Orthopedic Physical Therapy (Ⅰ)

PT for Shoulder Disorders

Evaluations
Date: Mar. 14, 2023
Po-Tsun Chen, Ph.D.

School of Physical Therapy, Chang Gung University

Patient history
• What is the patient’s age?
• Idiopathic frozen shoulder: 45-60 years
• Frozen shoulder due to trauma: any age
• Injury mechanism
• fall on out-stretched hand (FOOSH) → GH dislocation or
fracture
• Fall on elbow→ humerus against acromion: AC dislocation
• Movements or positions that cause the patient pain or
symptoms
• cervical movements may cause pain in the shoulder
• SICK
• malposition of Scapula, prominence of Inferior medial
border of scapula, Coracoid pain and malposition, and
scapular dysKinesia
• Differential diagnosis of
common shoulder problem
• The extent and behavior of the patient’s pain
• Strains of the rotator cuff: dull pain
• Acute calcific tendinitis: hot and burning pain
• Activities that cause or increase the pain
➢ Indication of injured tissue
• Positions relieve/increase the pain
• Nerve root pain: elevating the arm over the head relieves symptoms
• How long has the problem bothered the patient?
• Is there any indication of
• muscle spasm, deformity, bruising, wasting, paresthesia, or numbness?
• Weakness and heaviness in the limb after activity
• Venous symptoms: swelling or stiffness, extend to the fingers
• Arterial symptoms: coolness
✓ Thoracic outlet syndrome (Supplement 1)
• Nerve injury
• history of weakness, numbness, or paresthesia
• The dysfunction of
• swallow, walk, drink, driving…….
Supplement 1

Thoracic outlet syndrome

(TOS)
Supplement 1

• A group of disorders that occur when blood vessels or nerves in the

space between clavicle and 1st rib (thoracic outlet) are compressed
• Types • Numbness or tingling in your arm or fingers
• Pain or aches in your neck, shoulder, arm
• Neurogenic thoracic outlet syndrome or hand
• most common • Weakening grip

• brachial plexus • Discoloration of hand (bluish color)

• Venous thoracic outlet syndrome
• one or more of veins under clavicle
• blood clots
• Arterial thoracic outlet syndrome
• the least common type
• one of the arteries under clavicle
• result in bulging of the artery, aneurysm
• Arm pain and swelling
• Blood clot in veins
• Arm fatigue with activity
• Paleness or abnormal color in fingers or hand
• Throbbing lump near clavicle
• Cold finger or arm
• Hand and arm pain
• Lack of color (pallor) or bluish discoloration in
fingers or hand
• Weak or no pulse in affected arm
Observation
• The bony and soft-tissue contours (Supplement 2-4)
• cervical and thoracic spine, head and both shoulders (entire UE)
• undressed for observing
• Neutral pelvis
• abnormal pelvic position
➢ an abnormal scapulothoracic, glenohumeral, and cervical spine
position and movment

1. Can the patient get into the “neutral pelvis”?

2. Can the patient hold the static “neutral pelvis” position while doing
distal dynamic movement (e.g., shoulder movements)?
3. Can the patient control a dynamic “neutral pelvis” while doing
dynamic shoulder movements?
Supplement 2
• head and neck are in the midline ,
and its relation to shoulders
• Appearance of joints (step
deformity, sulcus sign)
T2
T4
T8
• Position of scapula A forward head posture ----rounded
→→ Kinetic chain shoulders, a medially rotated humerus and
• Scapula muscle contour a protracted scapula
→→ nerve palsy →→ humeral head translating anteriorly
→→ a tight posterior capsule
→→ tightness of the pectoralis, upper
trapezius, and levator scapulae muscles
→→ weakness of lower scapular muscles
Supplement 3

Anterior dislocation
Check the contour of deltoid
Which shoulder is dislocated?
Supplement 4

Muscle rupture
Rupture of the pectoralis major
✓ tearing sensation and pop
✓ ecchymosis and swelling
✓ weakness
✓ painful limitation of movement
✓ loss of axillary fold

