The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation

Management of irreparable subscapularis tears: Current concepts

Primary repair of acute subscapularis (SSC) tears provides excellent results, but tendon retraction, muscle atrophy, fatty infiltration, and humeral head migration may render a more chronic tear irreparable. These irreparable SSC tears present a diagnostic and treatment challenge for orthopaedic surgeons. Careful physical examination and imaging evaluation can help to distinguish those with reparable versus irreparable tears, but they are still not very reliable due to the methodological limitations of current evidence. Therefore, future research using 3D and quantitative measurement techniques is necessary to better predict the irreparability of the SSC. When conservative treatment of an irreparable SSC tear fails, reversed shoulder arthroplasty has been established as the preferred treatment option for older, low-demand patients with arthropathy, providing reliable improvements in pain and function. In younger patients without significant arthropathy, musculotendinous transfers are the treatment of choice. The pectoralis major transfer is historically the most frequently performed procedure and provides improved range of motion and pain relief, but fails to adequately restore strength and shoulder function. The latissimus dorsi transfer has gained increased interest over the last few years due to its biomechanical superiority, and early clinical studies suggest improved outcomes as well. More recently, anterior capsular reconstruction has been proposed as an alternative to musculotendinous transfers, but clinical data are completely lacking. Future high-quality randomised controlled trials are necessary to reliably compare the different musculotendinous transfers and anterior capsular reconstruction.

Bari Shoulder Telemedicine Examination Protocol (B-STEP): A Standard Protocol for Personalized Remote Shoulder Examination

The COVID-19 pandemic drastically changed many aspects of the traditional functioning of health systems all around the world. In Italy, as reported by the CIO, compared to the previous year, there was a significant reduction in 2020 in overall outpatient activities by up to 75%. These data support the need for telemedicine, which represents a current challenge and can no longer be postponed in the future. This study aims to elaborate on a possible model for remote shoulder examination based on traditional tests to improve the quality of telemedicine in orthopedic and rehabilitation. Between May 2020 and November 2020, ten orthopedic surgeons individually examined six patients with a known shoulder disorder, both in hospital and via webcam according to the previously shared protocol (B-STEP). According to the 10 observers, completing 100% of the ASES score and at least 87.5% of the Constant score is possible. Shoulder ROM and many specific tests are also reproducible via webcam, but with less sensitivity, according to the subjective opinion of observers. The B-STEP is a useful protocol for the standardization of the objective examination of the shoulder via webcam. Further studies are necessary to determine if the B-STEP protocol is useful for diagnosing pathology in unknown patients and evaluating its sensitivity and specificity for each pathology.

Diagnosis, prevention and treatment of common shoulder injuries in sport: grading the evidence - a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement paper summarises and appraises the evidence on diagnosis, prevention, and treatment of common shoulder injuries in sports. We systematically searched Medline and Embase. The Grading of Recommendations Assessment, Development and Evaluation tool was applied to evaluate the overall quality of evidence.For diagnosis, we included 19 clinical tests from mixed populations. Tests for anterior instability, biceps-labrum complex injuries and full subscapularis rupture had high diagnostic accuracy (low to moderate quality of evidence).For prevention, the Oslo Sports Trauma Research Center, the Shoulder Control, the FIFA 11+ shoulder injury prevention programmes, and a baseball-specific programme (range of motion, stretching, dynamic stability and strengthening exercises) showed moderate to large effect size in reducing the risk of shoulder injury compared with no intervention (very low to moderate quality of evidence).For treatment, a rehabilitation programme including stretching, ice packs, electrotherapy and compression, and strengthening exercises showed a large effect size in reducing pain and disability compared with no intervention in athletes with subacromial impingement syndrome (very low to moderate quality of evidence). For the treatment of supraspinatus tendinopathy, hyperthermia treatment (heating the skin to 38°C-40°C) resulted in large effect size in reducing pain and disability compared with ultrasound or pendular swinging and stretching exercises (moderate quality of evidence). Strengthening exercise alone or in combination with stretching exercises promoted a large effect in reducing shoulder pain (cohort studies, no comparators) (very low quality of evidence). The quality of evidence for most estimates was low to moderate, indicating that future high-quality research may alter our recommendations for clinical practice.

Description of Clinical Features and Diagnoses of 444 Cases with Neck-Shoulder-Upper Extremity Pain: A Single-Center Retrospective Review

PURPOSE

Neck-shoulder-upper extremity pain (NSUEP) is a frequently occurring clinical constellation of syndromes. However, its etiology is complicated, and the diagnosis is challenging. We aimed to present detailed clinical characteristics and diagnoses of NSUEP from a single center and heighten clinicians' understanding of this condition.

