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Yoon JY, Park WS, Jeong HJ, Jeon YD, Kim JU, Oh JH. Spontaneous resolution of spinoglenoid ganglion cyst: a case series. J Shoulder Elbow Surg 2024; 33:1828-1835. [PMID: 38237721 DOI: 10.1016/j.jse.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 11/07/2023] [Accepted: 11/20/2023] [Indexed: 05/05/2024]
Abstract
BACKGROUND Spontaneous resolution of a spinoglenoid notch ganglion cyst (SGC) without surgical treatment has been rarely reported; however, we have encountered this phenomenon occasionally. Therefore, we aimed to describe a case series of consecutive patients with SGC in whom it spontaneously resolved without surgical treatment. METHODS We retrospectively reviewed 12 patients with magnetic resonance imaging (MRI)-confirmed SGC in whom it resolved without surgical treatment between January 2011 and March 2023. We included patients without abnormally increased signal intensity or muscle atrophy due to denervation from suprascapular neuropathy on MRI. Resolution of the SGC was confirmed via MRI or ultrasound at the follow-up visit, and suprascapular neuropathy was assessed using electromyography and nerve conduction studies when needed. For functional assessments, the visual analog scale for pain and active range of motion of the shoulder were used to compare pre and postresolution follow-ups. RESULTS Eleven men and 1 woman with a median age of 54.0 years (interquartile range [IQR] 37.0-65.3) were included in this study. The SGCs resolved spontaneously at a median of 13.2 months with an IQR of 8.2-23.0 after initial evaluation using MRI. The SGCs were multiloculated cysts with superior labrum anterior and posterior II-IX lesions, with a median diameter of 2.5 cm (IQR 2.0-2.8). The median visual analog scale for pain (pre-resolution 5.0 [IQR 4.0-7.0] vs postresolution 1.0 [IQR 0.0-1.0], P = .002) and internal rotation at the back (preresolution 8.0 [IQR 7.0-10.3] vs postresolution 7.5 [IQR 7.0-8.0], P = .034) were significantly improved after the resolution. CONCLUSIONS Surgical treatment may not be necessary in all cases of SGC. Nonsurgical treatment may be a viable option in the absence of suprascapular nerve involvement or superior labrum anterior and posterior-related physical findings.
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Affiliation(s)
- Ji Young Yoon
- Department of Orthopaedic Surgery, National Police Hospital, Seoul, Republic of Korea
| | - Wan Soo Park
- Department of Orthopaedic Surgery, National Police Hospital, Seoul, Republic of Korea
| | - Hyeon Jang Jeong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young Dae Jeon
- Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Ji Un Kim
- Department of Orthopaedic Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Dean RS, Onsen L, Lima J, Hutchinson MR. Physical Examination Maneuvers for SLAP Lesions: A Systematic Review and Meta-analysis of Individual and Combinations of Maneuvers. Am J Sports Med 2023; 51:3042-3052. [PMID: 35997579 DOI: 10.1177/03635465221100977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Superior labrum anterior to posterior (SLAP) lesions are targeted on physical examination using a variety of provocative maneuvers. PURPOSE/HYPOTHESIS The purpose was to conduct a systematic review on the performance of physical examination maneuvers in diagnosing SLAP lesions and to perform a meta-analysis comparing the sensitivity and specificity of these examinations both individually and in combination. The null hypothesis stated that there would be no significant difference in the sensitivity or specificity of the included physical examination tests, neither individually nor in combination. STUDY DESIGN Meta-analysis and systematic review; Level of evidence, 4. METHODS A systematic review was performed with the inclusion criteria of studies that reported either the sensitivities and specificities or the number of true-positive, true-negative, false-positive, or false-negative results for at least 1 maneuver for identifying SLAP lesions. A meta-analysis was performed to determine the sensitivity and specificity of individual maneuvers. Additional analysis determined the performance of these maneuvers when combined in series and parallel. In series, all must be present to be considered positive. In parallel, any single positive test forces the overall combination to be considered positive. Only tests that were included in ≥3 studies were considered in the meta-analysis and those included in ≥4 studies were considered in the combination analysis. RESULTS Overall, 862 studies were identified, 18 of which were included in the systematic review and meta-analysis. The physical examinations included were the O'Brien (n = 16), speed (n = 8), Yergason (n = 6), anterior slide (n = 8), crank (n = 7), Jobe (n = 5), dynamic labral shear (n = 3), Kim 2 (n = 3), and biceps groove tenderness tests (n = 3). All combinations of 2 to 5 maneuvers in both series and parallel were considered. The O'Brien and crank test combination was the most sensitive 2-test combination in both parallel and series. The Yergason and anterior slide test combination was the most specific 2-test combination in parallel and series. CONCLUSION This systematic review and meta-analysis reports an updated meta-analysis considering the sensitivity and specificity of common physical examination maneuvers used in the diagnosis of SLAP lesions and considers these values for tests in both series and parallel combinations. The present analysis demonstrates improved specificities when tests are considered in series and improved sensitivities when considered in parallel combination.
