Diagnosis+of+GH+Labral+Tears

**Purpose**: To find the most reliable combination of tests/diagnostic procedures to accurately diagnose glenoid labral tear. **Clinical Question**: What tests are the most reliable for diagnosing glenoid labral tears? **Evidence**: Searched Pub-med and Google Scholar for "diagnosis of glenoid labral tear". A meta-analysis was found which was then used the sources included in the meta-analysis. As a result, our inclusion criteria mirrored the criteria from the meta-analysis(4). Eligibility criteria for inclusion in the meta-analysis:



**Review of Anatomy** Glenohumeral joint is made up of the head of the humerus and the glenoid fossa of the scapula. The Humerus is held in place by static and dynamic stabilizers.

Static stabilizers: superior, middle, and inferior glenohumeral ligaments, coracohumeral ligament, transverse humeral ligament, coracoacromial ligament.

Dynamic stabilizers: Intrinsic shoulder stabilizers: Supraspinatus, Infraspinatus, Teres Minor, Subscapularis Extrinsic shoulder stabilizers: Deltoid, Latissimus Dorsi, Teres Major

A ligamentous capsule encloses the GH joint, adds stability, and contains the synovial fluid needed to lubricate and provide nutrition to joint surfaces.

The labrum is a fibrocartilaginous structure seated in the glenoid fossa that serves to deepen the glenoid cavity by 50% and increase joint congruence. The labrum also provides attachment points for the glenohumeral ligaments and the long head of the biceps tendon (17).

For additional background information on the shoulder, see here



Mechanism of Injury (MOI)
Labral tears happen in a number of ways. Most often it is due to trauma or excessive force on the shoulder. This includes falling on an outstretched hand, landing on the shoulder joint, lifting a heavy object repeatedly or suddenly, or rapid eccentric contraction of the biceps, such as trying to catch a falling object. Repetitive overhead activities can also cause a labral tear. Throwing athletes (baseball/softball players, javelin throwers) and swimmers commonly present with labral tears because of the repetitive nature of their sports.

Signs and Symptoms:
<span style="font-family: Arial,Helvetica,sans-serif;">The patient will report pain with overhead motion, a “popping” or clicking sensation that is deep within the shoulder, possible weakness, and a feeling of instability.

<span style="font-family: Arial,Helvetica,sans-serif;">Superior Labral Tears (17)
<span style="font-family: Arial,Helvetica,sans-serif;">Superior Labrum Anterior-Posterior (SLAP)
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type I: this involves fraying of biceps anchor but no tear into tendon or labrum. It is common in young athletes performing repetitive overhead motions.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type II: the most common type of labral tear. The labrum has torn with both the biceps anchor and superior labrum showing separation from the glenoid fossa. There are 3 subtypes of type II tears: IIA, IIB, and IIC. IIA involves anterosuperior labrum. IIB involves posterosuperior labrum. IIC involves both tear of the labrum both anteriorly and posteriorly to the biceps tendon anchor.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type III: Also known as a “bucket handle” tear, the superior aspect of the labrum is torn but does not include the biceps tendon.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type IV: The labrum tears in the same fashion as a Type III, but the biceps tendon is also included in this type of tear.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type V: SLAP that extends into a Bankart lesion
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type VI: tear presents as a flap in the joint
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type VII: tear continues to involve middle GH ligament
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type VIII: tear moves posteriorinferiorly to reverse Bankart lesion
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type IX: Labrum tears throughout its circumference
 * <span style="font-family: Arial,Helvetica,sans-serif;">Type X: tear involves rotator interval through superior GH ligament



<span style="font-family: Arial,Helvetica,sans-serif;">Andrew's lesion: found mainly in throwers. Pure superior labrum detachment without extension posterior to biceps (3).

