated and adducted (similar to the original posterior instability, we cannot recommend its
description by Kessel [134]). When this position use in isolation given the potential for widely
produced pain in the shoulder, the examiner then varying results and the high rates of false positive
injected local anesthetic into the subacromial and false negative findings.
6.10 Testing for Posterior Instability 169
Fig. 6.40 Jerk test. (a) The patient’s arm is placed in 90° rotates the shoulder towards a position of 90° of lateral
of forward flexion, 90° of internal rotation and slight abduction. A positive test occurs when a “clunk” or “jerk”
adduction. The examiner applies an axial force through is felt during this motion as the subluxated humeral head
the long axis of the humerus. (b) The examiner then relocates back into the glenoid fossa.
6.10.2 Jerk Test dictive value (NPV) of 95 % for the jerk test in a
series of 172 painful shoulders; however, these
The jerk test (also known as the clunk test) was values are related to the diagnosis of a posteroin-
originally described by Matsen et al. [136] in ferior labral tear rather than clinical instability. In
1990 as a method used to detect posterior gleno- addition, the investigators used the incidence of
humeral instability. In this test, the examiner posterior shoulder pain as an indicator of a posi-
placed the arm in approximately 90° of forward tive test, regardless of whether a “jerk” occurred
flexion and 90° of internal rotation with the during extension of the humerus. Nevertheless,
humerus slightly adducted. The examiner then the authors noted that posterior instability was
applied a gentle axial force along the long axis of more common in shoulders that demonstrated a
the humerus through the elbow to allow the “jerk” on clinical examination whereas isolated
humeral head to subluxate over the posterior gle- posteroinferior labral tears (without posterior
noid rim. The examiner felt a so-called “jerk” as instability) were less likely to demonstrate a
the humeral head subluxated posteriorly. At this “jerk” on clinical examination.
point, the examiner then moved the shoulder
towards a position of 90° of abduction (i.e., the
humerus was extended from the initial position of 6.10.3 Kim Test
adduction) (Fig. 6.40). During this motion, the
humeral head spontaneously reduced back into The Kim test (developed by Kim et al. [138] in
the glenoid fossa, producing a second “jerk” sen- 2005) was initially used as a method to detect
sation (a positive test). Although we have found posteroinferior labral pathology. In this test, the
this maneuver helpful in the physical diagnosis of patient was placed in a sitting position with
posterior instability, few studies have formally the humerus abducted to approximately 90°.
validated its clinical efficacy despite satisfactory The examiner then used one hand to grasp the
anecdotal reports [137]. In one study, Kim et al. elbow and used the other hand to grasp the proxi-
[137] calculated a sensitivity of 73 %, a specific- mal arm. A strong axial load was applied through
ity of 98 %, a PPV of 88 %, and a negative pre- the long axis of the humerus while the arm was
negative Kim test, 6 shoulders actually did have a

posteroinferior labral lesion (six false negatives).
Based on this data, the sensitivity of the Kim test
was 80 %, the specificity was 94 %, the PPV was
73 %, and the NPV was 96 % with an excellent
inter-observer ICC of 0.96. The results of their
study indicated that the Kim test was more sensi-
tive in the detection of predominantly inferior
labral lesions whereas the jerk test was more sen-
sitive in the detection of predominantly posterior
labral lesions. The combination of tests improved
the overall sensitivity to approximately 97 % for
the detection of posteroinferior labral lesions.
6.10.4 Fukada Test
The first description of the Fukada test occurred

in a textbook published by Neer [139] in 1990.
This test is performed with the patient sitting on
Fig. 6.41 Kim test. The humerus is first laterally the examination table with the examiner standing
abducted to 90°. The examiner then applies and axial load directly behind the patient. The examiner places
through the long axis of the humerus while simultane-
ously adducting the arm to a position of 90° of forward the thumb of each hand in-line with the scapular
flexion. During the adduction maneuver, the examiner can spine with the fingers wrapped around each
also elevate (up to 45° of upward angulation) and lower humeral head. With the thumb of each hand sta-
the humerus (down to the horizontal plane) to stimulate bilizing the scapula, the fingers of each hand are
the posteroinferior and posterior aspects of the glenoid
labrum, respectively. used to apply a posteriorly directed force to the
anterior aspect of the humeral head (Fig. 6.42).
The detected amount of translation is then com-
simultaneously adducted and forward flexed (up pared between the affected and unaffected shoul-
to 45° of upward angulation) (Fig. 6.41). The ders. Although use of this test has been
sudden onset of posterior shoulder pain, regard- documented in the literature, its clinical efficacy
less of whether a “jerk” or a “clunk” occurred, in the diagnosis of posterior instability has not
defined a positive test. The developers also sug- been clearly established [45]. We believe this test
gested that the test could be performed in a chair is most useful in the estimation of posterior
with a solid backing (or supine on the examina- humeral head translation rather than a diagnostic
tion table, as we suggest) to help stabilize the tool for posterior instability.
scapula during axial loading.
The investigators performed a study in which
the diagnostic efficacy of the Kim test was com- 6.10.5 Push–Pull Test
pared to that of the jerk test in the diagnosis of
posteroinferior labral lesions in 172 painful The push–pull test, described by Matsen et al.
shoulders (as mentioned above). Two clinicians [136] in 1990, is a type of load-and-shift test
performed the examinations in order to calculate designed to detect posterior shoulder instability.
inter-observer reliability. In that study, 33 shoul- With the patient supine on the examination table,
ders had a positive Kim test, of which 24 actually the clinician places the humerus in approximately
had a posteroinferior labral lesion (nine false pos- 90° of abduction and 30° of forward flexion. With
itives). Of the remaining 139 shoulders that had a one hand stabilizing the distal arm at the wrist, the
6.11 Testing for Inferior Instability 171
Fig. 6.42 Fukada test.

While standing behind the
patient, the examiner
places their thumbs in-line
with each scapular spine
bilaterally with the fingers
reaching anteriorly over
the humeral head. The
examiner uses their fingers
to apply a posteriorly
directed load to the
humeral head while using
the scapular spine as a
fulcrum. Both shoulders
are tested simultaneously
for comparison.
the diagnostic validity of the push–pull test with

regard to posterior instability or the presence of a
pathologic lesion.
6.11 Testing for Inferior

Instability
Fortunately, inferior dislocations of the humerus

(also known as luxatio erecta humeri) are infre-
quently encountered in clinical practice [140–142].
In most cases, these injuries are the result of high-
energy trauma such as that which occurs in a motor
vehicle accident or a fall from significant height.
As a result, inferior shoulder dislocations are fre-
quently associated with concomitant injuries such
Fig. 6.43 Push–pull test. The patient is positioned supine as fractures (especially greater tuberosity frac-
with the humerus in 90° of abduction slightly anterior to
the scapular plane. The examiner stabilizes the distal arm tures), neurovascular injuries [143–146] and, most
at the wrist or elbow with one hand while the other hand likely, complete rupture of the IGHL complex.
is used to apply a posteriorly directed force through the Patients with inferior dislocations typically present
long axis of the humerus via the elbow. with the arm locked in an abducted, overhead posi-
tion. Closed reduction maneuvers usually involve
other hand is used to apply a posteriorly directed conversion of the injury to an anteroinferior dislo-
force through the long axis of the humerus cation followed by reduction [123, 147, 148].
(Fig. 6.43). Reproduction of pain or apprehension Symptomatic inferior subluxation of the
represents a positive test. At least two cadaveric humeral head is also rarely seen in clinical practice
studies have been performed to evaluate the push– despite the reportedly high prevalence of “inferior
pull test with regard to its ability to produce poste- instability” diagnosed using the sulcus sign (see
rior glenohumeral translation [89, 109]. We are Fig. 6.33). Although Neer [149] clearly indicated
unaware of any clinical studies that have assessed that the reproduction of symptoms related to infe-
Fig. 6.44 Inferior

apprehension. The patient’s
arm is laterally abducted to
90° with the forearm
resting on the examiner’s
shoulder. The examiner
then applies a gentle,
downward pressure on the
proximal humerus to
produce inferior humeral
head translation. Because
of the difficulty in
estimating the amount of
translation, this test should
be performed bilaterally
for comparison.
rior instability was required to produce a “posi- used it to study the effects of scapular inclina-
tive” sulcus sign, most clinicians still adhere to the tion on inferior glenohumeral stability in two
“2 cm rule” as a determinant of the test outcome cadaveric studies. When compared to the sulcus
and, as a result, often incorrectly diagnose patients sign, increased superior scapular inclination
with inferior instability (or multidirectional insta- (i.e., increased abduction angle), as which
bility) despite the lack of symptoms. occurred during the ABIS test, significantly
increased the translational force necessary to
inferiorly dislocate the humerus in each study.
6.11.1 Inferior Apprehension Sign These results were later confirmed by Kikuchi
et al. [17] who also concluded that there was an
Often attributed to Dr. John Feagin, the inferior increased resistance to inferior humeral head
apprehension sign was first mentioned in a text- dislocation when the scapula was angled superi-
book published by Rockwood [64] in 1984 as a orly. Another recent clinical study reached similar
method to assess inferior joint laxity or to detect conclusions [150].
inferior glenohumeral instability, especially in Although there is no evidence to suggest that
very large patients. According to the original the inferior apprehension sign (or the ABIS test)
description, the patient’s arm was abducted to has any clinical utility in the diagnosis of inferior
90° with the forearm resting on the examiner’s instability, the maneuver could feasibly be used
shoulder. The examiner then applied a gentle, as a method to assess laxity of the IGHL com-
downward pressure on the proximal humerus plex. However, it should be noted that the infe-
(Fig. 6.44). The test was considered positive if rior apprehension sign offers no advantage over
the patient became apprehensive or reported the the more traditional sulcus sign in the evaluation
reproduction of symptoms. This maneuver could of glenohumeral laxity and/or inferior stability
also be used to assess joint laxity by estimating and may also produce extreme discomfort in
the degree of inferior humeral head translation those being evaluated following a traumatic dis-
relative to the contralateral shoulder. location. We have limited experience with this
Itoi et al. [15, 16] referred to this test as the test in clinical practice and it remains primarily
Abduction Inferior Stability (ABIS) test and of academic interest.
6.12 Voluntary Instability 173
habitual, muscular, demonstrable, persistent, and

6.12 Voluntary Instability positional. Most individuals with this type of
instability have some form of multiligamentous
Some patients are capable of demonstrating their laxity that (1) allows the arm to be placed in an
ability to subluxate and/or dislocate the glenohu- awkward, unstable position through learned
meral joint at any time they wish. In the litera- asymmetric muscle contraction patterns and (2)
ture, many different terms have been used to allows the humerus to subluxate or dislocate as
describe this type of instability including volun- a result of inherited capsular laxity (Figs. 6.45
tary, volitional, unintentional, non-structural, and 6.46). Patients with voluntary instability very
Fig. 6.45 Clinical photographs of a patient with volun- dislocate posteriorly. (a) The patient elevates the humerus
tary posterior instability utilizing the “push” mechanism to the provocative position and (b) relaxes the posterior
to dislocate the humerus (voluntary positional instability). musculature to allow the humerus to dislocate posteriorly
In this case, the patient has learned the exact position of without experiencing pain or apprehension. (Courtesy of
the humerus that subsequently allows the humeral head to J.P. Warner, MD).
Fig. 6.46 Clinical photographs of a patient with volun- tracts the posterior musculature in order to pull the
tary posterior instability utilizing the “pull” mechanism to humeral head posteriorly out of the glenoid fossa.
dislocate the humerus (voluntary muscular instability). (Courtesy of J.P. Warner, MD).
(a) Beginning with the arm at the side, (b) the patient con-
rarely present with anatomic defects such as poor wound-healing, easy bruising, and visual
Bankart or reverse Bankart lesions. Because only defects should be ascertained to identify potential
a small proportion of these individuals actually risk factors for multiligamentous laxity.
seek medical attention for symptoms related to The physical examination should also adhere
shoulder instability, the prevalence of the condi- to the same principles that have been outlined
tion is still unknown. throughout this book. Inspection, palpation,
Unfortunately, some patients with voluntary range of motion testing, strength testing, and
shoulder instability may seek medical attention neurovascular testing should all be performed to
for reasons involving the potential for secondary generate a solid differential diagnosis before
gain or other psychological issues. This is espe- attempting any provocative maneuvers. Testing
cially true in Workers’ compensation cases in for generalized hyperlaxity is another important
which the patient may claim that their shoulder component of the physical examination in this
instability was somehow related to an occupa- subset of patients (Fig. 6.47) [151]. Assessment
tional hazard. The clinician should be especially of shoulder laxity (as described above) often
weary of patients seeking narcotic medications reveals an extremely abnormal amount of
for their condition and patients reporting early humeral head translation, most commonly in the
failure of surgical treatment in the absence of a absence of anterior or posterior apprehension. In
traumatic injury [135]. However, it is extremely fact, some patients can be completely dislocated
important to recognize that some patients with without showing any evidence of pain or discom-
voluntary instability seek medical treatment fort. Patients who display some degree of appre-
because they actually are functionally disabled as hension with laxity testing and/or instability
a result of their condition. In this scenario, testing are more likely to have an involuntary
patients may be capable of demonstrating the component related to their instability. It is also
instability, however, they often complain that the possible for a patient to sustain a traumatic injury
shoulder also occasionally subluxates or dislo- that converts their instability from a voluntary
cates outside of the patient’s control at inoppor- type to an involuntary type. Although it is more
tune times. difficult to determine the precise nature of the
An accurate assessment of patients who pres- instability in these cases, many of these patients
ent with voluntary instability is often difficult as will experience pain when the clinician forces the
a result of overlapping pathologies, the potential humeral head to translate over the injured area
for secondary gain and, in some cases, abnormal (e.g., Bankart and bony Bankart lesions).
psychology. However, despite these challenges,
the clinician must still perform a thorough,
objective evaluation to determine the correct 6.12.1 Posterior Subluxation
course of treatment.
The clinical evaluation should adhere to the Posterior subluxation or dislocation is the most
same principles that have been outlined through- common form of voluntary shoulder instability
out this book. A patient-centered approach to encountered in clinical practice and result from
history-taking should always be performed learned asymmetric muscle firing patterns that
regardless of the clinician’s initial perception of lead to posterior humeral head translation and
the patient’s reasons for seeking medical treat- subluxation [101, 152]. Pande et al. [152] utilized
ment. In patients with a history of voluntary electromyography (EMG) to evaluate the timing
instability, the clinician should especially ask and sequence of shoulder muscle activation dur-
about the primary direction of instability, the ing both joint subluxation and relocation in four
presence or absence of pain related to the insta- patients with voluntary posterior instability. In
bility and the family history to identify a possible that study, the investigators identified two distinct
predisposition to structural collagen disorders. patterns of muscle firing that led to posterior
Other patient-related historical factors such as humeral head subluxation: a “push” mechanism
6.12 Voluntary Instability 175
Fig. 6.47 Methods to assess generalized ligamentous with the forearm. (c) Passive hyperextension of digits 2–5
laxity [151]. (a) Hyperextension of the metacarpophalan- until parallel with the top of the forearm. (d)
geal (MCP) joint. (b) Thumb abducted to make contact Hyperextension of the elbow.
(with the arm flexed 20–30°) and a “pull” mecha- and subluxate the humeral head. In either case,
nism (with the arm at the side). In the “push” fir- joint relocation was achieved by extending the
ing pattern (also known as voluntary positional arm posteriorly (via contraction of the posterior
instability), near-maximal activation of the ante- deltoid) to lever the humeral head back into the
rior musculature (i.e. the anterior deltoid and glenoid fossa.
biceps brachii muscles) with simultaneous relax-
ation of the posterior musculature (i.e., the infra-
spinatus and posterior deltoid muscles) was 6.12.2 Anterior Subluxation
required to push the humeral head posteriorly
(see Fig. 6.45). Conversely, in the “pull” firing To produce a voluntary anterior subluxation, the
pattern (also known as voluntary muscular insta- patient will typically keep the arm in an adducted
bility), near-maximal activation of the posterior position (i.e., at the side). Simultaneous contrac-
musculature with simultaneous relaxation of the tion of the anterior musculature and extensors
anterior musculature was required to pull the pulls the humeral head anteriorly and out of the
humeral head posteriorly (see Fig. 6.46). Each glenoid fossa [101]. In most cases, the humeral
patient in the study demonstrated scapular wing- head appears to rest in an anteroinferior position
ing and characteristic EMG patterns indicating relative to the glenoid as a result of the unop-
that selective inhibition of the periscapular mus- posed tension generated by the musculature in
culature was necessary to posteriorly translate the anterior arm.
6.12.3 Inferior Subluxation 7. Burkhart SS, De Beer JF. Traumatic glenohumeral

bone defects and their relationship to failure of
arthroscopic Bankart repairs: significance of the
Voluntary inferior subluxation of the shoulder is inverted-pear glenoid and the humeral engaging
extremely uncommon. These patients will inferi- Hill–Sachs lesion. Arthroscopy. 2000;16(7):677–94.
orly translate the humeral head by abducting the 8. Lo IK, Parten PM, Burkhart SS. The inverted pear
glenoid: an indicator of significant glenoid bone
arm overhead and initiating an asymmetric muscle
loss. Arthroscopy. 2004;20(2):169–74.
firing pattern that drives the humeral head directly 9. Saha AK. Dynamic stability of the glenohumeral
downward and out of the glenoid fossa. We are not joint. Acta Orthop Scand. 1971;42(6):491–505.
aware of any studies that have clinically or biome- 10. Sauers EL, Borsa PA, Herling DE, Stanley
RD. Instrumented measurement of glenohumeral
chanically evaluated this small subgroup of
joint laxity and its relationship to passive range of
patients with voluntary inferior instability. motion and generalized joint laxity. Am J Sports
Med. 2001;29(2):143–50.
11. Lee T. Clinical anatomy and biomechanics of the
glenohumeral joint (including stabilizers). In:
6.13 Summary Romeo A, Provencher MT, editors. Shoulder insta-
bility: a comprehensive approach. Philadelphia:
There are numerous static and dynamic stabiliz- Saunders; 2012. p. 3–19.
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inclination, and version: an anatomic study.
tions are particularly complex. This complexity
J Shoulder Elbow Surg. 2001;10(4):327–32.
can produce confusing findings during the physi- 13. Brewer BJ, Wubben RC, Carrera GF. Excessive
cal examination process. However, a working retroversion of the glenoid cavity. A cause of non-
knowledge of the characteristic pathoanatomic traumatic posterior instability of the shoulder.
J Bone Joint Surg Am. 1986;68(5):724–31.
features and patterns of glenohumeral instability
14. Hurley JA, Anderson TE, Dear W, Andrish JT,
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15. Itoi E, Motzkin NE, Morrey BF, An KN. Bulk effect
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Med. 2005;29(1):85–9. Sports Med. 1989;17(5):644–8.
The Acromioclavicular Joint
7
motion (Fig. 7.2) [3]. Therefore, the AC joint

7.1 Introduction must be flexible enough to allow for acromiocla-
vicular motion while also being stiff enough to
When compared to other areas of the shoulder, confer stability. Unconstrained osseous anatomy,
physical examination of the AC joint is more capsular and extra-capsular ligamentous struc-
straightforward given its subcutaneous location— tures, and dynamic muscle contraction function
a factor that facilitates inspection, palpation and, in harmony to maintain the balance between
in some cases, pain localization. In addition, mobility and stability across the AC joint throu-
many of the provocative maneuvers used to diag- ghout the entire range of shoulder motion.
nose AC joint pathologies are more reliable due
to the limited potential for confounding vari-
ables. However, even if the AC joint is the most 7.2.1 Osseous Anatomy
likely source for the patient’s pain, the inciting
etiology is not always clear-cut. A thorough The clavicle is an S-shaped bone that develops
understanding of the anatomy, biomechanics, from three separate ossification centers via an
radiographic features, and relevant physical intramembranous ossification mechanism begin-
examination findings related to the AC joint will ning during the fifth gestational week [4].
ultimately contribute to the generation of an Complete ossification of the clavicle does not
accurate diagnosis, an effective treatment plan, occur until at least 25 years of age and physeal
and a successful clinical outcome. fusion may be delayed until 31 years of age [5–7].
Similarly, the acromion has four centers of ossifi-
cation which fuse together by approximately
7.2 Anatomy and Biomechanics 18 years of age [8]. The fusion sites of these ossi-
fication centers are referred to as the preacromion,
The AC joint represents a complex articulation mesoacromion, and meta-acromion (Fig. 7.3).
between the distal clavicle and the anteromedial In approximately 7 % of individuals, one or more
aspect of the acromion and plays an important of these ossifications centers may fail to fuse,
role in the coordination shoulder motion and producing a defect known as os acromiale which
force transmission between the shoulder girdle is primarily diagnosed with radiographs (Fig. 7.4)
and the axial skeleton (Fig. 7.1) [1, 2]. Because [9]. Bone scans can also be used to detect
the clavicle is linked to the acromion, three- increased metabolism of the bony fragment
dimensional scapular motion requires that the which is closely correlated with the presence of
clavicle also be capable of three-dimensional pain (Fig. 7.5). Because the symptoms related to
184 7 The Acromioclavicular Joint
Coracoclavicular
ligament Clavicle First rib
Acromioclavicular
ligament Anterior sternoclavicular
ligament
Acromion
Costoclavicular
Coracoid process ligament
Sternum
Humerus
Scapula
Fig. 7.1 Illustration showing the basic osseoligamentous responsible for the transmission of forces between the
anatomy of the shoulder girdle. The AC joint is the central axial skeleton and the glenohumeral joint.
coordinator of three-dimensional shoulder motion and is

highlighting the spatial
relationship between the
scapula, clavicle, and
sternum. Note that scapular
motion in any plane
requires a coordinated
motion to occur across
both the AC and SC joints.
os acromiale can mimic those of other painful AC The inclination of the joint surfaces may also be
joint pathologies, patients who present with pain highly variable [13]. When viewed from anteri-
at the top of the shoulder should always be eva- orly, the joint line can range from a vertical orien-
luated for the possibility of os acromiale [8]. tation to nearly 50° of angulation where the
Os acromiale is also frequently associated with articular surface of the distal clavicle overrides
rotator cuff impingement since the deltoid mus- that of the acromion (Fig. 7.7) [14, 15]. Some AC
cle can pull the loosely attached bone downward joints may have an “ellipsoid” shape that may
with arm elevation, thus decreasing the volume limit internal and external scapular rotation, thus
of the subacromial space (Fig. 7.6) [8]. elevating the risk for subacromial impingement
Overall, the mean size of the AC joint is [16]. In most cases, the articular surface of the
approximately 9 mm × 19 mm [10]. However, the acromion is concave whereas the articular sur-
size and shape of the distal clavicle and acromion face of the distal clavicle is convex [13]; both
can vary widely across the population [11, 12]. of these surfaces are initially covered in hyaline
made up of fibrocartilage whereas the lower

portion of the disk is primarily made up of dense
fibrous tissue, possibly reflecting differential
load-bearing across the AC joint [16, 20]. Normal
degeneration of the intra-articular disk begins
during adolescence and progresses through the
fourth decade, at which point the disk has become
a vestigial structure [21–23]. Degeneration of the
intra-articular disk has been associated with oste-
oarthritis of the AC joint; however, this finding is
inevitable since disk degeneration appears to be
nearly universal in normal adults.
Fig. 7.3 Illustration showing the fusion sites for each
ossification center of the acromion. The preacromion,
mesoacromion, and meta-acromion are shown. Os acro-
miale occurs when two of the ossification centers fail to 7.2.3 Capsular and Extra-Capsular
fuse together, sometimes leading to a pseudarthrosis.
Ligaments
The AC joint is surrounded by a fibrous joint

capsule with inward-facing synovial tissue that
facilitates joint mobility by providing adequate
lubrication (see Figs. 7.1 and 7.8). The joint cap-
sule inserts between approximately 3 and 5 mm
lateral to the acromial articular surface and
between approximately 3 and 6 mm medial to the
clavicular articular surface [24]. This capsule is
reinforced by closely integrated and confluent
AC joint ligaments (superior, inferior, anterior,
and posterior), the combined actions of which
primarily resist horizontal displacement, account-
Fig. 7.4 Axillary radiograph of a left shoulder in a patient
with symptomatic os acromiale. ing for up to 50 and 90 % of anterior and poste-
rior stability of the distal clavicle, respectively
[25–27]. More specifically, the superior AC liga-
cartilage (either completely or partially [17]) ment is thought to contribute up to 90 % of the
followed by a slow transformation to fibrocarti- overall strength of the AC joint capsule [82]. In
lage beginning in adolescence [18]. Rockwood addition, the fibers of the deltotrapezial fascia
et al. [19] stated that this transition to fibrocarti- merge and coalesce with those of the superior AC
lage is completed by ages 17 and 24 on the acro- ligament, thus providing even more structural
mial and clavicular joint surfaces, respectively. reinforcement. In contrast, the anterior, posterior,
and inferior AC ligaments have significantly
less tensile strength [28]. In general, the AC joint
7.2.2 Intra-Articular Disk capsular ligaments are responsible for resisting
relatively small horizontal translations of the dis-
An intra-articular disk (i.e., meniscal homologue) tal clavicle relative to the acromion [26].
of widely variable shapes and sizes attaches On the other hand, the coracoclavicular (CC)
firmly to the acromial side of the joint (Fig. 7.8). ligaments are primarily responsible for preventing
The disk functions to disperse the forces associ- large translations of the distal clavicle relative
ated with joint loading and corrects for any joint to the acromion [26]. The CC ligaments include
incongruency. The upper portion of the disk is the conoid (centromedial) and the trapezoid
Fig. 7.5 Positron emission

tomography (PET) scan in
a patient with symptomatic
os acromiale of the right
shoulder. (a) The coronal
sequence demonstrates
increased uptake of the
radioactive tracer at the site
of the os acromiale,
suggesting that the
patient’s pain was most
likely related to the os
acromiale itself instead of
another underlying
pathology. (b) The axial
sequence confirms that
the increased uptake did,
in fact, involve the
mesoacromion.

