Shoulder Upper Cut Test

The evaluation of shoulder pathology requires a comprehensive approach utilizing various clinical tests to accurately diagnose specific conditions. Among these diagnostic maneuvers, the Upper Cut Test has emerged as a valuable tool for identifying biceps tendon pathology, particularly long head of biceps (LHB) tendinopathy or instability. This article explores the Upper Cut Test’s technique, diagnostic value, and clinical applications.

Anatomy and Biomechanical Basis

The biceps brachii muscle consists of two heads – the long head and the short head. The long head originates from the supraglenoid tubercle and superior labrum, travels through the bicipital groove, and joins the short head to insert on the radial tuberosity. Due to its intra-articular course and functions in both shoulder and elbow movements, the LHB is susceptible to various injuries including tendinopathy, tears, and instability within the bicipital groove.

The Upper Cut Test specifically targets the assessment of biceps tendon pathology by recreating the biomechanical stresses placed on the tendon during combined shoulder and elbow movements that mimic the boxing “upper cut” motion.

See Also: Long Head of Biceps Tendon

How to Perform the Upper Cut Test?

The Upper Cut Test is performed as follows:

The patient stands with the shoulder in neutral position alongside the body. The elbow is flexed to 90 degrees, with the forearm fully supinated and the hand closed in a fist. The examiner places one hand over the patient’s fist to provide resistance. The patient is then instructed to quickly and forcefully perform an “upper cut” boxing motion, bringing the fist upward and toward the chin.

During this movement, the examiner observes for signs of pain, discomfort, or a painful clicking or popping sensation in the anterior shoulder region. The test is considered positive when the patient experiences pain or a painful pop over the anterior aspect of the shoulder during the maneuver, suggesting biceps tendon pathology.

Diagnostic Value

The diagnostic utility of the Upper Cut Test lies in its ability to specifically load the biceps tendon through a combined movement pattern. When the patient performs the upper cut motion, the biceps contracts forcefully while the shoulder moves through internal rotation and elevation, placing significant stress on the LHB tendon.

This test has demonstrated clinical value in detecting various biceps tendon pathologies, including:

• Long head of biceps tendinopathy or tendinitis
• Partial tears of the biceps tendon
• Biceps instability or subluxation within the bicipital groove
• SLAP (Superior Labrum Anterior to Posterior) lesions

The Upper Cut Test should be interpreted within the context of a comprehensive shoulder examination. It is particularly valuable when combined with other provocative tests for biceps pathology, such as Speed’s test, Yergason’s test, and the Active Compression Test (O’Brien’s test).

In a Cohort study on a total of 325 consecutive patients who were seen for shoulder pain underwent a standardized clinical testing battery, For biceps disease, the bear hug and upper cut were most sensitive (0.79 and 0.73, respectively), whereas the belly press and Speed’s test were most specific (0.85 and 0.81, respectively). The upper cut was most accurate (0.77) and produced the highest positive likelihood ratio (3.38).

For labral injury, the modified dynamic labral shear demonstrated sensitivity of 0.72, specificity of 0.98, accuracy of 0.84, and a positive likelihood ratio of 31.57. A binary logistic regression analysis revealed that the combination of the upper cut and Speed’s tests were significantly better at detecting biceps lesions (P = .021, R(2) = .400) than other tests, whereas labral lesions were best identified by combination of the modified dynamic labral shear and O’Brien’s maneuvers (P = .045, R(2) = .641).

Clinical Context and Interpretation

In clinical practice, the Upper Cut Test should not be used in isolation but rather as part of a systematic approach to shoulder evaluation. The test’s sensitivity and specificity vary depending on the specific biceps pathology being assessed. Therefore, correlation with patient history, physical examination findings, and advanced imaging is essential for accurate diagnosis.

When a patient presents with anterior shoulder pain, particularly with overhead activities or resistive elbow flexion and forearm supination, the Upper Cut Test can help differentiate biceps tendon pathology from other sources of anterior shoulder pain such as rotator cuff tears, acromioclavicular joint disorders, or glenohumeral instability.

It is important to note that a positive Upper Cut Test may indicate various biceps pathologies, necessitating further diagnostic evaluation. Ultrasonography, MRI, or MR arthrography may be required to confirm the specific diagnosis and determine the extent of pathology.

Treatment Implications

Identifying biceps tendon pathology through tests like the Upper Cut Test has significant treatment implications. Conservative management of biceps tendinopathy typically includes rest, activity modification, anti-inflammatory medications, physical therapy, and occasionally, corticosteroid injections.

For cases of biceps instability or partial tears that do not respond to conservative treatment, surgical interventions such as biceps tenotomy or tenodesis may be considered. The specific surgical approach depends on various factors including patient age, activity level, and concomitant shoulder pathologies.

See Also: Biceps Tendonitis

Limitations

Despite its clinical utility, the Upper Cut Test has certain limitations. The test may produce false-positive results in patients with concomitant shoulder pathologies, particularly those affecting the anterior structures such as the subscapularis or anterior labrum. Additionally, patients with significant pain may be unable to perform the test properly, limiting its diagnostic value in acute cases.

The test’s reliability and validity have been less extensively studied compared to other commonly used shoulder tests, highlighting the need for further research to establish its precise diagnostic metrics.

Conclusion

The Upper Cut Test represents a valuable addition to the shoulder examination toolkit for clinicians evaluating potential biceps tendon pathology. By simulating the stresses placed on the biceps during a specific movement pattern, the test can help identify various biceps-related conditions. However, like all clinical tests, it should be integrated into a comprehensive clinical evaluation rather than used as a standalone diagnostic tool.

Understanding the proper technique, interpretation, and limitations of the Upper Cut Test enhances the clinician’s ability to accurately diagnose and effectively manage biceps tendon pathologies, ultimately improving patient outcomes.

Resources

• Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009;80(5):470-476. https://www.aafp.org/pubs/afp/issues/2009/0901/p470.html
• Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. 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 Sep;37(9):1840-7. doi: 10.1177/0363546509332505. Epub 2009 Jun 9. PMID: 19509414. Pubmed
• Narvani AA, Imam MA, Godenèche A, et al. Degenerative rotator cuff tears, biceps tendinopathy, and long head of the biceps tendon insertion: which is the cause and which is the effect? Arthroscopy. 2020;36(1):173-185. https://www.arthroscopyjournal.org/article/S0749-8063(19)30828-0/fulltext
• Taylor SA, Newman AM, Nguyen J, et al. The “3-pack” examination is critical for comprehensive evaluation of the biceps-labrum complex and the bicipital tunnel: a prospective study. Arthroscopy. 2017;33(1):28-38. https://www.arthroscopyjournal.org/article/S0749-8063(16)30585-4/fulltext