Congenital absence
Winging of scapula
• Inferior angle moves away from rib cage
• weak lower trapezius or a tight pectoralis minor
• Winging of the medial border
• injury to the serratus anterior muscle or the long
thoracic nerve
 ➢ Static winging
• usually caused by a structural
Types of scapula winging deformity of scapula, clavicle, spine,
or ribs
➢ Sprengel’s deformity
◆ Primary scapular winging • congenital deformity
• Winging due to weakness of • a high or undescended scapula
one of scapular muscles
• scapular muscles are poorly developed
◆ Secondary scapular winging or replaced by a fibrous band
• Winging is due to the GH joint • associated with other anomalies (e.g.,
➢ Dynamic scapular winging scoliosis, rib anomalies)
• lesion of nerve
• Long thoracic N.→ SA
• Spinal accessory N.→ trapezius
• Multi-direcitonal instability
• Painful shoulder
• Rhomboid weakness
Which muscle is paralyzed?
• scapula depressed and
moved laterally with inferior
angle rotated laterally
• scapula winging occurs
before 90° abduction
• little winging on forward
flexion
• scapula elevated and moved
medially with inferior angle
rotating medially
• winging of the scapula occurs on
abduction and forward flexion
Examination
Knowledge of muscle balance and muscle force couples
becomes imperative in determining a diagnosis
X-ray for shoulder
A-P view
X-ray for shoulder
Y view
 Active movements
• To remember that shoulder
movements are a combination of
• glenohumeral, scapulothoracic,
acromioclavicular and
sternoclavicular movements
• Max. range of shoulder movement
may also involve the thoracic spine
and ribs
Force couple
• The groups of counteracting muscles
• show obvious action when a movement
is loaded or done quickly
➢Concentric/Eccentric contraction
➢Co-contraction or co-activation
 The pinched soft tissues have passed under the
acromion process and are no longer being pinched

Painful arc
The structures in the subacromial space are pinched
(e.g., subacromial bursa, rotator cuff tendon insertions,
especially supraspinatus)

The structures are not pinched under the acromion process

 Three-dimensional scapular movement
Scapulohumeral rhythm during scaption
Scapulohumeral Rhythm
during abduction
• Simultaneously 120° GH abduction and 60°
of scapulothoracic upward rotation
• 2:1 ratio
• 60° of scapula upward rotation
• the result of elevation at SC and AC
joints
• Scapula also posteriorly tilts and externally
rotates during full shoulder abduction
The elevation of AC and SC during abduction
Scapula active movement
• medial borders of scapula
remain parallel to the spine
• to do this movement without
excessive contraction of UT
Resting Retraction
✓ If the scapula sit lower than
• the inferior angle of the normal against the chest wall
scapula moving laterally or spinal kyphosis/rounded
shoulder
more than the superior angle
➢ the superior medial border
may “washboard” over the
ribs
Scapula rubbing over the
underlying ribs
Snapping scapula may be
found during scapula active
movement
Protraction
(Supplement 5)

How to treat the problems

due to scapular dyskinesia???
Supplement 5

Scapular dyskinesia
Supplement 5

Four types of scapula movement patterns

by Kibler et al.
✓ Weakness • Type I
• LT, LD, or SA
✓ Tightness • Inferior-medial border prominent
• PM or Pm • inferior angle tilts dorsally with movement (scapular
tilt
• the acromion tilts anteriorly over the top of the
thorax
✓ Weakness
• SA, Rh, LT, MT, UT
✓ Tightness
• rotators
✓ Nerve problem • Type II (classic winging)
• Long thoracic N. • whole medial border of scapula prominent and lift
away from the posterior chest wall
Supplement 5
• Type III
• Superior-medial border elevated
• shoulder shrug initiates the movement
• minimal winging
✓ Weakness
• SA, Rh, LT, MT, UT
✓ Over-activate
• LS and UT
✓ Imbalance
• UT/LT

• Type IV
• Rotate symmetrically upward with the inferior angles
rotating laterally away from midline

To evaluate the scapular dyskinesis in static and dynamic status

Supplement 5

Diagnostic algorithm

• Not all observed dyskinesis

is associated with shoulder
symptoms and dysfunction
Cases study of scapular dyskinesis
The impact of serratus anterior
• Injury to serratus anterior can affect several movements
✓Muscle weakness (Supplement 6)
➢Scapula winging
➢scapular stabilization is lost
➢Shoulder movement is affected
(Supplement 6)

