Numerous clinical tests are described for shoulder examination. Many similar tests have been described by different people and given different names. Also, many different tests have been described by the same person. This can cause confusion. So far tried to collect as many of the tests as can find and list them here. So far I have found 130.

SHOULDER CLINICAL TESTS

General Shoulder Pathology

• Mazion Shoulder Maneuver – -Pt. Seated, Pt. Places hand on the opposite shoulder, moves elbow to forehead – (+)intensifies & localized pain
• Codman Sign – tests passive motion of the shoulder. Examiner stands behind the patient and stabilizes the scapula with one hand, whilst the other hand holds the patient’s arm and moves the arm in every direction. In the early stages of cuff disease only active motion is reduced, but later passive motion reduces.
•  Palm Sign and Finger Sign Test – Patient demonstrates their pain in two ways: with the palm of the opposite hand over acromion (= subacromial or GHJ pain), or with an opposite finger over ACJ (= ACJ pathology)

Shoulder Dislocation

• Dugas – Pt. Seated & instructed to place a hand on the opposite shoulder and touch elbow to chest – (+)pain & inability to perform indicates dislocation
• Calloways – -measure the girth of affected shoulder & compare it to unaffected -(+)increased girth indicates dislocation
• Bryants Sign – look for lowering of axillary fold – (+)dislocation on the low side

Anterior Instability

• Anterior Load and Shift (laxity test) –
• Anterior Drawer Test   ( Gerber-Ganz Anterior Drawer Test) – Pt. is supine and their arm abducted over the edge of the couch. Examiner immobilizers scapula with one arm whilst the other grasps the arm and pulls it anteriorly.
• Anterior Apprehension
• Jobe Relocation  (Fulcrum Test) – Original Article
• Rowe Test – Pt. bends forward slightly with the arm relaxed. The examiner moves the arm slightly inferior and anterior by pulling on the forearm
• Throwing Test – Pt. executes a throwing motion against the examiner’s resistance. Anterior subluxation may occur.
• Leffert Test – Examiner displaces the humeral head anteriorly holding the humeral head over the shoulder with the thumb posteriorly and index finger anteriorly. Displacement of the index finger is positive
• Surprise/Release Test – This maneuver is variously described but essentially is the fmal component of the apprehension and relocation tests. It is an extremely provocative test and should be used with caution. As in the Jobe relocation tests, the patient’s arm is maximally externally rotated with a posteriorly directed force applied to the humeral head. At the limit of the range, the examiner suddenly removes the posteriorly directed force from the relocation test, and again a feeling of apprehension is considered a positive test. (courtesy of Jo Gibson, specialist shoulder therapist, Liverpool)
• Dynamic Anterior Jerk Test – The test combines a compression force and a translation force, applied along the arm between the humeral head and the glenoid cavity. In so doing, a subluxation of the humeral head is provoked and it is accompanied by a jerk recognized by the patient as his instability.
• Dynamic Relocation Test
• Dynamic Rotatory Stability Test
• Bony Apprehension Test – identical to the standard apprehension test except that the arm is brought to only 45 of abduction and 45 of external rotation. A positive result should alert the examiner to the possibility of a bony lesion as the cause of symptomatic shoulder instability. (Bushnell BD, Creighton RA, Herring MM. Arthroscopy 2008;24:974–82).\
• Kinetic Medial Rotation Test – used to differentiate to help determine whether symptoms are primarily impingement or instability. The subject lies supine with 90deg humeral abduction (hand to the ceiling with the humerus in the plane of the scapula). The assessor places one finger on the coracoid process and one on the humeral head. The subject is asked to actively medially rotate the humerus. The ideal is 70deg rotations without any finger movement. If the coracoid finger moves before 70deg then there is an increase in scapula relative flexibility and impingement risk. If the humeral finger moves before 70deg then there is displacing axis of rotation of the humeral head and an instability risk. If both fingers move forward then there is a combined impingement and instability risk. This test obviously needs to be used with other instability and impingement tests to confirm the diagnosis but it is a good rehab indicator for where the primary focus should be.   (Comerford MJ, Mottram SL. Manual Therapy 2001;6(1):15–26.)

