The surgical management of superior labral anterior posterior

Transcription

1 WAYNE A. DESSAUR, MSc 1 PhD 2 Diagnostic Accuracy of Clinical Tests for Superior Labral Anterior Posterior Lesions: A Systematic Review The surgical management of superior labral anterior posterior (SLAP) lesions of the shoulder has advanced in recent years, as arthroscopic techniques have led to a better understanding of labral anatomy and pathomechanics. With the complicated injuries that may occur at this site, greater emphasis is placed on accurate diagnosis and treatment to return patients to full function. As surgical procedures have advanced, so has our ability to diagnose and treat such injuries, as we have become more aware STUDY DESIGN: Systematic literature review. OBJECTIVES: To conduct a systematic review of case series and clinical trials that investigate the diagnostic accuracy of clinical tests for superior labral anterior posterior (SLAP) lesions. BACKGROUND: Primary contact practitioners are often presented with shoulder problems and use a battery of clinical tests to reach a diagnosis. Early detection of SLAP pathology may lead to more optimal interventions and better outcomes for patients. METHODS AND MEASURES: The OVID search interface was utilized with MEDLINE, AHMED, CI- NAHL, and SPORTDiscus databases searched from 1996 to Studies were retrieved that included patients with shoulder pain who underwent at least 1 clinical shoulder test for SLAP lesions. For an article to be included in this review, the results of the clinical tests needed to be compared with findings on arthroscopy. Quality of the manuscripts included in this review were rated using the QUA- DAS appraisal tool, so comparisons could be made across studies. RESULTS: Seventeen published manuscripts fit the inclusion/exclusion criteria and were used for this review. Eight studies were found to be of high quality. Within these 8 studies, 1 group of authors of the labral structure and the nature of SLAP injuries. The superior labrum has been found to have a loose attachment to reported high diagnostic accuracy values for the crank test: sensitivity, 91% (95% confidence interval [CI], 76%-97%); specificity, 93% (95% CI, 79%-98%); positive likelihood ratio, 13.6 (95% CI, ); and negative likelihood ratio, 0.1 (95% CI, ). One study on the resisted supination external rotation test also scored high on the QUADAS and reported diagnostic accuracy values of 83% (95% CI, 66-92), 82% (95% CI, 52-95), 4.6 (95% CI, ), and 0.20 (95% CI, ), respectively. Of significance is the fact that the majority of papers reporting highly accurate clinical diagnostic tests were of low quality, with the results not supported by other authors. CONCLUSION: It appears that no single test is sensitive or specific enough to determine the presence of a SLAP lesion accurately. Further research is required to determine whether subgrouping of patients by mechanism of injury or the type of SLAP lesion may improve diagnostic accuracy. Determining the diagnostic accuracy of a combination of 2 or more tests is also needed. LEVEL OF EVIDENCE: Diagnosis, level 2a-. J Orthop Sports Phys Ther 2008;38(6): doi: /jospt KEY WORDS: labral lesion, labrum, shoulder, SLAP the glenoid rim through an elastic connective tissue and to interconnect with the long head of the biceps tendon. 6,18 The vascularity of the labrum is less in the superior and anterosuperior regions compared to the inferior 6 region and has been found to decrease with age. 43 These factors ultimately lead to a higher risk of injury, along with decreased healing potential, in these areas of the labrum. The labral complex, consisting of the labrum itself and its attachments to the tendon of the long head of biceps, plays an important role in the stability and function of the glenohumeral joint, and accurate diagnosis has important implications in the pursuit of correct and successful treatment. 16 Primary contact practitioners are often presented with individuals with shoulder pain and use diagnostic clinical tests with or without radiological imaging to establish a diagnosis. SLAP lesions have been divided into 4 groups based on the extent of the lesion. 46 A type I lesion consists of degenerative fraying of the superior labrum and is often found in elderly patients. 37 A type II lesion consists primarily of a detachment of the biceps anchor from the superior glenoid tubercle, but may also involve some fraying. A type III lesion consists of a bucket handle tear of the superior labrum, with the biceps attachment appearing intact. A type IV lesion consists of a bucket-handle tear with an extension into the biceps tendon. Different combinations of these lesions may exist con- 1 Private Practitioner, Clinical Educator, University of South Australia, Adelaide, South Australia. 2 Senior Lecturer, Coordinator in Postgraduate Courses, Discipline of Physiotherapy, University of South Australia, Adelaide, South Australia. Address correspondence to Wayne A. Dessaur, Health on Grange Physiotherapy, 256 Grange Road, Flinders Park, 5025, South Australia. healthongrange@optusnet.com.au journal of orthopaedic & sports physical therapy volume 38 number 6 june

2 TABLE 1 currently with type III or IV commonly found with type II. 37 Management decisions for individuals with shoulder pain often depend on the results of the clinical examination and the ability to provide an accurate diagnosis. Therefore, the aim of this paper is to review the current literature related to the accuracy of clinical diagnosis of SLAP lesions. A good understanding of this information will help the clinician to decide which tests to use and how to interpret the outcome of the tests. METHODS exam$ MRI surg$ diagnos$ test arthroscop$ labr$ SLAP bankart shoulder Key Words Used in Search TABLE 2 Sensitivity = Specificity = Positive likelihood ratio = TABLE 3 Likelihood Ratios and Clinical Values 17 +LR LR Shift in Probability Condition Present Large, often conclusive Moderate but usually important Small, sometimes important Very small, rarely important Abbreviations: +LR, positive likelihood ratio; LR, negative likelihood ratio. Search Strategy MEDLINE, AHMED, CINAHL, and SPORTDiscus databases were searched to retrieve the specific papers for this review. The search was conducted over 10 years ( ) using related key words (TABLE 1) in various combinations (APPENDIX). Articles were limited to those written in English, performed on humans, and published in peer-reviewed journals. If the title appeared appropriate, the abstract was reviewed. If still undecided regarding the suitability of the article following