The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears

Physical Examination Maneuvers for SLAP Lesions: A Systematic Review and Meta-analysis of Individual and Combinations of Maneuvers

BACKGROUND

Superior labrum anterior to posterior (SLAP) lesions are targeted on physical examination using a variety of provocative maneuvers.

PURPOSE/HYPOTHESIS

The purpose was to conduct a systematic review on the performance of physical examination maneuvers in diagnosing SLAP lesions and to perform a meta-analysis comparing the sensitivity and specificity of these examinations both individually and in combination. The null hypothesis stated that there would be no significant difference in the sensitivity or specificity of the included physical examination tests, neither individually nor in combination.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic review was performed with the inclusion criteria of studies that reported either the sensitivities and specificities or the number of true-positive, true-negative, false-positive, or false-negative results for at least 1 maneuver for identifying SLAP lesions. A meta-analysis was performed to determine the sensitivity and specificity of individual maneuvers. Additional analysis determined the performance of these maneuvers when combined in series and parallel. In series, all must be present to be considered positive. In parallel, any single positive test forces the overall combination to be considered positive. Only tests that were included in ≥3 studies were considered in the meta-analysis and those included in ≥4 studies were considered in the combination analysis.

RESULTS

Overall, 862 studies were identified, 18 of which were included in the systematic review and meta-analysis. The physical examinations included were the O'Brien (n = 16), speed (n = 8), Yergason (n = 6), anterior slide (n = 8), crank (n = 7), Jobe (n = 5), dynamic labral shear (n = 3), Kim 2 (n = 3), and biceps groove tenderness tests (n = 3). All combinations of 2 to 5 maneuvers in both series and parallel were considered. The O'Brien and crank test combination was the most sensitive 2-test combination in both parallel and series. The Yergason and anterior slide test combination was the most specific 2-test combination in parallel and series.

CONCLUSION

This systematic review and meta-analysis reports an updated meta-analysis considering the sensitivity and specificity of common physical examination maneuvers used in the diagnosis of SLAP lesions and considers these values for tests in both series and parallel combinations. The present analysis demonstrates improved specificities when tests are considered in series and improved sensitivities when considered in parallel combination.

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

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

Bivariate Bayesian hypothesis testing with missing data in components

Multiple endpoints and historical data borrowing may be simultaneously incorporated for enhancing efficiency and speeding up the new drug development process in the pharmaceutical industry. O'Brien's test is a widely used weighted combination test for multiplicity adjustment on multiple endpoints to control the overall type error rate in a weak sense. In this research, a modification on the O'Brien's test more specifically on the weights is considered for a trial with two primary endpoints to potentially increase power. The method can handle missing data in the current study and in the prior derivation for dynamic historical data borrowing. Simulations are conducted to compare the performances of different methods. A data example is used to illustrate the applications of the methods.

Impact of Body Mass Index on the Accuracy of Physical Examination and MRI of the Shoulder

BACKGROUND

The physical examination of overweight patients can require specific adaptations. Orthopaedic literature on the impact of body mass index (BMI) on the physical examination of the shoulder is virtually nonexistent.

PURPOSE

To assess whether BMI affects the sensitivity and specificity of common shoulder tests, using arthroscopy as a gold standard. We also examined the effects of BMI on the sensitivity and specificity of magnetic resonance imaging (MRI) of the shoulder for reference.

STUDY DESIGN

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

METHODS

We analyzed the data of 116 consecutive patients who underwent shoulder arthroscopy for the treatment of rotator cuff tears, Bankart lesions, and superior labral anterior-posterior (SLAP) lesions. Preoperative BMI, physical examination of the shoulder findings, and MRI findings were extracted. Contingency tables and receiver operating characteristic curves were used to evaluate the sensitivity and specificity of provocative tests of the shoulder and MRI as well as their relationship to BMI.

RESULTS

The sensitivity and specificity of the Jobe supraspinatus test were 77.8% and 72.7% in patients with BMI ≤25, 82.6% and 70.6% in those with 25 < BMI ≤ 30, and 81.3% and 55.6% in those with BMI >30, respectively (P < .001). The apprehension and relocation tests demonstrated higher sensitivity and specificity for the overweight patients (25 < BMI ≤ 30) compared with the other BMI groups, with a sensitivity and specificity of 83.3% and 100% for the apprehension test and a sensitivity and specificity of 75% and 100% for the relocation test, respectively. The O'Brien, Speed, and Ebinger tests for SLAP tears had low accuracy and did not yield statistically significant results. MRI interpretation was found to be influenced by BMI in obese patients, especially when SLAP lesions were assessed.

CONCLUSION

Counterintuitively, tests for shoulder instability had greater specificity in overweight patients and should be encouraged, particularly in obese patients, in whom the specificity of shoulder MRI for the detection of a Bankart lesion is lower. The Jobe test was more sensitive but less specific in overweight patients. These findings may assist care providers in improving the interpretation of the shoulder examination of overweight patients and consequently lead to better treatment-related decisions.

The Top 50 Most-Cited Papers in the Diagnosis and Management of SLAP Tears

Purpose

To identify and characterize the top 50 most-cited articles regarding SLAP tears.

Methods

Referencing the methodology of previous citation analyses, varying Boolean searches were performed using the Web of Science database and the search terms yielding the greatest number of results was used. The top 50 most-cited articles were identified and the following data points were gathered from each article: author, institution, country of origin, year of publication, publishing journal, level of evidence, and citation density.

