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1. Shoulder Instability
Clinical Examination
Manos Antonogiannakis
Director of Center for Arthroscopy & Shoulder Surgery
IASO General Hospital
www.shoulder.gr

2. History:
degree of violence
Level of athletic participation
number of dislocations
Age of the patient
Clinical examination:
Generalized Joint laxity
direction of aprehension
dictates treatment

3. Contributors to stability
Static stabilizers
1. ligamentous structures labrum and
capsule
2. bony configuration of glenoid and
humeral head
Dynamic stabilizers
1. rotator cuff
2. scapula muscles

4. Clinical examination

5. Laxity vs. Instability
LAXITY
Looseness of
stabilizers
Asymptomatic
Control of joint
position
INSTABILITY
Abnormal joint
movement
Symptomatic
Pain,
Subluxation,
Dislocation
Loss of control of
Joint Position

6. Clinical examination
www.shoulder.gr

7. Active Range of Motion

8. Passive Range of Motion

9. Examination Under Anesthesia

10. Check for generalized Hyperlaxity
Hyperlaxity
Knee recurvatum
Elbow hyperextention
Thumb to wrist
Increased Shoulder ROM

11. Laxity Testing –
Hawkins Classification
Grade 0 =
No Translation
Grade 1 =
HH moves slightly
up face of glenoid
Grade 2 =
HH rides up glenoid
face to but not over
the rim - subluxation
Grade 3 =
HH rides up and
over the rim -
dislocation
Hawkins, 1987, Can J Sport Sci

12. Laxity Testing –
Hawkins Modification
On Clinical Examination
The examiner feels:
• HH go over the rim (Grade 2) or
• Not over the rim (Graded 1) or
• Dislocation (Grade 3)
Modified Hawkins scale is the
most valid and reproducible
method for reporting laxity
McFarland 2006

13. Shoulder Tests
• Over 114 tests have been described, so far
• Not all of them are reliable, reproducible, specific,
accurate
• Only some of them have been validated
• You DO NOT NEED ALL of them

14. Posterior Drawer Test
• Supine
• Shoulder out of the table
• Zero – loose packed position
• Hold wrist
• Elbow flexion
• Other hand=thumb anterior over
the HH and fingers posterior to
feel the move
• Thumb presses posterior to
sublux/dislocate HH
• Release pressure
• Grade according to Hawkins
Classification
Posterior Laxity Testing
Gerber & Ganz 1984

15. Posterior Drawer Test
Young, ASYMPOMATIC
athletes,
65% of females,
50% of males
Demonstrate Posterior
Drawer Test Grade II
laxity = Sublux
McFarland, 1996, AJSM
It is normal to be able to subluxate
posteriorly in young athletes
Posterior Laxity Testing

16. Posterior Drawer Test
• Asymmetry of laxity between one patient’s shoulder is
common. NOT to be mistaken for instability
• Shoulder laxity increases under anesthesia
• Grade III laxity (=dislocation) is very uncommon even
under anesthesia
Linter, 1996, AJSM
McFarland, 2006
Posterior Laxity Testing

17. Anterior Drawer Test
• Patient Supine
• Zero position, wrist to the
examiner’s hip
• One hand over the shoulder to
stabilize (thumb on the coracoid,
fingers over the shoulder to the
spine of the shoulder
• Other hand to the upper arm,
appying some axial load, anterior
force and roll HH
• Release force
• Grade according to Hawkins
Classification
Anterior Laxity Testing
Gerber & Ganz 1984

18. Load and Shift Test
• Sitting or supine
• One hand stabilizes scapula as on
ant drawer test
• Arm is held on the proximal
humerus in 20ABD, 20FF, NEU R
• Load HH to the glenoid
• Apply anterior and then posterior
force while keeping the load
• Grade according to Hawkins
Classification
Laxity Testing
Silliman and Hawkins, 1993

19. Push-Pull Test
• Supine
• Hold the wrist, elbow 90 flexion,
90ABD, scapular plane, NEU R
• Other hand midhumerus, applies
posterior force
• Grade according to Hawkins
Classification
Matsen, 1990
Posterior Laxity Testing

20. Sulcus Sign
• Sitting or Supine
• Forearms on midfemur,
• Both arms pulled inferiorly
simultaneously from the
elbow
• Then on each shoulder
separately (once in INT R and
repeat on EXT R)
Inferior Laxity Testing
Neer & Foster, 1980

21. Sulcus Sign
Inferior Laxity Testing
Neer & Foster, 1980
Positive = dimple at the
subacromial area

22. Sulcus Sign
• If increased translation with the arm in external
rotation, consider Rotator Interval lesion
Inferior Laxity Testing
Ferrari, 1990, AJSM
Harryman, 1992, JBJS
Warner, 1992, AJSM