PATIENTS AND METHODS

Prospectively collected databases were used to retrospectively evaluate patients with NSUEP who underwent treatment at the multidisciplinary consultation center for neck, shoulder, and upper extremity pain at the China-Japan Union Hospital of Jilin University between April 2014 and July 2021. We performed descriptive statistics regarding demographic data, symptoms, findings of physical and radiographic examinations, and each patient's diagnosis.

RESULTS

Development of NSUEP was primarily observed in individuals aged between 51 and 60 years (n = 157, 35.4%). Patients were most commonly referred for upper extremity pain (n = 306, 68.9%). Patients with upper extremity pain presented with hypoesthesia (n = 139, 45.4%), muscle weakness (n = 93, 30.4%), muscle atrophy (n = 90, 29.4%), hyperesthesia (n = 39, 12.7%), and turgidity (n = 18, 5.9%). Among the 22 patients with upper extremity swelling, 8 (36.4%) were diagnosed with autoimmune rheumatic diseases. Among the 352 patients with a single diagnosis, 51 (14.5%) presented with thoracic outlet syndrome, 49 (13.9%) with cervical radiculopathy, 16 (4.5%) with carpal tunnel syndrome, and 16 (4.5%) with brachial plexus injury. Further, among the 92 patients with compound diagnosis, 18 patients (19.6%) were diagnosed with cervical radiculopathy.

CONCLUSION

Among the NSUEP patients in this study, older individuals were the largest group. Pain, numbness, weakness, and mobility limitation are common complaints accompanying NSUEP. The common etiologies of NSUEP include cervical spondylosis, thoracic outlet syndrome, carpal tunnel syndrome, and brachial plexus injury. In addition, autoimmune rheumatic diseases should be considered in patients with NSUEP and swelling.

Association between changes in pain or function scores and changes in scapular rotations in patients with subacromial shoulder pain: a prospective cohort study

Background

Scapular dyskinesis is reported as one of the potential factors contributing to the presentation of pain in subacromial shoulder pain. In clinical practice, the evaluation and control of scapular dyskinesis is considered important for managing the subacromial shoulder pain. The aim is to determine the association between changes in pain or function and changes in scapular rotations in participants with subacromial shoulder pain.

Method

Pain, function and scapular rotations were measured in 25 participants with subacromial shoulder pain at baseline and after 8 weeks. Pain was measured with Numeric Pain Rating Scale (NPRS) and function was measured with Patient Specific Functional Scale (PSFS). Scapular rotations were measured with a scapular locator at 60°, 90° and 120° of scapular arm elevation. Spearman rank correlations (r_s) were used to assess the association between variables.

Findings

No association was observed between changes in pain or function scores with changes in scapular upward/downward rotations (r_s = 0.03 to 0.27 for pain and − 0.13 to 0.23 for function) and scapular anterior/posterior tilt (r_s = − 0.01 to 0.23 for pain and − 0.13 to 0.08 for function) of arm at 60°, 90° and 120° elevation. Data associated with scapular internal/external rotation was not reported due to low reliability.

Conclusion

These findings reject associations between changes in pain or function scores and scapular rotations. Future observational study is warranted using a multifactorial approach to understand potential factors that contribute to the presentation of subacromial shoulder pain.

Diagnostic Accuracy of Clinical Tests for Subscapularis Tears: A Systematic Review and Meta-analysis

Background:

Previous systematic reviews and meta-analyses on the diagnostic accuracy of shoulder clinical tests do not reach conclusions regarding subscapularis tears.

Purpose:

To compare the diagnostic accuracy of commonly used clinical tests for subscapularis tears.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

An electronic literature search was conducted using Medline, Embase, and the Cochrane Library/Central. Eligibility criteria were original clinical studies reporting the diagnostic accuracy of clinical tests to diagnose the presence of rotator cuff tears involving the subscapularis.

Results:

The electronic literature search returned 2212 records, of which 13 articles were eligible. Among 8 tests included in the systematic review, the lift-off test was most frequently reported (12 studies). Four tests were eligible for meta-analysis: bear-hug test, belly-press test, internal rotation lag sign (IRLS), and lift-off test. The highest pooled sensitivity was 0.55 (95% CI, 0.28-0.79) for the bear-hug test, while the lowest pooled sensitivity was 0.32 (95% CI, 0.13-0.61), for the IRLS. In all tests, pooled specificity was >0.90.

Conclusion:

Among the 4 clinical tests eligible for meta-analysis (bear-hug test, belly-press test, IRLS, and lift-off test), all had pooled specificity >0.90 but pooled sensitivity <0.60. No single clinical test is sufficiently reliable to diagnose subscapularis tears.

Registration:

PROSPERO (CRD42019137019).

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.

Is There a Decrease in the Acromiohumeral Distance Among Recreational Overhead Athletes With Rotator Cuff-Related Shoulder Pain?

