Journal of Orthopaedic & Sports Physical Therapy

Official Publication of the Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

N T - C A L C O M M E N T A R Y

The Physical Examination of the Glenohumeral

Joint: Emphasis on the Stabilizing Structures
Kevin E. Wilk, PT'
lames R. Andrews, MD*
Christopher A. Arrigo, MS, PT, A T C ~

he physical examination
of patients whose com-
plaints suggest subtle to
moderate shoulder insta-
bility can be extremely
difficult. Often, the clinical diagnosis of a patient whose
of instability is difficult because of
the normal amount of capsular laxity
appreciated during clinical examina-
tion. Clinicians may be challenged
when attempting to determine the
amount of normal acceptable liga-
mentous laxity compared with p a t h e
logic excessive laxity. Additionally,
there are few published papers in
which specific physical examination
tests used to determine glenohumeral
instability are thoroughly described.
The purpose of this paper is to dis-
cuss and illustrate the subjective his-
tory and physical examination of the
glenohumeral joint. An additional
purpose is to present specific stability
assessment tests to evaluate the gleno-
humeral joint and identify the spe-
cific anatomic structures injured.
The stability assessment maneu-
vers discussed in this paper have
been developed and based on recent
research in the area of arthrokine-
matic motions (5,13,16,34) and se-
lected ligamentous cutting studies
which determined the primary and
secondary restraints to directional
translations of the glenohumeral
joint (5,6,9,11,24,25,27,28,39,40).Be-
fore discussing the physical examina-
tion and assessment of static stability, Age is important because it suggests
we will discuss the importance and
Thorough descriptions of specific physical examination tests used to determine gleno-
humeral instability are lacking in the scientific literature. The purpose of this paper was to discuss
the importance of the subjective history and illustrate the physical examination of the gleno-
humeral joint. Additionally, the authors will illustrate specific stability assessment tests for the
glenohumeral joint based on current basic science and clinical research. The physical examination
history suggests subtle glenohumeral joint instability may be extremely difficult
for the clinician due to the normal amount of capsular laxity commonly present in most
individuals. An essential component of the physical examination is a thorough and meticulous
subjective history which includes the mechanisms of injury and/or dysfunction, chief complaint,
level of disability, and aggravating movements. The physical examination must include an
assessment of motion, static stability testing, muscle testing, and a neurologic assessment. A
comprehensive understanding of various stability testing maneuvers is important for the clinician to
appreciate. The evaluation techniques discussed in this paper should assist the clinician in
determining the passive stability of the glenohumeral joint.
Key Womls: glenohumeral joint, instability, assessment
' National Director, Research and Clinical Education, HealthSouth Rehabilitation Corporation, Birmingham,
AL; Associate Clinical Director, HealthSouth Sports Medicine and Rehabilitation Center, Birmingham, AL;
Director, Rehabilitative Research, American Sports Medicine Institute, 1313 13th Street South, Birmingham,
AL 35205
* Clinical Professor, Orthopaedicsand Sports Medicine, University of Virginia Medical School, Charlones-
ville, VA; Medical Director, American Sports Medicine Institute, Birmingham, AL; Orthopaedic Surgeon,
Alabama Sports Medicine and Orthopaedic Center, Birmingham, A1
' Physical Therapy Coordinator, HealthSouth Sports Medicine and Rehabilitation Center, Birmingham, AL;
Coordinator of Rehabilitation, Texas Rangers Baseball Club, Arlington, TX
clinical relevance of a thorough s u b most cases, shoulder instability pa-
jective history. tients will be younger than 30 years
of age (15). Conversely, patients in
SUBJECTIVE HISTORY or above their fourth or fifth decade
of life most often exhibit rotator cuff
Before any clinical physical exam- pathology (15). The patient should
ination can be performed, a thor- be questioned in regard to how this
ough and meticulous subjective his- condition has affected their daily ac-
tory must be obtained. Several key tivities and sports. In addition, the
facts play a major role in establishing patient's general health, occupation,
a diagnosis of shoulder instability. hand dominance, sports, and leisure
One of the first questions asked is activities should all be documented.
the patient's age and activity level. Next, establish the patient's chief
complaint (Why is he/she here to-
the type of pathology present. In day?). Additionally, when and how

