Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions

Can the presence of SLAP-5 lesions be predicted by using the critical shoulder angle in traumatic anterior shoulder instability?

OBJECTIVE

Although SLAP-5 lesions are associated with recurrent dislocations, their causes and pathomechanisms have not been fully elucidated. This study aimed to investigate the association between SLAP-5 lesions and scapular morphology in traumatic anterior shoulder instability (ASI). We hypothesized that there may be a relationship between SLAP-5 lesions and scapular morphology in traumatic ASI patients.

MATERIALS AND METHODS

The study included 74 patients with isolated Bankart lesions and 69 with SLAP-5 lesions who underwent arthroscopic labral repair for ASI. Critical shoulder angle (CSA) was measured on the roentgenograms, while glenoid inclination (GI) and glenoid version (GV) were measured on magnetic resonance imaging (MRI) by two observers in two separate sessions blinded to each other. Both groups were compared in terms of CSA, GI, and GV.

RESULTS

The mean ages of Bankart and SLAP-5 patients were 28.4±9.1 and 27.9±7.7 (P=0.89), respectively; their mean CSA values were 33.1°±2.6° and 28.2°±2.4°, respectively (P<0.001). The ROC analysis's cut-off value was 30.5°, with 75.0% sensitivity and 76.7% specificity (AUC = 0.830). SLAP-5 lesions were more common on the dominant side than isolated Bankart lesions (P=0.021), but no difference was found between the groups in terms of GI and GV (P=0.334, P=0.081, respectively).

CONCLUSIONS

In ASI, low CSA values appeared to be related to SLAP-5 lesions, and the cut-off value of CSA for SLAP lesion formation was 30.5° with 75.0% sensitivity and 76.7% specificity. Scapula morphology may be related to the SLAP-5 lesions, and CSA can be used as an additional parameter in provocative diagnostic tests and medical imaging techniques for the detection of SLAP lesions accompanying Bankart lesions.

LEVEL OF EVIDENCE

III retrospective case-control study.

Double Trouble: Combined Neurogenic Thoracic Outlet Syndrome and Superior Labrum Anterior Posterior Tear

Neurogenic thoracic outlet syndrome and superior labrum anterior posterior tears are usually treated in a staged manner due to different post-operative therapy needs. This case describes successful combined surgery with expedited physical therapy.

Physical Examination Maneuvers for SLAP Lesions: A Systematic Review and Meta-analysis of Individual and Combinations of Maneuvers

BACKGROUND

Superior labrum anterior to posterior (SLAP) lesions are targeted on physical examination using a variety of provocative maneuvers.

PURPOSE/HYPOTHESIS

The purpose was to conduct a systematic review on the performance of physical examination maneuvers in diagnosing SLAP lesions and to perform a meta-analysis comparing the sensitivity and specificity of these examinations both individually and in combination. The null hypothesis stated that there would be no significant difference in the sensitivity or specificity of the included physical examination tests, neither individually nor in combination.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic review was performed with the inclusion criteria of studies that reported either the sensitivities and specificities or the number of true-positive, true-negative, false-positive, or false-negative results for at least 1 maneuver for identifying SLAP lesions. A meta-analysis was performed to determine the sensitivity and specificity of individual maneuvers. Additional analysis determined the performance of these maneuvers when combined in series and parallel. In series, all must be present to be considered positive. In parallel, any single positive test forces the overall combination to be considered positive. Only tests that were included in ≥3 studies were considered in the meta-analysis and those included in ≥4 studies were considered in the combination analysis.

RESULTS

Overall, 862 studies were identified, 18 of which were included in the systematic review and meta-analysis. The physical examinations included were the O'Brien (n = 16), speed (n = 8), Yergason (n = 6), anterior slide (n = 8), crank (n = 7), Jobe (n = 5), dynamic labral shear (n = 3), Kim 2 (n = 3), and biceps groove tenderness tests (n = 3). All combinations of 2 to 5 maneuvers in both series and parallel were considered. The O'Brien and crank test combination was the most sensitive 2-test combination in both parallel and series. The Yergason and anterior slide test combination was the most specific 2-test combination in parallel and series.

CONCLUSION

This systematic review and meta-analysis reports an updated meta-analysis considering the sensitivity and specificity of common physical examination maneuvers used in the diagnosis of SLAP lesions and considers these values for tests in both series and parallel combinations. The present analysis demonstrates improved specificities when tests are considered in series and improved sensitivities when considered in parallel combination.

Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower

Symptomatic superior labral anterior and posterior (SLAP) tears have become an increasingly common diagnosis, particularly within the competitive overhead athlete population. Type II SLAP tears are the most encountered variant in overhead throwing athletes. Given the high incidence of false positives on advanced imaging, corroborating the history and physical examination with imaging is paramount to accurately establish a SLAP lesion diagnosis. Previous studies have reported conflicting success rates with conservative management, but the number of pitching athletes able to return to prior level of performance with nonsurgical management strategies has been unsatisfactory. Although there has historically been a notable disconnect between the incidence of SLAP tears in the literature and the number of SLAP repairs in recent investigations, high-grade or unstable tears may be candidates for débridement, labral repair, biceps tenodesis, or less frequently, biceps tenotomy. Biceps tenodesis has been increasingly used for the management of these lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

SLAP Injury and the Superior Labrum

Injuries around the superior labrum are a common cause of shoulder dysfunction and pain. The injuries sustained result mainly from repetitive microtrauma but can also occur following a fall on outstretched hand. Both athletic and general populations can be affected. Injuries to the superior labrum are called superior labrum anterior and posterior (SLAP) tears. Based on cross-sectional imaging findings, the literature defines four main SLAP tears (I–IV) and six extended types (V–X). An accurate description of imaging findings of the SLAP tear type, along with concomitant findings, aids clinicians in treatment planning. We also briefly discuss management options, postoperative appearance of superior labral repair, and the diagnosis of a retear.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Imaging of Patients Suspected of SLAP Tear: A Cost-Effectiveness Study

