The validity and accuracy of clinical tests used to detect labral pathology of the shoulder – A systematic review

The long head of biceps at the shoulder: a scoping review

BACKGROUND

This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions.

METHODS

PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English.

RESULTS

214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation.

CONCLUSIONS

The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required.

PRE-REGISTRATION

OSF: https://osf.io/erh9m.

Consistency of commonly used orthopedic special tests of the shoulder when used with the McKenzie system of mechanical diagnosis and therapy

BACKGROUND

Shoulder Orthopedic Special Tests (OSTs) are used to assist with diagnosis in shoulder disorders. Issues with reliability and validity exist, making their interpretation challenging. Exploring OST results on repeated testing within Mechanical Diagnosis and Therapy (MDT) shoulder classifications may offer insight into the poor performance of these tests.

OBJECTIVES

To investigate in patients with shoulder complaints, whether MDT classifications affect the agreement of OST results over the course of treatment.

METHODS

An international group of MDT clinicians recruited 105 patients with shoulder problems. Three commonly used OSTs (Empty Can, Hawkins-Kennedy, and Speed's tests) were utilized. Results of the OSTs were collected at sessions 1, 3, 5 and 8, or at discharge from an MDT classification-based treatment. The Kappa statistic was utilized to determine the agreement of the OST results over time for each of the MDT classifications.

RESULTS

The overall Kappa values for Empty Can, Hawkins-Kennedy and Speed's tests were 0.28 (SE = 0.07), 0.28 (SE = 0.07) and 0.29 (SE = 0.07), respectively. The highest level of agreement was for Articular Dysfunction for the Empty Can test (0.84, SE = 0.19). For shoulder Derangements, there was no agreement for any of the OSTs (P values > 0.05).

CONCLUSION

The lack of agreement when the OSTs were consecutively tested in the presence of the MDT Derangement classification contrasted with the other MDT classifications. The presence of Derangement was responsible for reducing the overall agreement of commonly used OSTs and may explain the poor consistency for OSTs.

The Posterior Unstable Shoulder: Natural History, Clinical Evaluation and Imaging

Background:

There is a low incidence of posterior instability which is present in only 2% to 10% of all unstable shoulders. The posterior instable shoulder includes different manifestations like fixed dislocation, recurrent subluxation or dislocation.

Methods:

Research and online content related to posterior instability is reviewed. Natural history, clinical evaluation and imaging are described.

Results:

An awareness of the disorder, together with a thoughtful evaluation, beginning with the clinical history, usually leads to proper diagnosis. An appropriate physical exam, taking in account hyperlaxity and specific tests for posterior instability should be done.

Conclusion:

Posterior shoulder instability is an uncommon condition and is challenging to diagnose. There is not a single injury that is responsible for all cases of recurrent shoulder dislocation or subluxation, and the presence of soft tissue lesions or bone alterations should be evaluated, with the use of adequate simple radiology and multiplanar imaging.

A systematic review and meta-analysis of diagnostic test of MRA versus MRI for detection superior labrum anterior to posterior lesions type II-VII

OBJECTIVE

To determine the diagnostic performance of magnetic resonance arthrography (MRA) and magnetic resonance imaging (MRI) in superior labrum anterior to posterior lesions (type II-VII) of the shoulder.

MATERIAL AND METHODS

PubMed and Scopus search engines, an electronic search of articles was performed from inception to February 19, 2016. Diagnostic performance of index tests was compared by the summary area under receiver operator characteristic curve (AUROC).

RESULTS AND CONCLUSIONS

In all, 117 of 493 studies were eligible and 32 studies (2,013 shoulders) and 11 studies (1,498 shoulders) were evaluated with MRA and MRI. The summary sensitivity, specificity, likelihood ratio (positive and negative) and AUROC were 0.87 (95 % confidence interval, CI: 0.82, 0.91), 0.92 (95 %CI: 0.85, 0.95), 10.28 (95 %CI: 5.84, 18.08), 0.14 (95 %CI: 0.10, 0.20) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRA, and 0.76 (95 %CI: 0.61, 0.86), 0.87 (95 %CI: 0.71, 0.95), 5.89 (95 %CI: 2.5, 13.86), 0.28 (95 %CI: 0.17, 0.47) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRI. The diagnostic performance of MRA was superior to MRI by both direct and indirect comparisons for the detection of SLAP lesions.

