Humeral Fracture Following Biceps Tenodesis in a Baseball Pitcher

At this year’s ASMI Injuries in Baseball course, one of the topics that we discussed at length was the use of biceps tendodesis in baseball pitchers.  Over the years, our understanding of SLAP lesions has evolved and many are advocating a biceps tenodesis procedure.  While this may be a viable option for older individuals, I have never been a fan of this in athletes that need to use their shoulder at maximum range of motion and velocity.  I just don’t think the concept of “if it hurts just cut if off” makes the most sense to me.

SEE ALSO: Is Biceps Tenodesis the Answer?

A recent case report in AJSM actually describes one of the biggest reasons why I am think we really need to question the use of biceps tenodesis in baseball pitchers: A humeral fracture.

humerus fracture after biceps tenodesis

The white arrow is the drill hole from the biceps tenodesis.  This came up at the ASMI course with the panel of surgeons, including Dr. James Andrews, Dr. Lyle Cain, and Dr. Xavier Duralde of the Braves.  The rotational torque observed on the humerus while pitching are extremely high.  Putting a screw in there scares me a bit.

SEE ALSO: Dr. Lyle Cain from the American Sports Medicine Institute discusses some facts and fiction related to the biceps tenodesis surgery.

What do you think?  Does this x-ray of a humeral fracture following a biceps tenodesis in a baseball pitcher scare you a little too?

Internal Impingement – What it is and How to Diagnose

Internal Impingement

The latest webinar recording for Inner Circle members is now available below.

Internal Impingement – What it is and How to Diagnose

This month’s Inner Circle webinars discussed a one of the most requested topics to date and featured a TON of people online live!  We’ll cover:

  • What is internal impingement?
  • The difference between internal and subacromial impingement
  • Anatomical, biomechanical, and pathological reasons for developing internal impingement
  • What do athlete’s that have internal impingement feel?
  • The #1 test to perform to diagnose internal impingement
  • What else you should look for on examination to develop the best treatment program

The topic is so big, I need to break it down into 2 parts.  This first part will cover the etiology and diagnosis.  I will follow this up in the upcoming months with an entire webinar dedicated to how to treat internal impingement.

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.



Is a Biceps Tenodesis the Answer?

I read a lot of stuff on the internet.  I like to keep up with a ton of blogs, websites, and journals to make sure I am on top of recent trends, but also to share with my readers.  I recently came across an article at Science Direct entitled Getting Athletes Back in the Game Sooner Following Shoulder Injuries.  Nice headline, right?  It made me want to click.

Interestingly, they were talking about how a biceps tenodesis can cut down the rehabilitation time from SLAP tears in comparison to a SLAP repair.  That wasn’t what I was expecting!

OK, would a tenodesis cut down (no pun intended…) the rehab time in comparison to a SLAP repair?  No doubt, I agree with that.  But I am not sure if this is what we want to do, especially in athletes, as the title of the article suggested.  Let’s dig into this deeper, but first, let’s discuss SLAP tears and what the biceps tenodesis surgery actually does.


What is a SLAP Tear and Biceps Tenodesis?

biceps labral complexI’ve covered superior labral tears, or SLAP tears extensively in the past.  If you don’t know much about SLAP tears, start there, but essentially a SLAP tear is a superior labral tear at the junction of where the long head of the biceps comes in and attaches to the superior labrum.  SLAP tears are common, and can be especially troublesome for overhead athletes.  (Photo from Wikipedia)

A biceps tenodesis is a surgical procedure that detaches the biceps attachment from the superior labrum and reattaches it to the humerus.  Here is a surgical demonstration from Smith and Nephew:

YouTube Preview Image


By removing the biceps, this essentially eliminates the patient’s pain from the SLAP lesion or biceps tendonitis, however at what consequence?  By performing a tenodesis, you are changing the anatomy of the shoulder and the function of the biceps.  This procedure has become more popular in older individuals, essentially those that chose a decrease in function for a decrease in pain.  But what about athletes, as the paper I mentioned above proposed was happening, can they return to sports faster by simply cutting the biceps off instead of trying to repair it?

