A 24-year-old man with a history of shoulder complaints presents to his primary care physician. At age 16 years, his shoulder was injured during karate. He recovered and did not notice recurrence of symptoms. At age 21 years, while throwing a baseball, he developed sudden sharp left shoulder pain, with a popping noise. He sensed that the arm stretched out of range. He experienced a short period with shoulder discomfort, followed by recovery.
Recently, he has started playing tennis and experiences shoulder pain that requires cessation of play. On examination, the shoulder displays no swelling or atrophy. Internal and external rotation is somewhat painful but not limited. His neck moves normally, through the full range of motion, without pain. In considering the differential diagnosis, one might wonder whether the medical history suggests instability of the shoulder and which physical examination findings confirm the diagnosis.
Why Is the Diagnosis Important?
The shoulder's wide range of motion gives great freedom of action because of the shallow structure of the glenoid fossa but lends minimal bony support for the large humeral head (Figure 44-1). The minimal bony support creates a delicate balance between muscular and ligamentous strength.1 Each year, 30% to 40% of adults experience shoulder discomfort, causing 1% to 5% of them to visit a general practitioner.2, 3, 4, 5, 6, 7, and 8 Although about half of the primary care patients with shoulder discomfort recover within a year, a substantial number experience continued discomfort or develop recurrent pain.6, 7, 9 Instability of the glenohumeral joint, frequently combined with tears of the labrum (the cartilage rim of the glenoid), creates continued problems for some of these patients.
Instability occurs when the shoulder's stabilizing structures provide too little control as the humerus moves on the glenoid. As a result, the upper arm fails to stay properly located in the glenoid fossa during normal motion. Dislocation occurs when the humeral head has no attachment to the glenoid fossa; thus, the articular surfaces separate completely. Subluxation is a symptomatic translation of the humeral head without complete separation.1, 10, 11, 12 The resultant symptoms and signs allow clinical classification according to the degree (dislocation or subluxation) and the direction (anterior, posterior, inferior, or multidirectional) of the observed defects.1, 10, 11, and 12 The incidence of shoulder dislocation is about 1.7% of the general population.13 Scientific literature shows no available data on the incidence or prevalence of subluxation.
1, 10, 11 of strengthening the muscles of the shoulder and increasing the coordination of the shoulder girdle. The alternative is surgery, a useful treatment if the patient has recurrent dislocation without generalized ligamentous laxity or multidirectional instability.1, 10, 11
Labral lesions are associated with instability, although they can occur without instability because of injuries or degeneration of the shoulder joint.14, 15, and 16 Labral lesions are classified according to their anatomic location and type of tear.14 A frequently described labral tear is the superior labrum anterior-posterior (SLAP) lesion.14, 15 The SLAP lesion is a tear located at the superior part of the labrum that runs from the anterior to the posterior part, with or without lesions at the attachment of the long head of the biceps muscle. Surgical repairs of labral tears require an open or arthroscopic procedure.14, 15
The shoulder is suited for mobility. The motions of the upper arm are the result of simultaneous motions in the glenohumeral joint, the acromioclavicular joint, the sternoclavicular joint, and the scapulothoracic junction.17 Shoulder instability and labral lesions affect the functioning of the glenohumeral joint.
The glenohumeral joint is the articulation between the large humeral head and the small glenoid fossa of the scapula (Figure 44-1). The fossa is extended by the glenoid labrum (a cartilage rim) that increases the depth and surface area of the articulation.1, 14 The labrum cushions the apposition of the humeral head on the glenoid fossa, similar to the function of the menisci in the knee. A loose capsule surrounds the joint, strengthened by 3 thickenings called the anterior glenohumeral ligaments.1
Seventeen muscles create the movement of the shoulder.17 The movement is a complex and subtle interaction between the 4 articulations and contributing muscles. Although knowledge of the biomechanics of the shoulder is growing, knowledge about the relationship with clinical diagnosis is still limited. An important finding related to instability is the functioning of the 4 muscles of the rotator cuff (infraspinatus, supraspinatus, teres minor, and subscapularis). These muscles play the most important roles in stabilizing the glenohumeral joint, even when the arm is in a neutral or relaxed position.17
Mechanism of Injuries Resulting in Instability or Labral Tears
Instability has 3 causes. A generally known cause of anterior luxation includes a sudden traumatic fall with an outstretched arm (seen frequently in skiers) or blocked throwing movement of the arm. Usually, this luxation will be reduced in the field or the hospital emergency department. More typically, primary care physicians observe a second type of shoulder instability, created without obvious trauma and attributed to chronic gradual stretching during overhead activities in work or sport.10 Finally, hyperlaxity of the glenohumeral capsule, a less common cause of instability and often without any trauma,1, 10, 11, and 12 is caused by congenital excessive joint laxity that allows the shoulder to slip in different directions (multidirectional instability). Some patients with hyperlaxity of the glenohumeral capsule can dislocate their shoulder voluntarily.
