Abstract
Background:
Superior labrum anterior posterior (SLAP) lesions are prevalent in athletes and the elderly. Therefore, acquiring accurate diagnoses is beneficial for improvement in return to play for athletes and quality of life. A well-done clinical examination can help detect these lesions leading to an early and accurate diagnosis.
Indications:
Being able to perform a clinical examination for diagnosing SLAP lesions is an important tool for a doctor to know. Currently, there is not a centralized location with published videos that show how to perform these examinations and describe their attributes. This video helps clinicians quickly ascertain how to perform these examinations and learn about the statistical measures associated with them.
Technique Description:
The 7 exams shown are as follows: modified dynamic labral shear (DLS) test, speed’s test, active compression test (O’Brien test), anterior slide test, crank test, Kim test, and the Jerk test.
Results:
These tests have a wide variety of statistical measures making different ones useful for specific results such as ruling in or ruling out labral lesions. The tests with the highest sensitivity are the modified dynamic labral shear test (72%) and Kim test (61%-92%). The tests with the highest specificity are the modified dynamic labral shear test (98%), anterior slide test (81%-89%), Kim test (88%-99%), and the Jerk test (94%-99%). All of these have a 95% confidence interval except DLS test.
Discussion/Conclusions:
Some of these tests are more reliable than others when diagnosing labral lesions. Since the dynamic labral shear test and Kim test have the highest sensitivity, they are the most useful tests at ruling out labral lesions. These tests along with the anterior slide test and the Jerk test are the most useful for ruling in labral lesions due to their high specificity. Even though these tests have been proven to be more reliable than others, it still matters which tests the doctors feel comfortable performing accurately for them to use in the clinical setting.
This is a visual representation of the abstract.
Video Transcript
SLAP Clinical Exam Techniques. This video is presented by the listed authors from the Medical University of South Carolina in Charleston, South Carolina.
The authors have nothing to disclose.
The tests that we will be describing are the modified dynamic labral shear test, Speed test, active compression test, anterior slide test, the Crank test, Kim test, and the Jerk test. We will also be describing the reliability measures of these examinations and pearls and pitfalls for these examinations.
Superior labrum anterior posterior (SLAP) lesions are usually diagnosed clinically. There are many different tests to help diagnose these lesions, but test grouping does not usually affect the results. Performing these examinations accurately can help guide the clinical examination. Most doctors choose 3 to 4 examinations to perform based on literature findings and personal clinical outcomes.
The first test is the modified dynamic labral shear test. This is done by placing the arm in horizontal abduction of approximately 90° to start. The arm is brought into full external rotation. The hand is placed on the posterior joint line palpating for pain as well as clicking. The arm is moved between 120° of abduction to 60° of abduction, and you are palpating for a click or report of pain from the patient.
The sensitivity for this examination is 72%, and the specificity is 98%. The positive likelihood ratio is 0.97, and the negative likelihood ratio is 0.77.
For this examination, the arm was abducted above 120° before being placed into maximal horizontal abduction. This is important because more false-positives are present when the arm was placed into maximal horizontal abduction at the beginning.
The next clinical examination is Speed test. Speed test is conducted with the arm in full extension and brought into forward flexion. This is designed to determine whether or not the long head of the biceps tendon is creating pain. The bicipital groove here, between the greater tuberosity and the lesser tuberosity, is the location of the biceps tendon. This should be the location of the reported pain for the individual experiencing pain in the biceps. On the clinical examination, again the arm is in full supination and the arm is resisted in supination, and as the patient is coming up, they should report pain in the biceps groove. They should point to this location as the area of pain. Originally, it was described with the arm approximately at 60° of forward flexion. In addition now, most examiners will do the arm in 90° of forward flexion with resisted extension again, and a positive test is a report of pain in the biceps groove.
The sensitivity for this examination ranges from 5% to 53%. The specificity ranges from 58% to 90%. The positive likelihood ratio ranges from 0.43 to 1.90, and the negative likelihood ratio ranges from 0.86 to 1.23.
This examination has a high percentage of false-negatives and also found that positive and negative tests are unlikely to assist in the diagnosis for labral injuries.
