The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears

Diagnostic accuracy of clinical tests for superior labral anterior posterior lesions: a systematic review

STUDY DESIGN

Systematic literature review.

OBJECTIVES

To conduct a systematic review of case series and clinical trials that investigate the diagnostic accuracy of clinical tests for superior labral anterior posterior (SLAP) lesions.

BACKGROUND

Primary contact practitioners are often presented with shoulder problems and use a battery of clinical tests to reach a diagnosis. Early detection of SLAP pathology may lead to more optimal interventions and better outcomes for patients.

METHODS AND MEASURES

The OVID search interface was utilized with MEDLINE, AHMED, CINAHL, and SPORTDiscus databases searched from 1996-2006. Studies were retrieved that included patients with shoulder pain who underwent at least 1 clinical shoulder test for SLAP lesions. For an article to be included in this review, the results of the clinical tests needed to be compared with findings on arthroscopy. Quality of the manuscripts included in this review were rated using the QUADAS appraisal tool, so comparisons could be made across studies.

RESULTS

Seventeen published manuscripts fit the inclusion/exclusion criteria and were used for this review. Eight studies were found to be of high quality. Within these 8 studies, 1 group of authors reported high diagnostic accuracy values for the crank test: sensitivity, 91% (95% confidence interval [CI], 76%-97%); specificity, 93% (95% CI, 79%-88%); positive likelihood ratio, 13.6 (95% CI, 3.6-52.1); and negative likelihood ratio, 0.1 (95% CI, 0.0-0.3). One study on the resisted supination external rotation test also scored high on the QUADAS and reported diagnostic accuracy values of 83% (95% CI, 66-92), 82% (95% CI, 52-95), 4.6 (95% CI, 1.3-16.1), and 0.20 (95% CI, 0.1-0.5), respectively. Of significance is the fact that the majority of papers reporting highly accurate clinical diagnostic tests were of low quality with the results not supported by other authors.

CONCLUSION

It appears that no single test is sensitive or specific enough to determine the presence of a SLAP lesion accurately. Further research is required to determine whether subgrouping of patients by mechanism of injury or the type of SLAP lesion may improve diagnostic accuracy. Determining the diagnostic accuracy of a combination of 2 or more tests is also needed.

A new SLAP test: the supine flexion resistance test

PURPOSE

This study describes a new test to detect SLAP lesions. The sensitivity, specificity, and positive and negative predictive values with respect to the diagnosis of a SLAP lesion were determined in comparison to Speed's test and the O'Brien test.

METHODS

One hundred fifty patients presenting for arthroscopic surgery with persisting pain or functional disability of the shoulder underwent a complete shoulder examination. All patients underwent Speed's test, the O'Brien test, and the new supine flexion resistance test. The clinical results of the tests were correlated with the presence of a SLAP lesion by direct arthroscopic visualization.

RESULTS

The supine flexion resistance test had a sensitivity of 80% and a specificity of 69%, whereas Speed's test and the O'Brien test had sensitivities of 60% and 94%, respectively, and specificities of 38% and 28%, respectively. Regarding isolated SLAP lesions, the supine flexion resistance test was highly sensitive, with a sensitivity of 92% (58% for Speed's test and 75% for the O'Brien test). For isolated tears of the supraspinatus, the specificity of the supine flexion resistance test was 75% (14% for Speed's test and 17% for the O'Brien test).

CONCLUSIONS

Compared with the O'Brien test and Speed's test, the supine flexion resistance test proves to be more specific, with a specificity of 69% for the whole study population (28% for the O'Brien test and 38% for Speed's test) and with a specificity of 75% for the group of patients with isolated supraspinatus lesions (17% for the O'Brien test and 14% for Speed's test). The new test is a useful and effective test for detecting type II SLAP lesions. The high specificity enables the elimination of false-positive results of other clinical tests that are more sensitive but not specific.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria with consecutive patients and universally applied gold standard.

Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis

PURPOSE

The overall purpose of our study was to examine the sensitivity of physical examination, magnetic resonance imaging (MRI), and magnetic resonance (MR) arthrogram for the identification of arthroscopically confirmed SLAP lesions of the shoulder.

METHODS

An analysis of 51 consecutive patients with arthroscopically confirmed SLAP lesions and no history of shoulder dislocation was performed. Before undergoing surgery, all patients underwent a standardized physical examination and had either an MRI and/or MR arthrogram performed. Sensitivity analysis was then performed on the results of both the physical examination maneuvers and the radiologic imaging compared to the arthroscopic findings at surgery.

