An assessment of the interexaminer reliability of tests for shoulder instability

Accurate noninvasive clinical tests of shoulder instability are important in assessing and planning treatment for glenohumeral joint instability. An interexaminer agreement trial was undertaken to estimate the reliability of commonly used clinical tests for shoulder instability. Thirteen patients with a history suggestive of instability, who had been referred to a shoulder specialist for treatment of their symptomatic shoulders, were examined by four examiners of differing experience. Good to excellent interexaminer agreement was found for most variations of the load-and-shift test, with the best agreement in the 90 degrees abducted position for the anterior direction (intraclass correlation coefficient [ICC] = 0.72) and in the 0 degrees abducted position for the posterior (ICC = 0.68) and inferior (ICC = 0.79) directions. Fair to good interexaminer reliability was found for the sulcus sign (ICC = 0.60). With regard to the provocative tests, agreement was best when apprehension was used as the criterion for a positive test and was better for the relocation (ICC = 0.71) and release tests (ICC = 0.63) than for the apprehension (ICC = 0.47) and augmentations tests (ICC = 0.48). Reliability was poor (ICC < 0.31) when pain was used as the criterion for a positive test. These results indicate that the load-and-shift, sulcus, and provocative tests (apprehension, augmentation, relocation, and release) are reliable clinical tests for instability in symptomatic patients when care is taken with respect to arm positioning and if apprehension is used as the criterion for a positive provocative test.     

Posterior shoulder pain and anterior instability: a preliminary clinical study

Different clinical tests have been suggested in the literature as significant indicators of anterior shoulder instability. Sometimes patients with recurrent anterior shoulder instability may show some muscular guarding thus making the evaluation of specific clinical tests very difficult. These patients may also report a medical history with posterior shoulder pain that can be also elicited during some clinical manoeuvres. From September 2005 to September 2006 we prospectively studied patients who underwent an arthroscopic anterior capsuloplasty. Shoulder clinical examination was performed including anterior shoulder instability tests (drawer, apprehension and relocation tests). Furthermore the exam was focused on the presence of scapular dyskinesia and posterior shoulder pain. The patients were also evaluated with ASES, Rowe, SST (Simple Shoulder Test), Constant and UCLA (University of California at Los Angeles) scoring system preoperatively and at the latest follow-up time. In the period of this study we observed 16 patients treated for anterior gleno-humeral arthroscopic stabilisation, who preoperatively complained also of a posterior scapular pain. The pain was referred at the level of lower trapezium and upper rhomboids tendon insertion on the medial border of the scapula. It was also reproducible upon local palpation by the examiner. Four of these patients also referred pain in the region of the insertion of the infraspinatus and teres minor. After arthroscopic stabilisation the shoulder was immobilised in a sling with the arm in the neutral rotation for a period of 4 weeks. A single physician supervised shoulder rehabilitation. After a mean time of 6.8 months of follow-up, all the shoulder scores were significantly improved and, moreover, at the same time the patients referred the disappearance of the posterior pain. Posterior scapular shoulder pain seems to be another complaint and sign that can be found in patients affected by anterior shoulder instability. It can also be related to eccentric work of posterior stabilising muscles of scapula during the altered biomechanics observed in case of anterior shoulder instability. This pain responds positively to surgical intervention showing that re-centring the humeral head probably also re-establishes the periscapular muscle-firing pattern with a mechanism mediated by the proprioceptive system.     

创伤性肩关节前不稳定的临床研究

目的探讨创伤性肩关节前不稳定的诊断标准和治疗原则。方法根据４１例创伤性肩关节前不稳定患者发病机制、病程、症状及体征,肩关节Ｘ线片、气碘双重造影ＣＴ,以及基于关节囊、盂唇愈合机制,采用康复治疗和前关节囊修复成形术治疗的经验,提出诊断标准和治疗原则。结果创伤性肩关节前不稳定的诊断标准为：（１）外伤史;（２）肩前侧痛、无力、关节活动受限和肩周肌肉萎缩;（３）前惧痛征和前抽屉试验阳性;（４）Ｘ线片ＨｉｌＳａｃｈｓ骨缺损和气碘双重造影ＣＴ异常。治疗原则：（１）病程３个月内行康复治疗;（２）病程３个月以上、关节囊撕裂、康复治疗无效者,行手术治疗。治疗结果：４１例患者平均随访１６个月,临床效果满意。结论创伤性肩关节前不稳定诊断标准和治疗原则的提出,对提高肩部损伤的治疗水平以及相关理论的临床研究等,具有重要的参考价值     

Clinical testing for tears of the glenoid labrum

Purpose: With the increasing use of shoulder arthroscopy, diagnosis of glenoid labral lesions has become increasingly common. However, a physical examination maneuver that would allow a definitive clinical diagnosis of a glenoid labral tear, and more specifically a SLAP lesion, has been elusive. This study correlated the results of commonly used examination maneuvers with findings at shoulder arthroscopy. The working hypothesis was that 7 commonly used clinical tests, alone or in logical combinations, would provide diagnoses with reliability greater than the accepted standards for magnetic resonance imaging arthrography; i.e., greater than 95% sensitivity and specificity. Type of Study: Consecutive sample, sensitivity-specificity study. Methods: Sixty shoulders undergoing arthroscopy for a variety of pathologies were examined before surgery. All subjects submitted to the Speed test, an anterior apprehension maneuver, Yergason test, O'Brien test, Jobe relocation test, the crank test, and a test for tenderness of the bicipital groove. The examination results were compared with surgical findings and analyzed for sensitivity and specificity in the diagnosis of SLAP lesions and other glenoid labral tears. Results: The results of the O'Brien test (63% sensitive, 73% specific) and Jobe relocation test (44% sensitive, 87% specific) were statistically correlated with presence of a tear in the labrum and the apprehension test approached statistical significance. Performing all 3 tests and accepting a positive result for any of them increased the statistical value, although the sensitivity and specificity were still disappointingly low (72% and 73%, respectively). The other 4 tests were not found to be useful for labral tears, and none of the tests or combinations were statistically valid for specific detection of a SLAP lesion. Conclusions: Clinical testing is useful in strengthening a diagnosis of a glenoid labral lesion, but the sensitivity and specificity are relatively low. Thus a decision to proceed with surgery should not be based on clinical examination alone.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: pp 517'523     

Classification and evaluation of recurrent instability of the elbow

The clinical presentation, diagnosis, radiographic features, mechanism, pathologic changes, and treatment of elbow instability are understood better now. Elbow instability can be classified according to five criteria: (1) the timing (acute, chronic or recurrent); (2) the articulation(s) involved (elbow versus radial head); (3) the direction of displacement (valgus, varus, anterior, posterolateral rotatory); (4) the degree of displacement (subluxation or dislocation); and (5) the presence or absence of associated fractures. Posterolateral rotatory instability is the most common pattern of elbow instability, particularly that which is recurrent. Posterolateral rotatory instability can be considered a spectrum consisting of three stages according to the degree of soft tissue disruption. Patients typically present with a history of recurrent painful clicking, snapping, clunking, or locking of the elbow and careful examination reveals that this occurs in the extension portion of the arc of motion with the forearm in supination. There are four principle physical examination tests. The most sensitive is the lateral pivot-shift apprehension test, or posterolateral rotatory apprehension test, just as the anterior apprehension test of the shoulder is the most sensitive test for a patient with shoulder instability. Next is the lateral pivot-shift test, or posterolateral rotatory instability test. Reproducing the actual subluxation and the clunk that occurs with reduction usually can be accomplished only with the patient under general anesthesia or occasionally after injecting local anesthetic into the elbow. The third test is the posterolateral rotatory drawer test, which is a rotatory version of the drawer or Lachman test of the knee. The final test is the stand up test as reported by Regan. The patient's symptoms are reproduced as he or she attempts to stand up from the sitting position by pushing on the seat with the hand at the side and the elbow fully supinated. A lateral stress radiograph can show the rotatory subluxation.     

In vivo quantification of the laxity of normal and unstable glenohumeral joints

The purpose of this study was to determine whether the magnitude of glenohumeral translation on clinical laxity tests could distinguish between clinically stable shoulders and shoulders with traumatic or atraumatic instability. Subjects included eight male volunteers with no history of symptoms of glenohumeral instability, eight patients with documented traumatic anterior instability and Bankart lesions, and eight patients with documented atraumatic multidirectional instability. The patients in the two instability groups had disabling instability that was refractory to nonoperative management and thus met the indications for surgical repair. All subjects were examined by an experienced shoulder surgeon using five standard manual tests: anterior drawer, posterior drawer, sulcus, push-pull, and fulcrum. The glenohumeral translations occurring during these laxity tests were quantitated with a spatial sensing system that had six degrees of freedom and was rigidly fixed to the scapula and humerus. The result showed substantial overlap in the translations found in members of the three groups for each of the laxity tests. Standard laxity tests demonstrate considerable translation in normal glenohumeral joints and do not reliably differentiate normal shoulders from those with two common forms of glenohumeral instability. This study suggests that assessment of the magnitude of glenohumeral translation on clinical laxity tests is not a specific test for the diagnosis of glenohumeral instability. Healthy subjects without symptoms may have as much translation as patients needing surgical repair for symptomatic shoulder instability. The need for and the type of surgical reconstruction for the unstable shoulder must be based on the patient's history and on duplication of the symptoms of instability on directed physical examination rather than on the magnitude of glenohumeral translation.     