Volume 25 Number 6 June 1997 JOSPT


did the problem begin? Was the on-
set insidious in nature, o r was there a
specific traumatic event? If a trau-
matic event is the primary cause, a
thorough description of the injury
mechanism and arm position during
that event should be established. A
common injury mechanism produc-
ing anterior instability occurs when
the arm is in abduction and external
rotation and is forced past the nor-
mal range of motion into external
rotation and horizontal abduction.
Often with posterior instability, the
patient's arm is flexed to 90" with the
elbow fully extended while perform-
ing a pushing maneuver o r a fall
onto the arm in the same position
drives the humeral head posteriorly.
During subjective questioning,
the clinician should attempt to estab-
lish the degree of instability (subluxa-
tion vs. dislocation), the onset (trau-
matic, atraumatic, overuse), the
severity (limitations at work, activities
of daily living, sports), and the direc-
tion of the instability (anterior, poste-
rior, multidirectional). The patient
should be asked what activities or
movements aggravate the condition
or reproduce the symptoms. Addi-
tionally, what positions or movements
alleviate this condition? Frequently,
patients with atraumatic shoulder in-
stability can voluntarily sublux their
shoulders. This is particularly true for
patients with posterior instability. Of-
ten, the posterior subluxator also ex-
hibits inferior instability and would
then be classified with multidirec-
tional instability (23). Patients with
multidirectional instability commonly
complain of a "loose feeling," espe-
cially with extreme motions or when
carrying a suitcase or heavy bag. Ad-
ditionally, this group of patients may
complain of tingling, paraesthesias,
weakness of the upper extremity, and
diffuse, poorly localized pain, which
may be from secondary tendinitis. In
contrast, patients who have sustained
a traumatic injury with unidirectional
instability frequently complain of lo-
calized pain and discomfort with spe-
cific arm positions. Pain can present
JOSPT Volume 25 Number 6 June 1997
in a variety of locations. Patients with
traumatic anterior instability fre-
quently describe posterior shoulder
pain secondly to impingement
against the posterior rim of the gle-
noid. Multidirectional unstable shoul-
der patients often present with local-
ized biceps tendon inflammation as
well as diffuse rotator cuff tendinitis-
type symptoms as the dynamic stabi-
lizers become overused.
The clinician should also deter-
mine the stage of the condition
(acute, subacute, or chronic) and the
possible involvement of other struc-
tures, such as the bony structures,
labrum, and/or muscular soft tissues.
For example, does the patient exhibit
glenohumeral joint instability with
rotator cuff tendinitis and/or bicipi-
tal tendinitis?
The spectrum of symptoms in
patients with shoulder instability can
be wide and varied. In many cases,
the condition is readily perceived and
described by the patient who reports
"my shoulder comes out of place
when I do this." In contrast, others
may report only vague shoulder pain.
Subjective complaints of slipping,
popping out, catching, a "dead arm,"
diffuse muscular soreness, or fear of
movement may all suggest the pres-
ence of shoulder instability. Also,
with an athletic patient, the clinician
may ask what specific movements
cause pain and/or instability. For ex-
ample, symptoms during the cocking
phase of throwing may suggest ante-
rior instability.
PHYSICAL EXAMINATION
The Assessment of Motion
The assessment of both active
and passive range of motion plays a
vital role in the physical examination
of a patient with suspected shoulder
instability. Active motion is utilized to
determine not only the quantity of
motion but also the quality of motion
present. It also reveals to the exam-
iner information regarding the pa-
tient's willingness and ability to move
CLINICAL COMMENTARY
FIGURE 1 . Passive range of motion assessment. Exter-
nal rotation assessed in the scapular plane. The hu-
merus is positioned 30 to 45" anterior to the coronal
plane.
the shoulder, especially in extremes
of motion such as external rotation
and abduction. We routinely ask the
patient to perform four active mo-
tions: elevation of the arms above the
head in either a seated or standing
position, horizontal adduction/ab-
duction, external rotation behind the
head, and internal rotation behind
the back. The patient is instructed to
move the arm as far as he/she can.
