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The O’Brien Test demonstrates a higher diagnostic value in identifying posteroinferior labral tears than superior labral anterior to posterior (SLAP) tears

  • Geert Alexander Buijze
    Correspondence
    Correspondence: Geert Alexander Buijze, MD PhD, Department of Orthopaedic Surgery, Clinique Générale, 4 Chemin de la Tour la Reine, 74000 Annecy, France. Tel: +33450330950
    Affiliations
    Alps Surgery institute, Hand, Upper Limb, Peripheral Nerve, Brachial Plexus and Microsurgery Unit, Clinique Générale Annecy, France

    Hand and Upper Extremity Surgery Unit, Department of Orthopaedic Surgery, Lapeyronie Hospital, Montpellier University Medical Center, Montpellier, France

    Amsterdam University Medical Center, Department of Orthopaedic Surgery, Amsterdam, The Netherlands
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  • Sandrine Mariaux
    Affiliations
    Alps Surgery institute, Hand, Upper Limb, Peripheral Nerve, Brachial Plexus and Microsurgery Unit, Clinique Générale Annecy, France
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  • Sanne H. van Spanning
    Affiliations
    Alps Surgery institute, Hand, Upper Limb, Peripheral Nerve, Brachial Plexus and Microsurgery Unit, Clinique Générale Annecy, France
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  • Lukas P.E. Verweij
    Affiliations
    Amsterdam University Medical Center, Department of Orthopaedic Surgery, Amsterdam, The Netherlands

    Academic Center for Evidence-based Sports Medicine (ACES), Amsterdam UMC, Amsterdam, The Netherlands

    Amsterdam Collaboration for Health and Safety in Sports (ACHSS), International Olympic Committee (IOC) Research Center, Amsterdam UMC, Amsterdam, The Netherlands
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  • Sybren K. van Rijn
    Affiliations
    Amsterdam University Medical Center, Department of Plastic Reconstructive and Hand Surgery, Amsterdam, The Netherlands
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  • Laurent Lafosse
    Affiliations
    Alps Surgery institute, Hand, Upper Limb, Peripheral Nerve, Brachial Plexus and Microsurgery Unit, Clinique Générale Annecy, France
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  • Thibault Lafosse
    Affiliations
    Alps Surgery institute, Hand, Upper Limb, Peripheral Nerve, Brachial Plexus and Microsurgery Unit, Clinique Générale Annecy, France
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Open AccessPublished:October 30, 2022DOI:https://doi.org/10.1016/j.jseint.2022.10.006

      Abstract

      Purpose

      The primary aim was to determine the diagnostic value of the O’Brien test in localizing labral tears of the shoulder.

      Methods

      A consecutive series of patients electing for labral repair between January 2005 and March 2021 were included in this retrospective study. Inclusion criteria were (1) any patient with a labral tear who was elected for arthroscopic labral repair that had (2) documentation of the O’Brien test in the preoperative evaluation. Exclusion criteria were patients that had a negative arthrographically enhanced CT or MRI scan. During arthroscopy, the localization and extension of the labral tear was documented in a standardized 12 o’clock configuration. Anteroinferior, posteroinferior, superior labrum anterior to posterior (SLAP), and combined labral tears were documented. The sensitivity, specificity, positive and negative predictive values, accuracy, positive and negative likelihood ratios, the Receiver Operator Characteristic (ROC) curve and the Area Under the Curve (AUC) were calculated to determine the diagnostic value.

      Results

      The cohort consisted of 271 patients (77% male) and included 105 anteroinferior, 86 posteroinferior, 46 SLAP and 32 combined parts of the labrum. The mean age at time of surgery was 30 (± 10.2). The O’Brien test was positive in 142 (52%) patients and showed the highest sensitivity and specificity for the posteroinferior tears (83%; 62%,) compared to the anteroinferior (16%; 25%), combined labral parts (69%; 50%) and SLAP (65%; 50%) tears. In addition, ROC-analysis demonstrated a significantly higher AUC for posteroinferior tears compared to the other tears (P < 0.001).

