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Special Test

Load and Shift Test

The Load and Shift test is used to test for anterior instability of the shoulder joint. It was first described by Silliman and Hawkins in 1993 as a method to assess anterior and posterior laxity.

How do you perform the Load and Shift Test?

Supine Position:

  • The patient lies in the supine position.
  • The clinician is beside the patient with the inside of the hand over the patient’s shoulder and forearm, stabilizing the scapula to the thorax.
  • The clinician places his or her hand across the glenohumeral joint line and humeral head, so that clinician’s little finger is positioned across the anterior G-H joint line and humeral head.
  • The humerus is then carefully pushed anteriorly or posteriorly in the glenoid if necessary to seat it properly in the glenoid fossa. This is the load portion of the test.
  • The examiner then tries to translate the humeral head in an anteromedial direction to assess anterior stability, and in a posterolateral direction, to assess posterior instability, and the amount of translation and end feel are noted. This is the shift portion of the test.
  • The test should be compared to the contralateral side.
See Also: Anterior Shoulder Instability

Sitting Position:

This test can also be performed in sitting position:

  • The arm by the side of the body, patient relaxed with forearm over the lap, examiner standing from back, with one hand hold the scapula with fingers in the front of shoulder over coracoid and thumb in the back over the angle of acromion, with the other hand hold the head of humerus.
  • Perform the anterior and posterior translation test as with supine position.
  • Comparison must be made to the asymptomatic contralateral side.

Load and shift test Grading

The amount of anterior translation in Load and shift test is graded:

  1. Grade 0: Little / no movement.
  2. Grade 1: humeral head rides up the glenoid slope but not over the rim.
  3. Grade 2: humeral head rides up and over the glenoid rim but reduces spontaneously when stress is removed.
  4. Grade 3: humeral head rides up and over the glenoid rim and remains dislocated on removal of stress.

What does a positive Load and Shift Test mean?

Load and Shift test is Positive when there is increased translation of the humeral head compared to the contralateral side.

For posterior translation, translation of 50% of the diameter of the humeral head is considered normal. Translation of 25% or less of the humeral head diameter anteriorly is considered normal, although results vary. Generally, anterior translation is less than posterior translation, although some authors disagree with this and say that anterior and posterior translation are virtually equal.

Sauers et al. and Ellenbecker et al. stated that hand dominance does not affect the amount of translation, but Lintner et al. disagreed, saying that the nondominant shoulder shows more translation.

The load and shift test can be used to classify degrees of instability based on distance of humeral head translation:

  • 1+: 0 to 1 cm of translation to before glenoid rim.
  • 2+: 1 to 2 cm of translation to glenoid rim.
  • 3+: more than 2 cm translation or over glenoid rim.

The normal motion anteriorly is half of the distance of the humeral head.

Load and Shift test grading
Load and Shift test Grading

Sensitivity & Specificity

  • Sensitivity: 50-55 %
  • Specificity: 78-100 %

Modifications of Load and Shift Test

Prone Anterior Instability Test

With the patient in prone position, the examiner abducts the patient’s arm to 90° and externally rotates to 90° with one hand at the elbow. Maintaining this position the examiner places his other hand over the humeral head and pushes it anteriorly.

A positive test is indicated by reproduction of the patient’s symptoms.

Prone Anterior Instability Test
Prone Anterior Instability Test

Andrews Anterior Instability Test

The patient lies in supine position with the shoulder abducted 130° and externally rotated to 90° by controlling from the elbow. The examiner uses the other hand to grasp the humeral head and lift it forward.

Reproduction of the patient’s symptoms is considered as a positive test.

Andrews Anterior Instability Test
Andrews Anterior Instability Test

Anterior Drawer Test of the Shoulder

In supine position, the examiner places the hand of the affected shoulder in his axilla, holding the patient’s hand with the arm. The shoulder is abducted between 80° and 120°, forward flexed up to 20°, and externally rotated up to 30°.