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Affiliation(s)
- Robert S Dean
- Department of Beaumont Health, Royal Oak Hospital, Royal Oak, Michigan, USA
| | - Leonard Onsen
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jeniffer Lima
- Department of Family Medicine, Amita St. Mary and Elizabeth Medical Center, Chicago, Illinois, USA
| | - Mark R Hutchinson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
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Moretti L, Bizzoca D, Farì G, Caricato A, Angiulli F, Cassano GD, Solarino G, Moretti B. Bari Shoulder Telemedicine Examination Protocol (B-STEP): A Standard Protocol for Personalized Remote Shoulder Examination. J Pers Med 2023; 13:1159. [PMID: 37511772 PMCID: PMC10381873 DOI: 10.3390/jpm13071159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/25/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- Lorenzo Moretti
- Orthopaedic and Trauma Unit, AOUC Policlinico di Bari, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Davide Bizzoca
- Orthopaedic and Trauma Unit, AOUC Policlinico di Bari, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Giacomo Farì
- Physical Medicine and Rehabilitation Unit, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Alessandro Caricato
- Orthopaedic and Trauma Unit, AOUC Policlinico di Bari, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Francesco Angiulli
- Orthopaedic and Trauma Unit, AOUC Policlinico di Bari, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Giuseppe Danilo Cassano
- Orthopaedic and Trauma Unit, AOUC Policlinico di Bari, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Giuseppe Solarino
- Orthopaedic and Trauma Unit, AOUC Policlinico di Bari, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Biagio Moretti
- Orthopaedic and Trauma Unit, AOUC Policlinico di Bari, University of Bari "Aldo Moro", Piazza Giulio Cesare 11, 70124 Bari, Italy
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Superior labral anterior and posterior (SLAP) lesions of the long bicep insertion on the glenoid: management in athletes. INTERNATIONAL ORTHOPAEDICS 2022; 46:1351-1360. [DOI: 10.1007/s00264-022-05385-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
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Siebenlist S, Hinz M, Scheiderer B. Behandlung der SLAP-Verletzung des jungen Sportlers. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-021-00488-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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The Effects of Treatment of Korean Medicine for Superior Labrum Anterior to Posterior Lesions: A Retrospective Chart Review. JOURNAL OF ACUPUNCTURE RESEARCH 2020. [DOI: 10.13045/jar.2019.00346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: This study aimed to investigate the clinical effectiveness of treatment of Korean medicine on superior labrum anterior to posterior (SLAP) lesions.Methods: A total of 55 inpatients diagnosed with SLAP lesions by magnetic resonance imaging, were investigated from May 1<sup>st</sup>, 2014 to May 31<sup>st</sup>, 2019 at Haeundae Jaseng Hospital of Korean Medicine. The patients were sorted by gender, age, causing factor, illness duration, period of hospitalization, SLAP lesion type, complications, and treatments. Treatments included acupuncture, pharmacopuncture, Chuna therapy, herbal treatment, and physiotherapy. After treatment, the Numeric Rating Scale, Shoulder Pain and Disability Index, and European Quality of Life 5-Dimension questionnaire were used to evaluate treatment effect.Results: There were more males than females in this study (1:0.83). Patients were more likely to be in their 50s (38.18%), have an unknown etiology (70.91%), and be in the subacute disease stage (41.82%). According to the SLAP lesion type, most of the inpatients had Type 2 lesions (69.09%). For inpatients diagnosed with SLAP lesions, the mean shoulder numeric rating scale score decreased from 5.55 ± 0.90, to 4.07 ± 1.18 (p < 0.001), the mean Shoulder Pain and Disability Index score decreased from 50.35 ± 18.36, to 39.90 ± 19.34 (p < 0.001), and the mean European quality of life 5-dimension index increased from 0.70 ± 0.16, to 0.75 ± 0.13 (p < 0.01) after treatment.Conclusion: Treatment of Korean medicine effectively decreased pain and increased the quality of life of the patients with SLAP lesions in this study.
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Rhee YG, Park I, Kim JY, Hyun HS, Shin SJ. Preoperative Diagnostic Rates and Clinical Outcomes After Arthroscopic Stabilization Procedures for Panlabral Tear of the Glenohumeral Joint. Arthroscopy 2020; 36:411-418. [PMID: 31883709 DOI: 10.1016/j.arthro.2019.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/01/2019] [Accepted: 09/02/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate preoperative diagnostic rates for panlabral tear using imaging studies or physical examinations and to evaluate clinical outcomes after arthroscopic stabilization procedures with 2 different patient surgical positions. METHODS Patients who underwent arthroscopic stabilization for recurrent anterior shoulder instability with panlabral tear and were followed up for at least 2 years were included. A panlabral tear was defined as labral tear involving at least 270° of the glenoid surface on arthroscopic examination. All patients underwent preoperative magnetic resonance (MR) imaging or MR arthrography and physical examinations including anterior apprehension, posterior jerk, and compressive rotation tests. The clinical outcomes were assessed by the American Shoulder and Elbow Surgeons, Rowe, and visual analog scale for pain scores, and recurrence rate. According to patient position during surgery, patients were divided into group I (beach chair position) and group II (lateral decubitus position). RESULTS Forty-eight patients (24 in group I and 24 in group II) were enrolled. Preoperative MR imaging or MR arthrography detected only 18.8% of panlabral tears. No patient had positive findings on all 3 physical examination tests for panlabral tear. Clinical outcomes were significantly improved after operation (American Shoulder and Elbow Surgeons score: 58.4 ± 6.2 preoperatively, 85.2 ± 6.4 at the final, P < .001; Rowe score: 49.0 ± 12.2 preoperatively, 86.8 ± 9.1 at the final, P < .001) and postoperative recurrence was occurred in 1patient (2%). No differences were found in clinical outcomes and recurrence rate (4% vs 0%) according to patient positioning, despite the larger number of suture anchors used in group II (6.2 ± 1.5 in group I, 7.6 ± 1.1 in group II, P < .001). CONCLUSIONS It remained difficult to preoperatively diagnose panlabral tear using standard physical examinations and imaging studies. Nevertheless, arthroscopic stabilization procedures for patients with panlabral tear provided satisfactory clinical outcomes with a low recurrence rate. Patient position during surgery did not alter clinical outcomes and recurrence rate, despite the use of different numbers of suture anchors. LEVEL OF EVIDENCE Level III, Retrospective comparative therapeutic trial.
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Affiliation(s)
- Yong-Girl Rhee
- Department of Orthopedic Surgery, Kyung Hee University, School of Medicine, Seoul, Republic of Korea
| | - In Park
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Jung-Youn Kim
- Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hwan-Sub Hyun
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Sang-Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea.
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Davis C, Immormino J, Higgins BM, Clark K, Engebose S, Garcia AN, Cook CE. Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review. Shoulder Elbow 2019; 11:321-331. [PMID: 31534482 PMCID: PMC6739753 DOI: 10.1177/1758573218811656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/02/2018] [Accepted: 10/10/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND The Active Compression Test has been proposed to have high diagnostic accuracy for superior labrum anterior to posterior tears. The aim of this systematic review was to compile the available evidence for this test and evaluate its diagnostic accuracy. METHODS The databases PubMed, Embase, Cochrane, CINAHL, and SCOPUS were searched for case control, diagnostic studies that evaluated the Active Compression Test between 1999 (date of test introduction) and February 2018. Two independent review authors screened the search results, assessed the risk of bias using QUADAS-2, and extracted the data. RESULTS Eighteen studies (pooled sample = 3091) were included in this review. Twelve out of 18 studies either had high or unclear risk of bias (66.6%). Results from the pooled analysis of all 18 studies provided that the Active Compression Test is more sensitive (71.5: 95% CI = 68.8, 74.0) than specific (51.9: 95% CI = 50.7, 53.1) and only marginally influenced posttest probability from a pretest probability of 31.7-40.72% with a positive finding and a pretest probability of 31.7-20.33% with a negative finding. DISCUSSION The Active Compression Test has both limited screening and confirmation ability; therefore, we do not advocate for its use in clinical decision making.
