Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Physical Findings

A systematic evaluation includes observation for abnormal motion patterns and atrophy, palpation to localize painful areas, assessment of both active and passive range of motion, measurement of strength of the rotator cuff, deltoid and scapular stabilizer muscles, neurovascular examination, and finally provocative testing maneuvers for instability. It is important to examine the opposite shoulder for comparison.

In evaluating shoulder motion, the examiner must carefully document any scapulothoracic substitution for glenohumeral motion, scapular winging, and other abnormal muscle patterns. Atrophy of the spinatus muscles may indicate longstanding associated rotator cuff tear or injury to the suprascapular nerve. Similarly, atrophy of the deltoid may indicate axillary nerve injury.

In addition, patients should always be assessed for findings of generalized ligamentous laxity, including the ability to hyperextend their elbows more than 10 degrees, apply the thumb to the forearm, hyperextend the metacarpalphalangeal joints more than 90 degree, or touch the palm of each hand to the floor while keeping the knees extended.

While there is no direct relationship between generalized laxity and shoulder instability, there is some association between hyperlaxity and glenocapsular development.

The patient with an acute, unreduced anterior shoulder dislocation typically holds the arm in slight abduction and internal rotation. Before attempting any reduction maneuvers, carefully perform a neurovascular examination to rule out brachial plexus injury, and specifically an axillary nerve injury.

The latter condition may sometimes escape detection, as decreased sensation over the lateral deltoid is not always present with an injury to this nerve. In patients older than 60 years of age or younger patients involved in severe trauma, be aware of the possibility of an associated fracture of the humerus. Therefore, proper radiographic imaging is particularly important before attempting closed reduction in such cases.

Regardless of the particular closed reduction maneuver employed, perform all maneuvers as a gradual and gentle technique with appropriate analgesia (either intravenous or intra-articular) to ensure muscle relaxation. A method of gentle traction in line with the arm using counter-traction is usually successful.

Always be alert to the possibility of an unrecognized chronic (fixed) dislocation. The direction is typically posterior, however a chronic anterior dislocation is also possible. Many of these patients are poor historians secondary to dementia or chronic alcohol abuse. On exam, a patient with a fixed posterior dislocation will have severe limitation of external rotation compared to their opposite shoulder.

Upon inspection, there is typically a flattening of the anterior aspect of the shoulder with an associated prominence of the coracoid process and possibly some prominence and rounding of the posterior aspect of the shoulder. The application of excessive force in attempting to close reduce such an injury risks neurovascular injury and/or fracture.

Athletes with instability are typically first seen by an orthopedic surgeon in the office, or in the training room, not in the emergency department. They may have had a documented episode of instability, or an injury with pain, but no true sense of shoulder instability.

After a careful neurovascular examination, it is important to assess both active and passive range-of-motion. A discrepancy between active and passive motion may indicate either an associated rotator cuff tear or a nerve injury.

It is particularly important to identify a subscapularis tear in the setting of shoulder instability, a condition that is frequently missed. Patients with such tears can passively increase externally rotation with the arm adducted at the side, as well as associated apprehension in this position. Strength assessment is also important. Significant external rotation weakness may indicate a rotator cuff tear.

A subscapularis tear also typically demonstrates internal rotation weakness. In this situation, the patient has an associated lift-off sign and belly-press test. The belly-press test maneuver is very useful in situations when the patient lacks adequate internal rotation to perform a lift-off test.

To perform the belly-press test, the patient places their hand on their abdomen, with their elbow flexed at 90 degree, and attempts to bring their elbow anterior to the coronal plane of their body, while keeping the hand on their abdomen at all times. If the elbow remains posterior to the anterior aspect of the mid-abdomen (i.e., the coronal plane of their body), there is likely a subscapularis tendon tear.

Specific tests for shoulder instability allow the clinician to classify the instability pattern. The apprehension test was originally described by Neer and Foster. With the patient seated or standing, place the symptomatic shoulder into a position of 90 degree of abduction and maximum external rotation. The patient’s withdrawing from the examiner or complaining about a sense of shoulder instability demonstrates apprehension.

Pain as a chief complaint is not specific for shoulder instability. Other shoulder conditions such as arthritis and rotator cuff disease commonly present with shoulder pain. Kvitne and Jobe proposed a modification of the apprehension maneuver to increase specificity for subtle anterior instability. Place the patient in a supine position, and perform the apprehension test as described above. Ask whether the patient has a sense of instability or simply pain.

Place posterior pressure on the humerus, and ask whether this pressure relieves the sense of apprehension or pain. This “relocation maneuver” increases specificity of the diagnosis of instability if the patient reports decreased apprehension. If this maneuver simply reduces pain, it is not diagnostic of instability and may be associated with a variety of other diagnoses, including a SLAP lesion or impingement syndrome.

Inconsistencies in the apprehension test led Gerber and Ganz to develop the anterior and posterior drawer test to assess the shoulder for excessive translation compared with the contralateral side. Others have found merit in this method of examination and have developed grading scales for the degree of shoulder laxity.

These tests may offer some insight into the degree and direction of the instability. If one assesses laxity of the shoulder in the office setting, it is important to determine whether translation of the humeral head is greater on the painful side and whether this translation causes symptoms.

Laxity testing assessment in the office setting can be of limited value if pain is causing the patient to guard the affected shoulder. Instead, this method is best used during examination under anesthesia to confirm the suspected degree and direction of shoulder instability.

It proposed a grading scale for translation of the humeral head on the glenoid. Instability is graded on a scale of 0 – 3+ for all three directions (anterior, posterior, and inferior). For anterior and posterior drawer testing, a grade of 0 represents no humeral head translation, while movement of the humeral head up to but not over the glenoid rim represents 1+ instability.

