Hi, my name is Mike Henehan, and I'm a faculty member in the Stanford O'Connor Sports Medicine Fellowship Program. This is a good example, this presentation is a good example of what we commonly see in the office of a patient comes in with vague shoulder pain and a distant history of injury sometimes. And the differential usually is going to include, amongst other things, it's going to include labral injury and injury resulting from impingement. Since Hawkins and Nears tests were mentioned in the case, I'm going to demonstrate those, but we're going to focus mainly on evaluating the labrum. So for Nears test, you're bringing the arm up near the ear, as we say, and then you're going to internal and external rotate back and forth between those two positions to see if there's any pain with that. With Hawkins test, you're going to bring the arm up, abduct it to 90 degrees, and then externally and internally rotate. Both of those are going to elicit impingement if it's present. And again, the key thing with any of these tests is having abduction and internal and external rotation. Moving now to the labrum, I like to think of my labrum test as falling into one of two buckets. One is using the long head of the biceps as your anatomical aid in pulling on the labrum, because if you recall your anatomy, the long head of the biceps goes over the humeral head and then attaches to the superior labrum. The other bucket for the testing is to use the humeral head as a bony probe as you go through your exam maneuvers. So let me demonstrate first in a sitting position, and then we'll show some tools that you can use for the supine position as well. But when the patient is in a sitting position, you can start first to evaluate the labrum using the long head of the biceps as your tool in this situation with O'Brien's test. To do this maneuver, you have the elbow extended, you bring the arm into 10 degrees adduction, and you have them fully pronate the wrist. And then you add a downward pressure and ask the patient if they have any pain with that. And then you bring the palm fully up, repeat that maneuver. And if they have pain with the thumb down and pain is better with the palm up, that would be suggestive of a labrum tear. The other maneuver that you can do to evaluate the labrum using the humeral head as your instrument to assist you in the exam, I like to stabilize the shoulder, grab the elbow, and then just sort of use the humeral head to probe anteriorly, superiorly, posteriorly, and then you can kind of glide back and forth to see if you're able to catch the labrum as you do that maneuver. Now I'm going to demonstrate exam maneuvers that you can use in the supine position. The patient in the supine position, I'll now demonstrate a maneuver that uses the long head of the biceps to help evaluate the glenoid labrum. So this is called the bicep load test. So you abduct the arm up to 90 degrees, elbows at 90 degrees, and you fully rotate the arm in. And then you ask the patient to pull their arm to them, and you add a counterforce movement, pulling in the outside direction. And if that elicits pain, that would be suggestive of a labrum tear. The test you can use to evaluate using a bony tool, if you will, is to have the patient slide over, and we're going to demonstrate the Mayo shear test, which is also called the dynamic labrum test. And in this case, you're going to bring the arm up, adduct it to 90 degrees. He's going to externally rotate, and you just let the arm kind of flop down. You're letting gravity help shift the humeral head down, and then you're going to just bring the arm up. And if there's pain in this position, that would be suggestive of a labrum tear. The reason that it's nice to use both the biceps and the bony tools as part of your testing is none of these are very sensitive and specific. And so I think if you're varying the type of testing you're doing between those two buckets, if you will, between the biceps and using the bone, that's going to increase your ability to make this diagnosis.

2nd Edition, CASE 48

2nd Edition

Shoulder

shoulder pain

labral injuries

clinical tests

diagnostic accuracy

sports medicine