title: The "3-Pack" Examination Is Critical for Comprehensive Evaluation of the Biceps-Labrum Complex and the Bicipital Tunnel: A Prospective Study.
abstract: OBJECTIVE
  To determine the diagnostic value of the 3-Pack examination for biceps-labrum complex (BLC) disease, assess interobserver reliability, and generate an evidence-based diagnostic and therapeutic algorithm.
  
  
  METHODS
  A total of 145 consecutive patients were enrolled in this prospective comparative study. The study included 116 chronically symptomatic patients indicated for arthroscopic subdeltoid transfer of the long head of the biceps tendon to the conjoint tendon and 29 asymptomatic comparison subjects. Each patient underwent examination that included the 3-Pack (active compression test [O'Brien sign], throwing test, and bicipital tunnel palpation) and traditional examination (Speed test; Yergason test; full can test; empty can test) in a blinded, randomized fashion by 3 investigators. Intraoperative BLC disease was prospectively categorized by location (inside, junctional, or bicipital tunnel).
  
  
  RESULTS
  3-Pack tests were highly sensitive (73% to 98%), but less specific (46% to 79%) for BLC in all 3 locations than some of the traditional tests, which were less sensitive (20% to 67%), but more specific (83% to 100%) for BLC disease in all 3 locations. With regard to hidden bicipital tunnel lesions, palpation and O'Brien sign were highly sensitive (97.8% and 95.7% respectively) and revealed high negative predictive value (NPV, 96.4% and 92.6% respectively). Speed and Yergason tests, conversely, were poorly sensitive but had high specificities (86.7% and 97.9%, respectively) and positive predictive value (76% and 92.3%, respectively). Inter-rater reliabilities were substantial to almost perfect for the 3-Pack examination (kappa 70% to 85%) and fair to moderate for the 4 traditional examinations (kappa 25% to 56%).
  
  
  CONCLUSIONS
  The 3-Pack has excellent inter-rater reliability, sensitivity, and NPV and is a critical screening tool for BLC disease in all zones. Hidden extra-articular bicipital tunnel disease can reliably be excluded based on negative tenderness to palpation or a negative O'Brien sign (NPV 93% to 96%).
  
  
  METHODS
  Level III, case control study.
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.. Electronic address: TaylorS@hss.edu.
authors.forename: Samuel A
authors.initials: SA
authors.lastname: Taylor
authors.affiliation: Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A.
authors.forename: Ashley M
authors.initials: AM
authors.lastname: Newman
authors.affiliation: Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.
authors.forename: Courtney
authors.initials: C
authors.lastname: Dawson
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Kelli Ann
authors.initials: KA
authors.lastname: Gallagher
authors.affiliation: Burlington County Orthopaedic Specialists, Mt Laurel, New Jersey, U.S.A.
authors.forename: Andrea
authors.initials: A
authors.lastname: Bowers
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Joseph
authors.initials: J
authors.lastname: Nguyen
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Fabricant
authors.affiliation: Hospital for Special Surgery, New York, New York, U.S.A.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: O'Brien
mesh_terms: D000328:Adult; D001132:Arm / Q000473:pathology; D001182:Arthroscopy; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D008297:Male; D018482:Muscle, Skeletal / Q000473:pathology; D015588:Observer Variation; D010808:Physical Examination; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012785:Shoulder Joint / Q000473:pathology* / Q000601:surgery; D013708:Tendon Injuries / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery