REVIEW ARTICLE

History and Physical Examination for Shoulder Instability

COL Chad A. Haley, MD

correct diagnosis (Table 1). Instability should always be

Abstract: Glenohumeral instability frequently occurs in young considered in the young, active patient who presents with a
active individuals especially those engaged in athletic and military shoulder problem. Younger patients will frequently recall a
activities. With advanced imaging and arthroscopic evaluation, our specific traumatic event leading to their instability. How-
understanding of the injury patterns associated with instability has
significantly improved. The majority of instability results from a
ever, they may also present with pain causing degradation
traumatic anterior event which presents with common findings in in physical performance. Apprehension in certain arm
the history, examination, and imaging studies. As such, a com- positions is more common with traumatic unilateral insta-
prehensive evaluation of the patient is important to correctly bility whereas pain is more common in instability due to
diagnose the instability patterns and thus provide appropriate ligamentous laxity.2
treatment intervention. With the correct diagnosis and improved Thomas and Matsen3 developed a useful classification
surgical techniques, the majority of patients with instability can for instability by dividing patients into 2 broad categories
return to preinjury levels. termed TUBS and AMBRI. TUBS include patients with a
Key Words: shoulder examination, shoulder instability, glenohumeral traumatic etiology, unidirectional, Bankart lesion, and
joint instability, shoulder dislocation, shoulder subluxation typically require surgery. AMBRI include those with an
atraumatic etiology, multidirectional, bilateral shoulders,
(Sports Med Arthrosc Rev 2017;25:150–155) initial rehabilitation, and inferior capsular shift if rehabil-
itation fails. However, it is important to recognize that
many patients will fall in between groups.

I t is important to define different terms that are commonly

used when describing glenohumeral instability. Instability
is a pathologic process that causes a symptomatic increase
PHYSICAL EXAMINATION
Physical examination of the shoulder starts with a
in humeral head translation relative to the glenoid which thorough evaluation of the cervical spine. Pathologic con-
can be quantified on physical examination tests. Instability, ditions within the cervical spine and neck region can
in turn, leads to a loss in physical performance, pain, and manifest with shoulder and arm pain. Motion is evaluated
sometimes weakness. Laxity, on the other hand, is an in all directions and nerve encroachment can be tested with
asymptomatic increase in joint translation that can be the Spurling test where the patient’s neck is extended
caused by a number of factors to include sex, muscular and rotated toward the involved side followed by axial
development, genetic conditions, and age.1 compression.4 Shoulder examination follows the typical
Another important distinction pertaining to instability evaluation for musculoskeletal symptoms which includes
is dislocation versus subluxation. A dislocation occurs inspection, palpation, range of motion, strength assess-
when there is no contact between the humeral head and ment, neurovascular assessment, and specialized testing. It
glenoid fossa which typically requires a reduction maneuver is important to expose both shoulders before the exam and
to relocate the humeral head. However, in cases where there one should first examine the unaffected shoulder to obtain a
is bone loss or fracture, it is possible for a spontaneous baseline reference.
reduction to occur without a reduction maneuver. A sub-
luxation can be defined as a partial or incomplete dis- Inspection
location where no reduction maneuver is required.1 Patients Inspection of the shoulder may reveal asymmetry from
will often describe subluxation as a slipping event. atrophy in the deltoid, supraspinatus, and infraspinatus
muscles. Deltoid atrophy may be caused by an axillary
nerve palsy resulting from shoulder dislocation which is
HISTORY evident by squaring of the lateral shoulder. Supraspinatus
A thorough patient history is important to enable the atrophy superior to the scapular spine can result from a
examiner to focus on pertinent aspects of the physical rotator cuff tear or suprascapular nerve entrapment at the
examination, and it plays a significant role in making the suprascapular notch. Infraspinatus atrophy inferior to
the scapular spine can result from a rotator cuff tear or
From the Department of Surgery, Keller Army Community Hospital, entrapment of the suprascapular nerve. Infraspinatus
West Point, NY. atrophy can be seen in overhead athletes where a ganglion
The views expressed in this article are those of the author and do not cyst compresses the nerve as it travels through the spino-
reflect the official policy or position of the Department of the Army, glenoid notch. One should also inspect the position of the
Department of Defense, or the United States government. The
author certifies that he has no affiliation with or financial involve- scapula at rest and during motion for winging. Finally, the
ment in any organization or entity with a direct financial interest in skin around the shoulder should be assessed for scars and
the subject matter or materials discussed in the article. for scar widening that may suggest a collagen disorder.
Disclosure: The author declares no conflict of interest.
Reprints: COL Chad A. Haley, MD, Department of Surgery, Keller Palpation
Army Community Hospital, 900 Washington Road, West Point,
NY 10996. All joints around the shoulder are palpated for
Copyright r 2017 Wolters Kluwer Health, Inc. All rights reserved. deformity, tenderness, and crepitus. Pain with palpation

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Sports Med Arthrosc Rev  Volume 25, Number 3, September 2017 Examination for Shoulder Instability

Motion Testing
TABLE 1. Comprehensive History for Glenohumeral Joint
Instability
Range of motion should include both active and pas-
sive movements in forward flexion, abduction, external
Age rotation in adduction and 90 degrees of abduction, and
Handedness internal rotation in adduction and 90 degrees of abduction.
Unilateral or bilateral involvement Internal rotation in adduction is assessed by documenting
Family history of instability
Initial or recurrent event the nearest vertebral level that the hand can reach whereby
Arm position during instability the superior scapular border is approximately T4, the
No. previous events inferior scapular border is T7, and the iliac crest is at the L4
Degree of force for recurrence level. A decrease in active motion compared with an
Instability during sleep increase in passive motion suggests a rotator cuff tear.
Can the patient voluntarily create event Overhead throwing athletes will often have an increase in
Was a reduction maneuver required external rotation with a similar decrease in internal rotation
Presence and location of pain or sensory disturbance resulting in a symmetric total arc of motion compared with
Presence of mechanical symptoms the nonthrowing shoulder. Internal impingement or labral
Previous shoulder surgeries
injuries can be seen with glenohumeral internal rotation
deficit where a side-to-side loss of total arc of motion >25
degrees exists.5 Active and passive loss of external rotation
over the acromioclavicular joint suggests a sprain, synovi- occurs with a posterior dislocation. As mentioned pre-
tis, or possibly an os acromiale. Tenderness over the ante- viously, one should inspect the patient posteriorly during
rior or lateral borders of the acromion is a common area for forward flexion to assess for scapular winging.
rotator cuff tendon pathology or impingement-type symp-
toms. In addition, there may be tenderness over the lateral Strength Testing
shoulder with a greater tuberosity fracture or Hill Sachs Muscular strength testing is performed for each of the
lesion sustained from an instability event. Tenderness along rotator cuff muscles by comparing them to the contralateral
the biceps tendon suggests tendinosis. The exact location of side. Examining both arms simultaneously makes it easier
crepitus is often difficult to pinpoint, however it is fre- to identify subtle differences in strength. The supraspinatus
quently felt in the area of the acromioclavicular joint which muscle is tested using the supraspinatus isolation test or
may not be symptomatic. Jobe test (Fig. 1).6 The arm is internally rotated with the

FIGURE 1. Rotator cuff strength tests.

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Haley Sports Med Arthrosc Rev  Volume 25, Number 3, September 2017

