Accuracy of physical examination in subacromial impingement syndrome

Physical examination tests in the acute phase of shoulder injuries with negative radiographs: a diagnostic accuracy study

BACKGROUND

Rotator cuff tears may easily be missed in patients with acute shoulder trauma. The evidence in support of shoulder physical examination tests has been considered insufficient in reviews and meta-analyses. The purpose of this study was to explore whether physical examination tests can effectively predict or rule out acute full-thickness rotator cuff tears in soft tissue shoulder injuries in emergency departments and primary health care.

METHODS

In a combined primary care walk-in clinic and secondary care orthopaedic emergency department, 120 consecutive patients aged ≥ 40 years with acute shoulder injury without fracture on plain x-rays were enrolled prospectively at the first follow-up within three weeks of the injury. Thirteen physical examination tests and ultrasound screening as reference standard, were performed blinded to each other.

RESULTS

The median age was 55 years, 51% were female. The prevalence of the target condition rotator cuff full-thickness tear and/or occult fracture of the insertion was 38% (n = 46; 38 tears and 8 occult avulsion fractures). Almost all tears involved the supraspinatus tendon (n = 36). The highest test accuracy was observed for the inability to abduct above 90°, resisted abduction pain and external rotation strength. The sensitivity, specificity and diagnostic odds ratio of the inability to abduct the arm above 90 ° was 84% (95% CI 69-93), 71% (95% CI 59-82) and 12.9 (95% CI 4.8-34.2), respectively, and 66% (51-80), 86% (77-93) and 12.4 (5.0-30.8) for external rotation strength assessed by the small finger test. Combining the inability to abduct above 90° and weakness in external rotation improved the sensitivity to above 90% and the diagnostic odds ratio to above 22, but specificity decreased.

CONCLUSIONS

The present study suggests that two simple tests, the inability to abduct above 90° and weakness in external rotation may effectively predict full-thickness tears of the supra- and infraspinatus and/or occult fracture at their insertion in the acute phase of soft tissue shoulder injuries. The test combination may be useful for selecting patients for advanced imaging and for diagnostic purposes when such imaging is not available.

TRIAL REGISTRATION

The Norwegian Regional Ethics Committee South East (2015/195) on 24th March 2015, and retrospectively registered on ClinicalTrials.gov (NCT02644564) on 31st December 2015.

Competitive swimming and shoulder adaptations: The role of stroke specialty in adolescent swimmers

OBJECTIVES

To examine sport-specific adaptations and the influence of stroke specialization on the shoulder complex among adolescent competitive swimmers.

DESIGN

Cross-sectional study.

SETTING

Athletic facilities.

PARTICIPANTS

76 adolescents (14.3 ± 1.3 years), including 28 non-swimmers (Control Group, CG) and 48 competitive swimmers (Swimmers Group, SWG).

MAIN OUTCOME MEASURES

Strength of glenohumeral (GH) and scapular muscles (SM), GH joint mobility (GH ROMs), proprioception, pectoralis minor length (PML), and posterior shoulder tightness (PST) were evaluated. The Kerlan-Jobe Orthopaedic Clinic (KJOC) Score was used to evaluate shoulder function in the SWG. A tested shoulder physical performance parameters were compared between the groups.

RESULTS

Comparisons showed that all GH, SM strength measures and PML were higher in the SWG (p < 0.05). GH ER/IR ratio was lower in SWG (MD = 0.8-0.11 N, p < 0.05). GH ROM comparisons revealed decreased IR and increased ER and total rotational ROM in the SWG (p < 0.05). No differences in proprioception or PST were found (p > 0.05). Additionally, no significant differences were observed when all parameters were compared among SWG subgroups based on stroke specialization (p > 0.05).

CONCLUSIONS

Adolescent competitive swimmers exhibited sport-specific, but not stroke-specific, adaptations in the shoulder complex.

Shoulder arthroscopy: comparison of preoperative and intraoperative evaluations

INTRODUCTION

Magnetic resonance imaging (MRI) is a commonly used radiological technique for diagnosing rotator cuff and shoulder pathologies. Orthopedists usually evaluate the MRI findings themselves.

