Sulcus Sign | Inferior Drawer Test

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

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 best position to test for inferior instability is at 20° to 50° of abduction with neutral rotation. Also, rotation causes the capsule to tighten anteriorly (lateral rotation) or posteriorly, and the sulcus distance decreases. Thus, more than one position should be tested.

Ren and Bicknell advocated also doing the sulcus sign in 30° of lateral rotation. If the amount of inferior translation does not decrease when the test is done in 30° of lateral rotation, it suggests that the superior glenohumeral ligament and the structures in the rotator interval are lax and not holding the humeral head up in the glenoid the way they should

The sulcus 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).
• Note: a sulcus sign is seen further laterally than a step deformity, which is seen with a 3° acromioclavicular sprain.

This sign should only be considered positive for inferior instability if the patient is symptomatic (e.g., pain/ache on activity, shoulder does not “feel right” with activity). A bilateral sulcus sign is not as clinically significant as unilateral laxity on the affected side.

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.

Humeral head displacement of more than 2 cm from the acromion has been reported to be indicative of a high degree of glenohumeral laxity.

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.

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

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. Pubmed
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. Ren H, Bicknell RT. From the unstable painful shoulder to multidirectional instability in the young athlete. Clin Sports Med. 2013 Oct;32(4):815-23. doi: 10.1016/j.csm.2013.07.014. PMID: 24079437. Pubmed
6. Rockwood CA. Subluxations and dislocations about the shoulder. In: Rockwood CA, Green DP, editors. Fractures in adults. Philadelphia: J. B. Lippincott; 1984.
7. Clinical Tests for the Musculoskeletal System 3rd Ed. Book.
8. Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.
9. Netter’s Orthopaedic Clinical Examination An Evidence-Based Approach 3rd Edition Book.