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Does This Patient Have an Instability of the Shoulder or a Labrum Lesion?
Abstract
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.
... De andere vormen van glenohumerale instabiliteit worden vaak toegeschreven aan chronische geleidelijke rek door activiteiten boven schouderhoogte of hyperlaxiteit en vaker gezien in de eerstelijn. De patiënt kan zich presenteren met een 'dood gevoel' in de arm en zonder duidelijk verlies aan schoudermobiliteit (Luime 2004). ...
... De prevalentie van schouderluxaties in de algemene populatie bedraagt ongeveer 1,7%, voor subluxaties van de schouder zijn geen cijfers bekend (Luime 2004). Bij instabiliteit door een acuut trauma wordt meestal direct hulp gezocht in de tweede lijn. ...
... De andere vormen van glenohumerale instabiliteit worden vaak toegeschreven aan chronische geleidelijke rek door activiteiten boven schouderhoogte of hyperlaxiteit en vaker gezien in de eerstelijn. De patiënt kan zich presenteren met een 'dood gevoel' in de arm en zonder duidelijk verlies aan schoudermobiliteit (Luime 2004). ...
... S uperior Labrum Anterior-to-Posterior (SLAP) lesions have been discussed, defined, and investigated since Andrews et al 1 first described this pathology in 1985. These lesions, which involve the superior region of the glenoid labrum, with or without the attachment of the long head of biceps, have been noted to be challenging to diagnose conservatively [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] . Non-surgical assessment tools, i.e., manual clinical tests and imaging studies, do not seem to paint a clear diagnostic picture and many authors have noted the need for arthroscopic visualization for sufficient diagnostic accuracy 2,3,[5][6][7][8][9][10][11][12][13][15][16][17][18][19] . ...
... These lesions, which involve the superior region of the glenoid labrum, with or without the attachment of the long head of biceps, have been noted to be challenging to diagnose conservatively [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] . Non-surgical assessment tools, i.e., manual clinical tests and imaging studies, do not seem to paint a clear diagnostic picture and many authors have noted the need for arthroscopic visualization for sufficient diagnostic accuracy 2,3,[5][6][7][8][9][10][11][12][13][15][16][17][18][19] . ...
... However, the numerical value for these statistics and hence their clinical interpretation are highly dependent on the methodological quality of the study in which they were derived. Various authors have written narrative reviews discussing the diagnostic accuracy of physical examination tests for SLAP lesions but only few have combined this report of diagnostic accuracy statistics with a methodological quality assessment of the diagnostic accuracy studies in the form of a systematic review 5,7,26,27 . The systematic reviews by Dinnes et al 26 studies retrieved for this review published after 2004 and another two published in the years that these reviews were published, an update was obviously justified. ...
SLAP lesions are often complex injuries with varied defects and tissue involvement that are challenging to diagnose clinically. The literature notes the need for visualization under arthroscopy for adequate diagnostic accuracy. The goal of this article is to provide a current best-evidence synthesis with regard to physical examination tests used for the diagnosis of SLAP lesions. A literature search yielded 17 studies that investigated the diagnostic utility of clinical tests for SLAP lesions. These studies investigated 19 clinical tests. A narrative review and a systematic review of methodological quality using the QUADAS methodological quality assessment tool yielded 3 high-quality diagnostic utility studies. Current best evidence indicates that a negative finding for the passive compression test provides the therapist with the greatest evidence-based confidence that a SLAP lesion is absent. A positive finding on the anterior apprehension maneuver, the anterior slide test, the Jobe relocation test, the passive compression test, the Speed test, and the Yergason test or a combination of positive findings on the Jobe relocation test and the active compression test or the Jobe relocation test and the anterior apprehension maneuver provides the therapist with the research-based confidence required to rule in a SLAP lesion. For ruling in a SLAP lesion, the greatest diagnostic value should likely be placed on a positive finding on the passive compression test. Suggestions for future research are provided.
... To our knowledge, no previous studies have considered history and patient characteristics as factors for diagnosis of traumatic anterior shoulder instability. 24 We hypothesized that clinical evaluations might be improved with a prediction model that combines patient characteristics, history, and results from a few clinical tests to predict traumatic anterior shoulder instability in patients with shoulder complaints who visit the orthopaedic outpatient clinic. This prediction model could guide clinicians in diagnosis and in the determination of which patients require additional imaging, like magnetic resonance arthrography (MRA), to establish the diagnosis. ...
... 45 Second, conservatively treated patients were not evaluated with the reference standard; this potentially led to a verification bias. 3,24 Finally, the relevance of that study was low because the greatest value in the clinical tests would be to achieve a diagnosis of traumatic anterior shoulder instability at the first visit to the outpatient clinic, not after the patient has been scheduled for an operation. In our prediction model, no combination of clinical tests increased the diagnostic value. ...
... Also, we included every patient with shoulder complaints who visited the orthopaedic outpatient clinic. This prevented a verification bias, as recommended by Luime et al. 24 Furthermore, the reference standard (MRA) was evaluated by individuals who were blinded from patient information. This increased the reproducibility. ...
It is unknown which combination of patient information and clinical tests might be optimal for the diagnosis of traumatic anterior shoulder instability. This study aimed to determine the diagnostic value of individual clinical tests and to develop a prediction model that combined patient characteristics, history, and clinical tests for diagnosis of traumatic anterior shoulder instability.
This prospective cohort study included 169 consecutive patients with shoulder complaints who were examined at an orthopaedic outpatient clinic. One experienced clinician conducted 25 clinical tests; of these, 6 were considered to be specific for testing of traumatic anterior shoulder instability (apprehension, relocation, release, anterior drawer, load and shift, and hyperabduction tests). Magnetic resonance arthrography was used to determine the final diagnosis. A prediction model was developed by logistic regression analysis.
In this cohort, 60 patients (36%) were diagnosed with anterior shoulder instability on the basis of magnetic resonance arthrography. The overall accuracy of individual clinical tests was 80.5% to 86.4%. Age, previous shoulder dislocation, sudden onset of complaints, and the release test were important predictors for the diagnosis of traumatic anterior shoulder instability. The prediction model demonstrated high discriminative ability (AUC 0.95).
Individual clinical shoulder tests provide good diagnostic accuracy. Young age, history of shoulder dislocation, sudden onset of complaints, and positive result of the release test were the most important predictors for traumatic anterior shoulder instability.
... 9 10 The former tests usually include the anterior shoulder instability and laxity tests; apprehension, relocation and surprise, and the laxity tests consisting of the load-and-shift, sulcus sign and Gagey tests. [11][12][13] An ongoing discussion is the use of pain as a diagnostic criterion in diagnosing anterior shoulder instability with the clinical tests apprehension, relocation and surprise. [14][15][16] In one way, it may be a confounding factor, since pain has shown to be less predictive and reliable as a diagnostic criterion. ...
... The clinical shoulder tests consisted of three shoulder joint-provoking tests for anterior shoulder instability (apprehension, relocation and surprise) besides three shoulder laxity tests (load-and-shift, sulcus sign and Gagey) (table 1). 11 13 14 22 23 29 The apprehension test (table 1, figure 1) was positive if glenohumeral apprehension and/or pain were evoked during testing whereas relief of symptoms with the relocation test (table 1, figure 2) was regarded as a positive test. As for the apprehension, the surprise test (table 1, figure 3) was positive if glenohumeral apprehension and/or pain were evoked during testing. ...
Objective
First, to investigate the intertester reliability of clinical shoulder instability and laxity tests, and second, to describe the mutual dependency of each test evaluated by each tester for identifying self-reported shoulder instability and laxity.
Methods
A standardised protocol for conducting reliability studies was used to test the intertester reliability of the six clinical shoulder instability and laxity tests: apprehension, relocation, surprise, load-and-shift, sulcus sign and Gagey. Cohen’s kappa (κ) with 95% CIs besides prevalence-adjusted and bias-adjusted kappa (PABAK), accounting for insufficient prevalence and bias, were computed to establish the intertester reliability and mutual dependency.
Results
Forty individuals (13 with self-reported shoulder instability and laxity-related shoulder problems and 27 normal shoulder individuals) aged 18–60 were included. Fair (relocation), moderate (load-and-shift, sulcus sign) and substantial (apprehension, surprise, Gagey) intertester reliability were observed across tests (κ 0.39–0.73; 95% CI 0.00 to 1.00). PABAK improved reliability across tests, resulting in substantial to almost perfect intertester reliability for the apprehension, surprise, load-and-shift and Gagey tests (κ 0.65–0.90). Mutual dependencies between each test and self-reported shoulder problem showed apprehension, relocation and surprise to be the most often used tests to characterise self-reported shoulder instability and laxity conditions.
Conclusions
Four tests (apprehension, surprise, load-and-shift and Gagey) out of six were considered intertester reliable for clinical use, while relocation and sulcus sign tests need further standardisation before acceptable evidence. Furthermore, the validity of the tests for shoulder instability and laxity needs to be studied.
... As imaging such as magnetic resonance imaging arthrogram (MRIa) can be invasive and costly, accurate physical examination tests would be an ideal component in the diagnosis of SLAP lesions. Three systematic reviews assessing the accuracy of physical examination maneuvers for SLAP lesions [16][17][18] established that there is no strong evidence to support the use of physical examination tests for SLAP lesions. Most studies did not meet the criteria for internal validity, and therefore report values of sensitivity and specificity that may be biased; most probably overestimating the true validity of these tests. ...
... All three reviews reporting on these examinations concluded that a methodologically robust study was necessary to inform clinical practice. [16][17][18] The purpose of this study is to determine whether existing physical examination tests can diagnose SLAP lesions accurately in patients who present with shoulder pathology. In addition, we will determine the ability of these tests to distinguish between SLAP lesions that are repairable and those that are not. ...
Purpose Shoulder pain and disability pose a diagnostic challenge owing to the numerous etiologies and the potential for multiple disorders to exist simultaneously. The evidence to support the use of clinical tests for superior labral anterior to posterior complex (SLAP) is weak or absent. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers for SLAP lesions by performing a methodologically rigorous, clinically applicable study.
Methods We recruited consecutive new shoulder patients reporting pain and/or disability. The physician took a history and indicated their certainty about each possible diagnosis (“certain the diagnosis is absent/present,” or “uncertain requires further testing”). The clinician performed the physical tests for diagnoses where uncertainty remained. Magnetic resonance imaging arthrogram and arthroscopic examination were the gold standards. We calculated sensitivity, specificity, and likelihood ratios (LRs) and investigated whether combinations of the top tests provided stronger predictions.
Results Ninety-three patients underwent physical examination for SLAP lesions. When using the presence of a SLAP lesion (Types I–V) as disease positive, none of the tests was sensitive (10.3–33.3) although they were moderately specific (61.3–92.6). When disease positive was defined as repaired SLAP lesion (including biceps tenodesis or tenotomy), the sensitivity (10.5–38.7) and specificity (70.6–93.8) of tests improved although not by a substantial amount. None of the tests was found to be clinically useful for predicting repairable SLAP lesions with all LRs close to one. The compression rotation test had the best LR for both definitions of disease (SLAP tear present = 1.8 and SLAP repaired = 1.67). There was no optimal combination of tests for diagnosing repairable SLAP lesions, with at least two tests positive providing the best combination of measurement properties (sensitivity 46.1% and specificity 64.7%).
Conclusion Our study demonstrates that the physical examination tests for SLAP lesions are poor diagnostic indicators of disease. Performing a combination of tests will likely help, although the magnitude of the improvement is minimal. These authors caution clinicians placing confidence in the physical examination tests for SLAP lesions rather we suggest that clinicians rely on diagnostic imaging to confirm this diagnosis.
... Sørensen 2000]. Bij instabiliteit van het glenohumerale gewricht, die vaak in combinatie voorkomt met een beschadiging van het labrum (de kraakbeenrand van het glenoïd), kunnen recidiverende klachten ontstaan door luxaties of subluxaties [Luime 2004b]. Bij een luxatie worden de gewrichtsvlakken volledig gescheiden, bij een subluxatie is er sprake van een symptomatische translatie zonder scheiding. ...