The mechanisms that create labral tears without dislocation are unclear.16 The shoulder capsule and ligaments are attached to the labrum; thus, strong forces on these structures are also potentially harmful to the labrum. The occurrence of labral tears has been predominantly studied in patients with throwing injuries.18 In this group, tears are associated with strong forces of strain on the anterior capsule, ligaments, and labrum generated during the throwing motion. Labral tears are distinct from rotator cuff tears. A labral tear involves a tear of cartilage, whereas a rotator cuff tear occurs in one of the tendons of the rotator cuff muscles. Instability of the joint or labral tears can occur with rotator cuff injuries. However, rotator cuff injuries do not normally create dislocations or labral tears. Their symptoms might be different, although it is not clear from the current evidence.
The diagnosis of an acute shoulder dislocation is easy to establish. It is a painful condition and the patient will hold the arm in a fixed position (Figure 44-2).1, 10, 11, and 12 However, patients with shoulder instability without dislocation present in a more subtle way. Some patients may complain about a “dead arm” feeling.1, 10 Symptoms of pain and functional disability seem to be nonspecific for the presence of instability.1, 19 Instability of the shoulder should be considered when patients have shoulder discomfort without clear restriction of motion. A history of dislocation increases the likelihood of recurrent instability. Instability occurs more commonly in young people, although traumatic dislocation also occurs in older patients.1, 13
Radiograph of Shoulder Luxation
The clinical examination of the shoulder for instability is performed to evoke recurrence of the symptoms (provocation tests) or to determine laxity of the glenohumeral joint (Table 44-1).1, 10 In a provocation test, the humeral head is placed in a position of imminent subluxation or dislocation, which makes the patient recognize the pain-provoking movement and react with anticipated fear or pain (an apprehension test) (Figure 44-3A, C). Laxity tests of the shoulder evaluate the amount of translation of the humeral head on the glenoid in different positions of the humerus in the anterior, posterior, and inferior directions. As opposed to apprehension tests, these laxity tests are not intended to evoke discomfort.
Clinical Tests to Evaluate Anterior Instability of the Shoulder
A, Apprehension test, although of limited clinical value because of low specificity, is included as part of a sequence of tests for shoulder instability. It is conducted with the patient sitting or standing, with the arm placed in 90-degree abduction and 90-degree external rotation, and the elbow flexed 90 degrees. Pressure is applied to the posterior aspect of the humerus. B, Relocation test, performed to relieve symptoms (pain and apprehension) of instability, is conducted with the patient supine and the arm abducted to 90 degrees and externally rotated to 90 degrees. Downward (posterior) pressure is applied to the humeral head. C, The anterior release test is conducted in a similar manner as the relocation test, then the examiner's hand is removed suddenly, releasing pressure on the humeral head.
Table 44-1Clinical Tests for Instability and Laxity |Favorite Table|Download (.pdf) Table 44-1 Clinical Tests for Instability and Laxity
|Diagnostic Test ||Provocation ||Patient Positioning ||Arm Positioning ||Technique ||Outcome |
|Provocation/Relief Tests for Instability |
|Relocationa ||Pain and apprehension ||Supine ||Abducted to 90 degrees and externally rotated to 90 degrees ||Humeral head pressed posteriorly while arm is externally rotated ||Relieves pain and apprehension |
|Anterior releasea ||Pain and apprehension ||Supine ||Abducted to 90 degrees and externally rotated to 90 degrees ||Same as relocation test; then posterior pressure is suddenly released ||Pain or apprehension |
|Apprehensiona ||Pain and apprehension ||Sitting or standing ||90-Degree abduction and full external rotation ||Arm is externally rotated while pressure is applied anteriorly to humeral head ||Pain or apprehension |
|Clunk ||Clunk or grinding ||Supine ||Full abduction ||Arm is rotated in full external rotation, caput humeri is pushed slightly in anterior direction ||Clunk or grinding |
|Laxity Tests for Instability |
|Load and shift anterior or posterior ||Anterior or posterior laxity ||Sitting, standing, or supine ||Neutral position ||Humeral head is fixed by clinician's hand; clinician tries to shift humeral head in anterior (or posterior) direction ||Does not evoke discomfort; degree of humeral head translation on the glenoid in different positions of the humerus is evaluated using the Hawkins grading schemeb |
|Sulcus sign ||Inferior laxity ||Sitting or standing ||Neutral position ||Arm is pulled vertically downward ||Positive when sulcus becomes visible between acromion and humeral head |
|Provocation/Relief Tests for Labral Tears |
|Biceps load I ||Pain ||Supine ||Arm is abducted 90 degrees, elbow is flexed 90 degrees ||Clinician applies flexion pressure as patient resists ||Positive if pain occurs |
|Biceps load IIc ||Pain ||Supine ||120-Degree abduction ||Clinician applies lateral force as patient resists ||Positive if pain occurs |