the review of the abstract, the full article was reviewed. To be included in this review, papers had to include patients with shoulder pain who underwent at least 1 clinical shoulder test for SLAP lesions. The results of the test must then have been compared with findings on arthroscopy (case series design). Also, statistical data to calculate sensitivity and specificity were required as an inclusion criterion. Therefore, any previous systematic reviews or investigations reporting only on results based on findings with musculoskeletal imaging were excluded. However, if studies reported data for both musculoskeletal imaging and arthroscopic findings, then calculations were only included for the reported arthroscopic findings. Papers were also excluded if the population had experienced trauma with diagnosis of fractures or were reported to have any systemic diseases. From the initial search strategy, the first author carefully reviewed the titles of the 1849 articles for possible inclusion. The abstracts from these relevant titles where then retrieved by both authors and assessed for their suitability. If thought to be appropriate, the full text article was retrieved and the inclusion/exclusion criteria were independently applied by each author. Any discrepancies were discussed until a consensus was reached, with the opinion of a third reviewer sought if necessary. Reference lists were checked from the selected articles and from any relevant reviews to identify any additional relevant publications. Manual searching was also conducted in the American Journal of Calculations for Diagnostic Accuracy Statistics Number of patients diagnosed as having condition based on clinical test Number of patients diagnosed as having condition based on gold standard Number of patients diagnosed as not having condition based on clinical test Number of patients diagnosed as not having condition based on gold standard Sensitivity (1 - Specificity) (1 - Sensitivity) Negative likelihood ratio = Specificity Sports Medicine, Journal of Arthroscopy and Related Research, Journal of Shoulder and Elbow Surgery, Manual Therapy, and the Journal of Orthopaedic & Sports Physical Therapy, to further ensure that no articles were missed. Diagnostic Accuracy Statistics For inclusion in the review, sufficient data were required so that sensitivity, specificity, and likelihood ratios could be calculated if these figures were not already presented in the text. Sensitivity and specificity refer to the ability of the clinical test to identify patients with and without a certain condition and are required to calculate likelihood ratios 8 (TABLE 2). Sensitivity indicates how good the test is at identifying people who have the condition, while specificity refers to the ability of the test to identify people who do not have the condition. A positive likelihood ratio (+LR) refers to how much more likely a positive test is to be found in people with the condition than in people without it. A negative likelihood ratio (-LR) refers to how much more likely a negative test is to be found in people without the condition than in people with it. 11 The values shown in TABLE 3 indicate how likelihood ratios can be used to as- 342 june 2008 volume 38 number 6 journal of orthopaedic & sports physical therapy

3 TABLE 4 QUADAS Scores for Each of the Studies Included in the Review Study Total Bennett (1998) 2 Y U Y U Y Y Y Y Y Y U Y N Y Guanche (2003) 12 Y Y Y Y Y Y Y Y U Y U Y N Y Hamner (2000) 14 Y U Y U Y Y Y Y U Y U Y N Y Holtby (2004) 15 Y Y Y N Y U Y Y Y Y Y Y N Y Kim (2001) 20 Y Y Y U Y Y Y Y N Y U N N Y Kim (1999) 21 Y Y Y Y Y Y Y Y N Y U U N Y Kim (2003) 24 Y U Y U Y Y Y N Y Y U Y N Y Lui (1996) 26 Y U Y U Y Y Y Y U Y U Y N Y Lui (1996) 27 Y Y Y U Y Y Y Y U Y U Y N Y McFarland (2002) 30 Y Y Y Y Y Y Y Y U Y U Y N Y Mimori (1999) 31 Y Y Y U N N Y Y N Y U Y N N Morgan (1998) 34 Y U Y U Y Y Y Y Y Y U Y N Y Myers (2005) 35 Y Y Y Y Y Y Y Y N Y Y Y N Y Nakagawa (2005) 36 Y Y Y U Y Y Y Y N Y Y Y N Y O'Brien (1998) 39 Y N Y U N N Y U N Y U N N U Parentis (2006) 41 Y Y Y U Y Y Y Y N Y U Y N U Stetson (2002) 47 Y U Y U Y Y Y Y N Y U Y N Y % ge agreement Item Criteria 1. Was the spectrum of patients representative of the patients who will receive the test in practice? 2. Were selection criteria clearly described? 3. Is the reference standard likely to correctly classify the target condition? 4. Is the time period between reference standard and index test short enough to be reasonably sure that the target condition did not change between the 2 tests? 5. Did the whole sample or a random selection of the sample, receive verification using a reference standard of diagnosis? 6. Did patients receive the same reference standard regardless of the index text result? 7. Was the reference standard independent of the index test (ie, the index test did not form part of the reference standard)? 8. Was the execution of the index test described in sufficient detail to permit replication of the test? 9. Was the execution of the reference standard described in sufficient detail to permit its replication? 10. Were the index test results interpreted without knowledge of the results of the reference standard? 11. Were the reference standard results interpreted without knowledge of the results of the index test? 12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice? 13. Were uninterpretable/intermediate test results reported? 14. Were withdrawals from the study explained? Abbreviations: % ge agreement, agreement found across the reviewed studies for each item of the QUADAS; N, no;quadas, quality assessment of diagnostic accuracy tool; U, unclear; Y, yes. Item journal of orthopaedic & sports physical therapy volume 38 number 6 june

