Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

Special Tests Covered in this Lesson:

• Anterior Shoulder Laxity (Apprehension) Test Cluster
  • Apprehension Test (Included in "Apprehension Tests Video")
  • Jobe's Relocation Test (Included in the "Apprehension Tests Video")
• Brookbush Institute's SLAP Tear Test-item Cluster (Best-of Cluster)
  • Biceps Load 2
  • Jerk Test
  • Obrien's Active Compression Test
• Posterior Inferior Labral Lesion
  • Jerk Test
• Additional Tests (Note: Additional tests are not on the exam)
  • Speed's Test
  • Yergason's Test
  • Compression Rotation Test
  • Kim's Test

Shoulder instability, in particular anterior shoulder instability, may contribute to shoulder pain, dysfunction, and a decrease in sports performance. Further, instability can increase the risk of shoulder injuries, including repetitive strain, rotator cuff tear, ligament damage, labral pathology and shoulder dislocation. Significant instability (and joint capsule laxity) can even result in recurrent dislocations, and/or spontaneous partial dislocations. Clinical professionals (physical therapists, physical therapy assistants, chiropractors, occupational therapists, athletic trainers, etc.) should be aware of the signs and symptoms of instability and labral pathology, and the special tests that may aid in diagnosing and screening patients and clients. Often mild to moderate instability and labrum injury can be successfully treated with interventions and exercises intended to improve thoracic and lower cervical spine soft tissue and joint mobility, rotator cuff activaty, and scapular (shoulder blade) motion.

Instability and Labrum Pathology Tests:

The tests for instability are included in the clusters to test for glenoid labral pathology, so the development of an ideal labral pathology cluster will result in testing for both pathologies. The research investigating clusters for labral pathology tend to group tests that compress the labrum, tests for apprehension (instability), tests that resist shoulder flexion, and/or tests that load the biceps tendon (4, 6, 7, 9, 24, 30, 32). However, the currently available research fails to investigate clusters that combine the best tests from each of these categories. That is, most of the investigated clusters include tests that later studies demonstrated were of little diagnostic value. Compression tests are particularly inaccurate (relatively low specificity and sensitivity) (9, 14). Our recommendation for practice is to group the best apprehension test, best biceps tendon load test, best shoulder flexion test, and exclude the compression tests. Additionally a test is needed for posterior inferior labral pathology, and order needs to be considered for potential continuation to testing clusters for other pathologies. The result is a "best of" cluster with higher utility for practice. Of course, further research is needed to confirm that this cluster exhibits higher specificity, sensitivity, and predictive value.

Brookbush Institute Recommendation

Clusters and Flow: The order of these tests has been carefully considered for optimal efficiency. Starting with the apprehension tests allows for a positive or negative diagnosis of instability, followed by the Biceps Load 2 which is the most accurate test to use if "screening" for labral pathology, and the cluster ends with O'Brien's to allow for a quick "pivot" to the AC Joint Testing cluster if the pain is noted in or on the AC Joint.

Brookbush Institute's "Best of" Instability and Labral Pathology Cluster

• Apprehension Test
• Jobe's Relocation Test
• Biceps Load 2
• Jerk Test
• Obrien's Active Compression Test

For an Introduction to Special Tests:

• For an introduction to Special Tests including definitions of specific terminology, what special tests measure, accuracy (specificity, sensitivity, reliability, etc.), how we chose the tests in each special test course lessons, and best practice recommendations:
• Special Tests: Introduction

Courses covering Special Tests for the Shoulder Girdle

• Special Tests: Shoulder Impingement Syndrome (SIS)
• Special Tests: Rotator Cuff Pathology
• Special Tests: Acromioclavicular (AC) Joint Pathology
• Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Text and Illustrations
• Audio Voice-over
• Technique Videos
• Practice Exam
• Pre-approved Final Exam

1. Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.
2. Dutton, M. (2012). Dutton's Orthopaedic examination, evaluation, and intervention. McGraw-Hill Medical.
3. Magee, D. J. (2013). Orthopedic physical assessment. Elsevier Health Sciences.
4. Hegedus, E. J., Goode, A., Campbell, S., Morin, A., Tamaddoni, M., Moorman, C. T., & Cook, C. (2008). Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. British journal of sports medicine, 42(2), 80-92.
5. Hegedus, E. J., Goode, A. P., Cook, C. E., Michener, L., Myer, C. A., Myer, D. M., & Wright, A. A. (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med, 46(14), 964-978.
   • Biceps Load II
6. Kim, S. H., Ha, K. I., Ahn, J. H., Kim, S. H., & Choi, H. J. (2001). Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 17(2), 160-164.
7. Kim, S. H., Ha, K. I., & Han, K. Y. (1999). Biceps load test: a clinical test for superior labrum anterior and posterior lesions in shoulders with recurrent anterior dislocations. The American journal of sports medicine, 27(3), 300-303.
8. Cook, C., Beaty, S., Kissenberth, M. J., Siffri, P., Pill, S. G., & Hawkins, R. J. (2012). Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. Journal of shoulder and elbow surgery, 21(1), 13-22.
9. Oh, J. H., Kim, J. Y., Kim, W. S., Gong, H. S., & Lee, J. H. (2008). The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. The American journal of sports medicine, 36(2), 353-359.
   • O'Brien's Active Compression Test
10. O'Brien, S. J., Pagnani, M. J., Fealy, S., McGlynn, S. R., & Wilson, J. B. (1998). The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. The American journal of sports medicine, 26(5), 610-613.
11. Guanche, C. A., & Jones, D. C. (2003). Clinical testing for tears of the glenoid labrum. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 19(5), 517-523.
12. Morgan, C. D., Burkhart, S. S., Palmeri, M., & Gillespie, M. (1998). Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 14(6), 553-565.
13. Parentis, M. A., Mohr, K. J., & ElAttrache, N. S. (2002). Disorders of the superior labrum: review and treatment guidelines. Clinical Orthopaedics and Related Research (1976-2007), 400, 77-87.
14. McFarland, E. G., Kim, T. K., & Savino, R. M. (2002). Clinical assessment of three common tests for superior labral anterior-posterior lesions. The American journal of sports medicine, 30(6), 810-815.
15. Stetson, W. B., & Templin, K. (2002). The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. The American journal of sports medicine, 30(6), 806-809.
16. Myers, T. H., Zemanovic, J. R., & Andrews, J. R. (2005). The resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions. The American journal of sports medicine, 33(9), 1315-1320.
17. Walton, J., Mahajan, S., Paxinos, A., Marshall, J., Bryant, C., Shnier, R., … & Murrell, G. A. (2004). Diagnostic values of tests for acromioclavicular joint pain. JBJS, 86(4), 807-812.
18. Nakagawa, S., Yoneda, M., Hayashida, K., Obata, M., Fukushima, S., & Miyazaki, Y. (2005). Forced shoulder abduction and elbow flexion test: a new simple clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 21(11), 1290-1295.
19. Parentis, M. A., Glousman, R. E., Mohr, K. S., & Yocum, L. A. (2006). An evaluation of the provocative tests for superior labral anterior posterior lesions. The American journal of sports medicine, 34(2), 265-268.
20. Jia, X., Petersen, S. A., Khosravi, A. H., Almareddi, V., Pannirselvam, V., & McFarland, E. G. (2009). Examination of the shoulder: the past, the present, and the future. JBJS, 91(Supplement_6), 10-18.
21. Ebinger, N., Magosch, P., Lichtenberg, S., & Habermeyer, P. (2008). A new SLAP test: the supine flexion resistance test. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 24(5), 500-505.
22. Ben Kibler, W., Sciascia, A. D., Hester, P., Dome, D., & Jacobs, C. (2009). Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. The American journal of sports medicine, 37(9), 1840-1847.
23. Oh, J. H., Kim, J. Y., Kim, W. S., Gong, H. S., & Lee, J. H. (2008). The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. The American journal of sports medicine, 36(2), 353-359.
