The belly-off sign: a new clinical diagnostic sign for subscapularis lesions

Diagnostic Performance of Belly-Press Angle in Predicting the Severity of Subscapularis Tear

BACKGROUND

Neglected partial subscapularis tears often cause functional impairment even after repair of the supraspinatus and infraspinatus tear is done. Numerous physical examinations for detecting partial subscapularis tears have been described in previous studies.

PURPOSE

To analyze the relationship between the preoperative clinical features and the severity of a partial subscapularis tear and to provide diagnostic clues for patients requiring subscapularis repair.

STUDY DESIGN

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

METHODS

This retrospective study included 286 patients who underwent arthroscopic shoulder surgery between 2020 and 2022. Preoperative clinical features, including range of motion, functional scores, muscle strength ratio, modified belly-press test (measuring belly-press angle), and bear-hug test, were collected. Magnetic resonance imaging (MRI) evaluation was done according to the Yoo and Rhee classification. Types of subscapularis tear, supraspinatus lesion, and biceps lesion were recorded during arthroscopic surgery. A comparison of preoperative clinical features between the no-repair group (type 2A or less) and surgical repair group (type 2B or more) was done. The optimal cutoff value of the belly-press angle was determined and the diagnostic performance of the belly-press angle, bear-hug test, and MRI were evaluated using the receiver operating characteristic curve.

RESULTS

Among 286 patients, 189 (66.1%) had subscapularis tears with type 2A or more. There was a significant difference in muscle strength ratio of the belly-press (P < .001), belly-press angle (P < .001), and bear-hug test (P < .001) between the no-repair group (type 2A or less) and the surgical repair group (type 2B or more). With a belly-press angle of 15° as a new cutoff value, the modified belly-press test showed 67.6% sensitivity, 73.9% specificity, and 69.6% accuracy in detecting type 2B or higher subscapularis tear.

CONCLUSION

Patients with type 2A and 2B subscapularis tears (according to the Yoo and Rhee classification) showed differences in belly-press strength ratio, belly-press angle, and bear-hug test. The cutoff value of the 15° belly-press angle showed an accuracy of 69.6% in detecting subscapularis tears with type 2B or higher.

The effect of subscapularis-specific rehabilitation following total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial

BACKGROUND

Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function.

METHODS

Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs.

RESULTS

Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P > .05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P < .05).

CONCLUSIONS

Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs.

[Anatomy and diagnostics of subscapularis tendon lesions]

Among lesions of the rotator cuff, subscapularis tendon tears are one of the less common injuries and mostly occur in combination with additional lesions of the posterosuperior rotator cuff and the long biceps tendon. If a subscapularis tendon rupture is suspected in the initial clinical testing, the primary diagnostics should include modern cross-sectional magnetic resonance imaging to assess the tendon lesion and to detect concomitant pathologies. Nevertheless, subscapularis tendon lesions are often initially overlooked and first correctly diagnosed during shoulder arthroscopy.

The scissors sign: a provocative test for detecting the leading-edge tear of subscapularis tendon: a diagnostic study

BACKGROUND

Several physical examination tests and signs have been described to aid in the diagnosis of subscapularis (SSC) tear, but have limitations and variable sensitivity. This study aimed to introduce a novel test for detecting a leading-edge tear of the subscapularis (LETS), the most important tendinous portion of SSC.

METHODS

A total of 233 patients who underwent arthroscopic repair for anterior and superior cuff tears between January 2018 to September 2019 were retrospectively reviewed. The provocative test we have coined as the "scissors sign" and the other related clinical tests (i.e., belly press, belly off, Napoleon, lift off, internal rotation lag, bear hug tests) were performed preoperatively. Whether the patient has a LETS or the complete tear of the SSC (CTS) was confirmed by arthroscopic findings. Sensitivity, specificity, and areas under the receiver operating characteristic curve were calculated for each test.

RESULTS

In patients who had LETS with or without supraspinatus tear, the scissors sign showed the highest sensitivity (91.4%) with a specificity of 81.6%, positive predictive value (PPV) of 80.2%, and negative predictive value (NPV) of 92.1%. In patients with isolated LETS, the scissors sign also showed the highest sensitivity (90.3%) with a specificity of 81.6%, PPV of 57.1%, and NPV of 96.8%. The scissors sign for the complete tear of the subscapularis (CTS) with or without supraspinatus tear and the isolated CTS had a sensitivity of 73.1 and 75%, respectively.

CONCLUSIONS

The scissors sign is a novel provocative test that can be helpful in the diagnosis of subscapularis tears, especially LETS, with its high sensitivity and diagnostic accuracy. In combination with other tests, the scissors sign will be a good screening tool.

Current concepts review in the management of subscapularis tears

Subscapularis (SSc) is the prime internal rotator of shoulder. It is the most powerful rotator cuff muscle, maintaining the anterior force couple of shoulder. The tears in SSc as any other rotator cuff muscles might result from a traumatic event or more commonly from intrinsic degeneration. With the advent and widespread use of shoulder arthroscopy, SSc tears, which were once considered as "forgotten or hidden lesions" are now being increasingly recognized. Isolated SSc tears are relatively rare. They occur in combinations. Clinically internal rotation can be near normal because of the compensation provided by other internal rotators. It is not uncommon for patients with SSc tear to be normal on routine physical examination. The Bear Hug test (BHT) has high sensitivity and accuracy in the diagnosis of SSc tear. The combined use of BHT with Belly Press Test has been found optimal for diagnosis. US is an accurate and reliable method for diagnosing SSc tears and outperformed MRI in diagnosing partial-thickness SSc tears. The MRI is currently the most advanced imaging available for diagnosis. The specificity is up to 100%. However, the sensitivity is between 36 and 40%. The earliest classification system for SSc tears was by Fox et al. The commonly used classification is by Lafosse et al. The recent system by Yoo et al. is based on the insertion of SSc. The comma sign is gaining importance not only in arthroscopic diagnosis but also in MRI identification and repair of SSc. The mode of management is mainly arthroscopic. The techniques of repair of SSc are continuously progressing. However, there is no clear consensus on the double vs single-row repairs, biceps tendon management, and the role of coracoplasty. Future research must focus on these areas. Reserve shoulder arthroplasty is reserved for salvage in older age groups. Tendon transfers are performed in young active individuals with irreparable tears.

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).

Arthroscopic iliac crest bone grafting in recurrent anterior shoulder instability: minimum 5-year clinical and radiologic follow-up

PURPOSE

To investigate the clinical and radiologic mid- to long-term results of arthroscopic iliac crest bone-grafting for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability.

