1
|
Hahn AK, Holmberg K, Hammarstedt JE, Philp F, DeMeo P, Lai VJ, Kindya MC, Paci JM, Farrow LD, Vardiabasis N, Nye D, Frey S, Moutzouros V, Purnell GJ, Wang P, Vaccariello M, Schweizer SK, Phillips DJ, Frank DA, Akhavan S. Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study. Orthop J Sports Med 2023; 11:23259671231204851. [PMID: 37954863 PMCID: PMC10638887 DOI: 10.1177/23259671231204851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 11/14/2023] Open
Abstract
Background Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors-such as age and sports played-affect the treatment algorithms, even across similarly classified SLAP tears. Purpose To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement. Results There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case. Conclusion This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.
Collapse
Affiliation(s)
- Alexander K. Hahn
- Investigation performed at the Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Kyle Holmberg
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Jon E. Hammarstedt
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Frances Philp
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Patrick DeMeo
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Vince J. Lai
- Department of Orthopedic Surgery, Mercy, Saint Louis, Missouri, USA
| | | | | | - Lutul D. Farrow
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Darin Nye
- Mercy Health-Tiffin Hospital, Tiffin, Ohio, USA
| | - Steven Frey
- Reconstructive Orthopedics, Cherry Hill, New Jersey, USA
| | | | - Gregory J. Purnell
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Patrick Wang
- MidJersey Orthopaedics, Flemington, New Jersey, USA
| | | | - Scott K. Schweizer
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Dennis J. Phillips
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Darren A. Frank
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Sam Akhavan
- Department of Orthopaedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
2
|
The Applicability of Provocative Functional Tests in the Diagnosis of Rotator Cuff Muscle Injuries of the Best University Athletes. BIOMED RESEARCH INTERNATIONAL 2022; 2022:7728277. [PMID: 36277881 PMCID: PMC9584688 DOI: 10.1155/2022/7728277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 09/28/2022] [Indexed: 11/18/2022]
Abstract
Rotator cuff disease, external and internal impingement syndromes, low shoulder stability, various types of trauma, and overuse injuries are all related to sports activities. In order to check symptoms in patients with disability and shoulder pain, clinicians use different methods and diagnostic imaging assessment. The research is aimed at evaluating whether there is a difference between provocation function tests (PFT) and ultrasonographic (US) testing of muscles within the rotator cuff in elite collegiate athletes. Patients (
) were recruited from university team sports selections and tested with a standardized US examination of the shoulder and five PFTs (Speed’s test, Neer’s test, Hawkins test, lift-off test, Yergason’s test). Based on the VAS pain assessment scale, 60 subjects had some pain, which was taken for further processing in the work (124 subjects did not have the presence of pain and were excluded from further processing). The US examination was conducted using Voluson 730 apparatus, by a linear probe, with the frequency in the range of 6-12 MHz. The chi-square test showed significant differences between PFT and the occurrence of shoulder muscle tendinitis for the following variables: Speed’s test and subscapularis tendinitis (
) and Speed’s test and infraspinatus tendinitis (
); Neer test and biceps brachii caput longum tendinitis (
), Neer test and supraspinatus tendinitis (
) and Neer test and infraspinatus tendinitis (
); lift-off test and subscapularis tendinitis (
); and Yergason’s test and biceps brachii caput longum tendinitis (
) and Yergason’s test and subscapitis tendinitis (
). The greatest effect of differences was observed in Neer’s test and biceps brachii caput longum tendinitis (
), while the other effects can be described as medium and small in most cases. It can be concluded that functional tests are good predictors of soft tissue changes in the muscles of the rotator cuff of the shoulder. Further monitoring and analysis are needed on a larger number of athletes.
Collapse
|
3
|
Christensen GV, Smith KM, Kawakami J, Chalmers PN. Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis. Open Access J Sports Med 2021; 12:61-71. [PMID: 33981168 PMCID: PMC8107051 DOI: 10.2147/oajsm.s266226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/21/2021] [Indexed: 01/02/2023] Open
Abstract
Superior labrum anterior-posterior (SLAP) lesions are common in overhead athletes. Though some patients have asymptomatic lesions, many tears cause pain and diminished athletic performance. Accurate diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging is questionable. Management is also difficult, as treatment can be life-altering or career-ending for many athletes. If first-line nonoperative treatment fails, surgical options may be considered. The optimal surgical management of SLAP lesions in athletes is debated. Historically, return to play (RTP) rates among athletes who have undergone arthroscopic SLAP repair have been unsatisfactory, prompting clinicians to seek alternate surgical options. Biceps tenodesis (BT) has been postulated to eliminate biceps tendon-related pain in the shoulder and is increasingly used as a primary procedure for SLAP lesions. The purpose of this text is to review the current literature on the surgical management of SLAP lesions in athletes with an emphasis on the role of BT.
Collapse
Affiliation(s)
- Garrett V Christensen
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Karch M Smith
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Jun Kawakami
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
| |
Collapse
|
4
|
Rotem G, Haziza S, Tenenbaum S, Thein R. MRA for SLAP - Is the threshold for referral too low? J Orthop 2020; 19:199-202. [PMID: 32055147 DOI: 10.1016/j.jor.2019.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/30/2019] [Indexed: 11/16/2022] Open
Affiliation(s)
- Gilad Rotem
- Department of Orthopedic Surgery, Chaim Sheba Medical Center at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Sagie Haziza
- Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Shay Tenenbaum
- Department of Orthopedic Surgery, Chaim Sheba Medical Center at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Ran Thein
- Department of Orthopedic Surgery, Chaim Sheba Medical Center at Tel Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Israel
| |
Collapse
|
5
|
Davis C, Immormino J, Higgins BM, Clark K, Engebose S, Garcia AN, Cook CE. Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review. Shoulder Elbow 2019; 11:321-331. [PMID: 31534482 PMCID: PMC6739753 DOI: 10.1177/1758573218811656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/02/2018] [Accepted: 10/10/2018] [Indexed: 01/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Cody Davis
- Division of Physical Therapy, Duke
University, Durham, USA
| | | | | | - Kyle Clark
- Division of Physical Therapy, Duke
University, Durham, USA
| | | | - Alessandra N Garcia
- Division of Physical Therapy, Duke
University, Durham, USA,Department of Orthopaedic Surgery,
Division of Physical Therapy, Duke University, Durham, USA,Alessandra N Garcia, PT 2200 W. Main St.,
Suite A210, Durham, NC 27705, USA.
