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:

Systematic Review Chart.jpg

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

external image capsule-300x219.jpg













Labral Tears


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:

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.

Superior Labral Tears (17)

Superior Labrum Anterior-Posterior (SLAP)
  • 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.
  • 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.
  • Type III: Also known as a “bucket handle” tear, the superior aspect of the labrum is torn but does not include the biceps tendon.
  • 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.
  • Type V: SLAP that extends into a Bankart lesion
  • Type VI: tear presents as a flap in the joint
  • Type VII: tear continues to involve middle GH ligament
  • Type VIII: tear moves posteriorinferiorly to reverse Bankart lesion
  • Type IX: Labrum tears throughout its circumference
  • Type X: tear involves rotator interval through superior GH ligament

external image slap-tear.jpg













Andrew's lesion: found mainly in throwers. Pure superior labrum detachment without extension posterior to biceps (3).

Anterior Labral Tears (3)

Pure anterior labral tears are rare and hard to distinguish from other types

Posterior Labral Tears (3)

Walch's internal impingement lesion: labral tear and partial tear of rotator cuff at supra/infraspinatus junction

Anterior and Antero-inferior Labral Tears (3)

Perthes lesion: detachment without displacement
Gleno-labral Articular Disruption (GLAD): rare, consists of superficial detachment or fissuring of the anterior and inferior labrum with adjacent cartilage defect
Bankart lesion: anterior detachment of the capsule and labrum in continuity with anterior part of the scapular neck

Posterior and Postero-inferior Labral Tears (3)

Kim's lesion: posterior capsulolabral and periosteal detachment with adjacent cartilage torn away

Medical Imaging Tests

Arthroscopy



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.



MRA/MRI: (5,8,17)

  • MRA
    • Sensitivity - 98%
    • Specificity - 99%
    • 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.
  • MRI
    • 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%
    • 1.5T MRI
      • Sensitivity - 42%
      • Specificity - 92%


SLAP tear.jpeg

Physical Examination Tests

Biceps Load Test I: (1,10,13)

  • 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.
  • Rationale: Evaluates the superior glenoid and tightening of the biceps to see if it is intact and provides stability.
  • Sensitivity - 83%
  • Specificity - 98%
  • Positve likelihood ratio: 29
  • Negative likelihood ratio: .09





















Biceps Load Test II: (1,10)

  • 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.
  • Rationale: Checks for SLAP lesion by assessing if biceps is intact and providing stability to the joint
  • Sensitivity- 89.7%
  • Specificity- 96.9%
  • Positive Likelihood ratio: 26
  • Negative Likelihood ratio: 0.11
  • Predictor values-Positive Predictor Value (PPV) 92.1%; Negative Predictor Value (NPV) 95.5%

















Crank Test: (1,4,18)

  • 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.
  • 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.
  • Sensitivity-46%
  • Specificity-56%
  • Positive likelihood ratio: 1.64
  • Negative likelihood ratio: .75
  • Predictor values: PPV- 41%; NPV 61%




Clunk Test: (12,15)

  • 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.
  • 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
  • Sensitivity- 67%
  • Specificity- 67%
  • Positive likelihood ratio: 16
  • Negative likelihood ratio: 0.67
  • Predictor values- PPV- 62% NPV-71%


Grind/Compression-Rotation Test: (4,12,13,14)

  • 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.
  • Rationale: The head of the humerus is compressed into the labrum and when it is rotated it will catch any pieces that are torn.
  • Sensitivity: 24%
  • Specificity: 76%
  • PPV: 9%
  • NPV: 90%
  • Positive likelihood ratio: 3.91
  • Negative likelihood ratio: .64


Internal Rotation Resistance Test (IRRT): (9,12,14)

  • 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.
  • 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
  • Sensitivity: 88%
  • Specificity: 96%
  • PPV: 88%
  • NPV: 96%


Jerk Test: (1, 3, 11)

  • 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.
  • 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.
  • Sensitivity - 73%
  • Specificity - 98%
  • Positive predictive value - 88%
  • Negative predictive value - 95%


Jobe Apprehension/Relocation: (1,4,12)

  • 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.
  • Rationale: The anterior force places tension on the anterior labrum, while the relocation test should relieve the tension
  • Sensitivity - 61%
  • Specificity - 47%
  • Positive likelihood ratio: 1.15
  • Negative likelihood ratio: .83



Kim Test: (1,11)

  • 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.
  • Rationale: The axial compression will compress the postero-inferior structures.
  • Sensitivity - 80%
  • Specificity - 94%
  • Positive predictive value - 73%
  • Negative predictive value - 96%



O'Brien's Test: (4,12,16,18)

  • 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.
  • Rationale: Examination starting position tightens the posterior capsule and posteriorly translates the humeral head, stressing the labrum which results in pain and weakness.
  • Sensitivity- 54%
  • Specificity- 31%
  • Positive likelihood ratios: 1.03
  • Negative likelihood ratio: .94
  • Predictor values- PPV-34%; NPV-50%


Yergason's: (4,7,12,19)

  • 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.
  • Rationale: Supination and external rotation place tension on the long head of the biceps tendon, which is involved in SLAP tears.
  • Sensitivity-43%
  • Specificity-79%
  • Positive predictive value- 60%
  • Negative predictive value- 65%
  • Positive likelihood ratio: 2.5
  • Negative likelihood ration: .87


Summary Statement (2,3,4,6)


physical exam chart.JPG

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
  • 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
For anterior labrum, the apprehension test has shown to be the most useful.

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.




References:

  1. Arnander, M., & Tennent, D. (2014). Clinical assessment of the glenoid labrum. Shoulder & Elbow, 6(4), 291–299. http://doi.org/10.1177/1758573214546156
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  3. Clavert, P. (2015). Glenoid labrum pathology. Surgery & Research, 101, 19–24. https://doi.org/10.1016/j.otsr.2014.06.028
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