Understanding Scapulohumeral Periarthritis: A Comprehensive Systematic Review

BACKGROUND

This systematic review examines the clinical presentations and prevalence of scapulohumeral periarthritis (SP) by synthesizing the relevant literature from open-access articles from international databases (Medline, Pedro, and EBSCO).

METHODS

Keywords guiding the review included 'scapulohumeral periarthritis', 'clinical forms', 'incidence', 'impingement syndrome, 'calcifying tendinitis', 'bicipital tendonitis', 'shoulder bursitis', 'adhesive capsulitis or frozen shoulder', 'rotator cuff tears', 'functional assessment', and 'clinical trials'. Eligible studies included randomized controlled trials, nonrandomized controlled trials, cross-sectional studies, and review articles published between 1972 and 2024.

RESULTS

Our screening identified 2481 initial articles, of which 621 were further reviewed for eligibility resulting in 107 articles that met the relevance criteria. The findings highlight six distinct clinical forms of SP, such as partial rotator cuff tears and calcific tendinitis, each characterized by specific pathological features and prevalence patterns. Key factors contributing to SP include injuries, scapular instability, acromion deformities, and degenerative rotator cuff changes. Functional assessments, including the Neer, Hawkins, Pain Arc, and Yocum tests, demonstrated diagnostic value in distinguishing SP from other shoulder conditions.

CONCLUSIONS

By comprehensively analyzing the clinical forms, functional assessment methods, and prevalent lesions of SP, functional testing can improve early diagnosis and guide personalized physiotherapy protocols for optimal rehabilitation in the physiotherapist's practice.

Evidence-based approach to the shoulder examination for subacromial bursitis and rotator cuff tears: a systematic review and meta-analysis

INTRODUCTION

Shoulder pain represents a common patient complaint evaluated in a primary care setting. Approximately two thirds of these patients have rotator cuff injuries, with rotator cuff tears (RCTs) and subacromial impingement syndrome (SIS) accounting for a majority of causes. An accurate and efficient diagnostic strategy focused on physical examination findings may lead to improved outcomes and less functional disability.

OBJECTIVE

To identify the most accurate physical examination tests for the diagnosis of RCT and SIS, we performed a systematic review and meta-analysis.

METHODS

The database for our systematic review was compiled by using keywords and common indexing strategies to search PubMed, Ovid MEDLINE, Embase and the Cochrane Library from January 1, 1980, to March 15, 2024. Included studies evaluated a physical examination being performed prior to a reference standard diagnostic test for either RCT or SIS. Data was extracted in dual fashion and meta-analyses were performed regarding physical examination tests identified in our included studies.

RESULTS

A total of twenty studies, which include 3,438 patients, met our inclusion criteria and had data extracted for statistical analysis. Data was adequate to perform meta-analyses on ten physical examination tests for RCT and five physical examination tests for SIS. There were six physical examination tests which had significant diagnostic odds ratios (DORs) when used in the diagnostic evaluation of suspected RCT, with the External Rotation Lag Sign at 90 Degrees having the highest magnitude of significance (DOR, 12.70; 95% CI, 3.68 - 43.86; P < .0001). Four physical examination tests had significant DORs for physical examination tests when used in the diagnostic evaluation of SIS, with the Yergason's Test having the highest magnitude of significance (DOR, 4.71; 95% CI; 2.16 - 10.32; P = .0001).

CONCLUSION

We present a large body of low-quality evidence for the diagnostic accuracies of physical examination tests for the identification of both RCT and SIS. We have identified novel data for the accuracy of the External Rotation Lag Sign at 90 Degrees and the Internal Rotation Lag Sign that have high to moderate diagnostic accuracy for ruling in tears of the rotator cuff.

Rotator cuff tears

Rotator cuff tears are the most common upper extremity condition seen by primary care and orthopaedic surgeons, with a spectrum ranging from tendinopathy to full-thickness tears with arthritic change. Some tears are traumatic, but most rotator cuff problems are degenerative. Not all tears are symptomatic and not all progress, and many patients in whom tears become more extensive do not experience symptom worsening. Hence, a standard algorithm for managing patients is challenging. The pathophysiology of rotator cuff tears is complex and encompasses an interplay between the tendon, bone and muscle. Rotator cuff tears begin as degenerative changes within the tendon, with matrix disorganization and inflammatory changes. Subsequently, tears progress to partial-thickness and then full-thickness tears. Muscle quality, as evidenced by the overall size of the muscle and intramuscular fatty infiltration, also influences symptoms, tear progression and the outcomes of surgery. Treatment depends primarily on symptoms, with non-operative management sufficient for most patients with rotator cuff problems. Modern arthroscopic repair techniques have improved recovery, but outcomes are still limited by a lack of understanding of how to improve tendon to bone healing in many patients.

