Superior Labral Lesions Clinical Presentation

Updated: Sep 14, 2020
  • Author: S Ashfaq Hasan, MD; Chief Editor: S Ashfaq Hasan, MD  more...
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Patients with superior labral (labrum) lesions often present describing a poorly defined pain that is posterior in location. They can also describe a painful popping and clicking similar to mechanical symptoms associated with a meniscal tear.

Nonthrowing individuals may report a history of a fall either on an outstretched arm or in which a direct impact on the shoulder occurred. A history of a sudden deceleration injury, such as occurs when one loses control of a heavy object that is being carried, may be present.

In a throwing athlete, a discrete injury with no prodromal period may be reported. In contrast, the athlete may not recall a specific injury and merely report a prodromal phase consisting of some mild posterior pain with a sense of posterior tightness.


Physical Examination

The patient's range of motion should be carefully assessed, especially in the throwing athlete. [28] Throwers often develop a loss of internal rotation in abduction. This loss of internal rotation with tightness of the posteroinferior capsule is thought to be a risk factor for the development of a SLAP (superior labrum, anterior and posterior) lesion. One should be especially cognizant of this entity in an individual who presents with loss of internal rotation at the expense of a 180° arc of motion with the arm abducted 90°. Burkhart and Morgan postulated that this finding defines a shoulder at risk of developing a type II SLAP lesion and the dead arm syndrome. [23]

An acute SLAP lesion, especially a posterior type II lesion, can manifest as posterior shoulder pain in abduction and external rotation, decreased throwing velocity, and easy fatigability. This symptom complex has been labeled the dead arm syndrome. Multiple physical examination tests for a SLAP lesion have been described; however, correlation with arthroscopic findings has been poor. Furthermore follow-up studies by independent investigators have been unable to reproduce the high sensitivities, specificities, and positive-predictive values reported by the authors who originally described the tests. [29, 30]

In Snyder's initial report describing SLAP lesions, he used the biceps tension (Speed) test and the compression rotation test. [3] The Speed sign is positive when pain is elicited with resisted flexion of the fully supinated arm with the elbow extended and the arm flexed to 90°. The compression-rotation sign is performed with the patient supine, the shoulder elevated to 90°, and the elbow flexed to 90°. An axial load is then applied to the humerus to compress the glenohumeral joint, and the arm is rotated. Pain as well as mechanical symptoms elicited during this test are considered positive test results. Multiple other tests have been described. [29]

The O'Brien sign, or the active-compression test, is elicited by first placing the arm in 90° of forward flexion and 10° of adduction. [31, 32, 33] The arm is then fully internally rotated into the thumbs-down position. The patient is then asked to resist downward pressure to the arm that is applied by the examiner. Differentiate deep-seated shoulder pain from that localized to the anterosuperior aspect of the shoulder because the latter is associated with acromioclavicular (AC) joint pathology.

The test is then conducted again, but with the arm in full supination; the pain should be decreased in this position as compared with the initial position for the test result to be considered positive. A positive Speed test as well as a positive O'Brien sign is thought to be consistent with an anterior type II SLAP tear.

Kibler described the anterior slide test to help diagnose anterior SLAP lesions. [34] The patient is instructed to place both hands on the hips. The examiner stabilizes the scapula with one hand over the acromion. The other hand is used to axially load the humerus in an anterior and superior direction. Pain with this motion is considered to be positive for an anterior-based SLAP lesion.

Kim et al described the biceps tension test II. [35] The shoulder is placed in 120° of abduction and full external rotation, and the elbow is flexed to 90° and fully supinated. The patient is then instructed to flex against resistance. Pain with this is consistent with a SLAP lesion.

Kim et al also described the biceps tension test I to help determine the presence of a SLAP lesion in the patient with unidirectional anterior instability. An anterior apprehension test is first performed, which in this subgroup of patients is positive for instability. Resisted elbow flexion with the arm fully supinated should decrease the sensation of instability if the superior labral–biceps complex is intact. In the presence of a SLAP lesion, no alleviation of the instability sensation occurs.

The Jobe relocation test has been used to help diagnose posterior type II SLAP lesions. [36] The patient is placed in the supine position. The arm is placed in 90° of abduction and maximum external rotation. Pain in this position that is alleviated with a posteriorly directed force to the proximal humerus is consistent with a posterior type II lesion. Differentiate the sensation of pain in this test as opposed to that of instability found in an anteriorly unstable shoulder. Patients with type III and type IV lesions are more likely to report mechanical symptoms, although eliciting these on physical examination is often difficult.

Despite the multitude of described tests for a SLAP lesion, none has proved reliable to date. Follow-up independent studies have demonstrated poor sensitivities, specificities, and positive predictive values. [37, 38]  A study by Somerville et al suggested that although a combination of these tests may be slightly superior to any single test for diagnostic purposes, clinicians should rely more on diagnostic imaging. [39]

Check for rotator cuff impingement signs on examination. [40] The prevalence of rotator cuff tears, either partial- or full-thickness, in patients with SLAP lesions has been noted to be in the 30-40% range.