History and Physical Exam

Fig. 2.1

The Jobe test, or “empty can test,” is useful to evaluate for tears that involve the supraspinatus. The test is performed with the patient’s shoulders flexed to 90° in the plane of the scapula and maximally internally rotated. The examiner then applies a downward force on the patients arm, and they are asked to resist. Weakness with this maneuver can indicate a tear in the supraspinatus tendon

Fig. 2.2

Resisted external rotation with the patient’s arm at their side can indicate a tear that involves the infraspinatus when weakness is present

Fig. 2.3

The subscapularis can be tested through three commonly used tests. The belly press is the easiest for a patient with a painful shoulder to perform (a). This involves asking the patient to press their hands into their belly and move their elbows forward. A positive test is obtained with the patient’s elbow drops back or is unable to be brought forward. The bear-hug test is also a useful test that many patients can easily perform (b). This involves having the patient place their hand on their opposite shoulder while elevating their elbow. The examiner then attempts to elevate the patient’s hand off of their shoulder, and a positive test is obtained when this is easily accomplished. The lift-off test is typically very difficult to perform with patients with significant shoulder pain, or who lack enough internal rotation to put their arm behind their back (c). This test involves pulling the patient’s hand away from their low back and asking them to hold it there. In a positive test, the hand falls back to the patient’s back. Typically, all three tests can be used in conjunction with one another when examining a patient

Lag signs are a useful adjunct to the physical examination and may be more sensitive and specific than manual muscle testing [8]. An external rotation lag can be evaluated with either the patient’s arm at their side to evaluate for tears of the supraspinatus and infraspinatus (Fig. 2.4a, b) or in 90° of abduction to evaluate for teres minor insufficiency (Fig. 2.5a, b). Patients with massive rotator cuff tears often present with a large external rotation lag, as evidenced by a Hornblower’s sign with functional activities [9]. This can often be ascertained upon initially greeting the patient with a handshake. The Hornblower’s sign is readily apparent if the patient’s elbow goes away from their side as they attempt to elevate their shoulder. This can be a devastating functional problem since the shoulder external rotation with elevation is necessary to put the hand in a functional position to perform many activities of daily living, such as hair care.

Fig. 2.4

An external rotation lag can be identified when the patient is unable to hold their arm in an externally rotated position. The examiner places the patient’s arm in external rotation (a) and then asks them to hold it there. If the arm falls back in internal rotation, then the test is positive (b). This is indicative of a tear that involves the infraspinatus tendon

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