thumb pointing down and elevated to 90 degrees in the

scapular plane. The patient is asked to push toward the
ceiling while the examiner provides a downward force to
both arms. The infraspinatus and teres minor muscles are
tested by resisting external rotation in 0 and 90 degrees of
abduction, respectively (Fig. 1).6 A lag sign for infra-
spinatus weakness is seen when the examiner passively
externally rotates the arm in 0 degrees of abduction and the
patient is unable to actively keep it in the same degree of
external rotation. The hornblower sign for teres minor
weakness is performed in a similar manner except that the
shoulder is in 90 degrees of abduction. Finally, evaluation
of the subscapularis muscle is performed using the lift off,
belly press, and bear hug tests.2 The lift off test is performed
by having the patient place their hand on their lumbar spine
and pushing it away from the body (Fig. 1). The elbow FIGURE 2. Adson test.
should not move and the examiner must ensure the patient
is not using their triceps muscle to move the hand away Laxity Assessment
from their back. This test may be limited in patients with an Stability of the glenohumeral joint is provided pas-
internal rotation contracture or excessive pain. The belly sively by the glenohumeral ligaments and dynamically by
press test is performed with the patient’s hand on their the rotator cuff muscles and surrounding scapular stabi-
abdomen with the wrist neutral and elbow in front of the lizing muscles. Generalized ligamentous laxity can by
body (Fig. 1). The patient is asked to press their abdomen assessed using different tests that added together provides a
without flexing their wrist or moving their elbow posteri- Beighton score from 0 to 9.7 These tests include: hyper-
orly. Finally, the bear hug test is performed with the arm in extension of the small finger metacarpophalangeal joint
90 degrees of forward flexion, elbow flexed, and hand on past 90 degrees, ability to place the thumb on the volar
the contralateral shoulder. The examiner attempts to lift the forearm, hyperextension of the elbow joint beyond 10
hand away from the shoulder while the patient maintains a degrees, hyperextension of the knee joint >10 degrees, and
downward force. the ability to place both palms flat on the floor with the
knees extended. The examiner test both left and right sides
Neurovascular Testing and 1 point is given for a positive test to include the palms
A thorough neurological assessment by the examiner flat on floor test. A score of 4 or more is associated with
should be performed before and after a reduction maneu- generalized ligamentous laxity.8
ver. Axillary nerve injury is the most common nerve injury Inferior laxity is evaluated by the sulcus test which can
after a dislocation or subluxation. It can be assessed by be performed with the patient sitting or supine (Fig. 3).1
testing resisted shoulder abduction (deltoid), abduction and The examiner pulls the adducted arm inferiorly and docu-
external rotation (teres minor), and by testing for sensation ments in centimeters the amount of translation of the
in the lateral shoulder. One should also examine for injuries humeral head from the lateral acromion border. The sulcus
to the radial, median, ulnar, and musculocutaneous nerves. test is repeated in maximum external rotation which tight-
A careful vascular examination is essential in these patients ens the anterior capsule and rotator interval. A lax or
also. It should begin with palpation of the radial and ulnar incompetent rotator interval is suspected if there is no
pulses and observation of capillary refill as compared with decrease in the sulcus sign.
the contralateral extremity. Inspection of the extremity for
changes in temperature, skin changes, or hair loss may
indicate a vascular problem. Thoracic outlet syndrome Anterior Instability
should always be considered in any patient that presents Anterior instability is evaluated with quantitative and
with nonspecific pain or weakness in the involved extremity. provocative tests. The anterior drawer test is performed
It is important to remember that most tests for thoracic with the patient sitting upright with the arm resting at the
outlet syndrome are not highly sensitive or specific, but
combined with a thorough history and examination may
assist the examiner in making the correct diagnosis. Adson
maneuver is commonly used where the arm is abducted 30
degrees and maximally extended (Fig. 2).6 The patient turns
their head toward the affected shoulder while holding their
breath for 15 to 30 seconds. At the same time, the examiner
palpates the radial pulse and compares it to the pulse with
the arm at the side. A diminution or disappearance of the
pulse raises the possibility of thoracic outlet syndrome with
compression of the subclavian artery between the anterior
and middle scalene muscles or the first rib.

Specialized Testing
Once a thorough history is taken and a generalized
examination performed, the examiner can focus on speci-
alized tests to confirm the diagnosis. FIGURE 3. Sulcus test.

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Sports Med Arthrosc Rev  Volume 25, Number 3, September 2017 Examination for Shoulder Instability