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.

The Applicability of Provocative Functional Tests in the Diagnosis of Rotator Cuff Muscle Injuries of the Best University Athletes

Rotator cuff disease, external and internal impingement syndromes, low shoulder stability, various types of trauma, and overuse injuries are all related to sports activities. In order to check symptoms in patients with disability and shoulder pain, clinicians use different methods and diagnostic imaging assessment. The research is aimed at evaluating whether there is a difference between provocation function tests (PFT) and ultrasonographic (US) testing of muscles within the rotator cuff in elite collegiate athletes. Patients ( $n=184$ ) were recruited from university team sports selections and tested with a standardized US examination of the shoulder and five PFTs (Speed’s test, Neer’s test, Hawkins test, lift-off test, Yergason’s test). Based on the VAS pain assessment scale, 60 subjects had some pain, which was taken for further processing in the work (124 subjects did not have the presence of pain and were excluded from further processing). The US examination was conducted using Voluson 730 apparatus, by a linear probe, with the frequency in the range of 6-12 MHz. The chi-square test showed significant differences between PFT and the occurrence of shoulder muscle tendinitis for the following variables: Speed’s test and subscapularis tendinitis ( $p=0.02$ ) and Speed’s test and infraspinatus tendinitis ( $p=0.01$ ); Neer test and biceps brachii caput longum tendinitis ( $p=0.01$ ), Neer test and supraspinatus tendinitis ( $p=0.02$ ) and Neer test and infraspinatus tendinitis ( $p=0.01$ ); lift-off test and subscapularis tendinitis ( $p=0.05$ ); and Yergason’s test and biceps brachii caput longum tendinitis ( $p=0.03$ ) and Yergason’s test and subscapitis tendinitis ( $p=0.01$ ). The greatest effect of differences was observed in Neer’s test and biceps brachii caput longum tendinitis ( $\phi =0.60$ ), while the other effects can be described as medium and small in most cases. It can be concluded that functional tests are good predictors of soft tissue changes in the muscles of the rotator cuff of the shoulder. Further monitoring and analysis are needed on a larger number of athletes.

Clinical and MRI outcomes of subacromial impingement syndrome with conservative treatment: a 21-month prospective study

BACKGROUND

Information is lacking on the natural history of early stages of degenerative rotator cuff disease. Such information can be obtained by using clinical and imaging assessment after conservative treatment in affected patients.

HYPOTHESIS

Subacromial impingement syndrome is a clinical presentation that can be associated with early stages of the disease. We aimed to describe the natural history of degenerative rotator cuff disease from the early stages by studying clinical and imaging outcomes in non-operated patients with subacromial impingement syndrome.

PATIENTS AND METHODS

Patients with subacromial impingement syndrome were prospectively included. They had conservative treatment and were assessed before treatment and during at least 12-month follow-up. Assessment included clinical evaluation on a 0- to 100-point Constant scale and subscales as well as MRI of the rotator cuff. Clinical results were compared to baseline MRI findings and according to lesional progression.

RESULTS

We included 26 patients with mean age 59.1 (SD 9.6), mean pain duration 23.1 (31.3) months; mean total Constant score 39.1 (12.1). Overall, 9 patients had no tear, 9 had a partial tear and 8 had a full-thickness tear. Mean follow-up was 21 (SD 10) months. Total Constant score and subscores improved at follow-up in the overall sample. Patients without tear and those with partial or full-thickness tear at baseline showed clinical improvement. MRI of the rotator cuff at follow-up indicated lesional worsening in 7 patients. However, clinical improvement did not differ by lesional progression or not.

CONCLUSION

We report on 21-month clinical and MRI assessments of degenerative rotator cuff disorders including early stages of the disease. Clinical improvement was not related to MRI changes over time. Further investigations are needed to verify our findings in larger study populations.

