Tests for Weakness Jobes Test

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This test is performed by placing the patient in 90 degrees of elevation in the scapular plane, classically with the thumbs pointed down (Fig. 16-7). This position is held against downward resistance. This test isolates the supraspinatus to a degree10 and is positive when there is asymmetrical weakness. Caution should be used in the patient with pain, as it can simulate weakness in patients with painful subacromial impingement.

Full Can Test

Because Jobe's test can be painful in patients with impingement, the full can test has been proposed as an alternative (Fig. 16-8). This test is performed exactly like Jobe's test, except that the

Full Can Test
Figure 16-8 Full can test.
Jobes Test
Figure 16-9 Resisted external rotation. Right side is abnormal.

thumbs are pointed up. This test has been shown to isolate the supraspinatus as well as Jobe's test, while producing less pain.11

Resisted External Rotation

This test is performed with the patient's elbows at his or her side, flexed 90 degrees (Fig. 16-9). A positive test is signified by asymmetrical weakness and indicates weakness of the infra-spinatus and posterior cuff.

Lift-off Test

This test is performed by having the patient place his or her arm behind the back, resting on the small of the lumbar spine. The patient's hand is lifted off the back, without extending the elbow, and the patient attempts to hold the arm off of the back once the examiner lets go (Fig. 16-10). Gerber et al12 found that this test reliably diagnosed or ruled out clinically significant sub-scapularis ruptures. This test is of limited value in patients with painful internal rotation or with stiffness that does not allow the patient to achieve the starting position. Careful attention should be paid to the technique, as it is possible to "lift off" the hand by extending the elbow, which can be misleading.

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Figure 16-10 Lift-off test.
Hip Sports Medicine Test

Figure 16-11 Belly press test. A, Normal; B, abnormal right side.

Figure 16-11 Belly press test. A, Normal; B, abnormal right side.

Belly Press Test

This test has been proposed as an alternative to the lift-off test in patients with either too much pain or stiffness to attempt the lift-off maneuver (Fig. 16-11). It is performed by having the patient place both hands on the belly with flat wrists. The elbows should remain anterior to the trunk while the patient pushes posteriorly against the belly. Patients with subscapularis weakness will demonstrate a dropped elbow because they use shoulder extension to compensate for weak internal rotation.

The belly press and lift-off tests tests have both been validated as tests for the subscapularis. The lift-off test is more specific for the lower subscapularis, and the belly press test is superior for the upper subscapularis.13

Lag Signs

These are three signs that have been shown to be reliable and efficient alternatives to more traditional rotator cuff testing.14 The external rotation lag sign is performed by placing a patient in 20 degrees of elevation, 90 degrees of elbow flexion and near maximal external rotation. A patient who cannot maintain this position (even with a 5-degree lag) has a positive test suggesting a supraspinatus or infraspinatus tear.14 The drop sign (or hornblower's sign) is evaluated much the same way, except that the patient holds the affected arm in 90 degrees of elevation, 90 degrees of elbow flexion, and near full external rotation. If a drop occurs when the examiner releases the wrist, the sign is considered positive for infraspinatus and posterior cuff (infraspinatus/teres minor) weakness. Finally, the internal rotation lag sign is very similar to the description of the lift-off test, noting a 5-degree drop toward the back. Hertel et al14 noted that the external rotation lag sign and drop sign had a positive predictive value of 100% and a negative predictive value of 56% and 32%, respectively. They also noted that the internal rotation lag sign had a positive predictive value of 97% and a negative predictive value of 69%.

Rent Test

This test, described by Codman,5,15 attempts to palpate a "rent" through the deltoid in a patient with a supraspinatus tear. Palpation is accomplished in a relaxed patient at Codman's point, just anterior to the anterolateral border of the acromion with the dorsum of the hand on the buttock. Wolf et al16 have reported on the diagnostic accuracy of this test, noting a sensitivity of 95.7%, a specificity of 96.8%, and a diagnostic accuracy of 96.3% for a rotator cuff tear.

It should be noted that patients may demonstrate pseudo-weakness on examination because many of these tests are subacromial impingement producing. It can be difficult to distinguish true weakness due to a rotator cuff tear from pseudo-weakness due to impingement-type pain. In those cases, use of the Neer impingement test, as described later, can be very helpful, as it may eliminate the pain, differentiating true weakness from that produced by pain.

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