RESULTS

The sensitivity of O'Brien's (active compression) test was 90%, whereas the Mayo (dynamic) shear was 80% and Jobe's relocation test was 76%. The sensitivity of a physical examination with any 1 of these 3 SLAP provocative tests being positive was 100%. Neer's sign (41%) and Hawkin's impingement tests (31%) each had low sensitivity for SLAP lesions. The sensitivity of MRI for SLAP lesions was 67% when interpreted by the performing surgeon, 53% when read by a radiologist. When the MR arthrograms were analyzed alone, the sensitivity was 72% (surgeon) and 50% (radiologist), respectively.

CONCLUSIONS

All 3 physical examination maneuvers traditionally considered provocative for SLAP pathology (O'Brien's, Mayo shear, and Jobe's relocation) were sensitive for the diagnosis of SLAP lesions. MRI and MR arthrogram imaging had lower sensitivity than these physical examination tests in diagnosing SLAP lesions. Patient history, demographics, and the surgeon's physical examination should remain central to the diagnosis of SLAP lesions.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears

BACKGROUND

Glenoid labral tears provide a diagnostic challenge.

HYPOTHESIS

Combinations of items in the patient history and physical examination will provide stronger diagnostic accuracy to suggest the presence or absence of glenoid labral tear than will individual items.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

History and examination findings in patients with shoulder pain (N = 55) were compared with arthroscopic findings to determine diagnostic accuracy and intertester reliability.

RESULTS

The intertester reliability of the crank, anterior slide, and active compression tests was 0.20 to 0.24. A combined history of popping or catching and positive crank or anterior slide results yielded specificities of 0.91 and 1.00 and positive likelihood ratios of 3.0 and infinity, respectively. A positive anterior slide result combined with either a positive active compression or crank result yielded specificities of 0.91 and positive likelihood ratio of 2.75 and 3.75, respectively. Requiring only a single positive finding in the combination of popping or catching and the anterior slide or crank yielded sensitivities of 0.82 and 0.89 and negative likelihood ratios of 0.31 and 0.33, respectively.

CONCLUSION

The diagnostic accuracy of individual tests in previous studies is quite variable, which may be explained in part by the modest reliability of these tests. The combination of popping or catching with a positive crank or anterior slide result or a positive anterior slide result with a positive active compression or crank test result suggests the presence of a labral tear. The combined absence of popping or catching and a negative anterior slide or crank result suggests the absence of a labral tear.

An evaluation of the anatomic basis of the O'Brien active compression test for superior labral anterior and posterior (SLAP) lesions

It has been suggested that the positive position of the O'Brien test (shoulder flexion, horizontal adduction, and internal rotation) tensions the bicipital labral complex relative to the negative position (shoulder flexion, horizontal adduction, and external rotation). This study measured active and passive tension in the long head of biceps in the 2 positions of the O'Brien test to validate the proposed anatomic basis of the test. Active tension was measured using surface electromyography of the long head of biceps in 12 healthy young adults. Passive tension was measured using a load cell attached to the intracapsular tendon of the long head of biceps in 5 cadaver specimens. Active and passive tension were higher in the negative position, thus refuting the proposed anatomic basis of the test. Although there may be an alternative basis for the test, the failure to support the proposed anatomic basis may partly explain the variable likelihood ratios obtained in clinical accuracy studies of the O'Brien test. The results of this study reinforce the need for anatomic validation during the development of clinical testing procedures.

The passive compression test: a new clinical test for superior labral tears of the shoulder

BACKGROUND

Even though there are several physical tests available for superior labrum anterior posterior lesions, there have been very few reports on their accuracy, and none can be regarded as completely predictive for the presence of a superior labrum anterior posterior lesion in the shoulder joint.

HYPOTHESIS

This new clinical test is a useful and accurate technique for detecting superior labral tears in the shoulder joint.

STUDY DESIGN

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

METHODS

This test was conducted independently by 2 physicians before any other diagnostic evaluation. In all cases, the glenohumeral joint was investigated first, and the appropriate treatments were performed on the lesion. A protocol was established to evaluate the sensitivity, specificity, and positive and negative predictive values of this new clinical test. The reproducibility of this test was evaluated with a kappa coefficient.

