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Jobe's test

Jobe's test, also known as the empty can test or supraspinatus test, is a widely used orthopedic clinical examination technique designed to evaluate the strength and integrity of the supraspinatus muscle and tendon within the rotator cuff of the shoulder, aiding in the diagnosis of conditions such as rotator cuff tears, tendinopathy, impingement syndrome, or suprascapular nerve involvement.^[1]^[2] The test was originally described in 1982 by Frank W. Jobe and Diane Radovich Moynes as part of a diagnostic and rehabilitation framework for rotator cuff injuries, emphasizing the isolation of individual rotator cuff muscles to improve accuracy in identifying pathology.^[3] Jobe, a pioneering orthopedic surgeon known for contributions to sports medicine including the Tommy John surgery, developed the maneuver to specifically target supraspinatus function while minimizing deltoid involvement.^[4]

Introduction

Definition and Purpose

Jobe's test, also known as the empty can test or supraspinatus test, is a manual muscle strength assessment that evaluates the function and integrity of the supraspinatus muscle within the rotator cuff.^[5] This test was originally described by Jobe and Moynes in 1982 as a method to isolate rotator cuff muscles for precise clinical evaluation.^[6] It is distinct from the Jobe relocation test, which is used to assess anterior shoulder instability rather than rotator cuff pathology.^[7] The primary purpose of Jobe's test is to detect abnormalities in the supraspinatus tendon, including full-thickness or partial tears, tendinopathy, and subacromial impingement syndrome, by measuring the patient's ability to resist downward pressure during shoulder abduction.^[8] By focusing on the supraspinatus, which primarily initiates abduction of the humerus in the scapular plane, the test helps clinicians differentiate rotator cuff issues from other sources of shoulder weakness, such as deltoid involvement.^[5] In performing the test, the shoulder is positioned to maximize supraspinatus weakness and minimize contributions from other muscles, achieved through abduction to 90 degrees in the scapular plane combined with full internal rotation of the humerus, resembling the motion of emptying a can.^[8] This configuration isolates the supraspinatus by placing its tendon under tension while reducing the mechanical advantage of the deltoid, allowing for a targeted assessment of tendon integrity through resisted elevation.^[6]

Clinical Relevance

Jobe's test serves as a key component in the orthopedic evaluation of the shoulder, integrated into a cluster of special tests performed after obtaining patient history and conducting inspection to help differentiate rotator cuff disorders from other causes of shoulder dysfunction.^[9] This approach enhances diagnostic precision in clinical practice by isolating supraspinatus involvement within the broader rotator cuff pathology.^[2] The test is particularly relevant in common clinical scenarios characterized by shoulder pain, muscle weakness, or restricted overhead activities, including those affecting athletes engaged in throwing sports, manual laborers performing repetitive overhead tasks, and older adults experiencing degenerative joint changes.^[2] In these populations, early identification of potential issues can inform targeted interventions to mitigate functional decline.^[4] Positive findings from Jobe's test influence patient management by prompting further diagnostic steps, such as magnetic resonance imaging to confirm rotator cuff integrity, or directing conservative strategies like physical therapy focused on strengthening and mobility restoration; in cases indicative of significant supraspinatus compromise, it may lead to surgical consultation for repair.^[9] This decision-making framework supports timely escalation of care to optimize outcomes.^[4] Given the prevalence of rotator cuff tears, which impacts 20-30% of individuals over 60 years—rising from approximately 15% in the 60s to 27% in the 70s—the test holds substantial value for facilitating early detection and preventing progression to chronic impairment or arthropathy.^[10]

Background Anatomy

Shoulder Structures Involved

The supraspinatus muscle, a key component targeted by Jobe's test, originates from the supraspinous fossa of the scapula and inserts onto the superior facet of the greater tuberosity of the humerus.^[11] Its primary function is to initiate shoulder abduction and assist the deltoid in elevating the humerus to the horizontal position.^[11] The supraspinatus forms part of the rotator cuff, a group of four muscles—including the supraspinatus, infraspinatus, teres minor, and subscapularis—that collectively stabilize the humeral head within the glenoid fossa of the scapula.^[12] These muscles provide dynamic stability to the glenohumeral joint by balancing force couples in both the coronal and transverse planes, preventing excessive translation of the humeral head during movement.^[12] Related structures in the subacromial region include the subacromial space, bounded superiorly by the acromion process of the scapula and the coracoacromial ligament, which extends from the coracoid process to the acromion, forming an arch over the space.^[13] The subacromial-subdeltoid bursa lies within this space, cushioning the rotator cuff tendons, particularly the supraspinatus, against the overlying bony and ligamentous structures. Biomechanically, the supraspinatus is most active during the initial phase of shoulder abduction, from 0 to 30 degrees, where it generates the primary force for humeral elevation before the deltoid assumes greater dominance.^[14] Internal rotation of the humerus increases the supraspinatus's vulnerability in this region by narrowing the subacromial space through approximation of the greater tuberosity toward the coracoacromial arch.^[15]

