承德医学院附属医院骨伤科科普号

神经根型颈椎病症状表现为颈痛和颈部发僵，可伴有肩背部肩胛间区酸痛不适，或者出现与神经根分布区相一致的感觉、运动障碍及反射改变，颈部活动、咳嗽、打喷嚏、用力及呼吸时疼痛加重。大多数医生熟知神经根型颈椎病的疼痛、麻木症状，但忽略了其他疾病也可引起上述症状。如患者合并有颈椎影像学检查所见的退行性改变，临床上极易将其他疾病误诊为神经根型颈椎病，有的甚至接受了颈椎手术治疗，对患者造成了很大的危害。本文整理了国内外被误诊为神经根型颈椎病的多个系统疾病，概述如下：1呼吸系统疾病被误诊为神经根型颈椎病肺癌的肺外表现复杂，起病隐匿，而首次就诊时许多肺癌患者呼吸道症状缺如。肺上沟癌常有肿瘤压迫臂丛神经造成以腋下为主、向上肢内侧放射的火灼样疼痛，在夜间尤甚。类似于神经根型颈椎病的症状。临床上对于此类病人一定要详细询问病史，有无慢性咳嗽、体重下降、食欲减退等伴随症状及Horner征表现或胸外转移引起的骨痛、病理性骨折等。如常规胸部正位X线片未见异常，不要草率除外胸部肿瘤，务必要进一步行胸部CT检查，已除外肺尖部X线不能发现的<5mm的肿瘤病灶。< span="">2 循环系统疾病被误诊为神经根型颈椎病循环系统疾病如心绞痛、心肌梗死、心包炎、动脉硬化闭塞症、血栓栓塞性脉管炎等也可以出现颈肩部及上肢的疼痛、麻木等症状。Stochkendahl等认为胸痛可以由颈椎病或心脏缺血性疾病引起，也可以由颈、胸脊柱病变或胸壁关节的病变引起，因而有时容易误诊。心肌梗死常以胸骨体中段或上段之后的疼痛为主要表现。这种疼痛反应在与自主神经进入水平相同脊髓段的脊神经所分布的区域，即胸骨后及两臂的前内侧与小指，尤其是在左侧。而神经根型颈椎病临床上亦常出现沿受压神经分布的左侧上肢麻痛等症状，因此对一些以非胸痛为主要表现的心梗患者要提高警惕，不要轻易诊断为神经根型颈椎病。急性纤维蛋白性心包炎常表现为心前区疼痛，可放射至颈部、左肩、左臂及左肩胛骨，疼痛常与呼吸有关。上肢动脉硬化闭塞症表现为上肢的疼痛、麻木、无力及营养障碍性改变，肢体动脉搏动不对称、减弱或消失。血栓栓塞性脉管炎常伴随有反复发作的浅静脉炎及雷诺现象。上述疾病经过仔细检查不易误诊。3 消化系统疾病误诊为神经根型颈椎病肝癌起病隐匿，早期可无症状，一旦出现症状而来就诊者，其病程大多已进入中晚期。膈神经主要由颈4神经组成，除支配膈肌外，还支配右肾上腺、肝上面的腹膜，若肿瘤位于肝右叶膈顶部，则疼痛可放射至右肩或右背部。4 内分泌及代谢疾病被误诊为神经根型颈椎病糖尿病并发症中的周围神经病变可表现为上肢的感觉异常，大多数病人病史较长，肢端感觉异常多呈对称性，可伴有痛觉过敏、疼痛或营养障碍性改变。糖尿病、吸烟、饮酒、类风湿性关节炎和甲状腺功能减退症等通常被认为是周围神经卡压的危险因素，有上述疾病或不良习惯的患者出现周围神经卡压后容易被误诊为神经根型颈椎病。5 周围神经系统疾病被误诊为神经根型颈椎病周围神经卡压可使周围神经出现炎症反应，表现为支配区域不同程度的运动及感觉障碍。如肘管综合征、腕管综合征、尺管综合征、旋前圆肌综合征及骨间前神经卡压综合征等。旋前圆肌综合征可以出现类似于C6-C7神经根型颈椎病表现的桡侧三个半手指及正中神经支配区肌肉的感觉障碍，受影响的肌肉包括旋前圆肌及桡侧腕屈肌。而由C6和C7神经根型颈椎病导致的桡神经支配区的肌肉（腕伸肌、肱三头肌）不受累。骨间前神经卡压会出现前臂近端的疼痛和拇长屈肌、旋前方肌和食指深屈肌的无力感，但没有感觉障碍。而C8神经根型颈椎病除了上述症状以外还会有感觉缺失。从运动角度讲，真正的C8神经根型颈椎病是以所有尺神经支配的肌肉无力为特征的。在肘管综合征中拇长屈肌、小鱼际肌和正中神经支配的食指、中指不被累及而C8或T1神经根型颈椎病可以累及上述肌肉。典型的尺管综合征的卡压表现为尺神经浅、深支受累，导致尺侧一个半手指的感觉减退。这些手指背侧的感觉不受影响，是因为支配这些区域的神经没有通过尺管。运动的受累是和尺神经深支支配的肌肉相一致的。桡神经通常在肘部容易受到一些结构的卡压，一般情况下它的运动支（骨间背神经）受卡压。这和C7神经根受累的颈椎病类似，但是没有感觉变化和肱三头肌或腕屈肌的受累。胸廓出口综合征通常会引起臂丛神经下干（正中神经和尺神经）支配区域的异常，当然血管源性和神经源性原因都有可能出现上述症状。如果有血管杂音、脉搏不对称、大鱼际肌萎缩重于骨间肌等应多考虑胸廓出口综合征。影像学上发现颈肋更要多考虑胸廓出口综合征，而少考虑C8或T1神经根型颈椎病的诊断。6风湿免疫类疾病被误诊为神经根型颈椎病风湿性多肌痛是一组以颈部、肩胛带和骨盆带肌明显疼痛和晨僵，伴有血沉增快为特点的临床综合症。该病早期症状无特异性，其主要表现颈、肩、背、腰疼痛及活动不便也常见于其他疾病。如：颈椎病、类风湿性关节炎等。对称性四肢近端肌无力是多发性肌炎的特征性表现，约一半的病人同时伴有肌痛和肌压痛，与神经根型颈椎病容易混淆，通过详细询问病史、查体并结合神经电生理检查不难鉴别。7 其他疾病被误诊为神经根型颈椎病急性臂丛神经炎是以早期肩背部及上肢剧烈的烧灼样疼痛，随着时间推移疼痛逐渐减弱，逐渐出现上肢肌肉无力为特征的一种临床少见的疾病，它多侵袭2-3个神经根。而神经根型颈椎病则多为单一神经根受累，出现与受累神经根皮节分布一致的疼痛、麻木等症状。神经根型颈椎病和颈肩部的带状疱疹早期都有沿着神经根走行分布的疼痛。前者是各种因素导致的颈神经根受压所致；后者则是潜伏于脊神经后根或神经节的神经元内的带状疱疹病毒，在机体抵抗力减弱时生长繁殖导致神经节发生炎症或坏死而引起。如无皮肤表现，早期多难以诊断。带状疱疹一般在出现全身或局部前驱疼痛症状1-4d后皮肤出现沿神经根走向带状排列的小水疱或丘疱疹，如患者颈椎影像学亦存在退行性改变，全身症状不明显，极易在早期误诊为神经根型颈椎病。而带状疱疹患者在出现疼痛或疱疹前多有病毒感染史、长期应用糖皮质激素或免疫抑制剂史，或者病人有某种免疫力低下的疾病，这些信息的获取有助于和神经根型颈椎病鉴别。通常，大部分恶性肿瘤会导致双侧脊髓症状，单侧脊髓症状在由脊柱后面结构发展而成的骨软骨瘤中可以见到。而来自于神经鞘的神经鞘膜瘤也可以出现单侧神经根症状，经常进展为脊髓症状。椎管外引起的神经根症状可以由甲状腺、食道、咽部肿瘤的直接蔓延所致。反射性上肢根性症状也可以由继发于结节病和动静脉瘘的直接压迫所致。布氏杆菌侵袭到颈椎较少，早期可无典型波浪热等热型，甚至有的患者无发热、盗汗等，而以颈肩部及上肢疼痛为首发症状。其它疾病如：神经官能症、反射性交感神经营养不良、颈椎感染、莱姆病等通过详细询问病史、查体及各种辅助检查不难和神经根型颈椎病鉴别。诊断神经根型颈椎病时一定要有发散性思维，不要受思维定式的影响，仅仅局限于在本科疾病范围内解释患者的疾患。应详细询问病史，全面查体并进行合理的辅助检查。神经电生理检测能直接反映神经根的功能受损状况，并可根据功能损害状况进行定量分析。神经根受压引起髓鞘和轴索变性，导致相应的周围神经传导速度减慢，潜伏期延长，诱发电位波幅降低等，而其所支配的相应节段肌肉则可出现异常电位，运动单位电位时限增宽，波幅增高，出现神经源损害的表现，灵活运用神经电生理检查可以为神经根型颈椎病的鉴别诊断提供很大帮助。影像学检查是临床上常用的检查手段，各种影像学征象对颈椎病的诊断具有重要参考价值，但仅有影像学检查所见的颈椎退行性改变不宜诊断为颈椎病，临床上有些医生过分依赖颈椎X线、CT或MRI，只要有退行性改变就匆匆做出神经根型颈椎病的诊断，不考虑患者出现肩背部或上肢症状的区域是否与影像学表现相吻合，更不在乎患者既往是否有结核、肿瘤等病史，导致误诊频发。总而言之，神经根型颈椎病非常容易与其他疾病混淆，只有掌握各种相关疾病知识，充分运用各种辅助检查，综合患者症状、体征、既往史、病史及辅助检查资料进行整体合参，才能做出正确诊断。

