Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests

Physical Therapy, High Point University, 833 Montlieu Ave, High Point, North Carolina, USA.
British Journal of Sports Medicine (Impact Factor: 5.03). 07/2012; 46(14):964-78. DOI: 10.1136/bjsports-2012-091066
Source: PubMed


To update our previously published systematic review and meta-analysis by subjecting the literature on shoulder physical examination (ShPE) to careful analysis in order to determine each tests clinical utility.
This review is an update of previous work, therefore the terms in the Medline and CINAHL search strategies remained the same with the exception that the search was confined to the dates November, 2006 through to February, 2012. The previous study dates were 1966 - October, 2006. Further, the original search was expanded, without date restrictions, to include two new databases: EMBASE and the Cochrane Library. The Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS 2) tool was used to critique the quality of each new paper. Where appropriate, data from the prior review and this review were combined to perform meta-analysis using the updated hierarchical summary receiver operating characteristic and bivariate models.
Since the publication of the 2008 review, 32 additional studies were identified and critiqued. For subacromial impingement, the meta-analysis revealed that the pooled sensitivity and specificity for the Neer test was 72% and 60%, respectively, for the Hawkins-Kennedy test was 79% and 59%, respectively, and for the painful arc was 53% and 76%, respectively. Also from the meta-analysis, regarding superior labral anterior to posterior (SLAP) tears, the test with the best sensitivity (52%) was the relocation test; the test with the best specificity (95%) was Yergason's test; and the test with the best positive likelihood ratio (2.81) was the compression-rotation test. Regarding new (to this series of reviews) ShPE tests, where meta-analysis was not possible because of lack of sufficient studies or heterogeneity between studies, there are some individual tests that warrant further investigation. A highly specific test (specificity >80%, LR+ ≥ 5.0) from a low bias study is the passive distraction test for a SLAP lesion. This test may rule in a SLAP lesion when positive. A sensitive test (sensitivity >80%, LR- ≤ 0.20) of note is the shoulder shrug sign, for stiffness-related disorders (osteoarthritis and adhesive capsulitis) as well as rotator cuff tendinopathy. There are six additional tests with higher sensitivities, specificities, or both but caution is urged since all of these tests have been studied only once and more than one ShPE test (ie, active compression, biceps load II) has been introduced with great diagnostic statistics only to have further research fail to replicate the results of the original authors. The belly-off and modified belly press tests for subscapularis tendinopathy, bony apprehension test for bony instability, olecranon-manubrium percussion test for bony abnormality, passive compression for a SLAP lesion, and the lateral Jobe test for rotator cuff tear give reason for optimism since they demonstrated both high sensitivities and specificities reported in low bias studies. Finally, one additional test was studied in two separate papers. The dynamic labral shear may be sensitive for SLAP lesions but, when modified, be diagnostic of labral tears generally.
Based on data from the original 2008 review and this update, the use of any single ShPE test to make a pathognomonic diagnosis cannot be unequivocally recommended. There exist some promising tests but their properties must be confirmed in more than one study. Combinations of ShPE tests provide better accuracy, but marginally so. These findings seem to provide support for stressing a comprehensive clinical examination including history and physical examination. However, there is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the many aspects of the clinical examination and what combinations of these aspects are useful in differentially diagnosing pathologies of the shoulder.

