Abstract
The active compression test (O'Brien Sign) is widely used by physicians to aid in the diagnosis of biceps-labrum complex disease. This maneuver has been particularly criticized in the literature, however, with regard to interobserver reliability. Criticisms may in fact stem from inaccurate and inconsistent practice of the examination maneuver, stemming from both patient- and physician-related errors. In this Technical Note, we introduce an easy modification to the O'Brien Sign that limits such errors and improves test uniformity.
The active compression test (ACT), also known as the O'Brien sign, was first described in 1998.1 The authors reported high sensitivity, specificity, and positive and negative predictive values for diagnosing both superior labral and acromioclavicular (AC) pathology. In its original description, the patient's arm is held in 90° of forward flexion, 10° to 15° degrees of adduction, and maximal humeral internal rotation (thumb down) with the elbow held in full extension. The examiner then applies a uniform downward force on the arm. The arm is then externally rotated (palm up) while maintaining the aforementioned forward flexion and adduction, and again the patient is instructed to resist a downward force. The test is considered positive if the patient's clinical pain was elicited with the first maneuver (thumb down) and was reduced or eliminated with the second maneuver (palm up). More specifically, pain or painful clicking felt deep inside the glenohumeral joint is thought to be indicative of superior labral pathology, whereas pain localized to the AC joint or the top of the shoulder suggests AC joint disease.
Since its introduction, the O'Brien Sign has become one of the most commonly used maneuvers for evaluating patients with suspected superior labral (SLAP) tears and, as such, it is considered a standard component of the shoulder physical examination.2, 3 Despite its popularity, the test has been criticized in recent literature with regard to its sensitivity and specificity.4, 5, 6 Moreover, others have reported a low interobserver reliability.7 One explanation for the poor reliability may be improper execution of the maneuver by care providers. For example, inaccurate arm positioning (examiner error) or a patient's unrecognized self-repositioning (e.g. rotating shoulders away from the examiner) will lead to incorrect performance of the test. Improper interpretation of the maneuver will lead to inaccurate test results. Such errors are more common than is believed, a fact highlighted by one recent study exploring the accuracy of internet-based orthopaedic instructional videos.8 In this study, Urch and colleagues found that open-access videos describing various maneuvers of the shoulder physical examination were frequently inconsistent and inaccurate. Notably, the O'Brien Sign was reported to be one of the most frequently misrepresented maneuvers.
In response, we introduce a simple modification to the Active Compression Test (O'Brien Sign) that guarantees appropriate positioning of the arm. This modification effectively eliminates both physician- and patient-related variability and ensures the test is performed accurately at every encounter as originally reported by O'Brien et al.1
Description of the Modification
Patient Positioning
In the examining room, the patient stands facing the examiner, both shoulders square to the examiner. Both arms are forward flexed to 90°, maintaining full elbow extension (Video 1). Maintaining 90° of forward flexion, both arms are fully internally rotated so that the thumbs point to the floor (empty can position). The arms are then adducted together until the dorsum of the hands meet at the patient's midline (Fig 1). This creates the necessary 10° to 15° of arm adduction.
Fig 1.
The patient stands facing the examiner. With the elbows in extension, both upper extremities are forward flexed to 90°, adducted to 10°-15°, and internally rotated so that the dorsum of the hands are opposed.
Test Steps
As the patient maintains the forward flexed, adducted, and internally rotated arm position, the examiner applies a uniform downward force to both arms simultaneously (step 1; Fig 2). The patient is instructed to resist the force, maintaining the 90° forward flexion angle.
Fig 2.
The examiner applies a uniform downward force simultaneously to both upper extremities at the level of the wrist as the patient resists to maintain arm position (step 1).
Next, keeping the arms in the forward flexed and adducted position, the patient externally rotates both arms such that the ulnar surfaces of the hands are now apposed and the palms of both hands are facing up to the ceiling (Fig 3). The examiner again applies a simultaneous, bilateral downward force as the patient resists to maintain the forward flexed and adducted position (step 2).
Fig 3.