患者女性，四肢寡关节肿痛2年，加重9天。 患者2年前出现右膝、右踝关节肿胀疼痛，就诊于北京某医院，围绕风湿类疾病全面检查，无特殊阳性发现，诊断“骨关节炎”，对症给予口服药物治疗，效果欠佳，后在当地诊所口服中药后症状缓解，其后，关节肿痛间断发作，未系统诊疗。9天前上述关节肿痛并出现左肩及左肘关节疼痛及腰部疼痛，翻身及行走受限，伴发热，体温最高达38.3，曾在当地县医院静点青霉素治疗3天，症状无改善，就诊于我处，查风湿三项ASO、血沉及CRP 异常，类风湿三项未见异常，抗核抗体测定未见异常，入院诊断：链球菌感染后反应性关节炎 入院后体温最高达38.5，行血培养检查5天无菌生长，入院查血常规示白细胞及中性粒细胞升高。入院后给予苄星青霉素120万u 肌肉注射。同时给予：柴胡9g 黄芩9g 法半夏9g 白术30g 茯苓30g 苍术15g 薏苡仁60g 泽泻9g 猪苓9g川牛膝30g。每日1剂水煎服 分2次服。第3天体温正常，1周时关节肿痛消失，后加用柳氮磺胺吡啶片1g 日2次 口服，治疗10天出院。 总结：中西医有机结合治疗风湿免疫性疾病可以达到优势互补，大有可为。

患者主因左膝关节骨关节炎入院。既往有高血压病史。昨日中午诉无明显诱因出现头晕，严重时恶心，欲呕无物，侧血压170/80mmHg。值班大夫嘱患者应用硝苯地平10mg含服，效果不佳。请神经内科会诊，神经内科大夫建议先查头颅CT，然后再看。未遵嘱处理。本人18：00接班，患者仍诉头晕，阵发性恶心，无呕吐。追问患者视物旋转，活动后加重。查体：BP 160/80mmHg。心率85次/分。颈部压痛，头后申旋转试验阳性。各病理征阴性。颈椎开口位未见异常，侧位示颈椎曲度直，颈3、4小关节呈双边征：诊断：颈性高血压。给予手法治疗后患者立即诉头晕、恶心缓解。10分钟后测血压140/70mmHg。晨查无头晕、恶心。BP 150/80mmHg.颈椎曲度变直+颈3旋转导致颈上神经节受刺激，交感神经兴奋而出现相应症状。手法调整后刺激解除，诸症缓解。

常听有些大夫和痛风患者说不能吃豆腐，此观点是错误的。不但可以吃，还可以多吃，理由如下： 一、豆腐虽蛋白含量高但嘌呤早已在其加工过程中随水流失，所以嘌呤含量与土豆、黄瓜相当，属于低嘌呤饮食； 二、豆腐的蛋白含量高，有利于促进痛风病人体内尿酸盐的排泄。 三、豆腐脂肪含量低、能量低，有利于控制痛风病人的体重及血浆中甘油三酯的含量，进而降低病人血浆中尿酸盐含量升高的风险性。 四、豆腐中含有一定量的嘌呤，满足现代营养学对痛风病人营养提出的要求，即痛风病人饮食中允许含有适量的嘌呤。 五、豆腐中含有丰富的异黄酮、低聚糖、不饱和脂肪酸、维生素等生物活性物质和营养素，这些成分具有多种保健功能，如预防和抑制肝功能疾病、预防和抑制动脉硬化，从而有利于痛风病人提高自身身体素质，增强自我恢复的能力。

急性腰扭伤损伤了哪些结构？1.腰部骶棘肌及其筋膜 髂肋肌及最长肌为主2.棘突上或者棘突间韧带 弯腰过大所致3.关节突关节 发生滑膜嵌顿4.骶髂关节 可产生骶骨上端向前，骶尾向后旋转5.腰骶关节 腰骶交界，动静枢纽，易受伤。

许多原因可以导致腰骶部疼痛如肌肉劳损及痉挛，韧带损伤，小关节问题及间盘突出等，最主要致痛原因是用你的腰背肌做你不常做的动作，如举重物、干重活等。椎间盘突出多于负重纵向旋转下而发。许多情况下，轻微的腰部疼痛可以通过以下简单方法而缓解。1.平卧于硬板床上或地板上，头及双膝下垫枕，或者足放于椅子上保持髋部及膝部屈曲，这样可以使你的腰部肌肉放松。此动作需要1-2天，过长会导致肌力减弱而延缓恢复。2.热垫也可以缓解肌肉痉挛，每次应用20-30分钟。冰敷及按摩也可以缓解疼痛。当然也可以应用非甾体抗炎药物。以下情况就医1.疼痛过膝2.腿部及足部、腹股沟区、肛周麻木3.恶心、呕吐、胃部疼痛、无力、出汗4.疼痛因外伤引发者5.疼痛在活动后加重6. 经上述方法2-3周内疼痛无缓解防扭伤建议1.莫弯腰搬物，拾物时下蹲或屈膝，保持上身直立，物体近身，勿持物旋转2.当移动重物时宁推勿拉3.当伏案及开车时间过长时，适当中断放松，4.穿平底或矮跟鞋（1英寸或以下）5.经常锻炼坐站有矩 坐的时候应使你的双膝高于臀部，站立时保持眼、肩、臀在一条直线上，如长时间站立可双脚下轮流垫物5-15分钟，以缓解腰部负重。最佳睡姿 屈膝侧卧或仰卧膝腰下垫枕，当然要小。床的要求以硬为上，不要过软。

伤寒汗后转归：或愈或出现身疼痛、四肢难以屈伸、心下悸、腹胀、欲做奔豚、奔豚、头晕、身动、振振欲扑地、渴而小便不利、振寒。总关乎：卫阳、心阳、脾阳、肾阳及膀胱气化功能。 治之以：桂枝加芍药、生姜各一两，人参三两新加汤、桂枝加附子汤、桂枝甘草汤、厚姜半甘人汤、苓桂枣甘汤、桂枝加桂汤、真武汤

Pathophysiology and Clinical FeaturesSevere flatfoot and hindfoot valgus deformity may present with lateral ankle pain in the region bounded by the anterior fibula and the sinus tarsi . This lateral ankle pain has been attributed to extraarticular lateral hindfoot impingement including talocalcaneal impingement (between the lateral talus and calcaneus) and subfibular impingement (between the calcaneus and fibula) fig.12A,12B,12C). Lateral hindfoot impingement is believed to be secondary to a lateral shift of weight-bearing forces from the talar dome to the lateral talus and fibula and to talocalcaneal joint subluxation . Talocalcaneal impingement typically occurs before subfibular or combined talocalcaneal–subfibular impingements .There are several causes of lateral hindfoot impingement including PTT dysfunction , healed intraarticular calcaneal fractures , neuropathic arthropathy, and inflammatory arthritides . Clinical presentation varies on the basis of the cause of flatfoot and hindfoot valgus. In patients