Pathophysiological Basis

The supraspinatus tendon is prone to several pathologies that manifest as pain and weakness during resisted shoulder abduction. Partial or full-thickness tears may arise traumatically from acute impacts or degeneratively through chronic attrition, compromising the tendon's structural integrity and leading to humeral head instability.^[16] Tendinitis, characterized by tendon inflammation and degeneration rather than acute inflammatory processes, often stems from repetitive microtrauma, resulting in nociceptive pain and functional impairment.^[17] Calcific tendinopathy involves the deposition of hydroxyapatite crystals within the tendon substance, progressing through formative, resting, and resorptive stages; this elicits pain from localized edema and pressure, with weakness emerging from inflammatory disruption and increased rupture risk.^[18] Impingement syndrome further contributes to supraspinatus pathology by mechanically compressing the tendon beneath the coracoacromial arch, particularly during overhead elevation, which irritates the tendon and subacromial bursa. This extrinsic narrowing of the subacromial space—exacerbated by acromial morphology or humeral head migration—promotes tendinopathy, neovascularization, and progression to partial tears, amplifying pain and weakness.^[15] Intrinsic factors, such as hypovascularity in the critical zone 1 cm proximal to the insertion, compound this compression by fostering degenerative changes.^[19] Suprascapular neuropathy represents a neural etiology, where compression or traction at the suprascapular notch denervates the supraspinatus muscle, yielding isolated weakness in abduction without prominent pain if sensory branches remain unaffected.^[20] This condition often links to paralabral cysts or repetitive traction in overhead activities, mimicking tendon-related deficits.^[21] Key risk factors include age-related degeneration, with tendon degradation accelerating after age 40 and affecting over 80% of individuals beyond 80, alongside collagen disorganization and fatty infiltration.^[16] Repetitive overhead motions in sports (e.g., volleyball, swimming) or occupations induce overuse tendinopathy and impingement through cumulative microtrauma.^[17] Acute trauma, such as direct shoulder injury, can initiate tears or neuropathy, disrupting tendon and nerve integrity to provoke these abnormal states.^[19]

Performing the Test

Patient Positioning

In Jobe's test, the patient is positioned either seated or standing with the shoulders relaxed to facilitate accurate assessment of supraspinatus function.^[22] The affected arm is elevated to 90 degrees of abduction in the scapular plane, which is approximately 30 degrees anterior to the coronal plane, to optimize isolation of the supraspinatus tendon and reduce deltoid activation.^[23] This positioning aligns with the anatomical rationale for targeting the supraspinatus, as discussed in the Shoulder Structures Involved section. The elbow is fully extended, and the forearm is pronated with the thumb pointing downward, simulating the "empty can" configuration to place the supraspinatus in a position of maximum weakness and stress the tendon. This arm orientation enhances the test's specificity for supraspinatus pathology by limiting contributions from other rotator cuff muscles.^[23] The test is typically performed bilaterally to evaluate for asymmetry in strength and pain response, using the unaffected side as a baseline for comparison.^[2] This comparative approach helps distinguish unilateral deficits from generalized weakness. Precautions include avoiding the test in cases of acute shoulder inflammation or severe pain to prevent aggravation of the condition, and instructing the patient to immediately report any discomfort during positioning or testing.^[2]

Examiner Technique

The examiner stabilizes the patient's elbow with one hand to prevent compensatory scapular elevation or movement, while using the other hand to apply a downward force proximal to the wrist or along the forearm.^[24] The patient resists this force isometrically by attempting to maintain the abducted and internally rotated arm position (thumbs pointing downward, as in the empty can posture).^[25] This resistance is applied gradually, building to maximal effort over 3-5 seconds to assess the patient's ability to sustain the isometric contraction without breakdown.^[2] Key observations during force application include the onset of pain in the superior or lateral shoulder, demonstrable weakness (such as dropping of the arm or inability to resist the applied pressure), and any substitution patterns, including trapezius shrugging or excessive upper trapezius or deltoid recruitment to compensate for rotator cuff insufficiency.^[25] The examiner ensures consistent force application bilaterally for comparison, typically matching the patient's perceived maximal effort on the unaffected side.^[2] As an alternative to minimize subacromial impingement and potential false positives from the internally rotated position, the full can modification can be employed, where the patient maintains the same 90-degree abduction but with the thumbs pointing upward (slight external rotation) during resisted downward pressure.^[1]

