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Yaka H, Erdem TE, Özer M, Kanatli U. Can the presence of SLAP-5 lesions be predicted by using the critical shoulder angle in traumatic anterior shoulder instability? Skeletal Radiol 2024:10.1007/s00256-024-04708-1. [PMID: 38758391 DOI: 10.1007/s00256-024-04708-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/03/2024] [Accepted: 05/12/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Although SLAP-5 lesions are associated with recurrent dislocations, their causes and pathomechanisms have not been fully elucidated. This study aimed to investigate the association between SLAP-5 lesions and scapular morphology in traumatic anterior shoulder instability (ASI). We hypothesized that there may be a relationship between SLAP-5 lesions and scapular morphology in traumatic ASI patients. MATERIALS AND METHODS The study included 74 patients with isolated Bankart lesions and 69 with SLAP-5 lesions who underwent arthroscopic labral repair for ASI. Critical shoulder angle (CSA) was measured on the roentgenograms, while glenoid inclination (GI) and glenoid version (GV) were measured on magnetic resonance imaging (MRI) by two observers in two separate sessions blinded to each other. Both groups were compared in terms of CSA, GI, and GV. RESULTS The mean ages of Bankart and SLAP-5 patients were 28.4±9.1 and 27.9±7.7 (P=0.89), respectively; their mean CSA values were 33.1°±2.6° and 28.2°±2.4°, respectively (P<0.001). The ROC analysis's cut-off value was 30.5°, with 75.0% sensitivity and 76.7% specificity (AUC = 0.830). SLAP-5 lesions were more common on the dominant side than isolated Bankart lesions (P=0.021), but no difference was found between the groups in terms of GI and GV (P=0.334, P=0.081, respectively). CONCLUSIONS In ASI, low CSA values appeared to be related to SLAP-5 lesions, and the cut-off value of CSA for SLAP lesion formation was 30.5° with 75.0% sensitivity and 76.7% specificity. Scapula morphology may be related to the SLAP-5 lesions, and CSA can be used as an additional parameter in provocative diagnostic tests and medical imaging techniques for the detection of SLAP lesions accompanying Bankart lesions. LEVEL OF EVIDENCE III retrospective case-control study.
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Affiliation(s)
- Haluk Yaka
- Department of Orthopaedics & Traumatology, School of Medicine, Necmettin Erbakan University, Konya, Turkey.
| | - Turgut Emre Erdem
- Department of Orthopaedics & Traumatology, Pazarcık State Hospital, Kahraman Maraş, Turkey
| | - Mustafa Özer
- Department of Orthopaedics & Traumatology, School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ulunay Kanatli
- Department of Orthopaedics & Traumatology, Gazi University School of Medicine, Ankara, Turkey
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2
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Stutsrim A, Albertson B, Waterman B, Freischlag J. Double Trouble: Combined Neurogenic Thoracic Outlet Syndrome and Superior Labrum Anterior Posterior Tear. Vasc Endovascular Surg 2024; 58:331-334. [PMID: 37858314 DOI: 10.1177/15385744231209911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Neurogenic thoracic outlet syndrome and superior labrum anterior posterior tears are usually treated in a staged manner due to different post-operative therapy needs. This case describes successful combined surgery with expedited physical therapy.
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Affiliation(s)
- Ashlee Stutsrim
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Benjamin Albertson
- Department of Orthopedic Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Brian Waterman
- Department of Orthopedic Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Julie Freischlag
- Department of Vascular and Endovascular Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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3
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Dean RS, Onsen L, Lima J, Hutchinson MR. Physical Examination Maneuvers for SLAP Lesions: A Systematic Review and Meta-analysis of Individual and Combinations of Maneuvers. Am J Sports Med 2023; 51:3042-3052. [PMID: 35997579 DOI: 10.1177/03635465221100977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Robert S Dean
- Department of Beaumont Health, Royal Oak Hospital, Royal Oak, Michigan, USA
| | - Leonard Onsen
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeniffer Lima
- Department of Family Medicine, Amita St. Mary and Elizabeth Medical Center, Chicago, Illinois, USA
| | - Mark R Hutchinson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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4
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Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower. J Am Acad Orthop Surg 2023; 31:e424-e434. [PMID: 36727732 DOI: 10.5435/jaaos-d-21-01199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/13/2022] [Indexed: 02/03/2023] Open
Abstract
Symptomatic superior labral anterior and posterior (SLAP) tears have become an increasingly common diagnosis, particularly within the competitive overhead athlete population. Type II SLAP tears are the most encountered variant in overhead throwing athletes. Given the high incidence of false positives on advanced imaging, corroborating the history and physical examination with imaging is paramount to accurately establish a SLAP lesion diagnosis. Previous studies have reported conflicting success rates with conservative management, but the number of pitching athletes able to return to prior level of performance with nonsurgical management strategies has been unsatisfactory. Although there has historically been a notable disconnect between the incidence of SLAP tears in the literature and the number of SLAP repairs in recent investigations, high-grade or unstable tears may be candidates for débridement, labral repair, biceps tenodesis, or less frequently, biceps tenotomy. Biceps tenodesis has been increasingly used for the management of these lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes.
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5
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Sudah SY, Menendez ME, Garrigues GE. Nonoperative Treatment of the Biceps-Labral Complex. Phys Med Rehabil Clin N Am 2023; 34:365-375. [PMID: 37003658 DOI: 10.1016/j.pmr.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.
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Affiliation(s)
- Suleiman Y Sudah
- Department of Orthopedics, Monmouth Medical Center, 300 2nd Avenue, Long Branch, NJ 07740, USA
| | - Mariano E Menendez
- Oregon Shoulder Institute at Southern Oregon Orthopedics, 2780 East Barnett Road, 200, Medford, OR 97504, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Orthopedic Building, Suite 400, Chicago, IL 60612, USA.
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6
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Accuracy of telemedicine for the diagnosis and treatment of patients with shoulder complaints. CURRENT ORTHOPAEDIC PRACTICE 2023. [DOI: 10.1097/bco.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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7
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Jain A, Aniq H, Mistry A. SLAP Injury and the Superior Labrum. Semin Musculoskelet Radiol 2022; 26:577-584. [DOI: 10.1055/s-0042-1758840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractInjuries around the superior labrum are a common cause of shoulder dysfunction and pain. The injuries sustained result mainly from repetitive microtrauma but can also occur following a fall on outstretched hand. Both athletic and general populations can be affected. Injuries to the superior labrum are called superior labrum anterior and posterior (SLAP) tears. Based on cross-sectional imaging findings, the literature defines four main SLAP tears (I–IV) and six extended types (V–X). An accurate description of imaging findings of the SLAP tear type, along with concomitant findings, aids clinicians in treatment planning. We also briefly discuss management options, postoperative appearance of superior labral repair, and the diagnosis of a retear.
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Affiliation(s)
- Abhishek Jain
- Liverpool University Hospitals, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Hifz Aniq
- Liverpool University Hospitals, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Alpesh Mistry
- Liverpool University Hospitals, Royal Liverpool University Hospital, Liverpool, United Kingdom
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8
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Lalehzarian SP, Agarwalla A, Liu JN. Management of proximal biceps tendon pathology. World J Orthop 2022; 13:36-57. [PMID: 35096535 PMCID: PMC8771414 DOI: 10.5312/wjo.v13.i1.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/10/2021] [Accepted: 12/25/2021] [Indexed: 02/06/2023] Open
Abstract
The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.
