Royal College of Surgeons in Ireland
Coláiste Ríoga na Máinleá in Éirinn
Diagnostic accuracy of clinical tests for subacromial
impingement syndrome (SIS): a systematic review
and meta analysis
Marwan Alqunaee, Rose Galvin and Tom Fahey
Division of Population Health Sciences
Outline
• Background and study aims
• Methods
• Results
• Clinical implications and discussion
• Limitation
Division of Population Health Sciences
Background
• Shoulder pain is the third most common musculoskeletal
consultation in primary care
• Subacromial impingement syndrome (SIS) is the most
frequent cause of shoulder pain
• SIS is a clinical syndrome that indicates pain and pathology
relating to the subacromial bursa and rotator cuff tendons
within the subacromial space
Division of Population Health Sciences
Clinical test
Description
End point sign
Neers sign
The examiner stabilizes the scapula and asks the patient to forward flex the arm until
Pain
he reports pain or until full elevation is reached.
Hawkins-
The examiner places the arm in a 90˚ of forward flexion and then gently internally
Kennedy test
rotates the arm. The end point for internal rotation is either when the patient feels
Pain
pain or when the rotation of the scapula is felt or observed by the examiner. The test is
positive when the patient experience pain during the maneuver.
Empty can test
The examiner asks the patient to elevate and internally rotate the arm with thumbs
(supraspinatus)
pointing downwards in the scapular plane. The elbow should be fully extended. In this
Weakness
position the examiner applies downward pressure on the upper surface of the arm.
Drop arm sign
The patient fully elevates the arm and then slowly reverses the motion in the same arc.
Pain or weakness
If the arm is dropped suddenly or the patient has severe pain the test is considered to
be positive.
Lift off test
The patient internally rotates the shoulder placing the hand on the ipsilateral buttock.
He is then asked to lift the hand off the buttock against resistance. A tear in the
subscapularis muscle produces weakness of this action.
Weakness
Aim
Perform a systematic review and meta-analysis to determine
the diagnostic accuracy of five common clinical tests to
detect SIS
Division of Population Health Sciences
Methods
• PRISMA guidelines
•
Inclusion criteria
1) Study design: prospective or retrospective cohort or cross sectional
studies
2) Patient population: patients (>16 years of age) with a painful shoulder
3) Explanatory variables: any of the five clinical tests reported in the study
4) Setting of care: inpatient and outpatient settings
5) Reference standard: arthroscopy or open surgery
Division of Population Health Sciences
Methods
• Data extraction
• Data synthesis and analysis
– Statistical software STATA version 10.1 – metandi commands
– Bivariate random effects model - summary estimates of sensitivity
and specificity and their corresponding 95% confidence intervals
• Quality assessment
– Quality of Diagnostic Accuracy Tool (QUADAS)
Division of Population Health Sciences
Results
PRISMA flow diagram of the studies
Records identified through database
searching (n = 1330)
Additional records identified through
other sources (n=8)
Records after duplicates removed (n=1338)
Records screened (n=1338)
Records excluded after reading
title/abstract (n=1307)
Full-text articles assessed for
eligibility (n=31)
Excluded (n=15)
Reference test not surgery
(n=12)
Index test used for different
shoulder condition (n=2)
Articles included narrative
review (n=16)
Articles included metaanalysis (n=10)
No relevant patient group (n=1)
The search yielded sixteen
studies including 2390
patients and are carried out
in orthopaedic or
musculoskeletal outpatient
clinics
Results
‘Rule out’ tests
Clinical
test
No. of
Studies
No. of
patients
Pooled
sensitivity
(95% CI)
Pooled
Specificity
(95% CI)
Hawkins
Kennedy
test
6
1029
0.74
(0.57-0.85)
0.57
(0.46-0.67)
Neers sign
5
1127
0.78
(0.68-0.87)
0.58
(0.47-0.68)
Empty can
test
6
695
0.69
(0.54-0.81)
0.62
(0.38-0.81)
Drop arm
test
5
1213
0.21
(0.14-0.30)
0.92
(0.86-0.96)
Lift off test
4
267
0.42
(0.19-0.69)
0.97
(0.79-1.00)
Results
‘Rule in’ tests
Clinical
test
No. of
Studies
No. of
patients
Pooled
sensitivity
(95% CI)
Pooled
Specificity
(95% CI)
Hawkins
Kennedy
test
6
1029
0.74
(0.57-0.85)
0.57
(0.46-0.67)
Neers sign
5
1127
0.78
(0.68-0.87)
0.58
(0.47-0.68)
Empty can
test
6
695
0.69
(0.54-0.81)
0.62
(0.38-0.81)
Drop arm
test
5
1213
0.21
(0.14-0.30)
0.92
(0.86-0.96)
Lift off test
4
267
0.42
(0.19-0.69)
0.97
(0.79-1.00)
Clinical implications
• Lift off test provides strongest evidence to rule in
SIS.
• Management of severity of SIS – physiotherapy or
surgery
• Other predictors of SIS – signs and symptoms
Division of Population Health Sciences
Discussion
• Five clinical tests suggestive of SIS have modest diagnostic
discriminative value when assessed against the surgical
reference standard
• The Hawkins-Kennedy, Neer’s test as well as the empty can
test are more likely to ‘rule out’ SIS when the clinical test
result is negative
• The drop-arm test and the lift-off test are more likely to
‘rule in’ SIS
Division of Population Health Sciences
Limitations
• Setting of care
• Reference standard
• Severity of SIS and subjective nature of tests
• Methodological quality
Division of Population Health Sciences