A Comparison of Quantitative and Qualitative Shoulder Range of Motion with Patient Reported Outcomes

BACKGROUND

The evaluation of shoulder function requires a combination of physical examination of shoulder range of motion and measures of functional outcome measures. Though efforts have been made to define range of motion for clinical evaluation with respect to functional outcomes, a disconnect still exists when defining a successful outcome. We aim to compare quantitative and qualitative measures of shoulder range of motion with patient reported outcome measures.

METHODS

Data from 100 patients who presented to the office of a single surgeon with a chief complaint of shoulder pain were evaluated for this study. Evaluation included American Shoulder and Elbow Surgeons Standardized Shoulder Form (ASES), Single Assessment Numeric Evaluation (SANE) relative to the shoulder of interest, demographic information, and range of motion in the shoulder of interest.

RESULTS

Internal rotation angle did not correlate with patient reported outcomes, while external rotation and forward flexion angles did. Qualitative internal rotation as measured by hand-behind-back demonstrated a weak to moderate correlation with patient reported outcomes and a significant difference in global range of motion and functional outcome measures were identified in patients who can or cannot reach above the belt line or to the thoracic spine. Qualitative assessment of forward flexion demonstrated that patients who can reach specific anatomical landmarks have significantly improved functional outcome measures, and the same is true when comparing patients that can externally rotate past neutral.

CONCLUSIONS

Hand-behind-back reach can be used as a clinical marker of global range of motion and functional outcome measures for patients with shoulder pain. Goniometer measurement of internal rotation has no relationship with patient reported outcomes. Forward flexion and external rotation assessment with qualitative cutoffs can additionally be used clinically to determine functional outcome for patients with shoulder pain.

The Virtual Shoulder and Knee Physical Examination

The COVID-19 crisis has forced a sudden and dramatic shift in the way that clinicians interact with their patients, from outpatient encounters to telehealth visits utilizing a variety of internet-based videoconferencing applications. Although many aspects of pre–COVID-19 outpatient sports medicine care will ultimately resume, it is likely that telehealth will persist because of its practicality and because of patient demand for access to efficient and convenient health care. Physical examination is widely considered a critical obstacle to a thorough evaluation of sports medicine patients during telehealth visits. However, a closer reflection suggests that a majority of the examination maneuvers are possible virtually with limited, if any, modifications. Thus, we provide a comprehensive shoulder and knee physical examination for sports medicine telehealth visits, including (1) verbal instructions in layman’s terms that can be provided to the patient before or read verbatim during the visit, (2) multimedia options (narrated videos and annotated presentations) of the shoulder and knee examination that can be provided to patients via screen-share options, and (3) a corresponding checklist to aid in documentation.

Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review

CONTEXT

There is a renewed interest in diagnosing and treating subscapularis tears, but there is a paucity of clinical guidance to optimize diagnostic decision-making.

OBJECTIVE

To perform a literature review to evaluate advanced maneuvers and special tests in the diagnosis of subscapularis tears and create a diagnostic algorithm for subscapularis pathology.

DATA SOURCES

PubMed, MEDLINE, Ovid, and Cochrane Reviews databases.

STUDY SELECTION

Inclusion criteria consisted of level 1 and 2 studies published in peer-reviewed scientific journals that focused on physical examination.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Individual test characteristics (bear hug, belly press, lift-off, Napoleon, and internal rotation lag sign) were combined in series and in parallel to maximize clinical sensitivity and specificity for any special test evaluated in at least 2 studies. A secondary analysis utilized subjective pretest probabilities to create a clinical decision tree algorithm and provide posttest probabilities.

RESULTS

A total of 3174 studies were identified, and 5 studies met inclusion criteria. The special test combination of the bear hug and belly press demonstrated the highest positive likelihood ratio (18.29). Overall, 3 special test combinations in series demonstrated a significant impact on posttest probabilities. With parallel testing, the combination of bear hug and belly press had the highest sensitivity (84%) and lowest calculated negative likelihood ratio (0.21).

CONCLUSION

The combined application of the bear hug and belly press physical examination maneuvers is an optimal combination for evaluating subscapularis pathology. Positive findings using this test combination in series with a likely pretest probability yield a 96% posttest probability; whereas, negative findings tested in parallel with an unlikely pretest probability yield a 12% posttest probability.

