Clinical Examination of Superior Labral Tears - What is the Best Test for a SLAP Tear? Part 1 of 2
Posted Dec 23 2008 9:43pm
That is a pretty common question that I hear at meetings - "What is the best test for a SLAP tear?" My past post of two new SLAP tests described a couple of tests that I am using all the time and prefer in my practice. However, there are many more tests available. I am going to divide this post into 2 parts as it is going to be long! Part 2 that includes how I choose different SLAP tests can be found here.
Clinical examination to detect SLAP lesions is often difficult because of the common presence of concomitant pathology in patients presenting with this type of condition. Andrews has shown that 45% of patients (and 73% of baseball pitchers) with superior labral lesions have concomitant partial thickness tears of the supraspinatus portion of the rotator cuff. Mileski and Snyder reported that 29% of their patients with SLAP lesions exhibited partial thickness rotator cuff tears, 11% complete rotator cuff tears, and 22% Bankart lesions of the anterior glenoid.
The clinician should keep in mind that while labral pathologies frequently present as repetitive overuse conditions, such as those commonly seen in overhead athletics, the patient may also describe a single traumatic event such as a fall onto the outstretched arm or an episode of sudden traction, or a blow to the shoulder. This is an extremely important differentiation you need to make when selecting which tests you should perform. We'll get to that towards the end but be sure to review my past posts on what exactly a SLAP tear is and how SLAP tears occur.
A wide variety of potentially useful special test maneuvers have been described to help determine the presence of labral pathology. Lets review some of them now.
Special Tests for a SLAP Tear
Active Compression Test
The active compression test is used to evaluate labral lesions and acromioclavicular joint injuries. This could be the most commonly performed test, especially in orthopedic surgeons. I am not sure why, though, I do not think it is the best. The shoulder is placed into approximately 90 degrees of elevation and 30 degrees of horizontal adduction across the midline of the body. Resistance is applied, using an isometric hold, in this position with both full shoulder internal and external rotation (altering humeral rotation against the glenoid in the process). A positive test for labral involvement is when pain is elicited wihen testing with the shoulder in internal rotation and forearm in pronation (thimb pointing toward the floor). Symptoms are typically decreased when tested in the externally rotated position or the pain is localized at the acromioclavicular (AC) joint. O’Brien et al found this maneuver to be 100% sensitive and 95% specific as it relates to assessing the presence of labral pathology. These results are outstanding, maybe too outstanding. Pain provocation using this test is common, challenging the validity of the results. In my experience, the presence of deep and diffuse glenohumeral joint pain is most indicative of the presence of a SLAP lesion. Pain localized in the AC joint or in the posterior rotator cuff is not specific for the presence of a SLAP lesion. The posterior shoulder symptoms are indicative of provocative strain on the rotator cuff musculature when the shoulder is placed in this position. The challenging part of this test is that many patients will be symptomatic from overloading their rotator cuff in this disadvantageous position.
Sensitivity: 47-100%, Specificity: 31-99%, PPV: 10-94%, NPV: 45-100% (a lot of variability between various authors)
The compression-rotation test is performed with the patient in the supine position. The glenohumeral joint is manually compressed through the long axis of the humerus while, the humerus is passively rotated back and forth in an attempt to tra p the labrum within the joint. This is typically performed in a variety of small and large circles while providing joint compression when performing this maneuver, in an attempt to grind the labrum between the glenoid and the humeral head. Furthermore, the examiner may attempt to detect anterosuperior labral lesions by placing the arm in a horizontally abducted position while providing an anterosuperior directed force. In contrast, the examiner may also horizontally adduct the humerus and provide a posterosuperiorly directed force when performing this test. I think of this test as "exploring" the joint for a torn labrum. It is hit or miss for me.
The Speed’s biceps tension test has been found to accurately reproduce pain in instances of SLAP lesions. I have not seen this to be true very often. It is performed by resisting downwardly applied pressure to the arm when the shoulder is positioned in 90 degrees of forward el evation with the elbow extended and forearm supinated. Clinically, we also perform a new test for SLAP lesions. Kevin Wilk and I developed a variation of the original Speed’s test, which we refer to as the “Dynamic Speed’s Test." (I came up with the name, what do you think?) During this maneuver, the examiner provides resistance against both shoulder elevation and elbow flexion simultaneously as the patient elevates the arm overhead. Deep pain within the shoulder is typically produced with shoulder elevation above 90 degrees if this test is positive for labral pathology. Anecdotally, we have found this maneuver to be more sensitive than the originally described static Speed’s test in detecting SLAP lesions, particularly in the overhead athlete. To me, it seems like you only get symptoms with greater degrees of elevation, making the original Speed's Test less sensitive in my hands.
Sensitivity: 90%, Specificity: 14%, PPV: 23%, NPV: 83% for the Speed’s test
Clunk and Crank Test
The clunk test is performed with the patient supine. The examiner places one hand on the posterior aspect of the glenohumeral joint while the other grasps the bicondylar aspect of the humerus at the elbow. The examiner’s proximal hand provides an anterior translation of the humeral head while simultaneously rotating the humerus externally with the hand holding the elbow. The mechanism of this test is similar to that of a McMurray’s test of the knee menisci, where the examiner is attempting to trap the torn labrum between the glenoid and the humeral head. A positive test is produced by the presence of a clunk or grinding sound and is indicative of a labral tear. The crank test can be performed with the patient either sitting or supine. The shoulder is elevated to 160 degrees in the plane of the scapula. An axial load is then applied by the examiner while the humerus is internally and externally rotated in this position. A positive test typically elicits pain with external rotation. Symptomatic clicking or grinding may also be present during this maneuver. These tests seem to do well with finding a bucket-handle tear of from a Type III or Type IV SLAP lesion more than anything else for me.