CONTEXT

Recreational overhead athletes are exposed to high overload, which increases the risk of shoulder injuries. Reduction of the acromiohumeral distance (AHD) is often associated with rotator cuff-related shoulder pain (RCRSP) among the general population. However, the AHD of symptomatic shoulders of recreational athletes has not yet been compared with their asymptomatic shoulders.

OBJECTIVE

To compare the AHD of a symptomatic to asymptomatic shoulder at rest (0°) and 60° abduction. To establish the relationship between AHD, pain, and functional limitations of recreational athletes with RCRSP.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

A total of 45 recreational overhead athletes with RCRSP were examined.

MAIN OUTCOME MEASURES

The AHD was measured by ultrasonography at 0° and 60° abduction (angles). Shoulder pain was assessed using a numeric pain scale, whereas functional limitations were assessed using the The Disabilities of the Arm, Shoulder, and Hand questionnaire. Differences in the between-shoulders condition (symptomatic and asymptomatic) were determined using 2-way analysis of variance for repeated measures. A Pearson correlation established the relationship between AHD, pain, and functional limitations.

RESULTS

No angles × shoulder condition interactions (P = .776) nor shoulder condition effects (P = .087) were detected, suggesting no significant differences (P > .05) between asymptomatic and symptomatic shoulders in the AHD at 0° or 60°. The AHD at 60° reduced significantly compared with 0° (3.05 [1.36] mm [2.77-3.33], angle effects: P < .001). The AHD at 0° and 60° was not correlated with pain or functional limitations (-.205 ≤ r ≤ .210, .167 ≤ P ≤ .585).

CONCLUSIONS

The AHD of recreational athletes is not decreased in symptomatic shoulders compared with asymptomatic shoulders. Reduction of the AHD in symptomatic shoulders is not associated with an increase in pain or functional limitations of recreational athletes with RCRSP.

Kinesiotaping for the Rehabilitation of Rotator Cuff-Related Shoulder Pain: A Randomized Clinical Trial

BACKGROUND

Kinesiotaping (KT) has been widely used in clinical practice. Current evidence is insufficient to support the use of KT for treating rotator cuff-related shoulder pain (RCRSP), as its mid- and long-term effects have not been investigated.

HYPOTHESES

Individuals using KT will achieve faster improvements in symptoms and functional limitations compared with those not using it. They will also present a greater increase in pain-free range of motion (ROM) and acromiohumeral distance (AHD) at the end of the treatment.

STUDY DESIGN

Randomized controlled trial (NCT02881021).

LEVEL OF EVIDENCE

Therapy, level 1b.

METHODS

A total of 52 individuals with RCRSP, randomly assigned to 1 of 2 groups (experimental: KT; control: no-KT), underwent a 6-week rehabilitation program composed of 10 physical therapy sessions. KT was added to the treatment of the KT group. Symptoms and functional limitations were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire (primary outcome); Brief Pain Inventory (BPI); and Western Ontario Rotator Cuff (WORC) index at baseline, 3 weeks, 6 weeks, 12 weeks, and 6 months. AHD, pain-free ROM, and full ROM were measured at baseline and at week 6. The effects of KT were assessed using a nonparametric analysis for longitudinal data.

RESULTS

No significant group × time interactions (0.112 ≤ P ≤ 0.726) were found for all outcomes. Time effects were observed as both groups showed significant improvements for all studied outcomes (DASH, BPI, and WORC, p < 0.0001; AHD, p = 0.017; pain-free ROM, p < 0.0001; and full ROM abduction, p ≤ 0.0001).

CONCLUSION

Whereas symptoms, functional limitations, ROM, and AHD improved in both groups, the addition of KT did not lead to superior outcomes compared with exercise-based treatment alone, in the mid and long term, for individuals with RCRSP.

CLINICAL RELEVANCE

Clinicians should not expect supplementary mid- or long-term gains with KT to reduce pain, improve shoulder function and ROM, or increase AHD if a rehabilitation program focusing on shoulder neuromuscular control is concurrently provided as treatment for individuals with RCRSP.

External rotator strength deficits in non-athletic people with rotator cuff related shoulder pain are not associated with pain intensity or disability levels

BACKGROUND

Strength deficits are often reported in people with rotator cuff related shoulder pain. However, these have mainly been tested in athletic populations and pain interference with testing has not been considered.

OBJECTIVES

To examine strength without pain interference in non-athletic people with rotator cuff related shoulder pain and its association with pain intensity and disability.

DESIGN

Cross-sectional study.