Results

The total number of citations was 7834, with a median of 106 citations. The top 50 list was largely composed of diagnostic level I, II, and III studies (5, 7, and 8 total publications, respectively) and therapeutic level III (6 publications) or level IV (10 publications). Most articles originated from the United States (40). In total, 19 of the top 50 most-cited articles were published in the American Journal of Sports Medicine, followed by Arthroscopy (15) and the Journal of Bone and Joint Surgery (5).

Conclusions

Our analysis demonstrated a correlation with earlier publications being cited more frequently than recent studies. Importantly, the current study found that therapeutic studies in the most cited list were largely level III or level IV evidence. This makes the management of SLAP tears seem anecdotal, with little in the way of high-impact level I or level II therapeutic studies. We must reconsider our current understanding of SLAP tears and their management with more studies that demonstrate a clearer treatment algorithm for these common injuries of the shoulder.

Clinical Relevance

Given the complexity of SLAP tears, this list of the most-cited articles can provide a reference point to better guide practice, resident education, and future areas of orthopaedic research.

Clinical Tests of the Shoulder: Accuracy and Extension Using Dynamic Ultrasound

Shoulder pain is a common musculoskeletal disorder that has a significant impact on the patient's quality of life and functional health. Because the shoulder joint is a complex structure, the relevant symptoms of shoulder pain may not directly reflect the underlying pathology. Hence, several shoulder tests have been developed to examine shoulder problems, and their diagnostic accuracy varies. Familiarization with the performance of those physical tests and their strength and limitation are of utmost importance for physicians dealing with shoulder disorders. Therefore, the present narrative review focuses on summarizing the most commonly used tests in physical examination and their diagnostic performance on several shoulder pathologies. This article also discusses how ultrasound imaging can serve as an extension of those tests.

The Correlation of the SLAP II Lesion Findings Between Physical Examination, Magnetic Resonance Imaging, and Arthroscopic Surgery

OBJECTIVES

The aim of this study is to demonstrate the importance of clinical diagnosis by comparing with preoperative physical examination and magnetic resonance imaging (MRI) images in patients who were arthroscopically diagnosed as having Superior Labrum Anterior-Posterior (SLAP) II lesions.

MATERIALS AND METHODS

134 patients, arthroscopically diagnosed as SLAP II, established the study group, and 200 patients who underwent shoulder arthroscopy for the other pathologies established the control group. Preoperative clinical examination of the patients, MRI findings, and the arthroscopic findings of the patients were recorded.

RESULTS

Out of the patients diagnosed with a SLAP II lesion, 107 (79.9) of those had an MRI finding while only 60 (30%) of the control group had it. The O'Brien test results of the patients diagnosed with SLAP were positive in 111 (82.8%) while those diagnosed with intact superior labrum were positive in 132 (66%). Of the 134 patients with a SLAP II lesion, 89 (66.4%) had both O'Brien test positiveness and MRI finding, and 129 (96%) had at least one positive result of the O'Brien test or MRI examination.

CONCLUSION

The O'Brien test and MRI examination are not capable enough to indicate a SLAP lesion one by one, because of the low sensitivity and specificity. But, combining the test with MRI findings provides more trustable information about the superior labrum.

Supraspinatus Muscle Tendon Lesion and Its Relationship with Long Head of the Biceps Lesion

Objective  To identify the clinical, radiological, and arthroscopic correlation of long head of the biceps tendon injuries and their influence on pain when associated with rotator cuff injuries. Methods  Between April and December 2013, 50 patients were evaluated, including 38 (76%) women and 12 (24%) men, with a mean age of 65.1 years old. The patients were operated by the Shoulder and Elbow Group, Discipline of Sports Medicine, Orthopedics and Traumatology Department, Universidade Federal de São Paulo. The subjects underwent repair of the rotator cuff lesion with clinical, radiological and/or arthroscopic evidence of involvement of the long head of the biceps tendon. Results  An association between pain at palpation of the intertubercular groove of the humerus and high-grade partial lesions (partial rupture of the tendon affecting more than 50% of its structure) was observed at the arthroscopy ( p  = 0.003). There was also an association between the high-grade lesion of the long head of the biceps and injury to the supraspinatus muscle tendon ( p  < 0.05). For each centimeter of the supraspinatus muscle tendon injury, the patient presented a 1.7 higher probability of having a high-grade lesion at the long head of the biceps. Conclusion  Pain at the anterior shoulder region during palpation of the intertubercular groove of the humerus may be related to high-grade lesions to the long head of the biceps. Rotator cuff injury and its size are risk factors for high-grade injuries to the long head of the biceps tendon.

Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability

BACKGROUND

The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability.

METHODS

This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control).

RESULTS

Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively).

CONCLUSION

Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.

Diagnostic utility of the Active Compression Test for the superior labrum anterior posterior tear: A systematic review

BACKGROUND

The Active Compression Test has been proposed to have high diagnostic accuracy for superior labrum anterior to posterior tears. The aim of this systematic review was to compile the available evidence for this test and evaluate its diagnostic accuracy.

METHODS

The databases PubMed, Embase, Cochrane, CINAHL, and SCOPUS were searched for case control, diagnostic studies that evaluated the Active Compression Test between 1999 (date of test introduction) and February 2018. Two independent review authors screened the search results, assessed the risk of bias using QUADAS-2, and extracted the data.