Results and Interpretation

Indicators of a Positive Test

A positive Jobe's test is primarily indicated by pain and/or weakness elicited during resisted shoulder abduction in the described position. Pain is typically localized to the supraspinatus insertion point on the greater tuberosity or the anterolateral aspect of the shoulder, reflecting irritation or pathology in the supraspinatus tendon.^[2]^[4] This pain may be reproducible during resisted abduction between 60 and 120 degrees, a range where the supraspinatus is maximally active, and can sometimes radiate to the deltoid region. Weakness manifests as reduced strength compared to the contralateral side, often graded as 4/5 or less on the manual muscle testing scale.^[26]^[8]^[27] In cases of significant weakness, the patient may demonstrate an inability to maintain horizontal abduction against moderate examiner pressure, suggesting a full-thickness tendon tear or suprascapular nerve involvement.^[8]^[1] However, a positive result due to pain alone can represent a false positive if stemming from subacromial bursitis or impingement without rotator cuff tear, necessitating correlation with imaging or additional tests for confirmation.^[13]^[28]

Indicators of a Negative Test

A negative Jobe's test is characterized by the absence of pain during resisted shoulder abduction in the empty can position, along with the maintenance of full strength.^[29] Specifically, the patient exhibits no discomfort and achieves a strength grade of 5/5 on manual muscle testing, indicating normal supraspinatus function against downward pressure applied by the examiner.^[29] This response confirms the patient's ability to hold the abducted and internally rotated arm steadily without compensatory movements. Symmetry assessment is a key component, involving comparison to the contralateral shoulder, where equivalent resistance capacity is demonstrated bilaterally without evidence of substitution by other muscles or rapid fatigue.^[29] Such bilateral equivalence underscores the reliability of the negative finding, as any asymmetry could suggest underlying pathology, though its absence supports normal performance.^[30] Clinically, these indicators suggest an intact supraspinatus tendon and preserved suprascapular nerve function, helping to exclude primary involvement of this structure in shoulder pain.^[29] A negative result prompts further evaluation of alternative shoulder components, such as the acromioclavicular joint, through targeted tests like cross-body adduction.^[31] However, this does not definitively rule out partial-thickness supraspinatus tears, as compensation from adjacent rotator cuff muscles, such as the deltoid or infraspinatus, can obscure subtle deficits, particularly in chronic cases.^[4]

Diagnostic Utility

Evidence on Accuracy

Research on the diagnostic accuracy of Jobe's test for detecting supraspinatus tears and rotator cuff pathology shows variable sensitivity across studies, ranging from approximately 47% to 88%.^[32]^[33] A 2024 meta-analysis of 9 studies reported a pooled sensitivity of 72% (95% CI: 59%-82%) and specificity of 57% (95% CI: 44%-69%) for rotator cuff tears, with a diagnostic odds ratio of 3.54.^[34] Earlier systematic reviews reported a pooled sensitivity of 77% (95% CI: 67%-85%) for rotator cuff disease.^[35] For full-thickness tears specifically, sensitivity is often higher, around 74%-88%, particularly in studies using imaging as the reference standard for confirmation.^[36]^[33] Specificity for Jobe's test ranges from 62% to 89%, reflecting a good capacity to rule in supraspinatus pathology but with a notable risk of false positives, especially in cases of subacromial impingement.^[33]^[4] Pooled specificity from systematic analyses is approximately 67%-77%, underscoring its utility in confirming disease but highlighting limitations in distinguishing isolated tears from other shoulder conditions.^[35]^[36] Reliability assessments indicate moderate inter-rater agreement for Jobe's test, with kappa values around 0.43-0.44 in earlier studies, suggesting variability depending on examiner experience.^[37] Intra-rater reliability is generally higher, ranging from 0.6 to 0.8, as reported in reviews up to 2011 and confirmed in later analyses through 2023.^[37]^[32] More recent evaluations, including a 2023 study on single- and double-arm variants, show improved inter-rater kappa values of 0.72-0.77, indicating substantial agreement in controlled settings.^[32] Diagnostic accuracy of Jobe's test is influenced by patient factors and testing context; it performs better when clustered with other maneuvers such as the Neer or Hawkins-Kennedy tests, enhancing overall sensitivity and specificity for rotator cuff tears.^[2]^[38] However, accuracy decreases in early-stage tendinopathy, limiting its value for subtle or partial lesions without confirmatory imaging.

