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Figs.3-6 Reproduced with kind permission from Sports Injuries - Their prevention and treatment.

Figure 3: Lift-off test

Figure 4: Neer’s impingement test

Figure 5: Sulcus sign

Figure 6: Speed’s test

● Limitations – restricted movement or pain restricting move- ment ie. can’t do bra up any more – decreased internal rotation

● Pain pattern

Physical examination 1. Initial impression • Generalised disease • Physiological age and appearance eg. athlete vs. accountant • Posture • Distress related to the shoulder • Performance of simple tasks and associated disability eg. shak- ing hands, undressing

2. Inspection • Wasting of deltoid or rotator cuff • Overactive upper trapezius • Elevated shoulder on one side • Deformities eg. scars, lumps, bumps • Swelling • Skin manifestations and colour

3. Cervical spine The shoulder and upper arm are common sites of referred pain from the cervical spine (C5-6). The upper thoracic spine especial- ly T4) may also refer to the shoulder. The patient may not com- plain of the spinal component. Test for: • Flexion/extension • Lateral flexion • Rotation • Compression

4. Joint motion I test the movements in the following order: Active – Passive – Resisted

Apply overpressure at end range of active movement – some movement should be present.

● Abduction – watch from behind – observe scapulohumeral rhythm • Painful arc – mid range or end range? • Pain on resisted abduction – predominantly supraspinatus • ‘Empty Can’ – resist abduction in position of 90º abduction, 30º horizontal flexion and full internal rotation – emphasis- es supraspinatus deficiency

● Internal rotation – often less on dominant side. • Lift-off test for power – internally rotate arm and place hand

on back. Apply resistance to hand being lifted away from back – subscapularis (Fig. 3)

● External rotation – test in neutral, elbow at 90º and in abduc- tion/external rotation – infraspinatus and teres minor in abduction/external rotation

● Horizontal adduction – compresses A-C joint - may produce pain

5. Impingement tests Impingement occurs when the rotator cuff or subacromial bursa is pinched between the acromion, coracoacromial arch and A-C joint above and the humeral head below. This could be due to: • Encroachment from above eg. poor scapular stabilisation or congenital abnormality of the acromion

• Swelling of the rotator cuff or bursa by overuse or trauma • Excessive elevation of the humeral head due to for example instability, imbalance between rotator cuff and deltoid

a) Neer’s impingement test The arm is placed in neutral and then fully internally rotated to bring the greater tuberosity under the arch, and then the arm is elevated forwards. Pain and restriction of motion is felt (Fig. 4) b) Hawkins and Kennedy test The arm is passively abducted to 90º with the elbow at 90º of flexion. With the elbow supported the arm is passively internally rotated looking for signs of pain. This is repeated with progres- sive horizontal abduction c) Injection Impingement tests can be confirmed by injecting lignocaine into the subacromial space. If abolition of the patient’s pain occurs and there is increased strength on resisted movements, then this helps to confirm your impingement diagnosis

6. Stability assessment It is important to assess the ligamentous laxity of the shoulder to assess for instability. If laxity is present it is prudent to assess general ligamentous laxity. Hypermobility = Beighton score ≥ 6 a) Glenohumeral translation (Load and Shift test) With the patient sitting, load the humeral head by grasping and pushing it into the glenoid fossa. The head is loaded and then both an anterior and posterior stress is applied, noting the amount of translation. • Grade Trace - small amount of translation • Grade I - head rides up the glenoid but not over the rim • Grade II - head rides up and over the glenoid reduces when stress is removed

• Grade III - head rides up and over the glenoid and remains dis- located upon removal of stress

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