| | - Chad E Cook
- Division of Physical Therapy, Duke
University, Durham, USA,Duke Clinical Research Institute, Duke
University, Durham, USA
| |
Collapse
|
6
|
Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg 2019; 28:1699-1706. [PMID: 31279721 DOI: 10.1016/j.jse.2019.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, subsequent findings may not be the source of symptoms. The aim of this study was to determine comparative MRI findings across both shoulders of individuals with unilateral shoulder symptoms. MATERIALS AND METHODS We prospectively evaluated 123 individuals from the community who had self-reported unilateral shoulder pain with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. Images in the coronal, sagittal, and axial planes with T1, T2, and proton density sequences were generated and independently and randomly interpreted by 2 examiners: a board-certified, fellowship-trained orthopedic shoulder surgeon and a musculoskeletal radiologist. Absolute and relative frequencies for each MRI finding were calculated and compared between symptomatic and asymptomatic shoulders. Agreement between the shoulder surgeon and the radiologist was also determined. RESULTS Abnormal MRI findings were highly prevalent in both shoulders. Only the frequencies of full-thickness tears in the supraspinatus tendon and glenohumeral osteoarthritis were higher (approximately 10%) in the symptomatic shoulder according to the surgeon's findings. Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate (0.00-0.51). CONCLUSION Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders. Clinicians should be aware of the common anatomic findings on MRI when considering diagnostic and treatment planning.
Collapse
Affiliation(s)
- Rodrigo Py Gonçalves Barreto
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Jonathan P Braman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Paula M Ludewig
- Division of Physical Therapy, Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA; Division of Rehabilitation Science, Department of Rehabilitation Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Larissa Pechincha Ribeiro
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Paula Rezende Camargo
- Laboratory of Analysis and Intervention of the Shoulder Complex, Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, Brazil.
| |
Collapse
|
7
|
Superior labral anterior to posterior (SLAP) injury in the workplace. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019. [DOI: 10.1016/j.recote.2019.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
8
|
Navío-Fernández F, Miranda I, Sánchez-Alepuz E, Shahin M, Pastor-Fernández E, Carratalá V, Lucas FJ. Superior labral anterior to posterior (SLAP) injury in the workplace. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 63:261-267. [PMID: 31109817 DOI: 10.1016/j.recot.2019.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/07/2019] [Accepted: 03/10/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Superior labral anterior to posterior (SLAP) injuries are widely recognised as a cause of pain and dysfunction in the shoulders of active patients. The aims of the present study were to analyze SLAP injuries in the workplace, and to evaluate the reliability of physical examination and imaging techniques for the diagnosis of work-related SLAP injuries. MATERIAL AND METHODS Retrospective chart review of 58 SLAP injuries treated in our occupational health centre from 2005 to 2015 in 815 patients undergoing shoulder arthroscopy. Data were collected on mechanism of injury, clinical proceedings, complementary tests (contrasting the initial magnetic resonance imaging report with that of a radiologist specializing in musculoskeletal pathology), arthroscopy findings and treatments performed. RESULTS The most common mechanism of injury was acute injury while handling weight, in the majority of cases, above the head. SLAP injury was suspected in 41% of cases through anamnesis and physical exam, in 29% through the initial magnetic resonance imaging report, and in 52% through the specialised radiologist's report. In 78%, associated injuries were present, the most common being rotator cuff injuries. CONCLUSIONS SLAP injuries in the workplace are rare and are often a diagnostic finding during surgical intervention performed for a different associated injury. Arthro-magnetic resonance imaging and magnetic resonance imaging have lower reliability than physical exams in the diagnosis of work-related SLAP injuries. A radiologist specializing in musculoskeletal pathology could probably improve the reliability of imaging test interpretation in work-related SLAP injuries.
Collapse
Affiliation(s)
- F Navío-Fernández
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España; Rotatorio de Formación en Unión de Mutuas, Valencia, España
| | - I Miranda
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España; Servicio de Cirugía Ortopédica y Traumatología de Unión de Mutuas, Valencia, España.
| | - E Sánchez-Alepuz
- Servicio de Cirugía Ortopédica y Traumatología de Unión de Mutuas, Valencia, España; Servicio de Cirugía Ortopédica y Traumatología, Hospital IMED Valencia, Burjassot, Valencia, España
| | - M Shahin
- ERESA (Unión de Mutuas), Valencia, España
| | - E Pastor-Fernández
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario y Politécnico La Fe, Valencia, España; Rotatorio de Formación en Unión de Mutuas, Valencia, España
| | - V Carratalá
- Servicio de Cirugía Ortopédica y Traumatología de Unión de Mutuas, Valencia, España
| | - F J Lucas
- Servicio de Cirugía Ortopédica y Traumatología de Unión de Mutuas, Valencia, España
| |
Collapse
|
9
|
Urch E, Taylor SA, Zitkovsky H, O'Brien SJ, Dines JS, Dines DM. A Modification of the Active Compression Test for the Shoulder Biceps-Labrum Complex. Arthrosc Tech 2017; 6:e859-e862. [PMID: 28706843 PMCID: PMC5495973 DOI: 10.1016/j.eats.2017.02.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/24/2017] [Indexed: 02/03/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Ekaterina Urch
- Kerlan-Jobe Orthopaedic Clinic, Los Angeles, California, U.S.A
- Address correspondence to Ekaterina Urch, M.D., Kerlan-Jobe Orthopaedic Clinic, 6801 Park Terrace Drive, Los Angeles, CA 90045, U.S.A.Kerlan-Jobe Orthopaedic Clinic6801 Park Terrace DriveLos AngelesCA90045U.S.A.
