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AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
Lennard Funk
Matt Owen
Thomas Boulter
Tanya Mackenzie
1
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
POSTERIOR INSTABILITY
2
• Posterior instability is a relatively rare condition in the shoulder
!
• Of all shoulder instabilities approximately 88-98% are anterior
instabilities
!
• Posterior instability can often be overlooked or missed
!
!
!
!
!
!
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
Lesions
3
ABER Tackle Direct Impact
Neurological Lesion 32% 15%
Soft tissue Bankart 79% 33%
Bony Bankart 26% 11%
Posterior Labral Tear 11% 50%
SLAP 7% 35%
Partial Cuff Tear 32% 12%
Collision shoulder injuries
Malone, Funk, Mohammed, Ball. Shoulder injury patterns in Rugby - the Collision Shoulder. 

JBJS (Suppl). 2008.
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
4
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
5
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
TRADITIONAL TESTS
6
Specificity Sensitivity Notes Reference
Posterior
Drawer Test
No data
Load & Shift 100% 14% For Laxity Gerber &
Ganz. JBJSB.
1984
Posterior
Apprehensio
n
99% 20% Jia et al.
JBJSA. 2009
Jerk Test 85% 90% posteroinf.
labral tear
Kim et al.
AJSM. 2004
Kim Test 95% 80% posteroinf.
labral tear
Kim et al.
CORR. 1993
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
7
• The Jerk Test has only been shown to be selective
in detecting a postero-inferior labral lesion
!
!
• None of the others have been shown to have good
clinical diagnostic value
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
MODIFIED O’BRIEN’S TEST (MOB)
WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
8
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
• Conducted in a similar manner to that initially described by
O’Brien
• Patient asked to forward flex the affected arm 90° with the
elbow in full extension.
• Adduct the arm fully, medial to the sagittal plane of the body.
• Internally rotate so that the thumb points downward.
• The examiner then applies a downward force to the arm being
resisted by the patient.
• The test is considered positive with objective weakness
observed by the examiner when downward force on the arm
resulted in loss of forward flexion from 90°.
9
MODIFIED O’BRIEN’S TEST (MOB)
WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
10
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
MECHANISM:
11
MODIFIED O’BRIEN’S TEST (MOB)
WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
AIMS
12
!
• How sensitive and specific is the new MOB test at correctly
diagnosing posterior instability?
!
• How does the new MOB test compare to the tests already
available?
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
METHODS
13
• Retrospective study
!
• 74 patients seen over a 3 year period with traumatic
instability
!
• All clinical tests recorded.
!
• The imaging and surgical findings were then recorded
and compared to the MOB test findings
!
• Patients with surgical findings consistent with a diagnosis
of posterior instability (according to the lesions previously
mentioned) and a positive MOB test formed the true
positive group and vice versa
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
RESULTS
• Included All arthroscopic stabilisations, incl. anterior
• n = 74
14
Post lesion
present
Post lesion
absent
MOB +ve 55 6 PPV 90%
MOB -ve 11 2 NPV 15%
Sensitivity
83%
Specificity
25%
N=74
Owen, Mackenzie, Boulter, Funk, 2014
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
DISCUSSION
15
• High sensitivity and PPV values shows that the test is
accurate at detecting the presence of posterior instability
!
• Unlikely to have a missed diagnosis, high confidence
in your diagnosis.
!
• Low specificity and NPV values however mean that the
test is unreliable in patients with no posterior instability
!
• Benefit is in conjunction with tests with high specificity
(i.e. Posterior Apprehension test)
!
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
POSTERIOR INSTABILITY TESTS
16
Specificity Sensitivity Notes Reference
Posterior
Drawer Test
No data
Load & Shift 100% 14% For Laxity Gerber &
Ganz. JBJSB.
1984
Posterior
Apprehension
99% 20% Jia et al.
JBJSA. 2009
Jerk Test 85% 90% posteroinf.
labral tear
Kim et al.
AJSM. 2004
Kim Test 95% 80% posteroinf.
labral tear
Kim et al.
CORR. 1993
MOB/WPIT 25% 83% Muscular
Athletes
AMSTERDAM / THE NETHERLANDS
www.esska-congress.org
CONCLUSIONS
17
MOB test has promise
!
MOB test could be used to help confirm a diagnosis of
posterior instability and better guide management from
there
!
This could mean that this test in combination with more
specific tests could be considered as a effective method of
diagnosing posterior instability clinically
!
!