RESULTS

Eighteen studies (pooled sample = 3091) were included in this review. Twelve out of 18 studies either had high or unclear risk of bias (66.6%). Results from the pooled analysis of all 18 studies provided that the Active Compression Test is more sensitive (71.5: 95% CI = 68.8, 74.0) than specific (51.9: 95% CI = 50.7, 53.1) and only marginally influenced posttest probability from a pretest probability of 31.7-40.72% with a positive finding and a pretest probability of 31.7-20.33% with a negative finding.

DISCUSSION

The Active Compression Test has both limited screening and confirmation ability; therefore, we do not advocate for its use in clinical decision making.

Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes

For overhead athletes and, in particular, baseball pitchers, the rates of success and return to play for those who have undergone arthroscopic repair of type II SLAP lesions are poor, ranging from 7% to 62%. The reasons for the poor results and high failure rates in overhead athletes with type II SLAP repairs are multifactorial and are a combination of many factors. These factors include the failure to establish the diagnosis and treat these athletes preoperatively; the inability of the operating surgeon to differentiate normal anatomic variants from pathologic SLAP lesions at the time of surgery; the surgical technique, which may violate the rotator cuff; or the placement of suture anchors, which restricts external rotation and alters overhead throwing mechanics. The proper diagnosis of SLAP lesions can be difficult because SLAP tears rarely occur in isolation and are often associated with other shoulder pathology. A proper history detailing the onset of symptoms and whether there was an acute episode of trauma or a history of repetitive use is critical. It is important to remember that no single physical examination finding is pathognomonic for SLAP tears. When seen in isolation, SLAP tears may mimic impingement syndrome (52%) or even anterior instability (39%). Surgical treatment of type II SLAP lesions should not be undertaken lightly in overhead athletes. If a 3-month rehabilitation period followed by a return to sports over the following 3 months does not allow the athlete to return to his or her preinjury level, diagnostic arthroscopy with SLAP repair is a reasonable option and can yield excellent results using the proper techniques. The technique described in detail in this article and our video can be technically demanding, but with the key points outlined, it can be reproduced and provide excellent results for overhead athletes undergoing SLAP repair. By not violating the rotator cuff, using a mattress configuration and keeping the suture knot away from the articular surface, and by not going anterior to the biceps tendon for repair, external rotation and strength can be preserved, leading to an excellent result with a predictable return to play for overhead athletes.

Comprehensive Review of Provocative and Instability Physical Examination Tests of the Shoulder

A detailed physical examination of the shoulder is crucial in creating a diagnosis in patients who present with shoulder pain. Tests of the cervical spine, scapula, and rotator cuff muscles have already been evaluated in a previous article. This article assesses provocative and instability examination tests of the shoulder. Descriptions on how the tests are performed and their diagnostic accuracy are presented.

National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries

OBJECTIVE

  To present recommendations for the diagnosis, management, outcomes, and return to play of athletes with superior labral anterior-posterior (SLAP) injuries.

BACKGROUND

  In overhead athletes, SLAP tears are common as either acute or chronic injuries. The clinical guidelines presented here were developed based on a systematic review of the current evidence and the consensus of the writing panel. Clinicians can use these guidelines to inform decision making regarding the diagnosis, acute and long-term conservative and surgical treatment, and expected outcomes of and return-to-play guidelines for athletes with SLAP injuries.

RECOMMENDATIONS

  Physical examination tests may aid diagnosis; 6 tests are recommended for confirming and 1 test is recommended for ruling out a SLAP lesion. Combinations of tests may be helpful to diagnose SLAP lesions. Clinical trials directly comparing outcomes between surgical and nonoperative management are absent; however, in cohort trials, the reports of function and return-to-sport outcomes are similar for each management approach. Nonoperative management that includes rehabilitation, nonsteroidal anti-inflammatory drugs, and corticosteroid injections is recommended as the first line of treatment. Rehabilitation should address deficits in shoulder internal rotation, total arc of motion, and horizontal-adduction motion, as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control. Most researchers have examined the outcomes of surgical management and found high levels of satisfaction and return of shoulder function, but the ability to return to sport varied widely, with 20% to 94% of patients returning to their sport after surgical or nonoperative management. On average, 55% of athletes returned to full participation in prior sports, but overhead athletes had a lower average return of 45%. Additional work is needed to define the criteria for diagnosing and guiding clinical decision making to optimize outcomes and return to play.

Physical exam of the adolescent shoulder: tips for evaluating and diagnosing common shoulder disorders in the adolescent athlete

PURPOSE OF REVIEW

In the young athlete, the shoulder is one of the most frequently injured joints during sports activities. The injuries are either from an acute traumatic event or overuse. Shoulder examination can present some challenges; given the multiple joints involved, the difficulty palpating the underlying structures, and the potential to have both intra- and/or extra-articular problems.

RECENT FINDINGS

Many of the shoulder examination tests can be positive in multiple problems. They usually have high sensitivity but low specificity and therefore low predictive value. The medical history coupled with a detailed physical exam can usually provide the information necessary to obtain an accurate diagnosis. A proficient shoulder examination and the development of an adequate differential diagnosis are important before considering advanced imaging.

SUMMARY

The shoulder complex relies upon the integrity of multiple structures for normal function. A detailed history is of paramount importance when evaluating young athletes with shoulder problems. A systematic physical examination is extremely important to guiding an accurate diagnosis. The patient's age and activity level are very important when considering the differential diagnosis. Findings obtain through history and physical examination should dictate the decision to obtain advanced imaging of the shoulder.

