a proposed evidence based shoulder special testing examination algorithm: adaptation of a reference...

A Proposed Evidence Based A Proposed Evidence Based Shoulder Special Testing Shoulder Special Testing Examination Algorithm: Examination Algorithm:

Adaptation of a Reference Adaptation of a Reference StandardStandard

Nicklaus Biederwolf, PT,DPT,OCS,CSCSNicklaus Biederwolf, PT,DPT,OCS,CSCS

Regis University Manual Therapy FellowshipRegis University Manual Therapy Fellowship

Phoenix Orthopedic Manual TherapyPhoenix Orthopedic Manual Therapy

September 2, 2010September 2, 2010

Reference Standard: George Reference Standard: George Davies’ Special Testing Davies’ Special Testing

AlgorithmAlgorithm11

• Based on the work of George Davies, PT, DPT, Based on the work of George Davies, PT, DPT, Med, SCS, ATC, LAT, CSCS, FAPTAMed, SCS, ATC, LAT, CSCS, FAPTA

• Professor Emeritus of the University of Wisconsin Professor Emeritus of the University of Wisconsin at La Crosseat La Crosse

• Professor at Armstrong State University in Professor at Armstrong State University in Savannah, GASavannah, GA

• Currently practices at Coastal Therapy in Currently practices at Coastal Therapy in Savannah Georgia and Gundersen Lutheran Savannah Georgia and Gundersen Lutheran Sports Medicine in La Crosse, WISports Medicine in La Crosse, WI



• Testing algorithm is based on Testing algorithm is based on “Critical Pathways”“Critical Pathways”– Pattern recognition based on clusters of Pattern recognition based on clusters of

signs and symptoms, subjective data, signs and symptoms, subjective data, and empirical dataand empirical data

– Implicates a specific group of special Implicates a specific group of special testing for a specific pathologytesting for a specific pathology

– Statistics of notice are shown in Statistics of notice are shown in GREEN GREEN if they are of particularly good utility if they are of particularly good utility and and RED RED if they are of questionable if they are of questionable clinical usage.clinical usage.

Proposed Evidence-Based Proposed Evidence-Based Examination Algorithm for Examination Algorithm for

Chosen TestsChosen Tests• Testing for a specific condition is only indicated Testing for a specific condition is only indicated

based on an individual’s cluster of subjective data, based on an individual’s cluster of subjective data, history, signs, and symptoms.history, signs, and symptoms.

• Pre-Test Probability is estimated at 50% for each Pre-Test Probability is estimated at 50% for each condition based on above findings; post-test condition based on above findings; post-test probability is calculated for chosen tests.probability is calculated for chosen tests.

• Statistics of notice are shown in Statistics of notice are shown in GREEN GREEN if of if of particularly good utility and particularly good utility and RED RED if of questionable if of questionable clinical usage.clinical usage.

• Testing is continued until a treatment threshold (or Testing is continued until a treatment threshold (or referral threshold) of 80% post-test probability is referral threshold) of 80% post-test probability is achieved (unless otherwise stated).achieved (unless otherwise stated).

Likelihood RatiosLikelihood Ratios

• Positive Likelihood Ratio:Positive Likelihood Ratio:– Sensitivity/(1-Specificity)Sensitivity/(1-Specificity)– Shifts Pre-Test Probability in a direction Shifts Pre-Test Probability in a direction

that favors the existence of a disorder.that favors the existence of a disorder.

• Negative Likelihood Ratio:Negative Likelihood Ratio:– (1-Sensitivity)/Specificity(1-Sensitivity)/Specificity– Shifts Pre-Test Probability in a direction Shifts Pre-Test Probability in a direction

that favors the absence of a disorder.that favors the absence of a disorder.

Post-Test ProbabilityPost-Test Probability• Pre-Test Probability=50%Pre-Test Probability=50%

– With use of a nonogram,With use of a nonogram,

+LR or –LR can be used+LR or –LR can be used

to determine Post-Test to determine Post-Test

Probability.Probability.