METHODS

Seventeen patients were evaluated after a minimum follow-up of 5 years. Clinical [range of motion, subscapularis tests, apprehension sign, Subjective Shoulder Value (SSV), Constant Score (CS), Rowe Score (RS), Walch Duplay Score (WD), Western Ontario Shoulder Instability Index (WOSI)], and radiologic [X-ray (true a.p., Bernageau and axillary views) and computed tomography (CT)] outcome parameters were assessed.

RESULTS

Fourteen patients [mean age 31.1 (range 18-50) years] were available after a follow-up period of 78.7 (range 60-110) months. The SSV averaged 87 (range 65-100) %, CS 94 (range 83-100) points, RS 89 (range 30-100) points, WD 87 (range 25-100) points, and WOSI 70 (range 47-87) %. The apprehension sign was positive in two patients (14%). One patient required an arthroscopic capsular plication due to a persisting feeling of instability, while the second patient experienced recurrent dislocations after a trauma, but refused revision surgery. CT imaging showed a significant increase of the glenoid index from preoperative 0.8 ± 0.04 (range 0.7-0.8) to 1.0 ± 0.11 (range 0.8-1.2) at the final follow-up (p < 0.01).

CONCLUSION

Arthroscopic reconstruction of anteroinferior glenoid defects using an autologous iliac crest bone-grafting technique yields satisfying clinical and radiologic results after a mid- to long-term follow-up period. Postoperative re-dislocation was experienced in one (7.1%) of the patients due to a trauma and an anatomic reconstruction of the pear-shaped glenoid configuration was observed.

LEVEL OF EVIDENCE

IV.

Improving the detection of subscapularis tears using a specific transverse CT arthrography image

BACKGROUND

The prevalence of subscapularis (SSC) tendon tears is often underestimated. This negatively impacts the shoulder function because the SSC muscle is a powerful internal rotator. The primary aim of this study was to compare a blended clinical and radiological preoperative index of suspicion for SSC tears to the arthroscopic findings. The secondary aim was to compare the surgeon's and radiologist's index of suspicion to determine which is more accurate.

HYPOTHESIS

Analyzing a transverse image passing under the tip of the coracoid process, in combination with clinical examination, will be the standard for detecting SSC tears.

METHODS

This prospective study enrolled 50 consecutive patients who underwent shoulder arthroscopy. Preoperatively, four clinical tests were doneto detect SSC tears: lift-off, internal rotation lag sign, bear-hug, belly-press. A CT arthrography slice passing under the coracoid process tip was analyzed by the surgeon. The surgeon deduced a radiological index of suspicion for SSC tears then a blended clinical and radiological index of suspicion based on the clinical examination. Lastly, the surgeon looked at the radiologist's findings and index of suspicion for a lesion. The three indexes of suspicion were compared with the actual arthroscopy findings.

RESULTS

The surgeon's blended clinical and radiological index of suspicion was similar to his radiological index. Both of the surgeon's indexes of suspicion were higher than the radiologist's. The prevalence of SSC tears was 58 %.

DISCUSSION

We recommend doing multiple clinical tests as they complement each other in detecting SSC tears, since each one activates a different portion of the muscle. We advise surgeons to supplement their clinical examination by analyzing a specific image of the tendon below the coracoid, as the reference view for the starting point of SSC tears.

LEVEL OF EVIDENCE

IV, prospective diagnostic study on consecutive patients.

Massive graft resorption after iliac crest allograft reconstruction for glenoid bone loss in recurrent anterior shoulder instability

INTRODUCTION

Donor site morbidity constitutes the most prevalent source of complications during anatomic glenoid reconstruction. Therefore, the aim of this study was to evaluate the clinical and radiologic results of arthroscopic anatomic glenoid reconstruction using an allogenic, tricortical iliac crest bone graft for glenoid bone loss in recurrent anterior shoulder instability.

MATERIALS AND METHODS

Ten patients [one female/nine male, mean age 31.9 years (range, 26-40)] underwent allogenic iliac crest bone grafting and were evaluated clinically [range of motion, subscapularis tests, apprehension sign, Constant score (CS), Rowe score (RS), Walch-Duplay score (WD), Western Ontario Shoulder Instability Index (WOSI), Subjective Shoulder Value (SSV)] and radiographically [3-dimensional computed tomography (CT) scans].

RESULTS

After 23.2 months, the CS averaged 90 points (range, 84-98), RS 83 points (range, 50-100), WD 81 points (range, 50-100), WOSI 72% (range, 41-86) and the SSV 83% (range, 70-95). All patients showed a free range of motion and intact subscapularis muscle function. The apprehension sign was positive in three patients (30%) with a recurrent subluxation in one patient (10%). The glenoid surface area increased significantly from 84.4% (range, 73.5-92.1) preoperatively to 118.4% (range, 105.6-131.2) after surgery, while the glenoid defect was significantly reduced from 16.2% (range, 9.2-26.5) to 0.6% (range, 0-1.6). One year postoperative, total resorption of the allografts was observed with a glenoid surface area of 86.6% (range, 76.4-98.0) and corresponding increase of the glenoid defect to 14.0% (range, 2.9-23.6).

CONCLUSION

Arthroscopic glenoid reconstruction using an iliac crest bone allograft achieves satisfactory clinical results and glenohumeral stability during a short-term follow-up. However, this procedure was not observed to accomplish an anatomic reconstruction of the glenoid concavity due to excessive graft resorption.

LEVEL OF EVIDENCE

Level IV, case series, therapeutic study.

Comprehensive review of the physical exam for glenohumeral instability

Glenohumeral instability is a common pathology of the shoulder joint, especially among young athletes. Despite advancements in technology and the widespread use of diagnostic imaging, a careful history and physical examination still remain the cornerstone of diagnosing patients with shoulder instability. Due to the involvement of many static and dynamic stabilizers, proficient physical examination can be challenging. With a systematic approach to clinical evaluation, the clinician can recognize characteristic patterns of relevant signs and symptoms and make an accurate diagnosis.

A Comprehensive Review of Physical Examination Tests of the Cervical Spine, Scapula, and Rotator Cuff

A thorough physical examination of the shoulder and cervical spine is critical in establishing a focused differential diagnosis of the pathology in and around the shoulder joint. Numerous tests have been described in the literature to help improve the diagnostic accuracy of specific shoulder or cervical spine pathology. A comprehensive approach for the physical examination of the cervical spine, scapula, and rotator cuff is presented and descriptions on how the tests are performed and the evidence behind why specific tests are used in enabling improved diagnosis of shoulder pathology are discussed.

Subscapularis Insufficiency: What’s All the Fuss About?