Background: Superior labral anterior-to-posterior (SLAP) tears are a common shoulder pathology. While MRI is the imaging gold standard for diagnosis of this pathology, the cost-effectiveness of the common MRI strategies is unclear. Objective: The primary objective of our study was to determine the cost-effectiveness of the common MRI-based strategies used for the diagnosis of SLAP tears. Methods: We created decision analytic models from the U.S. health care system perspective over a two-year time horizon for a hypothetical patient population of 25-year-olds with a previous diagnosis of SLAP tear. We used the decision models to compare the differences in incremental cost-effectiveness of the common MRI strategies and resulting treatment applied for this patient type, which included combinations of 1.5T and 3T imaging and unenhanced MRI and MR arthrogram protocols. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2017 U.S. dollars. Results: When all imaging strategies were considered, the unenhanced 3T MRI based imaging strategy was the preferred and dominant option over 3T MR arthrography (MRA) and 1.5T imaging (MRI/MRA). When the model was run without 3T imaging as an option, 1.5T MRA was the favored option. Probabilistic sensitivity analyses confirmed the same preferred imaging strategy results. Conclusion: An unenhanced 3T MRI based strategy is the most cost-effective imaging option for patients with suspected SLAP tear. When 3T imaging is not available, 1.5T MRA is more cost-effective than 1.5T imaging. The main driver of these results is the fact that 3T MRI and 1.5T MRA are the most specific tests in these respective scenarios which results in fewer false positives and prevents unnecessary surgeries leading to decreased costs. Clinical Impact: Our cost-effectiveness model findings complement prior diagnostic accuracy work, helping produce a more comprehensive approach to define imaging utility for the SLAP patient population for radiologists, clinicians, and patients who have access to various types of MRI options.

SLAP tears and return to sport and work: current concepts

Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities. Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors. For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies and unpredictable rates of return to play. As a consequence, the most appropriate surgical option in elite throwers is controversial. The objective of this current concepts review is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.

The Fifty Most-Cited Articles Regarding SLAP Lesions

Purpose

To identify and evaluate the top 50 most-cited articles pertaining to SLAP tears.

Methods

The ISI Web of Knowledge database was used to conduct a query for articles pertaining to SLAP tears. Our query was conducted in April 2020 with multiple Boolean operative combinations performed by 2 independent reviewers. Articles on the final list were further reviewed to extract the following data: manuscript title, first author, total citation count, year of publication, citation density since publication, current citation rate since 2013, journal, country of origin, and level of evidence.

Results

Our initial search yielded 2,597 articles. Within this cohort, the top 50 publications pertaining to SLAP tears were identified that met our search criteria. The top article was cited 802 times while the 50th ranked article was cited 46 times. The average number of citations per publication was 131, whereas the average citation density since year of publication was 7.3. No strong correlations were found between citation density and year published. Twelve journals published articles pertaining to SLAP tears, with Arthroscopy accounting for the greatest number (15 articles, 30%). Most articles were graded with a level of evidence (LOE) of IV (n = 24, 48%), followed by review articles without LOE (n = 8, 16%). Only 2 articles achieved an LOE of I (4%). Articles typically addressed the arthroscopic management (n = 11, 22%), whereas anatomy/classification (n =10, 20%), and outcomes (n = 9, 18%) also were reported.

Conclusions

This review provides a quantitative analysis of the most-referenced literature pertaining to SLAP tears. This body of knowledge helps surgeons search for literature regarding these injuries and identify trends regarding SLAP tear research.

Clinical Relevance

This research provides practitioners with an easily accessible and comprehensive collection of the major contributions regarding SLAP tears and offers insight into future areas for research.

Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability

BACKGROUND

The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability.

METHODS

This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control).

RESULTS

Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively).

CONCLUSION

Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.

Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review

BACKGROUND

The Active Compression Test has been proposed to have high diagnostic accuracy for superior labrum anterior to posterior tears. The aim of this systematic review was to compile the available evidence for this test and evaluate its diagnostic accuracy.

METHODS

The databases PubMed, Embase, Cochrane, CINAHL, and SCOPUS were searched for case control, diagnostic studies that evaluated the Active Compression Test between 1999 (date of test introduction) and February 2018. Two independent review authors screened the search results, assessed the risk of bias using QUADAS-2, and extracted the data.

RESULTS

Eighteen studies (pooled sample = 3091) were included in this review. Twelve out of 18 studies either had high or unclear risk of bias (66.6%). Results from the pooled analysis of all 18 studies provided that the Active Compression Test is more sensitive (71.5: 95% CI = 68.8, 74.0) than specific (51.9: 95% CI = 50.7, 53.1) and only marginally influenced posttest probability from a pretest probability of 31.7-40.72% with a positive finding and a pretest probability of 31.7-20.33% with a negative finding.

DISCUSSION

The Active Compression Test has both limited screening and confirmation ability; therefore, we do not advocate for its use in clinical decision making.

Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder

A detailed physical examination of the shoulder is crucial in creating a diagnosis in patients who present with shoulder pain. Tests of the cervical spine, scapula, and rotator cuff muscles have already been evaluated in a previous article. This article assesses provocative and instability examination tests of the shoulder. Descriptions on how the tests are performed and their diagnostic accuracy are presented.

Imaging-Based Prevalence of Superior Labral Anterior-Posterior Tears Significantly Increases in the Aging Shoulder

Background

Superior labral anterior-posterior (SLAP) tears can be associated with pain and shoulder dysfunction. Relatively little is known about the age-related prevalence of SLAP tears.

Purpose

To investigate the age-related prevalence of imaging-diagnosed SLAP tears in a heterogeneous grouping of shoulder conditions in a large cohort at a single institution with multiple blinded reviewers.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A total of 281 shoulder magnetic resonance imaging (MRI) scans obtained over 8 months were reviewed by a musculoskeletal radiologist and an orthopaedic surgeon. The mean ± SD age of the group was 49.6 ± 15.5 years, and 107 of the patients were female (38.1%). Patients were divided into 4 age groups: 35 years or younger, 36 to 50 years, 51 to 65 years, and older than 65 years. Statistical analyses were completed by use of the Fisher exact test to compare proportions of SLAP tears between age groups, odds ratios to determine the likelihood of having a SLAP tear in each age group, and a logistic regression to control for associated abnormalities.

Results

There was a significant diffference in the proportion of SLAP tears found on the MRIs for each age group (P < .001). Patients were significantly more likely to have SLAP tears if aged 51 to 65 years (66.7%; odds ratio [OR], 2.00; 95% CI, 1.27-3.15) and if older than 65 years (81.2%; OR, 4.31; 95% CI, 2.36-7.88). No increased prevalence was observed in patients aged 35 years or younger (47.5%; OR, 0.91; 95% CI, 0.55-1.50) or 36 to 50 years (51.8%; OR, 1.08; 95% CI, 0.70-1.67). Logistic regression demonstrated that age was the only significant predictor for having a SLAP tear (P < .001). Kappa values were 0.46 to 0.65 between reviewers, indicating moderate to substantial agreement.

Conclusion

An increasing prevalence of MRI-based SLAP tears was observed with increasing patient age. Patients older than 50 years were significantly more likely to have superior labral abnormalities regardless of other shoulder injury or disease.

An Age and Activity Algorithm for Treatment of Type II SLAP Tears

Background

Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy.

Objective

To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level.

Methods

A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm.

Results

Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker's compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis.

Conclusion

Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.

National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries

OBJECTIVE

  To present recommendations for the diagnosis, management, outcomes, and return to play of athletes with superior labral anterior-posterior (SLAP) injuries.

BACKGROUND

  In overhead athletes, SLAP tears are common as either acute or chronic injuries. The clinical guidelines presented here were developed based on a systematic review of the current evidence and the consensus of the writing panel. Clinicians can use these guidelines to inform decision making regarding the diagnosis, acute and long-term conservative and surgical treatment, and expected outcomes of and return-to-play guidelines for athletes with SLAP injuries.

RECOMMENDATIONS

  Physical examination tests may aid diagnosis; 6 tests are recommended for confirming and 1 test is recommended for ruling out a SLAP lesion. Combinations of tests may be helpful to diagnose SLAP lesions. Clinical trials directly comparing outcomes between surgical and nonoperative management are absent; however, in cohort trials, the reports of function and return-to-sport outcomes are similar for each management approach. Nonoperative management that includes rehabilitation, nonsteroidal anti-inflammatory drugs, and corticosteroid injections is recommended as the first line of treatment. Rehabilitation should address deficits in shoulder internal rotation, total arc of motion, and horizontal-adduction motion, as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control. Most researchers have examined the outcomes of surgical management and found high levels of satisfaction and return of shoulder function, but the ability to return to sport varied widely, with 20% to 94% of patients returning to their sport after surgical or nonoperative management. On average, 55% of athletes returned to full participation in prior sports, but overhead athletes had a lower average return of 45%. Additional work is needed to define the criteria for diagnosing and guiding clinical decision making to optimize outcomes and return to play.

MR Imaging of SLAP Lesions

Background:

SLAP lesions of the shoulder are challenging to diagnose by clinical means alone. Interpretation of MR images requires knowledge of the normal appearance of the labrum, its anatomical variants, and the characteristic patterns of SLAP lesions. In general, high signal extending anterior and posterior to the biceps anchor is the hallmark of SLAP lesions. Common diagnostic criteria for a SLAP lesion by MR or MR arthrography include the following: presence of a laterally curved, high signal intensity in the labrum on a coronal image, multiple or branching lines of high signal intensity in the superior labrum on a coronal image, full-thickness detachment with irregularly marginated high signal intensity and/or separation >2 mm on conventional MRI or 3 mm on MR arthrography between the labrum and glenoid on a coronal image, and a paralabral cyst extending from the superior labrum.

Methods:

MR diagnosis of SLAP tears may be improved with provocative maneuvers, such as longitudinal traction of the arm or positioning of the shoulder in abduction and external rotation during imaging. The use of intra-articular contrast distends the joint similar to what occurs during arthroscopy and forced diffusion under the labrum may improve the ability to detect SLAP lesions that might not be seen with standard MR. Improved diagnostic accuracy for SLAP tears is seen with 3-T compared with 1.5-T MR imaging, with or without intra-articular contrast material.

Conclusion:

Regardless of MR findings, however, physicians should be cautious when recommending surgery in the patient with a vague clinical picture. The patient’s history, physical exam, and imaging evaluation all should be considered together in making the decision to proceed with surgery.

Concomitant SLAP repair does not influence the surgical outcome for arthroscopic Bankart repair of traumatic shoulder dislocations

BACKGROUND

Prior studies revealed the presence of superior labrum anterior-to-posterior (SLAP) injury together with Bankart lesions in some patients. The purpose of the study is to compare the clinical results of isolated Bankart repairs with the clinical results of Bankart repairs when performed with concomitant SLAP repairs.

METHODS

The patients who underwent arthroscopic surgery for treatment of anterior glenohumeral instability were evaluated retrospectively. Group 1 consisted of 19 patients who had arthroscopic SLAP repair together with Bankart repair. The mean age of the patients was 23. Group 2 consisted of 38 patients who underwent isolated Bankart repair. The mean age was 24. Knotless anchors were used in both groups.

RESULTS

The mean follow-up was 34 months (range: 26-72). In group 1, the mean preoperative Constant score was 84 (range: 74-90, standard deviation (SD): 5.91) and Rowe score was 64.1 (range: 40-70, SD: 8.14). In group 2, the preoperative Constant score was 84.4 (range: 70-96, SD: 5.88) and Rowe score was 60 (range: 45-70, SD: 7.95). In group 1, the postoperative mean Constant score raised to 96.8 (range: 88-100, SD: 2.91) and the mean Rowe score raised to 92.3 (range: 85-100, SD: 5.17). In group 2, the postoperative mean Constant score was 94.9 (range: 88-100, SD: 3.70) and the mean Rowe score was 94.2 (range: 80-100, SD: 4.71). The difference between the scores of two groups was insignificant ( p > 0.05). When the numbers of redislocations and range of motion were compared, no significant difference was found ( p > 0.05).

CONCLUSION

Accompanying SLAP repair in surgical treatment with Bankart repair for shoulder instability does not affect the results negatively. Properly repaired labral tears extending from anterior inferior to the posterior superior of the glenoid in instability treatment have the same outcome in overall results as repaired isolated Bankart lesions.

Comprehensive Examination of the Athlete's Shoulder

Context:

Shoulder pain and dysfunction are common, with patients presenting complaints to both primary and orthopaedic physicians. History and physical examination remain essential to creating a differential diagnosis, even as noninvasive imaging has improved.

Evidence Acquisition:

Literature was obtained through keyword searches based on the pathology in question (eg, rotator cuff) and the keywords physical examination using PubMed from January 1, 1980, through September 20, 2017. Additional evidence was obtained through screening references from articles identified through the PubMed searches.

Study Design:

Clinical review.

Level of Evidence:

Level 3.