| | | | | | | | | | | |
Collapse
|
10
|
Physical exam of the adolescent shoulder: tips for evaluating and diagnosing common shoulder disorders in the adolescent athlete. Curr Opin Pediatr 2017; 29:70-79. [PMID: 27841778 DOI: 10.1097/mop.0000000000000443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW In the young athlete, the shoulder is one of the most frequently injured joints during sports activities. The injuries are either from an acute traumatic event or overuse. Shoulder examination can present some challenges; given the multiple joints involved, the difficulty palpating the underlying structures, and the potential to have both intra- and/or extra-articular problems. RECENT FINDINGS Many of the shoulder examination tests can be positive in multiple problems. They usually have high sensitivity but low specificity and therefore low predictive value. The medical history coupled with a detailed physical exam can usually provide the information necessary to obtain an accurate diagnosis. A proficient shoulder examination and the development of an adequate differential diagnosis are important before considering advanced imaging. SUMMARY The shoulder complex relies upon the integrity of multiple structures for normal function. A detailed history is of paramount importance when evaluating young athletes with shoulder problems. A systematic physical examination is extremely important to guiding an accurate diagnosis. The patient's age and activity level are very important when considering the differential diagnosis. Findings obtain through history and physical examination should dictate the decision to obtain advanced imaging of the shoulder.
Collapse
|
11
|
A systematic review and meta-analysis of diagnostic test of MRA versus MRI for detection superior labrum anterior to posterior lesions type II-VII. Skeletal Radiol 2017; 46:149-160. [PMID: 27826700 DOI: 10.1007/s00256-016-2525-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 10/26/2016] [Accepted: 10/27/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the diagnostic performance of magnetic resonance arthrography (MRA) and magnetic resonance imaging (MRI) in superior labrum anterior to posterior lesions (type II-VII) of the shoulder. MATERIAL AND METHODS PubMed and Scopus search engines, an electronic search of articles was performed from inception to February 19, 2016. Diagnostic performance of index tests was compared by the summary area under receiver operator characteristic curve (AUROC). RESULTS AND CONCLUSIONS In all, 117 of 493 studies were eligible and 32 studies (2,013 shoulders) and 11 studies (1,498 shoulders) were evaluated with MRA and MRI. The summary sensitivity, specificity, likelihood ratio (positive and negative) and AUROC were 0.87 (95 % confidence interval, CI: 0.82, 0.91), 0.92 (95 %CI: 0.85, 0.95), 10.28 (95 %CI: 5.84, 18.08), 0.14 (95 %CI: 0.10, 0.20) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRA, and 0.76 (95 %CI: 0.61, 0.86), 0.87 (95 %CI: 0.71, 0.95), 5.89 (95 %CI: 2.5, 13.86), 0.28 (95 %CI: 0.17, 0.47) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRI. The diagnostic performance of MRA was superior to MRI by both direct and indirect comparisons for the detection of SLAP lesions.
Collapse
|
12
|
Chalmers PN, Cvetanovich GL, Kupfer N, Wimmer MA, Verma NN, Cole BJ, Romeo AA, Nicholson GP. The champagne toast position isolates the supraspinatus better than the Jobe test: an electromyographic study of shoulder physical examination tests. J Shoulder Elbow Surg 2016; 25:322-9. [PMID: 26443105 DOI: 10.1016/j.jse.2015.07.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 07/25/2015] [Accepted: 07/30/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND While Jobe's test is widely used, it does not isolate supraspinatus activity. Our purpose was to examine the electromyographic (EMG) activity within the supraspinatus and deltoid with resisted abduction to determine the shoulder position that best isolates the activity of the supraspinatus. METHODS We performed EMG analysis of the supraspinatus, anterior head of the deltoid, and middle head of the deltoid in 10 normal volunteers. We measured EMG activity during resisted shoulder abduction in the scapular plane to both manual resistance and a standardized load in varying degrees of abduction and rotation. To determine which position best isolates supraspinatus activity, the ratio of supraspinatus to deltoid activity (S:D) was calculated for each position. Results were analyzed with a repeated-measures analysis of variance with Bonferroni correction. The posterior deltoid was excluded as it serves mostly to extend and externally rotate. RESULTS Our study confirmed Jobe's findings of maximal supraspinatus activity at 90° of abduction. However, decreasing abduction significantly increased S:D for both resisted manual testing and testing against a standardized load (P = .002 and .001, respectively). The greatest S:D ratio (4.6 ± 3.4 for standardized load testing) was seen at the "champagne toast" position, i.e., 30° of abduction, mild external rotation, 30° of flexion, and 90° of elbow flexion. The smallest ratio (0.8 ± 0.6) was seen at Jobe's position. CONCLUSIONS Testing of abduction strength in the champagne toast position, i.e., 30° of abduction, mild external rotation, and 30° of flexion, better isolates the activity of the supraspinatus from the deltoid than Jobe's "empty can" position.
Collapse
Affiliation(s)
- Peter N Chalmers
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
| | | | - Noam Kupfer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Markus A Wimmer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
13
|
Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. SLAP lesions: a treatment algorithm. Knee Surg Sports Traumatol Arthrosc 2016; 24:447-55. [PMID: 26818554 DOI: 10.1007/s00167-015-3966-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 12/23/2015] [Indexed: 01/02/2023]
Abstract
Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors' clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from "true" SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.