Likelihood Ratio Likelihood Ratio InterpretationInterpretation

+LR+LR -LR-LR InterpretatioInterpretationn

>10>10 <0.1<0.1 Large Large Probability Probability

ShiftsShifts5-105-10 0.1-0.20.1-0.2 Moderate Moderate

Probability Probability ShiftsShifts

2-52-5 0.2-0.50.2-0.5 Small Small Probability Probability

ShiftsShifts1-21-2 0.5-1.00.5-1.0 Minimally Minimally

Alter Alter ProbabilityProbability



MDI Screening on All Patients

RTC Pathology (Impingement Syndrome, RTC Tears, Internal Impingement)

Labral Pathology and Instability (Anterior Instability, Posterior Instability, SLAP Lesions,

and Bankart Lesions)

Other (AC Joint Lesions, LHB Tendinopathy)

Davies’ Algorithm: MDI Davies’ Algorithm: MDI ScreeningScreening11

• Critical Pathway: Performed on all patients Critical Pathway: Performed on all patients to assess GH stability.to assess GH stability.

TestTest Applicable Finding(s)Applicable Finding(s) SpSp SnSn +LR+LR -LR-LR

Sulcus Sign at 0Sulcus Sign at 0° ° 22 Identification of sulcusIdentification of sulcus .89.89 .31.31 2.82.8 .78.78

Sulcus Sign at 90Sulcus Sign at 90° ° ABDABD

Identification of sulcusIdentification of sulcus NRNR NRNR NRNR NRNR

Anterior Load and Anterior Load and ShiftShift33

Grade of Laxity (Trace, I, II, III)Grade of Laxity (Trace, I, II, III) .78.78 .54.54 2.52.5 .59.59

Posterior Load and Posterior Load and ShiftShift33

Grade of Laxity (Trace, I, II, III)Grade of Laxity (Trace, I, II, III) 1.01.000

0.00.000

1.71.7 .99.99

Proposed Screening TestProposed Screening Test

• Testing Indication: Perform on all patients (if able) Testing Indication: Perform on all patients (if able) to rule in or rule out both intra-articular pathology to rule in or rule out both intra-articular pathology and RTC pathology.and RTC pathology.


Test of Zaslav (IR Test of Zaslav (IR Resisted Strength Resisted Strength Test)Test)44

In 90In 90° ABD ° ABD and 80and 80° ER, if IR ° ER, if IR MMT<< ER MMT test is positive MMT<< ER MMT test is positive for intra-articular pathology. If IR for intra-articular pathology. If IR MMT>>ER MMT test is positive MMT>>ER MMT test is positive for RTC involvement.for RTC involvement.

.96.96 .86.86 22.022.0 .13.13

Post-Test probability for ruling in and ruling out both intra-articular pathology and RTC pathology are both respectively

91.6% and 6.1%.

Test of ZaslavTest of Zaslav44

Test of ZaslavTest of Zaslav44

• Operational definition of RTC pathology:Operational definition of RTC pathology: Findings that included a thickened or inflamed Findings that included a thickened or inflamed subacromial bursa, erosions on the CA ligament subacromial bursa, erosions on the CA ligament and undersurface of the acromion, and bursal and undersurface of the acromion, and bursal side partial or full thickness RTC tears.side partial or full thickness RTC tears.44

• Operational definition of Intra-Articular Operational definition of Intra-Articular pathology:pathology: Findings that included anterior Findings that included anterior glenoid erosion or labral tears, middle GH glenoid erosion or labral tears, middle GH ligament tearing, articular-sided RTC partial ligament tearing, articular-sided RTC partial tears, posterior labral lesions, and SLAP tears, posterior labral lesions, and SLAP lesions.lesions.44

Proposed Evidence-Based Proposed Evidence-Based Examination Algorithm for Chosen Examination Algorithm for Chosen

TestsTests

Screening:Test of

Zaslav (IRRST)

If IR>>ER MMT:RTC Pathology

(Impingement syndrome, RTCtendinopathy, RTC tears)

Other:AC Joint Lesions,LHBTendinopathy.