side (Fig. 4).6 For a right shoulder, the examiner stabilizes

the scapula by placing the left index finger on the coracoid
process and the left thumb on the scapular spine. The
examiner grasps the humeral head between the thumb and
fingers of his or her right hand and gently pushes the
humeral head anteriorly while assessing the amount of
translation on the glenoid. The translation is measured as
a percentage of the humeral head that can be subluxed
anterior to the glenoid rim.
The load and shift test can be performed with the
patient sitting upright or laying supine (Fig. 5).6 The
shoulder is gently abducted and flexed in the plane of
the scapular. For a right shoulder, the examiner grasps the
patient’s proximal forearm with their right hand and places
an axial load to the humerus to center the humeral head in
the glenoid. The humeral head is grasped with the exam- FIGURE 5. Load and shift test.
iner’s left thumb and index finger and an anterior-inferior–
directed force is applied to the proximal humerus. Trans- resting at the side. For a right shoulder, the examiner sta-
lation of the humeral head on the glenoid is graded by 1 of bilizes the scapula with the left hand then grasps the
2 classifications. Using the Gerber and Ganz classification,9 humeral head between the thumb and fingers of his or her
grade I is translation of the head to the glenoid rim, grade right hand and gently pushes the humeral head posteriorly
II is translation over the rim that spontaneously reduces, while assessing the amount of translation on the glenoid.
and grade III is over the rim without a spontaneous The translation is measured as a percentage of the humeral
reduction. For the modified Hawkins classification, grade I head that can be subluxed posterior to the glenoid rim. Up
is minimal translation of the head on the glenoid, grade II is to 50% of humeral head displacement on the glenoid may
translation of the head to the glenoid rim, and grade III is be normal which reiterates the importance of always com-
translation of the head over the glenoid rim.10 paring the affected shoulder to the contralateral side.
The apprehension test is performed with the patient The jerk test is performed with the patient laying
sitting upright or laying supine on the edge of the bed that supine on the edge of the bed which stabilizes the scapula
assists with stabilizing the scapula (Fig. 6).11 The arm is (Fig. 8).13 The examiner places the patient’s arm in 90
placed in 90 degrees of abduction while the examiner slowly degrees of forward flexion and maximal adduction and
externally rotates the shoulder to 90 degrees. Apprehension internal rotation. The examiner then applies a posterior-
or pain in this position suggests anterior instability or directed force on the elbow and monitors for dislocation or
injury to the anterior labrum. This test can be augmented subluxation. While maintaining the posterior load, the
by applying a posterior-directed to anterior-directed force examiner slowly abducts the arm and feels for a jerk or
on the proximal humerus. The relocation test can then be clunk as the humeral head relocates into the glenoid. This
performed in the same position as the apprehension test by test is also called the Jahnke test or posterior load test.
applying an anterior-directed to posterior-directed force to
the proximal humerus which will decrease or eliminate the
patient’s apprehension or pain (Fig. 7).12 Lastly, a release SLAP Lesions
test may be performed after the relocation test by removing Superior labral injuries can occur concomitantly with
the posterior force on the proximal humerus which will glenohumeral instability and therefore should be evaluated
once again reproduce the patient’s apprehension or pain. as part of a comprehensive shoulder examination. How-
ever, no one test is highly sensitive and specific. In the active
compression test, the examiner places the patient’s arm in
Posterior Instability 90 degrees of forward flexion and 15 degrees of adduction
Similar to anterior instability, the posterior drawer test with the elbow extended (Fig. 9).14 The patient resists a
is performed with the patient sitting upright with the arm downward force while the arm is internally rotated with the

FIGURE 4. Anterior drawer test. FIGURE 6. Apprehension test.

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Haley Sports Med Arthrosc Rev  Volume 25, Number 3, September 2017

FIGURE 7. Relocation test.

thumb pointing to the floor followed by external rotation

in full supination. Anterior shoulder pain while the arm is
internally rotated that is relieved in external rotation indi-
cates a positive test and suggests superior labral pathology.
It is important to note not only the presence but location of
pain as this position may produce pain over the superior
shoulder which may stem from acromioclavicular joint
pathology.
The anterior slide test also evaluates the superior
labrum.2 The patient stands with their hand on the hip with
the thumb pointing toward the posterior iliac crest. The
examiner stands behind the patient with one hand on the
elbow and other one on the acromion, and then applies a
FIGURE 9. Active compression test.
superior and anterior force on the elbow with the patient
resisting. Pain or a click over the anterior shoulder suggests
Injections
a superior labral lesion.
The long head of the biceps tendon is frequently Diagnostic injections about the shoulder may assist the
evaluated using Speed test and Yergason test (Fig. 10). The examiner in making the correct diagnosis as many shoulder
Speed test is performed with the patient’s elbow extended in injuries present with pain in a similar location. A sub-
full supination with the arm in 60 to 90 degrees of forward acromial injection will often relieve pain associated with
flexion. The patient resists a downward force at the wrist subacromial pathology to include bursitis, bursal rotator
and the examiner monitors for anterior shoulder pain which cuff tears, and impingement-type symptoms. The examiner
indicates a positive test for biceps pathology.2 The Yerga- can perform an impingement test before and after a sub-
son test is performed with the arm against the side and acromial injection to determine if the pain decreases. Pain
elbow flexed to 90 degrees in full pronation. The examiner and crepitus over the superior shoulder often emanates
grasps the patient’s hand and asks the patient to simulta- from the acromioclavicular joint which can also be injected.
neously flex the elbow and supinate the forearm while the In some patients, this joint is very narrow and the author
examiner resists.2 Pain in the anterior shoulder is suggestive finds it useful to use a mini fluoroscan to confirm needle
of biceps tendonitis or instability. placement in the joint before the injection. A biceps tendon
sheath injection is useful for patients with biceps tendonitis
presenting with anterior shoulder pain and positive biceps
tendon tests. It is useful to perform this injection under
ultrasound guidance as the biceps sheath may be difficult to
penetrate by palpation only and thus the injection may miss
the tendon sheath. Finally, an intra-articular glenohumeral
joint injection may be helpful to decrease pain associated
with labral tears, chondral lesions, and pain associated with
adhesive capsulitis.

