Clinical Shoulder Assessments Student Project

Created by: Lael N. Johnson OTS

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Table of Contents
Anatomy and Pathology Review3
Rotator Cuff, Shoulder/Scapular Instability, and SLAP Lesion Assessments...6
Neer Impingement Test..7
Hawkins-Kennedy Impingement Test8
Empty Can Test..9
Codmans Sign or Drop-Arm Test...10
Upper Cut Test.11
Posterior Apprehension Test or Stress Test.....12
Gerber Lift-Off Test.13
Sulcus Sign and Feagin Test (Modified Sulcus Sign)..14
Anterior Apprehension Test (Crank Test)15
SLAPprenension Test...16
Biceps Tendonitis Assessments17
Speeds Test..18
Yergasons Test........19
Thoracic Outlet Syndrome Assessments..20
Adson and Allen Maneuver Tests.21
References.22

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Anatomy and Pathology

Review

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Muscle
Supraspinatus
Infraspinatus
Teres Minor

Subscapularis

Origin
Supraspinatus fossa of
the scapula (posterior)
Infraspinatus fossa of
the scapula
Upper third of the
lateral border of the
scapula
Anterior subscapular
fossa of the scapula
(anterior)

Insertion
Superior aspect of the
greater tubercle
Medial aspect of the
greater tubercle
Inferior aspect of the
greater tubercle
Lesser tubercle &
articular capsule of the
glenohumeral joint

Action
Abduction
Horizontal abduction,
Abduction, ER
Horizontal abduction,
Abduction, ER,
Extension
Abduction, Adduction,
IR

(Magee, 1997)

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SLAP tear
Superior Labrum, Anterior Posterior. SLAP tear is a tear that occurs at the biceps tendon insertion
into the superior labrum of the shoulder.

Thoracic Outlet Syndrome (TOS)

Compression of neurovascular bundle (nerves, arteries, or veins) in the neck. Compression can
take place between the 1st rib and clavicle, between the anterior and middle scalene muscles, or
deep to the pectoralis minor causing nerve entrapment.

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Rotator Cuff,
Shoulder/Scapular Instability,
and SLAP Lesion Assessments

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Neer Impingement Test

Assessment: Supraspinatus tendonitis or impingement of supraspinatus tendon. Positive finding
could also indicate long-head bicipital tendonitis. This test is indicative of an overuse injury to the
supraspinatus and sometimes biceps tendon.
Pt position: Relaxed seated or standing
Test position: Internal rotation and pronation. Some practitioners perform with external rotation
and supination.
Administration: Passively elevate arm into shoulder flexion, causing a jamming of the greater
tuberosity against the anteroinferior border of the acromion.
Positive finding: A look of apprehension on the patients face, pain in the anterolateral aspect of
the shoulder, and/or reproduction of symptoms.

Literature:
Although some practitioners prefer to administer the Neer Impingement test in external
rotation, Yamamoto et al. (2009) reported the maximum contact pressure is with internal
rotation of the arm.
van Kampen et al. (2014) reported that the Neer Test has the best overall accuracy over the
Empty Can, Hawkins-Kennedy, Drop-Arm, and Lift-Off Tests.
Subacromial impingement sensitivity: 79% and specificity: 53% for (Hegedus et al., 2008)
Subacromial bursitis sensitivity: 75% (MacDonald, Clark, & Sutherland, 2000)
Rotator cuff tear sensitivity: 85% (MacDonald, Clark, & Sutherland, 2000)
When combined with the Hawkins-Kennedy Test, the two tests exhibited a high negative
predictive value: 96% for subacromial bursitis and 90% for rotator cuff tearing
(MacDonald, Clark, & Sutherland, 2000).
Neer signs were also positive in 46% of patients with SLAP lesions (Pappas, et al., 2006).
The Neer Test is useful for ruling out subacromial impingement (Alqunaee, Galvin, &
Fahey, 2012; Michener, Walsworth, Doukas, & Murphy, 2009).
(Alqunaee, Galvin, & Fahey, 2012; Magee, 1997)

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Hawkins-Kennedy Impingement Test

Assessment: Supraspinatus tendon impingement or tendonitis
Pt position: Relaxed seated or standing
Test position: Position the patient in 90 shoulder flexion and 90 elbow flexion in gravity
eliminated plan
Administration: Passively move patients arm into internal rotation, pushing the supraspinatus
tendon against the anterior surface of the coracoacromial ligament and coracoid process.
Positive finding: Pain

