Biceps load test II: A clinical test for SLAP lesions of the shoulder

Diagnosis, prevention and treatment of common shoulder injuries in sport: grading the evidence - a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement paper summarises and appraises the evidence on diagnosis, prevention, and treatment of common shoulder injuries in sports. We systematically searched Medline and Embase. The Grading of Recommendations Assessment, Development and Evaluation tool was applied to evaluate the overall quality of evidence.For diagnosis, we included 19 clinical tests from mixed populations. Tests for anterior instability, biceps-labrum complex injuries and full subscapularis rupture had high diagnostic accuracy (low to moderate quality of evidence).For prevention, the Oslo Sports Trauma Research Center, the Shoulder Control, the FIFA 11+ shoulder injury prevention programmes, and a baseball-specific programme (range of motion, stretching, dynamic stability and strengthening exercises) showed moderate to large effect size in reducing the risk of shoulder injury compared with no intervention (very low to moderate quality of evidence).For treatment, a rehabilitation programme including stretching, ice packs, electrotherapy and compression, and strengthening exercises showed a large effect size in reducing pain and disability compared with no intervention in athletes with subacromial impingement syndrome (very low to moderate quality of evidence). For the treatment of supraspinatus tendinopathy, hyperthermia treatment (heating the skin to 38°C-40°C) resulted in large effect size in reducing pain and disability compared with ultrasound or pendular swinging and stretching exercises (moderate quality of evidence). Strengthening exercise alone or in combination with stretching exercises promoted a large effect in reducing shoulder pain (cohort studies, no comparators) (very low quality of evidence). The quality of evidence for most estimates was low to moderate, indicating that future high-quality research may alter our recommendations for clinical practice.

Nonoperative Treatment of the Biceps-Labral Complex

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.

The Top 50 Most-Cited Papers in the Diagnosis and Management of SLAP Tears

Purpose

To identify and characterize the top 50 most-cited articles regarding SLAP tears.

Methods

Referencing the methodology of previous citation analyses, varying Boolean searches were performed using the Web of Science database and the search terms yielding the greatest number of results was used. The top 50 most-cited articles were identified and the following data points were gathered from each article: author, institution, country of origin, year of publication, publishing journal, level of evidence, and citation density.

Results

The total number of citations was 7834, with a median of 106 citations. The top 50 list was largely composed of diagnostic level I, II, and III studies (5, 7, and 8 total publications, respectively) and therapeutic level III (6 publications) or level IV (10 publications). Most articles originated from the United States (40). In total, 19 of the top 50 most-cited articles were published in the American Journal of Sports Medicine, followed by Arthroscopy (15) and the Journal of Bone and Joint Surgery (5).

Conclusions

Our analysis demonstrated a correlation with earlier publications being cited more frequently than recent studies. Importantly, the current study found that therapeutic studies in the most cited list were largely level III or level IV evidence. This makes the management of SLAP tears seem anecdotal, with little in the way of high-impact level I or level II therapeutic studies. We must reconsider our current understanding of SLAP tears and their management with more studies that demonstrate a clearer treatment algorithm for these common injuries of the shoulder.

Clinical Relevance

Given the complexity of SLAP tears, this list of the most-cited articles can provide a reference point to better guide practice, resident education, and future areas of orthopaedic research.

The Fifty Most-Cited Articles Regarding SLAP Lesions

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.

Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability

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.

USE of CLINICAL TEST CLUSTERS VERSUS ADVANCED IMAGING STUDIES in the MANAGEMENT of PATIENTS with a SUSPECTED SLAP TEAR

Background and Purpose

The Magnetic Resonance Arthrogram (MRA) has served as the gold standard for identifying patients with possible Superior Labrum Anterior-Posterior (SLAP) lesions and are often required by orthopaedic surgeons prior to clinical evaluation. However, as the literature shows MRA sensitivity as 0.65-0.98, and specificity between 0.80-1.00, there is still room for misinterpretation of the imaging study, and potential mismanagement of a patient who may or may not exhibit a true SLAP lesion. It is proposed that by grouping a series of clinical special tests it may be possible to develop greater sensitivity in identifying a SLAP lesion, resulting in the ability to better manage this patient population, thus avoiding unnecessary and costly imaging studies and decreased referrals to surgical specialists. The purpose of this study is to examine specific combinations of SLAP lesion special tests and identify which clusters of tests have the highest sensitivity and specificities. This may allow therapists to improve the management of their patients by reliably diagnosing a SLAP lesion and referring only those who may need surgery to a physician.