Examination Under Anesthesia

An examination under anesthesia is important to
confirm the diagnosis made in the clinic. The examiner can
gain a greater understanding of glenohumeral translation
under anesthesia as guarding is eliminated with muscle
paralysis. For anterior instability as previously mentioned,
one should examine the joint in the plane of the scapula and
recall that the instability pattern is typically anterior and
FIGURE 8. Jerk test. inferior versus straight anterior. Furthermore, it is common

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Sports Med Arthrosc Rev  Volume 25, Number 3, September 2017 Examination for Shoulder Instability

Traumatic anterior instability is frequently encountered

in this population and warrants a discussion with high
demand patients for surgical stabilization.

ACKNOWLEDGMENT
The author would like to acknowledge Dr. Brett Owens.

REFERENCES
1. Owens BD, Burns TC, DeBerardino TM. Examination and
Classification of Instability. Philadelphia, PA: Elsevier Saun-
ders; 2012:20–32.
2. Codsi M, McCarron J, Brems JJ. Clinical Evaluation of
Shoulder Problems. Philadelphia, PA: Elsevier Saunders; 2009:
145–176.
3. Thomas SC, Matsen FA III. An approach to the repair of
avulsion of the glenohumeral ligaments in the management of
traumatic anterior glenohumeral instability. J Bone Joint Surg
Am. 1989;71:506–513.
4. Wetzel FT, Reider B. Cervical and Thoracic Spine. Philadelphia,
PA: W.B. Saunders Company; 1999:301–342.
5. Burkhart SS, Morgan CD, Kibler WB. The disabled throwing
shoulder: spectrum of pathology. Part I: pathoanatomy and
biomechanics. Arthroscopy. 2003;19:404–420.
6. Arcand MA, Reider B. Shoulder and Upper Arm. Philadelphia,
PA: W.B. Saunders Company; 1999:19–66.
7. Beighton P, Solomon L, Soskolne CL. Articular mobility in an
African population. Ann Rheum Dis. 1973;32:413–418.
8. Cameron KL, Duffey ML, DeBerardino TM, et al. Associa-
tion of generalized joint hypermobility with a history of
glenohumeral joint instability. J Athl Train. 2010;45:253–258.
9. Gerber C, Ganz R. Clinical assessment of instability of the
shoulder with special reference to anterior and posterior
drawer tests. J Bone Joint Surg Br. 1984;66:551–556.
FIGURE 10. Speed and Yergason tests. 10. Hawkins RJ, Schutte JP, Janda DH, et al. Translation of
the glenohumeral joint with the patient under anesthesia.
J Shoulder Elbow Surg. 1996;5:286–292.
to find more posterior translation under anesthesia than in 11. Rowe CR, Zarins B. Recurrent transient subluxation of the
the clinic, and the examiner must ensure that this increased shoulder. J Bone Joint Surg Am. 1984;63:863–872.
translation is consistent with the patient’s symptoms before 12. Jobe FW, Kvitne RS, Giangarra CD. Shoulder pain in the
tightening the posterior joint. overhead or throwing athlete: the relationship of anterior
instability and rotator cuff impingement. Orthop Rev. 1989;
CONCLUSIONS 18:963–975.
13. Kim SH, Park JC, Park JS, et al. Painful jerk test. Am J Sports
Glenohumeral instability is a common entity especially Med. 2004;32:1849–1855.
in young, active individuals. A thorough history and 14. O’Brien SJ, Pagnani MJ, Fealy S, et al. The active compression
physical examination, appropriate imaging, and selective test: a new and effective test for diagnosing labral tears and
injections, as indicated, will help guide the examiner in acromioclavicular joint abnormality. Am J Sports Med. 1998;
making the correct diagnosis and treatment intervention. 26:610–613.

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