Collapse
Affiliation(s)
- Matthias Brockmeyer
- Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421, Homburg/Saar, Germany
| | - Marc Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.,TRIA Orthopaedic Center, Minneapolis, MN, USA
| | - Dieter M Kohn
- Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421, Homburg/Saar, Germany
| | - Olaf Lorbach
- Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421, Homburg/Saar, Germany.
| |
Collapse
|
14
|
|
15
|
Kibler WB, Sciascia A. Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey. Arthroscopy 2015; 31:2456-69. [PMID: 26321113 DOI: 10.1016/j.arthro.2015.06.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/09/2015] [Accepted: 06/18/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate current practice reported in the literature for making a SLAP lesion diagnosis and compare the findings with a survey sent to experienced shoulder surgeons assessing how they make a SLAP diagnosis. METHODS We performed a systematic review of articles reporting surgical repair of SLAP lesions, documenting the use of 4 diagnostic areas of evaluation: history, clinical examination, imaging, and diagnostic arthroscopy. A survey was distributed electronically to 175 surgeons with expertise in shoulder surgery. The survey listed common components within the 4 diagnostic areas and asked surgeons to indicate components they used in establishing the diagnosis. The 4 diagnostic areas were ranked from 1 to 4 (most to least important). RESULTS Of the articles, 23% reported using all 4 diagnostic areas, 58% used 3 areas, and 19% used 2 areas or fewer. Thirty-five percent did not report history components, 31% did not report clinical examination elements, 27% did not report imaging findings, and 4% did not report arthroscopic findings. Eight percent reported using a comprehensive history and examination but without describing specific symptoms or tests. The most common components reported in the literature were pain (42%), the active compression test (65%), magnetic resonance imaging/arthrography (65%), and tear/unstable biceps-labral complex (27%). A total of 70 surgeons (40%) responded to the survey. More specific history components, examination maneuvers, and imaging/arthroscopy variants were reported on the survey compared with the literature. Diagnostic arthroscopy and history ranked as the most important for a SLAP diagnosis. CONCLUSIONS The current literature and practice for making the SLAP diagnosis are variable and inconsistent. The SLAP diagnosis appears to be a clinical impression; however, the criteria described within the literature vary among the evaluation areas and differ from the results of the survey. These types of variability may have a significant influence on consistency and accuracy in making the diagnosis of the SLAP injury, developing the subsequent treatment, and maximizing outcomes. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies with cross-sectional survey.
Collapse
Affiliation(s)
- W Ben Kibler
- Shoulder Center of Kentucky, Lexington, Kentucky, U.S.A
| | - Aaron Sciascia
- Shoulder Center of Kentucky, Lexington, Kentucky, U.S.A..
| |
Collapse
|
16
|
van Grinsven S, van Loon C, van Gorp M, van Kints M, Konings P, van Kampen A. A feedback protocol improves the diagnostic performance of MR arthrography by experienced musculoskeletal radiologists in patients with traumatic anterior shoulder instability. Eur J Radiol 2015; 84:2242-9. [DOI: 10.1016/j.ejrad.2015.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 07/08/2015] [Accepted: 07/09/2015] [Indexed: 01/27/2023]
|
17
|
van Grinsven S, Nijenhuis TA, Konings PC, van Kampen A, van Loon CJM. Are radiologists superior to orthopaedic surgeons in diagnosing instability-related shoulder lesions on magnetic resonance arthrography? A multicenter reproducibility and accuracy study. J Shoulder Elbow Surg 2015; 24:1405-12. [PMID: 26175312 DOI: 10.1016/j.jse.2015.05.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/22/2015] [Accepted: 05/04/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND We compared the diagnostic reproducibility and accuracy of musculoskeletal radiologists with orthopaedic shoulder surgeons in 2 large medical centers in assessing magnetic resonance arthrograms (MRAs) of patients with traumatic anterior shoulder instability. METHODS Forty-five surgically confirmed MRAs were assessed by 4 radiologists, 4 orthopaedic surgeons, 2 radiologic teams, and 2 orthopaedic teams. During MRA assessment and surgery, the same 7-lesion scoring form was used. κ Coefficients, sensitivity, specificity, and differences in percentage of agreement or correct diagnosis (P < .05, McNemar test) were calculated per lesion and overall per the 7 lesion types. RESULTS The overall κ between the individual radiologists (κ = 0.51, κ = 0.46) and orthopaedic surgeons (κ = 0.46, κ = 0.41) was moderate. Although the overall percentage of agreement between the radiologists was slightly higher than that between the orthopaedic surgeons in both centers (80.0% vs 77.5% and 75.2% vs 73.7%), there was no significant difference. In each medical center, however, the most experienced orthopaedic surgeon was exceedingly more accurate than both radiologists per the 7 lesion types (81.9% vs 72.4%/74.6% and 76.5% vs 67.3%/73.7%). In 3 of 4 cases, this difference was significant. Overall accuracy improvement through consensus assessment was merely established for the weakest member of each team. CONCLUSION Experienced orthopaedic surgeons are more accurate than radiologists in assessing traumatic anterior shoulder instability-related lesions on MRA. In case of diagnosis disagreement, these orthopaedic surgeons should base their treatment decision on their own MRA interpretation.