depicting a possible
mechanism of rotator cuff
impingement in patients
with os acromiale. The
downward pull that the
deltoid imparts upon the
acromion displaces the
unfused bony fragment
downward, thus decreasing
the space available for the
rotator cuff tendons to pass
beneath the acromion as
the humerus is elevated.
(anterolateral) ligaments which travel between The conoid ligament is the primary restraint to
the inferior surface of the distal clavicle and excessive superior translation and rotation of the
the base of the coracoid process (Fig. 7.9). The distal clavicle whereas the trapezoid ligament
conoid and trapezoid ligaments insert approxi- helps prevent excessive anterior–posterior trans-
mately 32.1 and 14.7 mm medial to the articular lation of the distal clavicle and compression of
surface of the distal clavicle, respectively [24]. the AC joint [17, 26, 27]. The CC ligaments
Fig. 7.7 Illustrations showing the variable angulation 25 % of cases, (c) an incongruent joint occurs in approxi-
of the AC joint surfaces when viewed from anteriorly. mately 25 % of cases, and (d) lateral angulation occurs in
(a) Medial angulation occurs in approximately 50 % of approximately 5 % of cases.
cases, (b) a vertical joint line occurs in approximately
Fig. 7.8 Illustration Capsule

highlighting the intra- Articular disc
articular structure of the
Synovial membrane
AC joint. The intra- Clavicle
articular disk typically
adheres to the acromial Acromion
side of the joint. The AC
joint capsule inserts Coracoacromial
between 3 and 5 mm ligament
lateral to the acromial
articular surface and
between 3 and 6 mm
medial to the clavicular
articular surface [24]. Coracoid process
Trapezoid Conoid
ligament ligament
Coracoclavicular
ligament
assume complete responsibility for both horizon- 7.2.4 Dynamic Stability

tal and vertical stability when the AC joint cap-
sule has been disrupted [26, 29]. Therefore, Dynamic stability of the distal clavicle is pro-
dislocation of the AC joint is not possible unless vided by the serratus anterior, upper trapezius,
disruption of the CC ligaments has occurred [18]. and anterior deltoid (see Chap. 3 for a more
Acromioclavicular
ligament Clavicle
Acromion
Conoid
Coracoacromial ligament ligament
Coracoclavicular ligament
Coracoid process Trapezoid
Coracohumeral ligament ligament
Fig. 7.9 The coracoclavicular (CC) ligaments are com- to the conoid ligament and inserts approximately 15 mm
posed of the conoid and trapezoid ligaments. The conoid medial to the articular surface of the distal clavicle.
ligament travels between the coracoid base and the conoid The CC ligaments are responsible for preventing large
tubercle which is centrally located on the inferior aspect displacements of the distal clavicle relative to the
of the clavicle. The trapezoid ligament runs anterolateral acromion.
detailed anatomic description of these muscles). 7.2.6 Joint Motion

Of note, the upper trapezius inserts into the pos-
terosuperior aspect of the distal clavicle and the To achieve normal shoulder motion, the AC joint
medial acromion and its fibers blend into those of must be able of coordinating the unique three-
the superior AC joint ligament. The serratus ante- dimensional motion planes of both the scapula
rior and upper trapezius function in synchrony and the clavicle (Fig. 7.11) [1, 2]. Shoulder eleva-
to optimize the three-dimensional position of the tion requires long-axis rotation (up to 50° [31–34]),
scapula which facilitates glenohumeral stability elevation (up to 15° [35]), and posterior angula-
and supports a large arc of motion. The deltoid tion (i.e., retraction.; up to 30° [35]) of the clavicle
primarily functions to support the weight of the relative to its resting position; however, the AC
arm, thus reducing articular shear forces and joint itself may only be responsible for a portion
reducing tension across the AC joint capsuloliga- of this motion where sternoclavicular (SC) joint
mentous structures [30]. motion makes up the majority of this difference
[35]. More specifically, Ludewig et al. [35] found
that approximately 31° of posterior longitudinal
7.2.5 Neurovascular Anatomy rotation of the clavicle occurred at the SC joint
whereas about 19° of posterior scapular tilt was
The AC joint capsule receives its blood supply allowed across the AC joint. Disruption of the
from small branches derived from the suprascap- AC joint following an acute injury can therefore
ular and thoracoacromial arteries. The joint is result in uncoordinated scapular motion and
innervated by the suprascapular nerve just before global shoulder dysfunction (scapular dyskinesis
it passes beneath the transverse scapular ligament following an AC joint injury is discussed in fur-
(the suprascapular artery travels with the nerve ther detail in Chap. 9).
and passes above the transverse scapular liga- Relative positional changes of the scapula
ment). Branches of the lateral pectoral nerve and the clavicle also require a small amount of
which travel with the thoracoacromial artery also joint translation—up to 6 mm of translation in
provide some joint innervation (Fig. 7.10). any direction [29, 36]. Given the small articular
7.3 Instability of the Acromioclavicular Joint 189
Fig. 7.10 Illustration of Suprascapular Suprascapular

the neurovascular anatomy nerve artery
that supplies the AC joint.
The suprascapular nerve
and lateral pectoral nerve C5
provide the innervation
while the suprascapular C6
artery and thoracoacromial C7
artery provide the blood
supply. C8
T1
Thoracoacromial
artery
Lateral pectoral
nerve
surface area and the high compressive and shear 7.3.2 Physical Examination
forces that are applied to the joint with daily
activities, the AC joint is susceptible to locally 7.3.2.1 Acute AC Joint Injuries
elevated contact stresses which may favor the Patients with acute AC joint injuries will com-
development of osteoarthritis [13]. plain of pain at the top of the shoulder following
a significant impact-type injury to the lateral
shoulder. Examination of the patient in the sitting
7.3 Instability or standing position allows the weight of the arm
of the Acromioclavicular to pull the scapula downward, thus exaggerating
Joint the deformity (if present). Inspection of the
shoulder usually reveals swelling surrounding
7.3.1 Pathogenesis the area of the AC joint. In cases of higher-grade
injuries, an obvious step-off deformity may be
The vast majority of injuries to the AC joint occur present (Fig. 7.13). Patency of the deltotrapezial
during contact sports following an impact to the fascia can be assessed by having the patient shrug
lateral shoulder with the arm in an adducted posi- their shoulders—spontaneous joint reduction
tion (Fig. 7.12). Although much less common, with this maneuver indicates that the deltotrape-
other types of injury mechanisms such as a direct zial fascia is intact (discussed below for grades
blow to the distal clavicle or a fall onto an out- III and V injuries). The clinician should assess
stretched hand (driving the humeral head into the for a concomitant clavicle fracture by palpating
acromion and producing an inferior dislocation) the entire length of the clavicle, beginning at the
are also possible. SC joint and moving towards the AC joint.
a
Superior view Posterior view Lateral view
Posterior Anterior
tilting tilting
External
rotation
Internal
Downward Upward
rotation
rotation rotation
Elevation
Retraction
Posterior
rotation
Protraction
Depression
Fig. 7.11 Illustrations highlighting the three-dimensional the scapula. The kinetic energy from these motions travels
movements of the clavicle and the scapula. Note that any through the AC joint thus resulting in clavicular motion.
scapular motion requires force transmission through the (b) The three-dimensional motion planes of the clavicle
AC joint, leading to clavicular motion and, therefore, SC that are closely coordinated with scapular motion through
joint motion. (a) The three-dimensional motion planes of both mechanical and neuromuscular stimuli.
In most cases, these general physical findings clavicle, and other surrounding structures [17].
lie along a spectrum of severity that are closely Many practitioners prefer to obtain a Zanca view
related to radiographic findings. The Zanca view that includes both shoulders in order to compare
is most often used to evaluate injuries to the AC the amount of distal clavicle displacement
due to its accuracy, excellent diagnostic utility, between the injured and non-injured shoulders
and its ability to identify concomitant clavicle (Fig. 7.14). To objectively assess the amount of
fractures which can sometimes mimic an AC distal clavicle displacement, the CC distance can
joint dislocation, especially in younger patients be measured and compared between shoulders.
with open physes [37, 38]. To obtain this view, Using the same Zanca radiograph, the CC distance
the X-ray beam is centered on the AC joint and is determined by the length of a vertical line that
tilted 10–15° cephalad [39]. It is recommended to begins from the most superior point of the coracoid
decrease the X-ray penetrance by approximately and ends at the most inferior point of the clavicle
50 % to improve visibility of the coracoid, distal (Fig. 7.15). Although “normal” CC distances have
Fig. 7.14 (a) Illustration of the technique used to obtain

a Zanca radiograph. The X-ray beam is aimed directly
Fig. 7.12 Illustration of the most common injury mecha- towards the AC joint with 10–15° of cephalad angulation.
nism resulting in acute AC joint dislocations. Direct The X-ray beam can also be centered on the midline with
impact to the superolateral aspect of the shoulder forces cephalad angulation to obtain an image that includes the
the acromion inferiorly leading to rupture of the AC joint bilateral AC joints. (b) Example of a Zanca radiograph in
capsule and CC ligaments, thus allowing the distal clavi- a patient with an acute grade III AC joint dislocation of the
cle to translate superiorly. left shoulder.
Fig. 7.15 Measurement of the CC distance using a Zanca

radiograph. A vertical line is drawn connecting the most
Fig. 7.13 Clinical photograph of a patient’s left shoulder superior point of the coracoid to the most inferior point of
following an acute AC joint dislocation. This patient had a the distal clavicle. The length of the vertical line represents
grade V injury. the CC distance.
been reported, these raw measurements are highly

variable between individuals due to variations in
anatomy. Therefore, comparisons should be made
using a ratio in which the CC distance of the injured
shoulder is compared to that of the non-injured
shoulder. Bearden et al. [40] suggested that a 25 %
increase in the CC distance of the injured shoulder
probably represents complete disruption of the CC
ligaments. Pre- and postoperative Zanca radio-
graphs of the same patient are helpful to ensure
maintenance of joint reduction following operative
management of an AC joint injury. Of importance,
a normal-appearing CC distance in a patient with
signs, symptoms, and historical features charac-
teristic of an AC joint dislocation should generate
suspicion of a concomitant fracture of the cora-
coid with superior displacement. When a cora-
coid fracture is suspected, a Stryker notch view
should also be obtained. In this radiographic
view, the patient lies supine, places the hand
of the affected extremity on top of the head, and
the technician directs the X-ray beam towards
the coracoid process with approximately 10° of
cephalad angulation (Fig. 7.16).
Although less common, posterior dislocations
of the AC joint can also occur and may appear
normal on standard Zanca radiographs in some
cases. Therefore, in all cases of AC joint instabil-
ity, clinicians should also obtain an axillary view
(or Velpeau axillary view) of the shoulder to iden- Fig. 7.16 (a) Illustration of the technique used to obtain
a Stryker notch view. With the patient supine and the hand
tify posterior displacement of the distal clavicle of the affected extremity placed on top of the head, the
relative to the acromion (Figs. 7.17 and 7.18). X-ray beam is aimed towards the coracoid process with
Tossy et al. [41] and Rockwood [42] developed approximately 10° of cephalad angulation. (b) Example
a classification system for AC joint injuries based of a Stryker notch view obtained in a patient with a sus-
pected coracoid fracture following AC reconstruction.
on anteroposterior (AP), Zanca or axillary radio- The patient presented with loss of reduction following a
graphs (types I–VI, described below [Fig. 7.19]). skiing fall. The image demonstrates displacement of a
This classification system is closely related to cortical fixation button that was placed through a drill hole
injury severity which, in turn, is closely related to in the coracoid to reduce the initial dislocation (arrow).
physical examination findings. However, it should
be noted that up to 30 % of patients with an acute
AC joint injury are likely to have concomitant Type I Injuries
intra-articular injuries [43–45]. Therefore, the Patients with type I injuries typically present
clinical examination should involve an evaluation with mild to moderate pain and swelling over the
of the entire shoulder girdle in all cases to identify AC joint following a traumatic injury; however,
potentially treatable concomitant injuries. there are no visible or palpable deformities of the
Fig. 7.17 (a) The axillary view is obtained with the lateral to the midline). This method ensures that the axil-
patient supine (or standing) and the X-ray cassette posi- lary radiograph is obtained within the plane of the gle-
tioned above the injured shoulder. The shoulder must be noid. (b) The Velpeau axillary view is used when the
sufficiently abducted to allow the X-ray beam to pass patient cannot adequately abduct the arm to obtain the
between the humerus and the thorax. The X-ray tube is standard axillary view. While wearing a sling (e.g.,
positioned inferior to the shoulder and aimed directly Velpeau dressing), the patient is asked to lean backwards
towards the glenohumeral joint at approximately half the to approximately 30° over the X-ray table and cassette.
angle of abduction (e.g., an abduction angle of 30° would The X-ray beam is directed vertically downward towards
require the X-ray tube to be positioned approximately 15° the cassette.
AC joint on clinical examination. In these cases, distal clavicle relative to the acromion. Horizontal
shoulder motion does not consistently generate instability, which can be detected by manually
increased pain at the AC joint. Radiographically, grasping the clavicle and applying an anterior–
although some soft-tissue swelling may be pres- posterior pressure, may be present in some type
ent, the distal clavicle appears aligned with the II injuries. AP or Zanca radiographs may show
acromion without any significant increase in slight superior displacement of the distal clavicle;
the measured CC distance when compared to the however, there is no significant difference in CC
contralateral shoulder (Fig. 7.20). According to distances between the injured and non-injured
the original classification, type I injuries repre- shoulders (Fig. 7.21). In type II injuries, the AC
sent a sprain of the capsuloligamentous structures capsuloligamentous structures are torn which
without disruption of any associated structural allows the clavicle to migrate superiorly; how-
ligaments. ever, the CC ligaments remain intact.
Type II Injuries Type III Injuries

Type II injuries are characterized by moderate to Patients with type III injuries usually present
severe pain over the AC joint which usually in moderate to severe pain with the arm in an
increases when shoulder motion is initiated. adducted position and the weight of the arm
Palpation of the AC joint often reveals moderate supported either by a sling or the uninjured arm
swelling and slight superior migration of the to help provide pain relief. The joint is tender to
the injured AC joint by having the patient shrug

their shoulders indicates that the deltotrapezial
fascia is intact. If shrugging does not reduce the
joint, the deltotrapezial fascia has been ruptured
which usually signifies a type V injury [17].
Type IV Injuries
Type IV injuries are characterized by complete
posterior dislocation of the distal clavicle which
typically pierces or punctures the fascia of the
trapezius muscle. Patients with type IV injuries
often present with severe swelling and pain local-
ized to an area posterior to the medial acromion.
In some cases, the distal clavicle may also
produce skin tenting posteriorly. Evaluation of
Zanca radiographs may reveal mild superior
displacement whereas the axillary view will
show significant displacement of the distal clavi-
cle posteriorly, possibly making contact with the
anterior aspect of the scapular spine (Fig. 7.23).
Although infrequent, type IV AC joint injuries
Fig. 7.18 (a) Normal-appearing Zanca radiograph of the
left AC joint in a patient with pain at the top of the shoul-
can occur in combination with an anterior dislo-
der following an acute injury. Note the normal alignment cation of the medial clavicle at the SC joint, thus
between the distal clavicle and the acromion. (b) Axillary producing a “floating clavicle” (Fig. 7.24). There-
radiograph of the same shoulder demonstrating posterior fore, the clinician should also examine the SC
displacement of the distal clavicle (outlined in white) rela-
tive to the acromion (outlined in red) that was not detect-
joint for any signs of instability in cases where a
able on the Zanca view. type IV AC joint injury is suspected (details
regarding examination of the SC joint are
presented in Chap. 8).
palpation and an obvious deformity is usually
present which represents significant superior Type V Injuries
displacement of the distal clavicle. Manipulation Patients with type V injuries present similarly to
of the clavicle would reveal both horizontal and those with type III injuries; however, the degree
vertical instability although significant guarding of pain, swelling, and deformity are markedly
is usually present in the clinical setting. Radiogra- more severe. Type V injuries are characterized by
phically, the clavicle will appear superiorly dis- >100 % superior displacement of the distal clav-
placed relative to the acromion by approximately icle on Zanca radiographs, increased scapular
100 % the width of the distal clavicle (Fig. 7.22). protraction and more severe soft-tissue injuries
It should be recognized that the distal clavicle when compared to type III injuries (Fig. 7.25).
actually does not translate superiorly by a large Disruption of the deltotrapezial fascia is a hall-
amount—much of this superior displacement is mark for type V dislocations and may generate
related to the weight of the arm which pulls the radiating pain towards the side of the neck along
acromion inferiorly relative to the clavicle. This the superior margin of the trapezius muscle.
injury pattern requires complete disruption of
both the AC joint capsule and the CC ligaments Type VI Injuries
while the deltotrapezial fascia remain intact. Type VI AC joint injuries are inferior disloca-
A shrug test has been described to differentiate tions in which the distal clavicle may end up in
type III and V injuries. In this test, reduction of the subacromial space or beneath the coracoid
Fig. 7.19 Rockwood classification of AC joint injuries. 100 % the width of the distal clavicle; Type IV = disloca-
Type I = sprain of the AC joint capsule; Type II = rupture of tion with posterior displacement that often punctures the
the AC joint capsule with possible sprain of the CC liga- trapezial fascia; Type V = dislocation with superior dis-
ments; Type III = rupture of the CC ligaments (i.e., dislo- placement of >100 % of the width of the distal clavicle;
cation) with superior displacement equal to approximately Type VI = subcoracoid dislocation.
Fig. 7.20 Zanca

radiograph demonstrating a
right type I AC joint injury.
process following a severe hyperabduction injury 7.3.2.2 Chronic AC Joint Injuries

(see Fig. 7.19). These dislocations are infreque- Although controversy exists regarding the pre-
ntly encountered in clinical practice, although cise definition of “chronic” following an AC joint
they can be observed following polytraumatic injury (usually ranges between 30 and 90 days
events such as high-speed motor vehicle acci- post-injury), we prefer to assign the term
dents [46–50]. Subcoracoid dislocations may “chronic” to injuries in which inflammation, ten-
also involve neurovascular symptoms given the derness, and disability have begun to subside as
proximity of the brachial plexus and surrounding the patient returns to their normal activities.
vessels; however, symptoms usually resolve Based on anecdotal evidence and clinical experi-
following joint reduction. ence, we estimate that 20–30 % of patients who
are treated nonoperatively for an acute AC joint distal clavicle should be evaluated for occult
injury will experience continued symptoms and instability which can exacerbate the progression
seek further treatment at some point, although the of AC joint degeneration (discussed below).
timing is generally unpredictable. Patients with
chronic AC joint injuries who return for clinical Distal Clavicle Manipulation
evaluation should be thoroughly evaluated for Although the technique has only been described in
possible sequelae such as scapular dyskinesis patients who underwent previous distal clavicle
(see Chap. 9), rotator cuff disease (see Chap. 3), excision (i.e., no traumatic AC joint injuries
and osteoarthritis of the AC joint (discussed involved) [52], manipulation of the distal clavicle
below). In addition, concomitant injuries such as can be performed to evaluate increased anterior–
labral tears and superior labral anterior to poste- posterior or superior–inferior translation of the
rior (SLAP) tears may occur in up to 30 % of distal clavicle relative to the acromion in cases
acute high-grade AC joint dislocations [43, 44, of chronic AC joint instability. To perform this
51]—the symptoms related to these injuries may maneuver, the clinician places one hand on the lat-
have never resolved through nonoperative treat- eral shoulder for stability and uses the fingers and
ment or non-treatment. In all of these cases, the thumb of the other hand to grasp the mid-shaft of
the clavicle. From this position, the distal clavicle
can be translated anteriorly, posteriorly, superiorly,
and inferiorly when AC joint instability is present
(Fig. 7.26). The test should be repeated on the con-
tralateral shoulder for direct comparison. Although
there is no precise definition of what constitutes a
“positive” test, the original investigators did find
that increased translational distances were highly
correlated with increased pain. This finding sug-
gests that the pain related to increased distal clavi-
cle translation may be a primary contributor
to poor operative and nonoperative outcomes in
some patients. This technique is only useful in the
setting of a chronic AC joint injury, prior AC
reconstruction, or prior distal clavicle excision
since those with acute injuries usually exhibit
significant apprehension and guarding due to pain
and swelling. In addition, manipulating the clavi-
Fig. 7.21 AP radiograph of a right shoulder in a patient cle in the acute setting could displace a previously
with an acute type II AC joint injury. unidentified clavicle fracture.
Fig. 7.22 Zanca

a left type III AC joint
dislocation.
7.4 Osteoarthritis of the Acromioclavicular Joint 197
7.4 Osteoarthritis
of the Acromioclavicular
Joint
7.4.1 Pathogenesis
7.4.1.1 Post-traumatic Osteoarthritis

Although many patients become asymptomatic
with the passage of time, symptoms related to a
previous AC joint injury may reappear in the form
of post-traumatic osteoarthritis many years after
the initial injury. It is presumed that nonoperative
treatment of the initial injury (or non-treatment
Fig. 7.23 Axillary radiograph demonstrating posterior when patients do not seek medical attention)
displacement of the left distal clavicle (outlined in white) allows repetitive micromotion and elevated shear
relative to the acromion (outlined in red). This image is
diagnostic for a type IV AC joint dislocation.
stresses to occur across articular surfaces during
shoulder motion until joint destruction leads to
the development of pain (Fig. 7.27) [53]. In addi-
tion, many patients with chronic AC joint disloca-
tions display evidence of scapular dyskinesis
[54–56] which may increase the risk for other
conditions such as rotator cuff impingement.
Therefore, these patients should also undergo a
complete evaluation of scapular motion through-
out the course of their treatment, especially in
those with chronic dislocations who complain
non-AC joint-related shoulder pain (scapular dys-
kinesis is discussed in Chap. 9).
7.4.1.2 Repetitive Microtrauma

Repetitive microtrauma is also an important cause
Fig. 7.24 CT scan with 3-D reconstruction of the right of chronic AC joint degeneration and, similar to
shoulder demonstrating a type IV AC joint dislocation
with a concomitant anterior SC joint dislocation (com- post-traumatic osteoarthritis, is mostly attributed
monly referred to as a “floating clavicle”). to abnormally high stresses placed upon the distal
Fig. 7.25 Zanca

a left type V AC joint
dislocation.
intra-articular disk which occurs with normal

aging. Several authors have suggested that the
intra-articular disk is almost always non-
functional beyond 40 years of age [21–23].
Symptomatic disk degeneration is usually obser-
ved in patients over 50 years of age; however, the
degenerative process may begin during adoles-
cence [21] and it is unknown when symptoms
begin to occur, if they occur at all [63]. In fact, a
study by Stein et al. [64] found that up to 93 % of
asymptomatic patients over 30 years of age had
MRI evidence of AC joint osteoarthritis. Similar
results were found by Needell et al. [65] in which
75 % of asymptomatic volunteers had AC joint
osteoarthritis as evidenced by MRI (Fig. 7.28).
7.4.1.4 Inflammatory Arthropathies

Similar to other synovialized joints, the AC joint is
Fig. 7.26 Distal clavicle manipulation. The examiner also susceptible to inflammatory arthropathies
places one hand over the lateral shoulder to stabilize the such as rheumatoid arthritis [66] and psoriatic
upper torso and uses the fingers and thumb of the other
hand to grasp the mid-shaft of the clavicle. When instabil- arthritis [67] along with crystal deposition diseases
ity is present, the distal clavicle can then be translated such as gout and pseudogout [68, 69]. Patients
anteriorly, posteriorly, superiorly, and/or inferiorly. with inflammatory arthropathies typically present
with pain over the AC joint in the presence of
clavicle which increases the rate of bone turnover warmth, redness, swelling, and fever. Infectious
in the area. As a result of this remodeling process, etiologies related to the AC joint, such as osteo-
joint surfaces become incongruent and the articu- myelitis and septic arthritis, can occur due to
lar cartilage degenerates due to abnormally hematogenous spread or direct inoculation (such
elevated contact stresses and shear forces. Distal as during a joint injection) and may be related to
clavicle osteolysis most commonly occurs in immunocompromised [70, 71]. Infection should
those who regularly perform bench press exer- always be ruled out before any treatment interven-
cises [57], possibly as a result of repeated maxi- tions are undertaken.
mal contraction of the clavicular head of the
pectoralis major muscle which may lead to the 7.4.1.5 Synovial Cysts
development of small stress fractures within Synovial cysts can occur near the AC joint and
the subchondral bone of the distal clavicle and may be associated with various AC and glenohu-
subsequent bony remodeling [58, 59]. Although meral joint arthritides along with massive rotator
this diagnosis is difficult to distinguish from post- cuff tears (Fig. 7.29) [72]. Although painless, these
traumatic osteoarthritis due to similar symptoma- cysts can be alarming for some patients since the
tology, physical examination findings, and imaging lesion may enlarge very rapidly. According to
findings [60–62], surgical resection of the AC Hiller et al. [72], a type 1 cyst is isolated to the AC
joint is usually indicated for either case when non- joint and probably involves overproduction of
operative treatment fails to relieve the patient’s synovial fluid in response to degenerative changes.
symptoms. Type 2 cysts occur as a result of anterosuperior
humeral head migration (as in some cases of mas-
7.4.1.3 Advancing Age sive rotator cuff tears) which produces damage to
Osteoarthritis of the AC joint can also develop as the posteroinferior aspect of the AC joint capsule
an atraumatic, age-related phenomenon that is and the anterosuperior glenohumeral joint capsule.
most often associated with degeneration of the With concomitant synovial fluid overproduction
Close-up view of joint
Articular cartilage
Bone
During injury
Twisting forces crush

cartilage fibers Fig. 7.28 MRI of the right shoulder in a 30-year-old
male with posterior glenohumeral instability. In this case,
degeneration of the AC joint (arrow) was an incidental
finding. The patient’s AC joint was painless throughout
the physical examination.
synovial cyst. Lesions should be illuminated to

Post-traumatic arthritis confirm its cystic appearance before aspiration
since solid tumors in this area have been reported
Exposed bone
in the literature [73, 74]. These painless cysts may
Loose bony formation
fluctuate in size over a period of time and, espe-
floating in fluid cially in cases of cuff arthropathy, cysts may reap-
Osteophyte pear after aspiration since due to the existence of
Sclerosis of bone a persistent communication tract between the AC
and glenohumeral joints.