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Affiliation(s)
- Simon P Lalehzarian
- The Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, United States
| | - Avinesh Agarwalla
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, NY 10595, United States
| | - Joseph N Liu
- USC Epstein Family Center for Sports Medicine, Keck Medicine of USC, Los Angeles, CA 90033, United States
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9
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Imaging of Patients Suspected of SLAP Tear: A Cost-Effectiveness Study. AJR Am J Roentgenol 2021; 218:227-233. [PMID: 34406055 DOI: 10.2214/ajr.21.26420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Superior labral anterior-to-posterior (SLAP) tears are a common shoulder pathology. While MRI is the imaging gold standard for diagnosis of this pathology, the cost-effectiveness of the common MRI strategies is unclear. Objective: The primary objective of our study was to determine the cost-effectiveness of the common MRI-based strategies used for the diagnosis of SLAP tears. Methods: We created decision analytic models from the U.S. health care system perspective over a two-year time horizon for a hypothetical patient population of 25-year-olds with a previous diagnosis of SLAP tear. We used the decision models to compare the differences in incremental cost-effectiveness of the common MRI strategies and resulting treatment applied for this patient type, which included combinations of 1.5T and 3T imaging and unenhanced MRI and MR arthrogram protocols. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search. The primary effectiveness outcome was quality-adjusted life years (QALY). Costs were estimated in 2017 U.S. dollars. Results: When all imaging strategies were considered, the unenhanced 3T MRI based imaging strategy was the preferred and dominant option over 3T MR arthrography (MRA) and 1.5T imaging (MRI/MRA). When the model was run without 3T imaging as an option, 1.5T MRA was the favored option. Probabilistic sensitivity analyses confirmed the same preferred imaging strategy results. Conclusion: An unenhanced 3T MRI based strategy is the most cost-effective imaging option for patients with suspected SLAP tear. When 3T imaging is not available, 1.5T MRA is more cost-effective than 1.5T imaging. The main driver of these results is the fact that 3T MRI and 1.5T MRA are the most specific tests in these respective scenarios which results in fewer false positives and prevents unnecessary surgeries leading to decreased costs. Clinical Impact: Our cost-effectiveness model findings complement prior diagnostic accuracy work, helping produce a more comprehensive approach to define imaging utility for the SLAP patient population for radiologists, clinicians, and patients who have access to various types of MRI options.
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10
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LeVasseur MR, Mancini MR, Hawthorne BC, Romeo AA, Calvo E, Mazzocca AD. SLAP tears and return to sport and work: current concepts. J ISAKOS 2021; 6:204-211. [PMID: 34272296 DOI: 10.1136/jisakos-2020-000537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 01/02/2023]
Abstract
Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities. Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors. For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies and unpredictable rates of return to play. As a consequence, the most appropriate surgical option in elite throwers is controversial. The objective of this current concepts review is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.
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Affiliation(s)
- Matthew R LeVasseur
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Michael R Mancini
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Benjamin C Hawthorne
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Anthony A Romeo
- Musculoskeletal Institute, DuPage Medical Group, Downers Grove, Illinois, USA
| | - Emilio Calvo
- Department of Orthopaedic Surgery, Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
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11
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SLAP Tears in the Throwing Shoulder: A Review of the Current Concepts in Management and Outcomes. OPER TECHN SPORT MED 2021. [DOI: 10.1016/j.otsm.2021.150798] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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12
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Allegra PR, Greif DN, Desai SS, Yakkanti RR, Muñoz J, Kaplan LD, Baraga MG. The Fifty Most-Cited Articles Regarding SLAP Lesions. Arthrosc Sports Med Rehabil 2021; 3:e135-e147. [PMID: 33615258 PMCID: PMC7879178 DOI: 10.1016/j.asmr.2020.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/10/2020] [Indexed: 01/02/2023] Open
Abstract
Purpose To identify and evaluate the top 50 most-cited articles pertaining to SLAP tears. Methods The ISI Web of Knowledge database was used to conduct a query for articles pertaining to SLAP tears. Our query was conducted in April 2020 with multiple Boolean operative combinations performed by 2 independent reviewers. Articles on the final list were further reviewed to extract the following data: manuscript title, first author, total citation count, year of publication, citation density since publication, current citation rate since 2013, journal, country of origin, and level of evidence. Results Our initial search yielded 2,597 articles. Within this cohort, the top 50 publications pertaining to SLAP tears were identified that met our search criteria. The top article was cited 802 times while the 50th ranked article was cited 46 times. The average number of citations per publication was 131, whereas the average citation density since year of publication was 7.3. No strong correlations were found between citation density and year published. Twelve journals published articles pertaining to SLAP tears, with Arthroscopy accounting for the greatest number (15 articles, 30%). Most articles were graded with a level of evidence (LOE) of IV (n = 24, 48%), followed by review articles without LOE (n = 8, 16%). Only 2 articles achieved an LOE of I (4%). Articles typically addressed the arthroscopic management (n = 11, 22%), whereas anatomy/classification (n =10, 20%), and outcomes (n = 9, 18%) also were reported. Conclusions This review provides a quantitative analysis of the most-referenced literature pertaining to SLAP tears. This body of knowledge helps surgeons search for literature regarding these injuries and identify trends regarding SLAP tear research. Clinical Relevance This research provides practitioners with an easily accessible and comprehensive collection of the major contributions regarding SLAP tears and offers insight into future areas for research.
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Affiliation(s)
- Paul R Allegra
- Department of Orthopedics, University of Miami/Jackson Memorial Hospital, Miami, Florida, U.S.A
| | - Dylan N Greif
- University of Miami Sports Medicine Institute, Miami, Florida, U.S.A.,University of Miami Miller School of Medicine, Miami, Florida, U.S.A
| | - Sohil S Desai
- University of Miami Miller School of Medicine, Miami, Florida, U.S.A
| | - Ramakanth R Yakkanti
- Department of Orthopedics, University of Miami/Jackson Memorial Hospital, Miami, Florida, U.S.A
| | - Julianne Muñoz
- Department of Orthopedics, University of Miami/Jackson Memorial Hospital, Miami, Florida, U.S.A.,University of Miami Sports Medicine Institute, Miami, Florida, U.S.A
| | - Lee D Kaplan
- Department of Orthopedics, University of Miami/Jackson Memorial Hospital, Miami, Florida, U.S.A.,University of Miami Sports Medicine Institute, Miami, Florida, U.S.A
| | - Michael G Baraga
- Department of Orthopedics, University of Miami/Jackson Memorial Hospital, Miami, Florida, U.S.A.,University of Miami Sports Medicine Institute, Miami, Florida, U.S.A
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13
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Kandeel AAM. Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability. J Shoulder Elbow Surg 2020; 29:95-103. [PMID: 31471245 DOI: 10.1016/j.jse.2019.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/21/2019] [Accepted: 05/28/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability. METHODS This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control). RESULTS Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively). CONCLUSION Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.
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Affiliation(s)
- Amr Abdel-Mordy Kandeel
- Department of Orthopedics and Traumatology, Faculty of Medicine, Menoufia University, Menoufia Governorate, Egypt.
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14
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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.
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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
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15
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Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder. J Am Acad Orthop Surg 2019; 27:395-404. [PMID: 30383578 DOI: 10.5435/jaaos-d-17-00637] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A detailed physical examination of the shoulder is crucial in creating a diagnosis in patients who present with shoulder pain. Tests of the cervical spine, scapula, and rotator cuff muscles have already been evaluated in a previous article. This article assesses provocative and instability examination tests of the shoulder. Descriptions on how the tests are performed and their diagnostic accuracy are presented.
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16
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Lansdown DA, Bendich I, Motamedi D, Feeley BT. Imaging-Based Prevalence of Superior Labral Anterior-Posterior Tears Significantly Increases in the Aging Shoulder. Orthop J Sports Med 2018; 6:2325967118797065. [PMID: 30238014 PMCID: PMC6141924 DOI: 10.1177/2325967118797065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Superior labral anterior-posterior (SLAP) tears can be associated with pain and shoulder dysfunction. Relatively little is known about the age-related prevalence of SLAP tears. Purpose To investigate the age-related prevalence of imaging-diagnosed SLAP tears in a heterogeneous grouping of shoulder conditions in a large cohort at a single institution with multiple blinded reviewers. Study Design Cross-sectional study; Level of evidence, 3. Methods A total of 281 shoulder magnetic resonance imaging (MRI) scans obtained over 8 months were reviewed by a musculoskeletal radiologist and an orthopaedic surgeon. The mean ± SD age of the group was 49.6 ± 15.5 years, and 107 of the patients were female (38.1%). Patients were divided into 4 age groups: 35 years or younger, 36 to 50 years, 51 to 65 years, and older than 65 years. Statistical analyses were completed by use of the Fisher exact test to compare proportions of SLAP tears between age groups, odds ratios to determine the likelihood of having a SLAP tear in each age group, and a logistic regression to control for associated abnormalities. Results There was a significant diffference in the proportion of SLAP tears found on the MRIs for each age group (P < .001). Patients were significantly more likely to have SLAP tears if aged 51 to 65 years (66.7%; odds ratio [OR], 2.00; 95% CI, 1.27-3.15) and if older than 65 years (81.2%; OR, 4.31; 95% CI, 2.36-7.88). No increased prevalence was observed in patients aged 35 years or younger (47.5%; OR, 0.91; 95% CI, 0.55-1.50) or 36 to 50 years (51.8%; OR, 1.08; 95% CI, 0.70-1.67). Logistic regression demonstrated that age was the only significant predictor for having a SLAP tear (P < .001). Kappa values were 0.46 to 0.65 between reviewers, indicating moderate to substantial agreement. Conclusion An increasing prevalence of MRI-based SLAP tears was observed with increasing patient age. Patients older than 50 years were significantly more likely to have superior labral abnormalities regardless of other shoulder injury or disease.
