Sulcus Sign Test | Deep Sulcus Sign

Sulcus Sign Test is thus referred to as a clinical exam technique that is applied in order to evaluate inferior shoulder instability or laxity. This test assists in determining if there is a sulcus, a pit like formation known as deep sulcus sign, below the acromion, which is suggestive of inferior glenohumeral joint instability. It is especially helpful in identifying the condition referred to as multidirectional instability or MDI, affecting the shoulder.

Indication for the Sulcus Sign Test

The Sulcus Sign Test is indicated for patients who present with symptoms suggestive of inferior or multidirectional shoulder instability, such as:

• Sensation of instability of the shoulder, limberness, or feeling of being off-balance.
• Discomfort of some kind associated with some shoulder activities especially in regards to abduction or making overhead movements.
• Previous history of multiple shoulder episodes of subluxation or dislocation.
• Generalized ligamentous laxity.

How to Perform the Sulcus Sign Test

To perform the Sulcus Sign Test, the physiotherapist follows these steps:

1. Positioning: The patient is sitting or standing and the forearm is in a state of rest near the patient’s side.
2. Starting Position: Physiotherapist should either be to the side or behind the patient.
3. Inferior Traction: The physiotherapist stands behind the patient and puts one of his hands around the patient’s forearm, so that his thumb is at the level of the patient’s elbow, and pulls this downwards.
4. Observation and Palpation: The physiologist looks for the development of the sulcus below the acromion, and feels for joint slackness.

Assessment Outcome of Sulcus Sign Test

• Positive Test: Pain below the acromion particularly if a  deep sulcus sign or depression becomes visible or if one gets a feeling of an inferior subluxation, signals inferior shoulder instability.
• Negative Test: The lack of sulcus or depression indicates the lack of patient’s inferior shoulder instability.

Differential Diagnosis with Sulcus Sign Test

The Sulcus Sign Test is useful for differentiating inferior shoulder instability from other shoulder pathologies, such as:The Sulcus Sign Test is useful for differentiating inferior shoulder instability from other shoulder pathologies, such as:

• Pre-employment and anterior shoulder instability or dislocation.
• Posterior shoulder instability or dislocation/basic assessment and management of the acute shoulder injury in the emergency department.
• Rotator cuff tears.
• Labral tears.
• Adhesive capsulitis (frozen shoulder).
• Acromioclavicular joint pathology.

Related Sulcus Sign Test

• “Apprehension test” is done for anterior instability.
• Posterior Apprehension Test
• Jobe Relocation Test
• Load and Shift Test
• Kim Test
• Jerk Test

Evidence-Based Physiotherapy 

A review of the literature shows that Sulcus Sign Test has been critically referenced due to its evidence basing to allow for a compendium of exercises in assessing shoulder instability among patients. When used together with other clinical assessments and imaging techniques such as MRI or CT arthrography, this test increases the diagnostic yield.

Possible directions of research in physiotherapy may concern better, more specific diagnostic methods, improvement of diagnostics tools, and optimization of the shoulder instability rehabilitation program. Literature review also points to the need for an individualized rehabilitation program incorporating detailed progressive strength training, proprioceptive drills, scapular stabilization, manual therapy, and patients’ instructions about activity and ergonomic adjustments.

It has come out more and more that a variety of other options, such as achieving a defined program of physiotherapy might be beneficial to a high number of patients concerned with shoulder instability. Patients who have recurrent instability or significant structural abnormalities will require surgery that includes capsular shift or labral repair. Further investigation is required to define parameters of management of these patients and to prevent complications by providing ISCP specific treatment algorithms and evidence based interventions.