O’Brien Test

O’Brien Test (also known as active compression test) is used to test for labral injuries and SLAP lesions (Superior Labrum Anterior and Posterior injuries) of the shoulder joint. It’s sometimes used to evaluate the Acromioclavicular joint.

It was first devised by O’Brien et al. in 1998.

How do you perform an O’Briens test?

The O’Brien test is a two-part test:

Stage 1:

• The patient stands with the elbow joint extended.
• Then he/ she forward flexes his or her arm to 90 degrees,
• With the arm in 10 degrees of horizontal adduction across the body, and maximum internal rotation (pronate the forearm) so the thumbs pointing downward.
• In this position, the patient then resists a downward force applied by the clinician to the distal arm. The patient is asked to report any pain as either “on top of the shoulder” (A-C joint) or “inside the shoulder” (SLAP lesion).

Stage 2:

The OBrien Test is then repeated in maximum external rotation (forearm supination) while the examiner press the arm downward against resistance.

What does a positive Obrien’s test mean?

O’Brien Test is positive if the pain that is experienced with the arm internally rotated is decreased during external rotation:

1. Pain or clicking within the GH joint may indicate a labral tear.
2. Pain at the AC joint may indicate AC joint pathology.

Positive SLAP lesion tests are confirmed with pain relief when the hand is supinated; pain with cross-armed horizontal adduction is used to confirm AC pathology.

The presence of rotator cuff pathology and impingement may produce false-positive results.

See Also: SLAP Lesion

Accuracy

A study by J. Matthew Owen shows that O’Brien test has a high Sensitivity and Specificity for detecting a SLAP tear, as following:

• Sensitivity: 100 %
• Specificity: 98 %

It also suggests that the O’Briens test has a high sensitivity (83%) and highly predictive (90%) of posterior labral injury.

O’Brien et al. calculated a sensitivity of 100 %, a specificity of 99 %, a positive predictive value (PPV) of 95 %, and a negative predictive value of 100 % for the ability of the active compression test to diagnose SLAP tears. However, these outstanding results have never been reproduced despite numerous published attempts.

Another study by William B Stetson found that the O’Brien and Crank tests were not sensitive clinical indicators for detecting glenoid labral tears and other tears of the anterior and posterior labrum (O’Brien test has a Sensitivity of 54 %, and Specificity of 31 %).

Diagnostic Utility of O’Brien Test for Identifying Labral tears:

Population	Reference Standard	Sens	Spec
Pooled estimates from six studies (n = 782)	Labral tear diagnosed by arthroscopy	.67	.37
55 patients with shoulder pain scheduled for arthroscopic surgery	Glenoid labral tear observed during arthroscopy	.55	.18
133 patients who underwent diagnostic arthroscopy of the shoulder	SLAP lesion visualized during arthroscopy	.94	.28
68 patients with SLAP lesions and 78 age-matched controls	SLAP lesion visualized during arthroscopy	.63	.53
847 patients who underwent diagnostic arthroscopy of the shoulder	Partial biceps tendon tear visualized during arthroscopy	.68	.46

Diagnostic Utility of O’Brien Test for Identifying Acromioclavicular Lesions:

Population	Reference Standard	Sens	Spec	+LR	-LR
1013 patients with pain between midclavicle and deltoid	Acromioclavicular joint infiltration test: Acromioclavicular joint was injected with lidocaine. Patients who experienced a reduction in symptoms of at least 50% within 10 minutes were considered to have an acromioclavicular pathologic condition	.16	.90	1.6	.93

Notes

• It is crucial to inquire about the location of the pain as the O’Brien test can also yield positive results in the presence of acromioclavicular joint disorders.
• Pain reported within the shoulder suggests a SLAP lesion (Superior Labrum Anterior and Posterior injuries), whereas pain over the acromioclavicular joint may also be due to osteoarthritis of the acromioclavicular joint.

O’Brien Test Limitations

The active compression test has several important limitations that warrant discussion:

First, in the original study published by O’Brien et al., the investigators noted that this maneuver also had some efficacy in the diagnosis of pathology involving the acromioclavicular (AC) joint. For these reasons, the authors recommended that clinicians determine the location and quality of the pain that was produced during the first portion of the test. Pain that occurred “deep” in the shoulder was thought to be related to superior labral pathology whereas pain that occurred at the top of the shoulder (i.e., near the AC joint) was thought to be related to pathology involving the AC joint.

Second, because the perception of pain related to different shoulder pathologies can vary significantly between individuals, patients may misinterpret the location, quality, and/or intensity of the pain which may lead to an inaccurate clinical diagnosis. For example, some patients may complain of pain in areas that would not normally be indicative of a SLAP tear whereas others may complain of pain during both portions of the test. In addition, some patients who do not have pain with this test demonstrate significant superior labral pathology on subsequent imaging studies.

Third, although contrary to the original description, the presence of “clicking” within the shoulder during the first portion of the test should probably not be considered a positive result since several studies have demonstrated its lack of diagnostic utility. It should be noted that audible clicking with this maneuver can also be caused by various pathologies involving the AC joint and, therefore, the clinician should exercise caution when interpreting this finding.

In light of these limitations and the lack of convincing clinical data, we prefer to perform this test in combination with other tests to improve the overall accuracy and reliability of the physical diagnosis.

SLAP lesion

SLAP lesion (Superior Labrum Anterior and Posterior injuries) can results from compressive loading of the shoulder in the flexed abducted position (for example, in a fall on the outstretched hand). The injury of the superior labrum begins posteriorly and extends anteriorly, stopping before or at the mid-glenoid notch and including the ‘anchor’ of the biceps tendon to the labrum.

There are four main types described:

1. non-traumatic superior labral degeneration, usually in older people and often asymptomatic.
2. Avulsion of the superior part of the labrum, the most common type.
3. A ‘bucket handle’ tear of the superior labrum.
4. As for type 3 with an extension into the tendon of Long Head of Biceps.

Very few patients with SLAP lesion injuries return to full capability without surgical intervention. Arthroscopic repair of an isolated superior labral lesion is successful in the large majority (91%) of patients. However, the results in patients who participate in overhead sports are not as satisfactory as those in patients who are not involved in overhead sports. Simple lesions are simply debrided. In more significant detachments the labrum is either repaired or excised with a tenotomy or tenodesis of the biceps.

Reference

1. O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med 1998;26(5):610–613. PMID: 9784804
2. J. Matthew Owen, Thomas Boulter, Mike Walton, Lennard Funk, and Tanya Anne Mackenzie. Reinterpretation of O’Brien test in posterior labral tears of the shoulder. Int J Shoulder Surg. 2015 Jan-Mar; 9(1): 6–8. PMCID: PMC4325388
3. Stetson WB, Templin K. The crank test, the O’Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med 2002;30(6):806–809. PMID: 12435645.
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