Can SLAP Lesions be Clinically Diagnosed?
Eric Bales
Department of Applied Medicine and Rehabilitation ~ Indiana State University
Results
Objective
Superior labrum anterior to posterior lesions, or SLAP
lesions are injuries to the superior aspect of the glenoid
labrum of the shoulder. A SLAP lesion is commonly
associated with overhead athletics like baseball, tennis,
and volleyball. SLAP lesions can develop from both
chronic and acute mechanisms. Overhead sports cause
an increase in anterior and inferior translation of the
glenohumeral joint. Falling on an outstretched arm, the
compressive force of falling on an abducted and slightly
forward flexed is possible in any sporting event. The
patient typically presents with nonspecific shoulder pain,
pain with overhead activity, and/or clicking of the
shoulder.
Conclusion
There is a moderate level of evidence to support that specialized test can help evaluate a SLAP lesion.
Table 1. Summary of Study Designs of Articles Retrieved
Level of Evidence
Study Design/ Methodology
Number Located
Author (Year)
2
Case-Control
3
Study
Cohort Study
3
Misra et al (2011)
Kim et al (1999)
O’Brien et al (1998)
Myers et al (2005) Pandaya et al (2008)
Parentis et al (2006)
3
Cohort Study
Nonrandomized Prospective Study
2
1
Michener et al (2011)
Stetson et al (2002)
Table 2. Characteristics of Included Studies
Methods
Terms Used to Guide Search Strategy
Patient/Client group: adolescent AND collegiate AND
athlete
Intervention (or Assessment): evaluation AND shoulder
AND injury
Comparison: non-injury AND injury
Outcome(s): positive OR negative tests
Key Search Terms
SLAP Lesions
Shoulder Injuries
Labrum Tears
Shoulder Dislocation
Overhead Sports Injuries
Study design
Michener et al (2011)
Cohort
Parentis et al (2006)
Cohort
Pandaya et al (2008)
Cohort
Participants
55 patients presenting with
shoulder pain
47 males and 8 females; ages
40.6±15.1 years
Orthopaedic surgeon conducted a
clinical examination of history of
trauma
132 consecutive patient scheduled
51 patients with arthroscopic
confirmed SLAP lesions
Intervention Investigated
Control Group Characteristics
Experimental Group Characteristics
Outcome Measures
NA
NA
Diagnostic utility was calculated
using the receiver operating
characteristic curve and area under
the curve, sensitivity, specificity,
positive likelihood ratio, and
negative likelihood ratio.
Main Findings
Type I SLAP lesion had no
diagnostic accuracy in history items
or physical exam
Anterior slide test had utility to
confirm and exclude type II to IV
SLAP lesions(AUC=0.70,
+LR=2.25, -LR=0.44)
Combination of history of popping,
clicking, or catching and the
anterior slide test demonstrated
diagnostic utility for confirming type
II to IV SLAP lesions(+LR=6.00)
Inclusion and Exclusion Criteria
Inclusion
Level 2 evidence or higher
Limited to English language
Limited to humans
Studies investigating multiple evaluation techniques of the
shoulder with emphasis on SLAP lesions.
Exclusion
Limited to the last 15 years (1997-2012)
Multiple shoulder injuries (impingement or rotator cuff
tears)
Level of Evidence
Conclusion
Preoperatively over a 6-month
period.
O’Brien, anterior slide, pain
provocation, crank, Jobe relocation,
Hawkins, Neer, Speed, and
Yergason test were included in the
assessment.
Final diagnosis in each case was
made arthoscopically
NA
NA
Following assessments were done:
active compression (O’Brien),
anterior slide, pain provocation,
crank, Jobe relocation, Hawkins,
Neer, Speed, and
Yergason tests. The final
evaluation was done arthroscopic
to conclude the correct diagnosis.
Active compression: Sen. 62.5%,
spec. 50.0%, PPV 35.5%, and NPV
75.4. Ant. Slide: sen. 10.0%, spec.
81.5%, PPV 19.0% and NPV
67.6%. Crank: sen. 12.5%, spec.
82.6%, PPV 23.8, and NPV 68.4%.
Hawkins: sen. 67.5%, spec. 30.4%,
PPV 29.7%, and NPV 68.3%. Neer:
sen. 50.0%, spec. 52.2%, PPV
31.3% and NPV 70.6%. Relocation:
sen. 50.0%, spec. 53.3%, PPV
31.7%, and NPV 71.0%. Speed:
sen. 47.8%, spec 67.4%, PPV
34.8% and NPV 72.1. Yerganson:
sen. 12.5%, spec. 93.5%, PPV
45.5%, and NPV 71.1.
Stetson et al (2002)
Nonrandomized prospective
study
65 patients who had symptoms of
shoulder pain
No interventions beyond the normal
Minimum of 3 months of
treatment course for the patient’s
nonoperative treatment that
disease process were performed. included rest, physical therapy, use
of nonsteroidal anti-inflammatory
drugs, and a subacromial cortisone
injection.