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Affiliation(s)
- Drew A Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Ilya Bendich
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Daria Motamedi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
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Charles MD, Christian DR, Cole BJ. An Age and Activity Algorithm for Treatment of Type II SLAP Tears. Open Orthop J 2018; 12:271-281. [PMID: 30197708 PMCID: PMC6110066 DOI: 10.2174/1874325001812010271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/24/2018] [Accepted: 05/24/2018] [Indexed: 12/26/2022] Open
Abstract
Background Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy. Objective To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level. Methods A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm. Results Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker's compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis. Conclusion Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.
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Affiliation(s)
- Michael D Charles
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
| | - David R Christian
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
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DeFroda SF, Goyal D, Patel N, Gupta N, Mulcahey MK. Shoulder Instability in the Overhead Athlete. Curr Sports Med Rep 2018; 17:308-314. [DOI: 10.1249/jsr.0000000000000517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Michener LA, Abrams JS, Bliven KCH, Falsone S, Laudner KG, McFarland EG, Tibone JE, Thigpen CA, Uhl TL. National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries. J Athl Train 2018; 53:209-229. [PMID: 29624450 DOI: 10.4085/1062-6050-59-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To present recommendations for the diagnosis, management, outcomes, and return to play of athletes with superior labral anterior-posterior (SLAP) injuries. BACKGROUND In overhead athletes, SLAP tears are common as either acute or chronic injuries. The clinical guidelines presented here were developed based on a systematic review of the current evidence and the consensus of the writing panel. Clinicians can use these guidelines to inform decision making regarding the diagnosis, acute and long-term conservative and surgical treatment, and expected outcomes of and return-to-play guidelines for athletes with SLAP injuries. RECOMMENDATIONS Physical examination tests may aid diagnosis; 6 tests are recommended for confirming and 1 test is recommended for ruling out a SLAP lesion. Combinations of tests may be helpful to diagnose SLAP lesions. Clinical trials directly comparing outcomes between surgical and nonoperative management are absent; however, in cohort trials, the reports of function and return-to-sport outcomes are similar for each management approach. Nonoperative management that includes rehabilitation, nonsteroidal anti-inflammatory drugs, and corticosteroid injections is recommended as the first line of treatment. Rehabilitation should address deficits in shoulder internal rotation, total arc of motion, and horizontal-adduction motion, as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control. Most researchers have examined the outcomes of surgical management and found high levels of satisfaction and return of shoulder function, but the ability to return to sport varied widely, with 20% to 94% of patients returning to their sport after surgical or nonoperative management. On average, 55% of athletes returned to full participation in prior sports, but overhead athletes had a lower average return of 45%. Additional work is needed to define the criteria for diagnosing and guiding clinical decision making to optimize outcomes and return to play.
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Abstract
Background: SLAP lesions of the shoulder are challenging to diagnose by clinical means alone. Interpretation of MR images requires knowledge of the normal appearance of the labrum, its anatomical variants, and the characteristic patterns of SLAP lesions. In general, high signal extending anterior and posterior to the biceps anchor is the hallmark of SLAP lesions. Common diagnostic criteria for a SLAP lesion by MR or MR arthrography include the following: presence of a laterally curved, high signal intensity in the labrum on a coronal image, multiple or branching lines of high signal intensity in the superior labrum on a coronal image, full-thickness detachment with irregularly marginated high signal intensity and/or separation >2 mm on conventional MRI or 3 mm on MR arthrography between the labrum and glenoid on a coronal image, and a paralabral cyst extending from the superior labrum. Methods: MR diagnosis of SLAP tears may be improved with provocative maneuvers, such as longitudinal traction of the arm or positioning of the shoulder in abduction and external rotation during imaging. The use of intra-articular contrast distends the joint similar to what occurs during arthroscopy and forced diffusion under the labrum may improve the ability to detect SLAP lesions that might not be seen with standard MR. Improved diagnostic accuracy for SLAP tears is seen with 3-T compared with 1.5-T MR imaging, with or without intra-articular contrast material. Conclusion: Regardless of MR findings, however, physicians should be cautious when recommending surgery in the patient with a vague clinical picture. The patient’s history, physical exam, and imaging evaluation all should be considered together in making the decision to proceed with surgery.
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Affiliation(s)
- Robert D Boutin
- Department of Radiology, UC Davis School of Medicine, 4860 Y St., Suite 3100, Sacramento, CA 95817, USA
| | - Richard A Marder
- Department of Orthopaedic Surgery, UC Davis School of Medicine, 4860 Y St., Suite 3800, Sacramento, CA 95817, USA
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Aydin N, Unal MB, Asansu M, Tok O. Concomitant SLAP repair does not influence the surgical outcome for arthroscopic Bankart repair of traumatic shoulder dislocations. J Orthop Surg (Hong Kong) 2018; 25:2309499017718952. [PMID: 28675978 DOI: 10.1177/2309499017718952] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Prior studies revealed the presence of superior labrum anterior-to-posterior (SLAP) injury together with Bankart lesions in some patients. The purpose of the study is to compare the clinical results of isolated Bankart repairs with the clinical results of Bankart repairs when performed with concomitant SLAP repairs. METHODS The patients who underwent arthroscopic surgery for treatment of anterior glenohumeral instability were evaluated retrospectively. Group 1 consisted of 19 patients who had arthroscopic SLAP repair together with Bankart repair. The mean age of the patients was 23. Group 2 consisted of 38 patients who underwent isolated Bankart repair. The mean age was 24. Knotless anchors were used in both groups. RESULTS The mean follow-up was 34 months (range: 26-72). In group 1, the mean preoperative Constant score was 84 (range: 74-90, standard deviation (SD): 5.91) and Rowe score was 64.1 (range: 40-70, SD: 8.14). In group 2, the preoperative Constant score was 84.4 (range: 70-96, SD: 5.88) and Rowe score was 60 (range: 45-70, SD: 7.95). In group 1, the postoperative mean Constant score raised to 96.8 (range: 88-100, SD: 2.91) and the mean Rowe score raised to 92.3 (range: 85-100, SD: 5.17). In group 2, the postoperative mean Constant score was 94.9 (range: 88-100, SD: 3.70) and the mean Rowe score was 94.2 (range: 80-100, SD: 4.71). The difference between the scores of two groups was insignificant ( p > 0.05). When the numbers of redislocations and range of motion were compared, no significant difference was found ( p > 0.05). CONCLUSION Accompanying SLAP repair in surgical treatment with Bankart repair for shoulder instability does not affect the results negatively. Properly repaired labral tears extending from anterior inferior to the posterior superior of the glenoid in instability treatment have the same outcome in overall results as repaired isolated Bankart lesions.
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Affiliation(s)
- Nuri Aydin
- 1 Department of Orthopedics and Traumatology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Mehmet Bekir Unal
- 2 Department of Orthopedics and Traumatology, Marmara University, Istanbul, Turkey
| | - Mustafa Asansu
- 3 Department of Orthopedics and Traumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Okan Tok
- 4 Department of Orthopedics and Traumatology, Lutfiye Nuri Burat State Hospital, Istanbul, Turkey
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Cotter EJ, Hannon CP, Christian D, Frank RM, Bach BR. Comprehensive Examination of the Athlete's Shoulder. Sports Health 2018; 10:366-375. [PMID: 29443643 PMCID: PMC6044121 DOI: 10.1177/1941738118757197] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Context: Shoulder pain and dysfunction are common, with patients presenting complaints
to both primary and orthopaedic physicians. History and physical examination
remain essential to creating a differential diagnosis, even as noninvasive
imaging has improved. Evidence Acquisition: Literature was obtained through keyword searches based on the pathology in
question (eg, rotator cuff) and the keywords physical
examination using PubMed from January 1, 1980, through
September 20, 2017. Additional evidence was obtained through screening
references from articles identified through the PubMed searches. Study Design: Clinical review. Level of Evidence: Level 3. Results: A total of 7817 articles were screened for relevance. Several physical
examination maneuvers have been described for each specific pathology. The
Neer sign has a 75% sensitivity for subacromial impingement (SAI), while the
Hawkins-Kennedy test has an 80% sensitivity. The painful arc test has an 80%
specificity for SAI. The apprehension test has a hazard ratio of 2.96 for
anterior shoulder instability. The Jobe test has a sensitivity of 52.6% and
a specificity of 82.4% for full-thickness supraspinatus tears, confirmed on
arthroscopy. The lag sign is highly sensitive and specific for combined
full-thickness supraspinatus and infraspinatus tears at 97% and 93%,
respectively. The Speed test has a sensitivity of 54% and specificity of 81%
for biceps pathology. The anterior slide test and O’Brien active compression
test have been described for superior labrum anterior posterior tears with
inconsistent reliability. The cross-body adduction test has a sensitivity of
77% and a specificity of 79% for acromioclavicular joint pathology. Conclusion: Several physical examination maneuvers can isolate specific pathology of the
shoulder, with widely ranging sensitivity and specificity.
