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Clinical Examination of Superior Labral (SLAP) Tears - Part 2

Posted Dec 23 2008 9:43pm
ResearchBlogging.org
What is the best test for a SLAP tear?

Over the last series of posts of SLAP tears, we talked about many things:


Last week, we discussed part 1 of this series on how to choose the right test to detect a SLAP tear.  Today, we will continue with the discussion of "what is the best test for a SLAP tear" with part 2.  Here are more tests followed by my recommendations on how to choose which test to perform in your patient.  The feedback from part 1 was great and I could tell people were eager to get to this second part of the post!

Anterior Slide Test

The anterior slide test involves the arm to be examined is positioned with the hand on the ipsilateral hip with the thumb forward. The examiner then stabilizes the scapula with one hand and provides an anterosuperiorly directed axial load to the humerus with the other hand.  The test is considered positive if there is a click or deep pain in the shoulder during this maneuver.  Just my opinion, but this test has not been useful for me at all (sorry I don’t even have a photo of this test, I rarely use it).

Sensitivity: 8-78%, Specificity: 84%, PPV: 5%, NPV: 90% (These results are from a combination of many different studies, you can see the large variability)

Biceps Load and Biceps Load II Tests

The biceps load test, during this test, the shoulder is placed in 90 degrees of abduction and maximally externally rotated. At maximal external rotation and with the forearm in a supinated position, the patient is instructed to perform a biceps contraction SLAP-figure-8 against resistance. Deep pain within the shoulder during this contraction is indicative of a SLAP lesion. The original authors further refined this test with the description of the biceps load II maneuver. The examination technique is similar, although the shoulder is placed into a position of 120 degrees of abduction rather than the originally described 90 degrees.  The biceps load II test was noted to have greater sensitivity than the original test.  I like both of these tests.

Sensitivity: 91%, Specificity: 97%, PPV: 83%, NPV: 98% for Biceps Load I; Sensitivity: 90%, Specificity: 97%, PPV: 92%, NPV: 96% for Biceps Load II

Pain Provocation Test

Mimori et al described the pain provocation test. During this maneuver, the shoulder is passively abducted to 90-100 degrees and passively externally rotated with the forearm in full pronation and then full supination. The authors determined that a SLAP lesion was present if pain was produced with shoulder external rotation with the forearm in the pronated position or if the severity of the symptoms was greater in the pronated position. The authors note that positive symptoms with this test are due to the additional stretch placed on the biceps tendon when the shoulder is externally rotated with the forearm pronated.

Sensitivity: 100%, Specificity: 90%


Pronated Load and Supination External Rotation Tests

I won’t describe these two again.  My past post about these two new tests includes a video demonstration for those of you that are like me and learn better by seeing.

Anecdotally, I have found these tests (the Pronated Load and the Resisted Supination External Rotation tests) to be 2 of the most sensitive tests in detecting SLAP lesions, particularly in the overhead athlete with a peel-back lesion.

Sensitivity: 83%, Specificity: 82%, PPV: 92%, NPV: 64% for supinated ER test


What does the evidence say regarding all these tests?


These tests have all come under much scrutiny in recent years as conflicting reports on the accuracy of these tests have been published.  What you will find in research reports regarding these tests is that the original citation for each of these tests seem to have extremely high sensitivity, specificity, and negative and positive predictive values.  A good example is the active compression test.  The original article by O’Brien had shown 100% sensitivity, 98.5% specificity, positive predictive value of 94%, and a negative predictive value of 100%.  These are pretty high numbers, so high that they are actually even better than MRI!  Since then, no other other author has shown values like this.  This is not isolated to the active compression test, almost every SLAP test described is similar.

Dessaur and Magray reviewed 17 peer-reviewed manuscripts and noted that the majority of papers reporting highly accurate tests for SLAP lesions were of low quality with the results not supported by other researchers.  Jones and Galluch agreed and noted that subsequent independent testing of SLAP tests showed much poorer performance that the originally published studies.  There are many other research reviews and meta-analysis studies that agree.

An interesting study from Oh et al in AJSM earlier this year showed that a combination of tests used together may yield the best results.  They state that if you combine a couple of tests that have shown to have good sensitivity with a couple of tests that show good specificity, they reached sensitivity and specificity values between 70-95%.  This makes sense to me as none of these tests are perfect, think of it as covering your bases with a few tests.  (Sound familiar Chad??  Very similar to your comment to my post on part 1!)

