CLINICAL EXAMINATION

In patients with typical dislocation and radiographic evidence (radiographs showing the shoulder in the dislocated position), the diagnosis is fairly straightforward; the only pitfall being an associated hyperlaxity that may be missed. As more and more people practise sports intensively, an increasing proportion of clinic patients will present with a less well-defined pattern. In these patients, a methodical examination will be of the utmost importance.

History
Often, the patient will spontaneously report the initial traumatic event. The index event should always be carefully elicited. Sometimes, the first episode of dislocation would appear to have been atraumatic; however, detailed history taking may reveal fairly major shoulder trauma in the past, which must be taken into account. There are situations where trauma may cause all the lesions required for instability, without any dislocation occurring. In other patients, a history of intensive sports practice involving abduction and forced external rotation will provide useful clues. On the other hand, the existence of an initial trauma should not stop the physician from searching for an associated multidirectional hyperlaxity. The nature of the trauma is not always easy to identify. The only important pattern is a direct posterior blow to the shoulder, or indirect trauma (a blow or fall on the elbow or on the outstretched, externally rotated arm). Indirect trauma is by far the most frequent cause involved. In this analysis of the first parameter, there is much that is not clear-cut. It is important to obtain a description of the episodes of instability, trying to ascertain how many there have been, and how easily they tend to occur. If there have been many episodes of instability after very minor trauma, surgery should, obviously, be considered. Equally, though, a diver or a mountaineer with a first recurrence may be a candidate, given the risk involved in his or her sport.

Physical examination
This examination is performed in three stages, and involves a search for three broad patterns: apprehension, during dynamic manoeuvres designed to reveal instability; laxity, which will be discussed in greater detail below; and evidence of associated multidirectional hyperlaxity.

Fig 5 Crank test. This test serves to place the shoulder in a position of maximal instability (extremes of

abduction and external rotation). The test is positive if the patient expresses pain or apprehension.

Apprehension tests

All apprehension tests are designed to place the humeral head in a position of imminent subluxation or dislocation, which makes the patient recognize the familiar pattern of instability, and react with anticipated fear. Apprehension tes dirancang utk menempatkan humeral head pada posisi dekat dgn dislokasi atau subluksasi, yg membuat pasien merasakan pola ketidakstabilan dan bereaksi utk menghindari rasa sakit.

Crank test and fulcrum test

This test is designed to reproduce the position of instability. It is the oldest of the apprehension tests. The examiner places the arm in extreme abduction and external rotation, which may cause apprehension (Fig. 5). This is the most commonly used test. It has a high specificity. A negative test does not rule out shoulder instability. The test may be performed in the sitting or standing patient (crank test), or with the patient supine (fulcrum test). Tes ini dirancang utk menghasilkan posisi tdk stabil. Mirip dgn apprehension test. Ft menempatkan arm pd posisi abd ekstrim dan eks.rotasi, yg akan menyebabkan apprehension.

Relocation test
This is a more sensitive variant of the test described above. The patient is positioned supine. The first part of the test is a classic fulcrum test, in which the humeral head is pushed forward to elicit apprehension. In the second part of the test, a posteriorly directed force is applied to the humeral head. This prevents anterior subluxation, and produces a negative apprehension test (Fig. 6a and b).

Inferior apprehension test

This test was initially described by Feagin, and further refined by Itoi et al,16 who suggested the name ABIS (abduction inferior stability). For this test, the upper limb is held in abduction, with the patient's forearm resting on the examiner's shoulder. The examiner exerts downward pressure over the neck of the humerus. If the shoulder is unstable, the head will be pushed down, and a groove will appear; also, the patient may show apprehension (Fig. 7).

Fig 6 : Relocation test. This test is performed with the patient supine. 6a Pressure over the back of the humeral head causes apprehension, while 6b pressure over the front of the humeral head prevents the head suluxating anteriorly, and does not cause apprehension.

Tests for overall laxity

These tests are designed to show abnormal mobility of the humeral head. Since none of the articular ligaments is taut in the position used for these tests, the procedures should not be looked upon as ligamentous laxity tests. What is provided is global, and difficultto-interpret, information on excessive joint mobility, covering not only laxity of the capsuloligamentous apparatus, but also the control of muscle tone. These procedures are tests of excessive mobility.

Fig 7 : Abduction inferior stability (ABIS) test. The patient's arm is in abduction, with the forearm resting on the examiner's shoulder. The examiner exerts pressure on the arm, gradually pushing the humeral head downwards. The test is positive if there is downward displacement of the head, or if the patient shows apprehension.