23. Sulcus Sign
Inferior Laxity Testing
Grade I : < 1cm
Grade II: 1 - 2cm
Grade III: > 2cm
Or
Grade I = Low Grade
Grade II & III = High Grade
High Grade
Sulcus Sign shows
LAXITY,
NOT INSTABILITY
Better not to be Graded,
but reported as POSSITIVE or NEGATIVE

24. Sulcus Sign
Inferior Laxity Testing
No study defines how much inferior shoulder
laxity indicates structural insufficiency that
requires surgical treatment
Normally there is a wide range of inferior laxity in
the shoulder
It is very uncommon to reproduce patients
symptoms when performing the Sulcus sign
Sulcus Sign measures inferior laxity and
reflects instability only when reproduces
symptoms

25. Hyperabduction (Gagey) Test
• Sitting patient
• Examiner behind, stabilizes
with his forearm (or palm) the
scapula and abducts in 0FF and
NEU R until the scapula starts
moving.
• Measure the abduction
• The Range of Passive
Abduction (RPA) should be
<105°
Positive for laxity of inferior
glenohumeral complex if
RPA>105 °
Laxity Testing
Gagey, 2001, JBJS

26. Hyperabduction (Gagey) Test
Laxity Testing
Gagey, 2001, JBJS

27. Anterior Drawer
as an Instability Test
Anterior Instability Testing
The same maneuver as for the Anterior
Drawer test for laxity, but the patient
reports the test reproduces the
sensation of instability.
Limited sensitivity (McFarland, 2003)
It is not necessary for patients that have
confirmed ant. instability by other tests or
history.
Gerber & Ganz, 1984

28. Apprehension Test
Anterior Instability Testing
Rowe, 1981, JBJS
Standing, sitting or supine
(scapula unsupported)
One hand holds the wrist in 90
ABD, 90EXT R, 0FF
If the Other hand applies a gentle
pressure anteriorly
Positive if patient becomes
apprehensive and complained
for pain
May be positive in more EXT R or
ABD
Not positive at the same
position for all patients.
May be positive in thoracic outlet
syndrome (pain & weekness)

29. Apprehension Test
Anterior Instability Testing
Pain is not predictive of traumatic instability.
The Apprehension Test is important for true
anterior instability when it produces
apprehension, but not when reproduces pain
alone McFarland, 2006
Speer, 1994, AJSM

30. Apprehension Test
Anterior Instability Testing
Test in deferent abduction angles indicates:
45° anterior labrum and capsule lesion
90° anterior & inferior labrum and capsule lesion
120° lesion extends posteriorly
Rockwood & Wirth, 1996

31. Variations of Apprehension Test
Anterior Instability Testing
Augmentation Test
Instead of gentle anterior pressure, apply acute
anterior pressure. Can be painful or dislocate
Silliman & Hawkins, 1993, Clin. Orth

32. Variations of Apprehension Test
Anterior Instability Testing
Fulcrum test
Examiners fist is placed behind the shoulder on
the table, acts as a fulcrum
Matsen & Kirby, 1982, Orth Clin North Am

33. Relocation Test
Anterior Instability Testing
Jobe, 1989
First was described for internal
impingement in throwing athletes
causing pain.
Same as for the Apprehension
Test (supine)
When apprehension is felt, a
posterior force is applied by the
other palm, that releases
Apprehension in overt instability
cases or Pain in covert
instability on internal impingement
So the EXT R can be advanced

34. Relocation Test
Anterior Instability Testing
Jobe, 1989
The relocation test is not helpful for
the anterior instability diagnosis
when pain is used as a criterion for
a positive result.
The apprehension and relocation
test can cause pain in patients with
a variety of conditions or diagnosis
and they are not reliable when
pain is used as a positive result.
The relocation test when causes
pain may have a role in SLAP
diagnosis.

35. Release Test
Anterior Instability Testing
Can be performed as a
continuity to Relocation Test
When patient is relaxed from the
posterior applied force, advance
EXT R and acute release the
posterior pressure.
If you do not advance EXT R but
just release the posterior
pressure, the test is called
Surprise Test
Lo, 2004, AJSM
Can be very painful and has a
potential to dislocate shoulder.
Silliman & Hawkins, 1993, Clin. Orth

36. Combined Tests
Apprehension – Relocation - Release
Anterior Instability Testing

37. Combined Tests
Anterior Instability Testing
Apprehension test
Relocation test
Release/Surprise test
Reliable diagnosis
of Traumatic
Anterior Instability
Reliable diagnosis
of Occult Anterior
Instability
?