✓ Dysfunctional stabilizer
✓ Closed kinetic chain
✓ Reverse origin-insertion

• Examine the winging

• a resistance to ABD 30-60° of shoulder ABD is the best way to show scapular
winging
• eccentric loading of horizontal ADD also demonstrate the loss of scapular
control
 GH int. rotation deficit (GIRD)
&
GH ext. rotation gain (GERG)
• Definition of GIRD
• loss of IR of ≥20° or greater loss of IR compared to
contralateral shoulder
• When shoulder is used at extremes ROM and under
high loading, i.e., pitcher
• humeral retroversion or contracture of posterioinferior
capsule
• If the GIRD/GERG ratio >1
• probably develop shoulder problems
• SLAP
Capsular tightness
• Although commonly tested during passive movement
• Tight capsule can affect active movement
limiting some or all movements in GH joint
compensating excessive movement of the scapula
Passive movement

Capsular tightness

end-feel

More hard than the tissue stretch

Tightness of posterior capsule
• P’t posture
• Supine (side-lying) with arm forward flexed to 90° and
elbow flexed to 90°
• PT position/action
1. Palpate the lateral edge of the scapula
2. Horizontally adduct the patient’s arm
3. Feel the scapula begin to move, the horizontal ADD
is stopped
• Evaluation
• the angle relative to the vertical position
• Note
• may also be done in side lying but harder to stabilize
scapula
Passive abduction of GH joint
• P’t posture
• Sitting
• PT position (Supplement 7)
• Passive elevate the arm through abduction or scaption
• The other hand fix the clavicle or scapula
• Examine
• Determine the amount of ABD in the GH joint alone
• Positive
• An indication of capsular tightness or subacromial space pathology → pain
• Normally, this elevation can be 120°
Supplement 7

Scaption
neutral elevation
• Active elevation through the plane of scapula
➢ puts less stress on capsule and surrounding
musculature
➢ most of the functions of daily activity
➢ higher value of strength testing
➢ spontaneously choose in patient with shoulder
problem
➢ Similar scapulohumeral rhythm as ABD
➢ Little or no external rotation of humerus in 3rd phase of
scaption
➢ More scapular protraction
Quadrant position
• The humerus rotates automatically or subconsciously occurs with arm
elevation
• To examine whether the automatic or subconscious rotation is
occurring during movement
• The humerus moves forward at approximately 120° of abduction, is the
unconscious rotation occurring at GH joint
✓ Quadrant test, to notice that
✓ Rotation movement and quality
✓ Pain
✓ Restricted ROM
Quadrant position
Adduction test
• P’t posture
• Supine
• PT position
1. Stabilize the scapula and clavicle, place the hand under patient’s scapula (prevent
shrugging)
2. Elevate arm with external rotation to rest alongside patient’s head, and then, adduct
the arm on coronal plane
• Examine
• The “quadrant position” is reached at which the arm moves forward slightly from the
coronal plane
• After approximate 60° of ADD from head, the arm falls back to the previous coronal plane
• Note
• This position indicate at which the arm medially rotated during its descent to the
patient’s side
Quadrant position
Abduction test
• P’t posture
• Supine
• PT position
1. Stabilize the scapula and clavicle, place the hand under patient’s scapula (prevent
shrugging)
2. Abduct the medially rotated shoulder while maintaining extension
• Examine
• The quadrant position is reached (approximately 120° of ABD) when the shoulder no
longer ABD
• ABD is prevented from laterally rotating by the catching of the GT in the subacromial
space
• “locked quadrant position”
• Note
• After lateral rotation occurred, then full ABD can be achieved
Resisted isometric movement
• The PT should have noted which active movements caused discomfort or
pain
• It can be correlated with the results from resisted isometric movements
• If the patient complained of pain in one or more positions
• these positions should be tested, and concentric or eccentric
movements as well
• The scapula should not move during isometric testing in normal shoulder
• protraction, winging, or tilting indicates weakness of the scapular
muscles
• By carefully noting which resisted movements cause pain
➢ the examiner should be able to determine which muscle or muscles
are at fault
 Example for resisted isometric test
Resisted isometric test