Examination of the Biceps Tendon

The examination of the shoulder for conditions involving the biceps tendon continues to be challenging. Numerous examination tests for biceps and superior labrum anterior and posterior (SLAP) lesions have been scientifically evaluated. This section reports on how to perform these tests and summarizes the clinical utility of the tests. Many of the tests for the examination of the biceps and for SLAP lesions do not have high sensitivity and specificity, which limits their usefulness. Although the dynamic shear test has promise for making the diagnosis of SLAP lesions, the studies reporting its clinical utility are disparate.

Subscapularis tears and lesser tuberosity avulsion fractures in the pediatric patient

Background:

Pediatric subscapularis tears are known to be rare injuries. They are often associated with an avulsion fragment of the lesser tuberosity leading to dual description in the literature of either subscapularis tear or lesser tuberosity avulsion. Historically, they were managed nonoperatively; however, outcomes have improved with operative management. Nonoperative management often led to bony overgrowth at the lesser tuberosity that limited motion. The literature is limited to case reports and a few small case series, often not restricted to pediatric patients.

Study Design:

Case series.

Level of Evidence:

Level 5.

Methods:

Radiographic and operative databases were retrospectively reviewed to identify pediatric patients with subscapularis tears or lesser tuberosity avulsions in the past 10 years.

Results:

Five cases of pediatric subscapularis tears were identified that underwent operative management. Of the 5 cases, 4 had delayed presentation. In 1 case, the lesser tuberosity fragment was initially missed on radiographic imaging. All patients underwent operative management.

Conclusion:

These cases add to the body of knowledge of a rare pediatric injury that is commonly missed or diagnosis delayed. The importance of suspicion in the adolescent male patient without instability and unrelenting shoulder pain is stressed. Additionally, the importance of early magnetic resonance imaging with suspicion as well as an axillary view of the shoulder is demonstrated. As with all rare entities, it is important to disseminate information on natural history and interventions for this injury.

Clinical orthopedic examination findings in the upper extremity: correlation with imaging studies and diagnostic efficacy

Different orthopedic tests are used to evaluate internal derangements of joints. Radiologic examinations like magnetic resonance (MR) imaging are ordered on the basis of results of these tests to narrow the clinical diagnosis and formulate a treatment plan. Although these tests are clinically useful, the test terminology can be confusing and the significance of the tests not clearly understood. This article helps explain the clinical jargon of tests performed for the major joints of the upper extremity and their proper use and diagnostic value in conjunction with MR imaging. The article presents a structured algorithmic approach to explain the tests. For each joint, a hierarchy of clinical tests is performed, starting with general observation and range of motion, followed by more specific tests tailored to evaluate individual or grouped anatomic structures. MR imaging findings and clinical tests complement each other in making a final diagnosis. However, because of the varied sensitivity and specificity of the clinical tests and MR imaging, it is important to be familiar with their diagnostic value before making clinical decisions. Knowledge of clinical jargon and the proper use and diagnostic value of orthopedic tests can aid in interpretation of radiologic images by focusing search patterns, thus allowing comprehensive evaluation and optimized reporting. It also enhances communication with the orthopedist, thereby helping maintain continuity of care. Online supplemental material is available for this article.

Understanding and evaluating shoulder pain in the throwing athlete

Shoulder pain in the throwing athlete can present at any age and in any level of sport and can lead to dysfunction. A thorough evaluation of the throwing athlete can often determine the cause of symptoms, which is frequently multifactorial. Although the pathophysiology leading to pain in the shoulder of the throwing athlete is not entirely known, nonoperative modalities remain the mainstay of treatment. In general, surgical intervention should be reserved as a last resort. Effective treatment often requires collaboration among trainers, players, physicians, and therapists to determine an appropriate course of action.

Superior labrum anterior-to-posterior repair incidence: a longitudinal investigation of community and academic databases

BACKGROUND

Superior labrum anterior-to-posterior (SLAP) lesion repair is controversial regarding indications and potential complications.

METHODS

Databases were used to determine the SLAP repair incidence compared with all orthopaedic procedures over a period of 10 years. In part A, the New York Statewide Planning and Research Cooperative System ambulatory surgery database was investigated from 2002 to 2009. In part B, the California Office of Statewide Health Planning and Development ambulatory surgery database was investigated from 2005 to 2009. In part C, the American Board of Orthopaedic Surgery (ABOS) database was investigated from 2003 to 2010.

RESULTS

In part A, from 2002 to 2009, there was a 238% increase in SLAP repair volume compared with a 125% increase in all orthopaedic procedures. In part B, from 2005 to 2009, there was a 20.17% increase in SLAP repair volume compared with a decrease of 13.64% in all orthopaedic procedures. In part C, among candidates performing at least 1 SLAP repair, there was no statistically significant difference in likelihood of performing a SLAP repair (95% confidence interval, 0.973-1.003) in 2010 as compared with 2003 (P > .10).

CONCLUSIONS

There has been a significant increase in the incidence of SLAP repairs in the past 10 years in statewide databases. This pattern was not seen in the ABOS database, in which the annual volume of SLAP repairs remained stable over the same period. This suggests that SLAP lesions have been over-treated with surgical repair but that part II ABOS candidates are becoming more aware of the need to narrow indications.

LEVEL OF EVIDENCE

Epidemiology study, database analysis.

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

BACKGROUND

Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.

OBJECTIVES

To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.

SEARCH METHODS

We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English.

SELECTION CRITERIA

We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.

