Kim Maneuver: Understanding, Performance, and Interpretation

What is the Kim maneuver?

The Kim maneuver is a clinical orthopedic special test used to assess for a posterior-inferior labral lesion (tear) or a posterior glenohumeral instability in the shoulder joint, often indicative of a reverse Bankart lesion.

Understanding the Kim Maneuver

The Kim maneuver, also known as the Kim's test, is a diagnostic physical examination technique specifically designed to evaluate the integrity of the posterior-inferior labrum and the stability of the glenohumeral joint. It is particularly valuable in identifying subtle posterior instability or tears that may not be evident with other common shoulder tests.

Clinical Significance: Posterior labral tears are less common than anterior tears but can result from acute trauma (e.g., direct blow to the front of the shoulder, fall on an outstretched arm with the arm internally rotated and abducted) or repetitive microtrauma, especially in overhead athletes or individuals engaged in activities involving forceful pushing movements. Identifying these lesions is crucial for appropriate diagnosis and management, as they can lead to pain, clicking, catching, and a sense of instability in the shoulder.

Anatomy and Biomechanics Involved

The Kim maneuver directly challenges the posterior-inferior aspect of the glenohumeral joint capsule and labrum.

• Glenoid Labrum: A fibrocartilaginous ring that deepens the glenoid fossa (shoulder socket), increasing the stability of the glenohumeral joint. Tears in the posterior-inferior portion, often referred to as a reverse Bankart lesion, involve detachment of the labrum from the posterior rim of the glenoid.
• Glenohumeral Joint Capsule: The fibrous capsule surrounding the shoulder joint, reinforced by ligaments, provides passive stability. Excessive stress on the posterior capsule can contribute to posterior instability.
• Rotator Cuff Muscles: While not directly assessed for pathology by this test, the rotator cuff muscles (subscapularis, supraspinatus, infraspinatus, teres minor) play a vital role in dynamic shoulder stability. Dysfunction in these muscles can predispose the joint to instability.

The maneuver's biomechanical action involves applying a specific load and shear force that attempts to replicate the mechanism of injury or stress the compromised posterior structures, thereby eliciting pain or a palpable clunk.

How the Kim Maneuver is Performed

The Kim maneuver requires precise patient and examiner positioning and execution to yield accurate results.

Patient Positioning: The patient is seated with the affected arm relaxed at their side.

Examiner Positioning and Hand Placement: The examiner stands behind the patient.

• One hand stabilizes the patient's elbow, supporting the arm.
• The other hand grasps the patient's proximal arm/distal humerus, just below the shoulder joint.

Execution Steps:

1. The examiner abducts the patient's arm to 90 degrees.
2. The examiner flexes the patient's elbow to 90 degrees.
3. The examiner applies an axial compression force through the humerus towards the glenoid.
4. While maintaining the axial compression, the examiner simultaneously performs a diagonal upward and backward force (posteroinferior glide) on the proximal humerus while elevating the arm to approximately 120-130 degrees of abduction. This movement is often described as a "diagonal upward and backward push" on the humerus.

Positive Test Indicators: A positive Kim maneuver is indicated by:

• Sudden onset of posterior shoulder pain.
• A palpable clunk or jerk felt by the examiner's hand, which may or may not be accompanied by pain. This clunk often signifies the subluxation of the humeral head posteriorly over the glenoid rim, followed by its reduction.

Interpreting the Results

Interpreting the results of the Kim maneuver requires clinical expertise and should be done in conjunction with the patient's history and other physical examination findings.

Clinical Relevance of a Positive Test: A positive Kim maneuver strongly suggests the presence of a posterior-inferior labral lesion or posterior glenohumeral instability. The clunk typically indicates that the humeral head is translating posteriorly and then reducing, suggesting a defect in the posterior labral bumper. Pain without a clunk may still indicate posterior labral pathology or capsular irritation.

Differential Diagnosis: It's important to differentiate a positive Kim maneuver from other conditions that can cause posterior shoulder pain, such as:

• Posterior rotator cuff tendinopathy (e.g., infraspinatus, teres minor)
• Scapular dyskinesis
• Cervical radiculopathy
• Acromioclavicular (AC) joint pathology (though pain location differs)

Limitations of the Test: While the Kim maneuver has demonstrated good diagnostic accuracy (high sensitivity and specificity) in studies, no single orthopedic test is 100% definitive.

• False positives/negatives can occur.
• The test's effectiveness can be influenced by the examiner's technique and experience.
• It should always be part of a comprehensive shoulder examination. Further imaging, such as an MRI with contrast (MR arthrogram), is often necessary to confirm the diagnosis of a labral tear.

Importance of Professional Assessment

The Kim maneuver is a specialized diagnostic test performed by trained healthcare professionals, such as orthopedic surgeons, physical therapists, or sports medicine physicians. It is not a maneuver for self-diagnosis or self-treatment.

If you experience persistent shoulder pain, instability, clicking, or catching, it is crucial to seek a professional medical evaluation. A qualified practitioner can perform a thorough assessment, including a detailed history, physical examination (which may include the Kim maneuver and other special tests), and order appropriate imaging studies to arrive at an accurate diagnosis and develop an effective treatment plan. Early and accurate diagnosis is key to successful management of shoulder pathologies and preventing chronic issues.

Conclusion

The Kim maneuver is a valuable clinical tool for identifying posterior-inferior labral lesions and posterior glenohumeral instability. By applying specific forces to the shoulder, it helps elicit symptoms indicative of these often challenging-to-diagnose conditions. While a significant component of a comprehensive shoulder examination, its results must be interpreted within the broader clinical context to ensure an accurate diagnosis and guide appropriate management strategies.