Flexion

Pain on anterior Abduction

shoulder
Which muscle cause pain ?
Pain on anterior Adduction
shoulder

Internal
Pain on anterior
rotation
shoulder

External
rotation
Special tests
• Depending on the patient history
➢some tests are compulsory, and others may be used as confirming
or excluding tests
• As with all passive tests, results are more likely to be positive
➢in the presence of pathology
➢muscles are relaxed, the patient is supported, and minimal or no
muscle spasm
Shoulder instability
• Instability at the shoulder manifests itself as symptomatic abnormal
motion, due to
abnormal scapular or GH muscle patterning
hypo- or hypermobility of capsule
a labral tear (a Bankart or SLAP lesion)
a rotator cuff or biceps injury
altered surface area of contact between the glenoid and humeral head
problem with the central or peripheral nervous system
 ✓ Instability is unable to
Shoulder impingement syndrome control or stabilize a joint
during motion or in a static
position
• Primary impingement ➢ Injured static restraints
• > 40 years old ➢ weak muscles or
• Mechanical impingement due to degenerative changes unbalanced force couples to
• rotator cuff Intrinsic factors control joint
• acromion process  hypermobile or lax joint
• coracoid process does not imply instability
• anterior tissues from stress overload
• Secondary impingement Extrinsic factors
• 15-35 years old
• Problems of muscle dynamics, causing instability in
either GH joint or scapula
• Altered force couple
• Abnormal movement patterns
Outlet impingement
• The impinged area is the supraspinatus outlet area
• Primary (anterior primary impingement) and secondary (anterior secondary
impingement) impingement occurs anteriorly
• Classification by Jobe
• Grade I: Pure impingement with no instability (often in older)
• Grade II: Secondary impingement and instability caused by chronic capsular
and labral microtrauma
• Grade III: Secondary impingement and instability caused by generalized
hypermobility or laxity
• Grade IV: Primary instability with no impingement
Internal impingement
non-outlet impingement
• The impingement occurs posteriorly
when arm is ABD to 90° and laterally
rotated fully
• The impinged tissue includes
• undersurface of the rotator cuff
(primarily supraspinatus and
infraspinatus)
• posterosuperior glenoid labrum
(Translational (Gross/Anatomical
instability) instability)
Apprehension (Crank) Test
to check for traumatic instability (gross or anatomical instability )
Anterior apprehension (crank) test
• P’t posture
• Supine
• PT action
• ABD the arm to 90° and laterally rotates the shoulder
slowly
• Place a hand under the GH joint as a fulcrum, the
apprehension test becomes the fulcrum test
• Apply a mild anteriorly-directed force to the posterior
humeral head
• when in the test position to see if apprehension or pain
increases
• Positive
• patient looks or feels apprehensive or alarmed and
resists further motion
• Note
• Continued by Relocation test Fulcrum test
 Relocation test
(Fowler test or Jobe relocation test)
• P’t posture crank test
• Following apprehension test anterior
subluxation
• PT action
• apply a posterior translation stress to the head of
humerus
• Positive
• if pain decreases, even if there was no apprehension
• loses the apprehension
• pain decrease
relocation
• further lateral rotation is possible test
“Surprise” test
• GH instability, subluxation, dislocation, or
impingement
Anterior release (surprise test)
• P’t posture
• Following relocation test
• PT action
• the arm is released in the newly acquired range
• Positive
• pain and forward translation of the head are noted in positive tests
• Pain caused by
• anterior shoulder instability
• labral lesion
• bicipital peritenonitis or tendinosus
• Note
• Release should be done carefully (may cause apprehension or dislocation)
 Load and Shift Test
check primarily atraumatic instability
• P’t posture
• sit with the testing hand resting on the thigh
• Shoulder muscles should be as relaxed as possible
• PT position
• stand or sit behind the patient
• Action
• stabilize the shoulder with one hand
• the other hand grasp the humeral head with thumb
over the posterior and fingers over anterior head
➢ to feel where the humerus seated relative to the 1. Load portion
glenoid
humerus is gently pushed anteriorly or posteriorly in
➢ load and shift
the glenoid to seat it properly in the glenoid fossa
• Positive 2. Shift portion
• If fingers “dip in” anteriorly, it indicate the humeral push the head anteriorly or posteriorly , noting the
head sit anteriorly amount of translation and end feel
• Protraction cause humeral head translate anteriorly
Grade of GH translation
 Jerk Test
for posterior instability
• P’t posture
• Sit with arm medially rotated and forward flexed to 90
• PT action
• grasp the patient’s elbow and axially loads the humerus in
a proximal direction
• maintain the axial loading, move the arm horizontally
(cross-flexion/horizontal adduction) across the body
• Positive
• a sudden jerk or clunk as the humeral head slides off
(subluxes) the back of the glenoid
• a second jerk may be felt when returned to the original
90° abduction
• Note
• a posteroinferior labral tear
Test for Inferior Shoulder Instability
Sulcus Sign
• P’t posture
• stand with arm by side and muscles relaxed
• PT action
• To grasp the patient’s forearm below the elbow and pull
the arm distally
• Positive
• presence of a sulcus sign or if the patient is symptomatic
Hawkins-Kennedy Impingement Test
• P’t posture
• stand
• PT action
• To forward flex the arm to 90° and then forcibly medially
rotate the shoulder
• push the SS tendon against the anterior surface of
CC ligament and coracoid process
• May also be performed in different degrees of flexion or
horizontal ADD (coracoid impingement sign)
• Positive
• Pain
Neer Impingement Test
• P’t posture
• Sit or stand
• PT action
• Forcibly fully elevated in the scapular plane with the arm
medially rotated
• cause the GT to jam against the anteroinferior border
of the acromion
• Positive
• p’t show pain, reflecting a positive test result
• Overuse injury of SS or biceps tendon
Internal Rotation Resistance Strength Test
Zaslav Test Supplement 8
• P’t posture
• (follow-up to a Neer test) stand with the arm abducted
to 90° and laterally rotated 80° to 85°
• PT action
• apply isometric resistance into lateral rotation followed
by isometric resistance into medial rotation
• Positive
• External anterior (outlet) impingement: more weakness
on lateral rotation
• Internal (non-outlet) impingement: more weakness on
internal rotation
Supplement 8