... Bij een luxatie worden de gewrichtsvlakken volledig gescheiden, bij een subluxatie is er sprake van een symptomatische translatie zonder scheiding. Op basis van klinische bevindingen worden de symptomen ingedeeld in een luxatie of een subluxatie in de richting van het defect (anterior, posterior, inferior of multidirectioneel) [Luime 2004b]. Er zijn geen exacte cijfers bekend over de incidentie of prevalentie van schouderluxaties of subluxaties in de huisartsenpraktijk. ...
Omdat nekklachten, werkgerelateerde en psychosociale factoren het beloop mede kunnen beïnvloeden, wordt aanbevolen deze factoren bij het beleid te betrekken.
... 3 The US economic productivity losses due to obesity are projected to be between $48 billion and $66 billion per year by 2030. 4 Obese workers have difficulty performing job functions due to body size and associated physical limitations. 5 Obesity has also been widely associated with musculoskeletal or joint-related pain in the feet, 6 knees, 7-11 back, [12][13][14][15][16] shoulders, [17][18][19][20][21][22] and hands. 23,24 In addition, obesity has been associated with an increased risk of occupational injuries. ...
... Considering the well-documented impact of obesity on occupational illnesses, injuries, and overall increasing productivity costs, [5][6][7][8][9][10][11][12][13][14][15][18][19][20][21][22][23][24][25]47,48 this research identified target populations in manufacturing for interventions to improve weight and weight-related comorbidities. The workplace, therefore, may be an optimal location for workplace prevention programs that target weight loss interventions, with some potential differences needed depending on the physical nature of the manufacturing facilities' jobs. ...
To describe demographic and health characteristics, and factors associated with obesity among production workers.
This cross-sectional study analyzed baseline data from two occupational cohorts. Regression modeling was used to assess associations between worker characteristics and obesity.
A total of 1974 subjects were included in these analyses. The mean body mass index was 29.5 kg/m (SD = 6.5). Having smoked in the past and currently smoking decreased the odds of being obese in the WISTAH Distal Upper Extremity cohort, whereas those feeling depressed had increased odds of being obese. Being a Pacific Islander/Native Hawaiian and married increased the odds of obesity in the BackWorks Low Back Pain cohort.
Factors associated with obesity differed substantially between the two cohorts. Recognizing factors associated with obesity in specific work settings may provide opportunities for optimizing preventive workplace interventions.
... This finding should be helpful for the diagnosis of UPS in painful shoulders with a traumatic onset, but this type of pain is sometimes observed in other pathologies such as SLAP or MDI. 17 The diagnosis of UPS should be made comprehensively with a careful patient interview, physical examinations, and radiographic examinations. ...
Background
Boileau et al have reported on unstable painful shoulder (UPS), which was defined as painful shoulders without any recognized anteroinferior subluxations or dislocations that were associated with roll-over lesions (i.e., instability lesions) on imaging or at arthroscopy. However, they included various pathologies, probably due to the ambiguity in their definitions of UPS. We redefined UPS as follows: 1) shoulder pain during daily or sports activities, 2) traumatic onset, 3) no complaint of shoulder instability, and 4) soft-tissue or bony lesions, such as Bankart or humeral avulsion of glenohumeral ligament lesion, confirmed by arthroscopy. The purpose of this study was to retrospectively investigate pathologies of UPS based on our definitions. We also aimed to assess the outcomes after arthroscopic soft-tissue stabilization for UPS.
Methods
We reviewed patients who were retrospectively diagnosed as UPS based on our definition and underwent arthroscopic stabilization between January 2007 and September 2018. Patients’ demographics, physical and radiographic findings, intraoperative findings, clinical outcomes (Rowe scores, Subjective Shoulder Value [SSV], and the visual analog scale [VAS] for pain), and return to play sport (RTPS) were investigated.
Results
This study included 91 shoulders in 91 patients with a mean age of 23 years (range, 15–51). The mean follow-up was 37 months (range, 24–156). Eighty-seven patients were involved in sports activities: collision/contact, 55 patients (60%); overhead, 26 patients (29%). Pain was reproduced during the anterior apprehension test in 86 shoulders (95%). Normal type (49%) predominated in glenoid morphology followed by fragment (bony Bankart) type (37%). Most fragment-type lesions were seen in collision/contact athletes. Intraoperative findings demonstrated that Bankart lesions were found in all patients and Hill-Sachs lesions only in 42%. Magnetic resonance arthrography in the abducted and externally rotated positions showed a Bankart lesion in 76 shoulders (84%). Rowe score, SSV, and pain VAS significantly improved postoperatively (P < .001 for each). Forty-two of 70 athletes (60 %) with > 2-year follow-up returned to sport in a complete or near-preinjury level. Six (9%) athletes experienced reinjury.
Conclusion
All shoulders that were diagnosed as UPS with our definition had a Bankart lesion. There seemed to be two different types of pathologies: Bankart lesions in lax shoulders and bony Bankart lesions in collision/contact athletes. The pain experience during the anterior apprehension test may be useful for the diagnosis of UPS. Arthroscopic soft-tissue stabilization yielded good clinical outcomes with a high RTPS rate, but the reinjury rate was relatively high.
... Examinations included assessment of shoulder and elbow range of motion (ROM); manual muscle testing of rotator cuff strength on a scale of 1 to 5, with 3 representing strength against gravity and 5 representing full strength; and stability (anterior apprehension test, relocation tests, sulcus sign, and varus/valgus stress and moving valgus stress tests of the elbow). 6,10,14,20,21,23 An electronic inclinometer was used for all angular measurements. ...
Background
Prior studies have revealed magnetic resonance imaging (MRI) evidence of elbow pathology in single-season evaluation of competitive youth baseball players. The natural history of these findings and risk factors for progression have not been reported.
Purpose
To characterize the natural history of bilateral elbow MRI findings in a 3-year longitudinal study and to correlate abnormalities with prior MRI findings, throwing history, playing status, and physical examination.
Study Design
Cohort study; Level of evidence, 2.
Methods
A prospective study of Little League players aged 12 to 15 years was performed. All players had preseason and postseason bilateral elbow MRI performed 3 years before this study. Players underwent repeat bilateral elbow MRI, physical examination, and detailed assessment of throwing history, playing status, and arm pain. Imaging was read by a blinded musculoskeletal radiologist and compared with prior MR images to assess for progression or resolution of previously identified pathology.
Results
All 26 players who participated in the previous single-season study returned for a 3-year assessment. At the completion of the study, 15 players (58%) had dominant arm MRI pathology. Eighty percent (12/15 players) of MRI findings were new or progressive lesions. Players with postseason MRI pathology at the beginning of the study were more likely to have MRI pathology at the 3-year follow-up than players with previously normal postseason MRI ( P < .05), although 6 of the 14 players (43%) with previously normal MRI developed new pathology. Year-round play was a significant predictor of tenderness to elbow palpation ( P = .027) and positive MRI findings at 3 years ( P = .047). At the 3-year follow-up, 7 players (27%) reported having throwing elbow pain and 3 had required casting. Additionally, differences were noted in the dominant arm’s internal and external rotation in those that continued to play baseball ( P < .05).
Conclusion
Dominant elbow MRI abnormalities are common in competitive Little League Baseball players. Year-round play imparts significant risk for progression of MRI pathology and physical examination abnormalities.
... The shape of the glenoid cavity and the glenoid labrum determines the most remarkable feature of the gleno-humeral joint as they precisely stabilizes the humeral head in the center of the cavity as well as allowing a vast range of movements (15). There is a positive correlation in between small articulating surface areas of the gleno-humeral joint and dislocation (16,17). The glenoid notch is found at the anterior margin of the glenoid cavity (18). ...
... The shoulder joint is a very unstable joint because it is the most mobile joint in the body, and at the same time, it has unequal proportions of the glenoid surface areas compared with the humeral head in part. 1,2 The exact knowledge of the morphology of the surfaces forming the shoulder joint and the relationship between them is important in the diagnosis and treatment planning of conditions such as glenohumeral instability, labral and cuff pathologies. ...
Objective:
The aim of this study was to investigate whether there are glenohumeral morphological differences between normal population, glenohumeral instability, and rotator cuff pathology.
Method:
In this study, shoulder magnetic resonance (MR) images of 150 patients were evaluated. Patients included in the study were studied in three groups of 50 individuals: patients with anterior shoulder instability in group 1, patients with rotator cuff tear in group 2, and control subjects without shoulder pathology in group 3.
Results:
There were statistically significant differences between groups in evaluations for glenoid version, glenoid coronal height, glenoid coronal diameter, humeral axial and coronal diameters, and coracohumeral interval distances. Significant differences were observed between groups 2 and 3 in glenoid axial diameter, glenoid coronal height, glenoid depth, humeral coronal diameter, and coracohumeral distances.
Conclusion:
The results obtained in this study suggest that glenoid version, glenoid coronal height and diameter, humeral diameter, and coracohumeral interval parameters in glenohumeral morphology-related parameters in patients with anterior instability are different from those of normal population and patients with rotator cuff pathology. In cases where there is a clinically difficult diagnosis, these radiological measurements will be helpful to clinicians in diagnosis and treatment planning, especially in cases of treatment-resistant cases.
... 4 The glenoid labrum is a static stabilizer and provides increased stability to the glenohumeral joint through 3 main mechanisms: It doubles the depth of the glenoid socket (from 2.5 mm to 5 mm), increases surface area for contact of the humeral head, and serves as a fibrocartilaginous ring to which glenohumeral ligaments can attach. 14,15 The labrum attaches to the rim of the glenoid, where the capsule has attachments along the glenoid neck. Both entities can lose structural integrity with shoulder dislocations. ...
Background
The glenohumeral joint is the most commonly dislocated joint in the body. Failure rates of capsulolabral repair have been reported to be approximately 8%. Recent focus has been on restoration of the capsulolabral complex by a double-row capsulolabral repair technique in an effort to decrease redislocation rates after arthroscopic capsulolabral repair.
Purpose
To present a review of the biomechanical literature comparing single- versus double-row capsulolabral repairs and discuss the previous case series of double-row fixation.
Study Design
Narrative review.
Methods
A simple review of the literature was performed by PubMed search. Only biomechanical studies comparing single- versus double-row capsulolabral repair were included for review. Only those case series and descriptive techniques with clinical results for double-row repair were included in the discussion.
Results
Biomechanical comparisons evaluating the native footprint of the labrum demonstrated significantly superior restoration of the footprint through double-row capsulolabral repair compared with single-row repair. Biomechanical comparisons of contact pressure at the repair interface, fracture displacement in bony Bankart lesion, load to failure, and decreased external rotation (suggestive of increased load to failure) were also significantly in favor of double- versus single-row repair. Recent descriptive techniques and case series of double-row fixation have demonstrated good clinical outcomes; however, no comparative clinical studies between single- and double-row repair have assessed functional outcomes.
Conclusion
The superiority of double-row capsulolabral repair versus single-row repair remains uncertain because comparative studies assessing clinical outcomes have yet to be performed.
... To evaluate shoulder stability the apprehension test, load and shift test and test for sulcus sign was performed with player in a seated position. The test for sulcus sign was performed both with the shoulder in neutral position and externally rotated [25,26]. The apprehension test was performed with the player's arm in 90°abduction in the frontal plane and maximum rotated and was considered positive if the player experienced any discomfort in the shoulder or apprehend during the test [27]. ...
Background:
Handball is a physical contact sport that includes frequent overhead throwing, and this combination leads to a high rate of shoulder injuries. Several factors have been associated with shoulder injuries in overhead athletes, but strong scientific evidence is lacking for most suggested risk factors. We therefore designed the Karolinska Handball Study (KHAST) with the aim to identify risk factors for shoulder injuries in adolescent male and female elite handball players studying at handball-profiled secondary schools in Sweden. Secondary objectives are to investigate whether shoulder function changes during the competition season and whether the physical profile of the players changes during their time in secondary school.