|Mimoric ||Pain and apprehension ||Sitting or standing ||Arm is abducted 90 degrees, elbow is flexed 90 degrees, forearm is supine ||Forearm is brought from maximum supination to maximum pronation ||Positive if pain occurs |
|Zaslavc ||Compares strength in internal rotation to that of external rotation, excluding impingement from labral tears ||Sitting or standing ||Arm is in 90-degree abduction and 80-degree external rotation, elbow is flexed 90 degrees ||Patient resists external rotation force applied by the clinician, followed by applied internal rotation force ||Positive (labral tear present) when the patient has good strength against external rotation and apparent weakness against internal rotation |
|Active compression (O’Brien) ||Pain and relief ||Sitting or standing ||Arm is in 90-degree forward flexion, 10 to 15-degree abduction, and full internal rotation ||Clinician stands in front of patient and arm is pushed down as patient resists; repeated with arm in external rotation ||Positive if pain elicited with first maneuver is reduced or eliminated in the second |
|Compression rotation ||Pain or clicking ||Supine ||Arm at 90-degree abduction, elbow in 90-degree flexion ||Axial load placed on shoulder while rotated and circumducted (note McMurray knee test) ||Positive if pain or clicking occurs |
|SLAP-prehension ||Pain or clicking ||Sitting or standing ||Arm at 90-degree forward flexion ||Arm is rotated internally in 90-degree flexion of the humerus ||Positive if pain or clicking occurs |
|Speed ||Pain in the anterior shoulder ||Sitting or standing ||90-Degree elevation ||Downward force applied to forearm, full supination of forearm, and elbow is fully extended ||Positive if pain occurs |
|Tenderness of bicipital groove ||Pain ||Sitting ||Neutral ||Palpating the bicipital groove ||Positive if pain occurs |
|Yergason ||Pain in the biceps tendon ||Sitting with elbow at 90 degrees ||Neutral ||Patient supinates forearm against clinician's resistance, who simultaneously palpates biceps tendon ||Positive if pain occurs |
To assess the amount of translation, rehabilitation specialists and orthopedic surgeons use a classification system such as the Hawkins grading scheme. Grade 0 denotes little to no movement, grade 1 denotes the humeral head moves onto the glenoid rim, grade 2 indicates the humeral head can be dislocated but spontaneously relocates, and grade 3 indicates the humeral head does not relocate when the pressure is removed.1, 20 In the Hawkins scheme, grades 1 to 3 are considered positive outcomes on a laxity test.
When laxity is present in more than one direction, the diagnosis of multidirectional instability is considered and the patient should be examined for generalized ligamentous laxity (laxity in more joints of the body).1, 10, 11, 12 There are no uniformly accepted clinical criteria for generalized ligamentous laxity. One might suspect this type of laxity when finding positive laxity tests in both shoulders. Other examples of hyperlaxity include the ability to hyperextend the elbows and a positive thumb-to-forearm test, whereby the patient can pull his or her thumb back to the point of touching the forearm. Typically, such patients will know that they can demonstrate their loose joints.
Patients with labral tears present with a variety of symptoms.16 Snyder14 suggested that the most common clinical symptoms are pain with overhead activities, deep shoulder pain, or painful catching, popping, or clicking. Stetson and Templin21 suggested that these symptoms were not specific for labral tears because they mimic the presence of impingement disorders, rotator cuff tears, or other shoulder problems. Although an obvious clinical presentation for labral tears cannot be described, clinicians should consider the diagnosis when the shoulder pain is related to a traumatic injury that involves substantial forces on the glenohumeral joint (eg, falling while skiing).
Clinical tests for detecting labral tears evoke symptoms by compressing the humerus into the glenoid in an attempt to catch the labral fragment between the bony structures (compression rotation test).22 Other eponymous tests to evoke symptoms by rotating the humerus passively or actively, such as the pain provocation test of Mimori et al,18 are shown in Figure 44-4. Alternative physical examination maneuvers reproduce shoulder symptoms by asking the patient to resist the force of the clinician while the arm is held in a fixed position, such as the biceps load II test23 shown in Figure 44-4.
Clinical Tests for Labral Tears
A, Biceps load test II is performed with the patient supine, the arm is placed in 120-degree abduction (90-degree abduction in biceps load test I), and the elbow is placed in 90-degree flexion. The patient is asked to resist the lateral force applied by the examiner. B, In the pain provocation test of Mimori, the arm is placed in 90-degree abduction, the elbow in 90-degree flexion, and the forearm in maximum supination. To provoke symptoms, the examiner moves the forearm into maximum pronation. C, Internal rotation resistance strength test (test of Zaslav) is conducted with the patient standing or sitting, with the humerus in 90-degree abduction and 80-degree external rotation. The patient is asked to resist an external rotation force applied by the examiner and then to resist an applied internal rotation force.
