Combining orthopedic special tests to improve diagnosis of shoulder pathology

doi:10.1016/j.ptsp.2014.08.001

Physical Therapy in Sport

Volume 16, Issue 2, May 2015, Pages 87-92

https://doi.org/10.1016/j.ptsp.2014.08.001 Get rights and content

Abstract

The use of orthopedic special tests (OSTs) to diagnose shoulder pathology via the clinical examination is standard in clinical practice. There is a great deal of research on special tests but much of the research is of a lower quality implying that the metrics from that research, sensitivity, specificity, and likelihood ratios, is likely to vary greatly in the hands of different clinicians and in varying practice environments. A way to improve the clinical diagnostic process is to cluster OSTs and to use these clusters to either rule in or out different pathologies. The aim of the article is to review the best OST clusters, examine the methodology by which they were derived, and illustrate, with a case study, the use of these OST clusters to arrive at a pathology-based diagnosis.

Introduction

Physical examination of the shoulder involves a series of steps typically beginning with history, progressing with motion and muscle testing, and culminating in the use of orthopedic special tests (OSTs) with the aim of diagnosing shoulder pathology. While the process itself is systematic and straightforward, for evidence-based practitioners, there are numerous problems encountered when trying to arrive at a diagnosis. First, there is little evidence reporting the diagnostic accuracy of critical pieces of the clinical examination such as history, motion testing, and muscle testing causing a greater reliance on OSTs. Second, although there is a great deal of research on OSTs of the shoulder, much of that research is of moderate to low quality (Hegedus et al., 2008, Hegedus et al., 2012). Third, even in those OSTs that come from high quality literature, there are very few that display solid diagnostic metrics, high sensitivity and specificity (Hegedus et al., 2008, Hegedus et al., 2012). Fourth, although sensitivity and specificity are helpful internal test metrics, there are issues in the application of these metrics to clinical practice. Finally, clinicians and researchers improve diagnostic accuracy by clustering OSTs together; however, in some cases, the clusters are used incorrectly or provide metrics that lead to post-test probabilities that are no different than use of a single stand alone test.

Our aims in this paper are to discuss the importance of likelihood ratios and modified probability in the diagnostic process, to explain multivariate modeling and outline the most effective methods to combine tests for either screening or confirmation of diagnosis. For context, we'll briefly review the best test clusters that have been published, and finally, we'll use a case study to illustrate how the best available test clusters should be used to aid in diagnosis.

Section snippets

Likelihood ratios and modified probability

Diagnostic accuracy studies have design consistencies, standardized metrics, and assumptions. First and foremost, all diagnostic accuracy studies enroll populations of individuals with and without the condition of interest; the condition of interest being the diagnosis studied. Those without the condition of interest should be individuals with some other competing health malady that would normally be distinguished in a traditional clinical environment. For example, a typical shoulder study

Multivariate modeling

The goal in any data analysis is to extract from raw information the accurate estimation (Alexopoulos, 2010). The goal when clustering tests is to determine the best combination estimates that produce the strongest likelihood ratios and to do so, multivariate modeling is required. Thus, clustering is simply the act of evaluating a set of tests and measures, in combination, when making a clinical decision or a mathematical assessment. For example, when attempting to detect acromiocalvicular (AC)

Best test clusters

Before presenting the best published test clusters, “best” needs to be put in context. “Best” as used in this manuscript, is defined as those combinations of tests with the strongest likelihood ratios from research with the highest quality. The quality of the tests clusters is judged by using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) document and using a 0–14 (0 = lowest quality) scale (Whiting, Rutjes, Dinnes, Reitsma, Bossuyt, & Kleijnen, 2004). From our past experience(

Case study

Our fictitious patient is 67 years old and has complained of shoulder pain of 4 months in duration. He reported that his pain initiated while walking his dogs (when they jerked the leash he held) but notes that the pain has progressed markedly over the last two months. He is able to raise his arm above his head (with pain) but has noted that his arm now aches consistently, with a more noticeable ache at night. Frequent use of ibuprofen helps modulate his pain but the effects are only temporary

Conclusion

The clinical diagnostic process should be viewed through the lens of odds and probabilities. In order to do so, test clusters from high quality studies should be utilized. In our case study, the patient likely has a rotator cuff tear but we were unable to rule out or in a labral tear and impingement. High quality clinical test clusters with powerful diagnostic characteristics for labral tears do not presently exist and impingement is an all-encompassing term for tendon pathology at the shoulder

Conflict of interest

None.

Funding

None.

Ethical approval

None.