If ER>>IR MMT:Intra-Articular

Pathology(Anterior or posterior instability, SLAP Lesions, Bankart Lesions,

Posteroinferior Labral Lesions, RTCarticular internal impingement)

Davies’ Algorithm: SLAP Davies’ Algorithm: SLAP LesionsLesions11

• Critical Pathway: Macrotraumatic injury, history of eccentric Critical Pathway: Macrotraumatic injury, history of eccentric deceleration activities, pain complaint is “deep” or “in” the deceleration activities, pain complaint is “deep” or “in” the shoulder, sensations of locking, clicking, or clunking.shoulder, sensations of locking, clicking, or clunking.


Compression Compression RotationRotation55

Pain or click elicitedPain or click elicited .76.76 .24.24 1.01.0 1.01.0

Anterior Slide TestAnterior Slide Test66 Pain or click elicitedPain or click elicited .92.92 .78.78 9.759.75 .24.24

Posterior Slide TestPosterior Slide Test Pain or click elicitedPain or click elicited NRNR NRNR NRNR NRNR

Speed’s TestSpeed’s Test7,87,8 Pain deep in the shoulderPain deep in the shoulder .75-.75-.87.87

.09-.09-

.32.321.281.28--1.291.29

.91-.91-

.98.98

O’Brien’s TestO’Brien’s Test8,5,7,9,108,5,7,9,10 Pain or click elicited (part I), then Pain or click elicited (part I), then reduced (part II)reduced (part II)

.31-.31-

.98.98.54-.54-1.01.0

.78-.78-5050

0.0-0.0-1.41.488

Proposed SLAP Lesion TestsProposed SLAP Lesion Tests• Testing Indication: Intra-articular pathology per Testing Indication: Intra-articular pathology per

Zaslav’s test (if able) and Davies’ critical pathway Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms.cluster of signs and symptoms.


Biceps Load Test IBiceps Load Test I1111 Apprehension in ER or pain with Apprehension in ER or pain with resisted bicep contractionresisted bicep contraction

.97.97 .90.90 3030 .10.10

Biceps Load Test IIBiceps Load Test II1212 Pain with resisted bicep Pain with resisted bicep contractioncontraction

.97.97 .90.90 3030 .10.10

Pain Provocation Pain Provocation Test of MimoriTest of Mimori1313

Positive if pain is more severe in Positive if pain is more severe in pronated positionpronated position

.90.90 1.01.0 10.010.0 0.00.0

Post-Test probabilities are respectively 93.75%, 93.75%, 83.3% for positive tests, and 4.8%, 4.8%, and

0.0% for negative tests.

SLAP Lesion TestingSLAP Lesion Testing

Biceps Load Test II1212

Pain Provocation Test of Mimori1313

Davies’ Algorithm: LHB Davies’ Algorithm: LHB TendinopathyTendinopathy11

• Critical Pathway: History of eccentric deceleration Critical Pathway: History of eccentric deceleration activities, LHB is TTP, complaints of pain are in the activities, LHB is TTP, complaints of pain are in the anterior shoulder.anterior shoulder.


Yergason’s TestYergason’s Test1414 Pain is produced in the bicipital Pain is produced in the bicipital groovegroove

.86.86 .37.37 2.642.64 .73.73

Speed’s TestSpeed’s Test1414 Pain is elicitedPain is elicited .56.56 .69.69 1.571.57 .55.55

*These currently appear to be the best statistical utility tests we have for identification of LHB tendinopathy.

Post-Test probability with a + Yergason’s test is 56.8% (rule in) and with a – Speed’s test is 21.6% (rule out). Treatment threshold exception for lack of evidence is proposed to be both + tests.