METHODS

Sixty-seven participants with rotator cuff related shoulder pain were assessed for isometric strength of shoulder external rotator and internal rotator muscles without pain interference with a hand-held dynamometer. Strength was normalized (%body weight). Differences in external and internal rotation strength and external:internal rotator strength ratio between symptomatic and asymptomatic sides were examined (Independent t-tests, Wilcoxon rank sum tests). Spearman's rank correlation coefficients were used to examine associations between strength and pain and disability levels.

RESULTS

There was no significant difference in internal rotator strength normalized to body weight between symptomatic and asymptomatic sides. There was a significant difference in external rotator strength normalized to body weight (p < .001) and external:internal ratio (p < .001) between sides. No significant correlations were found between strength and pain or disability levels.

CONCLUSION

Non-athletic people with rotator cuff related shoulder pain had external rotator strength deficits without pain interference during strength testing, which were not associated with pain and disability levels.

Diagnostic Value of Clinical Tests for Infraspinatus Tendon Tears

PURPOSE

To analyze and compare the diagnostic value and interpretation of 6 established clinical tests for infraspinatus tendon tears; to assess their ability to distinguish between partial- and full-thickness tears of the infraspinatus tendon; and to investigate whether conducting multiple tests increases the precision of diagnosis.

METHODS

A total of 91 patients scheduled for shoulder arthroscopy from March 2015 to April 2017 were included in the present study. To assess the sensitivity, specificity, positive and negative predictive values, accuracy, diagnostic odds ratio, positive and negative likelihood ratios, and the area under the curve (AUC), intraoperative findings were compared with the results of 6 established clinical infraspinatus tests: the hornblower's test, the drop sign, the Patte sign, the external rotation lag sign (ERLS), the resisted external rotation test (RERT), and the infraspinatus scapular retraction test.

RESULTS

A significant correlation was found between the results of the drop sign (P = .02), the ERLS (P = .02), and the RERT (P = .02) and the intraoperative findings. The RERT achieved the highest AUC (0.673). Assessing muscle weakness led to the highest diagnostic precision on the RERT (AUC = 0.673) as compared with pain (AUC = 0.528) or using both criteria (AUC = 0.655). No single clinical test was found to be useful in distinguishing between partial- and full-thickness tears. The combination of at least 2 or more tests improved the diagnostic precision significantly (P ≤ .007). The combination of the RERT and the Patte sign showed the best AUC (0.681) and highest correlation with the intraoperative findings (P = .023).

CONCLUSIONS

The results of the present study indicate that out of all the clinical tests investigated, the drop sign and the RERT were in isolation able to accurately diagnose tears of the infraspinatus tendon. Only muscle weakness should be considered when interpreting the RERT because of its greater AUC values and correlation with the arthroscopic findings. The present study also showed that the analyzed tests are not capable of distinguishing between partial- and full-thickness tears of the infraspinatus tendon and that the combination of at least 2 tests improved the diagnostic value. The combination of the RERT and the Patte sign showed the best AUC and highest correlation with the intraoperative findings.

LEVEL OF EVIDENCE

Level II, diagnostic study, prospective comparative study.

Immediate effects of kinesiotaping on acromiohumeral distance and shoulder proprioception in individuals with symptomatic rotator cuff tendinopathy

BACKGROUND

Kinesiotaping is widely used for the rehabilitation of rotator cuff tendinopathy. It has been argued to reduce symptoms and functional limitations through improvement of proprioceptive feedback. In addition, kinesiotaping has been reported to increase the subacromial space in healthy subjects. However, its effects on the acromiohumeral distance and shoulder proprioception of individuals with rotator cuff tendinopathy have not been ascertained. This study investigated the immediate effects of kinesiotaping on the acromiohumeral distance and shoulder proprioception in individuals with rotator cuff tendinopathy.

METHODS

Twenty-two individuals with chronic rotator cuff tendinopathy were included. The acromiohumeral distance was measured using an ultrasound scanner at rest and 60° shoulder abduction. Proprioception was measured through active joint repositioning in low- (45°-65°) and mid-amplitude (80°-100°) of shoulder flexion and abduction. A wireless inertial measurement unit system was used to quantify shoulder angles. First, measurements were taken without kinesiotaping. Thereafter, kinesiotaping was applied on the symptomatic shoulder, and the same measurements were retaken. Repeated measures ANOVAs were used for statistical analyses.

FINDINGS

Kinesiotaping induced a significant increase in acromiohumeral distance at 60° abduction (∆AHD = 0.94 mm; 95%CI: 0.50-1.38, p < 0.001), exceeding the minimal detectable change (0.70 mm). No significant difference was observed in acromiohumeral distance at rest or in proprioception during active joint repositioning in both low- and mid-amplitude (p > 0.05).

INTERPRETATION

Kinesiotaping led to an immediate increase in acromiohumeral distance at 60° of abduction that, although it seems a minor change (↑10.5%), it may be significant for symptomatic patients, whereas it had no immediate effect on active joint repositioning.

