Sports Medicine Research: In the Lab & In the Field: Special Tests of the Shoulder: An Update of Evidence-based Support (Sports Med Res)


Friday, August 10, 2012

Special Tests of the Shoulder: An Update of Evidence-based Support

Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of systematic review with meta-analysis of individual tests.
Hegedus EJ. Br J Sports Med. 2012 July 7. [Epub ahead of print] Link to abstract:

One of the barriers for many clinicians with implementing evidence-based practice is sifting through and digesting the number and variety of studies in the literature. SMR has previously posted on clinical tests for SLAP lesions and a new study by Hegedus (2012) provides a detailed systematic review and meta-analysis of not just SLAP lesion tests but other special tests for the shoulder as well. It is these types of studies that provide a framework for not only the practicing clinician but also for educating students on which tests truly provide the ability to rule in/out pathology. Hegedus et al 2008 previously examined several special tests at the shoulder and this study served as an update. The purpose of this study was to examine the evidence for special tests related to shoulder injuries and to determine their usefulness in adult patients. The author utilized similar methods from the previous study but the search results were restricted to literature published from November 2006 to February 2012. A non-date restricted search was also completed to include two additional databases: Embase and the Cochrane Library. From this effort, 1,766 articles and abstracts were initially identified for inclusion; however, duplicates and those not appropriate for the intention of the meta-analysis were excluded resulting in 65 articles and abstracts. Further review of full text articles for appropriateness left 22 articles. The authors added 10 that were from the authors’ private collections. The remaining thirty-two new articles, in addition to ones compiled from the previous attempt, were reviewed using the Quality Assessment of Diagnostic Accuracy Studies, Version 2 (QUADAS 2) tool which determined the bias and applicability of each paper.  Results indicated that the Hawkins-Kennedy test demonstrates the ability to rule out subacromial impingement when the test is negative but the negative likelihood ratio was poor. Yeargson’s test, when used to detect SLAP lesion, initially demonstrated high specificity but the sensitivity was low. The apprehension, relocation, and surprise for anterior instability were the only tests to demonstrate clinical utility in ruling out the pathology. A number of other tests (posterior apprehension for posterior instability, passive distraction test for SLAP lesion, AC resisted extension, resisted belly press and coracoid palpation to name a few) showed promising results with high specificity and sensitivity and the authors note that further investigation is needed on these tests.

Assessing the impact of evidence-based studies such as this goes beyond attempting to answer the question “which test is the best?”. In fact, based on the data collected through this study, is it not possible to recommend a single test for a particular pathology. This is a direct reflection of the complex nature of most shoulder injuries as its large range of motion compounds the evaluation process. Shoulder impingement, for example, rarely involves one single structure and is often secondary to scapular or glenohumeral stability. A clinician often performs several special tests to determine its presence. Results of this study did demonstrate that a number of tests appear worthy of further investigation in their ability to determine the presence of pathology at the shoulder and furthermore, which tests do not demonstrate utility to a clinician. How do you, as a clinician, use information from studies such as this? Do you modify the tests you utilize in an exam based on evidence-based results?  Or do you continue to use what is best in your hands?

Written By:  Laura McDonald
Reviewed by:  Stephen Thomas

Related posts:
Hegedus EJ (2012). 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. British journal of sports medicine PMID: 22773322


Kyle Kosik said...

As a clinician when evaluating an injury, whether upper or lower extremity, it is important to know what special test is good for ruling in/out a pathology. This allows clinicians to be more confident in their diagnosis. I also believe however, that clinicians should not just rely on special test. Special tests have been shown to give both false positives and negatives. Secondly, I think we need to take the specificity and sensitivity with a grain-of-salt. Many times, the researchers performing the special tests in studies like this have often performed the special of tests hundreds of times and are able to detect subtle changes. Whereas a first-clinician might not be able to. Lastly, knowing information like this is just another tool in your tool box. Clinical judgement should not be taken away just because a Yeargon's test is positive or negative. A through history, an understanding of anatomy and underlying structures, and bony/soft tissue palpation should all play apart in a clinicians diagnosis.

Nick Rainey said...

I just put this journal article on my list of articles to obtain. Thank you for the quality preview. I am a DPT student and your evaluation helps me with my clinical decision making.

Laura M. McDonald, PhD, ATC said...

Thanks for your comment, Kyle. I agree with you. When I teach evidence-based practice concepts to our students,I emphasize your exact point. EBP is another tool that helps us to advance our clinical knowledge and make evaluation decisions.

Nick - thank you very much for your kind words and comment!

SandraK said...

There is an array of special tests that can be performed on the shoulder to diagnose or to rule out pathologies. It seems like every few years, more tests, or modifications appear in the literature, but it is key to know the sensitivity and specificity of each before attempting to perform every test on a patient. Looking at the most reliable and valid tests is the best option for a clinician, and sometimes sticking with the same ones can help, because the clinician can see the variability in these tests and understand when it is positive or when you are getting a false positive.
A thorough history is also very important part of the evaluation process, because most of the time it will guide you towards the right pathology, while the special tests will just confirm or rule out the differential diagnosis.
I agree that it would be good to have a list developed from EBP on the best tests, but it may seem unfeasible due to the fact that not one test determines a single pathology. At the shoulder there are a lot of structures and biomechanics that have to be taken into consideration, so multiple tests and assessments must be performed to determine and treat the correct thing. We just have to keep ourselves up to date with the literature to know what is best for our patients.

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