24. Walsworth, M. K., Doukas, W. C., Murphy, K. P., Mielcarek, B. J., & Michener, L. A. (2008). Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears. The American journal of sports medicine, 36(1), 162-168.
25. Powell, J. W., & Huijbregts, P. A. (2006). Concurrent criterion-related validity of acromioclavicular joint physical examination tests: A systematic review. Journal of Manual & Manipulative Therapy, 14(2), 19E-29E.
26. Taylor, S. A., Newman, A. M., Dawson, C., Gallagher, K. A., Bowers, A., Nguyen, J., … & O'Brien, S. J. (2017). The “3-pack” examination is critical for comprehensive evaluation of the biceps-labrum complex and the bicipital tunnel: a prospective study. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(1), 28-38.
27. Owen, J. M., Boulter, T., Walton, M., Funk, L., & Mackenzie, T. A. (2015). Reinterpretation of O'Brien test in posterior labral tears of the shoulder. International journal of shoulder surgery, 9(1), 6.
    • Apprehension Tests (11 - 13, 18 - 19)
28. Speer, K. P., Hannafin, J. A., Altchek, D. W., & Warren, R. F. (1994). An evaluation of the shoulder relocation test. The American journal of sports medicine, 22(2), 177-183.
29. Lo, I. K., Nonweiler, B., Woolfrey, M., Litchfield, R., & Kirkley, A. (2004). An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder instability. The American journal of sports medicine, 32(2), 301-307.
30. Malhi, A. M., & Khan, R. (2005). Correlation between clinical diagnosis and arthroscopic findings of the shoulder. Postgraduate medical journal, 81(960), 657-659.
31. Farber, A. J., Castillo, R., Clough, M., Bahk, M., & McFarland, E. G. (2006). Clinical assessment of three common tests for traumatic anterior shoulder instability. JBJS, 88(7), 1467-1474.
    • Composite Cluster (4, 9, 24, 30)
32. Liu, S. H., Henry, M. H., Nuccion, S., Shapiro, M. S., & Dorey, F. (1996). Diagnosis of glenoid labral tears: a comparison between magnetic resonance imaging and clinical examinations. The American journal of sports medicine, 24(2), 149-154.
    • Jerk Test (and Kim's Test) (18)
33. Kim, K. H., Cho, J. G., Lee, K. O., Seo, T. J., Shon, C. Y., Lim, S. Y., … & Kim, J. H. (2005). Usefulness of physical maneuvers for prevention of vasovagal syncope. Circulation Journal, 69(9), 1084-1088.
34. Kim, S. H., Park, J. S., Jeong, W. K., & Shin, S. K. (2005). The Kim test: a novel test for posteroinferior labral lesion of the shoulder—a comparison to the jerk test. The American journal of sports medicine, 33(8), 1188-1192.
    • Additional Research
35. Karlsson, J. (2010). Physical examination tests are not valid for diagnosing SLAP tears: a review. Clinical Journal of Sport Medicine, 20(2), 134-135.
36. Calvert, E., Chambers, G. K., Regan, W., Hawkins, R. H., & Leith, J. M. (2009). Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review. Journal of clinical epidemiology, 62(5), 558-563.
37. Dessaur, W. A., & Magarey, M. E. (2008). Diagnostic accuracy of clinical tests for superior labral anterior posterior lesions: a systematic review. journal of orthopaedic & sports physical therapy, 38(6), 341-352.
38. Munro, W., & Healy, R. (2009). The validity and accuracy of clinical tests used to detect labral pathology of the shoulder–a systematic review. Manual therapy, 14(2), 119-130.
39. Meserve, B. B., Cleland, J. A., & Boucher, T. R. (2009). A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. The American journal of sports medicine, 37(11), 2252-2258.
40. Ben Kibler, W., Sciascia, A. D., Hester, P., Dome, D., & Jacobs, C. (2009). Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. The American journal of sports medicine, 37(9), 1840-1847.
41. Fowler, E. M., Horsley, I. G., & Rolf, C. G. (2010). Clinical and arthroscopic findings in recreationally active patients. BMC Sports Science, Medicine and Rehabilitation, 2(1), 2.
42. Walsworth, M. K., Doukas, W. C., Murphy, K. P., Mielcarek, B. J., & Michener, L. A. (2008). Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears. The American journal of sports medicine, 36(1), 162-168.
43. Cook C, Beaty S, Kissenberth MJ, et al. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg 2012;21:13–22.