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Affiliation(s)
- Cody Davis
- Division of Physical Therapy, Duke
University, Durham, USA
| | | | | | - Kyle Clark
- Division of Physical Therapy, Duke
University, Durham, USA
| | | | - Alessandra N Garcia
- Division of Physical Therapy, Duke
University, Durham, USA,Department of Orthopaedic Surgery,
Division of Physical Therapy, Duke University, Durham, USA,Alessandra N Garcia, PT 2200 W. Main St.,
Suite A210, Durham, NC 27705, USA.
| | - Chad E Cook
- Division of Physical Therapy, Duke
University, Durham, USA,Duke Clinical Research Institute, Duke
University, Durham, USA
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Reinig Y, Welsch F, Hoffmann R, Müller D, Gramlich S, Fischer S, Schüttler KF, Zimmermann E, Stein T. Assessments of activities of daily living after arthroscopic SLAP repair with knot-tying versus knotless suture anchors. Arch Orthop Trauma Surg 2019; 139:981-990. [PMID: 30820694 DOI: 10.1007/s00402-019-03151-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE The clinical influence of knot-tying or knotless anchor systems for the arthroscopic repair of SLAP lesions (superior labrum lesion from anterior to posterior) remain unclear. MATERIALS AND METHODS In a retrospective cohort analysis, 61 of 78 (78.2%) patients with isolated symptomatic SLAP II lesions were examined with a minimum of 24 months after arthroscopic SLAP repair compared to a control group: 28 patients with knot-tying anchors (group I, G1; 28.95 ± 9.48 years, 23 male/5 female), 33 with knotless anchors (group II, G2; 31 ± 10.09 years, 26 male/7 female) and 140 healthy volunteers (group III, G3; 30.9 ± 8.9 years, 109 male/31 female). The clinical assessment included an examination and estimated parameters of ADL (activities of daily living), the CS (Constant score), ASES (American Shoulder and Elbow score), DASH (disability of arm-shoulder hand) and the RS (Rowe score). RESULTS The ROM analysis recorded no significant differences for the external rotation in 0° abduction (G1 63.75° ± 15.55° versus = vs G2 65.30° ± 18.15°; pERG1 vs G2 = 0.72). The clinical outcomes revealed significantly decreased pain status in G1 for the O'brien test and in G2 for the Palm-up test, whereas Yergason test showed similar pain levels (pO'brien = 0.03; ppalm up = 0.02; pyergason > 0.5). The pulley associated rotator cuff tests revealed a significantly inferior force status in G2 compared to G1 (plift-off = 0.005, pJobe = 0.02) whereas the further rotator cuff assessments were equal. In general, the intervention group showed increased pain level and functional deficits compared to the G3. The score analysis detected no significant differences with PCSG1 vs G2, PASESG1 vs G2, PDASHG1 vs G2 and PRSG1 vs G2 all > 0.05 and significant impairments compared to G3 in all scores pG1/G2 vs G3 < 0.05 (CSG1 = 88.28 ± 14.42, CSG2=92.73 ± 9.24, CSG3 = 96.2 ± 4.96; ASESG1 = 81.10 ± 21.69, ASESG2 = 85.35 ± 17.12, ASESG3 = 94.95 ± 10.39,; DASHG1= 35.75 ± 13.44, DASHG2 = 36.03 ± 17.55, DASHG3 = 27.13 ± 6.52; RSG1 = 90.71 ± 9.88, RSG2 = 88.33 ± 11.22, RSG3= 92.96 ± 11.27). CONCLUSIONS The clinical assessment revealed for both anchor systems similar outcomes but showed general underestimated impairments after the SLAP repair surgery compared to the healthy control. The clinical status only marginally differed between both techniques, wherefore the present assessment of ADL allowed no recommendation of one of these two specific surgery technique for SLAP repair.
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Affiliation(s)
- Y Reinig
- Department of Sporttraumatology-Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstraße 430, 60389, Frankfurt am Main, Germany
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - F Welsch
- Department of Sporttraumatology-Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstraße 430, 60389, Frankfurt am Main, Germany
| | - R Hoffmann
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - D Müller
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - S Gramlich
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - S Fischer
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
| | - K F Schüttler
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Marburg, Germany
| | - E Zimmermann
- Department of Sports Science, University of Bielefeld, Bielefeld, Germany
| | - Thomas Stein
- Department of Sporttraumatology-Knee- and Shoulder-Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstraße 430, 60389, Frankfurt am Main, Germany.
- Department of Trauma and Orthopedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany.
- Department of Sports Science, University of Bielefeld, Bielefeld, Germany.
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USE of CLINICAL TEST CLUSTERS VERSUS ADVANCED IMAGING STUDIES in the MANAGEMENT of PATIENTS with a SUSPECTED SLAP TEAR. Int J Sports Phys Ther 2019; 14:345-352. [PMID: 31681493 DOI: 10.26603/ijspt20190345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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11
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Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder. J Am Acad Orthop Surg 2019; 27:395-404. [PMID: 30383578 DOI: 10.5435/jaaos-d-17-00637] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A detailed physical examination of the shoulder is crucial in creating a diagnosis in patients who present with shoulder pain. Tests of the cervical spine, scapula, and rotator cuff muscles have already been evaluated in a previous article. This article assesses provocative and instability examination tests of the shoulder. Descriptions on how the tests are performed and their diagnostic accuracy are presented.
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Michener LA, Abrams JS, Bliven KCH, Falsone S, Laudner KG, McFarland EG, Tibone JE, Thigpen CA, Uhl TL. National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries. J Athl Train 2018; 53:209-229. [PMID: 29624450 DOI: 10.4085/1062-6050-59-16] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To present recommendations for the diagnosis, management, outcomes, and return to play of athletes with superior labral anterior-posterior (SLAP) injuries. BACKGROUND In overhead athletes, SLAP tears are common as either acute or chronic injuries. The clinical guidelines presented here were developed based on a systematic review of the current evidence and the consensus of the writing panel. Clinicians can use these guidelines to inform decision making regarding the diagnosis, acute and long-term conservative and surgical treatment, and expected outcomes of and return-to-play guidelines for athletes with SLAP injuries. RECOMMENDATIONS Physical examination tests may aid diagnosis; 6 tests are recommended for confirming and 1 test is recommended for ruling out a SLAP lesion. Combinations of tests may be helpful to diagnose SLAP lesions. Clinical trials directly comparing outcomes between surgical and nonoperative management are absent; however, in cohort trials, the reports of function and return-to-sport outcomes are similar for each management approach. Nonoperative management that includes rehabilitation, nonsteroidal anti-inflammatory drugs, and corticosteroid injections is recommended as the first line of treatment. Rehabilitation should address deficits in shoulder internal rotation, total arc of motion, and horizontal-adduction motion, as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control. Most researchers have examined the outcomes of surgical management and found high levels of satisfaction and return of shoulder function, but the ability to return to sport varied widely, with 20% to 94% of patients returning to their sport after surgical or nonoperative management. On average, 55% of athletes returned to full participation in prior sports, but overhead athletes had a lower average return of 45%. Additional work is needed to define the criteria for diagnosing and guiding clinical decision making to optimize outcomes and return to play.