Posterior Instability

• Posterior Load and Shift – Posterior Drawer Test
• Gerber-Ganz Posterior Drawer Test- same as anterior drawer except with posterior force.
• Posterior Apprehension test – arm adducted and flexed. Examiner pushes posteriorly – apprehension positive.
• Jerk Test
• Fukuda Test – Elicits a passive posterior drawer sign. The examiner stands with thumb resting on scapula spine and fingers over front of the humeral head exerting a posterior force.

Inferior Laxity

• Gagey’s Hyperabduction Test
• Sulcus Sign at 0 Degrees
• Sulcus Sign at 90 degrees
• Inferior Apprehension Test – The examiner supports the 90 degrees abducted arm with one hand. On the other hand, the examiner tries to invoke an inferior subluxation by applying pressure downward on the patient’s upper arm.

Core Stability

• Kibler’s Corkscrew test – for core instability
• SLAP Lesions
• O’Brien’s Test
• Anterior Slide Test (Kibler)   – Pt sitting with hands-on-hips and thumbs pointing posteriorly. The examiner places on hand on top of the affected shoulder and another hand on point of the elbow. Examiner then applies a forward and superior force on the elbow. Pt asked to resist this force. Pain over the front of the shoulder or a click is positive. (Kibler, Arthroscopy, 1995)
• Posterior Slide Test
• Luddington’s Test – hands on top of head & push down
• Curtain’s Test (Martin Holt) – opening curtain with arm in 90 deg abduction
• Kibler’s grind test
• LaFosse AERS Test – Ab duction Supination External Rotation
• SLAPprehension Test  – Original Article
• Feagin Test
• Biceps Load Test 1
• Biceps Load Test 2 – Original Article
• Crank Test”  – performed with the patient lying and elevating the shoulder with the elbow flexed at 90 degrees. An axial load is applied while the arm is rotated internally and externally and circumducted. A click associated with pain makes the test positive. This mechanism is similar to the McMurray test for a torn meniscus in the knee.
• O’Driscoll’s SLAP Test – Shoulder is placed in the extreme abducted and externally rotated position. From this position, valgus stress is applied and a positive response is signified by pain in the shoulder.  (from Krishnan, Hawkins & Adams. The Shoulder and the Overhead Athlete)
• Pain Provocation Test – Examiner places one hand over the scapula, whilst the other hand holds the patient’s wrist. The patient’s arm is in 90deg. abd & 90deg. ER, with the elbow flexed 90deg. Pt. then asked to supinate & pronate the forearm. Pain worse on pronation indicates a SLAP tear. (Mimori et al. Am J Sports Med, 1999)
• The Resisted Supination External Rotation Test – Original Article
• The Passive Compression Test – Original Article – Patient position: lateral decubitus position with the affected side up. The examiner stood behind the patient, stabilising the affected shoulder by holding the AC joint with one hand and the elbow with the other. The examiner externally rotates the shoulder in 30° of abduction and then pushes the arm proximally while extending the shoulder. Confirmatory findings: pain or a painful click in the glenohumeral joint. Test rationale: with glenohumeral external rotation and extension (late cocking phase), the long head of the biceps tendon is placed under tensile forces while wrapping around the lesser tuberosity and ultimately shifting the superior labrum from the superior glenoid rim. Proximal migration of the humerus aggravates the displacement of the unstable labrum and passively displaces the superior labrum. (Kim YS, Kim JM, Ha KY, et al. Am J Sports Med 2007;35:1489–94).
• Passive distraction test – Patient position: supine. The examiner stands on the affected side of the patient and positions the extremity off the edge of the table, at 150° elevation in the coronal plane, the elbow extended, the forearm supinated, and the upper arm stabilized to prevent humeral rotation. The examiner pronates the forearm while maintaining steady position of the humerus. Confirmatory findings: pain was reported deep inside the glenohumeral joint either anteriorly or posteriorly. Test rationale: peel-back phenomenon of the superior labrum. (Schlechter JA, Summa S, Rubin BD. Arthroscopy 2009;25:1374–9). The passive distraction test may be used for ruling in a SLAP lesion while the passive compression test may be used for both ruling in and ruling out a SLAP lesion.
• The Supine Flexion Resistance Test – Original Article