Study Design

Literature review, diagnostic sensitivity/specificity outcomes.

Methods

A retrospective search of the current peer-reviewed literature was performed in an effort to identify the clinical special tests with the greatest sensitivity and specificity in identifying SLAP lesions. Based upon that search, the study was limited to five special tests: Biceps Load I, Biceps Load II, Speed's, Passive Compression, and O'Brien's tests. A multiple regression analysis was performed that looked at grouping of the tests to determine the diagnostic sensitivity/specificity when grouped.

Results

Obtaining positive results on three of the five special tests resulted in a sensitivity of 0.992-0.999 and a specificity of 0.992-0.999. The combination of the Biceps Load I/II and O'Brien's showed the highest sensitivity and specificity.

Conclusion

The results indicate that a combination of at least three positive SLAP lesion tests may be clinically useful in diagnosing a shoulder SLAP lesion with greater diagnostic accuracy than those reported for MRI/MRA, thus improving patient management by referring only those who may require surgical intervention to a physician.

Level of Evidence

2c, "Outcomes" Research.

Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder

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.

Interrater agreement and reliability of clinical tests for assessment of patients with shoulder pain in primary care

Background: There is limited information about the agreement and reliability of clinical shoulder tests. Objectives: To assess the interrater agreement and reliability of clinical shoulder tests in patients with shoulder pain treated in primary care. Methods: Patients with a primary report of shoulder pain underwent a set of 21 clinical shoulder tests twice on the same day, by pairs of independent physical therapists. The outcome parameters were observed and specific interrater agreement for positive and negative scores, and interrater reliability (Cohen's kappa (κ)). Positive and negative interrater agreement values of ≥0.75 were regarded as sufficient for clinical use. For Cohen's κ, the following classification was used: <0.20 poor, 0.21-0.40 fair, 0.41-0.60 moderate, 0.61-0.80 good, 0.81-1.00 very good reliability. Participating clinics were randomized in two groups; with or without a brief practical session on how to conduct the tests. Results: A total of 113 patients were assessed in 12 physical therapy practices by 36 physical therapists. Positive and negative interrater agreement values were both sufficient for 1 test (the Full Can Test), neither sufficient for 5 tests, and only sufficient for either positive or negative agreement for 15 tests. Interrater reliability was fair for 11 tests, moderate for 9 tests, and good for 1 test (the Full Can Test). An additional brief practical session did not result in better agreement or reliability. Conclusion: Clinicians should be aware that interrater agreement and reliability for most shoulder tests is questionable and their value in clinical practice limited.

SLAP lesions: current controversies

Knowledge of the pertinent anatomy, pathogenesis, clinical presentation and treatment of the spectrum of injuries involving the superior glenoid labrum and biceps origin is required in treating the patient with a superior labrum anterior and posterior (SLAP) tear.Despite the plethora of literature regarding SLAP lesions, their clinical diagnosis remains challenging for a number of reasons.First, the diagnostic value of many of the available physical examination tests is inconsistent and ambiguous.Second, SLAP lesions most commonly occur concomitantly with other shoulder injuries.Third, SLAP lesions have no specific associated pain pattern.Outcomes following surgical treatment of SLAP tears vary depending on the method of treatment, associated pathology and patient characteristics.Biceps tenodesis has been receiving increasing attention as a possible treatment for SLAP tears. Cite this article: EFORT Open Rev 2019;4:25-32. DOI: 10.1302/2058-5241.4.180033.

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

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.

MR Imaging of SLAP Lesions

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.

Superior Labral Anterior to Posterior Tear Management in Athletes

Background:

The diagnosis and treatment of Superior Labrum Anterior to Posterior (SLAP) tears have been evolving and controversial. The lack of clear diagnostic criteria on physical examination, Magnetic Resonance Imaging (MRI), and arthroscopic evaluation clouds the issue. The high rate of MRI diagnosed SLAP lesions in the asymptomatic population of athletes and non-athletes warrants consideration when planning treatment for those with shoulder pain.

Objective:

To provide information on the evaluation, diagnosis and management of SLAP tears in athletes.

Methods:

The results of a structured non-operative rehabilitation program are discussed and compared to traditional surgical techniques. The evolution of the author’s treatment algorithm is presented. Results: The successful return to overhand throwing is more common with non-operative treatment than with surgical.

