CURRENT CONCEPTS IN SHOULDER EXAMINATION OF THE OVERHEAD ATHLETE

Abstract

Examination of the shoulder complex has long been described as challenging. This is particularly true in the examination of the overhead athlete who has structural differences when compared to a shoulder patient who is a non‐athlete. Complexity with the examination is due to unique biomechanical and structural changes, multiple joint articulations, multiple pain patterns, and the potential of injury to structures both inside (intra‐articular) and outside (extra‐articular) the glenohumeral joint. Repetitive stresses placed on the shoulders of overhead athletes may affect range of motion, strength, scapular position, and ultimately, the integrity of soft tissue and bony structures in any of the joints that comprise the shoulder complex. Furthermore, many shoulder examination tests thought to be unique to a single structure, joint, or condition can be positive in multiple conditions. The examination of the overhead athletes shoulder, coupled with a thorough medical history will provide a solid foundation to allow a functional physical therapy diagnosis and provide clues as to the presence of the lesion (s) causing disability. The purpose of this clinical commentary is to assist the reader to understand the unique physical characteristics of the overhead athlete, which will lead to a more accurate and reproducible evaluation of athletes who sustain injuries while participating in overhead sports.

Level of Evidence:

5

INTRODUCTION

The overhead and throwing/serving athlete is a very unique sports patient. In overhead athletes, the kinetic energy and force created in the lower extremities, pelvis and trunk is funneled through the shoulder complex including the glenohumeral, scapulothoracic, acromioclavicular, and sternoclavicular joints ultimately resulting in maximal distal upper extremity segmental velocity needed for optimal overhead performance. The arm, elbow, wrist, and hand then add to that force and provide the fine tuning required in order to direct (or target) the created energy into a specific action such as placing a pitch or serve.¹ Stresses placed upon the shoulder complex of the overhead athlete push the anatomical limits of the shoulders physiological capacity. During the throwing motion, angular velocity of the shoulder reaches over 7000 degrees per second.^2,3

The shoulder complex of the overhead athlete has the reputation of being difficult to examine due to several reasons. First, the complexity of the joints, and multiple articulations make it difficult to examine. Second, the multi‐layer envelope of soft tissue structures makes palpation of individual underlying structures challenging. Third, many of the commonly utilized examination special tests have been proven to be less accurate than previously believed.⁴ Finally, the over‐reliance of medical professionals on imaging techniques has allowed the physical examination of the shoulder to become a lost art. The over‐reliance of imaging is concerning since it is known that up to 34% of painless shoulders will demonstrate a rotator cuff (RC) tear on magnetic resonance imaging (MRI).⁵ In asymptomatic professional baseball pitchers abnormalities of the glenoid labrum are seen in 79% of throwers.⁶ Partial thickness RC tears are missed by MRI in the throwing or overhead athlete up to 44% of the time.⁷ In overhead athletes 40% of dominant shoulders have findings consistent with partial or full‐thickness RC tears, 25% of these findings consistent with Bennett’s lesion, none of which were symptomatic during testing or for 5 years later.⁸

Multiple factors related to the shoulders of overhead athletes may or may not cause symptoms. Several of these factors may include but not be limited to inflamed soft tissues, hypomobile or hypermobile joints, rotator cuff or scapular strength and endurance deficits, postural dysfunctions, and improper training. Additionally when and athlete has a painful shoulder, this pain can be caused by numerous conditions. Anterior shoulder pain can be caused by pathology such as tendinosis, partial thickness RC tears, full thickness RC tears, calcific tendonitis, and biceps tendon disorders, instability, superior labrum injuries, and coracoid impingement. To complicate matters even further, some of these problems occur from relatively uncommon pathologies rarely seen by the average clinician. These could include venous occlusions, arterial lesions, nerve lesions (such as of the long thoracic nerve or brachial plexus), or thoracic outlet syndrome. Finally, note that it is not uncommon for the physical stresses endured by the overhead athlete to cause stress fractures of the humerus or scapula.^9,10

History

As with any general musculoskeletal examination, the most important information used during the evaluation is obtained during the medical history. Skilled medical clinicians understand that in most cases diagnosis of any musculoskeletal problem can be made accurately through effective questioning and listening to the athlete. A thorough history of the athlete’s complaints includes the athlete’s age, the symptom onset, descriptions of pain and pain location, and referral symptoms. Some of the following are excellent questions to ask during the initial history portion of the examination of the overhead athlete (Table 1).

Table 1.

History Questions for the Overhead Athlete Examination.

Was pain onset traumatic or insidious? Is there a history of overuse? Where during activity does athlete have pain? (What phase of the throwing or serving motion?) Does the shoulder feel unstable? Does the athlete notice any popping, snapping, catching or clicking? Are the above symptoms associated with pain or just noise without pain? Does the athlete have any color changes in the extremity, does it swell, or do they lose sensation? Has the athlete noticed a loss of throwing velocity or racquet speed? Has there been any change in form or technique or changes in training frequency, duration or intensity?

Although most athletic patients are otherwise healthy, it is prudent to perform a quick review of general health and other joint involvement as systemic or referral sources of pain can easily create confusion when examining a variety of shoulder conditions. This would be pertinent in cases such as pitchers with neck and or medial elbow symptoms in addition to their shoulder pain. The clinician should ensure that the cervical spine or elbow is not contributing to the overall shoulder problem. Furthermore it must be ascertained in the case described above that the shoulder and elbow symptoms are not being caused by an undiagnosed cervical spine problem masked as extremity pain. For example, overpressure of the cervical spine in the motions of flexion and extension and lateral flexion and rotation, as well as the quadrant or Spurling tests, are commonly used to clear the cervical spine and rule out radicular symptoms.¹¹ Tong et al tested the Spurling maneuver to determine it’s diagnostic accuracy.¹¹ The Spurling test had a sensitivity of 30% and specificity of 93%. Caution therefore must be used when basing the clinical diagnosis solely on this examination maneuver. The test is not sensitive but is specific for cervical radiculopathy and therefore can be used to help confirm a cervical radiculopathy. This test is an excellent overall screening test that is applicable during examination of the overhead athlete.

Determining the reactivity of shoulder injury is commonly done through several mechanisms. The use of a pain diagram or analog pain scale will help determine the patient’s perception of amount of pain in shoulder. Trying to determine the reactivity or irritability of a shoulder and surrounding structures helps guide how the remainder of the examination should be organized. In an athlete with a highly reactive shoulder there is probably considerable pain, probable limitations of motion and strength. In an athlete with a mildly reactive shoulder the pain may be minimal or only present with overhead activity. Their symptoms may be minimal to absent when they are not doing overhead activities, but significantly limited when throwing or serving.