MAIN RESULTS

We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.

AUTHORS' CONCLUSIONS

There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.

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

CONTEXT

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

OBJECTIVE

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

DESIGN

Cross-sectional study.

SETTING

Descriptive survey administered via e-mail.

PATIENTS OR OTHER PARTICIPANTS

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

MAIN OUTCOME MEASURE(S)

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

RESULTS

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

CONCLUSIONS

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

Current concepts in the evaluation and treatment of the shoulder in overhead-throwing athletes, part 1: physical characteristics and clinical examination

The overhead-throwing athlete is a challenging sports medicine patient. The repetitive microtraumatic stresses imposed on the athlete's shoulder joint complex during the throwing motion constantly places the athlete at risk for injury. These stresses may effect several adaptations to normal shoulder range of motion, strength, and scapula position. The clinician should therefore appreciate the unique physical characteristics of the overhead-throwing athlete to accurately evaluate and treat throwing-related injuries.

Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates

BACKGROUND

Tears of the superior labrum (superior labrum anterior and posterior [SLAP] lesions) of the shoulder are uncommon injuries; however, the incidence of surgical correction seems to be increasing.

PURPOSE

To report the findings of a review of a proprietary descriptive database that catalogs cases for the purpose of board certification on the demographics of SLAP lesion repair. It is the authors' impression that the percentage of cases of SLAP lesion repairs reported by young orthopaedic surgeons is high and that complications associated with this are not insignificant.

STUDY DESIGN

Cohort study; level of evidence, 3.

METHODS

We searched the American Board of Orthopedic Surgery (ABOS) part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of arthroscopic repair of SLAP lesions. The database was searched for all SLAP lesions (ICD-9 code 840.7) and SLAP repairs (CPT code 29807) for the years 2003 through 2008. Utilization was analyzed by geographic region and was also obtained based on applicant subspecialty declaration.

RESULTS

There were 4975 SLAP repairs, representing 9.4% of all applicants' shoulder cases. Mean follow-up was 8.9 weeks because of the time-limited case collection period. There were 78.4% who were men, and 21.6% of patients were women. The percentage of shoulder cases that were SLAP repairs increased over the study period from 9.4% to 10.1% by 2008 (P = .0163). Mean age of male patients was 36.4 ± 13.0 years, with a maximum of 85 years. Mean age of female patients was 40.9 ± 14.0 years, with a maximum of 88 years. Pain was reported as absent in only 26.3% of patients at follow-up and function as normal in only 13.1%. There were 40.1% of applicants who self-reported their patients to have an excellent result. The self-reported complication rate was 4.4%. Declared sports medicine specialists had a higher percentage of SLAP repairs than did general orthopaedic surgeons: 12.4% versus 9.2%.

CONCLUSION

The percentage of shoulder cases that are SLAP repairs reported by the candidates is 3 times the published incidence supported by the current literature. The large number of repairs in middle-aged and elderly patients is concerning. Focusing on educating young orthopaedic surgeons to appropriately recognize and treat symptomatic SLAP lesions may bring the rate of SLAP repairs down.

Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions

BACKGROUND

The clinical diagnosis of a superior labral anterior posterior (SLAP) tear is extremely challenging. Most studies that advocate selected tests have errors in study design or significant bias, or both. The purpose of this study was to identify the diagnostic utility of the Active Compression/O'Brien's test, Biceps Load II test, Dynamic Labral Shear test (O'Driscoll's test), Speed's test, and the Labral Tension test when diagnosing isolated SLAP lesions (SLAP-only) and a SLAP lesion with concomitant disorders (eg, rotator cuff tear), as stand-alone and clustered tests, with diagnostic confirmation by arthroscopic surgery.

MATERIALS AND METHODS

This diagnostic accuracy study was a case-based, case-control design that included 87 individuals with variable shoulder pathology.

RESULTS

Of the 5 tests, only the Biceps Load II test demonstrated utility in identifying patients with a SLAP-only lesion, with a positive predictive value of 26 (95% confidence limits [CL], 18, 31), negative predictive value of 93 (95% CL, 84, 97), positive likelihood ratio of 1.7 (95% CL, 1.1, 2.6), and negative likelihood ratio of 0.39 (95% CL, 0.14, 0.91). No tests demonstrated diagnostic utility when diagnosing any SLAP lesion, including those with concomitant diagnoses. No clusters demonstrated better diagnostic accuracy than stand-alone findings.

CONCLUSION

There are a number of potential reasons for the poor utility in the 5 test findings. The heterogeneous sample included patients with a variety of shoulder disorders. The study was organized using very strict methodologic controls that should reduce the risk of bias, which normally overinflates the accuracy of a specific tool. The findings may truly reflect the stand-alone, diagnostic utility of the 5 tests, suggesting when used alone provides little usefulness toward decision making of the diagnostic clinician.

Glenohumeral muscle activation during provocative tests designed to diagnose superior labrum anterior-posterior lesions

BACKGROUND

Despite considerable medical advances, arthroscopy remains the only definitive means of superior labrum anterior-posterior (SLAP) lesion diagnosis. Natural shoulder anatomic variants limit the reliability of radiographic findings and clinical evaluations are not consistent. Accurate clinical diagnostic techniques would be advantageous because of the invasiveness, patient risk, and financial cost associated with arthroscopy.

