EXTREMITY AND JOINT CONDITIONS

The Evidenced-Based Shoulder Evaluation

John W. O’Kane, MD and Brett G. Toresdahl, MD

evidence for several physical examination

Abstract
techniques and imaging modalities and
The physical examination of the shoulder has been studied extensively,
to propose an evidenced-based strategy
but the quality and statistical power of the published research often is
for the evaluation of the painful shoulder.
lacking. The initial reports of new shoulder examination techniques com-
monly describe impressive performance. However recent meta-analyses
have found that when the majority of these tests are used in isolation, they Methodology
lack the ability to rule in or rule out the pathology in question, with few Articles were identified through a 2014
exceptions. The diagnostic accuracy of the physical examination improves PubMed search of ‘‘shoulder and phys-
when the shoulder tests are evaluated in combination, such as positive ical examination’’ and ‘‘shoulder and
passive distraction and active compression identifying a superior labral an- imaging.’’ Abstracts were screened for
terior to posterior (SLAP) lesion. The accuracy also can be improved when statistical assessment of examination or
the shoulder tests are evaluated in conjunction with specific historical find- imaging performance. In developing the
ings, such as age greater than 39 years, history of popping or clicking, and a evaluation algorithm, the few shoulder
positive painful arc (pain experienced between 60- and 120- of abduction) tests identified as performing well in a
identifying rotator cuff tendinopathy. The literature on shoulder imaging recent meta-analysis (9) were included.
demonstrates that rotator cuff tears can be ruled in or ruled out by both In addition, a number of studies iden-
ultrasound and magnetic resonance imaging. For SLAP lesions, magnetic tified as low bias using the Quality
resonance arthrography can be used to rule out a tear but may not be as Assessment of Diagnostic Accuracy Stud-
accurate as combined physical examinations to rule in a tear. ies version 2 (QUADAS-2) tool were re-
viewed, and their reported sensitivity and
specificity were used to calculate likeli-
Introduction hood ratios evaluating the role of those tests in the shoulder
Patients with shoulder complaints are evaluated frequently evaluation algorithm.
by primary care, sports medicine, and orthopedic providers. Likelihood ratios were used for the analysis of the ex-
Over the years, many physical examination techniques have aminations because they offer practical applicability for both
been developed to aid in the diagnosis of shoulder conditions, positive and negative results. The positive likelihood ratio is
such as osteoarthritis, glenohumeral instability, and tears of the probability that one with a condition has a positive test
the rotator cuff and labrum. Training in the physical exami- result divided by the probability that one without a condition
nation of the shoulder varies from learning the basic joint ex- has a positive test result. The negative likelihood ratio is the
amination (inspection, palpation, range of motion, and strength probability that one with a condition has a negative test result
testing) to learning dozens of special tests with unintuitive divided by the probability that one without a condition has a
eponyms. The statistical value of the tests, though, is omitted negative test result. Stated differently, the positive likelihood
often. This is also true for both shoulder imaging and ar- ratio is the sensitivity divided by one minus the specificity,
throscopy, which generally are assumed to be the gold stan- and the negative likelihood ratio is one minus the sensitivity
dard for all shoulder conditions, but has limitations in the divided by the specificity. Positive likelihood ratios greater
ability to detect reliably relevant pathology and variability than 5 reflects moderate increase in the likelihood that some-
in interpretation. The purpose of this article is to review the one with a positive test result has the condition, and negative
likelihood ratio less than 0.2 indicates moderate decrease in
Department of Family Medicine, University of Washington School of the likelihood of the condition with a negative test result. A
Medicine, Seattle, WA positive likelihood ratio from 0 to 2 only minimally increases
the odds that the condition is present, while a negative like-
Address for correspondence: John W. O’Kane, MD, University of
Washington Sports Medicine Center, Husky Stadium, 3800 Montlake
lihood ratio greater than 0.5 only minimally decreases the
Blvd. NE, Box 354060, Seattle, WA 98195; odds that the condition is absent.
