Clinical testing for tears of the glenoid labrum

Damage for gain: The useful damage of the Pitcher's paradox

Introduction

Sport-specific adaptations of the glenohumeral joint may arise in adolescent overhead athletes who begin high-performance sports early in life. Research mainly addresses overuse injuries, leaving gaps in prevention, with adults studied more than youths.

Objective

This study aims to investigate sport-adaptations of the glenohumeral joint in asymptomatic adolescent volleyball players to identify potential shoulder injury risk factors.

Design

Observational study.

Setting

Clinical screening campaign conducted at the Physical Medicine and Rehabilitation Unit of Policlinic Hospital in Catania, Italy.

Participants

Forty asymptomatic under-16 athletes were evaluated.

Interventions

Shoulder internal rotation (IR) and external rotation (ER), range of motion (ROM), total-rotation ROM, glenohumeral IR deficit (GIRD), general joint laxity using Beighton score, apprehension, relocation, O'Brian tests, and ultrasound (US) glenohumeral distance were tested bilaterally. Variables such as the player's position, the age they began the sport, limb dominance, weight, and height were also considered.

Results

The median US glenohumeral distance was at 0.42 ± 0.26 cm, which is consistent with the range found in non-dislocated shoulders of a healthy non-athletic population. The ER ROM was significantly greater in the dominant shoulder than the contralateral one (P = 0.0001), and there was a significant correlation between the ER ROM of attackers and their US glenohumeral distance (P = 0.0413). Furthermore, shoulder IR ROM and US glenohumeral distance were not significantly different between the dominant and contralateral limbs (P = 0.05). None of the athletes presented GIRD. Other tests, including the Beighton score, apprehension, and relocation tests, yielded no significant differences between the dominant and contralateral limbs.

Conclusions

Despite an increased shoulder ER in the dominant limb, the glenohumeral joint remains stable, suggesting that greater ROM in ER does not equate to instability in overhead athletes without hyperlaxity. Nevertheless, increased ER impacts glenohumeral distance in attacker volleyball players. This finding suggests that the shoulder morphological adaptation process starts early in attackers.

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

BACKGROUND

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

PURPOSE/HYPOTHESIS

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bari Shoulder Telemedicine Examination Protocol (B-STEP): A Standard Protocol for Personalized Remote Shoulder Examination

The COVID-19 pandemic drastically changed many aspects of the traditional functioning of health systems all around the world. In Italy, as reported by the CIO, compared to the previous year, there was a significant reduction in 2020 in overall outpatient activities by up to 75%. These data support the need for telemedicine, which represents a current challenge and can no longer be postponed in the future. This study aims to elaborate on a possible model for remote shoulder examination based on traditional tests to improve the quality of telemedicine in orthopedic and rehabilitation. Between May 2020 and November 2020, ten orthopedic surgeons individually examined six patients with a known shoulder disorder, both in hospital and via webcam according to the previously shared protocol (B-STEP). According to the 10 observers, completing 100% of the ASES score and at least 87.5% of the Constant score is possible. Shoulder ROM and many specific tests are also reproducible via webcam, but with less sensitivity, according to the subjective opinion of observers. The B-STEP is a useful protocol for the standardization of the objective examination of the shoulder via webcam. Further studies are necessary to determine if the B-STEP protocol is useful for diagnosing pathology in unknown patients and evaluating its sensitivity and specificity for each pathology.

Can indirect magnetic resonance arthrography be a good alternative to magnetic resonance imaging in diagnosing glenoid labrum lesions?: a prospective study

Background

This study was designed to evaluate and compare the diagnostic value of magnetic resonance imaging (MRI) and indirect magnetic resonance arthrography (I-MRA) imaging with those of arthroscopy and each other.

Methods

This descriptive-analytical study was conducted in 2020. All patients who tested positive for labrum lesions during that year were included in the study. The patients underwent conservative treatment for 6 weeks. In the event of no response to conservative treatment, MRI and I-MRA imaging were conducted, and the patients underwent arthroscopy to determine their ultimate diagnosis and treatment plan. Imaging results were assessed at a 1-week interval by an experienced musculoskeletal radiologist. Image interpretation results and arthroscopy were recorded in the data collection form.

Results

Overall, 35 patients comprised the study. Based on the kappa coefficient, the results indicate that the results of both imaging methods are in agreement with the arthroscopic findings, but the I-MRA consensus rate is higher than that of MRI (0.612±0.157 and 0.749±0.101 vs. 0.449±0.160 and 0.603±0.113). The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of MRI in detecting labrum tears were77.77%, 75.00%, 91.30%, 50.00%, and 77.14%, respectively, and those of I-MRA were 88.88%, 75.00%, 92.30%, 66.66%, and 85.71%.

Conclusions

Here, I-MRA showed higher diagnostic value than MRI for labral tears. Therefore, it is recommended that I-MRA be used instead of MRI if there is an indication for potential labrum lesions.

Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis

Superior labrum anterior-posterior (SLAP) lesions are common in overhead athletes. Though some patients have asymptomatic lesions, many tears cause pain and diminished athletic performance. Accurate diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging is questionable. Management is also difficult, as treatment can be life-altering or career-ending for many athletes. If first-line nonoperative treatment fails, surgical options may be considered. The optimal surgical management of SLAP lesions in athletes is debated. Historically, return to play (RTP) rates among athletes who have undergone arthroscopic SLAP repair have been unsatisfactory, prompting clinicians to seek alternate surgical options. Biceps tenodesis (BT) has been postulated to eliminate biceps tendon-related pain in the shoulder and is increasingly used as a primary procedure for SLAP lesions. The purpose of this text is to review the current literature on the surgical management of SLAP lesions in athletes with an emphasis on the role of BT.

The 50 Most-Cited Papers on Bankart Lesions

Purpose

To analyze the 50 most-cited articles pertaining to “Bankart lesions,” also known as anteroinferior labral tears, by means of citation analysis as well as to provide analysis and summary of the origins and trends of research on Bankart lesions.

Methods

Scopus was used to query the literature on Bankart lesions. Included articles were related to Bankart lesions and the indications, risk factors, techniques, and outcomes of arthroscopic and open Bankart repair. The 50 most-cited articles were analyzed in the following areas: year of publication, citations in the most recent year, total citation count, contributing authors, institutions, countries, and journals, article classifications, and level of evidence.

Results

Years of publication ranged from 1938 to 2013. There were 608 total citations in the most recent year. Total citation count was 12,441. Regarding country, journal, and authorship, United States, R. A. Arciero, and Arthroscopy were the highest respective contributors. Rush University had the greatest number of publications. The most common article classification was clinical outcomes. Of 49 clinical articles, the most frequent Level of Evidence was IV. The majority of the top 50 Bankart literature consisted of case series and retrospective studies performed in the United States.

Conclusions

Our findings are consistent with the hypothesis that the 50 most-cited articles about Bankart lesions are predominantly U.S.-based, produced by academic orthopaedic groups, clinical outcomes articles, and of Level IV and V evidence. This list of articles should serve as a reference tool for any orthopaedist looking to review Bankart literature.

Impact of Body Mass Index on the Accuracy of Physical Examination and MRI of the Shoulder

BACKGROUND

The physical examination of overweight patients can require specific adaptations. Orthopaedic literature on the impact of body mass index (BMI) on the physical examination of the shoulder is virtually nonexistent.

PURPOSE

To assess whether BMI affects the sensitivity and specificity of common shoulder tests, using arthroscopy as a gold standard. We also examined the effects of BMI on the sensitivity and specificity of magnetic resonance imaging (MRI) of the shoulder for reference.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

We analyzed the data of 116 consecutive patients who underwent shoulder arthroscopy for the treatment of rotator cuff tears, Bankart lesions, and superior labral anterior-posterior (SLAP) lesions. Preoperative BMI, physical examination of the shoulder findings, and MRI findings were extracted. Contingency tables and receiver operating characteristic curves were used to evaluate the sensitivity and specificity of provocative tests of the shoulder and MRI as well as their relationship to BMI.

RESULTS

The sensitivity and specificity of the Jobe supraspinatus test were 77.8% and 72.7% in patients with BMI ≤25, 82.6% and 70.6% in those with 25 < BMI ≤ 30, and 81.3% and 55.6% in those with BMI >30, respectively (P < .001). The apprehension and relocation tests demonstrated higher sensitivity and specificity for the overweight patients (25 < BMI ≤ 30) compared with the other BMI groups, with a sensitivity and specificity of 83.3% and 100% for the apprehension test and a sensitivity and specificity of 75% and 100% for the relocation test, respectively. The O'Brien, Speed, and Ebinger tests for SLAP tears had low accuracy and did not yield statistically significant results. MRI interpretation was found to be influenced by BMI in obese patients, especially when SLAP lesions were assessed.

CONCLUSION

Counterintuitively, tests for shoulder instability had greater specificity in overweight patients and should be encouraged, particularly in obese patients, in whom the specificity of shoulder MRI for the detection of a Bankart lesion is lower. The Jobe test was more sensitive but less specific in overweight patients. These findings may assist care providers in improving the interpretation of the shoulder examination of overweight patients and consequently lead to better treatment-related decisions.

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.

The Correlation of the SLAP II Lesion Findings Between Physical Examination, Magnetic Resonance Imaging, and Arthroscopic Surgery

OBJECTIVES

The aim of this study is to demonstrate the importance of clinical diagnosis by comparing with preoperative physical examination and magnetic resonance imaging (MRI) images in patients who were arthroscopically diagnosed as having Superior Labrum Anterior-Posterior (SLAP) II lesions.