Sulcus test

The patient is told to relax, while the examiner exerts gentle downward traction on the patient's arm (Fig. 8). The test is positive if traction makes the humeral head move down; this distal movement of the humeral head manifests itself as a groove or sulcus below the lateral border of the acromion.(20) The amount of downward movement of the humeral head may be measured and graded. Pasien diminta relaks, sementara ft memmberikan traksi ke bawah pada arm pasien. Tes positif jika traksi membuat humeral head bergerak kebawah;

Drawer tests
These tests, too, should be performed in a relaxed patient. The patient is asked to lean forward slightly, with both arms hanging down. The examiner holds the patient's shoulder girdle with one hand, while cupping the other around the humeral head, and sliding the head backwards and forwards to detect any abnormal mobility(27) (Fig. 9). This test may be performed with the patient sitting(26) or supine.(11)pasien diminta duduk agak condong kedepan, dgn kedua arm tergantung. Pemeriksa memegang shoulder girlde dgn satu tangan, sementara tangan yg lain memegang nech humeral sambil menekan kedepan dan kebelakang humeral head utk mendeteksi mobilitas abnormal.

Fig 8 : Sulcus test. In the relaxed patient, the examiner gently pulls the humerus downwards. The test is positive if the humeral head descends, with formation of a groove

Fig 9 : Drawer test. The patient is made to relax and slightly lean forward. The examiner holds the humeral head between his or her thumb and index finger, and tries to make the head slide backwards and forwards. This test demonstrates

or sulcus under the lateral border of the acromion. The amount of downward movement can be measured. A positive test is indicative of abnormal mobility.

overall hyperlaxity (without being specific of any particular ligament), and may provide information on the direction of the instability.

Is there a specific test for laxity?

Since passive abduction has a constant range, and since the range is controlled by the IGHL, we suggest that laxity of the IGHL will be associated with an increase in the range of abduction. The passive abduction test was performed in patients with post-traumatic shoulder instability without any associated hyperlaxity. In 85% of the cases, the range of passive abduction was at least 105, while, on the healthy side, it was limited to 90. In 15% of the cases, the test caused acute apprehension, making it impossible to measure passive abduction. In such cases, the test works as an apprehension test, along the lines of the procedure initially devised by Feagin, and proposed by Itoi et al as the ABIS test. The test was performed under general anaesthesia, immediately prior to surgery. In all the cases, passive abduction was at least 105, while, on the contralateral side, it was restricted to 90. Providing that the test is performed strictly in the coronal plane, it furnishes objective evidence of excessive IGHL length, and gives a direct demonstration of the laxity of the ligament. Thus, this test of passive hyperabduction is positive if the range on the affected side is greater than 105 (Fig. 10). This is the first test that allows shoulder ligament laxity to be directly assessed; however, it will need to be used more widely, in a prospective study, to establish its specificity and sensitivity.

Neurological examination
This part of the general work-up must not be overlooked: in almost 15% of cases of chronic shoulder instability, the axillary nerve is affected.

Looking for evidence of generalized ligamentous laxity

Multidirectional hyperlaxity affects the outcome of instability treatments.(29) On examination, there will be a groove of more than 2 cm in the sulcus test, as well as major anterior and posterior drawer movements. External Fig 10 : Positive hyperabduction test. rotation of the upper limb of more than 90 is also Marked asymmetry between the affected and the healthy side is considered to be a sign of abnormal laxity. The wrists characteristic of laxity of the ligament should be examined for increased palmar flexion, as complex. should the elbow for marked hyperextension, the knees for a recurvatum deformity, and the trunk for enhanced forward bending (palms of hands to floor). In patients with generalized ligamentous laxity, the passive hyperabduction test will be bilaterally positive. Where these tests are positive, the diagnosis will be one of instability associated with multidirectional hyperlaxity. Evidence of true multidirectional instability should be carefully sought. The most important feature is episodes of posterior instability when the arm is in forward elevation and internal rotation.

The patient should be questioned about episodes of posterior instability of the shoulder. Special attention should be devoted to eliciting previous incidents of voluntary shoulder dislocation. In some of the more difficult cases, especially when trying to confirm or exclude multidirectional instability, CT arthrography may be helpful. Arthroscopy may be indicated, to obtain objective evidence of laxity, as described by Detrisac and Johnson.(6).