Cryotherapy or gradual reloading exercises in acute presentations of rotator cuff tendinopathy: a randomised controlled trial

Objectives

Rotator cuff tendinopathies are the most common shoulder disorders. As persistent symptoms lasting more than 3 months have been shown to be a strong indicator of poor outcomes, it is important to have successful interventions in the acute stage. However, there is no evidence yet to guide clinical interventions in an acute pain context. The objective of this study was to compare the short-term effect of a 2-week gradual reloading exercises programme with the use of cryotherapy on symptoms and function for acute rotator cuff tendinopathy.

Methods

This simple-blind, randomised controlled trial included 44 participants with acute rotator cuff tendinopathy who were randomly allocated to either the exercises or cryotherapy group. Symptoms and functional limitations were evaluated at weeks 0, 2 and 6 using self-reported questionnaires (Disabilities of the Arm, Shoulder and Hand, Western Ontario Rotator Cuff, and Brief Pain Inventory), while acromiohumeral distance, shoulder strength and active range of motion were evaluated at weeks 0 and 2.

Results

Following interventions, both groups showed statistically significant improvements on symptoms and function at week 2 and week 6 compared with baseline. However, there was no significant group × time interaction. There was no time effect on acromiohumeral distance, shoulder strength and active range of motion, as well as no time × group interaction.

Conclusion

The results showed a statistically significant improvement in symptoms and function in both groups, but there was no difference between the short-term effect of a cryotherapy based-approach and a gradual reloading exercises programme.

Trial registration number

NCT02813304.

Diagnostic Accuracy of the Scapular Retraction Test in Assessing the Status of the Rotator Cuff

Background:

Currently, clinical physical examination maneuvers alone provide variable reliability in diagnosing full-thickness rotator cuff tears (RCTs).

Purpose:

To assess the diagnostic accuracy of the scapular retraction test (SRT) to predict full-thickness RCTs.

Study Design:

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

Methods:

A total of 331 patients were prospectively evaluated in this cohort study. SRT was performed to assess the status of the rotator cuff. A positive SRT indicates an intact rotator cuff, and a negative SRT indicates a full-thickness RCT. Magnetic resonance imaging (MRI) was used as the gold standard. The examiner was blinded to the results until completing the physical examination. Statistical analysis was performed to assess the sensitivity, specificity, accuracy, positive and negative predictive values, and positive and negative likelihood ratios of the SRT.

Results:

The prevalence of full-thickness RCTs diagnosed on MRI was 54.4% (180 of 331). Among the 180 patients with an MRI-confirmed full-thickness RCT, the SRT was negative for 147. Of 150 patients with an intact rotator cuff by MRI, 122 had a positive SRT. In diagnosing full-thickness RCTs, the SRT had a sensitivity of 81.7% (95% CI, 77.2%-85.4%), specificity of 80.8% (95% CI, 75.5%-85.3%), and accuracy 81.3%. The positive predictive value was 83.5% (95% CI, 78.9%-87.4%); the negative predictive value, 78.7% (95% CI, 73.5%-83.1%); the positive likelihood ratio, 4.3 (95% CI, 3.1-5.8); the negative likelihood ratio, 0.23 (95% CI, 0.17-0.30); and the diagnostic odds ratio, 18.7 (95% CI, 10.4-34.0).

Conclusion:

The results of this diagnostic study indicate that the SRT can accurately be used to clinically assess the status of the rotator cuff. This physical examination maneuver was found to be accurate, sensitive, and specific in diagnosing full-thickness RCTs. Additionally, our results indicate that it is equally as accurate to predict an intact rotator cuff tendon. Providing an accurate, reliable, and reproducible physical examination test will allow clinicians to diagnosis the integrity of the rotator cuff and will help guide treatment recommendations.

Diagnostic Value of Clinical Tests for Supraspinatus Tendon Tears

PURPOSE

The purpose of this study was to analyze the diagnostic value of 7 clinical tests for the diagnosis of supraspinatus tendon tears, to investigate the ability of these tests to distinguish between partial- and full-thickness tears, and to compare 3 different ways of interpreting positive test results (weakness and pain): (1) in case of pain, (2) in case of weakness, regardless if with pain or not, and (3) when any of the 2 symptoms occurs, regardless if in combination or not. Moreover, this study aimed to investigate whether a combination of tests can improve the diagnostic accuracy.