Correlation of pathology observed in double contrast arthrotomography and arthroscopy of the shoulder

Correlation of double contrast arthrotomography (DCAT) of the shoulder and arthroscopic surgery diagnostic results have been undertaken in 55 patients with persistent shoulder pain or involuntary shoulder instability. During the period March 1984 to December 1986, 55 patients underwent DCAT followed by videotaped diagnostic shoulder arthroscopy. The primary indication for DCAT was persistent pain in 36 patients and instability in 17 patients. DCAT was performed according to the method of El-Khoury and Albright, and all arthroscopies were performed in a similar fashion by the senior author (HJS). Both tests were reviewed separately, retrospectively, and their results were correlated. For combined (anterior and posterior) labral pathology, the sensitivity/specificity for the instability group was 0.91/0.91, respectively; sensitivity/specificity for the pain group was 0.63/0.94. DCAT accurately depicted the status of 76% of anterior labrums and 96% of posterior labrums. For complete rotator cuff tears, sensitivity/specificity was 1.0/0.94. The status of a complete rotator cuff tear was accurately depicted in 91% of patients. Partial rotator cuff tears were missed in 83% of patients by DCAT. The presence or absence of loose bodies was accurately represented by 96% of DCAT. Arthroscopy showed that 71% of the instability patients had a labral tear, compared with 44% of the pain patients. Rotator cuff pathology was present in 12% of instability patients and 42% of pain patients. These findings indicate that DCAT may be a conditionally reliable test in the diagnosis of shoulder instability. DCAT must be considered inconclusive, however, in the painful shoulder without instability. Its usefulness as a preoperative screening test is discussed, and a diagnostic algorithm is presented. DCAT does not equal the diagnostic accuracy of shoulder arthroscopy.     

Instabile Schulter

Shoulder instability can be divided into uni- and multidirectional types, each of which is subdivided into those with and without general hyperlaxity. Unidirectional instability without hyperlaxity is caused by a trauma of sufficient severity and is treated by refixation of the glenoid labrum-capsule-ligament aggregate. Unidirectional instability with hyperlaxity is precipitated by a mild trauma, diagnosed by a positive apprehension test and a positive sulcus sign, and treated surgically. Multidirectional instability with hyperlaxity is precipitated by a trivial injury and diagnosed by enhanced anterior, posterior, and inferior drawer signs with apprehension in at least 2 directions, and treated conservatively. At least 2 unrelated accidental events of adequate severity are required to cause the rare multidirectional instability without hyperlaxity. It becomes manifest in a positive anterior and posterior apprehension test and a negative sulcus sign. The anterior and posterior capsule-labrum structures are reconstructed surgically. The prognosis of traumatic shoulder dislocation depends primarily on the patient’s age. A longer period of immobilization has no influence on the recurrence rate, so that physiotherapy should be started early.     

Oxyphenbutazone (Tanderil®) in Surgery for Herniated Discs: A Double Blind Trial

Background and purpose In detection of glenoid labrum pathology, MR arthrography (MRA) has shown sensitivities of 88-100% and specificities of 89-93%. However, our practice suggested that there may be a higher frequency of falsely negative reports. We assessed the accuracy of this costly modality in practice.

Patients and methods We retrospectively reviewed MRA reports of 90 consecutive patients with clinical shoulder instability who had undergone shoulder arthroscopy. All had a history of traumatic anterior shoulder dislocation and had positive anterior apprehension tests. All underwent arthroscopy and stabilization during the same procedure. We compared the findings, using arthroscopic findings as the gold standard in the identification of glenoid labrum pathology.