There has been increase attention to the surgical treatment of the subscapularis (SSC) tendon with risk of postoperative dysfunction and early failures following shoulder arthroplasty. Studies investigating the clinical results after shoulder arthroplasty indicate that SSC tendon detachment or incision techniques and rehabilitation concepts may impair SSC recovery and consequently the postoperative function. In response to these results, technical modifications have been proposed and evaluated anatomically, biomechanically, and clinically. The aim of this article is to give an overview of current SSC take-down approaches, subsequent repair techniques, and postoperative rehabilitation protocols as well as to present the diagnostic algorithm and clinical impacts of the increasingly acknowledged condition of SSC insufficiency following shoulder arthroplasty procedures.

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.

Latissimus dorsi transfer for irreparable subscapularis tendon tears

BACKGROUND

There are several tendon transfers for reconstruction of irreparable subscapularis tears. The latissimus dorsi (LD) could be used because its direction and function are similar to those of the subscapularis. We performed LD transfers for irreparable subscapularis tears and evaluated clinical outcomes.

METHODS

The study enrolled 24 consecutive patients who underwent LD transfers. Clinical and functional outcomes were evaluated using the Constant score, American Shoulder and Elbow Surgeons score, pain visual analog scale, and range of shoulder motion preoperatively and at last follow-up. The lift-off and belly-press tests were performed to assess subscapularis integrity and function. Magnetic resonance imaging was performed preoperatively and 1 year postoperatively to evaluate tendon integrity.

RESULTS

Mean Constant, American Shoulder and Elbow Surgeons, and pain scores improved from 46 ± 6 to 69 ± 5 (P < .001), from 40 ± 3 to 70 ± 5 (P < .001), and from 6 ± 1 to 2 ± 1 (P = .006), respectively. The mean range of motion for forward elevation and internal rotation increased from 135° ± 17° to 166° ± 15° (P = .016) and from L5 to L1 (P = .010), respectively. Improvement in the range of motion for external rotation was not significant (51° ± 7° to 68° ± 7°; P = .062). At final follow-up, the belly-press test results were negative for 18 of 24 patients, and the lift-off test results were negative for 16 of 20 patients. No complications related to tendon transfer, including axillary and radial nerve injuries, were found. No retearing of the transferred LD was observed.

CONCLUSIONS

LD transfer resulted in pain relief and restoration of shoulder range of motion and function. LD transfer could be considered an effective and safe salvage treatment for irreparable subscapularis tears.

Factors Predictive of Healing in Large Rotator Cuff Tears: Is It Possible to Predict Retear Preoperatively?

BACKGROUND

Many studies have identified risk factors that cause retear after rotator cuff repair. However, it is still questionable whether retears can be predicted preoperatively.

PURPOSE

To determine the risk factors related to retear after arthroscopic rotator cuff repair and to evaluate whether it is possible to predict the occurrence of retear preoperatively.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

This study enrolled 112 patients who underwent arthroscopic rotator cuff repair with single-row technique for a large-sized tear, defined as a tear with a mediolateral length of 3 to 5 cm. All patients underwent routine magnetic resonance imaging (MRI) at 9 months postoperatively to assess tendon integrity. The sample included 61 patients (54.5%) in the healed group and 51 (45.5%) in the retear group.

RESULTS

In multivariate analysis, the independent predictors of retears were supraspinatus muscle atrophy ( P < .001) and fatty infiltration of the infraspinatus ( P = .027), which could be preoperatively measured by MRI. A significant difference was found between the two groups in sex, the acromiohumeral interval, tendon tension, and preoperative or intraoperative mediolateral tear length and musculotendinous junction position in univariate analysis. However, these variables were not independent predictors in multivariate analysis. The cutoff values of occupation ratio of supraspinatus and fatty infiltration of the infraspinatus were 43% and grade 2, respectively. The occupation ratio of supraspinatus <43% and grade ≥2 fatty infiltration of the infraspinatus were the strongest predictors of retear, with an area under the curve of 0.908, sensitivity of 98.0%, and specificity of 83.6% (accuracy = 90.2%).

CONCLUSION

In patients with large rotator cuff tears, it was possible to predict the retear before rotator cuff repair regardless of intraoperative factors. The retear could be predicted most effectively when the occupation ratio of supraspinatus was <43% or the fatty infiltration of infraspinatus was grade ≥2. Predicting retear preoperatively may help surgeons determine proper treatment and predict the postoperative prognosis.

Diagnostic performance of clinical tests for subscapularis tendon tears

PURPOSE

Tears of the subscapularis (SSC) tendon constitute a diagnostic challenge. The purpose of the present study was to evaluate the diagnostic capabilities of five clinical SSC tests.

METHODS

Five established clinical tests were evaluated in 106 consecutive patients prior to shoulder arthroscopy. The tests included the Lift Off Test, Internal Rotation Lag Sign, Belly Press Test, Belly Off Sign, and Bear Hug Test. The integrity of the SSC tendon at surgery was used as the gold standard. Lesions to the SSC were graded according to Fox and Romeo.

RESULTS

There were 32 SSC lesions accounting for an incidence of 30.2%. The sensitivity for all tests was 0.66, while the specificity was 0.82. For all tests, positive tests results were found to be dependent on subscapularis integrity (p < 0.001, respectively). The sensitivity for any type of SSC lesion for the Lift Off Test, Internal Rotation Lag Sign, Belly Press Test, Belly Off Sign, and Bear Hug Test was 0.35, 0.41, 0.34, 0.31, and 0.52, respectively. Specificity was found to be 0.98, 0.91, 0.96, 0.97, and 0.85, respectively. If only grade 2-4 tears were analysed, sensitivity was 0.32, 0.42, 0.37, 0.37, and 0.72 and specificity 0.94, 0.86, 0.92, 0.94, and 0.84. A positive correlation was found between the number of positive tests and the severity of the SSC lesions.

CONCLUSION

In the present study, the Bear Hug Test was found to have the highest sensitivity of all tests studied, especially for tears of the upper tendon border. It appears advisable to perform more than one clinical subscapularis test to further improve sensitivity. Nevertheless, SSC tears may still escape clinical recognition. Therefore, a high index of suspicion has to be maintained in order not to miss SSC tears.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

Rehabilitation for Shoulder Instability - Current Approaches

Background:

The shoulder relies predominantly on dynamic muscular control to provide stability. Successful treatment is highly dependent upon the correct clinical diagnosis, identification of anatomical structural defects and abnormal movement patterns so that rehabilitation programs can be designed accordingly and individualised to the patient.

Method:

A systematic outline is provided to guide the clinician on how to identify muscular insufficiencies both local to the shoulder joint and global muscles that can influence shoulder instability. Management is based on expert experience and current literature.