Results:

A total of 7817 articles were screened for relevance. Several physical examination maneuvers have been described for each specific pathology. The Neer sign has a 75% sensitivity for subacromial impingement (SAI), while the Hawkins-Kennedy test has an 80% sensitivity. The painful arc test has an 80% specificity for SAI. The apprehension test has a hazard ratio of 2.96 for anterior shoulder instability. The Jobe test has a sensitivity of 52.6% and a specificity of 82.4% for full-thickness supraspinatus tears, confirmed on arthroscopy. The lag sign is highly sensitive and specific for combined full-thickness supraspinatus and infraspinatus tears at 97% and 93%, respectively. The Speed test has a sensitivity of 54% and specificity of 81% for biceps pathology. The anterior slide test and O’Brien active compression test have been described for superior labrum anterior posterior tears with inconsistent reliability. The cross-body adduction test has a sensitivity of 77% and a specificity of 79% for acromioclavicular joint pathology.

Conclusion:

Several physical examination maneuvers can isolate specific pathology of the shoulder, with widely ranging sensitivity and specificity.

MRI to Arthroscopy Correlations in SLAP Lesions and Long Head Biceps Pathology

Superior labral anterior and posterior lesions and long head biceps injury are 2 common sources of shoulder pain. The presenting complaints and physical examination findings for these etiologies are often nonspecific, making diagnosis challenging. Further complicating their diagnoses, these 2 pathologies often cooccur together or with other shoulder pathologies such as subacromial bursitis, rotator cuff tear, and shoulder instability. However, with advancement in magnetic resonance imaging and shoulder arthroscopy techniques the ability to diagnose and treat these pathologies has vastly improved over the past 30 years. This review provides a case-based description of the correlation between magnetic resonance imaging and arthroscopic findings in common superior labral anterior and posterior and long head biceps injury, accompanied with current management strategies.

A Modification of the Active Compression Test for the Shoulder Biceps-Labrum Complex

The active compression test (O'Brien Sign) is widely used by physicians to aid in the diagnosis of biceps-labrum complex disease. This maneuver has been particularly criticized in the literature, however, with regard to interobserver reliability. Criticisms may in fact stem from inaccurate and inconsistent practice of the examination maneuver, stemming from both patient- and physician-related errors. In this Technical Note, we introduce an easy modification to the O'Brien Sign that limits such errors and improves test uniformity.

Diagnosis of Superior Labrum Anterior-to-Posterior Tears by Using MR Imaging and MR Arthrography: A Systematic Review and Meta-Analysis

Purpose To evaluate the diagnostic accuracies of nonenhanced magnetic resonance (MR) imaging and MR arthrography for diagnosis of superior labrum anterior-to-posterior (SLAP) tears by using a systematic review and meta-analysis. Materials and Methods A comprehensive literature search was performed on the two main concepts of MR imaging (MR imaging, and direct and indirect MR arthrography) and SLAP tears. Inclusion criteria consisted of original studies that assessed the diagnostic accuracy of MR imaging, direct MR arthrography, and/or indirect MR arthrography for the detection of SLAP tears, by using surgical findings as the reference standard. The Quality Assessment of Diagnostic Accuracy Studies 2, or QUADAS-2 Quality Assessment of Diagnostic Accuracy Studies 2 Quality Assessment of Diagnostic Accuracy Studies 2 , tool was used to assess methodologic quality. Meta-analyses were performed that compared MR imaging studies to direct MR arthrography studies and indirect MR arthrography studies, 3-T studies to 1.5-T studies, and low-bias MR imaging studies to low-bias direct MR arthrography studies. Study variation was analyzed by using the Cochran Q test of heterogeneity and the I² statistic. Results Thirty-two studies met inclusion and exclusion criteria, including 3524 imaging examinations: 1963 direct MR arthrography examinations (23 studies), 1402 MR examinations (14 studies), and 159 indirect MR arthrography examinations (three studies). Twelve studies had low risk for bias, two had questionable risk, and 18 had high risk. Mean sensitivities of direct MR arthrography, MR imaging, and indirect MR arthrography for SLAP tear diagnosis were 80.4%, 63.0%, and 74.2%, respectively. Mean specificities of direct MR arthrography, MR imaging, and indirect MR arthrography were 90.7%, 87.2%, and 66.5%, respectively. Summary receiver operator characteristic (ROC) curve demonstrated superior accuracy of direct MR arthrography compared with those of MR imaging and indirect MR arthrography. Similar findings were observed in the low-bias subanalysis. Summary ROC curve demonstrated overall superiority of 3-T imaging, with or without intra-articular contrast material compared with 1.5-T imaging, with or without intra-articular contrast material. Significant variance was observed for MR imaging and direct MR arthrography (P < .001) studies for both mean sensitivity and specificity. Conclusion Direct MR arthrography appears to be more accurate than nonenhanced MR imaging for diagnosis of SLAP tears, whereas 3-T MR imaging with or without intra-articular contrast material appears to improve diagnostic accuracy compared with 1.5-T MR imaging with or without intra-articular contrast material. ^© RSNA, 2017 Online supplemental material is available for this article.

Clinical Assessment of the Dynamic Labral Shear Test for Superior Labrum Anterior and Posterior Lesions

BACKGROUND

Diagnosing superior labrum anterior and posterior (SLAP) lesions through physical examination remains challenging. The dynamic labral shear test (DLST) has been shown to have likelihood ratios (LRs) of 31.6 and 1.1 for diagnosing SLAP lesions.

PURPOSE

To determine the clinical utility of the DLST for diagnosing SLAP lesions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

This prospective, consecutive case series included 774 patients who underwent diagnostic arthroscopy and a preoperative DLST between 2007 and 2013. Patients were divided into 3 groups: 610 control patients with no SLAP lesion but with other abnormalities, 9 patients with isolated SLAP lesion (ISL), and 155 patients with concomitant SLAP lesion (CSL), who had a SLAP lesion and another shoulder abnormality. We determined sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), odds ratio (OR), and diagnostic accuracy (DA) of the DLST with and without other tests.

RESULTS

The DLST was positive for 242 of 610 controls (40%), 7 of 9 patients (78%) in the ISL group, and 88 of 155 patients (57%) in the CSL group. In the ISL group, the DLST had a sensitivity of 78%, specificity of 51%, PPV of 2%, NPV of 100%, OR of 3.58, and DA of 51%. In comparison, the ORs were 1.09 for the active compression test, 1.30 for the lift-off test, and 1.53 for the relocation test, which were not significantly different from each other. For diagnosing a SLAP lesion existing in a joint with other associated injury, the DLST had a sensitivity of 57%, specificity of 52%, PPV of 23%, NPV of 83%, OR of 1.4, and DA of 53%. Combining all 4 tests did not improve the OR for detecting ISLs or CSLs.

