An anatomic evaluation of the active compression test

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

BACKGROUND

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

PURPOSE/HYPOTHESIS

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Successful injection of the acromioclavicular joint with use of ultrasound: anatomy, technique, and follow-up

BACKGROUND

Injection into the acromioclavicular (AC) joint is often inaccurate (approximately 50%) even in experienced hands. In light of new anatomic observations, we evaluate accuracy of an innovative ultrasound-guided method and follow the clinical course of successful therapeutic injections.

METHOD

Relevant anatomy was investigated in 200 three-dimensional computed tomography scans, 100 magnetic resonance images, and 14 cadavers. Baseline measurements of joint depth and width were performed ultrasonically in 100 normal volunteers; 50 symptomatic patients were injected. Uniquely in a clinical ultrasound study, injection success was documented by arthrography. Outcomes after concomitant steroid instillation were observed for 6 months by visual analog scale (VAS) scores and pain provocation test results.

RESULTS

Anatomic studies showed that the widest area for joint penetration was anterior superior. Injection success rate was 96%, overwhelmingly on the first needle pass. Shallow joint depth allowed access with a standard 3-cm needle. Joint width diminished with age but did not reduce injection success. Cadaveric joints admitted 1.2 ± 0.5 mL, but fluid ingress was initially blocked by soft tissues in one third of both cadaveric and clinical cases. Diligent follow-up after steroid injection showed sustained pain relief in the majority with isolated AC disease but significantly less in those with concomitant shoulder disorders.

CONCLUSION

This high level of clinical injection success, irrefutably substantiated with arthrography, has not been previously demonstrated. The anterior superior aspect of the joint is the preferred place for entry. Initial intra-articular blockage to fluid inflow is common but can be surmounted. Encouraging 6-month results of steroid instillation in isolated AC disease do not apply to patients with coexisting shoulder pathologic processes.

A new test for acromio-clavicolar pathology

BACKGROUND

A prospective study was established to assess the sensitivity and specificity of the new Saccomanni (SAC) test for isolated AC pathology, and compare with 4 commonly used clinical tests.

MATERIALS AND METHODS

The Saccomanni (Sac) test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the Saccomanni test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The Saccomanni test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of true positive tests.

STUDY DESIGN

Case series.

RESULTS

The SAC test showed a sensitivity of 98% and specificity is 91.7%. All 4 other tests were less sensitive.

CONCLUSION

The SAC test is a highly sensitive test in patients presenting with isolated AC related symptoms. This study is an innovation for clinical tests in the world. The primary aim of this study was to assess the diagnostic sensitivity of my newly described SAC test. From the present study, it can be concluded that the easy-to use SAC is a highly sensitive test to evaluate AC joint pathology, when compared to other standard tests.

CLINICAL RELEVANCE

Level III, Diagnostic Study of Nonconsecutive Patients.

Glenohumeral contact pressure in a simulated active compression test using cadaveric shoulders

BACKGROUND

The active compression test has been described to detect superior labrum anterior and posterior (SLAP) lesions. Some have speculated that contact between the lesser tuberosity and the superior glenoid in the testing position causes a positive test. This study evaluated the location of peak glenohumeral contact pressures during a simulated active compression test in a cadaveric model with and without SLAP lesions.

MATERIALS AND METHODS

Six specimens were tested. A pressure sensor was used to record glenohumeral contact, and a motion analysis system was used to measure humeral head translation. Contact pressures and translations were measured during serial deltoid and biceps loads. These were repeated for small and large SLAP lesions.

RESULTS

There was a notable shift in the location of peak contact pressure from the anterior-inferior glenoid to the anterior-superior glenoid with increasing deltoid load. Deltoid loading translated the humeral head posteriorly relative to the glenoid. Conversely, biceps loads countered the pull of the deltoid only when the biceps load was greater than the deltoid load. The SLAP tears did not significantly alter the degree of humeral head translation or location of the contact pressures.

CONCLUSIONS

In the active compression test, the posterior capsule is taut and the anterior capsule is lax, which permits the deltoid to translate the humeral head posteriorly. This shift in the peak contact pressure to the superior glenoid may elicit a positive active compression test.

LEVEL OF EVIDENCE

Basic Science Study, Biomechanics, Cadaver Model.