Results:

The Stanmore classification helps to correctly diagnose the type of instability and prioritise management. Symptom modification tests can help to guide management, however assessing individual muscle groups local to glenohumeral control is also recommended.

Conclusion:

Physical and psychosocial factors can influence motor control in the presence of pain and injury. A multi-disciplinary approach is required to avoid recurrence of symptoms with rehabilitation focusing on kinetic chain, scapular and gleno-humeral control.

Diagnostic Value of the Supine Napoleon Test for Subscapularis Tendon Lesions

PURPOSE

The purpose of this study was to compare the diagnostic value of the supine Napoleon test (a variation of the belly-press test that reduces compensatory motion) with other clinical tests for subscapularis tendon (SSC) tears.

METHODS

One hundred thirty consecutive patients who were scheduled for arthroscopic rotator cuff repair were evaluated preoperatively with the lift-off test, Napoleon test, bear-hug test, and supine Napoleon test. The supine Napoleon test was performed by placing the patient's hand on their belly while they lay supine with an examiner holding their hand and shoulder to prevent compensatory motion. The patient was asked to move their elbow upward and the test was considered positive if they were unable to do so. During surgery, SSC lesions were classified with the Lafosse classification system. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios (LR+, LR-) were calculated for each test. The ability to detect partial SSC tears was compared among the clinical tests.

RESULTS

Fifty-two of 130 patients (40%) had SSC tears confirmed arthroscopically. For diagnosis of these tears, the supine Napoleon test was the most sensitive (84%), followed by the bear-hug test (74%), and the bear-hug test was the most specific (97%), followed by the supine Napoleon test (96%). The LR+ was greatest for the bear-hug test (28.4) and next greatest for the supine Napoleon test (21.9). The LR- was lowest for the supine Napoleon test (0.16) and the bear-hug test was second (0.27). The sensitivity of the supine Napoleon test (65%) was highest for detecting partial tears.

CONCLUSIONS

In comparison with other clinical tests for SSC tears, the supine Napoleon test had the greatest diagnostic value for full-thickness SSC tears and was most able to detect partial tears.

LEVEL OF EVIDENCE

Level III, diagnostic nonrandomized study.

Arthroscopic reduction and fixation of large solitary and multifragmented anterior glenoid rim fractures

BACKGROUND

The optimal treatment of large anterior glenoid rim fractures is still a matter of debate. The purpose of this study was to evaluate the clinical and radiologic results of an arthroscopic reduction and fixation of acute displaced large solitary or multifragmented anterior glenoid rim fractures using anchors or bioabsorbable compression screws.

METHODS

Twenty-three consecutive patients (7 women, 16 men; mean age, 47.9 [15-74] years) were treated. The patients were followed up clinically (range of motion, instability testing, and shoulder outcome scores) and with conventional radiographs (true anterior-posterior, axillary, and Bernageau views).

RESULTS

With a minimum follow-up of 24 months, 21 patients could be evaluated. The average Constant score was 84.5 points, the Rowe score was 90.8 points, the Melbourne Instability Shoulder Score was 96.2 points, the Western Ontario Shoulder Instability Index was 89.2%, and the subjective shoulder value averaged 92.1%. No patient had suffered recurrent instability. The radiologic evaluation revealed signs of osteoarthritis in 7 cases, which was pre-existing in 1 patient. Patients with osteoarthritis were on average 10 years older at the time of surgery compared with patients without osteoarthritis. A postoperative step-off of the glenoid was detected in 7 cases and averaged 2 (1-3) mm. We could not find a correlation between the step-off and the presence of osteoarthritis.

CONCLUSION

Arthroscopic reconstruction of acute large solitary and multifragmented fractures of the glenoid rim shows good and excellent clinical results. In the majority of cases, an anatomic reduction and healing of the glenoid fracture can be achieved. The rate of osteoarthritis needs further investigation.

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.

Long-term effects on subscapularis integrity and function following arthroscopic shoulder stabilization with a low anteroinferior (5:30 o'clock) portal

PURPOSE

The use of a low anteroinferior (5:30 o'clock) portal for arthroscopic shoulder stabilization allows an anatomical refixation of the capsulolabral complex. This anteroinferior portal, however, penetrates the inferior subscapularis (SSC), which is criticized. Therefore, the aim of the study was to evaluate the functional and structural properties of the SSC in patients with anteroinferior shoulder stabilization. The hypothesis was that it does not harm the SSC by demonstrating full muscular function and imaging-based normal structure at a long-term follow-up.

METHODS

Twenty patients were examined (14 males and six females; mean age 37.0 years) retrospectively after a mean follow-up of 9.6 years. At final follow-up, clinical examination and clinical scores (ASES, Constant-Murley, WOSI, and Rowe score) were documented. Additionally, SSC strength was evaluated with a custom-made electronic force measurement plate. All patients underwent bilateral magnetic resonance imaging to assess structural integrity and fatty infiltration (grading according to Fuchs et al.) of the SSC. Furthermore, vertical and transversal (superior and inferior) diameters of the muscle and the muscle area in a parasagittal plane were measured.

RESULTS

Clinical scores revealed good-to-excellent long-term results (ASES 92 points, Constant-Murley 82 points, WOSI 85 %, and Rowe 84 points). Force measurement in comparison with the contralateral side showed no significant (p > 0.05) differences for the 'belly-press' test (ipsilateral 102 N vs. contralateral 101 N) and the 'lift-off' test (73 vs. 69 N). There were also no significant differences between the mean diameters and the areas of the SSC muscle belly (vertical diameter ipsilateral 92 mm vs. contralateral 94 mm; superior transversal 28 vs. 29 mm; inferior transversal 34 vs. 34 mm; area 2336 vs. 2526 mm(2)).

CONCLUSION

Arthroscopic labral repair with a low anteroinferior portal demonstrates no signs of structural and functional impairment of the SSC after 9.6 year follow-up. For clinical relevance, the lower part of the SSC can be penetrated for an optimal anchor placement in shoulder instabilities or Bankart fractures without concerns of a negative long-term effect on the SSC.

LEVEL OF EVIDENCE

Case series, Level IV.

Internal rotation resistance test at abduction and external rotation: a new clinical test for diagnosing subscapularis lesions

PURPOSE

A new clinical test for evaluating subscapularis (SSC) integrity was described, and its diagnostic value was compared with the present SSC tests (the lift-off, belly-press, IRLS and bear-hug tests). The new test is called internal rotation resistance test at abduction and external rotation (IRRT). The test is performed at maximal 90° of abduction and maximal external rotation.