4 TABLE 5 Patient Demographics Years of Age Author Tests Patient Population (Mean [Range]) SLAP Lesions Bennett (1998) 2 Speeds 45 patients (31 males, 14 females), 46 shoulders (26 dominant, 20 nondominant), pain in proximal part of shoulder Guanche (2003) 12 Active compression, anterior apprehension, crank, relocation, speeds, Yergason Abbreviation: SLAP, superior labral anterior posterior. 59 patients (48 males, 11 females), 60 shoulders males, 16-76; females, (15-76) Type I, 11; type II, 19; type III, 1; type IV, 2 Labral tears: anterior, 15; posterior, 4; inferior, 1 Hamner (2000) 14 Modified relocation 13 overhand athletes with shoulder pain and 24 (21-31) 13 (fraying, SLAP, Bankart) failed conservative treatment for 3 mo Holtby (2004) 15 Speeds, Yergason 50 patients (34 males, 16 females) 50 (24-79) Bicipital tendinitis, 2; type I, 15; type II, 12; type IV, 1 Kim (2001) 20 Biceps load II 127 patients (89 males, 38 females), (15-52) Type II, 43 dominant, 36 involved in athletic activities Kim (1999) 21 Biceps load, biceps tension 75 patients (64 males, 11 females) with unilateral recurrent dislocation, 61 dominant 24.8 (16-41) Type II, 11 Kim (2003) 24 Active compression, anterior apprehension, anterior slide, compression rotation, painful arc, relocation, speeds 544 patients (309 males, 235 females) 44.2 (12-86) Type I, 103; type II, 29; type III, 1; type IV, 6 Liu (1996) 26 Apprehension or relocation 54 patients (37 males, 17 females) 34 (17-57) 11 Liu (1996) 27 Crank 62 patients (40 males, 22 females), (18-57) 21 recreational athletes, 53 dominant McFarland (2002) 30 Active compression, anterior slide, compression rotation 426 patients (252 males, 174 females) 45 (SD, 17.8) Type I, 88; type II, 34; type III-V, 5 Mimori (1999) 31 Crank, new pain provocation 32 patients (30 males, 2 females); baseball 20.9 (17-29) Type II, 11 players, only 15 underwent arthroscopy Morgan (1998) 34 Active compression, bicipital groove tenderness, relocation, speeds 102 patients 33 (27-72) Type II, 102 Myers (2005) 35 Nakagawa (2005) 36 Active compression, crank, resisted supination external rotation Active compression, anterior apprehension, bicipital groove tenderness, clunk, sulcus, painful arc, compression rotation, forced abduction, Neer, Ellman, crank, Hawkins, relocation, speeds, Yergason, posterior jerk, abduction inferior instability, anterior slide 40 athletes (39 males, 1 female) 23.9 (17-50) Type II, 26; type III, 1; type IV, 2 54 throwing athletes (52 males, 2 females) 23 (14-40) Type II, 22; type III, 2 O Brien (1998) 39 Active compression 268 Not provided 53 labral abnormalities Parentis (2006) 41 Active compression, anterior slide, crank, Neer, Hawkins, pain provocation, relocation, speeds, Yergason 132 patients (98 males, 34 females) 42 (15-71) Type I, 17; type II, 23 Stetson (2002) 47 Active compression, crank 65 patients (45 males, 20 females), 45 dominant, 20 nondominant 45.9 (18-75) Type II, 10; type IV, 2 Labral tears: anterior, 10; posterior, 3 sess a change in the probability of the condition being present. Even though some papers did not report the likelihood ratios in their results, these values could be calculated using the reported results for sensitivity and specificity. Likelihood ratios are believed to be one of the most useful statistics when reporting on the diagnostic accuracy of clinical tests. 17 In cases where specificity was reported to be 100%, the +LR is computed as being infinite. However, it has been proposed that adding 0.5 to each cell of the contingency table enables this value to be calculated to an acceptable level. 1,48 Critical Appraisal To evaluate the quality of retrieved pa- 344 june 2008 volume 38 number 6 journal of orthopaedic & sports physical therapy

5 pers, the Quality Assessment of Diagnostic Accuracy tool (QUADAS) was used. 51 This evidence-based tool has undergone extensive development and evaluation 50 while demonstrating face validity under the Delphi procedure. 51 Interrater agreement has also been reported to be good (kappa, 0.65). 52 The tool consists of 14 questions that can be answered as yes, no, or unclear. Nine of these questions relate to bias, 3 relate to the quality of the reporting, and 2 relate to variability. 51 As the interpretation of each item may differ between reviewers, 52 an initial meeting was conducted by the authors of this paper to discuss and agree upon their understandings of each question. The original paper describing the QUADAS tool presents a useful guide as to how each item should be scored. 51 However, each item was discussed between the 2 authors of this review to ensure that interpretations were similar. For item 4, relating to the amount of time between the performance of the clinical tests and the arthroscopic evaluation, it was arbitrarily agreed by the authors that a period of 6 weeks would be acceptable. Therefore, for this particular item, anything less than 6 weeks scored a yes, anything greater scored a no, and, if nothing was reported, an unclear score was allocated. Item 13 also required some clarification. It was agreed that this question relates to any results of the test that were uninterpretable by the clinician. For example, any test where the examiner was not clear if it was positive or negative from the subjective response of the patient. If uninterpretable or unsure findings were reported, then this item scored a yes. If nothing was reported, a no was scored and, if readers were unsure, an unclear was allocated. Scoring and Quality of Papers Although QUADAS does not have an incorporated quality scoring method, for this systematic review we used the method subsequently proposed by the original developers. 51 This scoring system is weighted based on the evidence used to develop the QUADAS. 49 Items 1, 5, 10, 11, and 12 were scored 3 for yes, items 3 and 6 scored 2 for yes, and all other items scored 1 for yes (4, 7, 8, 9, 13, and 14). For those items which scored no or unclear, a zero was allocated. A maximum score attainable using this method was 26. This scoring system was based on the evidence found by the original developers relating to bias or variation. 49 Studies were classified as either high quality or low quality, using the quality scores. The median score of all the studies was calculated, and those with scores higher than the median were classified as high quality, while those with scores equal to or lower than the median were classified as low quality. 49 Two independent reviewers assessed the methodological quality of the retrieved papers using the QUADAS appraisal tool. The results were discussed and a final score for each paper decided. For any disagreements that were unable to be resolved by the reviewers, consensus was reached using a third reviewer. RESULTS The initial search strategy yielded a total of 1849 articles. Based on the titles, 42 were initially believed to be suitable for the review. The abstracts of these 42 were then examined for inclusion and exclusion criteria. Of those 42, 30 manuscripts that met the inclusion criteria or provided insufficient information through their abstracts were retrieved in-full before a final decision was made. Based on the full text of these 30 articles, inclusion/ exclusion criteria applied by the authors independently produced a total of 20 papers believed appropriate for this review. After discussion and reaching consensus without a third party, a further 3 articles were excluded, 23,29,54 leaving a final total of 17 papers for this review. Of the 13 papers excluded based on the review of the full text, 4 were excluded because they were descriptive papers of labral pathologies, 4,7,33,53 1 was a systematic review, 32 and 4 were studies in which the shoulder was investigated to some extent arthroscopically but without enough detail presented to compare individual tests for SLAP lesions with surgical findings. 