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: https://www.ncbi.nlm.nih.gov/pubmed/22773322

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
. 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
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?

By:  Laura McDonald
by:  Stephen Thomas


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