We routinely ask the patient if he/
she experienced any shoulder insta-
bility, such as slipping, popping out,
or pain during these motions. Passive
motion is assessed with the patient
supine and relaxed. It is important
for the clinician to stabilize the scap
ula during the assessment of passive
range of motion. The amount of pas-
sive motion is documented as well as
the end feel. In the normal shoulder,
most commonly a capsular end feel is
perceived at the end range of mo-
tion. Cyriax (10) describes this as a
"hardish arrest of movement with
some give to it, as if a thick piece of
leather was being stretched." Individ-
uals with shoulder instability may fre-
quently exhibit a spasm end feel or
an empty end feel (no resistance met
due to pain o r apprehension). The
passive motions typically assessed are
forward flexion, external rotation in
the plane of the scapula (Figure 1).
and external rotation/internal rota-
tion at 90" of shoulder abduction
(Figure 2). It is not uncommon for
the overhead athlete (especially the
CLINICAL COMMENTARY
. - - .-.
FIGURE 2. Extemal rotation passive rotation assessed at 90' oishoulder abduction. Note the hypermobility of the
shoulder joint capsule, allowing approximately 170' of external rotation.
overhead thrower) to exhibit a dis-
crepancy in motion between the two
shoulders, with the dominant shoul-
der exhibiting greater motion into
external rotation and relatively less
internal rotation. If excessive external
rotation is noted (Figure 2), particu-
larly with a soft end feel, this may
suggest hypermobility and hyperelas-
ticity, thus, excessive anterior gleno-
humeral displacement on clinical ex-
amination.
STABILITY ASSESSMENT
The assessment of glenohumeral
joint stability requires the examiner
to appreciate several interrelated ob-
jective components. First, the exam-
iner must document the amount of
passive translation present between
the humeral head and the glenoid
fossa during the examination. Sec-
ond, the examiner should attempt to
382
. *. .. -- --
assess the end feel to each directional
stress applied. Lastly, the clinician
should attempt to reproduce any
symptoms of subluxation and/or a p
prehension subjectively described by
placing and stressing the shoulder in
provocative, compromising positions.
Through an objective, static stability
assessment, the examiner may classify
the type and degree of shoulder in-
stability according to the direction of
laxity, including anterior, posterior,
inferior, and/or multidirectional.
Inferior Stability Assessment
The first direction the authors
routinely assess is the inferior direc-
tion. This can be accurately assessed
through the sulcus test. This test is
performed with the patient in a re-
laxed, seated position with arms at
the side resting on the thighs and
with the head facing forward. Next,
FIGURE 3. Sulcus sign. The patient is seated and re-
laxed. The examiner grasps the distal humerus and
gently pulls inferiorly. Palpation of the subacromial
may reveal a widening of the space between the hu-
meral head and acromion.
the elbow is grasped at the bicondy-
lar axis of the humerus, and an infe-
rior traction force is applied through
the long axis of the humerus (Figure
3). The area adjacent and lateral to
the acromion is observed for gapping
or dimpling of the skin. The space
underneath the acromion is palpated
to gain an impression of the amount
of inferior humeral head translation
present. If the amount of translation
is greater than the contralateral
shoulder, then the patient is believed
to exhibit a positive "sulcus sign"
(23). If the patient exhibits multidi-
rectional instability of the shoulder,
often, the opposite is also lax, mak-
ing a bilateral comparison useless.
We will discuss this point later in the
paper. We grade the translation
based on the amount of gapping
demonstrated between the lateral
acromion and the superior humeral
head (21). The grading of translation
is determined by the assessment of
the quantity of displacement of the
shoulder being tested. The grading
scale for inferior humeral head trans-
lation can be found in Table 1. With
the arm positioned at 0-20" of ab-
duction (arm at side) with an inferior
Grade Tramlation Measurement*
I t 0.5-1 ern
2t 1-2 crn
2-3 crn or more
- 3t
-
* lateral acrornion to superior hurneral head distance.
TABLE 1. The grading system for inferior translation.
Volume 25 Number 6 June 1997 JOSPT
 Anterior Stability Assessment
I I! The glenohumeral joint is the
most commonly dislocated joint in
the human body. Anterior disloca-

