Abstracts & Literature Review 6

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Examination of the Shoulder: The Past, the Present, and the Future

Xiaofeng Jia, MD, PhD, Steve A. Petersen, MD, Abtin H. Khosravi, MS, Venkat Almareddi, MD, Vinodhkumar Pannirselvam, MD, and Edward G. McFarland, MD

J Bone Joint Surg AM 2009;91 Suppl 6:10-18
© 2009 by The Journal of Bone And Joint Surgery, Incorporated

JACO Editorial Reviewer: Steven G. Yeomans, DC, FACO

Published:
Journal of the Academy of Chiropractic Orthopedists
June 2010, Volume 7, Issue 2
Received: June, 2010
Accepted: June 2010

The original article copyright belong s to the original publisher. This review is available from: http://www.dcorthoacademy.com.
© 2010 Yeomans and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Authors’ Abstract: No Abstract included

JACO Editorial Summary:

• The goals of this article include: To provide a current literature review of specific shoulder conditions and the relevant H&P data; to provide a summary of the clinical usefulness of the H&P findings, offer the author’s personal experience with shoulder examination procedures; to create a “modern” version of Codman’s 1934 Table with current statistical methods; and lastly, to speculate on the future roles the H&P will play in the diagnosis and treatment of shoulder conditions.
• The authors studied the pre-, intra-, and postoperative data on 1913 patients treated between 1995 and 2008, paying specific attention to the information gained by the H&P and how that related to the surgical findings in each case.
• A database was set up using subjective outcome measures that included the SF-36, the American Shoulder and Elbow Surgeons shoulder scale, the University of California at Los Angeles (UCLA shoulder scale, and the L’Insalata shoulder questionnaire. Objective measures included ROM, strength tests and provocative tests to elicit diagnosis specific findings.
• Specific diagnoses studied included: rotator cuff disease, AC joint abnormalities, shoulder instability, superior labrum lesions, and biceps tendon tears.
• Diagnostic tests included: the drop-arm sign, the shoulder shrug sign, the Neer impingement sign, the Hawkins-Kennedy impingement sign, the Speed test, the anterior and posterior apprehension tests, the active compression test, the anterior slide test, the lift-off test, the anterior and posterior drawer tests, the painful arc sign, the cross-body adduction test, the AC resisted extension test, the Whipple test, and the external rotation lag sign.
• The statistical analysis included the sensitivity, specificity, and likelihood ratio (LR) calculations.
• Five tables are included that report the sensitivity/specificity/LR’s of each diagnosis with the associated PE test.
• Discussion of each shoulder condition is included with a description of the challenges the clinician faces with each shoulder condition related to the available tests.
• Rotator cuff disease: includes 4 subcategories are described that range between no tearing (only tendinosis/bursitis), partial thickness tear, full thickness tear and massive tear with little ability to clearly differentiate these clinically. The best PE signs include the combination of 3 sepecific tests – weakness in external rotation, a drop arm sign, and a painful arc of motion.
• A full thickness tear (>75% of the tissue) is very common, estimated at 91% chance if >60 years old with the above 3 signs (likelihood ratio = 15). Another study reported 98% if >60 years old with a positive Neer or Hawkins-Kennedy sign + abduction weakness.
• AC joint conditions: Direct pain over the ACJ is still considered the best way to clinically assess for conditions affecting the ACJ. Local anesthetic injection can confirm whether or not the ACJ is the primary pain generator.
• Anterior instability: because of the wide range of “normal” mobility/laxity, one must compare side to side and, include the reproduction of symptoms (apprehension) in order to diagnose this condition with high specificity (95% specificity if symptoms + positive anterior apprehension test, the relocation test, and the surprise test).
• Posterior instability: if a patient can reproduce the subluxation with symptoms of apprehension, this is still considered the best diagnostic criterion. Only a few studies were available for these authors to utilize as this is much less common than anterior dislocations.
• Superior labrum lesions (anterior and posterior lesions): these are difficult to differentiate with physical examination methods. Several tests are offered but reports vary regarding their clinical usefulness and accuracy. Some studies suggested 2 or more tests while others prefer arthroscopy but other studies refute these claims. Hence, currently, there is no universally accepted approach for making the diagnosis.
• Biceps tendon tears: include biceps tenosynovitis, partial biceps tendon tears, biceps tendon subluxations, and biceps entrapment in the joint. Diagnosis is again challenging as the majority of the time, other shoulder injuries simultaneously coexist such as rotator cuff tears or other intra-articular abnormalities. For example, Speed’s Test is neither sensitive nor specific for biceps tendon lesions. Similarly, palpation is challenging as the supraspinatus and the subscapularis tendon insertions are in close proximity to the biceps tendon. The Lift-off test that reproduces anterior shoulder pain may be diagnostic (likelihood ratio of 2.6), but further study is recommended.
• Future forecast: The diagnosis of shoulder conditions by physical examination methods must be a blend of history, physical examination, and imaging to improve the diagnostic accuracy. It is speculated that a computer program could be designed that will take the information derived from these three assessment methods and correlate them resulting in a list of most likely conditions in chronological order. Also, determining the relationship of the physical examination and the treatment outcome (both surgical and non-surgical) may be possible.
• Conclusions: The shoulder continues to be a clinical challenge. Applying this statistical analysis to the various physical examination testing protocols commonly used when evaluating patients with shoulder conditions may not have resulted in a substantial improvement from the original 1934 observations of Codman. Correlating history, exam and imaging information remains the best approach in evaluating patients with shoulder pain.