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Abstract
Background: SLAP lesions of the shoulder are challenging to diagnose by clinical means alone. Interpretation of MR images requires knowledge of the normal appearance of the labrum, its anatomical variants, and the characteristic patterns of SLAP lesions. In general, high signal extending anterior and posterior to the biceps anchor is the hallmark of SLAP lesions. Common diagnostic criteria for a SLAP lesion by MR or MR arthrography include the following: presence of a laterally curved, high signal intensity in the labrum on a coronal image, multiple or branching lines of high signal intensity in the superior labrum on a coronal image, full-thickness detachment with irregularly marginated high signal intensity and/or separation >2 mm on conventional MRI or 3 mm on MR arthrography between the labrum and glenoid on a coronal image, and a paralabral cyst extending from the superior labrum. Methods: MR diagnosis of SLAP tears may be improved with provocative maneuvers, such as longitudinal traction of the arm or positioning of the shoulder in abduction and external rotation during imaging. The use of intra-articular contrast distends the joint similar to what occurs during arthroscopy and forced diffusion under the labrum may improve the ability to detect SLAP lesions that might not be seen with standard MR. Improved diagnostic accuracy for SLAP tears is seen with 3-T compared with 1.5-T MR imaging, with or without intra-articular contrast material. Conclusion: Regardless of MR findings, however, physicians should be cautious when recommending surgery in the patient with a vague clinical picture. The patient’s history, physical exam, and imaging evaluation all should be considered together in making the decision to proceed with surgery.
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Affiliation(s)
- Robert D Boutin
- Department of Radiology, UC Davis School of Medicine, 4860 Y St., Suite 3100, Sacramento, CA 95817, USA
| | - Richard A Marder
- Department of Orthopaedic Surgery, UC Davis School of Medicine, 4860 Y St., Suite 3800, Sacramento, CA 95817, USA
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Shin SJ, Lee J, Jeon YS, Ko YW, Kim RG. Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography. Knee Surg Sports Traumatol Arthrosc 2017; 25:3296-3302. [PMID: 27342986 DOI: 10.1007/s00167-016-4226-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 06/17/2016] [Indexed: 01/02/2023]
Abstract
PURPOSE In the present prospective study, the functional outcomes of non-operative treatment were evaluated in patients aged between 30 and 45 years presenting SLAP lesion in diagnostic provocative tests and magnetic resonance (MR) arthrography. METHODS Forty-six patients with a symptomatic SLAP lesion who participated in recreational level of sports were prospectively enroled. SLAP lesion was diagnosed using combinations of several clinical tests and MR arthrography findings. All patients were treated with intra-articular corticosteroid injections, followed by rotator cuff and periscapular muscle-strengthening exercises. Patients with persistent discomfort after second injection underwent arthroscopic SLAP repair. Functional outcomes were evaluated using ASES and Constant scores, and pain and satisfaction for visual analogue scale (VAS). RESULTS Pain had significantly improved from 5.2 ± 2.2 to 1.0 ± 1.1 (p < 0.001) in all patients after the first corticosteroid injection. SLAP symptoms relapsed in 12 patients at an average of 2.4 months after the first injection. Symptoms were relieved in 5 of 12 patients after the second injection and strengthening exercises. The remaining seven patients underwent arthroscopic SLAP repair. Thirty-nine patients (85 %) who were treated non-operatively showed improved VAS, Constant, and ASES scores at final follow-up (p < 0.001). CONCLUSIONS Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment. CLINICAL RELEVANCE Non-operative management using combined intra-articular corticosteroid injection with rotator cuff and periscapular strengthening exercises could be applied as primary treatment for patients with symptomatic SLAP lesion who participate in recreational level of sports. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Sang-Jin Shin
- Ewha Shoulder Disease Center, Department of Orthopaedic Surgery, School of Medicine, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Korea.
| | - Juyeob Lee
- Ewha Shoulder Disease Center, Department of Orthopaedic Surgery, School of Medicine, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Korea
| | - Yoon-Sang Jeon
- Ewha Shoulder Disease Center, Department of Orthopaedic Surgery, School of Medicine, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Korea
| | - Young-Won Ko
- Ewha Shoulder Disease Center, Department of Orthopaedic Surgery, School of Medicine, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Korea
| | - Rag-Gyu Kim
- Ewha Shoulder Disease Center, Department of Orthopaedic Surgery, School of Medicine, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul, 07985, Korea
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Sodha S, Srikumaran U, Choi K, Borade AU, McFarland EG. Clinical Assessment of the Dynamic Labral Shear Test for Superior Labrum Anterior and Posterior Lesions. Am J Sports Med 2017; 45:775-781. [PMID: 28298065 DOI: 10.1177/0363546517690349] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Diagnosing superior labrum anterior and posterior (SLAP) lesions through physical examination remains challenging. The dynamic labral shear test (DLST) has been shown to have likelihood ratios (LRs) of 31.6 and 1.1 for diagnosing SLAP lesions. PURPOSE To determine the clinical utility of the DLST for diagnosing SLAP lesions. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS This prospective, consecutive case series included 774 patients who underwent diagnostic arthroscopy and a preoperative DLST between 2007 and 2013. Patients were divided into 3 groups: 610 control patients with no SLAP lesion but with other abnormalities, 9 patients with isolated SLAP lesion (ISL), and 155 patients with concomitant SLAP lesion (CSL), who had a SLAP lesion and another shoulder abnormality. We determined sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), odds ratio (OR), and diagnostic accuracy (DA) of the DLST with and without other tests. RESULTS The DLST was positive for 242 of 610 controls (40%), 7 of 9 patients (78%) in the ISL group, and 88 of 155 patients (57%) in the CSL group. In the ISL group, the DLST had a sensitivity of 78%, specificity of 51%, PPV of 2%, NPV of 100%, OR of 3.58, and DA of 51%. In comparison, the ORs were 1.09 for the active compression test, 1.30 for the lift-off test, and 1.53 for the relocation test, which were not significantly different from each other. For diagnosing a SLAP lesion existing in a joint with other associated injury, the DLST had a sensitivity of 57%, specificity of 52%, PPV of 23%, NPV of 83%, OR of 1.4, and DA of 53%. Combining all 4 tests did not improve the OR for detecting ISLs or CSLs. CONCLUSION The DLST is sensitive but not specific for detecting ISLs. With an OR of 3.58, the DLST is useful for diagnosing ISLs. However, in patients who have CSLs, the DLST is not as useful for diagnosing SLAP lesions.
