Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. The passive compression test: a new clinical test for superior labral tears of the shoulder. Intraarticular findings in the chronically painful shoulder. A study of 32 posttraumatic cases. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Clinical testing for tears of the glenoid labrum. Biceps load test II: A clinical test for SLAP lesions of the shoulder. An evaluation of the provocative tests for superior labral anterior posterior lesions. The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. A prospective evaluation of a new physical examination in predicting glenoid labral tears. The passive distraction test: a new diagnostic aid for clinically significant superior labral pathology. Clinical presentation of complete tears of the rotator cuff. Arthrographic distension of the shoulder joint in the management of frozen shoulder. An evaluation of the shoulder relocation test. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. A new test of resistance in the diagnosis of postero-superior rotator cuff tears. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Are pain location and physical examinations useful in locating a tear site of the rotator cuff? Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques. Lag signs in the diagnosis of rotator cuff rupture. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. An exploratory trial of preventative rehabilitation on shoulder disability and quality of life in patients following neck dissection surgery. Specificity of the Speed's test: arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. The subacromial impingement syndrome. A study of results of treatment with special emphasis on predictive factors and pain-generating mechanisms. Which is more useful, the "full can test" or the "empty can test," in detecting the torn supraspinatus tendon? Rehabilitation of the mastectomy patient: a randomized, blind, prospective study. Is supraspinatus pathology as defined by magnetic resonance imaging associated with clinical sign of shoulder impingement? A prospective randomised study of anatomical single-bundle versus double-bundle anterior cruciate ligament reconstruction: quantitative evaluation using an electromagnetic measurement system. Comparison between single-and double-bundle anterior cruciate ligament reconstruction: a prospective, randomized, single-blinded clinical trial.
Clinical tests are a key element in diagnosing shoulder lesions.
                This study examined the clinical utility of traditional and new examination tests, the upper cut for biceps injuries, and the modified dynamic labral shear for superior glenoid labral lesions.
                Cohort study (Diagnosis); Level of evidence, 2.
                A total of 325 consecutive patients who were seen for shoulder pain underwent a standardized clinical testing battery. Six clinical tests that have been previously reported in the literature (Yergason's, Speed's, bear hug, belly press, O'Brien's, and anterior slide) and 2 new examination tests (upper cut and modified dynamic labral shear) were performed. Clinical examination findings were correlated with findings in those who came to surgery (101 patients). Sensitivity, specificity, accuracy, positive/negative predictive value, and positive/negative likelihood ratio were calculated for each test. A binary logistic regression analysis was used to determine which tests produced the most significant findings.
                For biceps disease, the bear hug and upper cut were most sensitive (0.79 and 0.73, respectively), whereas the belly press and Speed's test were most specific (0.85 and 0.81, respectively). The upper cut was most accurate (0.77) and produced the highest positive likelihood ratio (3.38). For labral injury, the modified dynamic labral shear demonstrated sensitivity of 0.72, specificity of 0.98, accuracy of 0.84, and a positive likelihood ratio of 31.57. A binary logistic regression analysis revealed that the combination of the upper cut and Speed's tests were significantly better at detecting biceps lesions (P = .021, R(2) = .400) than other tests, whereas labral lesions were best identified by combination of the modified dynamic labral shear and O'Brien's maneuvers (P = .045, R(2) = .641).
                The new tests are helpful additions to the clinical examination for shoulder injury. The modified dynamic labral shear test demonstrates high scores for clinical utility and exhibits a high likelihood ratio, indicating a significant probability of affecting the clinical decision, which should moderately or significantly improve the diagnostic conclusion and allow the clinician to be more efficient in making an accurate diagnosis. Many types of physical examinations have been used to diagnose superior labrum anterior and posterior lesions; no decisive clinical test is available for confirming the diagnosis.
                A selection from 10 well-established physical tests, alone or in combination, can be used to differentiate lesions with biceps anchor detachment from those with an intact biceps anchor with arthroscopic correlation.
