Which physical examination tests provide clinicians with the most value when examining the shoulder?

There are many tests available to clinicians when performing a physical examination of the shoulder in the attempt to reach an accurate diagnosis. In many instances there is more than one test that can be used to test a structure. The difficulty with physical examination tests recommended for shoulder is that many of these tests are not specific enough to localise one particular structure nor are they sensitive enough to comprehensively lead to diagnosis.

Here’s what they did

This paper in an update of a systematic review and meta-analysis of literature published on shoulder physical examination between 1996- October 2006. The researchers updated their search to February 2012 and added new databases EMBASE and the Cochrane Library with no date restrictions. The Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS 2) was used to critique the quality of the evidence.

Here’s what they found

From this review the following observations regarding specific shoulder tests were made.

There is less optimism that the biceps load II is a diagnostic for SLAP lesions
The belly-off and modified belly-off press tests may be helpful in diagnosing subscapularis tendinopathy
The bony apprehension test may be help diagnose bony instability
The olecranon-manubrium percussion test may be useful in a traumatic injury for bony abnormality requiring referral for x-ray
The passive compression test may be helpful in diagnosing a SLAP lesion
The modified dynamic shear test may be diagnostic of labral tears
The lateral Jobe test may be useful for diagnosing a rotator cuff tear
The shrug sign appears to be a sensitive test for stiffness-related disorders (osteoarthritis and adhesive capsulitis)as well as rotator cuff tendinopathy
The passive distraction test may be able to rule in a SLAP tear if positive

The authors concluded

“There is no one shoulder physical examination test that allows accurate diagnosis of shoulder pathology. “

The Musculoskeletal Elf’s view

The findings of this systematic review indicate that there is no one physical examination test of the shoulder on which a pathognomonic diagnosis can be made. It provides support for a comprehensive clinical examination including history and physical examination.

The authors used the QUADAS-2. This is a tool recommend for use in systematic reviews to evaluate the risk of bias and applicability of primary diagnostic accuracy studies. QUADAS-2, consists of four key domains: patient selection, index test, reference standard, flow and timing. The tool is completed in four phases: 1) state the review question; 2) develop review specific guidance; 3) review the published flow diagram for the primary study or construct a flow diagram if none is reported; 4) judgement of bias and applicability. Each domain is assessed in terms of the risk of bias and the first three are also assessed in terms of concerns regarding applicability. To help reach a judgement on the risk of bias, signalling questions are included. These flag aspects of study design related to the potential for bias and aim to help reviewers make risk of bias judgements.

Do you use physical examination tests for the shoulder? What is your experience of using them? How may the findings of this review influence your clinical practice?

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Here’s what they did

Here’s what they found

The authors concluded

The Musculoskeletal Elf’s view

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