Preliminary Development of a Clinical Prediction Rule for
Treatment of Patients With Suspected SLAP Tears
Stephanie D. Moore-Reed, Ph.D., A.T.C., W. Ben Kibler, M.D.,
Aaron D. Sciascia, M.S., A.T.C., and Tim Uhl, Ph.D., P.T., A.T.C.
Purpose: To use the clinical prediction rule process to identify patient variables, measured on initial clinical presentation,
that would be predictive of failure to achieve satisfactory improvement, while following a rehabilitation program, in the
modification of SLAP injury symptoms and dysfunction. Methods: A cohort of patients received the clinical diagnosis of a
SLAP lesion based on specific history and examination findings and/or magnetic resonance imaging. They underwent a
physical examination of the kinetic chain and shoulder, including tests for labral injury. Patients followed a standardized
physical therapy program emphasizing restoration of demonstrated strength, flexibility, and strength-balance deficits. At
6 weeks’ follow-up, patients were re-evaluated and divided into those recommended for surgery (RS) and those not
recommended for surgery (NRS). Bivariate logistic regression was performed to identify the best combination of predictive
factors. Results: Fifty-eight patients (aged 39 11 years, 45 men) were included. Of these, 31 (53%) were categorized as
NRS and 27 (47%) as RS. The presence of a painful arc of motion (odds ratio, 3.95; P ¼ .024) and the presence of increased
forward scapular posture (odds ratio, 1.27; P ¼ .094) on the injured side were predictive of being in the RS group. This
finding indicates that the odds of being in the RS group increased 4 times when a positive painful arc was present and
increased 27% with every 1-cm increase in involved anterior shoulder posture. Conclusions: A structured rehabilitation
program resulted in modification of symptoms and improved function at 6 weeks’ follow-up in over half of patients in the
study group. On initial evaluation, the presence of a painful arc of overhead motion, indicating loss of normal glenohumeral kinematics, and the presence of forward shoulder posture, indicating an altered scapular position, represent
negative predictive factors for success of rehabilitation. Future validation of the model in a larger population is necessary.
Level of Evidence: Level II, prospective comparative study.
T
here is a growing awareness of the need to develop
more efficacious methods of evaluating, accurately
diagnosing, and treating all types of shoulder pathology.
The clinical prediction rule process has been developed as
a method to identify which patient variables, measured
on initial clinical examination, could be predictive of
From the Department of Kinesiology, California State University (S.D.M-R.),
Fresno, California; Shoulder Center of Kentucky (W.B.K., A.D.S.), Lexington,
Kentucky; and Division of Athletic Training, University of Kentucky (A.D.S.,
T.U.), Lexington, Kentucky, U.S.A.
The authors report the following potential conflict of interest or source of
funding: The Lexington Clinic entered into a contract to pay the University of
Kentucky for a doctoral student, S.D.M-R. (co-author), as a part-time research
assistant as she completed her doctoral degree. T.U. receives support from
American Society of Shoulder and Elbow Therapists. T.U. received reimbursement to present components of these data at the International Congress of
Shoulder and Elbow Therapists in April 2013 in Nagoya, Japan.
Received September 11, 2013; accepted June 13, 2014.
Address correspondence to Aaron D. Sciascia, M.S., A.T.C., 1221 S
Broadway, Lexington, KY 40504, U.S.A. E-mail: ascia@lexclin.com
Ó 2014 by the Arthroscopy Association of North America
0749-8063/13668/$36.00
http://dx.doi.org/10.1016/j.arthro.2014.06.015
success of a particular treatment program. The prediction
rule process has the potential to instill continuity and
uniformity within health care decision making and can
help guide care.1
This article reports the outcomes of a study applying
the clinical prediction rule process to a cohort of patients
determined to have clinical findings consistent with a
SLAP injury. In patients with this diagnosis, surgical
outcomes are not uniformly successful,2,3 in part
because of inconsistency in the diagnostic process and
inconsistency in surgical indications.4 Rehabilitation
protocols are often advocated as the first step in the
treatment of SLAP and other shoulder injuries, but evidence regarding the exact indications, role, and effectiveness of rehabilitation in SLAP injury is sparse and not
clear. One previous retrospective study reported that
49% of patients managed with nonoperative rehabilitation had a positive outcome.5 Another study, performed in professional baseball players, all of whom had
a SLAP injury and in whom a rehabilitation program had
failed, showed that a comprehensive rehabilitation
program resulted in 40% of players returning to play.6
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol
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No
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(Month), 2014: pp 1-10
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S. D. MOORE-REED ET AL.
Fig 1. Participant flowchart.
The purpose of this prospective study was to use a
clinical prediction rule process to attempt to identify
patient variables, measured on initial clinical presentation, that would be predictive of failure to achieve
satisfactory improvement, while following a rehabilitation program, in the modification of symptoms and
dysfunction in patients with a clinical diagnosis of SLAP
injury. We hypothesized that in patients who did not
respond, there would be specific measurable patient
factors that were associated with failure to respond to a
rehabilitation program.
Methods
Patients
Fifty-eight patients (mean age, 39 11 years; mean
mass, 83 25 kg; mean height, 170 35 cm) who
were determined to have a clinical history consistent
with shoulder dysfunction resulting from injury to the
superior labrum were included.7 The history included
pain at the posterior joint line, pain with abduction/
external rotation, popping, clicking on shoulder rotation, and pain or limitation of performance with
repetitive overhead activity. These 58 patients were
part of a group of 211 patients presenting with shoulder
pain to an orthopaedic surgeon (W.B.K.) (Fig 1). All
participants were patients of the lead author (W.B.K.),
a sports medicine and shoulder surgeon with more than
30 years of experience in clinically evaluating and
treating shoulder pathology. There are varying opinions
regarding the exact criteria to establish a diagnosis of a
clinically significant SLAP tear, with no literatureestablished gold standard that is universally recognized. Therefore patient inclusion was based on meeting
specific criteria relating to history, clinical examination
findings, and/or diagnostic imaging findings to include
all possible criteria for detecting the anatomic and
functional alterations associated with the SLAP injury.
The clinical examination inclusion criteria were modified from previously identified criteria for diagnosing
labral tears reported by Walsworth et al.8 The criteria for
our study required a positive finding for at least 3 of the
following 4 clinical signs: history of popping or catching,
positive anterior-slide maneuver, positive modified dynamic labral shear (M-DLS) maneuver,9 or positive
active compression test.8,9 Patients with a SLAP tear
diagnosed by advanced imaging (i.e., magnetic resonance imaging [MRI] or magnetic resonance arthrography [MRA]) were included if they also had 1 or 2 of
the clinical examination inclusion criteria because the
addition of history and clinical examination evidence
has been shown to change the information from the
imaging.10 Reliance was not placed on 1 examination or
imaging test because no single test has been shown to be
uniformly satisfactory to make the complete diagnosis.4,11,12 A recent systematic review by Hegedus
et al.13 supports the concept of using clusters of tests to
make the diagnosis in shoulder pathology, although the
M-DLS maneuver has been shown in a Level I study to
have high clinical utility.9
Patients were excluded from the study if they had
numbness or tingling in the upper extremity; signs and
symptoms consistent with cervical radiculopathy,14
adhesive capsulitis,15 or glenohumeral arthritis16;
patient-reported steroid injections in the involved
shoulder within the previous month; or surgery on the
involved shoulder within the past year. They were also
excluded if they had clinical examination and/or imaging findings consistent with a diagnosis of acromioclavicular
joint
injury/arthrosis,
glenohumeral
instability, or full-thickness rotator cuff tear. This study
was approved by the appropriate institutional review
boards. Before enrollment in the study, all patients read
and signed an informed consent form that was
approved by the institutional review boards of the
University of Kentucky and Lexington Clinic.
Patients completed a standard history form and
underwent standard examination by the orthopaedic
surgeon (W.B.K.). All patients completed a numeric pain
rating scale regarding current pain, worst pain, and least
pain in the past week17 (0, no pain; 10, highest pain). In
addition, patients completed the Quick Disabilities of the
Arm, Shoulder and Hand (QuickDASH) questionnaire,
which is scored from 0, no disability, to 100, severe
disability; the American Shoulder and Elbow Surgeons
(ASES) Shoulder Assessment Form, with a score ranging
from 0, poor function, to 100, normal function18-20; and
the Patient-Specific Functional Scale (PSFS).21 The PSFS
questionnaire requires the patient to list 3 to 5 activities
that he or she has difficulty doing because of his or her
LABRAL CLINICAL PREDICTION DEVELOPMENT
shoulder problem and to rate each item from 0 (cannot
perform activity at all) to 10 (can perform activity at the
same level as before the injury).