Translation of the humeral head over the glenoid rim with an associated spontaneous reduction with relief of pressure represents 2+ instability. Frank dislocation and locking of the humeral head over the glenoid rim is graded as 3+ instability. Whether in the office or under anesthesia, when performing drawer tests, it is important to bear in mind that the position of the arm determines the degree of tension in the glenohumeral ligaments.

With the arm at the side in adduction, the IGHL is relatively lax, and anterior and posterior drawer testing may be of limited value. In abduction, the IGHL comes underneath the humeral head and forms a hammock that passively limits anterior, posterior, and inferior translation.

Perform anterior drawer testing with the shoulder positioned in abduction in the plane of the scapula. Maintain the arm in neutral rotation while using one hand to place an axial load along the humerus and the other hand to apply an anterior or posterior force to the humerus.

Often the examiner can feel the humeral head move back into the glenoid rather than out of the glenoid during the maneuver. The patient may note a painful click with such a maneuver. This can be particularly helpful in identifying posterior instability.

Posterior apprehension can be elicited by a modification of the posterior drawer test. To perform this modification, place the patient’s arm in 90 degree of forward flexion and adduction while applying an axial load down the shaft of the humerus. Pain and a palpable shift and click suggests posterior labral injury and instability.

A modification of this test, termed the jerk test, has been described for posterior instability. With the patient seated, load the adducted shoulder axially into the glenoid with one hand, and with the other hand, palpate the posterior aspect of the shoulder. Then bring the arm into horizontal abduction anterior to the plane of the scapula; the humeral head may sublux posteriorly.

Then bring the humerus posterior to the plane of the scapula; the humeral head may suddenly reduce into the glenoid. A palpable shift and pain accompany a positive test.

The sulcus sign is basically an inferior drawer test. Originally described by Neer and Foster, it was initially believed to be pathognomonic for inferior and multidirectional instability. Unfortunately, a common misconception has been that a large sulcus sign that is asymptomatic, thus indicates inherent joint laxity, is a positive finding.

The key point is that this maneuver should be associated with pain and should reproduce the patient’s symptoms to be clinically relevant as a finding of inferior instability. A positive sulcus sign in the absence of clinical symptoms is diagnostic only for inferior laxity, not inferior instability.

To perform the sulcus test, have the patient seated and the arm adducted at the side. Rotation of the shoulder is very important in assessing the degree of inferior instability. First, with the arm in neutral rotation, pull the humerus inferiorly, and estimate the amount of separation between the acromion and the humeral head.

Grade is based on a scale of 0 – 3+: A separation of 1 cm is a 1+ sulcus sign, 2 cm is a 2+ sulcus sign, and 3 cm is a 3+ sulcus sign. Anatomically, a sulcus sign greater than 2+ indicates a capacious capsule and specific laxity of the anterosuperior capsular region (rotator interval).

The sulcus sign should always be repeated with the arm placed in external rotation. If the sulcus sign remains greater than 2+ with the arm in external rotation, there is a marked deficiency of the superior capsule, and a large rotator interval defect in the capsule is likely.

This is the result of damage to the superior and MGHLs, as well as the CHL. With this information before surgical repair, the surgeon then knows that surgical reconstruction of this region (rotator interval closure) with a capsular shift must be a component of the operation.

The Gagey test or Hyperabduction test measures the range of passive abduction (RPA) of the shoulder joint with the scapula stabilized. Anatomical and clinical findings have demonstrated that when passive abduction occurs in the glenohumeral joint only, the abduction is controlled by the IGHL.

An RPA of more than 105 degree is associated with lengthening and laxity of the IGHL. Gagey and Gagey demonstrated a high association of an RPA of over 105 degree and instability.

Since the description of superior labral pathology by Andrews et al.In 1985 and of the SLAP lesion by Snyder et al.In 1990, several examination techniques have evolved to diagnose this pathology. Andrews reported increased pain in patients during full shoulder flexion and abduction, with noticeable catching and popping. Snyder reported pain in patients with resisted shoulder flexion with elbow extension and forearm supination (biceps tension test).

Another useful diagnostic test is the compression-rotation test. With the patient supine, abduct the shoulder 90 degree, with the elbow flexed 90 degree. Apply compression force to the humerus to trap the torn labrum (in the same manner as McMurray’s test for the knee is performed).

O’Brien et al. It also described a maneuver testing for the presence of superior labral injuries. Commonly known as the O’Brien’s Test, it is performed by placing the patient’s shoulder in 90 degree of forward flexion and then adducting it across the body. Ask the patient to flex the arm further against resistance when the shoulder is first internally rotated and then externally rotated.

If pain occurs when the shoulder is rotated internally but not when it is rotated externally, the test is positive. With the O’Brien Test, pain arising from acromioclavicular joint (AC) disease versus pain from a superior labral tear can be differentiated by where the patient localizes the pain with a positive test during internal rotation.

If the pain localizes to the acromialclavicular joint or “on top” of the shoulder the test is diagnostic for AC joint disease; whereas pain or painful clicking described by the patient as “inside” the shoulder is indicative of labral pathology.

Unfortunately, independent examination of several of the popular existing physical exam tests for SLAP lesions have failed to demonstrate high accuracy, sensitivity, or specificity.

Therefore, the results of such tests should be interpreted with caution when considering surgery, and therefore used as one of several pieces of information (along with appropriate history and radiological studies) which may point to a suspected superior labral anterior-posterior lesion .

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