Evidence to outlet and non-outlet impingement

Suupl. to Zaslav Test
• Outlet impingement
• thickened and inflamed subacromial bursa
• erosions on the coracoacromial ligament and
undersurface of the acromion
• bursal side partial- or full-thickness tearing of the
rotator cuff
• Non-outlet impingement
• anterior glenoid erosions or labral tears
• middle glenohumeral ligament tearing
• undersurface rotator cuff partial tears
• posterosuperior labral lesions
• SLAP lesions
Supine Impingement Test
• P’t posture
• supine
• PT action
• Hold the wrist and humerus and elevate the arm to end
range
1. Laterally rotate the arm and ADD into further elevation
with the supinated arm against the patient’s ear
2. Medially rotate the arm
• Positive
• the medial rotation causes a significant increase in pain
• Note
• rotator cuff pathology
Posterior internal impingement test

• P’t posture
• Supine
• PT action
• To ABD the arm (90-110°), extend (15-20°) beyond the
coronal plane, and laterally rotated (maximally)
• Positive
• localized pain in the posterior shoulder
• when rotator cuff impinges against the posterosuperior edge
of the glenoid
• Note
• primarily in overhead athletes
Bankart lesion and SLAP (Superior labral anterior-posterior tear) lesion
 Tests for Labral Tears
• The labrum is more prone to injury when anterior stress
➢the tensile strength of the labrum is less than the capsule ✓ Circle concept of instability
✓Bankart lesion Injury in one direction of the joint
results in injury to structures on
• a traumatic anterior dislocation leading to anterior the other side of the joint.
instability
• labrum detached from 3 to 7 o’clock
• both anterior and posterior structural injury
✓SLAP: superior labrum is torn
• labrum detached from the 10 to 2 o’clock position
• Labrum is pulled or peeled
• Resulted from FOOSH injury, during deceleration when
throwing, sudden traction is applied to the biceps

Types of SLAP
by Stephen J. Snyder (1990)
The increased lateral rotation, decreased medial rotation, and a tight
posterior capsule
➢ result in posterosuperior migration of the head during maximum
lateral rotation, causing a tear of the posterosuperior labrum