Bankart Lesions

• Clunk 1 Test
• Clunk 2 Test
• Dynamic Shear (Mayo) Test

Rotator Interval Laxity

• Sulcus with shoulder in external rotation (?test name)

Long Head of the Biceps

• Yergasons Test
• Upper Cut Test – performed with the shoulder in a neutral position and the forearm supinated and with the patient making a fist. The patient is then asked to rapidly bring the hand up to the chin as the examiner resists the motion with the examiner’s hand on the patient’s fist. If the patient has anterior shoulder pain or a painful click over the shoulder during the maneuver, the test is considered positive. VIDEO (Kibler et al, AJSM, 2009)
• Speed’s Test – resisted flexion with straight arm forward 90 degrees and externally rotated.
• Ludington’s Test – Pt. Seated & places both hands behind head with interlocked fingers, pt. Contracts & relaxes biceps while Dr. feels for tendons-(+)rupture of long heads if Dr. is unable to feel the tendon
• Abbot-Saunders – Pt. Seated, passive abduction, external rotation, and lowering of arm, Dr. Palpates long head tendon-(+)a palpable click indicates dislocation of the biceps tendon
• Transverse Humeral Ligament Test – Pt. Seated, passive abduction of the arm with the elbow extended, the shoulder is then internally rotated & externally rotated, Dr. palpates bicipital groove.-(+)If Dr. feels tendon snap in & out of the groove, indicates torn transverse humeral ligament
• Snap Test – test for subluxation of LHB. The examiner palpates the biceps groove with one hand whilst the other hand rotates the shoulder.
• Hueter Sign – Pt. seated with the elbow extended and forearm supinated. They asked him to flex their elbow against resistance. The formation of a biceps ‘ball’ shows an LHB rupture.
• Duga Sign – where an LHB lesion is present the patient will not be able to touch the contralateral shoulder
• Beru Sign – displacement of LHB can be palpated below the ant. deltoid when biceps is contracted.
• Traction Test – a passive extension of the shoulder with the elbow extended and forearm pronated causes pain in the anterior deltoid region along LHB
• Compression Test – Passive elevation of the arm to the end of ROM with continued application of posterior pressure produces pain as a result of compression of LHB betw. acromion and humeral head.

AC Joint

• Anterior/Posterior AC Shear Test -Pt. sitting, the examiner cups both hands with one over the scapula and one over the clavicle and then squeezes. (Davies et al. Phys Sports Med 1981)
• Cross chest Adduction (Scarf / Forced Adduction Test) – the 90 degrees flexed arm on the affected side is forcibly adducted across the chest. – video   [from Silliman JF, Hawkins RJ: Clinical Examination of the Shoulder Complex. In Andrews JR, Wilk KE (eds): The Athlete’s Shoulder. New York, Churchill Livingstone. 1994.]
• Forced Adduction Test on Hanging Arm – the examiner grasps the affected arm with one hand whilst the other hand rests on the patient’s opposite shoulder. The examiner forcible adducts the hanging affected arm behind the patient’s back against the patient’s resistance.
• Dugas Test – the seated patient touches the opposite shoulder with the hand
• AC Distraction (Bad cop) Test – place the arm in maximal internal rotation and apply slight pressure upward. A positive test is pain at the top of the shoulder.
• Paxinos Test – The examiner’s hand is placed superior to the ipsilateral mid-clavicle. Pressure is applied by the thumb in an anterosuperior direction and inferiorly with the index-middle finger to the midshaft of the clavicle. (from Krishnan, Hawkins & Adams. The Shoulder and the Overhead Athlete)