Davies’ Algorithm: AC Joint Davies’ Algorithm: AC Joint LesionsLesions11

• Critical Pathway: Age >40, macrotrauma to superior Critical Pathway: Age >40, macrotrauma to superior shoulder in CKC position, pain complaint is “on top” of the shoulder in CKC position, pain complaint is “on top” of the shoulder, AC joint is TTP, pain with horizontal adduction.shoulder, AC joint is TTP, pain with horizontal adduction.


AC Shear TestAC Shear Test Pain localized to AC jointPain localized to AC joint NRNR NRNR NRNR NRNR

O’Brien’s TestO’Brien’s Test9,159,15 Pain localized to AC jointPain localized to AC joint .90-.90-.97.97

.16-.16-1.01.0

1.6-1.6-33.333.3

0.0-0.0-.93.93

Cross-Body Cross-Body Adduction TestAdduction Test1515

Pain localized to AC jointPain localized to AC joint .79.79 .77.77 3.673.67 .29.29

Proposed AC Joint Lesion Proposed AC Joint Lesion TestsTests

• Testing Indicated: Per Davies’ critical pathway.Testing Indicated: Per Davies’ critical pathway.


Cross-Body Cross-Body Adduction TestAdduction Test1515


AC Resisted AC Resisted Extension TestExtension Test1515


O’Brien’s TestO’Brien’s Test99 Pain localized to AC jointPain localized to AC joint .90-.90-.97.97

.16-.16-1.01.0

1.6-1.6-33.333.3

0.0-0.0-.93.93

Test ClusterTest Cluster1515 Above three tests are positiveAbove three tests are positive .97.97 .25.25 8.38.3 .77.77

Post-Test probability when all three tests are positive is 80.5%.

Davies’ Algorithm: Davies’ Algorithm: Impingement SyndromeImpingement Syndrome11

• Critical Pathway: Age >40, history of overhead activities, recent Critical Pathway: Age >40, history of overhead activities, recent unaccustomed overuse of arm, painful arc of abduction, pain with overhead unaccustomed overuse of arm, painful arc of abduction, pain with overhead activities, pain complaints in lateral shoulder, pain at night, compensatory activities, pain complaints in lateral shoulder, pain at night, compensatory shoulder shrug sign.shoulder shrug sign.


Neer TestNeer Test14,16,1714,16,17 Positive if pain reproducedPositive if pain reproduced .31-.31-.48.48

.75-.75-

.89.891.291.29--1.441.44

.35-.35-

.52.52

Hawkins-Kennedy Hawkins-Kennedy TestTest14,16,1714,16,17

Positive if pain reproducedPositive if pain reproduced .25-.25-.44.44

.87-.87-

.92.921.231.23--1.641.64

.18-.18-

.32.32

Coracoid Coracoid Impingement TestImpingement Test

Positive if pain reproducedPositive if pain reproduced NRNR NRNR NRNR NRNR

Horizontal Adduction Horizontal Adduction TestTest1717

Positive if pain reproducedPositive if pain reproduced .28.28 .82.82 1.141.14 .64.64

Proposed Impingement Proposed Impingement Syndrome TestsSyndrome Tests

• Testing Indication: RTC pathology per Zaslav’s test (if able) Testing Indication: RTC pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms.and Davies’ critical pathway cluster of signs and symptoms.


Hawkins-Kennedy Hawkins-Kennedy TestTest14,16,1714,16,17

Positive if pain reproducedPositive if pain reproduced .25-.25-.44.44

.87-.87-

.92.921.231.23--1.641.64

.18-.18-

.32.32

Infraspinatus MMT18 Positive if weak and/or painfulPositive if weak and/or painful .81.81 .74.74 3.893.89 .32.32

Painful Arc Sign18 Positive if painful arc reproducedPositive if painful arc reproduced .81.81 .74.74 3.893.89 .32.32

Test of ZaslavTest of Zaslav44 In 90In 90° ABD ° ABD and 80and 80° ER, if IR ° ER, if IR MMT< ER test is positive for MMT< ER test is positive for intra-articular pathology. If IR intra-articular pathology. If IR MMT>ER MMT test is positive for MMT>ER MMT test is positive for RTC involvement.RTC involvement.

