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Jonathan T. Bravman, MDAssistant ProfessorDivision of Sports Medicine and Shoulder SurgeryDepartment of OrthopedicsUniversity of ColoradoTeam Physician for CU Buffaloes and DU Pioneers
SPORTS MEDICIN E
SPORTS MEDICIN E
1. Identify the pathology of both SLAP tear and bicep disease
2. Learn how to make/confirm diagnosis of SLAP tear/bicep disease
3. Compare/Contrast treatment options
Repair
Bicep tenotomy
Bicep tenodesis
“Superior labrum anterior to posterior”
Andrews 1985: 73 baseball players with bicep pathology
Snyder 1990: classified SLAP tears in 27 surgical patients
Nonspecific shoulder pain with overhead/cross-body motion
Often dull, posterior, “tooth-ache”
May have concomitant instability Traction injury – very common (climbers)
Diagnost ic accuracy of five orthopedic clinical tests
for diagnosis of superior labrum anterior posterior
(SLAP) lesions
Chad Cook, PT, PhD, MBAa,* , Stacy Beaty, MDb, Michael J. Kissenberth, MDc,Paul Sif fri , MDc, Stephan G. Pill, MDc, Richard J. Hawkins, MDc
aDivision of Physical Therapy, Walsh University, North Canton, OH, USAbShannon Clinic, San Angelo, TX, USAcSteadman Hawkins Clinic of the Carolinas, Greenville, SC, USA
Background: The clinical diagnosis of a superior labral anterior posterior (SLAP) tear is extremely chal-
lenging. Most studies that advocate selected tests have errors in study design or significant bias, or both.
The purpose of this study was to identify the diagnostic utility of the ActiveCompression/O’Brien’ s test,
Biceps Load II test, Dynamic Labral Shear test (O’Driscoll’s test), Speed’s test, and the Labral Tension test
when diagnosing isolated SLAP lesions (SLAP-only) and a SLAP lesion with concomitant disorders (eg,
rotator cuff tear), as stand-alone and clustered tests, with diagnostic confirmation by arthroscopic surgery.
Materials and methods: This diagnostic accuracy study was a case-based, case-control design that
included 87 individuals with variable shoulder pathology.
Results: Of the 5 tests, only the Biceps Load II test demonstrated utility in identifying patients with
a SLAP-only lesion, with a positive predictive value of 26 (95% confidence limits [CL], 18, 31), negative
predictive value of 93 (95% CL, 84, 97), positive likelihood ratio of 1.7 (95% CL, 1.1, 2.6), and negative
likelihood ratio of 0.39 (95% CL, 0.14, 0.91). No tests demonstrated diagnostic util ity when diagnosing
any SLAP lesion, including those with concomitant diagnoses. No clusters demonstrated better diagnostic
accuracy than stand-alone findings.
Conclusion: There are a number of potential reasons for the poor utility in the 5 test findings. The hetero-
geneous sample included patients with a variety of shoulder disorders. The study was organized using very
strict methodologic controls that should reduce the risk of bias, which normally overinflates the accuracy of
a specific tool. The findings may truly reflect the stand-alone, diagnostic utility of the 5 tests, suggesting
when used alone provides little usefulness toward decision making of the diagnostic clinician.
Level of evidence: Level I, Diagnostic Study.
Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Diagnostic accuracy; physical examination; sensitivity and specificity; SLAP lesion
A superior labral anterior posterior lesion (SLAP) is an
acquired pathologic detachment of the superior labrum,
anterior and posterior to the biceps anchor, which can lead
to instability, shoulder pain, and functional decline.4 The
condition generally involves a peeling of the superior
This project was approved by the Institutional Review Boards of
Greenville Hospital System (Pro00000304) and Mary Black Health
System (HS-31).
*Reprint requests: Chad Cook, PT, PhD, MBA, 2020 E MapleSt, North
Canton, OH 44720, USA.
E-mail address: [email protected] (C. Cook).