The symptoms experienced by overhead athletes are generally of insidious onset, and as such they may be subtle and initially may not alter an athlete’s performance. Symptoms can be vague and described as inability to “loosen up” or “warm‐up”, or they may complain that they cannot find their normal velocity or they have trouble with control. As they symptoms progress the athlete may have pain with throwing or may even be severe enough that they are now unable to throw.

For baseball and tennis athletes it is not simply enough to ask if there are symptoms during throwing or serving. The sports therapist must be more detailed and identify where within the throwing or serving motion does the symptom occur? Is it in the cocking stages, the follow‐through or somewhere in between? Additionally, asking whether any equipment changes have been made such as changes in string type or tension, racquet style/weight or grip changes can have enormous consequences on the musculoskeletal system in the tennis player.

Observation and Posture

The actual clinical examination begins by assessing and observing the shoulder and arm and viewing posture. A relaxed standing position is a good place to determine the posture of the head on the thorax. Forward head posture places significant strain on cervical spine and upper thoracic musculature. The authors typically subjectively grade the amount of forward head as normal, minimal, moderate or severe pending the distance of the external auditory meatus from the lateral tip of the acromion. Slight forward head position is not uncommon in overhead athletes. The clinician should then note any abnormalities seen in or around the shoulder initially with the athlete’s arms at rest by their sides. Abnormalities could include bruising or discolorations, unusual bumps, protrusions, or decreased contour of muscle that could be caused by swelling, thickening, or muscle atrophy. In most cases the dominant extremity is positioned slightly lower than the non ‐dominant side, and is associated with and known as handedness.¹² This is especially true of unilaterally dominant sports such as baseball and tennis. Theories for handedness include increased laxity, increased muscle mass, increased weight, and elongated soft tissue due to repetitive eccentric loading during sporting activities. Further examination can be done in the hands‐on‐hips position (Figure 1) in which shoulders are abducted about 45 degrees. Hands are also placed on the hips so that the thumbs point posteriorly on the iliac crest creating shoulder internal rotation. In this position it is easy for the clinician to note asymmetries of rotator cuff or posterior scapular muscles, or abnormal postures such as scapular internal rotation (winging) or anterior tilting (tipping). Muscular atrophy in areas such as infraspinatus or supraspinatus fossa could indicate rotator cuff tears or suprascapular nerve involvement. This can occur in the face of minimal symptoms or discomfort.

Figure 1.

Posterior view of an elite junior tennis player in the hands on hips position showing significantly lower dominant (right) shoulder, infraspinatus atrophy, and prominence of the inferior scapular border.

Evaluation of the scapulthoracic joint must be performed as an integral component of any complete shoulder complex examination. Although it is beyond the scope of this commentary a clear understanding of scapulohumeral mechanics is extremely useful. Coupled scapular motions include both rotations and translational movements. Rotations include upward and downward rotation, internal and external rotations, and anterior and posterior tilting. Translational coupled motions include superior and inferior translations and protraction and retraction translations. During any overhead shoulder motion in the healthy person the scapula must upwardly rotate, tilt posteriorly, and externally rotate.¹³

When muscle performance is impaired by loss of motor control, strength, or endurance, scapular dyskinesis will be produced with overhead shoulder motions. To better examine the dyskinesis, the athlete can be asked to repetitively lift the extremities overhead or an axial load can be applied. Special tests for scapular dysfunction will be described in the special testing portion of this commentary.

Range of Motion

One of the unique abilities of being a rehabilitation clinician is our clear understanding of assessment of shoulder range of motion. One cannot discount the crucial information that is gained from a detailed, isolated assessment of glenohumeral motion in evaluation of the athlete with shoulder complex dysfunction. Although historically some have described visual observation of motion during the clinical examination the authors of this commentary recommend use of a universal goniometer of some fashion. The overhead athlete has several distinguishing characteristics related to glenohumeral motion. Most overhead athletes exhibit an excessive amount of external rotation (ER) and a decrease in internal rotation (IR) when measured from 90° of abduction.^14,15 This physiological adaptation to the throwing shoulder occurs in those that play baseball, softball, and tennis.^16–21 Furthermore this increase in shoulder ER and decrease in shoulder IR is seen in both active and passive motions.^17,22,23

An important concept to note regarding the measurement of glenohumeral motion is scapular stabilization to ensure isolated glenohumeral motion. Wilk et al has assessed three methods of glenohumeral internal rotation measurement (no stabilization, humeral head stabilization and scapular stabilization).²⁴ The most reliable method of stabilization was use of a “C” shape grasp with thumb placed on the coracoid process anteriorly and the fingers on the posterior scapula. The athlete is supine on a table with the shoulder in 90 degrees of abduction. The arm is moved into IR and ER while the second hand is palpating the coracoid process for scapular motion (Figure 2). When scapular motion is initially detected the arm is held in place and the measurement is taken with a handheld goniometer. For completeness shoulder rotation should also be measured with the arm at 0 degrees of abduction at the side (Figure 3). Measurements taken using goniometers consistently show good intra‐observer reliability and modest inter‐observer reliability with most measurements demonstrating accuracy only up to 5 degrees.^25–26 McFarland suggests that clinically relevant differences in shoulder range of motion measurements for activities of daily living may be as high as 15 degrees.⁴

Figure 2.

Measurement of isolated glenohumeral A) internal rotation with palpation of coracoid process for indication of scapular motion and B) external rotation with palpation scapula for indication of motion.

Figure 3.

Measurement of shoulder external rotation with arm at 0 degrees.

In a study of 372 professional baseball players, passive range of motion measurements averaged 129 degrees of ER and 61 degrees of IR.²⁷ In this cohort, coincidently, the loss of IR was 7 degrees, while the gain in ER was 7 degrees in the dominant shoulder when compared to the non dominant. In simplistic terms, the amount of total range of motion (TROM) (glenohumeral internal rotation + glenohumeral external rotation) was symmetrical. It must be remembered that this full 180 degrees of shoulder total rotation is a combination of movements occurring throughout the kinematic chain, including contributions by the glenohumeral joint, scapulothoracic articulation, and spinal extension motion.