Glenohumeral range of motion (ROM), strength, and
posture were also assessed. ROM was assessed with a
digital inclinometer (Dualer; JTech Medical, Salt Lake
City, UT). Passive internal and external rotation ROM
and horizontal adduction ROM were measured with
the patient supine and shoulder abducted to 90 with
the scapula stabilized until resistance was first felt or the
patient reported pain, as previously described.22 Active
shoulder flexion ROM was measured with the patient
seated. The patient was instructed to raise his or her
arm as high as possible in the sagittal plane with the
thumb up.23 The clinician aligned the inclinometer with
the long axis of the humerus, and the angle was
recorded in degrees. Inter-rater intraclass correlation
coefficients (ICCs) were calculated a priori for internal
rotation ROM (ICC, 0.795), external rotation ROM
(ICC, 0.839), horizontal adduction ROM (ICC, 0.518),
and active flexion ROM (ICC, 0.863).
Isometric muscle strength was measured with a
handheld dynamometer24 (model 01163; Lafayette
Instruments, Lafayette, IN). Forward flexion strength
was measured with the participant seated, the scapula
in a retracted position, the shoulder in 90 of flexion,
and the palm down.24 The dynamometer was placed
just proximal to the wrist, and the participant was
instructed to push up for 5 seconds. External rotation
strength was measured with the participant supine, the
shoulder abducted to 90 , the elbow flexed to 90 , and
the humerus in neutral rotation and supported. The
dynamometer was placed parallel with the forearm. For
each strength measure, 2 maximum-effort trials were
performed and averaged for analysis. Each arm was
tested in alternating fashion to allow for approximately
30 seconds of rest between trials (flexion strength ICC,
0.897; external rotation strength ICC, 0.842).
Finally, scapular posture was assessed with the
participant standing and using a double square instrument as previously described by Kluemper et al.25 The
participant was asked to stand against the wall and assume his or her normal posture after taking a deep
breath to relax. The double square instrument was
aligned with the wall and the anterior aspect of the
acromion. This distance was measured and recorded
bilaterally. Reliability was determined a priori (ICC,
0.946).
After the initial clinical visit and data collection, all
patients were prescribed physical therapy and provided
with a standardized rehabilitation protocol consisting of
stretching exercises and strengthening exercises for
shoulder musculature, but the protocol was individualized depending on each patient’s examination findings by the treating physical therapist. This protocol was
well outlined (Table 1). It consisted of 4 phases, each
3
having mobility and strengthening components that
were progressed at each phase. The protocol was
designed based on the concepts put forth by Ellenbecker and Cools26 for treating patients with shoulder
pain and scapular dysfunction. Mobility exercises progressed from gentle mobility to static stretching of
posterior, anterior, and inferior shoulder mobility
restrictions. Strengthening exercises progressed from
scapular muscular orientation to gain motor control,
using the kinetic chain theories of incorporating the
entire body, to short and then to long lever-arm resistive exercises, on the basis of kinetic chain theories of
incorporating the lower extremity. Ballistic and eccentric exercises were incorporated in the protocol if the
treating therapist believed that they were appropriate
for an individual patient (Table 1). The rehabilitation
protocol was provided to the patients at the initial visit.
Patients were allowed to go to the physical therapists of
their choosing, with instructions to follow the specific
protocol. The physical therapists were provided a letter
describing the study and requesting that the patients
follow the established protocol. Exercise logs were
provided for the patients to record their compliance
with the therapy. Detailed physical therapy records
were obtained from over two-thirds of the patients
(40 of 58).
At a follow-up visit with the orthopaedic surgeon
(W.B.K.) 6 weeks after the initial visit (median, 6 weeks;
range, 4 to 24 weeks), participants again completed the
QuickDASH questionnaire, ASES form, numeric pain
rating scale, and PSFS questionnaire. Strength, ROM,
and posture were also reassessed. In addition, the Global
Rating of Change (GROC) score was obtained. The
GROC is a 15-point scale ranging from 7 (a great deal
worse) to þ7 (a great deal better), with 0 indicating no
change.27 Exercise logs and physical therapy notes were
collected from patients at this time.