L
tions follow as the most common di-
rection of instability, accounting for
84 to 93% of all shoulder dislocations
(7,8,30,36). Because of these facts,
there are numerous clinical tests to
assess anterior stability of the gleno-
FIGURE 5. The SUICUS sign performed at 90°0fabduc- humeml joint.
- . .- , tion. The examiner supports the arm and gently pushes
inferiorly. The arm is maintained in neutral rotation
The drawer test or load and shift
FIGURE 4. A sulcus sign performed at 45' of abduc- and in the scapularplane. test (14,15) is one of the commonly
tion. The examiner supports the a n by holding the performed tests to assess anterior gle-
elbow, thus reducing muscle activity and gently nohumeral stability. The patient is
pushes inferiorly. Note the humerus is placed in the posterosuperior, and the glenoid 'On-
scapular plane and in neutral rotation. tact area shifts posteriorly (34). The seated with h i d h e r arms resting in
examiner applies a gentle inferior his/her lap with the entire shoulder
force upon the superior humeral and neck complex relaxed. The ex-
traction force applied to the humer- head (Figure 5). Again, the amount aminer is behind and to the side of
us, the primary restraint to transla- of translation is observed and pal- the patient. The examiner stabilizes
tion is the superior glenohumeral pated during the test. The primary the scapula with one hand while the
ligament (38,39) (Figure 3). restraint to inferior translation in this other hand grasps the proximal hu-
Inferior stability is also assessed position is the posterior band of the ~ ~ ~ (Figure
r u s 6A). The h ~ m e r a l
with the arm in approximately 45" of inferior glenohumeral ligament com- head is then gently compressed into
abduction in the plane of the scap plex (38,39). the glenoid to center it within the
ula. The sulcus test is again per- Therefore, the assessment of glenoid fossa, assuring a neutral start-
formed with the patient in a relaxed, shoulder stability is determined by ing position. From this neutral posi-
seated position, and the arm elevated bilateral comparisons, end feel, re- tion, the h ~ m is ~ then~ pushed
s
to 45" of abduction and held in neu- production of symptoms, and ac- obliquely forward in the plane of the
tral rotation at the elbow by the ex- quired appreciation of acceptable scapula to determine the amount of
aminer. The examiner's other hand levels of laxity by the examiner. Mat- anterior glenohurnera1 displacement
applies an inferior directed stress sen et al (21) have reported a mean (Figure 6B). A normal shoulder
across the humeral head (Figure 4). of 11 ( 2 3 ) mm of inferior translation reaches a firm end point with only
The amount of translation is appreci- during a 0" abduction sulcus test on slight anterior displacement and no
ated by the examiner through palpa- eight normal asymptomatic shoul- clunking, popping, or pain. A clunk
tion and visualization of the dimpling ders. In contrast, Wuelker et al (42) or pop may suggest the presence of a
of the skin at the lateral margin of have reported approximately 4 mm labral pathology or a Bankart lesion
the acromion. The primary restraint of inferior displacement at 0" of ab- (20). In this arm position, the pri-
to inferior translation with the arm in duction. Therefore, there appears to mary anterior restraints are the supe-
this position is the anterior band of be a large variation of translation in rior and middle glenohumeral liga-
the inferior glenohumeral ligament normal asymptomatic individuals. It is ments (6).
(38). This portion of the capsule is a not uncommon for the stable shoul- The drawer test can also be per-
commonly injured area in the ante- der patient to exhibit one full centi- formed with the patient supine. In
rior dislocated shoulder and a com- meter (10 mm) of inferior glenohu- this position, the patient may be
mon site for a Bankart lesion (4). meral translation. This is important more relaxed, and the scapula is
Lastly, inferior stability is assessed to remember when examining a fixed by the examination table (Fig-
with the arm in 90" of abduction in shoulder of a patient with multidirec- ure 7A). The arm is grasped at the
the scapular plane. Again, the patient tional instability. The authors usually bicondylar axis of the distal humerus
remains in a relaxed, seated position, consider greater than 1 cm to be and held in neutral humeral rota-
and the arm is supported by the ex- pathologic in nature. It is also impor- tion. The arm is then placed in 30-
aminer at 90" of abduction with neu- tant to remember that when the pa- 45" of elevation in the plane of the
tral humeral rotation. With increas- tient exhibits a positive sulcus sign, a scapula. The examiner's other hand
ing elevation, the contact area of the multidirectional instability pattern grasps the humeral head, which is
humeral head shifts from inferior to may be present, if symptomatic. gently compressed within the gle-