with PTT dysfunction, medial ankle pain is the presenting symptom during the early stages of PTT dysfunction, whereas lateral ankle pain related to hindfoot valgus and lateral impingement predominates in long-standing PTT dysfunction . Regardless of the initial cause of flatfoot, patients with rigid flatfoot deformity experience decreased range of motion at the midfoot and hindfoot and decreased ankle dorsiflexion . Lateral ankle pain may develop because of lateral hindfoot impingement. With progressive deformity, secondary osteoarthrosis of the subtalar, talonavicular, and calcaneocuboid articulations contribute to pain symptoms . On physical examination, flatfoot and hindfoot valgus deformity are evaluated with the patient sitting and standing. There may be decreased range of motion of the ankle, hindfoot, midfoot, and forefoot and lateral ankle pain on palpation. The Achilles tendon may show contracture and tightness .The goal of conservative treatment early in the course of the disease is to prevent further disability and progressive deformity. Acute synovitis is treated with rest and NSAIDS to reduce inflammation. Physical therapy and orthotics relieve stress and pain in the ankle. In patients with advanced PTT dysfunction, soft-tissue balancing procedures alone are inadequate for restoring the longitudinal arch . Osseous correction of hindfoot deformity is required and consists of calcaneal osteotomy, either at the body (medial calcaneal displacement osteotomy) or at the anterior calcaneus (lateral column lengthening). Finally, marked deformity associated with arthritis and fixed osseous deformity are best managed with arthrodesis. These include talonavicular arthrodesis, double arthrodesis at Chopart joints, a subtalar arthrodesis, and a triple arthrodesis. The extent of arthro desis should be limited to minimize the stress transfer to proximal and distal joints .Fig. 12A—Schematic drawings show lateral extraarticular talocalcaneal and subfibular hindfoot impingements. (Reprinted from [10]) Normal hindfoot valgus (< 6°) and no lateral impingement. Hindfoot valgus angle is measured at intersection of line along medial calcaneal wall and line parallel to longitudinal axis of tibia. Fig. 12B—Schematic drawings show lateral extraarticular talocalcaneal and subfibular hindfoot impingements. (Reprinted from [10]) With progressive hindfoot valgus, abnormal contact between lateral talus and calcaneus (red) occurs first and results in talocalcaneal impingement. Fig. 12C—Schematic drawings show lateral extraarticular talocalcaneal and subfibular hindfoot impingements. (Reprinted from [10]) Subsequent abnormal contact between both lateral talus and calcaneus (red) and abnormal contact between calcaneus and fibula (orange) subsequently develop and produce combined talocalcaneal and subfibular impingement. Fig. 13A—66-year-old woman with talocalcaneal and calcaneofibular impingement due to pes planus and hindfoot valgus. Sagittal inversion-recovery image shows marrow edema of opposing lateral talar process (solid arrow) and calcaneus (open arrow) Fig. 13B—66-year-old woman with talocalcaneal and