After the intervention and follow-up appointment,
patients were categorized into 2 groups based on their
report of their clinical status and the clinical examination findings: recommended for surgery (RS) or not
recommended for surgery (NRS). The recommendation
for surgery was based on continued or worsened subjective and objective symptoms of shoulder pain and
dysfunction, failure to progress in rehabilitation, and a
patient’s unwillingness or inability to tolerate the
dysfunction, with clinical input from the physician
(Table 2). This process followed the normal procedure
of consultation and decision making regarding treatment between physician and patient. The decision to
counsel and recommend surgery was made at this time
point because most studies indicate that it takes around
6 weeks to observe significant changes in physiological
factors such as flexibility and strength and therefore
affect the clinical symptoms, which were the goals of
the rehabilitation protocol.28-30 In addition, this is
4
Table 1. Rehabilitation Exercise Program
Exercise Category
Scapular orientation
Below shoulder level: isometric
Scapular protraction
Humeral rotation
Level II
Level III
Below shoulder level: isotonic (e.g.,
dynamic low row, lawnmower,
robbery)
Punch (e.g., supine punch, scapular
punches)
Isotonic at shoulder level: short lever
arm (e.g., pull downs, fencing, rows)
Isotonic (e.g., prone horizontal abduction
lifts at 90 or 135 )
Push-ups (e.g., incline)
Push-ups (e.g., knee, standard)
Punch (e.g., standing punch)
At shoulder level (e.g., ER/IR with elastic
band, 90 /90 )
Diagonal (e.g., upper cut)
Humeral rotation at shoulder level (e.g.,
90 /90 rotation, side-lying ER eccentric
exercises)
Long lever arm (e.g., flexion, abduction,
plyometrics, weighted-ball drops)
Below shoulder level: isotonic
(e.g., IR/ER with arm at side with
resistance)
Humeral elevation
Stretching
Anterior
Posterior
Elevation
Short lever arm (e.g., overhead press)
Supine pectoral stretch with arm
at side
ER with arm at side
Cross body
Table slides
Forward bows
ER, external rotation; IR, internal rotation.
Active scapular retraction with arms at 90
Supine pectoral stretch with
overpressure
ER with arm away from side
Wall slides
Assisted elevation with pulley
Level IV
Sleeper stretch
Latissimus dorsi stretch
Sleeper stretch in more abducted position
Active latissimus dorsi stretch
S. D. MOORE-REED ET AL.
Muscle strengthening
Scapular retraction
Level I
Scapular protraction and
retraction (e.g., scapular clock)
Scapular and humeral depression
(e.g., inferior glide)
5
LABRAL CLINICAL PREDICTION DEVELOPMENT
Table 2. Improvements in Outcome Measures From Initial
Evaluation to 6 Weeks’ Follow-up
Outcome Measure
ASES score
QuickDASH score
Current pain
PSFS score
GROC score
NRS Group
(n ¼ 31)
14 16
13 15
1 2
23
32
RS Group
(n ¼ 27)
2 16
0 16
02
03
02
P Value
.006
.001
.047
.033
<.001
NOTE. Data are change scores and are given as mean SD unless
otherwise indicated.
standard procedure for the physician’s practice. The
patient-reported outcome measures were also analyzed
and compared with the RS/NRS status.
Statistical Analysis
Descriptive statistics were calculated for each variable
measured at baseline for continuous (Table 3) and
categorical (Table 4) data. Variable selection was performed by testing each variable’s univariate association
with the outcome by use of Student independent t tests
for continuous variables and c2 tests for categorical
variables. Variables with a univariate P .30 were
retained, leaving 5 continuous variables (scapular
posture, ASES score, QuickDASH score, PSFS score, and
current pain) and 5 categorical variables (scapular
assistance test, painful arc test, previous physical therapy, point-tender pain, and single-leg balance) as potential predictors in the model. Backward stepwise
logistic regression was used to determine the relative
contribution of each variable to outcome (i.e., RS or
NRS). Five variables were entered into the final
Table 3. Descriptive Statistics for Continuous Variables
Variable
Height (cm)
Mass (kg)
Age (yr)
Duration of symptoms (mo)
ROM ( )
Flexion
ER
IR
HAdd
Strength (lb)
ER
Flexion
Scapular posture (cm)*
ASES score*
QuickDASH score*
Current painy
PSFS score*
NRS Group
(n ¼ 31)
175 10
85 21
40 11
19 11
RS Group
(n ¼ 27)
178 8
89 18
39 55
25 42
144
75
60
10
28
24
17
10
142
76
61
9
22
28
20
9
10
7
14
62
34
3.5
3.6
6
3
2
16
16
1.8
1.9
9
8
15
56
41
4.7
3.1
5
3
2
21
17
2.5
1.7
NOTE. Data are given as mean SD.
