The validity of 9 physical tests for full-thickness rotator cuff tears after primary anterior shoulder dislocation in ED patients

Survey on Knowledge, Use, and Diagnostic Applicability of Special Tests for Rotator Cuff Involvement in Clinical Practice

Background

Recently, researchers have commented that shoulder special tests cannot identify the structure causing rotator cuff symptoms and should only be considered pain provocation tests. Others have disagreed, reporting that special tests were able to accurately detect the presence of rotator cuff involvement.

Purpose

The purpose of this study was to determine the knowledge, use, and perceived effectiveness of 15 selected special tests utilized to examine patients with possible rotator cuff dysfunction.

Study Design

Descriptive study using survey.

Methods

An electronic survey was returned by 346 members of the Academies of Orthopedic and Sports Physical Therapy through list serves. Descriptions and pictures for 15 special tests of the shoulder were included in the survey. Information regarding years of clinical experience and American Board of Physical Therapy Specialties (ABPTS) specialist certification in Sports or Orthopedics was collected. Respondents were asked if they could identify and use the special tests to evaluate dysfunction of the rotator cuff - and how confident they were in ability of the tests to diagnose dysfunction of the rotator cuff.

Results

The four tests most readily known by respondents included the empty can, drop arm, full can, and Gerber's tests, and the four tests used regularly by the respondents included the infraspinatus, full can, supraspinatus, and champagne toast tests. The infraspinatus, champagne toast, external rotation lag (ERLS), and the belly-off tests were found to be the be most useful for establishing a diagnosis of the muscle-tendon complex involved. Years of experience and clinical specialization was not relevant to knowledge or use or these tests.

Conclusions

This study will allow clinicians and educators to understand which special tests are easily identified, regularly used, and perceived as helpful for the diagnosis of muscles involved in a rotator cuff dysfunction.

Level of Evidence

3b.

The new dynamic isotonic manipulation examination (DIME) is a highly sensitive secondary screening tool for supraspinatus full-thickness tears

BACKGROUND

Traditional shoulder physical examination (PE) tests have suboptimal sensitivity for detection of supraspinatus full-thickness tears (FTTs). Therefore, clinicians may continue to suspect FTTs in some patients with negative rotator cuff PE tests and turn to magnetic resonance imaging (MRI) for definitive diagnosis. Consequently, there is a need for a secondary screening test that can accurately rule out FTTs in these patients to better inform clinicians which patients should undergo MRI. The purpose of this study was to assess the ability of 2 new dynamic PE tests to detect supraspinatus pathology in patients for whom traditional static PE tests failed to detect pathology.

METHODS

We prospectively enrolled 171 patients with suspected rotator cuff pathology with negative findings on traditional rotator cuff PE, who underwent 2 new dynamic PE tests: first, measurement of angle at which the patient first reports pain on unopposed active abduction and, second, the dynamic isotonic manipulation examination (DIME). Patients then underwent shoulder magnetic resonance arthrogram. Data from the new PE maneuvers were compared with outcomes collected from magnetic resonance arthrogram reports.

RESULTS

Pain during DIME testing had a sensitivity of 96.3% and 92.6% and a negative predictive value of 96.2% and 94.9% in the coronal and scapular planes, respectively. DIME strength ≤86.0 N had a sensitivity of 100% and 96.3% and a negative predictive value of 100% and 95.7% in the coronal and scapular planes, respectively. Pain at ≤90° on unopposed active abduction in the coronal plane had a specificity of 100% and a positive predictive value of 100% for supraspinatus pathology of any kind (ie, tendinopathy, "fraying," or tearing).

CONCLUSION

DIME is highly sensitive for supraspinatus FTTs in patients with negative traditional rotator cuff PE tests for whom there is still high clinical suspicion of FTTs. Thus, this test is an excellent secondary screening tool for supraspinatus FTTs in patients for whom clinicians suspect rotator cuff pathology despite negative traditional static PE tests. Given its high sensitivity, a negative DIME test rules out supraspinatus FTT well in these patients, and can therefore better inform clinicians which patients should undergo MRI. In addition, the angle at which patients first report pain on unopposed active shoulder abduction is highly specific for supraspinatus pathology.