Methods:
Players aged 15 to 19 years were included during the pre-season period of the 2014-2015 and the 2015-2016 seasons. At inclusion, players signed informed consent and filled in a questionnaire regarding playing position, playing level, previous handball experience, history of shoulder problems and athletic identity. Players also completed a detailed test battery at baseline evaluating the shoulder, neck and trunk. Players were then prospectively monitored weekly during the 2014-2015 and/or 2015-2016 competitive seasons regarding injuries and training/match workload. Results from the annual routine physical tests in the secondary school curriculum including bench press, deep squat, hand grip strength, clean lifts, squat jumps, counter movement jumps, <30 m sprints, chins, dips and Cooper's test will be collected until the end of the competitive season 2017-2018. The primary outcome is the incidence of shoulder injuries and shoulder problems. The secondary outcome is the prevalence of shoulder injuries and shoulder problems.
Discussion:
Shoulder problems are frequent among handball players and a reduction of these injuries is therefore warranted. However, in order to introduce appropriate preventive measures, a detailed understanding of the underlying risk factors is needed. Our study has a high potential to identify important risk factors for shoulder injuries in adolescent elite handball players owing to a large study sample, a high response rate, data collection during consecutive seasons, and recording of potential confounding factors.
... In addition, the release test had the best profile of diagnostic performance as calculated by overall accuracy in diagnosing anterior shoulder instability, although all tests were characterized by diagnostic accuracies above 80% [35]. Many of these findings have been corroborated in other studies as well [25,26,36,37]. ...
Purpose of review:
The goal of this paper is to provide an overview in evaluating the patient with suspected or known anteroinferior glenohumeral instability.
Recent findings:
There is a high rate of recurrent subluxations or dislocations in young patients with history of anterior shoulder dislocation, and recurrent instability will increase likelihood of further damage to the glenohumeral joint. Proper identification and treatment of anterior shoulder instability can dramatically reduce the rate of recurrent dislocation and prevent subsequent complications. Overall, the anterior release or surprise test demonstrates the best sensitivity and specificity for clinically diagnosing anterior shoulder instability, although other tests also have favorable sensitivities, specificities, positive likelihood ratios, negative likelihood ratios, and inter-rater reliabilities. Anterior shoulder instability is a relatively common injury in the young and athletic population. The combination of history and performing apprehension, relocation, release or surprise, anterior load, and anterior drawer exam maneuvers will optimize sensitivity and specificity for accurately diagnosing anterior shoulder instability in clinical practice.
... In spite of the glenoid cavity's lack of a deep socket or isometric ligaments, the normal shoulder accurately constrains the humeral head to the center of the glenoid cavity throughout most of the arc of movement 3-6 . However, its small articulating surface areas correlate with greater probability of dislocation 7,8 . The morphological implication of the glenoid cavity in shoulder stability has been extensively researched 3, 9,10 .There have also been various findings about the scapular anthropometry, kinanthroplogy and kinematics [11][12][13] . ...
p> Introduction: An understanding of the normal glenoid cavity morphometry is important in corroborating the basis of luxation at the glenohumeral joint (GHJ). This study was carried out to determine the morphomertic relationship of the glenoid cavity to joint stability and device models to estimateglenoid cavity dimensions ofthe scapular boneof Nigerian origin in a post-mortem skeletal state using selected angles and dimension
Methods: A total of 200wellmacerated unpaired scapulaebone (96 right and 104 left) with complete ossification were used for this study. Geometric measurements were taken using standard procedures. SPSS (IBM® version 20) was used to analyze the data and the results of all measured parameters (for both sides and total) were presented. Correlation was determined from the summation of the bilateral measurement of; the superior (SSA), inferior (ISA) and medial (SVA) angles of the scapulae, maximum height of the scapula (MHS), and maximum glenoid height and width (MGH and MGW). Glenoid index (GI) was calculated by dividing MGW by MGH. Regression formulae for estimation the glenoid cavity parameters were derived. Significance level was set at 95% (P≤0.05 was considered significant).
Result: The mean GIwas calculated as 68.18±5.93% (with min. and max. ratio of 54% and 87%respectively). Of the predictor variables for estimating MGH and MGW, SSA was weakly (-) correlated (r<0.2; R2<0.1), MSH was averagely (+) correlated (r<0.55; R2<0.3), while a strong (+) correlation was observed between the interglenoid cavity dimensions (r=0.785; R2=0.617).
Conclusion: Indices below 50% and above 89% are indications of possible GHJ problems.Using single measurements of various scapular parts to estimate the glenoid cavityis possible.Distortion of the morphometric relationship that exists between MGW and MGH is a clear pointer for glenohumeral luxation syndromes.
Bangladesh Journal of Medical Science Vol.16(4) 2017 p.572-579</p
... Glenohumeral instability is defined as an abnormal and symptomatic motion of the humeral head relative to the glenoid during active shoulder motion [1]. It represents one of the main causes of shoulder pain [2]. Imaging of shoulder instability plays an essential role in the management of the disease. ...
Glenohumeral joint instability is usually an intimidating topic for most radiologists due to both the complexity of related anatomical and biomechanical considerations and the increasing number of classifications and acronyms reported in the literature in association with this condition. In this short review, we aim to demystify glenohumeral instability by first focusing on the relevant anatomy and pathophysiology. Second, we will review what the important imaging findings are and how to describe them for the clinician in the most relevant yet simple way.
The role of the radiologist in assessing glenohumeral instability lesions is to properly describe the stabilizing structures involved (bone, soft-tissue stabilizers, and their periosteal insertion) to localize them and to attempt to characterize them as acute or chronic. Impaction fractures on the glenoid and humeral sides are important to specify, locate, and quantify. In particular, the description of soft-tissue stabilizers should include the status of the periosteal insertion of the capsulo-labro-ligamentous complex. Finally, any associated cartilaginous or rotator cuff tendon lesion should be reported to the clinician.
... Our survey shows that the apprehension test is the most frequently used provocation test (91 %). The accuracy of shoulder instability tests are, according to a review of Luime et al. [16], not high; a solely apprehension test was found to be of limited value. Combining the apprehension test with the relocation test and the anterior release test gives the highest accuracy. ...
Purpose
Recurrent anterior shoulder instability after surgical treatment can be caused by bony defects. Several diagnostic tools have been designed to measure the extent of these bony lesions. Currently, there is no consensus which measurement tool to use and decide which type of surgery is most appropriate. We therefore performed an evaluation of agreement in surgeons’ preference of diagnostic work-up and surgical treatment of anterior shoulder instability.
Methods
An international survey was conducted amongst orthopaedic shoulder surgeons. The survey contained questions about surgeons’ experience, clinical and radiological examination and the subsequent treatment for anterior shoulder instability. Descriptive statistics were used to present the data, and percentages of responding surgeons were calculated.
Results
The questionnaire was completed by 197 delegates from 46 countries. 55 % of the respondents think evidence in current literature is sufficient on diagnostic work-up for anterior shoulder instability. Anamnestic, number of dislocations was most frequently asked (by 95 % of respondents), the most frequently used test is the apprehension test (91 %). For imaging, conventional X-ray in various directions was most performed, followed by MR arthrography and plane CT scan respectively. The responding surgeons perform surgery (labrum repair or Latarjet) in 51 % of the patients. A median of 25 % glenoid bone loss was given by the respondents, as cut-off from when to perform a bony repair.
Conclusion
Many different diagnostic examinations for assessing shoulder instability are used and a high variety is seen in the use of diagnostic tools. Also no consensus is seen in the use of different surgical options (arthroscopic and open procedures). This implies the need for more research on diagnostic imaging and the correlation with specific subsequent surgical treatment.
Level of evidence
Survey, level of evidence IV.
... Regarding the function of the labrum, Luime et al. [41] have reported that the labrum mainly has three key roles in contributing to stability of the glenohumeral joint. First, it doubles the anteroposterior depth of the glenoid socket from 2.5 to 5 mm and deepens the concavity to 9 mm in the superior-inferior plane [26]. ...
The glenohumeral joint with instability is a common diagnosis that often requires surgery. The aim of this review was to present an overview of the anatomy of the glenohumeral joint with emphasis on instability based on the current literature and to describe the detailed anatomy and anatomical variants of the glenohumeral joint associated with anterior and posterior shoulder instability. A review was performed using PubMed/MEDLINE using key words: Search terms were “glenohumeral”, “shoulder instability”, “cadaver”, “rotator interval”, “anatomy”, and “anatomical study”. During the last decade, the interest in both arthroscopic repair techniques and surgical anatomy of the glenohumeral ligament (superior, middle, and inferior), labrum, and rotator interval has increased. Understanding of the rotator interval and attachment of the inferior glenohumeral ligament on the glenoid or humeral head have evolved significantly. The knowledge of the detailed anatomy and anatomical variations is essential for the surgeon in order to understand the pathology, make a correct diagnosis of instability, and select proper treatment options. Proper understanding of anatomical variants can help us avoid misdiagnosis.
Level of evidence V.
... 5 The US economic productivity losses due to obesity are projected to be between $48 billion to $66 billion per year by 2030. 6 In addition to cardiovascular health concerns, obesity has also been associated with musculoskeletal or joint-related pain in the feet 7 , knees [8][9][10][11][12] , back [13][14][15][16][17] , shoulders [18][19][20][21][22][23] , and hands. 24,25 Additionally, obesity has been associated with an increased risk of occupational injuries. ...
To ascertain worker health characteristics and psychosocial factors associated with changes in body weight and total cholesterol (TC) among two production operation populations.
We performed descriptive and predictive analysis of questionnaire data and biomedical measurements from two prospective cohort studies. Our key outcomes were changes in weight, and TC over 5 to 10 years between baseline and exit assessments.
A total of 146 subjects were analyzed. Increases in weight were associated with belief in being overweight and baseline overweight and obesity. Increases in TC levels were associated with female sex, belief that TC levels were "not good," and feeling depressed.
Most of the reported associations with increases in weight and TC levels are amenable to interventions and may be a target for workplace intervention programs.
... 13 Obese workers have difficulty moving to perform job functions because of body size and associated physical limitations. 13 Obesity has also been widely associated with musculoskeletal or joint-related pain in the feet, 14 knees, [15][16][17][18][19] back, [20][21][22][23][24] shoulders, 12,[25][26][27][28][29] and hands. 30,31 In addition, obesity has been associated with an increased risk of occupational injuries. ...
To assess the readiness to change dietary intake and body weight among production workers. We also ascertained differences between self-perceived and measured body mass index.
This cross-sectional study queried physical activity, psychosocial factors, fruit and vegetable intake, and readiness to change based on the transtheoretical model.
Sixty-three (28%) workers were overweight, and 114 (50%) were obese. Obese workers were in the following stages of weight change: precontemplation (4%), contemplation (45%), preparation (13%), action (21%), and (17%) maintenance. Ten percent of overweight workers erroneously reported their body mass index to be normal.
About half of overweight/obese workers were in the precontemplation or contemplation stages for healthy dietary changes or weight loss. Recognizing the stages of change with regard to weight and the self-perception of weight status may help tailor workplace health promotion programs.
... They have also found cervical rotation < 60º towards the involved side to possess 89% sensitivity with 49% specificity. Shoulder involvement due to glenohumeral instability was examined through the use of multiple diagnostic tests for labral lesions, as these lesions have been associated with anterior and inferior instability 39 . This glenohumeral instability was considered as a possible causative or contributory impairment leading to excessive tension of neural structures and subsequent symptoms in the upper extremity as described by this patient. ...
Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.
