What does a positive sulcus sign in the shoulder indicate and how is it managed?

Positive Sulcus Sign in the Shoulder: Indication and Management

A positive sulcus sign in the shoulder indicates inferior capsular laxity, which is a key component in diagnosing multidirectional instability when combined with other clinical findings. 1, 2

What is the Sulcus Sign?

• The sulcus sign is a clinical test that evaluates inferior shoulder laxity
• When positive, it creates a visible depression (sulcus) between the acromion and humeral head
• Grading system:
  • Grade I: <1.0 cm depression
  • Grade II: 1.0-2.0 cm depression
  • Grade III: >2.0 cm depression 3

Clinical Significance

A positive sulcus sign has different implications depending on other clinical findings:

1. Positive sulcus sign alone: Indicates capsular laxity, which may be asymptomatic hyperlaxity rather than pathological instability 4

2. Positive sulcus sign + positive apprehension test in one direction: Suggests unidirectional instability with hyperlaxity 2

3. Positive sulcus sign + positive apprehension tests in multiple directions: Indicates multidirectional instability with hyperlaxity 2, 4

Diagnostic Approach

• Clinical history is effective for diagnosing obvious shoulder instability 1
• Key clinical tests:
  • Sulcus sign (for capsular laxity)
  • O'Brien's sign (for superior labral lesions)
  • Apprehension sign (for anterior instability) 1
• Imaging recommendations:
  • Plain radiographs as initial imaging (AP view, Grashey view, axillary view, scapular Y view) 5
  • Advanced imaging for further evaluation:
    • MRI without contrast for suspected rotator cuff injury
    • CT for bone loss assessment 5

Management Algorithm

1. Conservative Management (First-Line Approach)

For multidirectional instability with hyperlaxity, conservative treatment is recommended first:

• Rehabilitation program (6-12 months) 4 with phased approach:

  • Phase 1: Pain control measures, gentle range of motion exercises, proper positioning education 5
  • Phase 2: Progressive ROM exercises, light strengthening of rotator cuff and periscapular muscles, scapular stabilization exercises 5
  • Phase 3: Progressive resistance training, advanced scapular stabilization, activity-specific training 5

• Pain management options:

  • Local thermal interventions (heat or cold)
  • NSAIDs for pain control
  • Activity modification to avoid painful movements
  • Ice, heat, and soft tissue massage 5
  • Limited corticosteroid injections (no more than 3-4 per year) for significant pain 5

2. Surgical Management

Surgical intervention is indicated in specific scenarios:

• Unidirectional instability with hyperlaxity: Best treated surgically 2, 4
• Failed conservative treatment: Consider after 3 months of appropriate rehabilitation without improvement 5
• High-risk patients: Under 30 years of age with high athletic demands or significant mechanical symptoms 5

Surgical options include:

• Reconstruction of the capsulolabral complex for traumatic instability 4
• Open capsular shift or thermal capsular shrinkage for failed conservative treatment of multidirectional instability 4
• Arthroscopic methods to restore labral disruptions and capsular laxity 1

Follow-up and Monitoring

• Initial follow-up: 1-2 weeks after treatment initiation 5
• Clinical reassessment: At 6 weeks to evaluate progress 5
• Rehabilitation progress evaluation: At 3 months 5
• Consider repeat imaging or surgical consultation if symptoms worsen or do not improve by 3 months 5

Common Pitfalls and Caveats

1. Distinguishing between asymptomatic hyperlaxity and symptomatic instability is crucial - not all laxity requires treatment 4

2. Misdiagnosis risk: A positive sulcus sign alone doesn't necessarily indicate pathological instability requiring intervention 4

3. Surgical timing: Rushing to surgery before adequate conservative management (especially for multidirectional instability with hyperlaxity) may lead to poor outcomes 4

4. Overlooking associated pathologies: Labral tears, rotator cuff injuries, and other soft tissue damage may coexist with instability 1

5. Inappropriate surgical technique: Standard operations for unidirectional instability may fail to correct multidirectional instability and can lead to arthritis if inferior instability is not addressed 6