MATERIALS AND METHODS

134 patients, arthroscopically diagnosed as SLAP II, established the study group, and 200 patients who underwent shoulder arthroscopy for the other pathologies established the control group. Preoperative clinical examination of the patients, MRI findings, and the arthroscopic findings of the patients were recorded.

RESULTS

Out of the patients diagnosed with a SLAP II lesion, 107 (79.9) of those had an MRI finding while only 60 (30%) of the control group had it. The O'Brien test results of the patients diagnosed with SLAP were positive in 111 (82.8%) while those diagnosed with intact superior labrum were positive in 132 (66%). Of the 134 patients with a SLAP II lesion, 89 (66.4%) had both O'Brien test positiveness and MRI finding, and 129 (96%) had at least one positive result of the O'Brien test or MRI examination.

CONCLUSION

The O'Brien test and MRI examination are not capable enough to indicate a SLAP lesion one by one, because of the low sensitivity and specificity. But, combining the test with MRI findings provides more trustable information about the superior labrum.

Atypical tear of the long head of the biceps tendon in a young male adult

A 34-year-old man, with previous anabolic steroid abuse, presented with right shoulder pain following an underhand bowling swing. Examination indicated a Popeye sign of the right biceps, and positive Speeds, Yergason and O'Brian's tests. MRI indicated a complete tear of the intra-articular portion of the long head of biceps tendon (LHBT). Interestingly, the tear occurred within the glenohumeral joint allowing the proximal portion of the LHBT to uniquely coil and fold on itself deep to the subscapularis causing mechanical symptoms. He was treated conservatively with physical therapy but failed to achieve pain relief and proceeded with arthroscopic debridement of the folded portion of the LHBT stump, which significantly improved clinical outcomes at 18 months postoperative. We report the first case of an LHBT tear during bowling in a young adult with a rare occurrence of the proximal portion of the LHBT uniquely coiling and folding on itself deep to the subscapularis.

Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review

BACKGROUND

The Active Compression Test has been proposed to have high diagnostic accuracy for superior labrum anterior to posterior tears. The aim of this systematic review was to compile the available evidence for this test and evaluate its diagnostic accuracy.

METHODS

The databases PubMed, Embase, Cochrane, CINAHL, and SCOPUS were searched for case control, diagnostic studies that evaluated the Active Compression Test between 1999 (date of test introduction) and February 2018. Two independent review authors screened the search results, assessed the risk of bias using QUADAS-2, and extracted the data.

RESULTS

Eighteen studies (pooled sample = 3091) were included in this review. Twelve out of 18 studies either had high or unclear risk of bias (66.6%). Results from the pooled analysis of all 18 studies provided that the Active Compression Test is more sensitive (71.5: 95% CI = 68.8, 74.0) than specific (51.9: 95% CI = 50.7, 53.1) and only marginally influenced posttest probability from a pretest probability of 31.7-40.72% with a positive finding and a pretest probability of 31.7-20.33% with a negative finding.

DISCUSSION

The Active Compression Test has both limited screening and confirmation ability; therefore, we do not advocate for its use in clinical decision making.

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.

Clinical characteristics of patients with posterosuperior labral tear: a comparison with patients with other shoulder disorders

Background

Among the various causes of shoulder pain, the glenoid labral tear is likely to be overlooked due to its ambiguous symptoms, especially if clinicians do not have a prior suspicion, making it difficult to diagnose, unlike adhesive capsulitis or a rotator cuff tear. Therefore, the aim of this study was to evaluate the clinical features of posterosuperior (PS) labral tear.

Methods

Of the patients who visited the clinic, the medical records of patients with shoulder pain who underwent shoulder magnetic resonance imaging or ultrasound after intra-articular injection (arthrosonography) were investigated retrospectively. Based on these criteria, a total of 120 patients with adhesive capsulitis, rotator cuff problem, or PS labral tear were included for analysis in this study.

Results

In the physical examination, all patients with a PS labral tear were positive on the O’Brien test (13/13, 100%) and the external rotation (ER) test with the upper arm in the abduction position (abduction and ER [ABER] test) (13/13, 100%), but they were negative on other tests, such as the Hawkins–Kennedy (1/13, 7.69%) and Neer (0/13, 0.00%) tests. Except one patient, all patients with a PS labral tear were negative on the ER test with the upper arm in the neutral position (ER test) (1/13, 7.69%). In the clinical history, all patients with a PS labral tear had a characteristic episode of shoulder pain occurring in the excessive ABER posture.

Conclusion

In patients with characteristic physical findings (no definite loss of motion of the shoulder joint, negative in an ER test, but positive in an ABER test and O’Brien test), and with a clinical history of PS labral tear (a history of pain occurring with the excessive ABER posture), clinicians need to have a suspicion of PS labral tear and to identify the PS labral tear using MRI or arthrosonography

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.

Comprehensive Examination of the Athlete's Shoulder

Context:

Shoulder pain and dysfunction are common, with patients presenting complaints to both primary and orthopaedic physicians. History and physical examination remain essential to creating a differential diagnosis, even as noninvasive imaging has improved.