Results 83 of the 90 patients had glenoid labrum tears at arthroscopy. Only 54 were correctly identified at MRA. All normal glenoid labra were identified at MRA. This gave a sensitivity of 65% and a specificity of 100% in identification of all types of glenoid labrum tear. 74 patients had anterior glenoid labral tears that were detected at an even lower rate of sensitivity (58%).

Interpretation The sensitivity of MRA in this series was substantially lower than previously published, suggesting that MRA may not be as reliable a diagnostic imaging modality in glenohumeral instability as previously thought. Our findings highlight the importance of an accurate history and clinical examination in the management of glenohumeral instability. The need for MRA may not be as high as is currently believed.     

Traumatic anterior shoulder dislocation: a case study of nonoperative management in a mixed martial arts athlete

Objective:

To present an evidence-informed approach to the nonoperative management of a first-time, traumatic anterior shoulder dislocation.

Clinical Features:

A 30-year-old mixed martial arts athlete, with no prior shoulder injuries, presented one day following a first-time, traumatic anterior shoulder dislocation. An eight-week, individualized, intensive, nonoperative rehabilitation program was immediately begun upon presentation.

Intervention and Outcome:

Management consisted of immobilization of the shoulder in external rotation and a progressive rehabilitation program aimed at restoring range of motion, strength of the dynamic stabilizers, and proprioception of the shoulder. Eight weeks post-dislocation the patient had regained full range of motion and strength compared to the unaffected limb and apprehension and relocation tests for instability were negative.

Conclusion:

This case illustrates successful management of a first-time, traumatic, anterior shoulder dislocation using immobilization in external rotation combined with an intensive rehabilitation program.     

Physical examination findings in young athletes correlate with history of shoulder instability

The goal of this study was to evaluate physical examination findings in a healthy cohort and determine potential correlations with a history of shoulder instability. A cross-sectional analysis was performed using the baseline data for an ongoing prospective cohort study to examine the risk factors for shoulder instability. A complete history of shoulder instability events was obtained, and a blinded physical examination was performed. The cohort comprised 711 patients (627 men, 84 women) with a mean age of 18.8 years. A total of 100 patients had a history of shoulder instability. Patients with a history of instability were more likely to have increased posterior translation (P=.010), positive apprehension sign (P=.003), positive relocation sign (P=.007), and sulcus sign (P=.017).     

Translation of the glenohumeral joint in patients with anterior instability: awake examination versus examination with the patient under anesthesia.

Fifty patients with a clinical diagnosis of traumatic anterior shoulder instability underwent bilateral shoulder translation testing while both awake and under anesthesia. Each patient was examined by 2 surgeons following guidelines developed by the American Shoulder and Elbow Surgeons. A single translation grade was established for anterior, posterior, and inferior directions. A comparison of means was performed with a paired t test. The mean anterior translation grade was significantly higher on the affected side when compared with that of the unaffected side both during awake examination and during examination with the patient under anesthesia (EUA). Ipsilateral comparison revealed significantly greater translation for both affected and unaffected shoulders in anterior, posterior, and inferior directions during EUA than during awake examination. Side-to-side comparison of posterior and inferior translation was similar for both awake examination and EUA. Clinical translation testing was helpful in the diagnosis of anterior shoulder instability. Side-to-side differences were subtle while awake and more apparent during EUA. The usefulness of awake translation testing for traumatic anterior instability was not clearly demonstrated; however, EUA provides helpful information to confirm the direction and degree of instability.     

Chronic instability and fixed dislocation of the shoulder

Chronic instabilities may be traumatic or atraumatic, unidirectional or multidirectional. It is important to distinguish between symptomatic instability and asymptomatic hyperlaxity. Posttraumatic, unidirectional anterior instability without hyperlaxity is the most common form of instability. The patient presents apprehension, the sulcus-sign is negative. Posttraumatic, unidirectional instability with hyperlaxity is due to an adequate trauma, both the apprehension test and the sulcus sign are positive. The treatment of traumatic instability is surgically with respect to the underlying pathology of the ligaments, labrum and capsule. The "golden standard" is the reconstruction of the capsulolabral complex. The repetitive microtraumatic instability is seen in overhead athletes with elongation or disruption of the capsule. The typical patient presents with painful subluxations, the instability may be unidirectional or multidirectional. The treatment is conservatively. Multidirectional instability with hyperlaxity is defined as symptomatic instability in at least two directions of instability with multidimensional hyperlaxity. These individuals will also report on pain rather than instability. The apprehension test is positive in at least two directions, the sulcus sign is positive as well. The patients are responsive to an intensive rehabilitation program for 6-12 months. Open capsular shift or thermal capsular shrinkage may be successful after failed conservative treatment. Multidirectional instability without hyperlaxity is extremely rare and is due to more than one adequate trauma with traumatic instability in different directions. The apprehension test is positive, the sulcus sign negative. The treatment is surgically. The fixed dislocation is posterior in most of the cases and frequently being missed primarily. It is seen in unconscious, multiple-injured patients or after grand mal or electroshock seizures. The reduction may be either closed or open depending on the interval between trauma and diagnosis. Voluntary instability represents a subset of individuals with atraumatic instability. The patients can dislocate and reduce their shoulder, have no pain and do not develop arthritis. They do not require a special therapy.     