Conclusion:

A rehabilitation program focused on stretching the posterior capsule and correcting scapular posture is more successful than surgery for most throwers with SLAP lesions.

Passive accessory joint mobilization in the multimodal management of chronic dysesthesia following thalamic stroke

Study design: Case Report. Purpose: Stroke is the most common cause of long-term disability. Dysesthesia, an unpleasant sensory disturbance, is common following thalamic stroke and evidence-based interventions for this impairment are limited. The purpose of this case report was to describe a decrease in dysesthesia following manual therapy intervention in a patient with history of right lacunar thalamic stroke. Case description: A 66-year-old female presented with tingling and dysesthesia in left hemisensory distribution including left trunk and upper/lower extremities, limiting function. Decreased left shoulder active range of motion, positive sensory symptoms but no sensory loss in light touch was found. She denied pain and moderate shoulder muscular weakness was demonstrated. Laterality testing revealed right/left limb discrimination deficits and neglect-like symptoms were reported. Passive accessory joint motion assessment of glenohumeral and thoracic spine revealed hypomobility and provoked dysesthesia. Interventions included passive oscillatory joint mobilization of glenohumeral joint, thoracic spine, ribs and shoulder strengthening. Results: After six sessions, shoulder function, active range of motion, strength improved and dysesthesia decreased. Global Rating of Change Scale was +5 and QuickDASH score decreased from 45% to 22% disability. Laterality testing was unchanged. Conclusion: Manual therapy may be a beneficial intervention in management of thalamic stroke-related dysesthesia. Implications for Rehabilitation While pain is common following thalamic stroke, patients may present with chronic paresthesia or dysesthesia, often in a hemisensory distribution. Passive movement may promote inhibition of hyperexcitable cortical pathways, which may diminish aberrant sensations. Passive oscillatory manual therapy may be an effective way to treat sensory disturbances such as paresthesias or dysesthesia.

Diagnosis and Treatment of Injuries to the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.

RECENT FINDINGS

A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.

Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability

PURPOSE OF REVIEW

The goal of this paper is to provide an overview in evaluating the patient with suspected or known anteroinferior glenohumeral instability.

RECENT FINDINGS

There is a high rate of recurrent subluxations or dislocations in young patients with history of anterior shoulder dislocation, and recurrent instability will increase likelihood of further damage to the glenohumeral joint. Proper identification and treatment of anterior shoulder instability can dramatically reduce the rate of recurrent dislocation and prevent subsequent complications. Overall, the anterior release or surprise test demonstrates the best sensitivity and specificity for clinically diagnosing anterior shoulder instability, although other tests also have favorable sensitivities, specificities, positive likelihood ratios, negative likelihood ratios, and inter-rater reliabilities. Anterior shoulder instability is a relatively common injury in the young and athletic population. The combination of history and performing apprehension, relocation, release or surprise, anterior load, and anterior drawer exam maneuvers will optimize sensitivity and specificity for accurately diagnosing anterior shoulder instability in clinical practice.

Clinical Assessment of Physical Examination Maneuvers for Superior Labral Anterior to Posterior Lesions

Purpose  Shoulder pain and disability pose a diagnostic challenge owing to the numerous etiologies and the potential for multiple disorders to exist simultaneously. The evidence to support the use of clinical tests for superior labral anterior to posterior complex (SLAP) is weak or absent. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers for SLAP lesions by performing a methodologically rigorous, clinically applicable study.

Methods  We recruited consecutive new shoulder patients reporting pain and/or disability. The physician took a history and indicated their certainty about each possible diagnosis (“certain the diagnosis is absent/present,” or “uncertain requires further testing”). The clinician performed the physical tests for diagnoses where uncertainty remained. Magnetic resonance imaging arthrogram and arthroscopic examination were the gold standards. We calculated sensitivity, specificity, and likelihood ratios (LRs) and investigated whether combinations of the top tests provided stronger predictions.

Results  Ninety-three patients underwent physical examination for SLAP lesions. When using the presence of a SLAP lesion (Types I–V) as disease positive, none of the tests was sensitive (10.3–33.3) although they were moderately specific (61.3–92.6). When disease positive was defined as repaired SLAP lesion (including biceps tenodesis or tenotomy), the sensitivity (10.5–38.7) and specificity (70.6–93.8) of tests improved although not by a substantial amount. None of the tests was found to be clinically useful for predicting repairable SLAP lesions with all LRs close to one. The compression rotation test had the best LR for both definitions of disease (SLAP tear present = 1.8 and SLAP repaired = 1.67). There was no optimal combination of tests for diagnosing repairable SLAP lesions, with at least two tests positive providing the best combination of measurement properties (sensitivity 46.1% and specificity 64.7%).