Fig. 7.27 Illustration showing the progression of post-
traumatic degenerative osteoarthritis of the AC joint. The In contrast to acute injuries, chronic pain related
initial articular cartilage injury creates a catabolic bio- to the AC joint can have numerous etiologies and
chemical environment that is exacerbated by repetitive determining the correct diagnosis can sometimes
micromotion. Uneven articular surfaces create stress ris-
ers that are subjected to elevated shear stresses when
be difficult. The spectrum of AC joint disease
motion occurs, thus accelerating cartilage degeneration. can produce symptoms that often overlap with
The joint may eventually become eburnated with charac- other common shoulder conditions. While some
teristic radiographic findings of osteoarthritis such as a patients may present with global, diffuse shoul-
narrowed joint space, subchondral cysts, subchondral
sclerosis, and osteophytosis.
der pain and dysfunction, others may only have
mild point tenderness located precisely at the AC
joint. In addition, physical examination findings
by the glenohumeral joint as a result of cuff can also be confusing since many provocative
arthropathy, synovial fluid can then transfer testing maneuvers designed for other types
between glenohumeral and AC joint compart- of pathologies can induce AC joint pain. How-
ments, thus potentially producing an AC joint ever, motion-dependent AC joint pain is mostly
Fig. 7.29 (a) Synovial cyst involving the AC joint. (b) Distal clavicle hypertrophy. These entities can be differentiated
by palpation and illumination.
induced by scapular motion when the humerus is pain and dysfunction. This step is important since
either extended or elevated above approximately other shoulder conditions may actually be identi-
90° (see Chap. 2 for further details regarding fied as primary symptomatic lesions. Pain associ-
isolated glenohumeral versus combined gleno- ated with rotator cuff disease is perhaps the most
humeral and scapulothoracic motion). Thus, common contributor and may be perceived by
patients who experience pain mostly during the patient as involving the superior aspect of the
simultaneous scapular motion are more likely to shoulder. Impingement signs may also be posi-
have AC joint pathology than patients who expe- tive since all of these tests involve overhead
rience pain throughout the entire range of motion. motion which requires motion to occur across the
Possible exceptions include those with inflamma- AC joint. While pain related to rotator cuff dis-
tory or infectious conditions in which AC joint ease and the AC joint often occur simultaneously,
pain is not motion-dependent. it is important to determine which condition is
Perhaps one of the more important methods the primary instigator since the treatment options
used in the physical diagnosis of AC joint pathol- for each can vary significantly. SLAP tears are
ogies is simple observation of the patient’s shoul- also commonly identified in patients with AC
ders. Although there is a wide range of variation joint-related pain and may be related to a previ-
in AC joint anatomy, comparison of the overall ous traumatic injury, such as an AC joint dislo-
contour of each AC joint can often provide a cation, for which the patient has developed
helpful hint (Fig. 7.30). Although not diagnostic, symptomatic post-traumatic osteoarthritis [43,
relative prominence of one AC joint relative the 44, 51]. The quality and distribution of pain
other may direct the clinicians towards a more related to SLAP tears frequently overlaps that of
thorough examination of the AC joint, especially AC joint pain which can therefore complicate the
if the prominence is located on the symptomatic diagnosis. Patients with cervical spine diseases,
side. As mentioned above, there are numerous such as zygoapophyseal joint degeneration and/
potential causes of a prominent AC joint such or nerve root irritation, may also complain of
as osteoarthritis, synovial cysts, tumors, chronic superior shoulder pain—however, this type of
dislocations, and many others and therefore pain is often dependent on the position of the
may necessitate full examination and diagnostic neck and is usually localized to the superior
imaging. border of the trapezius muscle. Spurling’s test,
Before making the physical diagnosis of a among other provocative cervical spine maneu-
chronic AC joint pathology, it is important to vers, can be used to successfully differentiate
rule in or out other potentially coexistent between shoulder pain and neck pain and is dis-
conditions that may contribute to the patient’s cussed in Chap. 10.
7.4.2.1 Distal Clavicle Manipulation

As mentioned above, the clavicle can be manipu-
lated by simply using one’s thumb and fingers to
grasp the mid-shaft of the clavicle and translate
the joint anteroposteriorly and superoinferiorly
(see Fig. 7.26) [52]. This can be a useful method
to help solidify the diagnosis of occult AC joint
instability. In addition, the clavicular motion
produced by the examiner may induce a certain
degree of painful sheer across the joint when
chronic instability has led to post-traumatic
osteoarthritis. This technique has not been evalu-
ated for its diagnostic utility; however, we find it
is helpful to determine the nature and mechanism
of the patient’s pain.
7.4.2.2 Paxinos Test

The Paxinos test was first described by Walton
Fig. 7.30 Observation of both shoulders is important to
et al. [75] in 2004 and is functionally similar to identify any evidence of asymmetry.
clavicle manipulation when evaluating the joint
for osteoarthritis. In this test, the examiner places
their hand over the top of the symptomatic shoul- 7.4.2.3 Cross-Body Adduction Test
der with the thumb overlying posterior aspect of In 1951, McLaughlin [77] noted that many
the acromion and the fingers resting over the patients with AC joint pathologies developed a
anterior aspect of the distal clavicle. The exam- sharp pain at the top of the shoulder when the arm
iner then squeezes the top of the shoulder which was actively adducted across the chest and
essentially forces the distal clavicle posteriorly towards the contralateral shoulder. The clinician
and the acromion anteriorly (Fig. 7.31). Pain in may also palpate the AC joint during this maneu-
the area of AC joint with this technique is con- ver to localize the source of the patient’s pain. To
sidered a positive test and may indicate joint confirm the diagnosis of AC joint-related pain,
degeneration. The original investigators calcu- McLaughlin then injected the joint with local
lated a sensitivity of 82 % and a specificity of anesthetic—when repetition of the test following
50 %; however, the presence of a positive bone this injection was painless, it was determined that
scan significantly increased the post-test pro- AC joint compression was causative and distal
bability of AC joint-related pain. Yelland [76] clavicle excision was recommended to alleviate
obtained similar results when bone scans were the patient’s symptoms.
used to help solidify the diagnosis. A potential Several years later, Moseley [78] described a
variation of this test involves the clinician using modified version of this test in which the patient
the heels of their clasped hands to squeeze the was asked to actively place the arm in a position
clavicle posteriorly and the scapular spine ante- of adduction as described by McLaughlin [77].
riorly (Fig. 7.32). Although no studies have eval- The clinician would then apply an additional pas-
uated this modified technique, we suspect that sive force to the patient’s elbow which effectively
the sensitivity and specificity values are similar increased the amount of adduction and AC joint
to those for the Paxinos test which requires compression (Fig. 7.33). Although this version of
ancillary maneuvers to confirm the suspected the test has not been validated by any study, it
diagnosis. may be a useful adjunct to detect more subtle
forms of AC joint-related pain when the diagnosis

is unclear.
While there are many studies that have used
the cross-body adduction test as a method of
diagnosis, very few studies have been conducted
with the purpose of evaluating the diagnostic
utility of the cross-body adduction test in patients
with and without AC joint pain. Maritz and
Oosthuizen [79] studied the test in a series of
22 patients with AC joint pain and calculated a
sensitivity of 100 % using joint injection as the
diagnostic standard. Chronopoulos et al. [80] eval-
uated the clinical efficacy of the test in 35 patients
who later underwent distal clavicle excisions.
In that study, the sensitivity was 77 %, the speci-
ficity was 79 %, the positive predictive value
(PPV) was 20 %, and the negative predictive
value (NPV) was 98 %.
7.4.2.4 Active Compression Test

The active compression test was first described
by O’Brien et al. [11] in 1998 as a method to
detect either SLAP tears or AC joint pathologies.
To detect AC joint pain, the test is performed
Fig. 7.31 Paxinos test. The examiner places one hand over exactly as described for SLAP tears in Chap. 5
the patient’s shoulder with the thumb over the scapular although the resulting pain is primarily localized
spine and the fingers over the distal clavicle. The scapula to the superior shoulder near the AC joint
and the clavicle are gently squeezed together, thus translat- (the resulting pain in patients with SLAP tears is
ing the clavicle posteriorly relative to the acromion.
usually located “deep inside” the glenohumeral
joint). Briefly, the patient’s arm is flexed to
approximately 90°, adducted 10–20° and inter-
nally rotated until the thumb points towards the
floor. The clinician first applies a downward
force to the top of the forearm while the patient
resists. The patient then turns the palm upward
and the clinician applies the same downward
force in this position (Fig. 7.34). Pain with the
first maneuver that is relieved by the second
maneuver signifies a positive test although, as
mentioned, the pain distribution in those with
SLAP tears is primarily deep within the glenohu-
meral joint whereas pain related to AC joint
pathology would be localized to the top of the
shoulder. The original investigators studied the
test in 318 patients (62 of which had AC joint
Fig. 7.32 Modified technique to produce AC joint shear- pain) and found a sensitivity of 100 %, a specific-
ing. The examiner places the heels of their clasped hands
ity of 96.6 %, a PPV of 89 %, and an NPV of
over the distal clavicle anteriorly and the spine of the
scapula posteriorly. The clavicle and the scapula are 100 %. On the other hand, the more recent inde-
squeezed together to produce joint shearing. pendent study by Chronopoulos et al. [80] calcu-
7.5 Conclusion 203
Fig. 7.33 Cross-body adduction test. The patient’s arm is the AC joint can also be performed. This test should be
placed in a position of 90° of forward flexion. With the avoided in patients with known subscapularis pathology
palm facing downward, the arm is slowly horizontally as this position may also produce pain related to subscap-
adducted towards the contralateral shoulder. Palpation of ularis impingement beneath the coracoid process.
lated a sensitivity of 41 %, a specificity of 95 %, tance is applied by the patient. Chronopoulos

a PPV of 29 %, and an NPV of 97 %. Therefore, et al. [80] calculated a sensitivity of 72 %, a
combination of the test with other provocative specificity of 85 %, a PPV of 20 %, and an NPV
maneuvers may be helpful in the diagnosis of AC of 98 %. Similar to the active compression test,
joint pathology. As with any other clinical it is recommended to use this test in combina-
maneuver, the results of this test can be con- tion with other maneuvers to help improve diag-
founded by other concomitant pathologies which nostic accuracy. We are unaware of any other
may produce similar pain distributions. studies that have evaluated the clinical utility of
this test in the diagnosis of AC joint pain.
7.4.2.5 Resisted Arm Extension Test
The resisted arm extension test was first
described by Jacob and Sallay [81] in 1997 as a 7.5 Conclusion
method to detect pain within the AC joint. In this
test, the humerus is flexed to 90°, the elbow is An understanding of the anatomy and biome-
flexed 90°, and the arm is internally rotated such chanics of the AC joint is required to arrive at the
that the forearm is positioned along the horizon- correct diagnosis. This knowledge, in addition
tal plane. The clinician places one hand over the to a thorough history, will guide the clinician
posterior scapula to stabilize the torso and uses towards the selection of high-yield diagnostic
the other hand to apply a medially directed force tests such as provocative physical examination
to the elbow at the olecranon while the patient maneuvers and appropriate imaging modalities.
provides resistance (Fig. 7.35). The test is con- An evidence-based approach improves the like-
sidered positive when pain is produced at the top lihood that an accurate diagnosis and effective
of the shoulder near the AC joint when resis- treatment plan will be produced.
Fig. 7.34 Active compression test. (a) With the patient force to the distal arm while the patient provides resistance.
standing, the humerus is forward flexed to 90° with appro- (b) The test is repeated with the palm facing upward.
ximately 10° of horizontal adduction and the thumb Characteristic pain with the first maneuver that is relieved
pointed downward. The examiner then applies a downward by the second maneuver indicates a positive test.
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The Sternoclavicular Joint
8
evaluated for both ligamentous integrity and

8.1 Introduction patency of the medial clavicular physis.
The SC joint is a diarthrodial joint lined with
The sternoclavicular (SC) joint is a complex artic- synovium that primarily functions to connect the
ulation that can have significant anatomic varia- shoulder girdle to the axial skeleton (Fig. 8.1).
tions within individuals, between individuals, and Because the articular surface of the medial clavi-
throughout a population. Nevertheless, the inher- cle is highly incongruent with the manubrium,
ent stability and biomechanics of the SC joint joint stability is maintained primarily by strong
remain relatively unchanged. While an acute trau- ligamentous attachments. Specifically, the articu-
matic injury can lead to an anterior or posterior lar surface of the medial clavicle is much larger
SC joint dislocation, repetitive micromotion and than that of the manubrium and has been described
shear can lead to degenerative changes which as having a “saddle-like” configuration (i.e., con-
may produce chronic symptomatology. Clinicians cave in the axial plane and convex in the coronal
should be familiar with the anatomy, biomechan- plane) which biomechanically functions similarly
ics, and process of diagnostic evaluation in to a ball-and-socket joint (Fig. 8.2) [4, 5].
patients with pain or disability related to the SC Both the manubrium and the medial clavicle
joint such that an accurate diagnosis and effective can have a variety of different anatomic configu-
treatment modality can be chosen. rations which may vary across populations,
between genders and, potentially, within the same
patient [6, 7]. Tuscano et al. [7] quantified this
8.2 Relevant Anatomy asymmetry in a series of 104 patients who had
and Biomechanics previously undergone a computed tomography
(CT) scan of the chest for other reasons. In their
8.2.1 Osseous Anatomy study, the investigators measured joint spaces and
the maximum diameter of the medial clavicular
Although the clavicle is the first bone to ossify head in each patient. Overall, joint spaces ranged
(fifth gestational week), the medial clavicular from 0.2 to 1.37 cm across the study population
physis typically does not close until at least 25 and medial clavicular head diameters ranged
years of age. In fact, some studies have shown from 1.2 to 3.7 cm. Interestingly, some patients
that physeal closure may not actually occur until displayed differences in medial clavicular head
31 years of age in some patients [1, 2]. Therefore, diameters between their right and left clavicles
patients younger than 31 years of age who pres- (range, 0.0–1.0 cm difference). Other authors
ent with possible SC joint dislocations should be have found that the manubrium may also be sub-
210 8 The Sternoclavicular Joint
Fig. 8.1 Illustration highlighting the important structural components of the SC joint. (From Martetschläger et al. [3];
with permission).
Clavicle Convex
Concave
Concave
Convex
1st rib
Manubrium
2nd rib
Fig. 8.3 Approximately two-thirds of the medial clavicle
is covered with articular cartilage. The forceps point to the
pectoralis ridge which may be an important landmark for
surgical orientation. (From Warth RJ, Lee JT, Millett
PJ. Anatomy and biomechanics of the sternoclavicular
Fig. 8.2 The articular surfaces of the sternum and medial joint. Oper Tech Sports Med. 2014;22(3):248–52; with
clavicle are incongruent, although the medial clavicle permission).
typically exists in a “saddle” configuration (i.e., concave
in the axial plane and convex in the coronal plane).
increasing age [9]. Recent dissections performed
ject to significant anatomic variation [8]. As a at this institution revealed that only approxi-
result, osseous asymmetry of the SC joint should mately two-thirds of the medial clavicle was cov-
be expected in the clinical setting to prevent mis- ered with articular cartilage: the majority of this
diagnoses and unnecessary surgery. cartilage was found anteriorly and inferiorly
where the medial clavicle was devoid of capsulo-
ligamentous attachments (Fig. 8.3). This finding
8.2.2 Chondral Surfaces has also been confirmed by others [10]. We also
identified a previously undescribed ridge that
The articular surfaces of the medial clavicle and traveled along the superior aspect of the clavicu-
the manubrium are covered with hyaline carti- lar head of the pectoralis major insertion site
lage that eventually become fibrocartilage with [11]. This “pectoralis ridge” may prove to be
8.2 Relevant Anatomy and Biomechanics 211
8.2.3.2 Costoclavicular Ligament

The costoclavicular ligament is a thick, robust
fibrous band that inserts across the costochondral
junction of the first rib and travels towards the
inferior aspect of the medial clavicle to insert on
the costoclavicular tubercle (see Fig. 8.1) [11].
The ligament is commonly described as being
composed of two separate fascicles (anterior and
posterior) oriented in a “twisted” configuration
with an interposed bursa spanning between the
first rib and the medial clavicle [14]. However,
Fig. 8.4 The forceps point to the pectoralis ridge of the
medial clavicle. The ridge extends from the tip of the for-
our recent cadaveric dissections revealed that the
ceps medially towards the articular surface. costoclavicular ligament may actually exist as a
single ligament since we were unable to identify
or separate the previously described anterior and
an important landmark for orientation during posterior fascicles [11]. The costoclavicular liga-
arthroscopy or rotational alignment during open ment may be the most important ligamentous sta-
reconstructive procedures (see Figs. 8.3 and 8.4). bilizer of the SC joint in both the vertical and the
horizontal axes [14, 15].
8.2.3 Ligamentous Anatomy 8.2.3.3 Interclavicular Ligament

The interclavicular ligament is a thick, fibrous
As mentioned above, the articular surfaces of the band that lies over the superior aspect of the
SC joint are highly incongruent and rely primar- manubrium as it runs between the superomedial
ily on the patency of static capsuloligamentous aspect of each SC joint capsule (see Fig. 8.1)
structures to maintain stability. These structures [11]. Despite its anatomic position and thickness,
include the capsular ligaments, costoclavicular the interclavicular ligament actually does not sig-
ligament, interclavicular ligament, and the intra- nificantly contribute to vertical stability of the SC
articular disc ligament. joint. Although we were able to identify the liga-
ment in all of our recent cadaveric dissections, its
8.2.3.1 Capsular Ligaments attachments to the manubrium and the SC joint
Integrated within the SC joint capsule are dis- capsules are quite weak and could potentially be
crete thickenings that represent the anterior and removed during the reflection of overlying soft
posterior capsular ligaments. The anterior capsu- tissues [11].
lar ligament runs from an area just superior to the
articular cartilage of the medial clavicle to an 8.2.3.4 Intra-Articular Disc
area just superior to the articular cartilage of the Ligament
manubrium. The posterior capsular ligament is The intra-articular disc ligament attaches near the
essentially a thickening of the entire posterior chondral junction of the first rib, passes through
capsule and spans between the posterosuperior the SC joint (thus creating two separate joint
aspect of the medial clavicle to the posterior spaces), and inserts along the superior margin of
aspect of the manubrium. Several studies have the articular cartilage of the medial clavicle (see
shown that the posterior capsule is most impor- Fig. 8.1). This ligament does not confer joint sta-
tant for the maintenance of horizontal stability, bility. Rather, it probably functions to diminish
thus preventing anterior and posterior translation the force transmission between the manubrium
of the medial clavicle [12, 13]. The anterior cap- and the medial clavicle which is thought to
sular ligament most likely plays a secondary role decrease the detrimental effects of bony incon-
in the maintenance of horizontal stability. gruity on the health of the articular surfaces [9,
16, 17]. The morphology of the intra-articular 8.2.4 Mediastinal Vessels

disc has also been shown to vary considerably
between individuals. Although DePalma [9] Traumatic injuries to the SC joint can result in
found the intra-articular disc to be complete in severe complications due to the proximity of the
97 % of his specimens, others have found that as mediastinal vessels, especially in those with poste-
many was 52 % of specimens may have disc rior SC joint dislocations. These mediastinal ves-
degeneration which is often clinically associated sels include the subclavian vessels, the right and
with symptomatic osteoarthritis of the SC joint left brachiocephalic veins, the brachiocephalic
[10, 13, 17, 18]. artery and the left carotid artery (Fig. 8.5).
a
Left anterior jugular vein
Left internal jugular vein
Left external jugular vein
Right vagus nerve
Left common carotid artery
Left subclavian vein

Right
brachiocephalic vein
Innominate artery Left vagus nerve
Aortic arch
Superior vena cava

Pulmonary artery
Fig. 8.5 (a) Illustration showing the important structures showing the orientation of these structures in the axial
that are situated posterior to the SC joint. (b) CT scan plane.
8.2 Relevant Anatomy and Biomechanics 213
Elevation
Superior
capsule
Clavicle
Rotation
Slide
1st rib
Costoclavicular
ligament Sternum
Fig. 8.7 Anterior view showing the motion across the SC

joint as the humerus is elevated above 90º.
Fig. 8.6 Cadaveric dissection photograph showing the

Retraction
fascial raphe between the sternohyoid and sternothyroid
muscles which is thought to provide some protection to Posterior
the mediastinal vessels. Clavicle capsule
Rotation
According to Ponce et al. [6], the closest vessel Slide
lies approximately 6.6 mm deep to the posterior Sternum

1st rib
SC joint capsule (left or right brachiocephalic
vein). In some cases, the subclavian vein may
actually cross over the first rib along the postero- Anterior
Costoclavicular
lateral aspect of the costoclavicular ligament ligament Anterior capsule
before merging with the brachiocephalic vein [14].
Fig. 8.8 Axial view showing the motion across the SC
In our cadaveric dissections, the fascial raphe joint as the shoulder is protracted and retracted.
between the sternohyoid and sternothyroid mus-
cles was found to provide some protection to the
mediastinal vessels since it forms a physical bar- 8.2.5 Biomechanics
rier between the medial clavicle and the mediasti-
nal vessels (Fig. 8.6). We also noted a “safe zone” For every 10° of humeral elevation, the SC joint
for posterior dissection in the interval between contributes approximately 4° of rotation (Fig. 8.7)
the sternothyroid muscle and area directly [19]. The SC joint also contributes approximately
posterior to the manubrium and the medial 50° of posterior rotation with every 35° of eleva-
clavicle [11]. However, in the event of posterior tion, flexion and extension of the humerus
dislocation, the sternohyoid and sternothyroid (Fig. 8.8) [20, 21]. Therefore, surgical procedures
muscle bellies may become disrupted, placing the involving rigid fixation of the SC joint have
posterior vessels at an increased risk for iatro- largely been abandoned due to the potential for
genic injury during posterior surgical dissection poor functional outcomes in addition to the high
of the SC joint. Disruption of the sternohyoid and reported incidence of hardware failure. Large
sternothyroid muscle bellies can easily be identi- resections of the medial clavicle have also been
fied on diagnostic axial MRI scans. reported; however, this can result in uncontrolla-
ble scapulothoracic motion and, therefore, may

require subsequent scapulothoracic fusion [22].
In a biomechanical study performed to evalu-
ate the structures involved in resisting vertical
displacement of the medial clavicle, Bearn [12]
applied a downward force to the distal clavicle
and determined the structures providing the most
resistance to upward migration of the medial
clavicle after sequential ligament sectioning. In
that study, the posterosuperior capsule was found
to be the primary restraint to superior migration
of the medial clavicle while the interclavicular
ligament, the intra-articular disc ligament, and the
anterior joint capsule provided little resistance to
vertical displacement. More recently, Spencer
et al. [13] evaluated the ligamentous restraints to
horizontal translation of the medial clavicle. In
their study, 24 cadaveric SC joints were dissected
and sub-failure horizontal loads were applied to
the medial clavicle to measure anteroposterior
joint translation. They found that the costoclavicu-
Fig. 8.9 Most common mechanisms that result in acute
lar and interclavicular ligaments did not signifi- SC joint dislocations. (a) A blow to the shoulder from the
cantly contribute to the resistance of horizontal posterolateral direction can force the medial clavicle pos-
translation of the medial clavicle. However, tran- teriorly relative to the sternum. (b) A blow to the shoulder
section of posterior capsule resulted in an from the anterolateral direction can force the medial clav-
icle anteriorly relative to the sternum (more common).
increased posterior translation of 106 % and an
increased anterior translation of 41 % relative to
an intact control specimen. Division of the ante- trauma (Fig. 8.9) [25, 26]. In fact, many patients
rior capsule resulted in an increased anterior trans- who present with these injuries often sustain
lation of 25 %; however, this degree of anterior other, more dramatic injuries that require more
translation was less than that which was observed immediate attention [27, 28]. As a result, the
after sectioning of the posterior capsule. The diagnosis can be missed which can have devastat-
results of these studies indicate that the posterior ing consequences, especially in some cases of
capsule is important for both vertical and horizon- posterior SC joint dislocation where disruption of
tal stability and restoring its function should be the mediastinal vessels may have occurred. Injury
the primary goal of ligamentous reconstruction. to the mediastinal vessels is much more likely
when a posterior dislocation results in disruption
of the sternohyoid and sternothyroid muscles as
8.3 Acute Sternoclavicular Joint evidenced by axial imaging studies [11].
Dislocation Instability of the SC joint is typically classi-
fied according to etiology (traumatic versus
8.3.1 Pathogenesis atraumatic), chronicity (acute versus chronic,
direction (anterior versus posterior), and severity
Injuries to the SC joint are uncommon and (sprain, subluxation or complete dislocation) [26,
account for less than 3 % of all injuries to the 29, 30]. The most referenced classification sys-
shoulder girdle [23, 24]. Due to the strength of its tem for SC joint instability, developed by Allman
ligamentous stabilizers, subluxation or disloca- in 1967, accounts for the degree of ligamentous
tion of the SC joint typically requires high-energy disruption [29]. Type I injuries represent a simple
8.4 Osteoarthritis of the Sternoclavicular Joint 215
sprain of the SC capsuloligamentous structures

without evidence of increased medial clavicular
mobility. Type II injuries involve a partial disrup-
tion of the SC capsuloligamentous structures and
results in anterior or posterior subluxation of the
medial clavicle. Type III injuries are the most
severe and represent a complete rupture of all
supporting ligaments which leads to complete
anterior or posterior dislocation of the medial
clavicle. It is important to remember that an
apparent SC joint injury in a patient younger than
31 years of age may actually represent fracture of
the medial clavicular physis (e.g., Salter–Harris
type 1 or 2 injury) rather than injury to the capsu-
loligamentous structures of the SC joint (i.e.,
“pseudodislocation”) [1, 2, 30, 31].