ER, external rotation; HAdd, horizontal adduction; IR, internal
rotation.
*Significant at P .30.
ySignificant at P .05.
Table 4. Counts and Percentages for Categorical Variables
Variable
Apprehension
Anterior load and shift
Posterior jerk
Sulcus
ER lag
Drop arm
Belly press
Liftoff
Bear hug
Upper cut
Speed’s test
M-DLS
Active compression test
Anterior slide
Point-tender pain*
Crepitus
Paxinos test
Pain with horizontal adduction
Painful arc (forward flexion)y
Hawkins impingement
Neer impingement
SICK scapular position
Scapular dyskinesis
Scapular assistance test*
Scapular retraction test
Single-leg balance*
Single-leg squat
Pain with resisted abduction
Patient-reported pop/grind/click
Previous physical therapy*
Gradual onset of symptoms
Male sex
NRS Group
(n ¼ 31)
2 (6%)
1 (3%)
1 (3%)
1 (3%)
0 (0%)
0 (0%)
0 (0%)
4 (13%)
6 (19%)
11 (35%)
5 (16%)
28 (90%)
18 (58%)
21 (68%)
8 (26%)
3 (10%)
3 (10%)
3 (10%)
15 (48%)
10 (32%)
9 (29%)
18 (58%)
30 (97%)
17 (55%)
21 (68%)
13 (42%)
12 (39%)
26 (84%)
24 (77%)
12 (39%)
17 (55%)
23 (74%)
RS Group
(n ¼ 27)
2 (7%)
0 (0%)
0 (0%)
2 (7%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)
5 (19%)
11 (41%)
6 (22%)
22 (81%)
14 (52%)
11 (41%)
3 (11%)
2 (7%)
3 (11%)
4 (15%)
21 (78%)
11 (41%)
9 (33%)
18 (67%)
23 (85%)
20 (74%)
18 (67%)
7 (26%)
9 (33%)
27 (100%)
20 (74%)
14 (52%)
14 (52%)
22 (81%)
ER, external rotation; SICK, scapular malposition inferior medial
border prominence coracoid pain and malposition and dyskinesis of
scapular movement.
*Significant at P .30.
ySignificant at P .05.
backward stepwise logistical regression analysis (scapular posture, scapular assistance test, painful arc test,
previous physical therapy, and point-tender pain).
Compliance was examined in 2 ways: average number of physical therapy visits per week and compliance
with the rehabilitation protocol. Compliance with the
protocol was determined by the percentage of exercises
performed by the patient that were from the protocol
provided to the physical therapists as part of study
participation. Student independent t tests were performed for average visits per week and compliance with
the protocol. Statistical analyses were conducted using
SPSS software, version 19 (SPSS, Chicago, IL).
Results
Of the 58 patients, 27 (47%) were categorized as
RS at 6 weeks. Twenty-six of these 27 patients had
advanced imaging performed; in 24 of these, the imaging yielded positive findings for a SLAP injury.
Twenty-two of the 27 patients in the RS group (81%)
6
S. D. MOORE-REED ET AL.
Table 5. Logistic Regression Predicting “Recommended for
Surgery”
Variable
Scapular
protraction
Painful arc test
Constant
Regression
Coefficient
0.242
SE
0.145
P Value
.094
OR (95% CI)
1.27 (0.96 to 1.69)
1.375
4.581
0.609
2.141
.024
.042
3.95 (1.20 to 13.05)
CI, confidence interval; OR, odds ratio; SE, standard error.
went on to undergo arthroscopic surgery, and all were
found to have an anatomic labral injury that met the
criteria for a clinically significant SLAP injury.11 The 5
patients who did not undergo surgery ultimately
declined because of insurance issues or did not schedule
surgery after the recommendation.
Thirty-one patients (53%) were categorized as NRS at
6 weeks. Eighteen of these 31 had advanced imaging
performed; in 16 of these, the imaging yielded positive
findings for a SLAP injury. Two patients in the NRS
group (6%) eventually had enough functional limitations that they returned after the study and elected to
undergo surgery. Both patients were found to have an
arthroscopically confirmed anatomic labral injury that
met the criteria for a clinically significant SLAP injury.11
The logistic regression analysis showed that the
presence of a painful arc of motion in forward flexion
and the presence of increased forward scapular posture
on the injured side at the initial examination were
predictive of being in the RS group at 6 weeks (P ¼
.015, df ¼ 2, c2 ¼ 8.413) (Table 5). The odds of being in
the RS group increased 4 times when a positive painful
arc was present and increased 27% with every 1-cm
increase in involved anterior shoulder posture. The
final model predicted 72% of the outcomes correctly.