RESULTS

Sixty-one patients (61 shoulders) were examined with the passive compression test, and all underwent arthroscopic surgery. In 31 patients with a positive passive compression test result, 27 had a superior labrum anterior posterior lesion, and in 30 patients with a negative passive compression test result, 6 had a superior labrum anterior posterior lesion. The sensitivity of the test was 81.8%, and the specificity was 85.7%. The positive predictive value was 87.1%, and the negative predictive value was 80.0%. The kappa coefficient was 0.771 between the 2 independent examiners (P< .01).

CONCLUSION

The passive compression test is a useful and accurate technique for predicting superior labral tears of the shoulder joint.

Clinical assessment of superior glenoid labral lesions: a systematic review

Superior labral anterior posterior (SLAP) lesions of the glenoid have proven difficult to diagnose clinically. SLAP-lesion-specific physical examination tests have been developed to improve clinical acumen. Initial reported performance of these tests has not been reproduced by independent investigation. We hypothesized SLAP-specific physical examination tests could not provide a definitive diagnosis of a SLAP lesion. We further intended to elucidate factors responsible for the variable performance of SLAP-specific tests. A review of the literature through Medline and Embase database searches was conducted. All studies with level of evidence of III or better involved in the reporting of diagnostic accuracy of SLAP-specific physical examination tests were included and reviewed. Each instance of independent evaluation of a SLAP-specific examination showed poorer examination performance than in the originating study. Considerable variability existed between independent evaluations of a given SLAP-specific examination as well. We concluded SLAP-specific physical examination results cannot be used as the sole basis of a diagnosis of a SLAP lesion. Differences in patient populations between studies and the accompanying differences in SLAP lesion prevalence and comorbid conditions played the greatest role in test result variance.

SLAP tears of the glenoid labrum in contact athletes

OBJECTIVE

To describe the distribution and clinical presentation of labral injuries in rugby players and the time taken for them to return to sports.

DESIGN

Retrospective cohort study.

SETTING

Busy shoulder practice in the North West of England, treating a large number of professional athletes.

PATIENTS

A review of 51 shoulder arthroscopies performed on professional rugby players over a 35 month period. All patients diagnosed with a SLAP lesion at arthroscopy were identified. Eighteen patients had a documented SLAP tear; this group represented our study population.

INTERVENTIONS

Arthroscopic debridement and/or stabilization was carried out for all labral injuries using Panaloc anchors and No. 2 PDS via a 2 portal technique.

MAIN OUTCOME MEASUREMENTS

Classification of injury, Satisfaction, Time to return to play.

RESULTS

The incidence of SLAP tears in our study population was 35%. There were 11 isolated SLAP tears (61%), 3 SLAP tears associated with a Bankart lesion (17%), 2 SLAP tears associated with a posterior labral lesion (11%), and 2 SLAP tears associated with an anterior and posterior labral injuries (11%). Of the 18 SLAP tears, 14 (78%) were type 2, 3 (17%) were type 3, and 1 (5%) was type 4. None of the patients with a SLAP tear presented with symptoms of instability. MR Arthrogram had a 76% sensitivity for detecting SLAP tears. By 6 months postsurgery, 89% of patients were satisfied. Patients with isolated SLAP tears were the quickest to return to sports, at an average of 2.6 months postsurgery.

CONCLUSIONS

SLAP tears are a common injury in rugby players. These can often be diagnosed with MR arthrography. Arthroscopic repair is associated with excellent results and early return to sports.

Electromyographic analysis of physical examination tests for type II superior labrum anterior-posterior lesions

Physical examination tests that place tension on the long head of the biceps may best reproduce symptoms in patients with type II superior labrum anterior-posterior (SLAP) lesions. The objective of this study is to compare the normalized electromyographic signal of the long head of the biceps for SLAP lesion physical examination tests. The active compression test, anterior-superior SLAP test, biceps load test II, biceps tension test, and pain provocation test were performed on 13 subjects while biceps electromyographic data were recorded. The active compression test and biceps tension test had significantly higher electromyographic signals than the other tests. We found no significant differences when comparing forearm supination and pronation within individual tests. Because the active compression and biceps tension tests maximize muscle activation on the long head of the biceps, they may be the best physical examination tests by which to identify type II SLAP lesions.