Reinterpretation of O'Brien test in posterior labral tears of the shoulder

Background:

Injuries to the posterior labrum are less common and more difficult to diagnose compared to anterior labral pathology. This may be in part due to difficulties in preoperative diagnosis. Posterior labral injuries cause abnormal loading of the rotator cuff with subsequent weakness. Examination using the O'Briens test tightens the posterior capsule and posteriorly translates the humeral head, stressing the labrum resulting in pain and weakness.

Method:

A retrospective study.

Results:

Of 74 patients diagnosed with a posterior labral tear at arthroscopy 55 had subjective weakness on performing a O'Briens test, a sensitivity of 83% and a positive predictive value (PPV) of 90%.

Conclusion:

Multiple tests have been described for posterior labral pathology and none of these, on their own, have a high sensitivity rate. Posterior labral injuries can often be missed on magnetic resonance imaging scanning and also at surgery if not specifically looked for. Using a sign of clinically demonstrated weakness when performing the O'Briens test, and hence reinterpretation of the test, is sensitive, with a high PPV for posterior labral pathology and can help guide further treatment.

Glenoid labrum pathology

The glenoid labrum is the fibrocartilage of the shoulder joint, anchoring the joint capsule and shoulder ligaments. Morphology varies regionally, especially in the superior and anterior region; these variants can sometimes be confused with pathological aspects. The labrum is often involved in shoulder pathology, by single trauma or, more often, repeated microtrauma. It seems logical to classify and to describe tears according to two criteria: the sector involved, and associated pain or instability. In the superior labrum, SLAP lesions are the most frequent. These combine labral lesion and lesion of the proximal insertion of the long head of the biceps brachii tendon. The most frequent form is SLAP II. They may be associated with instability or not. In the antero-inferior and postero-inferior labrum, lesions are mainly due to instability, particularly Bankart lesions (capsulolabral avulsion) anteriorly and Kim's lesion posteriorly. Circumferential labral lesions may be found in unstable shoulder. Finally, postero-superior lesions involve Walch's internal impingement: repeated contact between the deep surface of the cuff and the labrum, which takes on a degenerative aspect, with a kissing lesion of the cuff. There is no general rule for management: some labral lesions are resected and others fixed. The cause (which is usually shoulder instability), however, needs to be assessed and treated.

Identification and treatment of existing copathology in anterior shoulder instability repair

Recurrent anterior instability is a common finding after traumatic glenohumeral dislocation in the young, athletic patient population. A variety of concomitant pathologies may be present in addition to the classic Bankart lesion, including glenoid bone loss; humeral head bone loss; rotator interval pathology; complex/large capsular injuries including humeral avulsions of the glenohumeral ligaments (HAGL lesions), SLAP tears, near circumferential labral tears, and anterior labral periosteal sleeve avulsions (ALPSA lesions); and rotator cuff tears. Normal anatomic variations masquerading as pathology also may be present. Recognition and treatment of these associated pathologies are necessary to improve function and symptoms of pain and to confer anterior shoulder stability. This review will focus on the history, physical examination findings, imaging findings, and recommended treatment options for common sources of copathology in anterior shoulder instability repair.

Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain

OBJECTIVE

To investigate the inter-examiner reliability of Mechanical Diagnosis and Therapy (MDT)-trained diplomats in classifying patients with shoulder disorders. The MDT system has demonstrated acceptable reliability when used in patients with spinal disorders; however, little is known about its utility when used for appendicular conditions.

METHODS

Fifty-four clinical scenarios were created by a group of 11 MDT diploma holders based on their clinical experience with patients with shoulder pain. The vignettes were made anonymous, and their clinical diagnoses sections were left blank. The vignettes were sent to a second group of six international McKenzie Institute diploma holders who were asked to classify each vignette according to the MDT categories for upper extremity. Inter-examiner agreement was evaluated with kappa statistics.

RESULTS

There was 'very good' agreement among the six MDT diplomats for classifying the McKenzie syndromes in patients with shoulder pain (kappa = 0.90, SE = 0.018). The raw overall level of multi-rater agreement among the six clinicians in classifying the vignettes was 96%. After accounting for the actual MDT category for each vignette, kappa and the raw overall level of agreement decreased negligibly (0.89 and 95%, respectively).

DISCUSSION

Using clinical vignettes, the McKenzie system of MDT has very good reliability in classifying patients with shoulder pain. As an alternative, future reliability studies could use real patients instead of written vignettes.

