Which is more useful, the "full can test" or the "empty can test," in detecting the torn supraspinatus tendon?

Reliability of the Single-Arm and Double-Arm Jobe Test for the Diagnosis of Full-Thickness Supraspinatus Tendon Tear

Background

The Jobe test is commonly used to diagnose full-thickness (FT) supraspinatus (SSP) tendon tear. The original Jobe test used single-arm testing, although the double-arm Jobe test has also been used in clinical practice.

Purpose

To evaluate the reliability, accuracy, and diagnostic value of the single-arm and double-arm Jobe test for diagnosis of FT SSP tear.

Study Design

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

Methods

Patients with shoulder pain requiring magnetic resonance imaging (MRI) of the shoulder between March 1, 2021, and March 31, 2022, were enrolled. Each patient underwent both single-arm and double-arm Jobe tests by 2 orthopaedic surgeons independently, and the presence of pain, weakness, or both during the test was documented. Diagnosis of FT SSP tear on MRI scan was used as the gold standard to compare the diagnostic value of the Jobe test. The interrater reliability of the Jobe test, and the inter- and intrarater reliability of the MRI evaluation (patients with vs without FT SSP tear) was performed using the kappa (κ) coefficient.

Results

A total of 80 patients (57 females [71%]; mean age, 61.46 ± 9.61 years) were included. MRI scans revealed FT SSP tears in 32 (40%) of the patients. Both single- and double-arm Jobe tests had low diagnostic values (accuracy, 46.25% to 60%; sensitivity, 46.9% to 84.4%; specificity, 25% to 66.7%). The single-arm test with weakness revealed the highest sensitivity (84.4%). The double-arm test with weakness plus pain revealed the highest specificity (66.7%). Double-arm testing with pain had the highest accuracy (60%), with the highest positive likelihood ratio (1.5). The interrater reliability of the Jobe test indicated substantial agreement (double-arm vs single-arm, κ = 0.771 and 0.716, respectively, agreement 85%; P < .05). The interrater reliability of MRI scan evaluation of the FT SSP tear indicated substantial agreement (κ = 0.750, agreement 85%; P < .05), while the intrarater reliability indicated almost perfect agreement (κ = 0.917, agreement 96%; P < .05).

Conclusion

The Jobe test, either single- or double-arm, had low accuracy and diagnostic value in diagnosing FT SSP tear. The concern with a single-arm examination for weakness is that it may be an inappropriate diagnostic test for ruling out FT SSP with 84% sensitivity, while a double-arm examination provides a higher specificity.

Accuracy of Critical Shoulder Angle and Acromial Index for Predicting Supraspinatus Tendinopathy

Critical shoulder angle (CSA) is the angle between the superior and inferior bony margins of the glenoid and the most lateral border of the acromion. The acromial index (AI) is the distance from the glenoid plane to the acromial lateral border and is divided by the distance from the glenoid plane to the lateral aspect of the humeral head. Although both are used for predicting shoulder diseases, research on their accuracy in predicting supraspinatus tendinopathy in patients with shoulder pain is limited. Data were retrospectively collected from 308 patients with supraspinatus tendinopathy between January 2018 and December 2019. Simultaneously, we gathered the data of 300 patients with shoulder pain without supraspinatus tendinopathy, confirmed through ultrasound examination. Baseline demographic data, CSA, and AI were compared using the independent Student’s t test and Mann–Whitney U test. Categorical variables were analyzed using the chi-square test. A receiver operating characteristic curve (ROC) analysis was performed to investigate the accuracy of CSA and AI for predicting supraspinatus tendinopathy, and the optimal cut-off point was determined using the Youden index. No statistical differences were observed for age, sex, body mass index, evaluated side (dominant), diabetes mellitus, and hyperlipidemia between the groups. The supraspinatus tendinopathy group showed higher CSAs (p < 0.001) than did the non-supraspinatus tendinopathy group. For predicting supraspinatus tendinopathy, the area under the curve (AUC) of ROC curve of the CSA was 76.8%, revealing acceptable discrimination. The AUC of AI was 46.9%, revealing no discrimination. Moreover, when patients with shoulder pain had a CSA > 38.11°, the specificity and sensitivity of CSA in predicting supraspinatus tendinopathy were 71.0% and 71.8%, respectively. CSA could be considered an objective assessment tool to predict supraspinatus tendinopathy in patients with shoulder pain. AI revealed no discrimination in predicting supraspinatus tendinopathy in patients with shoulder pain.

Evaluation of the tissue thickness of the supraspinatus and biceps long head tendons using ultrasound among elderly patients with unilateral adhesive capsulitis in the freezing phase

[Purpose] This study aimed to clarify the changes in the tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and evaluate the treatment effects in the freezing phase of adhesive capsulitis. [Participants and Methods] Thirty-two elderly patients with unilateral shoulder pain underwent ultrasound of the supraspinatus and biceps long-head tendons, pain evaluation, and orthopedic testing. Both the supraspinatus and biceps long-head tendons were classified as normal, abnormal, and other groups. Participants with negative orthopedic test results were assigned the “normal group”. Participants with positive orthopedic test results and resting and night pain were assigned the “abnormal group”. Differences in tissue thickness were calculated from the differences between the symptomatic and non-symptomatic sides. [Results] The thickness of the supraspinatus and biceps long-head tendons was significantly higher in the abnormal than in the normal group. [Conclusion] This study clarified the changes in tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and assess the treatment effects in the freezing phase of adhesive capsulitis. The study results suggest the usefulness of ultrasound for selecting the treatment targets for analgesia and assessing the treatment efficacy in cases of adhesive-capsulitis freezing phase.