Evidence Acquisition:

Literature was obtained through keyword searches based on the pathology in question (eg, rotator cuff) and the keywords physical examination using PubMed from January 1, 1980, through September 20, 2017. Additional evidence was obtained through screening references from articles identified through the PubMed searches.

Study Design:

Clinical review.

Level of Evidence:

Level 3.

Results:

A total of 7817 articles were screened for relevance. Several physical examination maneuvers have been described for each specific pathology. The Neer sign has a 75% sensitivity for subacromial impingement (SAI), while the Hawkins-Kennedy test has an 80% sensitivity. The painful arc test has an 80% specificity for SAI. The apprehension test has a hazard ratio of 2.96 for anterior shoulder instability. The Jobe test has a sensitivity of 52.6% and a specificity of 82.4% for full-thickness supraspinatus tears, confirmed on arthroscopy. The lag sign is highly sensitive and specific for combined full-thickness supraspinatus and infraspinatus tears at 97% and 93%, respectively. The Speed test has a sensitivity of 54% and specificity of 81% for biceps pathology. The anterior slide test and O’Brien active compression test have been described for superior labrum anterior posterior tears with inconsistent reliability. The cross-body adduction test has a sensitivity of 77% and a specificity of 79% for acromioclavicular joint pathology.

Conclusion:

Several physical examination maneuvers can isolate specific pathology of the shoulder, with widely ranging sensitivity and specificity.

Evaluation of Posterosuperior Labral Tear with Shoulder Sonography After Intra-articular Injection: A Case Series

Detection of a posterior glenoid labral lesion can be challenging. Clinicians may overlook this diagnosis because of its vague symptoms, unlike rotator cuff tear or adhesive capsulitis. Together with magnetic resonance (MR) imaging, shoulder MR arthrography is considered the imaging method of choice for the detection of posterior glenoid labral lesions. However, MR arthrography is associated with high cost and low accessibility, and to circumvent these shortcomings, efforts are being made to use sonography (US). However, prior experience in shoulder US is required to evaluate glenoid labrum using US because glenoid labrum is not located superficially and is surrounded by the rotator cuff musculature. There were a few studies that reported the potential for arthrosonography in finding the tear of anterior glenoid labrum and rotator cuff. Until now, however, there was no report regarding arthrosonography in posterosuperior glenoid labral tear and its efficacy and potential for overcoming the limitations of conventional US. In this report, we described 3 cases with posterosuperior glenoid labral tear that were not diagnosed by conventional US but by arthrosonography. In addition, the authors also present their history, physical examinations, and response to treatment, which may be helpful in the diagnosis of posterosuperior glenoid labral tear.

Clinical Assessment of the Dynamic Labral Shear Test for Superior Labrum Anterior and Posterior Lesions

BACKGROUND

Diagnosing superior labrum anterior and posterior (SLAP) lesions through physical examination remains challenging. The dynamic labral shear test (DLST) has been shown to have likelihood ratios (LRs) of 31.6 and 1.1 for diagnosing SLAP lesions.

PURPOSE

To determine the clinical utility of the DLST for diagnosing SLAP lesions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

This prospective, consecutive case series included 774 patients who underwent diagnostic arthroscopy and a preoperative DLST between 2007 and 2013. Patients were divided into 3 groups: 610 control patients with no SLAP lesion but with other abnormalities, 9 patients with isolated SLAP lesion (ISL), and 155 patients with concomitant SLAP lesion (CSL), who had a SLAP lesion and another shoulder abnormality. We determined sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), odds ratio (OR), and diagnostic accuracy (DA) of the DLST with and without other tests.

RESULTS

The DLST was positive for 242 of 610 controls (40%), 7 of 9 patients (78%) in the ISL group, and 88 of 155 patients (57%) in the CSL group. In the ISL group, the DLST had a sensitivity of 78%, specificity of 51%, PPV of 2%, NPV of 100%, OR of 3.58, and DA of 51%. In comparison, the ORs were 1.09 for the active compression test, 1.30 for the lift-off test, and 1.53 for the relocation test, which were not significantly different from each other. For diagnosing a SLAP lesion existing in a joint with other associated injury, the DLST had a sensitivity of 57%, specificity of 52%, PPV of 23%, NPV of 83%, OR of 1.4, and DA of 53%. Combining all 4 tests did not improve the OR for detecting ISLs or CSLs.

CONCLUSION

The DLST is sensitive but not specific for detecting ISLs. With an OR of 3.58, the DLST is useful for diagnosing ISLs. However, in patients who have CSLs, the DLST is not as useful for diagnosing SLAP lesions.

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.

Magnetic resonance imaging evaluation of meniscoid superior labrum: normal variant or superior labral tear

Objective

The objective of this study was to determine the incidence of a "meniscoid" superior labrum.

