Pruebas físicas para el pinzamiento del hombro y lesiones locales de la bursa, el tendón o el labrum que pueden acompañar el pinzamiento
Resumen
Antecedentes
El pinzamiento es una causa frecuente de dolor de hombro. Los mecanismos de pinzamiento pueden ocurrir de forma subacromial (bajo el arco coracoacromial) o de forma interna (dentro de la articulación del hombro) y se pueden asociar algunas patologías secundarias. Las mismas incluyen bursitis subacromial‐subdeltoidea (inflamación de la porción subacromial de la bursa, la porción subdeltoidea, o ambas), tendinopatía o desgarros que afectan el manguito rotador o la cabeza larga del tendón del bíceps, y lesiones del labrum glenoideo. El diagnóstico certero basado en pruebas físicas facilitaría la optimización temprana del enfoque clínico terapéutico. La mayoría de los pacientes con dolor de hombro son diagnosticados y tratados en el contexto de la atención primaria.
Objetivos
Evaluar la exactitud diagnóstica de las pruebas físicas para el pinzamiento del hombro (subacromial o interno) o las lesiones locales de la bursa, el manguito rotador o el labrum que pueden acompañar el pinzamiento, en pacientes cuyos síntomas o antecedentes indican cualquiera de estos trastornos.
Métodos de búsqueda
Se realizaron búsquedas en bases de datos electrónicas de estudios primarios en dos etapas. En la primera etapa se realizaron búsquedas en MEDLINE, EMBASE, CINAHL, AMED y DARE (todas desde el inicio hasta noviembre de 2005). En la segunda etapa, se realizaron en MEDLINE, EMBASE y AMED (desde 2005 hasta el 15 de febrero de 2010). La búsqueda se limitó a artículos escrito en inglés.
Criterios de selección
Se consideraron para inclusión los estudios de exactitud de pruebas diagnósticas que compararon directamente la exactitud de una o más pruebas físicas índice para el pinzamiento del hombro versus una prueba de referencia en cualquier contexto clínico. Se consideraron los estudios de exactitud de pruebas diagnósticas con diseños transversales o de cohortes (retrospectivos o prospectivos), los estudios de casos y controles y los ensayos controlados aleatorizados.
Obtención y análisis de los datos
Dos pares de autores de la revisión, de forma independiente, realizaron la selección de los estudios, evaluaron la calidad de los estudios mediante QUADAS y extrajeron los datos en un formulario diseñado para esta finalidad, observando las características de los pacientes (incluido el ámbito de atención), el diseño del estudio, las pruebas índice y el estándar de referencia y la tabla de diagnóstico de 2 x 2. Se presentó la información sobre las sensibilidades y las especificidades con intervalos de confianza del 95% (IC del 95%) para las pruebas índice. No se realizó metanálisis.
Resultados principales
Se incluyeron 33 estudios con 4002 hombros en 3852 pacientes. Aunque 28 estudios fueron retrospectivos, en general, la calidad de los estudios fue baja. Debido principalmente al uso de la cirugía como la prueba de referencia en la mayoría de los estudios, se consideró que todos, excepto dos estudios, no cumplían los criterios en cuanto a un espectro representativo de pacientes. Sin embargo, incluso estos dos estudios sólo incluyeron en parte a participantes de la atención primaria.
Las afecciones objetivo evaluadas en los 33 estudios se agruparon en cinco categorías principales: pinzamiento subacromial o interno, tendinopatía o desgarros del manguito rotador, tendinopatía o desgarros de la cabeza larga del bíceps, lesiones del labrum glenoideo y afecciones objetivo múltiples indiferenciadas. La mayoría de los estudios utilizaron la cirugía artroscópica como el estándar de referencia. Ocho estudios utilizaron estándares de referencia potencialmente aplicables a la atención primaria (anestesia local, un estudio; ultrasonido, tres estudios) o al ámbito ambulatorio del hospital (resonancia magnética, cuatro estudios). Un estudio utilizó diversos estándares de referencia, algunos aplicables a la atención primaria o a los ámbitos ambulatorios. En dos de estos estudios el estándar de referencia utilizado fue aceptable para identificar la afección objetivo, aunque en seis sólo fue parcialmente aceptable. Los estudios evaluaron numerosas pruebas índice estándar, modificadas o combinadas y 14 pruebas índices nuevas. Hubo 170 combinaciones de afección objetivo/pruebas índice, pero sólo seis casos de cualquier prueba índice se realizaron e interpretaron de igual manera en dos estudios. Sólo dos estudios de una prueba de lata vacía modificada para el desgarro de espesor total del manguito rotador, y dos estudios de una prueba de deslizamiento anterior modificada para las lesiones de tipo II del labrum superior anterior a posterior (LSAP), fueron clínicamente homogéneos. Debido al número pequeño de estudios, se consideró que los metanálisis no eran adecuados. Los cálculos de sensibilidad y de especificidad de cada estudio se presentan en diagramas de bosque para las 170 combinaciones de afección objetivo/pruebas índice agrupadas según la afección objetivo.
Conclusiones de los autores
No hay evidencia suficiente sobre la cual basar la selección de las pruebas físicas para el pinzamiento del hombro y las lesiones locales de la bursa, el tendón o el labrum que pueden acompañar la compresión, en la atención primaria. La gran cantidad de bibliografía reveló una diversidad extrema en el rendimiento y la interpretación de las pruebas, lo cual obstaculiza la síntesis de las pruebas y la aplicabilidad clínica.
Resumen en términos sencillos
Pruebas físicas para el pinzamiento del hombro en la atención primaria
El pinzamiento (o pellizco) de los tejidos blandos en o alrededor del hombro es una causa frecuente de dolor y a menudo se relaciona con el daño de los tejidos en y alrededor de la articulación. Si los médicos y los terapeutas pudieran identificar el pinzamiento y los daños asociados mediante pruebas físicas sencillas, les ayudaría a informar sobre el mejor enfoque de tratamiento en una etapa temprana. Había interés particular en el entorno de atención primaria (comunitaria), porque es donde se diagnostica y se trata la mayor parte de los dolores de hombro. Se revisaron los artículos originales de investigación para buscar evidencia sobre la exactitud de las pruebas físicas para el pinzamiento del hombro o el daño asociado, en pacientes cuyos síntomas y antecedentes indican cualquiera de estos trastornos. Para encontrar los documentos de investigación, se buscó en las principales bases de datos electrónicas de literatura médica y afines hasta 2010. Dos autores de la revisión evaluaron la calidad de cada documento de investigación y extrajeron información importante. Si varios documentos de investigación informaron del uso de la misma prueba para la misma afección, se pretendía combinar sus resultados para obtener una estimación más precisa de la exactitud de la prueba. Se incluyeron 33 documentos de investigación. Estos se relacionaban con estudios de 4002 hombros en 3852 pacientes. Ninguno de los estudios se centró exclusivamente en los pacientes de atención primaria, aunque dos reclutaron algunos de sus pacientes de la atención primaria. La mayoría de los estudios utilizaron la cirugía artroscópica como el estándar de referencia. Hubo 170 combinaciones diferentes de afección objetivo/prueba índice, pero sólo seis casos en los que se utilizó la misma prueba de la misma manera, y por la misma razón, en dos estudios. Por esta razón, no fue apropiado combinar los resultados. Se concluyó que no hay evidencia suficiente en la que basar la selección de las pruebas físicas para el pinzamiento del hombro ni las afecciones potencialmente relacionadas, en la atención primaria.
Authors' conclusions
Summary of findings
| Setting | Most people with shoulder pain symptomatic of impingements and related pathologies are diagnosed and managed in the primary care setting. | |||
| Index tests | Physical tests used single or in combination to identify shoulder impingement and related pathologies. | |||
| Reference standard | While a definitive reference standard is lacking, surgery, whether open or arthroscopic, is generally regarded as the nest available. Non‐invasive contenders include ultrasound and magnetic resonance imaging (MRI). | |||
| Importance | Accurate diagnosis using readily applied, convenient, low‐cost physical tests would enable appropriate and well‐timed management of these common causes of shoulder pain. | |||
| Studies | Index were 33 studies including 4002 shoulders in 3852 patients. These incorporated numerous standard, modified or combinations of index tests and 14 novel index tests. | |||
| Quality concerns | Although 28 studies were prospective, study quality was generally poor. All but two studies failed to meet the criteria for having a representative spectrum of patients. | |||
| Data analysis | The studies tested 170 target condition/index test combinations, with only six instances of any index test being performed and interpreted similarly in two studies. Meta‐analysis of the latter was inappropriate, however. | |||
| Target condition | Subcategory of target condition, if applicable | Studies | Shoulders/patients | Tests or variants evaluated |
| Subacromial and internal impingement | Subacromial impingement | 5 | 361/356 | 13 |
| subacromial versus Internal impingement | 1 | 110/110 | 1 | |
| Internal impingement | 0 | 0 | 0 | |
| Rotator cuff tendinopathy or tears | Non‐specific disease of the 'rotator cuff' | 5 | 466/466 | 17 |
| Specific diseases of the 'rotator cuff' | 5 | 503/503 | 15 | |
| Non‐specific disease of the 'posterosuperior rotator cuff' | 2 | 220/220 | 4 | |
| Specific disease of the 'posterosuperior rotator cuff' | 2 | 166/157 | 3 | |
| Non‐specific disease of supraspinatus | 4 | 792/678 | 11 | |
| Specific disease of supraspinatus | 6 | 887/870 | 18 | |
| Disease of infraspinatus | 3 | 719/605 | 5 | |
| Non‐specific disease of subscapularis | 5 | 887/773 | 10 | |
| Specific disease of subscapularis | 3 | 145/136 | 10 | |
| LHB tendinopathy or tears | 3 | 660/557 | 10 | |
| Glenoid labral lesions | Non‐specific labral lesions | 4 | 364/364 | 5 |
| Non‐specific SLAP lesions | 3 | 222/221 | 15 | |
| Type II‐IV SLAP lesions | 2 | 315/307 | 5 | |
| Type II SLAP lesions | 3 | 405/405 | 18 | |
| Multiple, undifferentiated target conditions | LHB/labral pathology; LHB/SLAP lesions; SA‐SD bursitis/bursal‐side degeneration of supraspinatus; and SIS/rotator cuff tendinitis or tear. | 4 | 201/200 | 10 |
Background
Target condition being diagnosed
Shoulder pain and dysfunction are common in the general population. A systematic review reported point prevalences for shoulder pain ranging from 7% to 26% with some indication that prevalence increases with age (Luime 2004a). Data from the US National Ambulatory Medical Care Survey (NAMCS) 1993 to 2000 indicate that one per cent of all office visits to physicians are for shoulder pain, and that a quarter of these visits are to primary care physicians (Wofford 2005). Moreover, shoulder pain has little tendency to resolve quickly or completely; according to a Dutch study, one half of all sufferers still report problems a year after their initial consultation (Van der Heijden 1997).
Shoulder pain and dysfunction may result from various aetiologies and pathologies. A common cause is impingement (pinching), which causes ‘catching’ or aching pain without appreciable joint stiffness, and which has a number of subtypes.
Impingement was originally characterised by Neer and Welsh (Neer 1977) as pinching of the soft‐tissue structures between the humerus (upper arm bone) and the bone‐and‐ligament coraco‐acromial arch of the scapula (shoulder blade) on movement. These structures include the contents of the so‐called subacromial outlet: the ‘rotator cuff’ of muscles and tendons that surrounds the shoulder joint and the large lubricating sac (the subacromial bursa) that overlies it; and also the biceps tendon, which arches over the humerus, deep to the rotator cuff and within the shoulder joint itself. Neer 1977 proposed a continuum of impingement severity, from irritation of the bursa and cuff (normally due to overuse, and reversible by conservative management) to full thickness tears of the cuff. It has since been theorised that any abnormal reduction in the subacromial outlet’s volume (e.g. by bone shape, soft‐tissue thickening, posture or minor joint instability) may predispose to, contribute to, perpetuate or aggravate this train of events (discussed by Hanchard 2004).
It is increasingly recognised that other forms of impingement exist which, in distinction from subacromial outlet impingement, involve pinching of intra‐articular (internal joint) structures at the extremes of movement. The socket’s rim (the glenoid rim), its fibrocartilage extension (the glenoid labrum), and the deep surface of the rotator cuff are all at risk from this internal impingement mechanism, which may be subcategorised as anterosuperior or posterosuperior glenoid impingement (respectively affecting the front and back of the shoulder joint). It is unclear to what extent internal impingement is limited to athletes, and whether instability is a prerequisite (Jobe 1996).
Sometimes, primary partial thickness tears occur inside the substance of the rotator cuff, possibly due to internal shear stress (Fukuda 2003). Such tears also have the potential to cause impingement pain (Fukuda 2003; Uchiyama 2010).
Index test(s)
When a person presents with a history and symptoms suggestive of shoulder impingement, the clinician performs a series of physical (non‐invasive) tests that aim to establish the diagnosis, and inform treatment and prognosis. Such tests may include the 'painful arc' test, intended to identify impingement in general terms (Cyriax 1982); tests to identify subacromial impingement (e.g. Neer 1977) or internal impingement (e.g. Meister 2004); tests to differentiate subacromial from internal impingement (Zaslav 2001); tests to diagnose rotator cuff involvement, including tears (e.g. Gerber 1991a; Gerber 1996; Hertel 1996a), or biceps tendon involvement (e.g. Yergason 1931); or tests to diagnose glenoid labrum tears (e.g. Kim 2001; Liu 1996b; O'Brien 1998a). These tests are described in Table 1, and include tests that were identified in studies included in this review. See Table 2 for explanations of terms used in Table 1 and elsewhere. Sometimes, local anaesthetic is injected into or around the subacromial bursa on the premise that negation of a previously positive (painful) physical test for subacromial outlet impingement will confirm and localise the diagnosis (Neer 1977). While not encompassing local anaesthesia per se, we will consider it for inclusion in this review when it is used in this special adjunctive mode. (Some studies of diagnostic accuracy may use local anaesthesia as a reference test rather than an index test, as considered below.)
| Tests intended to identify impingement in general | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Painful arc test | None | The patient actively elevates, then lowers, the shoulder through abduction. | Onset and offset of pain during elevation, during lowering, or both. | Subacromial impingement; calcific tendonitis; pain secondary to shoulder joint instability; or internal impingement (involving the deep aspect of the rotator cuff or the LHB tendon) | |
| Tests intended to identify subacromial impingement | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Hawkins' test | None | The upright patient's arm is passively positioned in 90° of flexion at shoulder and elbow. The tester then forcibly medially rotates the patient's shoulder. | Reproduction of the patient's pain | Subacromial impingement | |
| Neer's sign | Neer 1977;Neer 1983 (Neer 1972a, sometimes cited, does not give a clear account of this test) | None | The tester forcibly elevates the sitting patient's arm through scaption, preventing scapular movement by pressing down on the clavicle and acromion with the other hand. | Pain constitutes a positive Neer's sign. | Subacromial Impingement and 'many other shoulder conditions, including stiffness (partial frozen shoulder), instability (e.g. anterior subluxation), arthritis, calcium deposits, and bone lesions'. |
| Neer's test | None | The tester forcibly flexes the sitting patient's arm, preventing scapular movement by pressing down on the clavicle and acromion with the other hand (*Neer's sign). The patient is given an injection of 10 ml, 1% xylocaine beneath the anterior acromion before the manoeuvre is repeated. | A positive *Neer's sign which is abolished by the injection is termed a positive Neer's test. | Subacromial impingement | |
| 'Yocum's (impingement) test' | Leroux 1995 and Naredo 2002 cite Yocum 1983: apparently a misconception (see under technique). | None | Yocum did not describe a novel impingement test in the article cited (but see comment relating to the *empty can test, further in this table). Leroux 1995 and Naredo 2002 may have misinterpreted a photograph depicting Hawkins' test. According to Naredo 2002, the patient places the hand of the affected arm on his or her other shoulder and, keeping the point of the affected shoulder down, raises the elbow of the same limb. | Reproduction of the patient's pain | Subacromial impingement |
| Tests intended to identify internal impingement | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Anterior apprehension test at 90° for pain | None | The test may be performed with the patient sitting or supine. In the latter position the test may be termed the fulcrum test. With the elbow flexed 90, the patient's shoulder is positioned in 90° abduction and full lateral rotation. (As distinct from the version of this test described by Jobe 1989, no anterior pressure is applied to the humeral head (see below). | Pain is considered a positive result | Internal impingement | |
| Anterior apprehension test at 90° for pain | None | The supine patient's shoulder is placed in in 90° abduction and full lateral rotation, with the elbow flexed 90°. Maintaining this position, the tester applies an anterior pressure to the posterior aspect of the humeral head. | Pain but no apprehension. (Note that Rowe 1981 described a test which, apart from the patient being in sitting, was performed comparably to that presented here. However, Rowe's test, which was for subluxation, required that both pain and apprehension be present for a positive result.) | Pain associated with anterior subluxation. Since the original description of this test, this pain has more specifically been ascribed to posterosuperior glenoid impingement (Jobe 1995, Jobe 1996). | |
| Anterior release test | None | The patient lies supine, affected shoulder over the edge of the examination couch. The shoulder is passively abducted to 90° while the tester applies a posteriorly directed force to the humeral head. Maintaining this force, the tester brings the arm into full lateral rotation. Then the posteriorly directed force is released. | Sudden pain, an increase in pain or reproduction of symptoms [on release] | Primarilrily occult instability; but the authors link this to posterosuperior glenoid impingement. | |
| Modified relocation test for postero‐superior glenoid impingement | None | The patient liessupine. The shoulder is held by the tester in full lateral rotation and positioned at each of 90°, 100° and 120° of abduction. In each of these positions the tester applies a force to the patient's upper humerus, first directed anteriorly, then posteriorly. | Pain on the anteriorly directed force which is relieved by the posteriorly directed force | Internal impingement | |
| Posterior impingement test | None | The supine patient's shoulder is placed into 90°‐110° degrees of abduction and 10°‐15° extension. Full lateral rotation is then added. | Pain felt deeply within the posterior aspect of the shoulder joint | Posterior glenoid impingement and concomitant tear of the internal surface of the rotator cuff, of the posterior glenoid labrum, or both. | |
| Relocation test for pain | Positive apprehension test | This is an extension of the apprehension test for pain at 90°, which it immediately follows. With the patient's arm still abducted and laterally rotated, posterior pressure is applied to the humeral head. | The pain of the apprehension test is relieved. While posterior pressure is maintained, reduced pain may allow greater lateral rotation. | Pain associated with anterior subluxation. Since the original description of this test, this pain has more specifically been ascribed to posterosuperior glenoid impingement (Jobe 1995, Jobe 1996). | |
| Tests intended to differentiate between subacromial and internal impingement | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Internal rotation resistance strength test | Positive Neer's sign | The patient and tester stand, the tester to the rear. The patient's elbow is flexed to about 90°, and the shoulder positioned at 90° abduction and 80°lateral rotation. In this position, lateral‐ and medial rotation are manually, isometrically resisted. | Lateral rotation is strong. Medial rotation is weak. | Internal impingement. The converse is a 'negative' finding, and signifies subacromial outlet impingement | |
| Tests intended to diagnose rotator cuff tears or tendinosis | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Bear‐hug test | None | The patient places the palm of the affected limb, fingers extended, on the opposite shoulder. The patient is asked to hold this position, while the tester, by applying a force perpendicular to the forearm, attempts to laterally rotate the shoulder. | The patient is unable to hold the hand in contact with the shoulder, or is > 20% weaker than on the unaffected side. | Tear of subscapularis | |
| Belly‐press test | Inadequate range of motion to perform the *lift‐off test (see below) | The patient, in a sitting position, presses against the abdomen with the palm of the hand while trying to keep the shoulder in full medial rotation. | Full medial rotation cannot be maintained. The patient feels weak and the shoulder drops back into extension. The patient tries to exert pressure by extending the elbow and flexing the wrist. | Weakness of subscapularis, implying a partial or complete tear | |
| Drop arm test | None | This test was not clearly described in its primary source. By convention, it is applied in the plane of abduction, with the patient's arm placed passively above 90° by the tester; the support is removed, and the patient attempts to lower the arm actively. | The patient is unable to actively lower the arm under control beyond the horizontal, and it drops to his or her side. | Tear of supraspinatus | |
| Drop sign | Normal passive range of movement at the shoulder is required: capsular contracture (hypomobility) or ruptured subscapularis (hypermobility) might cause false ‐ve and false +ve results, respectively. The authors suggest proceeding to this test if the external rotation lag sign is positive. | The patient sits. The tester stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder elevated to 90° in the plane of the scapula, then laterally rotates the shoulder to just short of full range. The tester continues to support the elbow while releasing the wrist and asking the patient to maintain the lifted‐off position. | The patient cannot maintain the position and there is a 'drop' or 'lag', which is recorded to the nearest 5°. | Tear of postero‐superior rotator cuff, particularly infraspinatus, or neuropathy. The authors suggest that the value of the test is in assessing involvement of infraspinatus having established the presence of a poster‐superior cuff tear using the external rotation lag sign. | |
| Empty can test (Jobe's test, supraspinatus test). Note that Yocum 1983 described the same test (minus the preliminary deltoid component) in the same year, apparently derived from the same studies at the Centinela Hospital Medical Centre Biomechanics Laboratory, California. Thus the empty can test has also been termed 'Yocum's test' (REF and see separate entry for *'Yocum's impingement test' above). Jobe 1982 is often cited as the source of this test, but the manoeuvre described in that report was a strengthening exercise, not a diagnostic test. | None | There are two stages. Preliminarily, the tester evaluates the deltoid, with the patient's arm at 90° of abduction and neutral rotation. To evaluate supraspinatus, the arm is then moved into medial rotation (thumb pointing down) and 90° of scaption, where the patient is asked to isometrically resist a downward pressure applied by the tester. | Pain or weakness on testing supraspinatus | Supraspinatus impingement (pain) or tear (weakness) | |
| External rotation lag sign | Normal passive range of movement at the shoulder is required: capsular contracture (hypomobility) or ruptured subscapularis (hypermobility) might cause false ‐ve and false +ve results, respectively. | The patient sits. The tester stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder in 20° of elevation (in the plane of the scapula), then laterally rotates the shoulder to 5° short of full range. The tester asks the patient to maintain the lateral rotation and, while continuing to support the elbow, releases the wrist. | An angular 'drop' or 'lag', which is recorded to the nearest 5° | Tear of supraspinatus ± infraspinatus. A 15° lag or greater signifies a complete tear of both or a neuropathy. | |
| Full can test | None | The patient sits, arm laterally rotated (thumb pointing up) and in 90° of scaption. The patient is then asked to isometrically resist a downward pressure applied on the arm by the tester. | Weakness (the test was described in the context of strength assessment, not pain‐provocative testing). However, by convention, the test is often interpreted as for the *empty can test. | Supraspinatus dysfunction | |
| Gum‐turn test | None | Starting in the *empty can test position, the patient traces a 20‐cm wide spiral drawn on the wall, from centre to periphery and back 10 times, resting for one minute, then repeating the procedure. | The test is positive if weakness or pain prevent completion. (For positive results, the number of turns completed were recorded, but it is unclear how these data were used. Results were compared with the contralateral arm but, again, it is unclear how these data were used.) | Postero‐superior rotator cuff tear | |
| Internal rotation lag sign. | Adequate range of medial rotation. If this is not available, the belly press test (see above) should be used. | The patient sits. The tester, standing to the rear, brings the patient's hand behind the back and flexes the elbow to 90°, so that the back of the hand rests on the spine at waist level. Gripping the patient's wrist, the tester then lifts the back of the hand clear of the spine until the shoulder is in almost full medial rotation. The tester, who continues to support the elbow but releases the wrist, asking the patient to actively maintain this position. | A lag occurs, the magnitude of which is recorded to the nearest 5°. | 'An obvious drop of the hand may occur with large tears. A slight lag indicates a partial tear of the cranial part of the subscapularis tendon.' | |
| Lift‐off test. | Adequate passive range of medial rotation. Active medial rotation not inhibited by pain. | The arm is brought passively behind the patient's body into medial rotation, such that the hand rests against the spine at waist level, palm backwards. The patient attempts to lift the hand off his or her back. | Inability to lift the hand off the back | Tear of subscapularis | |
| Lift‐off test. (Also see *internal rotation lag sign, Hertel 1996a, and *lift‐off test, Gerber 1991a.) | Adequate range of internal rotation. If this is not available, the *belly‐press test should be used instead. | The arm is brought passively behind the patient's body into full internal rotation. The hand, palm facing backwards, is at waist level but not in contact with the spine. The patient attempts to maintain this position. (This description differs slightly from that above, despite apparently relating to the same patient sample, but tallies with the internal rotation lag sign.) | (a) The patient cannot maintain the position: the hand drops back to the body and cannot be actively lifted off without elbow extension; or (b) the patient is weak, so that the hand drops back more than 5°, but not all the way to the spine. | Tear of subscapularis. No information is given on differential interpretation of (a) and (b). | |
| Lift‐off test with force | Adequate medial rotation. If this is not available, the *belly press test should be used instead. | As above, except the patient is asked to maintain the lift‐off position against manually applied resistance. | Weakness (the test was described in the context of strength assessment, not pain‐provocative testing). | Subscapularis dysfunction | |
| Napoleon test | Schwamborn 1999 [German] Burkhart 2002 | None | This is a modification of the belly‐press test. The patient adopts a Napoleonic pose, palm on abdomen and with the elbow positioned laterally. | Burkhart 2002 refined the test's interpretation thus. A negative (normal) result is where the patient can press against the abdomen without wrist flexion. A positive result is an inability to press against the abdomen without wrist flexion to 90°. Intermediate results may occur. | Subscapularis tear (positive result) or partial tear (intermediate result) |
| Passive horizontal adduction (scarf test) | None | The patient's arm is passively horizontally adducted across the chest. | Pain | Lesions of the ACJ, but also of the lower part of the tendon of subscapularis | |
| Patte's test | Patte 1987 [French], Leroux 1995 | None | With the arm supported in 90° of scaption, the patient is asked to laterally rotate maximally against the tester's isometric resistance. The starting position in terms of the degree of rotation was not specified. | There are three possible responses: (A) strong and painless; (B) normal ability to resist despite pain; and (C) inability to resist, with gradual lowering of the forearm. (C) is subcategorised as follows: (1) decreased resistance compared to the other side, allowing the tester to lower the forearm; (2) the patient can perform the test against gravity but is cannot resist the pressure applied by the tester; and (3) the patient cannot perform the test against gravity. | (1) Normal; (2) simple tendinitis of infraspinatus; (3) ruptured infraspinatus tendon. The score 1‐3 'has been claimed to increase in parallel with the severity of muscle atrophy and the size of the tear'. |
| Rent test (transdeltoid palpation) | None | The tester draws the upright patient's shoulder into extension, palpating anterior to the acromion. | There is a tender depression (rent) anterior to the acromion and, just distal to this, an eminence. | A rent represents a full thickness tear of supraspinatus; the associated eminence is the greater tuberosity, and possibly a stump of supraspinatus' attachment distal to the tear. If portions of the adjacent rotator cuff tendons are torn, the tenderness, eminence and rent may be a little internal or external to the mid‐point of the insertion of supraspinatusitself. | |
| Resisted abduction | None | The patient stands, arm at side, and is asked to abduct the arm maximally against the tester's isometric resistance, which is applied at the elbow. | Pain or weakness (either or both) | Supraspinatus lesion. (1) pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy. | |
| Resisted lateral rotation from neutral rotation | None | The patient stands, elbow at side and flexed to 90°, shoulder in neutral rotation. He or she is then asked to laterally rotate the shoulder maximally against the tester's isometric resistance, which is applied at the wrist. | Pain or weakness (either or both) | Infraspinatus or (less likely) teres minor lesion. (1) pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy. | |
| Resisted medial rotation from neutral rotation | None | The patient stands, elbow at side and flexed to 90°, shoulder in neutral rotation. He or she is then asked to medially rotate the shoulder maximally against the tester's isometric resistance, which is applied at the wrist. | Pain or weakness (either or both) | Lesion of subscapularis or another medial rotator. (1) Pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy. | |
| Whipple test | None | The patient horizontally adducts the straight arm, so that the hand, palm down is in front of the unaffected shoulder. In this position the tester applies a downwards force at the wrist, which the patient isometrically resists. | No details of interpretation were given. | Tear of anterior supraspinatus | |
| Tests intended to diagnose LHB tears or tendinosis | |||||
| Gilcreest's test (Gilcreest's palm up test) | None | The patient elevates the arms in full lateral rotation, holding a weight (e.g. 5 lb dumbbells) in each hand. The tester palpates the LHB while the patient, maintaining full lateral rotation, lowers both arms through abduction. Occasionally | When the arms reach an angle of from 110° to 90° | Recurrent dislocation of LHB tendon. Since used in a modified form for LHB tendinitis (Naredo 2002). | |
| Speed's test | None | The patient flexes his or her shoulder against isotonic resistance with the elbow extended and the forearm supinated. | Pain localised to the bicipital groove | Degenerative changes of the LHB, or synovitis of its tendon sheath. Recently the test has also been applied to the diagnosis of SLAP lesions (see below). | |
| Upper cut test | None | The patient, elbow at the side and flexed to 90°, palm upwards and with the shoulder in neutral rotation, is asked to make a fist. The tester, with a hand placed over the fist, applies isotonic resistance as the patient attempts to rapidly bring the hand up towards the chin, in the manner of a boxing upper cut. | Pain or a painful pop over the anterior portion of the involved shoulder during the resisted movement is interpreted as a positive result. | LHB or SLAP lesions (see below) | |
| Yergason' test (supination sign) | None | The patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the tester's resistance. | Pain localised to the bicipital groove. | Degenerative changes of the LHB, or synovitis of its tendon sheath. Recently, the test has also been applied to the diagnosis of SLAP lesions (see below). | |
