The Accurate Diagnosis of Biceps-Labral Complex Lesions with MRI and “3-Pack” Physical Examination: A Retrospective Analysis with Prospective Validation
Authors: O'Brien Stephen J. , Newman Ashley M. , Taylor Samuel , Dawson Courtney , Gallagher Kelli Ann , Bowers Andrea , Nguyen Joseph , Baret Nikolas 
Published: September 2013

Objectives:

Effective treatment of Biceps-Labral (B-L) Complex lesions is predicated upon accurate diagnosis. Diagnostic algorithms include both physical examination and MRI. We sought to evaluate the contribution of MRI and physical examination to the accurate diagnosis of B-L Complex lesions.

Methods:

A retrospective review of 273 surgical cases of lesions of the B-L Complex was performed comparing the preoperative documented clinical "Three Pack" examination to the preoperative Radiologist's MRI reading in accurately predicting lesions of the B-L Complex seen at the time of surgery, and as documented by intraoperative photos and videos. After the completion of this retrospective review, an additional 145 patients(116 symptomatic, 29 matched controls) were enrolled in a prospective validation study of the "Three Pack" examination. All patients were examined independently and separately by three examiners without contamination: the senior surgeon, the sports medicine fellow, and the senior surgeon' s PA. Results were adjusted for order of examination.All B-L Complex Lesions were documented at surgery by digital photos and or video.

Results:

In the retrospective review, the MRI accurately described the labral tears found at surgery in only 45% of the cases. Of the documented biceps lesions, only 28% of the time was the biceps read on MRI as abnormal. When the preop ACT was positive, a positive"arthroscopic"ACT (where the biceps incarcerates between the humeral head and glenoid) or labral tear was noted in 88% of the cases. There were no cases where the preop ACT was negative and the "arthroscopic" ACT was positive. However, when the "arthroscopic"ACT was positive, 46% of the time there was no tear of the labrum. The average age of the patients with a positive "arthroscopic" ACT was 34 yo. In the subsequent prospective validation of the "Three Pack", The interobserver reliability for the "three pack" evaluation was quite strong with Kappa values between.700 to.850 for all tests, indicating substantial (.61-.80) to almost perfect (.81-1.00) agreement categories. This was in contrast to other "traditional" tests performed (Speed's, Yergason's, full and empty can tests), where only moderate agreement at best (.41-.60) was noted. Tenderness to BGP had a high sensitivity and specificity of.978 and.703 respectively for groove lesions; a positive throwing test had a moderate sensitivity of.694 and higher specificity of.745; the ACT (O'Brien Sign) had a very high sensitivity for labral tears and biceps incarceration,.897 and.914 respectively, with moderate specificities of.562 and.602 respectively. Seventy percent of patients had more than 1 site of pain and pathology confirmed at surgery. 88% of patients had a positive ACT in the symptomatic shoulder vs 11% in the unaffected shouder (and 18% of controls) for a p value<.001; 87% of patients had a positive BGP testversus 18% in the unaffected shoulder ( and 11% of controls) for a p value of <.001 as well.Seventy six percent of unaffected shoulders had all three tests negative.

Conclusion:

The "Three Pack" Examination is a highly reliable approach for evaluating painful lesions of the B- L Complex, with strong interobserver reliability. This more comprehensive approach to the B-L complex is also important as many patients have more than one site of pain and pathology. A positive Active Compression Test appears to be a normal finding as well, seen in 18% of patients who have never had shoulder pain, and had never felt that pain before.