Excellent summary of the valid research on clinical tests used in clinical assessment of the shoulder, from Eleanor Richardson

1.
Clinical Assessment of the
Shoulder:
What the research says…
Eleanor Richardson
Senior MSK Physiotherapist
2015

2. Are the Clinical Tests we use Valid?
Sensitivity
“SNOUT”:
➢ A sensitive test can rule out a
disease when the result is
negative
● A sensitive test = sensitivity >
80%, -LR < 0.20
Specificity
“SPIN”:
➢ A very specific test rules in a
disease with a high degree of
confidence
● A specific test = specificity >
80%, +LR > 5.0

3. SLAP lesions
● Hegedus et al. (2012):
Passive Distraction and Active
Compression = s:70% sp: 90%,
+ve LR:7.0, –ve LR: 0.11
(Schlecter, 2009)
Compression-rotation AND
Apprehension AND Speed = s:
25%, sp: 92%, +LR: 3.13, -LR:
0.82 for Type 2 only (Oh et al.
2008)
➢ Less optimism for Biceps load
II than in Hegedus (2008)
● MRI may be helpful but
anatomical variants and
Buford complex are normal
● MRI and MR Arthrogram
imaging have lower sensitivity
than physical examination
tests in diagnosing SLAP
lesions
➢ in others words, both
negative scans and negative
cluster testing does NOT rule
out a SLAP lesion

4. Labral Pathology (not exclusive to SLAP)
● Hegedus et al. (2012):
Anterior Slide AND Crank = s:
34%, sp: 91%, +LR: 3.75, -LR:
0.73 (Walsworth et al., 2008)
Apprehension AND Relocation
= s: 38%, sp: 93%, +LR: 5.43, -
LR: 0.67 (Gaunche & Jones,
2003)
➢ These combinations are good
at ruling IN labral pathology
but a negative test cannot
confidently this rule out…
● Munro (2009):
Kim = s: 80%, sp: 93%, +LR:
12.6, -LR:0.21 (Kim, 2005)
Jerk = s: 73%, sp: 98%, +LR:
34.7, -LR: 0.21 (Kim, 2005)
IRRT (differentiate intra-articular
pathology from impingement) =
s: 88%, sp: 96%, +LR: 24.7, -LR:
0.12 (Zaslav, 2001)

5. Rotator Cuff Tears
● Hegedus et al. (2012):
Age ≥ 65 AND Weakness in ER
(infraspinatus) AND night pain
= s: 49%, sp: 95%, +LR: 9.84, -
LR: 0.54 (Litaker, 2000)
Lift off and/or resisted IR
(subscapularis) = s: 50%, sp:
95%, +LR: 10.0, -LR: 0.53
(Naredo, 2002)
● Hegedus (2008):
Recommend a combination of
bear hug & belly press (s:
40-60%, sp: 88-98%)
● Miller et al. (2008):
ERLS for SSP & ISP, s: 46%, sp:
94%
➢ Tests here appear to be good
at ruling in an RCT but a
negative test does not mean
a RCT/pathology does not
exist

6. AC joint
● No clinical test met the
criteria for recommendation
by Hegedus (2012) due to
high risk of bias from
QUADAS 2 assessment
● Two studies looked at clinical
tests for the AC joint: Jia et al.
(2009) & Goyal et al. (2010)
● Jia et al. (2009) found:
● AC resisted extension = s:
72%, sp: 85%, +ve LR:4.8 -
LR: 0.33
● Active Compression for AC =
s: 41%, sp: 95%, +LR: 8.2, -
LR: 0.62
● Cross body for AC joint = s:
77%, sp: 79%, +LR: 3.67, -
LR: 0.29
● Goyal et al. (2010) found:
● Adductor stress = s: 57%, sp:
96%, +LR:15, -LR: 0.45