calcaneofibular impingement due to pes planus and hindfoot valgus. Sagittal T1-weighted (B) and coronal fat-suppressed proton density–weighted (C) images depict edema and scarring (arrowheads,B) surrounding thickened, entrapped calcaneofibular ligament (arrow). Hindfoot valgus angle, formed by intersection of line along medial calcaneal wall and line parallel to long axis of tibia, is increased (30°). Fig. 13C—66-year-old woman with talocalcaneal and calcaneofibular impingement due to pes planus and hindfoot valgus. Sagittal T1-weighted (B) and coronal fat-suppressed proton density–weighted (C) images depict edema and scarring (arrowheads,B) surrounding thickened, entrapped calcaneofibular ligament (arrow). Hindfoot valgus angle, formed by intersection of line along medial calcaneal wall and line parallel to long axis of tibia, is increased (30°).Fig. 14A—61-year-old woman with talocalcaneal and calcaneofibular impingements related to severe hindfoot valgus. Sagittal inversion-recovery image depicts contact between calcaneus and fibula with opposing marrow edema and subchondral cysts (arrows).Fig. 14B—61-year-old woman with talocalcaneal and calcaneofibular impingements related to severe hindfoot valgus. Coronal proton density–weighted image depicts neocalcaneal facet (solid arrow) articulating with distal fibula. Lateral subluxation of calcaneus and subchondral changes in posterior subtalar facet (arrowheads) are compatible with talocalcaneal impingement. Peroneal tendons (open arrow) are minimally laterally subluxed

The Tensor Fasciae Latae is a muscle, which helps in flexing and abducting the thigh. It becomes very vital for a runner due to this function. If the TFL is consciously kept flexible, it will help in keeping the body injury free as well as being fit. Activities like walking, bending and moving around can get affected if the muscles of the thighs and hip are injured. They will also affect exercise pattern. Tensor fasciae latae pain can be caused due to a tear or strain in the muscle. With proper directed exercise, the muscle can be healed and strengthened.What Are the Symptoms?The symptoms include:Pain in the outer hipReferred pain down the outer thighPain when lying on the affected hipWhen weight bearing on the affected side, the pain worsensThe trigger points for TFL myofascial can get misdiagnosed as trochanteric bursitis because they have very similar symptoms. In the beginning the treatment for either case should be to get the surrounding muscles in good condition and make corrections in existing imbalance in the muscles. If the case persists, it should be investigated for bursa involvement.What Causes Tensor Fasciae Latae Pain?Tensor fasciae latae and Iliotibial band muscle pain can be caused due to the following activities:Running, climbing, cycling, dancing, excessive walking when not in shape and playing court sports like basketball, volleyball and tennis.How to Relieve Tensor Fasciae Latae PainTherapiesWarm and Cold Therapy Gel:A pain relieving gel, which provides therapeutic warmth with burning, can be used. Or else a cooling gel, which reduces inflammation by cooling the