| Tests intended to diagnose tears of the glenoid labrum | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Active compression test | None | The patient, who is standing, flexes his or her shoulder to 90°, then adducts 10‐15° and medially rotates fully. The elbow remains extended throughout. The tester stands behind the patient and applies a uniform downward force to the arm. This is repeated in full lateral rotation. | Pain on the 1st manoeuvre, reduced or eliminated on the 2nd | SLAP lesion | |
| Anterior slide test | None | The patient sits or stands, hands on hips and thumbs pointing posteriorly. One of the tester’s hands is placed across the top of the shoulder from behind, with the last segment of the index finger extending over the anterior aspect of the acromion at the shoulder joint. The tester’s other hand is placed behind the elbow, and a forward and slightly superiorly directed force is applied to the elbow and upper arm. The patient is asked to push back against this force. | Pain localised to the front of the shoulder under the tester’s hand, and/or a pop or click in the same area, or reproduction of the symptoms felt during overhead activity | Unstable SLAP lesion | |
| Biceps load II test | None | The patient lies supine. The tester gently grips his or her wrist and elbow, elevating the shoulder to 120° and laterally rotating it fully. The patient's forearm is supinated, and elbow flexed to 90°. The patient is now asked to flex his or her elbow against the tester'sisometric resistance. | Pain provoked by resisted elbow flexion. | SLAP lesion | |
| Biceps tension test | None | Probably as for *Speed’s test, but whether resistance is isometric or isotonic was not made clear | Not defined | Unstable SLAP lesion | |
| Compression‐rotation test | None | The patient lies supine, shoulder abducted to 90° and elbow flexed to 90°. The tester holds the patient’s wrist with one hand, while cradling the elbow with the other. The tester then applies a compression force along the line of the humerus while rotating the shoulder, in an attempt to trap the torn labrum. | Palpable catching & snapping, analogous to that felt during a positive McMurray’s test for a torn meniscus at the knee | Unstable SLAP lesion | |
| Crank test | None | The patient lies supine. The tester, holding the patient's arm and wrist, forward flexes the shoulder fully (c.f. the entry below) and, while axially loading the shoulder through the humerus, rotates it medially and laterally. | Clicking, apprehension or both (c.f. the entry below). | Tear of the glenoid labrum | |
| Crank test | None | The patient sits or lies (the lying variant is stated to be the more sensitive test: c.f. the entry above) with the elbow flexed 90° and the shoulder elevated 160° in the plane of the scapula (c.f. the entry above). The tester compresses the joint along the line of the humerus with one hand, while fully rotating the shoulder in either direction with the other. | Pain, usually during lateral rotation, with or without a click; or reproduction of symptoms (usually pain or a sensation of catching: c.f. the entry above). | Tear of the glenoid labrum. Interpretation is confused by the discrepancies with the entry above, but also by the recommendation, here, to conduct the test in sitting as well as in supine, especially since, ‘frequently, a positive crank test in the upright position will also be positive in the supine position’. If the supine test is more accurate, the rationale for additionally testing in sitting is unclear | |
| Modified dynamic labral shear | None | The patient stands. The elbow is flexed and the shoulder elevated to above 90° of scaption, then externally rotated to the point of tightness. The shoulder is then guided into maximal horizontal abduction. The tester then applies a shear load by maintaining external rotation and horizontal abduction while lowering the arm to 60° of scaption. Reportedly, this differs from the test described by O’Driscoll (no further citation information given) in that the arm is not placed into maximal horizontal abduction until it is elevated above 120°. (Reportedly, in pilot testing this modification was found to reduce the high number of false positive tests due to pain through the whole motion.) | Reproduction of the pain and/or a painful click or catch along the posterior joint line between 120° and 90° of scaption is interpreted as a positive result. | SLAP lesion | |
| Pain provocation test | None | The sitting patient’s shoulder is passively abducted to between 90 & 100° & fully externally rotated. With the patient’s elbow flexed to 90°, his or her forearm is fully pronated, then supinated, by the tester. | Pain, greater in the pronated position | Unstable SLAP lesion | |
| Palpation for bicipital groove tenderness | None | Deep pressure applied to the bicipital groove on the symptomatic and (for comparison) the asymptomatic arm | Pain elicited by deep pressure on the symptomatic arm, compared to no pain on the asymptomatic arm | SLAP lesion | |
| Passive compression test | None | The patient is in side‐lying, affected arm uppermost. The tester places one hand over the acromion, using the other to cradle the elbow, which is flexed to 90°. The shoulder is abducted to 30° and laterally rotated. The tester then applies a compressive force through the axis of the humerus while drawing the shoulder into extension. | Pain or a painful click | SLAP lesion | |
| Passive distraction test | None | The patient lies supine with the shoulder off the examining | Pain. If asked, the patient will frequently indicate | SLAP lesion | |
| SLAPprehension test | None | The arm of the seated or standing patient is horizontally adducted across the chest with the elbow extended and the shoulder medially rotated. The test is repeated with the shoulder laterally rotated. | ‘SLAPprehension’ (meaning unclear), pain which may be referred to the bicipital groove, and sometimes an audible or palpable click. Repeating the manoeuvre in lateral rotation must be less painful, or the test is negative or indeterminate. | Unstable SLAP lesion | |
| Speed's test | None | The patient flexes his or her shoulder against isotonic resistance with the elbow extended and the forearm supinated. | Pain | Originally developed to diagnose LHB lesions (see above), the test has recently also been applied to the diagnosis of SLAP lesions. | |
| Upper cut test | None | The patient, elbow at the side and flexed to 90°, palm upwards and with the shoulder in neutral rotation, is asked to make a fist. The tester, with a hand placed over the fist, applies isotonic resistance as the patient attempts to rapidly bring the hand up towards the chin, in the manner of a boxing upper cut. | Pain or a painful pop over the anterior portion of the involved shoulder during the resisted movement is interpreted as a positive result. | SLAP orLHB lesions (see above) | |
| Yergason' test, Supination sign | None | The patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the tester's resistance. | Pain localised to the bicipital groove. | Originally developed to diagnose biceps lesions (see above), the test has recently also been applied to the diagnosis of SLAP lesions. | |
| Abduction. Sideways movement of a limb away from the body, as in flapping the arms. The opposite of *adduction. The range of abduction is measured from the arm‐at‐side position (0°). Adduction. Movement of a limb towards the midline of the body. The opposite of *abduction. Accuracy. Formally, the proportion of all cases correctly identified by the test. Estimated as (TP+TN)/(TP+FP+FN+TN). ACJ. See ACROMIOCLAVICULAR JOINT. Acromioclavicular joint. The joint between the outer end of the *clavicle and the *acromion. Acromion. A bony process that projects from the *scapula and forms the point of the shoulder. It lies above the shoulder joint. Anterior. Towards the front. The opposite of *posterior. Arthrography. A diagnostic technique in which X‐rays are taken after injection of a contrast material into a joint. Biceps. See LONG HEAD OF BICEPS. Bicipital groove. A groove on the front of the upper *humerus that accommodates the Tendon of the *long head of biceps. Bursa. A lubricating sac. Bursae are often found where ligaments, muscles, tendons or bones rub together. Bursal‐side. Pertaining to the outer (superficial) aspect of the *rotator cuff: the aspect adjacent to the *subacromial‐subdeltoid bursa. Bursography. A diagnostic technique in which X‐rays are taken after injection of a contrast material into a *bursa. Calcific tendonitis. An inflammation of tendon characterised by deposition of calcium within the tendon’s substance. The tendon of *supraspinatus is commonly affected in this way. Clavicle. The collarbone. Cranial. Towards the head. Caudal. Away from the head. Deltoid. The muscle which gives rise to the rounded contour of the shoulder. Its major function, in concert with *supraspinatus, is to *abduct the shoulder. Distal. The direction away from the body. Elevate. To move upwards. At the shoulder, elevation may be through *flexion, *abduction or in the *plane of the scapula. In each case the range of the movement is measured from the arm‐at‐side position (0°). Extend. See EXTENSION. Extension. In general terms, straightening a joint to lengthen a limb. The opposite of *flexion. At the shoulder, it denotes movement backwards. The range of shoulder extension is measured from the arm‐at‐side position (0°). External rotation. See LATERAL ROTATION. False Negative (FN). The cases which a test incorrectly classifies as not having a disease. False Positive (FP). The cases which a test incorrectly classifies as having a disease. Flex. See FLEXION. Flexion. In general terms, bending a joint to shorten a limb (as in bending the arm up at the elbow).The opposite of *extension. At the shoulder it denotes movement forwards. The range of shoulder flexion is measured from the arm‐at‐side position (0°). FN. See FALSE NEGATIVE. FP. See FALSE POSITIVE. Glenoid. The socket of the shoulder joint. Glenoid labrum. A fibrocartilage (gristly) extension of the *glenoid rim that deepens the socket of the shoulder joint. Gold standard. A reputedly optimal *reference standard. Greater tuberosity. A protuberance on the upper *humerus to which *supraspinatus attaches. Horizontal abduction. The movement in which the arm is positioned parallel to the ground and brought backwards. The opposite of *horizontal adduction. Horizontal adduction. The movement in which the arm is positioned parallel to the ground and brought forwards. The opposite of *horizontal abduction. Humerus. The upper arm bone. Humeral head. The rounded upper part of the *humerus, which forms the ball of the shoulder joint. Impingement. Pinching. This causes ‘catching’ or aching pain without appreciable joint stiffness, and may lead to local inflammation and tissue damage. Subcategories include *internal impingement, *subacromial outlet impingement. Index test. The test undergoing evaluation against a *reference standard. Inferior. Relating to the lower portion of a structure. Opposite of *superior. Inferiorly. Downwards. Opposite of *superiorly. Infraspinatus. See ROTATOR CUFF. Internal rotation. See MEDIAL ROTATION. Internal impingement. Pinching of structures inside the shoulder joint at the extremes of movement. The *glenoid rim, the *glenoid labrum and the deep surface of the *rotator cuff are vulnerable to this type of *impingement, and may be affected singly or in combination. Isometric resistance. Tester‐applied resistance that prevents an attempted movement. Isotonic resistance. Tester‐applied resistance that allows an attempted movement Joint‐side. Pertaining to the inner (deep) aspect of the *rotator cuff: the aspect adjacent to the shoulder joint. Labrum. See GLENOID LABRUM. Lateral. Away from the midline of the body. The opposite of *medial. *Lateral rotation. At the shoulder this denotes a twisting movement as in unfolding the arms. The opposite of *medial rotation. Lesion. An area of tissue damage. LHB. See LONG HEAD OF BICEPS. Long head of biceps (LHB). The portion of the biceps that arises inside the shoulder joint. The tendon arches over the *humerus to pass into the arm. LR̶̶‐. See NEGATIVE LIKELIHOOD RATIO. LR+. See POSITIVE LIKELIHOOD RATIO. Magnetic resonance arthrography (MRA). *MRI following injection of a contrast material into a joint. Magnetic resonance Imaging (MRI). A non‐invasive diagnostic technique. Tissues' differing responses in a strong electromagnetic field are analysed by computer and translated into an accurate anatomical image. Medial. Towards the midline of the body. The opposite of *lateral. Medial rotation. At the shoulder, a twisting movement as in folding the arms or bringing the hand behind the back. The opposite of *medial rotation. MRA. See MAGNETIC RESONANCE ARTHROGRAPHY. MRI. See MAGNETIC RESONANCE IMAGING. Negative likelihood ratio (LR‐). The ratio between the probability of a negative test result when the disease is present, and the probability of a negative test result when the disease is absent; estimated as (1‐Sn)/Sp. Negative predictive value. The probability that the disease is absent when the test is negative; estimated as TN/(FN+TN). Neuropathy. A disorder of a nerve that may result in muscle weakness. Neutral rotation. A position of neither *lateral nor *medial rotation. Plane of the scapula. A plane of shoulder movement between *flexion/*extension and *abduction/*adduction. Posterior. Towards the back. The opposite of *anterior. Positive likelihood ratio (LR+). The ratio between the probability of a positive test result when the disease is present, and the probability of a positive test result when the disease is absent; estimated as Sn/(1‐Sp). Positive predictive value (PPV). The probability that the disease is present when the test is positive; estimated as TP/(TP+FP). PPV. See POSITIVE PREDICTIVE VALUE. Pronation. The movement of the forearm that, in relaxed standing, would bring the palm to face backwards. Prone. Lying face downwards. Proximal. The direction towards the body. Reference standard. A highly accurate method of diagnosis. It provides a benchmark against which other methods are judged. Rheumatoid disease. A systemic disease, one manifestation of which is inflammation of joints. Rotator cuff. A musculotendinous cuff that surrounds and blends with the shoulder joint, contributing to stability as well as producing movements. It comprises four overlapping units: supraspinatus, which lies on top of the joint and produces *abduction is the most commonly damaged; infraspinatus lies behind the joint, produces *lateral rotation and is the second most commonly damaged; subscapularis lies in front of the joint, produces *medial rotation and is damaged comparatively rarely. The fourth unit, teres minor, lies below *infraspinatus. It is relatively unimportant. SA‐SD *bursa. See SUBACROMIAL‐SUBDELTOID BURSA. Scaption. *Elevation of the arm in the *plane of the scapula. Scapula. Shoulder blade. Scapular. Relating to the *scapula. Sensitivity (Sn). The proportion of cases with the disease that are correctly identified by the *index test i.e. the true positive rate; estimated as TP/(TP+FN). SIS. See SUBACROMIAL IMPINGEMENT SYNDROME. SLAP lesion (Superior Labrum Anterior to Posterior *lesion). A tear in the upper part of the *glenoid labrum that extends forwards and backwards (Snyder 1990a; see Footnotes). It may result from *internal impingement. Sn. See SENSITIVITY. Sp. See SPECIFICITY. Specificity (Sp). The proportion of cases without the disease that are correctly identified by the *index test i.e. the true negative rate; estimated as TN/(FP+TN). Subacromial impingement. Pinching of the *subacromial‐subdeltoid bursa, the *rotator cuff, the *long head of biceps, or a combination of these, between the *humerus and the *acromion. Subacromial impingement syndrome. A collection of signs and symptoms considered characteristic of *subacromial impingement. Subacromial‐subdeltoid *bursa. A palm‐sized *bursa centred deep to the anterolateral tip of the *acromion. Extending *distally ‐ under the *deltoid ‐ as well as *proximally, and being superficial to the tendons of the *rotator cuff, it facilitates movement at the shoulder. Subacromial outlet impingement. See SUBACROMIAL IMPINGEMENT. Subluxation. A loss of joint congruity lesser in degree than in dislocation. Subscapularis. See ROTATOR CUFF. Superior. Relating to the upper portion of a structure. Opposite of *inferior. Superiorly. Upwards. Opposite of *inferiorly. Supination. The movement of the forearm that, in relaxed standing, brings the palm to face forwards. Supine. Lying flat with face upwards. Supraspinatus. See ROTATOR CUFF. Synovitis. Inflammation of *synovium. Synovium. Slippery tissue that lines joints, bursae and the sheaths that surround some tendons, such as the *long head of biceps. Systemic. Body‐wide, as opposed to local. Tendon Sheath. See SYNOVIUM. Teres minor. See ROTATOR CUFF. Tendinitis. Inflammation affecting a tendon. Tendinosis. Degenerative changes affecting a tendon. TN. See TRUE NEGATIVE. True Negative (TN). The cases which a test correctly identifies as not having a disease. True Positive (TP). The cases which a test correctly identifies as having a disease. Ultrasonography. A non‐invasive diagnostic technique in which high‐ frequency sound waves are bounced from the tissues in order to form images of the body's internal structures. Xylocaine. A local anaesthetic. |
Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6(4):274‐9.
The attraction of physical tests is that they can be used at any stage in the patient’s care pathway and in any setting. They are non‐invasive (apart from optional, adjunctive local anaesthesia), convenient, quick, and yield immediate results. Their aim of replicating pain or functional deficits lends them implicit relevance to patients’ symptoms whereas, by contrast, lesions detected by imaging or at open surgery may actually be asymptomatic (Dinnes 2003; MacDonald 2000a; Milgrom 1995; Sher 1995). Furthermore, they involve no cost additional to that of a clinical consultation.
Physical tests involve clinical and interpretative skills, and results have been shown to differ with testers’ expertise (Hanchard 2005). This has implications for the generalisation of results relating to test performance from individual studies. Given this, we will summarise data on variability in test results reported by the included studies, whether this is between individuals, across settings, or both.
Alternative test(s)
Other tests, usually conducted subsequently and in secondary care settings by specialists, include ultrasonography, arthrography, bursography, magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). Those considered as potential reference standards for this review are described in Table 3. Some of these tests are invasive and none is completely valid (Dinnes 2003). Specifically, the generally accepted gold standard of diagnosis, direct observation at open or arthroscopic ('keyhole') surgery (Table 3), is not completely valid because tears within the substance of the rotator cuff are not directly visible (Fukuda 2003) and conversely, visible tears may be asymptomatic (Dinnes 2003; MacDonald 2000a; Milgrom 1995; Sher 1995). Surgery carries a risk of complications (Blumenthal 2003; Boardman 1999; Borgeat 2001), and is not applicable in the primary care setting where the majority of consultations and treatment prescriptions occur. Moreover, approximately 70% of patients with shoulder impingement respond to conservative treatment (Morrison 1997a) and so those having surgery cannot be considered representative (spectrum bias).
| Test | Definition | Adequate reference standard for: | Qualifications |
| Open surgery | A diagnostic 'gold' standard. An invasive procedure during the course of which the interior of the shoulder joint and subacromial‐subdeltoid bursa may be directly visualised through an open incision. | (1) Subacromial impingement. (2) Subacromial‐subdeltoid bursitis. (3) Bursal side rotator cuff tears. (4) Full thickness rotator cuff tears. | (1) Tears of the rotator cuff's internal substance and joint side may be missed, as may SLAP lesions and disorders of the LHB. (2) Rotator cuff tears may be missed if obscured e.g. by inflammation. (3) Not applicable to primary care. |
| Arthroscopy | A diagnostic 'gold' standard. A 'keyhole' surgical procedure, in which the interior of the shoulder joint and subacromial‐subdeltoid bursa may be visualised through a flexible fibre‐optic tube. | (1) Subacromial‐subdeltoid bursitis. (2) Subacromial impingement. (3) Anterosuperior glenoid impingement. (4) Posterosuperior glenoid impingement. (5) Bursal side rotator cuff tears. (6) Full thickness rotator cuff tears. (7) Joint side rotator cuff tears. (8) Disorders of LHB. (9) SLAP lesions.
| (1) There is a technical and interpretive learning curve. (2) Tears of the rotator cuff's internal substance may be missed. (3) Rotator cuff tears may be missed if obscured, e.g. by inflammation. (4) Not applicable to primary care. |
| Ultrasonography | A non‐invasive diagnostic technique in which high‐frequency sound waves are bounced (reflected) from the tissues in order to form images of the body's internal structures. | (1) Full thickness rotator cuff tears. | (1) Technique and interpretation are highly operator‐dependent. The presence/absence of data/material confirming accuracy in individual diagnostic studies should be taken into account. (2) SLAP lesions cannot be visualised using ultrasound. |
| Magnetic Resonance Imaging (MRI) | A non‐invasive diagnostic technique. Tissues’ differing responses in a strong electromagnetic field are analysed by computer and translated into an accurate anatomical image. | (1) Full thickness rotator cuff tears. | This applies in settings (such as general primary care) where there is likely to be a low incidence of this disorder. |
| Arthrography | A diagnostic technique in which X‐rays are taken after injection of a fluid contrast material into a joint. | (1) Joint side rotator cuff tears. (2) Full thickness rotator cuff tears. | |
| Magnetic Resonance Arthrography (MRA) | A combination of Magnetic Resonance Imaging (MRI) and arthrography. An MRI scan is done after injection of contrast material into a joint. | (1) Joint side rotator cuff tears. (2) Full thickness rotator cuff tears. (3) SLAP lesions. | |
| Bursography | A diagnostic technique in which X‐rays are taken after injection of a contrast material into a bursa. | (1) Bursal side rotator cuff tears. | |
| Local anaesthesia | A minimally invasive procedure in which a local anaesthetic is injected, usually into the subacromial space (this is the second part of Neer's impingement test) and the effect on signs and/or symptoms noted. | (1) Subacromial outlet impingement. | (1) Correct interpretation is dependent on the injection's accuracy. 'Guided' injection, using fluoroscopy or ultrasound, is therefore preferable to 'blind' injection technique. |
The reference tests are also affected by clinical and interpretation skills. Varying degrees of ‘operator dependence’ apply to the imaging techniques, among which ultrasonography is the most susceptible. Surgery is also operator dependent; evaluations using videotaped arthroscopies have demonstrated disappointing agreement between surgeons as to the presence, absence and extent of pathology (Mohtadi 2004). As with the index tests (above), we will therefore summarise data reported by the included studies on the variability of the alternative reference tests.
Rationale
In a systematic review of interventions for shoulder pain, Green et al (Green 2003) observed that diverse and often conflicting diagnostic labelling hampered interpretation of the literature. Our review should help in this regard. In addition, timely diagnosis of impingement and the underlying structural deficits should enable rationalisation of patients’ diagnostic pathways, as well as informing their management and prognosis.
At the inception of this review, we identified two relevant systematic reviews in this area. Dinnes et al (Dinnes 2003) reviewed diagnostic tests for shoulder pain due to soft tissue disorders, including cohort studies of physical tests, ultrasound, MRI or MRA in patients suspected of having soft tissue disorders (search date October 2001). Though they reported inclusion of 'clinical impingement syndrome', Dinnes et al's primary emphasis was on the detection of rotator cuff tears. Tests for disorders of the glenoid labrum were specifically excluded. Conversely, a systematic review by Luime et al (Luime 2004b) concentrated on clinical diagnostic studies of tests for glenoid labral tears and shoulder joint instability (reported search dates '2001' for CINAHL and EMBASE, and '2003' for MEDLINE). Our own review, as well as conducting an updated search for studies of clinical examination, extends the definition of shoulder impingement, as described above. The mutually distinct nature of tests for impingement and instability (despite the potential interrelationships between the two conditions) has enabled the review to focus on the former. Our review also differs from the others in placing emphasis on the primary care setting (while not excluding secondary or tertiary care) as most people with shoulder pain are diagnosed and managed in this setting (Broadhurst 2004). From the primary care perspective, patients studied at a later stage in the referral pathway or undergoing more than minimally invasive reference tests are not representative, and this issue of applicability is explicit in the quality assessment of included studies.
Objectives
To evaluate the diagnostic accuracy of physical tests, applied singly or in combination, 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.
We also examined the physical tests according to whether they were intended to:
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identify impingement in general (or differentiate it from other causes of shoulder pain, e.g. 'frozen shoulder')
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subcategorise impingement as subacromial outlet impingement (impingement under the acromion process) or internal impingement (impingement within the shoulder joint)
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diagnose lesions of bursa, tendon or glenoid labrum that may be associated with impingement
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form part of a diagnostic package or process and, if so, according to the stages at which they may apply.
Investigation of sources of heterogeneity
We planned to investigate the following potential sources of heterogeneity.
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Study population: older general population; young athletic population; other well defined groups e.g. wheelchair users or swimmers (see the Differences between protocol and review)
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Stage of clinical care: primary (generally in the community setting), secondary (referral following preliminary screening) or tertiary (referral to a specialist centre)
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Study design: cross sectional (or cohort) versus case‐control; retrospective versus prospective design
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Type of reference test. This will vary according to the target condition and setting, but generally surgery versus non‐invasive imaging will be considered (seeTable 3)
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Aspects of study conduct, specifically: blinding and reporting of uninterpretable or intermediate results.
Methods
Criteria for considering studies for this review
Types of studies
We considered diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test. We considered diagnostic test accuracy studies with cross‐sectional or cohort designs (retrospective or prospective), case‐control studies and randomised controlled trials. In particular, we noted whether the cases and controls in case‐control studies were highly selected or acceptably representative of the patient population normally tested by the index test(s). We considered, but decided against, excluding cohort studies with an excessively long period between the index and reference test. We defined this as a period that, on average, equals or exceeds the reported mean duration of symptoms, or one month (whichever is shorter). We excluded studies that were reported only in abstract form.
Participants
Patients of any age and in any clinical setting with pain, dysfunction or both suspected to be due to shoulder impingement of any type (seeTarget conditions), whether subacromial, internal or secondary to rotator cuff disease, and with or without rotator cuff tears. Excluded were studies evaluating physical (index) tests under anaesthesia, or intra‐ or post‐operatively. We also excluded studies that focused solely on pain due to acromioclavicular joint (ACJ) disorders; or that focused primarily on shoulder joint instability, fracture, acute or recurrent shoulder dislocation, or systemic disease (e.g. rheumatoid disease). Subsequent to the protocol we excluded studies with highly selected populations, such as overhead throwing athletes.
After evaluation of a patient’s history, physical tests are normally the first stage in the diagnosis of shoulder impingement. However, the applicability of one physical test may be conditional upon the result of another (e.g. Zaslav 2001), and this was taken into account.
Index tests
Physical tests used singly or in combination to identify shoulder impingement, such as the painful arc test (Cyriax 1982); to classify shoulder impingements, e.g. Neer’s test (Neer 1977; Neer 1983), the modified relocation test (Hamner 2000), the internal rotation resistance strength test (Zaslav 2001); or to diagnose localised conditions that may accompany impingement, e.g. Yergason’s test (Yergason 1931), the lift off test (Gerber 1991a; Gerber 1996; Hertel 1996a), the crank test (Liu 1996b), the active compression test (O'Brien 1998a) and the biceps load II test (Kim 2001) (seeTable 1).
Ideally, articles for inclusion should have described a physical test, or reference a source that did so, in sufficient detail to enable its replication, and clearly indicate what constituted a positive index test result. Those that did not were included only if they provided sufficient information to be of clinical value. Studies reporting the collective diagnostic accuracy of a series of tests were considered, providing each component, and its manner of inclusion, were adequately described. Generic terms such as 'physical examination', as used to denote an unspecified combination of physical tests, led to exclusion unless further details were obtained from authors.
Target conditions
Subacromial or internal impingement of the shoulder and the localised conditions that may accompany these classifications, namely bursitis, rotator cuff tears, glenoid labrum tears, and inflammation or rupture of the biceps tendon.
Instability may underlie impingement, but tests of instability were only included if they were intended to demonstrate associated impingement pain, as in the modified relocation test (Hamner 2000), as opposed to instability per se. Similarly, tests for ACJ disorders were only included if, like the active compression test (O'Brien 1998a), they had a component intended to reproduce impingement pain.
Reference standards
In the absence of a definitive reference standard, surgery, whether open or arthroscopic, is generally regarded as the best available. We additionally considered ultrasound, which may be conducted in the primary care setting, and magnetic resonance imaging, magnetic resonance arthrography, subacromial local anaesthesia, arthrography and bursography, all of which may have more general applicability than surgery. These additional ‘reference’ tests are defined in Table 3. Their validity varies according to context, and are discussed case by case (seeTable 3).
Search methods for identification of studies
Electronic searches
The search for studies was carried out in two stages (up to November 2005; 2005 to February 2010)
In the first stage, we searched MEDLINE (1966 to 14 November 2005), EMBASE (1974 to 14 November 2005), CINAHL (1982 to 14 November 2005) and AMED (Allied and Complementary Medicine Database) (1985 to 14 November 2005). We developed a sensitive search strategy (Appendix 1) as recommended in Chapter 5 and Appendix 5.4 of the Handbook (de Vet 2005). We also searched DARE (Database of Abstracts of Reviews of Effectiveness, The Cochrane Library) (1995 to 14 November 2005). While we recognise the potential association between language restriction and selection bias, pragmatic considerations required that the searches were restricted to articles written in the English language.
In the second stage, we searched MEDLINE, EMBASE and AMED (CINAHL had been removed to a separate search platform) from 2005 to 15 February 2010 (Appendix 2).
Searching other resources
We checked the reference lists of all relevant retrieved articles of primary diagnostic studies and systematic reviews.
Data collection and analysis
Selection of studies
Assisted by a pro‐forma stating the review inclusion criteria, two review authors (NH and HH) independently screened the results of the electronic searches for the first batch (up to November 2005); and one review author (HH) screened the results of the second batch. Throughout, benefit of doubt was given for the assessment of study eligibility. After obtaining full text articles, two pairs of review authors (NH and HH; NH and ML) independently performed study selection. Disagreements were resolved by discussion between three review authors (NH, HH and ML).
Data extraction and management
We designed a review‐specific data collection form (Whiting 2005a) and piloted it on three studies of diagnostic accuracy that focused on physical tests for shoulder instability (a condition outside the scope of the present review). Pairs of review authors (NH and HH; NH and ML) independently extracted all key study and participant information and data from the included studies without masking of trial authors and other identifying information. All disagreements were resolved by consensus.
We extracted the diagnostic 2 x 2 table data (number of true positives, false positives, false negatives, and true negatives) from the publications. If these were not available we attempted to reconstruct the 2 x 2 table(s) from summary estimates (Whiting 2005b). Studies presenting insufficient data for construction of 2 x 2 tables were excluded from the review.
We contacted authors mainly in regard to the availability of trial reports and more rarely identification of index tests and where there were minor and isolated discrepancies impeding the construction of 2 x 2 tables.
Discrepancies in 2 x 2 tables due to rounding errors were a common finding. A rule was devised whereby data were considered for inclusion only where the discrepancies in the back‐calculated 2 x 2 table did not exceed 10% in any cells. Studies with multiple discrepant analyses were excluded. Where incorrectly reported summary statistics (borderline discrepancies in sensitivity or specificity not attributable to rounding error; or positive predictive value, negative predictive value or accuracy) were identified in included studies, this was highlighted as a cause for concern.
Assessment of methodological quality
At the same time as data collection, pairs of review authors (NH and HH; NH and ML) independently assessed study quality using all items of the QUADAS form (Whiting 2003), tailored to the review. Prior to the protocol, we had already undertaken a preliminary piloting exercise to establish a coding manual setting out review‐specific criteria (seeAppendix 3). Disagreements were resolved by consensus.
Statistical analysis and data synthesis
For each index test, we plotted the observed sensitivities and specificities (with 95% confidence intervals) on forest plots for visual examination of variation in test accuracy across studies.
We planned to perform meta‐analysis using hierarchical models if adequate data were available. However, due to the limited number of studies included for each test, meta‐analysis was not possible and so descriptive analyses were undertaken.
Investigations of heterogeneity
We planned to use meta‐regression (by adding covariates to the hierarchical models) or subgroup analyses to explore the effect of potential sources of heterogeneity, such as the type of reference standard, on sensitivity and specificity. However, due to the limited number of studies available for each test, this was not possible.
Results
Results of the search
We screened 3127 records from the first stage of the search and 1888 from the second stage (seeAppendix 2). We obtained over 400 full text articles, some (numbers not fully documented) prompted by our scrutiny of references lists of reviews and primary studies. Of the 205 potentially eligible studies, 162 were excluded, 10 await classification, and 33 were included. The study flow diagram is shown in Figure 1.
Flow diagram.
Included studies
The Characteristics of included studies table gives details of the 33 studies, which evaluated a total of 4002 shoulders in 3852 patients. Apart from five studies (Castoldi 2009; Itoi 2006; Norwood 1989; Oh 2008 and Schlechter 2009), all were prospective. Fourteen (42%) were conducted in the USA. The remainder took place in Canada (Holtby 2004a; Holtby 2004b; MacDonald 2000; Razmjou 2004), South Korea (Kim 2001; Kim 2006; Kim 2007b; Oh 2008), Italy (Castoldi 2009; Gumina 2008; Iagnocco 2003), Denmark (Frost 1999; Suder 1994), Japan (Itoi 1999; Itoi 2006), Spain (Naredo 2002), Switzerland (Hertel 1996), Turkey (Calis 2000) and the UK (Miller 2008b).
Most of the studies were set in secondary or tertiary care, and only a few used reference standards that would be applicable to primary care, the intended focus of this review, or to the hospital outpatient setting. These were Calis 2000 (local anaesthesia, MRI); Iagnocco 2003, Miller 2008b, Naredo 2002 (ultrasonography); Frost 1999, Itoi 1999, Kim 2006 (MRI); and O'Brien 1998 (radiography and MRI, but also arthroscopic and open surgery, in various unspecified combinations). Apart from O'Brien 1998, previously mentioned, four studies (Castoldi 2009; Hertel 1996; Razmjou 2004; Speer 1994) used a mixture of arthroscopic and open surgery. The remainder, comprising 20 (61%) studies, used arthroscopic surgery alone.
Studies were grouped according to their target condition (seeTable 4).
| Target condition | Studies | Shoulders/patients |
| Subacromial or internal impingement | 5 | 471/466 |
| Rotator cuff tendinopathy or tears | 18 | 2477/2337 |
| LHB tendinopathy or tears | 3 | 660/557 |
| Glenoid labral lesions | 11 | 1245/1236 |
| Multiple undifferentiated target conditions* | 4 | 201/200 |
*LHB/labral pathology; LHB/SLAP lesions; SA‐SD bursitis/bursal‐side degeneration of supraspinatus; and SIS/rotator cuff tendinitis or tear.
Subacromial impingement
Five studies (Calis 2000; Gumina 2008; Iagnocco 2003; MacDonald 2000; Naredo 2002) evaluated tests for subacromial impingement explicitly, or SA‐SD bursitis, which we considered synonymous, on a total of 889 shoulders in 781 patients (seeTable 5 for overview). One of these studies, Calis 2000, evaluated tests not only for subacromial bursitis but also, using dynamic ultrasonography as a reference standard, for subacromial impingement as an observable event in real time.
| Study ID | Shoulders (patients, if different) | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| Subacromial impingement | |||||
| 125 (120) | SIS | ● Combination: ALL 7 +ve ● Drop arm test (modified interpretation 2) ● Hawkins' test (standard) ● Neer's sign (standard) ● Painful arc test (standard) ● Passive horizontal adduction (modified interpretation) ● Speed's test (modified interpretation 2) ● Yergason's test (modified interpretation 2) | D |
| |
| 120 | SIS | ● Gum‐Turn test (novel) | E |
| |
| 85 | SA‐SD bursitis | ● Hawkins' test (standard) | No | ||
| ● Neer's sign (modified procedure) | |||||
| ● Hawkins' test OR Neer's sign (modified procedure) | |||||
| ● Hawkins' test AND Neer's sign (modified procedure) | |||||
| 31 | SA‐SD bursitis | ● Combination: Hawkins’ test, Neer's sign, 'Yocum's (impingement) test' (overall criterion for +ve result not stated) |
| No | |
| Subacromial impingement in real time (dynamic ultrasonography) | |||||
| Differentiating subacromial from internal impingement | |||||
| 110 | Subacromial versus internal impingement | ● Internal rotation resistance strength test (novel) | No | ||
| Internal impingement | |||||
| None | None | ||||
Modified interpretation 1: criteria for a positive test result not as described in the primary source
Modified interpretation 2: target condition of test not as described in the primary source
A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error
B: Isolated absolute discrepancy of 5% to <10% ‐ a suspected or confirmed typographical error
C: Isolated discrepancy of 10% or more ‐ a suspected or confirmed typographical error
D: Multiple absolute discrepancies of which the greatest is 1% to <5%
E: Multiple absolute discrepancies of which the greatest is 5% to <10%
F: Multiple absolute discrepancies of which the greatest is 10% or more
?: 2 X 2 table not reported and cannot be deduced with certainty.
NR: Summary statistics not reported
Internal impingement
No studies evaluated tests for internal impingement in isolation.
Subacromial versus internal impingement
One study (Zaslav 2001) of 110 shoulders in 110 patients evaluated a test to differentiate subacromial from internal impingement (seeTable 5 for overview).
Rotator cuff tendinopathy or tears
Eighteen studies (Barth 2006; Calis 2000; Castoldi 2009; Frost 1999; Gumina 2008; Hertel 1996; Holtby 2004b; Iagnocco 2003; Itoi 1999; Itoi 2006; Kim 2006; MacDonald 2000; Miller 2008b; Naredo 2002; Norwood 1989; Speer 1994; Suder 1994; Wolf 2001) evaluated tests for rotator cuff tendinopathy or tears on a total of 2477 shoulders in 2337 patients (seeTable 6 for overview).
| Study ID | Shoulders | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 68 | Subscapularis, any tear of | ● Bear‐hug test (novel) ● Belly‐press test (modified procedure) ● Lift‐off test (Gerber 1991a: modified interpretation 1) ● Napoleon test (Burkhart 2002: standard) | No | ||
| Subscapularis, complete tear of | |||||
| Subscapularis, partial tear of | |||||
| 395 (390) | Supraspinatus, FTT of, full‐width | ● External rotation lag sign (standard) | No | ||
| Supraspinatus, PTT of, isolated | |||||
| 125 (120) | Supraspinatus, FTT of | ● Drop arm test (standard) ● Hawkins' test (modified interpretation 2) ● Neer's sign (modified interpretation 2) ● Painful arc test (modified interpretation 2) ● Passive horizontal adduction (modified interpretation 2) ● Speed's test (modified interpretation 2) ● Yergason's test (modified interpretation 2) | F | ||
| 73 | Supraspinatus, FTT, degeneration or tendinitis of | ● Hawkins' test (modified procedure, modified interpretation 2) | NR | NR | |
| Supraspinatus, FTT or degeneration of | |||||
| Supraspinatus, FTT of | |||||
| 120 | Rotator cuff, postero‐superior, FTT of | ● Gum‐Turn test (novel) | E |
| |
| Rotator cuff, postero‐superior, supraspinatus AND infraspinatus, FTT of | |||||
| Supraspinatus, FTT of | |||||
| 100 | Rotator cuff, postero‐superior FTT or PTT of | ● Drop sign (novel) ● Empty can test for weakness ± pain (modified interpretation 2) ● External rotation lag sign (novel) | C | ||
| Subscapularis, any tear of | ● Internal rotation lag sign (novel) ● Lift‐off test (Gerber 1991a: probably standard) | ||||
| 50 | Supraspinatus, PTT or tendinitis of | ● Empty can test for pain WITHOUT weakness (standard) | No | ||
| Supraspinatus, FTT of | ● Empty can test for weakness ± pain (standard) | ||||
| Rotator cuff, large or massive FTT of | ● Empty can test for weakness ± pain (modified interpretation 2) | ||||
| 528 (425) | Supraspinatus, any disease of, including calcification | ● Empty can test (no reference or details given) | NR | NR | |
| Infraspinatus, any disease of, including calcification | ● Resisted lateral rotation from neutral rotation (no reference or details given) | ||||
| Subscapularis, any disease of, including calcification | ● Resisted medial rotation from neutral rotation (no reference or details given) | ||||
| 143 (136) | Supraspinatus, FTT of | ● Empty can test for pain ± weakness (modified interpretation 1) ● Empty can test for pain AND/OR weakness (modified interpretation 1) ● Empy can test for weakness ± pain (standard) ● Full can test for pain ± weakness (modified interpretation 1) ● Full can test for pain AND/OR weakness (modified interpretation 1) ● Full can test for weakness ± pain (standard) | No | ||
| 160 (149) | Supraspinatus FTT or PTT of | ● Empty can test for pain ± weakness (modified interpretation 1) ● Empty can test for weakness ± pain (standard) ● Empty can test for weakness < grade 3 ± pain (modified interpretation 1) ● Full can test for pain ± weakness (modified interpretation 1) ● Full can test for weakness ± pain (standard) ● Full can test for weakness < grade 3 ± pain (modified interpretation 1) | B |
| |
| Infraspinatus, FTT or PTT of | ● Resisted external rotation from neutral rotation for weakness < grade 3 (modified interpretation 1) | ||||
| Subscapularis, any tear of | ● Lift‐off test with force for weakness < grade 2 ± pain (Gerber 1991a: modified procedure; modified interpretation 1) | ||||
| 200 | Rotator cuff, FTT or PTT of | ● Empty can test for pain ± weakness (modified interpretation 1,2) ● Empty can test for pain OR weakness (ONE ONLY) (modified interpretation 1,2) ● Empty can test for pain AND weakness (BOTH) (modified interpretation 1,2) ● Empty can test for weakness ± pain (modified interpretation 2) ● Full can test for pain ± weakness (modified interpretation 1,2) ● Full can test for pain OR weakness (ONE ONLY) (modified interpretation 1,2) ● Full can test for pain AND weakness (BOTH) (modified interpretation 1,2) ● Full can test for weakness ± pain (modified interpretation 2) | B |
| |
| Rotator cuff, FTT of | |||||
| 85 | Rotator cuff, FTT or PTT of | ● Combination: Hawkins' test (modified interpretation 2) OR Neer's sign (modified procedure, modified interpretation 2) +ve ● Combination: Hawkins' test (modified interpretation 2) AND Neer's sign (modified procedure, modified interpretation 2) +ve ● Hawkins' test (modified interpretation 2) ● Neer’s sign (modified procedure, modified interpretation 2) | C | ||
| 46 (37) | Rotator cuff, postero‐superior, FTT of | ● Drop sign (modified interpretation 2) ● External rotation lag sign (modified interpretation 2) | A | ||
| Subscapularis, FTT of | ● Internal rotation lag sign (modified interpretation 2) | ||||
|
| 31 | Supraspinatus, FTT, PTT or tendinitis of | ● Empty can test for pain AND/OR weakness (standard) | E | |
| Infraspinatus, FTT, PTT or tendinitis of | ● Patte’s test for pain AND/OR weakness (Leroux 1995: standard) | ||||
| Subscapularis, any tear or tendinitis of | ● Combination: lift‐off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described); resisted medial rotation from neutral rotation. Overall criterion for +ve result not given. | ||||
| Supraspinatus, FTT or PTT of | ● Empty can test for weakness ± pain (standard) | ||||
| Infraspinatus, FTT or PTT of | ● Patte’s test for weakness ± pain (Leroux 1995: standard) | ||||
| Subscapularis, any tear of | ● Combination: lift‐off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described), resisted medial rotation from neutral rotation. Overall criteria for +ve result not given. | ||||
| Supraspinatus, tendinitis of | ● Empty can test for pain WITHOUT weakness (standard) | ||||
| Infraspinatus, tendinitis of | ● Patte’s test for pain WITHOUT weakness (Leroux 1995: standard) | ||||
| Subscapularis, tendinitis of | ● Combination: lift‐off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described, modified interpretation 2), resisted medial rotation from neutral rotation. Overall criterion for +ve result not given. | ||||
| 103 | Rotator cuff, FTT of, multiple‐ versus single‐tendon | ● Active abduction to < 90° (novel) | NR | NR | |
|
| 100 | Rotator cuff, any disease of | ● Relocation test for pain (Jobe 1989: modified procedure) ● Relocation test for pain (Jobe 1989: standard) | No | |
|
| 31 | Rotator cuff, FTT or PTT of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | NR | NR |
| Rotator cuff, FTT of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | ||||
| Rotator cuff, PTT of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | ||||
|
| 119 | Rotator cuff, FTT of | ● Rent test (standard) | No | |
Modified interpretation 1: criteria for a positive test result not as described in the primary source
Modified interpretation 2: target condition of test not as described in the primary source
A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error
B: Isolated absolute discrepancy of 5% to <10% ‐ a suspected or confirmed typographical error
C: Isolated discrepancy of 10% or more ‐ a suspected or confirmed typographical error
D: Multiple absolute discrepancies of which the greatest is 1% to <5%
E: Multiple absolute discrepancies of which the greatest is 5% to <10%
F: Multiple absolute discrepancies of which the greatest is 10% or more
?: 2 X 2 table not reported and cannot be deduced with certainty.
NR: Summary statistics not reported
LHB (long head of biceps) tendon tendinopathy or tears
Three studies (Iagnocco 2003; Kibler 2009; Naredo 2002) evaluated tests for LHB tendon tendinopathy or tears on a total of 660 shoulders in 557 patients (seeTable 7 for overview).
| Study ID | Shoulders | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 528 (425) | LHB, any lesion of | ● Speed's test (standard) | NR | NR | |
| 101 | LHB, any lesion of | ● Active compression test (modified interpretation 2) ● Anterior slide test (modified procedure, modified interpretation 1,2) ● Bear‐hug test (modified interpretation 1,2) ● Belly‐press test (modified interpretation 2) ● Modified dynamic labral shear (novel) ● Speed's test (modified procedure) ● Upper cut test (novel) ● Yergason's test (modified procedure) | E | ||
| 31 | LHB, any lesion of | ● Combination: Yergason's test (standard), Gilcreest's palm up test (modified procedure, modified interpretation 1,2). Criteria for +ve result not given. | No | ||
Modified interpretation 1: criteria for a positive test result not as described in the primary source
Modified interpretation 2: target condition of test not as described in the primary source
A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error
B: Isolated absolute discrepancy of 5% to <10% ‐ a suspected or confirmed typographical error
C: Isolated discrepancy of 10% or more ‐ a suspected or confirmed typographical error
D: Multiple absolute discrepancies of which the greatest is 1% to <5%
E: Multiple absolute discrepancies of which the greatest is 5% to <10%
F: Multiple absolute discrepancies of which the greatest is 10% or more
?: 2 X 2 table not reported and cannot be deduced with certainty.
NR: Summary statistics not reported
Glenoid labral lesions
Eleven studies (Guanche 2003; Kibler 2009; Kim 2001; Kim 2007b; Liu 1996b; O'Brien 1998; Oh 2008; Parentis 2006; Schlechter 2009; Stetson 2002; Suder 1994) evaluated tests for glenoid labral lesions on a total of 1245 shoulders in 1236 patients (seeTable 8 for overview).
| Study ID | Shoulders (patients, if different) | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 60 (59) | Labrum, any SLAP lesion of | ● Active compression test (modified procedure, modified interpretation 2: 2 x 2 table not calculable for this test) ● Anterior apprehension test at 90° for pain (Krishnan 2004: modified interpretation 2) ● Anterior release test described as in Gross 1997 with modified interpretation 2, but erroneously labelled as Jobe's relocation test. ● Crank test (Liu 1996b: modified procedure, modified interpretation 2) ● Palpation for bicipital groove tenderness (standard) ● Speed's test (modified interpretation 1,2) ● Yergason's test (modified interpretation 1,2) | No | ||
| 101 | Labrum, any SLAP lesion of | ● Active compression test (modified interpretation 2) ● Anterior slide test (modified procedure, modified interpretation 1, 2) ● Bear‐hug test (modified interpretation 1,2) ● Belly‐press test (modified interpretation 2) ● Modified dynamic labral shear (novel) ● Speed's test (modified procedure, modified interpretation 2) ● Upper cut test (novel) ● Yergason's test (modified procedure, modified interpretation 2) | E | ||
| 127 | Labrum, type II SLAP lesion of | ● Biceps load II test (novel) | No | ||
| 61 | Labrum, any SLAP lesion of | ● Passive compression test (novel) | No | ||
| Labrum, type II‐IV SLAP lesion of | ● Passive compression test (novel, modified interpretation 2) | ||||
| 62 | Labrum, any tear of | ● Crank test (novel) | No | ||
| 206 | Labrum any tear of | ● Active compression test (novel) | No | ||
| 146 | Labrum, type II SLAP lesion of | ● Active compression test (modified interpretation 2) ● Anterior apprehension test at 90° for pain OR apprehension (Rowe 1981: modified interpretation 1,2) ● Anterior slide test (modified interpretation 2) ● Biceps load II test (standard) ● Compression‐rotation test (modified interpretation 2) ● Palpation for bicipital groove tenderness (modified interpretation 2) ● Relocation test for pain OR apprehension (modified interpretation 2) ● Speed's test (modified procedure, modified interpretation 1,2) ● Whipple test (modified interpretation 2) ● Yergason's test (modified interpretation 2) | E | ||
| 132 | Labrum, type II SLAP lesion of | ● Active compression test (modified interpretation 1,2) ● Anterior slide test (modified interpretation 2) ● Crank test (Liu 1996b: modified procedure, modified interpretation 2) ● Hawkins' test (modified procedure, modified interpretation 2) ● Neer's sign (modified procedure, modified interpretation 2) ● Pain provocation test (modified interpretation 2) ● Modified relocation test for posterosuperior glenoid impingement (modified interpretation 2) mislabelled as Jobe's relocation test ● Speed's test (modified interpretation 1,2) ● Yergason's test (modified interpretation 1,2) | A | ||
| 254 (246) | Labrum, type II‐IV SLAP lesion of | ● Active compression test (modified interpretation 2) ● Anterior slide test (modified procedure) ● Combination: active compression test (modified interpretation 2) OR passive distraction test (standard) ● Passive distraction test (standard) | E | ||
| 65 | Labrum, any tear of | ● Active compression test (modified interpretation 1) ● Crank test (standard) | No | ||
| 31 | Labrum, any tear of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | NR | NR | |
Modified interpretation 1: criteria for a positive test result not as described in the primary source
Modified interpretation 2: target condition of test not as described in the primary source
A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error
B: Isolated absolute discrepancy of 5% to <10% ‐ a suspected or confirmed typographical error
C: Isolated discrepancy of 10% or more ‐ a suspected or confirmed typographical error
D: Multiple absolute discrepancies of which the greatest is 1% to <5%
E: Multiple absolute discrepancies of which the greatest is 5% to <10%
F: Multiple absolute discrepancies of which the greatest is 10% or more
?: 2 X 2 table not reported and cannot be deduced with certainty.
NR: Summary statistics not reported
Multiple, undifferentiated target conditions
Four studies evaluated tests for multiple, undifferentiated target conditions. These were Bennett 1998 (LHB/labral pathology; 46 shoulders in 45 patients), Holtby 2004a (LHB/SLAP lesions; 50 shoulders in 50 patients), Michener 2009 (SA‐SD bursitis/bursal‐side degeneration of supraspinatus; 55 shoulders in 55 patients) and Razmjou 2004 (subacromial impingement syndrome/rotator cuff tendinitis or tear; 50 shoulders in 50 patients) (seeTable 9 for overview).
| Study ID | Shoulders (patients, if different) | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 46 (45) | LHB tendinitis/LHB avulsion/SLAP lesion, any | ● Speed's test (modified procedure, modified interpretation 1) | C | ||
| 50 | LHB lesion, any/SLAP lesion, any | ● Speed's test (modified procedure, modified interpretation 1, 2) | No | ||
| ● Yergason's test (modified interpretation 1, 2) | |||||
| 55 | SA‐SD bursitis/ bursal‐side degeneration of supraspinatus (but patients with PTT or FTT inter alia were not excluded) | ● Empty can test (modified interpretation 2) | No | ||
| ● Hawkins' test (standard) | |||||
| ● Neer's sign (modified procedure) | |||||
| ● Painful arc test (standard) | |||||
| ● Resisted lateral rotation from neutral rotation for weakness ± pain (modified interpretation 1,2) | |||||
| ● 3 or more tests +ve | |||||
| 50 | SIS/rotator cuff tendinitis or tear | ● Hawkins' test (modified interpretation 2) |
| No | |
| ● Neer's sign (modified interpretation 2) | |||||
Modified interpretation 1: criteria for a positive test result not as described in the primary source
Modified interpretation 2: target condition of test not as described in the primary source
A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error
B: Isolated absolute discrepancy of 5% to <10% ‐ a suspected or confirmed typographical error
C: Isolated discrepancy of 10% or more ‐ a suspected or confirmed typographical error
D: Multiple absolute discrepancies of which the greatest is 1% to <5%
E: Multiple absolute discrepancies of which the greatest is 5% to <10%
F: Multiple absolute discrepancies of which the greatest is 10% or more
?: 2 X 2 table not reported and cannot be deduced with certainty.
NR: Summary statistics not reported
Excluded studies
The reasons for excluding, usually from inspection of the full text article, 162 studies are given in the Characteristics of excluded studies. Table 10 shows the trials grouped by their primary reason. The main and often listed as the sole reason for exclusion was that the study was not a diagnostic test accuracy study. Of the 104 studies for which this was the case, 11 were systematic reviews without reporting of results from an associated primary study. Three studies were not reported in full and it appears unlikely that this will ever be the case. The rest were confirmed diagnostic test accuracy studies. Of these, five were not of physical tests and eight did not study a target condition of this review. Twenty‐one trials studied a highly selected population, either in terms of a high risk population (e.g. overhead throwing athletes as in Hamner 2000), previous injury (e.g. anterior shoulder dislocation), 100% prevalence of a condition by intent (e.g. all had SLAP lesions in Berg 1998) or a highly selected population by exclusion of key conditions (e.g. Liu 1996a). Two studies were excluded because special equipment (a hand held dynamometer) was used and four studies were excluded because the reference test was unacceptable (e.g. MRI was used as a reference standard for impingement in Silva 2008). In seven studies there was unclear reporting of physical tests, testing and/or the population. Lastly, eight studies were excluded because of the lack, incompleteness or gross inconsistency of reported data.
| Main reason | N | Details |
| Not DTA study | 93 | Not shown |
| Not DTA study. Systematic review only | 11 | Beaudreuil 2009; Calvert 2009; Dessaur 2008; Hegedus 2008; Hughes 2008; Jones 2007; Luime 2004; Meserve 2009; Munro 2009; Pugh 2009; Walton 2008 |
| Abstract only / no published full report | 3 | |
| Not DTA study of physical tests | 5 | Birtane 2001; Cullen 2007; El Dalati 2005; Jee 2001; O'Connor 2005 |
| Not DTA study of included condition | 8 | Chronopoulos 2004; Kim 2004b; Kim 2005 (all not impingement); Kim 2007a (rheumatoid disease); Lafosse 2007 (timing of surgery); Lewis 2007 (not impingement); Odom 2001; Walton 2004 (not impingement) |
| Highly selected population ‐ sports / lesion | 9 | (post traumatic dislocation); Brasseur 2004 (veteran tennis players); Hamner 2000 (overhead throwing athletes); Kibler 2006a (athletes); Kim 1999 (all post anterior dislocation); Meister 2004 (all overhead athletes); Mimori 1999(throwing injuries); Myers 2005 (all athletes); Walsworth 2008 (military) |
| Highly selected pop: 100% prevalence or by exclusion | 12 | Berg 1998 (slap); Burkhart 2000 (slap), Burkhart 2002 (rotator cuff); Fukuda 1996 (rotator cuff); Gschwend 1988 (no disease negative; no specificity); Liu 1996a (tears removed); Lyons 1992 (all RCT ‐ tear size study); Morgan 1998 (slap); Pandya 2008 (slap); Read 1998 (100% prevalence by exclusion); Rhee 2005a (all slap); Watson 1989 (all subacromial impingement ‐ no specificity) |
| Special equipment used | 2 | |
| Unsatisfactory / unacceptable reference test / control: 4 | 4 | Gerber 1991; Lo 2004; Scheibel 2005 (control); Silva 2008 (MRI for impingement) |
| Unclear reporting of tests, testing and/or population | 7 | Adolfsson 1991; Ardic 2006; Malhi 2005; Miller 2008a; Murrell 2001; Norregaard 2002; Wnorowski 1997 |
| Lack of, incomplete or grossly inconsistent data: | 8 | Ebinger 2008; Fodor 2009; Leroux 1995 (very large discrepancies); Litaker 2000 (large discrepancies); Polimeni 2003 (no data); Rowan 2007 (no test‐specific data); Sandenbergh 2006 (no 2 x 2); Sorensen 2007 (data presentation) |
DTA = Diagnostic test accuracy, N = number of studies
Studies awaiting classification
Ten studies await classification. The reasons are given in the Characteristics of studies awaiting classification. The reports for eight of these studies (Gill 2007; Jia 2008; Jia 2009; Kim 2003a; Kim 2003b; Kim 2004a; McFarland 2002; Park 2005), which apparently draw on the same clinical database, demonstrate substantial threats to validity. Verification is especially warranted in view of these studies' large patient numbers and potentially influential nature. The remaining two studies (Kelly 2010; Nanda 2008) presented insufficient data for adequate analysis.
Methodological quality of included studies
The methodological quality tables in the Characteristics of included studies give details of the results of the methodological quality assessment based on the 14 items of the QUADAS tool and using the coding manual set out in Appendix 3. In these tables, the results are expressed in terms of the methodological quality ('high', 'low' or 'unclear'). relating respectively to the review author's judgements ('yes', 'no', 'unclear'). Figure 2 summarises the judgements on each of the 14 methodological quality items for each included study.
Methodological quality summary: review authors' judgements about each methodological quality item for each included study. Coding: + = 'Yes'; ‐ = 'No'; ? = unclear.
Figure 3 presents a graph showing the percentages of each of the three judgements for each quality item across all included studies. Some observations on these are given below.
Representative spectrum?: Mainly reflecting the use of surgery as a reference test, it is noteworthy that all but two studies (Calis 2000; Miller 2008b) were judged as not meeting the criteria for having a representative spectrum of patients. The reference tests in Calis 2000 were subacromial local anaesthetic injection and MRI, and ultrasound in Miller 2008b. However, the setting was mixed primary, secondary and tertiary in Calis 2000 and probably secondary in Miller 2008b and thus both were rated as having unclear risk of spectrum bias.
Selection criteria described?: The patient selection criteria were clearly described in seven studies and described but insufficiently clearly so in four others. The majority of studies (22 studies), however, gave a very limited description of their selection criteria.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Acceptable reference standard?: While 26 studies were considered to have an acceptable reference standard, the reference tests were sub‐optimal (meriting an 'unclear' rating) in six studies (Calis 2000; Iagnocco 2003; Itoi 1999; Miller 2008b; Naredo 2002; O'Brien 1998). While not covered in our coding scheme for this item, Kim 2006 was given a 'No' rating for this item, which reflected the very unsatisfactory nature of the application of the two reference tests in this study.
Acceptable delay between tests?: Six studies met the criteria for an acceptable time period between the performance of the index and reference tests but in the majority (21) of studies there was insufficient information to judge this. The interval between the index and reference test was inappropriately long in six studies (Holtby 2004a; Holtby 2004b; Kim 2007b; Michener 2009; Norwood 1989; Razmjou 2004) putting them at risk of disease progression bias.
