Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement
Abstract
This is a protocol for a Cochrane Review (Diagnostic test accuracy). The objectives are as follows:
We will 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. Such studies will compare the findings of physical tests to those of surgery or other suitable reference tests, as defined below.
We will also examine the physical tests according to whether they are 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.
Background
Target condition being diagnosed
Shoulder pain and dysfunction are common in the general population. A recent systematic review reports a point prevalence for shoulder pain of 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.
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 1991; Gerber 1996; Hertel 1996), or biceps tendon involvement (e.g. Yergason 1931); or tests to diagnose glenoid labrum tears (e.g. Kim 2001; Liu 1996; O'Brien 1998). These tests are described in Table 1, and we will add to this table any others identified in studies included in this review. 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‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Painful arc test | Cyriax 1982 | None | The patient actively elevates, then lowers, the shoulder through abduction. | Onset and offset of pain during elevation, during lowering, or both. | Subacromial outlet impingement; calcific tendonitis; pain secondary to shoulder joint instability; or internal impingement (involving the deep aspect of the rotator cuff or the long head of biceps tendon) |
| Tests intended to identify subacromial outlet impingement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Neer's test | Neer 1977, Neer 1983 | None | The examiner forcibly flexes the sitting patient's arm, preventing scapular movement by pressing down on the clavicle and acromion with the other hand. | Pain, which is abolished by injection of 10 ml of 1% xylocaine beneath the anterior acromion. | Subacromial outlet impingement |
| Tests intended to identify internal impingement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Modified relocation test for postero‐superior glenoid impingement | Hamner 2000 | None | The patient lies supine. The shoulder is held by the examiner in full lateral rotation and positioned at each of 90°, 100° and 120° of abduction. In each of these positions the examiner 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 | Meister 2004 | 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. |
| Tests intended to differentiate between subacromial outlet and internal impingement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Internal rotation resisted strength test | Zaslav 2001 | Positive Neer's test | The patient and examiner stand, the examiner 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 involvement, including tears, or biceps' tendon involvement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Belly press test | Gerber 1996 | 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 the subscapularis (one of the four musculotendinous units that collectively form the rotator cuff), [implying a partial or complete tear]. |
| Drop sign | Hertel 1996 | None | The patient sits. The examiner stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder in 90° of elevation (in the plane of the scapula), then laterally rotates the shoulder to just short of full range. The examiner asks the patient to maintain the lateral rotation and, while continuing to support the elbow, releases the wrist. | The patient cannot maintain the position and there is a "drop" or "lag". | Tear of infraspinatus (one of the four musculo‐tendinous units that collectively form the rotator cuff) or neuropathy. |
| External rotation lag sign | Hertel 1996 | None | The patient sits. The examiner 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 examiner asks the patient to maintain the lateral rotation and, while continuing to support the elbow, releases the wrist. | An angular "drop" or "lag". | A 5‐10° lag signifies a complete tear of supraspinatus or infraspinatus (two of the four musculo‐tendinous units that collectively form the rotator cuff). A 10‐15° lag signifies a complete tear of both these units, or a neuropathy. |
| Lift‐off test, Internal rotation lag sign | Gerber 1991, Gerber 1996, Hertel 1996 | Adequate range of internal rotation. If this is not available, the belly press test (see above) should be used. | The patient sits. The examiner, 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 examiner then medially rotates the shoulder fully, lifting the back of the hand clear of the spine. The patient is asked to actively maintain this position as the wrist is released. | (A) Inability to maintain the lifted‐off position: the hand drops back to the spine and the patient cannot actively lift it clear without extending the elbow. (B) Inability to fully maintain the lifted‐off position. The hand drops back by more than 5°, but not all the way to the spine. | (A) Complete tear of subscapularis (one of the four musculotendinous units that collectively form the rotator cuff). (B) Partial tear of subscapularis. |
| Yergason' test, Supination sign | Yergason 1931 | None | The patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the examiner's resistance. | Pain localised to the bicipital groove. | Degenerative changes of the long head of biceps, or synovitis of its tendon sheath. |
| Tests intended to diagnose tears of the glenoid labrum | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Active compression test | O'Brien 1998 | 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 examiner stands behind the patient and applies a uniform downward force to the arm. This is repeated in full external rotation. | Pain on the 1st manoeuvre, reduced or eliminated on the 2nd | Tear of the glenoid labrum (SLAP lesion). |
| Biceps load II test | Kim 2001 | None | The patient lies supine. The examiner 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 examiner's isometric resistance. | Pain provoked by resisted elbow flexion. | Tear of the glenoid labrum (SLAP lesion). |
| Crank test | Liu 1996 | None | The patient sits or lies (the lying variant is stated to be the more sensitive test) with the elbow flexed 90° and the shoulder elevated 160° (in the plane of the scapula). The examiner 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). | Tear of the glenoid labrum |
