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Shoulder Apprehension Test

 Shoulder Apprehension Test


Shoulder Apprehension Test is used to test for anterior instability of the shoulder joint. It’s used alongside with Jobe Relocation Test. It’s a passive external rotation of the GH joint, places the joint in the closed-pack position and replicates the mechanism of injury for anterior GH dislocations

This test is similar to the load and shift test, except that manual pressure is applied anteriorly by the clinician in an attempt to provoke a subluxation, before using manual pressure in the opposite direction to relocate the subluxation.

See Also: Anterior Shoulder Instability

How do you Perform the Shoulder Apprehension Test?

The examination begins with the patient seated:

  • The examiner palpates the humeral head through the surrounding soft tissue with one hand and guides the patient’s arm with the other hand.
  • The examiner passively abducts the patient’s shoulder with the elbow flexed and then brings the shoulder into maximum external rotation, keeping the arm in this position.
  • The test is performed at 60°, 90°, and 120° of abduction to evaluate the superior, medial, and inferior glenohumeral ligaments.
  • With the guiding hand, the examiner presses the humeral head in an anterior and inferior direction (Jobe relocation test).

The Shoulder Apprehension Test can also be performed in the supine position with improved muscular relaxation:

  • The shoulder lies on the edge of the examining table, which acts as a fulcrum.
  • In this position the apprehension test can be initiated in various external-rotation and abduction positions.
  • The healthy shoulder serves for comparison.

What does a positive Apprehension test mean?

Anterior shoulder pain with reflexive muscle tensing is a sign of an anterior instability syndrome.

  • The patient has apprehension, the fear that the shoulder will dislocate. Prompted by pain, he or she tries to avoid the examiner’s movement.
  • Even without pain, however, the tension of the anterior shoulder musculature (pectoralis) alone may be a sign of instability.
  • Placing the patient supine improves the specificity of the apprehension test.

Apprehension coupled with pain is often associated with instability secondary to rotator cuff pathology. Pain in the deep posterior shoulder may be associated with internal impingement.

Jobe Relocation test:

  • From the apprehension position, the examiner applies a posterior translational stress to the head of the humerus, thereby leading to a sudden decrease in pain and of the fear of dislocation (the humeral head reduces into the socket, and external rotation can be increased).
  • In a further stage of the apprehension and relocation test, releasing the posteriorly directed pressure causes a sudden increase in pain with the apprehension phenomenon (anterior release test).

Sensitivity & Specificity

A study by Vincent A. Lizzio to evaluate the patient with suspected or known anteroinferior glenohumeral instability, he found the Sensitivity and Specificity of the Apprehension test as following:

  • Sensitivity: 68-88 %
  • Specificity: 50-100 %

Another study on 29 patients with symptoms of instability undergoing shoulder surgery found that Sensitivity and Specificity was 100% and 86%, respectively.

and for Relocation test:

  • Sensitivity: 57-85 %
  • Specificity: 87-100 %

The performance of the relocation part of the test (based on operative findings and manual examination under anesthesia) was compared between two groups of patients: those with anterior instability and with rotator cuff disease. The study found that it is not possible to discriminate between anterior instability and rotator cuff disease by using the relocation test for assessing pain response only.

Modified Jobe Relocation Test:

The patient lies in the supine position, and the clinician stands on the involved side of the patient. The clinician prepositions the shoulder at 120 degrees of abduction and then grasps the patient’s forearm and maximally externally rotates the humerus. The clinician then applies a posterior to anterior force to the posterior aspect of the humeral head. If the patient reports pain with this maneuver, an anterior-to-posterior force is then applied to the proximal humerus.

A positive test for labral pathology is indicated by a report of pain with the anterior-directed force and release of pain with the posterior directed force.

In a small study of 14 overhead throwing athletes, aged 21–31 years, Hamner found that the Modified Jobe Relocation Test has a high sensitivity (92%) and high specificity (100%).

Rockwood Test for Anterior Instability:

Rockwood Test for Anterior Instability depends on the feeling of apprehension.

The patient is seated with the clinician standing. With the arm by the patient’s side, the clinician passively externally rotates the shoulder. The patient then abducts the arm to approximately 45 degrees and the test is repeated.

The same maneuver is again repeated with the arm abducted to 90 degrees, and then 120 degrees to assess the different stabilizing structures.