While maintaining 90° forward flexed position, the arms are fully supinated such that the palms are facing up and the ulnar surfaces of the hands are apposed. The examiner applies a simultaneous bilateral downward force as the patient resists (step 2).
Test Interpretation
As previously described, a positive test is denoted by re-creation of the patient's clinical pain (either deep within the shoulder or at the AC joint) during step 1 (arms fully internally rotated) that is relieved or eliminated during step 2 (arms fully externally rotated).
Discussion
The technique modification for the Active Compression Test (O'Brien Sign) described here presents several advantages. First, bilateral forward flexion and internal rotation standardizes arm adduction and maximal internal rotation. This ensures that the arm is positioned as originally described in a reproducible fashion (Table 1). Second, application of a downward force simultaneously to both arms prevents the patient from altering arm position, and provides an internal (contralateral) control. These factors ensure the test is executed correctly and improve the test's reliability.
Table 1.
Pearls and Pitfalls of the Modification of the Active Compression Test
| Pearls | Pitfalls |
|---|---|
| Position the arms such that the hands meet at the midline of the patient. | Incomplete apposition of the hands will lead to inappropriate technique and may skew the results of the modified ACT. |
| Testing the arms simultaneously standardizes arm positioning and provides a contralateral control to the injured shoulder. | Failure to fully internally and externally rotate the arms may lead to inaccurate results. |
| Performing a comprehensive shoulder examination is key to ensuring an accurate diagnosis. | Failure to interpret the results of the modified ACT in context of a complete shoulder exam may lead to misdiagnosis. |
ACT, active compression test.
The literature suggests that no single physical examination maneuver is adequate for accurate, consistent diagnosis of biceps-labrum complex (BLC) disease.6, 9 This is due to the complex nature of the BLC and its frequent association with various other shoulder pathologies.10 For example, a patient with rotator cuff tendinopathy is likely to experience pain with resisted shoulder abduction regardless of the status of his or her BLC. This is commonly seen in the older patient population.11 Additionally, patients with cuff tendinopathy or impingement often struggle to maintain adequate shoulder forward flexion secondary to pain. In these situations, the active compression test becomes more difficult to interpret. This fact is one limitation of the active compression test that extends itself to the proposed modification of the maneuver. In such cases, the examiner may use the information from the modified ACT to supplement his or her findings to fine-tune the differential diagnosis.
Nonetheless, the physical examination is the first line of diagnosis and provides insight into the etiology of the patient's pain and a road map to interpreting subsequent imaging studies.12 As such, it is important to ensure that the physical examination component of a patient workup is performed both accurately and consistently. Furthermore, in young athletes and in roughly 30% of patients with isolated BLC disease, the modified ACT is a useful diagnostic tool that can quickly guide the physician toward an accurate diagnosis.10 This is especially true when the test is used as part of the “3-pack” examination (bicipital groove palpation, resisted throwing test, and active compression test).13, 14, 15
In conclusion, our modification standardizes the execution of the active compression test. Taken in concert with other key investigative modalities, the modified ACT further refines the clinician's diagnostic prowess in identifying biceps-labrum complex disease and AC arthrosis.
Footnotes
The authors report the following potential conflicts of interest or sources of funding: D.M.D. is a consultant for Biomet. J.S.D. is a consultant for Arthrex and Conmed.
The work was performed at the Hospital for Special Surgery.
Supplementary Data
The patient stands facing the examiner. With the elbows in extension, both upper extremities are forward flexed to 90°, adducted, and internally rotated so that the dorsum of the hands are opposed. The examiner applies a uniform downward force simultaneously to both upper extremities at the level of the wrist (step 1). Next, while maintaining the forward flexed position, the arms are fully supinated such that the palms are facing up and the ulnar surfaces of the hands are apposed. The examiner again applies a simultaneous, bilateral downward force (step 2).