<span style="font-family: Arial,Helvetica,sans-serif;">Anterior Labral Tears (3)
<span style="font-family: Arial,Helvetica,sans-serif;">Pure anterior labral tears are rare and hard to distinguish from other types

<span style="font-family: Arial,Helvetica,sans-serif;">Posterior Labral Tears (3)
<span style="font-family: Arial,Helvetica,sans-serif;">Walch's internal impingement lesion: labral tear and partial tear of rotator cuff at supra/infraspinatus junction

<span style="font-family: Arial,Helvetica,sans-serif;">Anterior and Antero-inferior Labral Tears (3)
<span style="font-family: Arial,Helvetica,sans-serif;">Perthes lesion: detachment without displacement <span style="font-family: Arial,Helvetica,sans-serif;">Gleno-labral Articular Disruption (GLAD): rare, consists of superficial detachment or fissuring of the anterior and inferior labrum with adjacent cartilage defect <span style="font-family: Arial,Helvetica,sans-serif;">Bankart lesion: anterior detachment of the capsule and labrum in continuity with anterior part of the scapular neck

<span style="font-family: Arial,Helvetica,sans-serif;">Posterior and Postero-inferior Labral Tears (3)
<span style="font-family: Arial,Helvetica,sans-serif;">Kim's lesion: posterior capsulolabral and periosteal detachment with adjacent cartilage torn away

<span style="font-family: Arial,Helvetica,sans-serif;">Arthroscopy
<span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; vertical-align: baseline;">Gold standard. Surgeon uses small incisions and a scope to examine the labrum. This is the definitive answer to decide if the tear exists. If the surgeon finds a tear when the arthroscopy is performed they are able to repair or excise it. If no tear is found then it means all the tests were false positives.

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<span style="font-family: Arial,Helvetica,sans-serif;">MRA/MRI: (5,8,17)

 * <span style="font-family: Arial,Helvetica,sans-serif;">MRA
 * Sensitivity - 98%
 * Specificity - 99%
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; vertical-align: baseline;">Physician uses contrast injected into the capsule to highlight any possible defects in the labrum. A T2 image is used during an MRA and this greatly increases the sensitivity compared to normal MRI.
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 13.3333px;">MRI
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 10pt; vertical-align: baseline;">Regular MRI T2 image can be used to diagnose labral tears but it is not highly sensitive. A 3T MRI is different than a 1.5T MRI in that it uses a much stronger magnetic field to create the image. 3T MRIs have a much more defined picture than 1.5T MRIs and that is why the sensitivity is higher for the 3T MRI.
 * 3T MRI
 * Sensitivity 82%
 * Specificity 99%
 * <span style="font-family: Arial,Helvetica,sans-serif;">1.5T MRI
 * Sensitivity - 42%
 * Specificity - 92%

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<span style="font-family: Arial,Helvetica,sans-serif;">Biceps Load Test I: (1,10,13)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient's arm abducted to 90 degrees, externally rotated 90 degrees, and elbow flexed at 90 degrees. Clinician pulls elbow toward extension while patient resists, putting tension on the biceps. Test is positive if patient is apprehensive or pain is reproduced.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: Evaluates the superior glenoid and tightening of the biceps to see if it is intact and provides stability.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity - 83%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity - 98%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positve likelihood ratio: 29
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative likelihood ratio: .09

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<span style="font-family: Arial,Helvetica,sans-serif;">Biceps Load Test II: (1,10)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient's arm is abducted to 120 degrees, externally rotated to 90 degrees, and elbow flexed to 90 degrees. Clinician pulls elbow toward extension while patient resists, putting tension on the biceps. Test is positive if patient's pain is reproduced or patient becomes apprehensive.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: Checks for SLAP lesion by assessing if biceps is intact and providing stability to the joint
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity- 89.7%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity- 96.9%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive Likelihood ratio: 26
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative Likelihood ratio: 0.11
 * <span style="font-family: Arial,Helvetica,sans-serif;">Predictor values-Positive Predictor Value (PPV) 92.1%; Negative Predictor Value (NPV) 95.5%