Collapse
Affiliation(s)
- Susan van Grinsven
- Department of Orthopaedics, Rijnstate Hospital, Arnhem, The Netherlands.
| | - Thijs A Nijenhuis
- Department of Orthopaedics, Rijnstate Hospital, Arnhem, The Netherlands
| | - Peer C Konings
- Department of Orthopaedics, Rijnstate Hospital, Arnhem, The Netherlands
| | - Albert van Kampen
- Department of Orthopaedics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | |
Collapse
|
18
|
Werner BC, Burrus MT, Miller MD, Brockmeier SF. Tenodesis of the Long Head of the Biceps: A Review of Indications, Techniques, and Outcomes. JBJS Rev 2014; 2:01874474-201412000-00003. [DOI: 10.2106/jbjs.rvw.n.00020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
19
|
van Grinsven S, Hagenmaier F, van Loon CJM, van Gorp MJ, van Kints MJ, van Kampen A. Does the experience level of the radiologist, assessment in consensus, or the addition of the abduction and external rotation view improve the diagnostic reproducibility and accuracy of MRA of the shoulder? Clin Radiol 2014; 69:1157-64. [PMID: 25218253 DOI: 10.1016/j.crad.2014.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 07/05/2014] [Accepted: 07/09/2014] [Indexed: 12/21/2022]
Abstract
AIM To prospectively evaluate the influence of observer experience, consensus assessment, and abduction and external rotation (ABER) view on the diagnostic performance of magnetic resonance arthrography (MRA) in patients with traumatic anterior-shoulder instability (TASI). MATERIALS AND METHODS Fifty-eight MRA examinations (of which 51 had additional ABER views) were assessed by six radiologists (R1-R6) and three teams (T1-T3) with different experience levels, using a seven-lesion standardized scoring form. Forty-five out of 58 MRA examination findings were surgically confirmed. Kappa coefficients, sensitivity, specificity, and differences in percent agreement or correct diagnosis (p-value, McNemar's test) were calculated per lesion and overall per seven lesion types to assess diagnostic reproducibility and accuracy. RESULTS Overall kappa ranged from poor (k = 0.17) to moderate (k = 0.53), sensitivity from 30.6-63.5%, and specificity from 73.6-89.9%. Overall, the most experienced radiologists (R1-R2) and teams (T2-T3) agreed significantly more than the lesser experienced radiologists (R3-R4: p = 0.014, R5-R6; p = 0.018) and teams (T2-T3: p = 0.007). The most experienced radiologist (R1, R2, R3) and teams (T1, T2) were also consistently more accurate than the lesser experienced radiologists (R4, R5, R6) and team (T3). Significant differences were found between R1-R4 (p = 0.012), R3-R4 (p = 0.03), and T2-T3 (p = 0.014). The overall performance of consensus assessment was systematically higher than individual assessment. Significant differences were established between T1-T2 and radiologists R3-R4 (p<0.001, p = 0.001) and between T2 and R3 (p<0.001/p = 0.001) or R4 (p = 0.050). No overall significant differences were found between the radiologists' assessments with and without ABER. CONCLUSION The addition of ABER does not significantly improve overall diagnostic performance. The radiologist's experience level and consensus assessment do contribute to higher reproducibility and accuracy.
Collapse
Affiliation(s)
- S van Grinsven
- Department of Orthopaedics, Rijnstate Hospital, PO Box 9555, 6800 TA, Arnhem, The Netherlands.
| | - F Hagenmaier
- Department of Orthopaedics, Rijnstate Hospital, PO Box 9555, 6800 TA, Arnhem, The Netherlands
| | - C J M van Loon
- Department of Orthopaedics, Rijnstate Hospital, PO Box 9555, 6800 TA, Arnhem, The Netherlands
| | - M J van Gorp
- Department of Radiology, Rijnstate Hospital, PO Box 9555, 6800 TA, Arnhem, The Netherlands
| | - M J van Kints
- Department of Radiology, Rijnstate Hospital, PO Box 9555, 6800 TA, Arnhem, The Netherlands
| | - A van Kampen
- Department of Orthopaedics, Radboud University Medical Centre, PO Box 9101, 6501 HB, Nijmegen, The Netherlands
| |
Collapse
|
20
|
Abstract
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.
Collapse
|
21
|
Abstract
Throwers, or athletes who engage in repetitive overhead motions, are a unique subset of athletes that experience distinct shoulder injuries. Athletes engaged in baseball comprise the majority of patients seeking orthopedic care for throwing related injuries. Injuries specific to throwers most commonly involve the labrum and the undersurface of the rotator cuff. In addition, tissue changes in both the anterior and posterior glenohumeral capsule are common with repetitive overhead motions. These capsular changes alter. This article will examine the pathomechanics of injuries to throwers, elaborate means of diagnoses of cuff and labral injury and discuss recent advances in both non-operative and operative interventions, including preventative principles.
Collapse
Affiliation(s)
- Stuart D Kinsella
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Stephen J Thomas
- Division of Nursing and Health Sciences, Neumann University, 1 Neumann Drive, Aston, PA 19104, USA
| | - G Russell Huffman
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Street, Philadelphia, PA 19104, USA
| | - John D Kelly
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Street, Philadelphia, PA 19104, USA.
| |
Collapse
|
22
|
JOURNAL CLUB: Shoulder MRI Utilization: Relationship of Physician MRI Equipment Ownership to Negative Study Frequency. AJR Am J Roentgenol 2013; 201:605-10. [DOI: 10.2214/ajr.12.9977] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
23
|
Freeman R, Khanna S, Ricketts D. Inappropriate requests for magnetic resonance scans of the shoulder. INTERNATIONAL ORTHOPAEDICS 2013; 37:2181-4. [PMID: 23793463 DOI: 10.1007/s00264-013-1968-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 06/03/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) scans are a useful investigation for some shoulder pathology. They are costly however and a significant burden on radiology departments. In most cases clinical examination, plain radiography or ultrasound scan (USS) are sufficient for a diagnosis. There are no current UK guidelines regarding MRI shoulder scan requests. METHODS We reviewed 100 consecutive MRI shoulder scan requests and the associated formal reports; other investigations were also assessed. RESULTS Overall, 56% of MRI scans were ordered inappropriately. Shoulder consultant's requests were more appropriate than other groups (70% vs. 38%. p = 0.04). Excluding shoulder consultants 63 % of scans were inappropriately ordered. Shoulder consultants were more likely to order a preceding X-ray (80% vs. 53% respectively, p = 0.03). Of those with a clinical diagnosis of cuff pathology only 29% had an USS. CONCLUSION A high percentage of MRI shoulder scans are performed inappropriately. Shoulder consultants are more appropriate in their ordering than other groups. If all groups performed as well 50 % less MRI scans would need to be performed.