One of the most popular studies on this subject was in AJSM in 2009.  The authors reported that the results of biceps tenodesis were superior to SLAP repairs in athletes with superior labral tears.  The authors mention both “overhead athletes” and “return to sport” in the paper, though they report the age range of subjects was 24-69 years old.  Furthermore, significant differences in age existed between the two groups, with the mean age of 37 years old in the SLAP repair group and mean age of 52 years old in the biceps tenodesis group.  One could certainly argue that the level of “sport” participation was different between the groups and could certainly influence their subjective satisfaction.


What is the Function of the Biceps?

Biomechanical studies have shown that the biceps labrum complex has a role in providing both translational and rotational stability, and that repair of a SLAP lesion restores this ability to provide static stability.  This is especially true in overhead athletes who need to use their arm in the abducted and externally rotated position.  Contraction of the long head of the biceps in this position has been shown to reduce anterior humeral head displacement, a functional that is critical in preventing throwing injuries.  In fact, peak biceps EMG activity has been shown to occur during this cocking phase of throwing, and has been shown to be higher in pitchers that have anterior instability.

Also, don’t forget that release of the long head of the biceps has been shown to increase superior humeral head migration by over 15%.

As all my readers know, superior humeral head migration is disadvantageous and causes many of the dysfunctions we see with the shoulder.  Our whole goal of most shoulder rehabilitation programs is to train the rotator cuff to dynamically stabilize to resist superior humeral head migration.  I’ve written about the role of rotator cuff fatigue in shoulder mechanics and how rotator cuff fatigue increases superior humeral head migration.

So if the biceps is involved with translational and rotational glenohumeral stability and helps prevent superior humeral head migration, is this something you want to sacrifice just to reduce pain?  How will this impact function, and more importantly, future injuries?


Is a Biceps Tenodesis the Answer?

Is there a role for biceps tenodesis?  I am sure there is.  I like the recommendations my friend Brian Busconi reports in this paper, stating that he likes to perform SLAP repairs, but will consider biceps tenodesis in patients over the age of 45.  This serves a different purpose and return to high level athletics is probably not as important to the patient than reducing their pain.  I have heard Dr. Altchek from New York report in meetings that he thinks biceps tenodesis may be an option, but one he reserves for those who fail a SLAP repair.   Still, I have to wonder what the long term effects of the biceps tenodesis will do on this patient population as well.  Will the increased superior humeral head cause rotator cuff pathology or degenerative changes?  Only time will tell.

There is also recent chatter about the use of the biceps tenodesis procedure in overhead athletes and the risk of humeral head fracture.  This is a consequence that must be considered.

Noted orthopedist, Dr. James Andrews was recently asked about the biceps and the potential for biceps tenodesis, to which he replied “The biceps is there for a purpose — it’s too intrinsically associated with the shoulder joint.  Until we know what the real function of it is, we’re stabbing in the dark.”  When asked if a biceps tenodesis is the answer to athletes returning to sport, similar to a Tommy John procedure, he replied “With Tommy John surgery, we’re actually restoring anatomy. In the case of biceps tenodesis, you’re deleting anatomy.”

SEE ALSO: Dr. Lyle Cain from Dr. Andrews’ American Sports Medicine Institute discusses some of the facts and fiction related to the biceps tenodesis surgery.

So, sadly, I don’t think we all learned a great new way “get athletes back in the game sooner following shoulder injuries” like the Science Direct title would suggest.  Perhaps I’m wrong, but I would have to agree with Dr. Andrews, I always prefer procedures that restore anatomy when possible.  Don’t get me wrong, a biceps tenodesis has it’s place.  But I’m not sure if it is the magical secret to getting athletes back faster, there just has to be some consequences.

What has your experience been?  Have you seen many athletes opt for a biceps tenodesis rather than a SLAP repair?