An update and further testing of a knowledge-based diagnostic clinical decision support system for musculoskeletal disorders of the shoulder for use in a primary care setting

RATIONALE, AIMS AND OBJECTIVES

A prototype diagnostic clinical decision support system (CDSS) was developed to assist primary care clinicians (general practitioners) in clinical decision making, aimed at reducing diagnostic errors. The prototype CDSS showed some promise with high levels of validity and reliability; however, issues regarding the underlying Bayesian belief network (BBN), small sample size and use of radiological imaging as a gold standard measure were highlighted that required further investigation before considering clinical testing.

METHODS

The prototype CDSS was reviewed and updated based on computer science literature and expert (orthopaedic consultant) opinion. The updated CDSS was tested by comparing its diagnostic outcome against the diagnosis of 93 case studies as determined by expert opinion combined with arthroscopy findings or radiological imaging.

RESULTS

The updated CDSS showed significant high levels of sensitivity (91%), specificity (98%), positive likelihood ratio (53.12) and negative likelihood ratio (0.08) with a kappa value of 0.88 to a confidence level of 99% compared with expert diagnosis combined with arthroscopy findings or radiological imaging.

CONCLUSIONS

The results suggest that the updated CDSS has addressed the issues highlighted from the initial research while maintaining high levels of validity and reliability. The updated CDSS is now ready for clinical testing.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

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

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

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

RESULTS

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

CONCLUSIONS

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

MR-arthrography in superior instability of the shoulder: correlation with arthroscopy

PURPOSE

This study was undertaken to evaluate magnetic resonance (MR) arthrography in the detection and classification of lesions that may cause superior instability.

MATERIALS AND METHODS

Forty-two consecutive patients with clinical signs of chronic superior instability of the shoulder underwent MR arthrography followed by arthroscopic surgery. For each patient we retrospectively reviewed the MR arthrography and surgical findings.

RESULTS

We detected 31 superior labral anterior posterior (SLAP) lesions, all confirmed on arthroscopy with three cases of underestimation: in the detection of SLAP lesions, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MR arthrography were 100%; in the evaluation of the type of SLAP lesion, sensitivity was 100%, specificity was 78.5%, accuracy was 92.8%, PPV was 71.7% and NPV was 100%. All cases of capsular laxity (13/42) and biceps tendon lesions (3/42) were confirmed on arthroscopy with sensitivity, specificity, accuracy, PPV and NPV of 100%. Eleven cuff lesions were detected on MR arthrography, 10 of which confirmed at arthroscopy: sensitivity was 100%, specificity was 96.8%, accuracy was 97.6%, PPV was 90.9% and NPV was 100%. Associated lesions were found in 38/42 patients.

CONCLUSIONS

Superior instability is frequently associated with different anatomical variants or pathological conditions, such as SLAP lesions. The role of MR arthrography is to describe the key features of lesions affecting the superior portion of the shoulder, including location, morphology, extent, and associated injuries and leanatomical variants and to correlate these features with clinical symptoms.

Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain

BACKGROUND

Despite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort.

METHODS

Consecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (XylocaineTM) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O'Brien's test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests.

RESULTS

Twenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84).

CONCLUSIONS

In this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort.

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

BACKGROUND

Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.

OBJECTIVES

To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.

SEARCH METHODS

We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English.

SELECTION CRITERIA

We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.

MAIN RESULTS

We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.

AUTHORS' CONCLUSIONS

There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

A survey of the McKenzie Classification System in the Extremities: prevalence of mechanical syndromes and preferred loading strategies

BACKGROUND

Classification of patients with extremity problems is commonly based on patho-anatomical diagnoses, but problems exist regarding reliability and validity of the tests and diagnostic criteria used. Alternatively, a classification system based on patient response to repeated loading strategies can be used to classify and direct management.

OBJECTIVE

The purpose of this study was to investigate the prevalence of McKenzie's classification categories among patients with extremity problems and the loading strategies used in their management.

DESIGN

This was a prospective, observational study.

METHODS

Thirty therapists among 138 invited (response rate=22%) with a Diploma in Mechanical Diagnosis and Therapy (MDT) were identified from the McKenzie Institute International registry and recruited worldwide to complete an e-mailed questionnaire. They provided data about their age, years qualified, years since gaining a diploma, and practice, and prospectively provided data on anatomical site and categorization for 15 consecutive patients with extremity problems.

RESULTS

Data were gathered on 388 patients; classification categories were as follows: derangement (37%); contractile dysfunction (17%); articular dysfunction (10%); and "other" (36%), of which 20% were postsurgery or posttrauma. Exercise management strategies and syndrome application varied considerably among anatomical sites. Classification categories remained consistent in 85.8% of patients over the treatment episode.