      Conclusion

      The O’Brien test demonstrates more diagnostic value for posteroinferior tears than other labral tears. This includes the SLAP tear, for which the O’Brien test was originally designed.

      Keywords

      Clinical Relevance
      These findings are helpful towards reinterpreting the O’Brien test as well as diagnosing and more specifically localizing labral tears in clinics.
      Posterior labral lesion is becoming an increasingly recognized pathology in patients with shoulder instability, with incidences of up to 24%.
      • Javed S.
      • Gheorghiu D.
      • Torrance E.
      • Monga P.
      • Funk L.
      • Walton M.
      The Incidence of Traumatic Posterior and Combined Labral Tears in Patients Undergoing Arthroscopic Shoulder Stabilization.
      ,
      • Swan E.R.
      • Lynch T.B.
      • Sheean A.J.
      • Schmitz M.R.
      • Dickens J.F.
      • Patzkowski J.C.
      High Incidence of Combined and Posterior Labral Tears in Military Patients With Operative Shoulder Instability.
      It is commonly caused by a posteriorly directed force with the arm in an adducted position.
      • Castagna A.
      • Conti M.
      • Garofalo R.
      Soft tissue-based surgical techniques for treatment of posterior shoulder instability.
      ,
      • Mair S.D.
      • Zarzour R.H.
      • Speer K.P.
      Posterior labral injury in contact athletes.
      However, the trauma often seems minor and dislocation is not often reported.
      • Castagna A.
      • Conti M.
      • Garofalo R.
      Soft tissue-based surgical techniques for treatment of posterior shoulder instability.
      Symptoms are typically vague and include intermittent posterior pain, fatigue or weakness during certain activities, which are associated with decreased performance in sports.
      • Mair S.D.
      • Zarzour R.H.
      • Speer K.P.
      Posterior labral injury in contact athletes.
      If the labral tear is associated with a mobile bucket handle, it can sometimes create blockages and falsely orientate the physician to diagnose a stiffness.
      A variety of clinical tests have been described to evaluate a posterior labral tear such as the Kim test, which has a reported sensitivity of 80% and a specificity of 94%, and the Jerk test, with a reported sensitivity of 73% and a specificity of 98%.
      • Kim S.H.
      • Park J.S.
      • Jeong W.K.
      • Shin S.K.
      The Kim test: a novel test for posteroinferior labral lesion of the shoulder--a comparison to the jerk test.
      The low sensitivity of these and other described tests remains one of the main challenges making the clinical diagnosis of posterior labral tear difficult – hence tend to be missed if not specifically looked for. Imaging is mandatory to confirm its diagnosis, but even MRI underestimates true labral tear.
      • Legan J.M.
      • Burkhard T.K.
      • Goff 2nd, W.B.
      • Balsara Z.N.
      • Martinez A.J.
      • Burks D.D.
      • et al.
      Tears of the glenoid labrum: MR imaging of 88 arthroscopically confirmed cases.
      Consistent with other shoulder pathology, combining clinical tests provides increased (pooled) diagnostic performance.
      • Ladermann A.
      • Meynard T.
      • Denard P.J.
      • Ibrahim M.
      • Saffarini M.
      • Collin P.
      Reliable diagnosis of posterosuperior rotator cuff tears requires a combination of clinical tests.
      Therefore, it remains key to keep fine-tuning and reinterpreting the value of existing, combined and new clinical tests to improve the clinical diagnosis of complex shoulder pathology as posteroinferior labral tears.
      The O’Brien test was originally described for superior labrum anterior to posterior (SLAP) lesions, however, the diagnostic performance is quite low with a sensitivity of 64% and accuracy of 54%.
      • Fowler E.M.
      • Horsley I.G.
      • Rolf C.G.
      Clinical and arthroscopic findings in recreationally active patients.
      Moreover, based upon our clinical experience and recent biomechanical data, we hypothesized that the O’Brien test would be most predictive of posteroinferior labral tears.
      • Green R.A.
      • Taylor N.F.
      • Mirkovic M.
      • Perrott M.
      An evaluation of the anatomic basis of the O'Brien active compression test for superior labral anterior and posterior (SLAP) lesions.
      ,
      • O'Brien S.J.
      • Pagnani M.J.
      • Fealy S.
      • McGlynn S.R.
      • Wilson J.B.
      The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality.
      ,
      • Wood V.J.
      • Sabick M.B.
      • Pfeiffer R.P.
      • Kuhlman S.M.
      • Christensen J.H.
      • Curtin M.J.
      Glenohumeral muscle activation during provocative tests designed to diagnose superior labrum anterior-posterior lesions.
      Therefore, the primary aim was to determine the diagnostic value of the O’Brien test in localizing labral tears of the shoulder.