E-mail: jokane@uw.edu.

1537-890X/1305/307Y313
Meta-analyses
Current Sports Medicine Reports Two extensive systematic reviews by Hegedus et al., first
Copyright * 2014 by the American College of Sports Medicine in 2008 (8) and subsequently in 2012 (9), evaluated the

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diagnostic accuracy of different shoulder tests using meta-
analysis. The 2012 review includes articles published in
MEDLINE and CINAHL from 2006 to 2012 as well as
EMBASE and Cochrane reviews with no date restrictions.
Articles or meta-analyses known to the authors but were
published outside the date range also were included. In to-
tal, 1,766 articles were identified, 22 of which met the inclu-
sion criteria. Ten articles then were added based on the ‘‘hand
search’’ of the authors, for a total of 32. Two-by-two tables
were constructed using data from these 32 articles in combi-
nation with data from the 2008 review. In total, 57 named
shoulder tests were identified. Meta-analysis was possible for
16 tests assessing 5 diagnoses, as follows: subacromial im-
pingement, superior labral anterior to posterior (SLAP) tear,
anterior or posterior labral tear, anterior instability, and ro-
tator cuff tendinopathy. Each of the physical examinations
was evaluated for sensitivity, specificity, positive likelihood
ratio (LR+), and negative likelihood ratio (LRj).
Study Bias
Hegedus et al. (9) also categorized the shoulder test stud-
ies as low, moderate, and high bias using the QUADAS-2
tool. The major flaws that define high-bias studies include in-
consistent or questionable reference (gold) standard, lengthy
or indeterminate time from the index test to the reference
standard, assignment of the reference standard by an indi-
vidual that was biased to the index test result, and failure to
describe the index test adequately. The likelihood ratios sup-
porting the shoulder tests in the evaluation algorithm are
derived from studies identified as low bias.
Shoulder Conditions
Subacromial Impingement
A common cause of shoulder pain is subacromial pain
syndrome or impingement. The term impingement refers to
the rotator cuff tendons and bursa being pinched between
the acromion/coracoacromial ligament and the greater tuber-
osity of the humerus as the arm is elevated. The proposed
mechanism is that either the humeral head is not depressed
adequately by the rotator cuff as the arm elevates or the
acromion does not elevate adequately secondary to scapular
dyskinesis. Other diagnostic terms that describe more speci-
fic pathophysiology but are generally interchangeable include
rotator cuff tendonitis, cuffitis, tendinosis, and subacromial
bursitis. The pain usually localizes to the deltoid and is mild
or absent with the arm at the side but increases with shoulder
abduction. Night ache is a common complaint.
Positive impingement test results include maneuvers that
reproduce the impingement mechanism and elicit pain. Two
well-known tests are the Neer and Hawkins-Kennedy im-
pingement tests. The Hawkins-Kennedy test is performed
by forward-flexing the arm to 90- combined with forceful
internal rotation, and the Neer test is performed by stabiliz-
ing the scapula while passively forward-flexing the arm, with
the shoulder in internal rotation and the elbow in extension.
In the Hegedus meta-analysis (9), the Hawkins-Kennedy test
has the highest sensitivity of the impingement tests at 80%
but lower specificity at 56%. The low specificity diminishes
the diagnostic accuracy of the test, with an LR+ of 1.84 and
LRj of 0.35. The Neer test performed similarly, with LR+
of 1.79 and LRj of 0.47. For both tests, a positive result
308 Volume 13 & Number 5 & September/October 2014
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minimally increases the likelihood of disease and a negative
result minimally decreases the likelihood of disease. There-
fore used in isolation, the physical examinations identified
with impingement provide little diagnostic value.
Labral Tears
A SLAP lesion describes the peeling away of the superior
labrum and attachment of the long head of biceps from the
glenoid. This injury occurs most frequently in throwing ath-
letes, and it was described initially by Andrews et al. (2) in
1985 and later was named by Snyder et al. (22) in 1990. The
meta-analysis (9) of physical examination for a SLAP lesion
found that all eight tests evaluated were not clinically signi-
ficant (had diagnostic odds ratios with confidence intervals
containing the null value). These included active compres-
sion, speeds, anterior slide, crank, Yergason’s, relocation, bi-
ceps palpation, and compression relocation.
