Speed's Test and Yergason's Test for Biceps Tendon Pathology

1. Speed's Test

• Patient is seated or standing
• Shoulder is forward flexed to 90° with the elbow fully extended and forearm supinated (palm facing up)
• The examiner applies downward resistance against the shoulder flexion
• The test is positive if pain is localized to the bicipital groove

Speed's Test (Campbell's Operative Orthopaedics, 15th Ed): patient forward flexes shoulder to 90° with elbow extended and forearm supinated; resistance is applied to the forearm.

• Bicipital tendinitis or tendinopathy
• SLAP (superior labrum anterior to posterior) lesion
• If weakness (rather than just pain) is produced, a tear of the LHB tendon may be present

• Firestein & Kelley's Rheumatology: Sensitivity 53%, Specificity 67%
• Holtby & Razmjou (2004): Sensitivity 32%, Specificity 75%

2. Yergason's Test (Yergason's Supination Sign)

• Patient is seated or standing, elbow flexed to 90°, forearm pronated (palm facing down), arm stabilized against the body
• Patient is asked to actively supinate the forearm against the examiner's resistance applied at the wrist
• Alternatively described: examiner resists supination + external rotation of the arm simultaneously

1. Pain in the bicipital groove - indicates bicipital tendinitis, tendinosis, or SLAP tear
2. Snapping or clicking felt at the bicipital groove - indicates laxity or tear of the transverse humeral ligament, with the LHB tendon subluxing out of the groove

• Inflammation of the long head of the biceps tendon
• Instability of the LHB in its groove (transverse humeral ligament tear)
• Note: Yergason himself observed the test may be negative with partial or complete rupture of the supraspinatus tendon

• Holtby & Razmjou: Sensitivity 43%, Specificity 79%
• Ultrasound-based study: Sensitivity 32%, Specificity 78%
• For SLAP lesions specifically: Sensitivity 12%, Specificity 87%

Key Comparison Table

Clinical Limitations

• Visible or palpable deformity ("Popeye" sign - bunching of the muscle belly distally after proximal rupture)
• Palpable gap at the proximal bicipital groove
• History of a snapping sound with sudden anterior shoulder pain
• Weakness of elbow flexion and forearm supination (especially with distal rupture)

SLAP Tear (Superior Labrum Anterior to Posterior)

Anatomy

• 50% of fibers insert into the superior labrum
• 50% insert into the supraglenoid tubercle (6.6 mm from the glenoid face at the 12-o'clock position)

Important anatomical variants that can mimic SLAP tears on imaging:

• Sublabral foramen (anterosuperior)
• Sublabral foramen + thickened MGHL (~9% of shoulders)
• Buford complex - absence of the anterosuperior labrum + thickened MGHL (1.5% of shoulders)

Snyder Classification

• IIA - tear extends Anteriorly to biceps anchor
• IIB - tear extends posteriorly (Back)
• IIC - Combined (anterior + posterior)

Type II is the most common SLAP lesion overall. The original four-type classification has been expanded to 10 subtypes. - Miller's Review of Orthopaedics

Epidemiology & Risk Factors

• SLAP tears are uncommon, accounting for ~5% of all shoulder injuries
• Most common in overhead athletes (pitchers, swimmers, volleyball players) and laborers
• Onset may be traumatic or insidious

Mechanism of Injury

1. Traction - fall on an outstretched hand, sudden pull on the arm, or throwing motion generating traction on the biceps anchor
2. Peel-back - torsional force during the late cocking phase of throwing (shoulder in maximum abduction + external rotation). The biceps-labral complex twists and peels medially off the superior glenoid. This is the classic mechanism for posterior Type II SLAP lesions

Clinical Features

• Anterior shoulder pain radiating into the biceps
• Catching, clicking, or popping with overhead activity
• "Dead arm" syndrome in throwing athletes - sudden loss of strength/control during throwing
• Pain with overhead activities, especially in the late cocking phase
• May present with instability symptoms if the labral detachment is significant

Physical Examination

• Most sensitive combination: O'Brien + Crank test (in parallel)
• Most specific combination: Yergason + Anterior slide test (in series)
• Running tests in series (both must be positive) increases specificity; running in parallel (either positive) increases sensitivity

Imaging

• Abnormal signal or contrast extending into the substance of or beneath the superior labrum
• Signal extending lateral to the glenoid or posterior to the biceps tendon
• A paralabral cyst (almost pathognomonic for a SLAP or posterior labral tear); if it extends to the spinoglenoid notch it can compress the suprascapular nerve causing infraspinatus wasting

Arthroscopic Findings

• Superior sulcus >5 mm in depth
• Displaceable biceps root with a probe
• Positive drive-through sign
• Positive peel-back sign - in abduction + external rotation, the posterior labrum and biceps-labral complex drop medially over the glenoid edge (diagnostic of posterior type II SLAP)

Treatment

Nonoperative (first line for virtually all patients)

• Rotator cuff strengthening + scapular stabilization
• Posterior capsule stretching (especially in throwers)
• Intraarticular corticosteroid injections
• Activity modification

Operative

Key principle: Primary SLAP repair is NOT recommended in patients >35-40 years old. Multiple studies show poor results with SLAP repair in older individuals. Biceps tenodesis is a more reliable option for this group. - Campbell's Operative Orthopaedics 15th Ed, p. 3161