Machine Learning-Based Ultrasomics for Predicting Subacromial Impingement Syndrome Stages

OBJECTIVES

To determine the performance of machine learning (ML)-based ultrasomic analysis of subacromial impingement syndrome (SIS) stage evaluation.

METHODS

In this retrospective study, 324 patients with SIS were included. The SIS stage was evaluated with a Neer test. Regions of the musculi supraspinatus were manually segmented by an experienced radiologist. Then, 5936 ultrasomic features were extracted from the Ultrasomics Platform software. The Wilcoxon test was used to identify differentially expressed radiomic features. Then, these differentially expressed features were submitted to the least absolute shrinkage and selection operator (LASSO) for model construction. The area under the curve (AUC) of the receiver operating characteristic was used to evaluate the performance of the ultrasonic model for SIS stage evaluation.

RESULTS

Finally, a total of 223 early-stage and 101 advanced-stage SIS patients were randomly divided into a training cohort (n = 227) and a validation cohort (n = 97). After feature-dimensionality reduction, a total of 28 radiomic features were submitted to LASSO analysis. Finally, 10 radiomic features were finally included for radiomics model construction. The AUC results showed that the ultrasomics model had moderate performance for SIS stage evaluation in both the training cohort (AUC = 0.839) and the validation cohort (AUC = 0.789).

CONCLUSIONS

ML-derived ultrasomics can discriminate the SIS stage in patients with SIS. This noninvasive and low-cost approach may be helpful in the preliminary screening of shoulder pain.

Percussion test: description and diagnostic accuracy of a new manual test for bone marrow edema of the knee

Background

Prompt diagnosis of bone marrow lesion (BML) is difficult but critical for correct treatment. Magnetic resonance imaging is the gold standard, although expensive and time consuming. Simple and reliable clinical test for BML detection is lacking. Aim of the study is to describe a new manual clinical test called Percussion Test (PT) and to statistically determine its diagnostic accuracy in BML, compared to MRI imaging.

Methods

After evaluation of the inclusion and exclusion criteria, 218 consecutive patients with unilateral knee pain and age comprised between 18 and 80 years old were enrolled in our observational prospective study. Informed consent was obtained for each patient. After medical history collection, PT was performed by a single operator as described. MRI was performed in the affected knee to detect the presence of BML. Coherence in PT and MRI assessment was evaluated in each quadrant of the knee via contingency tables, as sensitivity, specificity, NPV, PPV and diagnostic accuracy were calculated.

Results

No correlation with a positive PT was demonstrated for the covariables gender (p = 0.156), age (p = 0.272) and BMI (p = 0.639).

PT showed a sensitivity ranging from 60.6 (40.6–80.6) to 79.5 (63.0–96.0) and a specificity ranging from 85.7 (80.0–91.5) to 96.0 (93.1–98.9) depending on knee quadrant. Diagnostic accuracy ranged from 81.6 (75.9–86.6) to 89.4 (84.6–93.2), and p-value was < 0.00001 in a chi-squared analysis for all quadrants.

Conclusions

PT showed sensitivity and specificity values that are comparable with other clinical tests routinely adopted in clinical practice. In the absence of other reliable clinical test, PT has the potential to become a useful bedside tool in the diagnosis and management of BMLs.

Evidence-Based Examination Techniques for the Shoulder Joint

OBJECTIVE

Digitalisation now almost covers all areas of medical student teaching. Teaching videos are a good way to help students learn practical skills. The existing evidence is a recognised aid for the classification of the respective technology.

METHOD

This video presents the usual examination techniques of the shoulder joint on a patient with an unstable shoulder. The respective techniques, if available, were backed up with appropriate evidence.

CONCLUSION

The examination techniques presented allow students to view them in a standardized manner on a patient. The evidence for the examination techniques can help with the classification of the respective technique.

Diagnostic ultrasound in patients with shoulder pain: An inter-examiner agreement and reliability study among Dutch physical therapists

STUDY DESIGN

A cross-sectional inter-examiner agreement and reliability study among physical therapists in primary care.

BACKGROUND

musculoskeletal ultrasound (MSU) is frequently used by physical therapists to improve specific diagnosis in patients with shoulder pain, especially for the diagnosis rotator cuff tendinopathy (RCT) including tears.

OBJECTIVES

To estimate the inter-examiner agreement and reliability in physical therapists using MSU for patients with shoulder pain.