      METHODS

      Study design

      A retrospective cross-sectional study was performed using prospectively collected data. The data was entered into a database prior to undergoing arthroscopic examination and procedure.

      Patient selection

      Between January 2005 and March 2021, all consecutive patients who were operated for an elected labral repair by one of three surgeons (LL, TL, GAB) at our clinics were included in the study. Inclusion criteria for participation in this study were (1) any patient with labral tear who elected for arthroscopic labral repair (including patients in whom the procedure was converted to an arthroscopic bone block procedure after intra-operative evaluation) that had (2) documentation of the O’Brien test in the preoperative evaluation. Exclusion criteria included: patients with a clinical suspicion of labral tear that was deemed either not electable for repair (e.g. elected for primary bone block reconstruction) or that had a negative arthrographically enhanced CT or MRI scan and patients with concomitant biceps and AC joint pathologies.

      O’Brien test

      The O’Brien test was performed by an attending orthopedic surgeon preoperatively in clinics following the original description for the diagnosis of SLAP lesion.
      • O'Brien S.J.
      • Pagnani M.J.
      • Fealy S.
      • McGlynn S.R.
      • Wilson J.B.
      The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality.
      The patient positions his arm at 90° elevation, 10° adduction and internal rotation (thumb down) with the elbow in extension. He then elevated his arm against the downward force applied by the examiner. The test was considered positive if this movement was painful, and if the pain decreased when the test was performed with the forearm in external rotation (thumb up).
      • O'Brien S.J.
      • Pagnani M.J.
      • Fealy S.
      • McGlynn S.R.
      • Wilson J.B.
      The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality.

      Labral tear examination

      Surgeries were performed in the beach chair position under general anesthesia in combination with an interscalene regional block. Arthroscopic evaluation consisted of documenting the exact localization and extension of the labral tear using a standardized 12-hour clockwise configuration. Tears were categorized as involving the anteroinferior (defined between 2 and 6-o'clock position), posteroinferior (defined between 6 and 10-o'clock position), SLAP (vast majority was Type 2) (defined between 10 and 2-o'clock position) or combined parts of the labrum (defined as involving at least two of the former categories).

      Data extraction

      The following baseline characteristics were extracted from the database: gender, age at surgery, pain, apprehension, dislocation (defined as radiographically confirmed dislocations), subluxation, hyperelasticity (defined as an external rotation of ≥85°). The arthroscopic evaluation of the labral tears was extracted from the operative report. The preoperative O’Brien test results were extracted from the database.