area. The gel should be applied on the outside of thighs and knees. It will help in reducing the tensor fasciae latae pain as well as tightness.Hot and Cold Compress/Wrap:This kind of wraps can be used on thighs, knee, hip and back. It can be cooled in the freezer or heated in the microwave. It helps in reducing the pain and swelling in the injured muscle by cold therapy and chronic pain and swelling by warm therapy.Tensor Fasciae Latae Brace and Support:This brace is useful in providing compression and support to the TLF muscle. This type of support can be used in high thigh and groin injuries as well. The brace is held in place by wrapping around thigh and abdomen.Compression Leggings:Compression leggings are usually used for preventing injuries, however, they are excellent when used as support for injured muscle. They help in reducing swelling as well. Good compression leggings cover the thighs and end below the knee. Tight compression at lower end of limb and decreased compression at top is essential for reducing inflammation and circulation.Massage Tools for Self Treatment:A roller is an excellent massage tool, which can be used on upper and lower leg muscles. It is easy to use and helps in relieving tension and pain. It just needs to be rolled up and down the muscle and usually does not strain the hands and wrists.Stretching and Strengthening Exercise for Tensor Fasciae Latae PainSome exercises are described below which help in strengthening the muscles and dealing with the tensor fasciae latae pain.Outer Hip StretchStart by lying down on the back, and bend your right knee. Cross the bent leg over the left knee and pull with your left hand. Hold this position for 10 to 30 seconds. This exercise stretches the gluteus medius, gluteus minimus and tensor fascia latae muscles.Standing Outer Hip StretchStart by placing the leg to be stretched behind the other leg. Lean your body on the side, which is not going to be stretched. The hip to be stretched should be pushed out to the other side. Hold for 10 – 30 seconds. The muscles stretched in the exercise are TFL, Iliotibial band and Sartorius.Hip Abduction with BandThis exercise is done to strengthen the hip abductors present on the outside of the joint. To start wrap a resistance band around the ankle and other end to a doorway or chair leg. Stretch the leg outside, as far as possible and slowly come back to position. Muscles stretched in this exercise are TFL, Gluteus medius and gluteus minimus.TFL Trigger PointingA trained person should help you in this exercise. A massage ball is laid on the bad side, under the TFL and moved around. It helps in identifying the painful or sensitive spot. The pressure is maintained for 10 – 15 seconds till the tenderness decreases. It should be done twice in the beginning, and repeated every 2-3 hours.Squatting ExerciseSquats are helpful in strengthening the TFL muscle and also in increasing the hip rotation and flexion. To start stand with the feet at shoulder distance, keep the back straight and abdominal muscles pulled in. Bend your knees while pushing the butt out, till your thighs are parallel to the floor. Push upwards from the heels and stand straight. This can be done 5 to 10 times.Watch this video to learn how to stretch TFL (tensor fascia latae) the right way.