NA
NA
Evaluated patients using the
O’Brien, Mayo Shear, Jobe’s
relocation, Neer’s, and Hawkin’s
tests then a MRI to validate the
accuracy of tests.
Sensitivity of O’Brien’s test was
90%, whereas the Mayo shear was
80% and Jobe’s relocation test was
76%
Neer’s sign (41%) and Hawkin’s
impingement tests (31%) each had
low sensitivity for SLAP lesions.
NA
NA
Evaluated patients using the crank
and O’Brien test then used a MRI
to verify if the findings where
correct.
The crank test result was positive in
29 patients (45%), and the O’Brien
test was positive in 41 patients
(63%).
The crank test had a positive
predictive value of 41%, was 56%
specific, 46% sensitive, and had a
negative predictive value of 61%.
The O’Brien test had a positive
predictive value of 34%, was 31%
specific, 54% sensitive, and had a
negative predictive value
of 50%.
Magnetic resonance imaging had a
positive predictive value of 63%,
was 92% specific, 42% sensitive,
and had a
negative predictive value of 83%.
3
2
2
3
The anterior slide test had limited The authors’ results contradict the O’Brien’s, Mayo shear, and Jobe’s The O’Brien and crank tests were
diagnostic utility for confirming and
current literature regarding
relocation were sensitive for the
not sensitive clinical indicators for
excluding type II to IV SLAP
provocative testing for both stable
diagnosis of the SLAP lesions.
detecting glenoid labral tears and
lesions.
and unstable superior labral
Patient history, demographics, and
other tears
Combination of the anterior slide
lesions.
surgeon’s physical examination
of the anterior and posterior
test and history of popping, clicking, Arthroscopy remains the standard
should remain central to the
labrum.
or catching had a moderate
by which to diagnose such lesions.
diagnosis of SLAP lesions.
Results were often falsely positive
diagnostic utility for confirming type
for patients with other shoulder
II to IV SLAP lesions.
conditions, including impingement
or rotator cuff tears.
Based on the sensitivity, specificity, positive likelihood ratio
and negative likelihood, we can determine the best tests to
diagnose a SLAP lesion include Biceps Load test I and II,
and Jobe’s relocation tests. With further investigation other
tests may be developed to clinically diagnose the condition.
better tests can be developed to diagnosis SLAP lesions.
References
1. Misra S, Watson L, Taylor N F, Green R A, and Hairodin Z. Testing
procedures for SLAP lesions of the shoulder involving contraction and
torsion of biceps long head and glenohumeral glides. Journal of
Science and Medicine in Sport. 2011;14(6):462-8.
2. Pandya N K, Colton A, Webner D, Sennett B, and Huffman G R.
Physical examination and magnetic resonance imaging in the diagnosis
of superior labrum anterior-posterior lesions of the shoulder: a
sensitivity analysis. The Journal of Arthroscopic and Related Surgery.
2008;24(3):311-317.
3. Manske R., and Prohaska D. Superior labrum anterior to posterior
(SLAP) rehabilitation in the overhead athlete. Physical Therapy in Sport.
2010:110-120.
4. Myers T H, Zemanovic J R, and Andrews J R. The resisted supination
external rotation test: a new test for the diagnosis of superior labral
anterior posterior lesions. The American Journal of Sports Medicine.
2005;33(9):1315-1320.
5. Stetson W B, and Templin K. The crank test, the o’brien test, and
routine magnetic resonance imaging scans in the diagnosis of labral
tears. American Journal of Sports Medicine. 2002;30(6):806-809.
6. Kim S, Ha K, and Han K. Biceps load test: a clinical test for superior
labrum anterior and posterior lesions in shoulders with recurrent
anterior
dislocations.
The
American
Journal
of
Sports
Medicine.1999;27(3):300-303.
7. O’Brien S J, Pagnani M J, Fealy S, McGlynn S R, and Wilson J B. The
active compression test: a new and effective test for diagnosing labral
tears and acromioclavicular joint abnormality. American Journal of
Sports Medicine.1998;26(5):610-613.
8. Parentis M A, Glousman R E, Mohr K S, and Yocum L A. An evaluation
of the provocation tests for superior labral anterior posterior lesions.
American Journal of Sports Medicine. 2006;34(2):265-268.
9. Michener L A, Doukas W C, Murphy K P, and Walsworth M K.
Diagnostic accuracy of history and physical examination of superior
labrum anterior-posterior lesions. Journal of Athletic Training.
2011;46(4): 343-348.
10. Hegedus E J, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman
C T, and Cook C. Physical examination tests of the shoulder: a
systematic review with meta-analysis of individual tests. British Journal
of Sports Medicine. 2008;42(2):80-92.
Acknowledgements
I would like to acknowledge and thank my ACI Chris
Compton and Dr. Lindsey Eberman for making my
Critically Appraised Topic research project a success.
Chris Compton was very helpful in giving me advice on
how to understand and interpret research articles. Dr.
Eberman was very helpful when I had questions about my
topic and helped get me back on track when I was having
trouble. Thank you very much.