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Affiliation(s)
- Sonal Sodha
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Uma Srikumaran
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Kyubo Choi
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Amrut U Borade
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Edward G McFarland
- Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
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Gismervik SØ, Drogset JO, Granviken F, Rø M, Leivseth G. Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskelet Disord 2017; 18:41. [PMID: 28122541 PMCID: PMC5267375 DOI: 10.1186/s12891-017-1400-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 01/11/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Sigmund Ø Gismervik
- Department Physical Medicine and Rehabilitation, St.Olavs University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway. .,Department of Public Health and General Practice, Norwegian University of Science and Technology, P.B. 8905 MTFS, 7491, Trondheim, Norway.
| | - Jon O Drogset
- Institute of Neuromedicine, Faculty of Medicine, Norwegian University of Science and Technology, P.B 8905 MTFS, 7491, Trondheim, Norway.,Department of Orthopedic Surgery, Trondheim University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway
| | - Fredrik Granviken
- Department Physical Medicine and Rehabilitation, St.Olavs University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway
| | - Magne Rø
- Department Physical Medicine and Rehabilitation, St.Olavs University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway
| | - Gunnar Leivseth
- Department of Clinical Medicine, Neuromuscular Diseases Research Group, UiT The Arctic University of Norway, N-9037, Tromsø, Norway.,Unicare Medical Rehabilitation Centre, Hokksund, Norway
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Thorsness RJ, Erickson BJ, Hamamoto JT, Cole BJ, Verma NN. Management of the Biceps Tendon. OPER TECHN SPORT MED 2016. [DOI: 10.1053/j.otsm.2016.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Raynor MB, Kuhn JE. Utility of features of the patient's history in the diagnosis of atraumatic shoulder pain: a systematic review. J Shoulder Elbow Surg 2016; 25:688-94. [PMID: 26711472 DOI: 10.1016/j.jse.2015.09.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 09/22/2015] [Accepted: 09/29/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Whereas physical examination tests for shoulder disorders have numeric values that describe the utility of the test and its effect on the probability of having a diagnosis, this information is lacking for elements of the history. The purpose of this study was to conduct a systematic review of the literature to determine numeric data (sensitivity, specificity, predictive values, and likelihood or odds ratios) for elements of the history with regard to diagnoses in patients with chronic atraumatic shoulder pain. METHODS We performed a systematic review to extract information from the existing literature regarding the numeric utility of different features of the patient history as they pertain to chronic atraumatic shoulder pain. Data sources were MEDLINE through PubMed (1946-January 2012) and EMBASE through Ovid (1980-January 2012). RESULTS Twenty-one studies met inclusion criteria. A diagnosis of rotator cuff tear was more likely with a history of hypercholesterolemia, having a relative with rotator cuff disease, excessive lifting, above-shoulder work, hand-held vibration work, or age older than 60 years. Acromioclavicular arthritis was more likely in weightlifters. Glenohumeral arthritis was more likely if the patient has a history of prior dislocation, age >75 years, or a diagnosis of knee osteoarthritis. Adhesive capsulitis was more likely with a history of diabetes or thyroid disorder. Posterior labral tear was more likely in football players. CONCLUSIONS The numeric values for the utility of these history features will help establish numeric probabilities for diagnoses in patients with shoulder pain.
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Affiliation(s)
- Martin B Raynor
- Vanderbilt Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John E Kuhn
- Vanderbilt Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA.
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Kibler WB, Sciascia A. Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey. Arthroscopy 2015; 31:2456-69. [PMID: 26321113 DOI: 10.1016/j.arthro.2015.06.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/09/2015] [Accepted: 06/18/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate current practice reported in the literature for making a SLAP lesion diagnosis and compare the findings with a survey sent to experienced shoulder surgeons assessing how they make a SLAP diagnosis. METHODS We performed a systematic review of articles reporting surgical repair of SLAP lesions, documenting the use of 4 diagnostic areas of evaluation: history, clinical examination, imaging, and diagnostic arthroscopy. A survey was distributed electronically to 175 surgeons with expertise in shoulder surgery. The survey listed common components within the 4 diagnostic areas and asked surgeons to indicate components they used in establishing the diagnosis. The 4 diagnostic areas were ranked from 1 to 4 (most to least important). RESULTS Of the articles, 23% reported using all 4 diagnostic areas, 58% used 3 areas, and 19% used 2 areas or fewer. Thirty-five percent did not report history components, 31% did not report clinical examination elements, 27% did not report imaging findings, and 4% did not report arthroscopic findings. Eight percent reported using a comprehensive history and examination but without describing specific symptoms or tests. The most common components reported in the literature were pain (42%), the active compression test (65%), magnetic resonance imaging/arthrography (65%), and tear/unstable biceps-labral complex (27%). A total of 70 surgeons (40%) responded to the survey. More specific history components, examination maneuvers, and imaging/arthroscopy variants were reported on the survey compared with the literature. Diagnostic arthroscopy and history ranked as the most important for a SLAP diagnosis. CONCLUSIONS The current literature and practice for making the SLAP diagnosis are variable and inconsistent. The SLAP diagnosis appears to be a clinical impression; however, the criteria described within the literature vary among the evaluation areas and differ from the results of the survey. These types of variability may have a significant influence on consistency and accuracy in making the diagnosis of the SLAP injury, developing the subsequent treatment, and maximizing outcomes. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies with cross-sectional survey.
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Affiliation(s)
- W Ben Kibler
- Shoulder Center of Kentucky, Lexington, Kentucky, U.S.A
| | - Aaron Sciascia
- Shoulder Center of Kentucky, Lexington, Kentucky, U.S.A..
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Abstract
The examination of the shoulder for conditions involving the biceps tendon continues to be challenging. Numerous examination tests for biceps and superior labrum anterior and posterior (SLAP) lesions have been scientifically evaluated. This section reports on how to perform these tests and summarizes the clinical utility of the tests. Many of the tests for the examination of the biceps and for SLAP lesions do not have high sensitivity and specificity, which limits their usefulness. Although the dynamic shear test has promise for making the diagnosis of SLAP lesions, the studies reporting its clinical utility are disparate.
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Affiliation(s)
- Edward G McFarland
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 10753 Falls Road, Pavilion II, Suite 215, Lutherville, Baltimore, MD 21093, USA.
| | - Amrut Borade
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, 601 North Caroline Street, Baltimore, MD 21287, USA
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Hegedus EJ, Cook C, Lewis J, Wright A, Park JY. Combining orthopedic special tests to improve diagnosis of shoulder pathology. Phys Ther Sport 2015; 16:87-92. [DOI: 10.1016/j.ptsp.2014.08.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 07/05/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
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Kwon J, Kim YH, Yeom TS, Oh JH. Age-related Outcome of Arthroscopic Repair of Isolated Type II Superior Labral Anterior to Posterior Lesions. Clin Shoulder Elb 2015. [DOI: 10.5397/cise.2015.18.1.36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Abstract
Tennis places high loads on the joints of players, with supraphysiologic forces being generated at the shoulder and elbow hundreds of times per match. Acute injuries tend to affect the lower extremity; chronic injuries usually involve the upper extremity. Commonly encountered upper extremity conditions include rotator cuff injury, internal impingement, superior labral tears, and epicondylitis of the elbow. Serving is the most strenuous stroke in tennis, with the highest peak muscle activity in the shoulder and forearm occurring during this stroke. The kinetic chain links upper extremity, lower extremity, and core muscle segments by transmitting coordinated activation and motion; in this regard, any pathologic process that disturbs the groin, hip, and abdominal musculature can further result in an increased risk of injury to the shoulder and upper extremity. Evolution in equipment and in play surfaces has also affected the type and frequency of injuries. Prevention programs that address the muscular imbalances throughout the kinetic chain may help reduce the incidence of both acute and chronic injuries experienced by tennis athletes.
