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Testing for Glenoid Labrum Tears—Avoiding Surprises
Abstract & Commentary
Synopsis: Seven clinical examinations for shoulder labral tears were performed, and it was found that none of the examinations, either alone or in combination, was consistently reliable in diagnosing labral tears preoperatively.
Source: Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy. 2003;19(5):517-523.
We all frequently encounter unsuspected labral tears (surprises) during shoulder arthroscopy. Guanche and Jones took a closer look at several common clinical tests for labral pathology with a goal of reducing the number of arthroscopic surprises. Sixty shoulders were prospectively examined prior to surgery. The preoperative diagnosis in these patients was roughly divided into 3 groups, including suspected labral tears (mostly SLAP tears), acromioclavicular DJD, and subacromial impingement. All patients had failed an appropriate course of nonoperative management and were indicated for shoulder arthroscopy. Guanche performed 7 examinations on each patient immediately prior to surgery: speed test, anterior apprehension maneuver, Yergason test, O’Brien test, Jobe relocation test, crank test, and bicipital groove tenderness.
Following examination, a thorough shoulder arthroscopy was accomplished, and labral findings were compared with the results of physical examination independently and in combinations with appropriate statistical tools. Fifty-three labral lesions were found in the study population (33 SLAP tears [including 11 type I and 19 type II tears] and 20 other labral tears [including 15 anterior labral tears]).
Of the 7 examinations performed, only the Jobe relocation test and the O’Brien test showed a statistically significant correlation between a labral tear and a positive test. The sensitivities of these 2 tests (44% and 63%, respectively) were low, however, limiting their clinical utility. Combining the 3 most reliable tests (Jobe relocation, O’Brien, and apprehension) did not significantly improve the sensitivity. Guanche and Jones conclude that these 7 tests are not adequate for prospective diagnosis of labral tears.
Comment by Mark D. Miller, MD
I have several concerns that this study has highlighted. First of all, there is no way that almost 90% of my patient population has a labral tear at the time of arthroscopy. I feel that this highlights the essential dilemma—there is no gold standard in the diagnosis of labral tears. Findings at the time of arthroscopy, which is the gold standard for many diagnoses, are very subjective for the diagnosis of labral tears. This is because there is a great deal of variability in the normal anatomy of the labrum, and there are no clear criteria for what is "normal." MRI or MR-Arthrography is also not completely reliable, and studies that proport to show high sensitivity and specificity are compared with suspect arthroscopic findings.
Guanche and Jones correctly point out the importance of knowing the surgical pathology preoperatively in order to obtain a proper patient consent, to have the right equipment available, and for the surgeon to be prepared to address all pathology at the time of arthroscopy.
Unfortunately, MRI and (as this study shows) physical examination findings do not consistently make that possible.
Dr. Miller is Associate Professor, UVA Health System, Department of Orthopaedic Surgery, Charlottesville, VA.