This prospective study was performed to determine which clinical and imaging tests were most helpful for diagnosing acromioclavicular joint pain.
Of 1037 patients with shoulder pain, 113 who mapped pain within an area bounded by the midpart of the clavicle and the deltoid insertion were eligible for inclusion in the study. Forty-two subjects agreed to participate, and four of them were lost to follow-up. Twenty clinical tests, radiography, bone-scanning, magnetic resonance imaging, and an acromioclavicular joint injection test were performed on all patients. The patients were divided into two groups according to whether they had a > or =50% decrease in pain following the acromioclavicular joint injection. Statistical analysis, including multivariate regression analysis, was performed in order to evaluate the diagnostic effectiveness of the various tests.
Acromioclavicular joint pain was confirmed in twenty-eight of the thirty-eight patients. The most sensitive tests were examination for acromioclavicular tenderness (96% sensitivity), the Paxinos test (79%), magnetic resonance imaging (85%), and bone-scanning (82%), but these studies had low specificity. In the stepwise regression model, with the response to the injection used as the dependent variable, bone-scanning and the Paxinos test were the only independent variables retained. Patients with a positive Paxinos test as well as a positive bone scan had high post-test odds (55:1) and a 99% post-test probability of having pain due to pathological changes in the acromioclavicular joint. The likelihood ratio for patients with one negative test and one positive test was indeterminate (0.4:1). Patients with both a negative Paxinos test and a negative bone scan had a likelihood ratio of 0.03:1 for having acromioclavicular joint pain, which basically rules out the disorder.
The highly sensitive tests had low specificity, and the highly specific tests had low sensitivity. However, the combination of a positive Paxinos test and a positive bone scan predicted damage to the acromioclavicular joint as the cause of shoulder pain with a high degree of confidence.
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"Thus, clustering is simply the act of evaluating a set of tests and measures, in combination, when making a clinical decision or a mathematical assessment. For example, when attempting to detect acromiocalvicular (AC) joint pathology, two or more positive findings of cross-body adduction, the AC resisted extension test, and the active compression test, have an LRþ of 7.36 and an LRÀ of 0.21 which are better metrics than, for example, the active compression test alone with an LRþ of 1.6 and an LRÀ of 0.93 (Chronopoulos, Kim, Park, Ashenbrenner, & McFarland, 2004; Walton et al., 2004). Clustering tests more closely reflects how many clinicians make decisions because it takes into account a number of findings from the clinical assessment. "
[Show abstract][Hide abstract] ABSTRACT: The use of orthopedic special tests (OSTs) to diagnose shoulder pathology via the clinical examination is standard in clinical practice. There is a great deal of research on special tests but much of the research is of a lower quality implying that the metrics from that research, sensitivity, specificity, and likelihood ratios, is likely to vary greatly in the hands of different clinicians and in varying practice environments. A way to improve the clinical diagnostic process is to cluster OSTs and to use these clusters to either rule in or out different pathologies. The aim of the article is to review the best OST clusters, examine the methodology by which they were derived, and illustrate, with a case study, the use of these OST clusters to arrive at a pathology-based diagnosis.
Physical Therapy in Sport 08/2014; 16(2). DOI:10.1016/j.ptsp.2014.08.001 · 1.65 Impact Factor
"Five medical doctors worked in the clinic during the registration period: four were specialists in physical medicine and rehabilitation and one was undergoing speciality training. Diagnostic criteria for the various diagnoses were established in accordance with the literature
[8,10-17] as listed in Table
1. The diagnostic criteria was based on an unsystematic literature search of PubMed and references cited in the captured articles. "
[Show abstract][Hide abstract] ABSTRACT: Shoulder pain is common in the general population. Reports on specific diagnoses in general populations are scarce and only from primary care. The diagnostic distribution of shoulder disorders in secondary care is not reported. Most of the clinical research in the shoulder field is done in hospital settings. The aim of this study was to identify the diagnoses in a 1-year cohort in a hospital-based outpatient clinic using standardized diagnostic criteria and to compare the results with previous studies.
A diagnostic routine was conducted among patients referred to our physical medicine outpatient clinic at Oslo University Hospital. Diagnostic criteria were derived from the literature and supplemented with research criteria.
Of 766 patients diagnosed, 55% were women and the mean age was 49 years (range 19-93, SD +/- 14). The most common diagnoses were subacromial pain (36%), myalgia (17%) and adhesive capsulitis (11%). Subacromial pain and adhesive capsulitis were most frequent in persons aged 40-60 years. Shoulder myalgia was most frequent in age groups under 40. Labral tears and instability problems (8%) were most frequent in young patients and not present after age 50. Full-thickness rotator cuff tears (8%) and glenohumeral osteoarthritis (4%) were more prevalent after the age of 60. Few differences were observed between sexes. We identified three studies reporting shoulder diagnoses in primary care.
Subacromial pain syndrome, myalgia and adhesive capsulitis were the most prevalent diagnoses in our study. However, large differences in prevalence between different studies were found, most likely arising from different use of diagnostic criteria and a difference in populations between primary and secondary care. Of the diagnoses in our cohort, 20% were not reported by the studies from primary care (glenohumeral osteoarthritis, full thickness rotator cuff tears, labral tears and instabilities).
"Of the traditional tests, the positive likelihood ratio of the Active Compression/O'Brien's test was only 1.73, with a lower 95% confidence limit of 0.53, reducing confidence that a positive test improved the likelihood of a PAR in individual patients above the level of 'chance' (1.0). These results are similar to those reported by Walton et al. (2004) (LR + 1.6) in a small cohort of patients (n=38) referred to a specialist shoulder centre . Other authors, including those who developed the test  have reported larger positive likelihood ratio values for the Active Compression test (8.2 and 23.1)  , however the sample size was small in one study  and no confidence intervals were reported in either of the studies. "
[Show abstract][Hide abstract] ABSTRACT: Background
Despite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort.
Consecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (XylocaineTM) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O’Brien’s test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests.
Twenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84).
In this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort.