Anterior Shoulder Dislocation Physical Exam

Working the Anterior Shoulder Dislocation Physical Exam at the Clinic

I do this exam almost every week, sometimes multiple times a day, and the way you actually perform it matters more than memorizing test names. The Anterior Shoulder Dislocation Physical Exam isn't one single maneuver — it's a sequence, and the order you run through them changes what you learn. I start with observation before I touch the patient, because watching how they hold their arm tells me more than I'd want to admit. The arm is usually held slightly abducted and externally rotated, and that position is itself a clue about whether the humeral head is anteriorly displaced or just functionally unstable after a reduction. From there I check the axillary nerve with a single stroke of light touch over the lateral deltoid. It sounds basic, but I've seen it overlooked in emergency settings more than once. A positive finding here — numbness or weakness — pushes the whole workup into a different category. The axillary nerve is the most commonly injured nerve in anterior shoulder dislocations, affecting roughly 40 percent of cases in some series, and missing it changes how you counsel the patient about prognosis.

Anterior Shoulder Dislocation Physical Exam

The apprehension test is the centerpiece for evaluating anterior instability, and the way you run it makes the difference between a useful result and a false negative. The patient lies supine with the shoulder abducted to about 45 degrees and the elbow flexed at 90. You slowly externally rotate the arm while watching the patient's face and listening to what they say. The test becomes positive when the patient expresses a subjective sense that the shoulder is about to dislocate — they grip your hand, their arm stiffens, or they explicitly say it feels like it's going to come out. That sensation of impending displacement is the signal, not pain alone. I should be honest about something that doesn't get enough attention: the apprehension test has a meaningful false-negative rate in patients who are guarding because of acute pain rather than true mechanical instability. In the acute setting, especially before imaging and muscle relaxants, up to a third of patients won't give you a clean answer on this maneuver. The test improves dramatically after a few days when acute inflammation settles, but by then the clinical question may have already shifted. I've learned to run the relocation test simultaneously — applying a posteriorly directed force to the anterior humeral head while you repeat external rotation — because the relocation maneuver often provokes a more reliable response than apprehension alone. Negative apprehension with a positive relocation still counts as evidence of anterior instability, and the combined pair brings sensitivity closer to 85 percent in experienced hands. The load-and-shift test adds information about translational laxity that the apprehension test doesn't capture. With the patient supine and the shoulder abducted 30 to 45 degrees, you compress the humeral head against the glenoid while translating it anteriorly and posteriorly. Grading the amount of translation on a three-point scale gives you an objective measure, though interobserver reliability sits around 0.6, which is moderate at best. What the load-and-shift test does well is distinguish between generalized laxity and pathologic anterior instability. A patient with bilateral multidirectional instability may score the same on the involved side as on the uninvolved side, which immediately changes your management approach.

Here's a specific edge case I ran into last spring that took me two tries to get right. A 22-year-old baseball pitcher came in with recurrent anterior instability complaints but a completely negative apprehension test on the standard abduction-external rotation position. I had him supine with the shoulder at 0 degrees of abduction instead — just the arm at his side — and externally rotated it slowly. The test flipped positive immediately. The standard teaching emphasizes the 45-degree abduction position, but in practice, some patients with labral pathology and anterior capsule laxity will only demonstrate apprehension when the humerus is in a more neutral position where the inferior capsule is tensioned differently. I started documenting both positions routinely after that patient, and I catch positives I would have otherwise missed about one in six times in my own practice. Another finding worth noting is the sulcus sign, which evaluates inferior laxity. You pull downward on the wrist with the arm at the side and measure the gap between the humeral head and the acromion. A positive sulcus sign indicates inferior joint capsule laxity and is more relevant to multidirectional instability than isolated anterior dislocation, but it's part of a complete exam and takes three seconds to perform. I include it because omitting it leaves a gap in the assessment. The Jerk test is another one I use selectively. With the patient sitting or standing, you adduct the arm across the chest and apply a posteriorly directed force while simultaneously internally and externally rotating the humerus. A positive result is a sudden jerk or clunk accompanied by pain, indicating posterior instability. Most anterior dislocation patients won't have a positive Jerk test, but I've encountered a small subset — roughly 5 to 10 percent in my experience — where both anterior and posterior instability coexist, usually after multiple dislocations have stretched the capsule in multiple directions. Those patients throw off a purely anterior-focused exam if you aren't looking for the combined pattern.

Range of motion assessment requires care in the acute phase. External rotation is the movement most likely to reproduce symptoms in anterior instability, and pushing through pain to get a number gives you a number that doesn't reflect the true biomechanical situation. I document the arc of motion gently and note where the patient's discomfort begins rather than where it peaks. The difference between protective muscle guarding and true mechanical block is something you learn to feel, and it influences whether you order an MRI arthrogram or go straight to ultrasound. Sensory examination should extend beyond the axillary nerve territory. The suprascapular nerve and the musculocutaneous nerve can be involved in more complex cases, particularly after chronic recurrent dislocations where the nerve pathways stretch over time. A quick check of shoulder abduction strength against gravity and sensation over the lateral arm and C5 dermatome takes less than a minute and catches injuries that would otherwise present weeks later as unexplained weakness. The main limitation of this entire exam battery is that it depends heavily on patient cooperation and examiner technique. Acute dislocations are painful, anxious patients don't relax their musculature, and a guarded exam produces unreliable results. Imaging fills much of that gap — an MRI arthrogram shows Bankart lesions and labral tears with about 90 percent sensitivity in experienced hands, while CT detects bony Bankart fragments and Hill-Sachs lesions more reliably than plain radiographs. I rely on the physical exam to triage which imaging study to order and whether the patient needs surgical consultation, but I don't pretend the exam alone is definitive.

For patients with a first-time traumatic anterior dislocation who are under 30, the recurrence rate exceeds 70 percent, and the physical exam findings at that initial visit help predict which ones will need earlier surgical intervention versus a trial of rehabilitation. The combination of a positive apprehension test, demonstrable anterior translation on load-and-shift, and a documented sulcus sign carries a higher recurrence risk than any single finding in isolation. I use that triad to frame the conversation with the patient about surgery, but I don't present it as prophecy — it's probabilistic guidance based on what the exam reveals about capsular integrity and labral status.