METHODS

Two hundred and thirty-five consecutive patients suffering from rotator cuff injury were evaluated preoperatively. Six tests were performed to assess the function of the SSC: the lift-off, belly-press, IRLS, the bear-hug, IRRT at 0° abduction and 0° external rotation (IRRT0°) and IRRT at maximal 90° abduction and maximal external rotation (IRRTM). Arthroscopic findings were the reference for diagnosing of SSC lesions.

RESULTS

The IRRTM test showed the greatest sensitivity (76.5 %), and IRLS (31.6 %) test had the lowest sensitivity. The IRRTM had the highest accuracy (79.0 %), and lift-off had the lowest accuracy (65.3 %). Positive IRRTM, bear-hug, belly-press, IRRT0° tests indicate that about one-third of the SSC is torn, and a positive lift-off and IRLS tests predict a severe tear at least two-thirds of the SSC.

CONCLUSIONS

The IRRTM represents a sensitive diagnostic test for SSC lesions and improves the chance of finding the upper part of the SSC tears. When the IRRTM is positive, the surgeon should pay particular attention to detecting the SSC tendon during arthroscopy.

LEVEL OF EVIDENCE

Diagnostic study, Level I.

Accuracy of long head of the biceps subluxation as a predictor for subscapularis tears

PURPOSE

The aim of this study is to understand the relation between long head of the biceps tendon (LHBT) subluxation and full-thickness tears of the subscapularis.

METHODS

Magnetic resonance imaging (MRI) scans of 94 patients undergoing shoulder arthroscopy were evaluated preoperatively for the presence or absence of LHBT subluxation. Intraoperative pathology of the biceps and subscapularis tendons was recorded. The diagnostic accuracy of LHBT subluxation on preoperative MRI in determining full-thickness subscapularis tendon tears was calculated.

RESULTS

Of the 94 patients in this study, 26 were diagnosed with LHBT subluxation preoperatively. Of these 26 patients, 9 were confirmed to have full-thickness tears of the subscapularis tendon (Lafosse grade 2 or higher). Of the remaining 68 patients who did not appear to have LHBT subluxation preoperatively, 2 were confirmed to have full-thickness tears of the subscapularis tendon. Thus LHBT subluxation on MRI as a predictor for full-thickness subscapularis tears had a sensitivity of 82%, specificity of 80%, positive predictive value of 35%, and negative predictive value of 97%. LHBT subluxation was directly correlated with the severity of the subscapularis tendon tear (P < .001).

CONCLUSIONS

The diagnostic value of subluxation of the LHBT, as seen on an axial MRI scan, lies primarily in its negative predictive value. If the LHBT is not subluxated, it is unlikely that a full-thickness tear of the subscapularis tendon is present. Surgeons should be cautious about relying on biceps subluxation as a primary diagnostic tool in predicting subscapularis tears.

LEVEL OF EVIDENCE

Level IV, study of diagnostic test.

Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

BACKGROUND

Irreparable posterosuperior rotator cuff tears are treated in several ways. Transfer of the latissimus dorsi is an alternative with acceptable mid-term results, but long-term results have rarely been published.

METHODS

The cases of 108 consecutive patients with 115 shoulders treated with latissimus dorsi transfer between 2000 and 2005 were reviewed clinically and radiographically. Ninety-three shoulders in eighty-six patients were included in the follow-up analysis. The mean duration of follow-up was 9.3 years (range, 6.6 to 11.7 years), and the mean age at the operation was fifty-six years (range, forty to seventy-two years). Outcome measures included the Constant-Murley score (Constant score), American Shoulder and Elbow Surgeons (ASES) index, and visual analog scale (VAS) for pain. The progress of cuff tear arthropathy was determined with radiographic evaluation according to the system described by Hamada et al.

RESULTS

The mean relative Constant score improved from 44% preoperatively to 71% at the time of follow-up (p < 0.0001, effect size = 0.6), excluding the clinical failures. Similarly, the mean ASES index improved from 30 to 70 (p < 0.0001, effect size = 0.7), and the mean VAS score decreased from 7.8 to 2.4 (p < 0.0001, effect size = 0.8). A pain-free outcome was reported in only eighteen shoulders (19%). Active shoulder movement improved significantly (p < 0.05). The mean Hamada radiographic grade of cuff tear arthropathy increased from 1.7 (range, 0 to 2) preoperatively to 2.2 (range, 1 to 5) (p < 0.0001, effect size = 0.2). The rate of clinical failure of latissimus dorsi transfer was 10%, and the rate of shoulder prosthetic replacement after latissimus dorsi transfer was 4%.

CONCLUSIONS

Pain relief and improvement of shoulder function were maintained a mean of 9.3 years after latissimus dorsi transfer for irreparable posterosuperior cuff defects. The younger the patient, the better the outcome.

Isolated subscapularis repair for massive rotator cuff tear

The best surgical treatment for an irreparable rotator cuff tear is controversial. In such cases, partial rotator cuff repair, primarily involving the posterior cuff in most reports, has been shown to be beneficial. The authors retrospectively investigated 41 patients who underwent arthroscopic subscapularis-only repair and greater tuberoplasty between April 2003 and August 2009 for massive 3-tendon cuff tears with irreparable supraspinatus and infraspinatus tendons after 3 months of conservative management was unsuccessful. Twenty-five patients (61%) underwent biceps tenotomy, and the remaining 39% had preexisting biceps tenotomy or rupture. The patients were assessed with American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Of the 41 patients, 34 (83%) were available for a follow-up telephone questionnaire after a minimum of 12 months (mean, 35 months; range, 12-84 months). Mean ASES and SANE scores were 76% and 63%, respectively. Mean postoperative passive range of motion was 156° of forward flexion and 39° of external rotation. Of the patients queried, 74% (25 of 34) were able to actively raise their arms above shoulder level. For those with a positive belly-press test result preoperatively, 22 of 27 patients had a negative test result postoperatively. A total of 3 complications (7.3%) occurred. Workers' compensation claim was a strong predictor of lower shoulder scores. Arthroscopic subscapularis-only repair and greater tuberoplasty may offer a promising and safe method for treating massive rotator cuff tears when the supra-spinatus and infraspinatus tendons are irreparable. Workers' compensation claim may predict lower outcome scores.

Clinical Assessment of Physical Examination Maneuvers for Rotator Cuff Lesions

BACKGROUND

Shoulder pain and disability pose a diagnostic challenge for clinicians owing to the numerous causes that exist. Unfortunately, the evidence in support of most clinical tests is weak or absent.