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    • "Clinical examination revealed mild tenderness on greater tuberosity and positive Neer's impingement and Hawkins sign.5 Speed's test was negative with no tenderness over biceps tendon. Jobe's supraspinatus test5 and Belly press sign5 were negative. There was a full range of movement with a painful course in terminal flexion and abduction. "
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    ABSTRACT: Though rare, many anomalous origins of long head of the biceps tendon (LHBT) have been reported in the literature. Anatomic variations commonly explained are a third humeral head, anomalous insertion, congenital absence and adherence to the rotator cuff. We report a rare case who underwent shoulder arthroscopy with impingement symptoms where in LHBT was found to be bifurcated with a part attached to superior labrum and the other part to the posterior capsule of joint. Furthermore, intraarticular portion of LHBT was adherent to the undersurface of the supraspinatus tendon. Awareness of such an anatomical aberration during the shoulder arthroscopy is of great importance as it can potentially avoid unnecessary confusion and surgery.
    Indian Journal of Orthopaedics 07/2014; 48(4):432-4. DOI:10.4103/0019-5413.136313 · 0.64 Impact Factor
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    • "The new guideline on shoulder syndromes advises physiotherapists to use the classification of pain and functional limitations, as practised by GPs. Given the limited value of clinical shoulder tests, even when combined [22], this could be a helpful approach. Perhaps with early detection, a once-off consultation during which advice is given will be sufficient. "
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    ABSTRACT: Background Shoulder complaints are commonly seen in general practice and physiotherapy practice. The only complaints for which general practitioners (GPs) refer more patients to the physiotherapist are back and neck pain. However, a substantial group have persistent symptoms. The first goal of this study is to document current health care use and the treatment process for patients with shoulder syndromes in both general practice and physiotherapy practice. The second goal is to detect whether there are differences between patients with shoulder syndromes who are treated by their GP, those who are treated by both GP and physiotherapist and those who access physiotherapy directly. Methods Observational study using data from the Netherlands Information Network of General Practice and the National Information Service for Allied Health Care. These registration networks collect healthcare-related information on patient contacts including diagnoses, prescriptions, referrals, treatment and evaluation on an ongoing basis. Results Many patients develop symptoms gradually and 35% of patients with shoulder syndromes waited more than three months before visiting a physiotherapist. In 64% of all patients, treatment goals are fully reached at the end of physiotherapy treatment. In general practice, around one third of the patients return after the referral for physiotherapy. Patients with shoulder syndromes who are referred for physiotherapy have more consultations with their GP and are prescribed less medication than patients without a referral. Often, this referral is made at the first consultation. In physiotherapy practice, referred patients differ from self-referrals. Self-referrals are younger, they more often have recurrent complaints and their complaints are more often related to sports and leisure activities. Conclusions There is a fairly large group of patients with persistent symptoms. Early referral by a GP is not advised under current guidelines. However, in many patients, symptoms develop gradually and a wait-and-see policy means more valuable time may pass before physiotherapy intervention takes place. Meanwhile a long duration of complaints is a predictor for poor outcome. Therefore, future research into early referral is required. As physiotherapists, we should develop a way of educating patients to avoid lengthy waiting periods before seeking help. To prevent high costs, physiotherapists could consider a classification of pain and limitations and wait-and-see policy as used by GPs. With early detection, a once-off consultation might be sufficient.
    BMC Musculoskeletal Disorders 04/2013; 14(1):128. DOI:10.1186/1471-2474-14-128 · 1.72 Impact Factor
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    ABSTRACT: Background: Shoulder complaints are among the commonest causes of musculoskeletal pain. They are potentially disabling and frequently cause absenteeism from work and claims for sickness benefits. One of the most prevalent subtypes of shoulder pain is impingement. This is often managed physiotherapeutically, with 'hands-on' manual therapy and exercises being mainstays. Objectives: To assess the effectiveness of manual therapy and exercises to improve pain, disability and function in people with shoulder impingement. Methods: A systematic review was conducted including systematic reviews, quasi-randomized trials and randomized controlled trials published up to October 2008. Searches included the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline, Embase, Cinahl and PEDro. Methodological quality and risk of bias were assessed with appropriate instruments. All findings were critically analysed and discussed, and summary conclusions formulated. Results: Eight systematic reviews and six randomized controlled trials were included. Methodological quality and risk of bias as well as population and treatment parameters varied. Clinical heterogeneity prevented meta-analysis, thus all findings were synthesized narratively. The included research provides limited evidence to support the use of manual therapy and exercise interventions for shoulder impingement. This primarily relates to subacute and chronic conditions and short to medium-term effectiveness. Conclusions: Manual therapy and exercise seem effective for shoulder impingement, but varying methodological quality and risk of bias in reviews and trials warrant caution in the interpretation of the results. There is a need for further good-quality primary research.
    Physical Therapy Reviews 03/2010; 15(2):62-83. DOI:10.1179/174328810X12786297204675
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