Expert tips: Mastering your assessment of shoulder instability

6 min read. Posted in Shoulder
Written by Dr Jahan Shiekhy info

Shoulder instability affects athletes in both contact and non-contact sports. It also has a high recurrence rate, so excellent assessment is crucial for both effective management, and informing the decision to undergo surgical repair. In this blog, I’ll outline how expert physio Hamish Macauley assesses shoulder instability in athletes.

If you’d like a more in-depth understanding of how the experts assess shoulder instability, watch Hamish Macauley’s full shoulder instability assessment Practical HERE.

 

Classification

Shoulder instability exists on a continuum, where its causes can be related to both motor patterning and structural factors. The Stanmore classification system (1) delineates three types of shoulder instability, which can be interrelated:

  1. Traumatic, structural: A traumatic event causes the structural change, leading to instability.
  2. Atraumatic, structural: Some form of physiological abnormality predisposes the patient to instability, such as generalised joint laxity.
  3. Muscle patterning, non-structural: A neurological deviation causes the shoulder to be unstable, often in early ranges of motion.

In this blog we’ll focus on traumatic, structural type instability. However, many of these tools may also pertain to the other types of instability.

 

Subjective assessment

The subjective element of the assessment is crucial to determine the need for referral, prioritise the objective exam, and develop a plan of care for the patient. Typically after a traumatic incident, a patient should receive X-ray imaging to check for osseous damage. It’s also important to ask about neurological symptoms, as ‘burner and stinger’ injuries can occur along with shoulder dislocation.

As well as addressing these acute concerns, it’s important to identify patterns of pain and instability, history of dislocation(s), psychosocial factors that may influence recovery, coping strategies, and the patient’s goals and expectations of physiotherapy.

 

Objective assessment

Objective assessment will depend on the irritability of the shoulder. Start with less provocative tests, such as cervical spine assessment and basic shoulder Range Of Motion (ROM). Then you can begin to load the shoulder further with symptom modification and reproduction tests, instability assessments, and rotator cuff assessment. Later assessment will involve performance testing, including stability tests and return to sport testing.

 

Basic cervical spine and shoulder assessment

Cervical spine screen

The cervical spine must be assessed because nerve traction or compression injuries can occur concurrently with shoulder instability. Cervical assessment can include neck ROM, quadrant testing, Spurling’s test, and dermatome testing.

Shoulder ROM

It is important to examine all ranges of shoulder ROM, noting the patient’s movement patterns, as well as which movements provoke pain at which stage of range.

 

Shoulder loading and instability testing

Symptom modification procedures

These consist of assessing the patient’s painful movement, such as flexion, and then attempting to decrease pain by applying a change, such as a tactile cue. Changes that decrease pain can directly inform management by guiding our choice of rehab exercises.

If a patient has pain in flexion, there are several techniques to test out:

  • Perform flexion with a short lever by lifting the arm overhead, like in a dumbbell press
  • Cue thoracic spine extension
  • Cue gripping (this can activate the rotator cuff via the feedforward mechanism)
  • Tactile cues for external rotator activation
  • Step forward with the contralateral leg (the motor pattern of shoulder flexion is coupled with stepping forward with the opposite leg)
  • Manually cue upward scapular rotation

Hamish Macauley demonstrates how to cue the external rotators in shoulder flexion in the below video taken from his Practical:

Symptom reproduction tests

These are intended to gauge the patient’s tolerance to loading of the shoulder. These include manual resistance in external rotation, internal rotation, and the full-can position (scaption). Note that the patient should ramp up force slowly, as quick movements may irritate unstable shoulders.

Instability testing

The primary instability assessments for shoulder instability are the Beighton scale, apprehension/relocation test and posterior instability test. It’s important to note that the Beighton scale is more reliable in younger athletes. However, you may still find generalised joint laxity in adults. The apprehension and relocation tests are used to detect apprehension, while the posterior instability test is used primarily to assess for pain.

Rotator cuff function and strength

Start by comparing active and passive ROM as Hamish demonstrates in this snippet taken from his Practical:

After examining rotator cuff function through a full ROM, it’s then time to perform isometric strength testing at midrange, assessing internal and external rotation strength.

 

Return to sport testing

Higher level return to sport testing requires a battery of tests, since no single test carries sufficient predictive power to inform a safe return to play. It’s important to look at tests of stability, concentric force production, and eccentric control.

Stability assessment

Assessment of stability can include the posterior shoulder endurance test, the upper limb Y-balance test, the Closed Kinetic Chain Upper Extremity Stability test (CKCUES), and the Athletic Shoulder Test (ASH).

The posterior shoulder endurance test requires the patient to complete loaded horizontal abduction until failure, see Hamish demonstrate this test in the below video from his Practical:

The upper limb Y-balance test examines shoulder stability in multiple directions, at slow speeds, while the CKCUES challenges shoulder stability and endurance at higher speeds. The ASH test assesses shoulder strength in the “I” (full abduction), “Y” (135-degrees of abduction), and “T” (90-degrees of abduction) positions.

Upper limb power and plyometric testing

In terms of return to sport testing, it’s important to examine shoulder capacities like concentric force production, eccentric control, and single arm endurance in plyometric activities.

If you have access to force plates, you can examine left-right differences in plyometric movements including the upper limb counter movement jump, drop landing, and power press. However, more traditional tests can include a med ball throw, clap pushup, and single arm line hop.

 

Wrapping up

Shoulder instability assessment is largely focused on examining shoulder function and performance, which informs the patient’s management plan. With such a thorough assessment, you can be confident in successfully guiding your patients with shoulder instability back to what they love, whether they choose non-invasive treatment or opt for surgery.

For a full walk-through on how to master your assessment of shoulder instability check out Hamish’s shoulder instability assessment Practical HERE

👩‍⚕️ Want an easier way to develop your assessment & treatment skills?

🙌 Our Practical video sessions are the perfect solution!

🎥 They allow you to see exactly how top experts assess and treat specific conditions.

💪 So you can become a better clinician, faster.

preview image

References

Don’t forget to share this blog!

Leave a comment

If you have a question, suggestion or a link to some related research, share below!

You must be logged in to post or like a comment.

Elevate Your Physio Knowledge Every Month!

Get free blogs, infographics, research reviews, podcasts & more.