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Three Part Question

In [adults with a suspected full thickness rotator cuff tear] is [one clinical test better than another] at [diagnosing this injury]

Clinical Scenario

A 45 year old male presents to the emergency department after feeling a wrenching sensation in his shoulder when lifting a box onto an overhead shelf. He cannot actively elevate his arm and radiographs reveal no fracture. You suspect he has a full rotator cuff tear, but wonder what is the best clinical test to confirm your suspicions.

Search Strategy

MEDLINE via the OVID interface 1966–August 2009 week 3; EMBASE 1980–2009 week 36, CINAHL, AMED, SPORTDiscus and the Cochrane database. In addition, the PEDro database was searched.
Medline, CINAHL, AMED, EMBASE, SPORTSDiscus, [{(labral tear.mp OR glenoid adj5 lesion OR exp rotator cuff OR exp shoulder impingement syndrome OR subacromial bursa.mp OR subdeltoid bursa.mp) AND (exp shoulder OR exp shoulder joint OR exp shoulder pain) AND (exp physical examination)] limit to diagnosis (sensitivity). Cochrane database (shoulder AND exam). PEDro database: [rotator cuff OR labral tear OR impingement syndrome].

Search Outcome

Studies of patients with rheumatoid arthritis were excluded from analysis. Single reports of new examination tests performed on patients with known rotator cuff tears were also excluded. One systematic review reported published studies up to April 2007. Four more papers published after this date were found by the search

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Miller et al. 2008 UK	37 patients (46 shoulders) referred to a shoulder orthopaedic surgeon. Exclusion criteria were prior surgery or neurological symptoms. Reference standard test was ultrasonography	Prospective Diagnostic Study	Internal rotation lag sign for subscapularis	Sensitivity 100% Specificity 84%	Performed in a clinic setting, not after acute injury. Recruitment took 6 months, suggesting this is not a consecutive cohort. One examiner only. Sample too small to give meaningful results. Ultrasound as the reference standard test.
			External rotation lag for supraspinatus and infraspinatus	Sensitivity 46% Specificity 94%
			Drop arm test for subscapularis	Sensitivity 73% Specificity 77%
Kim et al. 2007 S.Korea	120 patients (176 shoulders) with shoulder pain in rheumatology clinic. Patients with rheumatoid arthritis excluded. Reference standard test was ultrasonography	Prospective diagnostic study	Gerber’s lift-off test for subscapularis	Sensitivity = 6%, Specificity = 23%	Performed in a clinic setting, not after acute injury. Only one rheumatologist examiner. Ultrasound as the reference standard test.
			Pattes’test	Sensitivity = n/d, Specificity = 86%
			Jobe’s test for supraspinatus	Sensitivity 31% Specificity 52%
Nanda et al. 2008 UK	63 patients referred to a specialist shoulder clinic with symptoms suggestive of rotator cuff injury. Exclusion criteria were shoulder instability and neck or shoulder trauma. Reference standard test was arthroscopy in 50/63, and may have been resolution of symptoms in the other 13 (this is not clear)	Prospective diagnostic study	Drop arm test	Sensitivity=31%, Specificity=75%	Performed in a clinic setting, not after acute injury. Tests performed by a consultant and registrar in shoulder surgery. It is unclear whether the results were based on the 50 patients who had surgery or also included those who did not have surgery. If the latter, there is significant bias from the reference standard. Results not clearly laid out to allow calculation. Lack of sample size estimate and small patient cohort.
			Gerber’s test for infraspinatus	Sensitivity 50% Specificity 82%
			Gerber’s test for subscapularis	Sensitivity 50% Specificity 88%
			Interobserver agreement for clinical examination	No single test had kappa score .0.55
Fodor et al, 2009, Romania	100 consecutive patients (with 130 symptomatic shoulders) in a rheumatology clinic. Excluded patients with trauma, surgery, arthirits or chronic renal disease. Reference standard was ultrasound.	Prospective diagnostic study.	Jobe’s test for supraspinatus	Sensitivity 50% Specificity 84%	Study designed to assess clinical exam for both impingement syndrome and rotator cuff tears. Clinic based assessment rather than at time of injury. Examination performed by one experienced rheumatologist. Ultrasound was the reference standard. Results are not clearly laid out, so it is impossible to check calculation of results.
			Patte’s test and external rotation strength test for infraspinatus	Sensitivity 17% Specificity 83%
			Gerber’s lift test and internal rotation strength test for subscapularis	Sensitivity 86% Specificity 79%
Hughes et al, 2008, Australia	1990 patients with painful shoulder(s), from 13 studies comparing clinical examination to either MR scan or operative findings as a reference standard.	Systematic review	Impingement tests for diagnosing rotator cuff tears	Hawkins- Kennedy test N=639 shoulders. Sensitivity range 69–100% Specificity range 23–66% Horizontal adduction N=639 shoulders Sensitivity range 17–90% Specificity range 23–82% Neer’s test N=639 shoulders Sensitivity range 50–92% Specificity range 27–69%	Heterogeneity between studies meant meta-analysis of results was impossible. This table reports the range of results between studies and not the spread of results. For greater detail please see the paper referenced.
			Supraspinatus tests	Drop arm N=1039 Sensitivity range 4–35% Specificity range 88–100% Full can N=503 shoulders Sensitivity range 42–89% Specificity range 50–91% Painful arc N=639 shoulders Sensitivity range 10–76% Specificity range 47–88% Empty can (Jobe’s test) N=1160 shoulders Sensitivity range 32–99% Specificity range 40–91% Palpation for tendon defect N=151 shoulders Sensitivity range 91–97% Specificity range 75–97%
			Infraspinatus tests	External rotation strength N=701 Sensitivity range 19–84% Specificity range 53–90% Patte’s test N=55 Sensitivity range 83–92% Specificity range 30–61%
			Suscapularis tests	Bear-hug test N=68 Sensitivity 60% Specificity 92% Belly-press test N=68 Sensitivity 40% Specificity 98% Lift-off test N=272 Sensitivity range 0–79% Specificity range 59–100% Napoleon test N=68 Sensitivity 25% Specificity 98%

Comment(s)

There are numerous clinical special tests purported to assess rotator cuff integrity, but there is a mixed picture about their ability to confidently diagnose a full rotator cuff tear.

Clinical Bottom Line

There appears to be no clinical test to diagnose accurately a full thickness rotator cuff tear.

References

1. Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. Archives of Physical Medicine & Rehabilitation. 2008;89(6): 1162-1168.
2. Kim HA, Kim SH, Seo YI. Ultrasonographic findings of painful shoulders and correlation between physical examination and ultrasonographic rotator cuff tear Modern Rheumatology 2007; 17: 213-219.
3. Nanda R, Gupta S, Kanapathipilai P, Liow RYL, Rangan A An assessment of the interexaminer reliability of clinical tests for subacromial impingement and rotator cuff integrity. European Journal of Orthopdaedic Surgery & Traumatology 2008;18:495-500.
4. Fodor D, Poanta L, Felea I, et al. Shoulder impingement syndrome: correlations between clinical tests and ultrasonographic findings. Ortop Traumatol Rehabil 2009;11:120–6.
5. Hughes P, Taylor N, Green R. . Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Aust J Physiother 2008;54: 159–70.