Partial verification avoided?: This was avoided in all studies except three studies (Bennett 1998; Frost 1999; O'Brien 1998) that were considered at high risk of partial verification bias.
Differential verification bias avoided?: Just two studies (Kim 2006; O'Brien 1998) were considered to be a high risk of differential verification bias.
Incorporation avoided?:Schlechter 2009 alone was considered to be a high risk of incorporation bias. In Schlechter 2009, the pathology found at surgery was "matched [to] the history, clinical presentation and symptoms".
Sufficient description of index tests?: All except Suder 1994 were judged as giving sufficient details to permit replication of the index test(s). Lack of sufficient details of the index tests generally resulted in exclusion of studies but we judged that the two tests, which were neither referenced nor described, in Suder 1994 were almost certainly the Neer's sign and Neer's test.
Sufficient description of reference test?: It was considered that sufficient details were given to replicate the reference test(s) in 20 studies but not in the other 13 studies, where often very limited or no detail was provided.
Index test results blinded?: There was a clear statement of blinding of the index tests in 15 studies and sufficient indication to merit an 'unclear' risk of test review bias in 10 prospective studies where the index test(s) clearly preceded the reference test. The other eight studies were judged to be an high risk of test review bias.
Reference tests blinded?: There was a clear statement of blinding of the reference test in 10 studies and sufficient indication that the reference test had been conducted independently in a further two studies (thus given an 'unclear' risk of bias rating). However, the lack of blinding in the remaining 21 studies meant that there was high risk of diagnostic review bias as foreknowledge of the index test result(s) may have influenced the interpretation of the reference test results.
Relevant clinical information?: Appropriate demographical and historical data were judged as being available when index tests were being interpreted in 26 studies; there being insufficient information to judge this in a further four studies. Such data were not available for interpreting the index tests in three studies (Frost 1999; Kim 2001; Kim 2007b).
Uninterpretable results reported?: Based on an assessment of the study design, recruitment and participant flow, 13 studies were judged to have fulfilled the criteria for this item and a further 17 studies may have done so but provided insufficient information to be certain. We judged that three studies (Frost 1999; Itoi 1999; O'Brien 1998) were at high risk of bias for this item.
Withdrawals explained?: Again, based on an assessment of the study design, recruitment and participant flow, 13 studies were judged to have had no withdrawals or to have accounted for these. In 10 studies there was insufficient information to be certain of this and in the remaining 10 studies, withdrawals were possible but either not reported or considered.
Findings
Overview of analyses and target condition/index test combinations
The complexity of the evidence is illustrated by the large number (170) of target condition/index test combinations. These were grouped by five main target conditions: subacromial or internal impingement; rotator cuff tendinopathy or tear; tendinopathy of the long head of biceps; glenoid labral lesions; and undifferentiated target conditions. The five main target conditions, which are also shown in Table 4, are exploded in Table 5 to Table 9. There were numerous standard, modified (see below) or combination index tests, and 14 novel index tests (tests being evaluated for the first time in the report in question, and originated by the authors of the report). The latter included the internal rotation resistance strength test for differentiating subacromial from internal impingement; active abduction, the drop sign, the external rotation lag sign, the Gum‐Turn test and the internal rotation lag sign for rotator cuff tears; the upper cut test for LHB (long head of biceps) or labral lesions; and the active compression test, the biceps load II test, the crank test, modified dynamic labral shear, the passive compression test and the passive distraction test for labral lesions.
Subacromial and internal impingement (five studies)
The sensitivity and specificity estimates from each study for the tests of subacromial and internal impingement are shown in forest plots in Figure 4.
Subacromial and internal impingement
Four studies evaluated 13 standard, modified or combination tests for subacromial impingement. The standard tests were Hawkins’ test, Neer’s sign and the painful arc test. The modified tests were Neer’s sign, passive horizontal adduction, Speed’s test and Yergason’s test. There were three combination tests, which comprised: all of seven specific tests (seeCalis 2000 in Table 5); Hawkins’ test or Neer’s sign; and Hawkins’ test and Neer’s sign. The sensitivity estimates ranged from 5% (95% CI 1% to 11%) for the combination of seven tests to 96% (95% CI 79% to 100%) for the combination of Hawkins’ test or Neer’s sign. The specificity estimates ranged from 26% (95% CI 13% to 43%) for the standard Hawkins’ test in Calis 2000 to 99% (95% CI 93% to 100%) for the Gum‐Turn test. Only one test was performed and interpreted similarly in two studies. This was the standard Hawkins’ test, but different and possibly incomparable reference standards were used (Calis 2000; MacDonald 2000).
One study evaluated the novel external rotation resistance strength test to differentiate subacromial from internal impingement and gave a sensitivity of 88% (95% CI 70% to 98%) and specificity of 96% (95% CI 90% to 99%).
No study evaluated any test for internal impingement.
Rotator cuff tendinopathy or tears (18 studies)
Non‐specific disease of the 'rotator cuff' (five studies)
The sensitivity and specificity estimates from each study for the tests of non‐specific disease of the 'rotator cuff' are shown in forest plots in Figure 5.
Rotator cuff tendinopathy or tears ‐ non‐specific disease of the 'rotator cuff'
One study evaluated two tests for diseases of the 'rotator cuff', without attempting to discriminate between these diseases. The tests were a standard (Jobe 1989) and a modified relocation test for pain with sensitivities of 44% (95% CI 27% to 62%) and 56% (95% CI 38% to 73%), and specificities of 67% (95% CI 54% to 78%) and 47% (95% CI 35% to 60%) respectively.
Three studies evaluated 14 standard, modified or combination tests for tears of the 'rotator cuff' without attempting to discriminate between full thickness tears (FTT) and PTT. The same test was not performed and interpreted similarly in any two studies. The standard test was the full can test. The modified tests included four variants of the empty can test, three variants of the full can test, Hawkins’ test and Neer's sign. There were two combination tests: Hawkins’ test or Neer’s sign; and Hawkins’ test and Neer’s sign. Two tests, an ‘impingement sign’ and an ‘impingement test’ were insufficiently defined to be categorised. The sensitivities ranged from 0% (95% CI 0% to 34%) for the undefined ‘impingement test’ to 88% for a modified Hawkins' test and the combination of Hawkins’ test or Neer’s sign (95% CI 68% to 97% in both instances). The specificities ranged from 38% (95% CI 26% to 51%) for the combination of Hawkins’ test or Neer’s sign to 96% (95% CI 78% to 100%) for the undefined ‘impingement test’.
One study evaluated a modified empty can test for partial thickness tears (PTT) or tendinitis of the 'rotator cuff' without attempting to discriminate between these diseases and gave a sensitivity of 62% (95% CI 41% to 80%) and specificity of 54% (95% CI 33% to 74%).
Specific diseases of the 'rotator cuff' (five studies)
The sensitivity and specificity estimates from each study for the tests of specific diseases of the 'rotator cuff' are shown in forest plots in Figure 6.
Rotator cuff tendinopathy or tears ‐ specific disease of the 'rotator cuff'
Four studies evaluated one or more of 11 standard or modified tests for FTT of the 'rotator cuff'. The standard test was the rent test. The modified tests were the empty can test (four variants) and the full can test (four variants). Two tests, an ‘impingement sign’ and an ‘impingement test’ were insufficiently defined to be categorised. The sensitivity estimates ranged from 0% (95% CI 0% to 71%) for the undefined ‘impingement test’ to 100% (95% CI 29% to 100%) for the undefined ‘impingement sign’. The specificity estimates ranged from 43% (95% CI 35% to 52%) for a variant of the empty can test to 97% for an undefined ‘impingement test’ and the rent test (95% CI 82% to 100% and 89% to 100% respectively). There was one instance of a test being performed and interpreted similarly in two studies. This was a modified empty can test (Holtby 2004b; Kim 2006).
One study evaluated a modified empty can test for massive or large FTT of the 'rotator cuff' with a sensitivity of 100% (95% CI 29% to 100%) and a specificity of 70% (95% CI 55% to 83%).
One study evaluated two tests for PTT of the 'rotator cuff'. These were an undefined ‘impingement sign’ and an undefined ‘impingement test’. The sensitivity estimates were 67% (95% CI 22% to 96%) for the undefined ‘impingement sign’ and 0% (95% CI 0% to 36%). The specificity estimates were 65% (95% CI 44% to 83%) and 96% (95% CI 80% to 100%) respectively.
One study evaluated a novel active abduction range test to discriminate between single‐ and multiple‐tendon FTT of the 'rotator cuff' with a sensitivity of 84% (95% CI 74% to 92%) and a specificity of 77% (95% CI 56% to 91%).
Non‐specific disease of the 'posterosuperior rotator cuff' (two studies)
The sensitivity and specificity estimates from each study for the tests of non‐specific disease of the 'posterosuperior rotator cuff' are shown in forest plots in Figure 7.
Rotator cuff tendinopathy or tears: non‐specific disease of the 'posterosuperior rotator cuff'
One study evaluated the novel Gum‐Turn test for non‐specific disease of the 'posterosuperior rotator cuff' (affecting supraspinatus AND infraspinatus) with a sensitivity of 90% (95% CI 70% to 99%) and a specificity of 98% (95% CI 93% to 100%).
One study evaluated three novel or modified tests for tears of the 'posterosuperior rotator cuff' without attempting to discriminate between FTT and PTT. The novel tests were the drop sign and the external rotation lag sign. The modified test was the empty can test. The sensitivity estimates ranged from 21% (95% CI 11% to 33%) for the novel drop sign to 84% (95% CI 73% to 92%) for the modified empty can test. The specificity estimates ranged from 58% (95% CI 37% to 78%) for the modified empty can test to 100% for the novel drop sign and novel external rotation lag sign (95% CI 86% to 100% in both instances).
Specific diseases of the 'posterosuperior rotator cuff' (two studies)
The sensitivity and specificity estimates from each study for the tests of specific diseases of the 'posterosuperior rotator cuff' are shown in forest plots in Figure 8 .
Rotator cuff tendinopathy or tears: specific disease of the 'posterosuperior rotator cuff'.
Two studies evaluated three novel or modified tests for FTT of the 'posterosuperior rotator cuff'. The novel test was the Gum‐Turn test. The modified tests were the drop sign and the external rotation lag sign. The sensitivity estimates ranged from 47% (95% CI 21% to 73%) for the modified external rotation lag sign to 73% (95% CI 45% to 92%) for the modified drop sign. The specificity estimates ranged from 77% (95% CI 59% to 90%) for the modified drop sign to 98% (95% CI 88% to 100%) for the Gum‐Turn test.
Non‐specific disease of supraspinatus (four studies)
The sensitivity and specificity estimates from each study for the tests of non‐specific disease of the supraspinatus are shown in forest plots in Figure 9.
Rotator cuff tendinopathy or tears: non‐specific disease of supraspinatus
One study evaluated an undefined empty can test for diseases (calcification included) of supraspinatus without attempting to discriminate between these, with a sensitivity of 94% (95% CI 91% to 97%) and a specificity of 39% (95% CI 32% to 46%).
One study evaluated a modified Hawkins’ test for FTT, degeneration or tendinitis of supraspinatus without attempting to discriminate between these, with a sensitivity of 59% (95% CI 42% to 74%) and a specificity of 44% (95% CI 27% to 62%).
One study evaluated the standard empty can test for FTT, PTT or tendinitis of supraspinatus without attempting to discriminate between these, with a sensitivity of 96% (95% CI 79% to 100%) and a specificity of 50% (95% CI 1% to 99%).
One study evaluated a modified Hawkins’ test for FTT or degeneration of supraspinatus without attempting to discriminate between these, with a sensitivity of 66% (95% CI 47% to 81%) and a specificity estimate of 49% (95% CI 33% to 65%).
Two studies evaluated six standard or modified tests for FTT or PTT of supraspinatus, without attempting to discriminate between these diseases. The standard tests were the empty can test and the full can test. The modified tests were the empty can test (two variants) and the full can test (two variants). The estimates of sensitivity ranged from 6% (95% CI 3% to 12%) for a modified full can test to 87% (95% CI 80% to 92%) for a standard empty can test, and the specificity estimates ranged from 40% (95% CI 23% to 59%) for a modified empty can test to 100% for a standard empty can test, a modified empty can test, and a modified full can test (95% CI 78% to 100%; 88% to 100% and 88% to 100% respectively). One test was performed and interpreted similarly in both studies. This was the standard empty can test (Itoi 2006; Naredo 2002).
Specific diseases of supraspinatus (six studies)
The sensitivity and specificity estimates from each study for the tests of specific diseases of the supraspinatus are shown in forest plots in Figure 10.
Rotator cuff tendinopathy or tears: specific disease of supraspinatus.
Four studies evaluated 15 novel, standard or modified tests for FTT of supraspinatus. There were no instances of the same test being performed and interpreted similarly in two or more studies. The novel test was the Gum‐Turn test. The standard tests were the drop arm test, the empty can test and the full can test. The modified tests were the empty can test, the full can test and Hawkins’ test (two variants each), and Neer’s sign, the painful arc test, passive horizontal adduction, Speed’s test and Yergason’s test (one variant each). The sensitivity estimates ranged from 11% (95% CI 1% to 35%) for modified passive horizontal adduction to 100% (81% to 100%) for a modified Hawkins' test. The specificity estimates ranged from 28% (95% CI: 20% to 38%) for both the modified passive horizontal adduction and the modified Neer’s sign to 100% (95% CI 97% to 100%) for the standard drop arm test.
One study evaluated the standard external rotation lag sign for full‐width, FTT of supraspinatus, with a sensitivity of 56% (95% CI 38% to 74%) and a specificity of 98% (95% to 100%).
One study evaluated the standard external rotation lag sign for isolated PTT of supraspinatus, with a sensitivity of 12% (95% CI 5% to 23%) and a specificity of 98% (95% CI 95% to 100%).
One study evaluated the standard empty can test for tendinitis of supraspinatus, with a sensitivity of 72% (95% CI 47% to 90%) and a specificity of 38% (95% CI 14% to 68%).
Disease of infraspinatus (three studies)
The sensitivity and specificity estimates from each study for the tests of disease of infraspinatus are shown in forest plots in Figure 11.
Rotator cuff tendinopathy or tears: disease of infraspinatus
One study evaluated undefined resisted lateral rotation from neutral rotation for diseases of infraspinatus (calcification included) without attempting to discriminate between these, with a sensitivity of 94% (95% CI 87% to 98%) and a specificity of 95% (95% CI 92% to 96%).
One study evaluated the standard Patte’s test for identifying and discriminating between tears and tendinitis of infraspinatus, with a sensitivity of 71% (95% CI 42% to 92%) and a specificity of 88% (95% CI 64% to 99%).
One study evaluated the standard Patte’s test and another study evaluated modified resisted lateral rotation from neutral rotation for tears of infraspinatus. In neither case was there an attempt to differentiate between FTT and PTT. The sensitivity estimates were 36% (95% CI 11% to 69%) for the standard Patte’s test and 84% (95% CI 74% to 91%) for resisted lateral rotation; and the specificity estimates were 95% (95% CI 75% to 100%) and 53% (95% CI 41 to 64%) respectively.
One study evaluated the standard Patte’s test for infraspinatus tendinitis with a sensitivity of 57% (95% CI 18% to 90%) and a specificity of 71% (95% CI 49% to 87%).
Non‐specific disease of subscapularis (five studies)
The sensitivity and specificity estimates from each study for the tests of non‐specific disease of subscapularis are shown in forest plots in Figure 12.
Rotator cuff tendinopathy or tears: non‐specific disease of subscapularis
One study evaluated undefined resisted medial rotation from neutral rotation for diseases of subscapularis (calcification included) without attempting to discriminate between these, with a sensitivity of 96% (95% CI 78% to 100%) and a specificity of 99% (95% CI 97% to 100%).
One study evaluated an incompletely defined combination of the lift‐off test and resisted medial rotation from neutral rotation for any tear or tendinitis of subscapularis without attempting to differentiate between these diseases, with a sensitivity of 50% (95% CI 21% to 79%) and a specificity of 84% (95% CI 60% to 79%).
Four studies evaluated eight novel, standard, modified or combination tests for tears of subscapularis, without attempting to discriminate between types of tears. There were no instances of a test being performed and interpreted similarly in two or more studies. The novel tests were the bear‐hug test and the internal rotation lag sign. The standard tests were the belly‐press test, the lift‐off test and the Napoleon test. The modified tests were the lift‐off test and the lift‐off with force. The combination test, which was incompletely defined, comprised the lift‐off test and resisted medial rotation from neutral rotation. The sensitivity estimates ranged from 18% (95% CI 4% to 43%) for the modified lift‐off test to 97% (95% CI 82% to 100%) for the internal rotation lag sign. The specificity estimates ranged from 59% (95% CI 50% to 67%) for the modified lift‐off test with force to 100% for the standard lift‐off test and the modified lift‐off test (95% CI 86% to 100% and 92% to 100% respectively).
Specific diseases of subscapularis (three studies)
The sensitivity and specificity estimates from each study for the tests of specific diseases of subscapularis are shown in forest plots in Figure 13.
Rotator cuff tendinopathy or tears: specific disease of subscapularis
One study evaluated four novel, standard or modified tests for a complete tear of subscapularis. The novel test was the bear‐hug test. The standard test was the Napoleon test. The modified tests were the belly‐press test and the lift‐off test. The sensitivity estimates ranged from 67% (95% CI: 9% to 99%) for the modified lift‐off test to 100% for the novel bear‐hug test, the standard Napoleon test and the modified belly‐press test (95% CI 29 to 100% in each instance). The specificity estimates ranged from 80% (95% CI 68% to 89%) for the novel bear‐hug test to 98% (95% CI 91% to 100%) for the modified lift‐off test.
One study evaluated a modified internal rotation lag sign for FTT of subscapularis, with a sensitivity of 47% (95% CI 21% to 73%) and specificity of 94% (95% CI 79% to 99%).
One study evaluated four novel, standard or modified tests for a partial tear of subscapularis. The novel test was the bear‐hug test. The standard test was the Napoleon test. The modified tests were the belly‐press test and the lift‐off test. The sensitivity estimates ranged from 7% (95% CI 0% to 34%) for the modified lift‐off test to 53% (95% CI 28% to 77%) for the novel bear‐hug test, and the specificity estimates ranged from 92% (95% CI 80% to 98%) for the novel bear‐hug test to 100% (95% CI 92% to 100%) for the modified lift‐off test.
One study evaluated an incompletely defined combination comprising the lift‐off test and resisted medial rotation from neutral rotation for subscapularis tendinitis, with a sensitivity of 50% (95% CI 12% to 88%) and a specificity of 88% (95% CI 69% to 97%).
LHB tendinopathy or tears (three studies)
The sensitivity and specificity estimates from each study for the tests of LHB tendinopathy or tears are shown in forest plots in Figure 14.
LHB tear or tendinitis
Three studies evaluated 10 novel, standard, modified or combination tests for LHB tears or tendinosis without attempting to differentiate between these diseases. There were no instances of a test being performed and interpreted similarly in two or more studies. The novel tests were modified dynamic labral shear and the upper‐cut test. The standard tests were Speed’s test, the active compression test and the belly‐press test. The modified tests were the anterior slide test, the bear‐hug test, Speed’s test and Yergason’s test. The combination test comprised Yergason’s test and Gilcreest’s test but was incompletely defined. The sensitivity estimates ranged from 17% (95% CI 6% to 36%) for the novel modified dynamic labral shear to 87% (95% CI 82% to 91%) for the standard Speed’s test. The specificity estimates ranged from 53% (95% CI 41% to 65%) for the novel modified dynamic labral shear to 85% (95% CI 74% to 92%) for the standard belly‐press test.
Labral lesions (11 studies)
Non‐specific labral lesions (four studies)
The sensitivity and specificity estimates from each study for the tests of non‐specific labral lesions are shown in forest plots in Figure 15.
Glenoid labral lesion: non‐specific labral lesion
Four studies evaluated five novel/standard or modified tests for labral lesions without attempting to discriminate between these lesions. The novel/standard tests were the active compression test and the crank test. The novel/standard crank test was performed and interpreted similarly in both studies, but the results were heterogeneous. The modified test was the active compression test. Two tests, an ‘impingement sign’ and an ‘impingement test’ were insufficiently defined to be classified. The sensitivity estimates ranged from 0% (95% CI 0% to 71%) for the undefined ‘impingement test’ to 100% (95% CI 93 to 100%) for the novel active compression test. The specificity estimates ranged from 31% (95% CI 17% to 48%) for the modified active compression test to 98% (95% CI 94% to 100%) for the novel active compression test.
Non‐specific SLAP lesions (three studies)
The sensitivity and specificity estimates from each study for the tests of non‐specific SLAP lesions are shown in forest plots in Figure 16.
Glenoid labral lesions: non‐specific SLAP lesion
Three studies evaluated 15 novel or modified tests. There were no instances of a test being performed and interpreted similarly in two or more studies. The novel tests were modified dynamic labral shear, the passive compression test and the upper cut test. The modified tests were the active compression test, the anterior apprehension test at 90°, the anterior release test, the anterior slide test, the bear‐hug test, the belly‐press test, the crank test and palpation for bicipital groove tenderness (one variant each) and Speed’s test and Yergason’s test (two variants each). The sensitivity estimates ranged from 9% (95% CI 2% to 24%) for a modified Speed’s test to 82% (95% CI 65% to 93%) for the novel passive compression test. The specificity estimates ranged from 32% (95% CI 20% to 46%) for the modified bear‐hug test to 98% (95% CI 90% to 100%) for the novel modified dynamic labral shear.
Type II‐IV SLAP lesions (two studies)
The sensitivity and specificity estimates from each study for the tests of type II‐IV SLAP lesions are shown in forest plots in Figure 17.
Glenoid labral lesions: type II‐IV SLAP lesion
Two studies evaluated five novel, standard, modified or combination tests for type II‐IV SLAP lesions without attempting to differentiate between these types. None of the tests was performed and interpreted similarly in both studies. The novel test was the passive compression test. The standard test was the passive distraction test. The modified tests were the anterior slide test and the active compression test (one variant each). The combination test comprised the active compression test or the passive distraction test. The sensitivity estimates ranged from 21% (95% CI 12% to 34%) for the modified anterior slide test to 89% (95% CI 72% to 98%) for the novel passive compression test. The specificity estimates ranged from 82% (95% CI 65% to 93%) for the novel passive compression test to 98% (95% CI 95% to 99%) for the modified anterior slide test.
Type II SLAP lesions (three studies)
The sensitivity and specificity estimates from each study for the tests of type II SLAP lesions are shown in forest plots in Figure 18.
Glenoid labral lesions: type II SLAP lesion
Three studies evaluated 18 novel/standard or modified tests for type II SLAP lesions. The novel/standard test was the biceps load II test. The modified tests were the active compression test, Speed’s test and Yergason’s (two variants each) and the anterior slide test, the compression‐rotation test, the crank test, Hawkins’ test, the modified relocation test for postero‐superior glenoid impingement, Neer’s sign, the pain provocation test, the relocation test for pain or apprehension and Whipple’s test (one variant each). The sensitivity estimates ranged from 9% (95% CI 1% to 28%) for the modified crank test to 90% (95% CI 76% to 97%) for the novel/standard biceps load II test. The specificity estimates ranged from 30% (95% CI 22% to 40%) for the modified Hawkins’ test to 97% (95% CI 90% to 99%) for the novel/standard biceps load II test.
Two tests were performed and interpreted similarly in two studies. These were the novel/standard biceps load II test by Kim 2001 and Oh 2008 and the modified anterior slide test by Oh 2008 and Parentis 2006.
Tests for multiple target conditions: undifferentiated (four studies)
The sensitivity and specificity estimates from each study for the tests of undifferentiated multiple target conditions are shown in forest plots in Figure 19.
Non‐specific
One study evaluated a modified Speed’s test for LHB tendinitis or avulsion or any SLAP lesion without attempting to differentiate between these, with a sensitivity of 90% (95% CI 55% to 100%) and a specificity of 14% (95% CI 5% to 29%).
One study evaluated a modified Speed’s test and a modified Yergason’s test for any LHB lesion, a type II or a type IV SLAP lesion without attempting to distinguish between these diseases, with a sensitivity of 32% (95% CI 14% to 55%) for the modified Speed’s test and 43% (95% CI 22% to 66%) for the modified Yergason’s test; and specificity estimates of 75% (95% CI 55% to 89%) and 79% (95% CI 59% to 92%) respectively.
One study evaluated six standard, modified or combination tests for SA‐SD bursitis or bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability, without attempting to distinguish between these diseases. The standard tests were Hawkins’ test and the painful arc test. The modified tests were the empty can test, Neer’s test and resisted lateral rotation from neutral rotation. The combination test comprised all the foregoing, of which three were required to be positive. The sensitivity estimates ranged from 50% (95% CI 25% to 75%) for the modified empty can test to 81% (95% CI: 54% to 96%) for the modified Neer’s test. The specificity estimates ranged from 54% (95% CI 37% to 70%) for the modified Neer’s test to 90% (95% CI 73% to 98%) for the standard painful arc test.
One study evaluated two modified tests, Hawkins’ test and Neer’s sign, for SIS or rotator cuff tendinitis or tear without attempting to discriminate between these diseases, with a sensitivity of 43% (95% CI 28 to 59%) for the modified Hawkins’ test and 50% (95% CI 35 to 65%) for the modified Neer's sign; and specificity estimates of 67% (95% CI 22% to 96%) and 50% (95% CI 12% to 88%) respectively.
Between‐tester reliability
Kappa coefficients were reported as 0.815 for the biceps load II test (Kim 2001); 0.39 (95% CI 0.12 to 0.65) for the empty can test (Michener 2009); respectively 0.47 (0.22 to 0.72) and 0.29 (0.180 to 0.398) for Hawkins’ test (Michener 2009; Razmjou 2004); respectively 0.40 (0.13 to 0.67) and 0.506 (0.366 to 0.645) for Neer's test (Michener 2009; Razmjou 2004); 0.45 (0.18 to 0.72) for the painful arc test (Michener 2009); 0.771 for the passive compression test (Kim 2007b); 0.67 (0.40 to 0.94) for resisted lateral rotation from neutral rotation (Michener 2009).
Discussion
We set out to identify and review studies evaluating the diagnostic accuracy of defined physical tests, whether applied singly or in combination, 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. Our particular focus was primary care (while not excluding secondary or tertiary care, especially in the hospital outpatient setting).
Summary of main results
Seesummary of findings Table. The 33 included studies, of 4002 shoulders in 3852 patients, incorporated numerous standard, modified, or combination index tests and 14 novel index tests. In consequence they embodied 170 target condition/index test combinations, with only six instances of any index test being performed and interpreted similarly in two studies. However, only two studies of a modified empty can test for FTT of the rotator cuff (Holtby 2004b;Kim 2006) and a modified anterior slide test for type II SLAP lesions (Kim 2001; Oh 2008) were clinically homogenous.
Variations in index tests’ provenance, procedure and interpretation
The provenance given for index tests was diverse. Primary sources for at least one index test were cited in 20 studies (Barth 2006; Calis 2000; Castoldi 2009; Guanche 2003; Hertel 1996; Holtby 2004a; Itoi 1999; Itoi 2006; Kibler 2009; MacDonald 2000; Michener 2009; Miller 2008b; Naredo 2002; Oh 2008; Parentis 2006; Razmjou 2004; Schlechter 2009; Speer 1994; Stetson 2002; Wolf 2001); secondary/tertiary sources in eight (Bennett 1998; Calis 2000; Guanche 2003; Iagnocco 2003; Kibler 2009; Michener 2009; Naredo 2002; Oh 2008); and none in six (Frost 1999; Kim 2006; Norwood 1989; Oh 2008; Parentis 2006; Suder 1994). In two studies (studies reporting novel tests were not included in this) neither a reference nor a description of the index tests was offered (Norwood 1989; Suder 1994). We identified some misattributions, most commonly of the empty can test to Jobe 1982 (Holtby 2004b;Hertel 1996;Itoi 1999;Itoi 2006;Michener 2009). Neer’s sign was misattributed to Neer 1972a, a report which gave no clear account of this index test, by Razmjou 2004. Speed’s test was incorrectly referenced by Oh 2008. In one instance, a figure depicting Hawkins’ test was apparently misinterpreted as a novel test, Yocum’s test (Naredo 2002).
Some studies cited index tests' primary sources as well as providing a description, often revealing substantive, apparently unintentional inconsistencies in procedures, criteria for positive results, or both. This applied to the active compression test (Guanche 2003), the anterior release test (Guanche 2003), the anterior slide test (Kibler 2009;Schlechter 2009), the belly press test (Barth 2006), the crank test (Guanche 2003), the drop sign (Miller 2008b), Hawkins’ test (Parentis 2006), Neer’s sign (MacDonald 2000;Michener 2009;Parentis 2006), the palm up test (Naredo 2002), Yergason’s test (Guanche 2003;Kibler 2009). There were also three instances in which the originators of index tests described the method of performance and interpretation differently across reports: the anterior slide test (Kibler 1995a;Kibler 2009), the crank test (Liu 1996a;Liu 1996b) and the lift‐off test (Gerber 1991;Gerber 1996). In two of these instances, (Liu 1996a and Liu 1996b; Gerber 1991 and Gerber 1996), the differing descriptions apparently related to the same patient samples, revealing internal inconsistencies.