Signs and symptoms for shoulder instability must be recorded accurately to add appropriate diagnostic information. We reviewed the literature on the accuracy of diagnostic studies for shoulder instability.
This review is based on the guidelines for systematic reviews of studies evaluating the accuracy of diagnostic tests24 identified through the MEDLINE (1966-2003), EMBASE (1980-2001), and CINAHL (1982-2001) databases. To retrieve all relevant publications related to diagnosing shoulder complaints in adults, the term “exp shoulder” was searched. In addition, text word searches were completed for “glenohumeral,” “scapula,” “clavicula,” “acromion,” “rotator cuff,” “supraspinatus,” “supra-spinatus,” “infraspinatus,” “infra-spinatus,” “serratus anterior,” and “subscapularis.” Diagnostic studies were retrieved by exploding the phrase “sensitivity and specificity,” with additional text word searches of “specificity,” “false negative,” “screening,” and “accuracy” based on the search strategy of Deville et al.25 Bibliographies of known primary and review articles were examined. One reviewer (J.J.L.) screened abstracts of the retrieved citations on clinical tests, sensitivity and specificity figures, and shoulder pain. Relevant articles were researched and their reference lists were screened to find additional studies.
We selected studies that compared a clinical test to surgical or arthroscopic findings, rather than noninvasive imaging tests (eg, magnetic resonance imaging, ultrasonography, or computed tomography). Although these imaging tests may be useful in confirming the presence of instability or a labral tear, they have a sensitivity of only 60% to 90%, depending on the type of injury26 and in comparison with surgery or arthroscopy. Approximately 10% to 20% of patients with a normal reading on shoulder magnetic resonance imaging or ultrasonography26 may still have shoulder instability or labral tears. Thus, these noninvasive tests might ultimately prove useful as a pragmatic reference standard for some physicians, although the presence of verification bias (no surgery or arthroscopy implemented when the noninvasive study result is normal) and possible low sensitivity create uncertainty when the utility of the clinical examination is reviewed.
For each study, details were extracted on study population (setting, sampling, age, sex, and diagnosis), clinical tests, reference tests, and outcome (sensitivity and specificity). When raw data were available, the likelihood ratios (LRs) were calculated for individual findings, thereby describing the increase in odds that the patient had shoulder instability when a symptom or sign was present or the opposite effect when a sign or symptom was absent.
The methodologic quality of the studies was evaluated by 2 reviewers (A.P.V., J.J.L.) with the Quality Assessment of Diagnostic Accuracy Studies checklist.27 This list includes 14 questions about the spectrum of patients studied, selection criteria, test verification, test description, blinding, uninterpretable results, and study withdrawals. These questions could be scored as positive if the item was fulfilled, negative if the item was not fulfilled, or unclear if the item was not described. The limitations of each study were described. The studies were not allocated into arbitrary categories of low, medium, or high quality.
Our search strategy used a broad spectrum of terms for the shoulder, yielding about 21 000 articles. Combined with the search strategy of Deville et al25 on diagnosis, this resulted in 1449 abstracts from the 3 databases. About 130 abstracts contained information on shoulder disorders and diagnostic outcome measurements. However, most of the articles evaluated sonography vs surgery, magnetic resonance imaging vs surgery, or one type of magnetic resonance imaging vs another type.
Formal reviews were conducted for 35 articles that evaluated clinical tests. Seventeen of these studies16, 18, 19, 21, 22, and 23, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38 met the selection criteria for inclusion in this review (Table 44-2). Eighteen studies were excluded: 11 because no information on instability or IAP was presented,39, 40, 41, 42, 43, 44, 45, 46, 47, 48, and 49 4 because data were missing on sensitivity and specificity or clinical tests,50, 51, 52, and 53 and 3 because they were published in French.54, 55, and 56 Of the 17 studies that were selected, 5 enrolled patients when the clinician suspected shoulder instability19, 33, 35, 37, 38 and 12 enrolled patients when the clinician suspected labral tears or other IAP.16, 18, 21, 22, 23, 28, 29, 30, 31, and 32, 34, 36 All the studies were conducted in orthopedic clinics. Each study evaluated a varying number of clinical tests but lacked data on patient medical history. Surgery was used as a reference test in 6 studies,19, 29, 30, 33, 35, 37 and arthroscopy in 11.16, 18, 21, 22, and 23, 28, 31, 32, 34, 36, 38 The apprehension test,19, 38, 39 relocation test,19, 38 active compression test,21, 29 anterior slide test,22, 34 and the test of Speed30, 38 were evaluated in more than 1 study. Two studies reported the clinical examination of the shoulder under anesthesia with the same protocol.33, 37 These studies were not pooled because of lack of clinical homogeneity in study populations. Although most studies had the same inclusion criterion for participant selection (having surgery or arthroscopy for shoulder complaints), the selection standards for undergoing surgery or arthroscopy were unclear. Hence, the constitution of the population might have differed. In addition, different end points of the diagnoses made it impossible to evaluate the influence of the diagnostic threshold for sensitivity and specificity.