... Unfortunately, a second high quality study (Oh et al., 2008) showed the test to have no ability to rule out (or in) a labral tear. Guanche and Jones (2003) reported a test cluster with an LRþ of 5.43 but this likelihood ratio is of only moderate assistance in diagnosing a labral tear which does not have an established set of signs and symptoms (Luime et al., 2004) and a likely low prevalence, somewhere around 6% (Snyder, Banas, & Karzel, 1995). Therefore, the best decision in this case is to treat the diagnosis of labral tear as one of exclusion and move on to rule out one of the diagnoses of either rotator cuff tear or impingement. ...
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.
... The shoulder joint is the most mobile joint in the body and at the same time a very unstable articulation due in part to the unequal proportions of the surface areas of the glenoid compared to the humeral head. Small articulating surface areas correlate with greater probability of dislocation [1]. Shoulder instability and rotator cuff injuries represent the most common reasons of shoulder pain and dysfunction and often correlate with secondary glenohumeral osteoarthritis. ...
Background
Radial mismatch, glenohumeral conformity ratios and differences between cartilaginous and osseous radii highly depend on the measured plane. The comparison of cartilaginous radii between humeral head and glenoid in different planes provides new information to understand the degree of conformity during abduction of the upper limb.
Methods
To investigate the radii, CT-images in soft-tissue kernel of 9 specimen were analysed using an image visualization software. Statistical analysis of the obtained data was performed using the t-test.
Results
Measurements of the radii in the glenoid revealed a significantly larger radius for bone than cartilage, whereas for the humeral head the opposite was the case. Highest ratios for cartilage in the transverse plane were found in the inferior and central areas of the joint surface, whereas the smallest ratios were found in the superior area. The radial mismatch varied between 0.1 mm and 13.6 mm, depending on the measured plane.
Conclusions
The results suggest that in abduction, the cartilaginous guidance of the humeral head decreases. This might permit the humeral head an anterior-posterior shifting as well as superior-inferior translation. Surgical reconstruction of the normal glenohumeral relationships necessitates precise information about the glenohumeral morphology to ensure proper sizing and correct placement of prosthetic components and osteochondral allografts.
... Luime et al. [26] ...
Objectives
To provide an overview of reporting and methodological quality in diagnostic test accuracy (DTA) studies in the musculoskeletal field and evaluate the use of the QUality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist.
Study Design and Setting
A literature review identified all systematic reviews that evaluated the accuracy of clinical tests to diagnose musculoskeletal conditions and used the QUADAS checklist. Two authors screened all identified reviews and extracted data on the target condition, index tests, reference standard, included studies, and QUADAS items. A descriptive analysis of the QUADAS checklist was performed, along with Rasch analysis to examine the construct validity and internal reliability.
Results
A total of 19 systematic reviews were included, which provided data on individual items of the QUADAS checklist for 392 DTA studies. In the musculoskeletal field, uninterpretable or intermediate test results are commonly not reported, with 175 (45%) studies scoring “no” to this item. The proportion of studies fulfilling certain items varied from 22% (item 11) to 91% (item 3). The interrater reliability of the QUADAS checklist was good and Rasch analysis showed excellent construct validity and internal consistency.
Conclusion
This overview identified areas where the reporting and performance of diagnostic studies within the musculoskeletal field can be improved.
... Predisponerende factoren voor instabiliteit zijn: armdominantie, werk / sport / algemene dagelijkse levensverrichtingen (ADL) en kenmerken van hyperlaxiteit (CBO-Richtlijn Luxatie schouder; www.cbo.nl/richtlijnen). Voor het testen van (anterieure) instabiliteit van de schouder kunnen de Apprehension test, de Relocation and release test, de Load and shift test en de Sulcus sign worden gebruikt (Cools et al., 2008;Hegedus et al., 2008;Luime et al., 2004). NB. ...
... 19 We used the QUADAS because it is short, has already been used in earlier diagnostic reviews and has an established validity. [20][21][22][23][24] The QUADAS consists of 14 items on methodological quality that can be scored as "yes", "no" or "unclear" (Table 1). Scoring was performed in accordance to the QUADAS user's guide. ...
De herkenning van depressieve stoornissen (DS) door huisartsen is niet optimaal. Een screeningsprogramma gericht op patiënten met een verhoogd risico op depressie, zou de herkenning van DS in huisartsenpraktijken kunnen verbeteren. Karin Wittkampf selecteerde drie groepen patiënten met verhoogd risico op DS: patiënten die veelvuldig de huisarts bezoeken, patiënten met onverklaarde lichamelijke klachten en patiënten met psychosociale klachten. Uit de resultaten van dit screeningsonderzoek blijkt dat invoering van een screeningsprogramma voor DS niet wenselijk lijkt. DS komt in de geselecteerde patiëntengroep veel voor, maar te weinig patiënten met DS willen zich daarvoor laten behandelen.
... These maneuvers are a common component in establishing a diagnosis and determining a treatment plan however, the accuracy of many of these tests has not been adequately addressed. Several systematic reviews [6-10] have noted a lack of methodological quality in studies reporting the accuracy of physical exam maneuvers for diagnosing shoulder pathology. The most recent reviews [9,10] have argued for the need for large, well designed studies that examine the accuracy of numerous physical examination tests for the shoulder. ...
Background
Shoulder complaints are the third most common musculoskeletal problem in the general population. There are an abundance of physical examination maneuvers for diagnosing shoulder pathology. The validity of these maneuvers has not been adequately addressed. We propose a large Phase III study to investigate the accuracy of these tests in an orthopaedic setting.
Methods
We will recruit consecutive new shoulder patients who are referred to two tertiary orthopaedic clinics. We will select which physical examination tests to include using a modified Delphi process. The physician will take a thorough history from the patient and indicate their certainty about each possible diagnosis (certain the diagnosis is absent, present or requires further testing). The clinician will only perform the physical examination maneuvers for diagnoses where uncertainty remains. We will consider arthroscopy the reference standard for patients who undergo surgery within 8 months of physical examination and magnetic resonance imaging with arthrogram for patients who do not. We will calculate the sensitivity, specificity and positive and negative likelihood ratios and investigate whether combinations of the top tests provide stronger predictions of the presence or absence of disease.
Discussion
There are several considerations when performing a diagnostic study to ensure that the results are applicable in a clinical setting. These include, 1) including a representative sample, 2) selecting an appropriate reference standard, 3) avoiding verification bias, 4) blinding the interpreters of the physical examination tests to the interpretation of the gold standard and, 5) blinding the interpreters of the gold standard to the interpretation of the physical examination tests. The results of this study will inform clinicians of which tests, or combination of tests, successfully reduce diagnostic uncertainty, which tests are misleading and how physical examination may affect the magnitude of the confidence the clinician feels about their diagnosis. The results of this study may reduce the number of costly and invasive imaging studies (MRI, CT or arthrography) that are requisitioned when uncertainty about diagnosis remains following history and physical exam. We also hope to reduce the variability between specialists in which maneuvers are used during physical examination and how they are used, all of which will assist in improving consistency of care between centres.
Background:
Throwing guidelines have been implemented in Little League baseball in an attempt to minimize injuries in young baseball players. We hypothesized that playing pitcher or catcher and increased innings played during the season would result in dominant shoulder magnetic resonance imaging (MRI) abnormalities.
Methods:
A prospective evaluation of Little League players aged 10 to 12 years was performed. Players recruited before the start of the season underwent bilateral preseason and dominant shoulder postseason MRI, physical examination, and questionnaires addressing their playing history and arm pain. Innings played, player position, pitch counts, and all-star team selection were recorded.
Results:
In total, 23 players were enrolled. The majority (19/23, 82.6%) were right-handed and 16 of 23 (69.6%) played at least 10 innings as pitcher or catcher. Sixteen were selected for the all-star team. Fourteen players (60.9%) had positive dominant shoulder MRI findings not present in their nondominant shoulder. Eight players (34.8%) had new or worsening postseason MRI findings. Thirteen players (81.3%) selected to the all-star team had abnormal MRI findings whereas only one (14.3%) player not selected as an all-star had MRI abnormalities (P=0.005). Year-round play (P=0.016), innings pitched (P=0.046), innings catcher (P=0.039), and number of pitches (P=0.033) were associated with any postseason MRI abnormality, but not for new or worsening MRI changes. Single sport athletes and players playing for multiple teams were significantly more likely to have abnormal MRI findings (P=0.043 and 0.040, respectively) when compared with multisport athletes playing on a single team.
Conclusions:
MRI abnormalities involving the dominant shoulder are common in Little League baseball players and often develop or worsen during the season. Contrary to our hypothesis, MRI abnormalities were not associated with player position and pitch counts. Instead, they were most closely associated with year round play, single sports participation, and all-star team selection. The increased demands required for all-star selection comes at a price to the young athlete as the majority of players selected for this honor had abnormal MRI findings in their throwing shoulder while few non all-stars demonstrated such pathology.
Level of evidence:
Level II.
Background: Wound infections are a common complication of surgery that add significantly to the morbidity of patients and costs of treatment. The global trend towards reducing length of hospital stay post-surgery and the increase in day case surgery means that surgical site infections (SSI) will increasingly occur after hospital discharge. Surveillance of SSIs is important because rates of SSI are viewed as a measure of hospital performance, however accurate detection of SSIs post-hospital discharge is not straightforward. Methods: We conducted a systematic review of methods of post discharge surveillance for surgical wound infection and undertook a national audit of methods of post-discharge surveillance for surgical site infection currently used within United Kingdom NHS Trusts. Results: Seven reports of six comparative studies which examined the validity of post-discharge surveillance methods were located; these involved different comparisons and some had methodological limitations, making it difficult to identify an optimal method. Several studies evaluated automated screening of electronic records and found this to be a useful strategy for the identification of SSIs that occurred post discharge. The audit identified a wide range of relevant post-discharge surveillance programmes in England, Scotland and Wales and Northern Ireland; however, these programmes used varying approaches for which there is little supporting evidence of validity and/or reliability. Conclusion: In order to establish robust methods of surveillance for those surgical site infections that occur post discharge, there is a need to develop a method of case ascertainment that is valid and reliable post discharge. Existing research has not identified a valid and reliable method. A standardised definition of wound infection ( e. g. that of the Centres for Disease Control) should be used as a basis for developing a feasible, valid and reliable approach to defining post discharge SSI. At a local level, the method used to ascertain post discharge SSI will depend upon the purpose of the surveillance, the nature of available routine data and the resources available.
In dit hoofdstuk wordt, aan de hand van een casus, het klinisch redeneerproces van de fysiotherapeut geschetst vanaf het moment dat de patiënt binnenkomt en de fysiotherapeut nog niet weet wat er aan de hand is. Het hoofdstuk start met algemene informatie over de epidemiologie van schouderpijn, de risicofactoren en de prognose. Vervolgens wordt besproken wat er wetenschappelijk bekend is over de validiteit van de anamnese, het lichamelijk onderzoek, provocatietesten en beeldvormende diagnostiek in het valide diagnosticeren van subgroepen van patiënten met schouderpijn. Met name de specifieke testen komen uitgebreid aan de orde.
Abstract
Object: The effectivity of active exercises in the reduction of pain in the disease pattern of adult shoulderimpingement syndrome was evaluated in this systematic literature research.
Method: By using the databases PubMed and PEDro only studies in English and German language and in the design of randomized clinical and clinical trials were selected. The quality of the studies was measured according to the PEDro scale, ranging from zero to maximum 10 points, while only studies with 4 to 9 points were included.
Results: An evidence for the pain reduction via active exercises of mean 17.75 % in the relevant pain scale was found.
Conclusion: The founded results showed the evidence that pain reducing in the shoulderimpingement syndrome would not only achieved through active exercises. Other methods like manual therapy could reach a similar effect. That outcome build the further question: What method is the most effective way to reduce pain in the shoulderimpingement syndrome? A considerable pain reduction through active exercises in this injury could be proved.
Musculoskeletal disorders (MSDs) are universally prevalent among all age and gender groups and across all socio-demographic strata of society. Besides causing pain and decreased functional capacity, MSDs have a substantial influence on work capacity and quality of life. Altogether, they inflict an enormous financial burden on society through direct medical costs as well as indirect costs due to loss of productivity and social security benefits. The yearly burden of disease in the Netherlands for the two most important groups of MSDs, low back pain (LBP) and neck and upper extremity complaints, is over € 5.500 million.
The majority of MSDs fall into the category of nonspecific disorders. Often these nonspecific disorders are related to overload, deconditioning or workrelated overexertion. Although much research has been performed, especially with regard to LBP, knowledge about the long-term pain patterns or predictors over the life course is limited. For many possible prognostic indicators, especially regarding the psychosocial domain, consistent evidence is lacking. Early identification of patients more likely to develop persistent symptoms could help to guide decisions regarding medical management. However, optimal management strategies, including attention for psychological and workrelated factors, are still unclear.
In this thesis several studies are brought together about the course, prognosis and management of LBP and neck and upper extremity complaints. Together, these studies provide insight into the possibilities to identify subgroups of patients through the assessment of non-medical criteria, especially within the category of nonspecific complaints. These subgroups might profit from a different approach in treatment or guidance.
(ISBN 978-94-6169-888-9)
Incidence of Shoulder Injury Assessment of Injury Risk Rehabilitation Case Study References
Shoulder instability in a contact or collision athlete presents a significant treatment challenge to the sports medicine surgeon. Making appropriate treatment decisions that allow for a safe return to play without increasing the risk of further injury are important to the career of any athlete. The decision to allow an injured athlete to return to the field of play or to undergo more definitive surgical management is complex. The current article reviews the diagnosis, management, and outcomes of contact and collision athletes who sustain a shoulder dislocation or subluxation and provides guidelines for optimal management of these patients.
Clinical testing is an easy and inexpensive tool that provides an informative guide toward initial diagnosis for shoulder joint dysfunctions. Clinical tests can be a powerful aid toward a correct diagnosis or at the least narrowing the differential diagnosis. Family physicians with good understanding of the underlying basic science knowledge of the commonly used clinical tests will be better able to employ a systematic approach in the initial workup and be able to avoid mistakes and errors in patient care.
In this article, common clinical tests to differentiate the etiology of shoulder supraspinatus rotator cuff disorders are presented. The tests presented include the Neer impingement, the Hawkins-Kennedy, the Jobe (empty-can), the painful arc, and the drop-arm tests. This article shows the correct performance and positioning for all tests. Each test is presented with a rational analysis of the test concept, procedure, and clinical application integrated to the relevant underlying basic science.
Rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians.
To perform a meta-analysis to identify the most accurate clinical examination findings for RCD.
Structured search in MEDLINE, EMBASE, and CINAHL from their inception through May 2013.
For inclusion, a study must have met the following criteria: (1) description of history taking, physical examination, or clinical tests concerning RCD; (2) detailing of sensitivity and specificity; (3) use of a reference standard with diagnostic criteria prespecified; (4) presentation of original data, or original data could be obtained from the authors; and (5) publication in a language mastered by one of the authors (Danish, Dutch, English, French, German, Norwegian, Spanish, Swedish).
Likelihood ratios (LRs) of symptoms and signs of RCD or of a tear, compared with an acceptable reference standard; quality scores assigned using the Rational Clinical Examination score and bias evaluated with the Quality Assessment of Diagnostic Accuracy Studies tool.
Twenty-eight studies assessed the examination of referred patients by specialists. Only 5 studies reached Rational Clinical Examination quality scores of level 1-2. The studies with quality scores of level 1-2 included 30 to 203 shoulders with the prevalence of RCD ranging from 33% to 81%. Among pain provocation tests, a positive painful arc test result was the only finding with a positive LR greater than 2.0 for RCD (3.7 [95% CI, 1.9-7.0]), and a normal painful arc test result had the lowest negative LR (0.36 [95% CI, 0.23-0.54]). Among strength tests, a positive external rotation lag test (LR, 7.2 [95% CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95% CI, 2.6-12]) were the most accurate findings for full-thickness tears. A positive drop arm test result (LR, 3.3 [95% CI, 1.0-11]) might help identify patients with RCD. A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95% CI, 0.0-0.58]).
Because specialists performed all the clinical maneuvers for RCD in each of the included studies with no finding evaluated in more than 3 studies, the generalizability of the results to a nonreferred population is unknown. A positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting RCD, whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear.
Deze NHG-Standaard geeft richtlijnen voor diagnostiek en behandeling van schouderklachten. Onder ‘schouderklachten’ wordt
in deze standaard verstaan: pijn met of zonder bewegingsbeperking van de bovenarm, waarbij de pijn gelokaliseerd is in een
(deel van het) gebied dat loopt vanaf de basis van de nek tot aan de elleboog (zie figuur 1) en waarbij de klachten niet het gevolg zijn van een ernstig recent trauma. Het begrip ‘schouderklachten’ wordt hier tevens
gebruikt als (werk)diagnose.
Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.
To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.
We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English.
We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.
Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.
We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.
There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.
Background:
Estimation of size, shape, and curvature of the humeral head is important for shoulder replacement procedures and allograft transplantation, especially as we try to recreate normal anatomy. The purpose of this study was to investigate the value of various anthropometric measurements for predicting humeral head curvature.
Materials and methods:
Cadaveric humeri were scanned with a 3-dimensional laser scanner. Length of the humerus, epicondylar breadth, and humeral head curvature were determined using data from the scans. A linear regression was performed for the length of the humerus, epicondylar breadth, gender, age, height, and weight. A stepwise linear regression with forward and backward substitution (α = 0.15) was performed for the most predictive variables from the initial linear regression. An equation for the prediction of humeral head radius of curvature was generated using this data.
Results:
The most predictive factors (R(2) > 0.5) were epicondylar breadth, height, sex, and humeral length. These 4 factors were included in a forward and backward stepwise regression. The resulting equation had an R(2) value of 0.812.
Conclusion:
Of the predicted measurements evaluated, patient height, maximum humeral length, epicondylar breadth, and gender were most correlated with humeral head curvature. Including these 4 factors in a linear regression model increased the R(2) value to 0.812. If only a single measurement can be used to size the humeral head curvature, patient height will give the same accuracy as epicondylar breadth and can more easily be obtained. A patient's height can help accurately predict the patient's humeral head anatomy.
To evaluate the evidence for the effectiveness and cost-effectiveness of the newer diagnostic imaging tests as an addition to clinical examination and patient history for the diagnosis of soft tissue shoulder disorders.
Literature was identified from several sources including general medical databases.
Studies were identified that evaluated clinical examination, ultrasound, magnetic resonance imaging (MRI), or magnetic resonance arthrography (MRA) in patients suspected of having soft tissue shoulder disorders. Outcomes assessed were clinical impingement syndrome or rotator cuff tear (full, partial or any). Only cohort studies were included. The methodological quality of included test accuracy studies was assessed using a formal quality assessment tool for diagnostic studies and the extraction of study findings was conducted in duplicate using a pre-designed and piloted data extraction form to avoid any errors. For each test, sensitivity, specificity and positive and negative likelihood ratios with 95% confidence intervals were calculated for each study. Where possible pooled estimates of sensitivity, specificity and likelihood ratios were calculated using random effects methods. Potential sources of heterogeneity were investigated by conducting subgroup analyses.
In the included studies, the prevalence of rotator cuff disorders was generally high, partial verification of patients was common and in many cases patients who were selected retrospectively because they had undergone the reference test. Sample sizes were generally very small. Reference tests were often inappropriate with many studies using arthrography alone, despite problems with its sensitivity. For clinical assessment, 10 cohort studies were found that examined either the accuracy of individual tests or clinical examination as a whole: individual tests were either good at ruling out rotator cuff tears when negative (high sensitivity) or at ruling in such disorders when positive (high specificity), but small sample sizes meant that there was no conclusive evidence. Ultrasound was investigated in 38 cohort studies and found to be most accurate when used for the detection of full-thickness tears; sensitivity was lower for detection of partial-thickness tears. For MRI, 29 cohort studies were included. For full-thickness tears, overall pooled sensitivities and specificities were fairly high and the studies were not statistically heterogeneous; however for the detection of partial-thickness rotator cuff tears, the pooled sensitivity estimate was much lower. The results from six MRA studies suggested that it may be very accurate for detection of full-thickness rotator cuff tears, although its performance for the detection of partial-thickness tears was less consistent. Direct evidence for the performance of one test compared with another is very limited.
The results suggest that clinical examination by specialists can rule out the presence of a rotator cuff tear, and that either MRI or ultrasound could equally be used for detection of full-thickness rotator cuff tears, although ultrasound may be better at picking up partial tears. Ultrasound also may be more cost-effective in a specialist hospital setting for identification of full-thickness tears. Further research suggestions include the need for large, well-designed, prospective studies of the diagnosis of shoulder pain, in particular a follow-up study of patients with shoulder pain in primary care and a prospective cohort study of clinical examination, ultrasound and MRI, alone and/or in combination.
To study the incidence and management of intrinsic shoulder disorders in Dutch general practice, and to evaluate which patient characteristics are associated with specific diagnostic categories.
In 11 general practices (35,150 registered patients) all consultations concerning shoulder complaints were registered during a period of one year. Patients with an intrinsic shoulder disorder who had not consulted their general practitioner for the complaint during the preceding year (incident cases) were asked to participate in an observational study. Participants completed a questionnaire regarding the nature and severity of their complaints. The general practitioners recorded data on diagnosis and therapy.
The cumulative incidence of shoulder complaints in general practice was estimated to be 11.2/1000 patients/year (95% confidence limits 10.1 to 12.3). Rotator cuff tendinitis was the most frequently recorded disorder (29%). There were 349 incident cases enrolled in the observational study. Patient characteristics showed small variations between different diagnostic categories. Age, duration of symptoms, precipitating cause and restriction of movement seemed to be discriminating factors. Twenty two percent of all participants received injections during the first consultation; most (85%) were diagnosed as having bursitis. The majority of patients with tendinitis (53%) were referred for physiotherapy.
With respect to diagnosis and treatment, the practitioners generally appeared to follow the guidelines issued by the Dutch College of General Practitioners. Although the patient characteristics of specific disorders showed some similarities with the clinical pictures described in the literature, further research is required to demonstrate whether the proposed syndromes indeed constitute separate disorders with a different underlying pathology, requiring different treatment strategies.
We assessed the relative value of lag signs for the evaluation of rotator cuff rupture in a prospective study of 100 consecutive painful shoulders with impingement syndrome, stages 1 to 3. Lag signs were compared with the Jobe and lift-off signs. Three tests were designed to assess the main components of the rotator cuff: the external rotation lag sign (ERLS) for the supraspinatus and the infraspinatus tendons, the drop sign for the infraspinatus, and the internal rotation lag sign (IRLS) for the subscapularis tendon. For assessment of the supraspinatus and infraspinatus the ERLS was less sensitive but more specific than the jobe sign. The drop sign was the least sensitive but was as specific as the ERLS. Partial ruptures of the supraspinatus remained concealed to the ERLS. For assessment of the subscapularis the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS. The magnitude of the lag correlated with the size of the rupture for both the ERLS and the IRLS. Clinical testing for lag signs was efficient, reproducible, and reliable. In patients with little or no restriction of motion it enhanced the accuracy of clinical diagnosis in rotator cuff lesions.
To compare estimates of the occurrence of shoulder pain according to (a) different approaches to defining 'shoulder' and (b) restricting the definition to only include those with associated disability.
A postal questionnaire survey was sent to a sample of 500 patients registered with a general practice in south Manchester. After additional mailings to non-responders, 312 questionnaires were returned (66% adjusted response rate). Four definitions of shoulder pain were used to estimate the occurrence of symptoms derived from answers to the questionnaire. Two were based on questions asking directly about pain in the shoulder and the upper trunk and neck region respectively and two were based on markings on a pain drawing in the shoulder complex and the upper trunk respectively. To determine the occurrence of disabling shoulder pain responders were subsequently approached for interview. Of the responders, 232 (74%) were successfully interviewed. Those indicating that they were suffering from 'current' shoulder symptoms, pain on the day of interview, were asked to complete a short, 23 item, questionnaire enquiring about disability in daily living associated with such symptoms.