Subscapularis Release for Loss of External Rotation

image We have a great guest post today from my friend Trevor Winnegge.  Trevor wrote a nice article last year on complications following distal radius fractures that ranked as my number 1 guest post in 2009!  This time, he presents the results of really nice case series on restoring external rotation ROM using subscapularis release massage techniques.  Great idea and some common manual techniques that I use as well with all of my patients.  Thanks Trevor!

The Role of Soft Tissue Mobilization to Subscapularis to Improve External Rotation in a Type II SLAP Repair-A Case Series

Our clinic is a smaller clinic and doesn’t have the time or resources for a full research study but we did have the opportunity to perform a very small pilot study/case series. I decided to contribute this information because I think it is an underutilized technique and is valuable in assisting our post operative shoulder patients.

We looked at the role that subscapularis has on limiting external rotation (ER) in a post operative shoulder patient. Given that subscapularis is an internal rotator and also assists with some adduction, it is stretched with abduction and ER of the shoulder[1]. Many shoulder surgeries place the patient in a sling in the internally rotated position to some degree. Standard Type II SLAP repair protocols limit the passive range of motion (PROM) into ER to anywhere from 0-30 degrees for the first four weeks, limiting the ability of the subscapularis to stretch[2]. Therefore, we felt if we could perform soft tissue mobilization to the subscapularis in the initial post operative period while range of motion is limited, then they would be less stiff once they were allowed to progress into ER. To my knowledge there has been only one study to date looking at the role of soft tissue mobilization to subscapularis on improving ER and that was published in JOSPT in December of 2003[3]. In that study, conducted by Godges et al, they excluded any patient that was in the immediate four week post operative healing phase. We felt that this immediate healing phase is when we can be most successful at preventing excessive subscapularis tightness by performing soft tissue mobilization, thereby improving ER ROM once they are allowed to progress past 30 degrees of ER.


Research Design

We took four patients (two males, two females) between the ages of 17 and 26 who had undergone primary Type II SLAP repair and randomly assigned them into two groups. The first group received standard ROM treatment for all motions and had ER ranged only to 30 degrees per the doctors protocol. The second group had the same exact treatment, however also received five minutes of subscapularis soft tissue mobilization[4]. Soft tissue mobilization was performed while the patient was in sidelying for the first one or two treatment sessions until the patient had enough abduction ROM to allow for good access to subscapularis in a supine position. The technique was using thumb or fingertips to hook inside the lateral border of the scapula and dig deep down between the scapula and ribs. A combination of deep pressure and soft tissue mobilization were performed for a total of five minutes. Every patient in each group was seen at the one week post operative timeframe and was seen twice a week for the next three weeks.


Video Demonstration

I do have two videos of the soft tissue techniques. The first is for the immediate post op patient while patient is in sidelying. The second video is while the patient is in supine. This video also incorporates the soft tissue technique with some elevation ROM.





The results were as we had expected. The group that received the soft tissue mobilization had about twenty five more degrees of ER ROM (measured with goniometer in 45 degrees of abduction while supine) at the four week mark than did the group that did not receive the treatment.

Control Group-ER ROM


1 week post op

4 weeks post op

Subject 1

10 degrees

40 degrees

Subject 2

15 degrees

38 degrees

Intervention Group- ER ROM


1 week post op

4 weeks post op

Subject 1

12 degrees

64 degrees

Subject 2

15 degrees

63 degrees


I understand that these results should be taken with a grain of salt, as strong conclusions can not be made with such a small sample size. As I previously stated we simply do not have the time or resources in our clinic to perform a large scale study. It is my hope that someone reading this who works in a much larger center can take this information and use it as a stepping stone to a full blown research study. Clinically, I use these techniques on a daily basis and achieve great results. I truly feel the results of a larger study would be quite similar. What was also interesting is that shoulder elevation was also improved in the soft tissue mobilization group. This is likely due to the close proximity of the latissimus dorsi to the subscapularis, it is hard to truly isolate the subscapularis. We focused on SLAP repairs, but Bankart repairs could also benefit from this as well as rotator cuff repair patients who require sling use for extended amounts of time, provided a subscapularis repair wasn’t performed. I think the possibilities for research in this area are endless and I would love to see it published as a large research study. Please give me any feedback if you currently use this technique, or tried it after reading this. It really works well.