Type I Type II Type III Type IV

➢Superior labrum ➢Superior labrum has small ➢Bucket-handle tear of ➢Bucket-handle tear of
markedly frayed but tear; instability of the labrum that may displace labrum that extends to
attachments intact labral-biceps complex into joint; labral biceps biceps tendon, allowing
(SLAP, most common) attachment intact tendon to sublux into joint
Mechanisms of injury for SLAP lesions
Active Compression Test of O’Brien
for SLASP (type II) or superior labral lesions
• P’t posture
• Stand with arm forward flexion to 90° and the elbow fully
extended
• PT action 1st
1. To horizontally ADD 10° to 15° and medially rotated so the
thumb faces downward
• Then, to apply a downward eccentric force
2. The arm is returned to starting position with the shoulder is
laterally rotated
• Then, to apply a downward eccentric force
• Positive
• Pain on the joint line or painful clicking in the 1st step, and pain
eliminated or decreased in the 2nd step
• Note
• take care to differentiate between labral and acromioclavicular 2nd
Anterior slide test
• P’t posture
• Sitting with hands on waist, thumb posterior
• PT action
• Stabilize the scapula and clavicle with one hand
• The other hand apply an anterosuperior force at
the elbow along the long-axis of humerus
• Positive
• If SLAP lesion
• humeral head slide over the labrum with a pop or crack
with pain
• patient complains of anterosuperior pain
Biceps Load Test (Kim Test I)
for superior labrum
• P’t posture
• sit with back supported
• PT action
• To support the arm in ABD 90° with the elbow in 90°
flexion
1. (one hand) apply an axial compression force to glenoid through
the humerus , and elevate diagonally upward
2. (the other hand) apply downward and backward force to
proximal arm
• Positive
• Sudden pain on posterior shoulder pain
• posterior labral lesion
 Biceps Load Test (Kim Test II)
for superior labrum
• P’t posture
• in supine or seated position
• shoulder ABD to 120° and laterally rotated, elbow flexed to
90° and forearm supinated
• PT action
• To perform apprehension test by taking into full lateral
rotation
• If apprehension appears, to stop lateral rotation and hold the
position
• To ask p’t to flex the elbow against the examiner’s resistance
at the wrist
• Positive
• The test is positive for SLAP lesions, if the apprehension
remains the same or shoulder becomes more painful
Test for scapular stability
• The muscles in shoulder complex should work in a coordinated manner
➢ The scapula must be stabilized by scapular muscles to act as a firm base for GH muscles
• When access the scapula stability, examiner should watching for the movement
pattern for dyskinesia
 Lateral Scapular Slide Test
scapula stability during GH movements
• P’t posture
• sit or stand with the arm resting at the side
• PT action
1. To measure the distance
✓ from the base of spine of scapula to SP of T2 or T3
✓ from the inferior angle of scapula to SP of T7 to T9  In each position, the distance should
✓ from T2 to superior angle of scapula not vary more than 1 ~1.5 cm from
2. To achieving following positions the original measure
✓ 45° ABD ➢ Actually, it increased after ABD 90°
✓ 90° ABD with medial rotation
✓ 120° ABD
✓ 150° ABD Watch the
Asymmetry of mv’ pattern
Scapular load test
• P’t posture
• Follow “Lateral Scapular Slide Test”
• Put hands on waist and shoulder in ABD 45°
• PT action
• Apply load to arm anteriorly, posteriorly, inferiorly or
superiorly
• Positive
• The scapula move more than 1.5 cm
• Note
• The stabilizing ability of scapular muscles and whether
abnormal winging or abnormal movement patterns
occur
Scapula assistance test (SAT)
• P’t posture
• Standing
• PT action
• To place fingers of one hand over clavicle with heel
of hand over spine of the scapula
• To stabilize and holds the scapula retracted during arm
mv’
• (other hand) To hold the inferior angle of the
scapula
• Push the scapula up and laterally during arm mv’ To simulate the activity of
• Positive SA and LT during elevation
• Pain decreased
Scapular Retraction Test (SRT)
• P’t posture
• Standing
• PT action
• To hold the scapula retracted by placing the fingers over
the clavicle with the heel over the spine of the scapula
• The other hand compresses the scapula against the chest
wall
• Positive
• If pain decreased during SRT
➢ weak scapular stabilizers must be addressed in the
treatment
• Note
• Holding the scapula in this position can provide a
firm stable base for the rotator cuff muscles
• to improve the rotator cuff strength
Wall Pushup Test
• P’t posture
• stand arms length from a wall
• PT action
• To ask p’t to do a “wall pushup” 15 to 20 times
• Positive
• Any weakness of the scapular muscles or winging shows up with 5 -10 pushups
• Note
• pushup on the floor for younger or stronger people
Acromioclavicular Crossover
(Crossbody, or Horizontal Adduction Test)
• P’t posture
• Stand or sit and reach the hand across to
opposite shoulder
• PT action
• The examiner passively forward flexes the arm
to 90°, and then horizontally ADD the arm as far
as possible
• Positive
• Localized pain over the AC joint
• Note
Abdominal Compression Test
Belly-Press
• P’t posture
• For subscapularis strength
• if the patient cannot medially rotate shoulder behind back
• PT action
• To place a hand on the abdomen to feel how much pressure
the patient applied
• Positive
• Weakness or tear of subscapularis, if unable to maintain the
pressure on the examiner’s hand while
• moving the elbow forward
• posteriorly flexing the wrist
• extending the shoulder
Tightness of biceps
• If the biceps is tight
• full elbow extension does not
occur
• the end feel is a muscular
tissue stretch
Drop-Arm (Codman’s) Test
• P’t posture
• Stand or sitting
• PT action
• To ABD the p’t shoulder to 90°
• Then, ask to slowly lower arm to side in the same
arc of movement
• Positive
• If unable to return the arm to the side slowly or
severe pain
• tear in the rotator cuff complex
Dropping sign
for infraspinatus