Conclusion  Our study demonstrates that the physical examination tests for SLAP lesions are poor diagnostic indicators of disease. Performing a combination of tests will likely help, although the magnitude of the improvement is minimal. These authors caution clinicians placing confidence in the physical examination tests for SLAP lesions rather we suggest that clinicians rely on diagnostic imaging to confirm this diagnosis.

Disorders of the long head of the biceps: tenotomy versus tenodesis

Disorders of the long head of biceps tendon are common in clinical practice. Their causes could be degenerative, inflammatory, instability (subluxation or luxation) or traumatic. They are generally associated to other diseases of the shoulder, mainly rotator cuff injuries. Currently, there is controversy in the literature regarding the indications for surgical treatment and the choice of the best technique for each case, due to the possibility of esthetic deformity, loss of muscle strength, and residual pain.

The objective of this study was to identify the indications for surgical treatment, the best surgical technique, and the advantages and disadvantages of each technique described in the orthopedic literature for the treatment of long head of biceps tendon injuries.

A revision of the orthopedic medical literature on the following databases: Biblioteca Regional de Medicina (BIREME), Medline, PubMed, Cochrane Library and Google Scholar, comprising articles published in the period from 1991 to 2015.

Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance

BACKGROUND

Physical examination tests of the shoulder (PETS) are clinical examination maneuvers designed to aid the assessment of shoulder complaints. Despite more than 180 PETS described in the literature, evidence of their validity and usefulness in diagnosing the shoulder is questioned.

METHODS

This meta-analysis aims to use diagnostic odds ratio (DOR) to evaluate how much PETS shift overall probability and to rank the test performance of single PETS in order to aid the clinician's choice of which tests to use. This study adheres to the principles outlined in the Cochrane guidelines and the PRISMA statement. A fixed effect model was used to assess the overall diagnostic validity of PETS by pooling DOR for different PETS with similar biomechanical rationale when possible. Single PETS were assessed and ranked by DOR. Clinical performance was assessed by sensitivity, specificity, accuracy and likelihood ratio.

RESULTS

Six thousand nine-hundred abstracts and 202 full-text articles were assessed for eligibility; 20 articles were eligible and data from 11 articles could be included in the meta-analysis. All PETS for SLAP (superior labral anterior posterior) lesions pooled gave a DOR of 1.38 [1.13, 1.69]. The Supraspinatus test for any full thickness rotator cuff tear obtained the highest DOR of 9.24 (sensitivity was 0.74, specificity 0.77). Compression-Rotation test obtained the highest DOR (6.36) among single PETS for SLAP lesions (sensitivity 0.43, specificity 0.89) and Hawkins test obtained the highest DOR (2.86) for impingement syndrome (sensitivity 0.58, specificity 0.67). No single PETS showed superior clinical test performance.

CONCLUSIONS

The clinical performance of single PETS is limited. However, when the different PETS for SLAP lesions were pooled, we found a statistical significant change in post-test probability indicating an overall statistical validity. We suggest that clinicians choose their PETS among those with the highest pooled DOR and to assess validity to their own specific clinical settings, review the inclusion criteria of the included primary studies. We further propose that future studies on the validity of PETS use randomized research designs rather than the accuracy design relying less on well-established gold standard reference tests and efficient treatment options.

Common sports-related shoulder injuries

Shoulder pain is commonly treated in general practice; its causes are often multi-factorial. The focus of this article is on sports-related shoulder injuries likely to be seen in the community. This article aims to overview the presentation, assessment and management of these conditions in general practice.

Predictive factors associated with failure of nonoperative treatment of superior labrum anterior-posterior tears

BACKGROUND

Uncertainty remains in the natural course of superior labrum anterior-posterior (SLAP) tears treated conservatively with rehabilitation and activity modification. Our purpose was to evaluate clinical outcomes after nonoperative treatment of type II SLAP tear in young active patients and to identify factors related to negative outcomes.

