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Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology Audio

Special tests for shoulder instability. The Apprehension Test, Jobe's Relocation Test, Composite SLAP Tear Test-item Cluster, Jobe's Relocation Test (Apprehension Tests), Biceps Load 2, Obrien's Active, Compression Test, Posterior Inferior Labral Lesion, Jerk Test, Speed's Test, Yergason's Test, Compression Rotation Test, Kim's Test. The reliability, specificity, sensitivity, validity, safety, and screening for shoulder pain, instability, labral tears, glenohumeral (shoulder) joint stability, SLAP tears, AC (acromioclavicular) joint pathology, and posterior to inferior labral lesions.

Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

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Anterior Shoulder Laxity (Apprehension) Test Cluster

 (Included in "Apprehension Tests Video")

 (Included in the "Apprehension Tests Video")

Brookbush Institute's SLAP Tear Test-item Cluster (Best-of Cluster)

Additional Tests (Note: Additional tests are not on the exam) 

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.

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.

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 

 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

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:

Courses covering Special Tests for the Shoulder Girdle

Special Tests: Shoulder Impingement Syndrome (SIS)

Special Tests: Acromioclavicular (AC) Joint Pathology

Course Discription: Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

Shoulder Instability (Apprehension) and Labrum Pathology

Course Study Guide: Shoulder Instability (Apprehension) and Labrum Pathology

For an introduction to Special Tests including definitions of specific terminology, what special tests measure, how we chose the tests in these lessons, and best use, check out:

 demonstrates both high sensitivity and specificitymay, and may be the the most accurate test included in the Brookbush Institute's "Best of" Labral Pathology and Instability Cluster (1, 4 - 9). More research is needed, but if one test was going to be used for screening purposes this test would be recommended. Unfortunately, the 

 was only included in one of the research studies investigating test-item clusters (23).

 Apprehension tests may have validity for identifying glenoid labrum pathology because the laburm assists in maintaining glenohumeral stability by "extending" the rim of the glenoid fossa, and may create a "suction cup-like effect" that approximates the humeral head via intra-articular pressure. Further, labrum injuries are often the result of acute trauma (shoulder anterior dislocation) which commonly damages other structures that contribute to stability (e.g. the glenohumeral ligaments). The special tests for 

 are similar to one another. Although research suggests the "Surprise/Lift-Off" test has the highest sensitivity, it has been our clinical experience that this test is the most painful/uncomfortable for patients (29). The 

Apprehension Test and Jobe's Relocation Test

 (easily performed in sequence) is much less uncomfortable, and also has significant sensitivity and specificity (30, 31).

Choosing a Resisted Shoulder Flexion Test:

 is not a compression test, as much as a resisted shoulder flexion test. Further, research demonstrates this is one of the more accurate tests in the cluster recommended below (1-5, 9 - 27). This test also adds a potential evaluation "pivot point", as this test is included in the special test cluster for acromioclavicular joint (AC) joint pathology (10, 17, 25).

Choosing a Posterior Inferior Labral Pathology Test:

 There are relatively few tests to choose from for posterior inferior labral pathology. The few research studies available suggest the 

; however, both tests exhibit high sensitivity and slightly higher specificity (18, 33, 34). No research exists to determine whether clustering these tests would improve accuracy.

Introduction

The patient assumes a supine position, with the examiner on the patient's involved side.

The examiner places the patient's involved arm in 90-120° of abduction, 90° of elbow flexion, and end-range external rotation (apprehension position).

A posterior to anterior force is applied to the proximal humerus.

If the patient reports apprehension (unwillingness to move arm/guarding) or pain, the examiner then applies an anterior to posterior force on the proximal humerus.

The test is positive if a posterior to anterior force increases pain and apprehension, and/or an anterior to posterior force reduces pain and apprehension.

There are several variations of this test, all starting with the "apprehension" position. In general, if the apprehension position, the apprehension position with a posterior to anterior force, or the removal of manual stability in the apprehension position provokes symptoms, the test is positive. The test may also be positive if symptoms are reduced by applying an anterior to posterior force to the proximal humerus/stabilizing the humeral head.