Supraspinatus tears: predictability of magnetic resonance imaging findings based on clinical examination

BACKGROUND

The shoulder physical examination is frequently performed to diagnose rotator cuff tears in clinical practice; however, there is insufficient evidence on which physical tests are efficient for shoulder impingements in primary care settings. The purposes of this study were (1) to analyze the accuracy of 8 clinical tests to diagnose supraspinatus tendon lesions and investigate whether the combination of these tests can improve the diagnostic values; (2) to assess which are the best positivity criteria for shoulder maneuvers-pain and/or weakness; and (3) to investigate the ability of these tests to distinguish between partial- and full-thickness tears.

METHODS

A total of 733 consecutive patients were prospectively evaluated by 4 shoulder surgeons in this multicenter diagnostic study from May 2017 to December 2018, and 8 clinical tests (empty-can, full-can test, drop arm, painful arc, Neer sign, Hawkins test, Patte test, and resisted external rotation) were compared with magnetic resonance imaging performed by blinded radiologists. We assessed the sensitivity, specificity, accuracy, positive and negative predictive values, and diagnostic odds ratio (DOR) for all tests.

RESULTS

For overall supraspinatus tears, the empty-can test showed the highest sensitivity (0.81), the Patte test (positive for pain and weakness) and the drop-arm test showed the highest specificity (0.99 and 0.98, respectively), and the best combination was the Neer sign and the drop-arm test (DOR, 12.92). The positivity criteria for pain associated with weakness showed the highest performance, with DORs of 16.94 for the Patte test and 10.45 for the empty-can test. The Patte test and resisted external rotation, positive for pain and weakness, showed the highest ability to distinguish between full- and partial-thickness tears (DOR, 5.69 and 5.35, respectively). The shoulder maneuvers showed low negative predictive values; the highest value (0.58) was found with the empty-can test.

CONCLUSIONS

(1) The clinical tests demonstrated excellent diagnostic values; the empty-can test had the highest sensitivity, whereas the drop-arm test and the Patte test had the highest specificity; and the best combination for detecting supraspinatus tears was the Neer sign and the drop-arm test. On the other hand, the physical examination findings showed limited values to rule out tears. (2) The best positivity criterion for shoulder maneuvers was pain associated with weakness. (3) The Patte test and resisted external rotation showed the highest ability to distinguish between full- and partial-thickness tears.

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.

Master swimmers with shoulder pain and disability have altered functional and structural measures

CONTEXT

Supraspinatus tendinopathy and shoulder pain are common in competitive youth swimmers; however, no studies have investigated clinical and structural factors contributing to shoulder pain and disability in master level swimmers.

OBJECTIVE

The objectives of this study were: 1) to determine the prevalence of shoulder pain and disability in master level swimmers, 2) to identify the most provocative special tests for shoulder pain, and 3) to determine if shoulder clinical and tissue specific measures, training variables and volume vary between those with and without shoulder pain, dissatisfaction and disability.

DESIGN

Cross-sectional.

SETTING

Collegiate swimming facilities.

PATIENTS OR OTHER PARTICIPANTS

Thirty-nine adult masters level swimmers were evaluated and included in the data analysis.

MAIN OUTCOME MEASURES

A survey of demographics, training, and pain and disability ratings using the Penn Shoulder Score and Disability of Arm Shoulder Hand sports module. Swimmers underwent a clinical exam including shoulder passive range of motion (PROM), posterior shoulder endurance test (PSET), supraspinatus tendon structure and posterior capsule thickness. One-way ANOVAs were used to compare demographics, clinical and structural findings between those with significant pain, dissatisfaction and disability (+PDD) and those without (-PDD).

RESULTS

Fifteen percent of subjects reported pain at rest, 28% with normal activities (eating, dressing), and 69% with strenuous activities (sports) and 50% reported disability. The +PDD group had less shoulder internal rotation (10°), less ER (8°), and completed less yardage per day and per year. There were significant differences in the supraspinatus tendon structure between the +PDD and -PDD groups.

CONCLUSION

Masters swimmers with pain and disability are able to self-limit yardage and likely why they recorded less yardage. The reduced shoulder motion (IR and ER) without posterior capsule differences may be due to rotator cuff muscle/tendon restrictions and the supraspinatus tendon structure may indicate degeneration caused by previous overuse resulting in pain.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of efficacy of supraspinatus tendon tears diagnostic tests: a prospective study on the "full-can," the "empty-can," and the "Whipple" tests

PURPOSE

This study compares the clinical results of the Whipple, empty-can, and full-can tests to detect supraspinatus tendon tears. We determined the sensitivities, specificities, and positive and negative predictive values of each test with respect to the intraoperative supraspinatus tendon lesion confirmation.

METHODS

We examined 61 patients (26 women, 35 men) presenting for arthroscopic surgery with functional disability or persisting shoulder pain. All the patients underwent Whipple, empty-can, and full-can testing. We correlated the clinical results of the tests with the confirmation of a supraspinatus tendon lesion by direct arthroscopic visualization.

RESULTS

We examined 34 right and 27 left shoulders. For full and partial supraspinatus tendon tears, the Whipple test showed a sensitivity of 88.6% and a specificity of 29.4%, whereas the empty-can test and the full-can test had sensitivities of 88.6% and 75.0%, and specificities of 58.8% and 47.1%, respectively.

CONCLUSIONS

Compared with the empty-can test and the full-can test, the Whipple test was less specific, while its sensitivity was equal to that of the empty-can test and higher than that for the full-can test. Because of its low specificity, the Whipple test has a high risk of false-positive results in comparison with the other tests.