METHODS

We retrospectively reviewed 63 patients who initially underwent nonoperative treatment for isolated type II SLAP tear. Assessments were made at baseline and at 6 months, and telephone survey was used to evaluate the final outcome. All included patients underwent a consistent nonoperative treatment protocol, and patient-specific data on the outcome were assessed. Failure was defined as abandonment of nonoperative management for surgery at any time points, <20-point improvement in American Shoulder and Elbow Surgeons score at final follow-up, or inability to return to activities.

RESULTS

At the average follow-up of 21 months, pain relief and function improved significantly (American Shoulder and Elbow Surgeons score, 54.2-86.4; Visual Analog Scale score, 4.6-1.7; P < .05) in 45 patients (71.4%) with successful nonoperative treatment. Eighteen patients (28.5%) were either dissatisfied with treatment or had arthroscopic surgery and were considered a failure group. Multivariate analysis showed that failure of nonoperative treatment is strongly linked with history of trauma, positive compression-rotation test result, and participation in overhead activities (P < .05).

CONCLUSIONS

An initial trial of nonoperative management may be considered in young active patients with isolated SLAP tear. Patients with history of trauma, mechanical symptoms, and demand for overhead activities are less likely to succeed.

Clinical orthopedic examination findings in the upper extremity: correlation with imaging studies and diagnostic efficacy

Different orthopedic tests are used to evaluate internal derangements of joints. Radiologic examinations like magnetic resonance (MR) imaging are ordered on the basis of results of these tests to narrow the clinical diagnosis and formulate a treatment plan. Although these tests are clinically useful, the test terminology can be confusing and the significance of the tests not clearly understood. This article helps explain the clinical jargon of tests performed for the major joints of the upper extremity and their proper use and diagnostic value in conjunction with MR imaging. The article presents a structured algorithmic approach to explain the tests. For each joint, a hierarchy of clinical tests is performed, starting with general observation and range of motion, followed by more specific tests tailored to evaluate individual or grouped anatomic structures. MR imaging findings and clinical tests complement each other in making a final diagnosis. However, because of the varied sensitivity and specificity of the clinical tests and MR imaging, it is important to be familiar with their diagnostic value before making clinical decisions. Knowledge of clinical jargon and the proper use and diagnostic value of orthopedic tests can aid in interpretation of radiologic images by focusing search patterns, thus allowing comprehensive evaluation and optimized reporting. It also enhances communication with the orthopedist, thereby helping maintain continuity of care. Online supplemental material is available for this article.

Physical examination of the shoulder

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.

Clinical assessment of the glenoid labrum

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.

Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions

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.

Inappropriate requests for magnetic resonance scans of the shoulder

PURPOSE

Magnetic resonance imaging (MRI) scans are a useful investigation for some shoulder pathology. They are costly however and a significant burden on radiology departments. In most cases clinical examination, plain radiography or ultrasound scan (USS) are sufficient for a diagnosis. There are no current UK guidelines regarding MRI shoulder scan requests.

METHODS

We reviewed 100 consecutive MRI shoulder scan requests and the associated formal reports; other investigations were also assessed.

RESULTS

Overall, 56% of MRI scans were ordered inappropriately. Shoulder consultant's requests were more appropriate than other groups (70% vs. 38%. p = 0.04). Excluding shoulder consultants 63 % of scans were inappropriately ordered. Shoulder consultants were more likely to order a preceding X-ray (80% vs. 53% respectively, p = 0.03). Of those with a clinical diagnosis of cuff pathology only 29% had an USS.

CONCLUSION

A high percentage of MRI shoulder scans are performed inappropriately. Shoulder consultants are more appropriate in their ordering than other groups. If all groups performed as well 50 % less MRI scans would need to be performed.

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.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Basic Science Study, Biomechanics, Cadaver Model.

Diagnosis and management of superior labral anterior posterior tears in throwing athletes

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum-biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.

Validity of noncontrast magnetic resonance imaging in diagnosing superior labrum anterior-posterior tears

BACKGROUND

The biceps labral complex has received much interest in recent years as a source of shoulder pain. Magnetic resonance imaging (MRI) is the imaging modality of choice for those patients with a suspected superior labrum anterior-posterior (SLAP) tear. The goal of this study was to look at the accuracy of MRI without arthrography to correctly identify SLAP tears.

METHODS

The study had a prospective, case-based, case-control design. Participants were consecutive patients seen at an orthopaedic outpatient clinic who received an MRI scan as part of their diagnostic cycle. All patients were aged at least 18 years, with various shoulder dysfunctions (impingement, rotator cuff tear, and so on) that were evaluated during a routine clinical evaluation. Arthroscopic surgery was performed as the reference standard for a SLAP lesion.