Detailed physical therapy records were collected and
analyzed for 19 of 27 patients in the RS group and 21 of
31 patients in the NRS group. There was no significant
difference in average visits per week between the RS
patients (1 2 weeks) and NRS patients (2 1) (P ¼
.638). There was also no significant difference between
compliance with the provided rehabilitation protocol
between the RS patients (55% 38%) and NRS patients (71% 29%) (P ¼ .159).
There was a statistically significant difference in 3
patient-reported outcome measuresdASES score,
QuickDASH score, and GROC scoredbetween the RS
and NRS groups. The NRS group reported statistically
significantly larger improvements in these scales, which
would provide some further confirmation for the basis
for the treatment decision (Table 1).
Discussion
This study confirms the research hypothesis; the
clinical prediction rule process identified 2 specific
variables, a painful arc of motion in forward flexion
and increased anterior scapular position, as factors
associated with failure to achieve a satisfactory
improvement so that the patient and physician agreed
that surgery was recommended. A structured rehabilitation program resulted in modification of symptoms, increased outcome measures, and improved
function to the point that the patient and physician
agreed that surgery was not necessary in 31 patients
(53%) in the study group at 6 weeks, although 2 of
these patients ended up requesting surgery at a later
time. Because these patients were not recommended
to undergo surgery at the 6-week time point of interest, they were kept in their original group (RS or
NRS) as determined by the physician at 6 weeks for
follow-up analysis.
The clinical prediction rule process has the potential
to be a significant element in improving the delineation
of the factors that can influence the content and
timing of treatment of musculoskeletal injury. Clinical
prediction models serve as formal, evidence-based
approaches to clinical decision making by using statistical models to provide quantitative estimates of probability of outcome, diagnosis, or treatment success.31-33
They have the potential to instill continuity and uniformity within health care decisions and can help guide
care.1,31 However, the validity and clinical impact of a
prediction rule must be determined before the model is
translated to a clinical decision rule intended to affect
clinical decision making.34 The need for more carefully
derived and validated prediction models in orthopaedics and rehabilitation has been identified.35 These
models have the potential to help the patient by
avoiding surgery while continuing to restore acceptable
function, help the physician by more clearly defining
which patients need surgery, and help the health care
system by increasing the efficiency of the content and
timing of treatment. This particular model was designed
to try to identify patient factors that could influence the
outcome of a specific treatment program (a rehabilitation program) in patients with clinical findings suggestive of a SLAP injury.
The research decision to evaluate this process in this
population was based on several factors. SLAP lesions
are being more commonly diagnosed and treated. SLAP
injuries are reported to be present in 6% to 12% of
shoulder arthroscopies,36-38 and the incidence of surgery appears to be increasing.2,39 The rationale for
operative intervention is to restore the anatomic alteration in the labrum and its attachment to the glenoid
that is assumed to be responsible for the patient’s pain
and dysfunction. However, surgical outcomes vary
widely and are not uniformly successful,40-43 highlighting the need for a more consistent diagnostic process and for a better understanding of more precise
indications for and timing of surgery.
LABRAL CLINICAL PREDICTION DEVELOPMENT
Attention toward using rehabilitation as the first step
in the treatment of patients with SLAP lesions has
increased. Protocol content would be directed toward
improving motion and strength deficits, maximizing
kinetic chain function, and modifying or minimizing
the dysfunction that these patients report. There are a
few reports that show the benefits of this approach. A
recent retrospective study observed that 19 of 39 patients (49%) diagnosed with SLAP lesions treated
nonoperatively reported successful outcomes at 3 years
after diagnosis and that 10 of 15 athletes (67%) had
returned to their preinjury status.5 The exact rehabilitation program was not described completely. Another
study examined treatment of SLAP lesions in professional baseball players.6 These players had undergone 1
session of rehabilitation that had failed. A specific program of nonoperative intervention focused on correcting scapular dyskinesis and glenohumeral internal
rotation deficit resulted in a 40% rate of return to play,
although not all of these patients returned to their
preinjury level of performance.