I feel that this may be for multiple reasons. Different patient populations will present with different mechanisms of injury.  In most studies, several variations of SLAP lesions are grouped together to obtain enough statistical power to analyze the data. It is my opinion that different tests will result in different specificity and sensitivity results based on the variation of SLAP lesion present. For example, overhead athletes with a type II or IV posterosuperior peel back SLAP lesion may be more symptomatic during tests that simulate the aggravating position and mechanism of injury, such as the biceps load II, clunk, crank, pain provocation tests, and pronated load test; whereas patients with type I or III SLAP lesions due to a traumatic type of injury may be more symptomatic during tests that provide compression to the labral complex such as the active-compression, compression-rotation and anterior slide tests. Further investigation on the diagnostic characteristics of these tests based on the type of SLAP lesion is warranted.
Choosing which SLAP test to perform during your examination

I know it sounds cliché, but first and foremost, your subjective examination should lead your clinical tests.  If you patient is a construction worker who fell on an outstretched arm, you probably don’t need to perform any tests that simulate a peel-back lesion.  And vice-versa, if your patient is a recreational tennis player with a desk job that only feels pain while serving in tennis, you can probably jump straight to the peel-back tests.
For simplicity sake, lets divide SLAP tears into three categories (for more information read my post on classifying SLAP lesions ):
  1. Overhead Athletes that present with peel-back lesions
  2. Compression injuries from someone that falls onto an outstretched arm or on the side of the shoulder.  This will compress and sheer the labrum, similar to a meniscus tear.
  3. Traction injuries from a sudden eccentric biceps contraction.  This one is the least common and I even have some mild doubts of this mechanism. 

Choosing a Test Based on The Mechanism of Injury

Here are the tests I perform based on the type of injury mechanism. 
I actually find this to be much more helpful in selecting my tests than by selecting based on research results only.  
Remember, we have no idea the exact patient population or injury mechanism for those research reports, you can not go on them alone!  You do, however, have this information for the patient that is sitting in the exam room right in front of you!

Peel-Back Injury:Pronated Load
(Overhead Athlete)Resisted Supination ER
Biceps Load I & II
Pain Provocation
Crank
Compression Injury:Active Compression
Compression Rotation
Clunk
Anterior Slide
Traction Injury:Speed's
Dynamic Speed's
Active Compression

  Choosing a Test Based on The Type of SLAP Tear

If you want to try to determine the type of SLAP tear, Type I, Type II, Type III, or Type IV, this is more challenging but you can try to give it a shot based on the below table.  This is definitely more of guess work, but the more information we can try to obtain the better.  Remember that each of the tests described will try to reproduce symptoms in different ways, you should try to correlate the pathology of the different types of SLAP lesions with specific special tests.  Use this as a grain of salt, it may be helpful but hasn’t been backed by research to show how well this classification works (this more for just a game I play against myself!)

Type I SLAP:Compression Rotation
Type II SLAP:Tests for a Peel-Back Injury
Type III & IV SLAP:Crank
(Bucket Handle Tear)Clunk
Compression Rotation
Anterior Slide

In summary, the research results of the numerous SLAP tests are extremely variable and should not be relied on solely to determine which test to perform on your patient.  In contrast, I propose that you:
  1. Use the patient’s mechanism of injury to lead your decision on which group of tests to perform.  The subjective exam is important!
  2. Perform a cluster of a few tests for that group that have shown decent sensitivity and specificity to enhance your results using a group of tests rather than just one.
  3. Don’t hang your hat on one test.  It may be good for a specific patient population and not another
  4. Don’t get frustrated, SLAP lesions are difficult to detect on clinical examination.  When in doubt refer back to the doctor for a MRI.
For those that like to see video of these tests, you can obtain information on Kevin Wilk and I's DVD on Clinical Examination of the Shoulder, which includes demonstrations of all these test, by visiting theAdvanced Continuing Education Institute, remember to use coupon code "Reinold" for a 10% discount.


Wayne A. Dessaur (2008). Diagnostic Accuracy of Clinical Testing for Superior Labral Anterior Posterior Lesions: A Systematic Review Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2008.2676

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