There are two additional tests from low-bias studies that
have been shown to be useful when evaluating a suspected
SLAP lesion. Ben Kibler et al. (4) describe the modified dy-
namic labral shear test, which strongly supports the diagno-
sis of a SLAP lesion (LR+, 31.57) when positive. A negative
test result provided a small decrease in the likelihood of a
SLAP lesion (LRj, 0.29). The test is performed by the ex-
aminer standing behind the patient and abducting the shoul-
der to 120-, with maximal external rotation and the elbow
flexed to 90-. The posterior joint line is palpated with one
hand while the arm is lowered from 120- to 60-. A positive
test result is a click with pain at the posterior joint line. The
second test for a SLAP lesion is the passive distraction test
described by Schlechter et al. (21). The test is performed by
having the patient lie supine with the involved shoulder at
the edge of the table. The shoulder is forward-flexed to 150-,
with the elbow fully extended and the forearm supinated. The
humerus then is stabilized, preventing rotation, and the fore-
arm is pronated fully, which produces shoulder pain in a pos-
itive test result. The test was developed, noting that divers
with SLAP lesions would have pain as they assume this po-
sition when entering the water. A positive test result moder-
ately increases the likelihood of a SLAP lesion (LR+, 8.83),
but a negative test result offers only a minimal decrease in
the likelihood of a lesion (LRj, 0.5).
In the meta-analysis (9), the accuracy of tests for anterior
and posterior labral tears was relatively poor and similar to
that for SLAP lesions. The crank test, which involves fully
abducting the arm and then passively internally and exter-
nally rotating the humerus to elicit symptoms, performed the
best, with LR+ of 2.44 and LRj of 0.51.
In the study by Schlechter et al. (21), the authors also
evaluated the combined performance of the passive distrac-
tion test and active compression test for diagnosing SLAP
lesions. The active compression test was described by O’Brien
et al. (17) in 1998. It is performed by flexing the shoulder
forward to 90-, with the elbow extended, and then adduct-
ing the shoulder to approximately 15-. With the shoulder
in internal rotation and the forearm pronated (thumb down),
the patient then is asked to elevate the arm against resistance.
If this is painful, the test is repeated with the shoulder exter-
nally rotated and the forearm supinated (palm up). The test
result is considered positive if the pain is present with thumb-
down and decreased with palm-up. The active compression
The Evidenced-Based Shoulder Evaluation
Figure 1: Flow diagram outlining evidenced-based shoulder examination.

test (17) initially was reported to be nearly perfect, with sen- Anterior Instability
sitivity of 1 and specificity of 0.98. As is often the case with The apprehension test to detect anterior instability per-
physical examinations in the literature, further evaluation of forms better in meta-analysis (9) than tests previously dis-
the tests resulted in diminished performance (16). In the meta- cussed. It is performed by abducting the patient’s shoulder
analysis (9), 6 studies with 782 patients were included, eval- to 90- then externally rotating the shoulder and is positive
uating the active compression test, and neither a positive or if this produces sense of instability. The apprehension test
negative test result had any significant influence on the like- has an LR+ of 17.21, showing conclusive relationship be-
lihood of a SLAP lesion (LR+, 1.06; LRj,0.89). However tween a positive test result and the condition. Conversely
Schlecter et al. (21) reported that if the passive distraction and the LRj is 0.39, with a negative test result representing a
active compression tests are used in combination and have small decrease in the likelihood of instability.
the same results (both positive or both negative), the results
are more meaningful with LR+ of 7.00 and LRj of 0.11.