Fig. 8.10 Anterior subluxation of the medial clavicle with
In most cases, patients with acute injuries to the humeral elevation. (a) The medial clavicle remains in a
SC joint typically complain of pain and swelling in reduced position when the humerus is at the side. (b) The
the vicinity of the medial clavicle after a traumatic medial clavicle subluxates anteriorly (arrow) as the humerus
event. While anterior dislocations are usually evi- is elevated above the horizontal plane. Note that this par-
ticular patient presented with chronic instability. Pain and
dent due to the prominence of the medial clavicle swelling over the SC joint with additional guarding is gen-
with scapulohumeral motion (Fig. 8.10 ), posterior erally present in cases of acute traumatic instability.
dislocations are less obvious since the medial clav-
icle has migrated posteriorly and, thus, does not
produce an anterior prominence despite the possi- spontaneous re-dislocation may occur immedi-
bility of extensive swelling. These injuries may be ately after the clinician removes this pressure
more difficult to recognize in patients with multi- [30]. When maintenance of reduction cannot be
ple trauma (especially in narcotized and ventilated safely achieved, outpatient reconstruction of the
patients) since other, more dramatic injuries may SC joint may be needed to restore shoulder func-
mask the SC joint injury. Thorough inspection and tion, to maintain joint stability and to prevent the
palpation of the entire clavicle is necessary to rule progression of post-traumatic osteoarthritis [3].
out concomitant fractures and the possibility of Acute posterior SC joint dislocations should
acromioclavicular (AC) joint dislocation (“float- always be considered an emergency since up to
ing clavicle”) [32–34]. In patients with Allman 30 % of these injuries result in compromise of the
type I or II injuries, severe anterior chest and mediastinal vasculature [37]. These patients may
shoulder pain is often exacerbated by arm motion display evidence of venous congestion in the neck
and supine repositioning [30]. or ipsilateral arm in addition to coughing, dyspnea,
In acute anterior SC joint dislocations, closed hoarseness, or dysphagia which may suggest dis-
reduction is usually attempted in the emergency ruption of airway patency. Standard anteroposte-
room [30, 35, 36]. In most cases, the medial clav- rior (AP) radiographs (including a Serendipity
icle will reduce when a firm posteriorly directed view [26]) and a computed tomographic (CT) scan
pressure is applied by the clinician with the of the chest should always be obtained in the set-
patient supine and a thick pad placed beneath the ting of any acute SC joint dislocation (Figs. 8.11
thoracic spine to retract the scapulae. However, and 8.12). In the case of a posterior dislocation, a
40°
b Anterior dislocation of Posterior dislocation of

Normal right clavicle right clavicle
R
R L L L
Fig. 8.11 (a) The technique used to obtain a Serendipity of cephalad angulation. (b) Illustration showing the inter-
view of the SC joint. With the patient supine, the X-ray pretation of the resulting Serendipity view.
beam is centered over the SC joint with approximately 40º
Fig. 8.12 Axial CT scan

demonstrating a left
posterior SC joint
dislocation. This patient
presented with dysphagia
and underwent urgent
reconstruction.
CT angiogram should also be obtained and the on- posterior SC joint dislocation should never be per-
call cardiothoracic surgeon should be made aware formed in the emergency room without prior con-
of the situation [27, 30]. Closed reduction of a sultation with a cardiothoracic surgeon.
References 217
the condition is mostly asymptomatic, some

8.4 Osteoarthritis patients may develop symptoms related to insta-
of the Sternoclavicular Joint bility or chondral degeneration due to the high
frequency of subluxation, especially in those
8.4.1 Pathogenesis involved in overhead sports or manual labor.
Progressive articular cartilage degeneration of

the SC joint most commonly occurs following an 8.6 Summary
acute injury to surrounding capsuloligamentous
structures, especially in cases that were initially Unfortunately, pathologies related to the SC joint
treated nonoperatively [35, 38]. On the other have been less well studied when compared
hand, osteoarthritis of the SC joint can also have to other areas of the shoulder girdle. However,
atraumatic etiologies such as SAPHO syndrome the clinician is still charged to make accurate
(synovitis, acne, pustulosis, hyperostosis, oste- and rapid diagnoses and treatment decisions.
itis), avascular necrosis, tumors, septic arthritis, Knowledge of basic anatomy and biomechanics
and rheumatoid arthritis, among other potential along with pertinent radiographic features and
causes. The indications for surgical treatment of physical examination findings will allow clini-
these conditions are case-based [3]. cians to successfully evaluate and treat patients
with SC joint pathologies in an efficient manner.

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Scapular Dyskinesis
9
shoulder motion (see Chap. 3 for a detailed

9.1 Introduction explanation of normal three-dimensional scapu-
lar motion). A complete understanding of the
The scapula is a complex osseous structure that osseous, muscular, bursal, and neurovascular
plays a critical role in the maintenance of gleno- anatomy along with the biomechanics of normal
humeral stability throughout the entire range of scapular motion is critical to the evaluation of
motion of the shoulder. Therefore, an evaluation any patient with shoulder pathology.
of scapular motion should be performed in each
patient to prevent the development or progression
of various shoulder conditions such as rotator cuff 9.2.1 Osseous Anatomy
disease and glenohumeral instability. Specific
physical exam findings and observations related The scapula is a large, flat, triangular-shaped
to scapular motion can have a significant effect on bone positioned over the posterior thorax between
the approach to either operative or nonoperative the second and seventh ribs. The scapula has
management in patients who present with shoul- three borders (superior, medial, and lateral) and
der pain. As an example, increased upward rota- two important angles (superomedial and infero-
tion of the scapula may be a compensatory medial) that primarily serve as sites for muscle
mechanism to prevent pain related to shoulder attachment (Fig. 9.1). According to Lewitt [2],
pathology whereas increased downward rotation the three-dimensional resting position of the
may be factor associated with the production of scapula is defined as being tilted anteriorly
shoulder pathology [1]. An understanding of the between 10° and 20° and medially rotated in the
pertinent anatomy and biomechanics of scapular coronal plane between 30° and 40° (in other
motion is required before any diagnosis can be words, the glenoid faces more in the superior
made regarding scapular motion. direction). As discussed in Chap. 2, the scapula is
also angled anteriorly between 10° and 20° from
the coronal plane. This position of anterior angu-
9.2 Anatomy and Biomechanics lation is often referred to as the “scapular plane”
when evaluating the shoulder.
The primary function of the scapula is to provide While the general shape of the scapula is
a stable fulcrum against which humeral elevation fairly consistent across the population, there exist
and rotation can occur. This is achieved through several known topographical variations that may
dynamic positioning of the glenoid to maximize predispose some individuals to certain pathologic
glenohumeral contact through all planes of conditions (such as scapulothoracic bursitis
220 9 Scapular Dyskinesis
Fig. 9.1 Posterior view of

a normal scapula. The
superior, medial, and
lateral borders along with
the superomedial and
inferomedial angles are
labeled.
or snapping scapula syndrome). For example, known to have various morphological features
Aggarwal et al. [3] performed measurements in 92 that may predispose some individuals to supra-
dried scapulae and found that the costal (anterior) scapular nerve entrapment [9–12]. The transverse
surface of the scapula “undulated” and also varied scapular ligament travels mediolaterally between
in depth between 10.5 and 26.5 mm. The investi- the crests of the suprascapular notch. In most
gators noted that the thickness of the superomedial cases, the suprascapular nerve is found below the
angle ranges between 2 and 4 mm whereas the ligament and within the notch whereas the supra-
inferomedial angle had a thickness between 5 and scapular artery is found above the ligament and
8 mm. Anterior angulation of the superomedial outside of the notch (Fig. 9.2). The transverse
angle also varied between 124° and 162° in the scapular ligament is also known to have sig-
majority of their specimens. In addition, the inves- nificant anatomic variations that can also gener-
tigators also identified an anterior “horn-like” pro- ate symptoms related to suprascapular nerve
jection along the lateral border of at least one entrapment [13, 14].
scapula. Several researchers have described other
osseous abnormalities that may predispose some
individuals to painful scapular snapping. These 9.2.2 Muscular Anatomy
include the superomedial “bare area,” [4] the
“Luschka tubercle” (bony protuberance at the The scapulothoracic articulation is unique in that
superomedial angle) [5], the teres major tubercle its motion is not dictated by osseous constraints.
(located at the insertion of this muscle) [6], and Rather, the scapula is positioned through the
anterior “hooking” of the superomedial angle [7]. dynamic, coordinated action of surrounding
The suprascapular notch is located near the periscapular muscles (see Chap. 3). Therefore,
junction of the lateral third of the superior scapu- disruption or dysfunction of any one of these
lar border, just medial to the confluence of the muscles can result in scapular malposition or
coracoid process with the scapular body [8]. dyskinetic motion which can lead to disordered
The anatomy of the suprascapular notch is also shoulder function.
Fig. 9.2 Posterior view of a normal scapula with impor- to the medial scapular border. The suprascapular nerve
tant neurovascular structures highlighted. The dorsal travels below the transverse scapular ligament whereas
scapular nerve and artery lie approximately 2 cm medial the suprascapular artery passes above the ligament.
9.2.3 Bursal Anatomy angles and are thought to be significant patho-

logical pain generators [17, 18]. Some research-
Bursae are fluid-filled sacs lined with synovial- ers have suggested that pain near the superomedial
like cells that facilitate gliding of opposing sur- angle can be due to pathologic infraserratus or
faces over one another. In the case of the scapula, supraserratus bursal tissue [19, 20], pain near the
there are several periscapular bursae that allow inferomedial angle is most likely the result of
the scapula to glide smoothly over interposed pathologic infraserratus bursal tissue [21, 22],
muscle layers. These bursae are commonly and pain near the confluence of the scapular spine
defined as either “anatomic” or “adventitial” bur- may be caused by a pathologic scapulotrapezial
sae, depending on their propensity to cause bursa which is most commonly located deep to
periscapular pain [15]. Anatomic bursae are typi- the trapezius and superficial to the scapular spine
cally thought to represent normal, physiologic (Fig. 9.3) [23].
bursae that allow smooth gliding over the poste-
rior thorax. The infraserratus and supraserratus
bursae lie on either side of the serratus anterior 9.2.4 Neurovascular Anatomy
muscle along the medial scapular border and are
the most frequently recognized anatomic bursae Knowledge of pertinent neurovascular anatomy
[15, 16]. Adventitial bursae are most often located around the scapula is necessary to fully evaluate
at the superomedial or inferomedial scapular any patient with a condition related to disordered
Fig. 9.3 Illustrations demonstrating the positions of the view showing the positions of the periscapular bursae
pertinent periscapular bursae. (a) Positions of the relative to the surrounding musculature from [23].
periscapular bursae relative to the scapular body. (b) Axial
shoulder motion (see Chap. 3). The spinal acces- scapula provides a stable fulcrum against which
sory nerve, which innervates the levator scapulae glenohumeral motion can occur through the
muscle, travels with the transverse cervical artery dynamic action of the periscapular musculature,
along the levator scapulae muscle which is situ- including the rotator cuff and deltoid muscles. In
ated deep to the trapezius muscle. In some cases, fact, several authors have shown that external sta-
the spinal accessory nerve may penetrate through bilization of the scapula may improve the contrac-
the central portion of the levator scapulae [24]. tion strength of the rotator cuff [26, 27]. Smith
As the transverse cervical artery travels distally, et al. [27] found that stabilizing the scapula in a
it becomes the dorsal scapular artery which, in position of retraction substantially increased exter-
turn, travels with the dorsal scapular nerve nal rotation strength in 20 normal subjects when
beneath the rhomboid musculature a few finger- compared to external rotation strength with the
breadths medial to the medial scapular border scapula protracted. Similarly, in a series of 20
(see Fig. 9.2) [25]. The long thoracic nerve is patients with shoulder pain (but without rotator
relatively protected as it travels along the anterior cuff tears) and ten healthy controls, Kibler et al.
aspect of the serratus anterior muscle. The supra- [26] demonstrated a 13–24 % increase in supraspi-
scapular nerve arises from the superior trunk of natus strength when the “empty can” test was per-
the brachial plexus and courses towards the formed with the scapulae in a retracted position
suprascapular notch with the suprascapular (see Chap. 4 for details regarding Jobe’s “empty
artery. As mentioned above, the suprascapular can” test). In 29 overhead athletes with scapular
nerve passes beneath the transverse scapular liga- dyskinesis, Merolla et al. [28] measured sig-
ment whereas the suprascapular artery travels nificantly increased contraction forces of both
above the ligament (see Fig. 9.2). the supraspinatus and the infraspinatus muscles
following the completion of specially designed
rehabilitation protocols designed to improve
9.2.5 Biomechanics periscapular muscle balance. The same group
published similar results in a series of volleyball
With respect to normal shoulder kinematics, the players who also demonstrated scapular dyskine-
scapula has several important functions that sis upon initial presentation [29]. Second, accurate
should be considered before evaluating any patient positioning of the scapula through coordinated
with a complaint related to the shoulder. First, the muscle contractions facilitates glenohumeral
9.3 Scapular Dyskinesis 223
articular congruency by maintaining alignment of issue altogether. Once scapular dyskinesis has
opposing force couples, thus preserving the so- been detected by the initial screening examina-
called concavity compression mechanism of tion, the remainder of the patient encounter should
dynamic stability (concavity compression is dis- focus on the evaluation and treatment of its poten-
cussed more thoroughly in Chaps. 4 and 6). Third, tial causes and effects.
the scapula plays an important role in the trans-
mission of force through the kinetic chain. In
short, the scapula facilitates the transfer of kinetic 9.3.1 Possible Etiologies of Scapular
and potential energy from the largest muscles of Dyskinesis
the core and trunk towards site of action [30].
Dynamic scapular stability, which is facilitated by There are numerous potential etiologies respon-
adequate core and trunk strength, is necessary to sible for the development of scapular dyskinesis,
optimize the efficiency of this complex system most of which can be divided into primary and
[31]. Perhaps one of the most well-known exam- secondary causes.
ples of this concept is the classic pitching motion
most often utilized to deliver a high-velocity pitch 9.3.1.1 Primary Causes of Scapular
in baseball. Dyskinesis
Primary causes of scapular dyskinesis are most
commonly related to mechanical or neurogenic
9.3 Scapular Dyskinesis defects. Mechanical problems may be associated
with a decrease in the scapulothoracic space, such
Although most established sports medicine clini- as kyphoscoliosis, rib fracture callus or hypertro-
cians (both generalists and upper extremity sub- phic nonunion, shortened clavicle as a result of
specialists) evaluate and treat patients with some fracture malunion and enlarging soft-tissue or
form of scapular dyskinesis on a regular basis, the skeletal masses, among several other potential
disorder is still an understudied, underappreci- defects, can produce symptoms such as scapulo-
ated, and often overlooked category of shoulder thoracic crepitation with shoulder motion (caused
dysfunction, especially in novice examiners. The by any abnormality that results in a decreased
knowledge deficiency in this area may be caused scapulothoracic space) or clinical findings such
by the relatively infrequent need for surgical as the gradual appearance of scapular malposition
intervention, by the lack of sufficient education on (caused by the presence of an enlarging mass
the topic or, perhaps, by generational differences within the scapulothoracic space which can push
in examination and treatment philosophies (such the scapular body away from the posterior thorax,
as the gradual transition from primarily experi- thus producing the appearance of scapular wing-
ence-based practice to primarily evidence-based ing and dyskinesis). In addition to disordered
practice). In addition to these potential chal- scapular motion, many of these mechanical issues
lenges, the precise cause of the condition is often manifest as periscapular bursitis, crepitus, or so-
unknown, the risk for secondary injury is often called scapular “snapping” and are discussed
unknown and its effect on shoulder mechanics is later in this chapter (see the Sect. 9.3.3.7 below).
probably very complex. In most cases, we prefer
to view this problem as a manifestation of some 9.3.1.2 Secondary Causes of Scapular
underlying condition rather than an isolated disor- Dyskinesis
der, regardless of whether the pathology is aca- Many patients with shoulder pain develop com-
demically defined as “primary” or “secondary” pensatory periscapular muscle contraction (or
(described below), since appropriate treatment of relaxation) that functions to limit the pain associ-
the underlying condition (ranging from a specific ated with shoulder motion. This abnormal firing
physical therapy protocol to surgical excision of a pattern produces disordered scapular motion that,
space-occupying mass) typically resolves the in some cases, may exacerbate the inciting injury.
Fig. 9.4 (a) Scapular winging due to trapezius muscle weakness. (b) Scapular winging due to serratus anterior muscle
weakness.
Fig. 9.5 Clinical photographs showing a patient with goniometer revealed increased external rotation capacity.
GIRD. (a) Measurement of passive internal rotation with Because the total arc of motion was decreased, the loss of
a goniometer revealed decreased internal rotation capac- internal rotation was deemed pathologic (Courtesy of
ity. (b) Measurement of passive external rotation with a Craig Morgan, MD).
In at least one study, the amplitude of activation medial scapular border) and the spinal accessory
and the contraction strength of the serratus ante- nerve (results in more subtle scapular winging
rior muscle was significantly decreased in with difficulty in abduction) (Fig. 9.4).
patients with subacromial impingement. This Currently, most forms of scapular dyskinesis
produced an abnormal scapular resting position are attributed to underlying defects related to soft-
(increased anterior tilt and downward rotation) tissue structures around the shoulder. For example,
and subsequent scapular dyskinesis due to the many overhead athletes display physical evidence
unbalanced opposing force couple between the of a glenohumeral internal rotation deficit (GIRD)
serratus anterior muscle (weaker muscle) and which generally is not considered pathologic
the trapezius muscle (stronger muscle). Other unless there is an associated range of motion loss
potential etiologies of scapular dyskinesis include relative to the total arc of motion (Fig. 9.5).
AC joint instability and/or degenerative osteoar- However, posterior capsular contractures are often
thritis, some forms of glenohumeral instability found in these same athletes due to repeated throw-
and neurogenic causes such as cervical radicu- ing [32]. These contractures essentially “stiffen”
lopathy and the oft-cited palsies involving the the posterior capsule such that glenohumeral
long thoracic nerve (results in prominence of the adduction and internal rotation causes the scapula
to internally rotate (or “windup”) without input Regardless of the precise cause, recognition
from the periscapular musculature [1]. In this and correct interpretation of disordered scapular
example, the scapula can no longer be placed in a motion is an extremely important part of the clin-
position of maximal glenohumeral contact when ical examination that should never be overlooked
the arm is adducted and internally rotated, poten- in any patient who presents with a shoulder com-
tially leading to subsequent injuries if not clini- plaint. It is important to remember that the scap-
cally addressed (often related to the SICK scapula ula also plays an important role in force
syndrome). Other common findings in patients transmission through the kinetic chain. Therefore,
(most commonly athletes) with scapular dyskine- in most athletic (i.e., non-sedentary) individuals
sis are tightness of the short head of the biceps ten- with secondary scapular dyskinesis, a thorough,
don and the pectoralis minor tendon [33]. Because yet efficient assessment of scapular motion can
each of their tendons forms an attachment to the be considered a reflection of muscular symmetry
coracoid process, tightness of either muscle (or and the overall health of the kinetic chain.
both) can result in scapular malposition and disor-
dered scapular motion.
Overall, many of the above-mentioned etiolo- 9.3.2 Physical Examination
gies (except for the specific nerve palsies) result
in the same general pattern of scapular malposi- Scapular dyskinesis is usually diagnosed by sim-
tion and dyskinesis—that is, a protracted resting ple palpation of the relevant scapular landmarks
position and further protraction with arm motion. while also observing both scapulae during move-
This is the most common manifestation of scapu- ment of the shoulder through the various motion
lar dyskinesis which can lead to subacromial planes. The condition is most often characterized
impingement (due to a decreased volume within by prominence of the inferomedial angle and the
the subacromial space), diminished rotator cuff medial scapular border (as a result of protraction
contraction strength (due to alterations in the in the resting position), early upward rotation of
length-force relationship of each muscle [dis- the scapula during arm elevation and/or early
cussed in Chap. 3]) [26–28], and chronic overuse downward rotation of the scapula when lowering
injuries such as symptomatic internal impinge- the arm back to the side (variations in dyskinetic
ment in throwing athletes (due to repeated supra- patterns are described below for specific condi-
physiologic scapulohumeral angulation) and tions). Recent evidence suggests that increased
superior labral anterior to posterior (SLAP) tears upward rotation may be associated with symptom
(due to the “peel back” mechanism proposed by compensation whereas increased downward rota-
Burkhart et al. [34] [discussed in Chap. 6] and/or tion may be associated with symptom causation.
repeated maximal tension placed on the anterior Regardless, any abnormal scapular motion can
capsule). These common secondary effects, compromise normal shoulder function by reduc-
which are often at least partially attributed to ing glenohumeral articular congruency, reducing
scapular dyskinesis, can also lead to tertiary the acromiohumeral distance, increasing tension
pathologies, thus initiating a so-called vicious and strain across the AC joint capsule, decreasing
cycle. The most commonly encountered cascade the strength of rotator cuff contraction (which can
of events occurs in the following sequence: (1) also reduce glenohumeral stability) and shifting
primary or secondary dyskinesis, which leads to the arc of glenohumeral motion as which com-
(2) submaximal supraspinatus contraction, which monly occurs in overhead athletes. In addition to
leads to (3) gradual superior humeral head migra- these changes, scapular dyskinesis can also mask
tion, which leads to (4) a gradual decrease in sub- or enhance the symptoms related to other concom-
acromial space, which leads to (5) subacromial itant shoulder pathologies, such as rotator cuff
impingement and supraspinatus tears, which lead tears and labral tears, thus complicating the physi-
to (6) pain, which leads to (7) compensatory, cal diagnosis and subsequent treatment decisions.
asymmetric muscle firing patterns, which lead to Clinical examination of the scapulae should
(8) worsening of scapular malposition, dyskine- begin with an assessment of posture and symme-
sis, superior humeral head migration, and so on. try. In many overhead athletes, the dominant
Fig. 9.6 Clinical photograph of right-handed overhead

throwing athlete with a depressed right shoulder (Courtesy
of Craig Morgan, MD).
shoulder will appear to rest in a slightly lower, or

depressed, position relative to the contralateral
shoulder (Fig. 9.6). This abnormality often occurs
in conjunction with SICK scapula syndrome
(scapular malposition, inferomedial angle promi-
nence, coracoid pain, and scapular dyskinesis) Fig. 9.7 Clinical photograph of a patient performing a
wall push-up (also discussed in Chap. 3). Note the promi-
which can often be corrected by a focused reha- nence of the medial scapular border of the left shoulder, a
bilitation program. As necessary components of common finding in patients with scapular dyskinesis.
scapular motion, AC and SC joints should also be
evaluated for any evidence of pain and/or instabil-
ity (see Chaps. 7 and 8 for details regarding the AC
and SC joints, respectively). The clavicle should
also be palpated to confirm adequate length and to
identify any abnormal angulation or malrotation.
In most cases, the clinician can identify dyski-
netic scapular motion by simple observation, pal-
pation and compression of the medial scapular
border as the patient elevates and lowers the
affected arm (forward flexion, horizontal abduc-
tion, and scaption). Specifically, the appearance
of a visible prominence of the medial scapular
border with any of these motions can be consid-
ered dyskinetic motion (Fig. 9.7) [35]. Weights
(e.g., 3 or 5 pounds) can also be used to increase
the visibility of medial border prominence with
shoulder motion (also known as the scapular dys-
Fig. 9.8 Flip test. Resisted external rotation can often
kinesis test). Similarly, resisted external rotation
elicit signs of scapular dyskinesis when the examiner is
can also produce same pattern of scapular dyski- positioned behind the patient in order to visualize both
nesis as that which is observed during humeral scapulae from posteriorly.
Fig. 9.9 Lateral scapular slide test. (a) This test is meant marked by the spinous processes (be wary of patients with
to identify a difference in the medial-lateral positioning of abnormal spinal curvature, such as those with scoliosis).
the scapula relative to the thoracic spine. (b) With the The measurement is repeated for the contralateral scapula.
patient standing and their arms at the side, the examiner (c) The measurement is repeated with the hands on the
uses measuring tape to measure the distance between the iliac crests and/or with the arms abducted.
inferomedial scapular angle and the midline, typically
elevation (i.e., a positive “flip test”; Fig. 9.8). Pain position. However, a study by Odom et al. [38]
with compression of the scapular body against found no improvement in sensitivity or specific-
the thoracic wall with shoulder motion may also ity for the detection of scapular dyskinesis with
be an indicator of snapping scapula syndrome. any of the three testing positions or when the
threshold for diagnosis was increased from 1.0 to
9.3.2.1 Lateral Scapular Slide Test 1.5 cm. Another study by Shadmehr et al. [39]
The lateral scapular slide test was originally found that the test was unreliable. However, it
developed by Kibler [36] in 1991 as a method to should be noted that any study that evaluates the
detect asymmetric scapular resting positions with accuracy of a physical examination test for the
the arms in various degrees of abduction. detection of a specific pathology or defect, the
According to the original description, the dis- findings on examination should always be cou-
tance from the inferomedial scapular angle to the pled with the findings obtained from the diagnos-
corresponding spinous process along the same tic gold standard. In the case of scapular
horizontal plane was measured bilaterally with dyskinesis, there currently does not exist a diag-
both arms (1) at the side, (2) abducted to approxi- nostic gold standard and, thus, inhibits study
mately 30° and slightly internally rotated (i.e., interpretation.
hands on hips), and (3) abducted to 90° in the
coronal plane (Fig. 9.9). Kibler [36] suggested 9.3.2.2 Scapular Assistance Test
that the latter two testing positions required sub- The scapular assistance test was first described
stantial muscular activation involving the upper by Kibler et al. [26] in 2006 and is typically used
and lower trapezius and the serratus anterior to assess the effect of scapular malposition on
muscle—weakness of any of these muscles rotator cuff impingement. In this test, the exam-
would therefore produce increased lateral devia- iner applies an anterior and superior force to the
tion of the scapular body. Thus, a difference in inferomedial scapular angle to assist upward
bilateral measurements in any of the three testing rotation and posterior tilt of the scapula while the
positions was considered a positive test. Kibler patient flexes and/or abducts the arm (Fig. 9.10).
[37] more recently proposed that this cut-off A positive test occurs when the patient reports
point be increased to 1.5 cm based on experi- relief of impingement-like symptoms as the scap-
ences within clinical practice combined with ula of the affected extremity is manipulated.
other unpublished work involving scapular mal- Acceptable inter-rater reliability has been
noid labrum followed by the Jobe test to evaluate

supraspinatus strength (empty- or full-can posi-
tion; however, it is advisable to use the full-can
position in the setting of a positive scapular
assistance test to minimize symptoms of impinge-
ment which can decrease strength measurements)
(Fig. 9.11). The test is considered positive when
the above-described scapular manipulation
decreases the symptoms associated with labral
injury or rotator cuff impingement. A similar test
has been described for the evaluation of infraspi-
natus strength in overhead athletes with scapular
dyskinesis [42].
9.3.2.4 Scapular Reposition Test

