With one hand, the examiner stabilizes the patient’s contralateral shoulder while applying a distal pull on the patient’s relaxed affected arm with the other hand.
This is best done by grasping the patient’s arm at the elbow, with the elbow slightly flexed.
The test should be done firstly with the arm in neutral rotation and secondly with the arm in external rotation.
The test can also be performed so that the examiner supports the patient’s 90°-abducted arm. Applying pressure to the proximal one-third of the upper arm from above can then provoke distal subluxation of the humeral head, this will create a significant step-off beneath the acromion.
What does a positive Sulcus Sign mean?
If there is a sulcus that forms at the superior aspect of the humeral head, the test is positive.
Sulcus sign is considered positive if it stays increased (2+ or 3+) with external rotation at side (pathologic rotator interval).
The sulcus sign can be graded by measuring the distance from the inferior margin of the acromion to the humeral head:
A distance of less than 1 cm is graded as 1+ sulcus.
1–2 cm as a 2+ sulcus.
Greater than 2 cm as a grade 3+ sulcus.
< 1 cm
1- 2 cm
> 2 cm
Sulcus Grading System
Sensitivity & Specificity
Tzannes and Murrell 2 found that a positive sulcus sign of more than 2 cm had a sensitivity of 28% and a specificity of 97%.
Sensitivity: 28 %
Specificity: 97 %
Gradation in the clinical assessment of the sulcus sign is expressed in millimeters.
In reference to the grade of inferior instability, however, there is a large range of physiologic and individual variation.
Aside from testing for the sulcus sign in the neutral position, it is recommended to perform the test with the arm externally and internally rotated as well.
Increased inferior translation in external rotation suggests elongation of the rotator interval.
A positive sign that occurs with the arm in internal rotation demonstrates laxity of the posterior capsular structures.
Superior glenohumeral ligament
The Glenoid labrum
Anatomical neck of the humerus
Restrains external rotation and inferior translation of adducted or slightly abducted arm
Lateral border of the coracoid process
The lesser and greater tubercles of the humerus
Restrains inferior translation and external rotation of adducted arm
Neer CSI, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg 62A:897– 908, 1980.
An assessment of the interexaminer reliability of tests for shoulder instability.Tzannes A, Paxinos A, Callanan M, Murrell GAJ Shoulder Elbow Surg. 2004 Jan-Feb; 13(1):18-23. PMID: 14735068
Callanan M, Tzannes A, Hayes KC, et al: Shoulder instability. Diagnosis and management. Aust Fam Physician 30:655–661, 2001.
Clinical Tests for the Musculoskeletal System 3rd Ed. Book.
Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.