In total 160 (51%) people reported shoulder pain according to at least one definition. This one month period prevalence ranged from 31% to 48% across the four definitions with the lowest estimate being for the question asking directly about shoulder symptoms. In total 84 people (27% of all respondents) answered positively to all four definitions. Only seven people who answered positively when asked directly about shoulder pain did not indicate symptoms on the pain drawing in the shoulder complex. By contrast 65 (30%) of those answering negatively to the direct question about shoulder pain indicated symptoms on the pain drawing in the upper trunk region or answered positively to the direct question about pain in the upper trunk or neck region. However only 19 (9%) of those answering negatively to the direct question indicated symptoms in the shoulder complex on the pain drawing, compared with 38 (18%) indicating symptoms in the upper trunk region and 59 (27%) symptoms in the upper trunk and neck region. Limiting the definition to only include current symptoms with some associated disability (at least one item on the disability questionnaire being answered positively) restricted the point prevalence to 20% (n = 46).
Using a pain drawing based definition with case ascertainment restricted to an area in and around the shoulder complex is recommended for surveys assessing the occurrence of shoulder symptoms in the general population. To solve the problem of the poor specificity associated with symptom based definitions it is useful to incorporate an additional classification to restrict the definition to more disabling problems.
To determine the natural history of shoulder pain in the population, and predictors of outcome on the basis of clinical and individual factors. In addition, to determine whether outcome is influenced by the definition of shoulder pain used.
A prospective cohort study, over a 3 year period, of subjects recruited from a cross sectional population screening study of shoulder pain, conducted in the Greater Manchester area of the UK.
Of 92 subjects classified as having shoulder pain in the cross sectional study, 50 (54%) reported shoulder pain at followup about 3 years later. In 90% of cases this was accompanied by some disability specifically relating to the symptoms. Baseline factors that predicted symptoms at followup were: pain (indicated on a manikin) within a more narrowly defined shoulder region, shoulder pain related disability, pain on the day of examination, symptoms lasting more than one year, and a high score on the General Health Questionnaire, a measure of psychological distress.
Shoulder pain in the population is a longterm disabling symptom, although many subjects do not seek early medical consultation. Disability (independent of whether there was restriction of movement on examination) is a strong predictor of continuing symptoms. The outcome observed in epidemiological studies of shoulder pain will be influenced by the initial definition of symptoms.
Epidemiologically-based rheumatology healthcare needs assessment requires an understanding of the incidence and prevalence of musculoskeletal disorders in the community, of the reasons why people consult in primary care, and of the proportion of people who would benefit from referral to secondary care and paramedical services. This paper reports the first phase of such a needs assessment exercise.
To estimate the relative frequency of musculoskeletal pain in different, and multiple, anatomical sites in the adult population.
Three general practices in the former Tameside and Glossop Health Authority, Greater Manchester, UK, a predominantly urban area.
Population survey.
An age and sex stratified sample of 6000 adults from the three practices was mailed a questionnaire that sought data on demographic factors, musculoskeletal symptoms (pain in the past month lasting for more than a week), and physical disability (using the modified Health Assessment Questionnaire--mHAQ). The areas of pain covered were neck, back, shoulder, elbow, hand, hip, knee, and multiple joints. The Carstairs index was used as a measure of social deprivation of the postcode sector in which the person lived.
The response rate after two reminders was 78.5%. Non-responders were more likely to live in areas of high social deprivation. People who lived in more deprived areas were also more likely to report musculoskeletal pain, especially backpain. After adjusting for social deprivation the rates of musculoskeletal pain did not differ between the practices and so their results were combined. After adjustment for social deprivation, the most common site of pain was back (23%; 95% CI 21, 25) followed by knee (19%; 95% CI 18, 21), and shoulder (16%; 95% CI 14, 17). The majority of subjects who reported pain had pain in more than one site. The prevalence of physical disability in the community rose with age. It was highest in those with multiple joint problems but was also high in those with isolated back or knee pain.
Musculoskeletal pain is common in the community. People who live in socially deprived areas have more musculoskeletal symptoms. Estimates of the overall burden of musculoskeletal pain that combine the results of site specific surveys will be too high, those that do not adjust for socioeconomic factors will be too low.
Thirty patients with unilateral, traumatic recurrent anterior instability were assessed by examination under anesthesia of both shoulders in the anterior, anteroinferior, inferior, posterior, and posteroinferior directions while the examiner controlled the patients' arm rotation. There were significant side-to-side differences in humeral head translation, depending on arm rotation. Humeral head translation was significantly greater in the abnormal shoulder only in the anteroinferior direction with 40 degrees and 80 degrees of external rotation of the arm. Defining an "abnormal" examination as grade 3 translation (translation of the humeral head up onto the glenoid rim) or grade 4 translation (translation of the humeral head over the glenoid rim, that is, dislocated) and translation two grades greater than the contralateral uninjured side, the test sensitivity was 83%, and the test specificity was 100%. Assessing humeral head translation by examination under anesthesia is a useful adjunct to the diagnostic tools for shoulder instability, but the number of tests should be expanded to include the anteroinferior and posteroinferior directions, and the tests should be done with the arm in varying degrees of rotation.
To describe the prevalence, risk factors and consequences of shoulder joint impairment in the population.
A representative sample (n = 7217) of the Finnish population aged > or = 30 yr participated in a health examination survey (the Mini-Finland Health Survey). The design of the survey allowed an independent assessment of disability, reported shoulder pain, shoulder joint impairment and major chronic co-morbidity.
Shoulder impairment was observed in 8.8%, while pain was reported by 30%. The prevalence of shoulder pain decreased among the elderly, whereas impairments increased up to 20% of those aged 75-80 yr. In addition to age, sex, previous injury to the shoulder joint and a history of physically heavy work, diabetes was associated with shoulder impairment (OR 1.6, 95% CI 1.2-2.1). Shoulder impairment was associated with disability (adjusted OR 2.0, CI 1.6-2.5).
Shoulder impairment is an important component of ill health among the elderly, and cannot be reduced to reported pain alone.
Subacromial impingement syndrome (SIS) is a frequent cause of shoulder pain. The aim of this study was to investigate the diagnostic values of clinical diagnostic tests, in patients with SIS.
72 female, 48 male patients with shoulder pain were included in the study. Five had bilateral shoulder pain, so 125 painful shoulders were evaluated. Details were recorded about the patients' ages and sexes, as well as characteristics of pain and related problems. Detailed physical examination and routine laboratory tests were performed. Conventional radiography and subsequent magnetic resonance imaging of the shoulder region of all patients were performed. Patients were divided into two groups according to the results of subacromial injection test, a reference standard test for SIS. Test positive patients constituted SIS group and test negative patients the non-SIS group. Sensitivity, specificity, accuracy, positive and negative predictive values of some clinical diagnostic tests such as Neer, Hawkins, horizontal adduction, painful arc, drop arm, Yergason and Speed tests for SIS were determined by using 2 x 2 table.
The most sensitive diagnostic tests were found to be Hawkins test (92.1%), Neer test (88.7%) and horizontal adduction test (82.0%). Tests with highest specificity were drop arm test (97.2%), Yergason test (86.1%) and painful arc test (80.5%) consecutively.
The highly sensitive tests seem to have low specificity values and the highly specific ones to have low sensitivity values. Although this finding suggests that these diagnostic tests are insufficient for certain diagnosis, it is suggested they play an important part in clinical evaluation.
Search strategies for articles reporting on diagnostic test evaluations have been subjected to less research than those in the domain of clinical trials. We set out to develop an optimal search strategy for publications on diagnostic test evaluations in general, that could be added to keywords describing the specific diagnostic test at issue. Nine Family Medicine journals were searched from 1992 through 1995 for primary publications on diagnostic test evaluation by hand searching and a Medline search strategy published earlier. Additionally, new search strategies have been developed with stepwise logistic regression, using Mesh terms and free text words related to diagnosis and test evaluation as independent variables. Hand searching identified 75 primary publications on diagnostic test evaluation from a total of 2467 primary publications. The previously published search strategy had a sensitivity of 73%, a specificity of 94%, and a positive predictive value of 29%. The most accurate new search strategy had a sensitivity of 80.0% (60/75; 95% CI: 71.0-89.1), a specificity of 97.3% (2327/2392; 95% CI; 96.6-97.9%), a positive predictive value of 48% (95% CI: 40-56) and diagnostic odds ratio of 149. All four new strategies used the Mesh term "sensitivity and specificity" (exploded with the Mesh terms "predictive value" and "ROC")and cumulatively added the text words "specificity," "false negative," "accuracy," and "screening." The search strategy using the Mesh term "sensitivity and specificity" (exploded) and the text words "specificity," "false negative," and "accuracy" has both higher sensitivity and specificity than the previously published strategy. The increase in specificity in three strategies reduces the absolute number of false-positive articles that have to be screened by 50-75%, compared to the number of false positives in the earlier strategy.
This prospective study introduces a new sign to differentiate between outlet impingement and non-outlet (intra-articular) causes of shoulder pain in patients with positive impingement sign: the internal rotation resistance strength test (IRRST). It was hypothesized that positive test results are predictive of non-outlet impingement, whereas negative test results confirm outlet impingement. A prospective comparison between IRRST and arthroscopic findings of 115 consecutive patients showed the test to be highly accurate in differentiating between these two diagnoses (positive predictive value 88%, negative predictive value 96%, sensitivity 88%, specificity 96%, and accuracy 94.5%). The IRRST, in conjunction with impingement and apprehension signs, adds to our armamentarium of tests that distinguish between subacromial outlet impingement and intra-articular forms of pathology.
Although guidelines for critical appraisal of diagnostic research and meta-analyses have already been published, these may be difficult to understand for clinical researchers or do not provide enough detailed information.
Development of guidelines based on a systematic review of the evidence in reports of systematic searches of the literature for diagnostic research, of methodological criteria to evaluate diagnostic research, of methods for statistical pooling of data on diagnostic accuracy, and of methods for exploring heterogeneity.
Guidelines for conducting diagnostic systematic reviews are presented in a stepwise fashion and are followed by comments providing further information. Examples are given using the results of two systematic reviews on the accuracy of the urine dipstick in the diagnosis of urinary tract infections, and on the accuracy of the straight-leg-raising test in the diagnosis of intervertebral disc hernia.
In the era of evidence based medicine, with systematic reviews as its cornerstone, adequate quality assessment tools should be available. There is currently a lack of a systematically developed and evaluated tool for the assessment of diagnostic accuracy studies. The aim of this project was to combine empirical evidence and expert opinion in a formal consensus method to develop a tool to be used in systematic reviews to assess the quality of primary studies of diagnostic accuracy.
We conducted a Delphi procedure to develop the quality assessment tool by refining an initial list of items. Members of the Delphi panel were experts in the area of diagnostic research. The results of three previously conducted reviews of the diagnostic literature were used to generate a list of potential items for inclusion in the tool and to provide an evidence base upon which to develop the tool.
A total of nine experts in the field of diagnostics took part in the Delphi procedure. The Delphi procedure consisted of four rounds, after which agreement was reached on the items to be included in the tool which we have called QUADAS. The initial list of 28 items was reduced to fourteen items in the final tool. Items included covered patient spectrum, reference standard, disease progression bias, verification bias, review bias, clinical review bias, incorporation bias, test execution, study withdrawals, and indeterminate results. The QUADAS tool is presented together with guidelines for scoring each of the items included in the tool.
This project has produced an evidence based quality assessment tool to be used in systematic reviews of diagnostic accuracy studies. Further work to determine the usability and validity of the tool continues.