PURPOSE

The purpose of this study was to examine the behavior of the joint-stabilizing muscles in provocative tests for SLAP lesions. Electromyography was used to characterize the muscle behavior, with particular interest in the long head of the biceps brachii (LHBB), as activation of the long head and subsequent tension in the biceps tendon should, based on related research, elicit labral symptoms in SLAP lesion patients.

STUDY DESIGN

Controlled laboratory study.

METHODS

Volunteers (N = 21) without a history of shoulder injury were recruited. The tests analyzed were active compression, Speed's, pronated load, biceps load I, biceps load II, resisted supination external rotation, and Yergason's. Tests were performed with a dynamometer to improve reproducibility. Muscle activity was recorded for the long and short heads of the biceps brachii, anterior deltoid, pectoralis major, latissimus dorsi, infraspinatus, and supraspinatus. Muscle behavior for each test was characterized by peak activation and proportion of muscle activity.

RESULTS

Speed's, active compression palm-up, bicep I, and bicep II produced higher long head activations. Resisted supination external rotation, bicep I, bicep II, and Yergason's produced a higher LHBB proportion.

CONCLUSION

Biceps load I and biceps load II elicited promising long head behavior (high activation and selectivity). Speed's and active compression palm up elicited higher activation of the LHBB, and resisted supination and Yergason's elicited selective LHBB activity. These top performing tests utilize a unique range of test variables that may prove valuable for optimal SLAP test design and performance.

CLINICAL RELEVANCE

This study examines several provocative tests that are frequently used in the clinical setting as a means of evaluating a potential SLAP lesion.

Diagnostic accuracy of history and physical examination of superior labrum anterior- posterior lesions

CONTEXT

Type I superior labrum anterior-posterior (SLAP) lesions involve degenerative fraying and probably are not the cause of shoulder pain. Type II to IV SLAP lesions are tears of the labrum.

OBJECTIVE

To determine the diagnostic accuracy of patient history and the active compression, anterior slide, and crank tests for type I and type II to IV SLAP lesions.

DESIGN

Cohort study.

SETTING

Clinic.

PATIENTS OR OTHER PARTICIPANTS

Fifty-five patients (47 men, 8 women; age = 40.6 ± 15.1 years) presenting with shoulder pain.

INTERVENTION(S)

For each patient, an orthopaedic surgeon conducted a clinical examination of history of trauma; sudden onset of symptoms; history of popping, clicking, or catching; age; and active compression, crank, and anterior slide tests. The reference standard was the intraoperative diagnosis. The operating surgeon was blinded to the results of the clinical examination.

MAIN OUTCOME MEASURE(S)

Diagnostic utility was calculated using the receiver operating characteristic curve and area under the curve (AUC), sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). Forward stepwise binary regression was used to determine a combination of tests for diagnosis.

RESULTS

No history item or physical examination test had diagnostic accuracy for type I SLAP lesions (n = 13). The anterior slide test had utility (AUC = 0.70, +LR = 2.25, -LR = 0.44) to confirm and exclude type II to IV SLAP lesions (n = 10). The combination of a history of popping, clicking, or catching and the anterior slide test demonstrated diagnostic utility for confirming type II to IV SLAP lesions (+LR = 6.00).

CONCLUSIONS

The anterior slide test had limited diagnostic utility for confirming and excluding type II to IV SLAP lesions; diagnostic values indicated only small shifts in probability. However, the combination of the anterior slide test with a history of popping, clicking, or catching had moderate diagnostic utility for confirming type II to IV SLAP lesions. No single item or combination of history items and physical examination tests had diagnostic utility for type I SLAP lesions.

Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete

Due to the complexity of shoulder pathomechanics in the overhead athlete, injuries located in the superior aspect of the glenoid, known as superior labral anterior to posterior (SLAP) lesions, are often a surgical and rehabilitation challenge. In an effort to determine surgical versus conservative care of SLAP lesions a thorough clinical examination and evaluation are necessary. If surgery is identified as the treatment of choice, post operative rehabilitation will vary pending surgical findings including the extent and location of the SLAP lesion, and other concomitant findings and procedures. This manuscript will provide an overview of the pathology, examination and evaluation of SLAP lesions, surgical management and post operative rehabilitation following various SLAP categories.

Management of the throwing shoulder: cuff, labrum and internal impingement

Repetitive throwing or other overhead activity places great stress on the shoulder. As a result, the shoulder is a common site of injury in athletes. Addressing throwing-related injuries requires an understanding of throwing biomechanics and pathology. Nonoperative treatment is directed at restoring strength, flexibility, and neuromuscular control to the entire kinetic chain. Surgery is indicated when nonoperative treatment fails, and is directed at correcting labral, capsular, and rotator cuff pathology.

The passive distraction test: a new diagnostic aid for clinically significant superior labral pathology

PURPOSE

The purpose of this report is to present a new provocative maneuver, the passive distraction test (PDT), as an examination tool to be used in the evaluation of patients thought to have a SLAP lesion and to compare its accuracy, precision, and reproducibility alone and in conjunction with previously published maneuvers.

METHODS

A retrospective analysis of 319 consecutive arthroscopies performed between May 2001 and November 2003 was performed. A total of 65 cases were excluded, 53 because of limitation of elevation to less than 150 degrees or pain in the starting test position and 12 who had previous shoulder procedures performed by the senior author, leaving 254 cases for review. A thorough history was obtained and a thorough physical examination performed with a focus on the involved shoulder including specific provocative maneuvers for the clinical diagnosis of a SLAP lesion. The active compression test, the anterior slide test, and the PDT were used to clinically diagnose a SLAP lesion. The results from the 3 provocative maneuvers were compared with the arthroscopic findings to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value of each test alone and in a logical combination.

