Hyperextension Internal Rotation Test (HERI Test)

The Hyperextension Internal Rotation Test (HERI Test) is a new test developed to assess the integrity of the inferior glenohumeral ligament and inferior capsule of the shoulder joint. What sets this test apart is its unique approach to evaluation while maintaining a reduced risk of shoulder dislocation during examination – a crucial consideration when dealing with potentially unstable shoulders.

How to perform the Hyperextension Internal Rotation Test (HERI Test)?

The execution of the HERI Test requires precise technique and careful attention to patient positioning. The examining clinician should follow these key principles:

The examiner position posterior to the patient, ensuring proper access to both shoulders. Initially, the clinician focuses on the unaffected shoulder, which serves as a baseline for comparison. The non-test limb is carefully elevated to its maximum range, serving a dual purpose: establishing a comparative baseline and restricting thoracic spine and scapulothoracic joint movement during the examination.

While maintaining this position, the examiner then focuses on the test arm. The movement involves a combination of medial rotation and maximal extension. This manipulation requires particular attention to patient comfort and response, as individuals with shoulder pathology may experience apprehension during arm elevation.

See Also: Normal Shoulder Range of Motion

What is a positive HERI Test?

Test interpretation centers on comparing the extension range between the affected and unaffected shoulders. A positive HERI Test is indicated when the examiner observes greater than 10 degrees of additional extension in the affected arm compared to the contralateral side. This differential serves as a quantifiable marker for potential pathology in the inferior glenohumeral ligament complex.

In the cadaver study, isolated IGHL section increased the angle of extension by a mean of 14.5° (11°-18°) compared to the pre-injury values. In the clinical study, the mean difference in extension angles between the normal and abnormal sides was 14.5°. The patients reported no apprehension during the HERI test. The angle of extension increases after section or injury of the IGHL in cadaver specimens and patients, respectively. When the inferior capsule and IGHL are damaged, the angle of extension increases compared to the normal side. Lesions to these structures can be evaluated clinically by performing the HERI test.

Patient apprehension during arm elevation should be carefully monitored, as it may indicate underlying pathology or risk of instability.

See Also: Shoulder Apprehension Test

The test’s value lies not only in its diagnostic capability but also in its ability to be performed with minimal risk of iatrogenic injury.

The HERI Test should not be viewed in isolation but rather as part of a comprehensive shoulder examination protocol. Its findings should be correlated with other clinical tests, imaging studies when indicated, and the overall clinical presentation to establish an accurate diagnosis and appropriate treatment plan.

References & More

1. Orthopedic Physical Assessment by David J. Magee, 7th Edition.
2. Lafosse T, Fogerty S, Idoine J, Gobezie R, Lafosse L. Hyper extension-internal rotation (HERI): A new test for anterior gleno-humeral instability. Orthop Traumatol Surg Res. 2016 Feb;102(1):3-12. doi: 10.1016/j.otsr.2015.10.006. Epub 2015 Dec 22. PMID: 26726100. Pubmed