Table 44-2Study Characteristics |Favorite Table|Download (.pdf) Table 44-2 Study Characteristics
|Source, y ||Selection Criteria ||Total No. of Participants (% of Women) ||Mean Age, y ||Index Test ||Limitationsa |
|Reference Test Arthroscopy; Retrospective Design |
|Berg and Ciullo,36 1998 ||Identified SLAP lesions during arthroscopy ||66 (NA) ||NA ||SLAP-prehension test ||b, d, f, g |
|Reference Test Arthroscopy; Prospective Design |
|Guanche and Jones,16 2003 ||First arthroscopy for shoulder pain, complete range of motion under anesthesia ||61 (19) ||38 ||Active compression test; anterior apprehension test; crank test; relocation test; test of Speed; test of Yergason; tenderness in bicipital groove ||e |
|Kibler,34 1995 ||Isolated glenoid labral tear, partial-thickness rotator cuff pathology, Bankart lesion, capsular deficiency, or 25-degree internal rotation deficit ||226 (33) ||NA ||Anterior slide test ||a, b, c, d, f, g, h |
|Kim et al,32 1999 ||Arthroscopy for unilateral recurrent anterior shoulder dislocation (based on physical examination, plain radiograph, and MRI) with a Bankart lesion ||75 (15) ||25 ||Biceps load test I ||a, b, e, f |
|Exclusion: multidirectional instability |
|Kim et al,23 2001 ||Arthroscopy for shoulder problems ||127 (30) ||31 ||Biceps load test II ||a, b, e |
|Exclusion: dislocation; stiff shoulder |
|Liu et al,28 1996 ||Shoulder surgery after failure of conservative treatment ||62 (22) ||28 ||Crank test ||b, d, e |
|Exclusion: traumatic dislocation; weakness of subscapularis |
|McFarland et al,22 2002 ||Diagnostic arthroscopy for shoulder pain ||426 (NA)b ||NA ||Compression rotation test; anterior slide test; active compression test ||a |
|Mimori et al,18 1999 ||Shoulder pain during throwing motions ||32 (6) ||21 ||Crank test; anterior apprehension test in external and internal rotation ||a, b, c, f |
|Exclusion: instability; indications of rotator cufftears on MRI or arthrography |
|Stetson and Templin,21 2002 ||Diagnostic arthroscopy after failure of conservative treatment ||65 (31) ||46 ||Crank test; active compression test ||a, b, f, h |
|T’Jonck et al,38 2001 ||Shoulder arthroscopy due to disabling shoulder pain ||71 (45) ||NA ||Active compression test; apprehension test; clunk test; lift-off test; load-and-shift test; posterior stress test; release test; relocation test; resistance test external rotation; test of Speed; sulcus sign ||a |
|Exclusion: >65 y; previous surgery of shoulder; interaction with complaints in elbow or neck |
|Zaslav,31 2001 ||Shoulder surgery after failure of conservative treatment; positive Neer overhead sign ||110 (41)c ||44 ||Internal rotation resistance strength test ||b |
|Reference Test Surgery; Prospective Design |
|Bennett,30 1998 ||Surgery for shoulder pain ||45 (31) ||NA ||Test of speed ||a, b |
|Cofield et al,33 1993 ||Surgery after referral for suspected recurrent instability ||55 (27) ||29 ||Laxity tests under anesthesia in anterior, posterior, inferior, anterior-inferior and posterior-inferior direction ||a, b, e |
|Gross and Distefano,35 1997 ||Subluxation or gross dislocation on examination under anesthesia; abnormal excursion during arthroscopic examination; Hill-Sachs lesion or Bankart lesion ||82 (38)d ||37 ||Anterior release test ||a, b, e, f |
|O’Brien et al,29 1998 ||Shoulder pain ||268 (NA) ||NA ||Active compression test ||a, b, c, d, e, f, g, h |
|Oliashirazi et al,37 1999 ||Shoulder surgery for unilateral traumatic recurrent anterior instability ||30 (17) ||23 ||Laxity tests under anesthesia in anterior, posterior, inferior, anterior-inferior and posterior-inferior direction ||a, e, f |
|Speer et al,19 1994 ||Shoulder surgery; subtle anterior instability ||100 (NA) ||NA ||Relocation test apprehension test ||a, e |
|Exclusion: treatable/observable rotator cuff lesions; multidirectional instability |
Accuracy of Signs and Symptoms Related to Instability and Labral Tears
No diagnostic studies assessed the value of history taking in diagnosing instability. Four provocation tests for instability are presented in Table 44-3. The relocation test38 and the anterior release test35 have the best properties for increasing the likelihood of instability (relocation test38: positive LR, 6.5; 95% confidence interval [CI], 3.0-14; and negative LR, 0.18; 95% CI, 0.07-0.45; anterior release test35: positive LR, 8.3; 95% CI, 3.6-19; and negative LR, 0.09; 95% CI, 0.03-0.27). The relocation test does not work as well in determining more subtle degrees of anterior instability as opposed to more obvious cases of instability, although we were unable to evaluate the CI around the LRs for detecting less significant instability.19 The apprehension test and the clunk test were both of limited value because of low specificity and low sensitivity, respectively.