METHODS

Physical therapists performed diagnostic MSU in 62 patients with shoulder pain. Both physical therapists were blinded to each other's results and patients were not informed about the test results. We calculated the overall inter-examiner agreement, specific positive and negative inter-examiner agreement, and inter-examiner reliability (Cohen's Kappa's).

RESULTS

Overall agreement for detecting RC ruptures ranged from 61.7% to 85.5% and from 43.9% to 91.4% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures. Overall agreement for other pathology than ruptures related to SAPS, ranged from 72.6% to 93.6% and from 77.3% to 96% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures and 52.5%-83.3% for other pathology than ruptures related to SAPS. Reliability values varied from substantial for any thickness ruptures to moderate for partial thickness ruptures and fair for full thickness tears. Moreover, reliability was fair for cuff tendinopathy. The reliability for AC arthritis and no pathology found was fair and moderate. There was substantial agreement for the calcifying tendinopathy.

CONCLUSIONS

Physical therapists using MSU agree on the diagnosis of cuff tendinopathy and on the presence of RCT in primary care, but agree less on the absence of pathology.

Can the efficacy of subacromial corticosteroid injection be improved using a single- session mobilization treatment in subacromial impingement syndrome? A randomized single-blind controlled trial

Background/aim

The objective in this study is to assess the short-term effects of a single-session mobilization in addition to subacromial corticosteroid (SACS) injection in impingement syndrome.

Materials and methods

The study was designed as a prospective randomized controlled single-blind, parallel group clinical trial. Patients (totally 84) were divided randomly into two groups equally. Forty-two patients in Group 1 received mobilization and SACS injection, whereas 42 patients in Group 2 only received SACS injections. A single SACS injection was applied in all patients. Mobilization was administered as a single session right after SACS injection. Patients’ evaluations were performed measuring active range of motion (AROM), visual analogue scale (VAS) during activity and rest, and Disabilities of Arm, Shoulder, and Hand Score (DASH) prior to treatment and in the first and fourth weeks following the treatment.

Results

Both groups showed significant improvement in terms of AROM, VAS, and DASH scores in each evaluation step (P < 0.05). Visual analogue scale activity in the first week was significantly better in Group 1 (P = 0.028). Also, flexion and abduction degrees showed significantly better outcomes in Group 1 (P = 0.007, P = 0.036).

Conclusion

Addition of single-session mobilization might provide rapid improvement in flexion and abduction as well as early pain relief following SACS injections.

Single-Session Video and Electromyography Feedback in Overhead Athletes With Scapular Dyskinesis and Impingement Syndrome

CONTEXT

Subacromial impingement syndrome (SIS) is associated with scapular dyskinesis, or imbalanced scapular muscle activity. Evidence has shown that feedback can improve scapular control in patients with SIS. However, it is unknown whether real-time video feedback or electromyography (EMG) biofeedback is optimal for improving scapular kinematics and muscle activity during a functional task.

OBJECTIVE

To compare the effects of video and EMG feedback sessions on absolute muscle activity (upper trapezius [UT], lower trapezius [LT], serratus anterior), muscle balance ratios (UT/LT, UT/serratus anterior), and scapular kinematics (anterior-posterior tilt, external-internal rotation, upward rotation) in SIS participants during arm elevation and lowering.

DESIGN

Randomized controlled clinical trial.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Overhead athletes who were diagnosed with SIS and who also exhibited scapular dyskinesis (N = 41).

MAIN OUTCOME MEASURE(S)

Three-dimensional kinematics and EMG were recorded before and after feedback training.

RESULTS

Lower trapezius muscle activity increased (4.2%-18%, P < .011) and UT/LT decreased (0.56-1.17, P < .013) in the EMG biofeedback training group as compared with those in the video feedback training group. Scapular upward rotation during arm elevation was higher in the video group than in the EMG group after feedback training (2.3°, P = .024).

CONCLUSIONS

The EMG biofeedback improved muscle control and video feedback improved the correction of scapular upward rotation in patients with SIS.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT03252444.

Subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder manual therapy plus exercise intervention in individuals with subacromial impingement syndrome: a prospective, randomized controlled clinical trial pilot study

OBJECTIVES

To determine the subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder non-thrust plus exercise in patients with subacromial pathology.