Materials and Methods

This was a retrospective analysis of 582 magnetic resonance imaging examinations of shoulders. Of those 582 examinations, 110 were excluded, for a variety of reasons, and the final analysis therefore included 472 cases. Consensus readings were performed by three musculoskeletal radiologists using specific criteria to diagnose meniscoid labra.

Results

A meniscoid superior labrum was identified in 48 (10.2%) of the 472 cases evaluated. Arthroscopic proof was available in 21 cases (43.8%). In 10 (47.6%) of those 21 cases, the operative report did not include the mention a superior labral tear, thus suggesting the presence of a meniscoid labrum. In only one of those cases were there specific comments about a mobile superior labrum (i.e., meniscoid labrum). In the remaining 11 (52.4%), surgical correlation demonstrated superior labral tears.

Conclusion

A meniscoid superior labrum is not an infrequent finding. Depending upon assumptions and the requirement of surgical proof, the prevalence of a meniscoid superior labrum in this study was between 2.1% (surgically proven) and 4.8% (projected). However, superior labral tears are just as common and are often confused with meniscoid labra.

SLAP lesions: a treatment algorithm

Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors' clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from "true" SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.

Examination of the Biceps Tendon

The examination of the shoulder for conditions involving the biceps tendon continues to be challenging. Numerous examination tests for biceps and superior labrum anterior and posterior (SLAP) lesions have been scientifically evaluated. This section reports on how to perform these tests and summarizes the clinical utility of the tests. Many of the tests for the examination of the biceps and for SLAP lesions do not have high sensitivity and specificity, which limits their usefulness. Although the dynamic shear test has promise for making the diagnosis of SLAP lesions, the studies reporting its clinical utility are disparate.

The usefulness of the three-dimensional enhanced T1 high-resolution isotropic volume excitation MR in the evaluation of shoulder pathology: comparison with two-dimensional enhanced T1 fat saturation MR

OBJECTIVE

To evaluate the diagnostic accuracy of three-dimensional (3D) enhanced T1 high-resolution isotropic volume excitation (eTHRIVE) shoulder MR for variable shoulder pathology such as rotator cuff tear, labral injury and synovial pathology in comparison with two-dimensional enhanced fast spin echo T1 fat saturation (2D T1 FS) sequences MR.

METHODS

This retrospective study included 86 patients who underwent MRI of the shoulder using eTHRIVE technique. Two radiologists evaluated anatomic identification of the supraspinatus, glenoid labrum and acromioclavicular joint (AC joint) on routine MRI sequences (2D T1 FS) and compared them with the reformatted eTHRIVE images. Subjective scoring of the images was performed with a four-point scale that rated the degree of discrimination of the shape of the supraspinatus, glenoid labrum and AC joint. The diagnostic accuracy of eTHRIVE compared with routine MR images was evaluated in terms of rotator cuff pathology, labral pathology and synovial pathology.

RESULTS

Anatomic identification scores of the supraspinatus tendon and labrum were significantly lower for eTHRIVE than for 2D T1 FS. There were no significant differences between eTHRIVE and 2D T1 FS in anatomic identification of the AC joint. There were no significant differences between eTHRIVE and 2D T1 FS in diagnosing the three disease categories.

CONCLUSION

eTHRIVE had comparable diagnostic accuracy to 2D T1 FS imaging in the evaluation of rotator cuff tears, labral injury and synovial pathology, but anatomic identification was inferior to that of 2D T1 FS.

ADVANCES IN KNOWLEDGE

The accuracy of 3D eTHRIVE imaging is comparable to that of 2D T1 FS for the diagnosis of rotator cuff tears, labral injury and synovial pathology.

Superior Labrum Anterior Posterior Lesions and Associated Injuries: Return to Play in Elite Athletes

Background:

Superior labrum anterior posterior (SLAP) lesions often cause shoulder pain, dysfunction, and instability. Professional athletes require a high level of shoulder function for competition and overhead activities.

Purpose:

To evaluate elite athletes who had arthroscopic surgery for common shoulder pathologies and SLAP lesions with a follow-up of more than 3 years. The associated intra-articular pathologies and return to play were documented.

Study Design:

Case series; Level of evidence, 4.

Methods:

Thirty-five shoulders in 34 elite athletes (4 women and 30 men; mean age, 25 years [range, 18-32 years]) had arthroscopic repair of SLAP lesions and accompanying Bankart or rotator cuff tears between January 2008 and November 2011. The documentation included patient symptoms, physical examination, radiological analysis with radiographs, and magnetic resonance imaging. Shoulder function was evaluated preoperatively and at follow-up using American Shoulder and Elbow Surgeons (ASES) and Kerlan Jobe Orthopaedic Clinic (KJOC) scores. The mean follow-up was 52 months.