7. And now for the less well
defined pathologies….

8. Subacromial Impingement Syndrome (SIS)
● Hegedus et al. (2012):
At least 3 or more positives of
the following: Hawkins-
Kennedy, Neer, Painful Arch,
Empty Can, resisted ER = s:
75%, sp: 74%, +LR: 2.93 and –
LR: 0.34 (Michener et al., 2009)
● Park et al. (2005) also
recommend this cluster but
without the arch sign
● Even with cluster testing
adequate levels of sensitivity,
specificity, positive & negative
LRs are not reached for SIS
● However, consider relevance
as would this inform clinical
decision making?
● Structural Vs Patterning?
● Consider SSMP (Lewis, 2009)
and neuromodulation/
patterning re-education

9. Rotator Cuff Tendinopathy
● Hegedus et al. (2012):
Age > 39, Painful Arch, Self-
report of popping or clicking
(Chew et al. 2010):
➢ 2 or more positives= s:
75%, sp: 81%, +LR: 3.82 -
LR: 0.32
➢ 3 positives = s: 38%, sp:
99%, +LR: 32.20, -LR: 0.63
Lift off and/or Resisted IR = s:
50%, sp: 84%, +LR: 3.13, -LR:
0.60 (Naredo et al, 2002)
However…
● Inadequate sensitivity means
a negative test does not
mean a tendinopathy doe not
exist
● Large cross over with RCT
and SIS
● Difficult to evaluate the use of
cluster testing in light of Cook
and Purdum’s (2009)
tendinopathy continuum

10. Shoulder Instability
● Hegedus et al. (2012) Strong
evidence only for Type 1 – 2
anterior instability (Stanmore)
Apprehension and Relocation = s:
81%, sp: 98%, +LR: 39.68, -LR:
0.19 (Farber et al. 2006)
EUA:
● Laxity (Colfield’s technique):
● Ant/post drawer signs
● Sulcus sign & Gagey Test for
inferior capsule/Rotator interval
For atraumatic instabilities (type III)
consider:
● Muscle patterning
● Kinetic Chain
● Beighton score
➢ Load and shift (no data)
➢ Ant/Post draw (no data)

11. Adhesive Capsulitis
● Not assessed as current
diagnosis is clinical so no
criterion standard
● Hegedus et al. (2012):
Shrug Sign appears sensitive for
stiffness related disorders (OA
and adhesive capsulitis)(Jia et al,
2008)
➢ Essential physical criteria for
diagnosis is a marked and
equal limitation of External
rotation, both passively and
actively
● Emig et al. (1995):
MR Arthrogram sensitivity of
70% and a specificity of 95%
➢ Difficult to interpret as etiology
and histology is not fully
understood

12. Osteoarthritis
● No data for sensitivity or
specificity for clinical shoulder
tests
● Based on clinical history,
presentation and XRAY
● >50yrs, incidence increase with
age
● Insidious and progressively
worsening
● Pain: activity dependent, usually
intermittent but can be at rest,
dull generalised aching, night
pain, reduced active and passive
ROM all planes, esp. ER, disuse
atrophy, possible grinding
sensation with joint movements
● XRAYs:
● Subchrondral sclerosis +/- cysts
● Osteophytes
● For the knee 24-56% of patients
with OA X-ray findings have pain
and higher grades of OA are
linked with pain ?relevant to
shoulder, a none weight bearing
joint?
(Parsons et al., 2004)

13. The best* test combinations and reported values…
● SLAP: Passive Distraction AND Active Compression
● SLAP (T2): Compression-rotation AND Apprehension AND Speed
● Labral Tear: Anterior Slide AND Crank AND/OR Apprehension AND
Relocation
● RCT (degen): Age≥65 AND weakness in ER AND night pain
● RCT (none degen): Lift-off and/or Resisted ER
● SIS: Hawkins-Kennedy, Neer, Painful Arch, Empty Can, Resisted ER (3 or
more positives)
● RC Tendinopathy (supra): Age > 39, Painful Arch, self-report of popping
or clicking
● RC Tendinopathy (subscap): Lift-off and/or Resisted IR
● Anterior Instability (T1): Apprehension AND Relocation
*Defined as highest sensitivity, specificity, or both from studies with least bias