.96.96 .86.86 22.022.0 .13.13

Post-Test probability for the TIC of the first three tests is 95.5% if all 3 are positive, and 91.0% if 2 of 3 are positive (based on reported TIC of 10.56 for 3

+ tests and 5.03 for 2 + tests)18. Post-Test probability for a positive and negative Test of Zaslav are 91.6% and 6.1% to rule in and rule out

impingement, respectively.

Davies’ Algorithm: RTC Davies’ Algorithm: RTC TearsTears11

• Critical Pathway: Age >40, macrotraumatic injury with major functional Critical Pathway: Age >40, macrotraumatic injury with major functional disabilities, idiopathic onset of major functional disabilities, painful arc of disabilities, idiopathic onset of major functional disabilities, painful arc of abduction, dull constant ache in shoulder, pain complaints in lateral abduction, dull constant ache in shoulder, pain complaints in lateral shoulder, pain at night, compensatory shoulder shrug sign.shoulder, pain at night, compensatory shoulder shrug sign.


External Rotation External Rotation Lag Sign for Lag Sign for SupraspinatusSupraspinatus1717

Inability to hold shoulder in ERInability to hold shoulder in ER 1.01.000

.70.70 NANA .30.30

External Rotation External Rotation Lag Sign @ 90/90 Lag Sign @ 90/90 (Drop Sign) for (Drop Sign) for Supraspinatus and Supraspinatus and InfraspinatusInfraspinatus1717

Inability to arm in placeInability to arm in place 1.01.000

.36.36 NANA .64.64

Internal Rotation Lag Internal Rotation Lag Sign for Sign for SubscapularisSubscapularis1717

Inability to actively IR shoulderInability to actively IR shoulder .96.96 .97.97 24.324.3 .03.03

Proposed Tests for RTC Proposed Tests for RTC TearsTears

• Testing Indication: RTC pathology per Zaslav’s test (if Testing Indication: RTC pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and able) and Davies’ critical pathway cluster of signs and symptoms.symptoms.


External Rotation External Rotation Lag Sign for Lag Sign for SupraspinatusSupraspinatus1717

Inability to hold shoulder in ERInability to hold shoulder in ER 1.01.000

.70.70 NANA .30.30

Dropping Sign @ 90Dropping Sign @ 90° ° ABD and 45° ER for ABD and 45° ER for InfraspinatusInfraspinatus1919

Inability to arm in placeInability to arm in place 1.01.000

1.01.000

NANA 0.00.0

Hornblower’s Sign Hornblower’s Sign for Teres Minorfor Teres Minor1919

Inability to externally rotate to Inability to externally rotate to “Hornblower” position“Hornblower” position

.93.93 1.01.000

14.214.299

0.00.0

Internal Rotation Lag Internal Rotation Lag Sign for Sign for SubscapularisSubscapularis1717

Inability to actively IR shoulderInability to actively IR shoulder .96.96 .97.97 24.324.3 .03.03

Post-Test probabilities are respectively (+)~100% and (-)13.0%, (+)~100% and (-)~0.0%, (+)87.7% and (-)~0.0%, (+)92.4% and (-)1.48%.

Davies’ Algorithm: Anterior Davies’ Algorithm: Anterior InstabilityInstability11

• Critical Pathway: Macrotrauma (especially in ABD and ER), repetitive Critical Pathway: Macrotrauma (especially in ABD and ER), repetitive microtrauma (overhead activities), history of recurrent microtrauma (overhead activities), history of recurrent subluxations/dislocations, complaints of “dead arm” syndrome, subluxations/dislocations, complaints of “dead arm” syndrome, sensations of weakness.sensations of weakness.


Apprehension TestApprehension Test2020 Apprehension to test positionApprehension to test position .99.99 .53.53 5353 .47.47

Anterior Relocation Anterior Relocation TestTest2121

Anterior pain is positive for Anterior pain is positive for anterior microinstabilityanterior microinstability

.44.44 .54.54 .96.96 1.01.055

Proposed Anterior Instability Proposed Anterior Instability TestsTests

• Testing Indication: Intra-articular pathology per Testing Indication: Intra-articular pathology per Zaslav’s test (if able) and Davies’ critical pathway Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms.cluster of signs and symptoms.


