Inferior Sulcus Tegn

The Sulcus Test is a clinical examination used to assess inferior instability of the glenohumeral joint. It evaluates laxity of the superior glenohumeral ligament and the coracohumeral ligament, which may allow excessive inferior translation of the humeral head¹. The test was first described by Neer and Foster in 1980 as part of the assessment of multidirectional shoulder instability².

Test procedure

Patient position

• The patient may be seated, standing, or supine.

• A seated position with arms resting at the side provides the most reliable results².

Stabilization

• The examiner stabilizes the shoulder girdle to prevent compensatory movements.

Inferior traction

• The examiner applies a caudal traction force on the distal humerus, pulling downward along the arm³⁴.

Observation

• Positive test: A visible “sulcus” or indentation appears inferior to the acromion, typically > 1 cm, indicating inferior glenohumeral instability³².

• For greater diagnostic accuracy, the test should be repeated in neutral rotation and external rotation.

• Increased inferior translation in external rotation suggests a rotator interval lesion².

Diagnostic accuracy

Sulcus size grading²:

• Grade I: < 1.5 cm

• Grade II: 1.5–2 cm

• Grade III: > 2 cm

Validity²:

• Sensitivity: 28%

• Specificity: 97%

Although a sulcus greater than 2 cm may indicate pathological instability, studies show that marked inferior laxity can also be present in asymptomatic individuals. Therefore, interpretation should always be made in combination with other clinical findings².

The Sulcus Test demonstrates moderate intertester reliability (κ = 0.43), and individual anatomical variation can influence the outcome³.

Clinical relevance

• The Sulcus Test is useful for detecting inferior instability and as part of a broader assessment of multidirectional instability.

• Due to its low sensitivity, a negative test does not rule out pathology.

• A positive finding strongly suggests laxity but should be correlated with history, symptoms, and additional shoulder instability tests for clinical accuracy.

Conclusion

The Sulcus Test is a simple and reliable clinical maneuver for evaluating inferior glenohumeral instability. With high specificity (97%) but low sensitivity (28%), it is best applied in combination with other instability tests and imaging when necessary. A sulcus greater than 2 cm increases suspicion of pathological instability but may also appear in asymptomatic individuals.

References

1. Tzannes A, Murrell GA. Clinical examination of the unstable shoulder. Sports Medicine. 2002 Jun;32:447-57.

2. Valencia Mora M, Ibán MÁR, Heredia JD, Gutiérrez-Gómez JC, Diaz RR, Aramberri M, et al. Physical Exam and Evaluation of the Unstable Shoulder. Open Orthop J. 2017;11(1):946–56.

3. Eshoj H, Ingwersen KG, Larsen CM, Kjaer BH, Juul-Kristensen B. Intertester reliability of clinical shoulder instability and laxity tests in subjects with and without self-reported shoulder problems. BMJ open. 2018 Mar 1;8(3):e018472.

4. Dutton, M. (2008). Orthopaedic: Examination, evaluation, and intervention (2nd ed.). New York: The McGraw-Hill Companies, Inc.

5. bigesor. Sulcus Sign Test. Available from: https://www.youtube.com/watch?v=taN04xR4iAs [last accessed 10/7/2024]

6. Tzannes A, Murrell GA. Clinical examination of the unstable shoulder. Sports Medicine. 2002 Jun;32:447-57.

7. Valencia Mora M, Ibán MÁR, Heredia JD, Gutiérrez-Gómez JC, Diaz RR, Aramberri M, et al. Physical Exam and Evaluation of the Unstable Shoulder. Open Orthop J. 2017;11(1):946–56.

8. Eshoj H, Ingwersen KG, Larsen CM, Kjaer BH, Juul-Kristensen B. Intertester reliability of clinical shoulder instability and laxity tests in subjects with and without self-reported shoulder problems. BMJ open. 2018 Mar 1;8(3):e018472.

9. Dutton, M. (2008). Orthopaedic: Examination, evaluation, and intervention (2nd ed.). New York: The McGraw-Hill Companies, Inc.

10. bigesor. Sulcus Sign Test. Available from: https://www.youtube.com/watch?v=taN04xR4iAs [last accessed 10/7/2024]