If the patient has complaints of pain on the top of the shoulder, which is reproduced with pressing down on the clavicle, one should consider AC joint pathology. Palpation tenderness is quite a reliable sign for this condition because a clinically significant AC joint problem is rarely nontender.17 Three additional tests are good stressors of the AC joint.
This is a cross-body adduction maneuver that compresses the AC joint (Fig. 16-12). A positive test produces pain on top of the shoulder. An "augmented" AC compression test can be per-
formed with palpation of the AC joint during forced cross-body adduction.
Distraction Test ("Bad Cop" Test)
This is accomplished by placing the arm in maximal internal rotation and applying slight pressure upward. Again, a positive test is signified by pain on top of the shoulder.
Active Compression Test (O'Brien's Test)
This test is performed by having the patient place his or her arm forward flexed to 90 degrees with 10 degrees of horizontal adduction and internal rotation (thumb down; Fig. 16-13). A positive test is signified by pain on top of the shoulder when the arm is pushed in a downward direction, which is lessened when the test is repeated with the arm in external rotation (thumb up). This test has been shown to be positive in 89% of patients successfully treated for AC joint pathology.18
When performing these tests, it is very important that the examiner specifically look for pain at the top of the shoulder at the AC joint because the first two tests will often produce pain in the shoulder with impingement, whereas O'Brien's test will often produce "deep" pain in the presence of a SLAP tear (see "Superior Labral Pathology Tears"). When the previously described tests are positive, strong consideration should be given to injecting the AC joint with 1 to 3 mL lidocaine (as described later) to help confirm the diagnosis.
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