CONCLUSION

The DLST is sensitive but not specific for detecting ISLs. With an OR of 3.58, the DLST is useful for diagnosing ISLs. However, in patients who have CSLs, the DLST is not as useful for diagnosing SLAP lesions.

Shoulder Injuries in the Overhead Throwing Athlete

The overhead pitching motion is a coordinated sequence of movements that subjects the shoulder to extreme forces. The ultimate goal of this complex, dynamic activity is to generate high ball velocity and accuracy. In doing so, repetitive throwing can cause adaptive and pathologic changes in the thrower's shoulder. This article reviews the relevant shoulder anatomy, the kinetic chain, and throwing mechanics, as well as common shoulder injuries and surgical options for the treating orthopedic surgeon.

Outcomes following long head of biceps tendon tenodesis

Lesions of the proximal long head of the biceps tendon (LHB) have been considered as a major cause of shoulder pain and dysfunction. The role of the LHB in causing pain has been a source of controversy for many years, and extensive literature is available discussing anatomy, function, pathology, and most importantly appropriate treatment. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Biceps tenotomy and tenodesis are common surgical treatment options when dealing with LHB-related pathology. In this review, a brief discussion on surgical options is provided while focusing on the different options for biceps tenodesis including outcomes and complications.

Correlation between physical examination and intraoperative findings in shoulder disease treated by arthroscopy. Statistical analysis of 150 patients

INTRODUCTION

Only a few clinical exploratory manoeuvres are truly discriminatory and useful in shoulder disease. The aim of this study is to correlate the physical examination results of the shoulder with the true diagnosis found by arthroscopy.

METHODS

A retrospective case series of 150 patients with the most common surgical conditions of the shoulder. Data were collected on the suspicion of each pathology, the physical examination of the patient, and the actual discovery of the disease during arthroscopic surgery.

RESULTS

The Bankart examination manoeuvres of the lesion show the best results, with a 92.1% positive prediction value (PPV), a 99.1% negative predictive value (NPV), followed by the impingement syndrome, with a PPV of 94.4%, and total cuff rupture with a PPV of 92.3%.Exploration of the superior labrum anterior to posterior (SLAP) lesion had an NPV of 99.1%.

CONCLUSION

Physical examination is sufficient to diagnose or rule out Bankart. A positive physical examination provides the complete rupture of the rotator cuff, and requires further studies. The patients suspected of subacromial syndrome only need an NMR if the physical tests are negative. The conclusions drawn from this work can have a significant impact on both cost savings (by reducing forward tests), and saving time in certain cases in which, after appropriate physical examination, surgery may be indicated without losing time in intermediate steps.

High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders

Background:

The incidence of superior labral surgery has increased in the past decade in the United States, and a contributing factor could be an increased rate of superior labral tears diagnosed with magnetic resonance imaging (MRI). Prior MRI studies of the asymptomatic shoulder have focused on rotator cuff pathology or pathology in a narrow and specific group of athletes. Labral abnormalities have not previously been thoroughly evaluated in asymptomatic middle-aged individuals.

Purpose:

To evaluate the prevalence of superior labral tears diagnosed by MRI in the asymptomatic shoulders of middle-aged people (age range, 45-60 years).

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 53 asymptomatic adults (age range, 45-60 years) with no history of surgery or injury to either shoulder were included in the study. Physical examinations of all shoulders were performed. Noncontrast MRI (1.5 T) was performed in 1 randomly determined shoulder of each subject. Two fellowship-trained musculoskeletal radiologists who were blinded to the purpose of the study and ages of the subjects evaluated each MRI.

Results:

Radiologists interpreted the MRIs as consistent with superior labral tears in 55% and 72% of the cohort. Comparison of the radiological evaluations of the superior labra were moderate (κ = 0.410, P = .033). There were no differences in readings for superior labral tear regarding age (P = .87), sex (P = .41), whether the dominant shoulder underwent MRI (P = .99), whether the subject worked a physical job (P = .08), or whether the subject participated in overhead sports for a period of 1 year (P = .62).

Conclusion:

Superior labral tears are diagnosed with high frequency using MRI in 45- to 60-year-old individuals with asymptomatic shoulders. These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population.

Clinical Relevance:

To avoid overtreatment, physicians should realize that superior labral tears diagnosed by MRI in individuals between the ages of 45 and 60 years may be normal age-related findings.

Examination of the Biceps Tendon

The examination of the shoulder for conditions involving the biceps tendon continues to be challenging. Numerous examination tests for biceps and superior labrum anterior and posterior (SLAP) lesions have been scientifically evaluated. This section reports on how to perform these tests and summarizes the clinical utility of the tests. Many of the tests for the examination of the biceps and for SLAP lesions do not have high sensitivity and specificity, which limits their usefulness. Although the dynamic shear test has promise for making the diagnosis of SLAP lesions, the studies reporting its clinical utility are disparate.

Accuracy of magnetic resonance imaging to diagnose superior labrum anterior-posterior tears

PURPOSE

The purpose of this study was to evaluate the accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in diagnosing superior labral anterior-posterior (SLAP) lesions. We hypothesized that the accuracy of MRI and MRA was lower than previously reported.

METHODS

Between 2006 and 2008, 444 patients who had both shoulder arthroscopy and an MRI (non-contrast or MR arthrography) for shoulder pain at our institution prior to surgery were identified and included in the study. The radiologic diagnosis and surgical evaluation were compared to determine the accuracy of diagnosing a SLAP lesion by MRI. Using arthroscopy as the standard, sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all MRIs, as well as separately for the non-intra-articular contrast MRI group and the MR arthrography group.

RESULTS

Of the 444 patients having an MRI and arthroscopy for shoulder pain, 121 had a SLAP diagnosis by MRI and 44 had a SLAP diagnosis by arthroscopy. Overall, MRI had an accuracy of 76 %, a PPV of 24 %, and a NPV of 95 %. Sensitivity was 66 %, and specificity was 77 %. MR arthrography had an accuracy of 69 %, sensitivity of 80 %, and a PPV of 29 %. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %.