Table 44-3Diagnostic Accuracy of Physical Examination for Instability of the Shoulder |Favorite Table|Download (.pdf) Table 44-3 Diagnostic Accuracy of Physical Examination for Instability of the Shoulder
|Index Test and Source ||Diagnosis ||No. of Shoulders ||Sensitivitya ||Specificitya ||LR+ (95% CI) ||LR– (95% CI) |
|Provocation Tests |
|Apprehension test |
|T’Jonck et al,38 2001 ||Instability ||72 ||0.88 (23/26) ||0.50 (23/46) ||1.8 (1.3-2.5) ||0.23 (0.08-0.69) |
|Speer et al,19 1994 ||Subtle anterior instability || || || || || |
|Pain || ||100 ||0.54 ||0.44 ||…b ||… |
|Apprehension || ||100 ||0.68 ||1.0 ||… ||… |
|Relocation test |
|T’Jonck et al,38 2001 ||Instability ||72 ||0.85 (22/26) ||0.87 (40/46) ||6.5 (3.0-14) ||0.18 (0.07-0.45) |
|Speer et al,19 1994 ||Subtle anterior instability || || || || || |
|Pain || ||100 ||0.30 ||0.58 ||… ||… |
|Apprehension || ||100 ||0.57 ||1.0 ||… ||… |
|Clunk test |
|T’Jonck et al,38 2001 ||Instability ||72 ||0.35 (9/26) ||0.98 (45/46) ||16 (2.1-119) ||0.67 (0.5-0.89) |
|Anterior release test |
|T’Jonck et al,38 2001 ||Instability ||72 ||0.85 ||0.87 ||… ||… |
|Gross and Distefano,35 1997 ||Occult instability ||100 ||0.92 (34/37) ||0.89 (40/45) ||8.3 (3.6-19) ||0.09 (0.03-0.27) |
|Laxity Tests |
|Load and shift posterior test |
|T’Jonck et al,38 2001 ||Instability ||72 ||0 (0/26) ||1.0 (46/46) ||1.7 (0-83) ||0.99 (0.93-1.1) |
|Sulcus sign |
|T’Jonck et al,38 2001 ||Instability ||72 ||0.31 (8/26) ||0.89 (41/46) ||2.8 (1.0-7.7) ||0.78 (0.59-1.0) |
|Load and shift anterior test |
|T’Jonck et al,38 2001 ||Instability ||72 ||0.54 (14/26) ||0.78 (36/46) ||2.5 (1.3-4.8) ||0.59 (0.38-0.92) |
|Examination under anesthesia |
|Cofield et al,33 1993 ||Instability ||55 ||1.0 (25/25) ||0.93 (28/30)c ||13 (3.9-43) ||0.02 (0-0.31) |
|Oliashirazi et al,37 1999 ||Anterior instability ||60 ||0.83 (25/30) ||1.0 (30/30) ||51 (3.2-80) ||0.18 (0.08-0.38) |
Establishment of instability was not confirmed or ruled out with the sulcus sign38 or the load and shift anterior posterior laxity tests.38 The likelihood of instability increased when laxity tests were performed under anesthesia (positive LR, 13; 95% CI, 3.9-43)33; however, these tests cannot be performed in the general medical practice because of the use of anesthesia.