The backward traction test: a new and effective test for diagnosis of biceps and pulley lesions

BACKGROUND

The value of physical examination for diagnosis of lesions of the long head of the biceps (LHB) and the pulley remains unsatisfactory. The purpose of this study was to describe a new diagnostic test, the backward traction (BT) test, to detect lesions of the LHB and the biceps pulley.

METHODS

A prospective study of 143 patients was performed to evaluate the diagnostic value of the BT test and 2 traditional clinical tests (Speed and Yergason tests). Shoulder arthroscopy was used as the "gold standard."

RESULTS

For the detection of LHB injury, the BT test was the most sensitive (74%) and accurate (68%). The BT test had a higher diagnostic value for pulley lesions, with a high sensitivity of 81% and an accuracy of 71%. No significant differences in terms of specificity for LHB and pulley lesions were observed between tests. Regarding pulley lesions, the internally rotated and externally rotated BT test positions had high specificity for the diagnosis of specific anteromedial and posterolateral pulley lesions (79% and 73%, respectively). The BT test had a high κ coefficient of 0.768-0.811.

CONCLUSION

The BT test is more sensitive and accurate as a new test for LHB and pulley lesions and also specific to distinguish the medial sling and lateral sling lesions of the pulley.

The Use of Teaching Associates for Knee and Shoulder Examination: A Comparative Effectiveness Analysis

OBJECTIVE

Musculoskeletal diseases and injuries are the most common cause of long-term pain and physical disability. Thus, every medical graduate should be able to perform a structured examination of the musculoskeletal system. Besides the see-one-do-one principle, other teaching methods have been proposed to be effective. The use of teaching associates offers an established, proven pathway for teaching examination skills in urology and gynecology. During the patient experience method, students are examined first, thus giving them an opportunity to feel the examination before performing it themselves. The objective of this study was to compare the efficiency of 3 distinct teaching methods for both knee and shoulder examination.

DESIGN

The study took place during obligatory knee and shoulder examination training. Participants received basic training, including a demonstration of the structured examination by a specialist in trauma surgery. Afterward, group 1 examined each other under professional supervision; group 2 students examined the teaching associates, followed by mutual examinations; and group 3 students were each examined by the instructor, followed by mutual examinations. The acquired competence was assessed in 5-minute practical assessments directly after training and again 5 weeks later.

SETTING

The study was conducted at the medical faculty of Goethe University, Frankfurt, Germany.

PARTICIPANTS

Study participants were third-year undergraduate medical students completing their obligatory 3-week surgical training.

RESULTS

One hundred and forty-four students [group 1 (N = 53), group 2 (N = 46), and group 3 (N = 45)] participated in the first measurement, 92 students in the second measurement of the study. Directly after the training, group 2 and group 3 performed significantly better than group 1 regarding overall score (p < 0.001) and all 4 checklist parts (p < 0.001). At the second measurement, group 2 performed significantly better than group 1 regarding shoulder examination (p = 0.003) and significantly better than group 3 (p = 0.025) regarding knee examination.

CONCLUSIONS

The use of a teaching associate and the patient perspective can increase students' performance in knee and shoulder examinations.

A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review

OBJECTIVES

The clinical examination of the shoulder joint is an undervalued diagnostic tool for evaluating acromioclavicular (AC) joint pathology. Applying evidence-based clinical tests enables providers to make an accurate diagnosis and minimize costly imaging procedures and potential delays in care. The purpose of this study was to create a decision tree analysis enabling simple and accurate diagnosis of AC joint pathology.

METHODS

A systematic review of the Medline, Ovid and Cochrane Review databases was performed to identify level one and two diagnostic studies evaluating clinical tests for AC joint pathology. Individual test characteristics were combined in series and in parallel to improve sensitivities and specificities. A secondary analysis utilized subjective pre-test probabilities to create a clinical decision tree algorithm with post-test probabilities.