Assessments of activities of daily living after arthroscopic SLAP repair with knot-tying versus knotless suture anchors

PURPOSE

The clinical influence of knot-tying or knotless anchor systems for the arthroscopic repair of SLAP lesions (superior labrum lesion from anterior to posterior) remain unclear.

MATERIALS AND METHODS

In a retrospective cohort analysis, 61 of 78 (78.2%) patients with isolated symptomatic SLAP II lesions were examined with a minimum of 24 months after arthroscopic SLAP repair compared to a control group: 28 patients with knot-tying anchors (group I, G1; 28.95 ± 9.48 years, 23 male/5 female), 33 with knotless anchors (group II, G2; 31 ± 10.09 years, 26 male/7 female) and 140 healthy volunteers (group III, G3; 30.9 ± 8.9 years, 109 male/31 female). The clinical assessment included an examination and estimated parameters of ADL (activities of daily living), the CS (Constant score), ASES (American Shoulder and Elbow score), DASH (disability of arm-shoulder hand) and the RS (Rowe score).

RESULTS

The ROM analysis recorded no significant differences for the external rotation in 0° abduction (G1 63.75° ± 15.55° versus = vs G2 65.30° ± 18.15°; p_{ERG1 vs G2} = 0.72). The clinical outcomes revealed significantly decreased pain status in G1 for the O'brien test and in G2 for the Palm-up test, whereas Yergason test showed similar pain levels (p_O'brien = 0.03; p_{palm up} = 0.02; p_yergason > 0.5). The pulley associated rotator cuff tests revealed a significantly inferior force status in G2 compared to G1 (p_lift-off = 0.005, p_Jobe = 0.02) whereas the further rotator cuff assessments were equal. In general, the intervention group showed increased pain level and functional deficits compared to the G3. The score analysis detected no significant differences with P_{CSG1 vs G2}, P_{ASESG1 vs G2}, P_{DASHG1 vs G2} and P_{RSG1 vs G2} all > 0.05 and significant impairments compared to G3 in all scores p_{G1/G2 vs G3} < 0.05 (CS_G1 = 88.28 ± 14.42, CS_G2=92.73 ± 9.24, CS_G3 = 96.2 ± 4.96; ASES_G1 = 81.10 ± 21.69, ASES_G2 = 85.35 ± 17.12, ASES_G3 = 94.95 ± 10.39,; DASH_G1= 35.75 ± 13.44, DASH_G2 = 36.03 ± 17.55, DASH_G3 = 27.13 ± 6.52; RS_G1 = 90.71 ± 9.88, RS_G2 = 88.33 ± 11.22, RS_G3= 92.96 ± 11.27).

CONCLUSIONS

The clinical assessment revealed for both anchor systems similar outcomes but showed general underestimated impairments after the SLAP repair surgery compared to the healthy control. The clinical status only marginally differed between both techniques, wherefore the present assessment of ADL allowed no recommendation of one of these two specific surgery technique for SLAP repair.

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

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

Intra-rater and inter-rater reliability of six musculoskeletal preparticipatory screening tests

Background

High injury prevalence rates call for effective sports injury prevention strategies, which include the development and application of practical and reliable pre-participatory screening tools.

Objectives

The aim of this study was to investigate the intra-rater and inter-rater reliability of the one-legged hyperextension test (1LHET), the empty can (EC) and full can (FC) tests, the standing stork test (SST), the bridge-hold test (BHT) and the 747 balance test (747BT).

Method

Thirty-five healthy, injury-free male athletes (cricket and soccer players), aged 16–24 years, were evaluated by two physiotherapists. For each of the tests, the participants were evaluated twice (on two consecutive days) by each physiotherapist. Both the intra- and inter-rater reliability were determined. Cohen’s kappa (k) was calculated for the 1LHET, the EC and FC tests and the SST. The intraclass correlation coefficient (ICC) was used for the BHT and the 747BT. A confidence level of 95% (p ≤ 0.05) was applied as the criterion for determining the statistical significance of the results.

Results

The SST presented with the lowest level of intra-rater agreement (ICC = –0.20 to 0.10). On the other hand, the EC test was the only test where one rater achieved an excellent intersessional agreement (k = 0.80; 95% confidence interval [CI] 0.40–1.20). Substantial to excellent results for the inter-rater agreement for both sessions were recorded for the 1LHET (k = 0.70–0.90) and the BHT (ICC = 0.70–0.90).

Conclusion

Reliability values need to be considered when making clinical decisions based on screening tests. A more refined description of the testing procedures and criteria for interpretation might be necessary before including the six screening tests investigated in this study in formal screening protocols.

Clinical implication

Confirmed reliability of screening tests would enable sports professionals to make informed decisions when designing preparticipatory musculoskeletal screening tools and when dealing with the management of injury risks in athletes.

Keywords

musculoskeletal screening; injury risk management; intra-rater reliability; inter-rater reliability; soccer; cricket.

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

Background:

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

Purpose:

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

Study Design:

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

Methods:

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

Results:

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

Conclusion:

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

Diagnostic Value of Clinical Tests for Supraspinatus Tendon Tears

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level 1, diagnostic study.