Subacromial Impingement

• Neer Sign – pain with passive abd. in scapula plane, shoulder internally rotated – video
• Neer Test – injection test.
• Hawkin’s-Kennedy Test – video
• Empty can/ full can test – video
• Copeland Impingement Test – passive abduction pain eliminated with the shoulder in external rotation – video
• Horizontal Impingement test – Hawkins in 90deg abduction & no flexion
• Dawburn’s Test  – Pt. Seated, Dr. palpates painful subacromial bursa, & passively abducts arm-(+). If the pain disappears with increasing abduction this indicates bursitis
• Coracoid Impingement Test – pain directly over coracoid with arm passively adducted across chest (distinguish from ACJ scarf test
• Internal Rotation Resistance Strength Test (IRRST)  – The subject is asked to maximally resist first external rotation and then internal rotation with the arm in 90 abductions and 80 ER. (provided courtesy of Mohamed AbdAlla, Egypt)
• Bursitis Sign – Examiner palpates anterolateral subacromial region. Pain = positive for bursitis.
• Impingement Relief Test – the patient abducts the arm through full motion five times and indicates a painful arc. The examiner then applies an inferior and posterior force on the humeral head during the painful phase, which relieves the impingement pain.
• Scapular Assistance Test – the examiner assists the scapula with their hand to elevate as the patient elevates their arm. This eliminates the impingement mid-arc pain in patients with dynamic/secondary impingement and indicates scapula rehabilitation exercises are required (Rabin et al. J Orthop Sports Phys Ther. 2006)
• Shoulder Symptom Modification Procedure (SSMP) (Jeremy Lewis, 2009) – A series of four clinical tests to guide management

Rotator Cuff

1. Supraspinatus:

• Apley’s Scratch Test – Reach over the shoulder to “scratch” between scapula. Measure to which vertebrae thumb can reach
• Jobes Supraspinatus test (also called ‘ Empy can test ‘)
• Dawburn’s sign – The pain is worse when lowering the arm from overhead
• Sherry Party sign (Roger Emery)
• Codman’s Sign (Drop Arm Sign)  – A sign seen in the absence of rotator cuff function or when there is a rupture of the supraspinatus tendon: the arm can be passively abducted without pain, but when support of the arm is removed and the deltoid contracts suddenly, the pain produced causes the patient to hunch the shoulder and lower the arm.(E. A. Codman:The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or about the Subacromial Bursa. Boston : Privately printed, 1934. Reprint, Malabar, Florida : Krieger, 1965.)
• Rent Test – Described by Codman. Palpation of a supraspinatus tear through the deltoid. This is accomplished in a relaxed patient at the anterolateral border of the acromion.  Sensitivity = 95.7%, specificity = 96.8% (from Wolf et al. JSES 2001 )
• Zero Degree Abduction Test – Patient standing with arms by their side. Reisted abduction causing pain or weakness suggests a rotator cuff tear.
• Ludington Sign – The seated patient asked to place both hands behind the neck. If the patient has to make compensatory motions or is able to place one hand behind the neck only with assistance this may indicate a rotator cuff tear.
• Scapular Retraction Test – setting the scapular in a retracted position improves the supraspinatus strength, optimizing a weakened cuff and giving a truer idea of supraspinatus power.
• Burkhead’s Thumbs down & Burkhead’s Thumbs up (Many thanks to Nicholas Ansell) –  These are two alternative tests that can be used to test the integrity of the rotator cuff out of the painful arc. If there is pain on Hawkin’s test, Jobe’s test can be difficult to differentiate if the weakness observed is due to true supraspinatus weakness or an inability to maintain the position because of pain.
• Burkhead’s thumbs-up: the examiner place the patient’s arm to approximately 60-80 degrees of forwarding elevation in the scapular plane out of the painful arc. The patient attempts to raise the arm upwards while the examiner resists this movement. If there is pain this can be a sign of impingement due to anterosuperior cuff weakness.
• Burkhead’s thumbs down: the examiner places the patient’s arm to approximately 60-80 degrees of forward elevation in the scapular plane out of the painful arc and then pronates the forearm so that the thumb is facing downwards. The patient attempts to raise the arm upwards while the examiner resists this movement. If there is pain this can be a sign of posterosuperior cuff weakness.
• The Lateral Jobe Test – consists of the patient holding their arms in 90 degrees abduction in the coronal plane with the elbows flexed at 90 degrees and the hands pointing inferiorly with the thumbs directed medially.  A positive test consists of pain or weakness on resisting downward pressure on the arms or an inability to perform the tests. 81% sensitivity, 89% specificity, and 91% PPV according to the authors (Gillooly, Chidambaram, Mok, 2010)