METHODS

This was a randomized, single blinded controlled trial pilot study. This trial was registered at ClinicalTrials.gov (NCT01753271) and reported according to Consolidated Standards of Reporting Trials requirements. Patients were randomly assigned to either shoulder treatment plus cervicothoracic spinal thrust/non-thrust or shoulder treatment-only group. Primary outcomes were average pain intensity (Numeric Pain Rating Scale) and physical function (Shoulder Pain and Disability Index) at 2 weeks, 4 weeks, and patient discharge.

RESULTS

18 patients, mean age 43.1(15.8) years satisfied the eligibility criteria and were analyzed for follow-up data. Both groups showed statistically significant improvements in both pain and function at 2 weeks, 4 weeks, and discharge. The between-group differences for changes in pain or physical function were not significant at any time point.

DISCUSSION

The addition of cervicothoracic spinal thrust/non-thrust to the shoulder treatment-only group did not significantly alter improvement in pain or function in patients with subacromial pathology. Both approaches appeared to provide an equally notable benefit. Both groups improved on all outcomes and met the criteria for clinical relevance for both pain and function.

LEVEL OF EVIDENCE

2b.

Reliability and validity of the Norwegian version of the Disabilities of the Arm, Shoulder and Hand questionnaire in patients with shoulder impingement syndrome

BACKGROUND

Patient-rated outcome measures (PROMs) are an important part of clinical decision-making in rehabilitation of patients with shoulder pain. The Disabilities of Arm, Shoulder and Hand (DASH) questionnaire was designed to measure physical disability and symptoms in patients with musculoskeletal disorders of the upper extremity and is one the most commonly used outcome measures for patients with shoulder pain. The purpose of this study was to investigate the reliability and validity of the Norwegian version of the DASH in patients with shoulder impingement syndrome.

METHODS

Sixty-three patients diagnosed with shoulder impingement syndrome at an orthopaedic outpatient clinic were included in the study. Internal consistency of the DASH was evaluated by the Cronbach's alpha and item-to-total correlations. Test-retest reliability was analyzed by the intraclass correlation coefficient (ICC) and limits of agreement (LoA) according to the Bland Altman method. Standard error of measurement (SEM) and minimally detectable change (MDC) were calculated for the total DASH score. Construct validity was evaluated by testing six a priori hypotheses for the Pearson's correlation coefficient between the DASH and the Shoulder Pain and Disability Index (SPADI), the 36-item Short Form Health Survey (SF-36) and a Numeric Pain Rating Scale (NPRS).

RESULTS

Reliability: Cronbach's alpha of the DASH was 0.93 and item-to-total correlations ranged from 0.36 to 0.81. ICC was 0.89. The 95 percent LoA was calculated to be between -11.9 and 14.1. SEM was 4.7 and MDC 13.1. Construct validity: Eighty-three percent of the a priori hypotheses of correlation were confirmed. The DASH showed a high positive correlation of 0.75 with the SPADI, a negative moderate correlation of -0.48 to -0.62 with physical functioning, bodily pain and physical component summary of the SF-36 and a moderate positive correlation of 0.58 with the NPRS. DASH correlated higher with the physical component summary than with the mental component summary of the SF-36.

CONCLUSIONS

The Norwegian version of the DASH is a reliable and valid outcome measure for patients with shoulder impingement syndrome.

Development and reliability of a clinician-rated instrument to evaluate function in individuals with shoulder pain: a preliminary study

BACKGROUND AND PURPOSE

Subacromial impingement syndrome (SIS) is a common and disabling condition in the population. Interventions are often evaluated with patient-rated outcome measures. The purpose of this study was to develop a simple clinician-rated measure to detect difficulties in the execution of movement-related tasks among patients with subacromial impingement syndrome.

METHOD

The steps in the scale development included a review of the clinical literature of shoulder pain to identify condition-specific questionnaires, pilot testing, clinical testing and scale construction. Twenty-one eligible items from thirteen questionnaires were extracted and included in a pilot test. All items were scored on a five-point ordinal scale ranging from 1 (no difficulty) to 5 (cannot perform). Fourteen items were excluded after pilot testing because of difficulties in standardization or other practical considerations. The remaining seven items were included in a clinical test-retest study with outpatients at a hospital. Of these, four were excluded because of psychometric reasons. From the remaining three items, a measure named Shoulder Activity Scale (summed score ranging from 3 to 15) was developed.