38. Posterior Apprehension Test
Posterior Instability Testing
Patient sitting or standing
FF90, ADD in line with the
body and slight INT R,
while pushing posteriorly,
along the humeral axis.
Positive when causes
apprehension.
Kessel, 1982

39. Posterior Apprehension Test
Posterior Instability Testing
BUT:
The original position of Kessel is the resting position of
the head after posterior subluxation.
The real position of Apprehension is different in every
patient
When (rarely) posterior apprehension test is positive, the
patient usually have posterior instability
The exact position that joint subluxes posteriorly in most
patients with posterior instability is highly variable, so
finding the exact location to produce a subluxation is
difficult.
Hawkins, 1984, JBJS & McFarland, 1990

40. Posterior Subluxation Test
(Miniaci Test)
Posterior Instability Testing
Patient sitting or supine
FF90, ADD and INT R, while
pushing posteriorly, along the
humeral axis.
The other hand is behind the
patient’s shoulder to feel the
relationship of the HH to the
Glenoid rim
Then the arm is brought back
to extended position and a
clunk may be felt when the
HH is relocates.
Clarnette & Miniaci, 1998, Med Sci Sports Exerc

41. Push-Pull Test
• Supine
• Holds the wrist, elbow 90
flexion, 90ABD, scapular
plane, NEU R
• Other hand midhumerus,
applies posterior force
• Positive If produces pain or
reproduces symptoms
• Local Anesthetic to
subacromial space
differentiate pain from
tendinitis
• Other test for posterior
laxity maybe used for
posterior instability
(Posterior Drawer Test and
Load and Shift Test)
Matsen, 1990
Posterior Instability Testing

42. Sulcus Sign
Inferior Instability Testing
As previously described for evaluating inferior
laxity, but here it reproduced the symptoms.
Positive Sulcus Sign only if reproduces
symptoms Neer, 1985, Instr Course Lect

43. Sulcus Sign
Inferior Instability Testing
High grade Sulcus without reproducing
symptoms tends to MDI overdiagnosis
In High Grade Sulcus, the major restrain to
inferior translation with the arm aside is the
SuperiorGHL and the CoracoHumeralL.
Sulcus does not reflect laxity in Inferior GH
complex because with the arm adducted, that
complex is not stressed with an inferior load

44. Feagin Test
(Inferior Apprehension Test)
Inferior Instability Testing
Standing,
Patient places his elbow on
examiners shoulder who is
standing at his side
Examiners hand circulate
above shoulder and apply
inferior force.
Positive = apprehension or
reproduces symptoms
Compare with the other side
Faegin, 2004

45. Generalized Ligamentous Laxity
Criteria:
Relative risk factor for
surgical treatment
But NOT a
Contraindication

46. Generalized Ligamentous Laxity

47. Generalized Ligamentous Laxity
Increased Shoulder ROM

48. Tests for SLAP lesions
• More than 55 tests have been already described
• Non of them is accurate alone or pathogonomonic
• O’Brien
• Anterior Slide Test
• SLAPprehension Test
• Biceps Load Test 1
• Biceps Load Test 2
• Compression Rotation Test (Crank Test)

49. O’ Briens Test
(active compression test)
• Patient sitting or standing
• Ff 90, ADD 10-15 deg, max
INT R (thumb down) and
resist downward force
• Repeat in supination
• Loads AC joint and Superior
Labrum
• Pain indicates SLAP or AC
joint pathology
O’ Brien, 1988

50. Biceps Load Test 1
• Patient standing or sitting
• Examiner behind, ABD 90,
EXT R 90, palm forward (as in
apprehension test) produces
pain
• Then resisted active elbow
flexion releases pain
• Positive = Pain release
• Indicates SLAP lesion in
anterior instability cases
Kim, 1999, Arthroscopy

51. Biceps Load Test 2
• Similar to BLT1,
• but patient supine,
• ABD 120 deg, elbow flexion,
palm up
• Resisted active elbow flexion,
elicits or increase pain (the
opposite to BLT1)
• Indicates SLAP lesion
Kim, 2001, Arthroscopy

52. SLAPprehension test
• Similar to O’Briens, but repeat with the
arm in supination
• Positive = pain eliminated with
supination
• Indicates SLAP lesion
Berg, 1998

53. Anterior Slide Test
• Patient standing, puts hands on
hips, thumbs pointing back
• Examiner back, one hand holds
shoulder and the other pushes
the elbow anteriorly and
superiorly
• Positive if produces pain
• Indicative of SLAP lesion
Kibler, 1995, Arthroscopy

54. Compression Rotation Test
(Crank Test)
• Patient Supine
• FF 90, elbow flexed 90,
axial compression and
internal and external
rotation
• Pain and click makes
test positive, similar to
McMurray test for the
knee

55. Locked posterior dislocation is
easily missed
Locked external
rotation