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Superior Labrum Lesions Clinical Presentation

  • Author: Riley J Williams, III, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Jan 13, 2016
 

History

The initial evaluation of an individual with a suspected SLAP lesion should include a thorough review of the patient's activities, history of previous shoulder injuries, subsequent interventions, and aggravating factors. The majority of SLAP lesions occur in conjunction with other shoulder disorders, making the diagnosis difficult to establish.

Nonspecific shoulder pain with overhead or cross-body activities is the most common presenting symptom of patients with SLAP lesions. Reports of popping, clicking, or catching at the shoulder joint are common. Patients may describe a deep, vague pain within the shoulder joint in association with weakness or stiffness. Additionally, symptoms of instability may be present if the tear extends into the anterior ligament and labrum, resulting in a Bankart lesion.

The patient's history may reveal a traction injury or a direct blow to the shoulder area proper. A fall onto an outstretched arm may also cause a SLAP lesion. Compression (direct blow) injuries are most often traumatic in nature and can be sustained during a fall onto the affected extremity. Overhead throwing athletes may also be prone to the development of SLAP lesions because of the repetitive traction forces of the throwing motion. In many of these cases, no antecedent injury or activity is reported.

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Physical

Patients suspected of having a labral tear or SLAP lesion should undergo a thorough physical examination of the cervical spine, shoulder girdle, and upper extremity.

The physical examination should assess range of motion (ROM), glenohumeral stability, muscular strength, and neurologic function. Unfortunately, no single physical sign or test is specific for the detection of a SLAP lesion, and a diagnosis based solely upon the patient's history and the physical examination findings remains difficult. Some studies have advocated certain maneuvers that, when considered with other diagnostic modalities (eg, history, imaging), may be highly suggestive of labral pathology.

Note that commonly performed diagnostic maneuvers often elicit positive findings in patients with superior labral tears; thus, attention to detail is necessary when documenting physical findings. Associated lesions (eg, rotator cuff tears, instability) may produce confusing signs during the physical examination; thus, the correlation of all findings with information from the history and imaging studies is recommended.

The Speed biceps tension test (also Speed's test, biceps tendon test) may be useful in detecting SLAP lesions. This test is performed with the patient's forearm in maximal supination and the elbow extended. Then, the examiner resists active glenohumeral flexion, which may result in pain in the patient when the biceps attachment site is injured or inflamed.

Field and Savoie described the compression rotation test wherein the patient is placed in a lateral position and the affected arm is held in 90° of abduction.[18] Pain is noted with internal and external rotation of the arm.

The O'Brien active compression test (also O'Brien sign, active compression test) is often utilized to detect labral pathology.[19] This maneuver is performed with the examiner standing behind the patient. The patient stands upright with the affected arm flexed 90° and adducted 15° medial to the sagittal plane of the body. With the arm internally rotated (thumb down), the examiner places a downward force on the arm. Pain is localized to the shoulder joint or acromioclavicular (AC) joint. The test is then repeated with the forearm in maximal supination. A positive test result is recorded when pain is decreased by the second maneuver. Superficial pain is correlated with AC joint pathology, whereas a deep pain or click is correlated with labral abnormalities in 94% of the patients studied.[19]

Kibler described the anterior slide test to help diagnose anterior SLAP lesions. The patient is instructed to place both hands on the hips.[20] The examiner stabilizes the scapula of the affected side with one hand over the acromion. The other hand is used to axially load the humerus in the anterior and superior direction. Pain with this motion is considered to be a positive result for an anterior-based SLAP lesion.

Kim et al (2003) described the biceps load test II.[4] With the patient supine, the affected arm is flexed to 120° and maximally externally rotated, with the elbow at 90° of flexion. If pain is elicited with resisted elbow flexion, the test finding is positive. The authors stated a sensitivity of 89.7% and specificity of 96.9% in detecting SLAP lesions.

In a study by Kim et al (2007), the authors described the passive compression test to assess for SLAP lesions.[21] The patient is asked to lie down in a lateral position with the affected shoulder up and the physician standing behind the patient. The physician stabilizes the patient’s affected shoulder by holding the AC joint and controls the patient’s elbow with the other hand. The examiner rotates the patient’s shoulder externally with 30° of abduction and then pushes the arm proximally while extending the arm, which results in passive compression of the superior labrum onto the glenoid. The test finding is considered positive if pain or a painful click is elicited in the glenohumeral joint. The sensitivity of this test was reported to be 81.8%, and the specificity was 85.7%.

It should be noted that patients may also demonstrate a positive Neer (pain with passive forward elevation of the affected arm) or Hawkins sign (pain with passive internal rotation of the affected arm at 90° of flexion) in the presence of superior labral pathology.

Parentis et al completed a prospective study aimed at determining the most effective provocative maneuver with which to diagnose type I and II SLAP lesions.[22] The 2 most sensitive tests for type II SLAP lesions were found to be the active compression (65.2%) and Hawkins test (65.2%). None of the sensitive tests was highly specific for type I or type II lesions.

Swaringen et al reported that electromyographic analysis of physical examination tests for type II SLAP lesions demonstrated that the active compression test and biceps tension test had significantly higher electromyographic signals relative to other tests, and consequently, maneuvers which maximize muscle activation transmitted through the LHB may be the best to identify type II SLAP lesions.[23]

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Causes

In a series, Snyder et al reported that a compressive force or traction injury to the affected extremity was the most common mechanism of injury.[2] However, in 21% of these patients, the etiology of the SLAP lesion was insidious. Moreover, most throwing athletes examined by Andrews et al did not report a distinct traumatic event.[1] Thus, although an isolated injury may cause a labral injury, SLAP lesions may also occur as a result of the repetitive microtrauma that is associated with the overhead throwing motion.

Numerous authors have described a peel-back method for the development of SLAP II lesions. When the shoulder is in an abducted and externally rotated position, the biceps tendon is thought to assume a more vertical and posteriorly directed posture, which transmits a force to the superior labrum and causes it to peel off of the glenoid. Grossman et al supported this hypothesis in a cadaveric model.[24] A contracted posterior capsule and resulting internal rotation deficiency, which is commonly observed in overhead throwing athletes, may translate the humeral head anteriorly, further aggravating the patient's symptoms.

Related Medscape Reference topics:

Elbow and Forearm Overuse Injuries

Overuse Injury

Rotator Cuff Injury

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Contributor Information and Disclosures
Author

Riley J Williams, III, MD Associate Professor, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College; Director, HSS Institute for Cartilage Repair

Riley J Williams, III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Society for Sports Medicine, Medical Society of the State of New York

Disclosure: Received royalty from Arthrex Inc for none.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Acknowledgements

Frank A Petrigliano, MD  Orthopaedic Surgery Resident, Department of Orthopaedic Surgery, University of California Los Angeles

Frank A Petrigliano, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

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Upper left - Type I superior labrum anterior posterior lesion. Lower right - Type II superior labrum anterior posterior lesion.
Upper left - Type III superior labrum anterior posterior lesion. Lower left - Type IV superior labrum anterior posterior lesion.
Coronal magnetic resonance arthrogram. This image demonstrates detachment of the superior glenoid labrum.
Arthroscopic appearance of a type II superior labrum anterior posterior (SLAP) lesion.
Arthroscopic placement of a suture anchor in the superior glenoid.
Arthroscopic suture placement for superior labrum anterior posterior (SLAP) lesion repair.
Arthroscopic appearance of a superior labrum anterior posterior (SLAP) lesion after repair with a suture anchor.
Simple mattress suture configuration with a single anchor. (Arthroscopy. 2007 Feb;23(2):135-40.)
 
 
 
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