The Effect of Shoulder Muscle Fatigue on Acromiohumeral Distance and Scapular Dyskinesis in Women With Generalized Joint Hypermobility

Muscle fatigue is considered to be one cause of shoulder pain, and subjects with generalized joint hypermobility (GJH) are affected more by shoulder pain. The purpose of this study was to examine the effects of muscle fatigue on acromiohumeral distance (AHD) and scapular dyskinesis in women with GJH. Thirty-six asymptomatic participants were assigned to either a GJH (n = 20) or control group (n = 16) using the Beighton scale. Before and after elevation fatigue trials, AHD was measured with ultrasonography at rest and when the arm was in 90° active elevation. A scapular dyskinesis test was used to visually observe alterations in scapular movement. Our results showed that in both groups, the fatigue reduced AHD in the 90° elevation position and increased the presence of scapular dyskinesis; however, no differences were found between the two groups. Although GJH has been identified as a factor for developing musculoskeletal disorders, generalized joint hypermobility did not result in changes to scapular dyskinesis or AHD, even after an elevation fatigue task. More studies are needed to evaluate the effects of muscle fatigue in subjects with GJH and a history of shoulder instability.

Muscle Weakness in the Empty and Full Can Tests Cannot Differentiate Rotator Cuff Tear from Cervical Spondylotic Amyotrophy: Pain Provocation is a Useful Finding

Purpose:

Rotator cuff tears and cervical spondylotic amyotrophy (CSA) are often confused as the main symptom in those with difficulty in shoulder elevation. Empty and full can tests are frequently used for the clinical diagnosis of rotator cuff tears. The aim of the present study was to investigate whether the empty and full can test results can help differentiate rotator cuff tears from CSA.

Methods:

Twenty-seven consecutive patients with rotator cuff tears and 25 with CSA were enrolled. We prospectively performed empty and full can tests in patients with rotator cuff tears and CSA. The following signs were considered positive: (a) muscle weakness during the empty can test, (b) muscle weakness during the full can test, (c) pain provocation during the empty can test, and (d) pain provocation during the full can test. We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of rotator cuff tears for each positive finding.

Results:

The sensitivity and specificity of each index were as follows (sensitivity, specificity, PPV, NPV): (a) 77.8%, 0%, 45.7%, 0%; (b) 66.7%, 4.0%, 42.9%, 10.0%; (c) 88.9%, 96.0%, 96.0%, 88.9%; and (d) 74.1%, 96.0%, 95.2%, 77.4%. There were significant differences for each index.

Conclusion:

Muscle weakness during the empty and full can tests was not useful in differentiating rotator cuff tears from CSA because of low specificity and PPV. However, pain provocation was useful in differentiating these two conditions because of high specificity and PPV.

Magnetic resonance arthrography results that indicate surgical treatment for partial articular-sided supraspinatus tendon avulsion: a retrospective study in a tertiary center

Background Specific findings on magnetic resonance arthrography (MRA) that indicate the need for surgery in patients with partial articular-sided supraspinatus tendon avulsion (PASTA) are not well understood. Purpose To determine which MRA findings are characteristic of patients who undergo surgery for PASTA. Material and Methods From July 2011 to February 2014, MRA findings for patients treated for PASTA were retrospectively reviewed. The patients were divided into two groups: conservative treatment and surgical repair. MRA findings were compared between the groups. The following MRA results were assessed: length grade, width grade, co-existing superior labrum anterior posterior (SLAP) lesions, degenerative changes in the glenohumeral joint, presence of subacromial-subdeltoid bursitis, acromion type, presence of adhesive capsulitis, and tears of the subscapularis or infraspinatus tendon within the rotator cuff. Logistic regression analyses were conducted to identify which MRA findings were significantly associated with surgical treatment. Results Forty-five surgically treated patients and 203 conservatively treated ones were evaluated. The MRA findings showed significant differences between the groups with respect to length grade, width grade, degenerative changes in glenohumeral joint, bursitis, and co-existing rotator cuff tears ( P < 0.05). Multivariate logistic regression showed correlations between surgical repair and both grade 3 length tears (odds ratio, 30.8) and co-existing tears of the subscapularis or infraspinatus tendon (odds ratio, 2.9). Conclusion Surgical treatment is commonly performed in PASTA patients whose lesion lengths are grade 3 or who have co-existing tears in the subscapularis or infraspinatus tendon. Radiologists should pay attention to these MRA signs when evaluating PASTA patients.

Proximal ingrowth coating decreases risk of loosening following uncemented shoulder arthroplasty using mini-stem humeral components and lesser tuberosity osteotomy

BACKGROUND

Mini-stem humeral component (MSHC) use during total shoulder arthroplasty (TSA) provides bone preservation and ease of revision. MSHCs rely solely on proximal metaphyseal fixation; some early reports have demonstrated an unacceptably high rate of early loosening. To our knowledge, no study analyzing the effect of proximal porous coating on MSHCs has been performed.

METHODS

We performed a retrospective review of consecutive patients who underwent anatomic TSA using coated or uncoated MSHCs with minimum 2-year follow-up. Postoperative radiographs were assessed for risk of or frank stem loosening, subsidence, and presence of radiolucencies. Range of motion, outcome scores (visual analog scale pain, American Shoulder and Elbow Surgeons, and Single Assessment Numeric Evaluation), and any complications were noted.

RESULTS

We analyzed 68 shoulders with a mean follow-up of 27.3 months (range, 24-50 months). Of these, 34 had proximal coating and 34 were uncoated. In the coated group, no stems loosened, 1 (2.9%) subsided, and 7 (20.6%) developed radiolucencies. In the uncoated group, 1 stem (2.9%) became aseptically loose (requiring revision after 26 months), 7 (20.6%) were judged at risk of loosening (2 because of subsidence), and 15 (44.1%) developed radiolucencies. There was also an increased risk of proximal medial humeral radiolucencies among uncoated MSHCs. There were no significant differences in final range of motion or outcome scores.