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<span style="font-family: Arial,Helvetica,sans-serif;">Crank Test: (1,4,18)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: With the subject standing, the examiner places the distal hand on the subject's elbow and the proximal hand on the subject's proximal humerus and then passively elevates the subjects shoulder to 160 degrees in the scapular plane. With the distal hand, the examiner applies a load along the long axis of the humerus while the proximal hand externally and internally rotates the humerus. Test is positive if symptoms are reproduced.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: With humerus in the scapular plane, axial compression of the humeral head into the glenoid in addition to internal rotation will compress the labrum and indicate tears.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity-46%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity-56%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive likelihood ratio: 1.64
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative likelihood ratio: .75
 * <span style="font-family: Arial,Helvetica,sans-serif;">Predictor values: PPV- 41%; NPV 61%

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<span style="font-family: Arial,Helvetica,sans-serif;">Clunk Test: (12,15)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient is supine with shoulder fully flexed, elbow flexed. Clinician applies anterior force at the humeral head while applying compression and external rotation to humerus by holding the elbow. A positive test is pain, clicking, or grinding at the shoulder joint.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: With humerus in 120 degrees of flexion, axial compression of the humeral head into the glenoid in addition to external rotation will compress and/or indicate labral tears
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity- 67%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity- 67%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive likelihood ratio: 16
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative likelihood ratio: 0.67
 * <span style="font-family: Arial,Helvetica,sans-serif;">Predictor values- PPV- 62% NPV-71%

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<span style="font-family: Arial,Helvetica,sans-serif;">Grind/Compression-Rotation Test: (4,12,13,14)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient is supine with shoulder abducted to 90 and in neutral rotation. The clinician applies an axial force down the humerus and rotates the humerus against the labrum. A positive sign is an uncomfortable clunk, pop, or catching during compression and rotation.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: The head of the humerus is compressed into the labrum and when it is rotated it will catch any pieces that are torn.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity: 24%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity: 76%
 * <span style="font-family: Arial,Helvetica,sans-serif;">PPV: 9%
 * <span style="font-family: Arial,Helvetica,sans-serif;">NPV: 90%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive likelihood ratio: 3.91
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative likelihood ratio: .64

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<span style="font-family: Arial,Helvetica,sans-serif;">Internal Rotation Resistance Test (IRRT): (9,12,14)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient is seated with arm abducted to 90 degrees and externally rotated 80. Examiner tests external rotation and internal rotation strength from this position. Test is positive if internal rotation force is lacking but external rotation force is normal.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: When attempting to internally rotate, the humeral head is pushed anteriorly toward labrum, which places tension along biceps complex and capsule border which will elicit pain and weakness
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity: 88%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity: 96%
 * <span style="font-family: Arial,Helvetica,sans-serif;">PPV: 88%
 * <span style="font-family: Arial,Helvetica,sans-serif;">NPV: 96%

<span style="font-family: Arial,Helvetica,sans-serif;">Jerk Test: (1, 3, 11)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient is seated, examiner stands behind to stabilize scapula while moving patient's arm to a 90° abduction, 90° internally position. Examiner then applies axial pressure and horizontally adducts the arm. Test is positive if pain or clicking/snapping sound.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: If the patient lacks posterior instability, the glenoid will be subluxated and the clicking sound occurs as the humerus is reduced into the joint.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity - 73%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity - 98%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive predictive value - 88%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative predictive value - 95%

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<span style="font-family: Arial,Helvetica,sans-serif;">Jobe Apprehension/Relocation: (1,4,12)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient is supine with arm maximally abducted and externally rotated. Examiner applies anterior force to humerus. Test is positive if patient becomes apprehensive or experiences pain. Relocation test is the same except examiner pushes humeral head backwards.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: The anterior force places tension on the anterior labrum, while the relocation test should relieve the tension
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity - 61%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity - 47%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive likelihood ratio: 1.15
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative likelihood ratio: .83