Results:

Isolated SLAP lesions were seen in 17.1% of patients, SLAP lesions and partial cuff tear occurred in 25.7%, associated Bankart lesions in 37.1%, full-thickness rotator cuff tears in 8.6%, Bankart and posterior labrum lesions in 8.6%, and Bankart and full-thickness rotator cuff tears in 2.9%. Return to play was a mean 6.4 ± 1.5 months. The mean postoperative ASES and KJOC scores were 89.6 ± 4.6 and 80.9 ± 6.8, respectively, compared with preoperative scores of 64.0 ± 7.2 and 50.5 ± 10.3 (t test, P < .01).

Conclusion:

The majority (88.2%) of professional athletes returned to their preinjury levels. SLAP lesions may frequently occur with Bankart lesions and rotator cuff tears. A high rate of return to sport at the same level of athletic performance can be achieved by anatomic repair and effective rehabilitation.

Labrum and rotator cuff injuries in the throwing athlete

The large amount of force imparted across the shoulder during the act of throwing makes the glenohumeral joint highly susceptible to injury in the athlete performing overhead throwing motions. The bony incongruity of the shoulder enables greater range of motion than any other joint in the body, but it also results in significant strain on the surrounding soft tissues during the throwing motion. Throwers can present with acute injuries, but more commonly they suffer from chronic overuse conditions resulting from repetitive overload. Proper management requires early recognition with treatment directed toward the athlete's safe return to sports. Failure to institute an appropriate management strategy may result in significant complications, including prolonged disability, progression of symptoms, and further injury. We discuss the functional anatomy, pathophysiology, clinical presentation, evaluation, and treatment of common injuries of the glenoid labrum and rotator cuff in the overhead throwing athlete.

Understanding and evaluating shoulder pain in the throwing athlete

Shoulder pain in the throwing athlete can present at any age and in any level of sport and can lead to dysfunction. A thorough evaluation of the throwing athlete can often determine the cause of symptoms, which is frequently multifactorial. Although the pathophysiology leading to pain in the shoulder of the throwing athlete is not entirely known, nonoperative modalities remain the mainstay of treatment. In general, surgical intervention should be reserved as a last resort. Effective treatment often requires collaboration among trainers, players, physicians, and therapists to determine an appropriate course of action.

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.

Superior labrum anterior-to-posterior repair incidence: a longitudinal investigation of community and academic databases

BACKGROUND

Superior labrum anterior-to-posterior (SLAP) lesion repair is controversial regarding indications and potential complications.

METHODS

Databases were used to determine the SLAP repair incidence compared with all orthopaedic procedures over a period of 10 years. In part A, the New York Statewide Planning and Research Cooperative System ambulatory surgery database was investigated from 2002 to 2009. In part B, the California Office of Statewide Health Planning and Development ambulatory surgery database was investigated from 2005 to 2009. In part C, the American Board of Orthopaedic Surgery (ABOS) database was investigated from 2003 to 2010.

RESULTS

In part A, from 2002 to 2009, there was a 238% increase in SLAP repair volume compared with a 125% increase in all orthopaedic procedures. In part B, from 2005 to 2009, there was a 20.17% increase in SLAP repair volume compared with a decrease of 13.64% in all orthopaedic procedures. In part C, among candidates performing at least 1 SLAP repair, there was no statistically significant difference in likelihood of performing a SLAP repair (95% confidence interval, 0.973-1.003) in 2010 as compared with 2003 (P > .10).

CONCLUSIONS

There has been a significant increase in the incidence of SLAP repairs in the past 10 years in statewide databases. This pattern was not seen in the ABOS database, in which the annual volume of SLAP repairs remained stable over the same period. This suggests that SLAP lesions have been over-treated with surgical repair but that part II ABOS candidates are becoming more aware of the need to narrow indications.

LEVEL OF EVIDENCE

Epidemiology study, database analysis.

Anterior dislocation of the shoulder in skeletally immature patients

The ideal treatment for traumatic anterior dislocation of the shoulder in the skeletally immature patient is controversial. The aim of this study is to evaluate the outcomes after either conservative and/or surgical treatment using the Latarjet technique. A retrospective series of 49 out of 80 patients were reviewed. We found no significant differences between either treatment method regarding functional scores and pain levels. Although not statistically significant, post-surgical patients showed better signs of shoulder stability than others who have a higher rate of recurrence. Further, 92% of the post-surgical group had returned to the same level of activity versus 52% in the non-surgically treated group. We found no contraindications to operate on a skeletally immature patient.

Cite this article: Bone Joint J 2014;96-B:354–9.

Superior labral anterior posterior lesions of the shoulder

Superior labrum anterior and posterior (SLAP) lesion is of fairly recent description and its understanding is rapidly evolving. Its incidence and need for surgical treatment has increased exponentially in line with the increase in shoulder arthroscopies. It is of particular importance in the elite over head athlete and the young. A range of arthroscopic techniques and devices have been described with good functional results. The ability to return to pre injury level of sports remains a concern.

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.