29,38,44,54 One paper was excluded because the reported results were based on magnetic resonance imaging arthrograms and not arthroscopy. 22 One manuscript had insufficient data to calculate specificity. 3 Another paper was excluded because the authors had republished the data in a later study 42 and 1 paper because it investigated only postero-inferior labral lesions. 23 All 17 papers meeting the final inclusion criteria were scored independently by the 2 authors with a Cohen s kappa and showed substantial agreement (0.74). The percentage agreement shown in TABLE 4 provides details of which items were commonly discussed and resolved. In all instances, consensus was reached between the 2 reviewers and a third party was not required. All items had a percentage agreement of greater than 70% (TABLE 4), with the exception of item 9, which had 59% agreement. Four items (3, 7, 10, and 13) had a 100% agreement between the 2 reviewers. The quality scores, agreed response for each item, and the total quality score for each paper are presented in TABLE 4. The median quality score calculated from the appraised studies was 19, with 8 studies classifying as high quality 2,12,15,27,30,34-36 and 9 as low quality. 14,20,21,24,26,31,39,41,47 The mean appraisal score was 19.1, with a standard deviation of 3.5 and a range of 9 to 24. The study by Myers et al, 35 which investigated the active compression, crank, and the resisted supination external rotation tests, had the highest (24/26) QUADAS score. The lowest QUADAS score of 9/26 was given to the study by O Brien et al, 39 who investigated the active compression test they developed. Two papers 31,36 reported specificity of 100%, leading to a recalculation of the +LR by adding 0.5 to each cell in the contingency table. 1 The study populations investigated in the reviewed articles are presented in journal of orthopaedic & sports physical therapy volume 38 number 6 june

6 TABLE 6 Summary of Diagnostic Accuracy QUADAS Number of Test Authors Score shoulders Sensitivity (95% CI) Specificity (95% CI) +LR (95% CI) LR (95% CI) Active compression O Brien (1998) % (92-100) 98% (96-99) 61.1 ( ) 0.0 ( ) Parentis (2006) Type II, 23 65% (50-78) 49% (39-59) 1.3 ( ) 0.7 ( ) Type I & II, 40 63% (47-76) 50% (40-60) 1.3 ( ) 0.7 ( ) Stetson (2002) % (36-71) 31% (19-46) 0.8 ( ) 1.5 ( ) Kim (2003) Type I, % (45-68) 53% (47-59) 1.2 ( ) 0.8 ( ) Type II, % (33-71) 53% (47-59) 1.1 ( ) 0.9 ( ) Type III/IV, % (4-63) 53% (47-59) 0.4 ( ) 1.5 ( ) Guanche (2003) % (38-70) 47% (31-66) 1.1 ( ) 0.9 ( ) McFarland (2002) % (33-63) 55% (50-60) 1.1 ( ) 1.0 ( ) Morgan (1998) anterior 88% (71-96) 42% (25-64) 1.6 ( ) 0.3 ( ) 102 posterior 32% (18-51) 13% (5-35) 0.4 ( ) 4.8 ( ) 102 combined 85% (68-94) 41% (25-64) 1.5 ( ) 0.4 ( ) Myers (2005) % (59-89) 11% (2-44) 0.9 ( ) 2.0 ( ) Nakagawa (2005) % (35-72) 60% (42-75) 1.4 ( ) 0.8 ( ) Anterior apprehension Guanche (2003) % (17-47) 63% (44-79) 0.8 ( ) 1.1 ( ) Kim (2003) Type I, % (9-23) 77% (72-81) 0.7 ( ) 1.1 ( ) Type II, % (14-46) 77% (72-81) 1.2 ( ) 1.0 ( ) Type III/IV, % (16-75) 77% (72-81) 1.8 ( ) 0.8 ( ) Nakagawa (2005) % (64-93) 40% (25-58) 1.4 ( ) 0.4 ( ) Abduction inferior stability Nakagawa (2005) % (15-49) 90% (74-97) 2.9 ( ) 0.8 ( ) Apprehension or relocation Liu (1996) % (78-96) 85% (58-96) 5.9 ( ) 0.1 ( ) Anterior slide McFarland (2002) % (3-21) 84% (80-87) 0.5 ( ) 1.1 ( ) Kim (2003) Type I, % (9-25) 83% (78-87) 0.9 ( ) 1.0 ( ) Type II, % (5-32) 83% (78-87) 0.8 ( ) 1.1 ( ) Type III/IV, 253 0% (0-48) 83% (77-87) 0.5 ( ) 1.1 ( ) Parentis (2006) Type II, 23 13% (6-26) 84% (75-90) 0.8 ( ) 1.0 ( ) Type I & II, 40 10% (4-23) 82% (72-88) 0.5 ( ) 1.1 ( ) Nakagawa (2005) % (0-20) 93% (79-98) 0.6 ( ) 1.0 ( ) Biceps load Kim (1999) % (62-98) 97% (90-99) 29.1 ( ) 0.1 ( ) Biceps load II Kim (2001) % (76-96) 97% (91-99) 30.0 ( ) 0.1 ( ) Biceps tension Kim (1999) % (43-90) 78% (67-87) 3.3 ( ) 0.4 ( ) Bicipital groove tenderness Morgan (1998) anterior 98% (85-100) 48% (29-67) 1.9 ( ) 0.0 ( ) 102 posterior 32% (18-51) 13% (5-35) 0.4 ( ) 4.8 ( ) 102 combined 74% (55-87) 35% (17-55) 1.1 ( ) 0.8 ( ) Guanche (2003) % (32-65) 52% (34-69) 1.0 ( ) 1.0 ( ) Nakagawa (2005) % (12-45) 80% (63-91) 1.3 ( ) 0.9 ( ) Clunk test Nakagawa (2005) % (28-65) 68% (49-81) 1.4 ( ) 0.8 ( ) Compression rotation Kim (2003) Type I, % (14-36) 77% (70-82) 1.0 ( ) 1.0 ( ) Type II, % (10-50) 77% (70-82) 1.1 ( ) 1.0 ( ) Type III/IV, % (6-80) 77% (70-82) 1.4 ( ) 0.9 ( ) McFarland (2002) % (12-42) 76% (70-80) 1.0 ( ) 1.0 ( ) Nakagawa (2005) % (13-46) 98% (86-100) 16.1 ( ) 0.8 ( ) Crank Guanche (2003) % (25-56) 67% (48-81) 1.2 ( ) 0.9 ( ) Stetson (2002) % (29-65) 56% (41-71) 1.1 ( ) 1.0 ( ) Parentis (2006) Type II, 23 9% (4-23) 83% (74-89) 0.6 ( ) 1.1 ( ) Type I & II, 40 13% (6-26) 83% (74-89) 0.7 ( ) 1.1 ( ) Liu (1996) % (76-97) 93% (79-98) 13.6 ( ) 0.1 ( ) Nakagawa (2005) % (39-76) 72% (56-86) 2.2 ( ) 0.6 ( ) Myers (2005) % (19-54) 70% (40-89) 1.2 ( ) 0.9 ( ) Mimori (1999) % (42-95) 75% (20-97) 3.1 ( ) 0.3 ( ) Forced abduction test Nakagawa (2005) % (47-82) 67% (49-81) 2.0 ( ) 0.5 ( ) Ellman Nakagawa (2005) % (25-61) 63% (46-79) 1.1 ( ) 0.9 ( ) 346 june 2008 volume 38 number 6 journal of orthopaedic & sports physical therapy

7 TABLE 6 Summary of Diagnostic Accuracy (continued) QUADAS Number of Test Authors Score shoulders Sensitivity (95% CI) Specificity (95% CI) +LR (95% CI) LR (95% CI) Neer Parentis (2006) Type II, 23 48% (33-63) 51% (41-61) 1.0 ( ) 1.0 ( ) Type I & II, 40 50% (35-65) 52% (42-62) 1.1 ( ) 1.0 ( ) Kim (2003) Type I, % (54-72) 40% (35-45) 1.0 ( ) 0.9 ( ) Type II, % (41-75) 40% (35-45) 1.0 ( ) 1.1 ( ) Type III/IV, % (16-75) 40% (35-45) 0.7 ( ) 1.4 ( ) Nakagawa (2005) % (18-53) 60% (42-75) 0.8 ( ) 1.1 ( ) Hawkins Parentis (2006) Type II, 23 65% (50-78) 30% (22-41) 0.9 ( ) 1.2 ( ) Type I & II, 40 68% (52-80) 30% (22-41) 1.0 ( ) 1.1 ( ) Kim (2003) Type I, % (62-80) 39% (34-44) 1.2 ( ) 0.7 ( ) Type II, % (51-83) 39% (34-44) 1.1 ( ) 0.8 ( ) Type III/IV, % (25-84) 39% (34-44) 0.9 ( ) 1.1 ( ) Nakagawa (2005) % (31-69) 67% (49-81) 1.5 ( ) 0.8 ( ) Pain provocation Parentis (2006) Type II, 23 17% (9-32) 90% (82-95) 1.8 ( ) 0.9 ( ) Type I & II, 40 15% (7-29) 90% (82-95) 1.5 ( ) 0.9 ( ) Painful arc test Kim (2003) Type I, % (44-69) 53% (46-59) 1.2 ( ) 0.8 ( ) Type II, % (36-77) 