Tuesday, September 29, 2009

SLAP Lesions

A NEW Slap Test-Trying to figure out the shoulder

     The athletes shoulder can be one of the most challenging concerns of health professionals when treating athletes. Along with the knee and back it is probably the most studied and researched topics in the sport injury world. However, each professional has a different outlook and “experts” on the topic are constantly being recycled.

     One injury in particular leaves many professionals constantly second guessing themselves. A SLAP lesion is a pathology which occurs in the superior aspect of the labrum and often involves a tear traveling from an anterior to posterior manner. (Hense the term SLAP lesion –superior labrum anterior to posterior).

     The problem with this injury is its ability to often replicate other shoulder pathologies such as shoulder impingement, bicep tendinopathies, shoulder instability and rotator cuff disease. The combination of this overlap and the delay of access to mri imaging in small towns and Canada leaves quite a dilemma. That’s why it’s important to be constantly updated on new test which are evolving in the literature. This is a review of a new test described and its validity for detecting SLAP lesions.

     The study involved 113 subjects all which tried conservative treatment but failed to be successful. These subjects were put through three orthopaedic tests before undergoing an arthroscopic procedure. Once the procedure confirmed or denied a suspected SLAP lesion correlations were made. Subjects were tested using the Speed’s Test, Obrien’s Test and the evaluated supine flexion resistance test (See Links)
O'Brien's Test Video   Speed's Test Video Supine flexion resistance test

     The supine flexion resistance test is performed with the patient lying in the supine position. Both of the patient’s arms are elevated above their head with the forearms resting on the table and their palms facing upward. The examiner stands on the same side as the tested shoulder. The examiner then grasps the forearm just distal to the elbow. The patient is then instructed to attempt forward flexion while the examiner applies resistance. The idea is to emulate a throwing motion. Positive – Pain deep inside the shoulder joint or along the dorsal aspect of the joint line. (See Link for video)

     The problem with the study was the author’s lack of correlating the test with all forms of SLAP lesions and never stated why such exclusion was done? Many statistical evaluations were performed in the study but many of non importance. Sensitivity and Specificity of the test to all groups of pathologies (all injuries found on subjects) are clinically irrelevant. This tells me the test is positive when patients are in pain but not where the pain is coming from. As you can see multiple test have multiple over lap of findings with a wide arrange of pathologies. Needless to say their rarely ever is a clear cut answer when performing testing. Subjects were found to have everything from 3 different types of SLAP lesions to AC joint arthritis.

     The presenting of the results wasn’t done very effectively by the authors. They were quick to point out the good results of their study yet completely fail to discuss some of the more important findings. Such as the specificity of the test for SLAP lesions. However the specificity for supraspinatous lesions was mentioned ....go figure?

     Sensitivity for isolated SLAP Lesions was 92% compared to 58% for Speeds and 75% for O’Briens

     This means 92% of the time if a patient has a SLAP lesion this test will pick it up. It doesn’t mean 92% of the time the test is positive it is a SLAP lesion. This is often the big problem with orthopaedic testing for the shoulder. For example the test also had high sensitivity for pathologies as a whole in the study (80%).This is why it’s important to look at the entire clinical picture with the shoulder and not just rely on one test alone.
 Sometimes treatment can even help figure out the diagnosis down the road.

The idea

     Although the article lacks a good explanation of why such a test would provoke symptoms it is fairly easy to understand. The test is merely a different version of the Speed’s test. The bicep has attachments to the superior aspect of the labrum. SLAP orthopaedic test are designed to contract and tension the bicep muscle taking advantage of this bicep labrum complex. The hope is to provoke pain in which the patient is feeling due to this complex. The idea behind both the supine flexion resistance test and Speed’s is to contract the bicep tendons head and thus pull on the inflamed torn labrum.

Obrien’s is usually a test used for better confirmation because it attempts to twist and torsion the head of the bicep which may continue to provoke symptoms. However my favourite test for SLAP lesions is the bicep load test number 1 and 2 (Sen 90.9%, Spec 96.9% & Sen 89.7%, Spec 96.9%). Bicep Load Test 2 Video Bicep Load Test Video Reasoning being this test actually helps rule a SLAP lesion out by attempting to lessen the patient’s symptoms. As we all know if someone is in pain most tests will be positive and thus give us insignificant clinical findings. It is much harder when given an acute injury to find test which lessen the pain then provoke it. When the bicep load tests are negative and ease symptoms it is a significant tool for ruling out a SLAP lesion. To understand this test and other articles on SLAP lesions check out the following references.

1. Ebinger, N., Magosch, P., Lichtenberg, S., & Habermeyer, P. (2008). A New SLAP Test: The Supine Flexion Resistance Test Arthroscopy: The Journal of Arthroscopic & Related Surgery, 24 (5), 500-505 DOI: 10.1016/j.arthro.2007.11.017
2. KIM, S., HA, K., AHN, J., KIM, S., & CHOI, H. (2001). Biceps load test II: A clinical test for SLAP lesions of the shoulder Arthroscopy: The Journal of Arthroscopic & Related Surgery, 17 (2), 160-164 DOI: 10.1053/jars.2001.20665
3.Shanley KJ, Green RA, & Taylor NF (2008). An evaluation of the anatomical basis of the Biceps Load tests I and II for superior labral anterior and posterior (SLAP) lesions. Clinical anatomy (New York, N.Y.), 21 (7), 647-51 PMID: 18773481
4.Munro W, & Healy R (2009). The validity and accuracy of clinical tests used to detect labral pathology of the shoulder--a systematic review. Manual therapy, 14 (2), 119-30 PMID: 18996735
5. Green RA, Taylor NF, Mirkovic M, & Perrott M (2008). An evaluation of the anatomic basis of the O'Brien active compression test for superior labral anterior and posterior (SLAP) lesions. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.], 17 (1), 165-71 PMID: 17936025

1 comment:

  1. Really great information shared. Shoulder arthroscopy one of the best way to examine or repair tissue.