Reduced acromiohumeral distance and increased critical shoulder angle: implications for primary care clinicians

Objectives: The literature indicates that reduced acromiohumeral distance (AHD) and increased critical shoulder angle (CSA) are associated with large and massive rotator cuff (RC) tears which may not be amenable to a successful repair. The purpose of this study was to examine the overall accuracy of these two radiographic features in diagnosing significant RC pathology. Methods: This was a diagnostic study of patients with shoulder pain. To examine the overall accuracy of the measurements, the area under the Receiver Operating Characteristic curves (AUC) were calculated. The validity indices (sensitivity, specificity and likelihood ratios) examined the predictive value of specific cutoff categories of AHD<6 mm and the CSA >35°. Results: Data of 200 consecutive patients; mean age: 59(11), 117 males were used for analysis. There was a weak inverse correlation (r = 0.46) between the AHD and CSA. The AUCs for presence and size of RC tear and different stages of fatty infiltration of supraspinatus and infraspinatus muscles varied from fair to excellent for AHD and poor to good for CSA. Specificity was high for the cutoff categories of both AHD and CSA (>90%). The positive LRs were large for AHD and small to moderate for CSA. Conclusion: The AHD and CSA were reliably measured in the true AP radiographic view. Both radiographic features (AHD<6mm and CSA>35°) were able to confirm the presence of a major RC pathology. However, the AHD<6 mm, an acquired radiologic abnormality secondary to failure of the RC muscles/tendons had better measurement properties. This information is of value to primary care physicians, sports medicine specialists and advanced practice physiotherapists in their clinical decision making.

Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists

Purpose: The primary purpose of this study was to examine the inter-tester reliability and criterion validity of reduced acromiohumeral distance (AHD; <6 mm) visualized on plain radiographs in detecting rotator cuff (RC) pathology. The secondary objective was to examine the relationship between this radiographic feature and patient demographics and clinical examination. Method: This was a diagnostic study of patients seen in a tertiary care centre. Two advanced-practice physiotherapists measured AHD in two radiographic views. MRI was used as the gold standard. Results: A total of 150 consecutive patients (mean age 59 [SD 11] y, 57 women, 93 men) were included. AHD less than 6 millimetres was highly specific in both views for the presence of tear (99%), tear size (96%-98%), and fatty infiltration in the supraspinatus and infraspinatus muscles (93%-96%). The absence of AHD less than 6 millimetres was associated with a lack of advanced fatty infiltration in the supraspinatus and infraspinatus muscles (92%-100%). Sensitivity values were low for the presence and size of RC tear (21%-55%). We found a statistically significant positive association between the AHD categories and clinically observed muscle wasting and weakness of the RC muscles (p < 0.05). Conclusions: AHD less than 6 millimetres was reliably measured in plain radiographs and was strongly associated with important clinical and imaging features of advanced RC pathology; this may assist with clinical decision making by allowing judicious use of more costly investigations and referral for surgery.

Does My Patient With Shoulder Pain Have a Rotator Cuff Tear?: A Predictive Model From the ROW Cohort

Background:

Rotator cuff tears are the leading cause of shoulder pain and disability. However, the diagnosis of a rotator cuff tear based on patient characteristics, symptoms, and physical examination findings remains a challenge because of a lack of data. Moreover, data on the predictive ability of a combination of these characteristics and tests are not available from a large cohort of patients. Consequently, clinicians rely on expensive imaging, such as magnetic resonance imaging (MRI), to make a diagnosis.

Purpose:

To model patient characteristics, symptoms, and physical examination findings that predict a rotator cuff tear. We present a nomogram based on our predictive model that can be used in patients with shoulder pain to determine the probability of the diagnosis of a rotator cuff tear without the need for imaging.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

We recruited patients from outpatient clinics who were ≥45 years of age and who had shoulder pain of at least 4 weeks’ duration. A rotator cuff tear was diagnosed based on expert clinical impression and the presence/absence of a tear on a blinded review of MRI. Ultimately, 301 patients were included in the analysis.

Results:

A total of 123 patients (41%) had rotator cuff tears, and 178 patients (59%) did not. The predictors of the diagnosis of a rotator cuff tear included external rotation strength ratio of the affected versus unaffected shoulder (odds ratio [OR], 1.20 [95% CI, 1.08-1.34]), male sex (OR, 1.98 [95% CI, 1.10-3.56]), positive lift-off test result (OR, 4.33 [95% CI, 1.46-12.86]), and positive Jobe test result (OR, 9.19 [95% CI, 4.69-17.99]). A nomogram based on these predictor variables was plotted.

Conclusion:

Presented is a model that can accurately predict the diagnosis of a rotator cuff tear with satisfactory discrimination and calibration based on 4 variables: sex, lift-off test, Jobe test, and external rotation strength ratio. Data from this study can be used to aid in the diagnosis of a rotator cuff tear in day-to-day clinical practice in outpatient settings without the need for expensive imaging such as MRI.