Whether intentional or unintentional, variations in index tests' procedure or interpretation were prevalent, such that, as observed above, there were only six instances of any index test being performed and interpreted (in terms of criteria for, and implications of, a positive result) similarly in two studies; and no instances of three studies or more using any one test similarly.
As previously stated, 14 of the tests identified ‐ a surprisingly large proportion ‐ were novel, and we were particularly interested to explore their provenance. The justifications given included synthesis of empirical evidence from other studies (the internal rotation resistance strength test), application of biomechanical principles (the biceps load II test, the drop sign, the external rotation lag sign, the internal rotation lag sign, the passive compression test), or mechanisms of pain‐provocation described by patients (the active compression test and the upper‐cut test). Some tests appear to have been developed on a trial and error basis: active abduction, which was developed retrospectively from routinely collected data; the modified dynamic labral shear, which was adapted from an existing test; and the passive distraction test, the postulated mechanism of which was confirmed arthroscopically. For two tests (the crank test, the Gum‐Turn test), no clear justification was reported.
Arithmetical discrepancies
Arithmetical discrepancies in reported statistics, over and above those attributable to rounding error, were prevalent. In three studies, substantial discrepancies in the 2 x 2 tables, as back‐calculated from reported sensitivity and/or specificity, warranted exclusion (Ebinger 2008; Fodor 2009; Litaker 2000). Seven studies presented multiple but smaller errors of this type, multiple errors associated with other summary statistics, or both (Bennett 1998;Hertel 1996;Itoi 2006;Kim 2006;MacDonald 2000; Miller 2008b; Parentis 2006).
We adopted a policy of excluding studies in which, allowing for the possibility of an isolated typographical/transcription error, back‐calculation of 2 x 2 tables from the reported sensitivity and specificity demonstrated greater‐than 10% discrepancies in any cell (which was not attributable to unit‐of‐analysis issues). We excluded three studies (Ebinger 2008; Fodor 2009; Litaker 2000) on this basis.
Many of the remainder presented with errors which were either too small to warrant study exclusion or which related to summary statistics other than sensitivity or specificity. We divided these errors into two categories: isolated discrepancies within study reports which (extending the benefit of doubt) we attributed to typographical errors, or confirmed as such by communication with the authors; and multiple discrepancies within a report, which we attributed to miscalculation. Seven studies (Bennett 1998; Hertel 1996;Itoi 2006;Kim 2006;MacDonald 2000;Miller 2008b;Parentis 2006) fell within the former category and six within the latter (Calis 2000;Gumina 2008;Kibler 2009;Naredo 2002;Oh 2008;Schlechter 2009). We subcategorised each type of error according to its absolute magnitude in reported percentage terms: seeTable 5.
Tests' potential to inform diagnoses
Sensitivity and specificity are test properties, and not directly applicable at the interface between clinician and patient. Useful statistics in this context are the positive and negative likelihood ratio (LR+, LR‐). The LR+ may be defined as true positive rate/false positive rate = sensitivity/(1‐specificity), and the LR‐ as false negative rate/true negative rate = (1‐sensitivity)/specificity. These statistics facilitate a Bayesian approach, which is intuitive to clinicians (Gill 2005), enabling estimation of the likelihood of a target condition post‐test when the pre‐test probability of the condition is known, by means of a nomogram (Jaeschke 1994). We had intended to tabulate LR+ and LR‐ data to optimise the clinical utility of our review. However, in the light of our findings, we decided that this step would overplay the evidence. For the most part, this evidence derives from small, methodologically compromised, single studies; often conducted by tests' originators, with negative implications for reproducibility. Over and above these considerations is the fact that few of the results, and none from methodologically and arithmetically robust studies, are directly applicable to primary care.
Between‐tester agreement
Few studies addressed this aspect, although it is fundamental to the validity of clinical tests. Agreement is best evaluated using the kappa coefficient, since this takes account of the fact that agreements may occur by chance. The coefficient ranges from 0 to 1, and interpretation has been recommended as follows by Altman 1991: less than 0.20 = poor; 0.21 to 0.40 = fair; 0.41 to 0.60 = moderate; 0.61 to 0.80 = good; 0.81 to 1 = very good. By these criteria, and based on point estimates, very good between‐rater agreement was achieved for only one test, the biceps load II test (Kim 2001). Good agreement was obtained for the passive compression test (Kim 2007b) and resisted lateral rotation from neutral rotation (Michener 2009). Agreement for the painful arc test was moderate (Michener 2009), while that for Neer's test was fair to moderate (Michener 2009; Razmjou 2004). For the empty can test (Michener 2009) and Hawkins' test (Michener 2009; Razmjou 2004), agreement was only fair.
Calis 2000 reported interobserver reliability for their battery of index tests of 'above 98%', but gave no breakdown and presumably did not account for chance agreement in their calculations. Miller 2008b stated that ‘to ensure test quality, the clinical tests were practiced on five separate occasions with an orthopaedic surgeon with a special interest in shoulders on a separate subgroup of subjects’, but no statistical analysis was presented. In Naredo 2002, two rheumatologists performed independent assessments, then established clinical diagnoses by consensus. Finally, although evaluation of reproducibility was mentioned in the abstract of Schlechter 2009, this aspect was not addressed in the report.
Comparison with other systematic reviews
We identified 12 other systematic reviews and one non‐systematic review which overlapped with aspects of ours. Two addressed multiple shoulder pathologies. These were Dinnes 2003, which covered impingement syndrome and rotator cuff tears (FTT, PTT or any) but excluded labral disorders and Hegedus 2008a, which had no exclusions. One systematic review (Alqunaee 2012) was nominally specific to subacromial impingement syndrome, but encompassed rotator cuff pathology tears (i.e. stage II and III impingement, according to the criteria of Neer 1977). Three (Beaudreuil 2009a; Hughes 2008a; Longo 2011) addressed rotator cuff disease. One, Munro 2009a, addressed labral disease. Disproportionately, considering the relatively low prevalence of this condition, six reviews (Dessaur 2008a; Calvert 2009a; Jones 2007a; Luime 2004b; Meserve 2009a; Walton 2008a) focused on SLAP lesions. Table 11 summarises these reviews and compares their main conclusions to our own.
| # | Target condition | Study ID | Search period | Included studies | N | Main conclusions | Notes and comments |
| 1 | Any | 1966 to October 2006 | 45 | 999 | Conclusion 1 'There is a lack of clarity with regard to whether common orthopaedic special tests are useful in differentially diagnosing pathologies of the shoulder' | General • Included studies with highly selected populations. • Pooled some clinically heterogeneous data. Re conclusion 1 • Our conclusions broadly agree. | |
| 2 | Impingement, Any tear, FTT, PTT | 1985 to October 2001 | 10 | 1235 | Conclusion 1 'Few tests provided convincing evidence of the presence or absence of disease ... [Although] individual tests did perform well in the study by [Hertel 1996] ... the sample size was small and CIs were very wide'. The internal rotation lag sign also had a very low negative LR ... Other tests demonstrating high positive and negative LRs were the rent test and internal rotation resistance strength test.' Conclusion 2 'In four studies [Litaker 2000; Lyons 1992; MacDonald 2000; Read 1998], negative LRs were sufficiently low to confirm that disease is absent in those with a negative diagnosis'. Conclusion 3 'The results suggest that [generic] clinical examination by specialists can rule out the presence of a rotator cuff tear'. | Re conclusion 1 • Our conclusions broadly agree. • We excluded three (Litaker 2000; Lyons 1992; Read 1998) of the four studies underpinning this conclusion on clinical or methodological grounds. Re conclusion 2 • We excluded those studies evaluating generic examination. | |
| 3 | SIS | to January 2011 | 16 | 2390 | Conclusion 1 'The Hawkins‐Kennedy test, Neer's sign and empty can test are ... more useful for ruling out rather than ruling in SIS.' Conclusion 2 'The drop arm test and lift‐off test ... are more useful for ruling in SIS if the test is positive.' | General • Pooled some clinically heterogeneous data. • Included several studies which we excluded on clinical or methodological grounds (Leroux 1995; Lyons 1992; Malhi 2005; Murrell 2001; Scheibel 2005; Walch 1998) or categorised as 'awaiting classification' pending clarification (Nanda 2008; Park 2005). • Included one study which post‐dated our search (Fowler 2010), but which concerned a selected population. Re conclusion 1 • Our conclusions partially agree. We suggest cautious interpretation, as the point estimates are small, the 95% CIs wide, and the pooled data clinically heterogeneous. Re conclusion 2 • The pooled point estimate for the drop arm test is small. That for the lift‐off test is large, but the 95% CIs are wide. Again, the pooled data are clinically heterogeneous. | |
| 4 | Rotator cuff disease | to June 2006 | 9 | 2116 | See notes and comments | General • A descriptive review with transliteration of data from the primary studies and no quality assessment. • The conclusions are not contentious. | |
| 5 | Rotator cuff disease | January 1966 to April 2007 | 13 | 2010 | Conclusion 1 One test, the rent test in Wolf 2001, is identified with LR+ >10 and LR ‐ < 0.1; but a contradictory result in Lyons 1992 is noted. Conclusion 2 Other tests with LR+ > 10 or LR‐ < 0.1 are listed. Conclusion 3 Hertel 1996 was excluded on the grounds of arithmetical discrepancies.
| Re conclusion 1 • We agree, but excluded Lyons 1992 on clinical grounds. Re conclusion 2 • We excluded four studies underpinning these conclusions on clinical or methodological grounds (Ardic 2006; Leroux 1995; Lyons 1992; Murrell 2001) and categorised one (Park 2005) as 'awaiting classification' pending clarification. Re conclusion 3 • Our back‐calculations identified only one discrepancy in Hertel 1996, which we attributed to a typographical error. | |
| 6 | Rotator cuff disease | Not reported | Not reported | Not reported | See notes and comments. | General • Included for completeness, but not a systematic review | |
| 7 | Labral disease | 1995 to June 2007 | 15 | Numbers reported by test, not by study. | Conclusion 1 The biceps load II and internal rotation resistance strength tests were identified as having large LR+ and moderate LR‐, based on single studies of good quality. | General • Pooled some clinically heterogeneous data. Re conclusion 1 • Our conclusions are broadly agree. | |
| 8 | SLAP | January 1970 to June 2004 | 15 | Unclear | Conclusion 1 'The current literature being used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful.' Conclusion 2 'There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion.' | General • Included studies with highly selected populations. Re conclusion 1 • While sharing concerns as to the validity of much of the diagnostic test accuracy literature, we consider this an over generalisation. Re conclusion 2 • We distinguish 'limited or contradictory evidence for accuracy' from 'evidence of inaccuracy', and place a number of tests former category. | |
| 9 | SLAP | 1996 to 2006 | 17 | 2148 | Conclusion 1 'It appears that no single test is sensitive or specific enough to to determine the presence of a SLAP lesion accurately'. | General • Included studies with highly selected populations. Re conclusion 1 • We distinguish between 'limited or contradictory evidence for accuracy' from 'evidence of inaccuracy', and place a number of tests in the former category. | |
| 10 | SLAP | January 1 1966 to July 1 2006 | 12 | 2260 | Conclusion 1 'SLAP‐specific physical examination results cannot be used as the sole basis of a diagnosis of a SLAP lesion.' | General • A descriptive review with transliteration of data from the primary studies and limited quality assessment. • Included studies with highly selected populations. Re conclusion 1 • Given the current state of knowledge, we agree with this conclusion. | |
| 11 | SLAP | 1966 to 2003 | 17 | 1901 | Conclusion 1 'Most promising [tests] for establishing labral tears are currently the biceps load I [not relevant to this review] and II, pain provocation of Mimori, and the internal rotation resistance strength tests.' | General • Included studies with highly selected populations. Re conclusion 1 • We agree regarding the biceps load II and internal rotation resistance strength tests. However, in the population relevant to the present review, the pain provocation test did not perform well. | |
| 12 | SLAP | 1966 to June 2007 | 6 | 777 | Conclusion 1 The anterior slide test is a poor test for predicting the presence of a labral lesion in the shoulder. Conclusion 2 Active compression, crank, and Speed tests are more optimal choices. Conclusion 3 Clinicians should choose the active compression test first, crank second and Speed test third when a labral lesion is suspected. | General • Included studies with highly selected populations. • Pooled some clinically heterogeneous data. Re conclusion 1 • Based on the results of Schlechter 2009 (notwithstanding that this study was prone to arithmetical error), which post‐dated the search of Meserve 2009a, we cannot unconditionally agree. Re conclusions 2 & 3 • Based on current knowledge, we agree concerning the active compression test. • In relatively unselected populations, we found the crank test inferior to biceps load II for ruling in labral tears; and LRs for Speed's test did not suggest that it would be clinically useful. | |
| 13 | SLAP | To May 2006 | 7 | Numbers reported by test, not by study. | Conclusion 1 'Yergason's test is the only [test] that shows a significant ability to influence clinical decision making, based on the results of the current analysis. Conclusion 2 'Methodologic inadequacies in the reporting of the publications are common, and caution must be exercised when drawing inferences from the results of these studies.' | General • Included studies with highly selected populations. • There was limited quality assessment. • Pooled some clinically heterogeneous data. Re conclusion 1 • In relatively unselected populations, LRs for Yergason's test did not suggest that it would be clinically useful. Re point 2 • We agree. |
Our own review differs from the remainder, except Dinnes 2003, in terms of its emphasis on relatively unselected populations such as might be encountered in primary care. We took this approach because it is in primary care that people with these problems are screened and, for most diagnoses, managed. We decided not exclude secondary or tertiary care, based in part upon the (correct) pragmatic assumption that few studies would use reference standards directly applicable to primary care. Extrapolation from the secondary and tertiary settings to primary care should be undertaken with caution, however. In primary care, patients will have travelled less far down the screening pathway, disease is likely to be less severe, and the expertise of clinicians conducting and interpreting the physical tests may be less. These aspects would tend to reduce diagnostic test accuracy. On the other hand, our results do have applicability to relatively unselected populations (in terms of occupation and sporting activity) in secondary and tertiary care.
Our review also differs in terms of its scope. We considered that shoulder impingements and those painful conditions that may be related to impingements present a coherent class of pathologies which would resonate with clinicians. Although we recognise that this class of pathologies may overlap with others (laxities and instabilities, capsular and acromio‐clavicular conditions), we omitted these in order to maintain focus and optimise the utility of an already large review. We believe that we have achieved an appropriate compromise.
Strengths and weaknesses of the review
Strengths of the review
This review has a number of strengths, principal among which are the following.
Search strategy
Our search strategy was comprehensive.
Definition of physical tests
As an integral part of the review, we have described the performance and interpretation of physical tests, by reference, wherever possible, to the primary sources (Table 1). We have also been careful to evince the detail of index tests from the included studies.
Comparisons revealed that modifications in the procedures and/or interpretation of tests, sometimes intentional and sometimes not, are highly prevalent in the literature. Unclear is the extent to which a test's performance may be changed in terms of the starting position, the plane and range of movement, inclusion or exclusion of passive, active and resisted components, and the forcefulness of application, before it must be regarded as a different test. Our alertness to such procedural modifications, and modifications of interpretation (the criteria for a positive response, the implications of a positive response, or both) has enabled us to avoid pooling data which on superficial inspection seem suitable, but which are actually clinically heterogeneous; and has brought to light numerous internal inconsistencies.
Back‐calculations
We double‐checked the summary statistics presented in the included studies for each target condition/index test combination, back‐calculating 2 x 2 tables. That we observed such a high frequency of arithmetical errors, some so serious as to warrant study exclusion (Ebinger 2008; Fodor 2009; Litaker 2000) and others sufficiently serious to cast doubt on the safety of results (Calis 2000; Gumina 2008; Kibler 2009; Naredo 2002; Oh 2008; Schlechter 2009), emphasises the inadvisability of uncritically accepting reported values.
Non‐blinding of reviewers
Perhaps counter‐intuitively, we consider non‐blinding of reviewers to study authors was a strength of this review, because it facilitated identification of inconsistencies across multiple publications.
Weaknesses of the review
As predicted in our protocol, non‐English literature was not included because of resource limitations, although we are aware that this may have led to selection bias. However, at minimum, very good quality and complete technical translations are required and even then some key subtleties (such as in population and test performance) may be missed. In practice, due to obscure presentation of data in much of the primary literature, extraction even in the English‐language frequently presented a considerable challenge. This emphasizes the unfeasibility of extracting data with similar stringency from literature in other languages
While our search strategy was comprehensive, specialist feedback at editorial review highlighted that a greater use of subject headings in the database searches for the conditions under investigation and terms found in diagnostic test accuracy filters terms would have been desirable. Specialist feedback also suggested other databases and pointed to various grey literature sources such as MEDION (database of systematic reviews of diagnostic studies). We cannot say how many studies may have been missed through these potential deficiencies in our search strategy but reflect that our search through the reference lists of other reviews did not reveal any relevant omissions.
We recognise the possible inclusion of a large number of studies with an unacceptable delay between the index and reference tests, which we defined as an interval exceeding either the average duration of symptoms or one month (whichever was the shorter), as a potential source of bias. Specifically, there is a possibility of misclassification due to spontaneous recovery or progression of disease. Of the 33 trials included, 22 provided no details of the interval between the index and reference test. Only seven trials would have met the acceptable delay criterion, had it been a condition for inclusion. These were Calis 2000 (no delay assumed), Guanche 2003 (immediate), Iagnocco 2003 (a few days' delay), Miller 2008b (no delay), Naredo 2002 (≤ 1 week), Oh 2008 (mean delay 1 day), and Speer 1994 (index and reference tests were on the same day). The other four trials providing data would not have met the inclusion criterion. These were Holtby 2004a, Holtby 2004b (mean delay 23 weeks); Michener 2009 (mean 2.6 months); and Razmjou 2004 (mean 23 weeks). Given that the majority of studies did not report on the delay between the index and reference tests, our decision to include these and other studies with longer than desirable delays between index and reference tests was pragmatic, and necessitated by the evidence.
Applicability of findings to the review question
In the light of limitations of the primary evidence, the practical diagnostic advice that may be offered to the primary care clinician faced with an impingement‐related disorder can only be very tentative. A first step may be to screen for those conditions, such as glenoid labral lesions and large rotator cuff tears, which are most likely to warrant surgical opinion, so that a timely referral made be made; even if the immediate plan, perhaps while the patient is on a waiting list, is to implement a trial of conservative treatment. Identifying the best tests for screening purposes, and thus ruling out these diseases, involves consideration of the reported sensitivity, but also the precision of the point estimate and the methodological quality of the reporting study (or studies). Taking these factors into account, the most promising screening test for glenoid labral lesions was the passive compression test (Kim 2007b) with a sensitivity of 89% (95% CI 72% to 98%). But the test was novel and the evaluation was by its originators, and firm conclusions as to its usefulness must await independent verification. For full thickness tears of the rotator cuff, the posterosuperior rotator cuff in general, supraspinatus or infraspinatus there were no strong candidate tests. Thus the decision whether to refer may rest upon patients’ response to conservative intervention. For any tear of subscapularis, the sensitivity of the internal rotation lag sign was very high (97% (95% CI 82% to 100%)), although the evaluation was by the test’s originators (Hertel 1996) and, as with the passive compression test for labral lesions, independent verification would be highly desirable.
The degree to which specific localization of lesions (and thus tests with high specificity) is necessary depends upon the therapeutic approach. For example, a diagnosis of impingement is sufficient to implement a programme of exercises which aims to centre the humeral head in the glenoid. On the other hand, administration of localized massage such as deep transverse friction (Cyriax 1984) would call for a tendon‐specific diagnosis. In fact, there were no strong candidates for diagnosing impingement per se, and it may be that greater emphasis should be placed on making this diagnosis by excluding other main causes of shoulder pain such as frozen shoulder. Regarding specific rotator cuff tendons, resisted lateral rotation from neutral rotation, a conventional test for any disease of infraspinatus, had not only very high specificity (95% (95% CI 92% to 96%)) but also high sensitivity (94% (95% CI 87% to 98%)); likewise resisted medial rotation from neutral rotation, with a specificity of 99% (95% CI 97% to 100%)) and sensitivity of 96% (95% CI 78% to 100%) (Iagnocco 2003). There was no test which appeared to be equivalently useful for ruling in any disease of supraspinatus, but the empty can test appeared very useful for ruling it out (Iagnocco 2003; Naredo 2002) with sensitivities of 94% (95% CI 91% to 97%)) and 96% (95%CI 79% to100%) for an undefined test and a standard test, respectively.
Assessments of diagnostic test accuracy are only meaningful for tests which are replicable in different target users' hands. Thus between‐tester reliability is a critical consideration. Few of the included studies (Calis 2000; Kim 2001; Michener 2009; Razmjou 2004) addressed this aspect, however. It is noteworthy that the sole test on which there was 'very good' agreement was novel, and reported by its originators, whom one would expect to be highly proficient in its application and interpretation. Likewise, of the two tests for which there was 'good' agreement, one was a novel test, and reported by its originators.
Methodological quality summary: review authors' judgements about each methodological quality item for each included study. Coding: + = 'Yes'; ‐ = 'No'; ? = unclear.
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
Subacromial and internal impingement
Rotator cuff tendinopathy or tears ‐ non‐specific disease of the 'rotator cuff'
Rotator cuff tendinopathy or tears ‐ specific disease of the 'rotator cuff'
Rotator cuff tendinopathy or tears: non‐specific disease of the 'posterosuperior rotator cuff'
Rotator cuff tendinopathy or tears: specific disease of the 'posterosuperior rotator cuff'.
Rotator cuff tendinopathy or tears: non‐specific disease of supraspinatus
Rotator cuff tendinopathy or tears: specific disease of supraspinatus.
Rotator cuff tendinopathy or tears: disease of infraspinatus
Rotator cuff tendinopathy or tears: non‐specific disease of subscapularis
Rotator cuff tendinopathy or tears: specific disease of subscapularis
LHB tear or tendinitis
Glenoid labral lesion: non‐specific labral lesion
Glenoid labral lesions: non‐specific SLAP lesion
Glenoid labral lesions: type II‐IV SLAP lesion
Glenoid labral lesions: type II SLAP lesion
Target condition: SIS. Index test: combination of ALL 7 tests +ve (see table 7)..
Target condition: SIS. Index test: combination of Hawkins' test AND Neer's sign (modified procedure) +ve..
Target condition: SIS. Index test: combination of Hawkins' test OR Neer's sign (modified procedure) +ve..
Target condition: SIS. Index test: drop arm test (modified interpretation)..
Target condition: SIS. Index test: Gum‐turn test (novel).
Target condition: SIS. Index test:. Hawkins' test (standard)..
Target condition: SIS. Index test: Neer's sign (standard)..
Target condition: SIS. Index test: Neer's sign (modified procedure)..
Target condition: SIS. Index test: painful arc test (standard)..
Target condition: SIS. Index test: passive horizontal adduction (modified interpretation)..
Target condition: SIS. Index test: Speed's test (modified interpretation)..
Target condition: SIS. Index test: Yergason's test (modified interpretation)..
Target condition: SIS (SA‐SD bursitis). Index test: combination of Hawkins' test, Neer's sign, 'Yocum's (impingement) test' (overall criterion for +ve result not given)..
Target condition: SIS versus internal impingement, differentiation. Index test: internal rotation resistance strength test (novel)..
Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: standard)..
Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: modified procedure)..
Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) OR Neer's sign (modified procedure, modified interpretation) +ve..
Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) AND Neer's sign (modified procedure,modified interpretation) +ve..
Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: full can test for weakness ± pain (standard)..
Target condition: rotator cuff, FTT or PTT of. Index test: Hawkins' test (modified interpretation)..
Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement sign' (no reference or details given)..
Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement test' (no reference or details given)..
Target condition: rotator cuff, FTT or PTT of. Index test: Neer's sign (modified procedure, modified interpretation)..
Target condition: rotator cuff, PTT or tendinitis of. Index test: empty can test for pain WITHOUT weakness (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: empty can test for pain ± weakness (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: empty can test for weakness ± pain (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: full can test for pain ± weakness (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: full can test for weakness ± pain (modified interpretation)..
Target condition: rotator cuff, FTT of. Index test: 'impingement sign' (no reference or details given)..
Target condition: rotator cuff, FTT of. Index test: 'impingement test' (no reference or details given)..
Target condition: rotator cuff, FTT of. Index test: rent test (standard)..
Target condition: rotator cuff, FTT of, massive or large. Index test: empty can test for weakness ± pain (modified interpretation)..
Target condition: rotator cuff, PTT of. Index test: 'Impingement sign' (no reference or details given)..
Target condition: rotator cuff, PTT of. Index test: 'Impingement test' (no reference or details given)..
Target condition: rotator cuff, postero‐superior (supraspinatus AND infraspinatus), FTT of. Index test: Gum‐turn test (novel)..
Target condition: rotator cuff, postero‐superior, FTT or PTT of. Index test: drop sign (novel)..
Target condition: rotator cuff, postero‐superior, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation)..
Target condition: rotator cuff, postero‐superior, FTT or PTT of. Index test: external rotation lag sign (novel)..
Target condition: rotator cuff, postero‐superior, FTT of. Index test: drop sign (modified interpretation)..
Target condition: rotator cuff, postero‐superior, FTT of. Index test: external rotation lag sign (modified interpretation)..
Target condition: rotator cuff, postero‐superior, FTT of. Index test: Gum‐turn test (novel)..
Target condition: rotator cuff, FTT, multiple‐ versus single‐tendon. Index test: active abduction range (novel)..
Target condition: supraspinatus, any disease of, including calcification. Index test: empty can test (no reference or details given)..
Target condition: supraspinatus, FTT, degeneration or tendinitis,of. Index test: Hawkins' test (modified procedure, modified interpretation)..
Target condition: supraspinatus, FTT, PTT or tendinitis,of. Index test: empty can test for pain AND/OR weakness (standard)..
Target condition: supraspinatus, FTT or degeneration of. Index test: Hawkins' test (modified procedure, modified interpretation)..
Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation)..
Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness ± pain (standard)..
Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness (< grade 3) ± pain.(modified interpretation).
Target condition: supraspinatus, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation)..
Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness (< grade 3) ± pain (modified interpretation)..
Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness ± pain (standard)..
Target condition: supraspinatus, FTT of. Index test: drop arm test (standard)..
Target condition: supraspinatus, FTT of. Index test: empty can test for pain ± weakness (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: empty can test for pain AND/OR weakness (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: empty can test for weakness ± pain (standard)..
Target condition: supraspinatus, FTT of. Index test: full can test for pain ± weakness (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: full can test for pain AND/OR weakness (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: full can test for weakness ± pain (standard)..
Target condition: supraspinatus, FTT of. Index test: Gum‐turn test (novel)..
Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified procedure, modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: Neer's sign (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: painful arc test (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: passive horizontal adduction (standard)..
Target condition: supraspinatus, FTT of. Index test: Speed's test (modified interpretation)..
Target condition: supraspinatus, FTT of. Index test: Yergason's test (modified interpretation)..
Target condition: supraspinatus, FTT of, full‐width. Index test: external rotation lag sign (standard)..
Target condition: supraspinatus, isolated PTT of. Index test: external rotation lag sign (standard)..
Target condition: supraspinatus, tendinitis of. Index test: empty can test for pain WITHOUT weakness (standard)..
Target condition: infraspinatus, any disease of, including calcification. Index test: resisted lateral rotation from neutral rotation (no reference or details given)..
Target condition: infraspinatus, FTT, PPT or tendinitis,of. Index test: Patte's test for pain AND/OR weakness (standard)..
Target condition: infraspinatus, FTT or PTT of. Index test: Patte's test for weakness ± pain (standard)..
Target condition: infraspinatus, FTT or PTT of. Index test: resisted lateral rotation from neutral rotation for weakness < grade 3 ± pain (modified interpretation)..
Target condition: infraspinatus, tendinitis of. Index test: Patte's test for pain WITHOUT weakness (standard)..
Target condition: subscapularis, any disease of, including calcification. Index test: resisted medial rotation from neutral rotation (no reference or details given)..
Target condition: subscapularis, any tear or tendinitis of. Index test: combination of lift‐off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given)..
Target condition: subscapularis, any tear of. Index test: bear‐hug test (novel).
Target condition: subscapularis, any tear of. Index test: belly‐press test (standard).
Target condition: subscapularis, any tear of. Index test: internal rotation lag sign (novel)..
Target condition: subscapularis, any tear of. Index test: lift‐off test (Gerber 1991: modified interpretation)..
Target condition: subscapularis, any tear of. Index test: lift‐off test (Gerber 1991: probably standard).
Target condition: subscapularis, any tear of. Index test: Napoleon test (Burkhart 2002: standard)..
Target condition: subscapularis, any tear of. Index test:: lift‐off test with force for weakness < grade 2 ± pain (modified procedure, modified interpretation)..
Target condition: subscapularis, any tear of. Index test: combination of lift‐off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given)..
Target condition: subscapularis, complete tear of. Index test: bear‐hug test (novel)..
Target condition: subscapularis, complete tear of. Index test: belly‐press test (modified procedure)..
Target condition: subscapularis, complete tear of. Index test: lift‐off test (Gerber 1991: modified interpretation)..
