Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests

Abstract

Objective To update our previously published systematic review and meta-analysis by subjecting the literature on shoulder physical examination (ShPE) to careful analysis in order to determine each tests clinical utility. Methods This review is an update of previous work, therefore the terms in the Medline and CINAHL search strategies remained the same with the exception that the search was confi ned to the dates November, 2006 through to February, 2012. The previous study dates were 1966 -October, 2006. Further, the original search was expanded, without date restrictions, to include two new databases: EMBASE and the Cochrane Library. The Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS 2) tool was used to critique the quality of each new paper. Where appropriate, data from the prior review and this review were combined to perform meta-analysis using the updated hierarchical summary receiver operating characteristic and bivariate models. Results Since the publication of the 2008 review, 32 additional studies were identifi ed and critiqued. For subacromial impingement, the meta-analysis revealed that the pooled sensitivity and specifi city for the Neer test was 72% and 60%, respectively, for the HawkinsKennedy test was 79% and 59%, respectively, and for the painful arc was 53% and 76%, respectively. Also from the meta-analysis, regarding superior labral anterior to posterior (SLAP) tears, the test with the best sensitivity (52%) was the relocation test; the test with the best specifi city (95%) was Yergason's test; and the test with the best positive likelihood ratio (2.81) was the compression-rotation test. Regarding new (to this series of reviews) ShPE tests, where meta-analysis was not possible because of lack of suffi cient studies or heterogeneity between studies, there are some individual tests that warrant further investigation. A highly specifi c test (specifi city >80%, LR+ ≥ 5.0) from a low bias study is the passive distraction test for a SLAP lesion. This test may rule in a SLAP lesion when positive. A sensitive test (sensitivity >80%, LR− ≤ 0.20) of note is the shoulder shrug sign, for stiffnessrelated disorders (osteoarthritis and adhesive capsulitis) as well as rotator cuff tendinopathy. There are six additional tests with higher sensitivities, specifi cities, or both but caution is urged since all of these tests have been studied only once and more than one ShPE test (ie, active compression, biceps load II) has been introduced with great diagnostic statistics only to have further research fail to replicate the results of the original authors. The belly-off and modifi ed belly press tests for subscapularis tendinopathy, bony apprehension test for bony instability, olecranon-manubrium percussion test for bony abnormality, passive compression for a SLAP lesion, and the lateral Jobe test for rotator cuff tear give reason for optimism since they demonstrated both high sensitivities and specifi cities reported in low bias studies. Finally, one additional test was studied in tw...

Nonoperative Management of Common Shoulder Conditions

“…A positive arc test is documented if a patient experiences pain between 60° -120° of active abduction and is best used in conjunction with the Neer test and Hawkins Kennedy test [23]. The painful arc test has a sensitivity and specificity of 53% and 76% respectively, though a positive test has a likelihood ratio of 3.7, with a negative likelihood ratio of 0.36, suggesting that is an effective test for diagnosing rotator cuff pathology [24,25]. The Neer test, used to assess impingement, is positive with a passive painful arc maneuver, with the examiner flexing the glenohumeral joint while preventing shoulder shrugging [23].…”

“…The Neer test, used to assess impingement, is positive with a passive painful arc maneuver, with the examiner flexing the glenohumeral joint while preventing shoulder shrugging [23]. The sensitivity and specificity of the Neer test is 72% and 60%, respectively [24]. The Hawkins Kennedy test, also used to assess impingement, is performed by the examiner stabilizing the shoulder with one hand while internally rotating the patient's arm with the elbow flexed at 90° [23].…”

“…The Hawkins Kennedy test, also used to assess impingement, is performed by the examiner stabilizing the shoulder with one hand while internally rotating the patient's arm with the elbow flexed at 90° [23]. Its sensitivity and specificity is 79% and 59%, respectively [24]. The Empty Can test, or Jobe Strength test, may be used to evaluate the supraspinatus, and has a positive and negative likelihood ratio of 2.08 and 0.31, respectively [26].…”

“…A recent review by Hegedus et al [24] examined clusters of shoulder examinations. A case study was used to illustrate the best available cluster of tests that could make a diagnosis of shoulder pathology.…”

Influence of shoulder pain on muscle function: implications for the assessment and therapy of shoulder disorders

“…However, this important physiological mechanism may impact upon clinicians' ability to diagnose shoulder injuries accurately, especially when differentiating neighboring tissues to establish a patho-anatomical diagnosis. Within this context, the subjectivity and the lack of reliability and the low diagnostic accuracy of the diagnostic tests for most shoulder disorders (Hegedus et al 2012) may be explained by a change in mechanosensitivity of the tissues in and around the shoulder girdle, which might account for the often unpredictable and disproportionate pattern of pain provocation in response to mechanical testing.…”