RESULTS

Of 254 shoulder arthroscopies, 61 had a clinically significant SLAP lesion, for an incidence of 24%. The sensitivity and specificity for the PDT were 53% and 94%, respectively, with an NPV of 87% and positive predictive value of 72%. In combination, the PDT and the active compression test yielded an NPV of 90.5%.

CONCLUSIONS

The PDT can be used alone or in combination to aid in the clinical evaluation and diagnosis of a SLAP lesion.

LEVEL OF EVIDENCE

Level IV, retrospective, diagnostic, sensitivity-specificity study.

Clinical and imaging assessment for superior labrum anterior and posterior lesions

In the evaluation of the painful shoulder, especially in the overhead athlete, diagnosing superior labrum anterior and posterior (SLAP) lesions continues to challenge the clinician because of 1) the lack of specificity of examination tests for SLAP; 2) a paucity of well-controlled studies of those tests; and 3) the presence of coexisting confounding abnormalities. Some evidence indicates that multiple positive tests increase the likelihood that a SLAP lesion is present, but no one physical examination finding conclusively makes that diagnosis. The goals of this article were to review the physical examination techniques for making the diagnosis of SLAP lesions, to evaluate the clinical usefulness of those examinations, and to review the role of magnetic resonance imaging in making the diagnosis.

Evaluation of clinical assessment methods for scapular dyskinesis

PURPOSE

The purposes of this study were to (1) assess the inter-rater reliability and validity of 2 clinical assessment methods of categorizing scapular dyskinesis and (2) quantify the frequency of asymmetry of bilateral scapular motion in injured and uninjured shoulders by use of 3-dimensional (3D) kinematic analysis.

METHODS

We evaluated 56 subjects, 35 with shoulder injury and 21 with no symptoms. Two blinded evaluators categorized the scapular motion of all subjects to determine inter-rater reliability using 2 observational methods ("yes/no" and "4 type") to evaluate scapular dyskinesis. Subjects were also instrumented with electromagnetic receivers to assess bilateral 3D scapular kinematics to determine the presence of dyskinesis and establish criterion validity of the 2 methods.

RESULTS

The inter-rater percent agreement and the degree of this agreement as measured by kappa statistic showed that the yes/no method produced a higher inter-rater percent agreement (79%, kappa = 0.40) than the 4-type method (61%, kappa = 0.44). The yes/no method had a higher sensitivity (76%) and positive predictive value (74%) when compared with the 3D criterion. A chi(2) analysis found significantly more multiple-plane asymmetries in symptomatic subjects (54%) in flexion compared with asymptomatic subjects (14%) (P = .002).

CONCLUSIONS

The yes/no method allows multiple-plane asymmetries to be considered in clinical assessment and therefore renders this a good screening tool for the presence of scapular dyskinesis. Kinematic analysis shows that asymmetries are common in symptomatic and asymptomatic populations. Testing in flexion showed a higher frequency of multiple-plane scapular asymmetries in the symptomatic group.

CLINICAL RELEVANCE

Identification of scapular dyskinesis is a key component of the shoulder examination. The clinician's ability to establish the presence or absence of scapular dyskinesis by observation is enhanced using a simple yes/no method especially when testing subjects in shoulder forward flexion. Although scapular asymmetries appear to be a prevalent finding, dyskinesis in the presence of shoulder symptoms should be considered a potential factor contributing to the dysfunction in the presence of shoulder symptoms should be considered a potential factor contributing to the dysfunction.

A meta-analysis examining clinical test utility for assessing superior labral anterior posterior lesions

BACKGROUND

The reported accuracy of clinical tests for superior labral anterior posterior lesions is extremely variable. Pooling results from multiple studies of higher quality is necessary to establish the best clinical tests to use.

HYPOTHESIS

Certain clinical tests are superior to others for diagnosing the presence or absence of a superior labral anterior posterior lesion.

STUDY DESIGN

Meta-analysis.

METHODS

A literature search of MEDLINE (1966-2007), CINAHL (1982-2007), and BIOSIS (1995-2007) was performed for (labrum OR labral OR SLAP OR Bankart) AND (shoulder OR shoulder joint OR glenoid) AND (specificity OR sensitivity AND specificity). Identified articles were reviewed for inclusion criteria. Sensitivity and specificity values were recorded from each study and used for meta-analysis.

RESULTS

Six of 198 identified studies satisfied the eligibility criteria. Active compression, anterior slide, crank, and Speed tests were analyzed using receiver operating characteristic curves. The accuracy of the anterior slide test was significantly inferior to that of the active compression, crank, and Speed tests. There was no significant difference in test accuracy found among active compression, crank, and Speed tests. Between studies, methodological scores did not significantly affect sensitivity and specificity values.

CONCLUSION

The anterior slide test is a poor test for detecting the presence of a labral lesion in the shoulder. Active compression, crank, and Speed tests are more optimal choices. Clinicians should choose the active compression test first, crank second, and Speed test third when a labral lesion is suspected.

Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder

BACKGROUND

Clinical tests are a key element in diagnosing shoulder lesions.

PURPOSE

This study examined the clinical utility of traditional and new examination tests, the upper cut for biceps injuries, and the modified dynamic labral shear for superior glenoid labral lesions.