53% (46-59) 1.2 ( ) 0.8 ( ) Type III/IV, % (5-70) 53% (46-59) 0.5 ( ) 1.4 ( ) Nakagawa (2005) % (9-41) 73% (56-86) 0.8 ( ) 1.1 ( ) Posterior jerk Nakagawa (2005) % (12-45) 80% (63-91) 1.3 ( ) 0.9 ( ) Sulcus Nakagawa (2005) % (7-36) 93% (79-98) 2.5 ( ) 0.9 ( ) Relocation Parentis (2006) Type II, 23 44% (29-58) 51% (41-61) 0.9 ( ) 1.1 ( ) Type I & II, 40 50% (35-65) 53% (43-63) 1.1 ( ) 0.9 ( ) Guanche (2003) % (22-53) 63% (44-79) 1.0 ( ) 1.0 ( ) Kim (2003) Type I, % (12-34) 78% (71-84) 0.9 ( ) 1.0 ( ) Type II, % (20-64) 78% (71-84) 1.8 ( ) 0.8 ( ) Type III/IV, % (1-60) 78% (71-84) 0.6 ( ) 1.1 ( ) Morgan (1998) anterior 4% (1-19) 27% (12-50) 0.1 ( ) 3.4 ( ) 102 posterior 85% (69-94) 68% (45-83) 2.6 ( ) 0.2 ( ) 102 combined 59% (41-76) 54% (32-72) 1.2 ( ) 0.8 ( ) Nakagawa (2005) % (55-88) 40% (25-58) 1.3 ( ) 0.6 ( ) Modified relocation Hamner (2000) % (73-100) 50% (6-95) 1.9 ( ) 0.1 ( ) New pain provocation Mimori (1999) % (70-100) 90% (46-99) 9.6 ( ) 0.1 ( ) Resisted supination external rotation Myers (2005) % (66-92) 82% (52-95) 4.6 ( ) 0.2 ( ) Speeds Guanche (2003) % (3-24) 74% (55-87) 0.4 ( ) 1.2 ( ) Holtby (2004) % (16-53) 75% (57-87) 1.3 ( ) 0.9 ( ) Kim (2003) Type I, % (34-54) 73% (67-77) 1.6 ( ) 0.8 ( ) Type II, % (17-50) 73% (67-77) 1.1 ( ) 1.0 ( ) Type III/IV, % (3-56) 73% (67-77) 0.6 ( ) 1.2 ( ) Parentis (2006) Type II, 23 48% (33-63) 68% (57-76) 1.5 ( ) 0.8 ( ) Type I & II, 40 48% (33-63) 67% (57-76) 1.5 ( ) 0.8 ( ) Bennett (1998) % (60-98) 14% (6-29) 1.1 ( ) 0.7 ( ) Morgan (1998) Anterior 98% (85-100) 70% (50-85) 3.3 ( ) 0.0 ( ) 102 Posterior 29% (15-47) 11% (3-29) 0.3 ( ) 7.5 ( ) 102 Combined 78% (59-89) 37% (21-59) 1.3 ( ) 0.6 ( ) Nakagawa (2005) % (1-22) 98% (86-100) 3.7 ( ) 1.0 ( ) Yergason Guanche (2003) % (5-27) 96% (82-99) 3.3 ( ) 0.9 ( ) Holtby (2004) % (25-64) 79% (61-90) 2.0 ( ) 0.7 ( ) Parentis (2006) Type II, 23 13% (6-26) 93% (87-97) 1.9 ( ) 0.9 ( ) Type I & II, 40 13% (6-26) 94% (87-97) 1.9 ( ) 0.9 ( ) Nakagawa (2005) % (5-32) 98% (86-100) 8.7 ( ) 0.9 ( ) journal of orthopaedic & sports physical therapy volume 38 number 6 june

8 TABLE 7 Tests Reporting High Levels of Accuracy Test Author QUADAS Sensitivity (% [95% CI]) Specificity (% [95% CI]) +LR (95% CI) LR (95% CI) Active compression O Brien (1998) (92-100) 98 (96-99) 61.1 ( ) 0.0 ( ) Compression rotation Nakagawa (2005) (13-46) 98 (86-100) 16.1 ( ) 0.8 ( ) Biceps load Kim (1999) (62-98) 97 (90-99) 29.1 ( ) 0.1 ( ) Biceps load II Kim (2001) (76-96) 97 (91-99) 30.0 ( ) 0.1 ( ) Crank test Liu (1996) (76-97) 93 (79-98) 13.6 ( ) 0.1 ( ) Abbreviations: CI, confidence interval; QUADAS, quality assessment of diagnostic accuracy tool; +LR, positive likelihood ratio; LR, negative likelihood ratio. TABLE 5. The heterogeneity across the different studies is clear. This increases the difficulties of generalizing the findings from 1 study to others, especially when comparing the statistical analyses. There was a wide range of population characteristics throughout the different studies and also within the study populations. For example, 1 study only included throwing athletes, 36 while another study only included individuals with recurrent dislocations. 21 TABLE 6 shows the sensitivity, specificity, and likelihood ratios provided by various authors. The ratios are presented under the individual tests, along with their respective appraisal scores from QUADAS. If the likelihood ratios were not provided in the original papers, the sensitivity and specificity values were used to calculate them. Confidence intervals (CIs) were calculated around all the point estimates by the first author and presented in TABLE 6, as these values were not provided in the original papers. DISCUSSION The results of this review provide little evidence that any one clinical test is accurate in detecting a SLAP lesion. These findings are consistent with other reviews that have investigated similar tests. 19,32,40 A total of 26 tests were reviewed from 17 retrieved papers. They were classified as 8 high-quality 2,12,15,27,30,34-36 and 9 as lowquality studies, 14,20,21,24,26,31,39,41,47 as determined using the QUADAS appraisal tool. The highest rated paper (24/26) was that of Myers et al, 35 who compared the resisted supination external rotation test to the active compression and the crank tests. The resisted supination external rotation test had the highest sensitivity (83%; 95% CI, 66%-92%) and specificity (82%; 95% CI, 52%-95%) of the 3 tests, with a +LR and LR of 4.6 (95% CI, ) and 0.2 (95% CI, ), respectively. Lui et al, 27 in another study classified as high quality (20/26), reported the crank test to have high accuracy, with sensitivity of 91% (95% CI, 76%-97%), specificity of 93% (95% CI, 79%-98%), a +LR of 13.6 (95% CI, ), and a LR of 0.10 (95% CI, ). However, these values were not supported by other authors investigating the crank test, including higher quality appraised papers. 35,36 The active compression test 39 was investigated by 8 other authors 12,24,30,34-36,41,47 other than O Brien et al, 39 with none reporting values similar to those reported in the original paper. Five clinical tests (TABLE 7) were reported to have a +LR greater than ,21,27,36,39 Such values would suggest a large, often conclusive shift in probability in the presence of a SLAP lesion. 17 However, in each case, such high values were not confirmed in other studies. Of 26 tests studied for a diagnosis of a SLAP lesion, 12 were investigated by more than 1 author. Based on the data presented in TABLE 6, there was a wide range of diagnostic accuracy values reported, with no particular single test appearing to have strong statistical support. O Brien et al 39 reported findings on the active compression test for both labral and acromioclavicular pathologies. They found high accuracy values in their testing for labral lesions, with a +LR of 61.1 (95% CI, ). No inclusion/ exclusion criteria were provided for the sample population and there was little demographic information reported. Fifty-six patients were found to have a positive test, with 53 of these confirmed at arthroscopy as having a labral lesion. One hundred fifty patients were reported as having a negative test with other shoulder pathology. However, it is not clear whether the results of all subjects with negative responses were confirmed with arthroscopy or simply radiography. The lack of standardization in reporting of these results makes interpreting the data for this paper quite difficult and unclear when calculating likelihood ratios. The study by Kim et al 21 on the biceps load test scored 18 on the QUADAS and high levels of diagnostic accuracy were reported. These authors only looked at individuals with unilateral recurrent dislocations and a Bankart lesion. The surgeons were not blinded to the results of the initial testing, but reproducibility of the clinical test was confirmed. The biceps load test appears an accurate test; however, these findings have not been confirmed by other authors, and the population group is quite specific. Therefore, these results cannot be generalized to other populations. The same authors also investigated the biceps load II test 20 and reported similar accuracy values. However, only type II lesions were investigated, and it is unclear whether the surgeons were blinded to the test results, which would have been necessary to eliminate any assessor bias. Also, these 348 june 2008 volume 38 number 6 journal of orthopaedic & sports physical therapy