CONCLUSION

MSHC use is appropriate for TSA, achieving desired pain relief and functional improvement. Overall, component loosening appears uncommon at early follow-up; however, uncoated stems appear to be at greater risk of loosening and developing radiolucencies. Selecting an MSHC with proximal porous coating may decrease the risk of implant-related complications.

The diagnostic value of a modified Neer test in identifying subacromial impingement syndrome

BACKGROUND

Subacromial impingement syndrome (SAIS) is characterized by pain experienced through an arc of elevation as the shoulder abducts and diagnosed commonly by Neer test (NT). However, the diagnostic accuracy of NT for SAIS is still limited. Here, a modified Neer test (MNT) was introduced to improve the accuracy of the clinical examination in diagnosing SAIS and differentiating it from frozen shoulder. The aim of this study was to investigate the diagnostic values of MNT in diagnosing SAIS and differentiating it from frozen shoulder.

METHODS

Between January 2015 and June 2015, a prospective study assessed 85 shoulders among 82 patients with shoulder joint disease; 42 patients underwent arthroscopic surgery, and all 82 patients received X-rays, magnetic resonance imaging (MRI) or MRI contrast examinations. The diagnostic criteria are based on arthroscopy and MRI scanning.

RESULTS

Using clinical epidemiology and diagnostic tests, we calculated the sensitivity, specificity, positive predictive value, negative predictive value and degree of accuracy of MNT in diagnosing SAIS. The diagnostic accuracy rate of MNT in identifying shoulder SAIS was 90.59%, and the specificity was 95.56%.

CONCLUSIONS

In the diagnosis of SAIS, MNT is a reliable and highly accurate maneuver and seems useful to distinguish this syndrome from frozen shoulder.

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.

Full can test: Mechanisms of a positive test in patients with shoulder pain

BACKGROUND

The full can test is theorized to produce compressive loads on the supraspinatus tendon within the subacromial space. Characterizing the width of the subacromial outlet, scapular orientation, and shoulder pain during the full can test will improve the mechanistic understanding of the positive full can test.

METHODS

Cross-sectional repeated measures design. Participants with subacromial pain syndrome (n=30) were compared to a matched control group (n=30) during 2 conditions: passive support, and the full can test. The full can test was performed with the arm elevated to 90° in the scapular plane. In both conditions, measurements were taken of acromiohumeral distance with ultrasonography, scapular position using electromagnetic tracking, shoulder strength using a dynamometer, and shoulder pain with the 11-point rating scale.

FINDINGS

During the full can test, both groups had a decreased acromial humeral distance, scapular upward rotation, posterior tilt, external rotation and clavicular protraction as compared to passive support (p<0.05). The subacromial pain group as compared to the control group reported greater shoulder pain (p<0.001), reduced strength (p=0.002) and greater scapular anterior tilt (p<0.05) during the full can test.

INTERPRETATION

This study indicates the mechanisms of a full can test are a reduction in the acromial humeral distance, accompanied by scapular kinematic changes. A positive test of increased pain and reduced strength in those with subacromial pain syndrome can be explained additionally by an increase in scapular anterior tilt. These mechanistic changes may lead to tendon compression, but this cannot be verified as direct tendon compression was not measured.

The Hug-up Test: A New, Sensitive Diagnostic Test for Supraspinatus Tears

Background:

The supraspinatus tendon is the most commonly affected tendon in rotator cuff tears. Early detection of a supraspinatus tear using an accurate physical examination is, therefore, important. However, the currently used physical tests for detecting supraspinatus tears are poor diagnostic indicators and involve a wide range of sensitivity and specificity values. Therefore, the aim of this study was to establish a new physical test for the diagnosis of supraspinatus tears and evaluate its accuracy in comparison with conventional tests.

Methods:

Between November 2012 and January 2014, 200 consecutive patients undergoing shoulder arthroscopy were prospectively evaluated preoperatively. The hug-up test, empty can (EC) test, full can (FC) test, Neer impingement sign, and Hawkins-Kennedy impingement sign were used and compared statistically for their accuracy in terms of supraspinatus tears, with arthroscopic findings as the gold standard. Muscle strength was precisely quantified using an electronic digital tensiometer.

Results:

The prevalence of supraspinatus tears was 76.5%. The hug-up test demonstrated the highest sensitivity (94.1%), with a low negative likelihood ratio (NLR, 0.08) and comparable specificity (76.6%) compared with the other four tests. The area under the receiver operating characteristic curve for the hug-up test was 0.854, with no statistical difference compared with the EC test (z = 1.438, P = 0.075) or the FC test (z = 1.498, P = 0.067). The hug-up test showed no statistical difference in terms of detecting different tear patterns according to the position (χ² = 0.578, P = 0.898) and size (Fisher's exact test, P > 0.999) compared with the arthroscopic examination. The interobserver reproducibility of the hug-up test was high, with a kappa coefficient of 0.823.

Conclusions:

The hug-up test can accurately detect supraspinatus tears with a high sensitivity, comparable specificity, and low NLR compared with the conventional clinical tests and could, therefore, improve the diagnosis of supraspinatus tears in clinical settings.

Diagnostic Accuracy of Clinical Examination and Imaging Findings for Identifying Subacromial Pain

BACKGROUND

The diagnosis of subacromial pathology is limited by the poor accuracy of clinical tests for specific pathologies. The aim of this study was to estimate the diagnostic accuracy of clinical examination and imaging features for identifying subacromial pain (SAP) defined by a positive response to diagnostic injection, and to evaluate the influence of imaging findings on the clinical diagnosis of SAP.