The specific rehabilitation program used in our study
was designed using the concepts put forth by Ellenbecker and Cools26 and is similar to previous protocols.6,11 This study adds further support to the use of
this type of rehabilitation program as the first method of
treatment because both studies report a similar success
rate. These results show that not all patients who
receive the diagnosis of a SLAP injury will require
surgery.
This study used statistical analysis to identify variables
associated with a particular outcome. It was not
designed to determine why or by what mechanisms
these variables were associated with the outcome.
However, the findings were consistent with the idea
that clinically symptomatic and dysfunctional SLAP lesions represent not only anatomic disruption of the
labrum and its glenoid attachment but also local and
distant physiological and biomechanical alterations that
add up to create the clinical dysfunction.11,44 None of
the variables most commonly associated with making
the diagnosis of an anatomic labral injury (clinical tests
such as ROM deficits,44 apprehension in external
rotation or positive biceps stress testing,45 a positive MDLS maneuver,9 an active compression test,46 or positive MRI findings) were associated with failure of
therapy and the need for surgery. This finding suggests
that the presence of physical impairments, in addition
to the results of isolated clinical maneuvers or imaging,
may provide stronger clinical relevance for making
treatment decisions.
This study used the clinical prediction rule process to
derive an actual clinical prediction rule that can help
guide management of patients presenting with the
aforementioned symptoms. The next step would
involve validation of this rule with a prospective study
7
in a different cohort of patients with the same clinical
presentation. One existing clinical prediction model has
been developed47 and externally validated48 to predict
persistent symptoms at 6 weeks in patients with
shoulder pain seen in the primary care setting. At
6 weeks, Kuijpers et al.47 observed that a longer duration of symptoms, gradual onset of pain, psychological
complaints, report of repetitive movements at least
2 days per week, and high pain severity in the shoulder
(scale from 0 to 10) and in the neck (scale from 0 to 18)
at presentation were associated with persistent symptoms. One fundamental difference between the existing
model and our analysis is that our patients were prescribed a standardized rehabilitation protocol whereas
the existing model was developed for patients treated
primarily with medication, corticosteroid injection, or a
“wait-and-see” approach. In addition, our study specifically included patients who had symptoms consistent with a SLAP lesion and all patients were seen by an
experienced orthopaedic surgeon (W.B.K.).
A significant percentage of patients with clinical
findings suggestive of SLAP lesions that have created
shoulder dysfunction can show modification of symptoms with lessening or elimination of the dysfunction
through a specific rehabilitation program and do not
require or request surgery. Subjective reports of
improved function can be objectively documented
using valid and reliable patient-reported outcome
measures. This finding is in agreement with and
reinforces the limited information in the literature.
However, 2 patient variables found on clinical examination, a positive painful arc of motion in forward
flexion between 60 and 100 and forward scapular
posture, were found to be associated with failure to
succeed in the therapy program. The odds of rehabilitation failure increased 3.95 times with the presence of
a painful arc of motion and increased 27% with every
1-cm increase in forward scapular position.
Factors that have been traditionally used to delineate
the anatomic SLAP lesion, such as isolated clinical examination tests, glenohumeral rotation asymmetries,
responses to scapular corrective maneuvers, or MRI, did
not predict success or failure of rehabilitation. Rehabilitation can be advocated as the first step in the
treatment of most patients with SLAP tears. Rehabilitation can frequently modify the physiological alterations that are a large part of the shoulder dysfunction,
even in the face of an anatomic labral injury, and
provide restoration of function so that surgery is not
deemed necessary by the patient and the clinician. At
this time, patients who, on initial examination, have a
painful arc of motion and scapular protraction and who
undergo rehabilitation have higher odds of eventually
being recommended for surgery. These 2 factors may
indicate a greater alteration of glenohumeral kinematics associated with the clinical dysfunction. Future
8
S. D. MOORE-REED ET AL.
directions from this study would include a validation
study to determine the effectiveness of the clinical
prediction rule in larger populations or in another
population with these findings, as well as extension to
other shoulder pathology.
