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The relationship between clinical shoulder tests and the findings in arthroscopic examination
Abstract
In a clinical setting, "shoulder instability" and "impingement" are two common diagnostic terms for shoulder complaints. Several clinical tests for these pathological conditions are described in the literature. However, there is a lack of research to confirm their reliability and validity. The aim of this study was to determine the inter-observer reliability, specificity, sensitivity and accuracy of common clinical shoulder tests. The study involved 71 subjects with shoulder pain, who were scheduled for an arthroscopy. The results of the clinical tests were compared with those obtained during arthroscopic visualisation. It was shown that relocation performed after apprehension is an adequate test for the diagnosis of "shoulder instability". Based on our results, we suggest resistance against external rotation, painful arc and the empty can test for the diagnosis of "impingement".
... Eighteen studies were excluded: 11 because no information on instability or IAP was presented [39][40][41][42][43][44][45][46][47][48][49] ; 4 because data were missing on sensitivity and specificity or clinical tests [50][51][52][53] ; and 3 because they were published in French. [54][55][56] Of the 17 studies that were selected, 5 enrolled patients when the clinician suspected shoulder instability 19,33,35,37,38 ; and 12 enrolled patients when the clinician suspected labral tears or other IAP. All the studies were conducted in orthopedic clinics. ...
... Each study evaluated a varying number of clinical tests but lacked data on patient history. Surgery was used as a reference test in 6 studies, 19 30,38 were evaluated in more than 1 study. Two studies reported the clinical examination of the shoulder under anesthesia using the same protocol. ...
... No diagnostic studies assessed the value of history taking in diagnosing instability. Four provocation tests for instability are presented in TABLE 3. The relocation test 38 and the anterior release test 35 have the best properties for increasing the likelihood of instability (relocation test 38 : positive LR, 6.5; 95% CI, 3.0-14.0 and negative LR, 0.18; 95% CI, 0.07-0.45) ...
History taking and clinical tests are commonly used to diagnose shoulder pain. Unclear is whether tests and history accurately diagnose instability or intra-articular pathology (IAP).
To analyze the accuracy of clinical tests and history taking for shoulder instability or IAP.
Relevant studies identified through PubMed, EMBASE, CINAHL, and bibliographies of known primary and review articles.
Studies comparing the performance of history items or physical examination with a reference standard were included. Studies on fibromyalgia, fractures, or systemic disorders were excluded. Of 1449 articles, 35 were eligible, and 17 were selected.
Data were extracted on study population, clinical tests, reference tests, and outcome. The studies' methodological quality (patient spectrum, verification, blinding, and replication) was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist.
Six tests showed positive likelihood ratios (LRs) and confidence intervals (CIs). Tests favoring the diagnosis for establishing instability included: relocation (LR, 6.5; 95% CI, 3.0-14.0) and anterior release (LR, 8.3; 95% CI, 3.6-19). Tests showing promise for establishing labral lesions included: the biceps load I and II (LR, 29; 95% CI, 7.3-115.0 and LR, 26; 95% CI, 8.6-80.0), respectively, pain provocation of Mimori (LR, 7.2; 95% CI, 1.6-32.0), and internal rotation resistance strength (LR, 25; 95% CI, 8.1-76.0). The apprehension, clunk, release, load and shift, and sulcus sign tests proved less useful. Results should be cautiously interpreted because studies were completed in select populations in orthopedic practice, mostly assessed by the test designers, and evaluated in single studies only. No accuracy studies were found for history taking or for clinical tests in primary care.
Shoulder complaints are frequently recurrent. Instability might cause some of these complaints. Best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests.
... In addition, due to language restrictions the possibility of language bias might exist. In this review, four studies were excluded according to language restrictions (Patel, Hossain, Colaco, El-Husseiny, & Lee, 2011;Perez-Santonja, Bellot, Claramonte, Ismail, & Alio, 1997;T'Jonck, De Smet & Lysens, 2001;Yang et al., 2015). Initially, we planned a meta-analysis, but due to the already discussed reasons for heterogeneity and the small number of included studies this was not possible. ...
Study design:
Systematic review.
Objectives:
The aim of this systematic review was to summarize and evaluate intra- and interrater reliability research of physical examination tests used for the assessment of scapular dyskinesis.
Background:
Scapular dyskinesis, defined as alteration of normal scapular kinematics, is described as a non-specific response to different shoulder pathologies.
Methods:
A systematic literature search was conducted in MEDLINE, EMBASE, AMED and PEDro until March 20th, 2015. Methodological quality was assessed with the Quality Appraisal of Reliability Studies (QAREL) by two independent reviewers.
Results:
The search strategy revealed 3259 articles, of which 15 met the inclusion criteria. These studies evaluated the reliability of 41 test and test variations used for the assessment of scapular dyskinesis.