METHODS

A total of 115 consecutive patients who presented with different shoulder symptoms were prospectively enrolled in the study from March 2015 to April 2017. The inclusion criterion was that a shoulder arthroscopy was scheduled. Patients with the following characteristics were excluded from the study: patients (1) with shoulder instability, (2) with adhesive capsulitis, or (3) with any history of previous shoulder surgery including rotator cuff repair or patients (4) who did not provide informed consent. To assess the sensitivity, specificity, positive and negative predictive values, accuracy, diagnostic odds ratio, positive and negative likelihood ratio, and area under the curve (AUC) of each test, the intraoperative findings were compared with the results of the preoperative clinical examination of 7 established clinical tests: the empty can test, the full can test, the zero-degree abduction test, the Whipple test, the scapular retraction test, the drop arm test, and the modified drop arm test.

RESULTS

A significant correlation was found between the findings for the empty can (P = .004) and full can (P = .001) tests and the intraoperative findings, wherein the full can test achieved better AUC. Muscle weakness showed the best diagnostic precision compared with pain or using both criteria. No single clinical test was found to be useful to distinguish between partial- and full-thickness tears. A combination of at least 3 or more tests improved the diagnostic value. The combination of the empty can, the full can, and the zero-degree abduction tests showed the best AUC (0.795) and correlation with the intraoperative findings (P = .02).

CONCLUSIONS

The results of the present study indicate that of all clinical tests studied, only the empty can and full can tests were effectively able to diagnose tears of the supraspinatus tendon accurately. The greater AUC and correlation with the arthroscopic findings suggest that muscle weakness should be considered the gold standard when interpreting the test results. Furthermore, the present study showed that the analyzed tests are not capable of distinguishing between partial- and full-thickness tears of the supraspinatus tendon and that the combination of at least 3 tests, including the empty can, the full can, and the zero-degree abduction tests, improved the diagnostic value significantly. In addition, the empty and full can tests have showed higher diagnostic precision and fair AUC when supraspinatus tendon tears were more than 1 cm in size.

LEVEL OF EVIDENCE

Level 1, diagnostic study.

Effects of kinesiotaping added to a rehabilitation programme for patients with rotator cuff tendinopathy: protocol for a single-blind, randomised controlled trial addressing symptoms, functional limitations and underlying deficits

INTRODUCTION

Rotator cuff tendinopathy (RCTe) is the most frequent cause of shoulder pain, resulting in considerable losses to society and public resources. Muscle imbalance and inadequate sensorimotor control are deficits often associated with RCTe. Kinesiotaping (KT) is widely used by clinicians for rehabilitation of RCTe. While previous studies have examined the immediate effects of KT on shoulder injuries or the effects of KT as an isolated method of treatment, no published study has addressed its mid-term and long-term effects when combined with a rehabilitation programme for patients with RCTe. The primary objective of this randomised controlled trial (RCT) will be to assess the efficacy of therapeutic KT, added to a rehabilitation programme, in reducing pain and disabilities in individuals with RCTe. Secondary objectives will look at the effects of KT on the underlying factors involved in shoulder control, such as muscular activity, acromiohumeral distance (AHD) and range of motion (ROM).

METHODS AND ANALYSIS

A single-blind RCT will be conducted. Fifty-two participants, randomly allocated to one of two groups (KT or no-KT), will take part in a 6-week rehabilitation programme. The KT group will receive KT added to the rehabilitation programme, whereas the no-KT group will receive only the rehabilitation programme. Measurements will be taken at baseline, week 3, week 6, week 12 and 6 months. Primary outcomes will be symptoms and functional limitations assessed by the Disabilities of the Arm, Shoulder and Hand questionnaire. Secondary outcomes will include shoulder ROM, AHD at rest and at 60° of abduction, and muscle activation during arm elevation. The added effects of KT will be assessed through a two-way analysis of variance for repeated measures.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of Quebec Rehabilitation Institute of the Centre Integrated University Health and Social Services. Results will be disseminated through international publications in peer-reviewed journals, in addition to international conference presentations.

TRIAL REGISTRATION NUMBER

Protocol was registered at ClinicalTrials.gov (NCT02881021) on 25 August 2016. The WHO Trial Registration Data Set can also be found as an online supplementary file.

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.

Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance

BACKGROUND

Physical examination tests of the shoulder (PETS) are clinical examination maneuvers designed to aid the assessment of shoulder complaints. Despite more than 180 PETS described in the literature, evidence of their validity and usefulness in diagnosing the shoulder is questioned.

METHODS

This meta-analysis aims to use diagnostic odds ratio (DOR) to evaluate how much PETS shift overall probability and to rank the test performance of single PETS in order to aid the clinician's choice of which tests to use. This study adheres to the principles outlined in the Cochrane guidelines and the PRISMA statement. A fixed effect model was used to assess the overall diagnostic validity of PETS by pooling DOR for different PETS with similar biomechanical rationale when possible. Single PETS were assessed and ranked by DOR. Clinical performance was assessed by sensitivity, specificity, accuracy and likelihood ratio.