Frequency of use of clinical shoulder examination tests by experienced shoulder surgeons

CONTEXT

Health care professionals have reported and used a multitude of special tests to evaluate patients with shoulder injuries. Because of the vast array of tests, educators of health care curriculums are challenged to decide which tests should be taught.

OBJECTIVE

To survey experienced shoulder specialists to identify the common clinical tests used to diagnose 9 specific shoulder injuries to determine if a core battery of tests should be taught to allied health professionals.

DESIGN

Cross-sectional study.

SETTING

Descriptive survey administered via e-mail.

PATIENTS OR OTHER PARTICIPANTS

Of 131 active members of the American Shoulder and Elbow Surgeons, 71 responded to the survey.

MAIN OUTCOME MEASURE(S)

Respondents were asked to complete a survey documenting their use of clinical tests during a shoulder examination. They answered yes or no to indicate their use of 122 different tests for diagnosing 9 shoulder conditions.

RESULTS

The average number of tests used for all pathologic conditions was 30 ± 9. The anterior apprehension and cross-body adduction tests were used by all respondents. At least 1 test was used for each of the 9 conditions listed (range = 1-7), and at least 50% of respondents used 25 tests. The tests were reviewed for valid diagnostic accuracy via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. High diagnostic value and a large amount of QUADAS variability have been reported in the literature for 16 of the 25 tests.

CONCLUSIONS

A small percentage (20%) of clinical tests is being used by most examiners. The 25 most common tests identified from this survey may serve as a foundation for the student's knowledge base, with the clear understanding that multiple clinical tests are used by some of the most experienced clinicians dealing with shoulder injuries.

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.

'Batter's shoulder': can athletes return to play at the same level after operative treatment?

BACKGROUND

Batter's shoulder has been defined as posterior subluxation of the lead shoulder during the baseball swing. However, it is unclear whether or how frequently patients may return to play after treatment of this uncommon condition.

QUESTIONS/PURPOSES

We therefore determined the rate of return to play after operative treatment for Batter's shoulder and whether ROM was restored.

METHODS

We retrospectively reviewed the records of 14 baseball players diagnosed with Batter's shoulder. Four played professionally, six were in college, and four were in varsity high school. The average age was 20.3 years (range, 16-33 years). All had physical examinations and MRI findings consistent with posterior labral tears involving the lead shoulder. Treatment involved arthroscopic posterior labral repair (n = 10), débridement (n = 2), or rehabilitation (n = 2). The minimum followup was 18 months (average, 2.8 years; range, 18-64 months).

RESULTS

Eleven of 12 surgically treated patients returned to their previous level of batting at an average of 5.9 months after surgery. The one patient who was unable to return to play also had an osteochondral lesion of the glenoid identified at surgery. Players typically returned to hitting off a tee at 3 months and to facing live pitching at 6 months postoperatively. All patients regained full internal and external ROM as compared with preoperative data.

CONCLUSIONS

Batter's shoulder is an uncommon form of posterior instability in hitters affecting their lead shoulder. Most athletes are able to return to play at the same level after arthroscopic treatment of posterior capsulolabral lesions.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

A physician's guide to the physical examination of the shoulder

Shoulder pain is the third most frequent musculoskeletal complaint presented to physicians. Often considered a benign entity by patients and even their physicians, shoulder disorders can have a devastating effect on a patient's ability to function, as well as serve as an indicator of poor general health. For these reasons, it is important for the physician to be able to identify the etiology of a patient's shoulder problem(s). However, making a correct diagnosis is often difficult because there can be many causes for a patient's shoulder pain, weakness, or loss of function. Moreover, the shoulder girdle is an intricate group of structures that work together to allow for the largest range of motion in the body. This complexity makes it difficult to diagnose a patient's condition(s) based on history alone. A thorough and well-performed physical examination is the key to making a correct diagnosis and helping to distinguish different etiologies of shoulder dysfunction. In this article, we review relevant shoulder anatomy and biomechanics, and general shoulder examinations with special tests for various shoulder pathologies. We provide an effective and methodical approach to the physical examination of the shoulder.

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.

Poly-L/D-lactic acid anchors are associated with reoperation and failure of SLAP repairs

PURPOSE

This study investigates factors associated with failure and reoperation after glenoid labrum repair.

METHODS

We studied a nonconcurrent cohort of consecutive patients undergoing arthroscopic superior labrum repair at a single institution by 2 fellowship-trained surgeons over a 10-year period.

