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.

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:  

• 1. Since structural abnormalities of the rotator cuff are common in asymptomatic shoulders (MacDonald 2000; Milgrom 1995; Sher 1995), subacromial local anaesthesia may be more relevant to the symptoms of subacromial outlet impingement than diagnostic imaging, arthroscopy or open surgery (Dinnes 2003). However, since the site of anaesthesia would be critical, only subacromial bursal injections performed under guidance (fluoroscopic or ultrasonographic) will be accepted as a satisfactory reference test.

  2. Based on data from eight primary studies (N = 687) that used arthroscopy and/or open surgery as reference standards for full‐thickness rotator cuff tears in low‐prevalence samples (range 3 to 37%; mean 25% (16.32 to 33.68%)), MRI had a pooled sensitivity of 0.90 (0.84 to 0.94) and specificity of 0.95 (0.92 to 0.96) (Dinnes 2003). On these grounds, MRI appears sufficiently accurate for use as a reference test for full thickness rotator cuff tears in settings (such as general primary care) where there is likely to be a low prevalence of this disorder

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