Jobe's Relocation (Apprehension Tests and "Cluster")

The examiner places the patient's involved arm in 120° of abduction, 90° of elbow flexion, and forearm supination.

The examiner then moves the patient to end range external rotation (apprehension position).

In this position, the patient is asked to perform resisted elbow flexion.

A positive test is pain or reproduction of the concordant sign during elbow flexion.

Image of shoulder capsule

Bicep's Load 2

The patient is standing with the involved shoulder flexed to 90° and internally rotated to end-range in the scapular plane, with the elbow extended.

The examiner stands on the side of the involved shoulder and asks the patient to resist a downward force applied to the wrist.

The patient is asked to report any pain and the location of that pain. The top of the shoulder may indicate acromioclavicular (AC) joint pathology, and the inside of the shoulder may indicate a superior labrum tear, anterior to posterior (SLAP lesion).

The practitioner then moves the patient's arm into end-range shoulder external rotation and asks the patient to again resist a downward force to the wrist.

A positive test is pain or painful clicking in the internally rotated position, and less or no pain in the externally rotated position.

Weakness may indicative of posterior labral tear (26), and pain on palpation of the bicipital tunnel during the test may be indicative of damage to the biceps tendon/labrum complex, or transverse ligament (27).

O'Brien's Active Compression Test

Image of the Rotator Cuff

Brookbush Institute's "Best of" SLAP Tear Test-item Cluster

The patient is sitting with the practitioner on the patient's involved side.

The practitioner stabilizes the scapula with one hand and uses the other hand in a lumbrical grip to bend and grasp the elbow at 90º.

The practitioner then passively abducts the shoulder to 90º (neutral rotation) and applies an axial load through the elbow, compressing the shoulder joint.

Maintaining the axial load, the practitioner horizontally adducts the arm.

A sharp pain, with or without a clunk/click is considered positive.

Jerk Test for Posterior Inferior Labral Lesion

(Note: Additional tests are not included on exam)

Additional Tests

Cook, C., & Hegedus, E. J. (2008). Orthopedic physical examination tests: an evidence-based approach.

Dutton's Orthopaedic examination, evaluation, and intervention

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. 

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. 

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

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. 

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. 

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. 

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. 

Guanche, C. A., & Jones, D. C. (2003). Clinical testing for tears of the glenoid labrum. 

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. 

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)

McFarland, E. G., Kim, T. K., & Savino, R. M. (2002). Clinical assessment of three common tests for superior labral anterior-posterior lesions. 

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. 

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. 

Walton, J., Mahajan, S., Paxinos, A., Marshall, J., Bryant, C., Shnier, R., … & Murrell, G. A. (2004). Diagnostic values of tests for acromioclavicular joint pain. 

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. 

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. 

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. 

Ebinger, N., Magosch, P., Lichtenberg, S., & Habermeyer, P. (2008). A new SLAP test: the supine flexion resistance test. 

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. 

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. 

Powell, J. W., & Huijbregts, P. A. (2006). Concurrent criterion-related validity of acromioclavicular joint physical examination tests: A systematic review. 

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. 

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

Speer, K. P., Hannafin, J. A., Altchek, D. W., & Warren, R. F. (1994). An evaluation of the shoulder relocation test. 

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. 

Malhi, A. M., & Khan, R. (2005). Correlation between clinical diagnosis and arthroscopic findings of the shoulder. 

Farber, A. J., Castillo, R., Clough, M., Bahk, M., & McFarland, E. G. (2006). Clinical assessment of three common tests for traumatic anterior shoulder instability. 

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. 

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. 

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. 

Karlsson, J. (2010). Physical examination tests are not valid for diagnosing SLAP tears: a review. 

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. 

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

Munro, W., & Healy, R. (2009). The validity and accuracy of clinical tests used to detect labral pathology of the shoulder–a systematic review. 

Meserve, B. B., Cleland, J. A., & Boucher, T. R. (2009). A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. 

Fowler, E. M., Horsley, I. G., & Rolf, C. G. (2010). Clinical and arthroscopic findings in recreationally active patients. 

BMC Sports Science, Medicine and Rehabilitation

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.

Bibliography

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Special Tests: Shoulder Instability (Apprehension) and Labrum Pathology

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