O’Brien active compression test is performed with the arm brought up to essentially 90° of forward flexion and 15° of adduction across the midline. The initial test is performed with the thumb or the palm up in the air, and a resisted pressure to forward flexion is performed. Then the arm is internally rotated into pronation or the thumbs facing downward again adducted across the midline with a resisted force to forward flexion. The test is positive if there is a click or pain or instability in the joint posteriorly that is worse with the arm pronated versus supinated.
The sensitivity for this examination ranges from 51% to 80%. The specificity ranges from 22% to 54%. The positive likelihood ratio ranges from 0.09 to 1.25, and the negative likelihood ratio ranges from 0.67 to 1.20.
This examination has a wide range of sensitivities and specificities across multiple reports, and due to this, it is not recommended to confirm or rule out SLAP lesions.
The next test is the anterior slide test which is used to detect anterior superior labral pathology. The position that the patient places his arms for this test is hands at the side with the thumb facing posteriorly with the arm essentially in the plane of the scapula. One hand is placed over the front of the shoulder with the index finger over the clavicle in line with the glenohumeral joint. The coracoid process is just lateral to the last segment of my index finger. My hand is placed on the elbow and a superior to anteriorly directed force is applied, and the patient resists me at the same time. And I am attempting to detect a click or a pop over the anterior glenohumeral joint or a positive response to a reproduction of symptoms that occurs when they are doing overhead throwing or overhead motion during their athletic event.
The sensitivity for this examination ranges from 3% to 55%. The specificity ranges from 81% to 89%. The positive likelihood ratio ranges from 0.22 to 6.51, and the negative likelihood ratio ranges from 0.96 to 1.36.
Testing with multiple positions of shoulder flexion or extension can improve the test, and making sure the patient’s muscles are relaxed also improves the test. If the biceps anchor is intact, the test can be negative even if the labrum is damaged.
The next test is the Crank test. This is conducted by taking the arm and placing it into 160° of abduction in the plane of the scapula. One hand is placed on the humerus, an axial load is placed on the humerus down toward the glenoid. The other hand is used to then maximally internally and externally rotate the humerus in an attempt to load the posterior glenohumeral joint to elicit a click or pain over the posterior glenohumeral joint line identifying a SLAP lesion or a labral tear.
The sensitivity for this examination ranges from 19% to 53%. The specificity ranges from 65% to 83%. The positive likelihood ratio ranges from 0.84 to 2.21, and the negative likelihood ratio ranges from 0.69 to 1.12.
This examination has been shown to have high false-positives with other shoulder conditions, and it is also helpful for confirming SLAP lesions.
Kim test is performed to detect posterior labral instability and labral tears. This is performed by bringing the arm into 90° of abduction. The patient is sitting upright, supported up against an upright chair to prevent thorax movement posteriorly. One hand is applying pressure down through the long axis of the humerus. The other hand is placed over the anterior aspect of the proximal humerus and a posterior force is applied. Longitudinal axial force here with one hand and a posterior force was applied this way. Simultaneously, the arm is brought into 45° arc of motion up and across while a posterior axial force is performed. Pain in the posterior shoulder and/or a click is considered a positive test.
The sensitivity for this examination range is 61% to 92%. The specificity range is 88% to 97%. The positive likelihood ratio range is 6.543 to 24.351, and the negative likelihood ratio range is 0.104 to 0.437.
This test is beneficial in ruling out posteroinferior labral lesions, and it can tell when a lesion such as a Bankart lesion extends all the way to the posteroinferior aspect of the glenoid.
The Jerk test is performed preferably with the patient in a seated position with back support. The arm is brought into 90° of abduction. The arm is loaded while the forearm is internally rotated, and the arm is brought across the body. A positive test will create a click or pain in the posterior glenohumeral joint line as the shoulder subluxes or even possibly dislocates creating pain over the posterior glenoid.
The sensitivity range is 54% to 87%, and the specificity range is 94% to 99%. The positive likelihood ratio range is 11.099 to 108.55, and the negative likelihood ratio range is 0.150 to 0.493.
Most shoulders with a painful Jerk test fail to improve with nonoperative treatment. Abrupt pain during Jerk test is most likely caused by rim loading of the humeral head over the pathologic posteroinferior labral lesion as well.
Our references are listed and thank you.
Footnotes
Submitted October 18, 2021; accepted February 8, 2022.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
