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

Survey on Knowledge, Use, and Diagnostic Applicability of Special Tests for Rotator Cuff Involvement in Clinical Practice

Background

Recently, researchers have commented that shoulder special tests cannot identify the structure causing rotator cuff symptoms and should only be considered pain provocation tests. Others have disagreed, reporting that special tests were able to accurately detect the presence of rotator cuff involvement.

Purpose

The purpose of this study was to determine the knowledge, use, and perceived effectiveness of 15 selected special tests utilized to examine patients with possible rotator cuff dysfunction.

Study Design

Descriptive study using survey.

Methods

An electronic survey was returned by 346 members of the Academies of Orthopedic and Sports Physical Therapy through list serves. Descriptions and pictures for 15 special tests of the shoulder were included in the survey. Information regarding years of clinical experience and American Board of Physical Therapy Specialties (ABPTS) specialist certification in Sports or Orthopedics was collected. Respondents were asked if they could identify and use the special tests to evaluate dysfunction of the rotator cuff - and how confident they were in ability of the tests to diagnose dysfunction of the rotator cuff.

Results

The four tests most readily known by respondents included the empty can, drop arm, full can, and Gerber's tests, and the four tests used regularly by the respondents included the infraspinatus, full can, supraspinatus, and champagne toast tests. The infraspinatus, champagne toast, external rotation lag (ERLS), and the belly-off tests were found to be the be most useful for establishing a diagnosis of the muscle-tendon complex involved. Years of experience and clinical specialization was not relevant to knowledge or use or these tests.

Conclusions

This study will allow clinicians and educators to understand which special tests are easily identified, regularly used, and perceived as helpful for the diagnosis of muscles involved in a rotator cuff dysfunction.

Level of Evidence

3b.

Acromioclavicular joint injuries revisited: Pathoanatomy, pathomechanics, and clinical presentation

Multiple papers have described aspects of treatment of acromioclavicular (AC) joint injuries. Most have emphasized aspects of surgical treatment, and some papers have addressed non-operative treatment. Few papers have highlighted the specific pathoanatomy of an AC joint injury or have described methods of evaluating the 3-dimensional pathomechanics resulting from the pathoanatomical injury. This paper is based on 3 observations: (1) AC joint injuries exist and present on a spectrum of pathoanatomy; (2) The effect of the pathoanatomy on normal AC joint mechanics to produce pathomechanics is dependent on the extent of the pathoanatomy; and (3) Treatment protocols should be developed to address the specific pathoanatomy to optimize the mechanics. A comprehensive clinical approach emphasizing the evaluation of the extent of the anatomic injury and understanding its mechanical consequences regarding shoulder and arm function is a key in the development of guidelines for developing operative or non-operative treatment protocols and for establishing outcomes of the treatment protocols.

Reliable diagnosis of posterosuperior rotator cuff tears requires a combination of clinical tests

PURPOSE

Clinical diagnosis of posterosuperior rotator cuff tears remains uncertain due to a lack of evidence-based consensus. This review aimed to compare the diagnostic accuracy of commonly used clinical tests for posterosuperior rotator cuff tears.

METHODS

The authors conducted an electronic literature search using Medline, Embase and the Cochrane library/Central, to identify original clinical studies reporting diagnostic accuracy of clinical tests to diagnose the presence of posterosuperior rotator cuff tears involving the infraspinatus, supraspinatus and/or teres minor.

RESULTS

The electronic literature search returned 1981 records, of which 14 articles were eligible. Among 17 tests included in the systematic review, 6 tests were eligible for meta-analysis: drop arm sign, Jobe test, external rotation lag sign, Hawkins-Kennedy test, Neer test and painful arc abduction test. According to QUADAS-2 criteria, risk of bias was low in 1 study, moderate in 2 and high in 4. The highest pooled sensitivity was 0.77 (CI 0.67-0.85), for the Jobe test, while the lowest pooled sensitivity was 0.38 (CI 0.01-0.98), for the drop arm sign.

CONCLUSIONS

The Jobe test had the best pooled sensitivity, while the drop arm sign had the best pooled specificity. As no single clinical test is sufficiently reliable to diagnose posterosuperior rotator cuff tears, clinicians should consider various combinations of patient characteristics and clinical tests, as well as imaging modalities, to confirm diagnosis and select the appropriate treatment option. More reliable clinical diagnosis of posterosuperior rotator cuff tears could reduce the reliance on magnetic resonance imaging or arthrography and their associated costs and waiting times.

LEVEL OF EVIDENCE

Level II.

Development of supraspinatus imaging guidance for primary care physicians with a focus on patient selection

Background

Primary care physicians frequently encounter patients with supraspinatus pathology and face a difficult task of managing this subset of patients using limited imaging resources. The purpose of this study was to develop a guidance that could help primary care physicians choose appropriate imaging tests judiciously for patients with suspected supraspinatus pathology.

Methods

The imaging reports of one hundred patients who underwent ultrasound and MRI for suspected supraspinatus tendinopathy were retrospectively assessed. The supraspinatus tendon was recorded as intact, partial tear (articular or bursal), or full-thickness tear (focal or complete width). The agreement between imaging modalities was then evaluated using factors such as pathology type and age.