RESULTS

There were 348 patients included in this study with a mean age of 33.4 years (95% confidence interval [CI], 32.1 to 35.9) and a mean clinical follow-up of 12.3 months (95% CI, 10.9 to 13.8). The overall reoperation rate was 6.3%, with a revision labrum repair rate of 4.3%. Subsequent surgery and failure after arthroscopic labrum repair were significantly correlated with Workers' Compensation claims (odds ratio [OR], 4.6; P < .001; 95% CI, 1.8 to 11.7), the use of tobacco (OR, 12.0; P = .03; 95% CI, 1.2 to 114.9), and the use of absorbable poly-L/D-lactic acid (PLDLA) anchors (100% correlation, P < .001). The OR for having repeat surgery was 12.7 (95% CI, 4.9 to 32.9; P < .001) with poly-96L/4D-lactic acid (Mini-Revo; Linvatec, Largo, FL) and also increased with the use of poly-70L/30D-lactic acid (Bio-Fastak and Bio-Suturetak; Arthrex, Naples, FL) anchor material (P = .04) after removal of the patients exposed to poly-96L/4D-lactic acid anchors. The rates of repeat surgery with PLDLA anchors from Linvatec and PLDLA anchors from Arthrex were 24% and 4%, respectively. None of the patients treated with nonabsorbable suture anchors (polyether ether ketone or metallic) returned to the operating room (P < .001). After we controlled for associated factors in a multivariate analysis, the use of absorbable anchors, in particular poly-96L/4D-lactic acid anchors (OR, 14.7; P < .001), and having a work-related injury (OR, 8.1; P < .001) remained independent factors associated with both repeat surgery and revision superior labrum repair.

CONCLUSIONS

Bioabsorbable PLDLA anchor material led to significantly more SLAP repair failures and reoperations compared with nonabsorbable suture anchors. Our recommendation is that glenoid labrum repairs be performed with nondegradable material and, specifically, that the use of anchors composed of PLDLA material should be avoided.

Diagnostic accuracy of history and physical examination of superior labrum anterior- posterior lesions

CONTEXT

Type I superior labrum anterior-posterior (SLAP) lesions involve degenerative fraying and probably are not the cause of shoulder pain. Type II to IV SLAP lesions are tears of the labrum.

OBJECTIVE

To determine the diagnostic accuracy of patient history and the active compression, anterior slide, and crank tests for type I and type II to IV SLAP lesions.

DESIGN

Cohort study.

SETTING

Clinic.

PATIENTS OR OTHER PARTICIPANTS

Fifty-five patients (47 men, 8 women; age = 40.6 ± 15.1 years) presenting with shoulder pain.

INTERVENTION(S)

For each patient, an orthopaedic surgeon conducted a clinical examination of history of trauma; sudden onset of symptoms; history of popping, clicking, or catching; age; and active compression, crank, and anterior slide tests. The reference standard was the intraoperative diagnosis. The operating surgeon was blinded to the results of the clinical examination.

MAIN OUTCOME MEASURE(S)

Diagnostic utility was calculated using the receiver operating characteristic curve and area under the curve (AUC), sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). Forward stepwise binary regression was used to determine a combination of tests for diagnosis.

RESULTS

No history item or physical examination test had diagnostic accuracy for type I SLAP lesions (n = 13). The anterior slide test had utility (AUC = 0.70, +LR = 2.25, -LR = 0.44) to confirm and exclude type II to IV SLAP lesions (n = 10). The combination of a history of popping, clicking, or catching and the anterior slide test demonstrated diagnostic utility for confirming type II to IV SLAP lesions (+LR = 6.00).

CONCLUSIONS

The anterior slide test had limited diagnostic utility for confirming and excluding type II to IV SLAP lesions; diagnostic values indicated only small shifts in probability. However, the combination of the anterior slide test with a history of popping, clicking, or catching had moderate diagnostic utility for confirming type II to IV SLAP lesions. No single item or combination of history items and physical examination tests had diagnostic utility for type I SLAP lesions.

Testing procedures for SLAP lesions of the shoulder involving contraction and torsion of biceps long head and glenohumeral glides

Testing procedures for SLAP lesions of the shoulder can combine resisted elbow flexion, forearm pronation and supination, and glenohumeral glides. These procedures reproduce symptoms by increasing biceps long head active tension or passive torsion, and by placing the shoulder in an unstable position. We compared activation of biceps long head and pain intensity, between supinated and pronated forearm positions, between different glides, and between individuals with and without shoulder impairment. A case control study. Twelve participants with suspected SLAP lesions and twelve with no history of shoulder injury volunteered. Electromyography measured muscle activity in biceps long head, normalised against maximum voluntary isometric contraction (MVIC). Subjective pain intensity scores were recorded. Biceps long head activity was greater in forearm supination (mean 39% MVIC) than pronation (mean 24% MVIC), but pain was higher in pronation (mean 4.5/10) than supination (3.2/10). Biceps long head activity was greater when testing without a glide, but there was no difference in pain comparing the glide conditions. The impaired group experienced more pain (mean 3.9/10) than controls (mean 0.3/10) but there was no difference in shoulder muscle activity. No one combination of testing procedures appeared to be diagnostic of SLAP lesions in our sample. This study supports the theory that biceps long head acts as a stabiliser of the shoulder, and suggests that clinical testing procedures for SLAP lesions may need to inhibit biceps long head activity. The addition of glides to SLAP testing procedures did not affect the reproduction of pain.