| 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. 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. 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. 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. 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. 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°). 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. Humerus. The upper arm bone. 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. 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. Examiner‐applied resistance that prevents an attempted movement. 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. A patch of tissue damage. Long head of biceps. The portion of the biceps that arises inside the shoulder joint. The tendon arches over the *humerus to pass into the arm. 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. Neuropathy. A disorder of a nerve that may result in muscle weakness. Plane of the scapula. A plane of shoulder movement between *flexion/*extension and *abduction/*adduction. Posterior. Towards the back. The opposite of *anterior. Pronation. The movement of the forearm that, in relaxed standing, would bring the palm to face backwards. Prone. Lying face downwards. 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. Scapula. Shoulder blade. Scapular. Relating to the *scapula. SLAP lesion (Superior Labrum Anterior to Posterior *lesion). A tear in the upper part of the *glenoid labrum that extends forwards and backwards (Snyder 1990; see Footnotes). It may result from *internal impingement. Subacromial outlet impingement. Pinching of the *rotator cuff, the *subacromial bursa, the *long head of biceps, or a combination of these, between the *humerus and the *acromion. Subscapularis. See ROTATOR CUFF. 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. 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 1990
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 2000; 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). The generally accepted gold standard of diagnosis is direct observation at open or arthroscopic (“keyhole”) surgery (Table 3). However, this is not completely valid, since tears within the substance of the rotator cuff are not directly visible (Fukuda 2003) and conversely, visible tears may be asymptomatic (Dinnes 2003; MacDonald 2000; 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 1997) 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 long head of biceps. (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 long head of biceps. (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. |
| Ultra‐sonography | 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 alternative 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.
We have 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, will extend 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) will enable the review to focus on the former. Our review will also differ from the others in placing emphasis on the primary care setting (while not excluding secondary or tertiary care). 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 will be explicit in the quality assessment of included studies.
Objectives
We will 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. Such studies will compare the findings of physical tests to those of surgery or other suitable reference tests, as defined below.
We will also examine the physical tests according to whether they are intended to:
-
identify impingement in general (or differentiate it from other causes of shoulder pain e.g. ‘frozen shoulder’)
-
subcategorise impingement as subacromial outlet impingement (impingement under the acromion process) or internal impingement (impingement within the shoulder joint)
-
diagnose lesions of bursa, tendon or glenoid labrum that may be associated with impingement
-
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 will specifically investigate the following potential sources of heterogeneity.
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The study population: the older mixed population; the young athletic population; other well defined groups e.g. wheelchair users or swimmers
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The stage of clinical care: whether 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 will consider diagnostic accuracy studies that directly compare (within‐study) the accuracy of one or more physical index tests for shoulder impingement against a reference test. We will consider diagnostic studies with cross‐sectional or cohort designs (retrospective or prospective), case‐control studies and, although these are highly unlikely to be encountered, randomised controlled trials. In particular, we will note 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 will consider excluding cohort studies with an excessively long period between the index and reference test. We define this as a period that, on average, equals or exceeds the reported mean duration of symptoms, or one month (whichever is shorter). We will exclude studies that are 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 (see ‘Target conditions’), whether subacromial, internal or secondary to rotator cuff disease, and with or without rotator cuff tears. Excluded will be studies evaluating physical (index) tests under anaesthesia, or intra‐ or post‐operatively. We will also exclude studies that focus solely on pain due to acromioclavicular joint disorders; or that focus primarily on shoulder joint instability, fracture, acute or recurrent shoulder dislocation, or systemic disease (e.g. rheumatoid disease).
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 will be 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 1991; Gerber 1996; Hertel 1996), the crank test (Liu 1996), the active compression test (O'Brien 1998) and the biceps load II test (Kim 2001) (seeTable 1).
Ideally, articles for inclusion should describe a physical test, or reference a source that does so, in sufficient detail to enable its replication, and clearly indicate what constitutes a positive index test result. Those that do not will be considered on their individual merits, and included only if they provide sufficient information to be of clinical value. Studies reporting the collective accuracy of a series of tests will be considered, providing each component, and its manner of inclusion, is adequately described. Generic terms such as “physical examination”, as used to denote an unspecified combination of physical tests, will lead to exclusion unless further details are 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 biceps tendon inflammation or rupture.
