Hara Test

Original Editor - Wataru Okuyama

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Introduction[edit | edit source]

Most baseball players don't know what's wrong with their bodies that prevents them from throwing[1]. Therefore, the players needs to be aware of any abnormal physical findings. The 11 items of shoulder physical examination used by the author were used to help the players experience their own abnormalities. The next step is to improve the accuracy of the diagnosis by incorporating the findings of X-ray and ultrasound examinations, which are supplementary diagnostic methods. When an player comes to the hospital complaining of shoulder pain, it is important to evaluate the player's medical condition, including an imaging evaluation based on his or her physical findings, rather than an imaging evaluation itself. The Hara test is useful for assessing abnormalities in the kinetic chain of upper extremity leading to shoulder pain in patients with throwing disorder and provides a more effective basis to understand the clinical course for a return to pitching[2]. The Hara test is useful for assessing abnormalities in the kinetic chain of upper extremity leading to shoulder pain in patients with throwing disorder[3]. The Hara test consists of 11 physical examinations items that are associated with the scapular and humeral kinetic chain.

Scapula Spine Distance: SSD[edit | edit source]

In the scapula-spine distance test, the distance from the medial edge of the scapular spine to spinous process of the thoracic spine is measured with the arms at the sides. The reference point on the thoracic spine is defined as the nearest spinous process. A difference of more than 1.0 cm between the left- and right-side measurements is considered abnormal.

Scapula spine distance.png

Combined Abduction Test: CAT[edit | edit source]

Combined abduction test for assessment of posterior shoulder tightness. The examiner completely prevents any movement of the scapula by holding it. The humerus is passively abducted in the coronal plane. This test is considered abnormal when the upper arm fails to touch the head during glenohumeral abduction with a fixed scapula.


Horizontal Flexion Test: HFT[edit | edit source]

To assess the posterior tightness of the shoulder joint, subjects perform the combined abduction test and horizontal flection test while the examiner fixes the scapula and prevents it from moving by holding it. The humerus is passively abducted in the coronal plane for the combined abduction test and horizontally flexed for the horizontal flexion test. If the subject's upper arm fails to touch his/her head during glenohumeral abduction with afixed scapula, the combined abduction test is graded as abnormal. The horizontal abduction test is considered abnormal when the subject is unable to reach around the other shoulder to touch the bed during horizontal flexion with a fixed scapula.


Muscle Testing of Infraspinatus(ISP), Supraspinatus(SSP) & Subscapularis(SSC)[edit | edit source]

Assessment of rotator muscle strength, including rotator cuff function, is necessary. Muscle stresngth is evaluated by manual muscle testing on a scale of o-5. We assess the muscle strength of shoulder abduction with the subject's thumb up; this is known as the "full can position"[6]. We measure external rotation strength, with the subject's arm at his/her back[7]. We consider the results of the elbow extension test, elbow push test, and manual muscle testing of abduction, external rotation, and internal rotation to be abnormal when the muscle strength on the dominant side is less than that on non-dominant side.

Elbow Push Test: EPT[edit | edit source]

To assess the scapular stabilizers, the elbow push test and elbow extension test are performed with the shoulders in 90° of forward flexion. For the elbow push test, while grabbing the contralateral elbow with each hand, the subject pushes each elbow in turn anteriorly with maximum force as the examiner resists the subject's pushing by holding the elbow.
Elbow push test.png

Elbow Extension Test: EET[edit | edit source]

Using the same technique as the manual strength test of the triceps muscle, auto-extension from 100° of elbow flexion in the evaluation of triceps muscle on the side of throwing disorder may cause weakness or weakness.
Elbow extension test.png

Capsular Laxity Test[edit | edit source]

Capsular laxity is evaluated by load-and shift testing in the anterior, posterior, and inferior directions; anterior apprehension and relocation tests are also done. When the dominant side shows increased laxity, or when the subject feels that the shoulder is unstable during any test, capsular laxity is considered abnormal.

Subacromial Impingement Test[edit | edit source]

To evaluate subacromial impingement, we perform the Neer[12], Hawkins[13], and Yocum tests. If the subject feels shoulder pain during any of these tests, subacromial impingement testing is graded as abnormal.