clip_image001Trevor has been practicing PT for over 9 years. He graduated from Northeastern University with a bachelors in PT and a master of science degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He is currently the Clinical Coordinator of Rehabilitation at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA.

[1] Palastanga, et al. Anatomy and Human Movement. Boston MA:Butterworth Heineman; 1993.

[2] Wilk K, Reinold M, Andrews J. Postoperative Treatment Principles in the Throwing Athlete. Sports Medicine and Arthroscopy Review. 2001;9:69-95.

[3] Godges et al. The Immediate Effects of Soft Tissue Mobilization with Proprioceptive neuromuscular Facilitation on Glenohumeral External rotation and Overhead reach. JOSPT. 2003; 12: 713-718.

[4] Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore MD:Williams and Wilkins; 1983.

Clinical Examination of Superior Labral (SLAP) Tears – Part 2
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
Compression Injury: Active Compression
Compression Rotation
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

Clinical Examination of Superior Labral Tears – What is the Best Test for a SLAP Tear? Part 1 of 2

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 DSC01942against 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)

  Compression-Rotation Test

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 traDSC01936p 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.
Sensitivity: 24%, Specificity: 76%, PPV: 90%, NPV: 9%

Speed’s and Dynamic Speed’s Test

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 elDSC01934evation 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 DSC01938translation 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.
Sensitivity: 39-91%, Specificity: 56-93%, PPV: 41-94%, NPV: 29-90%

Click here to jump to part 2 of Clinical Examination of Superior Labral Tears.  I know it seems confusing with all these tests but I will show you an easy way to use these clinically.  I want to hear from you as well, what has your success been with the tests presented here so far as well as the pronated load SLAP test and the resisted supination external rotation SLAP test?  For information on Kevin Wilk and I’s DVD on Clinical Examination of the Shoulder, which includes demonstrations of all these test, visit the Advanced Continuing Education Institute, remember to use coupon code “Reinold” for a 10% discount.

Mechanisms of Injury to the Superior Labrum

How does a SLAP Tear Occur?

Now that we have discussed the different types and classification of SLAP tears to the superior labrum, I wanted to now talk about how these shoulder injuries occur. There are several injury mechanisms that are speculated to be responsible for creating a SLAP lesion. These mechanisms range from single traumatic events to repetitive microtraumatic injuries.

Traumatic Events

Photo by bsv1990

Traumatic events, such as falling on an outstretched arm or bracing oneself during a motor vehicle accident, may result in a SLAP lesion due to compression of the superior joint surfaces superimposed with subluxation of the humeral head. Snyder referred to this as a pinching mechanism of injury. Other traumatic injury mechanisms include direct blows, falling onto the point of the shoulder, and forceful traction injuries of the upper extremity.

To be honest with you, I don’t know if this is actually the underlying cause of the SLAP lesion. I have questioned this theory in the past and don’t know the answer, but part of me at least wonders if these patients already had a certain degree of pathology to their superior labrum and the acute injury led to a MRI and diagnosis of a SLAP tear.

Repetitive Overhead Activities

Repetitive overhead activity, such as throwing a baseball and other overhead sports, is another common mechanism of injury frequently responsible for producing SLAP injuries.  This is the type of SLAP lesion that we most often see in our athletes. In 1985, Dr. Andrews first hypothesized that SLAP pathology in overhead throwing athletes was the result of the high eccentric activity of the biceps brachii during the arm deceleration and follow-through phases of the overhead throw. To determine this, they applied electrical stimulation to the biceps during arthroscopic evaluation and noted that the biceps contraction raised the labrum off of the glenoid rim.