2. Infraspinatus:

• External Rotation Lag Sign
• Infraspinatus Scapular Retraction Test – for infraspinatus weakness (not tear) in the overhead athlete – click here for more

3 Subscapularis:

• Internal Rotation Lag Sign Test
• Gerber’s Lift-off test (Gerber 1991 ,  Gerber 1996 ,  Greis 1996 )
• Belly Off Sign – Patient position: seated or standing. The examiner stood in front of the patient while passively moving the affected upper extremity into flexion and maximal internal rotation with the elbow flexed at 90°. The examiner supports the patient’s elbow while the other hand brings the arm into maximal internal rotation placing the palm of the hand on the abdomen. The patient is asked to keep the wrist straight and actively maintain this position of internal rotation as the examiner releases the wrist (maintaining elbow support). Confirmatory findings: the patient is unable to maintain the position, the wrist flexes or lag occurs and the hand is lifted off the abdomen. Test rationale: the subscapularis muscle acts as a strong internal rotator and this test evaluates the integrity of the musculotendinous unit. (Bartsch M, Greiner S, Haas NP, et al. Knee Surg Sports Traumatol Arthrosc 2010;18:1712–17).
• Belly Press / Napoleon Sign – if the patient cannot fully internally rotate and push on their belly, the elbow will drop backward if positive. The examiner pushes against the patient’s elbows. (Gerber C, Hersche O, Farron A. J Bone Joint Surg Am 1996;78:1015–23).
• Modified Belly Press Test – Patient position: seated or standing with the affected hand
  flat on the abdomen and elbow close to the body. The examiner stands on the affected side of the patient and instructs the patient to bring the elbow forward and straighten the wrist. The examiner measures the final belly-press angle of the wrist with a goniometer. Confirmatory findings: belly-press angle difference of 10° between affected and unaffected side. Test rationale: the subscapularis muscle acts as a strong internal rotator and this test evaluates the integrity of the musculotendinous unit. The modified version of this test measures side differences in the belly-press angle, unlike the original belly press test. (Bartsch M, Greiner S, Haas NP, et al. Knee Surg Sports Traumatol Arthrosc 2010;18:1712–17).
• Bear-Hug Test – for subscap – arm across chest holding opp. lat dorsi and try pull the arm away (Burkhart & De Beer)
  A study by Pennock et al. (AJSM, 2011) showed that there was no difference in the isolation in the subscapularis between these 3 tests for subscap, however it is not known whether different parts of subscap are activated more or less with each test.
• Lateral Jobe Test – Patient position: seated or standing. The examiner instructs the patient to abduct their
  affected shoulder to 90° in the coronal plane with the elbow flexed to 90° and the shoulder internally rotated so that the fingers point inferiorly and the thumbs medially. The examiner then applies an inferior force to the distal arm. Confirmatory findings: pain or weakness or inability to perform the test. Test rationale: the authors did not provide an explanation as to why this test mechanically differs from the original Jobe test. (Gillooly JJ, Chidambaram R, Mok D. Int J Shoulder Surg 2010;4:41–3).