Apprehension TestApprehension Test2020 Apprehension to test positionApprehension to test position .99.99 .53.53 5353 .47.47

Anterior Release Test Anterior Release Test (also known as (also known as Surprise Test) Surprise Test) 21,2221,22

Pain or apprehension when Pain or apprehension when posterior relocation is removedposterior relocation is removed

.89-.89-

.99.99.64-.64-.92.92

8.368.36--64.064.0

.09-.09-

.36.36

Post-Test probabilities are respectively 96.4% and, at worst, 80.7%.

Davies’ Algorithm: Internal Davies’ Algorithm: Internal Impingement SyndromeImpingement Syndrome11

• Critical Pathway: Specific pain inferior to the postero-lateral Critical Pathway: Specific pain inferior to the postero-lateral acromion, pain in the cocking phase of the throwing motion.acromion, pain in the cocking phase of the throwing motion.


Anterior Relocation Anterior Relocation TestTest

Posterior pain is positive for Posterior pain is positive for internal impingement internal impingement syndrome.syndrome.11

NRNR NRNR NRNR NRNR

*This is the only known suggested test for internal impingement syndrome. It is hypothesized, however, that positive impingement testing and a positive Test of Zaslav for an intra-articular lesion may suggest internal impingement syndrome.

Treatment Threshold exception for lack of evidence: All above subjective and objective findings.

Davies’ Algorithm: Posterior Davies’ Algorithm: Posterior InstabilityInstability11

• Critical Pathway: Macrotrauma, blunt force to anterior Critical Pathway: Macrotrauma, blunt force to anterior shoulder, volitional subluxator.shoulder, volitional subluxator.


Jerk TestJerk Test2323 Sharp pain and/or click/clunkSharp pain and/or click/clunk .98.98 .73.73 36.536.5 .28.28

Posterior Glide TestPosterior Glide Test Subluxation/Dislocation over Subluxation/Dislocation over glenoid rimglenoid rim

NRNR NRNR NRNR NRNR

Posterior Glide Test IIPosterior Glide Test II Subluxation/Dislocation over Subluxation/Dislocation over glenoid rimglenoid rim

NRNR NRNR NRNR NRNR

Proposed Tests for Proposed Tests for Posteroinferior Laxity and Posteroinferior Laxity and

Labral LesionsLabral Lesions• Testing Indication: Intra-articular pathology per Testing Indication: Intra-articular pathology per

Zaslav’s test (if able) and Davies’ critical pathway Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms.cluster of signs and symptoms.


Jerk TestJerk Test2323 Sharp pain and/or click/clunkSharp pain and/or click/clunk .98.98 .73.73 36.536.5 .28.28

Kim TestKim Test2323 Sharp pain and/or click/clunkSharp pain and/or click/clunk .94.94 .80.80 13.313.3 .21.21

Post-Test probability for the Jerk and Kim tests are respectively 94.8% and 86.9%.

The Kim TestThe Kim Test2323

A) With the patient in a sitting position with the arm in 90° of abduction, the examiner holds the elbow and lateral aspect of the proximal arm, and a strong axial loading force is applied. B) While the arm is elevated another 45° diagonally upward, downward and backward force is applied to the proximal arm. A sudden onset of posterior shoulderpain indicates a positive test result, regardless of accompanying posterior clunk of the humeral head. During the test, it is important to apply a firm axial compression force to the glenoid surface by the humeral head.

Davies’ Algorithm: Bankart Davies’ Algorithm: Bankart LesionsLesions11

• Critical Pathway: Macrotrauma, anterior/inferior subluxation or Critical Pathway: Macrotrauma, anterior/inferior subluxation or dislocation, history of recurrent subluxations/dislocations, “deep” dislocation, history of recurrent subluxations/dislocations, “deep” pain in the shoulder, complaints of clicking/clunking or locking.pain in the shoulder, complaints of clicking/clunking or locking.


