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Speed's Test of the Shoulder — Complete Guide

1. What Is Speed's Test?

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2. Relevant Anatomy

• The long head of biceps originates from the supraglenoid tubercle and glenoid labrum, passing over the humeral head as an intra-articular but extrasynovial structure
• It then descends through the bicipital groove (intertubercular sulcus) between the greater and lesser tuberosities
• It is stabilized in the groove by the coracohumeral ligament and transverse humeral ligament
• The LHBT is a shoulder stabilizer and serves as the primary supinator of the forearm and a flexor of the elbow
• The tendon travels within a synovial sheath that communicates with the glenohumeral joint — making it susceptible to both local and intra-articular inflammation

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3. How to Perform Speed's Test

Patient Position

• Patient is standing or seated
• The involved arm is at the side

Step-by-Step Technique

Positive Test

⚠️ Pain over the superior shoulder or AC joint instead of the bicipital groove suggests a different diagnosis (e.g., AC joint pathology).

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4. Mechanism — Why the Test Stresses the LHBT

• Full elbow extension — maximally lengthens and tensions the biceps muscle-tendon unit
• Forearm supination — supination is the primary action of the long head of biceps; supinating while loaded engages the LHBT maximally
• Shoulder forward flexion against resistance — creates an anterior shear force at the glenohumeral joint, directly stressing the LHBT origin at the supraglenoid tubercle and the tendon traversing the bicipital groove

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5. Diagnostic Accuracy

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6. What Speed's Test Diagnoses

Primary diagnosis: Bicipital Tendinopathy

• Bicipital tendinitis — inflammation of the LHBT and/or its synovial sheath (tenosynovitis), more common in younger patients with repetitive overhead activities
• Bicipital tendinosis — collagen degenerative changes, more common in older patients
• LHBT partial or complete tear — usually proximal; preceded by age-related microtrauma

• Middle-aged patient with repetitive overhead occupation/sport
• Anterior shoulder pain along the bicipital groove
• Pain worse at night, with external rotation, overhead activities
• Tenderness on palpation of the bicipital groove at 10° internal rotation

Secondary: SLAP Tear (Superior Labral Tear Anterior to Posterior)

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7. Imaging Correlation

MRI findings in LHBT pathology

• Ultrasound — excellent for complete rupture, subluxation, dislocation; less sensitive for partial tears; also guides injection
• MRI — preferred for labral (SLAP) evaluation and full characterization of tendon pathology

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8. Companion Tests — The Full Bicipital/Shoulder Examination

Yergason's Test

• Technique: Elbow flexed at 90°, arm adducted against body, patient supinates the forearm against the examiner's resistance
• Positive: Pain or painful pop at the bicipital groove
• Sensitivity: ~50% / Specificity: 83% / PLR: 2.20
• Target: Bicipital tendinopathy, biceps tendon stability in the groove

O'Brien (Active Compression) Test

• Technique: Shoulder flexed 90°, adducted 10–15°, internally rotated (thumb down) → examiner applies downward force; repeated with full supination
• Positive: Pain on first maneuver relieved by second → SLAP lesion
• Sensitivity: 60–100% / Specificity: 85–98%
• Target: SLAP lesions, AC joint pathology

Uppercut Test

• Technique: Shoulder neutral, elbow at 90°, forearm supinated (fist formed) — patient performs a resisted "uppercut" punch against examiner's hand
• Positive: Pain or painful pop at anterior shoulder
• PLR: 3.38 (most favorable for biceps tendinopathy diagnosis)
• When combined with ultrasound: 97% sensitivity, up to 100% specificity

Neer Impingement Sign

• Passive forward flexion >90° → pain = subacromial impingement

Hawkins-Kennedy Test

• Shoulder at 90° flexion + internal rotation → pain = impingement

Drop-Arm Test

• Inability to maintain arm in forward flexion after release = supraspinatus tear

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9. Clinical Conditions Diagnosed by Speed's Test

Bicipital Tendinitis

• Mechanism: Repetitive overhead use → microtrauma → synovial sheath inflammation
• Risk factors: Swimmers, weightlifters, overhead laborers; age >40 for tendinosis
• Associated with: Subacromial impingement, rotator cuff disease (rarely isolated)
• Management: Rest, NSAIDS, ice; ultrasound-guided corticosteroid injection (caution — direct tendon injection risks rupture); surgery for refractory cases