Results

There was agreement between modalities in 48/100 patients (Kappa statistic = 0.30). The consistency varied with type of pathology: intact tendons by ultrasound had 55.8% agreement with MRI, partial sided bursal tears 50%, partial sided articular tears 25%, and full-thickness focal tears 33.3%. Full-thickness complete-width tears had a much better agreement with MRI at 90.9%. Age was also significant, with increased disagreement between ultrasound and MRI in patients over 50 years old.

Conclusions

Our data showed that ultrasound findings correlated well with MRI in patients under 50 years of age and also in patients with full-thickness supraspinatus tears. We recommend that primary care physicians may consider using ultrasound as the initial test in younger patients and in patients with suspected full supraspinatus tears, based on clinical exam, with MRI as an option for further evaluation to quantify supraspinatus muscle atrophy. These patient selection recommendations will help promote mindful utilization of scarce resources.

Large Partial-Thickness Tear of the Subscapularis Tendon

A 27-year-old active-duty male sailor directly accessed physical therapy for deep left anterior shoulder pain. The patient sustained his injury the previous day, when he threw a left hook into the body of his sparring partner, creating a sudden high-energy external rotation force. Based on the patient's complaint, mechanism of injury, and internal rotation weakness, the examining physical therapist ordered magnetic resonance imaging. The images revealed a large partial tear, with retraction of the subscapularis tendon at the lesser tuberosity, a labral tear, and an intratendon biceps tendon tear with subluxation. J Orthop Sports Phys Ther 2018;48(12):983. doi:10.2519/jospt.2018.8221.

Many Shoulder MRI Findings in Elite Professional Throwing Athletes Resolve After Retirement: A Clinical and Radiographic Study

BACKGROUND

Anatomic findings on MRI scans of the shoulder likely affect patients differently based on their physical demands and fitness levels. The natural history of these anatomic findings once professional overhead athletes retire remains unclear. A better understanding of what happens with these findings after retirement may influence how we manage shoulder problems in athletes.

PURPOSE

(1) What is the natural history of MRI-observed findings in the throwing and nonthrowing shoulders of professional European handball players after retirement from the sport? What proportion of these individuals have diagnosable findings on MRI, and do these findings disappear after retirement? (2) Do clinical findings such as Constant and Murley score and shoulder ROM change after retirement in these professional overhead athletes?

METHODS

The inception cohort of this series consisted of the entire Swiss National European handball team except the goalkeepers. These 30 professional players also played in the highest Swiss handball league in 2001. None of these players previously had shoulder surgery. During their career, they had a clinical assessment and bilateral shoulder MRI as part of an earlier study. We sought to evaluate the players who had retired and did not have a history of shoulder surgery, to evaluate the natural history of MRI-observed findings made in the initial study during their professional career. Of the 30 players, 10 were excluded (four continued to play professionally, four declined participation, and two had surgery after the initial study), leaving 20 (66%) for analysis at a mean of 6 years (SD, 3 years) after retirement. To gain a better understanding of the evolution of these MRI findings in the longer-term, we also evaluated 18 additional former professional European handball players who did not have any history of shoulder surgery, had all played in the highest Swiss league and for the National Team, and had terminated their career at a mean of 15 years (SD, 3 years) ago. All the subjects in both study groups (those at 6 and 15 years after retirement) underwent a detailed interview, standardized clinical examination including ROM measurements, collection of the Constant and Murley scores and the subjective shoulder value of both shoulders, and bilateral shoulder MRI. MRI findings (consisting of abnormalities and normal variations) were reported as radiographic diagnoses, independent of the potential that these findings could be considered normal variations in people in this age group.

RESULTS

At the initial MRI evaluation, the proportion of active professional European handballers with diagnosable MRI findings in the throwing shoulder was 19 of 20 (95%) and for the handballers with nonthrowing shoulders was 17 of 20 (85%), while 15 years after retirement, both shoulders of all subjects showed MRI findings. None of the rotator cuff tears progressed to full-thickness tears after retirement. In the throwing shoulders, we observed fewer individuals with ganglion cysts larger than 5 mm (initial followup: six of 20 [30%] versus 6 years after retirement: 0 of 20 (0%); odds ratio, 14.5; [95% CI, 0.7-283]; p = 0.044). The Constant and Murley score increased in the throwing shoulder from 93 points (SD, 6 points) at initial followup to 98 points (SD, 3 points) at a mean of 6 years after retirement (mean difference, 5 points; SD, 5 points; 95% CI, 2.5-7.4; p < 0.001), and to 97 points (SD, 3 points) at a mean of 15 years after retirement. However these differences are below the typically reported minimum clinically important difference for the Constant and Murley score, and so are unlikely to be clinically relevant. External rotation in 90° abduction remained increased in the throwing shoulder compared with the nonthrowing shoulder up to 15 years after retirement (initial followup: mean difference, 8°; p = 0.014; 15 years after retirement: mean difference, 4°; SD, 15; p = 0.026). Internal rotation remained decreased in the throwing compared with the nonthrowing shoulders (during the career: mean difference, 5° [SD, 10°], p = 0.036; 15 years after retirement: mean difference, 3° [SD, 4°], p = 0.021).