Collapse
Affiliation(s)
- Richard Freeman
- Royal Sussex County Hospital, Brighton & Sussex University Hospital Trust, Eastern Road, Brighton, BN2 5BE, UK,
| | | | | |
Collapse
|
24
|
Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev 2013; 2013:CD007427. [PMID: 23633343 PMCID: PMC6464770 DOI: 10.1002/14651858.cd007427.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting. OBJECTIVES To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders. SEARCH METHODS We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English. SELECTION CRITERIA We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials. DATA COLLECTION AND ANALYSIS Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed. MAIN RESULTS We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition. AUTHORS' CONCLUSIONS There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.
Collapse
Affiliation(s)
- Nigel C A Hanchard
- Health and Social Care Institute, Teesside University, Middlesbrough, UK.
| | | | | | | |
Collapse
|
25
|
Sciascia AD, Spigelman T, Kibler WB, Uhl TL. Frequency of use of clinical shoulder examination tests by experienced shoulder surgeons. J Athl Train 2013; 47:457-66. [PMID: 22889662 DOI: 10.4085/1062-6050-47.4.09] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
CONTEXT Health care professionals have reported and used a multitude of special tests to evaluate patients with shoulder injuries. Because of the vast array of tests, educators of health care curriculums are challenged to decide which tests should be taught. OBJECTIVE To survey experienced shoulder specialists to identify the common clinical tests used to diagnose 9 specific shoulder injuries to determine if a core battery of tests should be taught to allied health professionals. DESIGN Cross-sectional study. SETTING Descriptive survey administered via e-mail. PATIENTS OR OTHER PARTICIPANTS Of 131 active members of the American Shoulder and Elbow Surgeons, 71 responded to the survey. MAIN OUTCOME MEASURE(S) Respondents were asked to complete a survey documenting their use of clinical tests during a shoulder examination. They answered yes or no to indicate their use of 122 different tests for diagnosing 9 shoulder conditions. RESULTS The average number of tests used for all pathologic conditions was 30 ± 9. The anterior apprehension and cross-body adduction tests were used by all respondents. At least 1 test was used for each of the 9 conditions listed (range = 1-7), and at least 50% of respondents used 25 tests. The tests were reviewed for valid diagnostic accuracy via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. High diagnostic value and a large amount of QUADAS variability have been reported in the literature for 16 of the 25 tests. CONCLUSIONS A small percentage (20%) of clinical tests is being used by most examiners. The 25 most common tests identified from this survey may serve as a foundation for the student's knowledge base, with the clear understanding that multiple clinical tests are used by some of the most experienced clinicians dealing with shoulder injuries.
Collapse
Affiliation(s)
- Aaron D Sciascia
- Shoulder Center of Kentucky, 700 Bob-O-Link Drive, Lexington, KY 40504, USA.
| | | | | | | |
Collapse
|
26
|
A meta-analysis of the diagnostic test accuracy of MRA and MRI for the detection of glenoid labral injury. Arch Orthop Trauma Surg 2012; 132:905-19. [PMID: 22395821 DOI: 10.1007/s00402-012-1493-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE Magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) have gained increasing favour in the assessment of patients with suspected glenoid labral injuries. The purpose of this study was to determine the diagnostic accuracy of MRI or MRA in the detection of gleniod labral lesions. MATERIALS AND METHODS A systematic review was undertaken of the electronic databases Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED and CINAHL, in addition to a search of unpublished literature databases. All studies which compared the ability of MRI or MRA (index test) to assess gleniod labral tears or lesions, when verified with a surgical procedure (arthroscopy or open surgery-reference test) were included. Data extraction and methodological appraisal using the QUADAS tool were both conducted by two reviewers independently. Data were analysed through a summary receiver operator characteristic curve and pooled sensitivity and specificity analysis were calculated with 95% confidence intervals. RESULTS Sixty studies including 4,667 shoulders from 4,574 patients were reviewed. There appeared slightly greater diagnostic test accuracy for MRA over MRI for the detection of overall gleniod labral lesions (MRA-sensitivity 88%, specificity 93% vs. MRI sensitivity 76% vs. specificity 87%). Methodologically, studies recruited and identified their samples appropriately and clearly defined the radiological procedures. In general, it was not clearly defined why patients were lost during the study, and studies were poor at recording whether the same clinical data were available to the radiologist interpreting the MRI or MRA as would be available in clinical practice. Most studies did not state whether the surgeon interpreting the arthroscopic procedure was blinded to the results of the MR or MRA imaging. CONCLUSIONS Based on the available literature, overall MRA appeared marginally superior to MRI for the detection of glenohumeral labral lesions. LEVEL OF EVIDENCE Level 2a.