Literature:
Sensitivity: 79% and specificity: 59% for subacromial impingement (Hegedus et al., 2008)
Sensitivity: 92% for subacromial bursitis (Pappas, et al., 2006)
Hawkins-Kennedy signs were also positive in 69% of patients with SLAP lesions (Pappas,
et al., 2006)
According to Pappas et al. (2006), The Hawkins-Kennedy Test elicits substantially greater
subacromial contact of the rotator cuff than the Neer Impingement Test.
When combined with the Neer Impingement Test, the two tests exhibited a high negative
predictive value: 96% for subacromial bursitis and 90% for rotator cuff tearing
(MacDonald, Clark, & Sutherland, 2000)
The Hawkins-Kennedy Test is useful for ruling out subacromial impingement (Alqunaee,
Galvin, & Fahey, 2012)

(Alqunaee, Galvin, & Fahey, 2012; Gerber, C., Terrier, F., & Ganz, R., 1985; Hawkins, & Kennedy, 1980; & Magee, 1997)

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Empty Can Test

Assessment: Supraspinatus muscle/tendon tear or weakness, or neuropathy of the suprascapular
nerve
Pt position: Relaxed seated or standing position
Test position: Position the patient in 90 shoulder flexion with slight abduction, full internal
rotation, and forearm pronation.
Administration: The examiner provides downward pressure just distal to the elbow
Positive finding: Pain or weakness in the subacromial region or upper arm may indicate
supraspinatus tendonitis or other inflamed structures.

Literature:
van Kampen et al. (2014) reported that the Empty Can Test is more sensitive (68.4%) than
the Neer, Hawkins-Kennedy, Drop-Arm, and Lift-Off.
According to Hegedus et al. (2008), the Empty Can Test may serve as a confirmatory test
for impingement due to its high specificity.
The test was 70% accurate when muscle weakness was interpreted as indicating a torn
supraspinatus tendon (Itoi et al., 1999).
The Empty Can Test is useful for ruling out subacromial impingement (Alqunaee, Galvin,
& Fahey, 2012).
According to Michener et al. (2009), The Empty Can Test is found to be useful in
confirming subacromial impingement.

(Alqunaee, Galvin, & Fahey, 2012; Magee, 1997 & Magee, 2014)

800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Codmans Sign or Drop-Arm Test

Assessment: Tear in the Rotator Cuff complex, specifically supraspinatus
Pt position: Relaxed seated or standing
Test position: While keeping the elbow extended, passively move the patients arm to 90
shoulder abduction
Administration: Instruct the patient to slowly adduct the arm to the side in the same arc of
movement once the examiner removes support.
Positive finding: Inability to actively support arm, a sudden drop of the arm, uncoordinated
lowering of arm during adduction, and/or pain when attempting to do so.

Literature:
Because of the Drop-Arms high specificity (98%), it is a predictor for rotator cuff tear.
However, the sensitivity is low (10%) (Murrell & Walton, 2001). Therefore, 98% of
patients with a positive finding have the chance of a rotator cuff tear.
van Kampen et al. (2014) reported that the Drop-Arm Test has a specificity and positive
predictive value of 100%.
According to Hegedus et al. (2008), the Drop Arm Test demonstrated value as a specific
tests for a tear of any rotator cuff muscle.
The Drop-Arm Test demonstrated high levels of diagnostic accuracy for a complete
supraspinatus tear (Cadogan et al., 2011).
The Drop-Arm Test is more useful for ruling in Subacromial Impingement Syndrome (SIS)
if the test is positive (Alqunaee, Galvin, & Fahey, 2012).

(Magee, 1997 & Magee, 2014)

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Upper Cut Test

Assessment: Rotator Cuff Tendinopathy
Pt position: Relaxed seated or standing
Test position: Neutral shoulder, elbow 90 flexion, forearm supination, have pt make a fist.
Administration: Instruct the patient to bring hand quickly to his/her chin. Examiner puts hand
over patients fist and provided downward resistance.
Positive finding: Pain or painful pop over anterior region of shoulder

Literature:
Biceps tendon injury sensitivity: 73%, specificity: 78%, and accuracy: 77%.
Kibler et al. (2009) reported that the Upper Cut was the most accurate in detecting biceps
tendon injury and produced the highest positive likelihood ratio amongst other tests
(Speeds, Yergasons, and five other biceps tendon tests that are not listed in this report).
Labral injury sensitivity: 22%, Specificity: 56%, and accuracy: 32%
This is a newer test, which requires further research

(Kibler et al., 2009)

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Posterior Apprehension Test or Stress Test

Assessment: Posterior shoulder instability and/or dislocation/subluxation
Pt position: Supine, GH joint off the end of the table or on soft mat to enable shoulder distraction.
Test position: Shoulder in 90 flexion and relaxed into 90 elbow flexion, allowing tightening of
posterior capsule.
Administration: Place one hand behind the scapula to increase stability, across the posterior
humeral head. The other hand applies a posterior compressive force through the humerus, while
horizontally adducting and internally rotating the arm.
Positive finding: Pain or a look of apprehension /alarm on the patients face and/or patients
resistance to further motion.