9 authors failed to report on any concurrent pathology with positive findings and did not discuss any clinical applicability. Liu et al 27 investigated the crank test on 62 patients and, in contrast to the study by Kim et al, 21 excluded individuals with a history of dislocations. This paper scored 20 on the QUADAS and the authors provided a thorough discussion of the clinical applicability of the test. The authors answered the question of differentiating between preoperative diagnoses with impingement and discussed their thoughts on symptomatic instability versus labral symptoms. The researchers could have blinded the surgeons to the findings of the clinical testing, which would have improved the paper s overall quality, but in the population investigated it appears an accurate test. However, findings from other authors 12,31,35,36,41,47 investigating the same test (TABLE 6), including higher quality papers, did not confirm this accuracy. The new pain provocation test 31 had high levels of accuracy and the study had a score of 14, based on the QUADAS. Thirty-two patients with shoulder pain while throwing were initially recruited for the study, but only 15 were investigated with arthroscopy. Patients were initially excluded if they had instability, which was probably assessed by anterior drawer and relocation tests, but this is unclear. Magnetic resonance imaging or arthrography was also used and any patients found with rotator cuff tears were also excluded. Therefore, the population sample was already narrowed after clinical testing and imaging, prior to any arthroscopic investigation. In their results, either type II SLAP lesions or subacromial bursitis are presented as single pathologies. There is no mention of SLAP lesions with any other concurrent pathology. The results of this paper appear limited when investigating the accuracy of the tests confirmed with arthroscopy due to the small and narrowed sample. The inconsistencies found among studies may be explained by a variety of factors. The different population groups included in the various studies would undoubtedly produce varying results and statistics. TABLE 5 presents patient demographics and differences in the included population samples. For example, the active compression test was investigated by 9 authors, 12,24,30,34-36,39,41,47 all on different population groups. In each paper, the description of the active compression test varied slightly, either in its method of application or interpretation of results, making comparison of results for this test across studies difficult. Even the original description by O Brien et al 39 is inconsistent within the text, with external rotation appearing to be used synonymously with supination. Therefore, unsurprisingly, subsequent studies on this test vary in their methodology. Nakagawa 36 only reported on throwing athletes, whereas Stetson 47 investigated 65 patients with pathologies affecting either the dominant or nondominant shoulders, with ages ranging between 18 and 75 years. Also, only a proportion of authors reported on statistical values for the different types of SLAP lesions. Subgroups of patients may exist with different tests being more specific or sensitive to a certain type of lesion. The majority of papers used the classification of SLAP lesions proposed by Snyder et al. 46 There was found to be variability in the different types of lesions included through the studies. Morgan et al 34 only investigated type II lesions and actually classified these into 3 subtypes. These subtypes make sense clinically but make an analysis of the data more difficult. Parentis et al 41 only investigated type I or II lesions, not considering types III or IV. Some authors considered type I lesions as a normal variant and subsequently excluded them as a positive surgical finding. 15,35 Holtby et al 15 did not consider superior labral fraying with an intact biceps tendon and a bucket handle labral tear with an intact biceps as positive surgical findings. These authors therefore reported no data for previously described type III lesions. These variations in classification of SLAP lesions and inclusion criteria, therefore, affect the ability to compare results across different studies. Many of the patients studied were found to have concurrent pathologies concurrently with the SLAP lesions. Therefore, positive responses found with testing cannot be accurately attributed to the SLAP lesions themselves. These concurrent pathologies included bursitis, 2,36,47 rotator cuff tears, 12,14,15,21,24,27,31,35,36,4 1,47 biceps tendon pathology, 2,15,39 capsular lesions, 12 Bankart lesions, 14,24,29,35 Hills- Sachs lesions, 12,24,29,35 and intra-articular or degenerative disease. 12,14,21,24,35,41 A number of the authors whose reports were reviewed in this paper provided clear explanations for the anatomical basis of the test under investigation. 2,14,20,21,31,34-36,39 Although this was not considered under the QUADAS scoring, such provision strengthens the quality of the paper and test itself. The biceps load II test 20 has a good anatomical explanation (via the peel-back mechanism) and the authors report on muscle activity of the biceps in the throwing position, a position closely reproduced by the test. Myers et al 35 expanded on this by providing evidence from electromyographic studies that supination preferentially loads the biceps in the abducted/externally rotated position, in contrast to elbow flexion. These 2 papers therefore provided an explanation for the mechanism by which load is applied to an unstable biceps anchor, thus creating a logical mechanism for provocation of pain. In contrast, while O Brien et al 39 provide explanations for use of the active compression test for diagnosis of both acromioclavicular and SLAP lesion pathology, the mechanisms described, particularly in relation to the SLAP lesions, do not appear logical. A change of arm position from full internal to full external shoulder rotation for the second component of the test, as would appear to be the intent described in the text, will alter the stress on a number of different structures, in particular, the subacromial and subcoracoid structures, not simply the superior labrum and biceps anchor. Thus a difference in response in the 2 journal of orthopaedic & sports physical therapy volume 38 number 6 june

