Physical Examination tests of the shoulder: A systematic review with meta-analysis of
individual tests.
Hegedus, E., Goode, A. & Campbell, S., (2008)
Basically, this article carried out a critique of literature on the diagnostic accuracy of
individual orthopaedic physical examination tests/special tests (OSTs) to see if they are
valuable tests to use in everyday practise.
A generic search strategy was employed using MEDLINE, CINAHL and SPORTDiscus
databases to find studies on diagnostic accuracy, as well as a subject specific strategy
addressing shoulder pathologies and physical examination.
From 922 articles, two independent authors scanned for the inclusion criteria of surgery,
MRI, injection, atleast one physical examination test/special test was studied, if one of the
paired statistics of sensitivity and specificity were reported. There were only 45 articles
which met the inclusion criteria. Each selected study was independently assessed by all
reviewers, any disagreements were concluded by a third authors decision.
Articles were then assessed for quality and data was extracted from them. Quality was
determined by examining external and internal validity, using the Quality Assessment of
Diagnostic Accuracy Studies (QUADAS) tool. Meta-analysis was used on articles representing
both specificity and sensitivity tests: Neer, and Hawkins-Kennedy for impingement are the
two which are relative to us. The article found only 3 articles which fit in their inclusion
criteria therefore there isn’t much evidence to base their findings on.
Meta-analyses results are as followed based on pathology.
Impingement: 4/6 articles addressing OSTs for impingement were of lower design quality by
their definition, they were concerned with bias in the studies. In short, after pooling the
tests for sensitivity and specificity it was was indicated that neither test has diagnostic utility
for impingement. Due to bias, it was recommended to use the supraspinatus/empty can or
infraspinatus tests to confirm impingement due to higher specificity.
Instability: All 5 articles examined attempted to identify anterior shoulder instability.
Results found that apprehension, relocation and anterior release tests appeared diagnostic
of anterior instability, especially when apprehension instead of pain was used as an
indicator of a positive test. 3/5 articles classified as high design quality.
AC joint pathology: Only 3 articles were examined, with findings suggesting that the active
compression test maybe diagnostic but is troublesome in that as the quality of the study
improves the statistics monitoring diagnostic accuracy worsens. However, in three studies
the active compression test was shown to be a specific test that would rule in the AC joint as
a source of shoulder pain if positive.
In short, this article demonstrates that Neer and Hawkins-kennedy are not accurate
diagnostic tests for their stated pathology.
It was found in one well-conducted study that the bear –hug and belly press tests are
valuable as specific tests for ruling in a subscapularis muscle tendon tear when positive. The
external rotation lag sign may be diagnostic of an infraspinatus muscle tear as well as a
specific confirmatory test of the rotator cuffs.
It is suggested that overall these recommendations should be used as a guide and not an
absolute due to the lack of study in this area.
What is already known on this topic
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Orthopaedic special tests (OSTs) are used extensively in clinical practice to detect
shoulder pathology.
OSTs are reported extensively upon in peer-reviewed articles and textbooks.
Varying levels of diagnostic accuracy have been reported for individual OSTs.
The literature examining the diagnostic accuracy of OSTs is generally of poor quality.
What this study adds
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This is the most comprehensive systematic review with meta-analysis of the
diagnostic value of individual orthopaedic special tests to date.
Meta-analysis for the Neer test of impingement, the Hawkins−Kennedy test of
impingement and the Speed test for a SLAP lesion shows these tests to have no
discriminatory ability for shoulder diagnosis.
Meta-analysis for other OSTs was not possible either because there is not enough
diagnostic accuracy research about the test or because statistical heterogeneity
between studies did not allow for summary results.
Recommendations are as follows:
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The Hawkins−Kennedy test may serve as a screen and either the
supraspinatus/empty can or infraspinatus test may serve as a confirmatory test for
impingement.
The supine impingement test may be valuable, when negative, as a screen for any
rotator cuff tear.
The ERLS test may have value as a specific test for any rotator cuff tear.
The hornblower's sign may be diagnostic of severe degeneration or absence of the
teres minor muscle.
The external rotation lag sign (ERLS) may be diagnostic of an infraspinatus muscle
tear.
The bear-hug and belly press tests may be valuable as specific tests for ruling in a
subscapularis muscle tear.
The biceps load II test appears diagnostic for SLAP lesions.
The apprehension, relocation and anterior release tests all appear to be diagnostic of
anterior instability, especially when apprehension is used as a “positive” test instead
of pain.
For AC joint pathology, pain with palpation may be valuable as a screen when
negative due to high sensitivity and the active compression test may have value as a
confirmatory test when positive due to its high specificity.