Instability may underlie impingement, but tests of instability will only be included if they are intended to demonstrate associated impingement pain, as in the modified relocation test (Hamner 2000), as opposed to instability per se. Similarly, tests for acromioclavicular joint disorders will only be included if, like the active compression test (O'Brien 1998), they have 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 will additionally consider 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 will be discussed case by case (seeTable 3).
Search methods for identification of studies
Electronic searches
We will search MEDLINE (1966 to present), EMBASE (1974 to present), CINAHL (1982 to present) and AMED (Allied and Complementary Medicine Database) (1985 to present). We developed a sensitive search strategy (Appendix 4) as recommended in Chapter 5 and Appendix 5.4 of the Handbook (de Vet 2005). We will also search DARE (Database of Abstracts of Reviews of Effectiveness) (1995 to present). While we recognise the potential association between language restriction and selection bias, pragmatic considerations require that the searches be restricted to articles written in the English language.
Searching other resources
We will check 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, both authors will independently filter the results of the electronic searches and subsequently perform independent study selection from retrieved articles. Disagreements will be resolved by consensus.
Data extraction and management
We will design a review‐specific data collection form (Whiting 2005a) and pilot it on three studies of diagnostic accuracy that focus on physical tests for shoulder instability (a condition outside the scope of the present review). The two review authors will independently extract all key trial and participant information and data from the included studies without masking of trial authors and other identifying information. Disagreements will be resolved by consensus.
We will extract the diagnostic two‐by‐two table data (true positive, false positive, false negative, and true negative) from the publications. If these are not available we will attempt to reconstruct the two‐by‐two table from summary estimates (Whiting 2005b). Authors will be contacted in respect of missing key information such as two‐by‐two table data, study participant numbers and application of blinding. Diagnostic studies presenting insufficient data for construction of a two‐by‐two table will be excluded from statistical analysis, but may be included in the narrative part of the review.
Assessment of methodological quality
At the same time as data collection, the two review authors will independently assess study quality using all items of the QUADAS form (Whiting 2003), tailored to the review. We have already undertaken a preliminary piloting exercise to establish a coding manual setting out review‐specific criteria (Table 4). Disagreements will be resolved by consensus.
| *Adapted from Whiting (2003), Cochrane Diagnostic Reviewers Handbook version 0.3 (2005) 1. Was the spectrum of patients representative of the patients who will receive the test in practice? [To define spectrum bias] Though clinical examination can be applied at all stages, our target population is the relatively unselected one in a primary care setting. This level of care may involve self‐referral to a physiotherapist or, more usually, consultation with a general medical practitioner and possible cross‐referral to a physiotherapist (often located in the community) or for imaging tests. Clearly defined patient populations are unlikely in retrospective studies (Bossuyt 2003; van der Schouw 1995: see Footnotes for citations). | |
| Y | (a) The setting was primary care AND (b) the population was unselected but defined by age and gender AND (c) the reference test was non‐ or minimally invasive (physical tests plus local anaesthesia, ultrasound, MRI) AND (d) there was diagnostic uncertainty AND (e) the study was prospective and (f) recruitment was consecutive |
| N | General factors (a) There was no diagnostic uncertainty i.e. the study compared diseased‐ with healthy subjects (case‐control study) OR (b) the study was not prospective OR (c) recruitment was not consecutive |
| Review‐specific factors (a) The setting was secondary or tertiary care OR (b) the population was clearly selected OR (c) the reference test was more than minimally invasive (surgery, arthroscopy, arthrography, MRA, CT) | |
| ? | Insufficient information |
| 2. Were selection criteria clearly described? This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but considered important in the present context, in which pain may arise from a number of conditions other than the target condition. | |
| Y | (a) The selection criteria were clearly described (e.g. pain in the shoulder/ deltoid region, painful arc of motion, pain on overhead activities contributing to a clinical suspicion of impingement) AND (b) the exclusion criteria were clearly described (e.g. referred pain, gross restriction of movement, inflammatory disease, fracture) |
| N | (a) The selection criteria were undescribed/ very unclearly described (e.g. “shoulder pain”) OR (b) the exclusion criteria were undescribed/ very unclearly described |
| ? | (a) The selection criteria were described AND (b) the exclusion criteria were described BUT (c) the description of the selection criteria was not completely clear (e.g. an unqualified statement such as, “patients with suspected impingement”) OR (d) the description of the exclusion criteria was not completely clear |
| 3. Is the reference standard likely to correctly classify the target condition? The generally recognised ‘gold’ standards are inapplicable to primary care. In general, the diagnostic tests that are applicable to primary care are less likely to correctly classify the target conditions. There two exceptions:
| |
| Y | The reference standard was (a) arthroscopy OR (b) surgery OR (c) a combination of these OR (d) local anaesthesia of the subacromial bursa by guided injection OR (e) the target condition was full‐thickness rotator cuff tears in a sample with a likely low prevalence of this condition and the reference standard was MRI |