Conclusion:
This review identified a lack of high-quality studies evaluating intra- as well as interrater reliability of tests used for the assessment of scapular dyskinesis. In addition, reliability measures differed between included studies hindering proper cross-study comparisons. The effect of manual correction of the scapula on shoulder symptoms was evaluated in only one study, which is striking, since symptom alteration tests are used in routine care to guide further treatment. Thus, there is a strong need for further research in this area.
Level of evidence:
Diagnosis, level 3a.
Shoulder complaints can be evaluated by a large number of clinical tests. It is unclear as to which tests can best be performed in different clinical presentations. This structured critical review was performed to answer these questions. The databases of PubMed, EMBASE, CINAHL and Cochrane Review up till 2007 were searched. After extensive literature search 55 articles were found that could be used in the review. Based on the current literature the following tests can be recommended for the following conditions: Impingement complaints: Neer test, Hawkins-Kennedy test and painful arc. Rotator cuff tears: empty can test, external rotation lag sign and external rotation strength test. The internal rotation lag sign should be performed to assess for subscapular tears. Although less well studied, a lack of better tests exists. SLAP lesions: anterior slide test, Yergason's test and the biceps load II test. Posterior labral lesion: Kim test. Shoulder instability: apprehension test, relocation test and anterior release test. AC complaints: O'Brien test, cross body adduction test and AC resisted extension test. Clinical tests are further clarified using photographs of the different tests along with a description of how the tests should be performed and interpreted.
Chronic instability of the shoulder is a common problem in athletes. There are only few reliable tests to make a proper diagnosis of the instability and its direction. X-rays are showing the bone lesions, but nowadays the MRI and MRI-A give more detailed information, both about the bone and soft tissue lesions. Several classifications have been developed, but no general consensus consists which one is the best to use in daily practice. Since the introduction of arthroscopic repair many series have been published, but at this moment the balance of the best postoperative results still tips towards the open repair. Recently more attention is paid to the influence of bone lesions on the effect of soft tissue repair. Long term studies on the natural history show a slightly higher incidence of arthritis in non-operated compared to operated shoulders. Complications after surgery are rare and mostly not serious.
The term minor instability refers to a condition in which chronic microtrauma involving the stabilising mechanisms of the glenohumeral joint leads to subluxation of the humeral head. The condition is commonly associated with athletes involved in repetitive high-velocity activities such as throwing or swimming. Minimal signs are found on physical examination of the shoulder joint but the patient presents with vague pain, catches of pain, apprehension with overhead movement or an impingement-like condition which appears resistant to treatment. The clinical examination findings which might alert the physiotherapist to the potential diagnosis of minor instability are reviewed. Following this, an approach to management with emphasis on establishing muscular control in the early stages of rehabilitation is presented.
The shoulder is the most unstable joint in the body. Patients with shoulder instability may present in a variety of ways, ranging from subtle complaints of pain including the "dead arm syndrome," to those with subjective instability, apprehension, or even those who can voluntarily demonstrate a dislocation. Instability can be classified according to the onset (traumatic, atraumatic, overuse), the direction (anterior, posterior, multidirectional), the timing or frequency (acute or recurrent), the degree of instability (subluxation or dislocation), and whether it occurs voluntarily or not. The physical examination should be directed toward ruling out other problems and determining whether generalized ligamentous laxity is present. Specifically, the stability assessment includes apprehension tests, the relocation test, or Fowler's sign and an estimation of glenohumeral translation. The use of a local anesthetic injection into the subacromial space can be very helpful in guiding the physical examination. An accurate diagnosis of shoulder instability can usually be made on a clinical basis by utilizing the information outlined in this report.
(C) Lippincott-Raven Publishers.
Because of the biomechanics of the glenohumeral joint, impairment of rotator cuff function leads to cranial migration of the humeral head, impinging the greater tubercle against the coraco-acromial arch and irritating the subacromial bursa. When bursal irritation has become established, active elevation of the arm against gravity will cause pain within an arc of motion. When a patient with a painful arc is asked to bend forward and let the arm hang, the same arc will become painless. This noninvasive clinical test called the "bow test" is a simple means by which subacromial impingement can be clinically identified as the source of pain in the painful arc of shoulder motion.
Shoulder impingement syndrome, a common disorder directly related to the unique anatomy, mobility, and biomechanics of the shoulder girdle complex, is a condition that results from repetitive microtrauma to the structures within the subacromial space, primarily the supraspinatus, the long head of the biceps, and the subacromial bursa. Several factors contribute to shoulder impingement syndrome, including rotator cuff weakness, capsular tightness, poor scapulohumeral rhythm, and muscle imbalance of the scapular upward rotation force couple. This article briefly reviews the biomechanics of the shoulder girdle complex and the pathology of shoulder impingement syndrome. The author introduces an adjunctive assessment procedure that assists the clinician in isolating the primary tissue and the structures involved with shoulder impingement syndrome. Conservative treatment management can then be directed to the involved contractile and/or noncontractile tissue involved with shoulder impingement syndrome.