Two New Clinical Examination Tests to Detect a Superior Labral Tear / SLAP Tear

It seems like once or twice a year I read an article about a new test to detect superior labral injuries of the shoulder, or SLAP labral tears.  Seems like the “best” test has been published many times!  With so many tests out there to detect SLAP tears, how do you choose which to perform on your patients?  Certainly you can’t perform them all?  Or should you?!?  I am working on a series of posts that discuss SLAP tears in detail, including classification, injury mechanisms, examination, and of course rehabilitation.

Do you know what it means when you have several examination techniques to determine the same pathology?

That is right, you guessed it, they all stink!  That is actually not true but wanted to state my case well.  Although there is no “gold standard” special test to detect SLAP tears, like the Lachman is for ACL injuries, there are some very useful tests if you know how to best use them.  The difficulty with SLAP test is that different tests are best used for different types of SLAPs or different mechanisms for SLAP injuries.  I will explain more in an upcoming post later this week.

Well, I am here to introduce to you two more tests to add to your bag of tricks!  I wanted to kick off the SLAP series with a new video that I have on YouTube that demonstrates these two tests.  These were actually published in a paper I wrote in JOSPT a few years ago, but I have modified them a little and wanted to share.  These two tests are both excellent at detecting peel-back SLAP lesions, specifically in overhead throwing athletes, but are useful for any population.  I share these two tests because I know that there is a lot of confusion regarding the “best” test.  These may not be them, but in my hands, both have been extremely helpful and, more importantly, accurate.

Pronated Load


The first test is the “Pronated Load Test,” it is performed in the supine position with the shoulder abducted to 90° and externally rotated.  However, the forearm is in a fully pronated position to increase tension on the biceps and subsequently the labral attachment.  When maximal external rotation is achieved, the patient is instructed to perform a resisted isometric contraction of the biceps to simulate the peel-back mechanism.  This test combines the active bicipital contraction of the biceps load test with the passive external rotation in the pronated position, which elongates the biceps.  A positive test is indicated by discomfort within the shoulder.


Resisted Supination External Rotation Test


The second new test was recently described by Myers in AJSM, called the “Resisted Supination External Rotation Test.”  Dr. Myers was a fellow at ASMI and a good friend of mine, he really wanted to call this the SUPER test (for SUPination ER) but I was one of many that advised him against this for obvious reasons!  During this test, the patient is positioned in 90° of shoulder abduction, and 65-70° of elbow flexion and the forearm in neutral position.  The examiner resists against a maximal supination effort while passively externally rotating the shoulder.  Myers noted that this test simulates the peel-back mechanism of SLAP injuries by placing maximal tension on the long head of the biceps by supinating.  Myers’ study of 40 patients revealed that this test had better sensitivity (82.8%), specificity (81.8%), positive predictive value (PPV) (92.3%), negative predictive value (NPV) (64.3%), and diagnostic accuracy  (82.5%) compared to the crank test and extremely popular O’Brien’s or active compression test.  A positive test is indicated by discomfort within the shoulder.



Have you tried these tests before?  Where they as accurate for you as they were for me?  These videos are taken from my Clinical Examination of the Shoulder DVD with Kevin Wilk.



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23 Responses to “Two New Clinical Examination Tests to Detect a Superior Labral Tear / SLAP Tear”

  1. Good videos. Thanks for posting the sensitivity/specificity and LRs.

    Christie

  2. Currently working on studying the Pronated Load test in more detail too, hope to have some data over next year or so. Thanks
    MR

  3. Scott M. Cameron, PT, MS November 4, 2008 at 7:05 am

    Mike,
    I have used both tests and find them helpful in testing for a “peel back” lesion. I would have to agree with you that you need the right test for the right patient. There is not 1 perfect test for all labral injuries.

    Good Post

    Scott

  4. Do you propose these two test are most specific to the baseball population or all overhead athletes?

    Do you find a history of catching or popping to be helpful to add to the clincal diagnostic process? I have read conflicting reports on this (McFarland AJSM 2002 versus Walsworth AJSM 2008).

    Additionally, do you find these athletes all have noteable anterior hypermobility/instability? What tests have you found helpful for this?

    I know Kim has reported high sensitivity and specificity for bicep load II, have you used this test?

  5. Amy, I am working on a post for later this week that addresses all of these questions, we think the same!

  6. Looking forward to it Mike!

  7. Trevor Winnegge PT,DPT,MS,OCS,CSCS November 5, 2008 at 5:20 pm

    Mike,
    Here is a point on the pronated load test, that for the record, I use often. Are we really changing length/tension of the biceps by pronating the forearm, when the biceps is flexed to 90? If the elbow was straight into full extension, i would completely agree that by pronating the forearm, you further tension and preload the biceps. However, if the biceps is flexed to 90, i often wonder if we really are changing the pre-tensioning of the biceps as much as we think we are. would be a good point to examine cadaverically or in the OR under anesthesia/scope. Just a thought.

    i like the “SUPER” test. Basically it is a Yergason’s at 90 degrees of abduction. I will definitely add this to my toolbox!

    Does Mark know he is now on youtube?????

  8. I would say we are changing the tension Trevor. The biceps supinates the arm in elbow flexion, if the elbow is extended, the supinator is the primary mover. Not sure exactly how much we are tensioning the biceps in the pronated position but would say it is more than in the supinated position. Agree would be a good study.