Studies evaluating the accuracy of physical examinations
to diagnose SLAP lesions can be influenced adversely by a
number of confounding variables. Kim et al. (13) reviewed
544 shoulder arthroscopy procedures, which included 139
SLAP lesions. The SLAP lesions included four morphologies
that varied in pathophysiology and were found also to vary
in the physical examination findings. For instance, a tear that
might catch in the joint could be diagnosed through a modi-
fied dynamic labral shear maneuver while a tear that is pulled
by the biceps tendon may be more likely to be positive with
an active compression maneuver. Kim et al. (13) also were
unable to identify demographic data and symptoms that
could differentiate those with SLAP lesions from a control
group. Examination findings for SLAP lesions further are
complicated by the high number of concomitant diagnoses
such as arthritis or rotator cuff tear (13). Lastly even the gold
standard for SLAP lesions, arthroscopy, can be unreliable,
which was demonstrated in a study by Sasyniuk et al. (20),
demonstrating only 60% diagnostic agreement that the
lesion was present among surgeons reviewing the arthro-
scopic video. Figure 2: Neer test.

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Figure 3: Hawkins-Kennedy test.
A low-bias study (7) revealed that the negative predictive
value can be improved by the addition of the relocation test,
which is performed by repeating the apprehension test with
the examiner’s hand pressing down on the anterior shoulder,
thereby causing relocation of the humeral head and is pos-
itive if there is decreased pain or sense of instability. If both
the apprehension and relocations test results are negative,
there is moderately decreased likelihood of instability, with
the LRj being 0.19.
Rotator Cuff Tendinopathy
Isometric rotator cuff strength testing is a core component
of the shoulder examination for most clinicians. Supraspinatus
strength is tested from a position of abduction in the plane
of the scapula, and infraspinatus is tested through external
rotation against resistance, with the elbow flexed at 90- and
the arm at the side. The evidence supporting this assessment
is limited. Kim et al. (12) performed cuff dynamometry and
diagnostic ultrasound on 237 asymptomatic subjects. They
found that as men age, their abduction and external rotation
strength decreases. As women age, their abduction strength
decreases but external rotation strength is preserved. In both
genders, those with cuff tears were weaker in abduction and
the ratio of abduction to external rotation decreased, suggest-
ing that a rotator cuff tear will cause isometric weakness
Figure 4: External rotation lag sign.
310 Volume 13 & Number 5 & September/October 2014
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Figure 5: Belly off test.
even in the absence of symptoms. Age was a critical variable
differentiating those with asymptomatic tears. No asymp-
tomatic rotator cuff tears were identified in those less than
50 years old. Asymptomatic cuff tears were identified in 10%
of those aged 50 to 59 years, 20% of those aged 60 to 69 years,
and 41% of those aged 70 years and above. Symptomatic ro-
tator cuff tears also present in typical age ranges, with in-
complete tears presenting at a mean age of 41 years and
complete tears at a mean age of 62 years (15). Understanding
both the typical age progression of rotator cuff tears and the
incidence of asymptomatic rotator cuff tears with advancing
age therefore must be considered in the interpretation of iso-
metric rotator cuff strength testing.
Two tests from low-bias studies assist with the diagnosis
of rotator cuff tears. The belly off test (3) strongly supports the
diagnosis of a subscapularis tendon tear when it is positive
(LR+, 9.67), while a negative test result moderately decreases
the likelihood of a tear (LRj, 0.14). The test is performed by
having the patient flex their elbow to 90- with their palm
over their belly. The examiner passively moves the elbow for-
ward, resulting in passive internal rotation of the shoulder.
The test result is positive if the patient cannot keep their hand
on their belly.
The second physical examination is the external rotation
lag sign, which evaluates for the presence of a full-thickness
supraspinatus or infraspinatus tear. It originally was de-
scribed by Hertel et al. (10) and reevaluated by Castoldi et al.
Figure 6: Passive distraction test.
The Evidenced-Based Shoulder Evaluation

Figure 7: Dynamic labral shear test.
(5). The test is performed by flexing the elbow to 90-
then abducting the shoulder to 20- in the scapular plane.
The shoulder then is rotated maximally externally, and
the inability to keep the shoulder in external rotation is a
positive test result. The low-bias study of Castoldi et al.