A concept that seems to be creating a lot of controversy in overhead athlete’s rehabilitation is the concept of glenohumeral internal rotation deficit (GIRD). GIRD has been described by multiple sources as one of the following: 1) A loss of either 20 or 25 degrees or more of IR on the dominant arm compared to the contralateral non dominant side, 2) A dominant shoulder loss of 10% of the TROM of the contralateral side.^28,29 More recently Kibler et al have defined GIRD as 3) side‐to‐side asymmetry of internal rotation loss greater than 18 degrees.³⁰

Decisions to determine whether glenohumeral hypomobility exists should not use GIRD in isolation. TROM may be an even more important measurement to consider. Wilk et al found that pitchers whose TROM arc was limited 5 degrees or more than the uninvolved side exhibited 2.5 times greater risk of sustaining a shoulder injury.¹⁹ When TROM is equal bilaterally, treatments designed to increase motion are not recommended as these may actually create too much mobility which would increase stress to surrounding soft tissues and capsular restraints. Therefore a loss of GIRD by itself may be considered a normal shoulder variant in the overhead athlete. Manske et al³¹ has proposed adopting two forms of GIRD, one which is a normal loss of IR with a concomitant equal or near equal gain in ER and symmetrical TROM, and another which would be considered pathologic in which a concomitant increased ER has not occurred or there is a significant loss of TROM on the involved side. Anatomical GIRD (aGIRD) is a normal loss of IR alone with adequate ER gain and TROM within 5 degrees of the uninvolved sides. Pathologic GIRD (pGIRD) occurs when the shoulder has GIRD and a concomitant loss of TROM > 5 degrees, or an increase in external rotation deficiency.

Wilk et al³² recently have introduced a concept referred to as external rotation deficiency (ERD). External rotation deficiency is defined as the difference between ER of the throwing shoulder and the non‐throwing shoulder of less than 5 degrees. When evaluating a throwers shoulder one would expect to see an ER difference of greater than 5 degrees which would indicate that the gain in ER on the throwing side is enough to tolerate the stress of throwing.

Other important shoulder motions measurements used to exam an overhead athlete include shoulder elevation (forward flexion and abduction), and both horizontal abduction and adduction. Each of these motions should be easily achieveable both actively and passively to allow enough mobility to achieve the extremes of physiologic motions required for pitching, serving, etc.

Strength Assessment

When performing a comprehensive examination of the athletes shoulder a clinically relevant method of strength assessment must be used. With over 100 years of utilization, manual muscle testing (MMT) is the method of choice for most practicing clinicians. Complete coverage of all manual muscle tests used in the upper extremity is beyond the scope of this article. However there are several excellent texts that describe in detail MMT of the entire body.^33,34 Although the importance of examining the entire kinetic chain is recognized, this commentary will focus upon the importance of the axioscapular, scapulohumeral, and scapulothoracic muscle groups.

It is important to consider the relationship of both pain and posture on results of the performance of MMTs. It is very common for pain or apprehension to invalidate an athlete’s true strength measurements due to a reflexive inhibition of motor units in an inflamed or irritated muscle. Likewise poor posture can place rotator cuff and scapular muscles into a state of lengthened or shortened positions creating alterations of normal length tension relationships that theoretically could alter the ability to produce force during standard MMT procedures. Kibler et al³⁵ have shown significant differences in rotator cuff strength when measured in either protracted or retracted postures of the scapula. Standardizing scapular positioning during testing is an important consideration to ensure accuracy with MMT in the overhead athlete.³⁵ This is an area of controversy as Smith et al and Smith et al, have found that MMT around the shoulder produce the most force with the scapula in a neutral position rather than in either retracted or protracted positions.^36,37

A “break test” in which the examiner applies the force to the limb or a “make” test in which the examiner allows the patient to exert the force against their limb can both be used. Because the examiner is not in control of the force given during the “make” test it may be more difficult to grade accurately. In instances where the clinician feels that pain may be involved either starting the “break” test with light resistance or allowing the patient to exert during the “make” test may be useful to not create an exaggerated pain response during testing.

Another commonly overlooked element of MMT is the use of palpation to ensure you are testing the appropriate musculature. Especially in instance of weakness in the muscles which could be caused by overuse, trauma or neurological issues, palpation is critical to ensure that testing is eliciting the appropriate response or not. This is especially true in the rare instances of extremely weak muscles due to neurologic issues such as long thoracic nerve palsy, thoracic outlet, or suprascapular nerve involvement, all of which can occur in overhead athletes.

Table 2 describes easy methods to clinically assess strength of various shoulder muscles during the clinical evaluation. Although some of these positions may be different than standard MMT as described in published textbooks, they are recommended by the authors of this commentary.

Table 2.

Manual Muscle Testing Technique and Position.

Scapulohumeral Rhythm

Another critical component of assessment of strength or motor control of the scapular muscles is viewing scapulohumeral rhythm. Normal scapulohumeral rhythm is a smooth unimpeded motion of the shoulder complex and associated musculature allowing full elevation of the shoulder. When an athlete exhibits pain, loss of muscle strength or endurance, general weakness, inhibition, or loss of motor control this smooth and coordinated movement becomes dysfunctional. Pathologies such as instability or labral pathology are common in shoulder patients with dysfunction.³⁸ Furthermore scapular stabilizer muscles such as the lower trapezius and serratus anterior are highly susceptible to inhibition in early stages of shoulder dysfunction resulting in dyskinesis.^39,40 Scapular dyskinesis has been defined as “an observable alteration of the position and motion of the scapula relative to the thoracic cage.”^41,42 This inhibition may be demonstrated by a lack of scapular control and disorganization of normal firing patterns or a loss of strength and ability to exert torque and stabilize the scapular during normal movement patterns.

Biomechanical analyses have shown that normal scapulohumeral rhythm occurs at a 2:1 ration with two degrees of humeral motion for every 1 degree of scapular motion during shoulder elevation movements.⁴³ During arm elevation the scapula tilts posteriorly around a horizontal axis and rotates laterally around a vertical axis (external rotation), and the lateral border and acromion upwardly rotate creating the composite motion of shoulder protraction. Conversely during arm depression the scapula adducts, internally rotates, and tilts anteriorly during the composite motion of shoulder retraction. When the scapular stabilizers are dysfunctional a dyskinesis occurs.