The scapular reposition test was first described
in 2008 by Tate et al. [43] as a modification of
the scapular retraction test. The investigators
aimed to decrease the amount of retraction
while also emphasizing increased posterior tilt
and external rotation of the scapula. In their
study, the Neer sign, Hawkins–Kennedy test,
and Jobe’s empty can test (these maneuvers are
Fig. 9.10 Scapular assistance test. With the patient stand-
ing, the examiner places on hand over the superior aspect of described in Chap. 4) were performed in 142
the involved scapula with the fingers resting on the anterior collegiate-level asymptomatic athletes. If any of
clavicle. The examiner’s other hand is placed on the infero- the above-mentioned tests were positive, each
medial scapular angle with the fingers pointed towards the maneuver was repeated with the addition of
lateral thorax. The patient is then asked to slowly abduct the
humerus (scapular plane or sagittal plane). During the pro- manual scapular repositioning. Manual scapular
cess of abduction, the examiner facilitates upward rotation repositioning was performed by first manually
of the scapula by pushing upward and laterally on the infer- grasping the top of the shoulder with the fingers
omedial angle. This maneuver encourages increased poste- over the AC joint and the thumb resting along
rior scapular tilt and may relieve symptoms of rotator cuff
impingement during humeral elevation. the scapula spine. The examiner’s forearm was
then obliquely positioned over the scapular
body. The examiner then applied a moderate
reported when the test was performed during ele- force to the scapula using both their hand and
vation in either the scapular plane (scaption) or forearm to encourage increased posterior tilt
the sagittal plane (forward flexion) [40]. and external rotation without achieving full
retraction (Fig. 9.12). Following scapular
9.3.2.3 Scapular Retraction Test manipulation, the Neer sign and Hawkins–
The scapular retraction test, described by Kibler Kennedy test were repeated to assess for any
et al. [41] in 2009, is often used in conjunction change in shoulder symptoms and the Jobe test
with the dynamic labral shear test (discussed in was repeated to assess for any change in rotator
Chap. 6) or the Jobe test (discussed in Chap. 4) to cuff strength. The intra-class correlation coeffi-
evaluate the potential role of scapular dyskinesis cients for the evaluation of rotator cuff strength
on supraspinatus strength and labral injuries. In (using Jobe’s empty can test) were above 0.95
this maneuver, the scapula is first positioned and when the scapula was in its original resting
stabilized in a fully retracted position. With the position and during manual repositioning. No
scapula in this position, the examiner performs other studies have evaluated the clinical utility
the dynamic labral shear test to evaluate the gle- of this test.
Fig. 9.11 Scapular

retraction test. With the
patient standing, the
examiner manipulates the
involved scapula into a
position of full retraction.
The patient then actively
abducts the arm within the
scapular plane while the
examiner continues to
apply a stabilizing pressure
to the scapula. This
posterior stabilization is
maintained while the
examiner performs both
the dynamic labral shear
test and Jobe test to assess
for pathology involving the
labrum or the rotator cuff,
respectively [109].
Fig. 9.12 Scapular reposition test. With the patient stand- the examiner’s elbow is used to push the inferomedial
ing, the examiner positions their forearm obliquely across angle anterolaterally while the fingers are used to pull the
the scapular body such that the fingers rest over the ante- scapula posteriorly. This posterior stabilization is main-
rior shoulder. The patient is then asked to abduct the tained while the examiner performs the rotator cuff
humerus in the scapular plane. During humeral elevation, impingement signs [110].
9.3.3 Selected Conditions Chap. 3. With specific regard to scapular dyskine-

Associated with Scapular sis, maneuvers such as the scapular assistance test
Dyskinesis [26] and the scapular retraction test [41] have been
developed as diagnostic methods that reposition
As mentioned above, there are many shoulder the scapula during humeral elevation (discussed
disorders that may have an association with scap- above). Scapular malposition with secondary rota-
ular dyskinesis. However, we have chosen to tor cuff impingement may be causative when the
focus on several of the more common conditions patient’s symptoms are relieved with either one of
that we believe are closely related to scapular these tests. Periscapular strengthening and pro-
dyskinesis. The purpose of this section is to high- prioceptive training are typical rehabilitation
light the most important concepts related to dis- options that are most often successful at providing
ordered scapular motion that can subsequently be symptomatic improvement.
applied to other, less common shoulder patholo-
gies that are not specifically mentioned below. 9.3.3.2 SLAP Tears
SLAP tears are often seen in combination with
9.3.3.1 Subacromial Impingement scapular dyskinesis, especially in overhead ath-
and Rotator Cuff Disease letes who demonstrate GIRD. This adaptation to
Numerous studies have documented the presence repetitive throwing places the scapula in a posi-
of scapular dyskinesis in patients with subacro- tion of decreased posterior tilt and increased
mial impingement and rotator cuff tears [44–48]. internal rotation, thus increasing the strain across
The precise abnormality in scapular motion that the biceps-labral complex via increased anterior
predisposes individuals to rotator cuff disease capsular tension, extraphysiologic torsional
appears to vary significantly; however, these stud- strain (i.e., the peel-back mechanism as dis-
ies have generally found decreased upward rota- cussed in Chap. 5) and posterosuperior glenoid
tion, decreased posterior tilt, and increased internal impingement (i.e., symptomatic internal impinge-
rotation of the scapula in patients with rotator cuff ment). The scapular retraction test (discussed
tears or impingement. Although these associations below) [41] can be used in conjunction with the
exist, it is not known whether scapular dyskinesis dynamic labral shear test (described in Chap. 5)
is the cause or the result (or both) of rotator cuff to determine the effect of scapular malposition
disease. If scapular dyskinesis is causative, and dyskinesis on the symptomatology related to
decreased upward rotation and decreased posterior SLAP tears. When the test results in symptomatic
tilt would most likely be implicated since these relief, periscapular weakness is most likely a sig-
factors would also decrease the functional acro- nificant contributor to the patient’s symptoms
miohumeral distance leading to mechanical and can probably be alleviated with periscapu-
impingement of the superior cuff tendons. lar strengthening and, in overhead athletes, an
Scapular dyskinesis could also be the result of additional supervised throwing program that
rotator cuff disease via alterations in periscapular encourages proper throwing mechanics and
muscle firing patterns that function to either maintenance of a normal scapulohumeral angle.
decrease the pain associated with impingement or
to compensate for rotator cuff weakness during 9.3.3.3 Multidirectional Instability
arm elevation. Inherited multiligamentous laxity is most com-
Both the serratus anterior and the lower portion monly implicated in patients who present with
of the trapezius have been suggested as major evidence of multidirectional instability (MDI)
points of periscapular muscle weakness in patients such as a positive sulcus sign, apprehension sign,
with rotator cuff disease and should be the pri- and relocation sign, among several others (details
mary focus of the clinical examination. The tech- regarding the testing for glenohumeral instability
niques commonly used for individual strength and laxity are presented in Chap. 6). Importantly,
testing of each of these muscles are presented in examination of the scapula can also provide
important diagnostic and therapeutic information 9.3.3.4 AC Joint Pathology

and should be performed in all patients with Currently, controversy exists regarding whether
MDI. Specifically, these patients often demon- patients with grade III acromioclavicular (AC)
strate decreased upward rotation, decreased pos- joint injuries should be treated using operative or
terior tilt, and increased internal rotation of the nonoperative treatment modalities (see Chap. 7
scpaula during humeral elevation [49, 50]. for more details related to the AC joint). However,
However, in contrast to many other shoulder con- the high prevalence of scapular dyskinesis fol-
ditions, the cause of scapular malposition and lowing nonoperative treatment may be an impor-
dyskinesis in patients with MDI is most likely tant factor that could convince surgeons to
secondary to increased capsular laxity. Several operate on these patients more frequently. A
studies by Jerosch et al. [51–53] concluded that study by Gumina et al. [55] in 2009 found that 24
both the glenohumeral ligaments and the gleno- of 34 patients (70.6 %) with chronic grade III AC
humeral joint capsule have mechanoreceptors that joint dislocations had clinical evidence of scapu-
respond to stretch by inducing a proprioceptive lar dyskinesis. In a recent cadaveric study, Oki
reflex mechanism that alters muscle firing pat- et al. [56] found that disruption of the AC capsu-
terns around the shoulder in order to optimize the lar ligaments and the coracoclavicular ligaments
position of the glenoid in three-dimensional delayed long-axis posterior rotation of the clavi-
space. A more recent study by Barden et al. [54] cle and increased the degree of scapular upward
found that patients with MDI have a decreased rotation when the humerus was passively
capability of utilizing this proprioceptive mecha- abducted in the coronal plane. Therefore, nonop-
nism, perhaps as a result of increased capsular erative treatment for AC joint dislocations may
laxity which decreases the potential for stretching decrease the continuity of force transmission
of capsuloligamentous structures. This hypothe- between the scapula and the clavicle through the
sis is supported by anecdotal reports of decreased AC joint, leading to altered muscle firing patterns
apprehension during the clinical assessment of and dyskinetic scapular motion. This notion is
patients with known capsular laxity, including supported by a recent study in which only 4 out
those with voluntary or positional instability pat- of 34 patients (11.7 %) displayed evidence of
terns. The above findings suggest that patients scapular dyskinesis following surgical manage-
with MDI may develop scapular dyskinesis due to ment of grade III AC joint injuries [57]. Although
the decreased ability to differentiate between nor- scapular dyskinesis related to grade III AC joint
mal and abnormal humeral head translations dislocations can be treated successfully using a
which, in normal patients, is detected by changes conservative approach, a recent study by Carbone
in capsuloligamentous tension. As a result, et al. [58] found that approximately 22 % of
patients with MDI may have decreased proprio- patients still had scapular dyskinesis despite
ceptive responses to humeral head translation, 12 months of rehabilitation (no improvements
leading to relative deactivation (and possibly dis- were documented in the interval between 6 weeks
use-related weakness) of certain shoulder muscles and 12 months after the injury). In addition,
and producing the observed dyskinetic scapular recent data from our institution revealed that
motion. Specific inhibition of the lower trapezius, more than 30 % of patients with grade III AC
the serratus anterior and the subscapularis along joint injuries who were initially treated nonoper-
with activation of the pectoralis minor and latis- atively eventually required surgical management
simus dorsi may be involved with the develop- due to the lack of clinical improvement (unpub-
ment of resting scapular protraction where the lished data). Taken together, the results of these
inferior pull of the latissimus dorsi and teres studies suggest that the combined effects of both
major muscles (along with the increased down- pain inhibition and mechanical dysfunction may
ward rotation of the scapula [50]) may be the pri- be the primary contributing factors associated
mary contributors related to increased inferior with scapular dyskinesis in patients with injuries
humeral head translation in patients with MDI. to the AC capsuloligamentous structures and/or
the coracoclavicular ligaments (including grades increased upward rotation is a compensatory

II–VI injuries) who are not treated surgically. adaptation that maximizes range of motion in the
Therefore, surgeons may be forced to undertake setting of shoulder stiffness. Lin et al. [62] stud-
more aggressive treatment strategies for lower- ied the scapular kinematics in patients with stiff
grade AC joint dislocations to help prevent the shoulders involving either the anterior or poste-
development of scapular dyskinesis and its asso- rior aspects of the glenohumeral joint capsule.
ciated sequelae. Regardless of whether operative When compared to those with predominantly
or nonoperative treatment is chosen, scapular posterior stiffness, those with anterior stiffness
motion should be evaluated in all patients at reg- demonstrated increased scapular upward rotation
ular intervals during the course of rehabilitation. and decreased posterior tilt both at rest and dur-
ing active motion. However, most of these
9.3.3.5 Clavicle Fractures patients were found to have range of motion defi-
Clavicle fractures can produce scapular dyskine- cits primarily involving internal and external
sis through a similar mechanism to that which rotation rather than humeral elevation.
was described above for AC joint dislocations— Nevertheless, Vermeulen et al. [64] found that a
that is, the inability to adequately (or accurately) course of physical therapy was particularly help-
transmit forces between the scapula and the ster- ful in correcting the scapular malposition related
noclavicular (SC) joint via the clavicular strut. In to shoulder stiffness and improving overall shoul-
other words, disruption of the cohesive relation- der function. Therefore, the scapula should be
ship between the scapula and the axial skeleton thoroughly evaluated in patients with shoulder
(through the clavicle) prevents normal scapulo- stiffness (with or without adhesive capsulitis) in
humeral rhythm. Realistically, any alteration in order to optimize rehabilitation and clinical out-
clavicular anatomy can produce disordered scap- comes following both operative and nonoperative
ular motion. These defects might include fracture treatment modalities.
malalignment, clavicle shortening as a result of
fragment overlap or angulation (especially when 9.3.3.7 Scapulothoracic Bursitis and
shortening exceeds 15 mm [59, 60]), external Snapping Scapula Syndrome
rotation of the distal fragment or fractures that In order to achieve smooth scapular motion in
extend into the AC or SC joint which can lead to three-dimensional space, the concave scapula
chronic pain and abnormal periscapular muscle must glide freely over the convex posterior tho-
firing patterns. Specifically, these patients often rax with the aid of interposed muscle layers (i.e.,
have clinical evidence of scapular protraction and the serratus anterior and subscapularis) and bur-
decreased posterior tilt which can lead to chronic sal tissue. Therefore, any disorder or abnormality
sequelae such as rotator cuff disease. Therefore, that produces an anatomic derangement within
scapulothoracic motion should be repeatedly the scapulothoracic space can lead to altered
evaluated in all patients with clavicle fractures painful bursitis and/or mechanical crepitation—a
during the course of rehabilitation, regardless of condition collectively referred to as scapulotho-
whether the patient was initially treated opera- racic bursitis and/or snapping scapula syndrome.
tively or nonoperatively. Scapulothoracic bursitis has numerous poten-
tial etiologies, many of which can be divided into
9.3.3.6 Shoulder Stiffness categories depending on patient symptomatol-
and Adhesive Capsulitis ogy. For example, patients who present with
The relationship between scapular dyskinesis and periscapular pain in the absence of mechanical
shoulder stiffness or adhesive capsulitis has crepitus during shoulder motion are more likely
become a topic of increased interest in recent to have bursitis which is most often the result of
years since several studies have noted increased chronic overuse, especially in those who partici-
ipsilateral scapular upward rotation in this sub- pate in overhead activities. In contrast, patients
group of patients [61–64]. It is theorized that this who present with painful crepitus during shoulder
activity are more likely to have an anatomic the majority of cases. Nevertheless, nonoperative
derangement involving the scapulothoracic space management is the first-line treatment strategy
that prevents smooth gliding of the scapula over and usually includes non-steroidal anti-inflam-
the posterior chest wall. Potential etiologies matory medications, injection of bursal tissue
include kyphoscoliotic posture [65], space- and periscapular muscle strengthening. Open or
occupying osseous or soft-tissue masses (such as arthroscopic management may be indicated in
fracture callus, anomalous musculature, benign patients who fail a course of nonoperative treat-
or malignant tumors, and fibrotic bursae) or pre- ment or those who have an obvious space-
disposing anatomic variations (such as hyperan- encroaching mass that is found on imaging
gulation of the superomedial angle [7], a Luschka studies.
tubercle [5], or a teres major tubercle [6], among
many other possibilities). However, it is impor- 9.3.3.8 Trapezius Myalgia
tant to recognize that symptomatic bursitis can Trapezius myalgia is vaguely defined as pain in
eventually lead to mechanical crepitus (as a result the region of the trapezius, most frequently involv-
of bursal fibrosis [5, 18, 21, 22]) while mechani- ing the superior division of the muscle that travels
cal crepitus can also lead to symptomatic bursitis along the neck between the occiput and the scapu-
(as a result of disordered scapular motion) [23]. lar spine [68–70]. However, in reality, the myalgia
Therefore, most patients will present with char- probably involves other muscles in the area such
acteristics that suggest both mechanical and non- as the levator scapulae, the rhomboid major and
mechanical etiologies. minor, and/or the paraspinal musculature [71].
Scapular dyskinesis is a common finding in The condition is often attributed to poor sitting
patients with scapulothoracic bursitis and is most posture and alterations in the neck flexion angle
likely caused by tightness or weakness of the ser- during prolonged periods of desk-related work
ratus anterior, upper trapezius, levator scapulae, [71–79]. Patients typically present with a dull
and/or pectoralis minor. This muscular imbal- ache, tenderness to palpation, and subjective
ance can be variable and may be the result of a “tightness” along the lateral side of the neck.
compensatory mechanism that functions to avoid Several studies have identified muscular imbal-
periscapular pain with shoulder motion. Scapular ances, derangements in upper trapezius muscle
“pseudowinging” may be present in patients with firing patterns (mostly increased activity), and
an enlarging scapulothoracic mass which physi- decreased maximum contraction strength and
cally pushes the scapular body away from the endurance in this group of patients (i.e., involve-
posterior chest wall. In cases of symptomatic ment of both fast- and slow-twitch muscle fibers)
bursitis, superficial palpation around the scapular [69, 80–83]. As a result, many patients with work-
margins most often reveals the site of maximal related neck pain have clinically significant scapu-
tenderness and inflammation. However, deeper lar malposition such as decreased posterior tilt and
palpation may be necessary in some cases—this increased protraction [78, 84, 85] which may pre-
typically involves placing the arm in the “chicken dispose these individuals to secondary rotator cuff
wing” position (dorsum of hand placed over lum- impingement as a result of a decreased acromio-
bosacral junction) which increases downward humeral distance [86]. A study by Juul-Kristensen
rotation of the scapula and allows deeper palpa- et al. [68] confirmed these findings and also noted
tion along the medial scapular border [66, 67]. that patients with trapezius myalgia demonstrated
During range of motion testing, the clinician can a statistically significant increased capacity for
also apply a compressive force to the posterior passive glenohumeral internal rotation (due to
scapular body to decrease the scapulothoracic increased scapular protraction) when compared to
space which may help reproduce the patient’s normal controls. In addition, those patients who
symptoms in the office setting [8]. reported the greatest work-related disability asso-
Clinical management of this entity is diffi- ciated with trapezius myalgia also demonstrated
cult because its precise etiology is unknown in a 20° increase in passive glenohumeral internal
rotation capacity when compared to the rest of

the cohort.
Given the very high prevalence of neck pain
associated with desk-related work, trapezius
myalgia is probably much more common than
most physicians and researchers have been able
to document to this point. This presumed discrep-
ancy between the reported prevalence and the
true prevalence of trapezius myalgia is likely
present due to multiple factors. Most notably,
highly accessible media outlets often misinter-
pret this work-related neck pain as a manifesta-
tion of cervical spine pathology. As a result,
Fig. 9.13 Clinical photograph demonstrating bilateral
many afflicted patients likely seek treatment for scapular malposition in a patient with facioscapulohumeral
pain related to the cervical spine rather than the dystrophy (FSHD). Although the scapulae appear asym-
scapula or the shoulder. This misperception may metric, they are both in a position of protraction with prom-
lead patients to undergo expensive, ineffective, inence of the medial scapular border indicating bilateral
weakness of the trapezius muscle. Asymmetric periscapu-
and unnecessary treatments such as cervical lar weakness typically differentiates patients with FSHD
spine manipulation, injections, and acupuncture, from patients with other limb-girdle dystrophies.
among many other possibilities. Therefore, it is
crucial for clinicians of all specialties to recog-
nize the primary and secondary risk factors for patients with FSHD initially complained of
trapezius myalgia in order to minimize the effects shoulder girdle weakness, 10 % initially com-
of misguided communication on clinical out- plained of orofacial muscle weakness, and the
comes. Appropriate physical therapy should remaining 10 % initially complained of ankle
focus on correcting both the acquired muscular dorsiflexion weakness (i.e., foot drop). However,
imbalance and the hyperkyphotic sitting posture physical examination of these patients revealed
with the ultimate goals of re-establishing normal objective weakness in all three of these muscle
scapular motion, preventing secondary sequelae groups. Although the recognition of FSHD dur-
(such as rotator cuff disease) and eliminating the ing infancy and early childhood has been reported
patient’s symptoms. on occasion [91], the condition most often goes
unrecognized until early adulthood (typically
9.3.3.9 Facioscapulohumeral during the second or third decade of life).
Dystrophy With specific reference to the shoulder,
Facioscapulohumeral dystrophy (FSHD), the patients with FSHD often display evidence of
third most common type of muscular dystrophy atrophy and/or hypotonia of the middle and lower
(behind Duchenne muscular dystrophy and myo- divisions of the trapezius muscle which forces
tonic muscular dystrophy) [87] occurring in the scapulae into significant elevation, protrac-
approximately 1 in 20,000 individuals [88, 89], is tion, upward rotation (Fig. 9.13) [88, 92].
an inherited autosomal dominant condition that Because the glenoid faces more anteriorly in this
was first described by Landouzy and Dejerine in type of scapular malposition, the glenohumeral
the late 1800s [90]. Characteristic features of joint almost always assumes a position of
FSHD include weakness involving the periscapu- increased internal rotation. However, it is impor-
lar muscles (e.g., scapular dyskinesis), the facial tant to recognize that although patients with
muscles (e.g., the inability to smile), and the FSHD have bilateral periscapular weakness, the
ankle (e.g., difficulty walking due to foot drop) in relative amount of weakness between each shoul-
addition to postural defects related to abdominal der is typically asymmetric. In other words,
weakness (e.g., hyperlordosis). In a retrospective active forward flexion and abduction of the
study by Padberg [90], approximately 80 % of shoulder in patients with FSHD usually reveals
asymmetric scapular winging—a clinical finding the scapular malposition and to relieve the
which can be used to differentiate between patient’s symptoms.
patients with FSHD and those with other types of
limb-girdle muscular dystrophies who most often
present with symmetric scapular winging. 9.3.4 Scapular Dyskinesis
Clinical management of this entity is chal- in Overhead Athletes
lenging since there is very little evidence to sup-
port any possible operative or nonoperative In overhead athletes, the scapula plays a central
treatment modality. Currently, most treatment role in the kinetic chain—muscle contraction
strategies involve symptomatic management in forces produced by the trunk are transmitted
order to improve the patient’s overall function through the scapula and into the hand where
and quality of life. potential energy is converted into kinetic energy
[32, 95]. It follows that any disruption of the
9.3.3.10 Medial Scapular Muscle kinetic chain may lead to disordered scapular
Detachment motion and inefficient energy transmission.
Avulsion or detachment of the musculature that Most competitive overhead athletes display
inserts along the medial scapular border has only differences in scapular resting positions between
recently been described as a distinct clinical their dominant and non-dominant shoulders as a
entity with specific physical examination find- result of physiologic adaptation [96–99]. These
ings [93, 94]. More specifically, the condition is differences typically include increased internal
thought to primarily involve detachment of the rotation along with alterations in upward rotation
lower trapezius and rhomboids from the scapular and posterior tilt (increased or decreased).
spine and/or the medial scapular border follow- However, regardless of the resting position, most
ing an acute traumatic injury (especially seatbelt- overhead athletes display the same pattern of
related motor vehicle accidents). Other possible scapular motion when the arm is elevated [100].
etiologies include seizure, electrocution, or lift- During the competitive season, specific abnor-
ing a heavy object with full elbow extension, malities of scapular motion are only treated when
among other potential causes (most of which they are found to be associated with an injury;
involve a push–pull mechanism of injury). Most however, during the offseason, efforts should be
patients present with an acute onset of severe made to correct scapulohumeral kinematics
pain along the medial scapular border which which can prevent injuries such as SLAP tears
increases in severity as the humerus is mobilized. [34], symptomatic internal impingement [101],
Increased activity of the upper trapezius may also and valgus overload of the medial elbow [102].
produce tension-type headaches in some patients Although the scapula is usually found to be
[93, 94]. internally rotated in overhead athletes, many of
Physical examination findings are fairly uni- these same individuals display seemingly para-
form in these patients and are critical to making doxical evidence of GIRD upon physical exami-
the correct diagnosis. These findings often nation. Physiologic adaptations such as capsular
include localized tenderness along the medial contractures, muscle inflexibility, and osseous
scapular border with or without a palpable soft- changes (e.g., humeral retrotorsion) which allow
tissue defect, an altered scapular resting position the athlete to achieve greater degrees of abduc-
and secondary findings such as rotator cuff tion, extension, and external rotation are respon-
impingement, snapping scapula, and symptom- sible for these findings. These changes produce a
atic relief following scapular manipulation pro- pattern of scapular dyskinesis characterized by
cedures during arm elevation (discussed below). markedly increased protraction and decreased
Although many of these patients present after posterior tilt during forward flexion, internal
having undergone numerous treatments, surgical rotation and horizontal adduction which typically
reattachment is only indicated after a course of occurs during the follow-through phase of the
appropriate scapular rehabilitation fails to correct throwing motion.
As mentioned above, untreated scapular dys- 8. Millett PJ, Gaskill TR, Horan MP, van der Meijden
O. Technique and outcomes of arthroscopic bursec-
kinesis in the overhead athlete can lead to sec-
tomy and partial scapulectomy. Arthroscopy.
ondary injuries that, in some cases, may be 2012;28(12):1776–83.
severe. However, scapular dyskinesis, along with 9. Polguj M, Jędrzejewski K, Podgórski M, Topol M.
its many potential sequelae, can be avoided when Correlation between morphometry of the suprascapu-
lar notch and anthropometric measurements of the
overhead athletes maintain balanced periscapular
scapula. Folia Morphol (Warsz). 2011;70(2):109–15.
strength [103–105], neuromuscular control, and 10. Polguj M, Jędrzejewski K, Podgórski M, Topol M.
proprioception [104, 106]. For more information Morphometry study of the suprascapular notch: pro-
regarding injury prevention in overhead athletes, posal of classification. Surg Radiol Anat. 2011;33(9):
781–7.
we refer the reader to an excellent two-part
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9.4 Conclusion 13. Polguj M, Jędrzejewski K, Majos A, Topol
M. Variations in bifid superior transverse scapular
An understanding of the etiology of disordered ligament as a possible factor of suprascapular entrap-
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scapular motion requires comprehension of the
2095–100.
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Neurovascular Disorders
10
10.2.1 Pathogenesis
10.1 Introduction
Many conditions related to the cervical spine can
The diagnosis of neurovascular-related shoulder cause impingement of exiting nerve roots, leading
dysfunction is a challenging, but necessary to radiating pain towards the ipsilateral shoulder
component of clinical practice. Although basic (Fig. 10.1). Oftentimes, patients perceive this pain
screening tests such as Tinel’s sign and Hoffman’s as coming from the shoulder and radiating towards
sign are useful, it is important to identify the pre- the neck as if to suggest that a shoulder disorder is
cise cause of the patient’s symptoms in order to causative. However, the difference is that radiating
provide an effective treatment protocol. The fol- pain from the cervical region will be distributed in
lowing sections will describe the pathogenesis a dermatomal pattern whereas that of a shoulder
and physical examination findings that will aid in condition would not necessarily be related to any
the establishment of an effective operative or specific dermatome (Fig. 10.2). Cervical spine
nonoperative treatment plan. pathology should always be considered in patients
who complain of constant pain regardless of
shoulder motion, especially when the pain seems
10.2 Cervical Radiculitis to be isolated to a specific dermatome. On the
other hand, patients with a shoulder condition are
Cervical radiculitis is one of the most important also more likely to have positional night pain and
pathologies to be ruled out in patients presenting pain that occurs only with shoulder motion.
with acute or chronic shoulder pain. Degenerative
disc disease, disc herniation, spondylolisthesis,
and zygoapophyseal joint disease, among others, 10.2.2 Physical Examination
can all lead to neurogenic neck pain that may or
may not radiate to the shoulder. This pain can be Initial physical findings in patients with cervical
indistinguishable from that of many shoulder spine pathology may include postural imbal-
pathologies and should always be considered in ances, such as changes in lordosis or forward
any patient with shoulder pain or dysfunction. head positioning, as a result of contracture of
It is important to note, however, that cervical paravertebral and/or periscapular musculature.
spine pathology can coexist with shoulder pathol- Shoulder muscle atrophy can also be an impor-
ogy, making the clinical diagnosis difficult in tant clue since the innervation for many of the
some cases [1, 2]. shoulder muscles are derived from the C5 and C6
242 10 Neurovascular Disorders
a Bone spurs towards the shoulder; however, this is not always

