Scientific Research Journal of India (SRJI) Volume 3 Issue 4 2014

The Modified Prayer Test: a new clinical test for the diagnosis
of anterosuperior dysfunction of sternoclavicular joint
Krishna Nand Sharma, PhD

*Dean- St. Louis University Institute of Health & Biomedical Sciences, Mile III Nkwen, P.O. Box 661, Bamenda, North West Region,
Cameroon. Email: me@drkrishna.co.in Cont: +237-670556171.

Abstract

Purpose: A new clinical test for the diagnosis of anterosuperior dysfunction of the sternoclavicular joint is
described. This prospective study on four groups of patients divided subjects on the basis of type of
sternoclavicular dysfunction (by shrug test and prayer test). The hypothesis was that this clinical test would be
diagnostic the patients, osteopaths, therapists and patients.

Methods: In a period of 4 months, a team of 5 osteopaths and 5 physiotherapists from St. Louis University
Institute of Health and Biomedical Sciences (Cameroon) and Academy of Krishnas Kinetikinematic Manual
Therapy (India) collected data on 300 patients with sternoclavicular joint dysfunction and 100 individuals
without sternoclavicular joint dysfunction. Patients were divided into 4 equally sized groups on the basis of the
finding of the aforementioned tests. Group A consisted 100 patients with positive shrug test, Group B consisted
100 patients with positive prayer test, Group C consisted 100 patients with positive shrug test and prayer test
both, and Group D consisted 100 individuals with negative shrug or prayer test.

Results: At end of the study, Modified Prayer test was found as sensitive as the Shrug test and Prayer test. But
the Modified Prayer test proved to save 44.14% time in diagnosing sternoclavicular dysfunction.

Conclusion: Modified Prayer test was sensitive to diagnose both inferior and posterior dysfunction. The clinical
relevance is that it may save time of the clinicians in diagnosing a two dimensional dysfunction.

Keywords: Sternoclavicular joint, Somatic Dysfunction, Shrug test, Prayer test, Modified Prayer test

Introduction is the most common SC joint dysfunction[5][6] and it

may be caused by an indirect lateral compression
The sternoclavicular (SC) joint contributes to the
force applied to the anterolateral aspect of the
biomechanics of the shoulder girdle and allows the
posteriorly rolled shoulder.[7] The anterior or
clavicular motion during the arm elevation[1] and
anterosuperior displacement can cause restriction to
the ligaments around SC joint check the downward
posterior or posteroinferior glide of the sternal end
displacement of the distal clavicle[2].
of clavicle.
The SC joint dysfunction may be due to
The superior or anterior dysfunction of SC joint
dislocation, subluxation or joint restriction because
can be diagnosed by Shrug test and Prayer test.[8][9]
of direct trauma or indirect force. Indirect force is
The Shrug test evaluates the superior position and
the most common mechanism of SC joint
inferior glide of the sternal end of clavicle during
injury.[3][4] Anterior or anterosuperior displacement
shoulder elevation whereas the Prayer test

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Scientific Research Journal of India (SRJI) Volume 3 Issue 4 2014

evaluates the anterior position and posterior glide level of both sidess by looking at the fingers. If one
of the sternal end of clavicle during protraction.
protraction finger is more anterosuperior, then the SC joint
Though scholars have recommend these tests to be motion of that side is restricted.
part of routine shoulder examination[9][10], the
limitations with these tests are that these are
performed separately and evaluate only one degree
of freedom at a time.

In 2015, the authors modified the Prayer test as

Modified Prayer Test and put into practice. This
new test proved to be a time saving diagnostic tool
where the clinician may evaluate the anterosuperior
position and expected posteroinferior glide of
sternal end of clavicle during a combined motion of
shoulder flexion, slight adduction and protraction.
protraction
This test has never been described in the literature
to the best of the authors knowledge. In this paper,
the authors describe this new test and its use in a
prospective study performed with 400 patients and
healthy individuals.

Materials and Methods Picture 1: Therapist performing modified prayer test

Modified Prayer test Prospective study

he patient lies in supine position and the therapist

The In a period of 4 months, a team of 5 osteopaths and

stands near the patients head with his dominant 5 physiotherapists from St. Louis University
Institute of Health and Biomedical Sciences
eye in the middle of the body. The therapist places
the index fingers of both hands over the (Cameroon) and Academy of Krishnas

anterosuperior aspect of the sternal ends of both Kinetikinematic Manual Therapy (India) collected

clavicles and compares the level of his fingers data on 300 patients with sternoclavicular joint
dysfunction and 100 individuals without
(picture 1a). The
he patient is asked to extend both
b the
elbows, adduct the arms and touch the palms sternoclavicular joint dysfunction confirmed by

together (picture
icture 1b). Now the patient is asked to shrug test and prayer test. Patients were divided

protract the shoulders and raise both the arms
together above his/her head maintaining the
protraction and palms position (ppicture 1c). The
into 4 equally sized groups on the basis of the
finding of the aforementioned tests. Group A
consisted 100 patients with positive shrug test,
test

patient raises the arms above 90 (picture 1d) and
stops the motions when the therapists arms restrict
the motion (picture 1e).
During and after the motion, the therapist palpates
the expected posteroinferior glide and compares the
Group B consisted 100 patients with positive
prayer test, Group C consisted 100
1 patients with
positive shrug test and prayer test both, and Group
D consisted 100 individuals with negative shrug or
prayer test. The patients were added in the groups
until the number of patients/individuals became

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Scientific Research Journal of India (SRJI) Volume 3 Issue 4 2014