Excellent Clinical and Radiological Midterm Outcomes for the Management of Recurrent Anterior Shoulder Instability by All-Arthroscopic Modified Eden-Hybinette Procedure Using Iliac Crest Autograft and Double-Pair Button Fixation System: 3-Year Clinical Case Series With No Loss to Follow-Up

PurposeTo evaluate the clinical, functional, and radiological midterm outcomes of the all-arthroscopic modified Eden-Hybinette procedure in patients with recurrent anterior shoulder instability.MethodsA retrospective, single-center case series with prospectively collected data was conducted. The inclusion criterion was traumatic recurrent anterior shoulder instability with significant glenoid bone loss; patients with atraumatic or multidirectional instability were excluded. An all-arthroscopic modified Eden-Hybinette procedure using iliac crest autograft and double-pair button fixation was carried out. All patients were postoperatively assessed for recurrence and apprehension. Shoulder range of motion values and functional scores, including American Shoulder and Elbow Surgeons Score, Oxford instability, Rowe instability, and Walch-Dupplay, were recorded. Graft positions, healing, and absorption were evaluated with computed tomography. Comparisons of values were performed with paired t tests for normally distributed differences and with nonparametric Wilcoxon’s signed rank test otherwise.ResultsThe final study cohort included 28 patients, mean age 36 ± 10 years, and mean follow-up period 43 ± 6 months (range 36 to 53). Median glenoid bone loss was 12.4% (range 8% to 33%). No recurrence occurred, no subjective shoulder instability was reported, and no major complications were documented through the last follow-up. Postoperative shoulder range of motion had no significant differences compared with the healthy side. All final postoperative functional scores significantly increased to show excellent results compared with preoperative values. All grafts were positioned and healed optimally, and none was completely reabsorbed.ConclusionsThe all-arthroscopic modified Eden-Hybinette procedure is safe, leading to excellent clinical and radiological midterm outcomes in patients with recurrent anterior shoulder instability. This technique restores glenoid bone defects and preserves the normal shoulder anatomy.Level of EvidenceIV, therapeutic, retrospective case series     

Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results

Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of the iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (>25% of glenoid diameter). All athletes with recurrent anterior shoulder instability and a large glenoid defect that underwent open anterior shoulder stabilization and glenoid reconstruction with the iliac crest allograft were followed over a 4-year period. Preoperatively, a detailed history and physical exam were obtained along with standard radiographs and magnetic resonance imaging of the affected shoulder. All patients also completed the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms preoperatively. A computed tomography scan was obtained postoperatively to assess osseous union of the graft and the patient again went through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. 10 patients (9 males, 1 female) were followed for an average of 16 months (4–36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/relocation test and full shoulder strength at final follow-up. Eight of 10 patients had achieved osseous union at 6 months (80.0%). ASES scores improved from 64.3 to 97.8, and SST scores improved from 66.7 to 100. Average postoperative WOSI scores were 93.8%. The use of the iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency.     

Minor Shoulder Instability

The wide spectrum of shoulder instability is difficult to include in 1 classification. The distinction between traumatic, unidirectional, and atraumatic multidirectional instability is still widely used, even though this classification is not sufficiently precise to include all the different pathological findings of shoulder instability. We present “minor instability,” which is a pathological condition causing a dysfunction of the glenohumeral articulation, especially in combination with microtrauma, repetitive or not, or after a period of immobilization or inactivity. When “minor shoulder instability” is suspected, the patient’s history and detailed clinical examination represent the most important factors when establishing the diagnosis. In particular, the apprehension test stressing the middle glenohumeral ligament (MGHL)/labral complex in the position of midabduction and external rotation may be painful and may even reveal anterior instability or subluxation. Conventional radiographs are negative in most cases, as is magnetic resonance imaging arthrography. It is only after an accurate arthroscopic assessment that the pathological lesion can be found. The major pathological process can be identified at the level of the anterior superior labrum, in particular the MGHL complex, and appears as hyperemia, fraying, stretching, loosening, thinning, hypoplasia, or even absence. It may, however, be difficult to distinguish between a normal variant and a pathological lesion. Clinical symptoms and examination should always be correlated with arthroscopic findings. Recommended treatment is to restore shoulder stability and thereby prevent shoulder pain secondary to the increase in laxity. A reduction in range of motion should be expected during the postoperative phase, at least up to six to nine months. External rotation is usually permanently reduced by a few degrees.     

