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.
  • amy castillo

    In my population, which is a mixed athletic and industrial group of all ages, I am still struggling.

    It is hard to decide which test and how confident I feel in suggesting to their referral they may need an ortho consult. Or to refer back sooner if no progress versus an itis, or tendinosis or simply just laxity.

    As impingement test are non tissue specific and often these Type II ‘s have some signs of laxity as well…it is still hard to call without imaging. And even if I have a MRI, how how sensitive is non contrast MRI for these patients?

    Do you have the citations of the 45-75% populations with concomminant rotator cuff tears? I would love to have those.

    Thanks again.

  • Selena Horner

    I believe an important aspect you are missing to consider when providing information on the various tests are the likelihood ratios. It might be wiser to know the likelihood ratios to best determine the value a particular test has before performing all the tests under the sun.

    In the future, I can foresee research targeting the value of particular aspects of the subjective history to assist in narrowing the examination procedures to focus on performing an examination with a cluster of findings being key in ruling in or ruling out a labral tear.

    Cleland’s book does a nice job of providing, at a glance, the clinical value of various tests and measures. After looking at table after table of data, for some reason, historically, I know I have placed an inappropriate level of value on orthopaedic tests that are truly crappy tests (little did I know). Inherently, high utilization of a crappy test creates a poor foundation for building clinical decisions when designing a treatment plan. (And then, from a patient perspective/payor perspective, leads to poorer outcomes and less efficiency.)

    Current research for labral tears doesn’t lead to an efficient examination with the general population at this point in time. Athletes are but a narrow population and most practitioners treat a diverse population of people walking through clinic doors with complaints of “shoulder pain.”

  • Mike Reinold

    I couldn’t agree more Selena. Next week when I post part 2 of this series on clinical exam tests for SLAPs, I will discuss how to choose which test to perform and why. This will include information on the validity and reliability of these tests. I have felt the same way as you when I read a research report saying that a particular test I use is not that accurate. I think you will see, though, that there is not always a “gold standard.” And we need to be just as careful basing our decisions on one research report. Even though we can read their methodology, we can not always guarantee the quality. Unfortunately we have to do the best with what we currently have, I feel that is a combination of research and experience, not just one.

    Thanks for the comment!

  • Mike Reinold

    You are good Amy, I can’t slip anything past you! I have updated the post based on your recommendations above. Also I will discuss MRI and how to choose tests next week in part 2.

  • amy castillo

    Thanks…great discussion. Selena brings up great points. And Mike thanks for the links.

  • amy castillo

    Selena – I do know of at least one article that suggests the presence of popping or catching paired with either a postive anterior slide or active compression with positive likliehood ratios of 2.75 and 3.75. Not earth shattering shifts, but maybe meaningful with a high pre-test suspicion. Walsworth et al AJSM 36(1):162. (2008)

  • Chad Ballard, PT

    I’ve had pretty good success with a trio of labral tests I use with a suspected tear- Active Compression, Biceps Load II, and the Dynamic Speed’s. A number of patients I assess struggle with the active elevation component of the Speed’s, so in those cases I skip it and re-test at a later date prn (if the symptoms persist).

    Amy- it is a tough call if/when to recommend referral to an ortho. My personal take is that if 2/3 of the tests are positive and/or the patient does not respond to a progression of non-aggravating cuff and scapular strengthening within 6 sessions, an ortho referral/recommendation would be warranted.

  • Mike Reinold

    I like those recommendations Chad, sounds like when I would refer as well.

    In regard to your trio of tests, I think I know why you like those three, this will be part of the topic of part 2 of this post next week but those three tests all detect different types of SLAP lesions, putting them together will cover your bases for sure. I don’t want to steal all my own thunder for next week, though…

  • Juli

    I am an occupational therapist but one who has specialized in neurology and psychiatry. A friend, walking in heels over a brick walkway and having her heel catch, fell on her outstretched arm and sustained a SLAP tear and subsequent repair. She is saving the op report for me to read and is, of course, also seeing a PT. I know my friend and she is a bit hard headed so I have been re-inforcing that she mustn’t overdo while healing. Naturally as bad luck would have it, it is her R dominant UE and she drives a stick. Until I can read that op report and find out all of the structures that were repaired and how, I have found YOUR website to be heaven sent. Thanks for clear explanations. Best of luck in your work.

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