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2024, Journal of Shoulder and Elbow Surgery
Managing the painful shoulder in overhead athletes can be difficult because of a lack of time-loss injuries in overhead sports and focusing primarily on either pathoanatomic causes or movement impairments. Although managing the painful shoulder can be challenging, the combination of identifying pathoanatomic causes with movement impairments can provide a more focused rehabilitation approach directed at the causes of shoulder pain. Understanding the potential influence of scapular positioning as well as mobility and/or strength impairments on shoulder pain can help clinicians develop more directed rehabilitation programs. Furthermore, sports-specific methods such as long toss or the use of weighted balls for achieving physiological or performance-based gains have limited empirical evidence regarding their clinical and performance-based benefits, which may impede the rehabilitation process. Applying a comprehensive evaluation approach prior to and throughout the treatment process can assist clinicians with selecting the most appropriate treatment based on patient need. Reconsidering traditional treatments based on existing evidence may help refine the treatment process for overhead athletes with shoulder pain.
The shoulder joint complex in the throwing motion
2024, Journal of Shoulder and Elbow Surgery
The shoulder joint complex in the overhead athlete is organized to effectively transfer the proximally generated forces distally into the arm. The organization also protects the joints and anatomic structures against the repetitive high velocities, large ranges of motions, and compressive, shear, translational, and distraction loads in the overhead motion while placing the hand in the “launch window.” Coupling of the movements of the scapula, clavicle, and humerus results in scapulohumeral rhythm (SHR). Effective SHR requires the clavicle and scapula—and, at times, the mechanically linked claviscapular segment—to move the arm into the task-specific position and motion and requires the humerus to move through the ranges of motion to achieve the specific task in the throwing motion. Alterations in SHR can negatively affect effective shoulder joint complex function in the overhead throwing motion and increase injury risk. There are 4 phases of clavicular, scapular, and claviscapular motion that are coupled with arm motion in SHR. The first 3 phases occur in arm elevation motions from 0°-90° and result in the claviscapula and humerus being placed in task-specific positions. The fourth phase is coupling of claviscapular motion with humeral motion to maintain ball-and-socket kinematics throughout the throwing motion. Alterations in this composite motion are termed “scapular dyskinesis.” The dyskinesis is considered an impairment of the efficient mobility of the claviscapular segment of the shoulder complex. The most prevalent problem with scapular dyskinesis is the association of scapular protraction and consequent glenoid antetilt with alterations in humeral rotation and posterior humeral head translation to produce shoulder joint internal impingement. Task effectiveness in overhead throwing is also based on and determined by humeral range of motion, precision of humeral motion, and velocity of humeral motion, as well as humeral and arm position in 3-dimensional space. This activity requires maximum ball-and-socket kinematics to create the highest amount of concavity-compression that creates stability for the joint. There are bony and soft-tissue contributions to this stability. Injuries to the glenoid labrum are among the most common deficits that alter concavity-compression. Clinical evaluation of the shoulder joint complex in the injured throwing athlete should be comprehensive and systematic, following an evaluation pathway for proximal and distal causative factors and including observation of humeral motion. This type of evaluation can result in intervention protocols that address the pathoanatomic, pathophysiological, and pathomechanical deficits identified.
Assessing shoulder disability in orthopaedic specialist care: Introducing the Copenhagen Shoulder Abduction Rating (C-SAR)
2022, Musculoskeletal Science and Practice
Citation Excerpt :
The use of active abduction ROM was deemed relevant because assessment of active range of motion is advised in the examination of patients with shoulder disorders (Codsi and Howe, 2015) and low levels of active abduction ROM have been reported in some shoulder patients (Engebretsen et al., 2010). Furthermore, pain during active abduction is a key component in the test for painful arc syndrome (Kessel and Watson, 1977), which is often used in diagnostic examination (Hegedus et al., 2015), but the level of pain is not taken into account when performing the painful arc test. In this study, active abduction ROM was measured in degrees using a digital inclinometer.
Differences in shoulder-disability among common shoulder-disorders in orthopaedic specialist care is unknown. Furthermore, rating of shoulder-disability using patient-reported outcomes is time-consuming, and a faster approach is needed.
First, compare shoulder-disability among common shoulder-disorders. Secondly, rate shoulder-disability according to the new and quick Copenhagen Shoulder Abduction Rating (C-SAR) and investigate criterion validity of C-SAR.
Cross-sectional study including 325 consecutive patients with shoulder-disorders in orthopaedic specialist care. We assessed shoulder abduction range-of-motion and pain during testing (NRS:0-10), and shoulder-disability using Shoulder Pain and Disability Index (SPADI) subscales. Patients were sub-grouped using C-SAR, which is based on shoulder abduction range-of-motion and pain during testing: Severe (range-of-motion ≤90°), Medium (range-of-motion >90°, NRS:>5), Mild (range-of-motion >90°, NRS:≤5). Shoulder-disability was compared among diagnostic categories and C-SAR subgroups using ANCOVA-models.
Most patients were diagnosed with either subacromial impingement (n = 211) or full-thickness/complete rotator-cuff tear (n = 18), but adhesive capsulitis (n = 22) was the diagnostic category related to worst SPADI scores. Data for C-SAR subgrouping were available from 187/229 (82%) patients with rotator-cuff related disorders (subacromial impingement or rotator-cuff tears). C-SAR subgrouping was not feasible for patient with adhesive capsulitis or glenohumeral injury. Differences in shoulder-disability between Mild (n = 67) and Medium (n = 56) C-SAR subgroups were large for both SPADI-subscales (ES: 1.0, p < .0001). Only SPADI-function differed significantly between Severe (n = 64) and Medium C-SAR subgroups (ES: 0.4, p = .017).
In orthopaedic specialist care, adhesive capsulitis relates to highest level of shoulder-disability, while C-SAR is a promising test to rate shoulder-disability for most patients, namely those with rotator-cuff related disorders.
Clinical assessment of the shoulder
2022, Orthopaedics and Trauma
Citation Excerpt :
A systematic history, examination and judicious use of the special tests is important in the accurate diagnosis of shoulder problems and treatment can often be initiated on this basis. The sensitivity and specificity of individual tests can be increased by combining them into clusters of tests.4,24 Despite the multitude of described tests, none reach 100% specificity or sensitivity therefore, where there is diagnostic uncertainty, radiological imaging and nerve conduction studies are indicated.
This article is aimed at the general orthopaedic surgeon or trainee looking to have a useful summary and approach to clinical assessment of the shoulder joint. Here we discuss a systematic approach, including a description of some of the special tests. This is not exhaustive, as a large number (estimated at around 130^1,2) of these special tests have been described in the literature – far too extensive a list to be discussed in detail. We have therefore concentrated on a core of common, simple and useful tests that can be applied alongside the rest of the clinical assessment to aid in differential diagnosis and treatment.
International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study
2022, Brazilian Journal of Physical Therapy
There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP).
To identify the most relevant clinical descriptors for diagnosing RCRSP.
A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.
Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the “subjective examination” domain, 1 item was included in the “patient-reported outcome measures” domain, 3 items in the “diagnostic examination” domain, 2 items in the “physical examination” domain”, and 2 items in the “functional tests” domain. No items reached consensus within the “special tests” domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus.
In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.
Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology
2021, Journal of Shoulder and Elbow Surgery
In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE.
The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test.
We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87).
This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.