4. Massive cuff tear:

• Hornblower’s sign – an inability to externally rotate the elevated arm; demonstrates severe infraspinatus and teres minor weakness.
• The Dropping Sign (Walch) – With a seated patient the shoulder is placed in 0 of abduction, and 45 of external rotation with the elbow flexed to 90. The examiner holds the patient’s forearm in this position, and instructs the patient to “maintain this position when he lets go of the forearm.” On releasing the forearm a positive test is recorded when the patient’s forearm drops back to 0 of external rotation, despite the patient’s efforts to maintain external rotation.
• French Horn Shoulder Test (Internal & External rotation)
• 90/90 Drop Lag Test
• Posterior Impingement Sign – Pt. supine with the shoulder in 90 deg. abd and elbow in 90deg flexion. Examiner stabilizes elbow and applies ER force to maximum ER.
• Compression test
• GIRD – Glenohumeral Internal Rotation Deficit (Burkhart) – post capsular tightness

Posterior Labral Tear

• Push-Pull Test – The patient is supine and the arm held at the wrist with the shoulder at 90 degrees abduction and neutral rotation. The examiner places the other hand on the proximal humerus and while pulling with the arm holding the patient’s wrist, the examiner pushes with the arm on the proximal humerus. This is often enough to maximally translate the patient’s humeral head posteriorly. The test is positive if it reproduces the patient’s symptoms. (from Krishnan, Hawkins & Adams. The Shoulder and the Overhead Athlete)
  – Jahnke Jerk Test – Performed seated or supine. The affected arm is placed in maximal horizontal adduction and internal rotation and a posterior force is applied. This causes posterior subluxation. Next, the shoulder is brought back from horizontal adduction while maintaining posterior force on the humerus at the elbow. As the shoulder approaches normal a cluck may herald reduction of the subluxed shoulder, which is a positive test. (from Krishnan, Hawkins & Adams. The Shoulder and the Overhead Athlete)
• Painful Jerk Sign Test
• Kim Test   (provided courtesy of Mohamed AbdAlla, Egypt)

Subcoracoid Impingement

• Coracoid Impingement Sign – performed with the patient standing with the shoulder abducted 90 degrees with horizontal adduction in the coronal plane and maximally internally rotated (the tennis “follow through” position).  (from Krishnan, Hawkins & Adams. The Shoulder and the Overhead Athlete)

Others

• Military Brace Test (Roos Test)
• Brachial Plexus Stretch Test
• SC Joint stress test
• Scapula Pinch / Retraction Test (for scapula stability) – Pt sitting and maximally retracting scapula. Hold for 15 seconds(Kibler Am J Sports Med 1998).
• Thompson and Kopell Horizontal Flexion Test – Standing Pt. moves the 90 degrees abducted arm across the body into maximum horizontal flexion. Pain over the back of the scapula indicates possible suprascapular nerve entrapment (same as Scarf test).
• Lateral Scapular Slide Test (LSST) – to determine scapular position with the arm abducted 0, 45, and 90 degrees in the coronal plane. Assessment of scapular position is based on the derived difference measurement of bilateral scapular distances. (Odom et al. Phys Ther. 2001)
• Coracoid Pain Test, for frozen shoulder – pain elicited by pressure on the coracoid (Carbone. Int Orthop. 2010)
• Pectoralis Minor Length Test – used to assess shoulder protraction due to pec minor shortening. Although it is reproducible, it has been shown to have the little diagnostic benefit (Lewis & Valentine, 2007).
• Olecranon-manubrium percussion test – Patient position: seated or standing with elbows flexed at 90°. The examiner places the stethoscope bell over the manubrium and percusses each olecranon process. Confirmatory findings: a decrease in pitch or the intensity of the affected side. Test rationale: if there are any bony abnormalities, the affected side should have a duller sound than the normal side. (Adams SL, Yarnold PR, Mathews JJt. Ann Emerg Med 1988;17:484–7).
• Shrug sign – Patient position: standing. The examiner instructs the patient to abduct both arms in the coronal plane. Confirmatory findings: elevation of the scapula or shoulder girdle in order to achieve 90° of abduction. Measured with a goniometer, the magnitude of the shoulder shrug was defined as the angle between the arm and the horizontal point at which the shrug moment began. Test rationale: the authors conclude the shrug sign can detect shoulder abnormalities, especially those associated with loss of range of motion or weakness on manual muscle testing. (Jia X, Ji JH, Petersen SA, et al. Clin Orthop Relat Res 2008;466:2813–19).

