Clinical assessment of the glenoid labrum

Abstract

Background: The glenoid labrum is integral to shoulder stability and can be difficult to assess clinically. Whilst it is a single anatomical structure, damage to different regions results in very different clinical manifestations. A large number of provocative tests have been described, all of which initially purport to have excellent diagnostic accuracy. Clinical experience suggests that this is not the case and decision making can be difficult for the non-expert. The purpose of this study is to review the current evidence for the most commonly used tests and to provide suggestions for tests which have the most evidence for efficacy.

Methods: The glenoid labrum was divided into anterior, superior and posterior regions. The English language literature describing labral tests was reviewed. The evidence provided by the authors and any subsequent studies was analysed.

Results: Whilst a large number if tests have been described with the primary authors reporting excellent results the evidence for most is poor when later tested critically.

Discussion: No single test will accurately diagnose labral pathology. The clinician must use evidence from the clinical history combined with selective use and interpretation of tests with which they are familiar.

Keywords: Clinical assessment; labral tear; labrum; test.

Figure 1.

O’Brien’s test. The patient can be standing or seated. The straight arm is lifted into a horizontal position with 15° of adduction (best seen in D). The patient is asked to resist the downward pressure (arrow in C), both in maximal internal rotation (A) and full external rotation/supination (B). Pain or painful clicking felt within the joint that improves with supination is a positive result. This manoeuvre also stresses the ACJ, and so pain felt on top of the shoulder is indicative of ACJ pathology and is unaffected by arm rotation.

Figure 2.

Kim’s ‘biceps load test II’. (A). The patient is supine. The arm is elevated 120° and externally rotated maximally, with the examiner supporting the arm. The elbow is flexed 90° and maximally supinated. This position may or may not be painful in itself. (B). The patient then is asked to try to bend the elbow against resistance of the examiner. If pain occurs or is increased by this elbow flexion, then the test is positive.

Figure 3.

Apprehension test and relocation test. Note that this test can be performed either sitting or supine. Here, we demonstrate it in the sitting position, as well as supine for clarity. The arm is placed in a position of 90° of abduction and 90° of external rotation. (A) View from front. (B) View from side. (C) View from above. (D) View in supine position. An anteriorly directed force is applied to the back of the humeral head (red arrow in C). A positive test results if pain or apprehension is experienced by the patient. A star shows the point of labral stress by this manoeuvre. (E) In the relocation test, a posteriorly applied force (blue arrow in E) relieves the pain or apprehension if caused by labral pathology.

Figure 4.

The Kim test for posteriorinferior labral lesions. The patient is sitting. The arm is held in 90° abduction, and the examiner applies an axial combined with posterior and inferior force to the humerus. This force acts on the posterioinferior labrum. The patient should be sitting on a chair with a back (not a stool) to support this force. The examiner then moves the arm in a 45° diagonal direction upwards and across the patient. A sudden onset of posterior pain is a positive result, regardless of any clunk.