Burkhart and Morgan have hypothesized a “peel back” mechanism that produces SLAP lesion in the overhead athlete. They suggest that when the shoulder is placed in a position of abduction and maximal external rotation, the rotation produces a twist at the base of the biceps, transmitting torsional force to the anchor.

This mechanism has received a lot of attention and several studies seem to show its accuracy.  Pradham measured superior labral strain in a cadaveric model during each phase of the throwing motion. They noted that increased superior labral strain occurred during the late-cocking phase of throwing.  A recent study from ASMI simulated each of these mechanisms using cadaveric models. Nine pairs of cadaveric shoulders were loaded to biceps anchor complex failure in either a position of simulated in-line loading (similar to the deceleration phase of throwing) or simulated peel back mechanism (similar to the cocking phase of overhead throwing). Results showed that 7 of 8 of the in-line loading group failed in the midsubstance of the biceps tendon with 1 of 8 fracturing at the supraglenoid tubercle. However, all 8 of the simulated peel back group failures resulted in a type II SLAP lesion. The ultimate strength of the biceps anchor was significantly different when the 2 loading techniques were compared. The biceps anchor demonstrated significantly higher ultimate strength with the in-line loading (508 N) as opposed to the ultimate strength seen during the peel back loading mechanism (202 N).  You can see photos of the study below.  The first photo is a normal glenoid with the labrum and attaching long head of the biceps.  The second photo is the simulation of the traction and eccentric biceps contraction.  The final photo is simulation of the peel-back lesion.
In theory, SLAP lesions most likely occur in overhead athletes from a combination of these 2 previously described forces. The eccentric biceps activity during deceleration may serve to weaken the biceps-labrum complex, while the torsional peel back force may result in the posterosuperior detachment of the labral anchor.

Now that we understand the different types of SLAP lesions and the different mechanisms of SLAP tears, next week’s continuation of the SLAP series will overview a large selection of available clinical examination tests (in addition to the two new SLAP tests that I discussed earlier), and how to determine which one you should perform in your patient.

What Exactly Is a SLAP Lesion? Top 5 Things You Need to Know About a Superior Labral Tear

Glenoid fossa of right side.I received many great questions and comments regarding my last post discussing two new tests to detect a SLAP tear.  Sounds like there is still a little confusion about what exactly a SLAP tear is and how to classify them.  Understanding how a SLAP lesion occurs and what exactly is happening pathologically is extremely important to diagnose and treat these shoulder injuries appropriately.  Over the next few weeks I will be focusing more on a series of posts dedicated to SLAP injuries and try to relay the most important information and dispel a few myths along the way.  This week will be classification and pathomechanics of SLAP injuries.  (Image via Wikipedia)  
Classification of SLAP Lesions

There are several variations of injuries that can occur to the superior labrum where the biceps anchor attaches (see the above figure to view the biceps attaching into the labrum).  Following a retrospective review of 700 shoulder arthroscopies, Snyder et al: Arthroscopy ’90 identified 4 types of superior labrum lesions involving the biceps anchor.  Collectively they termed these SLAP lesions, in reference to their anatomic location: Superior Labrum extending from Anterior to Posterior.  This was the original definition but as we continue to learn more about SLAP tears, they certainly do not always extend from anterior to posterior.  But, the most important concept to know is that a SLAP lesion is an injury to the superior labrum near the attachment of the biceps anchor.