J Shoulder Elbow Surg (2012) 21, 13-22
www.elsevier.com/locate/ymse
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2011.07.012
Diagnost ic accuracy of five orthopedic clinical tests
for diagnosis of superior labrum anterior posterior
(SLAP) lesions
Chad Cook, PT, PhD, MBAa,* , Stacy Beaty, MDb, Michael J. Kissenberth, MDc,Paul Siffri, MDc, Stephan G. Pill, MDc, Richard J. Hawkins, MDc
aDivision of Physical Therapy, Walsh University, North Canton, OH, USAbShannon Clinic, San Angelo, TX, USAcSteadman Hawkins Clinic of the Carolinas, Greenville, SC, USA
Background: The clinical diagnosis of a superior labral anterior posterior (SLAP) tear is extremely chal-
lenging. Most studies that advocate selected tests have errors in study design or significant bias, or both.
The purpose of this study was to identify the diagnostic utility of the ActiveCompression/O’Brien’ s test,
BicepsLoad II test, Dynamic Labral Shear test (O’Driscoll’stest), Speed’stest, and theLabral Tension test
when diagnosing isolated SLAP lesions (SLAP-only) and a SLAP lesion with concomitant disorders (eg,
rotator cuff tear), as stand-alone and clustered tests, with diagnostic confirmation by arthroscopic surgery.
Materials and methods: This diagnostic accuracy study was a case-based, case-control design that
included 87 individuals with variable shoulder pathology.
Results: Of the 5 tests, only the Biceps Load II test demonstrated utility in identifying patients with
a SLAP-only lesion, with a positive predictivevalue of 26 (95% confidence limits [CL], 18, 31), negative
predictive value of 93 (95% CL, 84, 97), positive likelihood ratio of 1.7 (95% CL, 1.1, 2.6), and negative
likelihood ratio of 0.39 (95% CL, 0.14, 0.91). No tests demonstrated diagnostic utility when diagnosing
any SLAP lesion, including those with concomitant diagnoses. No clusters demonstrated better diagnostic
accuracy than stand-alone findings.
Conclusion: There area number of potential reasons for the poor utility in the 5 test findings. The hetero-
geneous sample included patients with avariety of shoulder disorders. Thestudy wasorganized using very
strict methodologic controls that should reduce therisk of bias, which normally overinflates theaccuracy of
a specific tool. The findings may truly reflect the stand-alone, diagnostic utility of the 5 tests, suggesting
when used alone provides little usefulness toward decision making of the diagnostic clinician.
Level of evidence: Level I, Diagnostic Study.
Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Diagnostic accuracy; physical examination; sensitivity and specificity; SLAP lesion
A superior labral anterior posterior lesion (SLAP) is an
acquired pathologic detachment of the superior labrum,
anterior and posterior to the biceps anchor, which can lead
to instability, shoulder pain, and functional decline.4 The
condition generally involves a peeling of the superior
This project was approved by the Institutional Review Boards of
Greenville Hospital System (Pro00000304) and Mary Black Health
System (HS-31).
*Reprint requests: Chad Cook, PT, PhD, MBA, 2020 EMapleSt, North
Canton, OH 44720, USA.
E-mail address: [email protected] (C. Cook).
J Shoulder Elbow Surg (2012) 21, 13-22
www.elsevier.com/locate/ymse
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
doi:10.1016/j.jse.2011.07.012
“No tests demonstrated diagnostic utility when diagnosing any SLAP lesion”
Xrays – nml MR Arthrogram
Debride… Repair… Bicep Tenodesis…
Who gets what??
Degenerative shoulder Type I, III ? RTC repair without bicep symptoms Poor results if truly “unstable” (40% success)
Controversial ! ~90% success rate in some populations
(though highly variable)
Considerations
▪ Age
▪ Sport
▪ Bicep pain
Provencher, 2011
215pts; SLAP II repair
38% failure rate
Age over 36 greatest predictor of failure
Rescued successfully with tenodesis
Boileau 2009
25pts (avg age 37), randomized to SLAP repair vstenodesis
87% RTP vs 20% with tenodesis vs repair
Take Home Points
Not everyone with a SLAP tear needs to be repaired (Weber –> 9x increase in SLAP repair on Part 2 ABOS)
Fix if isolated, history, imaging, arthroscopy match
Fix if combined with instability lesion (espposterior!)
Probably matters…
Though minimal biomechanical difference (thus far…)
71-97% success overall (Schroder, Arthroscopy 2012)
Controversial
Age -> ? >36… > 40??