reliable [3]. Tenderness of the trapezius muscle is
not reliable since this can indicate pathology of
Nerve
either the shoulder or the cervical spine; however,
Facet
joint trapezius muscle wasting with lateral scapular
winging suggests involvement of the spinal
accessory nerve (Fig. 10.3).
Spinal cord There are several methods by which physical
examination can be used to differentiate between
disorders of the shoulder or cervical spine. One
b method is to simply test the range of motion
capacity of the neck and shoulder. Patients who
demonstrate full, active, and painless neck range
of motion and who demonstrate difficulty with
isolated shoulder motion are more likely to have
a shoulder condition as opposed to cervical spine
Thickened pathology. The opposite would also be true for a
ligamentum flavum patient with a disorder related to the cervical
c spine—that is, painful neck motion with normal
Herniated disc shoulder motion. Provocative maneuvers are also
designed to differentiate between disorders of
the cervical spine and that of the shoulder girdle
(see below).
10.2.2.1 Spurling’s Test

Spurling’s test [5] is performed by bending the
neck laterally towards the affected shoulder. The
examiner then applies a downward axial force
(classically, ~7 kg) to the top of the head, thus
Fig. 10.1 Illustration highlighting the most common narrowing the space for cervical nerve roots to
causes of cervical radiculopathy. (a) Bone spurs can occur
along the articular facets which can impinge upon exiting
exit the spinal cord (Fig. 10.4). Reproduction of
nerve roots. (b) Thickening of the ligamentum flavum neck and shoulder pain with this maneuver is
may also produce a mass effect that can encroach upon the suggestive of a cervical nerve root lesion. Other
dorsal root ganglion. (c) Disc herniation often occurs authors have suggested various modifications to
along the posterolateral aspect of the vertebral disc and
may also irritate exiting nerve roots.
Spurling’s original test, such as the addition of
rotation and/or extension prior to applying a
downward pressure to the top of the head [3].
nerve roots (especially the suprascapular nerve L’hermitte’s sign, which also indicates cervical
and the dorsal scapular nerve). Prominence of the spine pathology, occurs when a “shooting” or
scapular spine may indicate atrophy of the supra- “electric-like” pain propagates down the neck
spinatus or infraspinatus muscles (innervated by and down the ipsilateral arm with rotation or flex-
the suprascapular nerve) and prominence of the ion of the neck without application of an axial
medial scapular border with excessive lateral load. Although a few studies have evaluated the
position of the scapula may indicate the presence validity of L’hermitte’s sign, these studies appear
of a lesion affecting the dorsal scapular nerve. to have significant methodological flaws that hin-
Tenderness to palpation over the posterior aspect der interpretation of their results [6, 7]. Thus, the
of the cervical spine may also indicate cervical value of L’hermitte’s sign to detect cervical spine
pathology, especially when the pain radiates pathology remains anecdotal at best.
10.2 Cervical Radiculitis 243
Fig. 10.2 Dermatome

map of the upper
extremity. Because the
boundaries of dermatome C2
maps often overlap,
clinical correlation is
needed before an
C3
interpretation can be made. C4 2
C5 3
4
5
C6
6
7
C7
C8
Fig. 10.3 Clinical photographs of a patient with spinal contralateral side. (b) When viewing from posteriorly,
accessory nerve palsy [4]. (a) The right trapezius mus- scapular winging can be seen during humeral elevation.
cle is visibly atrophied (arrow) when compared to the
Shah and Rajshekhar [8] studied the reliability an axial load to the top of the head. The investiga-
of Spurling’s test in the diagnosis of cervical disc tors did not rotate the head prior to application of
disease with the reference standard of magnetic an axial load. The sensitivity and specificity of
resonance imaging (MRI) in 25 patients who Spurling’s test was found to range between 0.90
were treated nonoperatively and direct visualiza- and 1.00, depending on whether MRI or surgery
tion at surgery in 25 patients who were treated was used as the reference standard. In contrast,
operatively. The test was performed by extending Wainner et al. [9] performed the same test; how-
and laterally bending the neck and then applying ever, they also rotated the head towards the
10.2.2.2 Shoulder Abduction Test

The shoulder abduction test is performed by
simply having the patient abduct the humerus
such that the hand is placed on the top of the
head (Fig. 10.5). This maneuver is thought to
increase the space available for the cervical
nerve roots to exit the spinal cord, thus dimin-
ishing symptoms. A cadaveric study by Farmer
and Wisneski [12] confirmed the theoretical
rationale for the test. In their study, pressure
transducers were placed within cervical foram-
ina and pressure readings were recorded with the
humerus and the neck in various positions. They
found that extension of the neck produced the
greatest intra-foraminal pressure while abduc-
tion of the humerus decreased this pressure, thus
further solidifying this maneuver as a viable
technique for the detection of cervical nerve root
compression. Wainner et al. [9] later found that
this maneuver was 17 % sensitive and 92 % spe-
cific for the detection of cervical spine-related
pathology.
Farshad and Min [13] recently described an
abduction extension test that was reported to have
Fig. 10.4 Spurling’s test. While sitting, the patient later-
ally bends the neck towards the affected shoulder. The
a sensitivity of 0.79 and a specificity of 0.98 in
examiner then applies a downward axial force to the top of the detection of cervical nerve root compression.
the head (approximately 7 kg of force). This maneuver is This test was performed by laterally abducting
thought to decrease the space available for cervical nerve the humerus to 80° with the neck rotated towards
roots to exit the spinal cord, thus reproducing the patient’s
symptoms.
the contralateral shoulder. With the patient in this
position, an anteriorly directed pressure was
applied to the posterior aspect of the humeral
ipsilateral side before applying an axial load. In head (Fig. 10.6). Reproduction of symptoms was
that study, they used electromyography (EMG) considered a positive test. In their preliminary
as the reference standard. The investigators cal- cadaveric study using this maneuver, nerve roots
culated a sensitivity of 0.50 and a specificity of were displaced by approximately 4–5 mm in all
0.93 for this version of Spurling’s test. In addi- cases, potentially explaining the resulting high
tion, Tong et al. [10] calculated an even lower sensitivity and specificity values.
sensitivity (0.30) when rotating the neck towards
the contralateral shoulder. Combining the results 10.2.2.3 Valsalva Maneuver
of these three studies, it appears that lateral rota- The Valsalva maneuver is performed with the
tion of the neck decreases the sensitivity of the patient in the seated position. The patient is then
test for the detection of cervical radiculopathy. asked to take a deep breath and to “bear down”
This rationale is supported by Anekstein et al. against a closed glottis for 2–3 s. This technique
[11] who found the greatest sensitivity with the increases intra-abdominal pressure which, in
combination of lateral bending and extension turn, increases pressure within the thecal sac. The
without rotation. Thus, we prefer to perform the test is positive for cervical radiculopathy when
Spurling’s test in neutral rotation to improve neck and shoulder symptoms are reproduced.
diagnostic efficacy. Wainner et al. found the sensitivity of this test to
10.2 Cervical Radiculitis 245
Fig. 10.5 Shoulder

abduction Test. In a patient
with suspected radiculopa-
thy, asking the patient to
place the palm of their
hand on top of their head
with the elbow pointed
laterally may relieve their
symptoms by increasing
the space available for the
cervical nerve roots to exit
the spinal cord.
Fig. 10.6 Modified

shoulder abduction test
proposed by Frashad and
Min [13]. In this test, the
arm is laterally abducted to
approximately 80° and the
neck is bent and/or rotated
towards the contralateral
shoulder. While applying a
gentle pressure to the
posterior aspect of the
humeral head, the
examiner applies a gentle
traction force along the
axis of abduction.
be only 0.22; however, the specificity was 0.94. sically, ~14 kg of force) (Fig. 10.7). This maneu-
Therefore, it is suggested to combine this test ver is thought to increase the space available for
with a more sensitive test, such as Spurling’s test exiting nerve roots. Relief of symptoms indicates
or the upper limb tension test (described below), a positive test and is indicative of cervical pathol-
to improve diagnostic accuracy. ogy. Wainner et al. [9] determined that the cervi-
cal distraction test was 44 % sensitive and 90 %
10.2.2.4 Cervical Distraction Test specific for the detection of cervical spine pathol-
The cervical distraction test is performed with ogy. Similarly, Viikari-Juntura [3] calculated
the patient in the supine position. The examiner a sensitivity of 0.44 and a specificity of 0.97.
cradles the jaw and occiput with their hands and Thus, similar to the Valsalva maneuver men-
slightly flexes the neck to improve patient com- tioned above, it is important to combine this test
fort. A distraction force is applied gently and with other, more sensitive provocative maneu-
gradually until significant resistance is felt (clas- vers to improve diagnostic efficacy.
Fig. 10.7 Cervical

distraction test. With the
patient lying supine on the
examination table, the
examiner cradles the jaw
and occiput with their
hands. The neck is placed
in a slightly flexed position
and a gentle superiorly
directed distraction force is
applied (approximately
14 kg of force). This
maneuver is also thought
to increase the space
available for exiting
nerves.
Fig. 10.8 Brachial plexus

distraction test. With the
patient supine, the
examiner uses one hand to
stabilize the scapula while
the other hand is used to
place the humerus in
abduction and external
rotation, the elbow
extended, the forearm
supinated, the wrist and
fingers extended and the
neck bent towards the
contralateral shoulder. The
neck is then slowly bent
laterally towards the
affected shoulder which
may reproduce the
patient’s symptoms.
10.2.2.5 Brachial Plexus Tension Test then abducted, the forearm is supinated, the
The brachial plexus tension test was first wrist and fingers are extended, the humerus is
described by Elvey [14] in 1986 and has been externally rotated, the elbow is extended, and the
modified on a few occasions [9, 15]. Although neck is bent towards the contralateral side and
less descriptive, some researchers refer to then towards the ipsilateral side (Fig. 10.8).
this maneuver as the “upper limb tension test.” Reproduction of the patient’s symptoms was con-
The test is performed as a series of steps with sidered a positive test. Wainner et al. [9] found
the patient in the supine position. The first step that the sensitivity and specificity values for
is to place the hand over the posterior aspect this test were 0.97 and 0.22, respectively.
of the scapula and to depress the scapula against Quintner [15] found slightly lower sensitivity
the thoracic wall. Sequentially, the shoulder is and specificity values; however, they used
10.3 Thoracic Outlet Syndrome 247
Fig. 10.9 Modified

brachial plexus distraction
supine, the examiner uses
one hand to depress the
scapula while the other
hand is used to place the
humerus in 30° of
abduction with internal
rotation, extend the elbow,
and flex the wrist and
fingers. The neck is then
laterally bent towards the
contralateral shoulder. The
neck is then slowly bent
laterally towards the
affected shoulder,
potentially reproducing the
patient’s symptoms.
cervical radiography to confirm the diagnosis Table 10.1 List of possible conditions that may mimic
as opposed to EMG which was performed by thoracic outlet syndrome
Wainner et al. [9]. Conditions that can mimic thoracic outlet syndrome
As an adjunct to this test, Wainner et al. [9] Cervical radiculitis Malignancy
proposed a second method to evaluate for cervi- (e.g. spinal cord tumors)
cal spine pathology. In this maneuver, the patient Brachial plexopathy Shoulder pathology
was positioned supine with the shoulder abducted Fibromyalgia Spastic disorders
Angina/acute Raynaud’s phenomenon/disease
to 30°. The examiner then sequentially depressed
coronary syndrome
the scapula, internally rotated the humerus, Complex regional Peripheral nerve entrapment
extended the elbow, flexed the wrist and fingers pain syndrome
and, finally, contralateral followed by ipsilateral Neurologic disorders Vasculitides
side-bending of the neck (Fig. 10.9). Reproduction
of the patient’s symptoms was considered a posi-
tive test. The sensitivity and specificity values for misdiagnoses and confusing clinical presenta-
this maneuver were 0.72 and 0.33, respectively, tions, especially since there are numerous condi-
representing an inferior result compared to tions that can mimic TOS, such as brachial
Elvey’s original test described above. neuritis, peripheral nerve entrapments, and cervi-
cal spine disease among many other possibilities
(Table 10.1).
10.3 Thoracic Outlet Syndrome
In 1956, Peet et al. [16] were the first to coin the 10.3.1 Pathogenesis
term “thoracic outlet syndrome” (TOS) as a result
of neurovascular compression between the ante- As the brachial plexus and subclavian vessels
rior and middle scalene muscles (i.e., the inter- course towards the axilla and the upper arm, there
scalene triangle). It is one of the most controversial are at least four areas of potential narrowing that
conditions in the orthopedic literature with regard can result in TOS. The first potential site of com-
to anatomy, diagnosis, and management. In 2004, pression occurs in patients with a congenital
Huang and Zager [17] reported that the incidence bony or fibrous extension of the transverse pro-
of TOS was approximately 3–80 cases per 1,000 cess of the seventh cervical vertebra (cervical rib;
people. This wide variability is likely due to Fig. 10.10) [18, 19]. The interscalene triangle is
Middle scalene muscle

Anterior scalene muscle
Cervical rib adheres

Cervical rib compresses to 1st thoracic rib by
the subclavian artery: a dense fibrous band
poststenotic dilation
Fig. 10.10 Cervical rib. (a) Illustration depicting the Radiograph demonstrating a cervical rib arising from the
anatomy of a cervical rib and its relationship with the seventh cervical vertebra.
nearby subclavian vessels and brachial plexus. (b)
the second of these stenotic areas and is the most first rib (costoclavicular syndrome; Fig. 10.12).
common site of compression (scalenus anticus Impingement in this area primarily involves the
syndrome; Fig. 10.11). The interscalene triangle subclavian artery and/or vein. The fourth poten-
is bordered by the anterior scalene muscle anteri- tial site of neurovascular compression is within
orly, the middle scalene posteriorly, and the the subcoracoid space in an area beneath the pec-
superiomedial aspect of the first rib inferiorly. toralis minor muscle-tendon unit (pectoralis
The subclavian artery, subclavian vein, and the minor syndrome; Fig. 10.13).
trunks of the brachial plexus are located within The numerous potential etiologies for TOS
this triangle and is thus a potential site of neuro- can be divided into static and dynamic causes.
vascular impingement. The costoclavicular space Static causes might include cervical ribs, frac-
is the third site of narrowing and is located ture callus, fibrous bands, anomalous or
between the middle 1/3 of the clavicle and the fibrotic musculature (such as pectoralis minor

depicting the interscalene
triangle with the brachial Middle scalene muscle
plexus and subclavian
vessels situated between Anterior scalene muscle
the middle and anterior Brachial plexus entrapment
scalene muscles.
Brachial
plexus

of the contents of the
costoclavicular space.
Regardless of cause,
compression of the
neurovascular structures as
they pass through the
costoclavicular space can
result in thoracic outlet
syndrome. Vascular
symptoms are most
common when impinge-
ment occurs within the
syndrome [20, 21]), poor posture, and patho- The potential causes of TOS can also be
logic lesions with significant mass effect such divided by the structure involved. Neurogenic
as a Pancoast tumor, tuberculosis, or osteomy- TOS, which has been reported to account for
elitis. Reproduction of symptoms with scapu- more than 95 % of all cases of TOS [23], involves
lothoracic or glenohumeral motion typically compression of the nerves within the brachial
indicates a dynamic cause which can occur plexus and is often the result of neck trauma.
within any of the three typically stenotic areas Vascular TOS, as the name suggests, involves
mentioned above. Repetitive microtrauma, as compression of the subclavian artery and/or vein.
which occurs commonly in athletes and man- Compression of the subclavian artery is typically
ual laborers, can also play an important role in associated with a cervical rib or rudimentary first
the pathogenesis of TOS; however, the exact rib [24, 25] (see Fig. 10.10). In contrast, com-
pathomechanism behind repetitive micro- pression of the subclavian vein usually occurs
trauma and the development of TOS has not within the costoclavicular space [26] (see
been clearly defined [21, 22]. Fig. 10.12). Mixed TOS is more nonspecific and
Fig. 10.13 Illustration of

the mechanism of
neurovascular compression
beneath the coracoid Middle scalene
process and pectoralis muscle
minor tendon (within the Anterior scalene
subcoracoid space) as the muscle
humerus is maximally Brachial plexus
abducted (also known as
pectoralis minor
syndrome).
Neurovascular bundle
Coracoid process
Subclavian artery
Subclavian vein
Pectoralis minor
may involve compression of nerves, arteries, and/ these may suggest the presence of a neuropathy or
or veins simultaneously with varying magnitudes myelopathy. Hoffman’s sign is a useful test for the
of compressive force. detection of cervical myelopathy (Fig. 10.14).
Many patients with TOS report an aching sen- Combined supraspinatus and infraspinatus atro-
sation over the shoulder or neck accompanied by phy can occur since innervation for both of these
upper limb paresthesias such as numbness or tin- muscles is derived from the C5 nerve root of the
gling. Sensory dysfunction of the arm and/or brachial plexus (suprascapular nerve). Weakness
hand often occurs simultaneously with occipital or atrophy of the rhomboid musculature may indi-
headaches. Compression of the subclavian vein cate compression of the dorsal scapular nerve
may result in ipsilateral swelling and/or discolor- (also from the C5 nerve root). The radial, median,
ation of the arm whereas compression of the sub- and ulnar nerves are also derived from the brachial
clavian artery can produce a subclavian bruit. plexus, and care must be taken to evaluate the
Cold, pale skin distal to the elbow may indicate appropriate musculature to potentially locate the
proximal compression of a sympathetic nerve. In site of impingement. Tinel’s sign should also be
reality, however, most patients with TOS present performed to rule out cubital tunnel syndrome at
with vague symptoms that are often difficult to the elbow and carpal tunnel syndrome at the wrist.
differentiate from other causes of shoulder pain. There are several provocative maneuvers that
can be used to help determine the site of impinge-
ment and the structure involved in TOS. However,
10.3.2 Physical Examination interpretation of clinical tests for TOS is contro-
versial and there is no individual test that is univer-
It is important to inspect the entire upper extrem- sally diagnostic. This is due to the wide variation
ity, including the intrinsic muscles of the hand, for in potential pathomechanisms involved with its
muscle atrophy, wasting, or fasciculations since development. In addition, the high false positive
Fig. 10.14 Hoffman’s

sign. The examiner gentle
flicks the dorsum of the
patient’s middle finger in a
downward direction.
Reflexive thumb flexion is
a common indicator of
cervical myelopathy.
rate for many of these tests calls to question their

application in clinical practice [27, 28]. Rayan and
Jensen [27] found that 91 % of asymptomatic sub-
jects developed symptoms from at least one of the
tests designed to detect TOS.
10.3.2.1 Adson’s Test

Adson’s test was first described by Adson and
Coffey [19] in 1927 as a method to assess for cir-
culatory disruption due to a cervical rib. The test is
performed with the patient sitting on the examina-
tion table. The radial pulse is then palpated prior
to initiating the test. The patient is then asked to
rotate the neck towards the affected shoulder,
extend the neck, and to take a deep breath while
the examiner simultaneously palpates the radial
pulse (Fig. 10.15). When there is a decrease in
pulse amplitude, the test is positive and indicates
that the vascular component of the neurovascular
bundle is being compressed within either the inter-
scalene triangle or the costoclavicular triangle.
Reproduction of paresthesias with this maneuver
can also occur, indicating compression of a neural
structure. However, in 1951, Adson [18] sug-
gested that subclavian artery compression can also Fig. 10.15 Adson’s test. In this test, the examiner first pal-
indicate compression and/or microtrauma of neu- pates the radial pulse to confirm adequate pulse amplitude.
ral elements even in the absence of paresthesias. The patient is then asked to rotate the neck towards the
affected shoulder and to inhale deeply. The examiner again
Adson’s test has been reported to have a
palpates the radial pulse. A decrease in pulse amplitude sug-
sensitivity between 0.79 and 0.94 and a specifi- gests that proximal arterial compression, possibly at the inter-
city ranging from 0.74 to 1.00 [27, 29–32]. scalene triangle, may be causative of the patient’s symptoms.
Fig. 10.16 Halsted

maneuver. This test is
performed exactly as
described for Adson’s test;
however, rather than
rotating the neck, the neck
is extended posteriorly.
Compression is thought to
occur either at the
interscalene triangle or the
However, the studies by Nord et al. [31] and asked to extend the neck while the examiner
Plewa and Delinger [32] displayed conflicting simultaneously palpates the radial pulse at the
results regarding the rate of false positives— wrist. A positive test occurs when the pulse
Nord et al. [31] calculated a false positive rate of amplitude decreases as the neck is extended and
nearly 50 % while Plewa and Delinger [32] cal- may indicate compression within either the inter-
culated a false positive rate of only 7 %. Several scalene triangle or the costoclavicular space
other authors have suggested that a positive test (Fig. 10.16). The examiner can also apply gentle
result may be associated with worse outcomes traction to the arm to help elicit symptoms. An
after either surgery or rehabilitation, especially in MRI study by Demirbag et al. [35] found that the
those with mixed neural and vascular symptoms Halsted maneuver produced a significantly
[33, 34]. Clearly, it is important to consider the decreased distance between neurovascular struc-
entire clinical picture before making the diagno- tures and the inferior border of the clavicle within
sis of TOS using any physical examination the costoclavicular space. Although this test has
maneuver. This includes a combination of the been widely referenced in the literature, there
history, other physical findings and, potentially, have been no clinical studies that have evaluated
imaging studies that serve to improve diagnostic the validity or reliability of the test for diagnos-
accuracy [29, 35]. ing TOS.
10.3.2.2 Halsted Maneuver 10.3.2.3 Costoclavicular Test

Dr. William Halsted was the first to identify and Compression of the subclavian vessels within the
treat lesions of the subclavian artery due to the costoclavicular space was first described in 1943
presence of cervical ribs in the late 1910s. The by Falconer and Weddel [37]. They described a
“Halsted maneuver” was developed to induce maneuver in which the sitting patient was asked
compression of the subclavian vessels and/or the to retract the scapulae and flex the cervical spine,
brachial plexus within the costoclavicular space; bringing the chin towards the chest. The exam-
however, the test is also purported to identify iner simultaneously palpated the radial pulse
compression within the interscalene triangle and (Fig. 10.17). A decrease in pulse amplitude dur-
may be a useful adjunct to Adson’s test [36]. ing this test indicated that compression of the
The Halsted maneuver is performed with the neurovascular structures between the clavicle
patient sitting on the examination table with the and the first rib was likely. Falconer and Weddel
arms in a neutral position. The patient is then [37] found a 60 % false positive rate indicating
Fig. 10.17 Costoclavicular

test. In this test, the patient
is asked to maximally
retract the shoulders and to
simultaneously bend the
neck into forward flexion.
The radial pulse is palpated
both before and after this
positioning. Compression
is thought to occur within
the costoclavicular space.
that this maneuver may cause compression even

in the absence of predisposing anatomy. Similarly,
Telford and Mottershead [38] found radial pulse
diminution in 68 % of normal subjects after
shoulder retraction. Although this technique has
been used extensively, there have been no studies
that have evaluated its actual sensitivity or speci-
ficity in the diagnosis of TOS.
10.3.2.4 Wright’s Test