CONCLUSIONS

In our retrospective study of 444 patients, sensitivity, specificity, and accuracy were all lower than previously reported in the literature for diagnosing SLAP lesions. Our data indicated that while MRI could exclude a SLAP lesion (NPV = 95 %), MRI alone was not an accurate clinical tool. MR arthrography had a large number of false-positive readings in this study. We concluded that even with intra-articular contrast, MRI had limitations in the ability to diagnose surgically proven SLAP lesions.

Labrum and rotator cuff injuries in the throwing athlete

The large amount of force imparted across the shoulder during the act of throwing makes the glenohumeral joint highly susceptible to injury in the athlete performing overhead throwing motions. The bony incongruity of the shoulder enables greater range of motion than any other joint in the body, but it also results in significant strain on the surrounding soft tissues during the throwing motion. Throwers can present with acute injuries, but more commonly they suffer from chronic overuse conditions resulting from repetitive overload. Proper management requires early recognition with treatment directed toward the athlete's safe return to sports. Failure to institute an appropriate management strategy may result in significant complications, including prolonged disability, progression of symptoms, and further injury. We discuss the functional anatomy, pathophysiology, clinical presentation, evaluation, and treatment of common injuries of the glenoid labrum and rotator cuff in the overhead throwing athlete.

Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear

The purpose of this study was to evaluate the outcomes of patients undergoing subpectoral biceps tenodesis for bicipital tendonitis with a superior labral anterior-posterior (SLAP) tear. Patients undergoing primary subpectoral biceps tenodesis for arthroscopically confirmed SLAP tears with signs or findings of bicipital tendonitis were included. An independent observer collected data prospectively as part of a data repository, which was then analyzed retrospectively. Primary outcome measures were the American Shoulder and Elbow Surgeons (ASES) score and pain relief via visual analog scale (VAS). Secondary outcome measures included the Simple Shoulder Test (SST), Constant, Single Assessment Numeric Evaluation (SANE), and Short Form 12 (SF-12) scores. Twenty-eight patients with a mean±SD age of 43.7±13.4 years and a mean±SD follow-up of 2.0±1.0 years met inclusion criteria. Workers' compensation was involved with 43% of cases, and 46% of the included patients were manual laborers. Eight (32%) patients were athletes, and 88% of the athletes were overhead athletes. Intraoperatively, 15 (54%) patients had type I SLAP tears, 10 (36%) had type II SLAP tears, 1 (3%) had a type III SLAP tear, and 2 (7%) had type IV SLAP tears. Significant improvements were seen in the following outcome measures pre- vs postoperatively: ASES score (58±23 vs 89±18; P=.001), SST score (6.3±3.6 vs 10.6±3.3; P=.001), SANE score (54±24 vs 88±25; P=.003), VAS score (3.8±2.0 vs 1.1±1.8; P=.001), SF-12 overall score (35±6 vs 42±6; P=.001), and SF-12 physical component score (39±6 vs 50±10; P=.001). Overall satisfaction was excellent in 80% of patients. Subpectoral biceps tenodesis demonstrates excellent clinical outcomes in select patients with SLAP tears. [Orthopedics. 2015; 38(1):e48-e53.].

Understanding and evaluating shoulder pain in the throwing athlete

Shoulder pain in the throwing athlete can present at any age and in any level of sport and can lead to dysfunction. A thorough evaluation of the throwing athlete can often determine the cause of symptoms, which is frequently multifactorial. Although the pathophysiology leading to pain in the shoulder of the throwing athlete is not entirely known, nonoperative modalities remain the mainstay of treatment. In general, surgical intervention should be reserved as a last resort. Effective treatment often requires collaboration among trainers, players, physicians, and therapists to determine an appropriate course of action.

The Impact of Superior Labral Anterior to Posterior Lesions on Functional Status in Shoulder Instability: A Multicenter Cohort Study

BACKGROUND

Type IV superior labral anterior to posterior (SLAP) lesions, which are superior labral detachments associated with Bankart tears, are reported to occur in up to 25% of recurrent shoulder instability patients. However, the clinical implications of this finding are debatable.

PURPOSE

To determine whether there are any functional differences between anterior instability patients with and without type IV SLAP lesions at the time of presentation and at short-term follow-up after surgical intervention.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective, multicenter database was established to follow the clinical evolution of patients with shoulder instability. Patients were diagnosed as having a type IV SLAP lesion at the time of arthroscopic Bankart surgery (SLAP+). These patients were compared with a group of patients who simply had a Bankart lesion (SLAP-). The 2 groups had their functional outcomes (Western Ontario Shoulder Instability Index [WOSI]; Disability of the Arm, Shoulder, and Hand [QuickDASH]; and Walch-Duplay) compared prior to surgery and 1 year postoperatively.

RESULTS

A total of 103 subjects were included in the study; of these, 56 (43 men, 13 women) completed 1-year follow-up. Twenty-three subjects had a type IV SLAP tear, and most had this repaired along with their Bankart lesion. At baseline, SLAP+ subjects had inferior QuickDASH scores compared with SLAP- subjects (37.8 vs 29.0) as well as poorer pain subscores on both the WOSI and QuickDASH. At 1-year follow-up, however, there were no significant differences in any of the outcome measures.

CONCLUSION

A type IV SLAP lesion can be expected in 22% of patients with recurrent shoulder instability. This finding implies that at baseline, the patient will have slightly worse functional scores related to pain. However, following surgical management of the labral pathology, these patients will have equivalent functional outcomes at short-term follow-up.

CLINICAL RELEVANCE

With surgical management of the superior and anteroinferior labrum, patients with type IV SLAP lesions will do as well as those with only Bankart tears. Thus, the presence of SLAP lesions should not alter the decision to provide surgical management and should not change the prognosis for a specific patient.

Physical examination of the shoulder

This article summarizes the overall assessment of the shoulder joint and seeks to help direct clinicians to diagnose shoulder pathology using standard and specific physical examinations. The history and standard examination can prompt the examiner to focus on specific tests to further evaluate the shoulder and limit the differential diagnoses. An appropriate and directed shoulder physical examination allows the clinician to focus on further diagnostic strategies and treatment options for the patient.

