Rotator Cuff Tests that Matter

     Testing the rotator cuff muscles can be tough when someone is in a lot of pain. It's hard for a clinician to determine what is causing the pain during motion testing. Isolating each individual muscle can be a challenge. Authors used electromyography (EMG) to determine the optimal position for testing the muscles of the rotator cuff in human subjects. They have determined four criterion in which position was optimal for the muscle to be tested: (1) maximal activation of the muscle, (2) minimal contribution from shoulder synergists, (3) minimal provocation of pain, and (4) good test-retest reliability. Please keep in mind that Special Tests for the shoulder are more comprehensive and this article only covers strength testing for the four (4) rotator cuff muscles. 
     
     Out of a plethora of shoulder tests out there, I am merely posting a few here that I have done many times for testing the rotator cuff and I have taken the liberty to reference them as best as I can below. I hope my patients and other clinicians will find this information useful.

     Here are the muscles and some of the updated tests used to test them based on studies done using electromyographic (EMG) studies:

SUPRASPINATUS

1. Full Can Testing - This is done with the shoulder in 90 degrees elevation, placed in the scapular plane (45 degree angle of horizontal adduction from the frontal plane), shoulder in neutral rotation and the thumb pointing upward toward the ceiling. Kelley and associates found this as the optimal position for testing the Supraspinatus muscle. This was also less painful than the Empty Can Test (which we will not include in this blog). Although the empty can test (thumb down position) showed high levels of activation on EMG, it was deemed uncomfortable for patients when performed. 

2. Champagne Toast Test - As the title implies, the position looks like you are toasting while holding a champagne glass. The position, as introduced by Chalmers, et al is a testing position for the Supraspinatus with the shoulder in 30 degrees of abduction, slight external rotation, and 30 degrees of flexion. The authors have also found favorable ratios of muscular activity between the deltoid and the supraspinatus muscles which means that when this test is positive, they recommend another testing to isolate the supraspinatus. Because it is a relatively new test, more studies are needed for this. 

INFRASPINATUS

The infraspinatus is tested with the arm in 90 degrees elevation in the sagittal plane, with the arm in half maximal external rotation (ER).

TERES MINOR

The Hornblower Test - I personally do not test this muscle very much in the clinic. There is also not much studies available on this. Some authors do recommend 90 degrees of shoulder abduction in the scapular plane and 90 degrees in ER.

SUBSCAPULARIS

Gerber Lift Off Test - Kelley et al have reported testing the muscle with the arm behind back with the dorsal aspect of the hand placed up near the inferior border of the scapula. The patient is then asked to lift off the hand from the back. Some patients may not even be able to go into this position when ask to be tested, and I might therefore just measure to as far as they can go.



Disclosure: This article is not meant to diagnose or treat a condition, if your condition warrants medical care, please contact your local physical therapist.
REFERENCES:

Correspondence information about the author MD Peter N. ChalmersEmail the author MD Peter N. Chalmers
1. Peter Chalmers Gregory L. Cvetanovich, MD, Noam Kupfer, MAMarkus A. Wimmer, MDNikhil N. Verma, MDBrian J. Cole, MD, Anthony A. Romeo, MD, Gregory P. Nicholson, MD. 
The champagne toast position isolates the supraspinatus better than the job test: an electromyographic study of shoulder physical examination tests 2016 Feb;25(2):322-9. doi: 10.1016/j.jse.2015.07.031. Epub 2015 Oct 9.

2. Lee CKItoi EKim SJLee SCSuh KT.Comparison of muscle activity between Full Can and Empty Can test 2014 Oct 1;9:85. doi: 10.1186/s13018-014-0085-4.

3. Kelly BT, Kadrmas WH, Speer KP. The manual muscle examination for rotator cuff strength. An electromyographic investigation. Am J Sports Med. 1996;24(5):581-588.

4. Greis PE1Kuhn JESchultheis JHintermeister RHawkins RValidation of the lift-off test and analysis of subscapularis activity during maximal internal rotation.  1996 Sep-Oct;24(5):589-93.

5. Philippe Collin, MD, Thomas Treseder, MD, PhD, Patrick J. Denard, MD, Lionel Neyton, MD, Gilles Walch, MD, and Alexandre L├Ądermann, MD What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears? . 2015 Sep; 473(9): 2959–2966.

6. Nitin B. Jain, MD, MSPH,1,2,3 Reginald Wilcox, PT,4 Jeffrey N. Katz, MD, MS,2,5 and  Laurence D. Higgins, MD2, Clinical Examination of the Rotator Cuff. PM R. 2013 Jan; 5(1): 10.1016/j.pmrj.2012.08.019.

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