BicepsLoadTest:Thistestassessestheintegrityofthesuperiorlabrum.Patientissupinewithshoulderabductedto90degreesandexternallyrotated,andforearmissupinated.Therapistpassivelyexternallyrotatestheshoulderuntilthepatientbecomesapprehensive.Rotationisstoppedandthetherapistresistselbowflexionwhileinthisposition.Ifapprehensiondecreasesorthepatientfeelsmorecomfortable,thetestisnegativeforaSLAPlesion.Ifpainstaysthesameorworsensandapprehensionremains,thetestisconsideredpositiveBicepsLoadTestII:ThistestisalsousedtoassessforaSLAPlesionPatientpositionissameasthebicepsloadtestexceptarmisabductedto120degrees.Elbowisbentto90degreesofflexion,forearminsupination.Therapistmovesarmtoendrangeexternalrotation.Inthisposition,theexaminerresistselbowflexion.PainduringflexionisapositivesignCrankTest:Thistestisusedtoevaluatethedifferentglenohumeralligamentsorforanteriorshoulderinstability.ThistestmayalsobeusedtoassessalabraltearWiththesubjectstanding,theexaminerplacesthedistalhandonthesubject’selbowandtheproximalhandonthesubject’sproximalhumerusandthenpassivelyelevatesthesubjectsshoulderto160degreesinthescapularplane.Withthedistalhand,theexaminerappliesaloadalongthelongaxisofthehumeruswhiletheproximalhandexternallyandinternallyrotatesthehumerusDropArmTest:Totestforsupraspinatustears“Patientisseatedwithexaminertothefront.Examinergraspsthepatient’swristandpassivelyabductsthepatient’sshoulderto90degrees.Examinerreleasesthepatient’sarmwithinstructionstoslowlylowerthearm.Testispositiveifthepatientisunabletolowerhisorherarminasmooth,controlledfashionFullCanTest:Thistestassessesforsupraspinatuspathology.Patientisseatedorstandingwitharmraisedinthescapularplaneto30-45degrees(someauthorssuggest90degreedwithshoulderexternallyrotated.Thetherapistappliesadownwardforcejustproximaltothepatient’swristwhilethepatientresists.Testispositiveifitelicitspainand/orweakness.:Apositivetestindicatesateartothesupraspinatustendonormuscleandcanalsoindicateaneuropathyofthesuprascapularnerve.Thepatientactivelyabductsthearmto90degreeswiththethumbsupwhichmakesthefullcanposition.Theexaminerthenprovidesdownwardpressureonthearmtotestthepatient’sstrength.Thepatientthenelevatesthearmsto90degreesandhorizontallyadducts30degreestothescapularplanewiththumbsdowntotheemptycanposition.Theexaminerprovidesdownwardpressuretotestthepatient’sstrengthinthisposition.Apositivetestforrotatorcufftearismoreweaknessintheemptycan,patientcomplaintofpain,orboth.Hawkins-KennedyImpingementTest:Thepatientstandswhiletheexaminerforwardflexesthearmto90degreesandthenforciblymediallyrotatestheshoulder.ThetestmaybeperformedindifferentdegreesofforwardflexionorhorizontaladductionHorizontalAdductionTest:TestsforACjointdamageorsub-acromialimpingementWiththepatientinasittingpositiontheexaminerstandswithonehandontheposterioraspectoftheshouldertostabilizethetrunkandtheotherhandholdingthesubjectselbowofthearmbeingtested.WiththetrunkstabilizedtheexaminerpassivelymovestheshoulderintomaximumhorizontaladductionHornblower’sSign(PatteTest):Thistestisusedtodeterminethestrengthoftheteresminor1.Boththetherapistandthepatientarestanding.Thetherapistelevatesthepatient’sarmto90degreesinthescapularplane.Thetherapistthenflexestheelbowto90degrees,andthepatientisaskedtolaterallyrotatetheshoulder.Apositivetestoccurswithweaknessand/orpainInfraspinatusTest:ThistestassessesforinfraspinatusstrainThepatientstandswiththearmatthesidewiththeelbowat90degreesandthehumerusmediallyrotatedto45degrees.Thetherapistappliesamedialrotationforcethatthepatientresists.PainortheinabilitytoresistmedialrotationindicatesapositivetestforaninfraspinatusstrainJerkTest:Testsforposteriorinstability/tornposteriororposteroinferiorlabrumWiththepatientseatedtheexaminergraspstheelbowwithonehandandthescapularwiththeotherandelevatesthepatient’sarmto90°ofadductionandinternalrotation.Followingthistheexaminerprovidesanaxialcompressionloadtothehumerusthroughtheelbowmaintainingthehorizontallyabductedposition.Thecompressionforceismaintainedastheexaminermovesthearmintohorizontaladduction.ApositivetestisindicatedbysharppainintheshoulderwithorwithoutaclickingsoundLift-offSign:TotestforalesionofthesubscapularismuscleandscapularinstabilityThepatientstandsandplacesthedorsumofthehandagainstmid-lumbarspine.Thepatientthenliftshishandawayfromtheback.Aninabilitytoperformthisactionindicatesalesionofthesubscapularismuscle.AbnormalmotionofthescapuladuringthetestmayindicatescapularinstabilityLoadandShiftTest:Thistestisusedtocheckforcapsularlaxity.Patientseatedwitharmslightlyabducted(andsupportedonpillowonlapwithelbowatapproximately90degrees).Examinerstabilizesthescapulainonehandandgraspsthehumeralheadintheotherhand,approximateshumeralheadintoglenoidfossaandappliesananteriorandposteriorforce.Excessivemovementindicateslaxityofthecapsule.Typically,thehumeralheadmovesapproximately25%ofthediameterofthehumeralhead.GradeIlaxityisindicatedby25-50%andgradeIIlaxityisindicatedbygreaterthan50%O’BrienTest:ThistestisusedtoassessforaSLAPlesionThepatientsitswiththetestshoulderin90degreesofforwardflexion,40degreesofhorizontaladduction,andmaximalinternalrotation.Theexaminerstandswithonehandgraspingthesubject’swrist.Thepatienthorizontallyadductsandflexesthetestshoulderagainsttheexaminer’smanualresistance.Thetestisthenrepeatedwiththesubject’sarminanexternallyrotatedposition.Painorpoppingintheinternallyrotatedposition(butnotintheexternallyrotatedpotition)isapositivetestPosteriorApprehensionTest:TestsfordislocationorposteriorinstabilityofthehumerusThepatientshouldbesupineorsittingwhiletheexaminerelevatesthepatient’sshoulderintheplaneofthescapulato90°whileusingtheotherhandtostabilizethescapula.Theexaminerthenappliesaforceposterioronthepatientselbowwhilehorizontallyadductingandinternallyrotatingthearm.ApprehensionisapositivesignRentSign/Test:TestsforatornrotatorcufforrotatorcuffimpingementHavethepatientseatedwitharmrelaxedandstandtotherearofthepatient.Theexaminerpalpatesanteriortotheanterioredgeoftheacromionwithonehandwhileholdingthepatient’sflexedelbowwiththeother.Theexaminerpassivelyextendstheshoulderwhileslowlyrotatingtheshoulderintoexternalandinternalrotation.Thegreatertuberositywillbeprominentandadepressionofabout1fingerwidthwillbefeltifarotatorcufftearispresentSpeed’sTest(Bicepsorstraightarmtest)：ThistestlooksforbicepsmuscleortendonpathologyThepatient’sarmisforwardflexedto90degreesandthenthepatientisaskedtoresistaneccentricmovementintoextension,firstwiththearmsupinated,thenpronated.Apositivetestelicitsincreasedtendernessinthebicipitalgroove,especiallywiththearmsupinatedYergason’sTest：ThistestisusedtochecktheabilityofthetransversehumeralligamenttoholdthebicepstendoninthebicipitalgroovePatientsitswhileexaminerstandsinfront.Thepatient’selbowisflexedto90degreesandtheforearmisinapronatedpositionwhilemaintainingtheupperarmattheside.Patientisinstructedtosupinatearmwhileexaminerconcurrentlyresistsforearmsupinationatthewrist.LocalizedpainatthebicipitalgrooveindicatesapositivetestSupineImpingementTest：ThistestisusedtoscreenforshoulderimpingementPatientisinasupinepositionwithexamineratthesideoftheinvolvedarm.Examinergraspsthepatient’swristanddistalaspectofthehumerusandelevatesthepatient’sarmtoendrange.Examinermovesthepatient’sarmintoexternalrotationandadductsthearmtothepatient’sear.Next,theexaminerinternallyrotatesthearm.ApositivetestisindicatedbysignificantincreaseinshoulderpainACShearTest:TotestforacromioclavicularpathologyThepatientisinsittingpositionwhiletheexaminercupshisorherhandsoverthedeltoidmusclewithonehandontheclavicleandtheotheronthespineofthescapula.Theexaminerthensqueezestheheelsofthehandtogether.Abnormalmovementisapositivetest.Apley’sScratchTest:Testsforlimitationsinmotionsoftheupperextremity.Eachmotionisperformedbilaterallytocompare.Action1:Thesubjectisinstructedtotouchtheoppositeshoulderwithhis/herhand.ThismotionchecksGlenohumeraladduction,internalrotation,horizontaladductionandscapularprotraction.Action2:Thesubjectisinstructedtoplacehis/herarmoverheadandreachbehindthenecktotouchhis/herupperback.ThismotionchecksGlenohumeralabduction,externalrotationandscapularupwardrotationandelevation.Action3:Thesubjectputshis/herhandonthelowerbackandreachesupwardasfaraspossible.Thismotionchecksglenohumeraladduction,internalrotationandscapularretractionwithdownwardrotationApprehensionTestAnteriorShoulder:ThistestchecksforapossibletornlabrumoranteriorinstabilityproblemTheexaminerstandseitherbehindorattheinvolvedside,graspsthewristwithonehandandpassivelyexternallyrotatesthehumerustoendrangewiththeshoulderin90degreesofabduction.Forwardpressureisthenappliedtotheposterioraspectofthehumeralheadbytheexaminerorthetable(ifthepatientisinsupine).Apositivetestforanteriorinstabilityisifapprehensionispresentedbythepatientorifthepatientreportspain.AbdominalCompression(Belly-Press)Test:Testsforsubscapularislesion-especiallyforpatients whocannot mediallyrotatetheshoulderenoughtotakeitbehindtheback.Theexaminerplacesahandontheabdomensothattheheorshecanfeelhowmuchpressurethepatientisapplyingtotheabdomen.Thepatientplaceshisorherhandoftheshoulderbeingtestedontheexaminer’shandandpushesashardasheorshecanintothestomach.Thepatientalsoattemptstobringtheelbowforwardinthescapularplanecausinggreatermedialshoulderrotation.Itisapositivetestifthepatientisunabletomaintainthepressureontheexaminer’shandwhilemovingtheelbowforwardorifthepatientextendstheshoulder.