JOSFT Volume 25 Number 6 June 1997 383

 Ann
Primary Restraint Secondary Restraint
Position
0° Superior and middle glenohumeral ligament Posterior capsule
45" Middle glenohumeral ligament Posterior capsule
lnferior glenohumeral ligament
90" Inferior glenohumeral ligament Middle glenohumeral ligament
Posterior capsule

TABLE 2. Primary and secondary restraints to the anterior drawer test.

meral ligament plays a major role in
limiting anterior translation in the
midrange of abduction (6,l l,27,28).
As the arm is progressively abducted.
the restraint shifts inferiorly, and, at
90" of abduction, the inferior gleno-
humeral ligament complex is the pri-
mary restraint to passive translation
(24,25).
The fulcrum test is performed
with the patient lying supine at the
edge of the examination table with
the arm abducted to 90" and exter-
nally rotated to tolerance (usually
FIGURE 6. The load and shift test. A) The patient is 80-90") (1) (Figure 8A). The exam-
sitting with arms relaxed and in their lap. The exam- iner places one hand on the poste-
iner standing behind and to the side of the patient
stabilizes the scapula while the other hand gently
rior aspect of the glenohumeral joint
grasps the humeral head. B) The examiner applies a to act as a fulcrum, while the other
gentle compression force and anterior force. Force hand grasps the elbow and gently
should be applied obliquely in the plane of the scap horizontally abducts the shoulder
ula. over the fulcrum (Figure 8B). The
proximally placed hand holds the
noid, and is then translated anteri- arm and gently lifts anteriorly. In this
orly. The anterior drawer test can be position, the anterior band of the
performed at 0, 45, and 90" of abduc- inferior glenohumeral ligament com-
tion successively to assess the integrity plex wraps around the anteroinferior
of specific capsular ligaments (Figure aspect of the humeral head and acts
7A-C). The primary and secondary as a hammock to prevent anterior
restraints to these tests can be found humeral head displacement (25).
in Table 2. The middle glenohu- There is a high concentration of
strain applied to the inferior gleno-
humeral ligament at 90" of glenohu-
meral abduction (26). When per-
forming this test, Matsen et al (20)
suggest maintaining gentle passive
external rotation for a minute to fa-
tigue the subscapularis muscle prior
to testing, thereby challenging only
the capsular contribution to anterior
shoulder stability. The examiner
should assess the amount of humeral
head translation and end point feel
bilaterally. The examiner should ex-
pect to feel minimal displacement
and an abrupt and hard end point in
the normal shoulder. In the patient
with anterior instability, there will be
excessive anterior displacement; the
end point may be soft or feel as
though the humeral head will con-
tinue to translate. Additionally, the
patient may become apprehensive as
this test is carried out. This maneuver
is an excellent test to assess anterior
laxity in the overhead athlete.
One of the most commonly per-
formed tests to determine anterior
instability is the apprehension test or
crank test. This test is designed to
reproduce the instability symptom or

FIGURE 7. Al The anterior drawer test. The patient is supine and relaxed. The examiner supports the arm through the bicondylar axis of the elbow and places the arm at
the patient's side in neutral rotation. The examiner's opposite handgrasps the humeral head andgently translates the head anteriorly. Note: The arm should be placed in
the scapular plane. Bl The anterior drawer test at 45" of abduction. The maneuver described in Figure 7A is repeated, except now the arm is placed at 45" of elevation
and the scapular plane. CI The anterior drawer test at 90" of abduction.