METHODS AND FINDINGS

In a prospective, diagnostic accuracy design, 208 consecutive patients presenting to their primary healthcare practitioner for the first time with a new episode of shoulder pain were recruited. All participants underwent a standardized clinical examination, shoulder x-ray series and diagnostic ultrasound scan. Results were compared with the response to a diagnostic block of xylocaineTM injected into the SAB under ultrasound guidance using ≥80% post-injection reduction in pain intensity as the positive anaesthetic response (PAR) criterion. Diagnostic accuracy statistics were calculated for combinations of clinical and imaging variables demonstrating the highest likelihood of a PAR. A PAR was reported by 34% of participants. In participants with no loss of passive external rotation, combinations of three clinical variables (anterior shoulder pain, strain injury, absence of symptoms at end-range external rotation (in abduction)) demonstrated 100% specificity for a PAR when all three were positive (LR+ infinity; 95%CI 2.9, infinity). A full-thickness supraspinatus tear on ultrasound increased the likelihood of a PAR irrespective of age (specificity 98% (95%CI 94, 100); LR+ 6.2; 95% CI 1.5, 25.7)). Imaging did not improve the ability to rule-out a PAR.

CONCLUSION

Combinations of clinical examination findings and a full-thickness supraspinatus tear on ultrasound scan can help confirm, but not exclude, the presence of subacromial pain. Other imaging findings were of limited value for diagnosing SAP.

Risk Factors, Pathobiomechanics and Physical Examination of Rotator Cuff Tears

Background:

It is important to appreciate the risk factors for the development of rotator cuff tears and specific physical examination maneuvers.

Methods:

A selective literature search was performed.

Results:

Numerous well-designed studies have demonstrated that common risk factors include age, occupation, and anatomic considerations such as the critical shoulder angle. Recently, research has also reported a genetic component as well. The rotator cuff axially compresses the humeral head in the glenohumeral joint and provides rotational motion and abduction. Forces are grouped into coronal and axial force couples. Rotator cuff tears are thought to occur when the force couples become imbalanced.

Conclusion:

Physical examination is essential to determining whether a patient has an anterosuperior or posterosuperior tear. Diagnostic accuracy increases when combining a series of examination maneuvers.

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

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

The accuracy of "subacromial grind test" in diagnosis of supraspinatus rotator cuff tears

Purpose:

The aim of this study is to assess the accuracy of a simple clinical test (subacromial grind test) in diagnosing supraspinatus tendon tears.

Patients and Methods:

The test is considered positive if palpable crepitus or grinding is detected on passive internal and external rotation of the shoulder while abducted in the scapular plane. Data were collected prospectively on 47 patients undergoing shoulder arthroscopy, and the results of the test and arthroscopy compared.

Results:

During arthroscopy, 17 patients had full thickness (FT) tears of supraspinatus tendon and 10 had partial thickness tears. For any supraspinatus tear, the sensitivity of the test was 63%, specificity 95%, positive predictive value 94%, negative predictive value 66% and overall accuracy 79%. For FT tears, the sensitivity was 82%, specificity 87%, positive predictive value 78%, negative predictive value 90% and overall accuracy 85%.

Conclusion:

We found that this is a useful single test for diagnosing FT supraspinatus tears.

Level of Evidence:

Level IV diagnostic study.

Electromyographic study of rotator cuff muscle activity during full and empty can tests

The empty can (EC) and full can (FC) tests are used as diagnostic tools for patients with rotator cuff disease. However, recently concerns have been raised that these tests do not selectively activate the muscle. Therefore, the purpose of this study was to evaluate the rotator cuff muscle activation levels during the EC and FC tests in various positions using electromyography. Twelve healthy, right-handed men without shoulder complaints (mean age: 26.1 years, range: 23-35 years) were included. The tests were performed isometrically with the shoulder elevated at 45° and 90° in the sagittal, scapular, and coronal planes, either in the thumb-up (FC test) or thumb-down (EC test) positions. During these positions, the electromyographic signal was recorded simultaneously from the four shoulder muscles using a combination of surface and intramuscular fine-wire electrodes. The average activation of the supraspinatus and subscapularis was greater during the EC test than during the FC test and in the scapular and coronal planes than in the sagittal plane at 90°. For the infraspinatus, there were no significant differences in any positions between the two tests. Thus, the rotator cuff muscles are influenced by arm position and the elevation plane during the EC and FC tests.

Assessment of function in patients with rotator cuff tears: Functional test versus self-reported questionnaire

Purpose:

The rotator cuff tears (RCT) are a well-known cause of shoulder pain and loss of upper extremity function. The purpose of this study was to evaluate the upper extremity function using two different methods in patients with RCT and to determine the parameters that influence the upper extremity function.

Materials and Methods:

A sample of 38 patients (27-76 years; 10 men and 28 women) who were diagnosed with a chronic full-thickness RCT, confirmed by magnetic resonance imaging (MRI), was studied. Upper extremity function was determined using Western Ontario Rotator Cuff Index (WORC) and 9 Hole Peg Test (9PEG). Other assessments included active range of motion (ROM), muscle strength, shoulder pain, and scapular dyskinesis.

Results:

There was a weak association between WORC scores and 9PEG. A statistically significant, negative relationship was found between 9PEG and ROM in supination, as well as muscle strength of shoulder extensors, adductors, internal and external rotators.

Conclusions:

In addition to the weak association between WORC and 9PEG, the difference between the parameters related to each method suggests that they should not be used interchangeably to determine the upper extremity function. We recommend the utilization of 9PEG instead of WORC in assessing the upper extremity function in the setting of loss of muscle strength.