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Affiliation(s)
- Eric J Cotter
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Charles P Hannon
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - David Christian
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Rachel M Frank
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Bernard R Bach
- Section of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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MRI to Arthroscopy Correlations in SLAP Lesions and Long Head Biceps Pathology. Sports Med Arthrosc Rev 2017; 25:179-190. [PMID: 29095396 DOI: 10.1097/jsa.0000000000000164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Superior labral anterior and posterior lesions and long head biceps injury are 2 common sources of shoulder pain. The presenting complaints and physical examination findings for these etiologies are often nonspecific, making diagnosis challenging. Further complicating their diagnoses, these 2 pathologies often cooccur together or with other shoulder pathologies such as subacromial bursitis, rotator cuff tear, and shoulder instability. However, with advancement in magnetic resonance imaging and shoulder arthroscopy techniques the ability to diagnose and treat these pathologies has vastly improved over the past 30 years. This review provides a case-based description of the correlation between magnetic resonance imaging and arthroscopic findings in common superior labral anterior and posterior and long head biceps injury, accompanied with current management strategies.
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Gilmer BB, Harnden E, Guttmann D. Diagnosis of long head of the biceps tendon pathology: current concepts. J ISAKOS 2017. [DOI: 10.1136/jisakos-2017-000128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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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.
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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.
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Symanski JS, Subhas N, Babb J, Nicholson J, Gyftopoulos S. Diagnosis of Superior Labrum Anterior-to-Posterior Tears by Using MR Imaging and MR Arthrography: A Systematic Review and Meta-Analysis. Radiology 2017; 285:101-113. [PMID: 28604236 DOI: 10.1148/radiol.2017162681] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Purpose To evaluate the diagnostic accuracies of nonenhanced magnetic resonance (MR) imaging and MR arthrography for diagnosis of superior labrum anterior-to-posterior (SLAP) tears by using a systematic review and meta-analysis. Materials and Methods A comprehensive literature search was performed on the two main concepts of MR imaging (MR imaging, and direct and indirect MR arthrography) and SLAP tears. Inclusion criteria consisted of original studies that assessed the diagnostic accuracy of MR imaging, direct MR arthrography, and/or indirect MR arthrography for the detection of SLAP tears, by using surgical findings as the reference standard. The Quality Assessment of Diagnostic Accuracy Studies 2, or QUADAS-2 Quality Assessment of Diagnostic Accuracy Studies 2 Quality Assessment of Diagnostic Accuracy Studies 2 , tool was used to assess methodologic quality. Meta-analyses were performed that compared MR imaging studies to direct MR arthrography studies and indirect MR arthrography studies, 3-T studies to 1.5-T studies, and low-bias MR imaging studies to low-bias direct MR arthrography studies. Study variation was analyzed by using the Cochran Q test of heterogeneity and the I2 statistic. Results Thirty-two studies met inclusion and exclusion criteria, including 3524 imaging examinations: 1963 direct MR arthrography examinations (23 studies), 1402 MR examinations (14 studies), and 159 indirect MR arthrography examinations (three studies). Twelve studies had low risk for bias, two had questionable risk, and 18 had high risk. Mean sensitivities of direct MR arthrography, MR imaging, and indirect MR arthrography for SLAP tear diagnosis were 80.4%, 63.0%, and 74.2%, respectively. Mean specificities of direct MR arthrography, MR imaging, and indirect MR arthrography were 90.7%, 87.2%, and 66.5%, respectively. Summary receiver operator characteristic (ROC) curve demonstrated superior accuracy of direct MR arthrography compared with those of MR imaging and indirect MR arthrography. Similar findings were observed in the low-bias subanalysis. Summary ROC curve demonstrated overall superiority of 3-T imaging, with or without intra-articular contrast material compared with 1.5-T imaging, with or without intra-articular contrast material. Significant variance was observed for MR imaging and direct MR arthrography (P < .001) studies for both mean sensitivity and specificity. Conclusion Direct MR arthrography appears to be more accurate than nonenhanced MR imaging for diagnosis of SLAP tears, whereas 3-T MR imaging with or without intra-articular contrast material appears to improve diagnostic accuracy compared with 1.5-T MR imaging with or without intra-articular contrast material. © RSNA, 2017 Online supplemental material is available for this article.
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Affiliation(s)
- John S Symanski
- From the Department of Radiology, NYU Langone Medical Center/Hospital for Joint Diseases, 660 First Ave, New York, NY 10016 (J.S.S., J.B., S.G.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (N.S.); and NYU Health Sciences Library, NYU School of Medicine, New York, NY (J.N.)
| | - Naveen Subhas
- From the Department of Radiology, NYU Langone Medical Center/Hospital for Joint Diseases, 660 First Ave, New York, NY 10016 (J.S.S., J.B., S.G.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (N.S.); and NYU Health Sciences Library, NYU School of Medicine, New York, NY (J.N.)
| | - James Babb
- From the Department of Radiology, NYU Langone Medical Center/Hospital for Joint Diseases, 660 First Ave, New York, NY 10016 (J.S.S., J.B., S.G.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (N.S.); and NYU Health Sciences Library, NYU School of Medicine, New York, NY (J.N.)
| | - Joseph Nicholson
- From the Department of Radiology, NYU Langone Medical Center/Hospital for Joint Diseases, 660 First Ave, New York, NY 10016 (J.S.S., J.B., S.G.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (N.S.); and NYU Health Sciences Library, NYU School of Medicine, New York, NY (J.N.)
| | - Soterios Gyftopoulos
- From the Department of Radiology, NYU Langone Medical Center/Hospital for Joint Diseases, 660 First Ave, New York, NY 10016 (J.S.S., J.B., S.G.); Department of Radiology, Cleveland Clinic, Cleveland, Ohio (N.S.); and NYU Health Sciences Library, NYU School of Medicine, New York, NY (J.N.)
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Sodha S, Srikumaran U, Choi K, Borade AU, McFarland EG. Clinical Assessment of the Dynamic Labral Shear Test for Superior Labrum Anterior and Posterior Lesions. Am J Sports Med 2017; 45:775-781. [PMID: 28298065 DOI: 10.1177/0363546517690349] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Diagnosing superior labrum anterior and posterior (SLAP) lesions through physical examination remains challenging. The dynamic labral shear test (DLST) has been shown to have likelihood ratios (LRs) of 31.6 and 1.1 for diagnosing SLAP lesions. PURPOSE To determine the clinical utility of the DLST for diagnosing SLAP lesions. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS This prospective, consecutive case series included 774 patients who underwent diagnostic arthroscopy and a preoperative DLST between 2007 and 2013. Patients were divided into 3 groups: 610 control patients with no SLAP lesion but with other abnormalities, 9 patients with isolated SLAP lesion (ISL), and 155 patients with concomitant SLAP lesion (CSL), who had a SLAP lesion and another shoulder abnormality. We determined sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), odds ratio (OR), and diagnostic accuracy (DA) of the DLST with and without other tests. RESULTS The DLST was positive for 242 of 610 controls (40%), 7 of 9 patients (78%) in the ISL group, and 88 of 155 patients (57%) in the CSL group. In the ISL group, the DLST had a sensitivity of 78%, specificity of 51%, PPV of 2%, NPV of 100%, OR of 3.58, and DA of 51%. In comparison, the ORs were 1.09 for the active compression test, 1.30 for the lift-off test, and 1.53 for the relocation test, which were not significantly different from each other. For diagnosing a SLAP lesion existing in a joint with other associated injury, the DLST had a sensitivity of 57%, specificity of 52%, PPV of 23%, NPV of 83%, OR of 1.4, and DA of 53%. Combining all 4 tests did not improve the OR for detecting ISLs or CSLs. CONCLUSION The DLST is sensitive but not specific for detecting ISLs. With an OR of 3.58, the DLST is useful for diagnosing ISLs. However, in patients who have CSLs, the DLST is not as useful for diagnosing SLAP lesions.