General orthopedic patients may exhibit tremendous amounts of scapular winging in the face of long thoracic nerve or dorsal scapular nerve injury. Scapular dyskinesis may be much more subtle to visualize in the overhead athlete. Kibler has described several types of scapular dyskinesis that could potentially be seen in the overhead athlete.⁴⁴ In a Kibler type I scapular dyskinesis the inferior angle appears more prominent. When viewed from the posterior surface of the thorax the inferior angle of the scapula is more prominent as the acromion tilts anteriorly and downward as it tilts along the sagittal plane (Figure 4). A Kibler type II scapular dyskinesis is one in which the entire medial border is prominent when viewed from the dorsal surface as it moves in the transverse plane (Figure 5). The Kibler type III scapular dyskinesis is the superior border type in which a shrugging or superior motion is used to initiate movement of the shoulder. The superior border of the scapular is more prominent as it rests or moves in the sagittal plane (Figure 6). These dysfunctions can be seen during resting posture or with active movements of the shoulder and scapula. Controversy remains regarding clear ability to detect these changes in either position or motor control as reliability studies have shown lack of agreement between testers.^45,46 Some issues that may cause discrepancies in reliability are related to populations in which studies were conducted, including healthy professional pitchers who more than likely had very subtle differences in scapular position. Also in each of the above mentioned studies visual estimates were derived from a single plane. As scapular dyskinesis occurs in multiple planes it is better to evaluate movement in several planes. Also it is not uncommon for dyskinesis to show up only after multiple repetitions of shoulder movement possibly demonstrating an alteration of endurance of the scapular stabilizers rather than a pure strength issue. Examiners should ensure to watch both movements of elevation including both the concentric and eccentric portion. Most often dyskinesis occurs during the lowering (eccentric) component of shoulder movement. Lastly, although Kibler has described the above mentioned three forms of dyskinesis the authors of this commentary feel that in many cases a clear single pattern of dysfunction is not discernible. Oftentimes there appear to be more than one type of dyskinetic movement occurring simultaneously, such as a Kibler type I and II as both the medial border and the inferior angle are prominent during the eccentric phase of shoulder movement.

Figure 4.

Kibler type I scapular dyskinesis with inferior angle protruding dorsally.

Figure 5.

Kibler type II scapular dyskinesis with entire medial border protruding dorsally.

Figure 6.

Kibler type III scapular dyskinesis with shoulder shrug.

Although Wright and colleagues⁴⁷ have recently questioned the usefulness of the scapular physical examination, the authors feel it is a necessary component of the overall assessment of the overhead athlete. There are several other forms of physical examination tests that can be done in conjunction with the assessment of scapular position to try to further implicate scapular pathology as being part of the pathological process in a dysfunctional overhead athletes shoulder. These tests include the Kibler lateral scapular slide test, scapular assistance test, scapular retraction test, and the flip sign.

Kibler Lateral Scapular Slide Test (LSST)

A clinical method for testing scapular positioning can be performed using the Kibler LSST in the neutral (arms at side), hands on hips position as described earlier, and 90° elevated positions.⁴¹ A tape measure is used to measure the distance from a thoracic spinous process to the inferior angle of the scapula. A difference of more than 1 cm to 1.5 cm is considered abnormal, and may indicate scapular muscular weakness and poor overall stabilization of the scapulothoracic joint.⁴¹ Several recent studies have questioned the reliability and validity of this test.^48,49

Scapular Assistance Test (SAT)

The SAT involves the assistance of the scapula through the application of an examiners hand to the inferior medial aspect of the scapula and second hand at the superior base of the scapula to provide an upward rotation assistance type motion while the patient actively elevates the arm in either the scapular plane or sagittal plane (Figure 7).⁴² Symptom resolution or increased ease in shoulder elevation during testing as compared to the response of the patient doing the movement independently without the assistance of the examiner implies a positive test. Additionally, a positive SAT occurs when greater ROM or decreased pain (negation of impingement type symptoms) occurs during the examiners assistance of the scapular upward rotation. Inter‐rater reliability of the SAT and found coefficient of agreements ranging between 77% and 91% (kappa range 0.53–0.62) for flexion and scapular plane movements concluding that this test is acceptable for clinical use.⁵⁰ The scapular assistance test can also be performed with the athletes shoulder in abduction and external rotation in a more provocative position commonly seen during the cocking and acceleration phase of the throwing motion or tennis serve (Figure 8). Kibler et al have also shown an increase in the posterior tilt of the scapula by 7° as well as movement improvement with a decrease in pain ratings of 56 % (8 mm VAS) during application of stabilization by the clinician.⁵¹

Figure 7.

Scapular assistance test.

Figure 8.

Scapular assist test performed in in abducted and externally rotated position.

Scapular Retraction Test (SRT)

The SRT involves retraction of the scapula manually by the examiner while a movement that previously was either unable to be performed secondary to weakness or loss of stability or a movement that was painful.^42,52 Manual retraction of the scapula is performed by compression of the scapular medial border as the athlete repeats of the index movement that provoked symptoms without scapular retraction (Figure 9). Research by Kibler⁵² profiling the kinematic and neuromuscular actions during the SRT showed an increase of 5° of scapular retraction during application of the clinician’s pressure created by moving the scapula into retraction during this maneuver. Additionally, mean increases of 12° of posterior tilting, and a reduction of scapular IR by 8° occurred during the performance of the SRT. These favorable kinematic changes during the application of the SRT place the GH joint in a biomechanically favorable position for overhead function. Additional applications of the SRT include stabilizing the scapula in a retracted position during manual muscle testing (MMT). Kibler et al have reported increases in muscular strength of the shoulder while performing the empty can maneuver during the SRT with mean strength increases of 24% with scapular stabilization.³⁵ The use of this maneuver demonstrates the important role proximal stabilization plays in shoulder function and can educate the patient on the need and result of improved scapular control and stabilization.

Figure 9.

Scapular retraction test performed in scapular plane elevation.

Flip Sign

Kelley et al⁵³ originally described this flip test which performed by the examiner providing resistance to ER with the arm at the side, with close visual monitoring of the medial border of the scapula during the ER resistance application (Figure 10). A positive flip sign is present when the medial border of the scapula “flips” away from the thorax and becomes more prominent indicating a loss of scapular stability. This finding would indicate the need for further scapular evaluation. It would additionally imply that integrated exercise progressions aimed at the serratus anterior and trapezius force couple (important for scapular stabilization) may be warranted. Although originally described for patients with spinal accessory nerve lesions, it is commonly used for those with apparent general scapular muscle weakness where excessive scapular dysfunction is observed. One added clinical sign to watch for is the apparent downward rotation of the scapula during the flip sign maneuver in patients with spinal accessory nerve lesions, which results in massive trapezius weakness and subsequent loss of function.

Figure 10.

Scapular flip sign indicating dynamic scapular stabilization weakness.

Proprioceptive Testing

Because of the extreme range of motion that most overhead athletes exhibit some degree of capsular laxity also exists. Due to this laxity the glenohumeral joint has a reliance on joint proprioception and neuromuscular control. Assessment of proprioception and neuromuscular control in the throwing shoulder will encompass both afferent and efferent neural function. These can be assessed through systems of kinesthesia, joint position sense, and sensation to resistance of movement.