References
- 1.O'Brien S.J., Pagnani M.J., Fealy S., McGlynn S.R., Wilson J.B. The Active Compression Test: A new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26:610–613. doi: 10.1177/03635465980260050201. [DOI] [PubMed] [Google Scholar]
- 2.Keener J.D., Brophy R.H. Superior labral tears of the shoulder: Pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg. 2009;17:627–637. doi: 10.5435/00124635-200910000-00005. [DOI] [PubMed] [Google Scholar]
- 3.Kibler W.B., Sciascia A. Current practice for the diagnosis of a SLAP lesion: Systematic review and physician survey. Arthroscopy. 2015;31:2456–2469. doi: 10.1016/j.arthro.2015.06.033. [DOI] [PubMed] [Google Scholar]
- 4.Brockmeyer M., Tompkins M., Kohn D.M., Lorbach O. SLAP lesions: A treatment algorithm. Knee Surg Sports Traumatol Arthrosc. 2016;24:447–455. doi: 10.1007/s00167-015-3966-0. [DOI] [PubMed] [Google Scholar]
- 5.Ben Kibler W., Sciascia A.D., Hester P., Dome D., Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009;37:1840–1847. doi: 10.1177/0363546509332505. [DOI] [PubMed] [Google Scholar]
- 6.Cook C., Beaty S., Kissenberth M.J., Siffri P., Pill S.G., Hawkins R.J. Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg. 2012;21:13–22. doi: 10.1016/j.jse.2011.07.012. [DOI] [PubMed] [Google Scholar]
- 7.Walsworth M.K., Doukas W.C., Murphy K.P., Mielcarek B.J., Michener L.A. Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid labral tears. Am J Sports Med. 2008;36:162–168. doi: 10.1177/0363546507307508. [DOI] [PubMed] [Google Scholar]
- 8.Urch E., Taylor S.A., Cody E. The quality of open-access video-based orthopaedic instructional content for the shoulder physical exam is inconsistent. HSS J. 2016;12:206–215. doi: 10.1007/s11420-016-9508-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Karlsson J. Physical examination tests are not valid for diagnosing SLAP tears: A review. Clin J Sport Med. 2010;20:134–135. doi: 10.1097/01.jsm.0000369406.54312.0b. [DOI] [PubMed] [Google Scholar]
- 10.Snyder S.J., Banas M.P., Karzel R.P. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4:243–248. doi: 10.1016/s1058-2746(05)80015-1. [DOI] [PubMed] [Google Scholar]
- 11.Onyekwelu I., Khatib O., Zuckerman J.D., Rokito A.S., Kwon Y.W. The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs. J Shoulder Elbow Surg. 2012;21:728–731. doi: 10.1016/j.jse.2012.02.001. [DOI] [PubMed] [Google Scholar]
- 12.Pandya N.K., Colton A., Webner D., Sennett B., Huffman G.R. Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: A sensitivity analysis. Arthroscopy. 2008;24:311–317. doi: 10.1016/j.arthro.2007.09.004. [DOI] [PubMed] [Google Scholar]
- 13.Gausden E.B., Taylor S.A., Ramkumar P. Tenotomy, tenodesis, transfer: A review of treatment options for biceps-labrum complex disease. Am J Orthop (Belle Mead NJ) 2016;45:E503–E511. [PubMed] [Google Scholar]
- 14.O'Brien S.J., Newman A.M., Taylor S.A. The accurate diagnosis of biceps-labral complex lesions with MRI and “3-pack” physical examination: A retrospective analysis with prospective validation. Orthop J Sports Med. 2013;1(4 suppl) 2325967113S00018. [Google Scholar]
- 15.Taylor S.A., Newman A.M., Dawson C. The “3-pack” examination is critical for comprehensive evaluation of the biceps-labrum complex and the bicipital tunnel: A prospective study. Arthroscopy. 2017;33:28–38. doi: 10.1016/j.arthro.2016.05.015. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The patient stands facing the examiner. With the elbows in extension, both upper extremities are forward flexed to 90°, adducted, and internally rotated so that the dorsum of the hands are opposed. The examiner applies a uniform downward force simultaneously to both upper extremities at the level of the wrist (step 1). Next, while maintaining the forward flexed position, the arms are fully supinated such that the palms are facing up and the ulnar surfaces of the hands are apposed. The examiner again applies a simultaneous, bilateral downward force (step 2).