Clinical assessment of the glenoid labrum

BACKGROUND

The glenoid labrum is integral to shoulder stability and can be difficult to assess clinically. Whilst it is a single anatomical structure, damage to different regions results in very different clinical manifestations. A large number of provocative tests have been described, all of which initially purport to have excellent diagnostic accuracy. Clinical experience suggests that this is not the case and decision making can be difficult for the non-expert. The purpose of this study is to review the current evidence for the most commonly used tests and to provide suggestions for tests which have the most evidence for efficacy.

METHODS

The glenoid labrum was divided into anterior, superior and posterior regions. The English language literature describing labral tests was reviewed. The evidence provided by the authors and any subsequent studies was analysed.

RESULTS

Whilst a large number if tests have been described with the primary authors reporting excellent results the evidence for most is poor when later tested critically.

DISCUSSION

No single test will accurately diagnose labral pathology. The clinician must use evidence from the clinical history combined with selective use and interpretation of tests with which they are familiar.

Etiology, Diagnosis, and Management of Failed SLAP Repair

In general, favorable outcomes have been achieved with arthroscopic repair of superior labral anterior-posterior (SLAP) tears. However, some patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment to alleviate their symptoms. The cause of persistent pain or recurrent symptoms after repair is likely multifactorial; therefore, careful preoperative workup is required to elucidate the cause of pain. Review of the details of previous surgical procedures is crucial because certain fixation methods are prone to failure or can cause additional injury. Failed SLAP repair can be managed with nonsurgical or surgical options. Nonsurgical modalities include physical therapy and strengthening programs, anti-inflammatory agents, and activity modification. Surgical options include revision SLAP repair and biceps tenotomy or tenodesis with or without revision SLAP repair. Outcomes after surgical management of failed SLAP repair are inferior to those of primary repair. Select patients may be better served by primary biceps tenodesis rather than SLAP repair.

Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions

BACKGROUND

Surgical repair remains the gold standard for most type II and type IV superior labral anterior and posterior (SLAP) lesions that fail nonoperative management. However, most recently, there have been data demonstrating unacceptably high failure rates with primary repair of type II SLAP lesions. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions.

HYPOTHESIS

Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV SLAP lesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent subpectoral biceps tenodesis and labral debridement for type II and type IV SLAP lesions by a single board-certified shoulder surgeon from 2006 to 2012 were evaluated. Exclusion criteria included those patients who underwent biceps tenodesis with an associated rotator cuff repair, anterior labral repair, or posterior labral repair. Outcome measures included the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, and demographic data.

RESULTS

Between 2006 and 2012, a total of 36 subpectoral biceps tenodesis procedures were performed in 33 patients for type II or IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow-up. The average age was 46.7 years, with 16 male and 10 female patients participating in the study. The average follow-up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared with 87.5 and 1.5 postoperatively, respectively (P < .001). There was no significant difference based on SLAP lesion type, patient age, or patient sex. Of 29 shoulders, 26 (89.66%) were able to return to the previous level of activity.

CONCLUSION

This study adds to the evolving literature supporting biceps tenodesis as a viable treatment for type II and IV SLAP lesions. Patient age had no effect on the outcomes. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.

Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management

After the improvement in arthroscopic shoulder surgery, superior labrum anterior to posterior (SLAP) tears are increasingly recognized and treated in persons with excessive overhead activities like throwers. Several potential mechanisms for the pathophysiology of superior labral tears have been proposed. The diagnosis of this condition can be possible by history, physical examination and magnetic resonance imaging combination. The treatment of type 1 SLAP tears in many cases especially in older patients is non-operative but some cases need arthroscopic intervention. The arthroscopic management of type 2 lesions in older patients can be biceps tenodesis, but young and active patients like throwers will need an arthroscopic repair. The results of arthroscopic repair in older patients are not encouraging. The purpose of this study is to perform an overview of the diagnosis of the SLAP tears and to help decision making for the surgical management.

Scapular muscle-activation ratios in patients with shoulder injuries during functional shoulder exercises

CONTEXT

Alterations in scapular muscle activation, which are common with glenohumeral (GH) injuries, affect stability and function. Rehabilitation aims to reestablish activation between muscles for stability by progressing to whole-body movements.

OBJECTIVE

To determine scapular muscle-activation ratios and individual muscle activity (upper trapezius [UT], middle trapezius [MT], lower trapezius [LT], serratus anterior [SA]) differences between participants with GH injuries and healthy control participants during functional rehabilitation exercises.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty-nine participants who had GH injuries (n = 20; age = 23.6 ± 3.2 years, height = 170.7 ± 11.5 cm, mass = 74.7 ± 13.1 kg) or were healthy (n = 19; age = 24.4 ± 3.3 years, height = 173.6 ± 8.6 cm, mass = 74.7 ± 14.8 kg) were tested.

INTERVENTION(S)

Clinical examination confirmed each participant's classification as GH injury or healthy control. Participants performed 4 exercises (bow and arrow, external rotation with scapular squeeze, lawnmower, robbery) over 3 seconds with no load while muscle activity was recorded.

MAIN OUTCOME MEASURE(S)

We used surface electromyography to measure UT, MT, LT, and SA muscle activity. Scapular muscle-activation ratios (UT:MT, UT:LT, and UT:SA) were calculated (normalized mean electromyography of the UT divided by normalized mean electromyography of the MT, LT, and SA). Exercise × group analyses of variance with repeated measures were conducted.

RESULTS

No group differences for activation ratios or individual muscle activation amplitude were found (P > .05). Similar UT:MT and UT:LT activation ratios during bow-and-arrow and robbery exercises were seen (P > .05); both had greater activation than external-rotation-with-scapular-squeeze and lawnmower exercises (P < .05). The bow-and-arrow exercise elicited the highest activation from the UT, MT, and LT muscles; SA activation was greatest during the external-rotation-with-scapular-squeeze exercise.

CONCLUSIONS

Scapular muscle activation was similar between participants with GH injuries and healthy control participants when performing the unloaded multiplanar, multijoint exercises tested. High activation ratios during the bow-and-arrow exercise indicate UT hyperactivity or decreased MT, LT, and SA activity. Our GH injury group may be comparable to high-functioning injured athletes. Study results may assist clinicians in selecting appropriate exercises for scapular muscle activation when caring for injured athletes.

Superior labral anterior posterior lesions of the shoulder

Superior labrum anterior and posterior (SLAP) lesion is of fairly recent description and its understanding is rapidly evolving. Its incidence and need for surgical treatment has increased exponentially in line with the increase in shoulder arthroscopies. It is of particular importance in the elite over head athlete and the young. A range of arthroscopic techniques and devices have been described with good functional results. The ability to return to pre injury level of sports remains a concern.