| N | Not applicable |
| ? | The reference standard was (a) arthrography OR (b) subacromial local anaesthesia by ‘blind’ injection OR (c) MRA OR (d) MRI, except as defined above OR (e) ultrasonography |
| 4. Is the time period between the reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests? [To identify disease progression bias] The acceptable interval would vary according to the average duration of symptoms. | |
| Y | The average interval was < (a) the average duration of symptoms OR (b) 1 month (whichever was the shorter) |
| N | The conditions for ‘Y’ were expressly not met |
| ? | Insufficient information |
| 5. Did the whole sample, or a random selection of the sample, receive verification using a reference standard? [To identify partial verification bias] | |
| Y | (a) All patients were accounted for as having undergone a reference test OR (b) a randomly selected sample of patients underwent a reference test. (Score ‘Y’ even if different reference tests were used) |
| N | (a) Not all patients were accounted for as having undergone a reference test OR (b) a non‐random selection of patients underwent a reference test |
| ? | Insufficient information |
| 6. Did patients receive the same reference standard regardless of the index test result? [To identify differential verification bias] | |
| Y | (a) All patients underwent the same reference test OR (b) patients underwent different reference tests, but these were probably equivalent (e.g. arthroscopy and open surgery) |
| N | Patients underwent different reference tests, which were probably not equivalent (e.g. arthrography and surgery) |
| ? | Insufficient information |
| 7. Was the reference standard independent of the index test? [To identify incorporation bias] | |
| Y | Self explanatory |
| N | Self explanatory |
| ? | Self explanatory |
| 8. Was the execution of the index test described in sufficient detail to permit replication of the test? This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but included here because minor technical variations may affect physical tests’ outcomes, and interpretation may not be straightforward. | |
| Y | (a) A clear, detailed description was given enabling replication and interpretation OR (b) a reference was given to an adequate source of this information |
| N | (a) The description lacked sufficient clarity to enable replication or interpretation AND (b) no reference was given to an adequate source of this information |
| ? | Not applicable |
| 9. Was the execution of the reference standard described in sufficient detail to permit its replication? This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but included here because the reference tests’ interpretation is ultimately subjective. | |
| Y | (a) A clear, detailed description was given enabling replication and interpretation OR (b) a reference was given to an adequate source of this information |
| N | (a) The description lacked sufficient clarity to enable replication or interpretation AND (b) no reference was given to an adequate source of this information |
| ? | Not applicable |
| 10. Were the index test results interpreted without knowledge of the results of the reference standard? [To identify test review bias?] Clinical examination is highly subjective, and retrospective interpretation is a potential concern. | |
| Y | There was a clear statement of blinding |
| N | There does not appear to have been blinding |
| ? | The study was prospective and it is unclear whether there was blinding, but the index test preceded the reference standard. This does not apply to retrospective studies, in which both tests are likely to have been re‐interpreted at the same time (Whiting 2003). In the absence of a clear statement of blinding, retrospective studies should be scored ‘N’ |
| 11. Were the reference standard results interpreted without knowledge of the results of the index test? [To identify diagnostic review bias] Since the clinical relevance of some arthroscopic and surgical findings (e.g. glenoid labral lesions, rotator cuff fraying and even rotator cuff tears) is uncertain, and interpretation of the other reference tests is subjective, foreknowledge of the index test result has potential to influence interpretation. | |
| Y | There was a clear statement of blinding |
| N | There does not appear to have been blinding |
| ? | The reference test was stated to have been conducted “independently” |
| 12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice? Patients’ demographic (age/ sex) and historical data would normally be available when physical test results are interpreted. | |
| Y | Demographic and historical data were available when index test/s was/were interpreted |
| N | Demographic or historical data were not available when index test/s was/were interpreted |
| ? | Insufficient information |
| 13. Were uninterpretable/ intermediate test results reported? | |
| Y | (a) The study was prospective AND (b) recruitment was consecutive AND (c) test results were reported for all initially included patients |
| N | (a) Recruitment was not consecutive OR (b) test results were not reported for all initially included patients |
| ? | (a) Insufficient information OR (b) the study was not prospective (due to inconsistent reporting in clinical records, uninterpretable/ intermediate test results are sometimes not identified in retrospective studies (van der Schouw 1995)) |
| 14. Were withdrawals from the study explained? | |
| Y | (a) The study was prospective AND (b) recruitment was consecutive AND (c) withdrawals were reported AND (d) withdrawals were explained (ideally by a flow chart) |
| N | (a) The study was not prospective OR (b) recruitment was not consecutive (unexplained non‐recruitment equating to unreported/explained withdrawal) OR (c) withdrawals did not appear to have been reported OR (d) withdrawals were unexplained |
| ? | Insufficient information |
Bossuyt 2003
Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Annals of Internal Medicine 2003;138(1):W1‐12.
