When a patient presents with a complaint of "deep" pain in the shoulder, especially in the absence of impingement signs or specific palpable points of tenderness, consideration should be given to the possibility of a SLAP tear. Since its description in 1990,21 there has been an aggressive search by authors to find an accurate physical examination technique for superior labral tears. Some of the more commonly used are described in the following.
When these tests are strongly positive, especially in the relative absence of impingement signs, consideration should be given to performing an intra-articular injection, as described later. Complete relief suggests an intra-articular source and points strongly to a diagnosis of a SLAP tear or internal impingement.
Active Compression Test (O'Brien's Test)
Described previously as an AC joint provocative test, this test will often produce dramatic pain "deep inside" in the presence of a SLAP tear (see Fig. 16-13). This test has been shown to be positive in 95% of patients who demonstrate superior labral pathology at arthroscopy.18 We find this test to be sensitive for labral tears, but not very specific, as it is often positive in patients with impingement.
This test is similar to the active compression test, but the arm is placed in 45 degrees of adduction and 90 degrees of shoulder flexion, with the elbow extended and forearm pronated, and a downward force on the arm is resisted by the patient. A positive test produces apprehension, pain referable to the bicipital groove, and/or an audible or palpable click. The test is repeated with the forearm supinated, which must cause diminution of the pain. The creators of this test found it to be 87.5% sensitive for unstable SLAP lesions.5,22
This test is performed by placing the supine patient's arm in 120 degrees of elevation and maximal external rotation with the elbow flexed 90 degrees and the forearm supinated. The patient is asked to flex the elbow against resistance, and the test is considered positive if this reproduces or accentuates the patient's pain. In one prospective study, this test was shown to be 90% sensitive and 97% specific for a type II SLAP lesion.5,23 We have not been able to reproduce the accuracy of this test for SLAP lesions in our practice.
This test is performed by having the patient place both hands on the hips with the thumbs facing forward. The examiner directs an axial force at the elbow in an anterior and superior direction. A positive test is marked by pain with this maneuver. The anterior slide test has been shown to be 78% sensitive and 92% specific24 for lesions of the superior labrum in throwing athletes.
O'Driscoll's Superior Labral Pathology Test
This test is similar to the test for valgus instability of the elbow. The patient is supine or upright, and the shoulder is placed in the extreme abducted, externally rotated position. From this position, a moving valgus stress is applied, and a positive response is signified by pain in the shoulder. We have found this test to be quite sensitive but not very specific for SLAP lesions.5
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