Double bucket handle tear of the superior labrum in a young patient presented with shoulder instability treated with arthroscopic debridement: A case report

Introduction and importanceThe two major etiologies of shoulder superior labral tears anterior to posterior (SLAP) are traumatic and degenerative processes. Bucket handle tears of the superior labrum represent one-third of labral lesions. However, in this article, we present a double bucket handle tear which has been reported once in the literature.Presentation of caseA 25-year-old male presented with complaint of chronic pain in his right shoulder with a remote history of traumatic dislocation. Physical examination revealed a positive apprehension test. Shoulder magnetic resonance imaging (MRI) showed a superior labral tear with a Hill-Sach lesion. Arthroscopy showed a double bucket handle tear of superior labrum and mild biceps tendonitis along with Bankart lesion. The tear was resected and the Bankart lesion was repaired followed by supervised physical therapy. Good clinical outcomes in form of resolution of pain and shoulder instability at six months were obtained.DiscussionSLAP tears are common shoulder lesion that is reported differently in the literature. Arthroscopic studies had reported the incidence between 3.9%-11.8. The diagnosis of such lesion relies on the clinical presentation and imaging. Knesek et al. classified SLAP lesions based on the integrity of the biceps anchor and the type of labral tear (Knesek et al., 2013). The standard treatment of symptomatic SLAP lesions is Arthroscopic debridement. However, non-operative management was described in the literature.ConclusionDouble bucket handle injuries of the superior labrum are reported in literature once. These lesions can be treated with arthroscopic debridement and Bankart repair and followed by supervised physical therapy.     

冈上肌腱撕裂查体试验的诊断价值研究

目的:探讨6种常用查体试验对冈上肌腱撕裂的诊断价值,并评估这6种临床查体是否可以区分冈上肌腱部分或全层撕裂.方法:选择2017年6月至2020年9月因肩关节疾病行肩关节镜下手术治疗的91例患者,其中男49例,女42例;年龄31～68(50.8±11.0)岁;右侧70例,左侧21例.术前采用Hug-up试验、Jobe试验...     

Disorders of the superior labrum: review and treatment guidelines

Advancements in shoulder arthroscopy have led to a better understanding of the anatomy and disorders of the superior labrum biceps tendon anchor complex and the role that lesions of the superior labrum anterior and posterior lesions play in pain and instability of the shoulder. Various injury mechanisms have been suggested and studied and it is likely that different mechanisms produce different types and areas of damage to the superior labrum. Classification systems have been proposed to describe the specific pathoanatomy of lesions of the superior labrum anterior and posterior lesions and to guide treatment. Presenting symptoms often are nonspecific and physical examination maneuvers have varying degrees of sensitivity and specificity making diagnosis challenging. Diagnostic ability is enhanced by the ultimate diagnostic test, arthroscopy. A clear appreciation for the various lesions and the potential resulting joint dysfunction is necessary to determine the appropriate treatment of this complex region of the shoulder. The current authors review the anatomy, classification, presentation, evaluation and treatment results of superior labrum anterior and posterior lesions, and includes novel evaluation methods and treatment guidelines useful in treating these lesions.     

Intra- and inter-observer reproducibility of shoulder laxity tests: Comparison of the drawer,modified drawer and load and shift tests

Background

Conventional tests of shoulder laxity have been shown to have poor reliability due to the difficulty in palpating the subtle movements of the shoulder joint beneath the musculature. Modified drawer test that is performed while the soft tissues surrounding the shoulder are loosened has been proposed to facilitate glenohumeral joint movement and improve reliability. We hypothesised that the modified drawer test would have an improved intra- and inter-observer reproducibility in comparison to the drawer and load and shift tests. Correlation of shoulder laxity measured by these tests with generalized joint laxity was also assessed.