From the Guidelines
Clinical testing for labral tears should primarily involve specific physical examination maneuvers, such as the anterior apprehension test, O'Brien's test, FABER test, and resisted supination external rotation test, followed by imaging confirmation with MRI arthrography as the gold standard, due to its superior sensitivity compared to conventional MRI, as supported by recent studies 1.
Key Physical Examination Maneuvers
- Anterior apprehension test
- O'Brien's test
- FABER test
- Resisted supination external rotation test
- For hip labral tears, the flexion-adduction-internal rotation (FADIR) test and FABER test are most useful
Importance of Imaging
Imaging is essential for confirmation of labral tears, with MRI arthrography being the most sensitive method, as it has been shown to have high sensitivity for detection of labral injury, ranging from 86% to 100% 1. Compared to noncontrast MRI, MR arthrography has increased sensitivity for detection of anterior labral and SLAP tears 1.
Diagnostic Approach
The diagnostic approach should involve a thorough history focusing on mechanism of injury, pain location, and mechanical symptoms like catching or locking, combined with physical examination maneuvers and imaging confirmation. Diagnostic injections can also help differentiate labral pathology from other conditions by providing temporary pain relief when anesthetic is injected into the joint.
Considerations
When performing these tests, it's essential to compare findings with the unaffected side and consider that labral tears often coexist with other pathologies. Early diagnosis is crucial as untreated labral tears can lead to joint instability and accelerated osteoarthritis, particularly in younger, active patients. Recent guidelines support the use of MRI arthrography as an appropriate study for assessing labroligamentous injuries, especially when physical examination and history suggest a prior dislocation event or the presence of instability 1.
From the Research
Labral Tear Clinical Testing
- The diagnosis of glenoid labral lesions can be challenging, and a physical examination maneuver that allows for a definitive clinical diagnosis of a glenoid labral tear has been elusive 2.
- Several clinical tests have been studied for their usefulness in diagnosing labral tears, including the O'Brien test, Jobe relocation test, crank test, and dynamic labral shear test 2, 3, 4, 5.
- The O'Brien test has been found to be statistically correlated with the presence of a tear in the labrum, with a sensitivity of 63% and specificity of 73% 2.
- The Jobe relocation test has also been found to be correlated with the presence of a labral tear, with a sensitivity of 44% and specificity of 87% 2.
- The crank test has been found to have a positive predictive value of 41%, a specificity of 56%, a sensitivity of 46%, and a negative predictive value of 61% 4.
- The dynamic labral shear test has been found to be sensitive but not specific for detecting isolated SLAP lesions, with a sensitivity of 78% and specificity of 51% 5.
- Combining multiple tests does not necessarily improve the accuracy of diagnosis, and the decision to proceed with surgery should not be based on clinical examination alone 2, 5.
Specific Tests for Labral Tears
- The O'Brien test is useful for diagnosing posterior labral tears, with a sensitivity of 83% and positive predictive value of 90% 3.
- The dynamic labral shear test is useful for diagnosing isolated SLAP lesions, with an odds ratio of 3.58 5.
- The crank test and O'Brien test are not sensitive clinical indicators for detecting glenoid labral tears and other tears of the anterior and posterior labrum 4.
Limitations of Clinical Testing
- Clinical testing for labral tears has relatively low sensitivity and specificity, and a decision to proceed with surgery should not be based on clinical examination alone 2.
- Magnetic resonance imaging scans are more reliable than clinical tests for diagnosing labral tears, with a positive predictive value of 63% and specificity of 92% 4.
- Arthroscopy is the gold standard for diagnosing labral tears, and clinical testing should be used in conjunction with other diagnostic tools to guide further treatment 2, 6.