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MasterclassCombining orthopedic special tests to improve diagnosis of shoulder pathology

Abstract

Introduction

Section snippets

Likelihood ratios and modified probability

Multivariate modeling

Best test clusters

Case study

Conclusion

Conflict of interest

Funding

Ethical approval

Introduction to multivariate regression analysis

Hippokratia

The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study

Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association

Clinical prediction rules: what are they and what do they tell us?

The Australian Journal of Physiotherapy

Clinical prediction rules for physical therapy interventions: a systematic review

Physical Therapy

Diagnostic value of physical tests for isolated chronic acromioclavicular lesions

The American Journal of Sports Medicine

Clustered clinical findings for diagnosis of cervical spine myelopathy

The Journal of Manual & Manipulative Therapy

Orthopedic physical examination tests: An evidence-based approach

Lumbopelvic manipulation for treatment of patients with patellofemoral pain syndrome: development of a clinical predication rule

The Journal of Orthopaedic and Sports Physical Therapy

A new SLAP test: the supine flexion resistance test

Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association

Clinical assessment of three common tests for traumatic anterior shoulder instability

The Journal of Bone and Joint Surgery

Bias reduction of maximum likelihood estimates

Biometrika

Clinical testing for tears of the glenoid labrum

Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association

Clinical prediction rules in the physiotherapy management of low back pain: a systematic review

Manual Therapy

Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests

British Journal of Sports Medicine

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

British Journal of Sports Medicine

Applied logistic regression

Biceps load test II: a clinical test for SLAP lesions of the shoulder

Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association

Applied linear regression models

Masterclass
Combining orthopedic special tests to improve diagnosis of shoulder pathology