RESULTS

Six thousand nine-hundred abstracts and 202 full-text articles were assessed for eligibility; 20 articles were eligible and data from 11 articles could be included in the meta-analysis. All PETS for SLAP (superior labral anterior posterior) lesions pooled gave a DOR of 1.38 [1.13, 1.69]. The Supraspinatus test for any full thickness rotator cuff tear obtained the highest DOR of 9.24 (sensitivity was 0.74, specificity 0.77). Compression-Rotation test obtained the highest DOR (6.36) among single PETS for SLAP lesions (sensitivity 0.43, specificity 0.89) and Hawkins test obtained the highest DOR (2.86) for impingement syndrome (sensitivity 0.58, specificity 0.67). No single PETS showed superior clinical test performance.

CONCLUSIONS

The clinical performance of single PETS is limited. However, when the different PETS for SLAP lesions were pooled, we found a statistical significant change in post-test probability indicating an overall statistical validity. We suggest that clinicians choose their PETS among those with the highest pooled DOR and to assess validity to their own specific clinical settings, review the inclusion criteria of the included primary studies. We further propose that future studies on the validity of PETS use randomized research designs rather than the accuracy design relying less on well-established gold standard reference tests and efficient treatment options.

Utility of features of the patient's history in the diagnosis of atraumatic shoulder pain: a systematic review

BACKGROUND

Whereas physical examination tests for shoulder disorders have numeric values that describe the utility of the test and its effect on the probability of having a diagnosis, this information is lacking for elements of the history. The purpose of this study was to conduct a systematic review of the literature to determine numeric data (sensitivity, specificity, predictive values, and likelihood or odds ratios) for elements of the history with regard to diagnoses in patients with chronic atraumatic shoulder pain.

METHODS

We performed a systematic review to extract information from the existing literature regarding the numeric utility of different features of the patient history as they pertain to chronic atraumatic shoulder pain. Data sources were MEDLINE through PubMed (1946-January 2012) and EMBASE through Ovid (1980-January 2012).

RESULTS

Twenty-one studies met inclusion criteria. A diagnosis of rotator cuff tear was more likely with a history of hypercholesterolemia, having a relative with rotator cuff disease, excessive lifting, above-shoulder work, hand-held vibration work, or age older than 60 years. Acromioclavicular arthritis was more likely in weightlifters. Glenohumeral arthritis was more likely if the patient has a history of prior dislocation, age >75 years, or a diagnosis of knee osteoarthritis. Adhesive capsulitis was more likely with a history of diabetes or thyroid disorder. Posterior labral tear was more likely in football players.

CONCLUSIONS

The numeric values for the utility of these history features will help establish numeric probabilities for diagnoses in patients with shoulder pain.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

In the clinic. Rotator cuff disease

Shoulder pain is a common musculoskeletal disorder and has a substantial negative effect on quality of life. Its monthly prevalence in the general population is reported to be between 18% and 31%, whereas lifetime prevalence ranges between 6.7% and 66.7%. Shoulder pain is the third most frequent musculoskeletal reason to present to primary care and accounts for up to 10% of all referrals to physical therapists. Although the natural history of shoulder pain varies and is often self-limiting,up to half of persons who present for care, particularly the elderly, might continue to have pain and/or functional disturbance for up to 2 years after presentation.

Diagnostic accuracy of clinical examination features for identifying large rotator cuff tears in primary health care

OBJECTIVES

Rotator cuff tears are a common and disabling complaint. The early diagnosis of medium and large size rotator cuff tears can enhance the prognosis of the patient. The aim of this study was to identify clinical features with the strongest ability to accurately predict the presence of a medium, large or multitendon (MLM) rotator cuff tear in a primary care cohort.

METHODS

Participants were consecutively recruited from primary health care practices (n = 203). All participants underwent a standardized history and physical examination, followed by a standardized X-ray series and diagnostic ultrasound scan. Clinical features associated with the presence of a MLM rotator cuff tear were identified (P<0.200), a logistic multiple regression model was derived for identifying a MLM rotator cuff tear and thereafter diagnostic accuracy was calculated.

RESULTS

A MLM rotator cuff tear was identified in 24 participants (11.8%). Constant pain and a painful arc in abduction were the strongest predictors of a MLM tear (adjusted odds ratio 3.04 and 13.97 respectively). Combinations of ten history and physical examination variables demonstrated highest levels of sensitivity when five or fewer were positive [100%, 95% confidence interval (CI): 0.86-1.00; negative likelihood ratio: 0.00, 95% CI: 0.00-0.28], and highest specificity when eight or more were positive (0.91, 95% CI: 0.86-0.95; positive likelihood ratio 4.66, 95% CI: 2.34-8.74).