Joint position sense is the ability of the athlete to determine where the extremity is oriented in space. Joint position sense can be tested by use of repositioning the shoulder in several patterns of movement. Clinically this is done via joint angular replication testing in which the extremity is placed in a position and held for a short time then moved back to an initial reference position. The athlete is then asked to return to the position initially selected. The examiner then measures the degree of accuracy on repositioning of the extremity voluntarily by the athlete. The score given is the difference between the reference angle and the actual matched angles by the athletes. In the seminal study on clinical use of active joint angular reproduction, Davies and Hoffman tested subjects seated with angles greater than and less than 90 degrees of flexion, abduction, followed by external rotation greater than and less than 45 degrees of abduction and internal rotation.⁵⁴ Normative data of 100 male subjects without shoulder pathology using 7 different angular measures to assess joint angular reproduction on each subject resulted in an average error or of 2.7 degrees.

Another method to test kinesthesia of the shoulder is through the threshold to detection of passive motion (TTDPM). This testing is used to assess the athlete’s ability to detect a passive movement at very slow velocities. Because this form of testing requires sophisticated equipment and more elaborate testing devices the authors have chosen not to describe it in detail but will refer the readers to literature that pertain to this form of testing.^55–58

Regardless of methods of testing numerous authors have demonstrated that muscular fatigue has an effect on proprioception of the glenohumeral joint and may indicate a need for proprioceptive challenges/exercises in the rehabilitation of the overhead athlete.^58–62 Additionally this loss of kinesthetic awareness in the overhead athlete provides rationale for continued research and into how it may affect the overhead athlete.

Shoulder Special Tests

Discussion of several types of manual orthopedic tests is important as their inclusion in the comprehensive examination sequence gives the clinician the ability to determine the underlying cause or causes of shoulder complex dysfunction. The tests to be covered in this commentary include impingement, instability, and labral tests. It is beyond the scope of this chapter to completely discuss all clinical tests; however several excellent texts can be referenced by readers wishing for a more complete discussion.^12,63 Tests discussed in this commentary will be specifically referenced relative to those tests that are the most important for examination of the overhead athlete.

Impingement tests

Tests to identify glenohumeral (GH) impingement primarily involve the re‐creation of subacromial shoulder pain using maneuvers that are known to reproduce and mimic functional positions in which significant subacromial compression is present. These motions involve forcible forward flexion (Neer impingement sign),⁶⁴ (Figure 11) forced IR in the scapular plane (Hawkins‐Kennedy impingement sign),⁶⁵ (Figure 12) forced IR in the sagittal plane (coracoid impingement test),⁶⁶ (Figure 13) and cross‐arm adduction impingement tests (Figure 14).¹² These tests all involve passive movement of the GH joint. The Yocum impingement test involves the active combination of elevation with IR and can provide a valuable understanding of the patient’s ability to control superior humeral head translation during active arm elevation in a compromised position⁶⁷ (Figure 15). Valadie et al⁶⁸ has provided objective evidence of the degree of encroachment and compression of the rotator cuff tendons against the coracoacromial arch during several impingement tests. These tests can be used effectively to reproduce a patient’s symptoms of impingement and to give important insight into positions that should be avoided in the exercise progressions used during treatment following evaluation.

Figure 11.

Neer impingement test.

Figure 12.

Hawkins‐Kennedy impingement test.

Figure 13.

Coracoid impingement test.

Figure 14.

Cross‐arm adduction impingement test.

Figure 15.

Yocum impingement test.

Interpretation of Clinical Tests (Diagnostic Accuracy)

The diagnostic accuracy of the impingement tests have been studied and profiled in a systematic review by Hegedus et al.^69,70 They report the pooled specificity and sensitivity of the Neer test to be 53% and 79%, respectively, and for the Hawkins–Kennedy impingement test 59% and 79%. These tests are important for the identification of rotator cuff impingement but must be used in combination with a complete examination to allow the clinician to discriminate between primary, secondary, and internal impingement for a more accurate and meaningful diagnosis.⁷¹

To further discuss the diagnostic accuracy of the clinical tests presented in this section of the monograph, several definitions should be discussed. The specificity of a clinical test measures the ability of the test to be positive when the patient actually has the condition being tested for.⁷² Often the pneumonic (SPIN) is used which stands for Specificity, Positive rules the condition IN. Sensitivity estimates the ability of a clinical test to be negative when the patient does not have that condition. The pneumonic for sensitivity is (SNOUT) standing for Sensitivity Negative rules the condition OUT. While commonly used, specificity and sensitivity they are less useful than likelihood ratios because they provide a less quantifiable estimate of the probability of a diagnosis.⁷³ Therefore when possible, this commentary has provided key tables including both (+) and (‐) likelihood ratios as well as (+) and (‐) predictive value in addition to specificity and sensitivity. Use of likelihood ratios can be best summarized or interpreted whereby a clinical test with a likelihood ratio of +2.0 or greater might result in an important increase in the likelihood that the patient has the condition being tested for by that clinical test.⁷⁴ Similarly, a likelihood ratio of ‐0.50 or less results in an important decrease in the likelihood that the patient does not have the condition being tested for by a negative response to that clinical test. The fact that no one impingement test has very high metrics indicates the value of combining the results from multiple impingement tests to assist or increase the diagnostic accuracy of the application of impingement tests for the patient with suspected rotator cuff disease from compression or impingement origins.

Instability tests

Another major type of clinical test that must be included during the examination of the shoulder of the overhead athlete is instability testing. While there may be gross instability from a traumatic incident such as a collision with another player, or the ground during diving, the main goal for the clinician during the examination of the overhead athlete with an overuse type of shoulder injury is to determine the presence of subtle anterior instability.⁷⁵ There are two main types of instability tests that are used and recommended. These are humeral head translation tests and provocation tests. Each type is presented in this section.

Humeral Head Translation Tests

Several authors believe that the most important tests used to identify shoulder joint instability are humeral head translation tests.^76,77 These tests attempt to document the amount of movement of the humeral head relative to the glenoid through the use of carefully applied directional stresses to the proximal humerus. There are three main directions of humeral head translation testing, anterior, posterior, and inferior. Inferior humeral head translation testing is also referred to as multidirectional instability or MDI.⁷⁶ It is important to know some reference values for the human glenohumeral joint when doing humeral head translation tests. Harryman et al⁷⁸ measured the amount of humeral head translation in vivo in healthy, uninjured subjects using a three‐dimensional spatial tracking system. They found a mean of 7.8 mm of anterior translation and 7.9 mm of posterior translation when an anterior and posterior drawer test was used. Translation of the human shoulder in an inferior direction was evaluated with a multidirectional instability (MDI) sulcus test. During in vivo testing of inferior humeral head translation, an average of 10 mm of inferior displacement was measured. Results from this detailed laboratory‐based research study indicate that approximately a 1:1 ratio of anterior‐to‐posterior humeral head translation can be expected in normal shoulders with manual humeral head translation tests. No definitive interpretation of bilateral symmetry in humeral head translation is available from this research. Important clinical recommendations for utilizing humeral head translation tests include testing the uninjured shoulder first, using firm but not overly aggressive holds to promote patient relaxation, using fairly rapid accelerative movements with the humeral head as well as comparing both the amount of translation and end feel during the translation test. Without patient relaxation during testing muscle guarding will likely create inaccuracy during testing of passive humeral head translation.