A positive test is indicated when apprehension is noted in the latter three positions (45, 90, and 120 degrees).

Rockwood Test for Anterior Instability
Rockwood Test for Anterior Instability

Anterior Release Test:

Anterior Release Test or Surprise Test is another test for anterior insability of the shoulder that depends on the apprehension feeling.

The patient lies in the supine position with the shoulder at 90 degrees of abduction and the elbow flexed to 90 degrees. The clinician passively moves the patient’s shoulder into ER while applying a posteriorly directed force to the head of the humerus. At the point of end-range ER, the clinician quickly releases the posterior force and notes whether the patient displays any sign of apprehension. 5

In a study by Lo et al which assessed the validity of the apprehension, relocation, and surprise tests as predictors of anterior shoulder instability, for those subjects who had a feeling of apprehension on all three tests, the mean positive and negative predictive values were 93.6% and 71.9%, respectively.

The surprise test was the single most accurate test (sensitivity 63.89%; specificity 98.91%). 6

An improvement in the feeling of apprehension or pain with the relocation test added little to the value of the tests. The results of this study would suggest that a positive instability examination on all three tests is highly specific and predictive of traumatic anterior G-H instability.

Anterior Release Test
Anterior Release Test

Notes

  • When the patient complains of sudden stabbing pain with simultaneous or subsequent paralyzing weakness in the affected extremity, this is referred to as the “dead arm sign.”
  • It is attributable to the transient compression the subluxated humeral head exerts on the plexus.
  • It is important to know that at 45° of abduction the test primarily evaluates the medial glenohumeral ligament and the subscapularis tendon.
  • At or above 90° of abduction, the stabilizing effect of the subscapularis is neutralized and the test primarily evaluates the inferior glenohumeral ligament.
  • The Apprehension and Relocation test must be performed slowly and carefully to avoid the danger of causing the humeral head to dislocate.

A traumatic anterior instability of the shoulder can lead to injury of the posterior structures. Thus, the clinician must always be aware of potential injuries on the opposite side of the joint even if symptoms are predominantly on one side. In addition, if a joint is hypermobile in one direction, it may be hypomobile in the opposite direction. For example, with anterior instability, the posteroinferior capsule tends to be tight and therefore requires mobilization, whereas the anterior capsule is hypermobile and requires protection.

Reference

  1. Vincent A. Lizzio, Fabien Meta, Mohsin Fidai, and Eric C. Makhni. Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability. Curr Rev Musculoskelet Med. 2017 Dec; 10(4): 434–441. PMID: 29043566.
  2. Speer KP, Hannafin JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test. Am J Sports Med. 1994 Mar-Apr;22(2):177-83. doi: 10.1177/036354659402200205. PMID: 8198184.
  3. Hamner DL, Pink MM, Jobe FW. A modification of the relocation test: arthroscopic findings associated with a positive test. J Shoulder Elbow Surg. 2000 Jul-Aug;9(4):263-7. doi: 10.1067/mse.2000.105450. PMID: 10979519.
  4. Rockwood CA: Subluxations and dislocations about the shoulder. In: Rockwood CA, Green DP, eds. Fractures in Adults—I. Philadelphia, PA: JB Lippincott, 1984.
  5. Gross ML, Distefano MC. Anterior release test. A new test for occult shoulder instability. Clin Orthop Relat Res. 1997 Jun;(339):105-8. doi: 10.1097/00003086-199706000-00014. PMID: 9186207.
  6. Lo IK, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A. An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder instability. Am J Sports Med. 2004 Mar;32(2):301-7. doi: 10.1177/0095399703258690. PMID: 14977651.
  7. Bushnell BD, Creighton RA, Herring MM. The bony apprehension test for instability of the shoulder: a prospective pilot analysis. Arthroscopy. 2008 Sep;24(9):974-82. doi: 10.1016/j.arthro.2008.07.019. PMID: 18760203.
  8. Farber AJ, Castillo R, Clough M, et al. Clinical assessment of three common tests for traumatic anterior shoulder instability. J Bone Joint Surg Am. 2006;88: 1467-1474.
  9. Meister, K: Injuries to the shoulder in the throwing athlete. Part One: biomechanics/Pathophysiology/Classification of injury. Am J Sports Med, 28:265, 2000
  10. Clinical Tests for the Musculoskeletal System 3rd Ed. Book.
  11. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.

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