Provocative Exam Of shoulder joint

In addition to the standard physical exam maneuvers described above, there are a number of provocative exam maneuvers that are specific in detecting inferior laxity in the setting of glenohumeral instability. One commonly performed exam maneuver is that of the sulcus sign. To perform the sulcus sign, the patient is first positioned upright with their arms resting at their side. The examiner then stabilizes the shoulder and applies an inferiorly-directed force on the elbow (Fig. 1). Excessive downward displacement of the humeral head that does not improve with external rotation suggests multi-directional instability of the shoulder or deficiency of the rotator interval.

The sulcus sign is graded by the amount of inferior translation; grade I is less than 1 cm translation, grade II is 1–2 cm translation, and grade III is greater than 2 cm translation.

The hyperabduction test is another maneuver for detecting inferior glenohumeral instability and specifically assesses the integrity of the IGHL [16]. To perform this maneuver, the examiner evaluates the passive abduction of the shoulder while using his or her forearm to stabilize the shoulder girdle in a low position (Fig. 2). Most healthy volunteers in this position only demonstrate passive abduction up to 90°, whereas passive abduction over 105° suggests excessive laxity of the glenohumeral joint.

Additionally, there are a number of other exam maneuvers that directly assess for anterior glenohumeral instability. Anterior apprehension may be elicited by bringing the patient’s shoulder into a position of 90° of abduction and 90° of external rotation (Fig. 3) in either the supine or upright position. A positive exam finding is the subjective feeling of impending subluxation or dislocation when in this provocative position. It is important to note that although these symptoms may be accompanied by pain, pain itself does not produce a positive test.

The bony apprehension test is a variant of the traditional apprehension test and is used to detect the involvement of bony lesions, specifically, as a contributing cause of anterior glenohumeral instability [17]. Rather than bringing the shoulder into 90° of abduction and 90° of external rotation, the shoulder is instead positioned at 45° of abduction or less and at 45° of external rotation or less. A positive finding is the same as the traditional apprehension test, that is, a sensation of apprehension or symptoms of instability. Interestingly, the bony apprehension test has been shown to be more sensitive than preoperative plain radiographs for detecting bony lesions at time of surgery [17].

The relocation test is a natural progression of the apprehension test and assesses for relief of apprehension after manual stabilization of the shoulder. After eliciting a positive apprehension test, the examiner maintains the patient in their current position and applies a posteriorly-directed force on the humeral head in an attempt to stabilize the shoulder and correct the symptoms (Fig. 4). In a patient with anterior shoulder instability, this maneuver should bring a subluxed humeral head back into the correct position relative to the glenoid fossa. Resolution of guarding and apprehension suggests anterior instability and is considered a positive relocation test.

Anterior release or surprise test – This maneuver contains aspects of both the apprehension test and relocation test. In this maneuver, the patient is supine on the exam table and the shoulder is again brought into an abducted and externally rotated position. During this time, the examiner places his/her hand on the shoulder with a posteriorly-directed force. Once the shoulder is at maximal external rotation, the hand is then suddenly removed, thus allowing the shoulder to translate anteriorly (Fig. 5). If the patient demonstrates guarding, apprehension, or instability once the posteriorly-directed force is removed, the test is considered positive and indicative of anterior glenohumeral instability [18]. Care is taken not to dislocate the patient’s shoulder with this exam maneuver.

Load and shift test – the patient is positioned supine while the examiner is to the side of the patient. In order to examine the left shoulder, for example, the patient’s left wrist is first held by the examiner’s left hand at a slightly flexed and limp position. The examiner then uses their right hand to grasp the humeral head. After loading the humeral head into the glenoid fossa, the examiner places an anteriorly-directed force on the humerus and assesses for the amount of anterior laxity [19] (Fig. 6).