384 Volume 25 Number 6 June 1997 JOSPT


FIGURE 8. The anterior fulcrum test. Al The patient is
supine, the shoulder is positioned at the edge o i the
table, and the arm is abducted to 904 B) The exam-
iner's right hand grasps the patient's elbow and hori-
zontally abducts the arm while in external rotation;
additionally, the examiner's leh arm gently lifts ante-
riorly, thus creating a fulcrum.
elicit apprehension in the unstable
shoulder. The apprehension test for
anterior instability can be performed
in the upright, supine, or prone posi-
tions, though maximal muscle relax-
ation is best achieved with the patient
supine (14,15,33). In the supine posi-
tion with the shoulder positioned at
the edge of the table, the examiner
grasps the elbow and gently abducts
and externally rotates the arm. The
examiner's opposite hand gently
grasps the humeral head with the
thumb placed on the posterior hu-
merus pushing anteriorly for lever-
age; the fingers anteriorly control any
sudden instability episode. With in-
creasing external rotation and gentle
forward pressure exerted against the
humeral head, an impending feeling
of anterior instability may be pro-
duced (ie., an apprehension sign)
(Figure 9). Additionally, an appre-
hensive look may appear on the pa-
tient's face as he/she resists the pas-
sive force with a protective muscular
contraction or he/she may report "it
JOSW Volume 25 Number 6 June 1997
FIGURE 9. The apprehension sign. The arm is held in
900oiabduction and external rotation. Jhe examiner's
leh hand stabilizes the shoulder, while the opposite
hand externally rotates the arm. The patient with an-
terior instability becomes apprehensive with this ma-
neuver.
feels like my shoulder will come out
or pop out if you push anymore."
Matsen et al (20) suggest watching
the patient's eyebrows for a clue of
apprehension. Pain may or may not
occur, and pain may be present from
other conditions, such as impinge-
ment, labral pathology, or capsular
inflammation.
The diagnosis of anterior gleno-
humeral instability in the overhead
or throwing athlete is often based on
subtle findings (12). A meticulous
physical examination and thorough
history taking (1,2,17-19,30,31) are
extremely beneficial because of sub-
tle signs of subluxation during these
extremely high demand activities.
Jobe and Jobe, and Jobe et al (17.19)
have advocated the use of the "relo-
cation test" to be the most sensitive
test of anterior instability in the over-
head athlete. Originally described by
Peter Fowler in 1982, the relocation
test is similar to the apprehension
test. The patient is positioned supine
with the arm abducted and externally
rotated, hence, in the apprehension
position, while the examiner gently
pushes anteriorly on the humeral
head (Figure 10). This maneuver
generally produces pain (not appre-
hension) in a patient with anterior
subluxation. The test is then re-
peated with a posteriorly directed
force on the anterior aspect of the
humeral head while the arm is exter-
CLINICAL COMMENTARY
abducted to 90" and fully external rotated. If pain
occurs anteriorly, the humeral head is then relocated
within the glenoid which reduces the pain complaint.
This may suggest anterior instability.
nally rotated. This force reduces the
humeral head to its normal position
within the center of the glenoid
fossa. Patients with primary impinge-
ment may have no change in their
pain with this test, whereas patients
with instability and secondary im-
pingement are able to tolerate maxi-
mal external rotation when the hu-
meral head is returned to its reduced
position with the posterior directed
An apprehensive look
may appear on the
patient's face as he/
she resists the passive
force with a protective
muscular contraction.
force. Clinically, we have found the
relocation test to be a sensitive test
for overhead athletes in identifying
posterior impingement as described
by Walch et a1 (37) and Andrews et
a1 (3).
Recently, Speer et a1 (35) studied
the sensitivity, specificity, and accu-
racy of the relocation test on 100 pa-
tients prior to shoulder surgery. The