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Affiliation(s)
- Sonal Sodha
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Uma Srikumaran
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Kyubo Choi
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Amrut U Borade
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Edward G McFarland
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
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Abstract
The overhead pitching motion is a coordinated sequence of movements that subjects the shoulder to extreme forces. The ultimate goal of this complex, dynamic activity is to generate high ball velocity and accuracy. In doing so, repetitive throwing can cause adaptive and pathologic changes in the thrower's shoulder. This article reviews the relevant shoulder anatomy, the kinetic chain, and throwing mechanics, as well as common shoulder injuries and surgical options for the treating orthopedic surgeon.
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Affiliation(s)
- Ryan A Mlynarek
- Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, Ann Arbor, MI 48109-5328, USA
| | - Simon Lee
- Department of Orthopaedic Surgery, University of Michigan, 2912 Taubman Center, Ann Arbor, MI 48109-5328, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, Shoulder and Sports Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby A, Suite 1000, Ann Arbor, MI 48106, USA.
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Abstract
Lesions of the proximal long head of the biceps tendon (LHB) have been considered as a major cause of shoulder pain and dysfunction. The role of the LHB in causing pain has been a source of controversy for many years, and extensive literature is available discussing anatomy, function, pathology, and most importantly appropriate treatment. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Biceps tenotomy and tenodesis are common surgical treatment options when dealing with LHB-related pathology. In this review, a brief discussion on surgical options is provided while focusing on the different options for biceps tenodesis including outcomes and complications.
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Affiliation(s)
- Saad M AlQahtani
- Division of Orthopedic Surgery, Department of Surgery, Queen's University, Kingston General Hospital, Watkins 3, 76 Stuart Street, Kingston, Ontario, Canada, K7L 2V7
- Department of Orthopedic Surgery, University of Dammam, Dammam, Saudi Arabia
| | - Ryan T Bicknell
- Division of Orthopedic Surgery, Department of Surgery, Queen's University, Kingston General Hospital, Watkins 3, 76 Stuart Street, Kingston, Ontario, Canada, K7L 2V7.
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García Parra P, Anaya Rojas M, Jiménez Bravo B, González Oria M, Lisbona Muñoz M, Gil Álvarez J, Cano Luis P. Correlation between physical examination and intraoperative findings in shoulder disease treated by arthroscopy. Statistical analysis of 150 patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016. [DOI: 10.1016/j.recote.2016.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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31
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García Parra P, Anaya Rojas M, Jiménez Bravo B, González Oria MO, Lisbona Muñoz M, Gil Álvarez JJ, Cano Luis P. Correlation between physical examination and intraoperative findings in shoulder disease treated by arthroscopy. Statistical analysis of 150 patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016; 60:306-14. [PMID: 27435988 DOI: 10.1016/j.recot.2016.05.002] [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: 08/30/2015] [Revised: 03/21/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Only a few clinical exploratory manoeuvres are truly discriminatory and useful in shoulder disease. The aim of this study is to correlate the physical examination results of the shoulder with the true diagnosis found by arthroscopy. METHODS A retrospective case series of 150 patients with the most common surgical conditions of the shoulder. Data were collected on the suspicion of each pathology, the physical examination of the patient, and the actual discovery of the disease during arthroscopic surgery. RESULTS The Bankart examination manoeuvres of the lesion show the best results, with a 92.1% positive prediction value (PPV), a 99.1% negative predictive value (NPV), followed by the impingement syndrome, with a PPV of 94.4%, and total cuff rupture with a PPV of 92.3%.Exploration of the superior labrum anterior to posterior (SLAP) lesion had an NPV of 99.1%. CONCLUSION Physical examination is sufficient to diagnose or rule out Bankart. A positive physical examination provides the complete rupture of the rotator cuff, and requires further studies. The patients suspected of subacromial syndrome only need an NMR if the physical tests are negative. The conclusions drawn from this work can have a significant impact on both cost savings (by reducing forward tests), and saving time in certain cases in which, after appropriate physical examination, surgery may be indicated without losing time in intermediate steps.
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Affiliation(s)
- P García Parra
- Servicio de Traumatología y Cirugía Ortopédica, HH. UU. Virgen del Rocío, Sevilla, España.
| | - M Anaya Rojas
- Servicio de Traumatología y Cirugía Ortopédica, HH. UU. Virgen del Rocío, Sevilla, España
| | - B Jiménez Bravo
- Servicio de Traumatología y Cirugía Ortopédica, HH. UU. Virgen del Rocío, Sevilla, España
| | - M O González Oria
- Servicio de Medicina Física y Rehabilitación, HH. UU. Virgen del Rocío, Sevilla, España
| | - M Lisbona Muñoz
- Servicio de Reumatología, HH. UU. Virgen del Rocío, Sevilla, España
| | - J J Gil Álvarez
- Servicio de Traumatología y Cirugía Ortopédica, HH. UU. Virgen del Rocío, Sevilla, España
| | - P Cano Luis
- Servicio de Traumatología y Cirugía Ortopédica, HH. UU. Virgen del Rocío, Sevilla, España
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Finnoff JT, Costouros JG, Kennedy DJ. Is ultrasound guidance needed for shoulder injections? PM R 2016; 7:435-42. [PMID: 25890640 DOI: 10.1016/j.pmrj.2015.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/10/2015] [Indexed: 11/18/2022]
Affiliation(s)
| | - John G Costouros
- Department of Orthopaedics, Stanford University, Redwood City, CA(†)
| | - David J Kennedy
- Department of Orthopaedics, Stanford University, MC 6342, 450 Broadway St, Redwood City, CA 94063(‡).
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Schwartzberg R, Reuss BL, Burkhart BG, Butterfield M, Wu JY, McLean KW. High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthop J Sports Med 2016; 4:2325967115623212. [PMID: 26779556 PMCID: PMC4710128 DOI: 10.1177/2325967115623212] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background: The incidence of superior labral surgery has increased in the past decade in the United States, and a contributing factor could be an increased rate of superior labral tears diagnosed with magnetic resonance imaging (MRI). Prior MRI studies of the asymptomatic shoulder have focused on rotator cuff pathology or pathology in a narrow and specific group of athletes. Labral abnormalities have not previously been thoroughly evaluated in asymptomatic middle-aged individuals. Purpose: To evaluate the prevalence of superior labral tears diagnosed by MRI in the asymptomatic shoulders of middle-aged people (age range, 45-60 years). Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 53 asymptomatic adults (age range, 45-60 years) with no history of surgery or injury to either shoulder were included in the study. Physical examinations of all shoulders were performed. Noncontrast MRI (1.5 T) was performed in 1 randomly determined shoulder of each subject. Two fellowship-trained musculoskeletal radiologists who were blinded to the purpose of the study and ages of the subjects evaluated each MRI. Results: Radiologists interpreted the MRIs as consistent with superior labral tears in 55% and 72% of the cohort. Comparison of the radiological evaluations of the superior labra were moderate (κ = 0.410, P = .033). There were no differences in readings for superior labral tear regarding age (P = .87), sex (P = .41), whether the dominant shoulder underwent MRI (P = .99), whether the subject worked a physical job (P = .08), or whether the subject participated in overhead sports for a period of 1 year (P = .62). Conclusion: Superior labral tears are diagnosed with high frequency using MRI in 45- to 60-year-old individuals with asymptomatic shoulders. These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population. Clinical Relevance: To avoid overtreatment, physicians should realize that superior labral tears diagnosed by MRI in individuals between the ages of 45 and 60 years may be normal age-related findings.
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Affiliation(s)
| | | | | | | | - James Y Wu
- Center for Diagnostic Imaging, Winter Park, Florida, USA
| | - Kevin W McLean
- Center for Diagnostic Imaging, Winter Park, Florida, USA
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Abstract
The examination of the shoulder for conditions involving the biceps tendon continues to be challenging. Numerous examination tests for biceps and superior labrum anterior and posterior (SLAP) lesions have been scientifically evaluated. This section reports on how to perform these tests and summarizes the clinical utility of the tests. Many of the tests for the examination of the biceps and for SLAP lesions do not have high sensitivity and specificity, which limits their usefulness. Although the dynamic shear test has promise for making the diagnosis of SLAP lesions, the studies reporting its clinical utility are disparate.