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Posterior instability Test - Lennard Funk

  • 1. AMSTERDAM / THE NETHERLANDS www.esska-congress.org Lennard Funk Matt Owen Thomas Boulter Tanya Mackenzie 1
  • 2. AMSTERDAM / THE NETHERLANDS www.esska-congress.org POSTERIOR INSTABILITY 2 • Posterior instability is a relatively rare condition in the shoulder ! • Of all shoulder instabilities approximately 88-98% are anterior instabilities ! • Posterior instability can often be overlooked or missed ! ! ! ! ! !
  • 3. AMSTERDAM / THE NETHERLANDS www.esska-congress.org Lesions 3 ABER Tackle Direct Impact Neurological Lesion 32% 15% Soft tissue Bankart 79% 33% Bony Bankart 26% 11% Posterior Labral Tear 11% 50% SLAP 7% 35% Partial Cuff Tear 32% 12% Collision shoulder injuries Malone, Funk, Mohammed, Ball. Shoulder injury patterns in Rugby - the Collision Shoulder. 
 JBJS (Suppl). 2008.
  • 4. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 4
  • 5. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 5
  • 6. AMSTERDAM / THE NETHERLANDS www.esska-congress.org TRADITIONAL TESTS 6 Specificity Sensitivity Notes Reference Posterior Drawer Test No data Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984 Posterior Apprehensio n 99% 20% Jia et al. JBJSA. 2009 Jerk Test 85% 90% posteroinf. labral tear Kim et al. AJSM. 2004 Kim Test 95% 80% posteroinf. labral tear Kim et al. CORR. 1993
  • 7. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 7 • The Jerk Test has only been shown to be selective in detecting a postero-inferior labral lesion ! ! • None of the others have been shown to have good clinical diagnostic value
  • 8. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MODIFIED O’BRIEN’S TEST (MOB) WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT) 8
  • 9. AMSTERDAM / THE NETHERLANDS www.esska-congress.org • Conducted in a similar manner to that initially described by O’Brien • Patient asked to forward flex the affected arm 90° with the elbow in full extension. • Adduct the arm fully, medial to the sagittal plane of the body. • Internally rotate so that the thumb points downward. • The examiner then applies a downward force to the arm being resisted by the patient. • The test is considered positive with objective weakness observed by the examiner when downward force on the arm resulted in loss of forward flexion from 90°. 9 MODIFIED O’BRIEN’S TEST (MOB) WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
  • 10. AMSTERDAM / THE NETHERLANDS www.esska-congress.org 10
  • 11. AMSTERDAM / THE NETHERLANDS www.esska-congress.org MECHANISM: 11 MODIFIED O’BRIEN’S TEST (MOB) WRIGHTINGTON POSTERIOR INSTABILITY TEST (WPIT)
  • 12. AMSTERDAM / THE NETHERLANDS www.esska-congress.org AIMS 12 ! • How sensitive and specific is the new MOB test at correctly diagnosing posterior instability? ! • How does the new MOB test compare to the tests already available?
  • 13. AMSTERDAM / THE NETHERLANDS www.esska-congress.org METHODS 13 • Retrospective study ! • 74 patients seen over a 3 year period with traumatic instability ! • All clinical tests recorded. ! • The imaging and surgical findings were then recorded and compared to the MOB test findings ! • Patients with surgical findings consistent with a diagnosis of posterior instability (according to the lesions previously mentioned) and a positive MOB test formed the true positive group and vice versa
  • 14. AMSTERDAM / THE NETHERLANDS www.esska-congress.org RESULTS • Included All arthroscopic stabilisations, incl. anterior • n = 74 14 Post lesion present Post lesion absent MOB +ve 55 6 PPV 90% MOB -ve 11 2 NPV 15% Sensitivity 83% Specificity 25% N=74 Owen, Mackenzie, Boulter, Funk, 2014
  • 15. AMSTERDAM / THE NETHERLANDS www.esska-congress.org DISCUSSION 15 • High sensitivity and PPV values shows that the test is accurate at detecting the presence of posterior instability ! • Unlikely to have a missed diagnosis, high confidence in your diagnosis. ! • Low specificity and NPV values however mean that the test is unreliable in patients with no posterior instability ! • Benefit is in conjunction with tests with high specificity (i.e. Posterior Apprehension test) !
  • 16. AMSTERDAM / THE NETHERLANDS www.esska-congress.org POSTERIOR INSTABILITY TESTS 16 Specificity Sensitivity Notes Reference Posterior Drawer Test No data Load & Shift 100% 14% For Laxity Gerber & Ganz. JBJSB. 1984 Posterior Apprehension 99% 20% Jia et al. JBJSA. 2009 Jerk Test 85% 90% posteroinf. labral tear Kim et al. AJSM. 2004 Kim Test 95% 80% posteroinf. labral tear Kim et al. CORR. 1993 MOB/WPIT 25% 83% Muscular Athletes
  • 17. AMSTERDAM / THE NETHERLANDS www.esska-congress.org CONCLUSIONS 17 MOB test has promise ! MOB test could be used to help confirm a diagnosis of posterior instability and better guide management from there ! This could mean that this test in combination with more specific tests could be considered as a effective method of diagnosing posterior instability clinically ! !