PURPOSE

To determine the diagnostic validity of physical examination maneuvers for rotator cuff lesions.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

Consecutive shoulder patients recruited for this study were referred to 2 tertiary orthopaedic clinics. A surgeon took a thorough history and indicated his or her certainty about each possible diagnosis. A clinician performed the physical examination for diagnoses where uncertainty remained. Arthroscopy was considered the reference standard for patients who underwent surgery, and MRI with arthrogram was considered the reference for patients who did not. The sensitivity, specificity, and likelihood ratios were calculated to investigate whether combinations of the top tests provided stronger predictions of the presence or absence of disease.

RESULTS

There were 139 participants. None of the tests were highly sensitive for diagnosing rotator cuff tears or tendinosis. Tests for subscapularis tears were all highly specific. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears. Closer analysis revealed the internal rotation and lateral rotation lag sign did not improve the ability to diagnose subscapularis or supraspinatus tears, respectively, although the lateral rotation lag sign demonstrated a discriminatory ability for tear size.

CONCLUSION

No test in isolation is sufficient to diagnose a patient with rotator cuff damage. A combination of tests improves the ability to diagnose damage to the rotator cuff. It is recommended that the internal rotation and lateral rotation lag signs be removed from the gamut of physical examination tests for supraspinatus and subscapularis tears.

Evaluation and management of adult shoulder pain: a focus on rotator cuff disorders, acromioclavicular joint arthritis, and glenohumeral arthritis

Shoulder pain is a common reason for a patient to see their primary care physician. This article focuses on the evaluation and management of 3 common shoulder disorders; rotator cuff disorders, acromioclavicular joint arthritis, and glenohumeral joint arthritis. The typical history and physical examination findings for each of these entities are highlighted, in addition to treatment options.

Rotator cuff crepitus: could Codman really feel a cuff tear?

BACKGROUND

The objective of this study was to assess the accuracy of palpating crepitus to diagnose rotator cuff tears.

METHODS

Seventy consecutive consenting patients who presented with shoulder pain and no previous imaging or surgery on the affected shoulder were prospectively enrolled during a 10-month period. A standardized patient history and examination, including the crepitus test, were recorded in addition to obtaining standard radiographs. Additional imaging after initial evaluation was performed with magnetic resonance imaging and interpreted by a musculoskeletal radiologist blinded to the examination findings. Statistical analysis was used to determine sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the crepitus test in the clinical diagnosis of a rotator cuff tear.

RESULTS

Sixty-three patients had histories, examinations, and imaging studies available for analysis. The crepitus test had a sensitivity of 67%, specificity of 80%, PPV of 91%, and NPV of 43% for all types of rotator cuff tears. The sensitivity and specificity for full-thickness or high-grade partial tears was 82% and 73%, respectively; the PPV and NPV were 77% and 79%. Increasing age improved accuracy as the presence of crepitus in patients older than 55 years had a sensitivity of 76%, specificity of 100%, PPV of 100%, and NPV of 38%.

CONCLUSION

The crepitus test has a favorable sensitivity, specificity, PPV, and NPV to assess the integrity of the rotator cuff and may be a useful examination in the clinical diagnosis of a rotator cuff tear.

[Clinical evaluation of the shoulder]

A systematic clinical examination of the shoulder joint, including a structured medical history, is essential for the diagnosis of shoulder pathologies. Complex clinical situations that are accompanied by pain, restriction of movement, loss of strength, or instability have to be considered in accordance with the functional interaction between the cervical spine, the shoulder girdle, and the glenohumeral joint. Only accurate diagnosis allows us to apply successful therapeutic interventions. In order to achieve this, the physician needs to use standardized clinical tests and signs combined with a profound knowledge of the anatomy and the possible underlying pathologies. To ensure a structured approach as well as a complete documentation of results, a shoulder assessment form should be used. The information obtained from the history, examination, and collected data form the basis for further diagnostic imaging.

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.

Sensitivity of physical examination versus arthroscopy in diagnosing subscapularis tendon injury

The purpose of this study was to examine the accuracy of physical examination in the detection of subscapularis tendon tears and compare it with the gold standard of arthroscopy to determine whether clinical examination can reliably predict the presence of subscapularis tendon tears. This was a retrospective analysis of 52 patients (52 shoulders) who underwent arthroscopic subscapularis tendon repairs between September 2008 and April 2012. Positive findings on any combination of the belly press, lift-off, and bear hug tests constituted a positive physical examination result. There was a positive finding on physical examination in 42 of 52 patients. The sensitivity of the physical examination as a whole was 81%. The literature has shown that the belly press, bear hug, and lift-off tests are specific to the subscapularis tendon. To the authors’ knowledge, this is the first study to evaluate the sensitivity of these 3 separate clinical tests as a composite. Knowledge regarding the sensitivity of the subscapularis-specific physical examination as a composite can lead practitioners to implement all 3 components, even when 1 test has a negative finding, thus promoting a more thorough physical examination. Because unrepaired subscapularis tendon tears can result in poor outcomes in the repair of other rotator cuff tendons, a complete physical examination would be beneficial to patients with shoulder pathology. The authors conclude that physical examination, when performed consistently by an experienced practitioner, can reliably predict the presence of subscapularis tendon tears.

Diagnostic value of four clinical tests for the evaluation of subscapularis integrity

HYPOTHESIS

The lift-off, internal rotation lag sign, belly-press, and bear-hug tests are widely used to evaluate the integrity of the subscapularis. We hypothesized that these tests might reflect different types of subscapularis tears and sought to ascertain whether these tests accurately determine the severity of the internal rotation strength deficit and fatty degeneration.

METHODS

Isokinetic testing and the 4 clinical tests were used preoperatively to evaluate 312 patients who had undergone arthroscopic rotator cuff surgery. Of these, 37 patients had a full-thickness subscapularis tear, 96 had a partial-thickness tear, and 179 had no tear.

RESULTS

For differentiating any tears from an intact subscapularis, the most sensitive test was the belly-press test (27.8%), and the most specific test was the lift-off test (100%). For differentiating a full-thickness tear from a partial tear, the most sensitive test was the belly-press test (56.8%), and the most specific was the lift-off test (96.9%). A positive lift-off test also most reflected loss of internal rotation strength (mean, 72.2%; 95% confidence interval, 61.9-82.5), followed by the internal rotation lag sign (55.1%; 44.2-66.1) and the belly-press test (45.9%; 36.4-54.4).

CONCLUSIONS

A positive lift-off test was highly specific for the detection of a full-thickness subscapularis tear and to reflect severe fatty degeneration. The lift-off, internal rotation lag sign, belly-press, and bear-hug tests sequentially predict internal rotation strength deficit and provide discrimination of internal rotation strength impairment.

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.