Biceps Tendon Rupture

• Proximal rupture (at bicipital groove/supraglenoid tubercle): most common; often spontaneous in older patients
• Classic sign: "Popeye deformity" — distal muscle belly bunches due to proximal tendon release
• Speed's test may be negative after complete rupture (nothing to stress)
• Supination is weakened; elbow flexion is relatively preserved (short head and brachialis intact)

SLAP Lesion

• Superior labral tear from anterior to posterior
• Associated with repetitive overhead (throwing athletes, swimmers)
• Speed's test sensitivity for SLAP: moderate; O'Brien test preferred

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10. Differential Diagnosis of Anterior Shoulder Pain

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11. Summary

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• Tintinalli's Emergency Medicine: A Comprehensive Study Guide, Chapter on Shoulder
• Rosen's Emergency Medicine: Concepts and Clinical Practice, Chapters 52 & 103
• Roberts and Hedges' Clinical Procedures in Emergency Medicine, Chapter 52
• Miller's Review of Orthopaedics, 9th Edition, Table 4.7

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Cubitus Varus Deformity — Comprehensive Guide

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1. Definition & Overview

• Males: 5–10°
• Females: 10–15°
• The angle normally allows the forearm to clear the hip when carrying objects — hence the name

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2. Normal Elbow Anatomy & Carrying Angle

• Disappears on full pronation
• Disappears on full flexion of the elbow
• Must be compared bilaterally

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3. Etiology & Causes

Primary (Most Common) Cause

Malunited Supracondylar Fracture of the Humerus

• Overwhelmingly the most common cause in children (peak age 5–8 years)
• Accounts for >95% of all cases of cubitus varus
• Results from malunion (not growth arrest — this is a critical distinction)
• Posteromedial angulation of the distal fragment leads to varus malalignment on healing
• The Gartland Type III fracture (completely displaced, posteromedial rotation of distal fragment) carries the highest malunion risk

Other Causes (Less Common)

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4. Pathology & Pathoanatomy

1. The distal fragment undergoes posteromedial rotation during displacement
2. If inadequately reduced or re-displaced in a cast, the fragment heals in this malrotated position
3. The result is medial tilting of the articular surface → varus carrying angle
4. Internal rotation component is frequently present but often underappreciated clinically
5. The distal humerus shows a "tilted" articular surface — the medial column is relatively lower than the lateral column

• Varus angulation (primary) — decreased carrying angle
• Internal rotation (secondary, often overlooked)
• Hyperextension deformity (may coexist)
• Lateral condyle prominence — the lateral epicondyle becomes more prominent due to the angulation, creating the characteristic "gunstock" silhouette

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5. Biomechanics

Altered Biomechanics in Cubitus Varus

Important Biomechanical Consequences:

1. Lateral compartment overloading — the medially angulated forearm transmits greater compressive force to the radiocapitellar (lateral) compartment during axial loading
2. Posterolateral rotatory instability (PLRI) — the malaligned distal humerus alters the course of the lateral collateral ligament complex. Over time, the LUCL (lateral ulnar collateral ligament) is stretched. This is the mechanism for late-onset elbow instability — a recognized late complication of untreated cubitus varus in adults
3. Valgus laxity of the medial side — the medial ulnar collateral ligament operates at a lower tension than normal, but the medial side is paradoxically less symptomatic than the lateral overloaded side
4. Snapping/subluxation of the triceps — the medial head of triceps may sublux over the medial epicondyle due to altered joint alignment, causing pain and a snapping sensation (another late complication)
5. Tardy ulnar nerve palsy (less common than in cubitus valgus) — but documented in cases where the deformity alters the cubital tunnel geometry

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6. Signs & Symptoms

Clinical Presentation

In Children (Shortly After Fracture Healing)

• Cosmetic complaint is the dominant issue
• Medial deviation of the forearm when the arm is extended
• The deformity is often not noticed initially because the elbow is swollen; becomes apparent after swelling subsides
• No pain — the deformity in children is typically painless
• Full range of motion usually preserved (elbow flexion-extension and forearm rotation intact)
• Deformity is progressive in appearance during growth (though not from growth arrest)

Clinical Signs

Late Complications (Adults with Untreated Cubitus Varus)

• Lateral elbow pain — from overloaded radiocapitellar compartment
• Posterolateral rotatory instability (PLRI) — episodic elbow instability, usually with the arm outstretched
• Snapping triceps syndrome — medial triceps subluxation causing painful snapping
• Tardy ulnar nerve palsy — late-onset ulnar neuropathy (rare, less common than in cubitus valgus)
• Osteochondral lesions of the radiocapitellar joint from chronic overloading