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King JJ, Wright TW. Physical examination of the shoulder. J Hand Surg Am 2014; 39:2103-12. [PMID: 25257491 DOI: 10.1016/j.jhsa.2014.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 04/03/2014] [Accepted: 04/06/2014] [Indexed: 02/02/2023]
Abstract
This article summarizes the overall assessment of the shoulder joint and seeks to help direct clinicians to diagnose shoulder pathology using standard and specific physical examinations. The history and standard examination can prompt the examiner to focus on specific tests to further evaluate the shoulder and limit the differential diagnoses. An appropriate and directed shoulder physical examination allows the clinician to focus on further diagnostic strategies and treatment options for the patient.
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Affiliation(s)
- Joseph J King
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, FL
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Rehabilitation, University of Florida, Gainesville, FL.
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Arnander M, Tennent D. Clinical assessment of the glenoid labrum. Shoulder Elbow 2014; 6:291-9. [PMID: 27582948 PMCID: PMC4935037 DOI: 10.1177/1758573214546156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 07/14/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND The glenoid labrum is integral to shoulder stability and can be difficult to assess clinically. Whilst it is a single anatomical structure, damage to different regions results in very different clinical manifestations. A large number of provocative tests have been described, all of which initially purport to have excellent diagnostic accuracy. Clinical experience suggests that this is not the case and decision making can be difficult for the non-expert. The purpose of this study is to review the current evidence for the most commonly used tests and to provide suggestions for tests which have the most evidence for efficacy. METHODS The glenoid labrum was divided into anterior, superior and posterior regions. The English language literature describing labral tests was reviewed. The evidence provided by the authors and any subsequent studies was analysed. RESULTS Whilst a large number if tests have been described with the primary authors reporting excellent results the evidence for most is poor when later tested critically. DISCUSSION No single test will accurately diagnose labral pathology. The clinician must use evidence from the clinical history combined with selective use and interpretation of tests with which they are familiar.
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Affiliation(s)
| | - Duncan Tennent
- D. Tennent, St George’s Hospital, Blackshaw Road,
Tooting, London SW17 0QT, UK. Tel: +44 (0)208 725 2032.
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Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev 2013; 2013:CD007427. [PMID: 23633343 PMCID: PMC6464770 DOI: 10.1002/14651858.cd007427.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Nigel C A Hanchard
- Health and Social Care Institute, Teesside University, Middlesbrough, UK.
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Shoulder functionality after manual therapy in subjects with shoulder impingement syndrome: A case series. J Bodyw Mov Ther 2013; 17:212-8. [DOI: 10.1016/j.jbmt.2012.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 07/16/2012] [Accepted: 07/17/2012] [Indexed: 11/20/2022]
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Sciascia AD, Spigelman T, Kibler WB, Uhl TL. Frequency of use of clinical shoulder examination tests by experienced shoulder surgeons. J Athl Train 2013; 47:457-66. [PMID: 22889662 DOI: 10.4085/1062-6050-47.4.09] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Aaron D Sciascia
- Shoulder Center of Kentucky, 700 Bob-O-Link Drive, Lexington, KY 40504, USA.
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Wood VJ, Sabick MB, Pfeiffer RP, Kuhlman SM, Christensen JH, Curtin MJ. Glenohumeral muscle activation during provocative tests designed to diagnose superior labrum anterior-posterior lesions. Am J Sports Med 2011; 39:2670-8. [PMID: 21876031 PMCID: PMC3261658 DOI: 10.1177/0363546511419822] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Vanessa J.C. Wood
- Center for Orthopaedic & Biomechanics Research, Boise State University Boise, Idaho,Department of Mechanical and Biomedical Engineering, Boise State University Boise, Idaho
| | - Michelle B. Sabick
- Center for Orthopaedic & Biomechanics Research, Boise State University Boise, Idaho,Department of Mechanical and Biomedical Engineering, Boise State University Boise, Idaho
| | - Ron P. Pfeiffer
- Center for Orthopaedic & Biomechanics Research, Boise State University Boise, Idaho,Department Kinesiology, Boise State University Boise, Idaho
| | - Seth M. Kuhlman
- Center for Orthopaedic & Biomechanics Research, Boise State University Boise, Idaho,Department of Mechanical and Biomedical Engineering, Boise State University Boise, Idaho
| | - Jason H. Christensen
- Center for Orthopaedic & Biomechanics Research, Boise State University Boise, Idaho,Department of Mechanical and Biomedical Engineering, Boise State University Boise, Idaho
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Michener LA, Doukas WC, Murphy KP, Walsworth MK. Diagnostic accuracy of history and physical examination of superior labrum anterior- posterior lesions. J Athl Train 2011; 46:343-8. [PMID: 21944065 DOI: 10.4085/1062-6050-46.4.343] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Lori A Michener
- Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA 23298, USA.
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Gramstad GG, Sears BW, Marra G. Variation of tension in the long head of the biceps tendon as a function of limb position with simulated biceps contraction. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2011; 4:8-14. [PMID: 20922087 PMCID: PMC2940169 DOI: 10.4103/0973-6042.68411] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Purpose: This study was designed to quantify tensile forces within the intra-articular long head of the bicep tendon (LHBT) under conditions of passive limb positioning and physiologic load, which simulate contraction of the LHBT. Materials and Methods: A force probe was inserted into the intra-articular LHBT, just distal to its supra-glenoid origin, in six fresh-frozen cadaveric specimens. Initially, specimens were manually manipulated through 30 glenohumeral joint positions, combining humeral rotation and elbow/forearm position. In the second phase, a 55 N tensile load was applied through the LHBT in 18 limb positions. Intra-tendinous tension was recorded in all positions under both conditions. Results: External humeral rotation significantly increased tension with glenohumeral forward flexion (P<0.0001). Conversely, internal humeral rotation significantly increased tension with glenohumeral abduction and extension (P<0.0001). A position of glenohumeral extension and internal rotation, with the elbow extended and forearm pronated, produced the highest tension in the intra-articular LHBT (P<0.0001). Under applied load conditions, observed LHTB tension was not statistically different in any glenohumeral position (P=0.1468, power = 88%). The greater tuberosity was noted to impinge on the force probe in forward flexion and internal rotation in two specimens. Conclusions: Variable tensile forces are seen in the intra-articular LHBT as a function of both limb position and simulated biceps contraction. Our findings provide a thorough data set that may be used to help substantiate or refute current or future hypotheses regarding LHBT function, pathology, and clinical tests. Clinical Relevance: Identifying positions of glenohumeral motion, which affect LHBT tension will provide an anatomic basis for clinical tests proposed to be for diagnosing LHBT lesions, including superior labral anterior and posterior tears.