The possibility of detecting labral tears by arthroscopy has renewed interest in clinical tests for detecting affected patients. Thirteen studies 16, 18, 21, 22, and 23, 28, 29, 30, 31, and 32, 34, 35, and 36 have evaluated 14 clinical signs, and 8 of these18, 21, 22, 23, 28, 29, 32, 34 allowed calculation of positive and negative LRs (Table 44-4). The anterior slide test,22, 34 the crank test,16, 21, 28 and the active compression test16, 21, 22, 29 were promising when their designers evaluated them. However, the accuracy and LRs found by other researchers were far less hopeful. Therefore, optimism should be reserved for test results that have not been duplicated in subsequent studies. The biceps load I test32 (positive LR, 29; 95% CI, 7.3-115), the biceps load II test23 (positive LR, 26; 95% CI, 8.6-80), the pain provocation test of Mimori et al18 (positive LR, 7.2; 95% CI, 1.6-32), and the internal rotation resistance strength test31 (positive LR, 25; 95% CI, 8.1-76) need confirmation before they become widely adopted. Conflicting evidence was found for the test of Speed.16, 30
Table 44-4Diagnostic Accuracy of Physical Examination for Labral Tears |Favorite Table|Download (.pdf) Table 44-4 Diagnostic Accuracy of Physical Examination for Labral Tears
|Index Test ||Diagnosis ||No. of Shoulders ||Sensitivitya ||Specificitya,b ||LR+ (95% CI)b ||LR– (95% CI)b |
|Anterior Apprehension |
|Guanche and Jones,16 2003 ||Labral tears (including SLAP) ||60 ||0.40 ||0.87 ||… ||… |
|Guanche and Jones,16 2003 ||SLAP lesions ||60 ||0.30 ||0.63 ||… ||… |
|Active Compression (O’Brien Test) |
|Stetson and Templin,21 2002 ||Labral tears ||65 ||0.54 (14/26) ||0.31 (12/39) ||0.8 (0.5-1.2) ||1.5 (0.8-2.8) |
|O’Brien et al,29 1998 ||Labral tears ||206 ||1.0 (53/53) ||0.98 (150/153) ||21 (10 42) ||0.01 (0-0.16) |
|O’Brien et al,29 1998 ||Acromial joint pathology ||212 ||1.0 (55/55) ||0.96 (150/157) ||44 (16-123) ||0.01 (0-0.16) |
|McFarland et al,22 2002 ||SLAP lesions ||409c ||0.47 (18/38) ||0.55 (203/371) ||1.0 (0.7-1.4) ||0.96 (0.70-1.3) |
|Guanche and Jones,16 2003 ||SLAP lesions ||60 ||0.54 ||0.47 ||… ||… |
|Guanche and Jones,16 2003 ||Labral tears (including SLAP) ||60 ||0.63 ||0.73 ||… ||… |
|Anterior Slide |
|Kibler,34 1995 ||Superior glenoid labral tear ||226 ||0.78 (69/88) ||0.92d (125/138) ||8.3 (4.9-14) ||0.24 (0.16-0.36) |
|McFarland et al,22 2002 ||SLAP lesions ||419c ||0.07 (3/38) ||0.83 (62/381) ||0.5 (0.2-1.5) ||0.99 (1.1-1.2) |
|Biceps Load I |
|Kim et al,32 1999 ||SLAP lesions ||74 ||0.83 (10/12) ||0.98 (62/63) ||29 (7.3-115) ||0.09 (0.01-0.58) |
|Biceps Load II |
|Kim et al,23 2001 ||SLAP lesions ||127 ||0.90 (35/38) ||0.96 (85/89) ||26 (8.6-80) ||0.11 (0.04-0.28) |
|Compression Rotation |
|McFarland et al,22 2002 ||SLAP lesions ||303c ||0.24 (7/29) ||0.76 (207/274) ||1.0 (0.5-2.0) ||1.0 (0.81-2.1) |
|Liu et al,28 1996 ||Labral tears ||62 ||0.91 (29/32) ||0.93 (28/30) ||14 (3.5-52) ||0.10 (0.03-0.29) |
|Stetson and Templin,21 2002 ||Labral tears ||65 ||0.46 (12/26) ||0.56 (22/39) ||1.1 (0.6-1.9) ||0.95 (0.61-1.5) |
|Guanche and Jones,16 2003 ||Labral tears (including SLAP) ||60 ||0.40 ||0.73 ||… ||… |
|Guanche and Jones,16 2003 ||SLAP lesions ||60 ||0.39 ||0.67 ||… ||… |
|Internal Rotation Resistance Strength |
|Zaslav,31 2001 ||Internal articular derangement ||110 ||0.88 (23/26) ||0.96 (81/84) ||25 (8.1-76) ||0.12 (0.04-0.35) |
|Pain Provocation Test of Mimori |
|Mimori et al,18 1999 ||Superior labral tears ||32 ||1.0 (22/22) ||0.90 (9/10) ||7.2 (1.6-32) ||0.03 (0-0.47) |
|Guanche and Jones,16 2003 ||Labral tears (including SLAP) ||60 ||0.44 ||0.87 ||… ||… |
|Guanche and Jones,16 2003 ||SLAP lesions ||60 ||0.36 ||0.63 ||… ||… |
|Berg and Ciullo,36 1998 ||SLAP lesions ||66 ||0.82 (54/66) ||… ||… ||… |
|Tenderness of Bicipital Groove |
|Guanche and Jones,16 2003 ||Labral tears (including SLAP) ||60 ||0.44 ||0.40 ||… ||… |
|Guanche and Jones,16 2003 ||SLAP lesions ||60 ||0.48 ||0.52 ||… ||… |
|Test of Speed |
|Bennett,30 1998 ||Biceps pathology (including labral tears) ||46 ||0.90 (9/10) ||0.14 (5/36) ||1.1 (0.8-1.3) ||0.72 (0.10-5.5) |
|Guanche and Jones,16 2003 ||Labral tears (including SLAP) ||60 ||0.18 ||0.87 ||… ||… |
|Guanche and Jones,16 2003 ||SLAP lesions ||60 ||0.09 ||0.74 ||… ||… |
|Test of Yergason |
|Guanche and Jones,16 2003 ||Labral tears (including SLAP) ||60 ||0.09 ||0.93 ||… ||… |
|Guanche and Jones,16 2003 ||SLAP lesions ||60 ||0.12 ||0.96 ||… ||… |
Limitation of the Literature