van der Schouw 1995
van der Schouw YT, Van Dijk R, Verbeek AL. Problems in selecting the adequate patient population from existing data files for assessment studies of new diagnostic tests. Journal of Clinical Epidemiology 1995;48(3):417‐22.
Statistical analysis and data synthesis
Statistical analysis and data synthesis will draw on the methods described in the Cochrane Diagnostic Reviewer’s Handbook. We will construct two‐by‐two tables (true positive (a), false positive (b), false negative (c), and true negative (d)) cross‐classifying the disease status (as determined by the reference test) and the index test’s outcome, for each index test evaluated in the included studies. From these tables we will derive values and 95% confidence intervals for:
-
sensitivity: the proportion of cases with the disease that were correctly identified by the index test; estimated as a / (a+c)
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specificity: the proportion of cases without the disease that were correctly identified by the index test; estimated as d / (b+d)
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positive likelihood ratio: the ratio between the probability of a positive test result when disease is present, and the probability of a positive test result when disease is absent; estimated as True positive rate / False positive rate = Sensitivity / (1 ‐ Specificity)
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negative likelihood ratio: the ratio between the probability of a negative test result when disease is present and the probability of a negative test result when disease is absent; estimated as False negative rate / True negative rate = (1 – Sensitivity) / Specificity.
A Forest plot will be presented for each index test, showing the paired sensitivities and specificities (and 95% confidence intervals) derived from the included studies. The numerators and denominators used in the individual sensitivity and specificity computations will also be shown, giving an indication of the estimates’ relative precision across studies. The order in which studies are presented on the plots may be varied in order to explore and highlight the effects of study characteristics on sensitivity and specificity. Summary estimates (minimum, maximum and median) of sensitivity and specificity over all studies will be presented for purely descriptive purposes.
Meta‐analysis
The threshold at which an index test is deemed positive influences the fraction of positive test results in diagnostic accuracy studies. ‘Threshold values’ may be explicit, but in the present review, which considers index tests whose thresholds are difficult to quantify, implicit threshold values are more likely. For example, different examiners may apply the same passive test with dissimilar force; they may variously interpret a report of “pulling” on an isometric test as an expression of pain (positive) or of the normal sensation of effort (negative); or their perceived thresholds for weakness might vary. For meta‐analysis, an approach must be adopted which accounts for such threshold effects, and Summary Receiver Operating Characteristic (SROC) plots satisfy this criterion. SROC plots are scattergrams depicting multiple studies, and whose axes respectively represent sensitivity (the true positive fraction) and the complement of specificity (the false positive fraction). Since both of their axes pertain to fractions, SROC plots are always framed within the unit of a square. They allow comparison of both threshold and accuracy across studies.
Corresponding tests from studies demonstrating sufficient clinical and methodological homogeneity (this will be based on an appraisal of the potential sources of heterogeneity listed above) will be plotted in this manner, and summary ROC curves computed using the Moses‐Littenberg method for exploratory analysis. Ranges of sensitivity/specificity points on these curves will be identified which appropriately characterise the performance of the test.
If required, in order to draw useful conclusions, computation of average operating points, confidence limits and pooling of heterogeneous data will be undertaken using random‐effects methods using hierarchical bivariate models.
The results will be presented in a summary table showing, for each test, estimates of sensitivity, specificity and likelihood ratios; the proportion of indeterminate and uninterpretable results; benefits and adverse effects; and likelihood ratios for relevant subgroups. This presentation is intended to optimise end users’ access to the results.