100. The patients who could not follow the simple Modified Prayer test took only 7.20 seconds. It
commands were excluded from the study. The means using Modified Prayer test may save
summary of demographic data (Table 1) did not 44.14% time than the combination of other two
show any significant difference among the 4 groups tests.
of patients.
Table 2 Percentage of patients and normal individuals
Table 1 Summary of Demographic Data diagnosed with Shrug test, Prayer test and Modified
Prayer test
Group Number of Sex Mean
Patients/ Age Group Positive Positive Positive
(% Male)
Participants (Years) Shrug Test Prayer Test Modified
Prayer Test
Group A 100 44 37.81
Group A 100% 0% 100%
Group B 100 48 40.11

Group C 100 45 40.79 Group B 0% 100% 100%

Group D 100 47 39.44

Group C 100% 100% 100%
Overall, the average age of the participants was
39.5413.996 years, with 46% being male and 54% Group D 0% 0% 0%

being female.
Group A (n = 100) comprised patients with positive
Statistical Analysis shrug test, group B (n = 100) comprised patients
with positive prayer test, group C (n = 100)
All the osteopaths and physiotherapists who
comprised patients with positive shrug test and
participated in data collection were trained to
positive prayer test and group D (n=100) comprised
perform Modified Prayer test by the authors. All
normal individuals negative shrug test and prayer
the evaluators were blind to the previous findings
test.
of SC dysfunction by the authors. During clinical
evaluation, every participant was evaluated by the
same series of tests, including the Shrug test and
Table 3 Mean time taken to perform Modified Prayer
Prayer test.
test and the combination of Shrug and Prayer tests

Results
Test N Mean Time Std.
The data for all the 4 groups is summarized in table (Seconds) Deviation
2 and 3.Modified Prayer test was positive in all the Modified 400 7.20 1.386
groups where one or both of the Shrug test and Prayer Test
Prayer test were positive and it was negative in the Shrug Test 400 12.89 1.524
group D (individuals without sternoclavicular joint and Prayer
dysfunction). It represents that Modified Prayer Test
test was as sensitive as the other two. The mean time taken to perform modified prayer

Table 3 shows that the combination of Shrug test test was 7.20 seconds whereas the total time to

and Prayer test took 12.89 seconds (mean) to perform the shrug test and prayer test together was

diagnose an anterosuperior dysfunction but the 12.89 seconds.

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Scientific Research Journal of India (SRJI)
Discussion
The most significant finding in this test was the
perfect agreement between the Shrug test and
Modified Prayer test as well as the Prayer test and
Modified Prayer test. The sensitivity for the
anterior, superior and anterosuperior dysfunctions
has been confirmed by the findings in 3
dysfunctional groups and 1 non-dysfunction group
in this study.
SC joint dysfunction may be asymptomatic locally,
but can cause dysfunctions at other joints and may
cause conditions like Thoracic Outlet Syndrome
(TOS). Though there is limited literature available
on SC dysfunctions, few scholars have suggested to
evaluate the SC joint dysfunction in the conditions
[11]
like shoulder pain and TOS too.
The limitation to this study is that the ability to
learn the Modified Prayer test in clinicians other
than osteopaths and physiotherapists has not been
evaluated.
Since the Modified Prayer test has been shown to
be as sensitive as Shrug test and Prayer test but less
time consuming, the clinical relevance of this
evidence is that it will save the time of the
clinician.
Conclusion
A new test to diagnose the anterosuperior
dysfunction or posteroinferior restriction of SC
joint has been described. In a prospective clinical
study, it was found as sensitive as Shrug and Prayer
tests, but proved to be a time saver during
evaluation.
References
[1] Rockwood CA Jr, Matsen FA III, Wirth MA,
Lippitt SB. (2004). The shoulder. Vol. 1. Third
edition. Philadelphia, PA: Saunders, 223226.
Volume 3 Issue 4 2014
[2] Bearn, J. (1967). Direct observations on the
function of the capsule of the sternoclavicular joint
in the clavicular support. J Anat., 101: 159-170.
[3] Mehta, J., Sachdev, A., & Collins, J. (1973).
Retrosternal dislocation of the clavicle. Injury,
5(1): 79-83.
[4] Heinig, C. F. (1968). Retrosternal dislocation of
the clavicle: early recognition, x-ray diagnosis, and
management. J Bone Joint Surg, 50A: 830.
[5] J.R. Rudzki, Matthew J. Matava, George A.
Paletta Jr. (2003). Complications of treatment of
acromioclavicular and sternoclavicular joint
injuries. Clin Sports Med, 22: 387-405
[6] Cave EF. (1958). Fractures and other injuries.
Chicago: Year Book Medical Publishers
[7] Wirth, M.A, & Rockwood, Jr. C.A (1996).
Acute and chronic traumatic injuries of the
sternoclavicular joint. JAAOS, 5: 268-278.
[8] Chaitow, L. (2003). Palpation and assessment
skills: assessment and diagnosis through touch.
Second edition. Edinburgh: Churchill Livingstone,
29.
[9] Chaitow, L. (2006). Muscle Energy Techniques.
Third Edition. Edinburgh: Churchill Livingstone.
224-225.
[10] Taranu, R., Feary, J., DuFosse, J. W. B. and
Bayliss, N. C. (2010), Sternoclavicular joint
arthritis: unrecognized cause of shoulder
impingement. Shoulder & Elbow, 2: 156160.
[11] Nichols, D.,& Seiger, C. (2013). Diagnosis
and treatment of a patient with bilateral thoracic
outlet syndrome secondary to anterior subluxation
of bilateral sternoclavicular joints: A case report.
Physiotherapy Theory and Practice, 29(7): 562
571.