Target condition: subscapularis, complete tear of. Index test: Napoleon test (Burkhart 2002: standard)..
Target condition: subscapularis, FTT of. Index test: internal rotation lag sign (modified interpretation)..
Target condition: subscapularis, partial tear of. Index test: bear‐hug test (novel)..
Target condition: subscapularis, partial tear of. Index test: belly‐press test (modified procedure)..
Target condition: subscapularis, partial tear of. Index test: lift‐off test (Gerber 1991: modified interpretation)..
Target condition: subscapularis, partial tear of. Index test: Napoleon test (Burkhart 2002: standard)..
Target condition: subscapularis, tendinitis of. Index test: combination of lift‐off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given)..
Target condition: LHB, tear or tendinitis of. Index test: Speed's test (standard)..
Target condition: LHB, tear or tendinitis of. Index test: active compression test (standard).
Target condition: LHB, tear or tendinitis of. Index test: anterior slide test (modified procedure, modified interpretation)..
Target condition: LHB, tear or tendinitis of. Index test: bear‐hug test (modified interpretation).
Target condition: LHB, tear or tendinitis of. Index test: belly‐press test (standard).
Target condition: LHB, tear or tendinitis of. Index test: modified dynamic labral shear (novel).
Target condition: LHB, tear or tendinitis of. Index test: Speed's test (modified procedure).
Target condition: LHB, tear or tendinitis of. Index test: upper‐cut test (novel).
Target condition: LHB, tear or tendinitis of. Index test: Yergason's test (modified procedure).
Target condition: LHB, tear or tendinitis of. Index test: combination of Yergason's test and Gilcreest's test (modified procedure, modified interpretation).(Overall criterion for +ve result not given.).
Target condition: labrum, any tear of. Index test: active compression test (novel)..
Target condition: labrum, any tear of. Index test: active compression test (modified interpretation)..
Target condition: labrum, any tear,of. Index test: crank test (novel/standard)..
Target condition: labrum, any tear,of. Index test: 'impingement sign' (no reference or details given)..
Target condition: labrum, any tear,of. Index test: 'impingement test' (no reference or details given)..
Target condition: labrum, any SLAP lesion of. Index test: active compression test (modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: anterior apprehension test at 90° for pain (Krishnan 2004: modified interpretation)..
Target condition: labrum, any SLAP lesion,of. Index test: anterior release test (Gross 1997: modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: anterior slide test (modified procedure, modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: bear‐hug test (modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: belly‐press test (modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: crank test (Liu 1996b: modified procedure, modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: modified dynamic labral shear (novel)..
Target condition: labrum, any SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: passive compression test (novel)..
Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: upper cut test (novel)..
Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified interpretation)..
Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified procedure, modified interpretation)..
Target condition: labrum, type II‐IV SLAP lesion of. Index test: active compression test (modified interpretation)..
Target condition: labrum, type II‐IV SLAP lesion of. Index test: anterior slide test (modified procedure)..
Target condition: labrum, type II‐IV SLAP lesion of. Index test: combination of active compression test (modified interpretation) OR passive distraction test (standard)..
Target condition: labrum, type II‐IV SLAP lesion of. Index test: passive compression test (novel, modified interpretation)..
Target condition: labrum, type II‐IV SLAP lesion of. Index test: passive distraction test (standard)..
Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 2)..
Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 1,2)..
Target condition: labrum, type II SLAP lesion of. Index test: anterior apprehension test at 90° for pain OR apprehension (Rowe 1981: modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: anterior slide test (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: biceps load test II (novel/standard)..
Target condition: labrum, type II SLAP lesion of. Index test: compression‐rotation test (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: crank test (modified procedure, modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: Hawkins' test (modified procedure, modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: modified relocation test for posterosuperior glenoid impingement (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: Neer's sign (modified procedure, modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: pain provocation test (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: relocation test for pain OR apprehension (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: Whipple's test (modified interpretation)..
Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 2)..
Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 1,2)..
Target condition: multiple (LHB tendinitis/LHB avulsion/SLAP lesion, any). Index test: Speed's test (modified procedure, modified interpretation 1)..
Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Speed's test (modified procedure, modified interpretation 1,2)..
Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Yergason's test (modified interpretation 1,2)..
Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Empty can test (modified interpretation)..
Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Hawkins' test (standard)..
Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Neer's sign (modified procedure)..
Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: painful arc test (standard)..
Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability) Index test: resisted lateral rotation from neutral rotation for weakness ± pain (modified interpretation 1,2)..
Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: combination of 3 or more tests +ve (see table 11)..
Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Hawkins' test (modified interpretation)..
Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Neer's sign (modified interpretation)..
| Setting | Most people with shoulder pain symptomatic of impingements and related pathologies are diagnosed and managed in the primary care setting. | |||
| Index tests | Physical tests used single or in combination to identify shoulder impingement and related pathologies. | |||
| Reference standard | While a definitive reference standard is lacking, surgery, whether open or arthroscopic, is generally regarded as the nest available. Non‐invasive contenders include ultrasound and magnetic resonance imaging (MRI). | |||
| Importance | Accurate diagnosis using readily applied, convenient, low‐cost physical tests would enable appropriate and well‐timed management of these common causes of shoulder pain. | |||
| Studies | Index were 33 studies including 4002 shoulders in 3852 patients. These incorporated numerous standard, modified or combinations of index tests and 14 novel index tests. | |||
| Quality concerns | Although 28 studies were prospective, study quality was generally poor. All but two studies failed to meet the criteria for having a representative spectrum of patients. | |||
| Data analysis | The studies tested 170 target condition/index test combinations, with only six instances of any index test being performed and interpreted similarly in two studies. Meta‐analysis of the latter was inappropriate, however. | |||
| Target condition | Subcategory of target condition, if applicable | Studies | Shoulders/patients | Tests or variants evaluated |
| Subacromial and internal impingement | Subacromial impingement | 5 | 361/356 | 13 |
| subacromial versus Internal impingement | 1 | 110/110 | 1 | |
| Internal impingement | 0 | 0 | 0 | |
| Rotator cuff tendinopathy or tears | Non‐specific disease of the 'rotator cuff' | 5 | 466/466 | 17 |
| Specific diseases of the 'rotator cuff' | 5 | 503/503 | 15 | |
| Non‐specific disease of the 'posterosuperior rotator cuff' | 2 | 220/220 | 4 | |
| Specific disease of the 'posterosuperior rotator cuff' | 2 | 166/157 | 3 | |
| Non‐specific disease of supraspinatus | 4 | 792/678 | 11 | |
| Specific disease of supraspinatus | 6 | 887/870 | 18 | |
| Disease of infraspinatus | 3 | 719/605 | 5 | |
| Non‐specific disease of subscapularis | 5 | 887/773 | 10 | |
| Specific disease of subscapularis | 3 | 145/136 | 10 | |
| LHB tendinopathy or tears | 3 | 660/557 | 10 | |
| Glenoid labral lesions | Non‐specific labral lesions | 4 | 364/364 | 5 |
| Non‐specific SLAP lesions | 3 | 222/221 | 15 | |
| Type II‐IV SLAP lesions | 2 | 315/307 | 5 | |
| Type II SLAP lesions | 3 | 405/405 | 18 | |
| Multiple, undifferentiated target conditions | LHB/labral pathology; LHB/SLAP lesions; SA‐SD bursitis/bursal‐side degeneration of supraspinatus; and SIS/rotator cuff tendinitis or tear. | 4 | 201/200 | 10 |
| Tests intended to identify impingement in general | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Painful arc test | None | The patient actively elevates, then lowers, the shoulder through abduction. | Onset and offset of pain during elevation, during lowering, or both. | Subacromial impingement; calcific tendonitis; pain secondary to shoulder joint instability; or internal impingement (involving the deep aspect of the rotator cuff or the LHB tendon) | |
| Tests intended to identify subacromial impingement | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Hawkins' test | None | The upright patient's arm is passively positioned in 90° of flexion at shoulder and elbow. The tester then forcibly medially rotates the patient's shoulder. | Reproduction of the patient's pain | Subacromial impingement | |
| Neer's sign | Neer 1977;Neer 1983 (Neer 1972a, sometimes cited, does not give a clear account of this test) | None | The tester forcibly elevates the sitting patient's arm through scaption, preventing scapular movement by pressing down on the clavicle and acromion with the other hand. | Pain constitutes a positive Neer's sign. | Subacromial Impingement and 'many other shoulder conditions, including stiffness (partial frozen shoulder), instability (e.g. anterior subluxation), arthritis, calcium deposits, and bone lesions'. |
| Neer's test | None | The tester forcibly flexes the sitting patient's arm, preventing scapular movement by pressing down on the clavicle and acromion with the other hand (*Neer's sign). The patient is given an injection of 10 ml, 1% xylocaine beneath the anterior acromion before the manoeuvre is repeated. | A positive *Neer's sign which is abolished by the injection is termed a positive Neer's test. | Subacromial impingement | |
| 'Yocum's (impingement) test' | Leroux 1995 and Naredo 2002 cite Yocum 1983: apparently a misconception (see under technique). | None | Yocum did not describe a novel impingement test in the article cited (but see comment relating to the *empty can test, further in this table). Leroux 1995 and Naredo 2002 may have misinterpreted a photograph depicting Hawkins' test. According to Naredo 2002, the patient places the hand of the affected arm on his or her other shoulder and, keeping the point of the affected shoulder down, raises the elbow of the same limb. | Reproduction of the patient's pain | Subacromial impingement |
| Tests intended to identify internal impingement | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Anterior apprehension test at 90° for pain | None | The test may be performed with the patient sitting or supine. In the latter position the test may be termed the fulcrum test. With the elbow flexed 90, the patient's shoulder is positioned in 90° abduction and full lateral rotation. (As distinct from the version of this test described by Jobe 1989, no anterior pressure is applied to the humeral head (see below). | Pain is considered a positive result | Internal impingement | |
| Anterior apprehension test at 90° for pain | None | The supine patient's shoulder is placed in in 90° abduction and full lateral rotation, with the elbow flexed 90°. Maintaining this position, the tester applies an anterior pressure to the posterior aspect of the humeral head. | Pain but no apprehension. (Note that Rowe 1981 described a test which, apart from the patient being in sitting, was performed comparably to that presented here. However, Rowe's test, which was for subluxation, required that both pain and apprehension be present for a positive result.) | Pain associated with anterior subluxation. Since the original description of this test, this pain has more specifically been ascribed to posterosuperior glenoid impingement (Jobe 1995, Jobe 1996). | |
| Anterior release test | None | The patient lies supine, affected shoulder over the edge of the examination couch. The shoulder is passively abducted to 90° while the tester applies a posteriorly directed force to the humeral head. Maintaining this force, the tester brings the arm into full lateral rotation. Then the posteriorly directed force is released. | Sudden pain, an increase in pain or reproduction of symptoms [on release] | Primarilrily occult instability; but the authors link this to posterosuperior glenoid impingement. | |
| Modified relocation test for postero‐superior glenoid impingement | None | The patient liessupine. The shoulder is held by the tester in full lateral rotation and positioned at each of 90°, 100° and 120° of abduction. In each of these positions the tester applies a force to the patient's upper humerus, first directed anteriorly, then posteriorly. | Pain on the anteriorly directed force which is relieved by the posteriorly directed force | Internal impingement | |
| Posterior impingement test | None | The supine patient's shoulder is placed into 90°‐110° degrees of abduction and 10°‐15° extension. Full lateral rotation is then added. | Pain felt deeply within the posterior aspect of the shoulder joint | Posterior glenoid impingement and concomitant tear of the internal surface of the rotator cuff, of the posterior glenoid labrum, or both. | |
| Relocation test for pain | Positive apprehension test | This is an extension of the apprehension test for pain at 90°, which it immediately follows. With the patient's arm still abducted and laterally rotated, posterior pressure is applied to the humeral head. | The pain of the apprehension test is relieved. While posterior pressure is maintained, reduced pain may allow greater lateral rotation. | Pain associated with anterior subluxation. Since the original description of this test, this pain has more specifically been ascribed to posterosuperior glenoid impingement (Jobe 1995, Jobe 1996). | |
| Tests intended to differentiate between subacromial and internal impingement | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Internal rotation resistance strength test | Positive Neer's sign | The patient and tester stand, the tester to the rear. The patient's elbow is flexed to about 90°, and the shoulder positioned at 90° abduction and 80°lateral rotation. In this position, lateral‐ and medial rotation are manually, isometrically resisted. | Lateral rotation is strong. Medial rotation is weak. | Internal impingement. The converse is a 'negative' finding, and signifies subacromial outlet impingement | |
| Tests intended to diagnose rotator cuff tears or tendinosis | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Bear‐hug test | None | The patient places the palm of the affected limb, fingers extended, on the opposite shoulder. The patient is asked to hold this position, while the tester, by applying a force perpendicular to the forearm, attempts to laterally rotate the shoulder. | The patient is unable to hold the hand in contact with the shoulder, or is > 20% weaker than on the unaffected side. | Tear of subscapularis | |
| Belly‐press test | Inadequate range of motion to perform the *lift‐off test (see below) | The patient, in a sitting position, presses against the abdomen with the palm of the hand while trying to keep the shoulder in full medial rotation. | Full medial rotation cannot be maintained. The patient feels weak and the shoulder drops back into extension. The patient tries to exert pressure by extending the elbow and flexing the wrist. | Weakness of subscapularis, implying a partial or complete tear | |
| Drop arm test | None | This test was not clearly described in its primary source. By convention, it is applied in the plane of abduction, with the patient's arm placed passively above 90° by the tester; the support is removed, and the patient attempts to lower the arm actively. | The patient is unable to actively lower the arm under control beyond the horizontal, and it drops to his or her side. | Tear of supraspinatus | |
| Drop sign | Normal passive range of movement at the shoulder is required: capsular contracture (hypomobility) or ruptured subscapularis (hypermobility) might cause false ‐ve and false +ve results, respectively. The authors suggest proceeding to this test if the external rotation lag sign is positive. | The patient sits. The tester stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder elevated to 90° in the plane of the scapula, then laterally rotates the shoulder to just short of full range. The tester continues to support the elbow while releasing the wrist and asking the patient to maintain the lifted‐off position. | The patient cannot maintain the position and there is a 'drop' or 'lag', which is recorded to the nearest 5°. | Tear of postero‐superior rotator cuff, particularly infraspinatus, or neuropathy. The authors suggest that the value of the test is in assessing involvement of infraspinatus having established the presence of a poster‐superior cuff tear using the external rotation lag sign. | |
| Empty can test (Jobe's test, supraspinatus test). Note that Yocum 1983 described the same test (minus the preliminary deltoid component) in the same year, apparently derived from the same studies at the Centinela Hospital Medical Centre Biomechanics Laboratory, California. Thus the empty can test has also been termed 'Yocum's test' (REF and see separate entry for *'Yocum's impingement test' above). Jobe 1982 is often cited as the source of this test, but the manoeuvre described in that report was a strengthening exercise, not a diagnostic test. | None | There are two stages. Preliminarily, the tester evaluates the deltoid, with the patient's arm at 90° of abduction and neutral rotation. To evaluate supraspinatus, the arm is then moved into medial rotation (thumb pointing down) and 90° of scaption, where the patient is asked to isometrically resist a downward pressure applied by the tester. | Pain or weakness on testing supraspinatus | Supraspinatus impingement (pain) or tear (weakness) | |
| External rotation lag sign | Normal passive range of movement at the shoulder is required: capsular contracture (hypomobility) or ruptured subscapularis (hypermobility) might cause false ‐ve and false +ve results, respectively. | The patient sits. The tester stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder in 20° of elevation (in the plane of the scapula), then laterally rotates the shoulder to 5° short of full range. The tester asks the patient to maintain the lateral rotation and, while continuing to support the elbow, releases the wrist. | An angular 'drop' or 'lag', which is recorded to the nearest 5° | Tear of supraspinatus ± infraspinatus. A 15° lag or greater signifies a complete tear of both or a neuropathy. | |
| Full can test | None | The patient sits, arm laterally rotated (thumb pointing up) and in 90° of scaption. The patient is then asked to isometrically resist a downward pressure applied on the arm by the tester. | Weakness (the test was described in the context of strength assessment, not pain‐provocative testing). However, by convention, the test is often interpreted as for the *empty can test. | Supraspinatus dysfunction | |
| Gum‐turn test | None | Starting in the *empty can test position, the patient traces a 20‐cm wide spiral drawn on the wall, from centre to periphery and back 10 times, resting for one minute, then repeating the procedure. | The test is positive if weakness or pain prevent completion. (For positive results, the number of turns completed were recorded, but it is unclear how these data were used. Results were compared with the contralateral arm but, again, it is unclear how these data were used.) | Postero‐superior rotator cuff tear | |
| Internal rotation lag sign. | Adequate range of medial rotation. If this is not available, the belly press test (see above) should be used. | The patient sits. The tester, standing to the rear, brings the patient's hand behind the back and flexes the elbow to 90°, so that the back of the hand rests on the spine at waist level. Gripping the patient's wrist, the tester then lifts the back of the hand clear of the spine until the shoulder is in almost full medial rotation. The tester, who continues to support the elbow but releases the wrist, asking the patient to actively maintain this position. | A lag occurs, the magnitude of which is recorded to the nearest 5°. | 'An obvious drop of the hand may occur with large tears. A slight lag indicates a partial tear of the cranial part of the subscapularis tendon.' | |
| Lift‐off test. | Adequate passive range of medial rotation. Active medial rotation not inhibited by pain. | The arm is brought passively behind the patient's body into medial rotation, such that the hand rests against the spine at waist level, palm backwards. The patient attempts to lift the hand off his or her back. | Inability to lift the hand off the back | Tear of subscapularis | |
| Lift‐off test. (Also see *internal rotation lag sign, Hertel 1996a, and *lift‐off test, Gerber 1991a.) | Adequate range of internal rotation. If this is not available, the *belly‐press test should be used instead. | The arm is brought passively behind the patient's body into full internal rotation. The hand, palm facing backwards, is at waist level but not in contact with the spine. The patient attempts to maintain this position. (This description differs slightly from that above, despite apparently relating to the same patient sample, but tallies with the internal rotation lag sign.) | (a) The patient cannot maintain the position: the hand drops back to the body and cannot be actively lifted off without elbow extension; or (b) the patient is weak, so that the hand drops back more than 5°, but not all the way to the spine. | Tear of subscapularis. No information is given on differential interpretation of (a) and (b). | |
| Lift‐off test with force | Adequate medial rotation. If this is not available, the *belly press test should be used instead. | As above, except the patient is asked to maintain the lift‐off position against manually applied resistance. | Weakness (the test was described in the context of strength assessment, not pain‐provocative testing). | Subscapularis dysfunction | |
| Napoleon test | Schwamborn 1999 [German] Burkhart 2002 | None | This is a modification of the belly‐press test. The patient adopts a Napoleonic pose, palm on abdomen and with the elbow positioned laterally. | Burkhart 2002 refined the test's interpretation thus. A negative (normal) result is where the patient can press against the abdomen without wrist flexion. A positive result is an inability to press against the abdomen without wrist flexion to 90°. Intermediate results may occur. | Subscapularis tear (positive result) or partial tear (intermediate result) |
| Passive horizontal adduction (scarf test) | None | The patient's arm is passively horizontally adducted across the chest. | Pain | Lesions of the ACJ, but also of the lower part of the tendon of subscapularis | |
| Patte's test | Patte 1987 [French], Leroux 1995 | None | With the arm supported in 90° of scaption, the patient is asked to laterally rotate maximally against the tester's isometric resistance. The starting position in terms of the degree of rotation was not specified. | There are three possible responses: (A) strong and painless; (B) normal ability to resist despite pain; and (C) inability to resist, with gradual lowering of the forearm. (C) is subcategorised as follows: (1) decreased resistance compared to the other side, allowing the tester to lower the forearm; (2) the patient can perform the test against gravity but is cannot resist the pressure applied by the tester; and (3) the patient cannot perform the test against gravity. | (1) Normal; (2) simple tendinitis of infraspinatus; (3) ruptured infraspinatus tendon. The score 1‐3 'has been claimed to increase in parallel with the severity of muscle atrophy and the size of the tear'. |
| Rent test (transdeltoid palpation) | None | The tester draws the upright patient's shoulder into extension, palpating anterior to the acromion. | There is a tender depression (rent) anterior to the acromion and, just distal to this, an eminence. | A rent represents a full thickness tear of supraspinatus; the associated eminence is the greater tuberosity, and possibly a stump of supraspinatus' attachment distal to the tear. If portions of the adjacent rotator cuff tendons are torn, the tenderness, eminence and rent may be a little internal or external to the mid‐point of the insertion of supraspinatusitself. | |
| Resisted abduction | None | The patient stands, arm at side, and is asked to abduct the arm maximally against the tester's isometric resistance, which is applied at the elbow. | Pain or weakness (either or both) | Supraspinatus lesion. (1) pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy. | |
| Resisted lateral rotation from neutral rotation | None | The patient stands, elbow at side and flexed to 90°, shoulder in neutral rotation. He or she is then asked to laterally rotate the shoulder maximally against the tester's isometric resistance, which is applied at the wrist. | Pain or weakness (either or both) | Infraspinatus or (less likely) teres minor lesion. (1) pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy. | |
| Resisted medial rotation from neutral rotation | None | The patient stands, elbow at side and flexed to 90°, shoulder in neutral rotation. He or she is then asked to medially rotate the shoulder maximally against the tester's isometric resistance, which is applied at the wrist. | Pain or weakness (either or both) | Lesion of subscapularis or another medial rotator. (1) Pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy. | |
| Whipple test | None | The patient horizontally adducts the straight arm, so that the hand, palm down is in front of the unaffected shoulder. In this position the tester applies a downwards force at the wrist, which the patient isometrically resists. | No details of interpretation were given. | Tear of anterior supraspinatus | |
| Tests intended to diagnose LHB tears or tendinosis | |||||
| Gilcreest's test (Gilcreest's palm up test) | None | The patient elevates the arms in full lateral rotation, holding a weight (e.g. 5 lb dumbbells) in each hand. The tester palpates the LHB while the patient, maintaining full lateral rotation, lowers both arms through abduction. Occasionally | When the arms reach an angle of from 110° to 90° | Recurrent dislocation of LHB tendon. Since used in a modified form for LHB tendinitis (Naredo 2002). | |
| Speed's test | None | The patient flexes his or her shoulder against isotonic resistance with the elbow extended and the forearm supinated. | Pain localised to the bicipital groove | Degenerative changes of the LHB, or synovitis of its tendon sheath. Recently the test has also been applied to the diagnosis of SLAP lesions (see below). | |
| Upper cut test | None | The patient, elbow at the side and flexed to 90°, palm upwards and with the shoulder in neutral rotation, is asked to make a fist. The tester, with a hand placed over the fist, applies isotonic resistance as the patient attempts to rapidly bring the hand up towards the chin, in the manner of a boxing upper cut. | Pain or a painful pop over the anterior portion of the involved shoulder during the resisted movement is interpreted as a positive result. | LHB or SLAP lesions (see below) | |
| Yergason' test (supination sign) | None | The patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the tester's resistance. | Pain localised to the bicipital groove. | Degenerative changes of the LHB, or synovitis of its tendon sheath. Recently, the test has also been applied to the diagnosis of SLAP lesions (see below). | |
| Tests intended to diagnose tears of the glenoid labrum | |||||
| Test | Reference | Specified pre‐requisites | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Active compression test | None | The patient, who is standing, flexes his or her shoulder to 90°, then adducts 10‐15° and medially rotates fully. The elbow remains extended throughout. The tester stands behind the patient and applies a uniform downward force to the arm. This is repeated in full lateral rotation. | Pain on the 1st manoeuvre, reduced or eliminated on the 2nd | SLAP lesion | |
| Anterior slide test | None | The patient sits or stands, hands on hips and thumbs pointing posteriorly. One of the tester’s hands is placed across the top of the shoulder from behind, with the last segment of the index finger extending over the anterior aspect of the acromion at the shoulder joint. The tester’s other hand is placed behind the elbow, and a forward and slightly superiorly directed force is applied to the elbow and upper arm. The patient is asked to push back against this force. | Pain localised to the front of the shoulder under the tester’s hand, and/or a pop or click in the same area, or reproduction of the symptoms felt during overhead activity | Unstable SLAP lesion | |
| Biceps load II test | None | The patient lies supine. The tester gently grips his or her wrist and elbow, elevating the shoulder to 120° and laterally rotating it fully. The patient's forearm is supinated, and elbow flexed to 90°. The patient is now asked to flex his or her elbow against the tester'sisometric resistance. | Pain provoked by resisted elbow flexion. | SLAP lesion | |
| Biceps tension test | None | Probably as for *Speed’s test, but whether resistance is isometric or isotonic was not made clear | Not defined | Unstable SLAP lesion | |
| Compression‐rotation test | None | The patient lies supine, shoulder abducted to 90° and elbow flexed to 90°. The tester holds the patient’s wrist with one hand, while cradling the elbow with the other. The tester then applies a compression force along the line of the humerus while rotating the shoulder, in an attempt to trap the torn labrum. | Palpable catching & snapping, analogous to that felt during a positive McMurray’s test for a torn meniscus at the knee | Unstable SLAP lesion | |
| Crank test | None | The patient lies supine. The tester, holding the patient's arm and wrist, forward flexes the shoulder fully (c.f. the entry below) and, while axially loading the shoulder through the humerus, rotates it medially and laterally. | Clicking, apprehension or both (c.f. the entry below). | Tear of the glenoid labrum | |
| Crank test | None | The patient sits or lies (the lying variant is stated to be the more sensitive test: c.f. the entry above) with the elbow flexed 90° and the shoulder elevated 160° in the plane of the scapula (c.f. the entry above). The tester compresses the joint along the line of the humerus with one hand, while fully rotating the shoulder in either direction with the other. | Pain, usually during lateral rotation, with or without a click; or reproduction of symptoms (usually pain or a sensation of catching: c.f. the entry above). | Tear of the glenoid labrum. Interpretation is confused by the discrepancies with the entry above, but also by the recommendation, here, to conduct the test in sitting as well as in supine, especially since, ‘frequently, a positive crank test in the upright position will also be positive in the supine position’. If the supine test is more accurate, the rationale for additionally testing in sitting is unclear | |
| Modified dynamic labral shear | None | The patient stands. The elbow is flexed and the shoulder elevated to above 90° of scaption, then externally rotated to the point of tightness. The shoulder is then guided into maximal horizontal abduction. The tester then applies a shear load by maintaining external rotation and horizontal abduction while lowering the arm to 60° of scaption. Reportedly, this differs from the test described by O’Driscoll (no further citation information given) in that the arm is not placed into maximal horizontal abduction until it is elevated above 120°. (Reportedly, in pilot testing this modification was found to reduce the high number of false positive tests due to pain through the whole motion.) | Reproduction of the pain and/or a painful click or catch along the posterior joint line between 120° and 90° of scaption is interpreted as a positive result. | SLAP lesion | |
| Pain provocation test | None | The sitting patient’s shoulder is passively abducted to between 90 & 100° & fully externally rotated. With the patient’s elbow flexed to 90°, his or her forearm is fully pronated, then supinated, by the tester. | Pain, greater in the pronated position | Unstable SLAP lesion | |
| Palpation for bicipital groove tenderness | None | Deep pressure applied to the bicipital groove on the symptomatic and (for comparison) the asymptomatic arm | Pain elicited by deep pressure on the symptomatic arm, compared to no pain on the asymptomatic arm | SLAP lesion | |
| Passive compression test | None | The patient is in side‐lying, affected arm uppermost. The tester places one hand over the acromion, using the other to cradle the elbow, which is flexed to 90°. The shoulder is abducted to 30° and laterally rotated. The tester then applies a compressive force through the axis of the humerus while drawing the shoulder into extension. | Pain or a painful click | SLAP lesion | |
| Passive distraction test | None | The patient lies supine with the shoulder off the examining | Pain. If asked, the patient will frequently indicate | SLAP lesion | |
| SLAPprehension test | None | The arm of the seated or standing patient is horizontally adducted across the chest with the elbow extended and the shoulder medially rotated. The test is repeated with the shoulder laterally rotated. | ‘SLAPprehension’ (meaning unclear), pain which may be referred to the bicipital groove, and sometimes an audible or palpable click. Repeating the manoeuvre in lateral rotation must be less painful, or the test is negative or indeterminate. | Unstable SLAP lesion | |
| Speed's test | None | The patient flexes his or her shoulder against isotonic resistance with the elbow extended and the forearm supinated. | Pain | Originally developed to diagnose LHB lesions (see above), the test has recently also been applied to the diagnosis of SLAP lesions. | |