Investigations of heterogeneity
Supplementary SROC analysis or meta‐regression analysis may be used to investigate parameters other than threshold values that might influence test performance, e.g. different study populations or stages of clinical care. These analyses will be based on the potential sources of heterogeneity listed under "Investigation of sources of heterogeneity". However, these approaches require analysis of a large number of studies pertaining to each test in question; and in respect of the present review we anticipate these are unlikely to be available.
| Tests intended to identify impingement in general | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Painful arc test | Cyriax 1982 | None | The patient actively elevates, then lowers, the shoulder through abduction. | Onset and offset of pain during elevation, during lowering, or both. | Subacromial outlet impingement; calcific tendonitis; pain secondary to shoulder joint instability; or internal impingement (involving the deep aspect of the rotator cuff or the long head of biceps tendon) |
| Tests intended to identify subacromial outlet impingement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Neer's test | Neer 1977, Neer 1983 | None | The examiner forcibly flexes the sitting patient's arm, preventing scapular movement by pressing down on the clavicle and acromion with the other hand. | Pain, which is abolished by injection of 10 ml of 1% xylocaine beneath the anterior acromion. | Subacromial outlet impingement |
| Tests intended to identify internal impingement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Modified relocation test for postero‐superior glenoid impingement | Hamner 2000 | None | The patient lies supine. The shoulder is held by the examiner in full lateral rotation and positioned at each of 90°, 100° and 120° of abduction. In each of these positions the examiner 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 | Meister 2004 | 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. |
| Tests intended to differentiate between subacromial outlet and internal impingement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Internal rotation resisted strength test | Zaslav 2001 | Positive Neer's test | The patient and examiner stand, the examiner 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 involvement, including tears, or biceps' tendon involvement | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Belly press test | Gerber 1996 | 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 the subscapularis (one of the four musculotendinous units that collectively form the rotator cuff), [implying a partial or complete tear]. |
| Drop sign | Hertel 1996 | None | The patient sits. The examiner stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder in 90° of elevation (in the plane of the scapula), then laterally rotates the shoulder to just short of full range. The examiner asks the patient to maintain the lateral rotation and, while continuing to support the elbow, releases the wrist. | The patient cannot maintain the position and there is a "drop" or "lag". | Tear of infraspinatus (one of the four musculo‐tendinous units that collectively form the rotator cuff) or neuropathy. |
| External rotation lag sign | Hertel 1996 | None | The patient sits. The examiner 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 examiner asks the patient to maintain the lateral rotation and, while continuing to support the elbow, releases the wrist. | An angular "drop" or "lag". | A 5‐10° lag signifies a complete tear of supraspinatus or infraspinatus (two of the four musculo‐tendinous units that collectively form the rotator cuff). A 10‐15° lag signifies a complete tear of both these units, or a neuropathy. |
| Lift‐off test, Internal rotation lag sign | Gerber 1991, Gerber 1996, Hertel 1996 | Adequate range of internal rotation. If this is not available, the belly press test (see above) should be used. | The patient sits. The examiner, 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 examiner then medially rotates the shoulder fully, lifting the back of the hand clear of the spine. The patient is asked to actively maintain this position as the wrist is released. | (A) Inability to maintain the lifted‐off position: the hand drops back to the spine and the patient cannot actively lift it clear without extending the elbow. (B) Inability to fully maintain the lifted‐off position. The hand drops back by more than 5°, but not all the way to the spine. | (A) Complete tear of subscapularis (one of the four musculotendinous units that collectively form the rotator cuff). (B) Partial tear of subscapularis. |
| Yergason' test, Supination sign | Yergason 1931 | None | The patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the examiner's resistance. | Pain localised to the bicipital groove. | Degenerative changes of the long head of biceps, or synovitis of its tendon sheath. |
| Tests intended to diagnose tears of the glenoid labrum | |||||
| Test | Reference | Specified pre‐requisits | Technique | Definition of positive response | Specific implication of a positive response, according to the author(s) |
| Active compression test | O'Brien 1998 | 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 examiner stands behind the patient and applies a uniform downward force to the arm. This is repeated in full external rotation. | Pain on the 1st manoeuvre, reduced or eliminated on the 2nd | Tear of the glenoid labrum (SLAP lesion). |
| Biceps load II test | Kim 2001 | None | The patient lies supine. The examiner 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 examiner's isometric resistance. | Pain provoked by resisted elbow flexion. | Tear of the glenoid labrum (SLAP lesion). |
| Crank test | Liu 1996 | None | The patient sits or lies (the lying variant is stated to be the more sensitive test) with the elbow flexed 90° and the shoulder elevated 160° (in the plane of the scapula). The examiner 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). | Tear of the glenoid labrum |