Rather than simply declaring the load and shift test positive or negative, there are a variety of grading systems used to describe the degree of glenohumeral translation. While some grading systems attempt to quantify the amount of translation, it is more practical and common to use a clinical-based grading system [20], where grade 0 is defined as minimal displacement, grade 1 is the humeral head reaching the glenoid rim, grade 2 is when the humeral head can be dislocated but spontaneously resolved, and grade 3 is when the humeral head does not spontaneously reduce [21].

The load and shift test is very similar to the anterior drawer test. However, the anterior drawer test does not involve loading the glenohumeral joint prior to translating the humeral head along with the glenoid [22].

The load and shift test also closely resembles the anterior jerk test, which similarly involves loading the humeral head into the glenoid fossa. The anterior jerk test differs in that the patient is positioned with his or her shoulder at 60–80° of abduction and 45° of flexion before applying an anteriorly-directed force on the humeral head [23]. The purpose of this test is to evaluate for subluxation of the humeral head, which is perceived as a noticeable jump or clunk due to excessive anterior translation over the glenoid rim. A similar finding may be demonstrated upon reentry of the humeral head into the glenohumeral joint.

An overall summary of how to perform each physical exam maneuver for anterior shoulder instability can be found in Table ​Table2.2. An overview of the statistical measures of performance for several of these physical exam maneuvers can be found in Table ​Table33.

 The O’brien’s active compression test – in particular, is very useful for testing the superior labrum and biceps anchor. With the patient’s shoulder in 90° flexion, 10° adduction, and maximum internal rotation, the patient resists a downward force placed on the hand. This is repeated with the shoulder in full external rotation. A positive result is when there is deep shoulder pain on internal rotation that is partially or completely lessened during external rotation. Associated-point tenderness over the biceps provides further evidence that the tear may extend to include a SLAP component. It is essential to elicit the location of the pain with this provocative exam. Dr. O’Brien originally described this exam for AC joint pain. If the location is on top of the shoulder then that indicates AC pathology, whereas if the pain is within the shoulder joint, then a SLAP tear is suspected.

3-pack” examination, which includes the O’Brien sign, throwing test – and bicipital tunnel palpation, has demonstrated excellent sensitivity, negative predictive value, and inter-rater reliability for comprehensive evaluation of the biceps/labral complex pathology, making it an ideal screening tool for this purpose [29].

Crank test, and dynamic labral shear test – To perform the biceps load test I, the patient is positioned supine with their shoulder at 90°, elbow at 90°, and forearm supinated. The examiner then performs the apprehension test. After producing instability symptoms, the patient is instructed to flex their elbow against resistance. Worsening of pain or symptoms is suggestive of a SLAP lesion [30]. A variant of this maneuver is the biceps load test II, which differs in that the shoulder is abducted to 120° instead of 90° [31].

The crank test is performed by abducting the patient’s shoulder to 160°, applying an axially-directed force from the humeral head into the glenoid, and alternating between internal and external rotation. Reproducible pain or clicking is indicative of a labral tear.

The dynamic labral shear test is performed by applying an anteriorly-directed force on the humeral head while passively elevating the arm from neutral position to maximal abduction. A positive finding is defined as pain or clicking between 90 and 120° of abduction and is suggestive of a SLAP lesion [32].

Jerk test or Kim test – To perform the jerk test, the patient is first positioned with their arm at 90° of abduction and 90° of internal rotation. The examiner then grasps the elbow while stabilizing the scapula, axially loads the humerus onto the glenoid, and then horizontally adducts the arm across the body. The sliding of the humeral head off of the glenoid with associated pain or click indicates a posterior or posteroinferior labral lesion [33]. To perform the Kim test, the patient begins in the same position but the examiner does not stabilize the scapula and instead holds the proximal arm and elbow, applies an axial load to the glenohumeral joint, and adducts/elevates the arm at 45° (Fig. 7). This maneuver is performed while placing additional posterior and inferior force on the arm. The presence of pain during this maneuver suggests a posterior or posteroinferior labral tear [34].