Multidirectional Instability Sulcus Tests (MDI) Sulcus Sign

One key test used to evaluate the stability of the shoulder is the MDI sulcus test (Figure 16). This test is the primary test used to identify the patient with MDI of the GH joint. Excessive translation in the inferior direction during this test most often indicates a forthcoming pattern of excessive translation in an anterior or posterior direction, or in both anterior and posterior directions.⁷⁶ This test, when performed in the neutral adducted position, directly assesses the integrity of the superior GH ligament and the coracohumeral ligament.⁷⁹ These ligaments are the primary stabilizing structures against inferior humeral head translation in the adducted GH position.⁷⁹ To perform this test, it is recommended that the patient be examined in the seated position with the arms in neutral adduction and resting gently in the patient’s lap. The examiner grasps the distal aspect of the humerus using a firm but unassuming grip with one hand, while several brief, relatively rapid downward pulls are exerted to the humerus in an inferior (vertical) direction. A visible “sulcus sign” (tethering of the skin between the lateral acromion and the humerus from the increase in inferior translation of the humeral head and the widening subacromial space) is usually present in patients with MDI.^76,80

Figure 16.

Multi‐directional instability test at 0 degrees of abduction.

Anterior & Posterior Translation (Drawer) Tests

McFarland et al⁷⁶ and Gerber and Ganz⁷⁷ believe that testing for anterior and posterior shoulder laxity is best performed with the patient in the supine position because of greater inherent relaxation of the patient. This test allows the patient’s extremity to be tested in multiple positions of GH joint abduction, thus selectively stressing specific portions of the GH joint anterior capsule and capsular ligaments. Seated humeral head translation tests are typically referred to as load and shift tests and involve testing of the glenohumeral joint in neutral (0 degrees) of GH joint abduction. Figure 17 shows the supine translation technique for assessing and grading the translation of the humeral head in both anterior and posterior directions. It is important to note that the direction of translation must be along the line of the GH joint, with an anteromedial and posterolateral direction used because of the 30° version of the glenoid. This is accomplished by ensuring that the examiner places the patient’s GH joint in the scapular plane as pictured. Testing for anterior translation is performed in the range between 0° and 30° of abduction, between 30° and 60° of abduction, and at 90° of abduction to test the integrity of the superior, middle, and inferior GH ligaments, respectively.^79,80 Posterior translation testing typically is performed at 90° of abduction because no distinct thickenings of the capsule are noted, with the exception of the posterior band of the inferior GH ligament complex.⁷⁹ Grading (assessing the translation) for this test is performed using the classification of Altchek and Dines.⁸¹ This classification system defines grade I translation as humeral translation within the glenoid without edge loading or translation of the humerus over the glenoid rim. Grade II represents translation of the humeral head up over the glenoid rim with spontaneous return on removal of the stress. The presence of grade II translation in an anterior or posterior direction without symptoms does not indicate instability but instead merely represents laxity of the GH joint. Unilateral increases in GH translation in the presence of shoulder pain and disability can ultimately lead to the diagnosis of GH joint instability.⁸² Grade III translation, which is not seen clinically in orthopaedic and sports physical therapy, involves translation of the humeral head over the glenoid rim without relocation upon removal of stress. Ellenbecker et al⁸³ tested the intrarater reliability of humeral head translation tests and found improved reliability when using the main criterion of whether the humeral head traverses the glenoid rim. The use of end‐feel classification and other estimators decreases intra‐rater, and inter‐rater reliability and interferes with the interpretation of findings from GH translation testing.⁸³

Figure 17.

Anterior and posterior load and shift performed in supine.

Subluxation / Relocation Test

One final instability test to be discussed in this section is the subluxation relocation test. This test may be one of the most important tests used to identify subtle anterior instability in the overhead‐throwing athlete or the individual with symptoms in overhead positions. The original apprehension test, which involves the combined movements of abduction and external rotation while monitoring the patients “apprehension” response is best suited to determine the presence of gross or occult instability of the GH joint. The subluxation relocation test is a subtle form of provocation test that does not measure actual humeral head translation. Originally described by Jobe,⁷⁵ the subluxation/relocation test is designed to identify subtle anterior instability of the GH joint. Credit for the development and application of this test is also given to Dr Peter Fowler.⁷⁵ Fowler described the diagnostic quandary of microinstability (subtle anterior instability) versus rotator cuff injury or both in swimmers and advocated the use of this important test to assist in the diagnosis. The subluxation/relocation test is performed with the patient’s shoulder held and stabilized in the patient’s maximal end‐range of ER at 90° of abduction in the coronal plane. The examiner then provides a mild anterior subluxation force (Figure 18‐A) being sure to exert the subluxation force to the proximal humerus to create anterior translational stress or loading. The patient is then asked if this subluxation force reproduces his or her symptoms. Reproduction of patient symptoms of anterior or posterior shoulder pain with subluxation leads the examiner to reposition his hand on the anterior aspect of the patient’s shoulder and perform a posterior‐lateral directed force, using a soft, cupped hand to minimize anterior shoulder pain from the hand‐shoulder (e.g. examiner‐patient) interface (see Figure 18‐B). Failure to reproduce the patient’s symptoms with end‐range ER and 90° of abduction leads the examiner to reattempt the subluxation maneuver with 110° and 120° of abduction. This modification has been proposed by Hamner et al⁸⁴ to increase the potential for contact between the undersurface of the supraspinatus tendon and the posterior superior glenoid. In each position of abduction (90°, 110°, and 120° of abduction), the same sequence of initial subluxation and subsequent relocation is performed as described previously.

Figure 18.

Glenohumeral subluxation (A) and relocation (B) test.

