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

• Published in: British Journal of Sports Medicine 2012-11, Vol.46 (14), p.964-978
• Main Authors: Hegedus, Eric J, Goode, Adam P, Cook, Chad E, Michener, Lori, Myer, Cortney A, Myer, Daniel M, Wright, Alexis A
• Format: Article
• Language: English
• Subjects: Accuracy; Adult; Aged; Aged, 80 and over; Agreements; Bias; Diagnosis, Differential; Humans; Medical personnel; Medical tests; Meta-analysis; Middle Aged; Physical Examination - methods; Physical Examination - standards; Physical examinations; Quality; Ratios; Rotator Cuff Injuries; Rupture - diagnosis; Sensitivity and Specificity; Shoulder; Shoulder Impingement Syndrome - diagnosis; Shoulder Joint - injuries; Sports medicine; Statistical analysis; Studies; Systematic review; Tendinopathy - diagnosis; Young Adult
• ISSN: 0306-3674; 1473-0480
• DOI: 10.1136/bjsports-2012-091066

Objective To update our previously published systematic review and meta-analysis by subjecting the literature on shoulder physical examination (ShPE) to careful analysis in order to determine each tests clinical utility. Methods This review is an update of previous work, therefore the terms in the Medline and CINAHL search strategies remained the same with the exception that the search was confined to the dates November, 2006 through to February, 2012. The previous study dates were 1966 – October, 2006. Further, the original search was expanded, without date restrictions, to include two new databases: EMBASE and the Cochrane Library. The Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS 2) tool was used to critique the quality of each new paper. Where appropriate, data from the prior review and this review were combined to perform meta-analysis using the updated hierarchical summary receiver operating characteristic and bivariate models. Results Since the publication of the 2008 review, 32 additional studies were identified and critiqued. For subacromial impingement, the meta-analysis revealed that the pooled sensitivity and specificity for the Neer test was 72% and 60%, respectively, for the Hawkins-Kennedy test was 79% and 59%, respectively, and for the painful arc was 53% and 76%, respectively. Also from the meta-analysis, regarding superior labral anterior to posterior (SLAP) tears, the test with the best sensitivity (52%) was the relocation test; the test with the best specificity (95%) was Yergason's test; and the test with the best positive likelihood ratio (2.81) was the compression-rotation test. Regarding new (to this series of reviews) ShPE tests, where meta-analysis was not possible because of lack of sufficient studies or heterogeneity between studies, there are some individual tests that warrant further investigation. A highly specific test (specificity >80%, LR+ ≥ 5.0) from a low bias study is the passive distraction test for a SLAP lesion. This test may rule in a SLAP lesion when positive. A sensitive test (sensitivity >80%, LR− ≤ 0.20) of note is the shoulder shrug sign, for stiffness-related disorders (osteoarthritis and adhesive capsulitis) as well as rotator cuff tendinopathy. There are six additional tests with higher sensitivities, specificities, or both but caution is urged since all of these tests have been studied only once and more than one ShPE test (ie, active compression, biceps load II) has been introduced w