The new 4-dimensional computed tomographic scanner allows dynamic visualization and measurement of normal acromioclavicular joint motion in an unloaded and loaded condition

OBJECTIVE

Using 4-dimensional computed tomographic scanner to determine the motion pattern of the acromioclavicular (AC) joint during adduction of the arm, with and without resisted superior elevation.

METHODS

Sixteen healthy volunteers (5 women and 11 men; mean ± SD age, 42 ± 11 years). Four different motions were measured: AC joint width, anteroposterior translation, superoinferior translation, and opening of the superior aspect of the joint. Measurements between arm positions of neutral, adduction, and loaded were compared.

RESULTS

Predominant movement is posterior translation (1.1 ± 0.9 mm, P = 0.001); in the coronal plane, superior translation of the clavicle (0.6 ± 0.5 mm, P = 0.001) and some opening of the superior joint space. Changes in the AC joint width and anteroposterior translation were significantly related to age (P = 0.016 and P = 0.006).

CONCLUSIONS

Four-dimensional computed tomographic scans record the motion pattern of an asymptomatic AC joint and demonstrated that in adduction plus resisted elevation of the arm, the main movement of the AC joint is posterior and superior translation of the clavicle.

Glenohumeral muscle activation during provocative tests designed to diagnose superior labrum anterior-posterior lesions

BACKGROUND

Despite considerable medical advances, arthroscopy remains the only definitive means of superior labrum anterior-posterior (SLAP) lesion diagnosis. Natural shoulder anatomic variants limit the reliability of radiographic findings and clinical evaluations are not consistent. Accurate clinical diagnostic techniques would be advantageous because of the invasiveness, patient risk, and financial cost associated with arthroscopy.

PURPOSE

The purpose of this study was to examine the behavior of the joint-stabilizing muscles in provocative tests for SLAP lesions. Electromyography was used to characterize the muscle behavior, with particular interest in the long head of the biceps brachii (LHBB), as activation of the long head and subsequent tension in the biceps tendon should, based on related research, elicit labral symptoms in SLAP lesion patients.

STUDY DESIGN

Controlled laboratory study.

METHODS

Volunteers (N = 21) without a history of shoulder injury were recruited. The tests analyzed were active compression, Speed's, pronated load, biceps load I, biceps load II, resisted supination external rotation, and Yergason's. Tests were performed with a dynamometer to improve reproducibility. Muscle activity was recorded for the long and short heads of the biceps brachii, anterior deltoid, pectoralis major, latissimus dorsi, infraspinatus, and supraspinatus. Muscle behavior for each test was characterized by peak activation and proportion of muscle activity.

RESULTS

Speed's, active compression palm-up, bicep I, and bicep II produced higher long head activations. Resisted supination external rotation, bicep I, bicep II, and Yergason's produced a higher LHBB proportion.

CONCLUSION

Biceps load I and biceps load II elicited promising long head behavior (high activation and selectivity). Speed's and active compression palm up elicited higher activation of the LHBB, and resisted supination and Yergason's elicited selective LHBB activity. These top performing tests utilize a unique range of test variables that may prove valuable for optimal SLAP test design and performance.

CLINICAL RELEVANCE

This study examines several provocative tests that are frequently used in the clinical setting as a means of evaluating a potential SLAP lesion.

Clinical evaluation of acromioclavicular joint pathology: sensitivity of a new test

BACKGROUND

A prospective study was established to assess the sensitivity of the newly described Bell-van Riet (BvR) test for isolated AC pathology, and compare with 4 commonly used clinical tests.

MATERIALS AND METHODS

The BvR test is essentially the cross-adduction test, with the addition of attempted elevation against resistance. In a positive test, this results in some pain and the inability of the patient to maintain the arm in the adducted and elevated position against resistance. Fifty-eight patients with isolated AC joint symptoms were assessed in random order with the BvR test and 4 other tests. A corticosteroid and local anaesthetic injection was administered into the AC joint space. The BvR test and 4 other tests were then repeated following the injection. After the injection, a symptom free clinical examination was used as a measure of truly positive tests.

RESULTS

The BvR test showed a sensitivity of 98%. All 4 other tests were less sensitive.

CONCLUSION

The BvR test is a highly sensitive test in patients presenting with isolated AC related symptoms, and demonstrates AC joint pathology better than other accepted tests.

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.