      Statistical analysis

      The findings at clinical examination were compared to the findings during arthroscopy, which was considered the gold standard for labral tears. The True positive (TP), True negative (TN), False positive (FP) and False negative (FN) values were determined. The sensitivity (TP/ (TP + FN)), specificity (TN / (TN+ FP)), positive predictive value (TP / (TP + FP)) and negative predictive values (TN / (TN + FN)), accuracy ((TP + TN) / total number of tests), positive likelihood ratio (sensitivity / (1-specificity)) and negative likelihood ratios ((1 - sensitivity) / specificity) of the O’Brien test to diagnose each lesion (anteroinferior, posteroinferior, SLAP or combined parts of the labrum) were calculated. To determine the ability of the O’Brien test to distinguish between lesions, the Receiver Operator Characteristic (ROC) curve was created and the Area Under the Curve (AUC) was determined. Diagnostic value definitions of the AUC-values were as follows: fail (< 0.6), poor (0.6-0.7), acceptable (0.7-0.8), excellent (0.8-0.9) and outstanding (0.9-1.0)
      • Mandrekar J.N.
      Receiver operating characteristic curve in diagnostic test assessment.
      . ROC-analysis was performed to compare the AUC of the O’Brien test to identify the different labral tears. Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) software (IBM SPSS Statistics for Apple, Version 26.0 Released 2019; IBM Corp. Armonk, NY, USA). Localization and extent of the labral tears were then analyzed in standard data managing software and the calculated frequencies rendered in 3D imaging software using color coding for improved infographic interpretation purposes (heatmapping) (Cinema 4D R23 Version R23 Released September 2020; Maxon, Friedrichsdorf, Germany).

      RESULTS

      Patient demographics

      A total of 271 patients met the inclusion criteria (table 1). There were 209 males (77%) and 62 females (23%). The mean age at time of surgery was 30 years (± 10.2). The dominant side was affected in 141 patients (52%), 174 patients complained of pain (64%) and 211 patients complained of apprehension (78%). In 143 patients had a dislocation (53%) and 147 subluxations were described (54%). In 210 patients, a trauma initiated the symptoms (78%) and 55 patients had shoulder hyperelasticity. A total of 105 patients had an isolated anteroinferior tear, 86 patients had an isolated posteroinferior tear, 46 patients an isolated SLAP tear and 32 patients had a tear of combined parts of the labrum. In total, 142 patients had a positive O’Brien test (52%).
      Table 1Patient demographics
      Anteroinferior (n = 104)Posteroinferior (n = 86)SLAP (n = 49)Combined parts (n = 32)Total (n = 271)
      Gender (m)72733727209
      Age (y, mean ±SD)28 ± 10.732 ± 10.931 ± 9.329 ± 7.130 ± 10.2
      Pain (n)50633427174
      Apprehension (n)93663022211
      Dislocation (n)70382213143
      Subluxation (n)65452116147
      Positive O’Brien tests (n)17713222142
      m = male, n = sample size, SD = standard deviation, SLAP = superior anteroposterior, y = year

      Diagnostic value of the O’Brien test for labral tears

      The O’Brien test demonstrated the highest sensitivity and specificity for posteroinferior tears (table 2), which were 83% and 62%, respectively. The diagnostic value of the test according to the AUC was classified as fail for anteroinferior (0.22), combined labral parts (0.54) and SLAP (0.55) tears and poor for posteroinferior (0.69) tears. The O’Brien test demonstrated the highest AUC for posteroinferior lesions according to the ROC-analysis (Figure 1, P < 0.001; table 3).
      Table 2Diagnostic value of the O’Brien test for each labral tear.
      Sensitivity (%)Specificity (%)PPV (%)NPV (%)Accuracy (%)LR+LR-AUC
      Posteroinferior (n = 86)83625088682.180.270.69
      SLAP (n = 46)65502387531.300.700.55
      Anteroinferior (n = 105)16251233220.213.360.22
      Combined parts (n = 32)69501592521.380.620.54
      AUC = Area Under the Curve, LR+ = positive likelihood ratio, LR- = negative likelihood ratio, n = sample size, NNV = negative predictive value, PPV = positive predictive value, SLAP = Superior Labral Antero-Posterior Lesion
      Figure thumbnail gr1
      Figure 1ROC-curves of O’Brien test to identify the labral tears.
      Table 3Statistical analysis of the inter-lesion differences of the O’Brien test to distinguish different lesions.
      AUC differencep-value95% Confidence interval
      SLAP - Posteroinferior-0.145< 0.001-0.224 - -0.066
      SLAP - Anteroinferior0.324< 0.0010.246 - 0.402
      SLAP - Combined parts0.0080.805-0.056 - 0.072
      Posteroinferior - Anteroinferior0.469< 0.0010.387 - 0.552
      Posteroinferior - Combined parts0.1530.0000.082 - 0.225
      Anteroinferior - Combined parts-0.3160.000-0.386 - -0.247
      AUC = area under the curve, SLAP = superior anteroposterior