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Sandhu B, Sanghavi S, Lam F. Superior Labrum Anterior to Posterior (SLAP) lesions of the shoulder. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.mporth.2010.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete. Phys Ther Sport 2010; 11:110-21. [PMID: 21055704 DOI: 10.1016/j.ptsp.2010.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 06/08/2010] [Accepted: 06/09/2010] [Indexed: 01/01/2023]
Abstract
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.
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Fowler EM, Horsley IG, Rolf CG. Clinical and arthroscopic findings in recreationally active patients. BMC Sports Sci Med Rehabil 2010; 2:2. [PMID: 20157421 PMCID: PMC2821297 DOI: 10.1186/1758-2555-2-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Accepted: 01/15/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the diagnostic accuracy of standard clinical tests for the shoulder in recreational athletes with activity related pain. DESIGN Cohort study with index test of clinical examination and reference standard of arthroscopy. SETTING Sports Medicine clinic in Sheffield, U.K. PARTICIPANTS 101 recreational athletes (82 male, 19 female; mean age 40.8 +/- 14.6 years) over a six year period. INTERVENTIONS Bilateral evaluation of movements of the shoulder followed by standardized shoulder tests, formulation of clinical diagnosis and shoulder arthroscopy conducted by the same surgeon. MAIN OUTCOME MEASUREMENTS Sensitivity, specificity, likelihood ratio for a positive test and over-all accuracy of clinical examination was examined retrospectively and compared with arthroscopy. RESULTS Isolated pathology was rare, most patients (72%) having more than one injury recorded. O'Brien's clinical test had a mediocre sensitivity (64%) and over-all accuracy (54%) for diagnosing SLAP lesions. Hawkins test and Jobe's test had the highest but still not impressive over-all accuracy (67%) and sensitivity (67%) for rotator cuff pathology respectively. External and internal impingement tests showed similar levels of accuracy. When a positive test was observed in one of a combination of shoulder tests used for diagnosing SLAP lesions or rotator cuff disease, sensitivity increased substantially whilst specificity decreased. CONCLUSIONS The diagnostic accuracy of isolated standard shoulder tests in recreational athletes was over-all very poor, potentially due to the majority of athletes (71%) having concomitant shoulder injuries. Most likely, this means that many of these injuries are missed in general practice and treatment is therefore delayed. Clinical examination of the shoulder should involve a combination of clinical tests in order to identify likely intra articular pathology which may warrant referral to specialist for surgery.
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Affiliation(s)
- Elizabeth M Fowler
- Centre for Health, Sport and Rehabilitation Sciences Research, University of Salford, Fredrick Road, Salford, UK
| | - Ian G Horsley
- Sheffield Centre of Sports Medicine, School of Biomedical Sciences, The University of Sheffield, Sheffield, UK
| | - Christer G Rolf
- Sheffield Centre of Sports Medicine, School of Biomedical Sciences, The University of Sheffield, Sheffield, UK
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Schlechter JA, Summa S, Rubin BD. The passive distraction test: a new diagnostic aid for clinically significant superior labral pathology. Arthroscopy 2009; 25:1374-9. [PMID: 19962062 DOI: 10.1016/j.arthro.2009.04.070] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 04/20/2009] [Accepted: 04/23/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this report is to present a new provocative maneuver, the passive distraction test (PDT), as an examination tool to be used in the evaluation of patients thought to have a SLAP lesion and to compare its accuracy, precision, and reproducibility alone and in conjunction with previously published maneuvers. METHODS A retrospective analysis of 319 consecutive arthroscopies performed between May 2001 and November 2003 was performed. A total of 65 cases were excluded, 53 because of limitation of elevation to less than 150 degrees or pain in the starting test position and 12 who had previous shoulder procedures performed by the senior author, leaving 254 cases for review. A thorough history was obtained and a thorough physical examination performed with a focus on the involved shoulder including specific provocative maneuvers for the clinical diagnosis of a SLAP lesion. The active compression test, the anterior slide test, and the PDT were used to clinically diagnose a SLAP lesion. The results from the 3 provocative maneuvers were compared with the arthroscopic findings to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value of each test alone and in a logical combination. RESULTS Of 254 shoulder arthroscopies, 61 had a clinically significant SLAP lesion, for an incidence of 24%. The sensitivity and specificity for the PDT were 53% and 94%, respectively, with an NPV of 87% and positive predictive value of 72%. In combination, the PDT and the active compression test yielded an NPV of 90.5%. CONCLUSIONS The PDT can be used alone or in combination to aid in the clinical evaluation and diagnosis of a SLAP lesion. LEVEL OF EVIDENCE Level IV, retrospective, diagnostic, sensitivity-specificity study.
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Affiliation(s)
- John A Schlechter
- Department of Orthopaedic Surgery, Children's Hospital Orange County, Orange, California, USA
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McFarland EG, Tanaka MJ, Garzon-Muvdi J, Jia X, Petersen SA. Clinical and imaging assessment for superior labrum anterior and posterior lesions. Curr Sports Med Rep 2009; 8:234-9. [PMID: 19741350 DOI: 10.1249/jsr.0b013e3181b7f042] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In the evaluation of the painful shoulder, especially in the overhead athlete, diagnosing superior labrum anterior and posterior (SLAP) lesions continues to challenge the clinician because of 1) the lack of specificity of examination tests for SLAP; 2) a paucity of well-controlled studies of those tests; and 3) the presence of coexisting confounding abnormalities. Some evidence indicates that multiple positive tests increase the likelihood that a SLAP lesion is present, but no one physical examination finding conclusively makes that diagnosis. The goals of this article were to review the physical examination techniques for making the diagnosis of SLAP lesions, to evaluate the clinical usefulness of those examinations, and to review the role of magnetic resonance imaging in making the diagnosis.
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Affiliation(s)
- Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD, USA.