Clunk Test Clunk Test (Anterior/inferior GH (Anterior/inferior GH scouring in maximal scouring in maximal scaption)scaption)

Pain, clicking, or clunking elicitedPain, clicking, or clunking elicited NRNR NRNR NRNR NRNR

Clunk Test II Clunk Test II (Anterior (Anterior relocation in multiple relocation in multiple anterior/inferior anterior/inferior positions)positions)


Crank TestCrank Test5,7,10,13,245,7,10,13,24 Pain is elicitedPain is elicited .56-.56-1.01.000

.40-.40-

.91.911.0-1.0-1313

.10-.10-

.96.96

Proposed Tests for Bankart Proposed Tests for Bankart LesionsLesions

• Testing Indication: Intra-articular pathology per Testing Indication: Intra-articular pathology per Zaslav’s test (if able) and Davies’ critical pathway Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms.cluster of signs and symptoms.


Clunk Test Clunk Test (Anterior/inferior GH (Anterior/inferior GH scouring in maximal scouring in maximal scaption)*scaption)*


Crank TestCrank Test5,7,10,13,245,7,10,13,24 Pain or clicking is elicitedPain or clicking is elicited .56-.56-1.01.000

.40-.40-

.91.911.0-1.0-1313

.10-.10-

.96.96

*Though no studies have been performed on the Clunk Test, I believe it has a high enough level of construct validity to be considered for use in examination.

Post-Test probability of the Crank test is 86.7% at best and 33.3% at worst. Proposed treatment threshold are + findings in both tests, and a click/clunk in

either.

Proposed Evidence-Based Proposed Evidence-Based Shoulder Special Testing Shoulder Special Testing Examination AlgorithmExamination Algorithm

RTC PathologyRTC Pathology•Test of Zaslav (IR MMT >> ER Test of Zaslav (IR MMT >> ER MMTMMT))

RTC ImpingementRTC Impingement•Hawkins-Kennedy TestHawkins-Kennedy Test

•Infraspinatus MMTInfraspinatus MMT

•Painful Arc SignPainful Arc Sign

RTC TearsRTC Tears•ER Lag SignER Lag Sign

•Dropping SignDropping Sign

•Hornblower’s SignHornblower’s Sign

•IR Lag SignIR Lag Sign

Intra-Articular PathologyIntra-Articular Pathology•Test of Zaslav (ER MMT >> IR MMT)Test of Zaslav (ER MMT >> IR MMT)

SLAP LesionsSLAP Lesions•Biceps Load Test IBiceps Load Test I

•Biceps Load Test IIBiceps Load Test II

•Pain Provocation Test of MimoriPain Provocation Test of Mimori

Bankart LesionsBankart Lesions•Clunk TestClunk Test

•Crank TestCrank Test

Posteroinferior Posteroinferior Capsulolabral Laxity and Capsulolabral Laxity and Labral LesionsLabral Lesions•Kim TestKim Test

•Jerk TestJerk Test

Anterior InstabilityAnterior Instability•Apprehension TestApprehension Test

•Anterior Release TestAnterior Release Test

MiscellaneousMiscellaneous•Test of Zaslav inconclusiveTest of Zaslav inconclusive

AC Joint LesionAC Joint Lesion•Cross-Body AdductionCross-Body Adduction

•AC Resisted ExtensionAC Resisted Extension

•O’Brien’s TestO’Brien’s Test

LHB TendinopathyLHB Tendinopathy•Yergason’s TestYergason’s Test

•Speed’s TestSpeed’s Test

RTC Internal RTC Internal ImpingementImpingement•Anterior Relocation TestAnterior Relocation Test

Questions?Questions?

• Email: [email protected]: [email protected]

REFERENCESREFERENCES

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a proposed evidence based shoulder special testing examination algorithm: adaptation of a reference...

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