| 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. 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. 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. 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. 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. 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°). 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. Humerus. The upper arm bone. 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. 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. Examiner‐applied resistance that prevents an attempted movement. 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. A patch of tissue damage. Long head of biceps. The portion of the biceps that arises inside the shoulder joint. The tendon arches over the *humerus to pass into the arm. 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. Neuropathy. A disorder of a nerve that may result in muscle weakness. Plane of the scapula. A plane of shoulder movement between *flexion/*extension and *abduction/*adduction. Posterior. Towards the back. The opposite of *anterior. Pronation. The movement of the forearm that, in relaxed standing, would bring the palm to face backwards. Prone. Lying face downwards. 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. Scapula. Shoulder blade. Scapular. Relating to the *scapula. SLAP lesion (Superior Labrum Anterior to Posterior *lesion). A tear in the upper part of the *glenoid labrum that extends forwards and backwards (Snyder 1990; see Footnotes). It may result from *internal impingement. Subacromial outlet impingement. Pinching of the *rotator cuff, the *subacromial bursa, the *long head of biceps, or a combination of these, between the *humerus and the *acromion. Subscapularis. See ROTATOR CUFF. 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. 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 1990 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 long head of biceps. (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 long head of biceps. (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. |
| Ultra‐sonography | 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. |
| *Adapted from Whiting (2003), Cochrane Diagnostic Reviewers Handbook version 0.3 (2005) 1. Was the spectrum of patients representative of the patients who will receive the test in practice? [To define spectrum bias] Though clinical examination can be applied at all stages, our target population is the relatively unselected one in a primary care setting. This level of care may involve self‐referral to a physiotherapist or, more usually, consultation with a general medical practitioner and possible cross‐referral to a physiotherapist (often located in the community) or for imaging tests. Clearly defined patient populations are unlikely in retrospective studies (Bossuyt 2003; van der Schouw 1995: see Footnotes for citations). | |
| Y | (a) The setting was primary care AND (b) the population was unselected but defined by age and gender AND (c) the reference test was non‐ or minimally invasive (physical tests plus local anaesthesia, ultrasound, MRI) AND (d) there was diagnostic uncertainty AND (e) the study was prospective and (f) recruitment was consecutive |
| N | General factors (a) There was no diagnostic uncertainty i.e. the study compared diseased‐ with healthy subjects (case‐control study) OR (b) the study was not prospective OR (c) recruitment was not consecutive |
| Review‐specific factors (a) The setting was secondary or tertiary care OR (b) the population was clearly selected OR (c) the reference test was more than minimally invasive (surgery, arthroscopy, arthrography, MRA, CT) | |
| ? | Insufficient information |
| 2. Were selection criteria clearly described? This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but considered important in the present context, in which pain may arise from a number of conditions other than the target condition. | |
| Y | (a) The selection criteria were clearly described (e.g. pain in the shoulder/ deltoid region, painful arc of motion, pain on overhead activities contributing to a clinical suspicion of impingement) AND (b) the exclusion criteria were clearly described (e.g. referred pain, gross restriction of movement, inflammatory disease, fracture) |
| N | (a) The selection criteria were undescribed/ very unclearly described (e.g. “shoulder pain”) OR (b) the exclusion criteria were undescribed/ very unclearly described |
| ? | (a) The selection criteria were described AND (b) the exclusion criteria were described BUT (c) the description of the selection criteria was not completely clear (e.g. an unqualified statement such as, “patients with suspected impingement”) OR (d) the description of the exclusion criteria was not completely clear |
| 3. Is the reference standard likely to correctly classify the target condition? The generally recognised ‘gold’ standards are inapplicable to primary care. In general, the diagnostic tests that are applicable to primary care are less likely to correctly classify the target conditions. There two exceptions:
| |
| Y | The reference standard was (a) arthroscopy OR (b) surgery OR (c) a combination of these OR (d) local anaesthesia of the subacromial bursa by guided injection OR (e) the target condition was full‐thickness rotator cuff tears in a sample with a likely low prevalence of this condition and the reference standard was MRI |
| N | Not applicable |
| ? | The reference standard was (a) arthrography OR (b) subacromial local anaesthesia by ‘blind’ injection OR (c) MRA OR (d) MRI, except as defined above OR (e) ultrasonography |
| 4. Is the time period between the reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests? [To identify disease progression bias] The acceptable interval would vary according to the average duration of symptoms. | |