    In my experience, the biceps load test is a good test, but with patients that only have subtle symptoms with the biceps load, immediately performing a pronated load afterward does tend to increase symptoms, which helps me with my diagnosis.

    That is right, a Yergason but in full passive ER to position the long head of the biceps to “peel back” the posterosuperor labrum.

    Amy – I have a few posts coming up over the next week that will answer all your questions. I have been receiving questions from readers that I think I need to address as well. Next post will be on the different types of SLAPs and then the following post will be on all the tests for SLAPs and how to chose which one to perform!

  9. Trevor Winnegge Pt,DPT,MS,OCS,CSCS November 9, 2008 at 3:09 pm

    Mike,
    Have you come across anything in your research or training on the 3 different types of anterior capsular insertions of the glenohumeral joint? Are people with a type III capsule insertion at more risk of instability or injury? Just curious if you have any info on this matter. thanks.

  10. Trevor, There has been recent discussion of this at a few meetings. I have always thought that anatomy is very individualized. I am sure there are far more than 3 different insertion points for the anterior capsular structures, but I understand the need to try to develop gross classification schemes. That being said, I think we can all assume that some individuals have variations of their capsule and GHL complex that may be make them more susceptible to injury. The difficult in studying this is that the these variations are difficult to assess and somewhat subjective between different observers. What do you think?

  11. Trevor Winnegge PT,DPT,MS,OCS,CSCS November 10, 2008 at 7:56 pm

    I agree that it is difficult to assess. Have a 16yo female,petite, swimmer with bilateral shoulder pain. On exam she had bilateral MDI, and equivocal biceps pronated load test and anterior slide test. pain much worse in right shoulder. increases with all overhead activity, reaching out away from body, and all fast or swimming motions. with a programof strengthening and stability exerices, her left shoulder pain is resolved. right mildly improved. program consists of tband, prone scap stab, CKC WB ex on unstable surfaces, PNF, and RS drills at multiple angles among other things. After 6 visits, no change in right shoulder. she went for MR-arthrogram last week which showed bursitis and a type III anterior capsule. i felt she may have a slap tear but MR-arthrogram was negative. MD doesn’t want to touch her surgically, and referred her to harvard sports medicine for a second opinion. pt and her mom are pushing for surgery so our doc referred her out to see what another sports guys ays first. he feels she just needs PT. Kind of a frustrating case. She probably weights about 90 pounds soaking wet and is really small framed-not the best swimmers body! any thoughts? suggestions?

  12. Sounds like she basically has MDI and moderate to severe collagen deficiency. I would agree with the doc, this patient is likely going to have an unsatisfactory surgery and recurrent instability. Keep plugging away, you are not going to “fix” 16 years of laxity in 6 visits, she has to be strict in her home exercises as well. Is she still swimming? Needs to take time off and focus on rehab. Hate to say it but maybe swimming isn’t for her.

  13. Denver Sports PT January 20, 2009 at 11:09 am

    Keep up the great work Mike. I’m very much enjoying and learning from you blog. I have a patient this afternoon who I’m curious to see how they respond to this test.

    Thanks again.

  14. Michael Schroder, DPT January 2, 2012 at 7:14 pm

    I am currently preparing for the OCS exam, and while reviewing the elbow, it was mentioned that little to no bicep muscle activity has been demonstrated during elbow flexion with the forearm pronated. They listed 2 references, one of which was from 1957, and the other is listed on the last page of references which is not part of the copy I borrowed. If this research is still accepted, does that throw a kink in the Pronated Load test?

    • Michael – You are correct, minimal would be likely correct. The pronated load stresses a SLAP passively more than actively. By placing the arm in max ER in the pronated position, you place the biceps in an elongated position to increase stress. The active component does still often produce pain, but the passive portion is just as important to me.

  15. Tanya Mackenzie April 18, 2012 at 8:44 am

    Hi Mike
    Thanks I really enjoy your weekely news letters. And I love the book The Athlete’s Shoulder. I have picked up on the pronated load test and the resisted supinatin in ER test, and tried to impliment these clinically. However, my concern is that if I suspect a SLAP I normally do the glenohumeral laxity and instability tests in addition to more specific SLAP tests. In almost all cases I find a postive instability test. In the majority it is anterior.If this is the case then I am wary of these two new tests in that prior to loading of the long head of biceps and simulating the peel-back mechanism, the humeral head will translate anteriorly in the passively abducted and ER shoulder position. So I am careful when interpreting how symptoms respond and to what is reported by the patient during this test. I am not always confident with the interpretation I am making with these two tests and patient feedback during these tests has been a but cloudy. I understand that with most specail orthopaedic tests it is the combination of tests and interpretation in context that is important, but would like to hear your thoughts on this. Thanks Tanya

    • Tanya, very good thoughts. I would agree you wouldnt have to go this far in the evaluation process. It sounds like the instability is the main issue to address with your rehabilitation program.

      Many patients with have a SLAP without pathological instability, these tests are probably better for them to detect the pathology.

      Good thoughts! Thanks!

      • Tanya Mackenzie April 18, 2012 at 1:12 pm

        Thanks for prompt reply. Good food for thought, I am now worried I am missing detecting the SLAP that presents without the instability. Will keep practicing. thanks. Tanya

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