14. References
● Hegedus et al. (2012) 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. Br J Sports Med, Nov;46(14):964-78
● Hegedus et al. (2008) Physical examination tests of the shoulder: a systematic review with meta-analysis of individual
tests. Br J Sports Med, 42: 80-92
● Oh et al. (2008) The Evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and
posterior lesion, Am J Sports Med, 36 (2): 353-359
● Walsworth et al. (2008) Reliability and diagnostic accuracy of history and physical examination for diagnosing glenoid
labral tears, Am J Sports Med, 36: 162-8
● Guanche & Jones (2003) Clinical testing for tears of the glenoid labrum, Arthroscopy, 19: 517-23
● Munro & Healy (2009) The validity and accuracy of clinical tests used to detect labral pathology of the shoulder – a
systematic review, Manual Therapy, 14:119-30
● Zaslav (2001) Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from
outlet (Neer) impingement syndrome in the shoulder, Journal of Shoulder & Elbow Surgery, 10(1):23-7
● Litaker et al. (2000) Returning to the bedside: using the history and physical examination to identify rotator cuff tears. J Am
Geriatric Soc, 48: 1633-7
● Naredo et al. (2002) Painful shoulder: comparison of physical examination and ultrasonographic findings. ANN Rheum
Dis, 61: 132-6
● Miller et al. (2008) The validity of the lag sing in diagnosing full thickness tears of the rotator cuff: a preliminary
investigation. Archives of Physical Medicine & Rehabilitation, 89(6): 1162-1168

15. References cont…
● Michener et al. (2009) Reliability and diagnostic accuracy of 5 physical examination tests for subacromial
impingement. Arch Phys Med & Rehabilitation, 90: 1898-903
● Park et al. (2005) Diagnostic accuracy of clinical tests for different degrees if impingement, JBJS
American, 87: 1446-1455
● Lewis JS. Rotator cuff tendinopathy. Br J Sports Med. 2009 Apr;43(4):236-41.
● Lewis, J. S. (2009) Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new
method of assessment? British Journal of Sports Medicine, Vol 43, pp. 259-264
● Lewis JS. Rotator cuff tendinopathy: a model for the continuum of pathology and related management.
Br J Sports Med. 2010 Oct;44(13):918-23. http://bjsm.bmj.com/content/44/13/918
● Lewis JS, Tennent TD. How effective are diagnostic tests for the assessment of rotator cuff disease of
the shoulder? In: MacAuley D, Best TM, editors. Evidenced Based Sports Medicine. 2nd ed. London:
Blackwell Publishing; 2007.
● Farber et al. (2006) Clinical assessment of three common tests for traumatic anterior shoulder instability,
J Bone Joint Surg Am, 88: 1467-74
● Emig et al. (1995) Adhesive capsulitis of the shoulder: MR diagnosis, Am J Roenthenol, 164(6): 1457-9
● Parsons et al. (2004) Glenohumeral arthritis and its management, Physical Medicine and Rehab Clinics
of North America, 15: 447-474

16. References cont…
● Jia et al. (2009) Examination of the shoulder: the past, the present and the future. J Bone Joint surg Am,
91(6): 10-8
● Jia et al. (2008) Clinical evaluation of the shrug sign. Clin Orthop Relap Res, 466:2813-9
● Goyal et al. (2010) High resolution sonographic evaluation of the painful shoulder. Internat J Radiology.
12:22
● Chew et al, (2010) Cinical predictions for the diagnosis of supraspinatus pathology, Physiotherapy
Singapore, 13: 12-17
● Cook & Purdum (2009) Is tendon pathology a continuum? A pathology model to explain the clinical
presentation of load-induced tendinopathy. Br J Sports Med, 43(6): 406-16