Study guide
2.1 Shoulder & Upper Extremity Diagnostics
ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam
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1 Chapter 1: Introduction & Exam Overview
1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown
2 Chapter 2: Musculoskeletal Medicine
2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns
3 Chapter 3: Spinal Cord Injury Rehabilitation
3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications
4 Chapter 4: Stroke & Neuromuscular Rehabilitation
4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder
5 Chapter 5: Electrodiagnostics (EMG/NCS)
5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies
6 Chapter 6: Traumatic Brain Injury
6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols
7 Chapter 7: Chronic Pain & Interventional Spine
7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy
8 Chapter 8: Amputee Rehabilitation & Prosthetics
8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain
9 Chapter 9: Pediatric Rehabilitation
9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders
10 Chapter 10: Prosthetics, Orthotics & Assistive Technology
10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping
11 Chapter 11: Medical Rehabilitation & Outcomes
11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation
12 Chapter 12: Cardiopulmonary Rehabilitation
12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management
13 Chapter 13: Foundational Rehabilitation Concepts
13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment
2.1 Shoulder & Upper Extremity Diagnostics
Key Takeaways Explain This Topic AI
Supraspinatus tears are identified using Empty Can and Full Can tests, while Hornblower sign isolates teres minor pathology and Gerber Lift-Off isolates subscapularis.
Subacromial impingement involves compression under the coracoacromial arch; Hawkins-Kennedy and Neer maneuvers provoke pain, confirmed by subacromial lidocaine injection.
Adhesive capsulitis presents with a capsular pattern restriction (External Rotation > Abduction > Internal Rotation) affecting both active and passive ROM, strongly associated with Diabetes Mellitus.
Glenohumeral anterior instability is diagnosed using Apprehension and Relocation tests, while sulcus sign indicates inferior multidirectional instability.
Last updated: July 2026
2.1 Shoulder & Upper Extremity Diagnostics
Physical Medicine and Rehabilitation (PM&R) physicians must master the diagnostic evaluation of shoulder and upper extremity disorders. Accurate diagnosis relies on integrating anatomical knowledge, targeted history, and structured physical examination maneuvers.
Rotator Cuff Pathology
The rotator cuff consists of four muscles that stabilize the glenohumeral joint and execute multiplanar movements: the supraspinatus (abduction, dynamic humeral head depression), infraspinatus (external rotation), teres minor (external rotation with shoulder abducted), and subscapularis (internal rotation). Spectrum of pathology ranges from subacromial tendinopathy to full-thickness tears and rotator cuff tear arthropathy.
Clinical Examination of Rotator Cuff Muscles
Supraspinatus : Tested via the Jobe / Empty Can test (shoulder abducted 90° in scapular plane, internally rotated with thumb down; resisted downward pressure). The Full Can test (thumb up) provides equal accuracy with less pain. Massive tears present with a positive Drop Arm test (inability to lower arm smoothly from full passive abduction).
Infraspinatus & Teres Minor : Evaluated with resisted external rotation at the side. An External Rotation Lag sign indicates severe infraspinatus and supraspinatus tears. The Hornblower sign (arm held in 90° abduction, flexed 90° at elbow; positive if arm drops into internal rotation during resisted external rotation) isolates teres minor pathology.
Subscapularis : Tested via the Gerber Lift-Off test (lifting dorsum of hand off lumbar spine). If internal rotation range of motion is restricted, the Belly Press test or Bear Hug test are sensitive alternatives.
Subacromial Impingement Syndrome
Subacromial impingement involves dynamic or structural compression of the supraspinatus tendon, subacromial bursa, and long head of biceps tendon beneath the coracoacromial arch. Structural factors include acromial morphology, categorized by Bigliani classification :
Type I : Flat (lowest association with tears).
Type II : Curved (parallel to humeral head).
Type III : Hooked (highest correlation with rotator cuff tears).
Provocative Impingement Signs
Neer Impingement test : Examiner stabilizes scapula while passively flexing the patient's arm overhead in maximal internal rotation (forearm pronated). Pain indicates positive impingement.