results indicated that the test was
highly sensitive, but specificity was
poor if pain alone was evaluated. The
385
CLINICAL COMMENTARY
specificity improved markedly if the
examiner was able to produce and
relieve the symptoms of apprehen-
sion.
Posterior Stability Assessment
The incidence of posterior glen*
humeral dislocation is estimated at
approximately 2%. However, the true
incidence of this pathology (subluxa-
tion) is difficult to ascertain because
of the frequency with which this diag-
nosis is missed. The presence of pos-
terior dislocation should be some-
what obvious, but the recurrence of
posterior subluxation is often difficult
to ascertain. Rowe and Zarins (32)
reported that the diagnosis was
missed in 79% of all cases in their
series. The literature suggests that
the diagnosis of posterior instability is
missed in over 60% of all cases of
shoulder instability (22.29). Hence, a
thorough history, including the
mechanism of injury or symptoms,
and a thorough clinical examination,
which includes posterior stability test-
ing, must be performed.
The posterior drawer test can be
performed with the patient in either
the seated or supine position. The
seated posterior drawer test or load
and shift test is performed in the
same manner as previously described
for the anterior load and shift. As the
examiner gently compresses the hu-
meral head into the glenoid fossa, he
then gently pushes the humerus
FIGURE 11. The posterior drawer test. The maneuver
is the same as described in the anterior drawer test
(Figure 71, except the humeral head is translated pos-
teriorly.
translation, noting the inability to
create a posterior dislocation after
excising the infraspinatus, teres mi-
nor, and entire posterior capsule
(40). Only when the anterior supe-
rior capsule was excised would a pos-
terior glenohumeral dislocation oc-
cur (40).
The posterior fulcrum test is an-
other useful maneuver to assess the
posterior stability of the glenohu-
meral joint. The patient lies supine
near the edge of the examination
table. The examiner places one hand
on the anterior glenohumeral joint
to act as a fulcrum while the other
hand grasps the elbow and gently
horizontally adducts the arm (Figure
1 2 4 . As the arm is brought across
the patient's body, the examiner gen-
tly pushes posteriorly on the anterior
FIGURE 12. Posterior fulcrum test: A) The examiner humerus (Figure 12B). The test is
supports the patient's arm in neutral rotation and performed in both 45 and 90" of a b
grasps the humeral head anteriorly and posteriorly
with the opposite hand. B) The examiner gently hori-
duction.
zontally adducts the arm while the opposite hand A test for posterior stability simi-
pushes the humeral head posteriorly. lar to the fulcrum test is the jerk test.
Matsen et al (20) describe this test
with the patient upright and the arm
backward to determine the amount internally rotated and flexed to 90".
of posterior displacement present. It The examiner grasps the e l b ~ wand
is important for the examiner to
translate the humeral head on an
oblique angle when performing a
posterior load and shift in order to
translate the humeral head in line
with the glenoid.
The posterior drawer test can
also be performed in the supine posi-
tion (Figure 11). The examiner and
patient positions are exactly the same
as those described in the perfor-
mance of the supine anterior drawer
test. The test is routinely performed
with the humerus placed in 45 and
90" of abduction. The humeral head
is gently compressed (centered) and
then translated posteriorly. The pri-
mary restraints to posterior displace-
ment with the humerus placed in 90"
of abduction are the posterior band
of the inferior glenohumeral liga-
ment complex, the posterior capsule,
FIGURE 13. The push-pull test: The patient is supine
and the anterior inferior glenohu- and relaxed. The examiner pulls up on the wrist with
meral ligament (25). Warren et a1 one hand, while the other hand pushes posteriorly on
examined the restraints to posterior the humeral head.
Volume 25 Number 6 June 1997 JOSPT