10 positions cannot be attributed simply to these latter structures. Variations were also found between different authors in what constitutes a positive test. For example, the active compression test originally described by O Brien et al 39 required the reproduction of pain deep inside for a positive test for SLAP lesions, whereas Parentis and colleagues 41 were not so specific. McFarland et al 30 considered deeply located pain as an indication of a positive test, while pain reported as being located elsewhere, including the anterior shoulder, was interpreted as a negative test. Conversely, Morgan et al 34 considered pain reproduced in the anterior shoulder as positive for the active compression test. The crank test was also a diagnostic test investigated by multiple authors. 12,27,31,35,36,41,47 Some reported a positive test with the reproduction of pain alone, 41 while others considered the perception of a click positive. 27 Therefore, these variations and inconsistencies reduce the validity of a test and may help explain the lack of agreement between the reported accuracy of the tests. One of the main issues when investigating diagnostic accuracy is that of blinding the assessors to the results of the first test when getting a true diagnosis from the gold standard. From the studies reviewed in this paper, the surgeons were blinded to the findings of the clinical tests in only 3 studies. 15,35,36 The QUADAS was used in this review as it has been researched and designed as an evidence-based quality assessment tool. 51 However, the scoring system used, as proposed in a later paper by the developers of the tool, remains controversial. 49 In a study investigating different methods of weighting and scoring the items, Whiting et al 49 found differing-quality scores with various weighting systems. These differences can change the classification regarding study quality (high or low). However, in this systematic review, it was felt that a scoring system was necessary to compare across the studies, and so the weighting system derived from an evidence base of the QUADAS was used. 49 Item 9 on the QUADAS showed the lowest agreement between the authors (59%), due to what was deemed sufficient detail with regard to the arthroscopic procedure. As neither author is an orthopaedic surgeon, opinions varied in what constituted sufficient and undoubtedly led to this lower agreement figure. Although this tool investigates assessor bias with its scoring, there are no items reflecting any reliability testing within the reviewed papers. Only 2 papers attempted to assess interobserver reliability, 20,21 a limitation of design that again weakens many studies. In the general population the incidence of SLAP lesions has been reported to be around 6%, 45 whereas in a sporting population it has been found to be as high as 35%. 10 The variability in prevalence rates seen throughout different studies affects both predictive values and test accuracy. 12 The accuracy of a clinical test not only depends on sensitivity and specificity values, but is also reliant on pretest probabilities that the condition is actually present. 9 Likelihood ratios overcome some of these issues and are able to quantify shifts in the probability of the tests used. As the prevalence rate varies between different studies, likelihood ratios were used in this review, which provided a more accurate estimate of predictive values or posttest probability. 12 The relationship between pretest probability and likelihood ratios is of utmost importance when assessing the accuracy of diagnostic testing. 9,13 Pretest probabilities are determined by the clinician and may come from a variety of sources. These include the prevalence rate of the pathology, clinical experience, and information gathered from the patient regarding the mechanism of injury. Symptoms such as catching, locking, popping, and grinding are reported in the literature. 46 The mechanism of the injury will lead the clinician to suspect such injuries and these commonly include a compression or traction force. 5 Therefore, falls on an outstretched hand or the deceleration force of a throw are likely to lead to different types of pathology. Clinical tests that replicate these positions may then show greater accuracy in finding SLAP lesions. 34 Some clinical tests appear more sensitive and specific when investigating certain types of SLAP lesions. Morgan et al 34 found that the Jobe relocation test had a higher sensitivity for posterior lesions (85%; 95% CI, 69%-94%) than for anterior lesions (4%; 95% CI, 1%-19%). In comparison, the active compression test was reported by these authors as having a sensitivity of 88% (95% CI, 71%-96%) for anterior lesions. These authors also found that posterior type II lesions were 3 times more common in throwers than individuals in a trauma group. In addition, individuals in the trauma group were found to have 3 times more anterior lesions than those in the throwing group. Therefore, it follows that the patient population under investigation will greatly influence the types of SLAP lesions present, and almost certainly, the accuracy of certain tests. The relevance of knowledge of presentation has also been highlighted in a paper where the authors assign a historyspecific prevalence value to a particular patient. 15 This value is thought to be the chance of having the condition based on the subjective signs and mechanism of injury. This value can then be calculated to produce more accurate predictive values. These results are then believed to be more accurate when interpreting the signs and symptoms of the clinical tests. Such calculations were not used in this review but are mentioned to highlight the importance of the history, particularly the knowledge of the mechanism of injury. On the basis of comparison of clinical and arthroscopic diagnosis in 261 subjects, including 121 with a primary diagnosis of a labral lesion, Magarey et al 28 reported that the most important predictor of labral pathology was the history. Therefore, further research into the accuracy of these SLAP lesion tests based on subgrouping by mechanism of injury may be warranted. The diagnostic accuracy of a combination of diagnostic tests has been investi- 350 june 2008 volume 38 number 6 journal of orthopaedic & sports physical therapy

