Sulcus Sign

Sulcus Sign is used to detect inferior instability due to a laxity of the superior glenohumeral and coracohumeral ligaments (Multidirectional Instability). It’s also called inferior drawer test.

The sulcus sign determines the amount of inferior glide of the humeral head when traction is applied to the humerus. It was described by Neer and Foster in 1980.

How do you perform Sulcus Sign?

• The patient is seated or standing, with the examined arm hanging at the side.
• With one hand, the examiner stabilizes the patient’s contralateral shoulder while applying a distal pull on the patient’s relaxed affected arm with the other hand.
• This is best done by grasping the patient’s arm at the elbow, with the elbow slightly flexed.
• The test should be done firstly with the arm in neutral rotation and secondly with the arm in external rotation.

The test can also be performed so that the examiner supports the patient’s 90°-abducted arm. Applying pressure to the proximal one-third of the upper arm from above can then provoke distal subluxation of the humeral head, this will create a significant step-off beneath the acromion.

What does a positive Sulcus Sign mean?

• If there is a sulcus that forms at the superior aspect of the humeral head, the test is positive.
• Sulcus sign is considered positive if it stays increased (2+ or 3+) with external rotation at side (pathologic rotator interval).

The sulcus sign can be graded by measuring the distance from the inferior margin of the acromion to the humeral head:

1. A distance of less than 1 cm is graded as 1+ sulcus.
2. 1–2 cm as a 2+ sulcus.
3. Greater than 2 cm as a grade 3+ sulcus.

Grade	Acromiohumeral Interval
Grade +1	< 1 cm
Grade +2	1- 2 cm
Grade +3	> 2 cm

Sensitivity & Specificity

Tzannes and Murrell found that a positive sulcus sign of more than 2 cm had a sensitivity of 28% and a specificity of 97%.

• Sensitivity: 28 %
• Specificity: 97 %

A study on 43 healthy college athletes, the Interexaminer was κ = .03 to .06, while the Intraexaminer was κ = .01 to .20 for sulcus sign.

Modified Sulcus Sign

The modified sulcus sign is called Feagin Test, it’s performed with the arm abducted to 90° and is supported on the examiner’s shoulders.

This test can be done either in sitting or in standing position. The examiner’s hands are clasped together over the patient’s humerus, between the upper and middle thirds. The examiner pushes the humerus down and forward. A sulcus may be seen as described before.

If both the sulcus sign and Feagin test are positive, it is a greater indication of multidirectional instability.

Notes

• The results of this test are more meaningful when the patient is anesthetized, indicating the influence of muscle tension on the findings.
• Gradation in the clinical assessment of the sulcus sign is expressed in millimeters.
• In reference to the grade of inferior instability, there is a large range of physiologic and individual variation.
• Aside from testing for the sulcus sign in the neutral position, it is recommended to perform the test with the arm externally and internally rotated as well.
• Increased inferior translation in external rotation suggests elongation of the rotator interval.
• A positive sign that occurs with the arm in internal rotation demonstrates laxity of the posterior capsular structures.
• To differentiate the results of sulcus sign from those of the AC traction test for AC joint instability, the movement of the humeral head is away from the scapula and clavicle in this test. In the AC traction test, the humerus and scapula move away from the clavicle.

Related Anatomy

Ligament	Origin	Insertion	Function
Superior glenohumeral ligament	The Glenoid labrum	Anatomical neck of the humerus	Restrains external rotation and inferior translation of adducted or slightly abducted arm
Coracohumeral ligament	Lateral border of the coracoid process	The lesser and greater tubercles of the humerus	Restrains inferior translation and external rotation of adducted arm

Reference

1. Neer CSI, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg 62A:897– 908, 1980.
2. An assessment of the interexaminer reliability of tests for shoulder instability. Tzannes A, Paxinos A, Callanan M, Murrell GAJ Shoulder Elbow Surg. 2004 Jan-Feb; 13(1):18-23. PMID: 14735068
3. Levy AS, Lintner S, Kenter K, et al. Intra- and interobserver reproducibility of the shoulder laxity examination. Am J Sports Med. 1999;27:460-463.
4. Callanan M, Tzannes A, Hayes KC, et al: Shoulder instability. Diagnosis and management. Aust Fam Physician 30:655–661, 2001.
5. Rockwood CA. Subluxations and dislocations about the shoulder. In: Rockwood CA, Green DP, editors. Fractures in adults. Philadelphia: J. B. Lippincott; 1984.
6. Clinical Tests for the Musculoskeletal System 3rd Ed. Book.
7. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
8. Netter’s Orthopaedic Clinical Examination An Evidence-Based Approach 3rd Edition Book.