| Y | The average interval was < (a) the average duration of symptoms OR (b) 1 month (whichever was the shorter) |
| N | The conditions for ‘Y’ were expressly not met |
| ? | Insufficient information |
| 5. Did the whole sample, or a random selection of the sample, receive verification using a reference standard? [To identify partial verification bias] | |
| Y | (a) All patients were accounted for as having undergone a reference test OR (b) a randomly selected sample of patients underwent a reference test. (Score ‘Y’ even if different reference tests were used) |
| N | (a) Not all patients were accounted for as having undergone a reference test OR (b) a non‐random selection of patients underwent a reference test |
| ? | Insufficient information |
| 6. Did patients receive the same reference standard regardless of the index test result? [To identify differential verification bias] | |
| Y | (a) All patients underwent the same reference test OR (b) patients underwent different reference tests, but these were probably equivalent (e.g. arthroscopy and open surgery) |
| N | Patients underwent different reference tests, which were probably not equivalent (e.g. arthrography and surgery) |
| ? | Insufficient information |
| 7. Was the reference standard independent of the index test? [To identify incorporation bias] | |
| Y | Self explanatory |
| N | Self explanatory |
| ? | Self explanatory |
| 8. Was the execution of the index test described in sufficient detail to permit replication of the test? This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but included here because minor technical variations may affect physical tests’ outcomes, and interpretation may not be straightforward. | |
| Y | (a) A clear, detailed description was given enabling replication and interpretation OR (b) a reference was given to an adequate source of this information |
| N | (a) The description lacked sufficient clarity to enable replication or interpretation AND (b) no reference was given to an adequate source of this information |
| ? | Not applicable |
| 9. Was the execution of the reference standard described in sufficient detail to permit its replication? This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but included here because the reference tests’ interpretation is ultimately subjective. | |
| Y | (a) A clear, detailed description was given enabling replication and interpretation OR (b) a reference was given to an adequate source of this information |
| N | (a) The description lacked sufficient clarity to enable replication or interpretation AND (b) no reference was given to an adequate source of this information |
| ? | Not applicable |
| 10. Were the index test results interpreted without knowledge of the results of the reference standard? [To identify test review bias?] Clinical examination is highly subjective, and retrospective interpretation is a potential concern. | |
| Y | There was a clear statement of blinding |
| N | There does not appear to have been blinding |
| ? | The study was prospective and it is unclear whether there was blinding, but the index test preceded the reference standard. This does not apply to retrospective studies, in which both tests are likely to have been re‐interpreted at the same time (Whiting 2003). In the absence of a clear statement of blinding, retrospective studies should be scored ‘N’ |
| 11. Were the reference standard results interpreted without knowledge of the results of the index test? [To identify diagnostic review bias] Since the clinical relevance of some arthroscopic and surgical findings (e.g. glenoid labral lesions, rotator cuff fraying and even rotator cuff tears) is uncertain, and interpretation of the other reference tests is subjective, foreknowledge of the index test result has potential to influence interpretation. | |
| Y | There was a clear statement of blinding |
| N | There does not appear to have been blinding |
| ? | The reference test was stated to have been conducted “independently” |
| 12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice? Patients’ demographic (age/ sex) and historical data would normally be available when physical test results are interpreted. | |
| Y | Demographic and historical data were available when index test/s was/were interpreted |
| N | Demographic or historical data were not available when index test/s was/were interpreted |
| ? | Insufficient information |
| 13. Were uninterpretable/ intermediate test results reported? | |
| Y | (a) The study was prospective AND (b) recruitment was consecutive AND (c) test results were reported for all initially included patients |
| N | (a) Recruitment was not consecutive OR (b) test results were not reported for all initially included patients |
| ? | (a) Insufficient information OR (b) the study was not prospective (due to inconsistent reporting in clinical records, uninterpretable/ intermediate test results are sometimes not identified in retrospective studies (van der Schouw 1995)) |
| 14. Were withdrawals from the study explained? | |
| Y | (a) The study was prospective AND (b) recruitment was consecutive AND (c) withdrawals were reported AND (d) withdrawals were explained (ideally by a flow chart) |
| N | (a) The study was not prospective OR (b) recruitment was not consecutive (unexplained non‐recruitment equating to unreported/explained withdrawal) OR (c) withdrawals did not appear to have been reported OR (d) withdrawals were unexplained |
| ? | Insufficient information |
| Bossuyt 2003 Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Annals of Internal Medicine 2003;138(1):W1‐12. van der Schouw 1995 van der Schouw YT, Van Dijk R, Verbeek AL. Problems in selecting the adequate patient population from existing data files for assessment studies of new diagnostic tests. Journal of Clinical Epidemiology 1995;48(3):417‐22. | |