(5) evaluating the performance of the test across a range
of rotator cuff pathology identified at surgery yielded inter-
esting results. Partial-thickness supraspinatus tears could not
be identified reliably, and full-thickness partial-width ante-
rior supraspinatus tears could not be ruled out with a negative
test result (LRj, 0.73), while a positive test result only in-
creased the likelihood of a tear a small amount (LR+, 4.6).
The likelihood of a full-width supraspinatus tear was in-
creased strongly with a positive test result (LR+, 28.00) but
again only a small decrease in likelihood with a negative test
result (LRj, 0.45). A combined full-thickness tear of the su-
praspinatus and infraspinatus could be ruled in effectively by
a positive test result (LR+, 13.86) and also ruled out by a
negative test result (LRj,0.03).
Jia et al. (11), in a low-bias study, identified the shrug sign
as having utility ruling out a rotator cuff tear. The shrug sign
is performed by having the patient begin with their arms at
their side, with the elbow flexed to 90- and then abduct to
90-. The test result is positive if scapular elevation (shrugging)
is observed with abduction. Many conditions can produce a
positive shrug sign, resulting in an LR+ of G5. However, a
negative test result is effective at ruling-out rotator cuff
Figure 8: A and B. Active compression test.
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tendinopathy (LRj, 0.08), adhesive capsulitis (LRj, 0.10),
and glenohumeral arthritis (LRj, 0.12) (11).
The clinical diagnosis of rotator cuff pathology becomes
more accurate when the physical examinations are evalu-
ated in the context of patient history. Chew et al. (6) assessed
which clinical findings would predict supraspinatus pathol-
ogy and found strong correlation with 3 positive findings, as
follows: age, 939; self-reported popping and clicking; and
a painful arc of motion. The likelihood of supraspinatus
tendinopathy in the setting of these findings increased dra-
matically, with an LR+ of 32.20.
Imaging
It may be assumed that imaging is more accurate in es-
tablishing a diagnosis than the physical examination, but the
literature does not support this assumption always. Imaging
for suspected rotator cuff tears includes magnetic resonance
imaging (MRI), MR arthrography (MRI following an arthro-
gram with gadolinium), and diagnostic ultrasound. As early
as 1998, Read and Perko (19) reported that preoperative ul-
trasound identified 100% of full-thickness rotator cuff tears
and the majority of significant biceps tendon injury. Ultra-
sound identified only approximately half of the partial rota-
tor cuff tears, but in a more recent study (23), MRI was no
better than ultrasound at detecting partial rotator cuff tears.
In 2013, Lenza et al. (14) reviewed studies comparing
MRI, MR arthrography, and ultrasound for the diagnosis of
rotator cuff tears, with open or arthroscopic surgery as the
gold standard. For partial-thickness tears, MRI and ultra-
sound both performed well (MR arthrography was not in-
cluded). A negative imaging test result strongly decreased
the likelihood of a tear, and a positive test result led to a
moderate-to-large increase in likelihood of tear. All three
imaging modalities performed well to rule in or rule out a
full-thickness rotator cuff tear. For both partial- and full-
thickness rotator cuff tears, there were no significant differ-
ences in the performance of the imaging modalities, which
in many settings argues for ultrasound because of lower cost
and argues against MR arthrography because of higher cost
and potential for morbidity as the only invasive modality.
For the diagnosis of SLAP lesions, the imaging results
are less accurate. Phillips et al. (18) prospectively evaluated
patients who were scheduled to have arthroscopy with non-
contrast MRI. They found that the MRI provided no value in
Current Sports Medicine Reports 311
Figure 9: Shrug sign (positive on right side).
diagnosing a SLAP lesion (LR+, 0.98; LRj, 1.1). Amin and
Youssef (1) also followed a group of patients with clinically
diagnosed SLAP lesions scheduled for arthroscopy and found
that a negative MR arthrogram was moderately effective to
rule out a SLAP lesion, while a positive test result only min-
imally increased the likelihood of a lesion (LR+, 1.8). The
authors concluded that MR arthrography was useful only in
the setting of a negative result, as it may prevent unnecessary
arthroscopy. Comparing combined physical examinations
with imaging, concordant findings with the active compres-
sion and passive distraction tests (21) perform better than
MR arthrography to confirm or rule out a SLAP lesion.
