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

SD, Kibler WB, Sciascia AD, & Uhl T. Arthroscopy.  Published online first August 14, 2014. doi:

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

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). 

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?
by: Nicole Cattano
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