Diagnosis of subscapularis tendon tears: are available diagnostic tests pertinent for a positive diagnosis?

HYPOTHESIS

Clinically, subscapularis tendon tears are suggested by the presence of increased passive external rotation compared to the opposite side, resisted internal rotation manoeuvres (Lift-Off test [LOT], Belly-Press test [BPT], Napoleon test and Bear-Hug test [BHT] and positive Internal Rotation Lag Sign and/or Belly-Off Signs). Associated bicipital involvement is frequent with subscapularis tendon tears, because it participates in the formation of the biceps pulley. The Palm-Up test (PUT) is used for the biceps, and the Jobe test for the supraspinatus.

MATERIAL AND METHODS

In this multicenter study, we evaluated the positive diagnostic value of the clinical tests, LOT, BPT, BHT, PUT, and the Jobe test for subscapularis tears as well as their anatomical value. The relationships of the different parameters studied were compared statistically by analysis of variance (ANOVA). This prospective multicenter study was performed from January 2009 to February 2010 and included 208 cases of subscapularis tendon tears, isolated or associated with partial (Ellman 1, 2 or 3) or full thickness (SFA stage 1) supraspinatus tears.

RESULTS

The severity of the subscapularis tear was quantified according to the SFA classification into four stages and according to the level of injury (the lower 1/3 and upper 2/3). The three tests LOT, BPT and BHT were correlated to the severity of observed tears (P<0.05). The more deficient the test results were, the more severe the anatomical damage. The LOT is the test that cannot be performed most often (18%) but when it is positive, it is predictive of very severe tears. The BHT is the most sensitive of all tests (82%). The frequency of biceps involvement was correlated to the severity of subscapularis damage. There was no significant correlation between biceps involvement and subscapularis tests, or between supraspinatus involvement and subscapularis tests. There was no correlation between the Palm-Up test and subscapularis tears with associated supraspinatus involvement however, it was significantly correlated to biceps involvement (P<0.05). The Jobe test was disappointing because it was often positive even for isolated subscapularis tears.

CONCLUSION

Even though all three tests were performed (LOT, BPT, BHT), 24% of the subscapularis tears were only diagnosed during surgery. The role of the Internal Rotation Lag Sign and Belly-Off Sign in improving the diagnosis of tears was not studied in this work.

Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis

OBJECTIVE

To examine the accuracy of clinical tests for diagnosing subacromial impingement syndrome (SIS).

DATA SOURCES

A systematic literature search was conducted in January 2011 to identify all studies that examined the diagnostic accuracy of clinical tests for SIS. The following search engines were used: Cochrane Library, EMBASE, Science Direct, and PubMed.

STUDY SELECTION

Two reviewers screened all articles. We included prospective or retrospective cohort studies that examined individuals with a painful shoulder, reported any clinical test for SIS, and used arthroscopy or open surgery as the reference standard. The search strategy yielded 1338 articles of which 1307 publications were excluded based on title/abstract. Sixteen of the remaining 31 articles were included. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed to conduct this review.

DATA EXTRACTION

The number of true positives, false positives, true negatives, and false negatives for each clinical test were extracted from relevant studies, and a 2×2 table was constructed. Studies were combined using a bivariate random-effects model. Heterogeneity was assessed using the variance of logit-transformed sensitivity and specificity.

DATA SYNTHESIS

Ten studies with 1684 patients are included in the meta-analysis. The Hawkins-Kennedy test, Neer's sign, and empty can test are shown to be more useful for ruling out rather than ruling in SIS, with greater pooled sensitivity estimates (range, .69-.78) than specificity (range, .57-.62). A negative Neer's sign reduces the probability of SIS from 45% to 14%. The drop arm test and lift-off test have higher pooled specificities (range, .92-.97) than sensitivities (range, .21-.42), indicating that they are more useful for ruling in SIS if the test is positive.

CONCLUSIONS

This systematic review quantifies the diagnostic accuracy of 5 clinical tests for SIS, in particular the lift-off test. Accurate diagnosis of SIS in clinical practice may serve to improve appropriate treatment and management of individuals with shoulder complaints.

Calcific tendonitis of the rotator cuff: an unusual case

Few case reports have described the surgical treatment of calcifying tendonitis of the subscapularis tendon. We present a case of symptomatic diffuse calcifying tendonitis involving the subscapularis and infraspinatus insertions that was difficult to detect arthroscopically. The patient was treated with arthroscopic incision of the tendinous insertions thorough removal of the calcific deposits and subsequent repair using a suture-anchor technique. Two years after the surgical procedure, the patient was completely pain-free and attained full range of motion. Radiographic evaluation performed 2 years after the procedure revealed no calcific deposits. We conclude that the combination of incision of the subscapularis and infraspinatus insertions, complete removal of the calcific deposits, and subsequent suture-anchor repair in an all-arthroscopic manner can lead to an excellent clinical outcome without compromising the functional integrity of the rotator cuff tendons.

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.

The influence of arm and shoulder position on the bear-hug, belly-press, and lift-off tests: an electromyographic study

BACKGROUND

Clinical testing for the integrity of the subscapularis muscle includes the belly-press, lift-off, and bear-hug examinations. While these tests have been widely applied in clinical practice, there is considerable variation in arm positioning within each clinical examination.

HYPOTHESIS

To determine the ideal arm and shoulder positions for isolating the subscapularis muscle while performing the bear-hug, belly-press, and lift-off tests.

STUDY DESIGN

Controlled laboratory study.

METHODS

The activity of 7 muscles was monitored in 20 healthy participants: upper and lower divisions of the subscapularis, supraspinatus, infraspinatus, latissimus dorsi, teres major, triceps, pectoralis major. Electromyogram data were collected and compared across each clinical test at varying arm positions: bear-hug (ideal position, 10° superior, 10° inferior to the shoulder line), belly-press (ideal position, maximum shoulder external rotation, and maximal shoulder internal rotation), and lift-off (ideal position, hand position 5 in. [12.7 cm] superior and 5 in. [12.7 cm] inferior to the midlumbar spine).

RESULTS

Regardless of arm and shoulder position, the upper and lower subscapularis muscle activities were significantly greater than all other muscles while performing each test. No significant differences were observed between the upper and lower subscapularis divisions at any position within and across the 3 tests. There were no significant differences in subscapularis electromyogram activities across the 3 tests.

CONCLUSION

The level of subscapularis muscle activation was similar among the bear-hug, belly-press, and lift-off tests. The 3 tests activated the subscapularis significantly more than all other muscles tested but were not different from one another when compared across tests and positions. Although the bear-hug and lift-off tests have been described to activate differential portions of the subscapularis, the findings of this study do not support the preferential testing of a specific subscapular division across the 3 tests. As such, all 3 tests are effective in testing the integrity of the entire subscapularis muscle, although there does not appear to be an ideal position for selectively testing its divisions.

