I have just got back from my first 2 week block at Griffith Uni as part of the Masters in Musculoskeletal and Sports Physio. It was a great couple of weeks, and I picked up a lot of great info. In a recent Clinical Edge newsletter, I discussed the good old Hawkins-Kennedy test, and quite a few people asked for a follow-up video on the special tests for the shoulder after discussing , so I will soon shoot a video on combinations of tests to help rule structures around the shoulder in or out.
Here is another shoulder test for you to have a think about - Yergason's test (or Yergy as I am starting to call him after reading all these articles). "Yergy" wrote about the test first in 1931, so there's a pretty slim chance he will read this blogpost and object to his new nickname.
One of the tests used around the shoulder is Yergason's test, which I personally have only recently started using. In this test, the elbow is flexed to 90 degrees, the forearm is in pronation, you hold above the wrist and create a pronation force, resisting the patient's supination . You then externally rotate the arm while keeping this pronation force/loading of the biceps (Kibler et al, AJSM 2009). I have read about 20 studies now on Yergason's test, something I never in my wildest dreams imagined I would ever do...
So what is it testing, and what is the use of Yergason's test?
Yergason's test has been proposed to test for Type II SLAP lesions, long head biceps tendinopathy and subluxing/dislocating of the long head of biceps tendinopathy. How does it test these structures?
To cut a long story short, the long head of biceps has some attachments to the superior aspect of the labrum, loading this structure when contracted. The biceps tendon compresses against the bicipital groove, and a painful response with this test shows up a biceps tendinopathy. Alternatively, if you get pain over the biceps tendon or clicking as you externally rotate, you are detecting the biceps tendon subluxing/dislocating from the bicipital groove.
A number of structures are loaded in this test, it is hard to isolate a particular structure when you get a positive.
As there are a number of structures tested, overall, the sensitivity of Yergason's test has been shown to be fairly poor (0.12 to 0.43), with pretty good specificity (0.79 -0.98). Thus you can use this test to rule in the biceps tendon and SLAP lesions if you get a positive, but a negative test does not mean these structures are not affected. Beware of false negatives with this test!
So when you perform Yergason's test, it is likely you will only identify a biceps tendinopathy if the specific part of the tendon that has the tendinopathy is compressed, in the mid part of the tendon. Have a tendinopathy in another part of the tendon? Probably won't show up. So to identify a biceps tendinopathy, you will need to tie in a positive test with the patients history ie anterior shoulder pain with extension, maybe a history of pain following an activity with excess shoulder tension eg ten pin bowling, or going really low in the bench press. They may have a common tendinopathy pattern, possibly some morning pain that settles, pain with compression eg shoulder extension, and a history of sudden increases in load on the biceps tendon (particularly into shoulder extension). I would also use another more sensitive test like the upper cut test (Kibler et al 2009).
Yergason's test may load the superior aspect of the labrum where part of the tendon attaches. You will have to tie in a positive with the test with a history of impact or trauma, a deep ache in the shoulder, and to be honest, you need to perform another more specific SLAP test such as Modified Dynamic Load Shift (which I will cover in another post) or passive compression test (Hegedus EJ et al, BJSM 2012) (Kibler et al, AJSM 2009).
Biceps tendon subluxation/dislocation
Gray’s Anatomy (2008 online edition) and Clinical Orthopaedic Examination (Magee, 2005) propose that the Transverse Humeral Ligament (THL) runs from the lesser tubercle to the greater tubercle of the humerus, covering the long head of biceps with the bicipital groove, and acting as a retinaculum, assisting the long head of biceps to stay in the bicipital groove.
One of my favourite facts to come out of this was when Gleason et al studied this in the AJSM in 2006, using MRI and careful dissection, they found that this THL may not actually exist. but the THL may have just been artificially created in the anatomy labs by just removing a bit too much subscapularis tissue, and that the biceps tendon actually sits in between the deep and superficial fibres of the subscapularis tendon. The implications of this are that the biceps tendon when it subluxes or dislocates, in the majority of cases it only occurs with concomitant subscapularis tears. Like the SLAP lesions above, you will probably have a history of trauma, a fall on an outstretched arm or something similar, and possibly reports of pain and/or clicking with external rotation of the shoulder. A positive test is painful clicking with Yergason's as the long head of biceps tendon moves out of the bicipital groove, which you may also be able to palpate.
So overall, Yergason's test leaves a bit to be desired in the sensitivity stakes, but it can be helpful if you tie it in with the patient history - how it started, trauma or insidious, 24 hour behaviour etc, and combine your history with at least two sensitive tests and one specific test.
What are your thoughts?
What tests do you use around the shoulder?
What other patterns in your patients history help to guide your diagnosis around the shoulder?
Let us know your thoughts on our Clinical Edge facebook page.
Clinical Orthopaedic Examination (Magee, 2005)
Gleason et al. Transverse Humeral Ligament. A separate anatomical structure or a continuation of the Osseous attachment of the rotator cuff. Am J Sports Med 2006; 34:72-77
Gray’s Anatomy (2008 online edition)
Hegedus EJ. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med 2012;46:964–78
Kibler et al. Clinical Utility of Traditional and New Tests in the Diagnosis of Biceps Tendon Injuries and Superior Labrum Anterior and Posterior Lesions in the Shoulder. Am J Sports Med 2009 Vol. 37, No. 9: 1840-1847