Type I-IV SLAP lesions from left to right
  • Type I SLAP lesions were described as being indicative of isolated fraying of the superior labrum with a firm attachment of the labrum to the glenoid.  These lesions are typically degenerative in nature.  At this time, it is currently believed that the majority of the active population may have a Type I SLAP lesion and this is often not even considered pathological by many surgeons.
  • Type II SLAP lesions are characterized by a detachment of the superior labrum and the origin of the tendon of the long head of the biceps brachii from the glenoid resulting in instability of the biceps-labral anchor.  These is the most common type of SLAP tear.  When we receive a script from a surgeon to treat a “SLAP repair” he or she is more than likely talking about a Type II SLAP and surgery to re-attach the labrum and biceps anchor.  Three distinct sub-categories of type II SLAP lesions have been further identified by Morgan et al: Arthroscopy ’90.  They reported that in a series of 102 patients undergoing arthroscopic evaluation 37% presented with an anterosuperior lesion, 31% with a posterosuperior lesion, and 31% exhibited a combined anterior and superior lesion. (33)  These findings are consistent with my clinical observations of patients.  Different types of patients and mechanisms of injuries will result in slightly different Type II lesions.  For example, the majority of overhead athletes present with posterosuperior lesions while individuals who have traumatic SLAP lesions typically present with anterosuperior lesions.  These variations are important when selecting which special tests to perform based on the patient’s history and mechanism of injury.  We’ll get to this in a future post on all the different clinical tests for SLAP tears.
  • Type III SLAP lesions are characterized by a bucket-handle tear of the labrum with an intact biceps insertion.  The labrum tears and flips into the joint similar to a meniscus.  The important concept here is that the biceps anchor is attached, unlike a Type II.
  • Type IV SLAP lesions have a bucket-handle tear of the labrum that extends into the biceps tendon.  In this lesion, instability of the biceps-labrum anchor is also present, similar to that seen in the type II SLAP lesion.  This is basically a combination of a Type II and III lesion.
What is complicated about this classification system is the fact that the Type I-IV scale is not progressively more severe.  For example a Type III SLAP lesion is not bigger, or more severe, or indicative to more pathology than a Type II SLAP lesion.
To further complicate things,  Maffet et al: AJSM ’95 noted that 38% of the SLAP lesions identified in their retrospective review of 712 arthroscopies were not classifiable using the I-IV terminology previously defined by Snyder et al (49).  They suggested expanding the classification scale for SLAP lesions to a total of 7 categories, adding descriptions for types V-VII. (29)
  • Type V SLAP lesions are characterized by the presence of a Bankart lesion of the anterior capsule that extends into the anterior superior labrum. 
  • Type VI SLAP lesion involve a disruption of the biceps tendon anchor with an anterior or posterior superior labral flap tear.
  • Type VII SLAP lesions are described as the extension of a SLAP lesion anteriorly to involve the area inferior to the middle glenohumeral ligament. 
These 3 types typically involve a concomitant pathology in conjunction with a SLAP lesion.  Although they provided further classification, this terminology has not caught on and is not frequqntly used.  For example, most people will refer to a Type V SLAP as a Type II SLAP with a concomitant Bankart lesion.  Since then there have been even more classification types described in the literatue, up to at least 10 that I know of, but don’t worry, nobody really uses them.

Top 5 things you need to know about classifying SLAP lesions

  1. Just worry about Type I-IV SLAP lesions and realize that any classification system above Type IV just means that there was a concomitant injury in addition to the SLAP tear.
  2. You can break down and group Type I and Type III lesions together.  Both involved degeneration of the labrum but the biceps anchor is attached.  Thus, these are not unstable SLAP lesions are not surgically repaired.  This makes surgery (just a simple debridement) and physical therapy easier.
  3. You can also break down and group Type II and Type IV lesions togther.  Both involve a detached biceps anchor and require surgery to stabilize the biceps anchor.  Type IV SLAP tears are much more uncommon and will involve the repair and a debridement of the bucket handle tear.
  4. Type II lesions are by far the most common that you will see in the clinic and are almost always what a surgeon is referring to when speaking of a “SLAP repair.”
  5. We all may have a Type I lesion, it is basically just fraying and degeneration of the labrum.

Be sure to visit for more information and education DVDs, CDs, and webinars.  Interested in training or rehabilitating the shoulder?  Then check out my 4-DVD set on Optimal Shoulder Performance.



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