Collapse
|
27
|
Park MJ, Hsu JE, Harper C, Sennett BJ, Huffman GR. Poly-L/D-lactic acid anchors are associated with reoperation and failure of SLAP repairs. Arthroscopy 2011; 27:1335-40. [PMID: 21890311 DOI: 10.1016/j.arthro.2011.06.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 06/13/2011] [Accepted: 06/14/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE This study investigates factors associated with failure and reoperation after glenoid labrum repair. METHODS We studied a nonconcurrent cohort of consecutive patients undergoing arthroscopic superior labrum repair at a single institution by 2 fellowship-trained surgeons over a 10-year period. RESULTS There were 348 patients included in this study with a mean age of 33.4 years (95% confidence interval [CI], 32.1 to 35.9) and a mean clinical follow-up of 12.3 months (95% CI, 10.9 to 13.8). The overall reoperation rate was 6.3%, with a revision labrum repair rate of 4.3%. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with Workers' Compensation claims (odds ratio [OR], 4.6; P < .001; 95% CI, 1.8 to 11.7), the use of tobacco (OR, 12.0; P = .03; 95% CI, 1.2 to 114.9), and the use of absorbable poly-L/D-lactic acid (PLDLA) anchors (100% correlation, P < .001). The OR for having repeat surgery was 12.7 (95% CI, 4.9 to 32.9; P < .001) with poly-96L/4D-lactic acid (Mini-Revo; Linvatec, Largo, FL) and also increased with the use of poly-70L/30D-lactic acid (Bio-Fastak and Bio-Suturetak; Arthrex, Naples, FL) anchor material (P = .04) after removal of the patients exposed to poly-96L/4D-lactic acid anchors. The rates of repeat surgery with PLDLA anchors from Linvatec and PLDLA anchors from Arthrex were 24% and 4%, respectively. None of the patients treated with nonabsorbable suture anchors (polyether ether ketone or metallic) returned to the operating room (P < .001). After we controlled for associated factors in a multivariate analysis, the use of absorbable anchors, in particular poly-96L/4D-lactic acid anchors (OR, 14.7; P < .001), and having a work-related injury (OR, 8.1; P < .001) remained independent factors associated with both repeat surgery and revision superior labrum repair. CONCLUSIONS Bioabsorbable PLDLA anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors. Our recommendation is that glenoid labrum repairs be performed with nondegradable material and, specifically, that the use of anchors composed of PLDLA material should be avoided.
Collapse
Affiliation(s)
- Min Jung Park
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104-4283, USA
| | | | | | | | | |
Collapse
|
28
|
|
29
|
McFarland EG, Tanaka MJ, Garzon-Muvdi J, Jia X, Petersen SA. Clinical and imaging assessment for superior labrum anterior and posterior lesions. Curr Sports Med Rep 2009; 8:234-9. [PMID: 19741350 DOI: 10.1249/jsr.0b013e3181b7f042] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In the evaluation of the painful shoulder, especially in the overhead athlete, diagnosing superior labrum anterior and posterior (SLAP) lesions continues to challenge the clinician because of 1) the lack of specificity of examination tests for SLAP; 2) a paucity of well-controlled studies of those tests; and 3) the presence of coexisting confounding abnormalities. Some evidence indicates that multiple positive tests increase the likelihood that a SLAP lesion is present, but no one physical examination finding conclusively makes that diagnosis. The goals of this article were to review the physical examination techniques for making the diagnosis of SLAP lesions, to evaluate the clinical usefulness of those examinations, and to review the role of magnetic resonance imaging in making the diagnosis.
Collapse
Affiliation(s)
- Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA.
| | | | | | | | | |
Collapse
|
30
|
Gates ME, Kou JX, Demetropoulos CK, Jurist KA, Guettler JH. Effects of zone-specific superior labral detachment on biceps anchor stability. Am J Sports Med 2009; 37:2445-50. [PMID: 19776338 DOI: 10.1177/0363546509343468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE This study aimed to elucidate the degree of biceps anchor displacement that occurs when specific zones of the superior labrum are detached from the glenoid. STUDY DESIGN Descriptive laboratory study. METHODS Twelve cadaveric scapulae with intact labrums were prepared by removing the surrounding musculature with the labrum, biceps anchor, and biceps tendon carefully preserved. Pulleys were used to apply traction in 3 different directions- superior, lateral, and combined posterior/superior/lateral, to simulate the "peel-back" mechanism-while a continuous 1.13 kg of traction was applied to the biceps tendon. Labral tears were created by sharp incisions in isolation and in combinations of 3 zones defined relative to the glenoid fossa: anterior, posterior, or superior. The displacement of the biceps anchor (position of the marker after the simulated lesion relative to the marker position with the labrum intact) was measured relative to a rigid reference frame. RESULTS The greatest degree of displacement occurred with the sectioning of all 3 zones, followed by the sectioning of 2 adjacent zones. Superior traction created the least displacement in all combinations, while lateral traction created maximal displacement, with one exception: in the setting of anterosuperior/superior lesions, maximal displacement was observed using the peel-back mechanism. CONCLUSION Biceps anchor displacement, particularly the degree and direction of displacement, is affected by the labral detachment pattern. All 3 labral zones assessed in this study have important biomechanical contributions to biceps anchor displacement. CLINICAL SIGNIFICANCE These findings have important implications relating to the clinician's arthroscopic assessment of superior labrum anterior and posterior (SLAP) tears, as well as the determination of need for stabilization. This information is particularly useful when treating SLAP tears in certain laborers and athletes, whose activities may cause specific biceps anchor displacement patterns.