Literature:
Sensitivity: 19.2%, specificity: 99.2%, and Likelihood ratio: 24.97%
PubMed, ProQuest Medical Library, and CINAHL Complete were searched with the
search terms Posterior Apprehension Test and Posterior Stress Test with no peerreviewed publications indicative of the test.

(Magee, 1997; Physical Therapy Haven, 2016a)

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800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Gerber Lift-Off Test

Assessment: Subscapularis lesion and scapular instability
Pt position: Relaxed seated or standing. If seated, the patients back must be free from a backrest.
Test position: The dorsum of the patients hand is positioned behind their mid-lumbar spine.
Administration: The patient is instructed to lift the dorsum of his/her off their back by
maintaining or increasing internal rotation of the humerus and shoulder extension. (To perform this
test, the patient must have full passive internal rotation and able to have arm placed in desired
position).
Positive finding: Inability to lift dorsum off the lower back indicates subscapularis
rupture/dysfunction. This test may also be used to test rhomboids. Medial border winging of the
scapula during the test may indicate that the rhomboids are effected.

Literature:
According to Gerber and Krushell (1991), the Lift-Off Test is highly reliable in detecting
subscapularis rupture.
Greis et al. (1996) concluded that the Lift-Off maneuver effectively isolated the
subscapularis muscle, indicating that the Lift-Off test is valid and specific for evaluation of
the subscapularis (Tokish et al., 2003).
The Lift-Off Test is more useful for ruling in Subacromial Impingement Syndrome (SIS) if
the test is positive (Alqunaee, Galvin, & Fahey, 2012).
According to Barth, Burkhart, and De Beer (2006), a positive Lift-Off Test is not found
unless 75% of the subscapularis is torn.
van Kampen et al. (2014) reported that the Lift-Off Test has a specificity and positive
predictive value of 100%

(Alqunaee, Galvin, & Fahey, 2012; Magee, 1997)

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800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Sulcus Sign
Assessment: Inferior shoulder instability or laxity
Pt position: Relaxed seated or standing
Test position: Arm at the patients side with shoulder relaxed
Administration: The examiner grasps the distal portion of the humerus and provides an inferior
traction force.
Positive finding: The presence of a sulcus sign beneath the acromion process is indicative of
inferior instability.

Feagin Test (Modified Sulcus Sign)

Assessment: Inferior shoulder instability or laxity
Pt position: Relaxed seated or standing
Test position: Position the patients arm in 90 of shoulder abduction with arm supported so it is
relaxed. Many examiners prefer to place patients arm on their shoulder for support.
Administration: Examiner positions hands distal to the acromion over the humeral head and
provides downward/anterior pressure.
Positive finding: Sulcus noted above the coracoid process, a look of apprehension on patients
face, and the presence of anteroinferior instability.

(Magee, 1997)

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800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Anterior Apprehension Test (Crank Test)

Assessment: Shoulder dislocation, SLAP lesion, anterior glenohumeral instability
Pt position: Supine (preferred) or relaxed seated/standing
Administration: Examiner places the patient in 90 of shoulder abduction and 90 elbow flexion
and slowly brings the patient into external rotation. Its important that this test be done slowly. If
the examiner externally rotates the patients arm too quickly, the humerus may become dislocated
Positive finding: Look or feeling of apprehension or alarm on patients face and the patients
resistance to further motion. The patient also may report that the feeling during the test felt similar
to when the shoulder was previously dislocated.

