Sports Medicine Research: In the Lab & In the Field: Painful Arc in Flexion and Forward Scapular Posture = SLAP Surgery Recommendation (Sports Med Res)
Wednesday, October 1, 2014

Painful Arc in Flexion and Forward Scapular Posture = SLAP Surgery Recommendation

Preliminary Development of a Clinical Prediction Rule for Treatment of Patients with Suspected SLAP Tears

Moore-Read SD, Kibler WB, Sciascia AD, & Uhl T. Arthroscopy.  Published online first August 14, 2014. doi: 10.1016/j.arthro.2014.06.015 

Take Home Message:  The presence of a painful flexion arc and forward scapular posture seem to be relatively accurate in predicting who will need surgery for a SLAP tear after trying 6 weeks of rehabilitation.  While this rule seems promising, more investigation is needed, and clinical decisions should be made on an individual basis.

Shoulder injury diagnosis and management is often a very complicated process.  Even once a SLAP tear diagnosis is made, it can be difficult to decide whether an athlete should have surgery or not, as outcomes vary by individual.  The purpose of this prospective study was to examine whether there are initial examination findings among 58 patients with a diagnosed SLAP tear that accurately predict whether a patient needs surgery after trying 6 weeks of rehabilitation. One orthopaedic surgeon evaluated the patients (on average 39 years of age) and diagnosed a SLAP tear based on predefined criteria relating to history, clinical examination, and/or diagnostic imaging. This initial evaluation included a traditional clinical examination, patient-reported outcome measures, glenohumeral range of motion, isometric shoulder strength, and scapular posture. After the initial evaluation, the patients completed a standardized rehabilitation program that included strengthening and stretching exercises, which could be tailored to the patient. After 6 weeks, the orthopaedic reevaluated the patient’s strength, scapular posture, range of motion, strength, pain, and functional outcomes.  After the evaluation, the patient was recommended for surgery if his/her signs and symptoms continued or worsened, s/he failed to progress with the rehabilitation program, and the patient was unilines or unable to tolerate the dysfunction. During the re-evaluation, 27 patients were recommended for surgery and 31 were not recommended for surgery.  The researchers determined that presence of a painful arc of motion in forward flexion and the presence of increased forward scapular posture at initial evaluation were predictive of being recommended surgery at 6 weeks.  Utilizing this combination of initial clinical findings, the researchers could correctly predict 72% of the outcomes (recommended for surgery or not recommended). 

A clinical prediction rule that includes a painful arc of motion in forward flexion and the presence of increased forward scapular posture seems to accurately predict which patients may or may not respond well to conservative management of a SLAP tear.  Among the 31 patients that were not recommended for surgery, 2 patients developed significant functional limitations that resulted in their undergoing SLAP surgery after the study.  It would be interesting to have followed the 27 patients who were recommended for surgery to determine what their outcomes were post surgery.  The authors stated that 5 patients decided not to get the recommended surgery due to insurance/health care costs.  Due to the wide patient variability in outcomes with conservative and surgical management of SLAP injuries, it is important to try to use clinical prediction rules to identify who will respond best to interventions.  These findings may help to inform decisions in the athletic and physically active populations but it will be important to see if these findings are verified in a larger study that includes patients of multiple clinicians.  Clinical prediction rules provide clinicians with the potential to help to mitigate rising health care costs by making informed evidence based decisions that are best for each individual patient. While it’ll be helpful to see if this new clinical prediction rule is verified we can begin to talk with our patients about the fact that some patients with SLAP tears will respond well to rehabilitation while others may not. We can also note that if they do not have a painful arc of motion in forward flexion nor the presence of increased forward scapular posture then their chances of improving with rehabilitation are improved.

Questions for Discussion:  What are some examples of clinical findings that you believe may be predictive of successful outcomes?  Are there any other clinical findings that you have think indicates a patient may need surgery for a SLAP tear?
    
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:
Assessing SLAP Lesions: Diagnostic Accuracy of Five Special Tests
Evaluation of Special Tests for SLAP Lesions
Special Tests of the Shoulder: An Update of Evidence-based Support


Moore-Reed, S., Kibler, W., Sciascia, A., & Uhl, T. (2014). Preliminary Development of a Clinical Prediction Rule for Treatment of Patients With Suspected SLAP Tears Arthroscopy: The Journal of Arthroscopic & Related Surgery DOI: 10.1016/j.arthro.2014.06.015

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