STUDY DESIGN

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

METHODS

A total of 325 consecutive patients who were seen for shoulder pain underwent a standardized clinical testing battery. Six clinical tests that have been previously reported in the literature (Yergason's, Speed's, bear hug, belly press, O'Brien's, and anterior slide) and 2 new examination tests (upper cut and modified dynamic labral shear) were performed. Clinical examination findings were correlated with findings in those who came to surgery (101 patients). Sensitivity, specificity, accuracy, positive/negative predictive value, and positive/negative likelihood ratio were calculated for each test. A binary logistic regression analysis was used to determine which tests produced the most significant findings.

RESULTS

For biceps disease, the bear hug and upper cut were most sensitive (0.79 and 0.73, respectively), whereas the belly press and Speed's test were most specific (0.85 and 0.81, respectively). The upper cut was most accurate (0.77) and produced the highest positive likelihood ratio (3.38). For labral injury, the modified dynamic labral shear demonstrated sensitivity of 0.72, specificity of 0.98, accuracy of 0.84, and a positive likelihood ratio of 31.57. A binary logistic regression analysis revealed that the combination of the upper cut and Speed's tests were significantly better at detecting biceps lesions (P = .021, R(2) = .400) than other tests, whereas labral lesions were best identified by combination of the modified dynamic labral shear and O'Brien's maneuvers (P = .045, R(2) = .641).

CONCLUSION

The new tests are helpful additions to the clinical examination for shoulder injury. The modified dynamic labral shear test demonstrates high scores for clinical utility and exhibits a high likelihood ratio, indicating a significant probability of affecting the clinical decision, which should moderately or significantly improve the diagnostic conclusion and allow the clinician to be more efficient in making an accurate diagnosis.

Internal impingement of the shoulder

Internal impingement of the shoulder is a pathologic condition characterized by excessive or repetitive contact of the greater tuberosity of the humeral head with the posterosuperior aspect of the glenoid when the arm is abducted and externally rotated. This arm positioning leads to rotator cuff and glenoid labrum impingement by the bony structures of the glenohumeral joint. Although some degree of contact between these structures occurs under normal conditions, to date most of the orthopaedic literature has focused on internal impingement as a disease state that affects overhead athletes and is characterized by the development of articular-sided rotator cuff tears and posterosuperior labral lesions. The precise cause of these impingement lesions remains unclear. However, it is believed that varying degrees of glenohumeral instability, posterior capsular contracture, and scapular dyskinesis may play a role in the development of symptomatic internal impingement. The purpose of this article is to review the pathomechanics, clinical complaints, physical examination findings, and imaging findings that are associated with internal impingement. The results of treatment will be reviewed, and a diagnostic and therapeutic algorithm for the management of internal impingement is presented.

Superior labral lesions anterior to posterior-evaluation and arthroscopic management

Lesions of the superior labrum are complex and difficult to both diagnose and treat effectively. The clinical diagnosis is challenging due to the nonspecific history and physical examination. MRI has substantially improved our ability to detect SLAP tears, although experience is necessary to distinguish pathologic findings from normal anatomic variants. Treatment is determined by patient age, functional demands, and the type of lesion identified.

SLAP lesions: an update on recognition and treatment

Superior labral tears (SLAP lesions) can pose a significant challenge to orthopaedic surgeons and rehabilitation specialists alike. Although advancement in arthroscopic techniques has enhanced arthroscopic repair of SLAP lesions, the clinical diagnosis of SLAP lesions can still be difficult. There is a variety of etiologic factors associated with SLAP lesions and a thorough clinical evaluation is crucial to make the diagnosis. Concomitant injury to the capsular-labral complex or rotator cuff is not uncommon and can further confuse the clinical presentation. The purpose of this paper is to review the pathomechanics, diagnosis, and treatment of SLAP lesions. We will specifically review some of the physical examination tests that are used to diagnose SLAP lesions and report on our technique of arthroscopic repair. Additionally, we will discuss the operative management of associated intra-articular pathology and, finally, we will briefly discuss our postoperative rehabilitation guidelines.

LEVEL OF EVIDENCE

Level 5.

Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury

OBJECTIVES

To investigate the presence of ultrasound (US) abnormalities in manual wheelchair users with spinal cord injury (SCI) using a quantitative Ultrasound Shoulder Pathology Rating Scale (USPRS). To investigate physical examination (PE) findings using a quantitative Physical Examination of the Shoulder Scale (PESS), and to obtain data about pain and other subject characteristics such as age, years with SCI, and weight.

DESIGN

Case series.

SETTING

National Veterans' Wheelchair Games 2005 and 2006.

PARTICIPANTS

Volunteer sample of manual wheelchair users with SCI participating in the National Veterans' Wheelchair Games.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Presence of relationships between US findings, PE findings, pain, and subject characteristics.

RESULTS

The USPRS correlated with age, duration of SCI, and weight (all P<.01), and showed a positive trend with the total Wheelchair User's Shoulder Pain Index (WUSPI) score (r=.258, P=.073). Several US findings related to presence of PE findings for specific structures. The PESS score correlated with the WUSPI (r=.679, P<.001) and duration of SCI (P<.05). The presence of untreated shoulder pain that curtailed activity was noted in 24.5% of subjects, and this was related to increased WUSPI scores (P=.002).

CONCLUSIONS

PE and US abnormalities are common in manual wheelchair users with SCI. The USPRS and PESS demonstrated evidence for external validity and hold promise as research tools. Untreated shoulder pain is common in manual wheelchair users with SCI, and further investigation of this pain is indicated.