Literature:
Sensitivity: 72%, specificity: 96%, and likelihood ratio: 20.2% (Farber et al., 2006)
According to Powell, Huijbregts, and Jensen (2008), a positive finding on the Anterior
Apprehension Test provides the examiner with research-based confidence to rule in a
SLAP lesion.
According to Lo et al. (2004), the anterior apprehension test is highly specific and likely to
predict traumatic anterior glenohumeral instability.
The anterior apprehension test is highly reliable when it was positive, with a positive
predictive value of 96%. Therefore, a MRI may be unnecessary in evaluating a young
patient with clinically evident anterior shoulder instability if the apprehension test is
positive (Kumar et al., 2015)

(Magee, 1997; Safran, 2010)

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SLAPprenension Test
Assessment: SLAP lesion, anterior instability
Pt position: Relaxed seated position
Test position: Position the patient in 90 of shoulder abduction with the elbow extended, shoulder
internally rotated, and forearm pronated.
Administration: Examiner slowly horizontally adduct the arm. The test is repeated with the
shoulder externally rotated and forearm supinated.
Positive finding: Any pain in the bicipital groove with or without an audible or palpable pop of
the biceps tendon in pronated position should decrease or be eliminated in the supinated test
position. No decrease in pain is indicative of a negative finding.

Test 1:

Test 2:
Literature:
Berg and Ciullo (1998) reported that a retrospective chart review of 66 consecutive
arthroscopically verified shoulders with SLAP lesions revealed the SLAPprehension test to
be 87.5% sensitive for unstable SLAP lesions. Therefore, the SLAPprehension test is
helpful in the clinical evaluation of patients with unstable superior glenoid labrum lesions
whose symptoms are often confused and overlap with those of shoulder impingement or
acromioclavicular arthrosis.

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Biceps Tendonitis Assessments

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Speeds Test
Assessment: Biceps Tendonitis
Pt position: Relaxed seated of standing
Test position: Palpate the bicipital groove (biceps tendon origin). Position the patient in 90
shoulder flexion, slight external rotation, full elbow extension, and forearm supination
Administration: Apply downward resistance distal to the radial tuberosity, and ask the patient to
resist the eccentric movement to shoulder extension.
Positive finding: Localized pain or increased tenderness in the bicipital groove

Literature:
Kibler et al. (2009) reported that the combination of the Upper Cut and Speeds tests were
significantly better at detecting biceps lesions than other tests.
According to Magee (1997), the Speeds test is more effective than Yergasons test because
the bone moves over the tendon during the test.
According to Guidi and Suckerman (1994), the Speeds test may cause pain and is positive
if a SLAP lesion is present.
According to Powell, Huijbregts, and Jensen (2008), a positive finding on the Speeds Test
provides the examiner with research-based confidence to rule in a SLAP lesion.
Sensitivity: 32% and specificity: 61% for SLAP tears (Hegedus et al., 2008)
According to Hegedus et al. (2008), the Speeds test has no diagnostic utility for a SLAP
lesion, contradicting the article published by Powell, Huijbregts, and Jensen (2008).

(Magee, 1997)

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800.528.8989 www.maryfreebed.com 235 Wealthy SE Grand Rapids, MI 49503-5299

Yergasons Test
Assessment: Biceps Tendonitis
Pt position: Relaxed standing or sitting
Test position: Position the patients elbow in 90 flexion and stabilized against the thorax with
forearm pronated (may ask patient to hold towel between medial epicondyle and thorax to ensure
stabilization and reduce compensation).
Administration: The examiner instructs the patient to supinate and externally rotate
simultaneously against resistance. While resisting, palpate the bicipital groove to feel for a pop in
the biceps tendon.
Positive finding: Tenderness in the bicipital groove. The tendon may also pop out of the groove
upon administration, which is indicative of a positive finding.

Literature:
According to Guidi and Suckerman (1994), Yergasons Test is not as effective as Speeds
Test because the tendon only moves a small amount in the bicipital groove during the test
and biceps tendon pain tends to occur with motion or palpation rather than with tension.
According to Powell, Huijbregts, and Jensen (2008), a positive finding on the Yergason
Test provides the examiner with research-based confidence to rule in a SLAP lesion.

(Magee, 1997)

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Thoracic Outlet Syndrome

Assessments

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Adson Maneuver Test

Assessment: Thoracic Outlet Syndrome (TOS)
Pt position: Relaxed seated position
Administration: Locate the patients radial pulse. Externally rotate
and extend the patients shoulder, while maintaining slight
abduction. Instruct the patient to rotate his/her head to face the tested
shoulder and to extend the neck. Some clinicians have the patient
take a deep breath and hold.
Positive finding: Disappearance of the pulse
Literature:
According to Orlando et al. (2016), a positive Adson Test
can verify vascular compression
Refuting literature reports that the Adson test, though is
commonly used, is misleading and should be replaced by
more specific maneuvers that elicit symptoms of TOS
(Sanders, 2008)
Duplex scanning of the thoracic outlet during Adsons Maneuver may help predict outcome
of thoracic outlet decompression surgery in cases of non-specific TOS.
Allen Maneuver Test
Assessment: TOS
Pt position: Relaxed seated position
Administration: Locate the patients radial pulse. Position the patient in 90 of abduction, 90 of
elbow flexion, and full external rotation. The patient then rotates his/her head away from the test
side.
Positive finding: Disappearance of the pulse