Glenoid Labrum Lesion in an Elite Tennis Player: A Clinical Challenge in Diagnosis

Shoulder pain among overhead-sport athletes is common and often presents a challenge to clinicians in making an accurate diagnosis. A case report of a young college tennis player is presented, with emphasis on the clinical examination process leading to the diagnosis of a superior labrum anteroposterior lesion. The current literature regarding the clinical diagnosis of glenoid labrum lesion in the shoulder with respect to specific clinical tests was reviewed. It is recommended that clinicians consider glenoid labral lesions in the context of shoulder instability. Glenohumeral internal-rotation deficit should be routinely evaluated and corrected in high-performance tennis players.

3T MR Imaging of the Musculoskeletal System (Part II): Clinical Applications

The gain in SNR that is afforded by 3T MR imaging systems has tremendous clinical applications in the musculoskeletal system. The potential for demonstrating and enhancing the visibility of normal osseous, tendinous, cartilaginous, and ligamentous structures is exciting. Furthermore, harnessing this added signal to increase spatial resolution may improve our diagnostic abilities in various joints dramatically. Radiologists have enjoyed great success in assessing joint disease with current MR imaging field strengths; however, many intrinsic joint structures remain poorly evaluated, which leads to a golden opportunity for 3T MR imaging. The articular cartilage of the knee, the glenoid labrum of the shoulder, the intrinsic ligaments and TFC of the wrist, the collateral ligaments of the elbow, the labrum and articular cartilage of the hip, and the collateral ligaments of the ankle have been evaluated suboptimally on 1 .5T systems using routine nonarthrographic MR images. Because of the enhanced SNR, the higher spatial resolution, and the greater CNR of intrinsic joint structures at higher field strengths, 3T MR imaging has the potential to improve diagnostic abilities in the musculoskeletal system vastly, which translates into better patient care and management. The author's 2 years of clinical experience with musculoskeletal MR imaging on 3T systems has met and exceeded his expectations, and has bolstered the confidence of his orthopedic surgeons in his diagnoses. As coil technology advances and as the use of parallel imaging becomes more available in the extremities, the author expects to see even more dramatic improvements in image quality.

Forced shoulder abduction and elbow flexion test: a new simple clinical test to detect superior labral injury in the throwing shoulder

PURPOSE

Although several clinical tests for detecting superior labral injury of the shoulder have been reported, some of the maneuvers involved are complicated and diagnosis is still inaccurate. The purpose of this report is to introduce our forced shoulder abduction and elbow flexion test (forced abduction test) along with an assessment of its efficacy in the throwing shoulder in comparison with other clinical tests.

TYPE OF STUDY

Prospective nonrandomized clinical trial.

METHODS

Fifty-four throwing athletes who underwent arthroscopic surgery were prospectively studied. Superior labral injury was present in 24 cases (Snyder's classification was type 2 in 22, and type 3 in 2). Several clinical tests were performed preoperatively and the results were recorded on our original chart. The condition of the superior labrum was then examined during arthroscopic surgery. The results of these tests were compared with the arthroscopic findings as a standard. The forced abduction test was defined as positive when pain at the posterosuperior aspect of the shoulder on forced maximal abduction was relieved or diminished by elbow flexion.

RESULTS

The sensitivity, specificity, and accuracy of the forced abduction test were 67%, 67%, and 67%, respectively. It was one of the most useful tests, along with the crank test and O'Brien's test (crank test, 58%, 72%, 66%; O'Brien's test, 54%, 60%, 57%; respectively). Furthermore, the results of the forced abduction test showed a significant correlation with the presence of superior labral injury (P = .0275, chi-square test).

CONCLUSIONS

The forced abduction test was technically simple and its usefulness was comparable to the O'Brien's and crank tests for diagnosing superior labral injury in throwing shoulders.

LEVEL OF EVIDENCE

Level II.

The resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions

PURPOSE

To evaluate a new clinical test, the resisted supination external rotation test, for the diagnosis of superior labral anterior posterior lesions of the shoulder.

STUDY DESIGN

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

METHODS

Forty athletes (average age, 23.9 years) with activity-related shoulder pain were enrolled in the study. The patients underwent 3 different tests designed specifically to detect superior labral anterior posterior lesions (the resisted supination external rotation test, the crank test, and the active compression test); the tests were performed in a random order on the affected shoulder. The results of the tests were compared with arthroscopic findings.

RESULTS

Out of 40 athletes, 29 (72.5%) had superior labral anterior posterior tears. The resisted supination external rotation test had the highest sensitivity (82.8%), specificity (81.8%), positive predictive value (92.3%), negative predictive value (64.3%), and diagnostic accuracy (82.5%) of all tests performed.

