Evaluation and Treatment of Shoulder Pain Deborah L. Greenberg, MD  Medical Clinics  Volume 98, Issue 3, Pages 487-504 (May 2014) DOI: 10.1016/j.mcna.2014.01.016 Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 1 Muscles: back and scapula region. From Netter illustration from www.netterimages.com. © Elsevier Inc. All rights reserved. Medical Clinics 2014 98, 487-504DOI: (10.1016/j.mcna.2014.01.016) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 2 General appearance of the shoulder. (A) Anterior; (B) Posterior. Medical Clinics 2014 98, 487-504DOI: (10.1016/j.mcna.2014.01.016) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 3 Abduction. Medical Clinics 2014 98, 487-504DOI: (10.1016/j.mcna.2014.01.016) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 4 Cross-body adduction. Medical Clinics 2014 98, 487-504DOI: (10.1016/j.mcna.2014.01.016) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 5 Additional range of motion/pain provocation tests for suspected impingement. (A) Hawkins-Kennedy Impingement Sign:10 Patient holds arm at 90° flexion with elbow at 90° flexion. Place downward pressure on the forearm and passively internally rotate the arm. (positive LR 1.5, negative LR 0.51).7 (B) Neer's Impingement Sign: The patient internally rotates their hand (thumb toward the ground). Place your hand on the back of the patient's shoulder to stabilize the scapula. Forward flex the patient's straight arm by grasping just below the elbow and lifting. (positive LR 1.3).7 Full ROM 180°. Medical Clinics 2014 98, 487-504DOI: (10.1016/j.mcna.2014.01.016) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 6 Strength testing of rotator cuff. (A) Empty Can Test: Patient starts with a straight arm at 90° abduction. The arm is then brought forward 30° toward center on the horizontal plane and the thumb rotated toward the floor. Apply gentle pressure downward above the elbow while patient attempts to resist this pressure. Pain suggests impingement of the supraspinatus. Weakness suggests a partial- or full-thickness tear.6 (B) Resisted isometric external rotation: Patient flexes their arm to 90° and attempts to externally rotate arm against resistance. (positive LR for RCD 2.6, negative LR 0.49).7 (C) Internal Rotation lag test∗: similar to lift-off test. One of the best tests when considering complete tear of subscapularis. Patient places hand on back with elbow at 90°. The examiner lifts the hand off the back. Failure to hold this position is a positive test. (positive LR for full thickness tear 5.6, negative LR 0.04).7 Medical Clinics 2014 98, 487-504DOI: (10.1016/j.mcna.2014.01.016) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 7 Further testing if suspecting something other than subacromial impingement syndrome. (A) Apprehension Test- patient lies on the table. With their arm positioned off the side of table it is abducted 90° and externally rotated 90° (positive LR 17.2).11 A positive test is patient apprehension in this position. (B) Speed's Test: The patient flexes their arm to 90° with palm facing upward. Press downward as the patient resists arm movement. A positive test is pain in area of bicipital groove. (C) Yergason's Test: The patient flexes their elbow to 90°. Provide resistance to supination. A positive test is pain in area of bicipital groove. Medical Clinics 2014 98, 487-504DOI: (10.1016/j.mcna.2014.01.016) Copyright © 2014 Elsevier Inc. Terms and Conditions