(Magee, 1997)

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References
Alqunaee, M., Galvin, R., & Fahey, T. (2012). Diagnostic accuracy of clinical tests for subacromial
impingement syndrome: A systematic review and meta-analysis. Archives of Physical Medicine
and Rehabilitation, 93(2), 229-236. doi:10.1016/j.apmr.2011.08.035
Barth, J., Burkhart, S., & De Beer, J. (2006). The bear-hug test: A new and sensitive test for diagnosing a
subscapularis tear. Arthroscopy-the Journal of Arthroscopic and Related Surgery, 22(10), 10761084. doi:10.1016/j.arthro.2006.05.005
Berg, E. E., & Ciullo, J. V. (1998). A clinical test for superior glenoid labral or SLAP lesions. Clinical
Journal of Sports Medicine, 8(121-123).
Cadogan, A., Laslett, M., Hing, W., McNair, P., & Williams, M. (2011). Interexaminer reliability of
orthopaedic special tests used in the assessment of shoulder pain.Manual Therapy, 16(2), 131-135.
doi:10.1016/j.math.2010.07.009
Farber, A.J., Castillo, R., Clough, M., Bahk, M., & McFarland, E.G. (2006). Clinical assessment of three
common tests for traumatic anterior shoulder instability. Journal of Bone and Joint Surgery, 88,
1467-1474. doi: 10.1177/0363546509357610
Gerber, C., & Krushell, R. J. (1991). Isolated rupture of the tendon of the subscapularis muscle. clinical
features in 16 cases. The Journal of Bone and Joint Surgery. British Volume, 73-B(3), 389.
Gerber, C., Terrier, F., & Ganz, R. (1985). The role of the coracoid process in the chronic impingement
syndrome. The Journal of Bone and Joint Surgery. British Volume, 67-B(5), 703.
Greis, P. E., Kuhn, J. E., Schultheis, J, Hintermeister, R, & Hawkins, R. (1996). Validation of the lift-off
test and analysis of subscapularis activity during maximal internal rotation. The American Journal
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Guidi, E. J., & Suckerman, J. D. (1994). Glenoid labral lesions. In Andrews, J. R., & K. E. Wild (eds.):
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Itoi, E., Kido, T., Sano, A., Urayama, M., & Sato, K. (1999). Which is more useful, the Full can test or the
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Kibler, B. W., Sciascia, A. D., Hester, P, Dome, D., & Jacobs, C. (2009). Clinical utility of traditional and
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lesions in the shoulder. American Journal of Sports Medicine, 37(9), 1840-1847. doi:
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Kumar, K., Makandura, M., Leong, N., Gartner, L., Lee, C.H., Ng, D.Z.W., Tan, C. H., & Kumar, V.
(2015). Is the apprehension test sufficient for the diagnosis of anterior shoulder instability in young
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Lee, A., Agarwal, S., & Sadhu, D. (2006). Doppler adson's test: Predictor of outcome of surgery in nonspecific thoracic outlet syndrome. World Journal of Surgery, 30(3), 291-292. doi:10.1007/s00268005-0191-x

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Lo, I.K., Nonweiler, B., Woolfrey, M., Litchfield, R., & Kirkley, A. (2004). An evaluation of the
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Physical Therapy Haven. (2016a). Posterior Apprehension Test. Retrieved from
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Sanders, R. J. (2008). Neurogenic thoracic outlet syndrome and pectoralis minor syndrome: A common
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the physical examination of the subscapularis muscle: Electromyographic validation and
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van Kampen, D., van den Berg, T., van der Woude, H., Castelein, R., Scholtes, V., Terwee, C., &
Willems, W. (2014). The diagnostic value of the combination of patient characteristics, history,
and clinical shoulder tests for the diagnosis of rotator cuff tear. Journal of Orthopaedic Surgery
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Yamamoto, N., Muraki, T., Sperling, J. W., Steinmann, S. P., Itoi, E., Cofield, R. H., & An, K. (2009).
Impingement mechanisms of the neer and hawkins signs.Journal of Shoulder and Elbow
Surgery, 18(6), 942-947. doi:10.1016/j.jse.2009.02.012

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