| Upper cut test | None | The patient, elbow at the side and flexed to 90°, palm upwards and with the shoulder in neutral rotation, is asked to make a fist. The tester, with a hand placed over the fist, applies isotonic resistance as the patient attempts to rapidly bring the hand up towards the chin, in the manner of a boxing upper cut. | Pain or a painful pop over the anterior portion of the involved shoulder during the resisted movement is interpreted as a positive result. | SLAP orLHB lesions (see above) | |
| Yergason' test, Supination sign | None | The patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the tester's resistance. | Pain localised to the bicipital groove. | Originally developed to diagnose biceps lesions (see above), the test has recently also been applied to the diagnosis of SLAP lesions. | |
| Abduction. Sideways movement of a limb away from the body, as in flapping the arms. The opposite of *adduction. The range of abduction is measured from the arm‐at‐side position (0°). Adduction. Movement of a limb towards the midline of the body. The opposite of *abduction. Accuracy. Formally, the proportion of all cases correctly identified by the test. Estimated as (TP+TN)/(TP+FP+FN+TN). ACJ. See ACROMIOCLAVICULAR JOINT. Acromioclavicular joint. The joint between the outer end of the *clavicle and the *acromion. Acromion. A bony process that projects from the *scapula and forms the point of the shoulder. It lies above the shoulder joint. Anterior. Towards the front. The opposite of *posterior. Arthrography. A diagnostic technique in which X‐rays are taken after injection of a contrast material into a joint. Biceps. See LONG HEAD OF BICEPS. Bicipital groove. A groove on the front of the upper *humerus that accommodates the Tendon of the *long head of biceps. Bursa. A lubricating sac. Bursae are often found where ligaments, muscles, tendons or bones rub together. Bursal‐side. Pertaining to the outer (superficial) aspect of the *rotator cuff: the aspect adjacent to the *subacromial‐subdeltoid bursa. Bursography. A diagnostic technique in which X‐rays are taken after injection of a contrast material into a *bursa. Calcific tendonitis. An inflammation of tendon characterised by deposition of calcium within the tendon’s substance. The tendon of *supraspinatus is commonly affected in this way. Clavicle. The collarbone. Cranial. Towards the head. Caudal. Away from the head. Deltoid. The muscle which gives rise to the rounded contour of the shoulder. Its major function, in concert with *supraspinatus, is to *abduct the shoulder. Distal. The direction away from the body. Elevate. To move upwards. At the shoulder, elevation may be through *flexion, *abduction or in the *plane of the scapula. In each case the range of the movement is measured from the arm‐at‐side position (0°). Extend. See EXTENSION. Extension. In general terms, straightening a joint to lengthen a limb. The opposite of *flexion. At the shoulder, it denotes movement backwards. The range of shoulder extension is measured from the arm‐at‐side position (0°). External rotation. See LATERAL ROTATION. False Negative (FN). The cases which a test incorrectly classifies as not having a disease. False Positive (FP). The cases which a test incorrectly classifies as having a disease. Flex. See FLEXION. Flexion. In general terms, bending a joint to shorten a limb (as in bending the arm up at the elbow).The opposite of *extension. At the shoulder it denotes movement forwards. The range of shoulder flexion is measured from the arm‐at‐side position (0°). FN. See FALSE NEGATIVE. FP. See FALSE POSITIVE. Glenoid. The socket of the shoulder joint. Glenoid labrum. A fibrocartilage (gristly) extension of the *glenoid rim that deepens the socket of the shoulder joint. Gold standard. A reputedly optimal *reference standard. Greater tuberosity. A protuberance on the upper *humerus to which *supraspinatus attaches. Horizontal abduction. The movement in which the arm is positioned parallel to the ground and brought backwards. The opposite of *horizontal adduction. Horizontal adduction. The movement in which the arm is positioned parallel to the ground and brought forwards. The opposite of *horizontal abduction. Humerus. The upper arm bone. Humeral head. The rounded upper part of the *humerus, which forms the ball of the shoulder joint. Impingement. Pinching. This causes ‘catching’ or aching pain without appreciable joint stiffness, and may lead to local inflammation and tissue damage. Subcategories include *internal impingement, *subacromial outlet impingement. Index test. The test undergoing evaluation against a *reference standard. Inferior. Relating to the lower portion of a structure. Opposite of *superior. Inferiorly. Downwards. Opposite of *superiorly. Infraspinatus. See ROTATOR CUFF. Internal rotation. See MEDIAL ROTATION. Internal impingement. Pinching of structures inside the shoulder joint at the extremes of movement. The *glenoid rim, the *glenoid labrum and the deep surface of the *rotator cuff are vulnerable to this type of *impingement, and may be affected singly or in combination. Isometric resistance. Tester‐applied resistance that prevents an attempted movement. Isotonic resistance. Tester‐applied resistance that allows an attempted movement Joint‐side. Pertaining to the inner (deep) aspect of the *rotator cuff: the aspect adjacent to the shoulder joint. Labrum. See GLENOID LABRUM. Lateral. Away from the midline of the body. The opposite of *medial. *Lateral rotation. At the shoulder this denotes a twisting movement as in unfolding the arms. The opposite of *medial rotation. Lesion. An area of tissue damage. LHB. See LONG HEAD OF BICEPS. Long head of biceps (LHB). The portion of the biceps that arises inside the shoulder joint. The tendon arches over the *humerus to pass into the arm. LR̶̶‐. See NEGATIVE LIKELIHOOD RATIO. LR+. See POSITIVE LIKELIHOOD RATIO. Magnetic resonance arthrography (MRA). *MRI following injection of a contrast material into a joint. Magnetic resonance Imaging (MRI). A non‐invasive diagnostic technique. Tissues' differing responses in a strong electromagnetic field are analysed by computer and translated into an accurate anatomical image. Medial. Towards the midline of the body. The opposite of *lateral. Medial rotation. At the shoulder, a twisting movement as in folding the arms or bringing the hand behind the back. The opposite of *medial rotation. MRA. See MAGNETIC RESONANCE ARTHROGRAPHY. MRI. See MAGNETIC RESONANCE IMAGING. Negative likelihood ratio (LR‐). The ratio between the probability of a negative test result when the disease is present, and the probability of a negative test result when the disease is absent; estimated as (1‐Sn)/Sp. Negative predictive value. The probability that the disease is absent when the test is negative; estimated as TN/(FN+TN). Neuropathy. A disorder of a nerve that may result in muscle weakness. Neutral rotation. A position of neither *lateral nor *medial rotation. Plane of the scapula. A plane of shoulder movement between *flexion/*extension and *abduction/*adduction. Posterior. Towards the back. The opposite of *anterior. Positive likelihood ratio (LR+). The ratio between the probability of a positive test result when the disease is present, and the probability of a positive test result when the disease is absent; estimated as Sn/(1‐Sp). Positive predictive value (PPV). The probability that the disease is present when the test is positive; estimated as TP/(TP+FP). PPV. See POSITIVE PREDICTIVE VALUE. Pronation. The movement of the forearm that, in relaxed standing, would bring the palm to face backwards. Prone. Lying face downwards. Proximal. The direction towards the body. Reference standard. A highly accurate method of diagnosis. It provides a benchmark against which other methods are judged. Rheumatoid disease. A systemic disease, one manifestation of which is inflammation of joints. Rotator cuff. A musculotendinous cuff that surrounds and blends with the shoulder joint, contributing to stability as well as producing movements. It comprises four overlapping units: supraspinatus, which lies on top of the joint and produces *abduction is the most commonly damaged; infraspinatus lies behind the joint, produces *lateral rotation and is the second most commonly damaged; subscapularis lies in front of the joint, produces *medial rotation and is damaged comparatively rarely. The fourth unit, teres minor, lies below *infraspinatus. It is relatively unimportant. SA‐SD *bursa. See SUBACROMIAL‐SUBDELTOID BURSA. Scaption. *Elevation of the arm in the *plane of the scapula. Scapula. Shoulder blade. Scapular. Relating to the *scapula. Sensitivity (Sn). The proportion of cases with the disease that are correctly identified by the *index test i.e. the true positive rate; estimated as TP/(TP+FN). SIS. See SUBACROMIAL IMPINGEMENT SYNDROME. SLAP lesion (Superior Labrum Anterior to Posterior *lesion). A tear in the upper part of the *glenoid labrum that extends forwards and backwards (Snyder 1990a; see Footnotes). It may result from *internal impingement. Sn. See SENSITIVITY. Sp. See SPECIFICITY. Specificity (Sp). The proportion of cases without the disease that are correctly identified by the *index test i.e. the true negative rate; estimated as TN/(FP+TN). Subacromial impingement. Pinching of the *subacromial‐subdeltoid bursa, the *rotator cuff, the *long head of biceps, or a combination of these, between the *humerus and the *acromion. Subacromial impingement syndrome. A collection of signs and symptoms considered characteristic of *subacromial impingement. Subacromial‐subdeltoid *bursa. A palm‐sized *bursa centred deep to the anterolateral tip of the *acromion. Extending *distally ‐ under the *deltoid ‐ as well as *proximally, and being superficial to the tendons of the *rotator cuff, it facilitates movement at the shoulder. Subacromial outlet impingement. See SUBACROMIAL IMPINGEMENT. Subluxation. A loss of joint congruity lesser in degree than in dislocation. Subscapularis. See ROTATOR CUFF. Superior. Relating to the upper portion of a structure. Opposite of *inferior. Superiorly. Upwards. Opposite of *inferiorly. Supination. The movement of the forearm that, in relaxed standing, brings the palm to face forwards. Supine. Lying flat with face upwards. Supraspinatus. See ROTATOR CUFF. Synovitis. Inflammation of *synovium. Synovium. Slippery tissue that lines joints, bursae and the sheaths that surround some tendons, such as the *long head of biceps. Systemic. Body‐wide, as opposed to local. Tendon Sheath. See SYNOVIUM. Teres minor. See ROTATOR CUFF. Tendinitis. Inflammation affecting a tendon. Tendinosis. Degenerative changes affecting a tendon. TN. See TRUE NEGATIVE. True Negative (TN). The cases which a test correctly identifies as not having a disease. True Positive (TP). The cases which a test correctly identifies as having a disease. Ultrasonography. A non‐invasive diagnostic technique in which high‐ frequency sound waves are bounced from the tissues in order to form images of the body's internal structures. Xylocaine. A local anaesthetic. |
| Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6(4):274‐9. |
| Test | Definition | Adequate reference standard for: | Qualifications |
| Open surgery | A diagnostic 'gold' standard. An invasive procedure during the course of which the interior of the shoulder joint and subacromial‐subdeltoid bursa may be directly visualised through an open incision. | (1) Subacromial impingement. (2) Subacromial‐subdeltoid bursitis. (3) Bursal side rotator cuff tears. (4) Full thickness rotator cuff tears. | (1) Tears of the rotator cuff's internal substance and joint side may be missed, as may SLAP lesions and disorders of the LHB. (2) Rotator cuff tears may be missed if obscured e.g. by inflammation. (3) Not applicable to primary care. |
| Arthroscopy | A diagnostic 'gold' standard. A 'keyhole' surgical procedure, in which the interior of the shoulder joint and subacromial‐subdeltoid bursa may be visualised through a flexible fibre‐optic tube. | (1) Subacromial‐subdeltoid bursitis. (2) Subacromial impingement. (3) Anterosuperior glenoid impingement. (4) Posterosuperior glenoid impingement. (5) Bursal side rotator cuff tears. (6) Full thickness rotator cuff tears. (7) Joint side rotator cuff tears. (8) Disorders of LHB. (9) SLAP lesions.
| (1) There is a technical and interpretive learning curve. (2) Tears of the rotator cuff's internal substance may be missed. (3) Rotator cuff tears may be missed if obscured, e.g. by inflammation. (4) Not applicable to primary care. |
| Ultrasonography | A non‐invasive diagnostic technique in which high‐frequency sound waves are bounced (reflected) from the tissues in order to form images of the body's internal structures. | (1) Full thickness rotator cuff tears. | (1) Technique and interpretation are highly operator‐dependent. The presence/absence of data/material confirming accuracy in individual diagnostic studies should be taken into account. (2) SLAP lesions cannot be visualised using ultrasound. |
| Magnetic Resonance Imaging (MRI) | A non‐invasive diagnostic technique. Tissues’ differing responses in a strong electromagnetic field are analysed by computer and translated into an accurate anatomical image. | (1) Full thickness rotator cuff tears. | This applies in settings (such as general primary care) where there is likely to be a low incidence of this disorder. |
| Arthrography | A diagnostic technique in which X‐rays are taken after injection of a fluid contrast material into a joint. | (1) Joint side rotator cuff tears. (2) Full thickness rotator cuff tears. | |
| Magnetic Resonance Arthrography (MRA) | A combination of Magnetic Resonance Imaging (MRI) and arthrography. An MRI scan is done after injection of contrast material into a joint. | (1) Joint side rotator cuff tears. (2) Full thickness rotator cuff tears. (3) SLAP lesions. | |
| Bursography | A diagnostic technique in which X‐rays are taken after injection of a contrast material into a bursa. | (1) Bursal side rotator cuff tears. | |
| Local anaesthesia | A minimally invasive procedure in which a local anaesthetic is injected, usually into the subacromial space (this is the second part of Neer's impingement test) and the effect on signs and/or symptoms noted. | (1) Subacromial outlet impingement. | (1) Correct interpretation is dependent on the injection's accuracy. 'Guided' injection, using fluoroscopy or ultrasound, is therefore preferable to 'blind' injection technique. |
| Target condition | Studies | Shoulders/patients |
| Subacromial or internal impingement | 5 | 471/466 |
| Rotator cuff tendinopathy or tears | 18 | 2477/2337 |
| LHB tendinopathy or tears | 3 | 660/557 |
| Glenoid labral lesions | 11 | 1245/1236 |
| Multiple undifferentiated target conditions* | 4 | 201/200 |
| *LHB/labral pathology; LHB/SLAP lesions; SA‐SD bursitis/bursal‐side degeneration of supraspinatus; and SIS/rotator cuff tendinitis or tear. | ||
| Study ID | Shoulders (patients, if different) | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| Subacromial impingement | |||||
| 125 (120) | SIS | ● Combination: ALL 7 +ve ● Drop arm test (modified interpretation 2) ● Hawkins' test (standard) ● Neer's sign (standard) ● Painful arc test (standard) ● Passive horizontal adduction (modified interpretation) ● Speed's test (modified interpretation 2) ● Yergason's test (modified interpretation 2) | D |
| |
| 120 | SIS | ● Gum‐Turn test (novel) | E |
| |
| 85 | SA‐SD bursitis | ● Hawkins' test (standard) | No | ||
| ● Neer's sign (modified procedure) | |||||
| ● Hawkins' test OR Neer's sign (modified procedure) | |||||
| ● Hawkins' test AND Neer's sign (modified procedure) | |||||
| 31 | SA‐SD bursitis | ● Combination: Hawkins’ test, Neer's sign, 'Yocum's (impingement) test' (overall criterion for +ve result not stated) |
| No | |
| Subacromial impingement in real time (dynamic ultrasonography) | |||||
| Differentiating subacromial from internal impingement | |||||
| 110 | Subacromial versus internal impingement | ● Internal rotation resistance strength test (novel) | No | ||
| Internal impingement | |||||
| None | None | ||||
| Modified interpretation 1: criteria for a positive test result not as described in the primary source A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error D: Multiple absolute discrepancies of which the greatest is 1% to <5% ?: 2 X 2 table not reported and cannot be deduced with certainty. | |||||
| Study ID | Shoulders | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 68 | Subscapularis, any tear of | ● Bear‐hug test (novel) ● Belly‐press test (modified procedure) ● Lift‐off test (Gerber 1991a: modified interpretation 1) ● Napoleon test (Burkhart 2002: standard) | No | ||
| Subscapularis, complete tear of | |||||
| Subscapularis, partial tear of | |||||
| 395 (390) | Supraspinatus, FTT of, full‐width | ● External rotation lag sign (standard) | No | ||
| Supraspinatus, PTT of, isolated | |||||
| 125 (120) | Supraspinatus, FTT of | ● Drop arm test (standard) ● Hawkins' test (modified interpretation 2) ● Neer's sign (modified interpretation 2) ● Painful arc test (modified interpretation 2) ● Passive horizontal adduction (modified interpretation 2) ● Speed's test (modified interpretation 2) ● Yergason's test (modified interpretation 2) | F | ||
| 73 | Supraspinatus, FTT, degeneration or tendinitis of | ● Hawkins' test (modified procedure, modified interpretation 2) | NR | NR | |
| Supraspinatus, FTT or degeneration of | |||||
| Supraspinatus, FTT of | |||||
| 120 | Rotator cuff, postero‐superior, FTT of | ● Gum‐Turn test (novel) | E |
| |
| Rotator cuff, postero‐superior, supraspinatus AND infraspinatus, FTT of | |||||
| Supraspinatus, FTT of | |||||
| 100 | Rotator cuff, postero‐superior FTT or PTT of | ● Drop sign (novel) ● Empty can test for weakness ± pain (modified interpretation 2) ● External rotation lag sign (novel) | C | ||
| Subscapularis, any tear of | ● Internal rotation lag sign (novel) ● Lift‐off test (Gerber 1991a: probably standard) | ||||
| 50 | Supraspinatus, PTT or tendinitis of | ● Empty can test for pain WITHOUT weakness (standard) | No | ||
| Supraspinatus, FTT of | ● Empty can test for weakness ± pain (standard) | ||||
| Rotator cuff, large or massive FTT of | ● Empty can test for weakness ± pain (modified interpretation 2) | ||||
| 528 (425) | Supraspinatus, any disease of, including calcification | ● Empty can test (no reference or details given) | NR | NR | |
| Infraspinatus, any disease of, including calcification | ● Resisted lateral rotation from neutral rotation (no reference or details given) | ||||
| Subscapularis, any disease of, including calcification | ● Resisted medial rotation from neutral rotation (no reference or details given) | ||||
| 143 (136) | Supraspinatus, FTT of | ● Empty can test for pain ± weakness (modified interpretation 1) ● Empty can test for pain AND/OR weakness (modified interpretation 1) ● Empy can test for weakness ± pain (standard) ● Full can test for pain ± weakness (modified interpretation 1) ● Full can test for pain AND/OR weakness (modified interpretation 1) ● Full can test for weakness ± pain (standard) | No | ||
| 160 (149) | Supraspinatus FTT or PTT of | ● Empty can test for pain ± weakness (modified interpretation 1) ● Empty can test for weakness ± pain (standard) ● Empty can test for weakness < grade 3 ± pain (modified interpretation 1) ● Full can test for pain ± weakness (modified interpretation 1) ● Full can test for weakness ± pain (standard) ● Full can test for weakness < grade 3 ± pain (modified interpretation 1) | B |
| |
| Infraspinatus, FTT or PTT of | ● Resisted external rotation from neutral rotation for weakness < grade 3 (modified interpretation 1) | ||||
| Subscapularis, any tear of | ● Lift‐off test with force for weakness < grade 2 ± pain (Gerber 1991a: modified procedure; modified interpretation 1) | ||||
| 200 | Rotator cuff, FTT or PTT of | ● Empty can test for pain ± weakness (modified interpretation 1,2) ● Empty can test for pain OR weakness (ONE ONLY) (modified interpretation 1,2) ● Empty can test for pain AND weakness (BOTH) (modified interpretation 1,2) ● Empty can test for weakness ± pain (modified interpretation 2) ● Full can test for pain ± weakness (modified interpretation 1,2) ● Full can test for pain OR weakness (ONE ONLY) (modified interpretation 1,2) ● Full can test for pain AND weakness (BOTH) (modified interpretation 1,2) ● Full can test for weakness ± pain (modified interpretation 2) | B |
| |
| Rotator cuff, FTT of | |||||
| 85 | Rotator cuff, FTT or PTT of | ● Combination: Hawkins' test (modified interpretation 2) OR Neer's sign (modified procedure, modified interpretation 2) +ve ● Combination: Hawkins' test (modified interpretation 2) AND Neer's sign (modified procedure, modified interpretation 2) +ve ● Hawkins' test (modified interpretation 2) ● Neer’s sign (modified procedure, modified interpretation 2) | C | ||
| 46 (37) | Rotator cuff, postero‐superior, FTT of | ● Drop sign (modified interpretation 2) ● External rotation lag sign (modified interpretation 2) | A | ||
| Subscapularis, FTT of | ● Internal rotation lag sign (modified interpretation 2) | ||||
|
| 31 | Supraspinatus, FTT, PTT or tendinitis of | ● Empty can test for pain AND/OR weakness (standard) | E | |
| Infraspinatus, FTT, PTT or tendinitis of | ● Patte’s test for pain AND/OR weakness (Leroux 1995: standard) | ||||
| Subscapularis, any tear or tendinitis of | ● Combination: lift‐off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described); resisted medial rotation from neutral rotation. Overall criterion for +ve result not given. | ||||
| Supraspinatus, FTT or PTT of | ● Empty can test for weakness ± pain (standard) | ||||
| Infraspinatus, FTT or PTT of | ● Patte’s test for weakness ± pain (Leroux 1995: standard) | ||||
| Subscapularis, any tear of | ● Combination: lift‐off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described), resisted medial rotation from neutral rotation. Overall criteria for +ve result not given. | ||||
| Supraspinatus, tendinitis of | ● Empty can test for pain WITHOUT weakness (standard) | ||||
| Infraspinatus, tendinitis of | ● Patte’s test for pain WITHOUT weakness (Leroux 1995: standard) | ||||
| Subscapularis, tendinitis of | ● Combination: lift‐off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described, modified interpretation 2), resisted medial rotation from neutral rotation. Overall criterion for +ve result not given. | ||||
| 103 | Rotator cuff, FTT of, multiple‐ versus single‐tendon | ● Active abduction to < 90° (novel) | NR | NR | |
|
| 100 | Rotator cuff, any disease of | ● Relocation test for pain (Jobe 1989: modified procedure) ● Relocation test for pain (Jobe 1989: standard) | No | |
|
| 31 | Rotator cuff, FTT or PTT of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | NR | NR |
| Rotator cuff, FTT of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | ||||
| Rotator cuff, PTT of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | ||||
|
| 119 | Rotator cuff, FTT of | ● Rent test (standard) | No | |
| Modified interpretation 1: criteria for a positive test result not as described in the primary source A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error D: Multiple absolute discrepancies of which the greatest is 1% to <5% ?: 2 X 2 table not reported and cannot be deduced with certainty. | |||||
| Study ID | Shoulders | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 528 (425) | LHB, any lesion of | ● Speed's test (standard) | NR | NR | |
| 101 | LHB, any lesion of | ● Active compression test (modified interpretation 2) ● Anterior slide test (modified procedure, modified interpretation 1,2) ● Bear‐hug test (modified interpretation 1,2) ● Belly‐press test (modified interpretation 2) ● Modified dynamic labral shear (novel) ● Speed's test (modified procedure) ● Upper cut test (novel) ● Yergason's test (modified procedure) | E | ||
| 31 | LHB, any lesion of | ● Combination: Yergason's test (standard), Gilcreest's palm up test (modified procedure, modified interpretation 1,2). Criteria for +ve result not given. | No | ||
| Modified interpretation 1: criteria for a positive test result not as described in the primary source A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error D: Multiple absolute discrepancies of which the greatest is 1% to <5% ?: 2 X 2 table not reported and cannot be deduced with certainty. | |||||
| Study ID | Shoulders (patients, if different) | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 60 (59) | Labrum, any SLAP lesion of | ● Active compression test (modified procedure, modified interpretation 2: 2 x 2 table not calculable for this test) ● Anterior apprehension test at 90° for pain (Krishnan 2004: modified interpretation 2) ● Anterior release test described as in Gross 1997 with modified interpretation 2, but erroneously labelled as Jobe's relocation test. ● Crank test (Liu 1996b: modified procedure, modified interpretation 2) ● Palpation for bicipital groove tenderness (standard) ● Speed's test (modified interpretation 1,2) ● Yergason's test (modified interpretation 1,2) | No | ||
| 101 | Labrum, any SLAP lesion of | ● Active compression test (modified interpretation 2) ● Anterior slide test (modified procedure, modified interpretation 1, 2) ● Bear‐hug test (modified interpretation 1,2) ● Belly‐press test (modified interpretation 2) ● Modified dynamic labral shear (novel) ● Speed's test (modified procedure, modified interpretation 2) ● Upper cut test (novel) ● Yergason's test (modified procedure, modified interpretation 2) | E | ||
| 127 | Labrum, type II SLAP lesion of | ● Biceps load II test (novel) | No | ||
| 61 | Labrum, any SLAP lesion of | ● Passive compression test (novel) | No | ||
| Labrum, type II‐IV SLAP lesion of | ● Passive compression test (novel, modified interpretation 2) | ||||
| 62 | Labrum, any tear of | ● Crank test (novel) | No | ||
| 206 | Labrum any tear of | ● Active compression test (novel) | No | ||
| 146 | Labrum, type II SLAP lesion of | ● Active compression test (modified interpretation 2) ● Anterior apprehension test at 90° for pain OR apprehension (Rowe 1981: modified interpretation 1,2) ● Anterior slide test (modified interpretation 2) ● Biceps load II test (standard) ● Compression‐rotation test (modified interpretation 2) ● Palpation for bicipital groove tenderness (modified interpretation 2) ● Relocation test for pain OR apprehension (modified interpretation 2) ● Speed's test (modified procedure, modified interpretation 1,2) ● Whipple test (modified interpretation 2) ● Yergason's test (modified interpretation 2) | E | ||
| 132 | Labrum, type II SLAP lesion of | ● Active compression test (modified interpretation 1,2) ● Anterior slide test (modified interpretation 2) ● Crank test (Liu 1996b: modified procedure, modified interpretation 2) ● Hawkins' test (modified procedure, modified interpretation 2) ● Neer's sign (modified procedure, modified interpretation 2) ● Pain provocation test (modified interpretation 2) ● Modified relocation test for posterosuperior glenoid impingement (modified interpretation 2) mislabelled as Jobe's relocation test ● Speed's test (modified interpretation 1,2) ● Yergason's test (modified interpretation 1,2) | A | ||
| 254 (246) | Labrum, type II‐IV SLAP lesion of | ● Active compression test (modified interpretation 2) ● Anterior slide test (modified procedure) ● Combination: active compression test (modified interpretation 2) OR passive distraction test (standard) ● Passive distraction test (standard) | E | ||
| 65 | Labrum, any tear of | ● Active compression test (modified interpretation 1) ● Crank test (standard) | No | ||
| 31 | Labrum, any tear of | ● 'Impingement sign' (no reference or details given) ● 'Impingement test' (no reference or details given) | NR | NR | |
| Modified interpretation 1: criteria for a positive test result not as described in the primary source A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error D: Multiple absolute discrepancies of which the greatest is 1% to <5% ?: 2 X 2 table not reported and cannot be deduced with certainty. | |||||
| Study ID | Shoulders (patients, if different) | Specific target condition | Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) | Discrepancies between reported and back‐calculated summary statistics (Sn, Sp, PPV, NPV or accuracy) | |
| Yes | No | ||||
| 46 (45) | LHB tendinitis/LHB avulsion/SLAP lesion, any | ● Speed's test (modified procedure, modified interpretation 1) | C | ||
| 50 | LHB lesion, any/SLAP lesion, any | ● Speed's test (modified procedure, modified interpretation 1, 2) | No | ||
| ● Yergason's test (modified interpretation 1, 2) | |||||
| 55 | SA‐SD bursitis/ bursal‐side degeneration of supraspinatus (but patients with PTT or FTT inter alia were not excluded) | ● Empty can test (modified interpretation 2) | No | ||
| ● Hawkins' test (standard) | |||||
| ● Neer's sign (modified procedure) | |||||
| ● Painful arc test (standard) | |||||
| ● Resisted lateral rotation from neutral rotation for weakness ± pain (modified interpretation 1,2) | |||||
| ● 3 or more tests +ve | |||||
| 50 | SIS/rotator cuff tendinitis or tear | ● Hawkins' test (modified interpretation 2) |
| No | |
| ● Neer's sign (modified interpretation 2) | |||||
| Modified interpretation 1: criteria for a positive test result not as described in the primary source A: Isolated absolute discrepancy of 1% to <5% ‐ a suspected or confirmed typographical error D: Multiple absolute discrepancies of which the greatest is 1% to <5% ?: 2 X 2 table not reported and cannot be deduced with certainty. | |||||
| Main reason | N | Details |
| Not DTA study | 93 | Not shown |
| Not DTA study. Systematic review only | 11 | Beaudreuil 2009; Calvert 2009; Dessaur 2008; Hegedus 2008; Hughes 2008; Jones 2007; Luime 2004; Meserve 2009; Munro 2009; Pugh 2009; Walton 2008 |
| Abstract only / no published full report | 3 | |
| Not DTA study of physical tests | 5 | Birtane 2001; Cullen 2007; El Dalati 2005; Jee 2001; O'Connor 2005 |
| Not DTA study of included condition | 8 | Chronopoulos 2004; Kim 2004b; Kim 2005 (all not impingement); Kim 2007a (rheumatoid disease); Lafosse 2007 (timing of surgery); Lewis 2007 (not impingement); Odom 2001; Walton 2004 (not impingement) |
| Highly selected population ‐ sports / lesion | 9 | (post traumatic dislocation); Brasseur 2004 (veteran tennis players); Hamner 2000 (overhead throwing athletes); Kibler 2006a (athletes); Kim 1999 (all post anterior dislocation); Meister 2004 (all overhead athletes); Mimori 1999(throwing injuries); Myers 2005 (all athletes); Walsworth 2008 (military) |
| Highly selected pop: 100% prevalence or by exclusion | 12 | Berg 1998 (slap); Burkhart 2000 (slap), Burkhart 2002 (rotator cuff); Fukuda 1996 (rotator cuff); Gschwend 1988 (no disease negative; no specificity); Liu 1996a (tears removed); Lyons 1992 (all RCT ‐ tear size study); Morgan 1998 (slap); Pandya 2008 (slap); Read 1998 (100% prevalence by exclusion); Rhee 2005a (all slap); Watson 1989 (all subacromial impingement ‐ no specificity) |
| Special equipment used | 2 | |
| Unsatisfactory / unacceptable reference test / control: 4 | 4 | Gerber 1991; Lo 2004; Scheibel 2005 (control); Silva 2008 (MRI for impingement) |
| Unclear reporting of tests, testing and/or population | 7 | Adolfsson 1991; Ardic 2006; Malhi 2005; Miller 2008a; Murrell 2001; Norregaard 2002; Wnorowski 1997 |
| Lack of, incomplete or grossly inconsistent data: | 8 | Ebinger 2008; Fodor 2009; Leroux 1995 (very large discrepancies); Litaker 2000 (large discrepancies); Polimeni 2003 (no data); Rowan 2007 (no test‐specific data); Sandenbergh 2006 (no 2 x 2); Sorensen 2007 (data presentation) |
| DTA = Diagnostic test accuracy, N = number of studies | ||
| # | Target condition | Study ID | Search period | Included studies | N | Main conclusions | Notes and comments |
| 1 | Any | 1966 to October 2006 | 45 | 999 | Conclusion 1 'There is a lack of clarity with regard to whether common orthopaedic special tests are useful in differentially diagnosing pathologies of the shoulder' | General • Included studies with highly selected populations. • Pooled some clinically heterogeneous data. Re conclusion 1 • Our conclusions broadly agree. | |
| 2 | Impingement, Any tear, FTT, PTT | 1985 to October 2001 | 10 | 1235 | Conclusion 1 'Few tests provided convincing evidence of the presence or absence of disease ... [Although] individual tests did perform well in the study by [Hertel 1996] ... the sample size was small and CIs were very wide'. The internal rotation lag sign also had a very low negative LR ... Other tests demonstrating high positive and negative LRs were the rent test and internal rotation resistance strength test.' Conclusion 2 'In four studies [Litaker 2000; Lyons 1992; MacDonald 2000; Read 1998], negative LRs were sufficiently low to confirm that disease is absent in those with a negative diagnosis'. Conclusion 3 'The results suggest that [generic] clinical examination by specialists can rule out the presence of a rotator cuff tear'. | Re conclusion 1 • Our conclusions broadly agree. • We excluded three (Litaker 2000; Lyons 1992; Read 1998) of the four studies underpinning this conclusion on clinical or methodological grounds. Re conclusion 2 • We excluded those studies evaluating generic examination. | |
| 3 | SIS | to January 2011 | 16 | 2390 | Conclusion 1 'The Hawkins‐Kennedy test, Neer's sign and empty can test are ... more useful for ruling out rather than ruling in SIS.' Conclusion 2 'The drop arm test and lift‐off test ... are more useful for ruling in SIS if the test is positive.' | General • Pooled some clinically heterogeneous data. • Included several studies which we excluded on clinical or methodological grounds (Leroux 1995; Lyons 1992; Malhi 2005; Murrell 2001; Scheibel 2005; Walch 1998) or categorised as 'awaiting classification' pending clarification (Nanda 2008; Park 2005). • Included one study which post‐dated our search (Fowler 2010), but which concerned a selected population. Re conclusion 1 • Our conclusions partially agree. We suggest cautious interpretation, as the point estimates are small, the 95% CIs wide, and the pooled data clinically heterogeneous. Re conclusion 2 • The pooled point estimate for the drop arm test is small. That for the lift‐off test is large, but the 95% CIs are wide. Again, the pooled data are clinically heterogeneous. | |
| 4 | Rotator cuff disease | to June 2006 | 9 | 2116 | See notes and comments | General • A descriptive review with transliteration of data from the primary studies and no quality assessment. • The conclusions are not contentious. | |
| 5 | Rotator cuff disease | January 1966 to April 2007 | 13 | 2010 | Conclusion 1 One test, the rent test in Wolf 2001, is identified with LR+ >10 and LR ‐ < 0.1; but a contradictory result in Lyons 1992 is noted. Conclusion 2 Other tests with LR+ > 10 or LR‐ < 0.1 are listed. Conclusion 3 Hertel 1996 was excluded on the grounds of arithmetical discrepancies.
