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.

Kvitne and Jobe recommended applying a mild anteriorly directed force to the posterior humeral head when in the test position to see if the patient’s apprehension or pain increases. If posterior pain increases, this indicates posterior internal impingement. Hamner et al. suggested that if posterior superior internal impingement is suspected, the relocation test should be done in 110° and 120° of abduction.

Similarly, Bak recommended doing the apprehension test in swimmers at 135° abduction, as this is the position of the arm at the initiation of the pull-through phase

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.

Shoulder Apprehension test 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

This Jobe Relocation test is sometimes referred to as the Fowler sign or test or the Jobe relocation test.

After performing the Apprehension Test, the examiner then applies a posterior translation stress to the head of the humerus or the arm (relocation test), the patient commonly loses the apprehension, any pain that is present commonly decreases, and further lateral rotation is possible before the apprehension or pain returns.

The Jobe Relocation test is considered positive if pain decreases during the maneuver even if there was no apprehension. If the patient’s symptoms decrease or are eliminated during the relocation test, the diagnosis is glenohumeral instability, subluxation, dislocation, or impingement. If apprehension predominated during the crank test and disappears with the relocation test, the diagnosis is glenohumeral instability, subluxation, or dislocation. If pain predominated during the crank test and disappears with the relocation test, the diagnosis is pseudolaxity or anterior instability either at the glenohumeral joint or scapulothoracic joint with secondary impingement or a posterior SLAP lesion.

The relocation test does not alter the pain for patients with primary impingement. If, when the relocation test is done posteriorly, posterior pain decreases, it is a positive test for posterior internal impingement.

See Also: Shoulder 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 Shoulder 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).

Bony Apprehension Test

This test is designed to look for bony defects (e.g., a Hill-Sach or Bankart lesion) in the patient with an anterior instability.

The patient is tested in standing or sitting first with the arm abducted to 90° and the elbow flexed 90°. Then the examiner, while holding the patient’s elbow and hand, laterally rotates the arm, watching for apprehension (this part of the test is similar to the apprehension test). The examiner then repeats the test in 45° of abduction and 45° of lateral rotation. If the patient shows apprehension with or without pain in both of these positions, the test is positive for a bony defect contributing to the anterior instability and confirmatory diagnostic imaging is required.

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 Shoulder 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

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