      Heatmapping

      Heatmapping of the lesions shows that a positive O’Brien test was most predictive of isolated posteroinferior labral tears, less predictive of SLAP lesions and least predictive of isolated anteroinferior lesions (Figure 2).
      Figure thumbnail gr2
      Figure 2Heatmap of the accuracy of a positive O’Brien test in our cohort of patients with variable color intensity along the various positions of the labrum.

      DISCUSSION

      The most important finding is that the present study confirms our primary hypothesis that the O’Brien test – originally described for SLAP lesions – demonstrates the highest diagnostic value in identifying posteroinferior labral tears. Interestingly, these findings are in conflict to the original description of the O’Brien test, aiming to diagnose a SLAP lesion.
      • O'Brien S.J.
      • Pagnani M.J.
      • Fealy S.
      • McGlynn S.R.
      • Wilson J.B.
      The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality.
      During a trauma, or after minor and repetitive trauma in overhead athletes, a SLAP lesion can occur due to the biceps exerting an eccentric and torsional force on its proximal insertion.
      • Andrews J.R.
      • Carson Jr., W.G.
      • McLeod W.D.
      Glenoid labrum tears related to the long head of the biceps.
      ,
      • Burkhart S.S.
      • Morgan C.D.
      The peel-back mechanism: its role in producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation.
      ,
      • Snyder S.J.
      • Karzel R.P.
      • Del Pizzo W.
      • Ferkel R.D.
      • Friedman M.J.
      SLAP lesions of the shoulder.
      In a cadaveric study, Lin et al reported that deltoid loading leads to an increased contact pressure on the superior glenoid compared to inferior glenoid, which can explain the pain elicited during O’Brien test in presence of SLAP lesion.
      • Lin T.
      • Javidan P.
      • McGarry M.H.
      • Gonzalez-Lomas G.
      • Limpisvasti O.
      • Lee T.Q.
      Glenohumeral contact pressure in a simulated active compression test using cadaveric shoulders.
      However, biomechanically one would expect an opposite result to the test as the tensile load onto the tendon of the long head biceps is increased in external rotation of the shoulder, when one expects a pain relieve during the second part of the test.
      • Green R.A.
      • Taylor N.F.
      • Mirkovic M.
      • Perrott M.
      An evaluation of the anatomic basis of the O'Brien active compression test for superior labral anterior and posterior (SLAP) lesions.
      ,
      • Wood V.J.
      • Sabick M.B.
      • Pfeiffer R.P.
      • Kuhlman S.M.
      • Christensen J.H.
      • Curtin M.J.
      Glenohumeral muscle activation during provocative tests designed to diagnose superior labrum anterior-posterior lesions.
      Green et al suggested that this failure to support its proposed anatomic basis may partly explain the variable likelihood ratios obtained in clinical accuracy studies of the O'Brien test.
      • Clark R.C.
      • Chandler C.C.
      • Fuqua A.C.
      • Glymph K.N.
      • Lambert G.C.
      • Rigney K.J.
      Use of clinical test clusters versus advanced imaging studies in the management of patients with a suspected slap tear.
      ,
      • Green R.A.
      • Taylor N.F.
      • Mirkovic M.
      • Perrott M.
      An evaluation of the anatomic basis of the O'Brien active compression test for superior labral anterior and posterior (SLAP) lesions.
      ,
      • Wilk K.E.
      • Macrina L.C.
      • Cain E.L.
      • Dugas J.R.
      • Andrews J.R.
      The recognition and treatment of superior labral (slap) lesions in the overhead athlete.
      ,
      • Wilk K.E.
      • Reinold M.M.
      • Dugas J.R.
      • Arrigo C.A.
      • Moser M.W.
      • Andrews J.R.
      Current concepts in the recognition and treatment of superior labral (SLAP) lesions.
      Biomechanically, it would be expected that the O’Brien test is positive in case of a posterior labral tear. As the posteroinferior capsule and the posteroinferior glenohumeral ligament are frail compared to the anterior capsule, posterior labrum tightness is mandatory to stabilize the glenohumeral joint.
