Identifying SLAP lesions: a meta-analysis of clinical tests and exercise in clinical reasoning

To identify all published accounts of diagnostic accuracy for clinical tests of Superior Labral Antero-Posterior (SLAP) lesion of the shoulder, and provide an estimate of the pooled likelihood ratio for those tests that have been evaluated at least three times. A clinical reasoning exercise is presented to illustrate clinical useability of the findings.

Systematic review and meta-analysis.

An extensive review of international electronic databases was performed to identify all published works of diagnostic accuracy of any test proposed to be diagnostic for SLAP lesions of the shoulder. Statistical pooling of likelihood ratios was performed using a random-effects model to provide an estimate of the pooled positive likelihood ratio (PLR) for each test with at least three data points available.

Twelve studies describing 14 tests were identified. Five tests had been evaluated at least 3 times in the published literature. Methodologic quality scoring was performed and data were extracted. The pooled PLR revealed that of the five tests studies, only Yergason's test demonstrates consistent evidence of significant diagnostic accuracy (PLR 2.29). Heterogeneity of effect sizes was present for the Crank test. The heterogeneity was substantially improved through removal of the effect from the study in which the test was initially described and validated. The fail-safe N statistic suggests that the findings for Yergason's test are robust to publication bias. None of the tests reviewed are very strong.

Among the clinical tests for SLAP lesions that have been published to date, Yergason's test is the only one that shows a significant ability to influence clinical decision making, based on the results of the current analysis. Methodologic inadequacies in the reporting of the publications are common, and caution must be exercised when drawing inferences from the results of these studies.