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<span style="font-family: Arial,Helvetica,sans-serif;">Kim Test: (1,11)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient is seated with arm in 90 degrees abduction. Examiner applies axial compression and moves patient's arm into 45 degrees of elevation.Test is positive with sharp pain.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: The axial compression will compress the postero-inferior structures.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity - 80%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity - 94%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive predictive value - 73%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative predictive value - 96%

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<span style="font-family: Arial,Helvetica,sans-serif;">O'Brien's Test: (4,12,16,18)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient sits with shoulder in 90 degrees of forward flexion, 10 degrees horizontal adduction, and thumb pointed down (internally rotated). Examiner applies pressure at the wrist pushing the arm down with patient resisting motion. Testing is repeated with the thumb then pointed upwards. Test is positive for a SLAP if pain is inside the joint and improves in the second positive. Can be indicative for AC joint impingment if pain is felt on top of the shoulder with both testing positions.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: Examination starting position tightens the posterior capsule and posteriorly translates the humeral head, stressing the labrum which results in pain and weakness.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity- 54%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity- 31%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive likelihood ratios: 1.03
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative likelihood ratio: .94
 * <span style="font-family: Arial,Helvetica,sans-serif;">Predictor values- PPV-34%; NPV-50%

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<span style="font-family: Arial,Helvetica,sans-serif;">Yergason's: (4,7,12,19)

 * <span style="font-family: Arial,Helvetica,sans-serif;">Procedure: Patient is seated with elbow flexed to 90 and stabilized against body with forearm pronated. Examiner places on hand on the forearm and palpates long head of biceps tendon. Patient attemps to supinate forearm while externally rotate humerus. A positive test is pain over the biceps tendon and at the insertion point.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Rationale: Supination and external rotation place tension on the long head of the biceps tendon, which is involved in SLAP tears.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Sensitivity-43%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Specificity-79%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive predictive value- 60%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative predictive value- 65%
 * <span style="font-family: Arial,Helvetica,sans-serif;">Positive likelihood ratio: 2.5
 * <span style="font-family: Arial,Helvetica,sans-serif;">Negative likelihood ration: .87

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Summary Statement (2,3,4,6)


There isn't a "one size fits all" test for shoulder labrum injuries. The patient's history and location of pain should be used in combination with the following: For superior labral injuries, 6 tests were shown to be reliable For anterior labrum, the apprehension test has shown to be the most useful.
 * Relocation test for internal impingement
 * Biceps load test II for SLAP lesion
 * IRRT to differentiate from subacromial impingement
 * Kim's test to diagnose postero-inferior tear
 * Crank test for diagnosing labral lesion

Our takeaway: many of the tests have similar positions and are easy to combine. This allows multiple tests to be performed in succession quickly to increase the likelihood of a correct diagnosis. = =

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<span style="font-family: Arial,Helvetica,sans-serif;">References:

 * 1) <span style="font-family: Arial,Helvetica,sans-serif;">Arnander, M., & Tennent, D. (2014). Clinical assessment of the glenoid labrum. Shoulder & Elbow, 6(4), 291–299. @http://doi.org/10.1177/1758573214546156
 * 2) <span style="font-family: Arial,Helvetica,sans-serif;">Biederwolf, N. E. (2013). A proposed evidence-based shoulder special testing examination algorithm: clinical utility based on a systematic review of the literature. International Journal of Sports Physical Therapy, 8(4), 427–40. Retrieved from []
 * 3) <span style="font-family: Arial,Helvetica,sans-serif;">Clavert, P. (2015). Glenoid labrum pathology. Surgery & Research, 101, 19–24. []
 * 4) <span style="font-family: Arial,Helvetica,sans-serif;">Gismervik, S. Ø., Drogset, J. O., Granviken, F., Rø, M., & Leivseth, G. (2017). Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskeletal Disorders, 18(1), 41. []
 * 5) <span style="font-family: Arial,Helvetica,sans-serif;">Grubin, J., Maderazo, A., & Fitzpatrick, D. (2015). Imaging evaluation of superior labral anteroposterior (SLAP) tears. American Journal of Orthopedics,44(10), 476-477. Retrieved March 30, 2017. []
 * 6) <span style="font-family: Arial,Helvetica,sans-serif;">Hegedus, E. J., Goode, A. P., Cook, C. E., Michener, L., Myer, C. A., Myer, D. M., & Wright, A. A. (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British Journal of Sports Medicine, 46(14), 964–978. []
 * 7) <span style="font-family: Arial,Helvetica,sans-serif;">Holtby, R., & Razmjou, H. (2004). Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 20(3), 231–236. []
 * 8) <span style="font-family: Arial,Helvetica,sans-serif;">Jee, W.-H., McCauley, T. R., Katz, L. D., Matheny, J. M., Ruwe, P. A., & Daigneault, J. P. (2001). Superior Labral Anterior Posterior (SLAP) Lesions of the Glenoid Labrum: Reliability and Accuracy of MR Arthrography for Diagnosis. Radiology, 218(1), 127–132. []
 * 9) <span style="font-family: Arial,Helvetica,sans-serif;">Johnson, C. (2002). Internal rotation resistance strength test: A new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. Journal Of Hand Therapy, 15(3), 297. @http://dx.doi.org/10.1016/s0894-1130(02)70025-2
 * 10) <span style="font-family: Arial,Helvetica,sans-serif;">Kim, S.-H., Ha, K.-I., Ahn, J.-H., Kim, S.-H., & Choi, H.-J. (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. []
 * 11) <span style="font-family: Arial,Helvetica,sans-serif;">Kim, S.-H., Park, J.-S., Jeong, W.-K., & Shin, S.-K. (n.d.). The Kim Test A Novel Test for Posteroinferior Labral Lesion of the Shoulder—A Comparison to the Jerk Test. [|https://doi.org/10.1177/036354650427268]
 * 12) <span style="font-family: Arial,Helvetica,sans-serif;">Konin et al. Special tests for orthopedic examination: 3rd edition. Thorofare, NJ: Slack inc. 2006
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 * 14) <span style="font-family: Arial,Helvetica,sans-serif;">Luime, J. J., Verhagen, A. P., Miedema, H. S., Kuiper, J. I., Burdorf, A., Verhaar, J. A. N., & Koes, B. W. (2004). Does This Patient Have an Instability of the Shoulder or a Labrum Lesion? JAMA, 292(16), 1989. []
 * 15) <span style="font-family: Arial,Helvetica,sans-serif;">Nakagawa, S., Yoneda, M., Hayashida, K., Obata, M., Fukushima, S., & Miyazaki, Y. (2005). Forced Shoulder Abduction and Elbow Flexion Test: A New Simple Clinical Test to Detect Superior Labral Injury in the Throwing Shoulder. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 21(11), 1290–1295. []
 * 16) <span style="font-family: Arial,Helvetica,sans-serif;">Oh, J. H., Kim, J. Y., Kim, W. S., Gong, H. S., & Lee, J. H. (2008). The Evaluation of Various Physical Examinations for the Diagnosis of Type II Superior Labrum Anterior and Posterior Lesion. The American Journal of Sports Medicine, 36(2), 353–359. []
 * 17) <span style="font-family: Arial,Helvetica,sans-serif;">Rowbotham, E., & Grainger, A. (2015). Superior Labrum Anterior to Posterior Lesions and the Superior Labrum. Seminars in Musculoskeletal Radiology, 19(3), 269–276. []
 * 18) <span style="font-family: Arial,Helvetica,sans-serif;">Stetson, W. B., & Templin, K. (n.d.). The Crank Test, the O’Brien Test, and Routine Magnetic Resonance Imaging Scans in the Diagnosis of Labral Tears*. Retrieved from []
 * 19) <span style="font-family: Arial,Helvetica,sans-serif;">Walton, D. M., & Sadi, J. (2008). Identifying SLAP lesions: A meta-analysis of clinical tests and exercise in clinical reasoning. Physical Therapy in Sport, 9(4), 167–176. []