Review article: Best practice management of common shoulder injuries and conditions in the emergency department (part 4 of the musculoskeletal injuries rapid review series)

Shoulder injuries are a commonly presenting complaint to the ED. In the absence of an obvious deformity, they can be difficult to assess and definitively diagnose because of the multiple structures that cause shoulder pain, the acuity and severity of pain and the lack of range of motion in the ED setting. The quality of ED care provided to patients with musculoskeletal shoulder pain is crucial to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common shoulder injuries and conditions in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines published in English-language in the past 12 years that addressed the acute assessment, management, follow-up plan or prognosis were considered for inclusion. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence. The search revealed 1902 articles, of which 73 were included in the review (n = 12 primary articles, n = 49 systematic reviews and n = 12 guidelines). This rapid review provides clinicians who manage shoulder dislocations, fractures and soft tissue injuries in the ED a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is strong evidence to support taking a thorough history and physical examination, with cautious use of special tests because of their poor diagnostic accuracy. Key points regarding the diagnosis and management of these injuries are provided.

Physical therapists as first-line diagnosticians for traumatic acute rotator cuff tears: a prospective study

BACKGROUND

Early diagnosis of traumatic acute full-thickness rotator cuff tears (FTRCT) is important to offer early surgical repair. Late repairs following fatty infiltration of the rotator cuff muscles have less favorable results. We think that physical therapists are valuable diagnosticians in a screening process. The objective of this study was to evaluate the usefulness of physical therapists as first-line diagnosticians in detecting acute traumatic FTRCT.

METHODS

Between November 2010 and January 2014, 394 consecutive patients having an age between 18 and 75 years who sought medical care because of acute shoulder trauma with acute onset of pain, limited abduction and negative plain radiographs were included in the study. A clinical assessment was conducted by a physical therapist 1 week after the trauma. The patients were divided into three groups by the physical therapist according to the findings: FTRCT (Group I, n = 122); sprain (Group II, n = 62); or other specific diagnoses (Group III, n = 210). Group III patients were discharged and excluded from the study. Magnetic Resonance Imaging shoulder was performed for all Group I patients and for all patients with persistent symptoms in Group II.

RESULTS

79/184 patients had FTRCTs documented by MRI in groups I and II. The clinical assessment of the physical therapist had a sensitivity of 85%, specificity of 68%, and usefulness index of 0.45 (> 0.35 considered useful) for diagnosing FTRCT.

CONCLUSION

Physical therapists can be useful as first-line diagnosticians in detecting traumatic FTRCT.

The Diagnostic Accuracy of Special Tests for Rotator Cuff Tear: The ROW Cohort Study

OBJECTIVE

The aim was to assess diagnostic accuracy of 15 shoulder special tests for rotator cuff tears.

DESIGN

From February 2011 to December 2012, 208 participants with shoulder pain were recruited in a cohort study.

RESULTS

Among tests for supraspinatus tears, Jobe test had a sensitivity of 88% (95% confidence interval [CI], 80%-96%), specificity of 62% (95% CI, 53%-71%), and likelihood ratio of 2.30 (95% CI, 1.79-2.95). The full can test had a sensitivity of 70% (95% CI, 59%-82%) and a specificity of 81% (95% CI, 74%-88%). Among tests for infraspinatus tears, external rotation lag signs at 0 degrees had a specificity of 98% (95% CI, 96%-100%) and a likelihood ratio of 6.06 (95% CI, 1.30-28.33), and the Hornblower sign had a specificity of 96% (95% CI, 93%-100%) and likelihood ratio of 4.81 (95% CI, 1.60-14.49).

CONCLUSIONS

Jobe test and full can test had high sensitivity and specificity for supraspinatus tears, and Hornblower sign performed well for infraspinatus tears. In general, special tests described for subscapularis tears have high specificity but low sensitivity. These data can be used in clinical practice to diagnose rotator cuff tears and may reduce the reliance on expensive imaging.

Accuracy of infraspinatus isometric testing in predicting tear size and tendon reparability: comparison with imaging and arthroscopy

BACKGROUND

The purpose of this study was to examine the accuracy of external rotation in neutral (0° external position) and in shortened position (45° external position) in relation to rotator cuff tear size, tendon reparability, and other clinical, surgical, and imaging findings.

METHODS

This was a prospective blinded diagnostic study of consecutive surgical candidates for rotator cuff repair using magnetic resonance imaging and arthroscopic surgery as the "gold standards." The area under a receiver operating characteristic (AUROC) curve was calculated for each position.