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Jia X, Petersen SA, Khosravi AH, Almareddi V, Pannirselvam V, McFarland EG. Examination of the shoulder: the past, the present, and the future. J Bone Joint Surg Am 2009; 91 Suppl 6:10-8. [PMID: 19884407 DOI: 10.2106/jbjs.i.00534] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Xiaofeng Jia
- Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224-2780, USA
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Ben Kibler W, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med 2009; 37:1840-7. [PMID: 19509414 DOI: 10.1177/0363546509332505] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinical tests are a key element in diagnosing shoulder lesions. PURPOSE This study examined the clinical utility of traditional and new examination tests, the upper cut for biceps injuries, and the modified dynamic labral shear for superior glenoid labral lesions. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 2. METHODS A total of 325 consecutive patients who were seen for shoulder pain underwent a standardized clinical testing battery. Six clinical tests that have been previously reported in the literature (Yergason's, Speed's, bear hug, belly press, O'Brien's, and anterior slide) and 2 new examination tests (upper cut and modified dynamic labral shear) were performed. Clinical examination findings were correlated with findings in those who came to surgery (101 patients). Sensitivity, specificity, accuracy, positive/negative predictive value, and positive/negative likelihood ratio were calculated for each test. A binary logistic regression analysis was used to determine which tests produced the most significant findings. RESULTS For biceps disease, the bear hug and upper cut were most sensitive (0.79 and 0.73, respectively), whereas the belly press and Speed's test were most specific (0.85 and 0.81, respectively). The upper cut was most accurate (0.77) and produced the highest positive likelihood ratio (3.38). For labral injury, the modified dynamic labral shear demonstrated sensitivity of 0.72, specificity of 0.98, accuracy of 0.84, and a positive likelihood ratio of 31.57. A binary logistic regression analysis revealed that the combination of the upper cut and Speed's tests were significantly better at detecting biceps lesions (P = .021, R(2) = .400) than other tests, whereas labral lesions were best identified by combination of the modified dynamic labral shear and O'Brien's maneuvers (P = .045, R(2) = .641). CONCLUSION The new tests are helpful additions to the clinical examination for shoulder injury. The modified dynamic labral shear test demonstrates high scores for clinical utility and exhibits a high likelihood ratio, indicating a significant probability of affecting the clinical decision, which should moderately or significantly improve the diagnostic conclusion and allow the clinician to be more efficient in making an accurate diagnosis.
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Affiliation(s)
- W Ben Kibler
- Shoulder Center of Kentucky, Lexington, KY 40504, USA
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Hsu SH, Miller SL, Curtis AS. Long head of biceps tendon pathology: management alternatives. Clin Sports Med 2009; 27:747-62. [PMID: 19064154 DOI: 10.1016/j.csm.2008.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The role of biceps tendon as a source of shoulder pain and pathology has been well documented in orthopedic literature. Recently, interest in the long head of the biceps tendon has been renewed as its association with subscapularis lesions, superior labral anterior to posterior (SLAP) lesions, rotator cuff pathology, impingement, and pulley or "hidden" lesions of the rotator interval are demonstrated. Advances in imaging and arthroscopy have increased our breadth of knowledge about the anatomy, pathology, and role of the biceps tendon. Management and treatment methods have evolved with improved patient selection and proper diagnosis of long head biceps pathology.
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Affiliation(s)
- Stephanie H Hsu
- Department of Orthopedic Surgery, New England Baptist Hospital and Tufts University School of Medicine, 125 Parker Hill Avenue, Boston, MA 02120, USA
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McFarland EG, Tanaka MJ, Papp DF. Examination of the Shoulder in the Overhead and Throwing Athlete. Clin Sports Med 2008; 27:553-78. [DOI: 10.1016/j.csm.2008.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Oh JH, Kim SH, Lee HK, Jo KH, Bae KJ. Trans-rotator cuff portal is safe for arthroscopic superior labral anterior and posterior lesion repair: clinical and radiological analysis of 58 SLAP lesions. Am J Sports Med 2008; 36:1913-21. [PMID: 18495968 DOI: 10.1177/0363546508317414] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are numerous accessory portals for the arthroscopic repair of superior labral anterior and posterior lesions. Many surgeons are reluctant to make a portal through the cuff because of concern about iatrogenic injury to the cuff. HYPOTHESIS An arthroscopic superior labral anterior and posterior lesion repair procedure using the trans-rotator cuff portal may yield favorable clinical and radiological outcomes, and cuffs may heal properly. STUDY DESIGN Case series; Level of evidence, 4. METHODS Fifty-eight consecutive patients undergoing superior labral anterior and posterior lesion repair using the trans-rotator cuff portal, who had available both functional and radiological outcomes after 1 year of the operation, were enrolled. We evaluated the structural outcomes for the labrum and cuff using computed tomographic arthrography and measured various clinical outcomes (the supraspinatus power, visual analog scale for pain and satisfaction, American Shoulder and Elbow Surgeons shoulder evaluation form, University of California-Los Angeles shoulder score, Constant score, and Simple Shoulder Test) at the final visit. RESULTS All functional outcomes were improved significantly (P < .001). On computed tomographic arthrography, labral healing to the bony glenoid was achieved in all patients. Subacromial leakage of contrast media was observed in 3 patients (5.2%) through the muscular portion without any retraction or gap of the tendon. Two of 3 had preoperative cuff pathologic changes, and they were older than 45 years of age. Partial articular cuff tears were observed in 6 patients (10.3%), and 4 had the lesion preoperatively. There were no statistical differences in functional scores according to the presence of preoperative lesion, postoperative leakage, or partial cuff tear. CONCLUSION The data demonstrate favorable outcomes for arthroscopic superior labral anterior and posterior lesion repair using the trans-rotator cuff portal. We suggest that the trans-rotator cuff portal is an efficient and safe portal for superior labral anterior and posterior lesion repair, although there are some valid concerns of damaging the cuff in patients with a superior labral anterior and posterior lesion with concurrent cuff disorders, as well as in older patients.
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Affiliation(s)
- Joo Han Oh
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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Bushnell BD, Creighton RA, Herring MM. Bony instability of the shoulder. Arthroscopy 2008; 24:1061-73. [PMID: 18760215 DOI: 10.1016/j.arthro.2008.05.015] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Revised: 04/17/2008] [Accepted: 05/07/2008] [Indexed: 02/08/2023]
Abstract
Instability of the shoulder is a common problem treated by many orthopaedists. Instability can result from baseline intrinsic ligamentous laxity or a traumatic event-often a dislocation that injures the stabilizing structures of the glenohumeral joint. Many cases involve soft-tissue injury only and can be treated successfully with repair of the labrum and ligamentous tissues. Both open and arthroscopic approaches have been well described, with recent studies of arthroscopic soft-tissue techniques reporting results equal to those of the more traditional open techniques. Over the last decade, attention has focused on the concept of instability of the shoulder mediated by bony pathology such as a large bony Bankart lesion or an engaging Hill-Sachs lesion. Recent literature has identified unrecognized large bony lesions as a primary cause of failure of arthroscopic reconstruction for instability, a major cause of recurrent instability, and a difficult diagnosis to make. Thus, although such bony lesions may be relatively rare compared with soft-tissue pathology, they constitute a critically important entity in the management of shoulder instability. Smaller bony lesions may be amenable to arthroscopic treatment, but larger lesions often require open surgery to prevent recurrent instability. This article reviews recent developments in the diagnosis and treatment of bony instability.
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