SUPERIOR LABRAL ANTERIOR POSTERIOR LESIONS
The definitive method for diagnosis of labral lesions is arthroscopy.26 However, a cornucopia of special tests for assessing superior labral anterior posterior (SLAP) lesions has been described in the literature. The more frequently used tests are reviewed here.
Speeds test Apply resistance as the patient forward flexes the shoulder while standing with the elbow at full extension. Pain in the anterior aspect of the shoulder is positive for a SLAP lesion.27 Although routinely used to assess for a SLAP lesion, sensitivity (9%) and specificity (74%) of this test is very poor.
Anterior slide test Position the patient standing with hands on hips and thumbs pointing to the back. Place one hand on top of the shoulder to stabilize the scapula and the other hand at the elbow; apply a forward and superiorly directed force into the glenoid (Figure 6). Ask the patient to resist and push back against this force. A pop or click felt under the hand on top of the patient's shoulder or reproducing the patient's symptoms is positive. Kibler reported this test to be 78% sensitive and 91% specific for type II SLAP lesions.28
The apprehension relocation test, as described by Jobe, is also used to assess type II SLAP lesions because the test reproduces lesion etiology.29 Pain in the posterior and anterior posterior aspects of the shoulder that is relieved by the test's relocation maneuver is considered positive. Morgan reported sensitivities of 4% for an anterior SLAP, 85% for a posterior SLAP, and 59% for SLAP lesions in the front and back of the shoulder.29 Specificities for the three lesion locations were 27%, 59%, and 54%, respectively.29
Active compression test Position the patient standing with the shoulder forward flexed 90 degrees and adducted 10 to 15 degrees with maximal internal rotation. Apply a downward pressure to the arm either at or below the elbow with the patient resisting (Figure 7). Repeat with the arm maximally supinated. The test finding is positive if the patient felt pain with the first maneuver and no pain or reduced pain with the second. A click during the first maneuver also correlated with a positive result. O'Brien reported this test to be 100% sensitive and 98% specific with 94% positive predictive value and 100% negative predictive value.30 However, one study found the sensitivity to be closer to 54% and the specificity to be 47%.27
Biceps load test II In the supine position and the arm elevated to 120 degrees with maximal external rotation and full forearm supination, the patient maximally flexes the elbow against resistance (Figure 8). A positive result is pain or increased pain in the shoulder while resisting elbow flexion. Sensitivity is 89%, specificity is 96%, positive predictive value is 92%, and negative predictive value is 95% for this test, which attempts to displace the torn superior labrum.31
Resisted supination external rotation test Place the patient supine with the arm in 90 degrees of abduction,
the elbow flexed 65 to 70 degrees, and the forearm in neutral or slight pronation. The patient maximally supinates the forearm against resistance with external rotation of the shoulder32 (Figure: Resisted supination external rotation test in the online version of this article).This test mimics a throwing motion in the hopes of reproducing SLAP lesion pain.32 The test result is positive if the patient reports deep anterior shoulder pain, clicking or catching within the shoulder, or the patient's symptoms are reproduced. The test is 82% sensitive, 81% specific, with a positive predictive value of 92% and a negative predictive value of 64%.
CONCLUSION
Physical examination of the shoulder can be intimidating for some and challenging for others; however, clinicians in primary and emergency/urgent care should understand how to perform a basic shoulder examination. A clear and concise history that takes patient age, pain, and mechanism of injury into account can help narrow the differential diagnosis. Selection of specific examination techniques can lead to an accurate diagnosis.
No test is absolutely diagnostic for any pathologic condition within the shoulder, and no clinician should rely solely on orthopedic techniques in the diagnostic process. Nor should every test be employed during the examination. Rather, the clinician should be directed by the historical facts given by the patient to select the appropriate examination techniques. JAAPA
Rob Powers practices in orthopedics at Mattern and Associates, Dover, Delaware. The author has indicated no relationships to disclose relating to the content of this article.
REFERENCES
1. Richards RR, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg. 1994;3(6):347-352.
2. Chronopoulos E, Kim TK, Park HB, et al. Diagnostic value of physical tests for isolated chronic acromioclavicular lesions. Am J Sports Med. 2004;32(3):655-661.
3. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder.
J Bone Joint Surg Am. 1972;54(1):41-50.
4. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J Sports Med. 1980;8(3):151-158.
5. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42(2):80-92.
6. Jobe FW, Moynes DR. Delineation of diagnostic criteria and a rehabilitation program for rotator cuff injuries. Am J Sports Med. 1982;10(6):336-339.
7. Jobe FW, Jobe CM. Painful athletic injuries of the shoulder. Clin Orthop Relat Res. 1983;(173):
117-124.
8. Reinold MM, Macrina LC, Wilk KE, et al. Electromyographic analysis of the supraspinatus and deltoid muscles during 3 common rehabilitation exercises. J Athl Train. 2007;42(4):464-469.
9. Itoi E, Kido T, Sano A, et al. Which is more useful, the "full can test" or the "empty can test,"
in detecting the torn supraspinatus tendon? Am J Sports Med. 1999;27(1):65-68.
10. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle: clinical features in 16 cases. J Bone Joint Surg Br. 1991;73(3):389-394.
11. Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis tendon: results of operative repair. J Bone Joint Am. 1996;78(7):1015-1023.
12. Altchek DW, Warren RF, Skyhar JM, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73(1):105-112.
13. Silliman JF, Hawkins RJ. Classification and physical diagnosis of instability of the shoulder.
Clin Orthop Relat Res. 1993;(291):7-19.
14. Neer CS 2nd, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder: a preliminary report. J Bone Joint Surg Am. 1980;62(6):897-908.
15. Ferrari DA. Capsular ligaments of the shoulder: anatomical and functional study of the anterior superior capsule. Am J Sports Med. 1990;18(1):20-24.
16. Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am. 1992;74(1):53-66.
17. Hawkins RJ, Schutte JP, Janda DH, Huckell GH. Translation of the glenohumeral joint with the patient under anesthesia. J Shoulder Elbow Surg. 1996;5(4):286-292.
18. Lintner SA, Levy A, Kenter K, Speer KP. Glenohumeral translation in the asymptomatic athlete's shoulder and its relationship to other clinically measurable anthropometric variables. Am J Sports Med. 1996;24(6):716-720.
19. Rowe CR, Zarins B. Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am. 1981;63(6):863-872.
20. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or throwing athlete. Orthop Rev. 1989;18(9):963-975.
21. Speer KP, Hannafin JA, Altchek DW, Warren RF. An evaluation of the shoulder relocation test.
Am JSports Med. 1994;22(2):177-183.
22. Gerber C, Ganz R. Clinical assessment of instability of the shoulder: with special reference to anterior and posterior drawer tests. J Bone Joint Surg Br. 1984;66(4):551-556.
23. Levy AS, Lintner S, Kenter K, Speer KP. Intra- and interobserver reproducibility of the shoulder laxity examination. Am J Sports Med. 1999;27(4):460-463.
24. Kim SH, Park JC, Park JS, Oh I. Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med. 2004;32(8):1849-1855.
25. Liu SH, Henry MH, Nuccion SL. A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am J Sports Med. 1996;24(6):721-725.
26. Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg. 1998;6(2):121-131.
27. Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy. 2003;
19(5):517-523.
28. Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glenoid labral tears. Arthroscopy. 1995;11(3):296-300.
29. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy. 1998;14(6): 553-565.
30. O'Brien SJ, Pagnani MJ, Fealy S, et al. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26(5):610-613.
31. Kim SH, Ha KI, Ahn JH, et al. Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy. 2001;17(2):160-164.
32. Myers TH, Zemanovic JR, Andrews JR. The resisted supination external rotation test. Am J Sports Med. 2005;33(9):1315-1319.