RESULTS

Seventy-seven patients were evaluated during arthroscopic surgery. The pretest probability of a SLAP lesion-only diagnosis was 18.2%, and for a SLAP lesion with or without a concomitant diagnosis, the pretest probability was 66.2%. In both cases, use of MRI led to post-test probability values that were worse when a positive finding was identified on the MRI scan.

DISCUSSION

The results of this study suggest that SLAP tears are often incorrectly diagnosed based on MRI evaluation, with MRI providing a high level of sensitivity and low level of specificity. On the basis of the results of this study, conventional MRI is not a suitable test to accurately evaluate the biceps labral complex for the presence of a SLAP tear.

Current concepts in the evaluation and treatment of the shoulder in overhead-throwing athletes, part 1: physical characteristics and clinical examination

The overhead-throwing athlete is a challenging sports medicine patient. The repetitive microtraumatic stresses imposed on the athlete's shoulder joint complex during the throwing motion constantly places the athlete at risk for injury. These stresses may effect several adaptations to normal shoulder range of motion, strength, and scapula position. The clinician should therefore appreciate the unique physical characteristics of the overhead-throwing athlete to accurately evaluate and treat throwing-related injuries.

Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates

BACKGROUND

Tears of the superior labrum (superior labrum anterior and posterior [SLAP] lesions) of the shoulder are uncommon injuries; however, the incidence of surgical correction seems to be increasing.

PURPOSE

To report the findings of a review of a proprietary descriptive database that catalogs cases for the purpose of board certification on the demographics of SLAP lesion repair. It is the authors' impression that the percentage of cases of SLAP lesion repairs reported by young orthopaedic surgeons is high and that complications associated with this are not insignificant.

STUDY DESIGN

Cohort study; level of evidence, 3.

METHODS

We searched the American Board of Orthopedic Surgery (ABOS) part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of arthroscopic repair of SLAP lesions. The database was searched for all SLAP lesions (ICD-9 code 840.7) and SLAP repairs (CPT code 29807) for the years 2003 through 2008. Utilization was analyzed by geographic region and was also obtained based on applicant subspecialty declaration.

RESULTS

There were 4975 SLAP repairs, representing 9.4% of all applicants' shoulder cases. Mean follow-up was 8.9 weeks because of the time-limited case collection period. There were 78.4% who were men, and 21.6% of patients were women. The percentage of shoulder cases that were SLAP repairs increased over the study period from 9.4% to 10.1% by 2008 (P = .0163). Mean age of male patients was 36.4 ± 13.0 years, with a maximum of 85 years. Mean age of female patients was 40.9 ± 14.0 years, with a maximum of 88 years. Pain was reported as absent in only 26.3% of patients at follow-up and function as normal in only 13.1%. There were 40.1% of applicants who self-reported their patients to have an excellent result. The self-reported complication rate was 4.4%. Declared sports medicine specialists had a higher percentage of SLAP repairs than did general orthopaedic surgeons: 12.4% versus 9.2%.

CONCLUSION

The percentage of shoulder cases that are SLAP repairs reported by the candidates is 3 times the published incidence supported by the current literature. The large number of repairs in middle-aged and elderly patients is concerning. Focusing on educating young orthopaedic surgeons to appropriately recognize and treat symptomatic SLAP lesions may bring the rate of SLAP repairs down.

Superior labral anterior-to-posterior lesions: comparison of external rotation and active supination CT arthrography with neutral CT arthrography

PURPOSE

To compare the diagnostic performance of computed tomographic (CT) arthrography performed with external rotation and active supination (ERAS) with that of CT angiography performed in the neutral position for superior labral anterior-to-posterior (SLAP) lesions.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. CT arthrography in neutral and ERAS positions was performed in 49 shoulders of 47 patients, with subsequent arthroscopic confirmation of the status of the superior labrum. Two musculoskeletal radiologists (1 and 8 years of experience) reviewed images and expressed the likelihood of SLAP lesions by using a continuous scale; they also measured gap widths and depths of labral detachment. Overall performances for the detection of SLAP lesions were determined with receiver-operating characteristic (ROC) analysis. Gap widths and depths measured with the two types of CT arthrography were also compared.