Level of Evidence:

Level IV, Therapeutic study.

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.

Comparison of muscle activity in the empty-can and full-can testing positions using 18 F-FDG PET/CT

Background

There has been much controversy over specific tests for diagnosis of supraspinatus tendon tear. The aim of this study was to evaluate the metabolic activity of the deltoid and rotator cuff muscles while maintaining the full-can and empty-can testing positions using 2-deoxy-2-[¹⁸ F]fluoro-D-glucose (¹⁸ F-FDG) positron emission tomography (PET)/computed tomography (CT).

Methods

Ten healthy volunteers without shoulder pain or diabetes mellitus participated in this study. Following FDG injection, both arms were maintained in either the empty-can or full-can position for 10 min. PET/CT was performed 40 min after injection. Maximum standardized uptake values (SUVs) were measured in the deltoid and rotator cuff muscles on axial PET images.

Results

The middle deltoid exhibited the most significant increase in muscle activity at both testing positions. Additionally, a significant increase in muscle activity was observed in the middle deltoid compared with the supraspinatus (P < 0.05) in the empty-can testing position. SUVs of the middle deltoid, supraspinatus, and subscapularis showed a significant increase in the empty-can testing position compared with the full-can testing position (P < 0.05).

Conclusions

Significantly increased activity of the supraspinatus in conjunction with the middle deltoid and subscapularis after empty-can testing may result in decreased specificity of the empty-can test in detecting isolated supraspinatus activity. The full-can test, however, may be used to test the function of the supraspinatus with the least amount of surrounding middle deltoid and subscapularis activity.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intensity and distribution of shoulder pain in patients with different sized postero-superior rotator cuff tears

BACKGROUND

The vast majority of studies regarding rotator cuff tears (RCTs) are focused on etiopathogenesis and treatments, but information on shoulder pain characteristics needs further investigation. We analyzed the intensity and distribution of shoulder pain in patients with different sizes of RCTs.

METHODS

Two hundred eighty-five consecutive patients with postero-superior RCTs were enrolled for this study. Tear size was intraoperatively classified. Before surgery, all patients completed an upper limb pain map (dermatome map made by Keegan). Shoulder pain intensity was assessed with a visual analogue scale (VAS). Data were submitted to statistical analysis.

RESULTS

Shoulder pain intensity caused by a RCT was greater in females (P = .024); it did not vary with the side nor with age. Pain intensity was less in massive tears (P < .05) and in patients whose pain was distributed only to the shoulder (P = .035). Furthermore, patients whose pain persisted for more than 6 months maintained the same pain intensity. Pain was localized predominantly on dermatomes C5-C6, was more diffuse in massive tears (P < .05), and rarely extended beyond the elbow. In the presence of intense shoulder pain, its precise distribution was not well-delimited.

CONCLUSION

Shoulder pain characteristics in patients with RCTs may be influenced by gender and size of tear. Cuff tear pain distribution principally involves the antero-lateral aspect of the shoulder with extension down the lateral surface of the arm to the elbow. Information about pain intensity and distribution in patients with RCTs may contribute to a more accurate diagnosis.

LEVELS OF EVIDENCE

Level III, cross sectional study.

Diagnostic value of clinical tests for degenerative rotator cuff disease in medical practice

OBJECTIVES

To assess the diagnostic value of clinical tests for degenerative rotator cuff disease (DRCD) in medical practice.

METHODS

Patients with DRCD were prospectively included. Eleven clinical tests of the rotator cuff have been done. One radiologist performed ultrasonography (US) of the shoulder. Results of US were expressed as normal tendon, tendinopathy or full-thickness tear (the reference). For each clinical test and each US criteria, sensitivity, specificity, negative predictive value and positive predictive value, accuracy, negative likelihood ratio (NLR) and positive likelihood ratio (PLR) were calculated. Clinical relevance was defined as PLR ≥2 and NLR ≤0.5.

RESULTS

For 35 patients (39 shoulders), Jobe (PLR: 2.08, NLR: 0.31) and full-can (2, 0.5) test results were relevant for diagnosis of supraspinatus tears and resisted lateral rotation (2.42, 0.5) for infraspinatus tears, with weakness as response criteria. The lift-off test (8.50, 0.27) was relevant for subscapularis tears with lag sign as response criteria. Yergason's test (3.7, 0.41) was relevant for tendinopathy of the long head of the biceps with pain as a response criterion. There was no relevant clinical test for diagnosis of tendinopathy of supraspinatus, infraspinatus or subscapularis.

CONCLUSIONS

Five of 11 clinical tests were relevant for degenerative rotator cuff disease.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

Clinical examination of the rotator cuff

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

Does adding heavy load eccentric training to rehabilitation of patients with unilateral subacromial impingement result in better outcome? A randomized, clinical trial

PURPOSE

To investigate superior value of adding heavy load eccentric training to conservative treatment in patients with subacromial impingement.

METHODS

Sixty-one patients with subacromial impingement were included and randomly allocated to the traditional rotator cuff training (TT) group (n = 30, mean age = 39.4 ± 13.1 years) or traditional rotator training combined with heavy load eccentric training (TT + ET) group (n = 31, mean age = 40.2 ± 12.9 years). Isometric strength was measured to abduction at 0°, 45° and 90° of scapular abduction and to internal and external rotation. The SPADI questionnaire was used to measure shoulder pain and function. Patients rated subjective perception of improvement. Outcome was assessed at baseline, at 6 and 12 weeks after start of the intervention. Both groups received 9 physiotherapy treatments over 12 weeks. At home, the TT group performed traditional rotator cuff strengthening exercises 1x/day. The TT + ET group performed the same exercises 1x/day and a heavy load eccentric exercise 2x/day.