LIMITATIONS

These findings are not generalizable to therapists who are not experienced with use of MDT in the extremities.

CONCLUSIONS

This study demonstrates that trained clinicians can classify patients with extremity problems into MDT classifications and that these classifications remain stable during the treatment episode. Further work is needed to test the efficacy of this system compared with other approaches, but if derangements are as common as this survey suggests, the findings have important prognostic implications because this syndrome is defined by its rapid response to repeated movements.

A meta-analysis of the diagnostic test accuracy of MRA and MRI for the detection of glenoid labral injury

PURPOSE

Magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA) have gained increasing favour in the assessment of patients with suspected glenoid labral injuries. The purpose of this study was to determine the diagnostic accuracy of MRI or MRA in the detection of gleniod labral lesions.

MATERIALS AND METHODS

A systematic review was undertaken of the electronic databases Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, AMED and CINAHL, in addition to a search of unpublished literature databases. All studies which compared the ability of MRI or MRA (index test) to assess gleniod labral tears or lesions, when verified with a surgical procedure (arthroscopy or open surgery-reference test) were included. Data extraction and methodological appraisal using the QUADAS tool were both conducted by two reviewers independently. Data were analysed through a summary receiver operator characteristic curve and pooled sensitivity and specificity analysis were calculated with 95% confidence intervals.

RESULTS

Sixty studies including 4,667 shoulders from 4,574 patients were reviewed. There appeared slightly greater diagnostic test accuracy for MRA over MRI for the detection of overall gleniod labral lesions (MRA-sensitivity 88%, specificity 93% vs. MRI sensitivity 76% vs. specificity 87%). Methodologically, studies recruited and identified their samples appropriately and clearly defined the radiological procedures. In general, it was not clearly defined why patients were lost during the study, and studies were poor at recording whether the same clinical data were available to the radiologist interpreting the MRI or MRA as would be available in clinical practice. Most studies did not state whether the surgeon interpreting the arthroscopic procedure was blinded to the results of the MR or MRA imaging.

CONCLUSIONS

Based on the available literature, overall MRA appeared marginally superior to MRI for the detection of glenohumeral labral lesions.

LEVEL OF EVIDENCE

Level 2a.

Critical reflection of the advanced rehabilitation of an elite rugby league player sustaining a posterior Bankart lesion

The following is a critical description and discussion of the successful assessment and rehabilitation of a right shoulder posterior Bankart repair in an elite rugby league player. The rehabilitation follows accelerated, goal based guidelines, widely adopted in current sports practice but not well documented in the literature (Funk & Snow, 2007; Park, Lin, Yokota, & McFarland, 2004). The study serves to be the first critical discussion of such a regime.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Controlled laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

The unstable painful shoulder (UPS) as a cause of pain from unrecognized anteroinferior instability in the young athlete

HYPOTHESIS

The etiology of shoulder pain in the overhead athlete is often difficult to determine. This study hypothesized that (1) instability can present in a purely painful form, without any apparent history of instability, but with anatomic lesions indicative of instability, termed unstable painful shoulder (UPS), and that (2) arthroscopic shoulder stabilization is effective.

MATERIALS AND METHODS

The study evaluated 20 patients (mean age, 22 ± 8 years) at a mean of 38 months postoperatively (range, 24-69 months). Inclusion criteria were painful shoulder with lesions indicative of instability on imaging or at surgery, minimum 2-year follow-up. Exclusion criteria were recognized instability, other associated pathologies, and previous shoulder surgery.

RESULTS

Patients were young, hyperlax athletes who complained of deep, anterior shoulder pain and denied any instability. Pain was reproduced with the arm in an anterior apprehension position and relieved by a relocation test; however, no actual apprehension was experienced. Patients often had glenohumeral laxity and hyperlaxity. Lesions indicative of instability confirmed that at least 1 unapparent shoulder subluxation occurred. The Rowe, Walch-Duplay, and University of California, Los Angeles scores improved significantly (P < .05); 19 patients (95%) were satisfied, and 15 (75%) returned to their previous level of sports.

DISCUSSION

The diagnosis of UPS is often missed but is important to consider in the young hyperlax athlete. Soft tissue and/or bony lesions consistent with instability are necessary to confirm the diagnosis. Arthroscopy certainly deserves a significant place in this form of anteroinferior instability because it allows both the assessment of lesions (ie, diagnosis) and a satisfactory functional result and return to sport.