RESULTS

For reader 1, area under the ROC curve increased insignificantly from 0.932 in the neutral position to 0.974 in the ERAS position (P = .210), whereas for reader 2, it increased significantly from 0.914 to 0.984 (P = .032). Mean gap width of SLAP lesion was significantly greater according to ERAS CT arthrography (3.98 mm ± 2.48 [standard deviation] vs 1.61 mm ± 1.11), whereas mean gap depth was not significantly different. Gap width and depth cutoff values for the detection of a SLAP lesion with ERAS CT arthrography were 1.7 mm and 1.6 mm, respectively.

CONCLUSION

ERAS CT arthrography might improve the detection of SLAP lesions compared with neutral-position CT arthrography.

Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions

BACKGROUND

The clinical diagnosis of a superior labral anterior posterior (SLAP) tear is extremely challenging. Most studies that advocate selected tests have errors in study design or significant bias, or both. The purpose of this study was to identify the diagnostic utility of the Active Compression/O'Brien's test, Biceps Load II test, Dynamic Labral Shear test (O'Driscoll's test), Speed's test, and the Labral Tension test when diagnosing isolated SLAP lesions (SLAP-only) and a SLAP lesion with concomitant disorders (eg, rotator cuff tear), as stand-alone and clustered tests, with diagnostic confirmation by arthroscopic surgery.

MATERIALS AND METHODS

This diagnostic accuracy study was a case-based, case-control design that included 87 individuals with variable shoulder pathology.

RESULTS

Of the 5 tests, only the Biceps Load II test demonstrated utility in identifying patients with a SLAP-only lesion, with a positive predictive value of 26 (95% confidence limits [CL], 18, 31), negative predictive value of 93 (95% CL, 84, 97), positive likelihood ratio of 1.7 (95% CL, 1.1, 2.6), and negative likelihood ratio of 0.39 (95% CL, 0.14, 0.91). No tests demonstrated diagnostic utility when diagnosing any SLAP lesion, including those with concomitant diagnoses. No clusters demonstrated better diagnostic accuracy than stand-alone findings.

CONCLUSION

There are a number of potential reasons for the poor utility in the 5 test findings. The heterogeneous sample included patients with a variety of shoulder disorders. The study was organized using very strict methodologic controls that should reduce the risk of bias, which normally overinflates the accuracy of a specific tool. The findings may truly reflect the stand-alone, diagnostic utility of the 5 tests, suggesting when used alone provides little usefulness toward decision making of the diagnostic clinician.

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.

Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete

Due to the complexity of shoulder pathomechanics in the overhead athlete, injuries located in the superior aspect of the glenoid, known as superior labral anterior to posterior (SLAP) lesions, are often a surgical and rehabilitation challenge. In an effort to determine surgical versus conservative care of SLAP lesions a thorough clinical examination and evaluation are necessary. If surgery is identified as the treatment of choice, post operative rehabilitation will vary pending surgical findings including the extent and location of the SLAP lesion, and other concomitant findings and procedures. This manuscript will provide an overview of the pathology, examination and evaluation of SLAP lesions, surgical management and post operative rehabilitation following various SLAP categories.

Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: a case series

STUDY DESIGN

Case series.

BACKGROUND

Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome. This case series describes a standardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period.

CASE DESCRIPTION

Ten patients (age range, 19-70 years) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a standardized protocol for 10 visits over 6 to 8 weeks. The protocol included a 3-phase progressive strengthening program, manual stretching, thrust and nonthrust manipulation to the shoulder and spine, patient education, activity modification, and a daily home exercise program of stretching and strengthening. Patients completed a history and measures of impairments and functional disability at 2, 4, 6, and 12 weeks.

OUTCOMES

Treatment success was defined as both a 50% improvement on the Disabilities of the Arm, Shoulder, and Hand (DASH) score and a global rating of change of at least "moderately better." At 6 weeks, 6 of 10 patients had a successful (mean +/- SD) DASH outcome score (initial, 33.9 +/- 16.2; 6 weeks, 8.1 +/- 9.2). At 12 weeks, 8 of 10 patients had a successful DASH outcome score (initial, 33.1 +/- 14; 12 weeks, 8.3 +/- 6.4). As a group, the largest improvement was in the first 2 weeks. The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness (10 of 10 patients), limited shoulder internal rotation motion (8 of 10 patients), and reduced kyphosis of the midthoracic area (7 of 10 patients).

DISCUSSION

A program aimed at strengthening rotator cuff and scapular muscles, with stretching and manual therapy aimed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients. This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks.

LEVEL OF EVIDENCE

Therapy, level 4.