Monday, October 21, 2013

Clinical Exam for Shoulder Injuries: Which are worth the time?

Author: Andrew W Phillips, MD Med
Stanford/Kaiser Emergency Medicine Residency Program

Shoulder injuries are not uncommon in the emergency department (ED), and although shoulder soft tissue injuries are typically non-emergent, the patient can be helped greatly knowing if s/he likely has a serious shoulder injury. Magnetic resonance imaging (MRI), however, is costly and not usually indicated in the ED setting, so the clinician is left with the physical exam. With over 70 different shoulder exams (1), which ones provide enough positive and negative likelihood ratios (LR) to be helpful?  (This free access article explains LR well: Look for a +LR>1.5 and a –LR<0.5 the minimum for clinical significance.)

If you have the time, Luime (3) and Hegedus (4) created what appear to be the definitive reviews to date, and a new, well-powered prospective study is on its way, based on a
recently published protocol (1).  See the Luime article for excellent exam illustrations, or look at Somerville’s free article that includes “physical examination guidelines” as an appendix. For now, here are the best exams and their numbers, based on the Luime and Hegedus review articles. (Note that majority of studies included patients who presented to orthopedics clinics, so these numbers do not represent the general population.)

For shoulder (glenohumeral) instability (essentially weakened tendons or ligaments that increase the risk of dislocation):
1)     Apprehension test
a.       +LR=1.8, -LR=0.23
2)     Relocation test:
a.       +LR=6.5, -LR=0.18
3)     Anterior release test:
a.       +LR=8.3, -LR=0.09
4)     Apprehension & Relocation together
a.       +LR=39, -LR=0.19

For labral tears (note that the “clunk” test does not make the cut):
1)     Biceps load test II
a.       +LR=26, -LR=0.11
2)     Pain provocation test of Mimori
a.       +LR=7.2, -LR=0.03
3)     Internal rotation resistance strength test (Test of Zaslav)
a.       +LR=25, -LR=0.12
4)     Apprehension & Relocation together
a.       +LR=5.4, -LR=0.67

For rotator cuff tears (partial to complete):
1)     Subscapularis                   Lift-off AND resisted IR          
a.       +LR=3.1, -LR=.60
2)     Subscapularis                   Lift-off OR resisted IR                        
a.       +LR=10, -LR=.53
3)     Subacromial impingement   3+ positive exams (Hawkins-Kennedy, Neer, Painful arc, Empty Can, Resisted ER)                                                                  
a.       +LR=2.9, -LR=.34

The take-home message is that some of these tests offer very strong +LR and can almost diagnose the disorder (e.g. biceps load test sporting a +LR of 26). Taking a combination of findings can be helpful as well, as demonstrated by the Hegedus review that combined tests. An MRI may still be indicated, as well as certainly follow up with the patient’s primary care doctor or an orthopedic surgeon, but these tests can go a long way to help clarify the picture.

1. Somerville L, Bryant D, Willits K, Johnson A. Protocol for determining the diagnostic validity of physical examination maneuvers for shoulder pathology. BMC musculoskeletal disorders. 2013;14:60. PubMed PMID: 23394210. Pubmed Central PMCID: 3579687.
2. McGee S. Simplifying likelihood ratios. J Gen Intern Med. 2002 Aug;17(8):646-9. PubMed PMID: 12213147.
3. Luime JJ, Verhagen AP, Miedema HS, Kuiper JI, Burdorf A, Verhaar JA, et al. Does this patient have an instability of the shoulder or a labrum lesion? JAMA. 2004 Oct 27;292(16):1989-99. PubMed PMID: 15507585.
4. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, et al. 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. Br J Sports Med. 2012 Nov;46(14):964-78. PubMed PMID: 22773322.

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