In 1945, Wright [39] described the diminution of
the radial pulse in 93 % of 150 asymptomatic
individuals with the arm hyperabducted to an
overhead position and the elbow flexed to 90°
(Fig. 10.18). He suggested this finding was the
result of axillary artery compression beneath the
pectoralis minor tendon within the subcoracoid
space (see Fig. 10.13). Along with Raaf [40],
Gilroy and Meyer [41] also found positive results
in up to 70 % of asymptomatic volunteers. Rayan
and Jensen [27] suggested that positive symp-
toms could be the result of ulnar nerve compres-
sion behind the medial epicondyle since the
original description of the test involved flexion of Fig. 10.18 Wright’s test. With the elbow flexed to 90°, the
the elbow. They proposed that the test be per- humerus is maximally abducted to an overhead position.
formed with the elbow extended; however, they Reproduction of symptoms may indicate neurovascular com-
did not evaluate the reliability or validity of this pression beneath the coracoid and pectoralis minor tendon.
technique. Tanaka et al. [42] performed a study
in which nerve contact pressures were mea- They found that Wright’s test induced the great-
sured with different tests for TOS in a series est amount of nerve compression compared to
of eight cadavers without a history of TOS. any of the other tested positions, further implying
10.4 Quadrilateral Space

Syndrome and Axillary
Neuropathy
10.4.1 Pathogenesis
There are numerous potential etiologies of axil-

lary nerve palsy, many of which occur as a result
of blunt trauma, iatrogenic injury, or nerve
compression. The axillary nerve branches from
the C5–C6 nerve root and courses towards
the quadrilateral space, passing just inferior to the
subscapularis and anteroinferolateral to the infe-
rior glenoid rim. The quadrilateral space, as the
name suggests, is bordered by four structures—
namely, the teres minor superiorly, the teres major
inferiorly, the proximal humerus laterally, and the
long head of the triceps medially (Fig. 10.20). The
posterior circumflex humeral artery, a branch of
the axillary artery, travels with the axillary nerve
through the quadrilateral space. Compression of
the neurovascular bundle within this space, termed
Fig. 10.19 Roos test. With the arm in the 90/90 position the “quadrilateral space syndrome” by Cahill and
(90° of abduction, 90° of external rotation with the elbow Palmer [46] in 1983, can occur from anomalous
flexed 90°), the patient is asked to rapidly open and close fibrous bands, traumatic scarring, mass lesions,
their fist for a minimum of 3 min. The clinical utility of glenolabral cysts, large humeral head osteophytes,
this test has not been firmly established.
and/or muscle hypertrophy [47–51]. Cahill and
Palmer [46], along with McKowen and Voorhies
that nerve compression in the hyperabducted [52], observed that axillary nerve compression
position may be a normal phenomenon—a within the quadrilateral space commonly occurred
concept that was originally suggested by Roos with the humerus in a hyperabducted and exter-
[43] in 1976. nally rotated position (such as which occurs dur-
ing the throwing motion). Although uncommon,
10.3.2.5 Roos Test this position may also cause arterial compression
Roos [43] also developed a test designed to detect more proximally where the axillary artery travels
vascular compression at the level of the brachial beneath a hypertrophied pectoralis minor muscle,
plexus. In this test, the humerus is flexed to 90° potentially resulting in thrombosis and distal
and externally rotated with the elbow also flexed embolization [53–56].
to 90°. The patient is then instructed to repeat-
edly open and close the fist at moderate speed for
approximately 3 min (Fig. 10.19). Reproduction 10.4.2 Physical Examination
of symptoms within the 3-min interval indicates
a positive test. However, this test has also been Quadrilateral space syndrome typically presents
reported to produce a high rate of false positives as a vague posterior or lateral pain over the domi-
on at least one occasion [32]. The sensitivity of nant shoulder of young, athletic individuals.
this test has been reported to range from 0.52 to Patients may also complain of night pain and
0.84 with a specificity between 0.30 and 1.00 [27, mild weakness, especially with forward elevation
29, 31, 32, 44, 45]. and/or abduction. The presence of paresthesias
10.4 Quadrilateral Space Syndrome and Axillary Neuropathy 255
Clavicle
a
Acromion
Suprascapular
artery and nerve
Supraspinatus
Capsule of
Scapular spine shoulder joint
Deltoid
Teres minor
Infraspinatus
Posterior circumflex
Medial border humeral artery and
axillary nerve
Circumflex
scapular artery Quadrilateral space
Profunda brachii artery
and radial nerve in
triceps hiatus
Teres major
Long head
Triceps brachii
Lateral head
Triangular space
Entrapment of posterior
humeral circumflex artery
and axillary nerve within the
quadrilateral space when the
humerus is in 90˚ abduction
Fig. 10.20 (a) Illustration depicting the anatomy of the space as the arm is abducted to approximately 90° in the
quadrilateral space. See text for anatomic description. (b) coronal plane.
Illustration showing the narrowing of the quadrilateral
over the lateral deltoid is not uncommon and Although physical examination findings are
strongly indicates axillary nerve involvement. nonspecific in many cases, it is most important to
Aside from these typical complaints, other his- rule out other, more common causes of shoulder
torical findings are largely nonspecific and gener- pain such as rotator cuff tears and labral lesions,
ally do not contribute to the diagnosis. especially in overhead throwing athletes.
Tenderness to palpation directly over the quadri- 10.5.1 Pathogenesis

lateral space may occur with concomitant weak-
ness and/or atrophy of the posterior deltoid. This Several types of brachial neuritis exist and differ
finding should alert the clinician to the potential in clinical presentation depending on the most
for neurovascular compromise within the quadri- likely cause. These include idiopathic, hypertro-
lateral space. phic, hereditary, and traumatic types.
Provocative maneuvers for the diagnosis of Idiopathic brachial neuritis is most com-
quadrilateral space syndrome are rarely reported; monly asymmetric (bilateral in 1/3 of cases [58])
however, there are a few techniques that can be and affects men more than women at a rate of at
used to piece together the diagnosis. Although least 2:1 [49]. The condition typically has a
not always present, the deltoid lag sign may indi- bimodal age distribution, occurring most com-
cate posterior deltoid weakness (see Chap. 3), monly in patients in their 20s and 60s [58].
and the Hornblower’s sign (see Chap. 4) may Approximately half of patients report preceding
indicate concomitant weakness of the teres events such as flu-like symptoms [59], recent
minor muscle (both the deltoid and the teres vaccination [61, 62], and/or recent surgery [63]
minor muscles are innervated by the axillary in the days just prior to the onset of symptoms,
nerve). In addition, abnormal sensation may be leading some to believe the condition may be
noted over the lateral deltoid since the sensory immune-modulated [58]. Pierre et al. [64] dem-
branch of the axillary nerve provides innervation onstrated oligoclonal banding consisting of ele-
to the skin overlying this area. Some authors vated IgG titers against herpes simplex and
suggest that forward flexion, abduction, and varicella zoster viruses in the cerebrospinal fluid
external rotation of the humerus can reproduce of patients with brachial neuritis. Biopsies of the
symptoms when the position is held for approxi- brachial plexus have also revealed mononuclear
mately 2 min; however, this method has not been infiltrates, further suggesting an immunological
evaluated in the literature [48]. Because of vague basis for the disease [65, 66]. In addition, treat-
presenting signs and symptoms, a high index of ment with immune-modulating drugs such as
suspicion is needed to correctly diagnose quadri- corticosteroids and IVIg has been helpful on
lateral space syndrome by physical examination. occasion [67–71].
Subclavian arteriography demonstrating stenosis Hypertrophic brachial neuritis has an unknown
or blockage of the posterior circumflex humeral cause; however, its features differ from that of the
artery with the arm abducted and externally above condition in that evidence of demyelin-
rotated is thought to confirm the suspected diag- ation is evident on histologic examination, simi-
nosis even though most patients do not have vas- lar to other demyelinating diseases such as
cular symptoms [46]. Gullain–Barre syndrome [72, 73]. Signs of gen-
eralized polyneuropathy, however, are absent. In
addition, brachial plexus edema manifests as an
10.5 Brachial Neuritis enlarged appearance on MRI that suggests the
diagnosis of hypertrophic brachial neuritis
Brachial plexus injuries, although most com- (Fig. 10.21) [58, 74].
monly idiopathic, have been reported to result Hereditary brachial neuritis is a rare autoso-
from inflammation, trauma, malignancy, and mal dominant condition that, unlike other forms
even excessive radiation [49, 57–59]. Parsonage of brachial neuritis, generally manifests in early
and Turner [60] first described these disorders in childhood with dysmorphic phenotypes such as
136 patients, labeling the condition as “neuralgic hypotelorism, facial asymmetry, and/or cleft
amyotrophy.” Others have labeled the condition palate, among others [58]. It is associated with
as a brachial radiculitis, neuropathy, neuritis and, missense mutations and heterogeneous duplica-
most commonly, Parsonage–Turner syndrome. tions of the SEPT9 gene on chromosome 17q25
10.5 Brachial Neuritis 257
Fig. 10.21 Coronal MRI

demonstrating brachial
plexus hypertrophy in a
patient who presented
with suspected brachial
neuritis [133].
and its prevalence is largely unknown [75, 76]. entire upper extremity which can last from days
Klein et al. [76] found intravenous corticoste- to weeks. Once the pain subsides (usually within
roids helpful in reducing symptoms thus sug- 1 month), significant weakness occurs progres-
gesting a potential immunological mechanism sively over several days and finally dissipates
for this condition. with full recovery of function in most patients
Traumatic injury is probably one of the more over time [59]. On the other hand, hypertrophic
common causes of brachial plexopathy (i.e., trau- brachial neuritis is a painless condition that pri-
matic brachial neuritis) and usually results from marily presents as progressive weakness over a
high-energy trauma, such as motorcycle and period of months to years. Finally, hereditary bra-
snowmobiling accidents [50], resulting in trac- chial neuritis begins in childhood and presents as
tion of the brachial plexus (i.e., the head and neck acute “attacks” (similar to the idiopathic form)
are stretched away from the affected shoulder) that can occur throughout the individual’s life-
and, potentially, nerve root avulsion from the spi- time. The patient will likely have a positive fam-
nal cord. The brachial plexus can also be injured ily history, may have cranial nerve involvement,
as a result of a violent hyperabduction motion as and may have dysmorphic facial features.
it becomes trapped beneath the coracoid process Initial inspection of the patient with brachial
[58, 77]. Midha [50] suggested that injuries neuritis may reveal muscle wasting and fascicu-
occurring more proximally to the clavicle (supra- lations involving the upper arm, forearm, and
clavicular injury) carry a much poorer prognosis hand muscles suggesting lower motor neuron
than those that occur distal to the clavicle (infra- involvement, especially during the “weakness”
clavicular injury). phase of the disease. The axillary, suprascapular,
long thoracic, and musculocutaneous nerves are
most commonly affected; [78] however, any
10.5.2 Physical Examination nerve branching from the brachial plexus, or any
nerve passing nearby such as the phrenic nerve,
Although physical examination findings across may be involved [79–81]. EMG is most useful in
patients with different brachial plexopathies are making the diagnosis of brachial neuritis as this
often similar, the natural history of the disease typically reveals a pattern consistent with acute
can differ widely thus providing a clue to the demyelination with axonal neuropathy during the
underlying sub-diagnosis. For example, most acute phase (within 3 weeks) and early regenera-
patients with idiopathic brachial neuritis experi- tion on repeat examination (after approximately
ence sudden, intense pain often involving the 3–4 months) [82].
suprascapular nerve courses a path consisting of

10.6 Suprascapular Neuropathy several distinct narrow areas including the supra-
scapular notch and, distal to the supraspinatus, the
Clinical symptomatology associated with entrap- spinoglenoid notch. The location of nerve entrap-
ment neuropathy of the suprascapular nerve was ment determines clinical signs and symptoms. For
first described by Kopell and Thompson [83] in example, proximal within the suprascapular notch
1959. Suprascapular neuropathy is a relatively will result in atrophy and weakness of both the
uncommon condition in the general population; supraspinatus and infraspinatus muscles. On the
however, more commonly, it can present as a other hand, entrapment that occurs more distal to
chronic traction injury in overhead athletes such as the supraspinatus (i.e., within the spinoglenoid
volleyball players and baseball players [84–89]. notch) will result in isolated atrophy and weakness
From its origin at the C5 nerve root (Erb’s point) to of the infraspinatus muscle (Fig. 10.22). The spino-
its termination at the infraspinatus muscle, the glenoid notch may also be a site of “bowstring”
Fig. 10.22 (a) Illustration depicting suprascapular nerve the scapular spine. (b) Illustration depicting suprascapular
entrapment at the level of the transverse scapular liga- nerve compression due to a large glenolabral cyst distal to
ment. The corresponding clinical photograph demon- the spinoglenoid notch. The corresponding clinical photo-
strates the observed atrophy of both the supraspinatus and graph demonstrates the observed isolated atrophy of the
infraspinatus muscles as evidenced by the prominence of infraspinatus muscle (asterisk) [90].
10.6 Suprascapular Neuropathy 259
result of nerve traction at tethering points, most

commonly involving the spinoglenoid notch.
Plancher et al. [106] identified increased traction
Tear in tendon
of the suprascapular nerve over the spinoglenoid
Suprascapular nerve
pulled medially against
ligament during the follow-through phase of the
the scapular spine overhand throwing motion. Their study suggests
that the spinoglenoid notch may provide a ful-
crum against which the nerve stretches, thus pro-
ducing chronic traction injuries in overhead
athletes. Ringel et al. [51] suggested that traction
forces may produce intimal damage to branches
of the suprascapular artery, generating micro-
Fig. 10.23 Illustration of the bowstring injury to the thrombi and subsequently microemboli that travel
suprascapular nerve in the presence of a massive, retracted
rotator cuff tear. As the muscle retracts, the neurovascular
distally thus producing ischemia of distal motor
pedicle of the infraspinatus pulls traction on the supra- nerve branches to the infraspinatus muscle.
scapular nerve, essentially using the spinoglenoid notch Suprascapular neuropathy typically does not
as a fulcrum. occur in isolation: rather, it is often associated
with other primary shoulder pathologies. In an
traction of the nerve in massive, retracted rotator EMG study, de Laat et al. [107] reported a 29 %
cuff tears (Fig. 10.23) [91, 92]. The precise mecha- rate of injury to the suprascapular nerve in a
nism of injury or entrapment should be determined series of 101 patients presenting with a shoulder
in all cases as this can affect the viability of treat- dislocation and/or a proximal humerus fracture—
ment options and overall prognosis. the authors also postulated that the presence of an
expanding hematoma after fracture may contrib-
ute to neural injury around the shoulder. Patients
10.6.1 Pathogenesis with massive, retracted rotator cuff tears have
also been reported to develop traction injuries to
Entrapment of the suprascapular nerve can occur the suprascapular nerve (see Fig. 10.23) [91, 92,
anywhere along its course towards the infraspi- 108]. Albritton et al. [91] performed a cadaveric
nous fossa; however, the most common sites of study in which a large supraspinatus tear was
entrapment occur in confined areas where there made and retraction was simulated. The investi-
exists limited mobility such as within the supra- gators found that 5 cm of retraction was neces-
scapular notch or the spinoglenoid notch. Nerve sary to significantly increase tension along the
insult can occur as a result of any pathology that first supraspinatus motor branch of the supra-
causes increased narrowing of these spaces— scapular nerve. Costouros et al. [92] followed by
some of these might include fractures, ganglion performing a clinical study in which 10/26 (38 %)
cysts, paralabral cysts with medial extension, patients with massive, retracted supraspinatus
spinoglenoid cysts, and even engorged veins [93– tears were found to have isolated suprascapular
97]. The morphologic features of the transverse neuropathy. In this study, the injuries resolved
scapular ligament [98, 99] and the suprascapular after repair of the rotator cuff and relief of supra-
notch [100–103] also exhibit significant variabil- scapular nerve tension. The authors also sug-
ity that may increase the propensity to develop a gested performing routine EMG analysis in
compression neuropathy in this region. In addi- patients with massive rotator cuff tears to identify
tion, anomalous ligaments and muscles have been those patients with suprascapular nerve lesions.
described to compress the suprascapular nerve at Iatrogenic injuries to the suprascapular nerve
various sites such as a coracoscapular ligament have also been reported, most commonly involv-
[104] and subscapularis fascial extensions [105]. ing the development of scar tissue after a surgical
Injuries to the suprascapular nerve have been procedure or overzealous retraction during a pos-
described in overhead athletes, especially as a terior approach to the glenohumeral joint [109].
10.6.2 Physical Examination tor cuff muscle atrophy, a more proximal lesion
should be suspected, such as the C5 nerve root
Suprascapular neuropathy can present either sud- from which the dorsal scapular nerve arises, thus
denly or gradually as a constant dull, aching pain highlighting the importance of a complete neuro-
over the posterior and lateral aspect of the shoul- vascular examination. The supraspinous fossa,
der that may radiate up the neck or down the lat- infraspinous fossa, and acromioclavicular joint
eral arm. Horizontal adduction and internal may be tender to palpation in those with nerve
rotation may exacerbate this pain as a result of the entrapment at the suprascapular notch. In con-
increased tension placed on the suprascapular trast, the patient with nerve entrapment at the
nerve in this position [106]. Patients may also spinoglenoid notch may be tender to palpation
complain of weakness with motions that involve near the posterior joint line. Active and passive
abduction and external rotation, especially in range of motion should be tested in all patients to
those patients with suprascapular nerve entrapment determine the degree of clinical weakness and the
proximal to the supraspinatus muscle (i.e., at the potential effects of general shoulder stiffness and
suprascapular notch) [110]. In contrast, patients scapular dyskinesis on the chief complaint.
with nerve entrapment distal to the supraspinatus There are no specific provocative maneuvers
(i.e., at the spinoglenoid notch) may not experi- designed specifically for the detection of supra-
ence any functional deficits since the teres minor scapular neuropathy; however, it is postulated that
and deltoid muscles can usually compensate for humeral adduction and internal rotation may be
the weakened infraspinatus muscle [86]. useful to reproduce symptoms in patients with ten-
Although a distinct traumatic injury is identi- sion-type suprascapular nerve injuries since a
fied in nearly half of patients with suprascapular study by Plancher et al. [106] found that this posi-
neuropathy [111], most cases are the result of tion increased tension across the nerve at the spino-
chronic traction from repeated overhead activity glenoid notch. If the clinician uses this maneuver
such as those who participate in overhead sports to detect suprascapular nerve injury, it is important
and heavy manual labor. As mentioned above, to recognize that this maneuver may induce symp-
suprascapular nerve injury should also be sus- toms related to AC joint pathology (see Chap. 7).
pected in patients with massive, retracted supra- When suspected, other provocative maneuvers
spinatus tears [91, 92, 112] in addition to those may be necessary to detect concomitant patholo-
who have undergone previous shoulder surgery. gies such as labral tears, rotator cuff disease, gleno-
Perhaps the most important physical examina- humeral instability, and/or scapular dyskinesis.
tion findings in patients with suprascapular neu-
ropathy are those obtained via simple inspection
of the affected shoulder. The presence of surgical 10.7 Long Thoracic Nerve Palsy
scars over the posterior shoulder should raise
concern for nerve entrapment as a result of scar The long thoracic nerve arises from the C5, C6,
tissue and adhesions. The most common proce- and C7 ventral rami of the spinal cord and passes
dures resulting in nerve entrapment include rota- through the muscle belly of the middle scalene
tor cuff repair, posterior approaches to the muscle to provide motor innervation to all three
glenohumeral joint and, in one case, distal clavi- anatomic divisions of the serratus anterior muscle
cle excision [113]. Prominence of the scapular along its proximal anterior surface. The nerve is
spine may indicate atrophy of both the supraspi- tethered to the middle scalene and the neural ped-
natus and infraspinatus muscle bellies, especially icle of the serratus anterior which explains its high
in cases of suprascapular nerve entrapment at the rate of traction-type injuries. As discussed in
suprascapular notch (see Fig. 10.22). When nerve Chap. 3, contraction of the serratus anterior results
entrapment occurs more distally at the spinogle- in upward rotation and protraction of the scapula
noid notch, isolated atrophy of the infraspinatus and also provides scapular stabilization with vari-
muscle belly can be appreciated. If periscapular ous arm motions. Weakness of the serratus ante-
muscle wasting occurs simultaneously with rota- rior produces characteristic scapular winging
10.7 Long Thoracic Nerve Palsy 261
Fig. 10.24 Wall push-up. The patient is asked to perform scapular dyskinesis involving the left shoulder. Note the
a push-up against a nearby wall as if the patient were in prominence of the medial scapular border which is a char-
the prone position. (a) Demonstration of the wall push-up acteristic feature of long thoracic nerve palsy.
in a normal subject. (b) Clinical photo of a patient with
which must be differentiated from that which shoulder pain after a distinct traumatic injury. This
occurs with spinal accessory nerve palsy (see pain typically occurs along the medial scapular
Chaps. 3 and 9). border due to spasm of the unopposed rhomboid
musculature. The patient may also complain of
mechanical crepitus which can result from scapu-
10.7.1 Pathogenesis lothoracic incongruity due to the decreased girth
of the atrophied serratus anterior muscle.
Many cases of long thoracic nerve palsy are the On physical examination, the patient may be
result of non-contact subacute traction in over- tender to palpation along the medial scapular
head athletes. Typically, the injury occurs when border. The patient may also exhibit a decrease in
the arm is elevated overhead with the neck rotated active forward elevation of the humerus [114].
towards the contralateral shoulder. This position There are a few provocative maneuvers that can
produces tension across the long thoracic nerve be performed to detect serratus anterior weakness
as it passes through the middle scalene muscle. (discussed further in Chaps. 3 and 9). The most
Although direct contact injuries have been useful test, however, is the wall push-up since it
reported to cause long thoracic nerve palsy, this has been shown to maximally activate the serra-
mode of injury is relatively uncommon although tus anterior muscle and to provoke medial scapu-
it is likely underreported. In addition, more gen- lar winging [115]. To perform the wall push-up,
eralized neural disorders, such as brachial neuri- the patient places their hands against a nearby
tis, have occasionally been reported to involve wall at approximately shoulder-height and
the long thoracic nerve [78]. shoulder-width apart. The patient then performs a
push-up as if they were in the prone position
while the clinician observes scapular motion
10.7.2 Physical Examination (Fig. 10.24). The inferior pole of the scapula will
rotate medially and away from the chest wall if
Patients with serratus anterior weakness often serratus anterior weakness is present. In addition
complain of gradually increasing posterior to physical examination, EMG studies involving
the serratus anterior and the trapezius muscle 10.8.1 Pathogenesis

should be performed to confirm the diagnosis and
to rule out concomitant spinal accessory nerve The spinal accessory nerve travels superficially
palsy which may compromise subsequent surgi- within the posterior triangle of the neck, leaving it
cal outcome if not addressed appropriately [116]. susceptible to traumatic injury especially in con-
tact sports such as hockey and lacrosse [117].
Although less commonly reported, traction inju-
10.8 Spinal Accessory Nerve Palsy ries to the nerve can also occur as a result of a fall
on the shoulder with the neck rotated towards the
The spinal accessory nerve (cranial nerve XI) contralateral shoulder or from excessive traction
provides motor innervation to the entire trapezius placed on the arm. Spinal accessory nerve palsy
muscle and the sternocleidomastoid muscle. The has been reported to occur concomitantly with
nerve exits the brain stem, travels inferiorly long thoracic nerve palsy—thus, both nerves
through the jugular foramen of the skull, and should be evaluated during physical examination.
receives contributions from the C2, C3, and C4
nerve roots as it enters the posterior triangle of
the neck. The posterior triangle is bordered ante- 10.8.2 Physical Examination
riorly by the sternocleidomastoid muscle, poste-
riorly by the trapezius muscle and inferiorly by Patients with spinal accessory nerve palsy often
the inferior belly of the omohyoid muscle just have vague clinical symptoms such as posterior
before its insertion along the distal 1/3 of the neck pain with or without distal radiation that is
clavicle (Fig. 10.25). made worse by shrugging the shoulders. Patients
Jugular foramen
Vagus nerve (X)
Pons
Medulla oblongata
Cranial root
Spinal root
Cranial root diverges