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7. Radiological Assessment

Standard Radiographs

The Baumann Angle (Humeral–Capitellar Angle)

AP Radiograph Findings in Cubitus Varus:

• Decreased or negative carrying angle on AP view
• Reduced Baumann angle (below normal 70–75°)
• Asymmetric metaphyseal height (medial column lower than lateral)
• Altered distal humeral shape
• Compare with contralateral normal elbow always

Additional Radiographic Lines (Lateral View):

• Anterior humeral line should bisect the middle third of the capitellum — displaced in type II/III fractures
• Fat pad signs — posterior fat pad displacement = pathologic (indicates joint effusion/fracture)

CT Scan

• Quantify degree of varus, internal rotation, and hyperextension
• Plan corrective osteotomy geometry
• Assess for associated intra-articular changes (lateral compartment OA, loose bodies)

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8. Classification

Classification of Cubitus Varus Deformity

A. Degree of Angular Deformity

B. Components of Deformity (Multiplanar Classification)

1. Varus angulation (coronal plane) — primary deformity
2. Internal rotation (axial plane) — often coexists, worsens cosmesis
3. Hyperextension (sagittal plane) — may coexist, impacts function

C. Gartland Classification (of the Causative Supracondylar Fracture)

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9. Investigations & Evaluation

Clinical Evaluation

• Prior elbow fracture in childhood (supracondylar fracture)?
• Age at injury, treatment received
• Duration and progression of deformity
• Functional complaints? (most children are asymptomatic; adults may have pain, instability)
• Dominant limb affected?

1. Inspect in anatomical position — compare carrying angles bilaterally
2. Quantify the varus angle (or loss of valgus)
3. Assess ROM — flexion-extension, pronation-supination (usually full)
4. Assess for lateral condyle prominence
5. Palpate medial epicondyle and assess ulnar nerve (Tinel's sign at cubital tunnel)
6. Lateral pivot-shift test — for PLRI (if suspected late complication)
7. Snapping triceps — check for medial triceps subluxation with flexion-extension

Imaging

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10. Treatment

Conservative (Non-surgical)

• Observation only for mild, asymptomatic deformities in children with good function
• No splinting or physiotherapy corrects an established bony deformity
• Appropriate when the deformity is cosmetically acceptable and there are no functional deficits

Surgical Treatment — Corrective Osteotomy

• Moderate-to-severe deformity with cosmetic concern
• Functional impairment
• Pain (lateral compartment overloading)
• Posterolateral rotatory instability
• Snapping triceps syndrome
• Tardy nerve palsy

Types of Corrective Osteotomy

• A wedge of bone is removed from the lateral side of the distal humerus (supracondylar region)
• The wedge is sized to correct the varus angle
• Medial cortex remains as a hinge
• Fixation: K-wires (crossed pins), plate and screws
• Advantages: Simple, reproducible, widely used
• Disadvantages: Increases lateral condyle prominence; does not correct rotational component

• Curved cut allows correction in multiple planes simultaneously
• Addresses varus AND rotation in one procedure
• Technically more demanding

• Step-shaped cut provides inherent stability
• Good rotational control

• A wedge is opened on the medial side
• Less popular; requires bone graft

• Modified lateral closing wedge with internal rotation correction
• Specifically designed to address the rotational component

• Crossed K-wires — most commonly used in children; removed at 4–6 weeks
• Plate and screws — preferred in adolescents and adults for stability
• External fixator — for complex or revision cases

Postoperative Management

• Long-arm cast/splint at 90° elbow flexion for 4–6 weeks
• K-wires removed at 4–6 weeks under sedation
• Physiotherapy for ROM recovery (though ROM usually returns spontaneously in children)
• Expected correction to normal or slight overcorrection to valgus (5–10°)

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11. Complications of Cubitus Varus (Untreated) & Post-Surgical

Untreated Complications

Post-Surgical Complications

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12. Cubitus Varus vs Cubitus Valgus — Comparison

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13. Summary

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• S. Das: A Manual on Clinical Surgery, 13th Edition, Chapter 13
• Miller's Review of Orthopaedics, 9th Edition, Chapters 4 & 11
• Rosen's Emergency Medicine, 8th Edition, Chapter 170
• Bailey and Love's Short Practice of Surgery, 28th Edition, Chapter 35