RESULTS

The optimal special test combination to screen and confirm AC joint pathology combined Paxinos sign and O'Brien's Test, with a specificity of 95.8% when performed in series; whereas, Paxinos sign and Hawkins-Kennedy Test demonstrated a sensitivity of 93.7% when performed in parallel. Paxinos sign and O'Brien's Test demonstrated the greatest positive likelihood ratio (2.71); whereas, Paxinos sign and Hawkins-Kennedy Test reported the lowest negative likelihood ratio (0.35).

CONCLUSION

No combination of special tests performed in series or in parallel creates more than a small impact on post-test probabilities to screen or confirm AC joint pathology. Paxinos sign and O'Brien's Test is the only special test combination that has a small and sometimes important impact when used both in series and in parallel. Physical examination testing is not beneficial for diagnosis of AC joint pathology when pretest probability is unequivocal. In these instances, it is of benefit to proceed with procedural tests to evaluate AC joint pathology. Ultrasound-guided corticosteroid injections are diagnostic and therapeutic. An ultrasound-guided AC joint corticosteroid injection may be an appropriate new standard for treatment and surgical decision-making.

LEVEL OF EVIDENCE

II - Systematic Review.

A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps

BACKGROUND

Clinical examination of the shoulder joint has gained attention as clinicians aim to use an evidence-based examination of the biceps tendon, with the desire for a proper diagnosis while minimizing costly imaging procedures. The purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing long head of biceps (LHB) pathology.

METHODS

A literature review of Level I and II diagnostic studies was conducted to extract characteristics of clinical tests for LHB pathology through a systematic review of PubMed, Medline, Ovid, and Cochrane Review databases. Tests were combined in series and parallel to determine sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pretest probability. The "gold standard" for diagnosis in all included studies was arthroscopy or arthrotomy.

RESULTS

The optimal testing modality was use of the uppercut test combined with the tenderness to palpation of the biceps tendon test. This combination achieved a sensitivity of 88.4% when performed in parallel and a specificity of 93.8% when performed in series. These tests used in combination optimize post-test probability accuracy greater than any single individual test.

CONCLUSION

Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of LHB pathology compared with diagnostic arthroscopy (practical, evidence-based, comprehensive examination). A decision tree analysis aides in the practical, evidence-based, comprehensive examination diagnostic accuracy post-testing based on the ordinal scale pretest probability.

CLINICAL RELIABILITY AND DIAGNOSTIC ACCURACY OF VISUAL SCAPULOHUMERAL MOVEMENT EVALUATION IN DETECTING PATIENTS WITH SHOULDER IMPAIRMENT

BACKGROUND

Clinical investigation of shoulder injuries commonly utilizes visual evaluation of scapular movement to determine if abnormal or asymmetrical movements are related to the injury. To date, the intrarater reliability and diagnostic accuracy of visual evaluation of scapular movement among physical therapists are not known.

PURPOSE

The aims of this study were to determine the clinical reliability and diagnostic accuracy of physical therapists visual evaluation of scapulohumeral movements when used to diagnose shoulder impairment.

STUDY DESIGN

University based laboratory and an internet based survey.

METHODS

Thirty-three physical therapists and 12 patient participants participated in this study. Reliability was measured as percent agreement and using the free marginal kappa statistic (κ) and Cronbach's alpha (α) for interrater and intrarater reliability respectively. Diagnostic accuracy variables such as sensitivity, specificity, likelihood ratios were calculated from contingency table analysis.

RESULTS

Visual evaluation yielded the following (95% CI): diagnostic accuracy 49.5%, specificity 60% (56 - 64), and sensitivity 35% (29 - 41), positive and negative likelihood ratios were 0.87 (0.66 - 1.14) and 1.09 (0.92 - 1.27) respectively. Percent agreements of evaluation findings between sessions for static and dynamic symmetry were 69% and 68%, respectively. The alpha statistics for static and dynamic symmetry were both 0.51. Percentage agreement in determining the injured shoulder was 59%, with an alpha statistic of 0.35.

CONCLUSION

Visual evaluation of scapular movements, without additional clinical information, demonstrated a poor to fair reliability and poor to fair diagnostic accuracy.

CLINICAL RELEVANCE

The clinical utility of the use of isolated visual scapular evaluation is cautioned. More reliable and valid objective measures are needed for diagnosing shoulder impairment.

LEVEL OF EVIDENCE

2b, Exploratory cohort study.