Bicep disease **
Intra-Articular Portion Intra-articular and extra-synovial Clearly visualized arthroscopically
Extra-Articular Portion Cannot be seen arthroscopically,
but typically involved in pathology
Biceps Sling Soft tissue restrains required to
maintain biceps stability in the groove
Commonly associated with other shoulder problems (SLAP, Supraspinatus and Subscapularis tears)
Tenosynovitis of the LHB tendon may occur with concomitant bursitis, rotator cuff pathology, SLAP, AC joint disorders, adhesive capsulitis, impingement or sometimes a combination of these conditions
However, may present as an isolated source of shoulder pain.
Over past decade the role of isolated biceps tendonitis (tenosynovitis) is increasingly recognized as a sole source of shoulder pain
Dx:
History of anterior shoulder pain
Tenderness to palpation over the intertubercular groove
positive provocative biceps tendon tension tests
Confirmatory + response to ultrasound guided biceps sheath injection
Tenderness in Bicipital Groove
Speed’s Test
90% Sensitive
14% Specific
Yergason’s Diagnostic Injection –
U/S
Imaging MRI
Subluxation/dislocation…(remember the subscap!)
Increased signal around biceps tendonSLAP lesion
Ultrasound
“Pain Generator”
Painful biceps tear Painful massive tear Painful SLAP Painful biceps instability Painful revision surgery
Tenotomy Proximal Tenodesis Subpectoral Tenodesis
Systematic review concluded only major difference was presence of cosmetic deformity in tenodesis group
Slenker, Arthroscopy 2012
Younger age group less than 55 years in active population (avg age 49.9 years)
42 (22 tenotomy, 20 tenodesis) patients Avg f/u 3.3 years Popeye in 35.0% (7/20) of tenotomy vs 18.2%
(4/22) of tenodesis patients.
Aircast Award Winner, Friedman and McCarty,
2012 AOSSM Annual Meeting
Strength was not significantly different between groups for isokinetic strength and endurance measures
Subjective functional outcome measured by the DASH, ASES and VAS scores were similar between groups.
Frequency of cramping higher in the tenotomy group (4/20 vs. 1/22)
Aircast Award Winner, Friedman and McCarty,
2012 AOSSM Annual Meeting
Supination/Flexion strength
Generally mixed results in literature
Important in certain populations
▪ Young males
▪ Laborers (screw driver/wrench)
▪ ?? Climbers / Extreme Athletes…??
Assume Tenodesis is the Answer!
Relieve anterior shoulder pain
Maintain tendon-length relationship
Avoid Cosmetic deformity
Avoid subjective or objective weakness
▪ supination
▪ flexion
Avoid fatigue/cramping
Decreased incidence of postoperative groove pain with distal tenodesis location
Lutton et al, CORR, 2011
Completely removes the tendon from the sheath and synovium (which may contribute to persistent pain)
Poor tendon quality proximally may make tenodesis challenging
Anatomy is easily defined and identified Efficient technique with “short” learning
curve Small cosmetic incision
Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, RomeoAA. Complications Associated with Subpectoral Biceps Tenodesis. Low Rates of incidence following Surgery JSES, 2010 Over 3 yrs, 7 of 353 Biceps Tenodesis had complications
with incidence of 2.0% 2 pts (0.57%) with persistent bicipital pain 2 pts (0.57%) with failure of fixation with Popeye deformity 1 pt (0.28%) with deep wound infection 1 pt (0.28%) with temporary musculocutaneous
neuropathy 1 pt (0.28%) with RSD
Unpublished data
200+ pts (JTB)
Tenodesis prior to bicep release
Bird beak vs “free needle” technique
▪ 13% vs 2% failure / deformity
Pre-op ultra-sound guided injection in bicipital groove (with positive response) will help confirm biceps sheath pain and indication for biceps tenodesis
Goals Protect Biceps Tenodesis site Full Shoulder motion
Early Concentrate on healing
Late Strengthening beginning with light 2 ½ lb
weight at 6 weeksReturn to sports Normally 4 months minimum
Consider tenotomy in low-demand, older, or larger patients who would be accepting of potential cosmetic deformities
Do NOT recommend tenotomy for: High Level Athletes
Workers comp patients
Concerns by anyone of cosmetic deformity If doing tenodesis for biceps pathology, then
recommend subpectoral biceps tenodesis
Summary““The greater the
ignorance the greater the
dogmatism”
Sir William Osler