Limitations
There are several limitations to this study. The first
and most important is that the diagnosis of a “labral
injury” was made by a combination of clinical examination and imaging techniques, with no actual visualization of the lesion. However, there is no accepted gold
standard for making this diagnosis either clinically, by
imaging, or by arthroscopy.10,13,49 Most studies evaluating clinical examination tests have found poor specificity for the detection of actual anatomic labral
injuries.13 The M-DLS test appears to have the highest
sensitivity, specificity, and likelihood ratio when performed correctly9 but is still best used as part of a
comprehensive evaluation.11 MRI has high sensitivity
but unreliable specificity for clinically significant labral
injury, as shown by the high prevalence of changes
consistent with labral injury seen in asymptomatic
overhead athletes.50 Even direct arthroscopic visualization has shown poor reliability in diagnosing and
classifying labral injuries.4 In the absence of a recognized gold standard, current practice guidelines were
reviewed to establish consistent criteria to distinguish
this group of patients with suspected SLAP tears.
In the absence of specific clinical examination tests,
specific imaging criteria, or even arthroscopic criteria to
establish a single standard, many recent authors
recommend basing the diagnosis on clusters of examination and imaging findings.9,10,12,13 For our cohort, it
was decided to use a modification of the criteria proposed by Walsworth et al.8 for the clustering of clinical
tests. Patients had to have 3 or more history and examination findings to be included. All patients who
had fewer than 3 of the history and examination inclusion criteria but had a diagnosis of labral injury by
magnetic resonance arthrogram were also included
because most studies use this as an inclusion criterion.
The exact percentages for each of the criteria are listed
in Table 4. Because very few patients in the NRS group
underwent arthroscopic evaluation, it may be that
some patients in this group did not actually have an
anatomic SLAP injury. However, all patients in both
groups had the same cluster of inclusion criteria and
exhibited the same clinical dysfunction. Our consistently applied inclusion criteria and the documented
exclusion criteria provided a fairly homogeneous
group whose dysfunction has usually been considered
to be due to SLAP injury.11,51 This study group is
considered to have clinical findings suggestive of a
SLAP injury6,11 and can be differentiated from other
groups with other diagnoses of shoulder injury.
The efficacy of this diagnostic approach was strengthened by the arthroscopic findings compatible with a
clinically significant SLAP injury7 in every patient who
underwent surgery.
The second limitation relates to the lack of control
over the rehabilitation program performed by the patients. However, the physical therapy notes showed
that both groups of patients participated in a high percentage of the expected sessions and completed the
exercises as prescribed, and the available therapists’
notes showed progression in the protocols. This type of
rehabilitation management is consistent with the realworld scenario of how therapy is performed and
implemented, and the overall impression was that
compliance was slightly higher than usual.
The third limitation is that the decision for surgery
was determined after only 6 weeks of therapy, and
perhaps a longer time of follow-up could have
better delineated the response. However, Tate et al.52
observed that the greatest rate of improvement in the
Disabilities of the Arm, Shoulder and Hand questionnaire occurred in the first 2 weeks of treatment.
Because the decision for surgery was based on the
surgeon’s findings of no significant improvement on
the clinical examination or in symptoms, as well as the
patient’s experience of no significant change in the
dysfunction, we believe that this decision represents an
accurate representation of the effects of the rehabilitation program. The accuracy of this determination at this
time is substantiated by the percentages of patients in
each group who eventually required surgery.
The fourth limitation is that our patient group represents an active and recreationally athletic population
but not a population of professional athletes. The
applicability of these results to the professional athlete
may be limited because of the higher level of demands.
This study should be viewed as a preliminary report. It
shows that the clinical prediction process can develop a
model that elucidates factors that are associated with
the results of an intervention. The model needs to be
validated in a larger population. Finally, the results
occurred with the use of a specific rehabilitation protocol. There may be other protocols that may show
improved results.
Conclusions
A structured rehabilitation program resulted in
modification of symptoms and improved function at
6 weeks’ follow-up in over half of patients in the study
group with clinical dysfunction and symptoms suggestive of a SLAP injury. On initial evaluation, the presence of a painful arc of overhead motion, indicating
potential loss of normal glenohumeral kinematics, and
the presence of forward shoulder posture, indicating
a potentially altered scapular position, represent negative predictive factors for success of rehabilitation.
LABRAL CLINICAL PREDICTION DEVELOPMENT
Future validation of the model in a larger population is
necessary.
Acknowledgment
The authors thank the Physical Therapists of PT Pros
and Lexington Clinic Physical Therapy for helping
create the rehabilitation protocol and Kelley Seekins,
M.S., A.T.C., for her assistance with data collection.
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