Collapse
Affiliation(s)
- Megan E Gates
- Harold W. Gehring Center for Biomechanics and Implant Analysis, William Beaumont Hospital, Research Institute, Royal Oak, Michigan, USA
| | | | | | | | | |
Collapse
|
31
|
Meserve BB, Cleland JA, Boucher TR. A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions. Am J Sports Med 2009; 37:2252-8. [PMID: 19095895 DOI: 10.1177/0363546508325153] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The reported accuracy of clinical tests for superior labral anterior posterior lesions is extremely variable. Pooling results from multiple studies of higher quality is necessary to establish the best clinical tests to use. HYPOTHESIS Certain clinical tests are superior to others for diagnosing the presence or absence of a superior labral anterior posterior lesion. STUDY DESIGN Meta-analysis. METHODS A literature search of MEDLINE (1966-2007), CINAHL (1982-2007), and BIOSIS (1995-2007) was performed for (labrum OR labral OR SLAP OR Bankart) AND (shoulder OR shoulder joint OR glenoid) AND (specificity OR sensitivity AND specificity). Identified articles were reviewed for inclusion criteria. Sensitivity and specificity values were recorded from each study and used for meta-analysis. RESULTS Six of 198 identified studies satisfied the eligibility criteria. Active compression, anterior slide, crank, and Speed tests were analyzed using receiver operating characteristic curves. The accuracy of the anterior slide test was significantly inferior to that of the active compression, crank, and Speed tests. There was no significant difference in test accuracy found among active compression, crank, and Speed tests. Between studies, methodological scores did not significantly affect sensitivity and specificity values. CONCLUSION The anterior slide test is a poor test for detecting the presence of a labral lesion in the shoulder. Active compression, crank, and Speed tests are more optimal choices. Clinicians should choose the active compression test first, crank second, and Speed test third when a labral lesion is suspected.
Collapse
Affiliation(s)
- Brent B Meserve
- Department of Rehabilitative Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
| | | | | |
Collapse
|
32
|
Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med 2009; 37:1840-7. [PMID: 19509414 DOI: 10.1177/0363546509332505] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinical tests are a key element in diagnosing shoulder lesions. PURPOSE This study examined the clinical utility of traditional and new examination tests, the upper cut for biceps injuries, and the modified dynamic labral shear for superior glenoid labral lesions. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS A total of 325 consecutive patients who were seen for shoulder pain underwent a standardized clinical testing battery. Six clinical tests that have been previously reported in the literature (Yergason's, Speed's, bear hug, belly press, O'Brien's, and anterior slide) and 2 new examination tests (upper cut and modified dynamic labral shear) were performed. Clinical examination findings were correlated with findings in those who came to surgery (101 patients). Sensitivity, specificity, accuracy, positive/negative predictive value, and positive/negative likelihood ratio were calculated for each test. A binary logistic regression analysis was used to determine which tests produced the most significant findings. RESULTS For biceps disease, the bear hug and upper cut were most sensitive (0.79 and 0.73, respectively), whereas the belly press and Speed's test were most specific (0.85 and 0.81, respectively). The upper cut was most accurate (0.77) and produced the highest positive likelihood ratio (3.38). For labral injury, the modified dynamic labral shear demonstrated sensitivity of 0.72, specificity of 0.98, accuracy of 0.84, and a positive likelihood ratio of 31.57. A binary logistic regression analysis revealed that the combination of the upper cut and Speed's tests were significantly better at detecting biceps lesions (P = .021, R(2) = .400) than other tests, whereas labral lesions were best identified by combination of the modified dynamic labral shear and O'Brien's maneuvers (P = .045, R(2) = .641). CONCLUSION The new tests are helpful additions to the clinical examination for shoulder injury. The modified dynamic labral shear test demonstrates high scores for clinical utility and exhibits a high likelihood ratio, indicating a significant probability of affecting the clinical decision, which should moderately or significantly improve the diagnostic conclusion and allow the clinician to be more efficient in making an accurate diagnosis.
Collapse
Affiliation(s)
- W Ben Kibler
- Shoulder Center of Kentucky, Lexington, KY 40504, USA
| | | | | | | | | |
Collapse
|
33
|
Abstract
Magnetic resonance imaging has become an important diagnostic adjunct in the evaluation of shoulder conditions, and the technology continues to evolve. Direct magnetic resonance arthrography can improve detection of labral and rotator cuff pathology, especially partial thickness tears of the rotator cuff. Special positioning, such as abducted-externally rotated views, improves visualization of the rotator cuff and posterior superior labrum in throwing athletes. Diagnosis-specific sequencing such as fat suppression, spin-echo and proton-density techniques, and higher power magnets (3.0 T) allow for an unprecedented level of soft tissue detail. Clinical expertize is required to differentiate between normal anatomic variants, incidental findings, and true pathology. Although magnetic resonance imaging findings may be diagnostic in some cases, clinical correlation with history and physical examination findings is critical.
Collapse
|
34
|
Affiliation(s)
- Matthew L Ramsey
- Shoulder and Elbow Service, Thomas Jefferson University, Rothman Institute, Philadelphia, PA 19107, USA.
| | | | | |
Collapse
|
35
|
Bushnell BD, Creighton RA, Herring MM. Bony instability of the shoulder. Arthroscopy 2008; 24:1061-73. [PMID: 18760215 DOI: 10.1016/j.arthro.2008.05.015] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 04/17/2008] [Accepted: 05/07/2008] [Indexed: 02/08/2023]
Abstract
Instability of the shoulder is a common problem treated by many orthopaedists. Instability can result from baseline intrinsic ligamentous laxity or a traumatic event-often a dislocation that injures the stabilizing structures of the glenohumeral joint. Many cases involve soft-tissue injury only and can be treated successfully with repair of the labrum and ligamentous tissues. Both open and arthroscopic approaches have been well described, with recent studies of arthroscopic soft-tissue techniques reporting results equal to those of the more traditional open techniques. Over the last decade, attention has focused on the concept of instability of the shoulder mediated by bony pathology such as a large bony Bankart lesion or an engaging Hill-Sachs lesion. Recent literature has identified unrecognized large bony lesions as a primary cause of failure of arthroscopic reconstruction for instability, a major cause of recurrent instability, and a difficult diagnosis to make. Thus, although such bony lesions may be relatively rare compared with soft-tissue pathology, they constitute a critically important entity in the management of shoulder instability. Smaller bony lesions may be amenable to arthroscopic treatment, but larger lesions often require open surgery to prevent recurrent instability. This article reviews recent developments in the diagnosis and treatment of bony instability.
Collapse
|
36
|
|