In the era of evidence based medicine, with systematic reviews as its cornerstone, adequate quality assessment tools should be available. There is currently a lack of a systematically developed and evaluated tool for the assessment of diagnostic accuracy studies. The aim of this project was to combine empirical evidence and expert opinion in a formal consensus method to develop a tool to be used in systematic reviews to assess the quality of primary studies of diagnostic accuracy. METHODS: We conducted a Delphi procedure to develop the quality assessment tool by refining an initial list of items. Members of the Delphi panel were experts in the area of diagnostic research. The results of three previously conducted reviews of the diagnostic literature were used to generate a list of potential items for inclusion in the tool and to provide an evidence base upon which to develop the tool. RESULTS: A total of nine experts in the field of diagnostics took part in the Delphi procedure. The Delphi procedure consisted of four rounds, after which agreement was reached on the items to be included in the tool which we have called QUADAS. The initial list of 28 items was reduced to fourteen items in the final tool. Items included covered patient spectrum, reference standard, disease progression bias, verification bias, review bias, clinical review bias, incorporation bias, test execution, study withdrawals, and indeterminate results. The QUADAS tool is presented together with guidelines for scoring each of the items included in the tool. CONCLUSIONS: This project has produced an evidence based quality assessment tool to be used in systematic reviews of diagnostic accuracy studies. Further work to determine the usability and validity of the tool continues
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".
Twenty-one patients who had had pain in the shoulder for more than three months were evaluated with ultrasonography and magnetic resonance imaging followed by computerized tomographic arthrography. The results of the imaging studies were then compared with the operative findings. Magnetic resonance imaging was found to be the most useful modality for establishment of the etiology of pain in the shoulder due to disease of the rotator cuff, instability associated with abnormality of the glenoid labrum, subacromial impingement, stenosis of the coracoacromial arch, and osteoarthrosis of either the glenohumeral or the acromioclavicular joint. The accuracy of magnetic resonance imaging was found to depend on both the operator and the technique and was decreased in extremely obese patients, due to difficulties in positioning, and in patients who had had a previous operation. Magnetic resonance imaging was more accurate than either computerized tomographic arthrography or ultrasonography in identifying partial-thickness tears (intrasubstance changes in the rotator cuff). Magnetic resonance imaging provided the same level of accuracy as computerized tomographic arthrography in the detection of abnormalities of the glenoid labrum.
We assessed the relative value of lag signs for the evaluation of rotator cuff rupture in a prospective study of 100 consecutive painful shoulders with impingement syndrome, stages 1 to 3. Lag signs were compared with the Jobe and lift-off signs. Three tests were designed to assess the main components of the rotator cuff: the external rotation lag sign (ERLS) for the supraspinatus and the infraspinatus tendons, the drop sign for the infraspinatus, and the internal rotation lag sign (IRLS) for the subscapularis tendon. For assessment of the supraspinatus and infraspinatus the ERLS was less sensitive but more specific than the Jobe sign. The drop sign was the least sensitive but was as specific as the ERLS. Partial ruptures of the supraspinatus remained concealed to the ERLS. For assessment of the subscapularis the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS. The magnitude of the lag correlated with the size of the rupture for both the ERLS and the IRLS. Clinical testing for lag signs was efficient, reproducible, and reliable. In patients with little or no restriction of motion it enhanced the accuracy of clinical diagnosis in rotator cuff lesions.
We have studied the reported clinical assessment of the presence and extent of a rotator cuff tear in 42 patients presenting to a special shoulder clinic. This pre-operative diagnosis was compared with the findings at operation. The clinical tests had a sensitivity of 91% and a specificity of 75%. It is important to exploit clinical examination before resorting to costly and sometimes harmful special investigations.
A specific pattern of injury to the superior labrum of the shoulder was identified arthroscopically in twenty-seven patients included in a retrospective review of more than 700 shoulder arthroscopies performed at our institution. The injury of the superior labrum begins posteriorly and extends anteriorly, stopping before or at the mid-glenoid notch and including the "anchor" of the biceps tendon to the labrum. We have labeled this injury a "SLAP lesion" (Superior Labrum Anterior and Posterior). There were 23 males and four females with an average age of 37.5 years. Time from injury to surgery averaged 29.3 months. The most common mechanism of injury was a compression force to the shoulder, usually as the result of a fall onto an outstretched arm, with the shoulder positioned in abduction and slight forward flexion at the time of the impact. The most common clinical complaints were pain, greater with overhead activity, and a painful "catching" or "popping" in the shoulder. No imaging test accurately defined the superior labral pathology preoperatively. We divided the superior labrum pathology into four distinct types. Treatment was performed arthroscopically based on the type of SLAP lesion noted at the time of surgery. The SLAP lesion, which has not been previously described, can be diagnosed only arthroscopically and may be treated successfully by arthroscopic techniques alone in many patients.
The extreme manifestation of anterior shoulder instability is anterior dislocation. Minor anterior instability often gives rise to vague symptoms from which a diagnosis is difficult. The use of arthroscopy may increase diagnostic accuracy in cases of anterior shoulder instability. Examinations were performed on 145 patients with shoulder complaints using stability testing under anesthesia and arthroscopy; of these, 62 patients were found to have anterior shoulder instability. The clinical signs were compared with the findings on stability testing and arthroscopy, and the morphological changes noted on arthroscopy were recorded. The combination of arthroscopy and stability testing proved valuable in the diagnosis of minor anterior instability and for the morphological changes and associated injuries in established anterior dislocations.
Shoulder joint dislocations collected from a randomized population were investigated in Sweden, wherein nearly 50% of people with primary dislocations never visit hospitals nor are treated by a physician. Thus information obtained from surgically treated patients is of limited value because cases requiring operative repair represent only a small and selected percentage of the population. The incidence of shoulder dislocation in people from 18 to 70 years of age was at least 1.7% and was three times more common in males. Spontaneous healing of recurrent dislocations in a period of many years was not uncommon. Shoulder joint dislocation was more common among children than was generally appreciated, with the prognosis usually good. Recurrences of primary dislocations in people 15 to 25 years of age were not as frequent as was expected.
Results of three clinical tests for detecting shoulder impingement syndrome (Neer's, Hawkins', and Yocum's tests) and four tests for determining the location of the rotator cuff lesion (Jobe's test [supraspinatus], Patte's test [infraspinatus], lift-off test [subscapularis], and palm-up test [long head of the biceps brachii]) were compared to intraoperatively observed anatomic lesions in 55 consecutive patients who had surgery for Neer's syndrome. For Jobe's and Patte's tests, both pain (denoting tendinitis) and functional impairment (denoting tendon rupture) were evaluated. All clinical tests were done by the same examiner and all surgical procedures (acromioplasty with or without rotator cuff repair) by the same surgeon. The location and extent of the lesions (size of the tear in the 34 patients with rotator cuff defects) were determined intraoperatively. The sensitivity, specificity, and positive and negative predictive values of each test were calculated. Sensitivity was satisfactory but specificity was poor, in particular for determining the location and type of rotator cuff lesions. The severity of functional impairment during Jobe's and Patte's maneuvers was not correlated with the size of the tear.
In a consecutive series of 98 patients presenting 100 full thickness cuff tears and managed by the same medico-surgical team, the authors studied the correlation between preoperative shoulder function values and the anatomic lesions found at surgery. Predictive factors of tear size were evaluated and any elements that were likely to improve preoperative function were determined so that patients could be best prepared for surgery. The validity of preoperative radiographic assessment of lesions was examined.
Prior to surgery, each patient was given the same rehabilitation program, the same arthrotomographic assessment of lesions and each was rated functionally using Constant's scoring method. Preoperative radiographic assessment of lesions showed supra-spinatus tears in 69 per cent, combined supraspinatus and infraspinatus tears in 22 per cent, and tears involving the supraspinatus, infraspinatus and subscapularis in 9 per cent.
The preoperative Constant score averaged 46/100 points. The score was higher when patients had been prepared by preoperative rehabilitation to overcome stiffness. The optimum duration of rehabilitation was found to be 3 months (p < 0.05). Active range of motion was 90 per cent of normal in 84 per cent of cases. The patients in this series therefore underwent surgery more for continuing severe pain (25 per cent) and muscle weakness (86 per cent) than for reduced active motion.
Examination of the correlations existing between an anatomic lesion and the preoperative rating of shoulder function shows that the Constant preoperative score provides a good prediction of the size of the tear to be repaired (p = 0.0063). The greater the tear size, the lower the preoperative Constant sore is. Active range of motion (especially in abduction and external rotation) and muscular strength are factors with the most predictive value contrary to pain and discomfort which are influenced by tear size.
Preparing patients suffering full thickness cuff defects through preoperative rehabilitation to overcome stiffness provides the best conditions for surgery. Constant's functional scoring method gives a reproducible and reliable reflection of the anatomic rotator cuff lesion to be repaired. Its use for preoperative rating is useful for determining a reference value for function prior to surgery.
This study documents the sensitivity and specificity of a clinical test to aid in the diagnosis of superior glenoid labral lesions. The anterior slide test, a method of applying an anteriorly and superiorly directed force to the glenohumeral joint, was performed on several groups of athletes. These included symptomatic athletes with isolated superior labral tears, rotator cuff tears, and instabilities, and asymptomatic athletes with rotational deficits. In addition, non-throwing athletes were tested. The sensitivity of the test was 78.4%, and the specificity was 91.5%. This study shows that the anterior slide test can be used in the clinical examination, in that it has high specificity for superior labral lesions, but not enough sensitivity to be the sole diagnostic criterion for these lesions.
The goal of this retrospective study is to describe the different anatomic lesions of the subscapularis and to precise the diagnostic value of the clinical and imaging tests.
Twenty-one cases of isolated tear of the subscapularis were operated on between 1989 and 1992. Affecting both sex, this lesion happens in younger patients than the rotator cuff tear concerning supra or infra-spinatus. The onset was most often traumatic but not specific. Four patients had no traumatic history.
In 16 cases, the complaint was an unspecific chronic painful shoulder. The Jobe test was positive in 12 cases. The lift-off test was positive in 9 cases. Arthrography showed extravasation of dye into the subacromial bursa in 11 cases. Subscapularis lesion was suspected with the presence of dye spot on the lesser tuberosity on the A.P. view in external rotation (18 cases). Arthro-CT-scan was diagnostic in 12 cases, revealing dye spot touching the lesser tuberosity. At surgery, 3 types of lesions were found: complete ruptures or ruptures concerning the superior two-thirds of the tendon and letting intact the inferior muscular third (15 cases): partial superior lesions (5 cases) and a muscular tear of the inferior two-thirds. The long head of the biceps was dislocated in 5 cases, subluxated in 5 cases, ruptured in 3 cases and normal in 8 cases.
The mechanisms of these lesions are probably different. The most common mechanism is traumatic but 4 patients had no traumatic injury. Degenerative changes of the tendon or subcoracoid impingement are also evocated. Arthrography permits a good screening but arthro-CT-scan is the most accurate to detect the lesion. Presence of dye touching the lesser tuberosity is a specific sign of the subscapularis lesion.
A new clinical test named "The shoulder anterior jerk test" is proposed to confirm the diagnosis of chronic shoulder anterior instability.
The test combines of a compression force and a translation force, applied along the arm between the humeral head and the glenoid cavity. In so doing, a subluxation of the humeral head is provoked and it is accompanied with a jerk recognised by the patient as his instability.
Three different populations of patients had been studied: Population A: 28 patients operated on for chronic anterior dislocation, uni or bilateral (32 shoulders), had been tested before the operation, without and under anesthesia. Population B: 100 patients without any problem at the shoulder, had been tested before and under anesthesia done for knee or hip surgery. Population C: 100 young sportive athletes with normal shoulder tested without anesthesia.
