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

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 contractionSLAP-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 the Advanced 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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8 Responses to “Clinical Examination of Superior Labral (SLAP) Tears – Part 2”

  1. Chad Ballard, PT November 25, 2008 at 4:47 pm

    Mike- once again very useful information and clinically relevant. I haven’t had a suspected SLAP on my schedule the past couple weeks, but I am looking forward to trying out the Pronated Load and Supination External Rotation tests next time.

  2. Chad, next time you have a patient with a suspected SLAP and a peel-back mechanism, I would actually saw do a few of the tests that do not simulate a peel-back, then do these in order:

    Biceps Load I
    Biceps Load II
    Pronated Load
    Resisted Sup ER

    I have seen a few times that patients with more subtle SLAP tears (is that an oxymoron?) have negative biceps loads but then when you pronate it lights them up.

  3. Mike,
    Thank you for the clinical information givenin this post! I am a new PT (graduated in May 08) and am really enthusiastic about the research out that gives us PTs a more accurate approach to diagnosing musculoskeletal disorders. I couldn’t agree with you more about the special tests you posted that give the most sensitive results. I am commenting about the O’Briens test for SLAP and the “great” values it gives for accuracy. However, the QUADAS score was 3/14 showing significant bias in the study. Not sure if you use this system or if many clinicians know of it to further make a sound decision from clinical special tests. If not, I think it’ll be a great topic to discuss.
    -Harrison

  4. Harrison, thanks for the comments. Great point, I didn’t think of including that QUADAS score. Do you have an interest in writing a post for this blog to help readers understand what the QUADAS score is and how they can find this information? Email me using the contact form. I have used:

    http://www.biomedcentral.com/1471-2288/3/25

    Thanks, Mike

  5. Hey Mike, this is a great idea for a blog!

    I do want to add one note about Biceps Load I and II though. They both have decent Quadas scores (9 and 10, respectively), but Kim et al. acknowledged the study for BL I was flawed by not having a broad sample of patients. The utility scores for BL II are likely much more accurate, since they had a better sample for testing. Also, just to plug a great reference book, Orthopedic Physical Examination Tests: An Evidence-Based Approach covers nearly all current tests and includes sp, sn, LRs, and QUADAS scores from all studies related to each test.

    -Jordan

  6. I am a 63 year old female–very athletic–ski, golf, back-pack, and row. Three years ago I sustained a pull injury (pulling a heavy ice chest up a river bank)felt a “pop” with subsequent overhead catching. Five months ago I caught, with arms extended, a cabinet that fell off of the kitchen wall. Four months ago I fell on my shoulder, in external rotation placement, sustained a concussion with 4 head sutures. My right shoulder then became quite painful with a deep aching and catching with overhead movement. My ROM is fairly good. I went to an Ortho MD 3 weeks ago. I brought up the possibility of a Labral injury and both the MD and his PA stated, “You don’t have that”–this was stated BEFORE taking a history and doing an exam. I challenged them and subsequently got an MRI. Results of MRI: 1)Long head of the biceps demonstrates an intrasubstance longitudinal tear; 2) Type III slap tear within the superior anchor of the labrum; 3)Anterior inferior labral tear with a papalabral cyst and also a subchondral cyst presumably from bony Bankart injury remotely; 4)No discrete rotator cuff tear; and 5)Mild a.c. DJD. The PA said that I have this because I am “old” and stated he would not do surgery. I start PT next week… I would appreciate your input regarding the success rate of PT with the above clinical presentation, plus my age and activity level. Thank you, Rue

  7. Mike,

    I know you say that the majority of the population likely as a Type 1 SLAP tear. My question is, with NO history of trauma, how likely are any of the other types of SLAP tears? Should it be suspected if a patient cannot recall any trauma and to what degree if so?

    Thank you for your time.

    Chris

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