CLINICAL RELEVANCE

Clinicians may feel comfortable in using any of the 3 tests, depending on the patient, to isolate the function of the subscapularis as a single muscle. Furthermore, clinicians should not solely focus on a patient's arm position when administering an examination but also compare the affected arm to the contralateral shoulder when appropriate.

Subscapularis tendon integrity: an examination of shoulder index tests

CLINICAL QUESTION

The systematic review focused on various index tests for the shoulder. We concentrated on the subscapularis tendon results to determine the accuracy of reported index tests for clinically diagnosing subscapularis integrity.

DATA SOURCES

Studies were identified by an OVID search using MEDLINE, SPORTDiscus, and CINHAL databases (1966-2006) and a hand search by 2 authors (E.J.H. and S.C.). Primary search terms were shoulder, examination, and diagnosis. In addition to the database searches, personal files were hand searched by one of the authors (E.J.H.) for publications, posters, and abstracts. The reference lists in review articles were cross-checked, and all individual names of each special test were queried using MEDLINE and PubMed.

STUDY SELECTION

The search was limited to English-language journals. Studies were eligible for inclusion if the criterion standard was surgery, magnetic resonance imaging, or injection (subacromial or acromioclavicular joint); at least 1 physical examination test or special test was studied; and one of the paired statistics of sensitivity and specificity was reported or could be determined. Excluded were studies in which the index test was performed under anesthesia or in cadavers, studies in which the index test was assigned the status of composite physical examination, and review articles. Studies were grouped according to the subscapularis index test assessed: lift off, internal-rotation lag sign, Napoleon sign, bear hug, belly off, and belly press.

DATA EXTRACTION

Studies were selected in a 2-stage process. First, all abstracts and articles found through the search process were independently reviewed by 2 authors (E.J.H. and S.C.). Disagreement on inclusion of an article was resolved by consensus. Second, each selected study was assessed by each reviewer independently. A third reviewer made the final decision on any disagreements for the selected studies. The primary outcome measures were sensitivity and specificity and positive and negative likelihood ratios. The quality of a study was determined by assessing its internal and external validity. Validity was determined by the primary author (E.J.H.) using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) statement. Our work required data extraction from the original articles, which we used to generate 2 x 2 contingency tables for each index test. Pooled indices of clinical usefulness were then determined for each index test.

MAIN RESULTS

The specific search criteria identified 922 articles for review. Of these, 4 met the inclusion and exclusion criteria for subscapularis tendon tears, resulting in the number of studies assessing each index test as follows: 4 for lift off, 2 for internal-rotation lag sign, 2 for Napoleon sign, 1 for bear hug, 1 for belly off, and 1 for belly press. Subscapularis tears were identified by the criterion standard of surgery to visually assess the torn fibers. Across all 4 studies, a total of 304 shoulders were examined, 95 of which had a subscapularis tear (45 full thickness, 50 partial thickness), and 106 were injury free. Indices of clinical usefulness for full-thickness and partial-thickness subscapularis tears are reported in Tables 1 and 2 , respectively.

Diagnostic values of clinical tests for subscapularis lesions

Subscapularis (SSC) lesions are often underdiagnosed in the clinical routine. This study establishes and compares the diagnostic values of various clinical signs and diagnostic tests for lesions of the SSC tendon. Fifty consecutive patients who were scheduled for an arthroscopic subacromial or rotator cuff procedure were clinically evaluated using the lift-off test (LOT), the internal rotation lag sign (IRLS), the modified belly-press test (BPT) and the belly-off sign (BOS) preoperatively. A modified classification system according to Fox et al. (Type I-IV) was used to classify the SSC lesion during diagnostic arthroscopy. SSC tendon tears occurred with a prevalence of 30% (15 of 50). Five type I, six type II, three type IIIa and one type IIIb tears according to the modified classification system were found. Fifteen percent of the SSC tears were not predicted preoperatively by using all of the tests. In six cases (12%), the LOT and the IRLS could not be performed due to a painful restricted range of motion. The modified BPT and the BOS showed the greatest sensitivity (88 and 87%) followed by the IRLS (71%) and the LOT (40%). The BOS had the greatest specificity (91%) followed by the LOT (79%), mod. BPT (68%) and IRLS (45%). The BOS had the highest overall accuracy (90%). With the BOS and the modified BPT in particular, upper SSC lesions (type I and II) could be diagnosed preoperatively. A detailed physical exam using the currently available SSC tests allows diagnosing SSC lesions in the majority of cases preoperatively. However, some tears could not be predicted by preoperative assessment using all the tests.

Magnetic resonance imaging analysis of the subscapularis muscle after arthroscopic and open shoulder stabilization

To evaluate the subscapularis muscle (SSC) after arthroscopic and open shoulder stabilization, three groups [after arthroscopic (A), after open shoulder stabilization (B), healthy volunteers (0)] underwent magnetic resonance imaging. Magnetic resonance parameters were compared with clinical SSC tests and shoulder scores. From Group 0 to B, the diameters of the SSC decreased, and the fatty degeneration of the upper SSC increased (P<.05) from Group 0 and A to B according to clinical findings. The functional shoulder scores did not differ (P>.05). Magnetic resonance analysis provides reasons of postoperative SSC dysfunction.

Modified L'Episcopo tendon transfers for irreparable rotator cuff tears: 5-year follow-up

Patients with posterosuperior cuff tears lose functional external rotation of the shoulder. Latissimus dorsi and teres major transfer is performed to restore external rotation. Twenty patients with a mean age was 55.8 +/- 6 years underwent this procedure and were examined at averages of 24.7 (n = 17) and 70.6 (n = 13) months. Two patients did not improve presumably because of failure of the transfer. The Constant and Murley score increased from 55.6 to 90.4 after 2 years and to 87.9 after 5 years. The mean active flexion increased from 119.4 degrees to 169.3 degrees and reached 170 degrees after 5 years, and mean external rotation increased from 12 degrees to 35 degrees , finally reaching 23 degrees . The grade of cuff arthritis progressed from initially Grade 1 in 17% and Grade 2 in 28% to Grade 2 in 8%, Grade 3 in 69%, and Grade 4 in 15% at final followup. The acromiohumeral distance increased from 4.5 mm to 6 mm and decreased to 3.8 mm after 5 years. Electromyographic analysis showed activity during isometric internal and external rotation in the transferred muscle in all patients. The L'Episcopo procedure can restore shoulder function, but cuff arthropathy may progress.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.