RESULTS

Eighty-five patients (35 female [41%] and 50 male [59%]; age, 65 years [standard deviation = 10]) were included. Sixty patients (71%) had a minor tear (4 small, 56 moderate), and 25 patients (29%) had a major tear (17 large and 8 massive). Seventy patients (82%) had a full repair, and 15 (18%) patients underwent a partial repair. There were 26 (31%) associated full-thickness tears of the infraspinatus. The isometric strength testing in both positions had good to excellent accuracy (range, 0.80-0.90) for detecting reparability, tear retraction, infraspinatus atrophic changes observed by the clinician, and infraspinatus fatty infiltration on magnetic resonance images. The shortened position had an overall higher accuracy than the neutral position and was more clinically useful for detecting an infraspinatus full-thickness tear (AUROC = 0.84 vs 0.78) and rotator cuff tear size (AUROC = 0.80 vs. 0.75).

CONCLUSIONS

The isometric external rotation is an accurate test in diagnosing different aspects of rotator cuff disease and specifically of the infraspinatus muscle. The isometric strength at the shortened position was a better predictor of clinical, surgical, and imaging findings.

Scapular muscle-activation ratios in patients with shoulder injuries during functional shoulder exercises

CONTEXT

Alterations in scapular muscle activation, which are common with glenohumeral (GH) injuries, affect stability and function. Rehabilitation aims to reestablish activation between muscles for stability by progressing to whole-body movements.

OBJECTIVE

To determine scapular muscle-activation ratios and individual muscle activity (upper trapezius [UT], middle trapezius [MT], lower trapezius [LT], serratus anterior [SA]) differences between participants with GH injuries and healthy control participants during functional rehabilitation exercises.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty-nine participants who had GH injuries (n = 20; age = 23.6 ± 3.2 years, height = 170.7 ± 11.5 cm, mass = 74.7 ± 13.1 kg) or were healthy (n = 19; age = 24.4 ± 3.3 years, height = 173.6 ± 8.6 cm, mass = 74.7 ± 14.8 kg) were tested.

INTERVENTION(S)

Clinical examination confirmed each participant's classification as GH injury or healthy control. Participants performed 4 exercises (bow and arrow, external rotation with scapular squeeze, lawnmower, robbery) over 3 seconds with no load while muscle activity was recorded.

MAIN OUTCOME MEASURE(S)

We used surface electromyography to measure UT, MT, LT, and SA muscle activity. Scapular muscle-activation ratios (UT:MT, UT:LT, and UT:SA) were calculated (normalized mean electromyography of the UT divided by normalized mean electromyography of the MT, LT, and SA). Exercise × group analyses of variance with repeated measures were conducted.

RESULTS

No group differences for activation ratios or individual muscle activation amplitude were found (P > .05). Similar UT:MT and UT:LT activation ratios during bow-and-arrow and robbery exercises were seen (P > .05); both had greater activation than external-rotation-with-scapular-squeeze and lawnmower exercises (P < .05). The bow-and-arrow exercise elicited the highest activation from the UT, MT, and LT muscles; SA activation was greatest during the external-rotation-with-scapular-squeeze exercise.

CONCLUSIONS

Scapular muscle activation was similar between participants with GH injuries and healthy control participants when performing the unloaded multiplanar, multijoint exercises tested. High activation ratios during the bow-and-arrow exercise indicate UT hyperactivity or decreased MT, LT, and SA activity. Our GH injury group may be comparable to high-functioning injured athletes. Study results may assist clinicians in selecting appropriate exercises for scapular muscle activation when caring for injured athletes.

Clinical examination of the rotator cuff

Rotator cuff tears are the leading cause of shoulder pain and shoulder-related disability and account for 4.5 million physician visits in the United States annually. A careful history and structured physical examination are often sufficient for diagnosing rotator cuff disorders. We are not aware of a clinical review article that presents a structured physical examination protocol of the rotator cuff for the interested clinician. To fill this void, we present a physical examination protocol developed on the basis of review of prior literature and our clinical experience from dedicated shoulder practices. Our protocol includes range of motion testing by using a goniometer, strength testing by using a dynamometer, and select special tests. Among the many tests for rotator cuff disorders that have been described, we chose ones that have been more thoroughly assessed for sensitivity and specificity. This protocol can be used to isolate the specific rotator cuff tendon involved. The protocol can typically be completed in 15 minutes. We also discuss the clinical implications and limitations of the physical examination maneuvers described in our protocol. This protocol is thorough yet time efficient for a busy clinical practice. It is useful in the diagnosis of rotator cuff tears, impingement syndrome, and biceps pathology.