Reproduction of anterior or posterior shoulder pain with the subluxation portion of this test, with subsequent diminution or disappearance of anterior or posterior shoulder pain with the relocation maneuver, constitutes a positive test. Production of apprehension with any position of abduction during the anteriorly directed subluxation force phase of testing would indicate occult anterior instability. The primary ramifications of a positive test would indicate subtle anterior instability and secondary GH joint impingement (anterior pain) or posterior or internal impingement in the presence of posterior pain with this maneuver. This test forms one of the key clinical indicators for identifying posterior impingement in the throwing athlete coupled with patient history of deep posteriorly directed pain in the position of 90 degrees or more of external rotation in 90 degrees of abduction (arm cocking position). A posterior type II superior labrum anterior to posterior (SLAP) lesion has also been implicated in patients with a positive subluxation/relocation test.⁸⁵ This test can form a very important part of the return to throw or return to serve evaluation. Reproduction of pain during this maneuver often indicates that the athlete is not able to return to aggressive overhead function due to a decrease in shoulder stabilization and can be used as a clinical test to determine readiness to return to throw by the clinician.

Beighton Hypermoblity Index

Instability testing of the overhead athlete with shoulder dysfunction can include a series of tests to assess the overall mobility or presence of generalized hypermobility as a valuable component or adjunct to the more specific tests performed during clinical evaluation.^63,86,87 The Beighton hypermobility scale or index was originally introduced by Carter and Wilkinson⁸⁶ and modified by Beighton and Horan.⁸⁷ This scale is comprised of four tests each assessed bilaterally (for a total of eight), and the trunk flexion test, which are used to assess the generalized hypermobility of the individual. These tests include: passive hyperextension of the 5^th MCP joint; passive thumb opposition to the forearm; bilateral elbow, and knee hyperextension; and standing trunk flexion with knees fully extended. Thus, there are nine measures that comprise the modified Beighton index. Several authors have documented the psychometric properties of the Beighton scale with reliability estimates ranging from 0.74–0.84.⁸⁸ Several cut‐off criterion have been used to determine how many of the individual tests must be positive to rate an individual as hypermobile with no overwhelming consensus.^88,89 Some studies have used 2 of the 9 measures as positive to grade the individual as hypermobile with other research using 4/9 to achieve this hypermobile rating.^63,87,88 This scale can be used as an important classification for patients with GH joint instability or in patients where an understanding of underlying mobility status is important to determine progression rates for ROM or mobilization.⁶³

Rotator Cuff Testing

Several clinical tests are presently recommended for use to assess the integrity of the rotator cuff muscle tendon unit. These include tests that assess strength of the rotator cuff (previously described in the section on manual muscle testing) as well as tests to provoke symptoms and pain reproduction.

Empty Can Test

In addition to using the empty or full can test to solely assess muscle strength of the rotator cuff, Itoi et al⁹⁰ tested the effectiveness of both the full can and empty can test to predict the presence of a rotator cuff tear. Their results showed that greater predictive values were present when only weakness was encountered during the use of both the full can and empty can tests as compared to when pain was encountered during testing. There was no significant difference in the ability of these two tests to predict a full thickness rotator cuff tear and the author concluded that both test positions could be used for supraspinatus testing.

Subscapularis Tests

Three tests are commonly used to assess the integrity of the subscapularis muscle tendon unit. These include the Gerber lift‐off position (Figure 19), Napoleon or Belly Press Test (Figure 20), and the Bear Hugger Sign.⁹¹ (Figure 21) Recent research has assessed the effects of subscapularis muscular activation in each of these three clinical tests as well as slight variations (+/‐) 10 degree positional changes to the reference positions described in the literature. This study concluded that all three tests (Gerber lift off / Napoleon & Bear Hugger) isolate the subscapularis and are recommended for use to evaluate the integrity of the subscapularis muscle tendon unit. Yoon et al,⁹² recently published a study testing the effectiveness of 4 tests to evaluate the integrity of the subscapularis. These authors found the lift‐off test to be highly specific for identification of a full‐thickness subscapularis tear and additionally to detect severe fatty infiltration of that muscle.

Figure 19.

Gerber lift‐off test.

Figure 20.

Should state: A) Napoleon or B) Belly press test

Figure 21.

Bear hugger sign.

Labral Testing

Glenoid labrum tears are among the most difficult clinical diagnoses to make, solely using clinical special tests This is evidenced by the wide variety and voluminous number of tests reported in the literature. In the throwing athlete, large anterior translational forces are present at levels up to 50% of body weight during arm acceleration of the throwing motion, with the arm in 90° of abduction and ER.² This repeated translation of the humeral head against and over the glenoid labrum can lead to labral injury. Labral injury can occur as tearing or as actual detachment from the bony glenoid rim.

In addition to the tearing that can occur in the labrum, actual detachment of the labrum from the glenoid rim has been reported. The two most common labral detachments encountered clinically are the Bankart lesion and the SLAP lesion. Perthes⁹³ in 1906 was the first to describe the presence of a detachment of the anterior labrum in patients with recurrent anterior instability. Bankart^94,95 initially described a method for surgically repairing this lesion that now bears his name. A Bankart lesion, which is found in as many as 85% of dislocations,⁸² is described as a labral detachment that occurs at between 2 o’clock and 6 o’clock on a right shoulder, and between the 6 and 10 o’clock positions on a left shoulder. This anterior‐inferior detachment decreases GH joint stability by interrupting the continuity of the glenoid labrum and compromising the GH capsular ligaments.⁸² Detachment of the anterior‐inferior glenoid labrum creates increases in anterior and inferior humeral head translation—a pattern commonly seen in patients with GH joint instability.⁸²

In addition to labral detachment in the anterior‐inferior aspect of the GH joint, similar labral detachment can occur in the superior aspect of the labrum. Superior labrum anterior posterior (SLAP) lesions are defined as superior labrum anterior posterior. Snyder et al⁹⁶ classified superior labral injuries into 4 main types with additional classifications being created as greater identification and study of the superior labrum has evolved. Snyder reported a type I labral tear as fraying with types II‐IV tears involving actual detachment of the labrum away from the glenoid with or without involvement of the actual biceps tendon.⁹⁶ One of the consequences of a superior labral injury is the involvement of the biceps long head tendon and the biceps anchor in the superior aspect of the glenoid. This compromise of the integrity of the superior labrum and loss of the biceps anchor lead to significant losses in the static stability of the human shoulder.⁹⁷ Cheng and Karzel⁹⁷ demonstrated the important role the superior labrum and biceps anchor play in GH joint stability by experimentally creating a SLAP lesion at between 10 and 2 o’clock positions. They found an 11% to 19% decrease in the ability of the GH joint to withstand rotational force, as well as a 100% to 120% increase in strain on the anterior band of the inferior GH ligament. This demonstrates a significant increase in the load on the capsular ligaments in the presence of superior labral injury.