The patient’s scapula is stabilized with the opposite hand by pushing the spine of the scapula forward with the index and middle fingers and by giving counter pressure on the patient’s coracoid process using the thumb. Using the arm that is holding the patient’s hand, the examiner places his or her hand around the patient’s relaxed upper arm and draws the humerus forward. Associated translation and presence of click are noted.

Anterior Drawer Test of the Shoulder
Anterior Drawer Test of the Shoulder

Anterior Instability Test of Leffert

The examiner stands behind the seated patient and places his near hand over the shoulder so that the index finger is over the head of the humerus anteriorly and the middle finger is over the coracoid process. The thumb is placed over the posterior humeral head. The other hand grasps the patient’s wrist and abducts and externally rotates the arm.

On movement, if the finger palpating the anterior humeral head moves forward, the test is said to be positive for anterior instability. Normally, the two fingers remain in the same plane.

Anterior Instability Test of Leffert
Anterior Instability Test of Leffert

Notes

  • By progressive external rotation and abduction there is less translation anteriorly, as inferior glenohumeral ligament becomes taut.
  • Similarly by internal rotation of the arm posterior translation is diminished with intact posterior capsular structure.
  • In addition to the translation and the pain that may be produced, the most important aspect of the Load and Shift Test is reproduction of the patient’s symptoms with the manoeuvre.

Reference

  1. Silliman JF, Hawkins RJ. Classification and physical diagnosis of instability of the shoulder. Clin Orthop Relat Res. 1993;291:7–19
  2. Vincent A. Lizzio, Fabien Meta, Mohsin Fidai, and Eric C. Makhnicorresponding author. Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability. Curr Rev Musculoskelet Med. 2017 Dec; 10(4): 434–441. PMID: 29043566.
  3. Gerber C, Ganz R: Clinical assessment of instability of the shoulder. J Bone Joint Surg 66B:551, 1984.
  4. Boublik M, Silliman JF. History and physical examination. In: Hawkins III ILJ, Misamore GW, editors. Shoulder injuries in the athlete. New York: Churchill Livingstone; 1996.
  5. Hawkins RJ, Mohtadi NG. Clinical evaluation of shoulder instability. Clin J Sport Med. 1991;1:59–64
  6. Harryman DT, Sidles JA, Harris SL, Matsen FA. Laxity of the normal glenohumeral joint: a quantitative in vivo assessment. J Shoulder Elb Surg. 1992;1:66–76.
  7. Andrews JA, Timmerman LA, Wilk KE. Baseball. In: Pettrone FA, editor. Athletic injuries of the shoulder. New York: McGraw-Hill; 1995.
  8. Gerber C, Ganz R. Clinical assessment of instability of the shoulder. J Bone Joint Surg (Br). 1984;66:551–6.
  9. Leffert RD, Gumley G. The relationship between dead arm syndrome and thoracic outlet syndrome. Clin Orthop Relat Res. 1987;(223):20–31
  10. Borsa PA, Sauers EL, Herling DE. Patterns of glenohumeral joint laxity and stiffness in healthy men and women. Med Sci Sports Exerc. 2000;32:1685–1690.
  11. Sauers EL, Borsa PA, Herling DE, et al. Instrumented measurement of glenohumeral joint laxity and its relationship to passive range of motion and generalized joint laxity. Am J Sports Med. 2001;29:143–150.
  12. Sauers EL, Borsa PA, Herling DE, et al. Instrumental measurement of glenohumeral joint laxity: reliability and normative data. Knee Surg Sports Traumatol Arthros. 2001;9:34–41.
  13. Ellenbecker TS, Maltalino AJ, Elam E, et al. Quantification of anterior translation of the humeral head in the throwing shoulder: manual assessment vs. stress radiography. Am J Sports Med. 2000;28:161–167.
  14. Clinical Tests for the Musculoskeletal System 3rd Edition.
  15. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
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