Conclusions
The literature is replete with studies describing physi-
cal examinations for the shoulder, although many are of
Figure 10: Apprehension test.
312 Volume 13 & Number 5 & September/October 2014
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Figure 11: Relocation test.
insufficient quality. Complicating these studies is the depen-
dence of the physical examinations on a subjective outcome,
namely, the patient report of pain with certain movements.
Many shoulder tests also are nonspecific, as similar patterns
of physical examination findings can be produced by multiple
pathological entities. In addition, shoulder pathologies, such
as rotator cuff tears, may be asymptomatic, creating chal-
lenges when interpreting the results of both physical exami-
nation and imaging tests.
Despite these challenges, there are well designed, low-bias
studies providing evidence for a number of shoulder tests.
Moreover, combining history and physical examination im-
proves accuracy over physical examinations in isolation. The
combined findings also may perform better than imaging
tests, which have higher cost and greater risk. There is value
in advanced imaging, but the clinician must understand the
diagnostic limitations and be discerning when ordering im-
aging tests when there is need for additional information to
support or refute the suspected diagnoses derived from the
history and physical examinations.
The process of evaluating a patient with shoulder pain var-
ies by provider and by the reported history. Figure 1 proposes
a standard algorithm based on the evidence presented in this
review. The algorithm is not intended for patients presenting
with shoulder pain in the setting of systemic illness or other
cancer risk factors. The first two pieces of history include age
and a clear traumatic event accounting for the symptoms. If
there is clear trauma or if age is 950 years, then radiographs
should be ordered to assess for fracture, arthritis, or other
bone abnormality. An apprehension or relocation test can be
used in the setting of trauma to evaluate for anterior insta-
bility. In patients over 50 years old without history of trauma,
a positive belly off, external rotation lag sign, or asymmetric
weak abduction suggests a rotator cuff tear, and a diagnostic
The Evidenced-Based Shoulder Evaluation
ultrasound or MRI can assist in making the diagnosis. The
next step is a shrug sign. If positive, radiographs are needed
to evaluate for arthritis. In the setting of normal radiographs,
passive range of motion can differentiate adhesive capsulitis
from rotator cuff tendinopathy along with consideration of
known age and gender risk factors for these conditions. If the
shrug is negative, then the combination of age over 39 years
with a report of popping or clicking and a painful arc makes
rotator cuff tendinopathy likely. Positive active compres-
sion, passive distraction, and modified labral shear, especially
in combination, increase the likelihood of a SLAP lesion. An
MR arthrogram then could be ordered, and if normal, a SLAP
lesion is unlikely. Conversely if the MR arthrogram is posi-
tive or equivocal, referral for arthroscopy may be indicated
if the patient has failed conservative management and bio-
mechanical optimization.
The authors have no disclosures or conflicts of interest to report.
References
1. Amin MF, Youssef AO. The diagnostic value of magnetic resonance arthro-
graphy of the shoulder in detection and grading of SLAP lesions: comparison
with arthroscopic findings. Eur. J. Radiol. 2012; 81:2343Y7.
2. Andrews J, Carson W, Mcleod W. Glenoid labrum tears related to the long
head of the biceps. Am. J. Sports Med. 1985; 13:337Y41.
3. Bartsch M, Greiner S, Haas NP, Scheibel M. Diagnostic values of clinical
tests for subscapularis lesions. Knee Surg. Sports Traumatol. Arthrosc. 2010;
18:1712Y7.
4. Ben Kibler W, Sciascia AD, Hester P, et al. Clinical utility of traditional and
new tests in the diagnosis of biceps tendon injuries and superior labrum
anterior and posterior lesions in the shoulder. Am. J. Sports Med. 2009;
37:1840Y7.