11 [ RESEARCH REPORT ] gated for pathologies in other areas of the body, 25 with higher numbers of positive tests increasing the predictive values of joint involvement. Guanche et al 12 found that if either the Jobe relocation, O Brien (active compression), or the anterior apprehension tests were positive, the sensitivity (72%) and specificity (73%) were relatively greater. However, if 2 or more of the 3 tests were required to be positive, sensitivity and specificity were decreased. Further research into the use of combinations of these tests with the potential to develop clinical prediction rules may increase our diagnostic accuracy for detecting SLAP lesions. CONCLUSION From this literature it is evident that no single test is sensitive or specific enough to accurately determine the presence or absence of a SLAP lesion. Some tests may appear more accurate for particular types of SLAP lesions, but further research is required to identify such subgroups based on mechanism of injury or anatomical features of the SLAP lesion. However, on the basis of the QUA- DAS scoring system used for evaluation, consideration of the anatomical basis for the test, and within the significant limitations in interpretation identified above, the resisted supination external rotation test and the biceps load test II would appear the most valuable, at least for SLAP lesions associated with injuries of the overhead athlete (predominantly type II lesions and their derivatives). REFERENCES abled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy. 2003;19: Burkhart SS, Morgan CD, Kibler WB. Shoulder injuries in overhead athletes. The dead arm revisited. Clin Sports Med. 2000;19: Cooper DE, Arnoczky SP, O Brien SJ, Warren RF, DiCarlo E, Allen AA. Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. J Bone Joint Surg Am. 1992;74: D Alessandro DF, Fleischli JE, Connor PM. Superior labral lesions: diagnosis and management. J Athl Train. 2000;35: Denegar CR, Fraser M. How useful are physical examination procedures? Understanding and applying likelihood ratios. J Athl Train. 2006;41: Fritz JM, Wainner RS. Examining diagnostic tests: an evidence-based perspective. Phys Ther. 2001;81: Funk L, Snow M. SLAP tears of the glenoid labrum in contact athletes. Clin J Sport Med. 2007;17: JSM.0b013e31802ede Greenhalgh T. How to read a paper. Papers that report diagnostic or screening tests. BMJ. 1997;315: Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy. 2003;19: jars Halkin A, Reichman J, Schwaber M, Paltiel O, Brezis M. Likelihood ratios: getting diagnostic testing into perspective. QJM. 1998;91: Hamner DL, Pink MM, Jobe FW. 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12 resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions. Am J Sports Med. 2005;33: org/ / Nakagawa S, Yoneda M, Hayashida K, Obata M, Fukushima S, Miyazaki Y. Forced shoulder abduction and elbow flexion test: a new simple clinical test to detect superior labral injury in the throwing shoulder. Arthroscopy. 2005;21: arthro Nam EK, Snyder SJ. The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med. 2003;31: Norregaard J, Krogsgaard MR, Lorenzen T, Jensen EM. Diagnosing patients with longstanding shoulder joint pain. Ann Rheum Dis. 2002;61: O Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26: Olmsted LC, Denegar CR. Physical examination of the shoulder: considerations of sensitivity and. specificity. Athl Ther Today. 2003;8: Parentis MA, Glousman RE, Mohr KS, Yocum LA. An evaluation of the provocative tests for superior labral anterior posterior lesions. Am J Sports Med. 2006;34: org/ / Parentis MA, Mohr KJ, ElAttrache NS. Disorders of the superior labrum: review and treatment guidelines. Clin Orthop Relat Res. 2002; Prodromos CC, Ferry JA, Schiller AL, Zarins B. Histological studies of the glenoid labrum from fetal life to old age. J Bone Joint Surg Am. 1990;72: Rao AG, Kim TK, Chronopoulos E, McFarland EG. Anatomical variants in the anterosuperior aspect of the glenoid labrum: a statistical analysis of seventy-three cases. J Bone Joint Surg Am. 2003;85-A: Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4: Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6: Stetson WB, Templin K. The crank test, the O Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30: Sweeting MJ, Sutton AJ, Lambert PC. What to add to nothing? Use and avoidance of continuity corrections in meta-analysis of sparse data. Stat Med. 2004;23: org/ /sim Whiting P, Harbord R, Kleijnen J. No role for quality scores in systematic reviews of diagnostic accuracy studies. BMC Med Res Methodol. 2005;5:19. org/ / Whiting P, Rutjes AW, Dinnes J, Reitsma J, Bossuyt PM, Kleijnen J. Development and validation of methods for assessing the quality of diagnostic accuracy studies. Health Technol Assess. 2004;8:iii, Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003;3:25. dx.doi.org/ / Whiting P, Weswood ME, Rutjes AWS, Reitsma JB, Bossuyt PNM, Kleijnen J. Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol. 2006(6): Wilk KE, Reinold MM, Dugas JR, Arrigo CA, Moser MW, Andrews JR. Current concepts in the recognition and treatment of superior labral (SLAP) lesions. J Orthop Sports Phys Ther. 2005;35: Zaslav KR. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg. 2001;10: MORE INFORMATION APPENDIX Number Search History Results 1 labr$.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] SLAP.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] bankart.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] shoulder.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] diagnos$.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] test.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] exam$.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] arthroscop$.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] MRI.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] surg$.mp. [mp=ab, hw, ti, it, ot, nm, da, fa, sh, ce, fc, fd] or 2 or 3 or or 6 or or 9 or and 12 and limit 14 to english limit 16 to humans [Limit not valid in: AMED,CINAHL,SPORTDiscus; records were retained] limit 17 to yr= remove duplicates from Titles reviewed Abstracts retrieved and reviewed Full texts retrieved and reviewed Included papers by authors independently Included papers after discussion and consensus reached june 2008 volume 38 number 6 journal of orthopaedic & sports physical therapy