RESULTS

A total of 33 men and 30 women were included in the clinical study; age range 27-80 years. The intraclass correlation coefficient results for inter-rater reliability and test-retest reliability were 0.80 (95% CI = 0.51-0.90) and 0.74 (95% CI = 0.58-0.84), respectively. The standard error of measurement and minimal detectable change were 1.19 and 3.32, respectively. The scale was linked to the International Classification of Functioning, Disability and Health second level categories lifting and carrying objects (d430), dressing (d540), hand and arm use (d445) and control of voluntary movement (b760).

CONCLUSION

The Shoulder Activity Scale showed acceptable reliability in a sample of outpatients at a hospital, rated by clinicians experienced in shoulder rehabilitation. The validity of the scale should be investigated in future studies before application to common practice. © 2013 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.

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.

Inter-examiner reproducibility of clinical tests and criteria used to identify subacromial impingement syndrome

Introduction A specific algorithm has been proposed for classifying impingement related shoulder pain in athletes with overhead activity. Data on the inter-examiner reproducibility of the suggested clinical tests and criteria and their mutual dependencies for identifying subacromial impingement symptoms (SIS) are not available. Objective To test the inter-examiner reproducibility of selected tests and criteria suggested for classifying SIS and the mutual dependencies of each of the individual tests and SIS. Method A standardised three-phase protocol for clinical reproducibility studies was followed, consisting of a training, an overall agreement and a study phase. To proceed to the study phase, an overall agreement of 0.80 was required. In total 10, 20 and 44 subjects were included in the three phases, respectively. The case prevalence in the study phase was 50%. The inclusion criterion for cases was ≥3, and for controls ≤1 positive test out of four. Cohen's κ statistics were used for calculating agreement. Results In the overall agreement phase, an agreement of 0.90 was obtained, while in the study phase it was 0.98 with a κ of 0.95 for SIS. κ Values for the individual tests varied between 0.60 and 0.95. Mutual dependencies between each test and SIS showed Neer's test with anterior pain to be most often used to determine SIS. Conclusions Inter-examiner reproducibility was moderate to almost perfect for the selected tests and criteria for SIS. The next challenge will be to establish reproducibility in clinical practice, as well as the validity of the tests and criteria for SIS.

Clinical value of single versus composite provocative clinical tests in the assessment of painful shoulder

OBJECTIVES

The aims of the present study were to investigate the clinical value of the provocative clinical tests and propose a composite index for the assessment of painful shoulder, using ultrasonography (US) as reference method.

METHODS

Two hundred three patients with painful shoulder underwent both clinical and US evaluations. The physical examination was carried out performing the Hawkins, Jobe, Patte, Gerber, and Speed tests. Each test was included in a composite index namely, SNAPSHOT (Simple Numeric Assessment of Pain by SHOulder Tests). The US examination was performed by a rheumatologist experienced in US and blinded to clinical findings. Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratio of each clinical test were calculated. The receiver operating characteristic (ROC) curve analysis was used to assess the performance of the composite SNAPSHOT index.

RESULTS

Sensitivity was low for the clinical diagnosis of all shoulder abnormalities. The highest sensitivity and smallest negative likelihood ratio were found for the Hawkins (63.88% and 0.50%) and Patte (62.21% and 0.52%) tests. Specificity was good for Speed (76.33%), Gerber (75.42%), and Patte (74.20%) tests. Patte and Speed tests were the most accurate (71.12% and 66.41%, respectively). The calculated area under the ROC curve related to the SNAPSHOT composite index was 0.881 +/- 0.026. With an optimal cut-off point of 3, the sensitivity and specificity were 75.8% and 87.5%, respectively.

CONCLUSION

The results of the present study showed that SNAPSHOT is a feasible, informative and quantitative composite index for the assessment of painful shoulder in the clinical setting.

Clinical tests in shoulder examination: how to perform them

BACKGROUND

This article describes the best clinical tests of shoulder function and injury as identified in a recent systematic review published in the British Journal of Sports Medicine.

DISCUSSION

A description of the different tests is given, with photographs of the exact test procedure.