Population A: The 28 patients suffering from shoulder instability had all a positive shoulder jerk test under anesthesia. Without anesthesia the test had been positive only in 10 cases (30 per cent). The jerk is potentially present for all the patients, but it is disturbed by apprehension. Population B: Among the 200 shoulders tested, 26 shoulders (17 patients) had a positive test under anesthesia (13 per cent). 5 had positive jerk test without anesthesia. Population C: 5 among the 200 shoulders tested had a positive jerk test (2.5 per cent) Under anesthesia the test has a sensitivity of 100 per cent, a specificity of 87 per cent, a positive predictive value of 55 per cent and a negative value of 100 per cent. Without anesthesia, the test has a sensitivity of 31 per cent, a specificity of 97.5 per cent, a positive predictive value of 66 per cent and a negative predictive value of 90 per cent.
The instability which is shown by the jerk test is in relation with the anterior subluxation of the humeral head in front of the anterior edge of the glenoïd cavity. It reproducts, with a minimal amplitude, the clinical instability which is recognized by the patient. The test is always positive under anesthesia in case of chronic anterior instability, it may confirm pre-operative diagnosis just before the begining of the procedure and may orientate the choice of it. Apprehension is a major obstacle to the research of the jerk, but it is the same with the other classical clinical tests of the shoulder anterior instability.
The anterior jerk test of the shoulder is thus a test which is able to prove the diagnosis of an anterior instability. The future will permit to confirm its efficiency and will confirm if the test may differenciate anterior and inferior instability with variation of the abduction, as it has been shown in this preliminary study.
To clarify their usefulness in screening massive rotator cuff tear, routine radiographs of the shoulder were compared in three groups: (1) shoulders with a massive rotator cuff tear (MRCT), (2) shoulders with a small full-thickness rotator cuff tear (SRCT), and (3) normal control shoulders. Two different statistical methods were employed to assess the gradation (order) of correlation in 83 shoulders (22 were MRCTs, 31 with SRCTs, and 30 controls). Superior migration of the humerus and deformity of the greater tuberosity showed by far the more significant contribution to MRCT than did other abnormalities. When the shoulders were screened for these two abnormalities, the sensitivity was 78% (21/27) and specificity was 98% (55/56).
The finite element method described in this study provides an easy method to simulate the kinetics of multibody mechanisms. It is used in order to develop a musculoskeletal model of the shoulder mechanism. Each relevant morphological structure has been represented by an appropriate element. For the shoulder mechanism two special-purpose elements have been developed: a SURFACE element representing the scapulothoracic gliding plane and a CURVED-TRUSS element to represent muscles which are wrapped around bony contours. The model contains four bones, three joints, three extracapsular ligaments, the scapulothoracic gliding plane and 20 muscles and muscle parts. In the model, input variables are the positions of the shoulder girdle and humerus and the external load on the humerus. Output variables are muscles forces subject to an optimization procedure in which the mechanical stability of the glenohumeral joint is one of the constraints. Four different optimization criteria are compared. For 12 muscles, surface EMG is used to verify the model. Since the optimum muscle length and force-length relationship are unknown, and since maximal EMG amplitude is length dependent, verification is only possible in a qualitative sense. Nevertheless, it is concluded that a detailed model of the shoulder mechanism has been developed which provides good insight into the function of morphological structures.
Musculo-skeletal complaints are widespread. In a population survey in Ullensaker, a local community 40 kilometers north-east of Oslo, only 15% reported no musculo-skeletal symptoms during the last year. Just as many, 15%, predominantly women aged 50-70 years years, reported having such symptoms every day during the last year. 53% reported that they had experienced low back pain during the last year. The corresponding figures for headache, neck symptoms and shoulder symptoms were 49%, 48% and 46% respectively. Headache was most common among the younger women and neck and shoulder symptoms among middle-aged, while hip and knee symptoms were most frequent in the elderly women. Women in all age groups reported symptoms from more parts of the body than the men did.
The purpose of this study was to evaluate the sensitivity, specificity, negative and positive predictive values, and accuracy of the shoulder relocation test in 100 patients who underwent shoulder surgery. Based on operative data and examination under anesthesia, the diagnoses were grouped into six categories: anterior instability (without cuff disease), posterior instability, rotator cuff disease (without associated anterior instability), acromioclavicular disorder, osteoarthrosis, and instability of the biceps tendon. The test was performed on the day of surgery by placing the arm in a position of 90 degrees of humerothoracic abduction and 90 degrees of external rotation (90 degrees/90 degrees). Patient responses of pain and apprehension (considered separately) were assessed in this position both with and without application of an anterior force to the proximal humerus. The relocation test assessed diminution of pain and apprehension after application of a posteriorly directed force to the proximal humerus relative to the position of 90 degrees/90 degrees alone and to the position of an anterior force being applied to the proximal humerus. Overall, 63 patients reported pain with 90 degrees/90 degrees; 74 reported pain when an anterior force to the proximal humerus was applied: the anterior instability group alone had 46 and 63 reports of pain, respectively; the rotator cuff group alone had 82 and 88 reports of pain, respectively. The only positive responses for apprehension were in the anterior instability group, of which 63% had apprehension with 90 degrees/90 degrees alone and 74 had apprehension when an anterior humeral force was applied.(ABSTRACT TRUNCATED AT 250 WORDS)
The results of clinical shoulder examination including 20 special tests were compared with subsequent arthroscopic findings in 45 patients. The sensitivity of the clinical diagnosis was 73%. Impingement syndrome was correctly diagnosed in 19 of 22 cases (86%), rotator cuff tears in 7 of 9 cases (78%). The highest sensitivity for stage II impingement was found for the supraspinatus test (85%) and the lift-up test (92%); the sensitivity of these tests for rotator cuff tears was 100% and 89% respectively. Differentiation between impingement syndrome with and without rotator cuff tear by one of these tests alone was not possible because of their low positive predictive values (26% and 56%). In contrast, in 90% of patients with negative rotator tests the rotator cuff was complete, while the negative predictive value of the supraspinatus test was 100%. Instability was confirmed in only 53% of cases; the Leffert test had the highest positive predictive value (73%). In conclusion, the clinical diagnosis of a shoulder lesion cannot reliably be achieved by single tests; rather overall evaluation by an experienced clinician is necessary.
A systematic method of examining the shoulder in anesthetized patients was developed. Humeral translocation on the glenoid was assessed in five directions and in three positions of arm rotation for four of these directions. Fifty-five patients thought to have shoulder instability were evaluated by history taking, physical examination, standard and special roentgenograms, examination under anesthesia, and either shoulder arthroscopy or operation. The findings at examination under anesthesia were compared with the pathologic conditions identified at arthroscopy or operation. Twenty-five shoulders had pathologic evidence of continuing instability: Bankart lesions in 19 and clearly excessive capsular laxity in six. All 25 had abnormal results on examination under anesthesia (no false-negative results). Thirty shoulders had no demonstrable pathologic condition. The results of examination under anesthesia were normal for 28 shoulders and abnormal for two (two false-positive results). The sensitivity of examination under anesthesia in these patients was 100%. The specificity and predictive value were 93%. Examination under anesthesia has proven to be reasonably precise in assessing shoulder stability. If the results of the examination are normal, more complex and invasive diagnostic testing may not be necessary.
This article deals with reliability aspects of standardized, active motor tests ("functional tests") when applied to patients with painful shoulder disorders. Motor performance was rated independently by the same two examiners in a standardized way in three different manoeuvres: the Hand in Neck, Hand in Back, and Pour out of a Pot tests. Pain experienced during these tests was rated by the patients on a verbal scale. A method of general applicability is presented for the analysis of reliability of standardized, active motor tests when applied to painful shoulder joint disorders. The importance of differential motivation is stressed, as is the importance of using reliability measures that are adapted to the specific purpose of a particular clinical investigation.
An understanding of the anatomy and biomechanical features of the glenohumeral joint is necessary when understanding the concept of shoulder laxity. Glenohumeral laxity is a normal feature of shoulder motion, but only when that laxity becomes excessive does instability occur. The clinician must use the history and physical examination to distinguish normal from pathological laxity. Several examination techniques are commonly used to evaluate anterior, posterior, inferior, and multidirectional shoulder laxity. It has become appreciated the subluxation of the shoulder is clinically or symptomatically unstable. This paper reviews the current techniques to evaluate shoulder laxity and discusses the interpretation of these examinations as they relate to normal and pathological laxities.
We studied 62 patients (40 men and 22 women) with an average age of 28 years over a 28-month period who presented with shoulder pain that was refractory to 3 months of conservative management. Patients with a prior glenohumeral dislocation or a rotator cuff tear were excluded. The "crank" test was performed with the arm elevated to 160 degrees in the scapular plane of the body, loaded axially along the humerus, and with maximal internal and external rotation. Although similar tests have been described, the crank test is a new examination previously unreported. Half of the patients (31) had a positive crank test. Arthroscopy performed on all 62 patients revealed glenoid labral tears in 32 patients. Two patients who had positive crank tests did not have labral tears but had partial-thickness, articular-side rotator cuff tears. The sensitivity of the crank test was 91%, the specificity was 93%, the positive predictive value was 94%, and the negative predictive value was 90%. With these data, the crank test fulfills the criteria as a single physical examination test that is highly accurate for the preoperative diagnosis of glenoid labral tears. Accordingly, expensive imaging modalities currently used in this patient population may be employed less in the future.
To describe a clinical test associated with unstable lesions of the superior glenoid labrum-long head biceps tendon origin, or SLAP (superior labrum anterior to posterior).
Description of a newly discovered clinical sign that correlated with SLAP pathology. Retrospective review of 66 consecutive arthroscopically confirmed SLAP lesions to determine the sensitivity of the SLAPprehension test.
Orthopedic sports medicine clinics with an emphasis on shoulder problems.
Patients with shoulder pain and arthroscopically verified lesions of the superior glenoid labrum and conjoined long head biceps tendon.
Shoulder arthroscopy and in some cases arthroscopic SLAP lesion repair.
Nonapplicable.
The SLAPprehension test involves cross chest adduction (horizontal flexion) of the affected shoulder with the elbow extended and forearm pronated. A positive maneuver produces either apprehension, pain referable to the bicipital groove, and an audible or palpable click. The test is repeated with the forearm supinated, which must cause diminution of the pain. Mechanically, elbow extension and forearm pronation places traction on the long head biceps tendon. When anterior scapular protraction is limited by the clavicle, further adduction entraps the unstable biceps tendon and superior glenoid labrum between the glenoid fossa and humeral head. Forearm supination decreases traction on the long head biceps tendon and allows for reduction of the unstable labrum complex with lessening of the pain. A retrospective chart review of 66 consecutive arthroscopically verified shoulders with SLAP lesions revealed the SLAPprehension test to be 87.5% sensitive for unstable SLAP lesions.
The SLAPprehension test is helpful in the clinical evaluation of patients with unstable superior glenoid labrum lesions whose symptoms are often confused and overlap with those of shoulder impingement or acromioclavicular arthrosis.
We sought to determine the accuracy of ultrasound for the preoperative evaluation of shoulder impingement syndrome, rotator cuff tear, and abnormalities of the long head of the biceps tendon. The findings in 42 consecutive surgical cases were compared with the preoperative sonographic readings. Ultrasound detected all of the 10 full-thickness cuff tears identified at surgery (sensitivity 1.0, specificity 0.97) but detected only 6 of 13 partial-thickness cuff tears (sensitivity 0.46, specificity 0.97). A full-thickness tear was falsely diagnosed in one case of severe cuff abrasion. Dynamic scan criteria correctly diagnosed impingement in 27 of 34 cases (sensitivity 0.79, positive predictive value 0.96). Abnormalities of the long head of the biceps were accurately diagnosed with the exception of low-grade tendinitis and the superior labral tear, anterior to posterior, lesion. We concluded that ultrasound is a sensitive and accurate method of identifying patients with full-thickness tears of the rotator cuff, extracapsular biceps tendon pathology, or both. Dynamic ultrasound can help confirm, but not exclude, a clinical diagnosis of impingement.