Clinical assessment of the shoulder

The shoulder joint is complex in structure and functionality. It is often difficult to assess clinically due to the great variety of associated pathology. This article presents an overview of the anatomy of the shoulder region and associated pathologies, whilst providing a summary of the clinical examination of the shoulder and associated 'special tests'. A full history is vital when assessing shoulder pathology. No particular test is fully sensitive or specific alone and accuracy varies between both clinicians and patients alike. Assessment of the shoulder should be conducted systematically with a range of tests combined.

Arthroscopic reconstruction of shoulder's labrum with extensive tears

BACKGROUND

With the continuous development of arthroscopic techniques, the majority of superior labrum anterior-posterior (SLAP) lesions can be treated with minimally invasive endoscopic repair. The aim of this study was to determine the efficacy of arthroscopic capsulolabral reconstruction of SLAP lesions with extensive tears.

METHODS

Eighteen patients with SLAP lesions with extensive tears (median age, 27.50 years) were included in this study. Twelve patients had type-V SLAP lesions, 4 patients had type-VIII SLAP lesions, and 2 patients had deeply located SLAP lesions. The average duration of follow-up was 15.83 months (range, 11-22 months). Outcome measures included shoulder range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores, and visual analogue scale (VAS) pain score.

RESULTS

After arthroscopic surgery, shoulder forward flexion, shoulder external rotation, and external rotation in 90° of abduction were significantly greater than before surgery (169.5° vs. 165.5°, P = 0.001), (90° vs. 63.5°, P < 0.001), and (90° vs. 81.5°, P = 0.004), respectively. Median ASES and Constant-Murley scores after surgery were both 94 as compared to 77.0 and 77.5, respectively, before surgery (both, P < 0.001). The median VAS score decreased to 1.5 after surgery as compared to 6 before surgery (P < 0.001).

CONCLUSIONS

Arthroscopic repair of SLAP lesions with extensive tears can achieve good outcomes.

Special physical examination tests for superior labrum anterior-posterior shoulder tears: an examination of clinical usefulness

REFERENCE/CITATION

Calvert E, Chambers GK, Regan W, Hawkins RH, Leith JM. Special physical examination tests for superior labrum anterior-posterior shoulder injuries are clinically limited and invalid: a diagnostic systematic review. J Clin Epidemiol. 2009;62(5):558-563.

CLINICAL QUESTION

The systematic review focused on diagnostic accuracy studies to determine if evidence was sufficient to support the use of superior labrum anterior-posterior (SLAP) physical examination tests as valid and reliable. The primary question was whether there was sufficient evidence in the published literature to support the use of SLAP physical examination tests as valid and reliable diagnostic test procedures.

DATA SOURCES

Studies published in English were identified through database searches on MEDLINE, EMBASE, and the Cochrane database (1970-2004) using the search term SLAP lesions. The medical subject headings of arthroscopy, shoulder joint, and athletic injuries were combined with test or testing, physical examination, and sensitivity and specificity to locate additional sources. Other sources were identified by rereviewing the reference lists of included studies and review articles.

STUDY SELECTION

Studies were eligible based on the following criteria: (1) published in English, (2) focused on the physical examination of SLAP lesions, and (3) presented original data. A study was excluded if the article was limited to a clinical description of 1 or more special tests without any research focus to provide clinical accuracy data or if it did not focus on the topic.

DATA EXTRACTION

The abstracts that were located through the search strategies were reviewed, and potentially relevant abstracts were selected. Strict epidemiologic methods were used to obtain and collate all relevant studies; the authors developed a study questionnaire to record study name, year of publication, study design, sample size, and statistics. Validity of the diagnostic test study was determined by applying the 5 criteria proposed by Calvert et al. If the study met the inclusion and validity criteria, 95% confidence intervals were calculated for each sensitivity, specificity, and positive and negative likelihood ratio reported. No specific information was provided about the procedure if the reviewers disagreed on how the evaluation criteria were applied.

MAIN RESULTS

The specific search criteria led to the identification of 29 full-text articles. The studies were reviewed, and inclusion and exclusion criteria were applied. This resulted in 14 excluded studies and 15 eligible studies for analysis. Of the 15 eligible studies, 1 evaluated only a single physical examination test for a SLAP lesion or biceps tendon injury, and 10 studies evaluated 2 to 6 physical examination tests for a SLAP lesion or biceps tendon injury. Nine studies reported sensitivities and specificities greater than 75%, 4 had sensitivities less than 75%, 3 had specificities less than 75%, 1 did not report sensitivity, and 2 did not report specificities. When validity was assessed for those 15 papers, only 1 study that evaluated the biceps tendon met the 5 critical appraisal criteria of Calvert et al and calculated 95% confidence intervals. When the Speed and Yergason tests were each compared with the gold standard (arthroscopy), the confidence intervals for the positive and negative likelihood ratios spanned 1. This indicated that the test result is unlikely to change the odds of having or not having the condition, respectively.

CONCLUSIONS

The literature currently used as a reference for teaching in medical schools and continuing education lacks the necessary validity to help rule in or out a SLAP lesion or biceps tendon involvement. Based on the results from the systematic review conducted by Calvert et al, no tests clinically diagnose a SLAP lesion. This is a cause for concern as magnetic resonance imaging or magnetic resonance arthrography, which are frequently used to assess a possible SLAP lesion, may also have diagnostic flaws and may be cost prohibitive. Performing arthroscopy on every patient to rule the condition in or out is unethical, especially if a SLAP lesion is not present. More rigorous validity studies should be conducted for SLAP lesion physical examination tests using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool or Standards for Reporting Diagnostic Accuracy (STARD) criteria.

Disorders of the proximal and distal aspects of the biceps muscle

PROXIMAL ASPECT OF BICEPS: Tenodesis of the long head of the biceps may offer improved cosmesis, improved strength, and diminished activity-related pain compared with tenotomy, although comparative studies have shown similar outcomes in some patient populations. DISTAL ASPECT OF BICEPS: Operative treatment of both partial and complete distal biceps ruptures results in better outcomes compared with nonoperative care, although the optimal technique and fixation are yet to be determined. Nonoperative management is an acceptable treatment for patients willing to accept some loss of forearm supination and elbow flexion strength as well as changes in endurance and cosmesis.