DISCUSSION

Combinations of patient history and physical examination findings were able to accurately detect the presence of a MLM rotator cuff tear. These findings may aid the primary care clinician in more efficient and accurate identification of rotator cuff tears that may require further investigation or orthopedic consultation.

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.

Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

BACKGROUND

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.

OBJECTIVES

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.

SEARCH METHODS

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Frequency of use of clinical shoulder examination tests by experienced shoulder surgeons

CONTEXT

Health care professionals have reported and used a multitude of special tests to evaluate patients with shoulder injuries. Because of the vast array of tests, educators of health care curriculums are challenged to decide which tests should be taught.

OBJECTIVE

To survey experienced shoulder specialists to identify the common clinical tests used to diagnose 9 specific shoulder injuries to determine if a core battery of tests should be taught to allied health professionals.

DESIGN

Cross-sectional study.

SETTING

Descriptive survey administered via e-mail.

PATIENTS OR OTHER PARTICIPANTS

Of 131 active members of the American Shoulder and Elbow Surgeons, 71 responded to the survey.

MAIN OUTCOME MEASURE(S)

Respondents were asked to complete a survey documenting their use of clinical tests during a shoulder examination. They answered yes or no to indicate their use of 122 different tests for diagnosing 9 shoulder conditions.

RESULTS

The average number of tests used for all pathologic conditions was 30 ± 9. The anterior apprehension and cross-body adduction tests were used by all respondents. At least 1 test was used for each of the 9 conditions listed (range = 1-7), and at least 50% of respondents used 25 tests. The tests were reviewed for valid diagnostic accuracy via the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. High diagnostic value and a large amount of QUADAS variability have been reported in the literature for 16 of the 25 tests.

CONCLUSIONS

A small percentage (20%) of clinical tests is being used by most examiners. The 25 most common tests identified from this survey may serve as a foundation for the student's knowledge base, with the clear understanding that multiple clinical tests are used by some of the most experienced clinicians dealing with shoulder injuries.

A physician's guide to the physical examination of the shoulder

Shoulder pain is the third most frequent musculoskeletal complaint presented to physicians. Often considered a benign entity by patients and even their physicians, shoulder disorders can have a devastating effect on a patient's ability to function, as well as serve as an indicator of poor general health. For these reasons, it is important for the physician to be able to identify the etiology of a patient's shoulder problem(s). However, making a correct diagnosis is often difficult because there can be many causes for a patient's shoulder pain, weakness, or loss of function. Moreover, the shoulder girdle is an intricate group of structures that work together to allow for the largest range of motion in the body. This complexity makes it difficult to diagnose a patient's condition(s) based on history alone. A thorough and well-performed physical examination is the key to making a correct diagnosis and helping to distinguish different etiologies of shoulder dysfunction. In this article, we review relevant shoulder anatomy and biomechanics, and general shoulder examinations with special tests for various shoulder pathologies. We provide an effective and methodical approach to the physical examination of the shoulder.

Clinical tests for the diagnosis of rotator cuff disease

Several tests have been described to examine the shoulder. However, there is a lack of consensus on clinical assessment of patients with shoulder pain and suspected rotator cuff pathology. This review reports the diagnostic accuracy of clinical tests for rotator cuff pathology. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 21 clinical tests for rotator cuff pathology are reported from the available literature. Twenty studies investigated supraspinatus pathology, 12 infraspinatus pathology, and 9 subscapularis pathology. Most tests for rotator cuff pathology are inaccurate, and the recent literature shows that there is insufficient evidence to recommend 1 clinical test over another for diagnosis of rotator cuff pathology. Poor diagnostic accuracy of clinical tests for rotator cuff pathology may be related to the close relationships of structures in the shoulder, to a lack of understanding of anatomical basis of the tests, or to their lack of reproducibility.

A musculoskeletal ultrasound course for physical medicine and rehabilitation residents

Musculoskeletal ultrasound is an imaging modality that can be used to evaluate nerve, tendon, muscle, ligament, and joint disorders and to guide therapeutic procedures. A growing proportion of physiatrists are interested in musculoskeletal ultrasound as demonstrated by the increasing number of musculoskeletal ultrasound articles published in physical medicine and rehabilitation journals and quantity of musculoskeletal ultrasound courses and workshops at physical medicine and rehabilitation conferences. The Mayo Clinic (Rochester, MN) Physical Medicine and Rehabilitation residency program developed a musculoskeletal ultrasound course for their physical medicine and rehabilitation residents, which was implemented in 2008. A detailed description of the course is provided in this article. In addition, results from a premusculoskeletal ultrasound course and postmusculoskeletal ultrasound course practical and written test are presented, and the results of a postmusculoskeletal ultrasound course resident survey are discussed. This information can be used by other physical medicine and rehabilitation residency programs to assist in the creation of their own musculoskeletal ultrasound course.