      • Bey M.J.
      • Hunter S.A.
      • Kilambi N.
      • Butler D.L.
      • Lindenfeld T.N.
      Structural and mechanical properties of the glenohumeral joint posterior capsule.
      Deltoid loading also induces a slight posterior translation of the humeral head. Lin et al showed that the posterior capsule becomes tight in during the first part of the O’Brien test, whereas the anterior capsule is loose, allowing posterior translation of the humeral head.
      • Lin T.
      • Javidan P.
      • McGarry M.H.
      • Gonzalez-Lomas G.
      • Limpisvasti O.
      • Lee T.Q.
      Glenohumeral contact pressure in a simulated active compression test using cadaveric shoulders.
      This is consistent with: (1) the typical mechanism of a posterior shoulder dislocation being an unresisted downward compression force in forward elevation, internal rotation and adduction – reflecting the position of the first part of the O’Brien test; and (2) the fact the shoulder is posteriorly stabilized by external rotation – reflecting the position of the second part of the O’Brien test. Interestingly, the O’Brien test demonstrated an AUC far below 0,5 in diagnosing anteroinferior tears, suggesting that a negative test is more predictive for anteroinferior tears. Therefore, the O’Brien test may be of additional value to distinguish between anteroinferior and posteroinferior lesions. At our clinic, we can even report anecdotal evidence of posterior shoulder dislocation at clinical examination during the first part of the O'Brien test. We therefore recommend to perform this test with caution, similar as when performing anterior shoulder apprehension tests.
      Owen et al already reported a relationship between O’Brien test and posterior labral tear.
      • Owen J.M.
      • Boulter T.
      • Walton M.
      • Funk L.
      • Mackenzie T.A.
      Reinterpretation of O'Brien test in posterior labral tears of the shoulder.
      Their retrospective study on 74 patients showed a sensitivity of 83% and a specificity of 25%.
      • Owen J.M.
      • Boulter T.
      • Walton M.
      • Funk L.
      • Mackenzie T.A.
      Reinterpretation of O'Brien test in posterior labral tears of the shoulder.
      This sensitivity is similar to the results of our study. However, O’Brien test was evaluated as positive when the patient presented weakness at the examination, and not pain. Our study was different as we retrospectively analyzed the labral tears that were confirmed by imaging and operated on, instead of evaluating patients with clinical suspicion of labral tear. As the sensitivity and specificity of the Kim test and Jerk test are 80% and 94%, and 73% and 98%, respectively, it is recommended to use a combination of these and the O’Brien tests to diagnose posterior labral lesions.
      • Kim S.H.
      • Park J.S.
      • Jeong W.K.
      • Shin S.K.
      The Kim test: a novel test for posteroinferior labral lesion of the shoulder--a comparison to the jerk test.

      Limitations

      The results of this study should be interpreted in light of its limitations, including those pertaining to any retrospective study. We only evaluate patients who had a confirmed labral tear at the time of surgery. Hence, some parameters such as test specificity in case of posterior labrum tear, positive and negative predictive values could not be evaluated. Also, patients with posterior instability caused by other pathology than labral tears were missed in the study. Another limitation of the study is the fact that we did not report on eventual concomitant glenoid dysplasia associated with a labral tear. A dysplastic glenoid, such as one with important retroversion, could cause a posterior translation of the humeral head and a discomfort of the patient, even without labral tear, and was not accounted for in this study. The long time inclusion phase was another limitation, as indications for labral repair have changed significantly over time.

      CONCLUSION

      The O’Brien test demonstrates more diagnostic value for posteroinferior tears than other labral tears. This includes the SLAP tear, for which the O’Brien test was originally designed.

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