Hyper External Rotation Test: HERT[edit | edit source]

This test evaluates peel back of the superior labrum[14][15][16] and pathologic internal impingement[17][18][19]. The test performed in 90° of shoulder abduction with the elbow flexed at 90°. The test is considered to be abnormal when a subject feels pain as the examiner applies external rotation torque beyond the maximum external rotation position.

The number of "intact" results among the 11 physical examinations is recorded as the total Hara test score for each subject. The maximum total score (11 points) represents all "intact" results (i.e., no abnormality found) for all tests; subjects with lower scores are considered likely to have a problem in the upper-extremity kinetic chain. Despite there being little evidence to support this test is a new test in its infancy that is still being monitored and as such does not have any data to support it or negate it.

References[edit | edit source]

  1. Masafumi H. Rehabilitation of Throwing Shoulder. The Japanese Journal of Rehabilitation Medicine, 2018, 55.6: 495-501.
  2. Teruhisa M. Current concepts: arthroscopic treatment of articular-sided partial-thickness rotator cuff tears. In: Sports Injuries to the Shoulder and Elbow. Springer, Berlin, Heidelberg, 2015. p. 85-97.
  3. Somu K, Noriaki M, Yukio U, Junpei S, Kei A, Ryohei S, Kazutaka Y, Masafumi H. Effect of short-term intervention on infraspinatus muscle activity during throwing motion and physical examination in baseball players with throwing disorder. Isokinetics and Exercise Science, 2020, Preprint: 1-9.
  4. maxthrow. Combined Abduction Test. Available from: https://youtu.be/gIl5mUzEhGk?t=1 [last accessed 15/10/2020]
  5. maxthrow. Horizontal flexion test. Available from: https://youtu.be/E6ARdaT3h20 [last accessed 10/15/2020]
  6. Kelly BT, Kadrmas WR, Speer KP. The manual muscle examination for rotator cuff strength. An electromyographic investigation. Am J Sports Med. 1996 Sep-Oct;24(5):581-8.
  7. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Joint Surg Br. 1991 May;73(3):389-94.
  8. Ccedseminars. Full Can Test. Available from: https://youtu.be/SGEIKmiP09s [last accessed 22/10/2020]
  9. AMBOSS: Medical Knowledge Distilled. Examination of the Rotator Cuff - Infraspinatus Test - Clinical Examination. Available from: https://youtu.be/R67cIKM3EAM [last accessed 20/10/2020]
  10. Scott Sailor. Shoulder - Apprehension Test. Available from: https://youtu.be/_JA-qvXcUdQ [last accessed 20/10/2020]
  11. UW - Department of Family Medicine and Community Health. Apprehension-Relocation Test. Available from: https://youtu.be/qKqJRrms4u8 [last accessed 20/10/2020]
  12. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972 Jan;54(1):41-50.
  13. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980 May-Jun;8(3):151-8.
  14. Mihata T, McGarry MH, Tibone JE, Abe M, Lee TQ. Type II SLAP lesions: a new scoring system--the sulcus score. J Shoulder Elbow Surg. 2005 Jan-Feb;14(1 Suppl S):19S-23S.
  15. Burkhart SS, Morgan CD. The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy. 1998 Sep;14(6):637-40.
  16. Mihata T, McGarry MH, Tibone JE, Fitzpatrick MJ, Kinoshita M, Lee TQ. Biomechanical assessment of Type II superior labral anterior-posterior (SLAP) lesions associated with anterior shoulder capsular laxity as seen in throwers: a cadaveric study. Am J Sports Med. 2008 Aug;36(8):1604-10.
  17. Jobe CM. Superior glenoid impingement. Current concepts. Clin Orthop Relat Res. 1996 Sep;(330):98-107.
  18. Mihata T, McGarry MH, Kinoshita M, Lee TQ. Excessive glenohumeral horizontal abduction as occurs during the late cocking phase of the throwing motion can be critical for internal impingement. Am J Sports Med. 2010 Feb;38(2):369-74.
  19. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J, Kennedy R. Scapulothoracic motion in normal shoulders and shoulders with glenohumeral instability and impingement syndrome. A study using Moiré topographic analysis. Clin Orthop Relat Res. 1992 Dec;(285):191-9.
  20. maxthrow. Hyper external rotation test. Available from: https://youtu.be/9Yu6lY2k4oA [last accessed 15/10/2020]