CONCLUSION

By re-creating the peel-back mechanism, the resisted supination external rotation test is more accurate than 2 other commonly used physical examination tests designed to diagnose superior labral anterior posterior tears in overhead-throwing athletes. By using this test in the context of a thorough clinical history and physical examination, lesions of the superior labrum can be more reliably diagnosed.

Superior labrum, anterior-posterior lesions and biceps injuries: diagnostic and treatment considerations

Proximal biceps tendon rupture, biceps tendinitis, and medical biceps subluxation are injuries that occur alone and in association with other pathologic conditions of the shoulder. The literature describes various strategies for imaging and treating these biceps tendon complex injuries but offers no clear consensus on a gold-standard approach. The keys to successful treatment are an accurate diagnosis, identification of associated pathologic conditions, and assessment of functional limitations of the injury.

Description of pain provocation tests used for the diagnosis of sports-related chronic groin pain: relationship of tests to defined clinical (pain and tenderness) and MRI (pubic bone marrow oedema) criteria

The clinical assessment of groin pain in athletes is difficult, with the lack of specific clinical tests being in part responsible. Three pain provocation tests used in the diagnosis of chronic groin pain are described and their relationship to defined clinical and MRI criteria has been assessed. Eighty-nine Australian Rules football players with and without groin symptoms underwent clinical examination followed by history. Three pain provocation tests were performed (named as the Single Adductor, Squeeze and Bilateral Adductor tests). All athletes subsequently underwent MRI of their groin region for the presence of significant pubic bone marrow oedema (BMO). Of the 89, 47 were defined as having chronic groin pain, and 46 had significant BMO with 37 having both chronic groin pain and BMO. The three pain provocation tests demonstrated only moderate sensitivity (range 30-65%). Positive predictive values were moderate to high (67-93%) depending upon the individual test. The Bilateral Adductor test was the most sensitive test with the highest positive predictive values. The high specificity (88-93%) demonstrated should be treated with caution due to the study methodology. Three pain provocation tests of potential value in assessing chronic groin pain in athletes are described. If positive, all three pain provocation tests demonstrated a high likelihood for the athlete having MR-detected parasymphyseal pubic BMO. Further research is required on assessing the clinical usefulness of these tests.

Current concepts in the recognition and treatment of superior labral (SLAP) lesions

Pathology of the superior aspect of the glenoid labrum (SLAP lesion) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important to determine the most appropriate nonoperative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum, while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions, including 3 newly described tests. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

Return to play for rotator cuff injuries and superior labrum anterior posterior (SLAP) lesions

The shoulder is a frequently injured joint in athletes, and the most common injuries in active patients include instability, rotator cuff injuries, and superior labrum lesions. These three types of injuries often involve different mechanisms of injury, variable methods of surgical repair, and different considerations in rehabilitation and return to play. This article focuses upon rotator cuff injuries and superior labrum lesions, treated nonoperatively and operatively. Return to play with these injuries depends upon many factors including upon the age of the patient, the severity of the pathology,the type of treatment rendered, and the expectations of the patient.

Clinical assessment of three common tests for superior labral anterior-posterior lesions

BACKGROUND

Three tests (active compression, anterior slide, and compression rotation) are commonly used to diagnose superior labral anterior-posterior lesions.

HYPOTHESIS

We hypothesized that the accuracy, sensitivity, and specificity for these tests was less than that previously reported and that a click in the shoulder during manipulation was not specific for the study lesion.

STUDY DESIGN

Case-control study.

METHODS

The three tests were performed on 426 patients who subsequently underwent shoulder arthroscopy. The results of physical examination were compared with the arthroscopic findings and analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy.

RESULTS

At arthroscopy, 39 patients had type II to IV lesions (study group); the remaining 387 patients had type I lesion or no lesion (control group). The incidences of positive results were not statistically different between the groups (P > 0.05). Our findings were as follows: most sensitive test, active compression (47%); most specific test, anterior slide (84%); highest positive predictive value, active compression (10%); highest overall accuracy, anterior slide test (77%); lowest overall accuracy, active compression test (54%). The presence of a click and the location of the pain were not reliable diagnostic indicators.

CONCLUSIONS

The results of such tests should be interpreted with caution when considering surgery for a possible superior labral anterior-posterior lesion.