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Affiliation(s)
- Edward G McFarland
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 10753 Falls Road, Pavilion II, Suite 215, Lutherville, Baltimore, MD 21093, USA.
| | - Amrut Borade
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA
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Sheridan K, Kreulen C, Kim S, Mak W, Lewis K, Marder R. Accuracy of magnetic resonance imaging to diagnose superior labrum anterior-posterior tears. Knee Surg Sports Traumatol Arthrosc 2015; 23:2645-50. [PMID: 24985524 DOI: 10.1007/s00167-014-3109-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 05/29/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the accuracy of magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) in diagnosing superior labral anterior-posterior (SLAP) lesions. We hypothesized that the accuracy of MRI and MRA was lower than previously reported. METHODS Between 2006 and 2008, 444 patients who had both shoulder arthroscopy and an MRI (non-contrast or MR arthrography) for shoulder pain at our institution prior to surgery were identified and included in the study. The radiologic diagnosis and surgical evaluation were compared to determine the accuracy of diagnosing a SLAP lesion by MRI. Using arthroscopy as the standard, sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all MRIs, as well as separately for the non-intra-articular contrast MRI group and the MR arthrography group. RESULTS Of the 444 patients having an MRI and arthroscopy for shoulder pain, 121 had a SLAP diagnosis by MRI and 44 had a SLAP diagnosis by arthroscopy. Overall, MRI had an accuracy of 76 %, a PPV of 24 %, and a NPV of 95 %. Sensitivity was 66 %, and specificity was 77 %. MR arthrography had an accuracy of 69 %, sensitivity of 80 %, and a PPV of 29 %. Non-contrast MRI had an accuracy of 85 %, sensitivity of 36 %, and a PPV of 13 %. CONCLUSIONS In our retrospective study of 444 patients, sensitivity, specificity, and accuracy were all lower than previously reported in the literature for diagnosing SLAP lesions. Our data indicated that while MRI could exclude a SLAP lesion (NPV = 95 %), MRI alone was not an accurate clinical tool. MR arthrography had a large number of false-positive readings in this study. We concluded that even with intra-articular contrast, MRI had limitations in the ability to diagnose surgically proven SLAP lesions.
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Affiliation(s)
- Kent Sheridan
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, 4860 Y Street, Suite 3800, Sacramento, CA, 95817, USA,
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Abstract
The large amount of force imparted across the shoulder during the act of throwing makes the glenohumeral joint highly susceptible to injury in the athlete performing overhead throwing motions. The bony incongruity of the shoulder enables greater range of motion than any other joint in the body, but it also results in significant strain on the surrounding soft tissues during the throwing motion. Throwers can present with acute injuries, but more commonly they suffer from chronic overuse conditions resulting from repetitive overload. Proper management requires early recognition with treatment directed toward the athlete's safe return to sports. Failure to institute an appropriate management strategy may result in significant complications, including prolonged disability, progression of symptoms, and further injury. We discuss the functional anatomy, pathophysiology, clinical presentation, evaluation, and treatment of common injuries of the glenoid labrum and rotator cuff in the overhead throwing athlete.
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Affiliation(s)
- Travis J Menge
- Department of Orthopedic Surgery and Rehabilitation, Vanderbilt University , Nashville, TN , USA
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Gupta AK, Chalmers PN, Klosterman EL, Harris JD, Bach BR, Verma NN, Cole BJ, Romeo AA. Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear. Orthopedics 2015; 38:e48-53. [PMID: 25611420 DOI: 10.3928/01477447-20150105-60] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 04/10/2014] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to evaluate the outcomes of patients undergoing subpectoral biceps tenodesis for bicipital tendonitis with a superior labral anterior-posterior (SLAP) tear. Patients undergoing primary subpectoral biceps tenodesis for arthroscopically confirmed SLAP tears with signs or findings of bicipital tendonitis were included. An independent observer collected data prospectively as part of a data repository, which was then analyzed retrospectively. Primary outcome measures were the American Shoulder and Elbow Surgeons (ASES) score and pain relief via visual analog scale (VAS). Secondary outcome measures included the Simple Shoulder Test (SST), Constant, Single Assessment Numeric Evaluation (SANE), and Short Form 12 (SF-12) scores. Twenty-eight patients with a mean±SD age of 43.7±13.4 years and a mean±SD follow-up of 2.0±1.0 years met inclusion criteria. Workers' compensation was involved with 43% of cases, and 46% of the included patients were manual laborers. Eight (32%) patients were athletes, and 88% of the athletes were overhead athletes. Intraoperatively, 15 (54%) patients had type I SLAP tears, 10 (36%) had type II SLAP tears, 1 (3%) had a type III SLAP tear, and 2 (7%) had type IV SLAP tears. Significant improvements were seen in the following outcome measures pre- vs postoperatively: ASES score (58±23 vs 89±18; P=.001), SST score (6.3±3.6 vs 10.6±3.3; P=.001), SANE score (54±24 vs 88±25; P=.003), VAS score (3.8±2.0 vs 1.1±1.8; P=.001), SF-12 overall score (35±6 vs 42±6; P=.001), and SF-12 physical component score (39±6 vs 50±10; P=.001). Overall satisfaction was excellent in 80% of patients. Subpectoral biceps tenodesis demonstrates excellent clinical outcomes in select patients with SLAP tears. [Orthopedics. 2015; 38(1):e48-e53.].
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38
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Garbis NG, McFarland EG. Understanding and evaluating shoulder pain in the throwing athlete. Phys Med Rehabil Clin N Am 2014; 25:735-61. [PMID: 25442157 DOI: 10.1016/j.pmr.2014.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Shoulder pain in the throwing athlete can present at any age and in any level of sport and can lead to dysfunction. A thorough evaluation of the throwing athlete can often determine the cause of symptoms, which is frequently multifactorial. Although the pathophysiology leading to pain in the shoulder of the throwing athlete is not entirely known, nonoperative modalities remain the mainstay of treatment. In general, surgical intervention should be reserved as a last resort. Effective treatment often requires collaboration among trainers, players, physicians, and therapists to determine an appropriate course of action.
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Affiliation(s)
- Nickolas G Garbis
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University, 2160 South 1st Avenue, Maywood, IL 60153, USA
| | - Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA.
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Gaudelli C, Hébert-Davies J, Balg F, Pelet S, Djahangiri A, Godbout V, Rouleau DM. The Impact of Superior Labral Anterior to Posterior Lesions on Functional Status in Shoulder Instability: A Multicenter Cohort Study. Orthop J Sports Med 2014; 2:2325967114554195. [PMID: 26535278 PMCID: PMC4555552 DOI: 10.1177/2325967114554195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Type IV superior labral anterior to posterior (SLAP) lesions, which are superior labral detachments associated with Bankart tears, are reported to occur in up to 25% of recurrent shoulder instability patients. However, the clinical implications of this finding are debatable. PURPOSE To determine whether there are any functional differences between anterior instability patients with and without type IV SLAP lesions at the time of presentation and at short-term follow-up after surgical intervention. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A prospective, multicenter database was established to follow the clinical evolution of patients with shoulder instability. Patients were diagnosed as having a type IV SLAP lesion at the time of arthroscopic Bankart surgery (SLAP+). These patients were compared with a group of patients who simply had a Bankart lesion (SLAP-). The 2 groups had their functional outcomes (Western Ontario Shoulder Instability Index [WOSI]; Disability of the Arm, Shoulder, and Hand [QuickDASH]; and Walch-Duplay) compared prior to surgery and 1 year postoperatively. RESULTS A total of 103 subjects were included in the study; of these, 56 (43 men, 13 women) completed 1-year follow-up. Twenty-three subjects had a type IV SLAP tear, and most had this repaired along with their Bankart lesion. At baseline, SLAP+ subjects had inferior QuickDASH scores compared with SLAP- subjects (37.8 vs 29.0) as well as poorer pain subscores on both the WOSI and QuickDASH. At 1-year follow-up, however, there were no significant differences in any of the outcome measures. CONCLUSION A type IV SLAP lesion can be expected in 22% of patients with recurrent shoulder instability. This finding implies that at baseline, the patient will have slightly worse functional scores related to pain. However, following surgical management of the labral pathology, these patients will have equivalent functional outcomes at short-term follow-up. CLINICAL RELEVANCE With surgical management of the superior and anteroinferior labrum, patients with type IV SLAP lesions will do as well as those with only Bankart tears. Thus, the presence of SLAP lesions should not alter the decision to provide surgical management and should not change the prognosis for a specific patient.