A brief discussion of the proposed mechanisms of superior labral injury is indicated as it will assist the clinician in better understanding the underlying mechanisms behind the present clinical tests that are used to provide stress and provoke the superior labrum. Andrews and Gillogly⁹⁸ first described labral injuries in throwers and postulated tensile failure at the biceps insertion as the primary mechanism of failure. The theory proposed by Andrews was based on the important role the biceps plays in decelerating the extending elbow during the follow‐through phase of pitching, coupled with the large distraction forces present during this violent phase of the throwing motion. Recent hypotheses have been developed based on the finding by Burkhart and Morgan et al⁹⁹ of a more commonly located posterior type II SLAP lesion in the throwing or overhead athlete. This posteriorly based lesion can best be explained by the “peel back mechanism” as described by Burkhart and Morgan.⁹⁹ The torsional force created when the abducted arm is brought into maximal ER is thought to “peel back” the biceps and posterior labrum. Several of the tests discussed in this chapter that are used to identify the patient with a superior labral injury utilize the position of abduction. External rotation similar to this position is described by Burkhart and Morgan⁹⁹ for the peel back mechanism. Kuhn et al¹⁰⁰ compared load vs failure of the superior labrum after repair was performed cadaverically using both distraction and peel back simulation models in the throwing motion. They found significantly lower load to failure for the peel back pathomechanical model than is seen with distraction, indicating the vulnerability of the superior labrum and of subsequent labral repair to this type of loading.

TESTS FOR LABRAL PATHOLOGY

General Labral Tests

Many general labral tests such as the clunk test (Figure 22), circumduction test (Figure 23), and compression rotation test (Figure 24), utilize a long axis compression exerted through the humerus to scour the glenoid and to attempt to trap the torn or detached labral fragment between the humeral head and the glenoid, much like a mortar and pestle type mechanism.^63,40,101 The circumduction and clunk tests literally scour the perimeter of the glenoid trying to trap the labral tear with the compression and rotation performed by the examiner during the test. Due to the large ranges of motion in the throwing motion, use of these types of test to scour the perimeter of the glenoid and glenoid labrum are indicated. One key clinical application with these tests is the frequent finding of crepitace and grating during the movements as well as increases in humeral head translation that can create “noise” from the joint. These tests typically when positive will recreate the pain experienced by the patient. Noise generation or a feeling of traversing across the glenoid rim does not indicate a torn labrum and can fool an inexperienced clinician during the interpretation of the exam findings. It is important to note laxity, and the type of crepitus and sensations encountered during the test along with the patient’s report of pain associated with the test to fully interpret the results.

Figure 22.

Clunk test.

Figure 23.

Circumduction test.

Figure 24.

Compression rotation test.

Superior Labrum (SLAP) Tests

There are many tests to identify superior labral injuries in the throwing athlete. The common biomechanical characteristic or mechanism of SLAP tests are to either product tension on the bicep long head tendon, or produce the peel back mechanism.^63,40,101 Both of these mechanisms are thought to produce significant tension and provoke the superior labrum and reproduce the patients symptoms. These tests also frequently create a click or audible response from the shoulder but the consistent feature of most tests is the recreation of the patient’s pain symptoms. Tests that specifically utilize muscular tension exerted in the bicep long head to tension the superior labrum include the O’Brien active compression test¹⁰² (Figures 25A and 25B), the Mimori test, speeds test¹⁰³ (Figure 26) and the biceps load test (Figure 27). These tests all place or develop a traction type force through and active contraction of the bicep muscle by the patient resisted by the examiner.⁶³

Figure 25.

O’Brien active compression test. Horizontal adduction with internal rotation component (A), and horizontal adduction with external rotation component (B).

Figure 26.

Mimori test.

Figure 27.

Biceps load test.

Additional tests for the glenoid labrum utilize the combined position of abduction and external rotation to create or mimic the peel back mechanism of the cocking position of the throwing motion. These tests include the ER supination test (Figure 28),¹⁰⁴ Dynamic labral shear tests¹⁰⁵ (Figure 29) and the crank test.¹⁰⁶ One additional test called the Anterior slide test^73,107 (Figure 30) utilizes internal rotation rather than external rotation in the hands on hips position to provoke the labrum through an anterior and superiorly directed movement by the examiner. A positive anterior slide test (reproduction of pain and/or a click or pop) and a combined finding of a clinical history of popping catching and clicking has been found to have moderate diagnostic utility for type II‐IV labral lesions.⁷³

Figure 28.

External rotation supination test.

Figure 29.

Dynamic labral shear test.

Figure 30.

Anterior and posterior slide test.

Diagnostic data from many of these labral tests has been reported in several review articles and publications.^{63,69–71,73} These articles show the variability in the clinical diagnostic characteristic / accuracy of these tests. Of particular importance is the difficulty involved when independent researchers report psychometric indices comparable to those reported in the literature by the originator of each test. One important variable in the interpretation of these tests for clinical application is the ability of virtually any examiner to reproduce the exceptional diagnostic accuracy reported in these tests.

Pandya et al¹⁰⁸, Hegedus et al^69,70 and Michener et al⁷³ have provided recent reviews of the diagnostic accuracy of clinical labral tests. Specificities and sensitivities for the O’Brien test range between 47–99% and 11–98%, respectively, in the reported review by Hegadus et al⁶⁹ Similar reports for the compression rotation test found 24–26% and 76–98% in their review of the literature.⁶⁹ Each of these studies ultimately compared the effectiveness of the clinical examination maneuver versus findings obtained at time of arthroscopic surgery or with magnetic resonance imaging (MRI) and identifies the difficulty in ultimately using a manual orthopaedic test to accurately diagnose glenoid labral tears. Noncontrast MRI has been reported in previous studies to have shown sensitivities ranging from 42% to 98% and specificity of 71% for the diagnosis of SLAP lesions.¹⁰⁹ Improved diagnostic accuracy has been reported with the use of contrast MRI or an MRI arthrogram with sensitivities ranging between 67% and 92% and specificities of 42% to 91%.¹¹⁰ Further research will assist the clinician in the utilization of clusters of labral tests to obtain the most efficient and effective evaluation of the glenoid labrum.

SUMMARY

A thorough history and physical examination of the overhead athletes shoulder will provide excellent insight into the pathology creating the dysfunction. A consistent systematic approach to the examination process will facilitate less risk of missing a diagnosis. The examination of the overhead athlete should include obtaining an accurate athlete medical history, and include areas such as assessment of observation, range of motion, muscle strength and endurance, sensation and proprioception, palpation, structural integrity, and special testing. With patience and practice, sports clinicians can examine and accurately assess most overhead athlete pathology with accurate results.