RESULTS

After treatment, isometric strength had significantly increased in all directions, and SPADI score had significantly decreased. The TT + ET group showed a 15% higher gain in abduction strength at 90° of scapular abduction. Chi-square tests showed patients' self-rated perception of improvement was similar in both groups.

CONCLUSION

Adding heavy load eccentric training resulted in a higher gain in isometric strength at 90° of scapular abduction, but was not superior for decreasing pain and improving shoulder function. This study showed that the combination of a limited amount of physiotherapy sessions combined with a daily home exercise programme is highly effective in patients with impingement.

LEVEL OF EVIDENCE

II.

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.

Rotator cuff tear: physical examination and conservative treatment

Rotator cuff tear is one of the most common shoulder diseases. It is interesting that some rotator cuff tears are symptomatic, whereas others are asymptomatic. Pain is the most common symptom of patients with a tear. Even in patients with an asymptomatic tear, it may become symptomatic with an increase in tear size. Physical examination is extremely important to evaluate the presence, location, and extent of a tear. It also helps us to understand the mechanism of pain. Conservative treatment often works. Patients with well-preserved function of the supraspinatus and infraspinatus are the best candidates for conservative treatment. After a successful conservative treatment, the symptom once disappeared may come back again. This recurrence of symptoms is related to tear expansion. Those with high risk of tear expansion and those with less functional rotator cuff muscles are less likely to respond to conservative treatment. They may need a surgical treatment.

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.

Short-term outcomes of extracorporeal shock wave therapy for the treatment of chronic non-calcific tendinopathy of the supraspinatus: a double-blind, randomized, placebo-controlled trial

Background

There is evidence supporting the use of extracorporeal shock wave therapy (ESWT) in calcific tendinopathy of the rotator cuff, but the best current evidence does not support its use in non-calcifying tendinopathy. We conducted a randomized placebo-controlled trial to investigate the efficacy and safety of low energy ESWT for non-calcifying tendinopathy of the rotator cuff.

Methods

20 patients with non-calcifying supraspinatus tendinopathy (NCST) were randomized to an active or a sham treatment group. Physical, blood, roentgenographic, and MRI examinations of the shoulder were conducted to verify that patients met the inclusion and exclusion criteria. These examinations were repeated six and twelve weeks after treatments. Effectiveness was determined by comparison of the mean improvement in the Constant and Murley score (CMS) between the treatment and the placebo groups at three months. Safety was assessed by analyzing the number and severity of adverse events.

Results

All the patients completed the investigation protocol. At the final follow-up, significant improvement in the total CMS score and most of the CMS subscales was observed in the ESWT group when compared to the baseline values. Significantly higher total CMS, and significantly higher scores for CMS pain and ROM were observed in the ESWT group when compared to the placebo. No serious adverse events were noted after ESWT.

Conclusions

Patients suffering from NCST may benefit from low energy ESWT, at least in short-term. The application protocol of ESWT is likely to play a key-role in a successful treatment. Future investigations should be undertaken on the long-term effects of this technique for the treatment of NCST.

Trial registration

Current Controlled Trials ISRCTN41236511

Evaluation and treatment of rotator cuff tears

Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.

Clinical tests for the diagnosis of rotator cuff disease

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

Comprehensive impairment-based exercise and manual therapy intervention for patients with subacromial impingement syndrome: a case series

STUDY DESIGN

Case series.

BACKGROUND

Few studies have defined the dosage and specific techniques of manual therapy and exercise for rehabilitation for patients with subacromial impingement syndrome. This case series describes a standardized treatment program for subacromial impingement syndrome and the time course and outcomes over a 12-week period.

CASE DESCRIPTION

Ten patients (age range, 19-70 years) with subacromial impingement syndrome defined by inclusion and exclusion criteria were treated with a standardized protocol for 10 visits over 6 to 8 weeks. The protocol included a 3-phase progressive strengthening program, manual stretching, thrust and nonthrust manipulation to the shoulder and spine, patient education, activity modification, and a daily home exercise program of stretching and strengthening. Patients completed a history and measures of impairments and functional disability at 2, 4, 6, and 12 weeks.

OUTCOMES

Treatment success was defined as both a 50% improvement on the Disabilities of the Arm, Shoulder, and Hand (DASH) score and a global rating of change of at least "moderately better." At 6 weeks, 6 of 10 patients had a successful (mean +/- SD) DASH outcome score (initial, 33.9 +/- 16.2; 6 weeks, 8.1 +/- 9.2). At 12 weeks, 8 of 10 patients had a successful DASH outcome score (initial, 33.1 +/- 14; 12 weeks, 8.3 +/- 6.4). As a group, the largest improvement was in the first 2 weeks. The most common impairments for all 10 patients were rotator cuff and trapezius muscle weakness (10 of 10 patients), limited shoulder internal rotation motion (8 of 10 patients), and reduced kyphosis of the midthoracic area (7 of 10 patients).

DISCUSSION

A program aimed at strengthening rotator cuff and scapular muscles, with stretching and manual therapy aimed at thoracic spine and the posterior and inferior soft-tissue structures of the glenohumeral joint appeared to be successful in the majority of patients. This case series describes a comprehensive impairment-based treatment which resulted in symptomatic and functional improvement in 8 of 10 patients in 6 to 12 weeks.

LEVEL OF EVIDENCE

Therapy, level 4.