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Affiliation(s)
- Cinzia Gaudelli
- Université de Montréal and Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
| | | | - Frédéric Balg
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Stéphane Pelet
- Centre Hospitalier Affilié Universitaire de Québec, Québec, Canada
| | - Ali Djahangiri
- Centre Hospitalier Universitaire de Vaudois, Lausanne, Switzerland
| | - Véronique Godbout
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Dominique M Rouleau
- Université de Montréal and Hôpital du Sacré-Coeur de Montréal, Montréal, Québec, Canada
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40
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King JJ, Wright TW. Physical examination of the shoulder. J Hand Surg Am 2014; 39:2103-12. [PMID: 25257491 DOI: 10.1016/j.jhsa.2014.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 04/03/2014] [Accepted: 04/06/2014] [Indexed: 02/02/2023]
Abstract
This article summarizes the overall assessment of the shoulder joint and seeks to help direct clinicians to diagnose shoulder pathology using standard and specific physical examinations. The history and standard examination can prompt the examiner to focus on specific tests to further evaluate the shoulder and limit the differential diagnoses. An appropriate and directed shoulder physical examination allows the clinician to focus on further diagnostic strategies and treatment options for the patient.
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Affiliation(s)
- Joseph J King
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, FL
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, FL.
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41
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Arnander M, Tennent D. Clinical assessment of the glenoid labrum. Shoulder Elbow 2014; 6:291-9. [PMID: 27582948 PMCID: PMC4935037 DOI: 10.1177/1758573214546156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 07/14/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND The glenoid labrum is integral to shoulder stability and can be difficult to assess clinically. Whilst it is a single anatomical structure, damage to different regions results in very different clinical manifestations. A large number of provocative tests have been described, all of which initially purport to have excellent diagnostic accuracy. Clinical experience suggests that this is not the case and decision making can be difficult for the non-expert. The purpose of this study is to review the current evidence for the most commonly used tests and to provide suggestions for tests which have the most evidence for efficacy. METHODS The glenoid labrum was divided into anterior, superior and posterior regions. The English language literature describing labral tests was reviewed. The evidence provided by the authors and any subsequent studies was analysed. RESULTS Whilst a large number if tests have been described with the primary authors reporting excellent results the evidence for most is poor when later tested critically. DISCUSSION No single test will accurately diagnose labral pathology. The clinician must use evidence from the clinical history combined with selective use and interpretation of tests with which they are familiar.
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Affiliation(s)
| | - Duncan Tennent
- D. Tennent, St George’s Hospital, Blackshaw Road,
Tooting, London SW17 0QT, UK. Tel: +44 (0)208 725 2032.
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42
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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.
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Gottschalk MB, Karas SG, Ghattas TN, Burdette R. Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions. Am J Sports Med 2014; 42:2128-35. [PMID: 25053696 DOI: 10.1177/0363546514540273] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical repair remains the gold standard for most type II and type IV superior labral anterior and posterior (SLAP) lesions that fail nonoperative management. However, most recently, there have been data demonstrating unacceptably high failure rates with primary repair of type II SLAP lesions. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions. HYPOTHESIS Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV SLAP lesions. STUDY DESIGN Case series; Level of evidence, 4. METHODS Patients who underwent subpectoral biceps tenodesis and labral debridement for type II and type IV SLAP lesions by a single board-certified shoulder surgeon from 2006 to 2012 were evaluated. Exclusion criteria included those patients who underwent biceps tenodesis with an associated rotator cuff repair, anterior labral repair, or posterior labral repair. Outcome measures included the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, and demographic data. RESULTS Between 2006 and 2012, a total of 36 subpectoral biceps tenodesis procedures were performed in 33 patients for type II or IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow-up. The average age was 46.7 years, with 16 male and 10 female patients participating in the study. The average follow-up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared with 87.5 and 1.5 postoperatively, respectively (P < .001). There was no significant difference based on SLAP lesion type, patient age, or patient sex. Of 29 shoulders, 26 (89.66%) were able to return to the previous level of activity. CONCLUSION This study adds to the evolving literature supporting biceps tenodesis as a viable treatment for type II and IV SLAP lesions. Patient age had no effect on the outcomes. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.
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Affiliation(s)
- Michael B Gottschalk
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Spero G Karas
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA Atlanta Falcons, Atlanta, Georgia, USA
| | - Timothy N Ghattas
- OrthoAtlanta Sports Medicine, Southern Orthopaedic Specialists LLC, Atlanta, Georgia, USA
| | - Rachel Burdette
- Department of Sports Medicine, Ochsner Health Systems, New Orleans, Louisiana, USA
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Aydin N, Sirin E, Arya A. Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management. World J Orthop 2014; 5:344-350. [PMID: 25035838 PMCID: PMC4095028 DOI: 10.5312/wjo.v5.i3.344] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Accepted: 04/03/2014] [Indexed: 02/06/2023] Open
Abstract
After the improvement in arthroscopic shoulder surgery, superior labrum anterior to posterior (SLAP) tears are increasingly recognized and treated in persons with excessive overhead activities like throwers. Several potential mechanisms for the pathophysiology of superior labral tears have been proposed. The diagnosis of this condition can be possible by history, physical examination and magnetic resonance imaging combination. The treatment of type 1 SLAP tears in many cases especially in older patients is non-operative but some cases need arthroscopic intervention. The arthroscopic management of type 2 lesions in older patients can be biceps tenodesis, but young and active patients like throwers will need an arthroscopic repair. The results of arthroscopic repair in older patients are not encouraging. The purpose of this study is to perform an overview of the diagnosis of the SLAP tears and to help decision making for the surgical management.
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45
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Moeller CR, Bliven KCH, Valier ARS. Scapular muscle-activation ratios in patients with shoulder injuries during functional shoulder exercises. J Athl Train 2014; 49:345-55. [PMID: 24840585 DOI: 10.4085/1062-6050-49.3.10] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
CONTEXT Alterations in scapular muscle activation, which are common with glenohumeral (GH) injuries, affect stability and function. Rehabilitation aims to reestablish activation between muscles for stability by progressing to whole-body movements. OBJECTIVE To determine scapular muscle-activation ratios and individual muscle activity (upper trapezius [UT], middle trapezius [MT], lower trapezius [LT], serratus anterior [SA]) differences between participants with GH injuries and healthy control participants during functional rehabilitation exercises. DESIGN Cross-sectional study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS Thirty-nine participants who had GH injuries (n = 20; age = 23.6 ± 3.2 years, height = 170.7 ± 11.5 cm, mass = 74.7 ± 13.1 kg) or were healthy (n = 19; age = 24.4 ± 3.3 years, height = 173.6 ± 8.6 cm, mass = 74.7 ± 14.8 kg) were tested. INTERVENTION(S) Clinical examination confirmed each participant's classification as GH injury or healthy control. Participants performed 4 exercises (bow and arrow, external rotation with scapular squeeze, lawnmower, robbery) over 3 seconds with no load while muscle activity was recorded. MAIN OUTCOME MEASURE(S) We used surface electromyography to measure UT, MT, LT, and SA muscle activity. Scapular muscle-activation ratios (UT:MT, UT:LT, and UT:SA) were calculated (normalized mean electromyography of the UT divided by normalized mean electromyography of the MT, LT, and SA). Exercise × group analyses of variance with repeated measures were conducted. RESULTS No group differences for activation ratios or individual muscle activation amplitude were found (P > .05). Similar UT:MT and UT:LT activation ratios during bow-and-arrow and robbery exercises were seen (P > .05); both had greater activation than external-rotation-with-scapular-squeeze and lawnmower exercises (P < .05). The bow-and-arrow exercise elicited the highest activation from the UT, MT, and LT muscles; SA activation was greatest during the external-rotation-with-scapular-squeeze exercise. CONCLUSIONS Scapular muscle activation was similar between participants with GH injuries and healthy control participants when performing the unloaded multiplanar, multijoint exercises tested. High activation ratios during the bow-and-arrow exercise indicate UT hyperactivity or decreased MT, LT, and SA activity. Our GH injury group may be comparable to high-functioning injured athletes. Study results may assist clinicians in selecting appropriate exercises for scapular muscle activation when caring for injured athletes.