• P’t posture
• Stand
• PT action
• To place the p’t’s elbow in 90° flexion 45° lateral rotation
• To ask to isometrically laterally rotate the arm against
resistance and then relax
• Positive
• If unable to maintain the laterally rotated position and
the arm drop back to the neutral position
• IS muscle tear
Hornblower’s sign
for teres minor
• P’t posture
• Standing
• PT action
• To elevate the p’t’s arm to 90° in scaption
• Then, flex the elbow to 90°, and ask p’t to laterally
rotate the shoulder against resistance
• Positive
• When the p’t is unable to laterally rotate the arm
• tear of teres minor
• Modified
• Ask to bring the hands to the mouth
✓ the p’t is unable to do this without ABD
the arm first (hornblower’s sign)
➢ With a massive posterior rotator cuff
tear
Infraspinatus Test
• P’t posture
• stand with the arm at the side with the elbow
at 90° and the humerus medially rotated to 45
• PT action
• To apply a medial rotation force that the
patient resists
• Positive
• Pain or the inability to resist
➢ infraspinatus strain
 Start position

Lift-Off Sign
• P’t posture
• Stand and place the dorsum of the hand on back
pocket
• PT action
• Ask the p’t then lift the hand away from the back
• If p’t is able to take hand away
• To apply a load pushing the hand toward back to test
✓ the strength of subscapularis
✓ the scapula acts under dynamic loading
• Positive Lift-off position
• Inability to do so → a lesion of the subscapularis
muscle
• Abnormal motion in the scapula during the test →
scapular instability
Resistance to lift off
Pectoralis Major/Minor Contracture Test
• P’t posture
1. Supine with clasping the hands together
behind the head
2. Supine lying position with arm forward
flexed 30°
• PT action
1. The arms are then lowered until the
elbows touch the examining table
2. To place the heel of the hand over the
coracoid process and push it toward the
table retracting the scapula
• Positive
1. If the elbows do not reach the table
2. if there is tightness over the pectoralis
minor muscle during the posterior
movement
Serratus Anterior Weakness
(Punch Out Test)
• P’t posture
• Stand and forward flex the arm to 90°
• PT action
• To apply a backward force to the arm
• Positive
• If SA is weak or paralyzed
➢the medial border wings
• Note
• Accomplished by doing a wall or floor pushup
Speed’s Test
Biceps or Straight-Arm Test
• P’t posture
• Stand
• PT action
• To resists shoulder forward flexion by p’t
✓ the p’t’s forearm is first supinated, then pronated,
and elbow is completely extended
• Positive
• Increased tenderness in the bicipital groove
especially with the arm supinated
➢bicipital paratenonitis or tendinosis
Supraspinatus test
Empty Can or Jobe Test
• P’t posture
• Stand with arm abducted to 90° and angled
forward 30° with internal rotation
• PT action
• To apply resistance to ABD (in ADD direction)
• Positive
• Weakness or pain
Thumbs point toward the floor
➢tear of the SS tendon or muscle, or neuropathy of
the suprascapular nerve