Clinician Article
Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review.
PMID: 23982370
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Physical Medicine and RehabilitationRelevance - 7/7
Newsworthiness - 7/7 -
Emergency MedicineRelevance - 7/7
Newsworthiness - 5/7 -
RheumatologyRelevance - 7/7
Newsworthiness - 5/7 -
Family Medicine (FM)/General Practice (GP)Relevance - 6/7
Newsworthiness - 5/7 -
General Internal Medicine-Primary Care(US)Relevance - 6/7
Newsworthiness - 5/7 -
Occupational and Environmental HealthRelevance - 6/7
Newsworthiness - 5/7 -
Surgery - OrthopaedicsRelevance - 6/7
Newsworthiness - 5/7
Abstract
IMPORTANCE: Rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians.
OBJECTIVE: To perform a meta-analysis to identify the most accurate clinical examination findings for RCD.
DATA SOURCES: Structured search in MEDLINE, EMBASE, and CINAHL from their inception through May 2013.
STUDY SELECTION: For inclusion, a study must have met the following criteria: (1) description of history taking, physical examination, or clinical tests concerning RCD; (2) detailing of sensitivity and specificity; (3) use of a reference standard with diagnostic criteria prespecified; (4) presentation of original data, or original data could be obtained from the authors; and (5) publication in a language mastered by one of the authors (Danish, Dutch, English, French, German, Norwegian, Spanish, Swedish).
MAIN OUTCOMES AND MEASURES: Likelihood ratios (LRs) of symptoms and signs of RCD or of a tear, compared with an acceptable reference standard; quality scores assigned using the Rational Clinical Examination score and bias evaluated with the Quality Assessment of Diagnostic Accuracy Studies tool.
RESULTS: Twenty-eight studies assessed the examination of referred patients by specialists. Only 5 studies reached Rational Clinical Examination quality scores of level 1-2. The studies with quality scores of level 1-2 included 30 to 203 shoulders with the prevalence of RCD ranging from 33% to 81%. Among pain provocation tests, a positive painful arc test result was the only finding with a positive LR greater than 2.0 for RCD (3.7 [95% CI, 1.9-7.0]), and a normal painful arc test result had the lowest negative LR (0.36 [95% CI, 0.23-0.54]). Among strength tests, a positive external rotation lag test (LR, 7.2 [95% CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95% CI, 2.6-12]) were the most accurate findings for full-thickness tears. A positive drop arm test result (LR, 3.3 [95% CI, 1.0-11]) might help identify patients with RCD. A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95% CI, 0.0-0.58]).
CONCLUSIONS AND RELEVANCE: Because specialists performed all the clinical maneuvers for RCD in each of the included studies with no finding evaluated in more than 3 studies, the generalizability of the results to a nonreferred population is unknown. A positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting RCD, whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear.
Clinical Comments
Family Medicine (FM)/General Practice (GP)
Confirming data to support unsurprising diagnostic findings about what are the most predictive tests for shoulder rotator cuff problems. What's especially nice is the set of figures describing how to DO the tests.
Family Medicine (FM)/General Practice (GP)
A very good review of a common problem in primary care. This information could simplify the shoulder examination to include only those elements with the greatest clinical significance.
General Internal Medicine-Primary Care(US)
This is a rare piece of sensible and clear analysis of the available literature dealing with RCD. The authors recognize the differences that can be found in examiners according to the level of training, and also the pitfalls that can be encountered in the examination. The graphical depiction of the anatomy and function of the shoulder joint is quite good. In musculoskeletal examinations, it is also important to consider biochemical parameters such as magnesium and calcium. Magnesium deficiency is quite frequent and low levels of magnesium can be associated with calcifications.
General Internal Medicine-Primary Care(US)
Shoulder injuries are common in primary care, and the performance of a good shoulder exam remains challenging for many primary care physicians. This article performs a robust review of the literature and reveals that there is limited data about the sensitivity/specificity of many of the maneuvers performed as part of the shoulder exam. The study also reveals that a few of these maneuvers may be of modest value in helping with diagnosis.
General Internal Medicine-Primary Care(US)
I loved this article. This is such a common clinical problem in my practice. It is very useful to know which eponymous test has the best PPV because most patients with shoulder pain also have other assorted chronic diseases. It takes time to do the whole gamut of physical manoevres.
Occupational and Environmental Health
Great review!
Occupational and Environmental Health
Although shoulder pain is not specifically an Occupational Medicine issue, this article is a well-written review that summarizes much information and would serve as a refresher on how to do the exam, while providing up-to-date information on the usefulness of the specific manoeuvres.
Physical Medicine and Rehabilitation
This is a very well done systematic review that presents a nice clinically relevant summary of the 6 most evidence-based physical examination procedures for diagnosing rotator cuff disease. The authors also provided a single-page summary with an artist's rendition of the the exam procedures. I am not used to seeing the results of systematic reviews presented in such a clinician-friendly manner. Kudos to these authors.
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