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Malal JJG, Khan Y, Farrar G, Waseem M. Superior labral anterior posterior lesions of the shoulder. Open Orthop J 2013; 7:356-60. [PMID: 24082975 PMCID: PMC3785040 DOI: 10.2174/1874325001307010356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 10/26/2012] [Accepted: 11/16/2012] [Indexed: 01/02/2023] Open
Abstract
Superior labrum anterior and posterior (SLAP) lesion is of fairly recent description and its understanding is rapidly evolving. Its incidence and need for surgical treatment has increased exponentially in line with the increase in shoulder arthroscopies. It is of particular importance in the elite over head athlete and the young. A range of arthroscopic techniques and devices have been described with good functional results. The ability to return to pre injury level of sports remains a concern.
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Donnelly TD, Ashwin S, MacFarlane RJ, Waseem M. Clinical assessment of the shoulder. Open Orthop J 2013; 7:310-5. [PMID: 24082969 PMCID: PMC3785041 DOI: 10.2174/1874325001307010310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Revised: 12/01/2012] [Accepted: 12/29/2012] [Indexed: 12/21/2022] Open
Abstract
The shoulder joint is complex in structure and functionality. It is often difficult to assess clinically due to the great variety of associated pathology. This article presents an overview of the anatomy of the shoulder region and associated pathologies, whilst providing a summary of the clinical examination of the shoulder and associated 'special tests'. A full history is vital when assessing shoulder pathology. No particular test is fully sensitive or specific alone and accuracy varies between both clinicians and patients alike. Assessment of the shoulder should be conducted systematically with a range of tests combined.
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Affiliation(s)
- Thomas D Donnelly
- Department of Trauma and Orthopaedics, East Cheshire Hospitals NHS Trust, Macclesfield District General Hospital, Victoria Road, Macclesfield, SK10 3BL, UK
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Arthroscopic reconstruction of shoulder's labrum with extensive tears. Int J Surg 2013; 11:876-81. [PMID: 23917210 DOI: 10.1016/j.ijsu.2013.07.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 06/26/2013] [Accepted: 07/22/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND With the continuous development of arthroscopic techniques, the majority of superior labrum anterior-posterior (SLAP) lesions can be treated with minimally invasive endoscopic repair. The aim of this study was to determine the efficacy of arthroscopic capsulolabral reconstruction of SLAP lesions with extensive tears. METHODS Eighteen patients with SLAP lesions with extensive tears (median age, 27.50 years) were included in this study. Twelve patients had type-V SLAP lesions, 4 patients had type-VIII SLAP lesions, and 2 patients had deeply located SLAP lesions. The average duration of follow-up was 15.83 months (range, 11-22 months). Outcome measures included shoulder range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores, and visual analogue scale (VAS) pain score. RESULTS After arthroscopic surgery, shoulder forward flexion, shoulder external rotation, and external rotation in 90° of abduction were significantly greater than before surgery (169.5° vs. 165.5°, P = 0.001), (90° vs. 63.5°, P < 0.001), and (90° vs. 81.5°, P = 0.004), respectively. Median ASES and Constant-Murley scores after surgery were both 94 as compared to 77.0 and 77.5, respectively, before surgery (both, P < 0.001). The median VAS score decreased to 1.5 after surgery as compared to 6 before surgery (P < 0.001). CONCLUSIONS Arthroscopic repair of SLAP lesions with extensive tears can achieve good outcomes.
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Sandrey MA. Special physical examination tests for superior labrum anterior-posterior shoulder tears: an examination of clinical usefulness. J Athl Train 2013; 48:856-8. [PMID: 23914880 DOI: 10.4085/1062-6050-48.3.14] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
REFERENCE/CITATION Calvert E, Chambers GK, Regan W, Hawkins RH, Leith JM. Special physical examination tests for superior labrum anterior-posterior shoulder injuries are clinically limited and invalid: a diagnostic systematic review. J Clin Epidemiol. 2009;62(5):558-563. CLINICAL QUESTION The systematic review focused on diagnostic accuracy studies to determine if evidence was sufficient to support the use of superior labrum anterior-posterior (SLAP) physical examination tests as valid and reliable. The primary question was whether there was sufficient evidence in the published literature to support the use of SLAP physical examination tests as valid and reliable diagnostic test procedures. DATA SOURCES Studies published in English were identified through database searches on MEDLINE, EMBASE, and the Cochrane database (1970-2004) using the search term SLAP lesions. The medical subject headings of arthroscopy, shoulder joint, and athletic injuries were combined with test or testing, physical examination, and sensitivity and specificity to locate additional sources. Other sources were identified by rereviewing the reference lists of included studies and review articles. STUDY SELECTION Studies were eligible based on the following criteria: (1) published in English, (2) focused on the physical examination of SLAP lesions, and (3) presented original data. A study was excluded if the article was limited to a clinical description of 1 or more special tests without any research focus to provide clinical accuracy data or if it did not focus on the topic. DATA EXTRACTION The abstracts that were located through the search strategies were reviewed, and potentially relevant abstracts were selected. Strict epidemiologic methods were used to obtain and collate all relevant studies; the authors developed a study questionnaire to record study name, year of publication, study design, sample size, and statistics. Validity of the diagnostic test study was determined by applying the 5 criteria proposed by Calvert et al. If the study met the inclusion and validity criteria, 95% confidence intervals were calculated for each sensitivity, specificity, and positive and negative likelihood ratio reported. No specific information was provided about the procedure if the reviewers disagreed on how the evaluation criteria were applied. MAIN RESULTS The specific search criteria led to the identification of 29 full-text articles. The studies were reviewed, and inclusion and exclusion criteria were applied. This resulted in 14 excluded studies and 15 eligible studies for analysis. Of the 15 eligible studies, 1 evaluated only a single physical examination test for a SLAP lesion or biceps tendon injury, and 10 studies evaluated 2 to 6 physical examination tests for a SLAP lesion or biceps tendon injury. Nine studies reported sensitivities and specificities greater than 75%, 4 had sensitivities less than 75%, 3 had specificities less than 75%, 1 did not report sensitivity, and 2 did not report specificities. When validity was assessed for those 15 papers, only 1 study that evaluated the biceps tendon met the 5 critical appraisal criteria of Calvert et al and calculated 95% confidence intervals. When the Speed and Yergason tests were each compared with the gold standard (arthroscopy), the confidence intervals for the positive and negative likelihood ratios spanned 1. This indicated that the test result is unlikely to change the odds of having or not having the condition, respectively. CONCLUSIONS The literature currently used as a reference for teaching in medical schools and continuing education lacks the necessary validity to help rule in or out a SLAP lesion or biceps tendon involvement. Based on the results from the systematic review conducted by Calvert et al, no tests clinically diagnose a SLAP lesion. This is a cause for concern as magnetic resonance imaging or magnetic resonance arthrography, which are frequently used to assess a possible SLAP lesion, may also have diagnostic flaws and may be cost prohibitive. Performing arthroscopy on every patient to rule the condition in or out is unethical, especially if a SLAP lesion is not present. More rigorous validity studies should be conducted for SLAP lesion physical examination tests using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool or Standards for Reporting Diagnostic Accuracy (STARD) criteria.
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McDonald LCDRLS, Dewing CDRCB, Shupe LCDRPG, Provencher CDRMT. Disorders of the proximal and distal aspects of the biceps muscle. J Bone Joint Surg Am 2013; 95:1235-45. [PMID: 23824393 PMCID: PMC6948813 DOI: 10.2106/jbjs.l.00221] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PROXIMAL ASPECT OF BICEPS: Tenodesis of the long head of the biceps may offer improved cosmesis, improved strength, and diminished activity-related pain compared with tenotomy, although comparative studies have shown similar outcomes in some patient populations. DISTAL ASPECT OF BICEPS: Operative treatment of both partial and complete distal biceps ruptures results in better outcomes compared with nonoperative care, although the optimal technique and fixation are yet to be determined. Nonoperative management is an acceptable treatment for patients willing to accept some loss of forearm supination and elbow flexion strength as well as changes in endurance and cosmesis.
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Affiliation(s)
- LCDR Lucas S. McDonald
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
| | - CDR Christopher B. Dewing
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
| | | | - CDR Matthew T. Provencher
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
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