Hawkins-Kennedy test : Shoulder flexed 90° with elbow flexed 90°. Passive forced internal rotation compresses supraspinatus against coracoacromial ligament.
Neer Diagnostic Injection Test : Subacromial injection of 10 mL 1% lidocaine. Relief of pain confirms subacromial impingement vs cervical or intra-articular pathology.
Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis is characterized by chronic inflammation, hypervascular synovitis, and progressive capsular fibrosis leading to contracture of the glenohumeral capsule, particularly the coracohumeral ligament and rotator interval .
Risk Factors and Pathophysiology
Strongly associated with Diabetes Mellitus (incidence up to 20%), thyroid disorders, Dupuytren disease, Parkinson disease, post-cardiac surgery, and prolonged immobilization. Female sex and age 40–60 years are major demographic risk factors.
Clinical Stages
Stage 1 (Pre-freezing / Painful Phase) (0–3 months): Insidious onset of severe achy night pain. Minimal motion loss.
Stage 2 (Freezing Phase) (3–9 months): Severe pain with progressive loss of active AND passive motion in a classic capsular pattern : External Rotation > Abduction > Internal Rotation .
Stage 3 (Frozen Phase) (9–15 months): Pain decreases, but severe global motion restriction persists with a fibrotic capsular end-feel.
Stage 4 (Thawing Phase) (15–24+ months): Pain is minimal. Slow, spontaneous regain of shoulder range of motion.
Acromioclavicular (AC) Joint Pathology
Acromioclavicular joint disorders arise from post-traumatic separation or degenerative acromioclavicular osteoarthritis .
Cross-body Adduction test : Shoulder flexed to 90° and passively adducted across chest. Localized pain over the AC joint confirms AC pathology.
O'Brien Active Compression test : Shoulder flexed to 90°, adducted 10°, internally rotated (thumb down); downward force is applied. Test repeated in supination (thumb up). Superior AC joint pain in thumb-down position indicates AC arthritis; deep intra-articular pain indicates a Superior Labrum Anterior to Posterior (SLAP) lesion .
AC Shear test : Squeezing anterior acromion and posterior clavicle together compresses the AC joint, reproducing pain.
Glenohumeral Instability
Glenohumeral instability spans traumatic anterior subluxation to atraumatic multidirectional instability.
Diagnostic Classification
TUBS : Traumatic, Unidirectional, Bankart lesion, Surgery indicated (anterior-inferior disruption).
AMBRI : Atraumatic, Multidirectional, Bilateral, Rehabilitation first-line, Inferior capsular shift if non-operative care fails. Associated with systemic hypermobility ( Beighton score ≥ 5/9).
Physical Exam Maneuvers
Apprehension Test : Patient supine; shoulder abducted 90° and passively externally rotated. Positive sign is subjective sense of impending dislocation.
Relocation Test : Posterior-directed force on anterior proximal humerus relieves apprehension and allows further external rotation.
Surprise / Release Test : Sudden removal of relocation force causes immediate return of apprehension.
Sulcus Sign : Downward traction at elbow with arm at side; visible depression (>1–2 cm) below acromion indicates inferior instability.
Bicipital Tendinopathy and Subluxation
The long head of the biceps tendon (LHBT) travels inside the bicipital groove held by the transverse humeral ligament and rotator interval roof.
Speed Test : Resisted shoulder flexion with elbow extended and forearm supinated. Bicipital groove pain indicates tendinopathy or SLAP lesion.
Yergason Test : Resisted forearm supination and external rotation with elbow flexed 90°. Bicipital groove pain indicates tendinopathy; a palpable pop indicates transverse ligament disruption with biceps tendon subluxation .
- Diagnostic Maneuver Targeted Structure / Pathology Primary Clinical Finding
- Jobe / Empty Can Test Supraspinatus Tendon Weakness/pain with resisted abduction in scapular plane
- Hawkins-Kennedy Test Subacromial Impingement Pain with passive internal rotation at 90° flexion
- Cross-body Adduction AC Joint Pathology Localized superior shoulder pain at AC joint
Apprehension & Relocation Anterior Glenohumeral Instability Apprehension relieved by posterior humeral translation