CONCLUSIONS

Our data suggest that findings of the throwing shoulder like partial rotator cuff tears, bony cysts and ganglions do not progress after retirement, and sometimes they resolve. Because of this and because many MRI changes correlate poorly with clinical symptoms, the indication for surgical treatment of these findings should be questioned very carefully.

LEVEL OF EVIDENCE

Level II, prognostic study.

Evaluation and Management of Rotator Cuff Tears: a Primary Care Perspective

PURPOSE OF REVIEW

To provide a primary care perspective regarding the evaluation and management of shoulder pain and rotator cuff tears.

RECENT FINDINGS

In the primary care setting, rotator cuff pathology is commonly encountered. Information regarding the risks of oral medications for the management of the associated pain keeps mounting. Partial-thickness rotator cuff tears remain difficult to diagnose with a single imaging modality. Musculoskeletal education in medical schools and non-orthopaedic residency and fellowship training programs continues to be an area for additional improvement. In the primary care office, the initial evaluation of shoulder pain should include a thorough musculoskeletal evaluation in order to identify the source of the pain (e.g., shoulder, cervical spine, chest wall), as well as the development of an initial treatment plan. Access to imaging modalities such as ultrasound and MRI can vary depending on the resources available in the primary care setting. The identification of patients who may benefit from early surgical referral is imperative for optimizing outcomes.

Physical therapists as first-line diagnosticians for traumatic acute rotator cuff tears: a prospective study

BACKGROUND

Early diagnosis of traumatic acute full-thickness rotator cuff tears (FTRCT) is important to offer early surgical repair. Late repairs following fatty infiltration of the rotator cuff muscles have less favorable results. We think that physical therapists are valuable diagnosticians in a screening process. The objective of this study was to evaluate the usefulness of physical therapists as first-line diagnosticians in detecting acute traumatic FTRCT.

METHODS

Between November 2010 and January 2014, 394 consecutive patients having an age between 18 and 75 years who sought medical care because of acute shoulder trauma with acute onset of pain, limited abduction and negative plain radiographs were included in the study. A clinical assessment was conducted by a physical therapist 1 week after the trauma. The patients were divided into three groups by the physical therapist according to the findings: FTRCT (Group I, n = 122); sprain (Group II, n = 62); or other specific diagnoses (Group III, n = 210). Group III patients were discharged and excluded from the study. Magnetic Resonance Imaging shoulder was performed for all Group I patients and for all patients with persistent symptoms in Group II.

RESULTS

79/184 patients had FTRCTs documented by MRI in groups I and II. The clinical assessment of the physical therapist had a sensitivity of 85%, specificity of 68%, and usefulness index of 0.45 (> 0.35 considered useful) for diagnosing FTRCT.

CONCLUSION

Physical therapists can be useful as first-line diagnosticians in detecting traumatic FTRCT.

Sensitivity, Specificity, and Predictive Values: Foundations, Pliabilities, and Pitfalls in Research and Practice

Within the context of screening tests, it is important to avoid misconceptions about sensitivity, specificity, and predictive values. In this article, therefore, foundations are first established concerning these metrics along with the first of several aspects of pliability that should be recognized in relation to those metrics. Clarification is then provided about the definitions of sensitivity, specificity, and predictive values and why researchers and clinicians can misunderstand and misrepresent them. Arguments are made that sensitivity and specificity should usually be applied only in the context of describing a screening test’s attributes relative to a reference standard; that predictive values are more appropriate and informative in actual screening contexts, but that sensitivity and specificity can be used for screening decisions about individual people if they are extremely high; that predictive values need not always be high and might be used to advantage by adjusting the sensitivity and specificity of screening tests; that, in screening contexts, researchers should provide information about all four metrics and how they were derived; and that, where necessary, consumers of health research should have the skills to interpret those metrics effectively for maximum benefit to clients and the healthcare system.

EXERCISE REHABILITATION IN THE NON-OPERATIVE MANAGEMENT OF ROTATOR CUFF TEARS: A REVIEW OF THE LITERATURE

The incidence of rotator cuff tears increases with age, with full-thickness rotator cuff tears present in approximately 25% of individuals in their sixties, and more than 50% of those in their eighties. While surgery is considered an effective treatment, recurrent tears at the insertion site are common, especially with degenerative tears, which are frequent in the older population. More recently, there has been increasing interest in exercise rehabilitation and physical therapy as a means to manage partial and full thickness tears of the rotator cuff by addressing weakness and functional deficits. Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery. When considering the increasing rate of shoulder surgery and the associated economic and social burden rotator cuff surgery places on both the patient and the health care system, non-surgical management such as physical therapy and exercise may, in selected cases, be a treatment alternative to surgical repair. The purpose of this clinical commentary is to provide an overview of rotator cuff pathology and pathogenesis, and to present an evidence-based case for the role of conservative rehabilitation in the management of rotator cuff injuries.

LEVEL OF EVIDENCE

Level 5.