Table 2

Clinical examination screening

Clinical examination components
History of presenting conditionA full history of the patient's condition will be recorded, including frequency, aetiology, direction and severity of subluxations.36
The presence of volitional instabilityPatients who present or report a predominance of volitional instability (voluntarily sublux their glenohumeral joint on a regular basis) will be excluded, as treatment for this type of instability primarily focuses on counselling to cease the habitual subluxation.14
Diagnosis of MDI with instability testsDiagnosis must be based on:

  1. A positive sulcus sign.37 The sulcus test is a valid and reliable test for inferior laxity38 with a fair to good interexaminer reliability (60–85%).38–40

    AND

  2. For at least one direction (anterior and/or posterior), a positive result for at least 2 out of 3 following tests:

    • Anterior and posterior draw tests (10–30° abduction)37 41

    • Anterior and posterior draw tests in (80–120° abduction)37 41

    • Anterior38 42 43 and posterior apprehension tests44 45

Effect of manual correction on scapula biomechanicsThe ‘effect of manual correction on scapula biomechanics’ is defined as the effect that therapist-assisted manual assistance of the scapula has on an objective test.21 46 47 The effect of manual correction of the scapula will be assessed via active abduction, active flexion and isometric external rotation. In order for participants to be eligible, the effect of manual correction of the scapula must symptomatically improve abduction range by a minimum of 20°, significantly reduce pain or guarding in range or improve strength on an isometric test. Poor scapular positioning through range and altered muscle patterning are predominant characteristics of non-traumatic MDI.3 14 An immediate improvement with manual assistance is likely to confirm the presence of these characteristics and indicate that the participant is appropriate for treatment with exercise.
Upward rotation testTo be eligible, participants must be able to perform a minimum of 5 repetitions of scapular upward rotation in standing position without the reproduction of any cervical spine pain or headaches.21 As both rehabilitation programmes require the participant to perform some scapular strengthening, inability to perform this test indicates that they are not appropriate for either exercise programme and may have a predominant cervical spine component to their pathology.
Generalised ligament laxityThe Beighton Scale48 will be used to assess generalised ligament laxity and has a good to excellent reliability.49
Cervical spine examinationPotential participants with a positive Spurlings test for cervical radiculopathy and radicular pain with be excluded.50 51 The test has a high sensitivity (92%)51 and specificity (93–95%)50 51 for cervical radiculopathy.

  • MDI, multidirectional instability.