| Re conclusion 1 • We agree, but excluded Lyons 1992 on clinical grounds. Re conclusion 2 • We excluded four studies underpinning these conclusions on clinical or methodological grounds (Ardic 2006; Leroux 1995; Lyons 1992; Murrell 2001) and categorised one (Park 2005) as 'awaiting classification' pending clarification. Re conclusion 3 • Our back‐calculations identified only one discrepancy in Hertel 1996, which we attributed to a typographical error. | |
| 6 | Rotator cuff disease | Not reported | Not reported | Not reported | See notes and comments. | General • Included for completeness, but not a systematic review | |
| 7 | Labral disease | 1995 to June 2007 | 15 | Numbers reported by test, not by study. | Conclusion 1 The biceps load II and internal rotation resistance strength tests were identified as having large LR+ and moderate LR‐, based on single studies of good quality. | General • Pooled some clinically heterogeneous data. Re conclusion 1 • Our conclusions are broadly agree. | |
| 8 | SLAP | January 1970 to June 2004 | 15 | Unclear | Conclusion 1 'The current literature being used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful.' Conclusion 2 'There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion.' | General • Included studies with highly selected populations. Re conclusion 1 • While sharing concerns as to the validity of much of the diagnostic test accuracy literature, we consider this an over generalisation. Re conclusion 2 • We distinguish 'limited or contradictory evidence for accuracy' from 'evidence of inaccuracy', and place a number of tests former category. | |
| 9 | SLAP | 1996 to 2006 | 17 | 2148 | Conclusion 1 'It appears that no single test is sensitive or specific enough to to determine the presence of a SLAP lesion accurately'. | General • Included studies with highly selected populations. Re conclusion 1 • We distinguish between 'limited or contradictory evidence for accuracy' from 'evidence of inaccuracy', and place a number of tests in the former category. | |
| 10 | SLAP | January 1 1966 to July 1 2006 | 12 | 2260 | Conclusion 1 'SLAP‐specific physical examination results cannot be used as the sole basis of a diagnosis of a SLAP lesion.' | General • A descriptive review with transliteration of data from the primary studies and limited quality assessment. • Included studies with highly selected populations. Re conclusion 1 • Given the current state of knowledge, we agree with this conclusion. | |
| 11 | SLAP | 1966 to 2003 | 17 | 1901 | Conclusion 1 'Most promising [tests] for establishing labral tears are currently the biceps load I [not relevant to this review] and II, pain provocation of Mimori, and the internal rotation resistance strength tests.' | General • Included studies with highly selected populations. Re conclusion 1 • We agree regarding the biceps load II and internal rotation resistance strength tests. However, in the population relevant to the present review, the pain provocation test did not perform well. | |
| 12 | SLAP | 1966 to June 2007 | 6 | 777 | Conclusion 1 The anterior slide test is a poor test for predicting the presence of a labral lesion in the shoulder. Conclusion 2 Active compression, crank, and Speed tests are more optimal choices. Conclusion 3 Clinicians should choose the active compression test first, crank second and Speed test third when a labral lesion is suspected. | General • Included studies with highly selected populations. • Pooled some clinically heterogeneous data. Re conclusion 1 • Based on the results of Schlechter 2009 (notwithstanding that this study was prone to arithmetical error), which post‐dated the search of Meserve 2009a, we cannot unconditionally agree. Re conclusions 2 & 3 • Based on current knowledge, we agree concerning the active compression test. • In relatively unselected populations, we found the crank test inferior to biceps load II for ruling in labral tears; and LRs for Speed's test did not suggest that it would be clinically useful. | |
| 13 | SLAP | To May 2006 | 7 | Numbers reported by test, not by study. | Conclusion 1 'Yergason's test is the only [test] that shows a significant ability to influence clinical decision making, based on the results of the current analysis. Conclusion 2 'Methodologic inadequacies in the reporting of the publications are common, and caution must be exercised when drawing inferences from the results of these studies.' | General • Included studies with highly selected populations. • There was limited quality assessment. • Pooled some clinically heterogeneous data. Re conclusion 1 • In relatively unselected populations, LRs for Yergason's test did not suggest that it would be clinically useful. Re point 2 • We agree. |
| Test | No. of studies | No. of participants |
| 1 Target condition: SIS. Index test: combination of ALL 7 tests +ve (see table 7). Show forest plot | 1 | 125 |
| 2 Target condition: SIS. Index test: combination of Hawkins' test AND Neer's sign (modified procedure) +ve. Show forest plot | 1 | 85 |
| 3 Target condition: SIS. Index test: combination of Hawkins' test OR Neer's sign (modified procedure) +ve. Show forest plot | 1 | 85 |
| 4 Target condition: SIS. Index test: drop arm test (modified interpretation). Show forest plot | 1 | 125 |
| 5 Target condition: SIS. Index test: Gum‐turn test (novel) Show forest plot | 1 | 120 |
| 6 Target condition: SIS. Index test:. Hawkins' test (standard). Show forest plot | 2 | 210 |
| 7 Target condition: SIS. Index test: Neer's sign (standard). Show forest plot | 1 | 125 |
| 8 Target condition: SIS. Index test: Neer's sign (modified procedure). Show forest plot | 1 | 85 |
| 9 Target condition: SIS. Index test: painful arc test (standard). Show forest plot | 1 | 125 |
| 10 Target condition: SIS. Index test: passive horizontal adduction (modified interpretation). Show forest plot | 1 | 125 |
| 11 Target condition: SIS. Index test: Speed's test (modified interpretation). Show forest plot | 1 | 125 |
| 12 Target condition: SIS. Index test: Yergason's test (modified interpretation). Show forest plot | 1 | 125 |
| 13 Target condition: SIS (SA‐SD bursitis). Index test: combination of Hawkins' test, Neer's sign, 'Yocum's (impingement) test' (overall criterion for +ve result not given). Show forest plot | 1 | 31 |
| 14 Target condition: SIS versus internal impingement, differentiation. Index test: internal rotation resistance strength test (novel). Show forest plot | 1 | 110 |
| 15 Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: standard). Show forest plot | 1 | 100 |
| 16 Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: modified procedure). Show forest plot | 1 | 100 |
| 17 Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) OR Neer's sign (modified procedure, modified interpretation) +ve. Show forest plot | 1 | 85 |
| 18 Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) AND Neer's sign (modified procedure,modified interpretation) +ve. Show forest plot | 1 | 85 |
| 19 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 200 |
| 20 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation). Show forest plot | 1 | 200 |
| 21 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation). Show forest plot | 1 | 200 |
| 22 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation). Show forest plot | 1 | 200 |
| 23 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 202 |
| 24 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation). Show forest plot | 1 | 200 |
| 25 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation). Show forest plot | 1 | 200 |
| 26 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for weakness ± pain (standard). Show forest plot | 1 | 200 |
| 27 Target condition: rotator cuff, FTT or PTT of. Index test: Hawkins' test (modified interpretation). Show forest plot | 1 | 85 |
| 28 Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement sign' (no reference or details given). Show forest plot | 1 | 32 |
| 29 Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement test' (no reference or details given). Show forest plot | 1 | 32 |
| 30 Target condition: rotator cuff, FTT or PTT of. Index test: Neer's sign (modified procedure, modified interpretation). Show forest plot | 1 | 85 |
| 31 Target condition: rotator cuff, PTT or tendinitis of. Index test: empty can test for pain WITHOUT weakness (modified interpretation). Show forest plot | 1 | 50 |
| 32 Target condition: rotator cuff, FTT of. Index test: empty can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 200 |
| 33 Target condition: rotator cuff, FTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation). Show forest plot | 1 | 200 |
| 34 Target condition: rotator cuff, FTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation). Show forest plot | 1 | 200 |
| 35 Target condition: rotator cuff, FTT of. Index test: empty can test for weakness ± pain (modified interpretation). Show forest plot | 2 | 250 |
| 36 Target condition: rotator cuff, FTT of. Index test: full can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 200 |
| 37 Target condition: rotator cuff, FTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation). Show forest plot | 1 | 200 |
| 38 Target condition: rotator cuff, FTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation). Show forest plot | 1 | 200 |
| 39 Target condition: rotator cuff, FTT of. Index test: full can test for weakness ± pain (modified interpretation). Show forest plot | 1 | 200 |
| 40 Target condition: rotator cuff, FTT of. Index test: 'impingement sign' (no reference or details given). Show forest plot | 1 | 32 |
| 41 Target condition: rotator cuff, FTT of. Index test: 'impingement test' (no reference or details given). Show forest plot | 1 | 32 |
| 42 Target condition: rotator cuff, FTT of. Index test: rent test (standard). Show forest plot | 1 | 109 |
| 43 Target condition: rotator cuff, FTT of, massive or large. Index test: empty can test for weakness ± pain (modified interpretation). Show forest plot | 1 | 50 |
| 44 Target condition: rotator cuff, PTT of. Index test: 'Impingement sign' (no reference or details given). Show forest plot | 1 | 32 |
| 45 Target condition: rotator cuff, PTT of. Index test: 'Impingement test' (no reference or details given). Show forest plot | 1 | 32 |
| 46 Target condition: rotator cuff, postero‐superior (supraspinatus AND infraspinatus), FTT of. Index test: Gum‐turn test (novel). Show forest plot | 1 | 120 |
| 47 Target condition: rotator cuff, postero‐superior, FTT or PTT of. Index test: drop sign (novel). Show forest plot | 1 | 87 |
| 48 Target condition: rotator cuff, postero‐superior, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation). Show forest plot | 1 | 87 |
| 49 Target condition: rotator cuff, postero‐superior, FTT or PTT of. Index test: external rotation lag sign (novel). Show forest plot | 1 | 87 |
| 50 Target condition: rotator cuff, postero‐superior, FTT of. Index test: drop sign (modified interpretation). Show forest plot | 1 | 46 |
| 51 Target condition: rotator cuff, postero‐superior, FTT of. Index test: external rotation lag sign (modified interpretation). Show forest plot | 1 | 46 |
| 52 Target condition: rotator cuff, postero‐superior, FTT of. Index test: Gum‐turn test (novel). Show forest plot | 1 | 120 |
| 53 Target condition: rotator cuff, FTT, multiple‐ versus single‐tendon. Index test: active abduction range (novel). Show forest plot | 1 | 96 |
| 54 Target condition: supraspinatus, any disease of, including calcification. Index test: empty can test (no reference or details given). Show forest plot | 1 | 528 |
| 55 Target condition: supraspinatus, FTT, degeneration or tendinitis,of. Index test: Hawkins' test (modified procedure, modified interpretation). Show forest plot | 1 | 73 |
| 56 Target condition: supraspinatus, FTT, PTT or tendinitis,of. Index test: empty can test for pain AND/OR weakness (standard). Show forest plot | 1 | 26 |
| 57 Target condition: supraspinatus, FTT or degeneration of. Index test: Hawkins' test (modified procedure, modified interpretation). Show forest plot | 1 | 73 |
| 58 Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 160 |
| 59 Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness ± pain (standard). Show forest plot | 2 | 191 |
| 60 Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness (< grade 3) ± pain.(modified interpretation) Show forest plot | 1 | 160 |
| 61 Target condition: supraspinatus, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 160 |
| 62 Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness (< grade 3) ± pain (modified interpretation). Show forest plot | 1 | 160 |
| 63 Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness ± pain (standard). Show forest plot | 1 | 160 |
| 64 Target condition: supraspinatus, FTT of. Index test: drop arm test (standard). Show forest plot | 1 | 125 |
| 65 Target condition: supraspinatus, FTT of. Index test: empty can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 143 |
| 66 Target condition: supraspinatus, FTT of. Index test: empty can test for pain AND/OR weakness (modified interpretation). Show forest plot | 1 | 143 |
| 67 Target condition: supraspinatus, FTT of. Index test: empty can test for weakness ± pain (standard). Show forest plot | 1 | 143 |
| 68 Target condition: supraspinatus, FTT of. Index test: full can test for pain ± weakness (modified interpretation). Show forest plot | 1 | 143 |
| 69 Target condition: supraspinatus, FTT of. Index test: full can test for pain AND/OR weakness (modified interpretation). Show forest plot | 1 | 143 |
| 70 Target condition: supraspinatus, FTT of. Index test: full can test for weakness ± pain (standard). Show forest plot | 1 | 143 |
| 71 Target condition: supraspinatus, FTT of. Index test: Gum‐turn test (novel). Show forest plot | 1 | 120 |
| 72 Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified interpretation). Show forest plot | 1 | 125 |
| 73 Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified procedure, modified interpretation). Show forest plot | 1 | 73 |
| 74 Target condition: supraspinatus, FTT of. Index test: Neer's sign (modified interpretation). Show forest plot | 1 | 125 |
| 75 Target condition: supraspinatus, FTT of. Index test: painful arc test (modified interpretation). Show forest plot | 1 | 125 |
| 76 Target condition: supraspinatus, FTT of. Index test: passive horizontal adduction (standard). Show forest plot | 1 | 125 |
| 77 Target condition: supraspinatus, FTT of. Index test: Speed's test (modified interpretation). Show forest plot | 1 | 125 |
| 78 Target condition: supraspinatus, FTT of. Index test: Yergason's test (modified interpretation). Show forest plot | 1 | 125 |
| 79 Target condition: supraspinatus, FTT of, full‐width. Index test: external rotation lag sign (standard). Show forest plot | 1 | 189 |
| 80 Target condition: supraspinatus, isolated PTT of. Index test: external rotation lag sign (standard). Show forest plot | 1 | 222 |
| 81 Target condition: supraspinatus, tendinitis of. Index test: empty can test for pain WITHOUT weakness (standard). Show forest plot | 1 | 31 |
| 82 Target condition: infraspinatus, any disease of, including calcification. Index test: resisted lateral rotation from neutral rotation (no reference or details given). Show forest plot | 1 | 528 |
| 83 Target condition: infraspinatus, FTT, PPT or tendinitis,of. Index test: Patte's test for pain AND/OR weakness (standard). Show forest plot | 1 | 31 |
| 84 Target condition: infraspinatus, FTT or PTT of. Index test: Patte's test for weakness ± pain (standard). Show forest plot | 1 | 31 |
| 85 Target condition: infraspinatus, FTT or PTT of. Index test: resisted lateral rotation from neutral rotation for weakness < grade 3 ± pain (modified interpretation). Show forest plot | 1 | 160 |
| 86 Target condition: infraspinatus, tendinitis of. Index test: Patte's test for pain WITHOUT weakness (standard). Show forest plot | 1 | 31 |
| 87 Target condition: subscapularis, any disease of, including calcification. Index test: resisted medial rotation from neutral rotation (no reference or details given). Show forest plot | 1 | 528 |
| 88 Target condition: subscapularis, any tear or tendinitis of. Index test: combination of lift‐off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given). Show forest plot | 1 | 31 |
| 89 Target condition: subscapularis, any tear of. Index test: bear‐hug test (novel) Show forest plot | 1 | 68 |
| 90 Target condition: subscapularis, any tear of. Index test: belly‐press test (standard) Show forest plot | 1 | 68 |
| 91 Target condition: subscapularis, any tear of. Index test: internal rotation lag sign (novel). Show forest plot | 1 | 53 |
| 92 Target condition: subscapularis, any tear of. Index test: lift‐off test (Gerber 1991: modified interpretation). Show forest plot | 1 | 63 |
| 93 Target condition: subscapularis, any tear of. Index test: lift‐off test (Gerber 1991: probably standard) Show forest plot | 1 | 53 |
| 94 Target condition: subscapularis, any tear of. Index test: Napoleon test (Burkhart 2002: standard). Show forest plot | 1 | 68 |
| 95 Target condition: subscapularis, any tear of. Index test:: lift‐off test with force for weakness < grade 2 ± pain (modified procedure, modified interpretation). Show forest plot | 1 | 159 |
| 96 Target condition: subscapularis, any tear of. Index test: combination of lift‐off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given). Show forest plot | 1 | 31 |
| 97 Target condition: subscapularis, complete tear of. Index test: bear‐hug test (novel). Show forest plot | 1 | 68 |
| 98 Target condition: subscapularis, complete tear of. Index test: belly‐press test (modified procedure). Show forest plot | 1 | 68 |
| 99 Target condition: subscapularis, complete tear of. Index test: lift‐off test (Gerber 1991: modified interpretation). Show forest plot | 1 | 63 |
| 100 Target condition: subscapularis, complete tear of. Index test: Napoleon test (Burkhart 2002: standard). Show forest plot | 1 | 68 |
| 101 Target condition: subscapularis, FTT of. Index test: internal rotation lag sign (modified interpretation). Show forest plot | 1 | 46 |
| 102 Target condition: subscapularis, partial tear of. Index test: bear‐hug test (novel). Show forest plot | 1 | 65 |
| 103 Target condition: subscapularis, partial tear of. Index test: belly‐press test (modified procedure). Show forest plot | 1 | 65 |
| 104 Target condition: subscapularis, partial tear of. Index test: lift‐off test (Gerber 1991: modified interpretation). Show forest plot | 1 | 60 |
| 105 Target condition: subscapularis, partial tear of. Index test: Napoleon test (Burkhart 2002: standard). Show forest plot | 1 | 65 |
| 106 Target condition: subscapularis, tendinitis of. Index test: combination of lift‐off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given). Show forest plot | 1 | 31 |
| 107 Target condition: LHB, tear or tendinitis of. Index test: Speed's test (standard). Show forest plot | 1 | 528 |
| 108 Target condition: LHB, tear or tendinitis of. Index test: active compression test (standard) Show forest plot | 1 | 101 |
| 109 Target condition: LHB, tear or tendinitis of. Index test: anterior slide test (modified procedure, modified interpretation). Show forest plot | 1 | 101 |
| 110 Target condition: LHB, tear or tendinitis of. Index test: bear‐hug test (modified interpretation) Show forest plot | 1 | 101 |
| 111 Target condition: LHB, tear or tendinitis of. Index test: belly‐press test (standard) Show forest plot | 1 | 101 |
| 112 Target condition: LHB, tear or tendinitis of. Index test: modified dynamic labral shear (novel) Show forest plot | 1 | 101 |
| 113 Target condition: LHB, tear or tendinitis of. Index test: Speed's test (modified procedure) Show forest plot | 1 | 101 |
| 114 Target condition: LHB, tear or tendinitis of. Index test: upper‐cut test (novel) Show forest plot | 1 | 101 |
| 115 Target condition: LHB, tear or tendinitis of. Index test: Yergason's test (modified procedure) Show forest plot | 1 | 101 |
| 116 Target condition: LHB, tear or tendinitis of. Index test: combination of Yergason's test and Gilcreest's test (modified procedure, modified interpretation).(Overall criterion for +ve result not given.) Show forest plot | 1 | 31 |
| 117 Target condition: labrum, any tear of. Index test: active compression test (novel). Show forest plot | 1 | 206 |
| 118 Target condition: labrum, any tear of. Index test: active compression test (modified interpretation). Show forest plot | 1 | 65 |
| 119 Target condition: labrum, any tear,of. Index test: crank test (novel/standard). Show forest plot | 2 | 127 |
| 120 Target condition: labrum, any tear,of. Index test: 'impingement sign' (no reference or details given). Show forest plot | 1 | 32 |
| 121 Target condition: labrum, any tear,of. Index test: 'impingement test' (no reference or details given). Show forest plot | 1 | 32 |
| 122 Target condition: labrum, any SLAP lesion of. Index test: active compression test (modified interpretation). Show forest plot | 1 | 101 |
| 123 Target condition: labrum, any SLAP lesion of. Index test: anterior apprehension test at 90° for pain (Krishnan 2004: modified interpretation). Show forest plot | 1 | 60 |
| 124 Target condition: labrum, any SLAP lesion,of. Index test: anterior release test (Gross 1997: modified interpretation). Show forest plot | 1 | 60 |
| 125 Target condition: labrum, any SLAP lesion of. Index test: anterior slide test (modified procedure, modified interpretation). Show forest plot | 1 | 101 |
| 126 Target condition: labrum, any SLAP lesion of. Index test: bear‐hug test (modified interpretation). Show forest plot | 1 | 101 |
| 127 Target condition: labrum, any SLAP lesion of. Index test: belly‐press test (modified interpretation). Show forest plot | 1 | 101 |
| 128 Target condition: labrum, any SLAP lesion of. Index test: crank test (Liu 1996b: modified procedure, modified interpretation). Show forest plot | 1 | 60 |
| 129 Target condition: labrum, any SLAP lesion of. Index test: modified dynamic labral shear (novel). Show forest plot | 1 | 101 |
| 130 Target condition: labrum, any SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation). Show forest plot | 1 | 60 |
| 131 Target condition: labrum, any SLAP lesion of. Index test: passive compression test (novel). Show forest plot | 1 | 61 |
| 132 Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation). Show forest plot | 1 | 101 |
| 133 Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified interpretation). Show forest plot | 1 | 60 |
| 134 Target condition: labrum, any SLAP lesion of. Index test: upper cut test (novel). Show forest plot | 1 | 101 |
| 135 Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified interpretation). Show forest plot | 1 | 60 |
| 136 Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified procedure, modified interpretation). Show forest plot | 1 | 101 |
| 137 Target condition: labrum, type II‐IV SLAP lesion of. Index test: active compression test (modified interpretation). Show forest plot | 1 | 254 |
| 138 Target condition: labrum, type II‐IV SLAP lesion of. Index test: anterior slide test (modified procedure). Show forest plot | 1 | 254 |
| 139 Target condition: labrum, type II‐IV SLAP lesion of. Index test: combination of active compression test (modified interpretation) OR passive distraction test (standard). Show forest plot | 1 | 254 |
| 140 Target condition: labrum, type II‐IV SLAP lesion of. Index test: passive compression test (novel, modified interpretation). Show forest plot | 1 | 61 |
| 141 Target condition: labrum, type II‐IV SLAP lesion of. Index test: passive distraction test (standard). Show forest plot | 1 | 254 |
| 142 Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 2). Show forest plot | 1 | 146 |
| 143 Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 1,2). Show forest plot | 1 | 132 |
| 144 Target condition: labrum, type II SLAP lesion of. Index test: anterior apprehension test at 90° for pain OR apprehension (Rowe 1981: modified interpretation). Show forest plot | 1 | 146 |
| 145 Target condition: labrum, type II SLAP lesion of. Index test: anterior slide test (modified interpretation). Show forest plot | 2 | 278 |
| 146 Target condition: labrum, type II SLAP lesion of. Index test: biceps load test II (novel/standard). Show forest plot | 2 | 273 |
| 147 Target condition: labrum, type II SLAP lesion of. Index test: compression‐rotation test (modified interpretation). Show forest plot | 1 | 146 |
| 148 Target condition: labrum, type II SLAP lesion of. Index test: crank test (modified procedure, modified interpretation). Show forest plot | 1 | 132 |
| 149 Target condition: labrum, type II SLAP lesion of. Index test: Hawkins' test (modified procedure, modified interpretation). Show forest plot | 1 | 132 |
| 150 Target condition: labrum, type II SLAP lesion of. Index test: modified relocation test for posterosuperior glenoid impingement (modified interpretation). Show forest plot | 1 | 132 |
| 151 Target condition: labrum, type II SLAP lesion of. Index test: Neer's sign (modified procedure, modified interpretation). Show forest plot | 1 | 132 |
| 152 Target condition: labrum, type II SLAP lesion of. Index test: pain provocation test (modified interpretation). Show forest plot | 1 | 132 |
| 153 Target condition: labrum, type II SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation). Show forest plot | 1 | 146 |
| 154 Target condition: labrum, type II SLAP lesion of. Index test: relocation test for pain OR apprehension (modified interpretation). Show forest plot | 1 | 146 |
| 155 Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified interpretation). Show forest plot | 1 | 132 |
| 156 Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation). Show forest plot | 1 | 146 |
| 157 Target condition: labrum, type II SLAP lesion of. Index test: Whipple's test (modified interpretation). Show forest plot | 1 | 146 |
| 158 Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 2). Show forest plot | 1 | 146 |
| 159 Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 1,2). Show forest plot | 1 | 132 |
| 160 Target condition: multiple (LHB tendinitis/LHB avulsion/SLAP lesion, any). Index test: Speed's test (modified procedure, modified interpretation 1). Show forest plot | 1 | 46 |
| 161 Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Speed's test (modified procedure, modified interpretation 1,2). Show forest plot | 1 | 50 |
| 162 Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Yergason's test (modified interpretation 1,2). Show forest plot | 1 | 49 |
| 163 Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Empty can test (modified interpretation). Show forest plot | 1 | 55 |
| 164 Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Hawkins' test (standard). Show forest plot | 1 | 55 |
| 165 Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Neer's sign (modified procedure). Show forest plot | 1 | 55 |
| 166 Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: painful arc test (standard). Show forest plot | 1 | 45 |
| 167 Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability) Index test: resisted lateral rotation from neutral rotation for weakness ± pain (modified interpretation 1,2). Show forest plot | 1 | 55 |
| 168 Target condition: multiple (SA‐SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: combination of 3 or more tests +ve (see table 11). Show forest plot | 1 | 55 |
| 169 Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Hawkins' test (modified interpretation). Show forest plot | 1 | 50 |
| 170 Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Neer's sign (modified interpretation). Show forest plot | 1 | 50 |