Foramen magnum
and joins vagus nerve
Cervical region of
Accessory nerve (XI) spinal cord (C1-C5)
Trapezius muscle
Sternocleidomastoid
muscle
Fig. 10.25 Illustration showing the course of the spinal accessory nerve as it travels from the brainstem, through the
jugular notch and through the posterior triangle towards the sternocleidomastoid and trapezius muscles.
10.9 Axillary Artery Occlusion 263
may also complain of subjective weakness with

forward elevation and abduction; however, this
feature is not commonly found on physical exam-
ination [118]. The most prominent physical
examination findings include scalloping of the
lateral neck as a result of upper trapezius atrophy
and subtle scapular winging that is reproduced
when the patient shrugs the shoulders against
resistance (see Fig. 10.3) [119, 120]. More spe-
cifically, scapular winging in the setting of acces-
sory nerve palsy manifests as increased lateral
scapular tilt and superomedial displacement of
the inferomedial border. In any patient with scap-
ular winging, dyskinesis or periscapular weak-
ness, testing for signs of subacromial impingement
is necessary since scapular malposition may
decrease the space available for the rotator cuff
tendons to pass beneath the acromion (see Chap. Fig. 10.26 The axillary artery is anatomically divided
according to the relative position of the pectoralis minor
4 for more information regarding subacromial
muscle. The first part of the artery is proximal and medial
impingement) [121–123]. to the pectoralis minor tendon, the second part of the
Provocative tests are available for testing each artery is deep to the pectoralis minor tendon, and the third
of the three divisions of the trapezius muscle and part of the artery is distal and lateral to the pectoralis
minor tendon.
are discussed in detail in Chap. 3; however, these
are generally unnecessary when evaluating a
patient for spinal accessory nerve palsy since the
entire muscle is likely to be affected. Clinically, it in the digits) which must be identified by history
is more useful to simply have the patient shrug and physical examination.
their shoulders against resistance to elicit patho-
logic lateral scapular winging. EMG studies are
also useful to confirm the diagnosis and to docu- 10.9.1 Pathogenesis
ment functional recovery after operative or non-
operative treatment. Thrombosis of the second portion of the axillary
artery was first reported in 1945 by Wright [39]
who also described the pathogenesis of
10.9 Axillary Artery Occlusion TOS. Wright [39] suggested that hyperabduction
of the arms, as which occurs during the late-
The axillary artery is a continuation of the sub- cocking phase of the throwing motion [55, 124],
clavian artery as it exits the thoracic cage inferior produces compression of the second part of the
to the middle 1/3 of the clavicle and superior to axillary nerve from the overlying pectoralis minor
the lateral aspect of the first rib. The axillary muscle (see Figs. 10.13 and 10.18). Turbulent
artery is anatomically divided into three parts blood flow from intimal hyperplasia, aneurysmal
according to its orientation relative to the pecto- dilatation, and intimal dissection results in even-
ralis minor muscle (Fig. 10.26). The first portion tual arterial thrombosis and, potentially, distal
lies proximal and medial to the muscle, the sec- embolization [55]. Since then, many other causes
ond portion lies deep to the muscle, and the third of axillary artery thrombosis have been reported
portion lies distal and lateral to the muscle. such as shoulder dislocations [125], radiation
Thrombosis in this area can result in distal embo- therapy [126], nearby surgical procedures [127],
lization and resulting ischemia (most commonly and arteritides [128], among many others.
10.9.2 Physical Examination triangle (described above for TOS), among many
others. Venous occlusion is thought to be primar-
The patient with axillary artery thrombosis may ily positional in nature. Kunkel and Machleder
complain of tenderness over the anterior shoul- [130] showed evidence that hyperabduction of
der, specifically over the pectoralis minor muscle. the arms produced subclavian vein occlusion in
When distal embolization has occurred, the 21/25 patients (84 %) with confirmed effort
patient may also complain of claudication, night thrombosis.
pain, and a cold sensation distal to the embolus.
Physical examination should always include a
thorough neurovascular examination including 10.10.2 Physical Examination
capillary refill and the palpation of distal pulses.
Provocative maneuvers can be used to elevate Although there are no provocative maneuvers
suspicion of axillary artery thrombosis and are to detect subclavian vein thrombosis, there are
performed exactly as described for TOS above. several clinical signs that point to the diagnosis.
However, regardless of the test result, arteriogra- For example, many patients present with a grad-
phy is necessary to definitively establish the ual increase in swelling with dull shoulder and
diagnosis of arterial thrombosis. arm pain over a period of several days.
Engorgement of surface veins may be evident,
especially within the cubital fossa. Swelling may
10.10 Spontaneous Subclavian also induce paresthesias as a result of increased
Vein Occlusion hydrostatic pressure and resulting ischemia of
(Effort Thrombosis) peri-neural arterial branches. Some patients also
develop mottling and discoloration of the extrem-
Also known as Paget–Schroetter syndrome, spon- ity in more severe cases. Treatments that involve
taneous subclavian vein thrombosis typically preservation of venous patency, such as antico-
occurs without obvious predisposing factors. The agulation therapy and venous stents, are most
condition is commonly associated with repetitive likely to produce the best outcome in these
overhead activities and, therefore, is often referred patients [131, 132].
to as “Effort Thrombosis.” Although the condi-
tion is rarely seen, the consequences of not recog-
nizing the disorder can be potentially devastating, 10.11 Summary
ranging from pitting edema to life-threatening
pulmonary emboli. Most patients who present The neurovascular conditions related to the
with the condition are young athletes who may shoulder are numerous and complex; however, a
participate in overhead sports such as baseball, systematic, evidence-based approach to physical
tennis, or swimming [129]. diagnosis will allow the clinician to develop an
effective treatment plan that should lead to a suc-
cessful treatment outcome.
10.10.1 Pathogenesis
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Index
A Biceps load test I, 127–128

Abduction, 7–8, 23, 29–30, 244–245 Biceps load test II, 124, 128–129
Acromioclavicular (AC) joint Bony bankart lesions, 153
capsular and extra-capsular ligaments, 185–187 Brachial neuritis, 256–257
dynamic stability, 187–188 Brachial plexus tension test, 246–247
injuries, 231–232
instability
pathogenesis, 189 C
physical examination, 189–197 Capsular distention, 150
intra-articular disk, 185 Capsuloligamentous structures, 143–144
joint motion, 188–189 Cervical distraction test, 245, 246
neurovascular anatomy, 188, 189 Cervical radiculitis
osseous anatomy, 183–185 pathogenesis, 241, 242
osteoarthritis physical examination
pathogenesis, 197–199 brachial plexus tension test, 246–247
physical examination, 199–204 cervical distraction test, 245, 246
Active compression test shoulder abduction test, 244, 245
acromioclavicular joint, 202–203 Spurling’s test, 242–244
long head of the biceps tendon, 126–127 Valsalva maneuver, 244, 246
Acute sternoclavicular joint dislocation Clavicle fractures, 232
pathogenesis, 214–215 Codman’s paradox, 12–13
physical examination, 215 Combined abduction test, 29–30
Adduction, 8, 10, 201–202 Concavity compression, 147–148
Adhesive capsulitis, 33, 232 Coracoacromial arch, 141–142
Adson’s test, 251–252 Coracoacromial ligament, 82
Anterior apprehension sign, 164–165 Costoclavicular test, 252–253
Anterior labral periosteal sleeve avulsion (ALPSA) Crank test, 125–126
lesion, 151 Cross-body adduction test
Anterior slide test, 124–125 acromioclavicular joint, 201–203
Anterior subluxation, 175 shoulder mobility, 29–30
Apley scratch test, 28–29
Arm wrestle test, 121–122
Articular congruency, 140–141 D
Asymptomatic pathologies, 2–3 Deltoid muscle, 61–66
Attritional glenoid bone loss, 153, 155–156 Digital photography, 21–23
Axillary neuropathy, 254–256 Distal clavicle manipulation
instability, 196–197
osteoarthritis, 201
B Drawer signs, 159–160, 163–164
Bankart lesions, 151 Drop arm sign, 95, 97
Bear-hug test, 101–103 Dynamic labral shear test, 133–134
Belly-press test, 97, 100 Dynamic stability, acromioclavicular joint,
Biceps brachii, 64–67 187–188
Biceps entrapment sign, 119–121 Dynamometry, 42–44
DOI 10.1007/978-1-4939-2593-3, © Springer Science+Business Media New York 2015
272 Index
E drawer signs, 159, 163

Effort thrombosis, 264 release test, 166–167
Electromyography (EMG), 44–45 relocation sign, 165–166
External rotation, shoulder, 8–9 surprise test, 167
testing for inferior instability, 171–172
testing for posterior instability, 167–168
F Fukada test, 170–171
Facioscapulohumeral dystrophy (FSHD), 234–235 jerk test, 169
Forward flexion, 6 Kim test, 169–170
Frozen shoulder, 33 posterior apprehension sign, 161, 167–168
Fukada test, 170–171 push–pull test, 170–171
voluntary instability, 173–175
Glenohumeral internal rotation deficit (GIRD), 224
G Glenohumeral motion, 5–6
Glenohumeral instability abduction, 6–8
anatomic variations, 148–149 adduction, 8, 10
anterior subluxation, 175 Codman’s paradox, 12–13
characteristic pattern of signs and symptoms, 139 extension, 6–7, 9
classification of instability, 148–150 external rotation, 8–9
dynamic constraints forward flexion, 6
concavity compression, 147–148 glenohumeral resting position, 11–12
periscapular musculature, 147 internal rotation, 7–10
rotator cuff, 146–147 resting position, 11–12
humeral head translation scapular plane, 7, 8, 11
millimeters, 157 Glenoid labrum, 140–143
objective instrumentation, 158 Glenoid version, 140–142, 154–156
percentage of humeral head diameter, 157 Goniometers, 21
tactile sensation, 157–158 Gyroscopes, 21
inferior subluxation, 176
laxity, 156–157
drawer signs, 159–160 H
hyperabduction test, 162–163 Halsted maneuver, 252
load-and-shift test, 160–161 Hawkins–Kennedy test, 88–89
sulcus signs, 161–162 Hill–Sachs lesion, 154, 156
osseous defects Horizontal flexion test, 31–32
attritional glenoid bone loss, 153, 155–156 Hornblower’s sign, 102–104
bony bankart lesions, 153 Humeral avulsion of glenohumeral ligament (HAGL)
glenoid version, 154–156 lesion, 152–153
Hill–Sachs lesion, 154, 156 Humeral head translation
pathoanatomic features, atraumatic instability, millimeters, 157
155–156 objective instrumentation, 158
posterior subluxation, 173–175 percentage of humeral head diameter, 157
soft-tissue defects tactile sensation, 157–158
ALPSA lesion, 151 Hyperabduction test, 162–163
Bankart lesions, 151
capsular distention, 150
HAGL lesions, 152–153 I
rotator interval lesions, 153 Inclinometers, 20–21
SLAP tears, 151–152 Inferior subluxation, 176
static constraints Infraspinatus muscle, 54, 56–58
articular congruency, 140–141 Infraspinatus tears, 96–99
capsuloligamentous structures, 143–144 Instability, acromioclavicular (AC) joint
coracoacromial arch, 141–142 pathogenesis, 189
glenoid labrum, 140–143 physical examination
glenoid version, 140–142 acute injury, 189–195
negative intra-articular pressure, 145–146 chronic injury, 195–197
rotator interval, 145 Internal rotation, 7–10
testing for anterior instability Intra-articular disk, acromioclavicular joint, 185
anterior apprehension sign, 164–165 Isokinetic dynamometer, 42
Index 273
J resisted supination external rotation test, 132–133

Jerk test, 169 SLAC test, 134–135
Jobe test, 95–96 tearing and rupture
biceps entrapment sign, 119–120, 119
lift-off test, 119
K palpation, 118–119
Kim test, 169–170 pathogenesis, 116–117
Popeye deformity, 117–118
speed test, 119–120
L Yergason test, 119–120
Lateral scapular slide test, 227 Long thoracic nerve palsy, 260–262
Latissimus dorsi, 51–53 Loose pack position, 11–12
Laxity testing
drawer signs, 159–160
hyperabduction test, 162–163 M
load-and-shift test, 160–161 Manual muscle testing (MMT), 41–42
sulcus signs, 161–162 Medial scapular muscle detachment, 235
LHB. See Long head of the biceps (LHB) tendon Mesoacromion, 183, 185
L’hermitte’s sign, 242 Meta-acromion, 183, 185
Lift-off test, 100–102, 119 Multidirectional instability (MDI), 230–231
Load-and-shift test, 160–161
Long head of the biceps (LHB) tendon
anatomy N
anterior circumflex humeral artery, 114 Neer impingement sign, 87–88
anterior humeral shaft, 112–113 Negative intra-articular pressure, 145–146
biceps reflection pulley, 112 Neurovascular anatomy, acromioclavicular joint, 188, 189
Buford complex, 110–111 Neurovascular disorders
coracoid process, 111 axillary artery occlusion, 263–264
distal biceps tendon, 109–110 brachial neuritis, 256–257
glenohumeral capsuloligamentous structure, cervical radiculitis (see Cervical radiculitis)
110–111 long thoracic nerve palsy, 260–262
glenolabral anatomic variation, 110–111 quadrilateral space syndrome and axillary neuropathy,
neurofilament antibodies, 114 254–256
normal bicipital sheath, 112, 114 spinal accessory nerve palsy, 262–263
proximal biceps muscle, 109–110 spontaneous subclavian vein thrombosis, 264
pulley lesion, 112–113 suprascapular neuropathy, 258–260
supraglenoid tubercle, 109–110 thoracic outlet syndrome, 247–253
biomechanics
cadaveric shoulders, 114
electromyography, 115 O
inferior glenohumeral ligament, 114 O’Brien test, 126–127
intact rotator cuff, 116 Os acromiale, 82, 184, 186
scapulohumeral kinematics, 115 Osseous defects
three-dimensional biplane fluoroscopy, 115 attritional glenoid bone loss, 153, 155–156
instability bony bankart lesions, 153
arm wrestle test, 121–122 glenoid version, 154–156
medial biceps subluxation, 120–121 Hill–Sachs lesion, 154, 156,
pathogenesis, 120–121 Osteoarthritis, acromioclavicular (AC) joint
SLAP tears pathogenesis
anterior slide test, 124–125 advancing age, 198
biceps load test I, 127–128 inflammatory arthropathies, 198
biceps load test II, 124, 128–129 post-traumatic osteoarthritis, 197, 198
classification system, 122–123 repetitive microtrauma, 197–198
crank test, 125–126 synovial cysts, 198–199
dynamic labral shear test, 133–134 physical examination
labral tearing, 122–123 active compression test, 202–203
O’Brien test, 126–127 cross-body adduction test, 201–203
pain provocation test, 128–130 distal clavicle manipulation, 201
pathogenesis, 122–123 Paxinos test, 201, 202
prehension test, 122, 126–127 resisted arm extension test, 203
relocation test, 129–131 Osteoarthritis, sternoclavicular joint, 215–217
274 Index
P extension, 6–7, 9
Paget–Schroetter syndrome, 264 external rotation, 8–9
Painful arc sign, 88–90 forward flexion, 6
Pain provocation test, 128–130 glenohumeral resting position, 11–12
Palpation, 118–119 internal rotation, 7–10
Patient’s history, nonspecific factors, 1 scapular plane, 7, 8, 11
Paxinos test, 201, 202 methods of measurement
Pectoralis minor tightness test, 32–33 digital photography, 21–23
Periscapular muscles goniometers, 21
pectoral muscles gyroscope, 21
pectoralis major, 68–69 inclinometers, 20–21
pectoralis minor, 68–70 visual inspection, 19–20
rotator cuff scapulothoracic motion, 13–14
infraspinatus muscle, 54, 56–58 roles of AC and SC joints, 16–17
subscapularis muscle, 53, 58–59 scapular resting position, 14
supraspinatus, 53–56 three-dimensional scapular motion, 15–16
teres minor muscle, 53, 59–61 two-dimensional scapular motion, 14–15
scapulohumeral muscles shoulder elevation
biceps brachii, 64–67 abduction measurement, 23
deltoid, 61–66 flexion measurement, 23–24
teres major, 60–63 shoulder rotation
triceps brachii, 65–68 external rotation measurement, 24–25
trapezius internal rotation measurement, 25–27
lateral scapular winging, 47 specific tests, shoulder mobility
latissimus dorsi, 51–53 Apley scratch test, 28–29
medial scapular winging, 47 combined abduction test, 29–30
mitochondrial ATPase activity, 46 cross-body adduction test, 29–30
rhomboids, 48–50 horizontal flexion test, 31–32
serratus anterior muscle, 49–52 pectoralis minor tightness test, 32–33
strength, 47–49 posterior tightness test, 30–32
superior, middle, and lower fibers, 46 quadrant test, 30–31
Periscapular musculature, 147 stiff shoulder and frozen shoulder, 33
Physical examination findings, 1–2 Release test, 166–167
Posterior apprehension sign, 164, 168 Relocation sign, 165–166
Posterior subluxation, 173–175 Relocation test, 129–131
Posterior tightness test, 30–32 Rent test, 94–95
Preacromion, 183, 185 Repetitive microtrauma, 197–198
Pulley lesion, 112–113 Resisted arm extension test, 203–204
Push–pull test, 170–171 Resisted supination external rotation test, 132–133
Rhomboids, 48–50
Rotator cuff, 146–147
Q anatomy and biomechanics, 77–80
Quadrant test, 30–31 infraspinatus muscle, 54, 56–58
Quadrilateral space syndrome, 254–256 rotator cuff tears
infraspinatus, 95–99
pathogenesis, 93–94
R subscapularis, 97, 99–103
Range of motion supraspinatus, 94–97
end feel classification, 18–19 teres minor muscle, 102–104
factors affecting accuracy subacromial impingement
arm dominance, 28 acromial morphology and glenoid version, 83–85
gender, 27 anterior acromioplasty, 80
increasing age, 27 coracoacromial ligament, 82
patient positioning, 27–28 Hawkins–Kennedy test, 88–89
posture, 28 Neer impingement sign, 87–88
glenohumeral motion, 5–6, 17–18 os acromiale, 82
abduction, 6–8 painful arc sign, 88–90
adduction, 8, 10 pathogenesis, intrinsic factors, 86–87
Codman’s paradox, 12–13 stages of impingement syndrome, 81
Index 275
subcoracoid impingement flexion measurement, 23–24

external tendon compression, 90–91 Shoulder rotation
narrowed coracohumeral interval, 89 external rotation measurement, 24–25
pathogenesis, 90–91 internal rotation measurement, 25–27
physical examination, 91–92 Shoulder stiffness, 232
subscapularis muscle, 53, 58–59 SLAC test, 134–135
supraspinatus, 53–56 Snapping scapula syndrome, 232–233
symptomatic internal impingement, 92–93 Soft-tissue defects
teres minor muscle, 53, 59–61 ALPSA lesion, 151
Rotator interval, 145 Bankart lesions, 151
capsular distention, 150
HAGL lesions, 152–153
S rotator interval lesions, 153
Scapular dyskinesis SLAP tears, 151–152
association conditions Specific pain patterns, 2
acromioclavicular joint injuries, 231–232 Speed test, 119–120
clavicle fractures, 232 Spinal accessory nerve palsy, 262–263
facioscapulohumeral dystrophy, 234–235 Spontaneous subclavian vein thrombosis, 264
medial scapular muscle detachment, 235 Spurling’s test, 242–244
multidirectional instability, 230–231 Sternoclavicular (SC) joint
scapulothoracic bursitis and snapping scapula acute joint dislocation
syndrome, 232–233 pathogenesis, 214–215
shoulder stiffness and adhesive capsulitis, 232 physical examination, 215
SLAP tears, 230 biomechanics, 213–214
subacromial impingement and rotator cuff chondral surfaces, 210–211
tears, 230 ligamentous anatomy, 211–212
trapezius myalgia, 233–234 mediastinal vessels, 212–213
definition, 223 osseous anatomy, 209–210
overhead athletes, 235–236 osteoarthritis, 215–217
physical examination voluntary dislocation, 217
flip test, 226 Stiff shoulder, 33
lateral scapular slide test, 227 Strain gauge dynamometer, 43
scapular assistance test, 227, 228 Strength testing
scapular reposition test, 228, 229 anatomic characteristics, scapular musculature, 45
scapular retraction test, 228, 229 dynamometry, 42–44
primary causes, 223 electromyography, 44–45
secondary causes, 223–225 length–force relationship, 39–41
Scapular motion manual muscle testing, 41–42
biomechanics, 222–223 muscle isolation, 41
bursal anatomy, 221 pectoral muscles
muscular anatomy, 220 pectoralis major, 68–69
neurovascular anatomy, 221–222 pectoralis minor, 68–70
osseous anatomy, 219–220 rotator cuff
Scapular plane, 7, 8, 11 infraspinatus muscle, 54, 56–58
Scapular resting position, 14 subscapularis muscle, 53, 58–59
Scapulohumeral muscles supraspinatus, 53–56
biceps brachii, 64–67 teres minor muscle, 53, 59–61
deltoid, 61–66 scapulohumeral muscles
teres major, 60–63 biceps brachii, 64–67
triceps brachii, 65–68 deltoid, 61–66
Scapulothoracic bursitis, 232–233 teres major, 60–63
Scapulothoracic motion, 13–14 triceps brachii, 65–68
vs. glenohumeral motion, 17–18 trapezius
roles of AC and SC joints, 16–17 lateral scapular winging, 47
scapular resting position, 14 latissimus dorsi, 51–53
three-dimensional scapular motion, 15–16 medial scapular winging, 47
two-dimensional scapular motion, 14–15 mitochondrial ATPase activity, 46
Serratus anterior muscle, 49–52 rhomboids, 48–50
Shoulder abduction test, 244, 245 serratus anterior muscle, 49–52
Shoulder elevation strength, 47–49
abduction measurement, 23 superior, middle, and lower fibers, 46
276 Index
Subacromial impingement T
acromial morphology and glenoid version, 83–85 Teres major muscle, 60–63
anterior acromioplasty, 80 Teres minor muscle, 53, 59–61, 102–104
coracoacromial ligament, 82 Thoracic outlet syndrome (TOS)
Hawkins–Kennedy test, 88–89 description, 247
Neer impingement sign, 87–88 pathogenesis, 247–250
os acromiale, 82 physical examination
painful arc sign, 88–90 Adson’s test, 251–252
pathogenesis, intrinsic factors, 86–87 costoclavicular test, 252–253
rotator cuff tears, 230 Halsted maneuver, 252
stages of impingement syndrome, 81 Wright’s test, 253–254
Subcoracoid impingement Three-dimensional scapular motion, 15–16
external tendon compression, 90–91 Trapezius
narrowed coracohumeral interval, 89 lateral scapular winging, 47
pathogenesis, 90–91 latissimus dorsi, 51–53
physical examination, 91–92 medial scapular winging, 47
Subscapularis muscle, 53, 58–59 mitochondrial ATPase activity, 46
bear-hug test, 101–103 myalgia, 233–234
belly-press test, 97, 100 rhomboids, 48–50
lift-off test, 100–102 serratus anterior muscle, 49–52
passive external rotation capacity, 97, 99 strength, 47–49
Sulcus signs, 161–162 superior, middle, and lower fibers, 46
Superior labral anterior to posterior (SLAP) tears, Triceps brachii, 65–68
151–152, 230 Two-dimensional scapular motion, 14–15
anterior slide test, 124–125
biceps load test I, 127–128
biceps load test II, 124, 128–129 U
classification system, 122–123 Utility of palpation, 2
crank test, 125–126
dynamic labral shear test, 133–134
labral tearing, 122–123 V
O’Brien test, 126–127 Valsalva maneuver, 244, 246
pain provocation test, 128–130
pathogenesis, 122–123
prehension test, 122, 126–127 W
relocation test, 129–131 Wright’s test, 253–254
resisted supination external rotation test, 132–133
SLAC test, 134–135
Suprascapular neuropathy, 258–260 Y
Supraspinatus muscle, 53–56 Yergason test, 119–120
Supraspinatus tendon tears
drop arm sign, 95, 97
Jobe test, 95–96 Z
rent test, 94–95 Zanca radiograph, acute AC joint
Surprise test, 167 injury, 190–197
Symptomatic internal impingement, 92–93
Synovial cysts, acromioclavicular (AC) joint, 198–199

Ryan J. Warth, Peter J. Millett Auth. Physical Examination of The Shoulder An Evidence-Based Approach

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Ryan J.

Physical Peter J. Millett

ISBN 978-1-4939-2592-6 ISBN 978-1-4939-2593-3 (eBook)

Library of Congress Control Number: 2015934007

Springer New York Heidelberg Dordrecht London

Printed on acid-free paper

Vail, CO, USA Ryan J. Warth, M.D.

1 About This Book ........................................................................... 1

Index ....................................................................................................... 271

tear size occurred. Thus, a thorough clinical

shoulder motion. He described a “zero point” for

Fig. 2.1 Demonstration of

2.2.1 Forward Flexion known as straight lateral abduction) (Fig. 2.2).

Extension of the shoulder typically refers to any

Fig. 2.2 Demonstration of

lateral abduction (also known as “horizontal 2.2.4 Internal Rotation

When viewing a right shoulder from superiorly to

Fig. 2.5 (a) Extension

Internal External Neutral

Fig. 2.9 Demonstration of

Fig. 2.10 Illustration of E

Fig. 2.12 Illustration Protraction Retraction

Fig. 2.13 Isolated

studies have found that experienced practitioners

2.6.2 Inclinometers mechanical inclinometer. In an adjunct study

Fig. 2.17 Demonstration

stabilizes the elbow and rotates the humerus

2.9 Factors That Affect

2.10 Specific Tests for General

2.10.3 Combined Abduction Test

Fig. 2.20 Demonstration

Fig. 2.21 Quadrant test.

resistance is felt. The position is held and the

2.10.7 Pectoralis Minor

Tightness or shortening of the pectoralis minor

Fig. 2.23 Horizontal

12. Magee DJ. Orthopaedic physical assessment. 3rd ed.

even if the muscle was passively stretched prior

Myofibril Light Dark

the purpose of strength testing is a nearly impos-

3.2.2 Muscle Isolation 3.3.1 Manual Muscle Testing

found to be reliable, reproducible, and valid on

cuff strength. Hosking et al. [47] examined the 3.3.3 Electromyography

Table 3.2 Anatomic characteristics of the periscapular musculature [8]

cause and exacerbate subacromial impingement

Fig. 3.10 Strength of

Fig. 3.11 Illustration

and inserts along the anterior surface of the

Fig. 3.13 Strength of

Serratus Serratus anterior muscle

Normal Shoulder and Rib Cage Shoulders and Rib Cage

Fig. 3.15 Wall push-up

The primary functions of the latissimus dorsi

Fig. 3.17 Strength testing

Posterior view Anterior view

Fig. 3.20 Jobe’s “empty

Fig. 3.21 Drop arm sign.

Fig. 3.22 Jobe’s “full

a Suprascapular Nerve Entrapment b Suprascapular Nerve Entrapment