American Shoulder and Elbow Surgeons
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A patient sustains a full thickness tear of their teres minor. Which of the following test/signs would most likely be positive in this patient?
Belly press test
Internal rotation lag sign
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Hornblower's test is completed by asking the patient to hold their shoulder in 90 degrees of abduction and 90 degrees of external rotation. The test is positive if the arm falls into internal rotation or they are unable to actively externally rotate against resistance. This suggests teres minor pathology.
There are various tests/signs used by clinicians to detect rotator cuff pathology. The teres minor is innervated by the axillary nerve and functions to externally rotate the humerus. The hornblower's test/sign has various descriptions, but all act to determine external rotation weakness. In addition to being sensitive and specific for teres minor pathology, it can also be positive with posterior supraspinatus tears.
Walch et al. review 54 patients that underwent repair of combined supraspinatus and infraspinatus rotator-cuff tears. They found that the hornblower's sign was highly sensitive and specific for irreparable degeneration of the teres minor, while the dropping-sign was highly sensitive and specific for irreparable degeneration of the infraspinatus.
Hertel et al. prospectively review 100 patients with painful shoulders and impingement syndrome. They compared various lag signs (ERLS-external rotation lag sign, IRLS-internal rotation lag sign, drop sign) to the Jobe and lift-off signs. The ERLS was less sensitive but more specific than the Jobe sign for the supraspinatus/infraspinatus. The drop sign was the least sensitive but was as specific as the ERLS. The IRLS was as specific but more sensitive than the lift-off sign for subscapularis tears.
Illustration A shows another variation of the hornblower's sign as originally desbribed by Arthui et a. in 1971. The patient is asked to bring both their hands to their mouth. The hornblower’s sign is positive if the patient is unable to do this without abducting the affected arm and demonstrates the difficulty in raising the hand to the mouth in the absence of external rotation of the shoulder. The video provided shows how to perform both variations of the hornblower's test.
Answer 1: Jobe's test is for supraspinatus weakness and/or impingement.
Answer 2: The belly press tests positive with subscapularis pathology.
Answer 3: The internal rotation lag sign is both sensitive and specific for subscapularis pathology.
Answer 5: Hawkin's sign is positive in patients with impingement.
Walch G, Boulahia A, Calderone S, Robinson AH
J Bone Joint Surg Br. 1998 Jul;80(4):624-8. PMID: 9699824 (Link to Abstract)
Walch, JBJS 1998
Hertel R, Ballmer FT, Lombert SM, Gerber C.
J Shoulder Elbow Surg. 1996 Jul-Aug;5(4):307-13. PMID: 8872929 (Link to Abstract)
Hertel, JSES 1996
Title: Physical Examination of the Shoulder Speaker: Christopher S. Ahmad, MD Le...
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In this segment about assessing the shoulder, Dr. Douglas Hanel covers the basic...
This video demonstrates two variations of the hornblower's test/sign.
This video is a complete overview of the physical exam of the shoulder. It cover...
Demonstrates the Lift Off test to evaluate the function of the subscapularis. T...