Research Review by Dr. Shawn Thistle©

Date:

Jan. 2006

Study Title:

An evaluation of the provocative tests for superior labral anterior posterior lesions

Authors:

Parentis MA et al.

Publication Information:

American Journal of Sports Medicine 2006; 34(2): 265-268.

Summary:

The initial description and classification of superior labral anterior to posterior lesions (commonly referred to as SLAP lesions) was in 1990. Since then, the understanding of these shoulder lesions has increased dramatically.

Despite this, there is still much controversy as to the best way to detect these lesions clinically, without having to rely of the gold standard of diagnostic arthroscopy to diagnose them.

Many clinical orthopedic tests have been developed and reported as highly sensitive and specific for diagnosing SLAP lesions. These include the active compression test (also called O'Brien's test), apprehension test, pain provocation test (also called the Mimori test), crank test, and anterior slide test.


Overall, these tests produce gleaming clinical results when studied by those who created them, but do not stand up well when studied by others.

This study attempted to determine the most effective provocative test for diagnosing SLAP lesions by evaluating data taken from 132 consecutive shoulder patients about to undergo diagnostic shoulder arthroscopy. Each patient underwent a standard pre-operative examination in addition to 9 clinical tests: active compression test, Jobe relocation test, pain provocation test, crank test, anterior slide test, Yergason test, Speed test, Hawkins test, and Neer test.

These tests are all designed at least in part to detect SLAP lesions and some also can suggest rotator cuff pathology or glenohumeral instability. All patients then underwent diagnostic arthroscopic surgery to determine the actual diagnosis. Clinical testing results were then analyzed against surgical results to determine the effectiveness of the clinical tests.

There were 98 men and 34 women (average age 42 years) included in this study, of which 40 were determined to have a SLAP lesion.

Pertinent Results:

  • the active compression and Hawkins tests were most sensitive for Types I and II SLAP lesions, but were still only in the 60% range
  • pain provocation, Yergason, crank, and anterior slide tests had poor sensitivity, with the highest reaching only 17.4%
  • generally, sensitive tests were not specific
  • overall, there is no single test that is both sensitive and specific for diagnosing SLAP lesions
  • secondary analysis revealed that the Hawkins test has high sensitivity (83%) for diagnosing shoulder impingement, and that Jobe's relocation test has high specificity for shoulder instability (both findings supporting existing literature)

Conclusions & Practical Application:

The patient population in this study had a higher percentage of SLAP lesions (at 30.3%) than the average population, reflecting the patient base of the study clinics (many overhead athletes). This minor weakness aside, this study provides further evidence that the ability of a clinician to diagnose SLAP lesions accurately using clinical tests is limited at best.

Astute clinicians will be most successful by utilizing a detailed history, combined with a thorough clinical examination (perhaps using a number of the above mentioned tests) when assessing patients with shoulder pain. If a SLAP lesion remains high on the list of differentials, you may want to consider referring for a surgical consult, or advanced imaging such as magnetic resonance arthrography (MRA) to more carefully assess the injury. Diagnostic ultrasound may also be a cheaper diagnostic imaging test but requires further study.

Overall, further studies are required to establish better clinical tests to assess the integrity of the glenohumeral labrum.