Background: Although traumatic anterior shoulder instability is
common, the usefulness of various physical examination tests as tools for the
diagnosis of this condition has been studied infrequently. We hypothesized
that (1) such tests would be specific but not sensitive for this condition,
(2) the usefulness of the anterior drawer test would be limited because of
pain during the test, and (3) an anterior drawer test would be a useful
adjunct for making the diagnosis if it reproduced the instability
Methods: Between 2000 and 2004, 363 patients underwent a physical
examination followed by shoulder arthroscopy. Forty-six patients with
traumatic anterior shoulder instability that had been noted arthroscopically
or documented radiographically after the trauma were included in our study
group, and the remaining patients served as controls. The clinical usefulness
of three tests (anterior apprehension, relocation, and anterior drawer tests)
performed during the physical examination to make a diagnosis of traumatic
anterior instability then was evaluated with statistical methods to assess
their sensitivity, specificity, and likelihood ratios.
Results: If demonstration (or relief) of apprehension was used as
the diagnostic criterion for a positive test, the sensitivity, specificity,
and likelihood ratio were 72%, 96%, and 20.2, respectively, for the
apprehension test and 81%, 92%, and 10.4, respectively, for the relocation
test. If pain (or relief of pain) was used as the diagnostic criterion for a
positive test, the values for the sensitivity, specificity, and likelihood
ratio of both tests were lower. The anterior drawer test could be performed
successfully in the physician's office for 87% of the patients. If
reproduction of instability symptoms was used as the criterion for a positive
anterior drawer test, the sensitivity, specificity, and likelihood ratio
values of that test were 53%, 85%, and 3.6, respectively.
Conclusions: The three physical examination tests for traumatic
anterior shoulder instability are specific but not sensitive. Apprehension is
a better criterion than pain for a positive apprehension or relocation test.
The anterior drawer test (when pain does not prevent it from being performed)
is helpful for diagnosing traumatic anterior instability.
Level of Evidence: Diagnostic Level I. See Instructions
to Authors for a complete description of levels of evidence.