5. Castoldi F, Blonna D, Hertel R. External rotation lag sign revisited: accuracy
for diagnosis of full thickness supraspinatus tear. J. Shoulder Elbow Surg.
2009; 18:529Y34.
6. Chew K, Pua Y, Chin J. Clinical predictors for the diagnosis of supraspinatus
pathology. Physiother. Singapore. 2010; 13:12Y7.
7. Farber AJ, Castillo R, Clough M, et al. Clinical assessment of three common
tests for traumatic anterior shoulder instability. J. Bone Joint Surg. Am.
2006; 88:1467Y74.
www.acsm-csmr.org
Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
8. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the
shoulder: a systematic review with meta-analysis of individual tests. Br. J.
Sports Med. 2008; 42:80Y92.
9. Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests
provide clinicians with the most value when examining the shoulder? Up-
date of a systematic review with meta-analysis of individual tests. Br. J.
Sports Med. 2012; 46:964Y78.
10. Hertel R, Ballmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis of
rotator cuff rupture. J. Shoulder Elbow Surg. 1996; 5:307Y13.
11. Jia X, Ji JH, Petersen SA, et al. Clinical evaluation of the shoulder shrug
sign. Clin. Orthop. Relat. Res. 2008; 466:2813Y9.
12. Kim HM, Teefey SA, Zelig A, et al. Shoulder strength in asymptomatic in-
dividuals with intact compared with torn rotator cuffs. J. Bone Joint Surg. Am.
2009; 91:289Y96.
13. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the
different types of SLAP lesions: an analysis of one hundred and thirty-nine
cases. J. Bone Joint Surg. Am. 2003; 85-A:66Y71.
14. Lenza M, Buchbinder R, Takwoingi Y, et al. Magnetic resonance imaging,
magnetic resonance arthrography and ultrasonography for assessing rotator
cuff tears in people with shoulder pain for whom surgery is being considered.
Cochrane Database Syst. Rev. 2013; 9:CD009020.
15. Matsen FA, Lippitt SB, Sidles JA, Harryman DT. Practical Evaluation and
Management of the Shoulder. WB Saunders Co., St. Louis, MO. 1994. 256 p.
16. McFarland EG, Tanaka MJ, Garzon-Muvdi J, et al. Clinical and imaging
assessment for superior labrum anterior and posterior lesions. Curr. Sports
Med. Rep. 2009; 8:234Y9.
17. O’Brien SJ, Pagnani MJ, Fealy S, et al. The active compression test: a new
and effective test for diagnosing labral tears and acromioclavicular joint
abnormality. Am. J. Sports Med. 1998; 26:610Y3.
18. Phillips JC, Cook C, Beaty S, et al. Validity of noncontrast magnetic reso-
nance imaging in diagnosing superior labrum anterior-posterior tears. J.
Shoulder Elbow Surg. 2013; 22:3Y8.
19. Read JW, Perko M. Shoulder ultrasound: diagnostic accuracy for impinge-
ment syndrome, rotator cuff tear, and biceps tendon pathology. J. Shoulder
Elbow Surg. 1998; 7:264Y71.
20. Sasyniuk TM, Mohtadi NG, Hollinshead RM, et al. The inter-rater reli-
ability of shoulder arthroscopy. Arthroscopy. 2007; 23:971Y7.
21. Schlechter JA, Summa S, Rubin BD. The passive distraction test: a new di-
agnostic aid for clinically significant superior labral pathology. Arthroscopy.
2009; 25:1374Y9.
22. Snyder SJ, Karzel RP, Del Pizzo W, et al. SLAP lesions of the shoulder.
Arthroscopy. 1990; 6:274Y9.
23. Vlychou M, Dailiana Z, Fotiadou A, et al. Symptomatic partial rotator
cuff tears: diagnostic performance of ultrasound and magnetic resonance
imaging with surgical correlation. Acta Radiol. 2009; 50:101Y5.
Current Sports Medicine Reports 313