axially loads the humerus in a proxi-
mal direction. While axially loading
the humerus, the arm is moved hori-
zontally across the body. In many pa-
tients with recurrent posterior insta-
bility, this test will produce a sudden
jerk when the humeral head slides off
the back of the glenoid. When the arm
is returned to the original position of
90" of abduction, a second jerk may be
obsewed a5 the humeral head relocates
within the glenoid.
The final posterior stability test is
the push-pull test, which is performed
with the patient in the supine posi-
tion and the shoulder positioned off
the edge of the table (20). The arm
is placed in 90" of abduction and 30"
In normal stable
shoulders, relaxed
individuals often will
allow 50% of the
humeral head to be
posteriorly translated
over the glenoid rim
during the test.
of flexion (Figure 13). The examiner
stands next to the patient's hip and
gently pulls up on the wrist with one
hand while pushing down on the
proximal humerus with the other.
Matsen et al (20) report that in nor-
mal stable shoulders, relaxed individ-
uals often will allow 50% of the hu-
meral head to be posteriorly
translated over the glenoid rim dur-
ing the test.
The quantification of the ante-
rior and posterior translation tests
can be difficult to accurately assess by
the clinician. Abnormal translation is
difficult to appreciate due to the sig-
nificant joint play normally exhibited
at the glenohumeral joint and the
Grade Glenohurneral Translation
Trace Small amount of humeral head
translation
I Less than 50% of the humeral head
translates over the glenoid rim
II Greater than 50% of the humeral head
translates over the glenoid rim but
does not completely sublux
Ill
Entire hurneral head can be translated
over the glenoid rim
TABLE 3. Grading of glenohurneral translation
(anteroposterior directions).
contributory asociated movement of
the shoulder girdle. For documenting
translation, we have found two tech-
niques to be helpful. Hawkins and
Rokor (14) have described a grading
scale that can be utilized for the load
and shift test and may be applied to
other anteroposterior translation
tests. In their proposed grading scale,
the examiner grades the amount of
translation based on the humeral
head's relationship to the glenoid
slope and rim (Figure 14). Warren
(39) has suggested a grading scale
from 1+ to 3+: 1+ implies that the
examiner can translate the humeral
head further than the contralateral
side, but not translate the humeral
head over the rim; 2+ means the
examiner can translate the humeral
head over the rim, but spontaneously
reduces when the force is removed;
and a 3+ grade refers to the ability
of the examiner to lock the humeral
head over the glenoid rim. Clinically,
we utilize a similar grading scale
which is described in Table 3. The
difficulty most therapists experience
with this grading technique is their
apprehension in applying sufficient
force to cause humeral head subluxa-
tion. Another type of grading scale is
one that assesses humeral head trans-
lation as determined by bilateral
comparison. The patient's normal or
asymptomatic shoulder is examined
first in order to provide a baseline
assessment for the amount of gleno-
humeral translation for this particu-
lar patient. In addition, by examining
the normal shoulder first, the tech-
nique is demonstrated to the patient,
CLINICAL COMMENTARY
which may alleviate any anxiety. The
examiner should compare both
shoulders and determine the side-to-
side difference in translation, end
point feel, and symptom reproduc-
tion. We urge the examiner to appre-
ciate not only the difference in total
glenohumeral joint translation but
the end point feel, which often can
be more of a sensitive assessment
tool.
Muscle and Sensory Function
Although the purpose of this pa-
per was to discuss the specific aspects
of stability testing, it is also important
to realize the importance of a thor-
ough muscle testing screening. The
glenohumeral joint relies tremen-
dously on the dynamic stabilizers for
functional stability (41). Thus, a mus-
cle test should be performed on all
shoulder muscles with each evalua-
tion. A neurologic examination of
the upper extremity, which includes
muscle testing, sensory function, and
the testing of reflexes, should also be
routinely performed. The purpose of
this examination is to exclude degen-
erative cervical disc disease, nerve
root encroachment, brachial plexus
lesions, or any other neurologic pa-
thology which may be contributing to
glenohumeral joint instability. Der-
matomal maps (10) may assist the
clinician in determining specific cer-
vical nerve root involvement (10).
SUMMARY
The clinical tests described in
this paper for the physical examina-
tion of the static stabilizers of the
glenohumeral joint are extremely
important. Appropriate assessment of
the competence and function of the
ligamentous restraints of the shoul-
der complex is both the crux and the
key to a proper differential shoulder
examination in the presence of any
shoulder pathology. This type of
hands-on examination requires the
patient to be relaxed and comfort-
able. The degree of translation must
CLINICAL COMMENTARY
GRADE GLENOHUMERAL
TRANSLATION
Trace
FIGURE 14. The clinical assessment of humeral head translation within the glenoid fossa during antemposterior
stability testing. (From Hawkins RI, Bokor Dl: Clinical evaluation of shoulder problems. In: Rockwood CA,
Matsen FA (eds): The Shoulder, Philadelphia: W.B. Saunden Company, 1990,reprinted with permission).
be graded for each clinical test and
compared with the uninvolved side.
A thorough and meticulous history
which includes the mechanism of
injury, chief complaints, and func-
tional limitations must be performed
for the physical examination to ren-
der an accurate diagnosis. It is also
helpful for the examiner to attempt
to reproduce the symptoms during
the examination process. This assists
in the identification of the symptom-
ology. The static stability tests dis-
cussed in this paper are extremely
difficult to perform correctly, particu-
larly when assessing the degree of
translation; thus, it is imperative for
CLINICAL
SMALL AMOUNT OF HUMERAL
HEAD TRANSLATION
HUMERAL HEAD RIDES UP
THE GLENOID SLOPE BUT
NOT OVER THE RIM
HUMERAL HEAD RIDES UP AND
OVER THE GLENOID RIM
REDUCES WHEN STRESS REMOVED
HUMERAL HEAD RIDES UP AND
OVER THE GLENOID RIM. REMAINS
DISLOCATED ON REMOVAL OF STRESS.
the clinician to practice these tests
repeatedly to gain expertise and an
appreciation of both normal and
pathologic amounts of glenohumeral
translation. JOSFT
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