The results of the presented studies pose some limitations and should be interpreted with caution (Table 44-2). The diagnostic studies were all executed in specialized care; therefore, the optimal spectrum of disease was defined as patients visiting an orthopedics clinic with shoulder pain. However, in 15 studies16, 19, 21, 22, 23, 28, 30, 31, 32, 33, 34, 35, 36, 37, and 38 patients were selected from waiting lists for shoulder surgery or shoulder arthroscopy. In these studies, spectrum bias cannot be excluded. Besides, this selection criterion resulted in a highly selected group of patients with severe shoulder disorders, which is also noticeable in the high prevalence values (15%-100%) of instability and labral lesions. A high prevalence among study subjects reduces the opportunity to detect both false-positive and true-negative results, which will overestimate the sensitivity and underestimate the specificity when the test is applied to patient populations with a lower prevalence of disease. It is likely that clinical findings in daily medical practice have lower sensitivity but higher specificity than suggested in the available literature.
Other limitations of the existing literature include modest sample sizes and methodologic problems. Twelve of the 17 studies did not describe the procedure for selecting patients.18, 19, 21, 22, 23, 29, 30, 32, 33, 35, 36, 38 The time between index and reference test was unknown in most studies.18, 23, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, and 38 The details of the reference test were missing or unclear in 9 studies.16, 19, 23, 28, 29, 32, 33, 35, 37 Furthermore, in 16 studies it was unclear whether the examiner of the reference test was blinded for the index test16, 18, 19, 21, 22, and 23, 28, 29, 30, 31, 32, 33, 34, 35, and 36, 38; in 1 study it was evident that the examiner was not blinded.37 These methodologic problems complicate reproduction of study results and may have biased the outcome.
Primary care physicians may consider the diagnosis of instability with or without a labral tear for this 24-year-old. The history of trauma at a young age and recurrent shoulder problems associated with a symptom that might have represented an acute dislocation (pop with an excessive stretch) mean that the attending physician may consider clinical tests to assess for instability and labral tears, but diagnostic accuracy would still be uncertain. Because the patient might opt for surgery to prevent recurrent dislocation, the primary care physician might consult an orthopedist to confirm the diagnosis and optimal management strategies for this patient's case.
The available evidence suggests that the relocation test and the anterior release test are best for establishing diagnosis of instability. For labral tears, the biceps loads I and II tests, the pain provocation test of Mimori, and the internal rotation resistance strength test have the best diagnostic performance characteristics (Figure 44-4). However, these results are based on single studies done in groups of selected patients who were evaluated by specialists. Despite the high prevalence of shoulder disorders in the general population, we are uncertain whether the diagnostic value of these tests or combinations thereof will be similar when used in primary care. Nonetheless, an understanding of the tests used in a specialist practice gives primary care physicians the opportunity to focus on physical examination maneuvers that might improve diagnostic skills. Although we recommend that clinicians take a careful history of the mechanism of shoulder injury, the role of the patient's medical history in diagnosing the presence of instability or labral tears has not been studied. A comparison of relevant historical characteristics of patients with shoulder complaints, physical examination findings, and noninvasive images (eg, magnetic resonance imaging), along with arthroscopy or surgical results, would greatly enhance the knowledge base of primary care physicians who are first to evaluate shoulder conditions.
Author Affiliations at the Time of the Original Publication
The Netherlands Expert Centre for Work related Musculoskeletal Disorders (Drs Miedema and Kuiper and Ms Luime), Department of General Practice (Drs Verhagen and Koes and Ms Luime), Department of Public Health (Dr Burdorf), and Department of Orthopedics (Dr Verhaar), Erasmus Medical Center, Rotterdam, The Netherlands.
We thank David L. Simel, MD, MHS, for his critical comments on the manuscript.
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