Comparisons and Limitations

Jobe's test, while valuable for assessing supraspinatus pathology, exhibits lower sensitivity compared to magnetic resonance imaging (MRI), which achieves sensitivities exceeding 90% for full-thickness rotator cuff tears, though it remains more accessible as a bedside clinical maneuver without the need for specialized equipment or radiation exposure.^[39]^[40] The full can modification of Jobe's test, performed with the thumb pointing upward to minimize subacromial impingement provocation, demonstrates higher specificity (up to 81%) relative to the original empty can position (62%), albeit with reduced sensitivity (70% versus 88%), making it preferable in scenarios prioritizing rule-in accuracy for supraspinatus tears.^[40] Although inferior to the lift-off test for detecting subscapularis tendon involvement—where the lift-off test offers targeted internal rotation assessment—Jobe's test complements it by providing broader rotator cuff screening, particularly for supraspinatus-dominant lesions.^[40] Key limitations of Jobe's test include its susceptibility to false positives, often arising from pain inhibition during resisted abduction, deltoid fatigue contributing to perceived weakness, or confounding conditions such as subacromial impingement, calcific tendonitis, or adhesive capsulitis.^[4]^[2] The test is not diagnostic in isolation and performs best within a cluster of maneuvers alongside patient history and imaging, as standalone use can lead to overinterpretation of nonspecific pain or weakness.^[2] It is contraindicated in cases of acute fractures, glenohumeral instability, recent surgery, or dislocations, where provocative maneuvers risk exacerbating injury.^[2] Clinical recommendations emphasize integrating Jobe's test with comprehensive history-taking and confirmatory imaging like MRI or ultrasound to enhance diagnostic confidence.^[40] Recent evaluations of the lateral Jobe variation, involving coronal plane abduction to better isolate supraspinatus activation, indicate improved sensitivity (81%) for rotator cuff tears compared to the original test (58%), supporting its adoption for refined screening.^[4] Evidence gaps persist regarding Jobe's test performance in asymptomatic populations, where rotator cuff tears occur in up to 39% of individuals over 60—often without clinical correlation—potentially leading to overdiagnosis and unnecessary interventions in older adults with incidental findings.^[41]

Historical Development

Original Description

Jobe's test, also known as the empty can test, was originally developed by Frank W. Jobe, an orthopedic surgeon renowned for his innovations in sports medicine, including the pioneering ulnar collateral ligament reconstruction procedure commonly referred to as Tommy John surgery.^[42] As the longtime physician for the Los Angeles Dodgers, Jobe focused on addressing shoulder injuries prevalent among overhead athletes, such as pitchers.^[43] The test was first described in 1982 by Jobe and Diane R. Moynes in their article titled "Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries," published in the American Journal of Sports Medicine.^[44] In this seminal work, they outlined specific maneuvers to isolate individual rotator cuff muscles during clinical evaluation, with the supraspinatus test designed to target weakness or pain in the supraspinatus tendon by positioning the arm in 90 degrees of abduction in the scapular plane and full internal rotation (thumbs pointing downward, resembling an empty can), followed by resisted downward pressure.^[3] This original formulation was informed by electromyographic (EMG) studies on shoulder function in throwing athletes, aiming to isolate supraspinatus activation while minimizing contributions from other muscles like the deltoid.^[44] The primary intent was to differentiate isolated supraspinatus pathology from broader rotator cuff deficits in overhead sports injuries, facilitating more precise diagnosis and tailored rehabilitation for athletes.^[44]

Subsequent Modifications

Following the original description of Jobe's test in 1982, subsequent modifications aimed to refine the procedure for greater clinical reliability and reduced provocation of extraneous shoulder structures. One prominent early adaptation is the full can test, introduced by Kelly et al. in 1996 through an electromyographic study of rotator cuff activation. This variant alters the hand position to neutral (thumb up) with slight external rotation of the shoulder at 90 degrees of abduction in the scapular plane, thereby minimizing subacromial impingement compared to the original empty can position while effectively isolating supraspinatus activity.^[45] In 2010, Johansen et al. proposed the lateral Jobe test as a procedural evolution to improve diagnostic precision for rotator cuff tears. Performed with the shoulder abducted 90 degrees in the coronal plane, the elbow flexed 90 degrees, and the forearm in internal rotation (thumbs pointing downward), this modification applies downward resistance to the forearm and was developed to better target supraspinatus pathology without the overhead elevation's confounding factors.^[4] A more contemporary bilateral variation, the double-arm Jobe test, was evaluated by Kim et al. in 2023 for enhanced reproducibility in clinical settings. This approach simultaneously tests both shoulders in the standard position to facilitate comparison and asymmetry detection, demonstrating moderate to substantial intra-rater reliability (kappa values ranging from 0.51 to 0.78) across examiners.^[46] By the 2010s, these adaptations gained traction in professional guidelines, including the American Academy of Orthopaedic Surgeons' clinical practice guidelines on rotator cuff injuries, which reference variants like the lateral Jobe test for routine use in evaluating diverse patient groups, including non-athletes with chronic shoulder complaints.^[47]

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