                Case control study (diagnosis); Level of evidence, 3.
                Among 297 patients who underwent shoulder arthroscopy between January 2004 and July 2005, 146 patients were enrolled in the study as a type II superior labrum anterior and posterior lesion group and an age-matched control group. Sensitivity, specificity, and predictive values of each test and all possible combinations of 2 and 3 tests were analyzed. The same procedures were repeated in patients younger than and older than 40 years.
                The sensitivities of the Whipple, O'Brien, apprehension, and compression-rotation tests and the specificities of the Yergason, biceps load II, and Kibler tests were relatively high. No single physical examination was found to be simultaneously highly sensitive and specific for the diagnosis of a type II superior labrum anterior and posterior lesion. When 2 of the 3 relatively sensitive tests (O'Brien, apprehension, or compression-rotation test) were combined with 1 of the 3 relatively specific tests (Speed, Yergason, or biceps load II test), sensitivity and specificity reached approximately 70% and 95%, respectively. Similar trends were noted in the younger and older patient groups and in the isolated type II superior labrum anterior and posterior lesion group.
                The data suggest that some combinations of 2 relatively sensitive clinical tests and 1 relatively specific clinical test increase the diagnostic efficacy of superior labrum anterior and posterior lesions. Requiring 1 of the 3 chosen tests to be positive will result in a sensitivity of about 75%, whereas requiring all 3 to be positive will result in a specificity of about 90%. Even though there are several physical tests available for superior labrum anterior posterior lesions, there have been very few reports on their accuracy, and none can be regarded as completely predictive for the presence of a superior labrum anterior posterior lesion in the shoulder joint.
                This new clinical test is a useful and accurate technique for detecting superior labral tears in the shoulder joint.
                Cohort study (diagnosis); Level of evidence, 2.
                This test was conducted independently by 2 physicians before any other diagnostic evaluation. In all cases, the glenohumeral joint was investigated first, and the appropriate treatments were performed on the lesion. A protocol was established to evaluate the sensitivity, specificity, and positive and negative predictive values of this new clinical test. The reproducibility of this test was evaluated with a kappa coefficient.
                Sixty-one patients (61 shoulders) were examined with the passive compression test, and all underwent arthroscopic surgery. In 31 patients with a positive passive compression test result, 27 had a superior labrum anterior posterior lesion, and in 30 patients with a negative passive compression test result, 6 had a superior labrum anterior posterior lesion. The sensitivity of the test was 81.8%, and the specificity was 85.7%. The positive predictive value was 87.1%, and the negative predictive value was 80.0%. The kappa coefficient was 0.771 between the 2 independent examiners (P< .01).
                The passive compression test is a useful and accurate technique for predicting superior labral tears of the shoulder joint. 32 consecutive patients suffering from chronic shoulder pain for more than 6 months after a single, nondislocating shoulder trauma were examined clinically and by special radiographs, dynamic sonography, MRI and arthroscopy. Typical complaints were pain during loading, especially during over the head activities. Symptoms of a "dead arm" and instability were also present. Patients with previous dislocations, traumas or radiographic signs of degenerative shoulder lesions were excluded. The patients had a decreased active range of motion and positive signs of apprehension and impingement, but only 4 had clinical signs of shoulder instability. Diagnostic evaluation identified labral tears, partial and total rotator cuff lesions with subacromial impingement and tendinitis of the biceps tendon. Surgery was performed in 24 patients, using capsulolabral and rotator cuff reconstruction, arthroscopic labral resection and open subacromial decompression. In conclusion, patients with chronic posttraumatic shoulder pain have intraarticular injuries, especially tears of the glenoid labrum. History, clinical findings, radiography and sonography are seldom diagnostic. MRI is valuable, particularly for identification of labral pathology, but arthroscopy appears necessary for a preoperative assessment. Labral tears and acromioclavicular joint abnormalities were differentiated on physical examination using a new diagnostic test. The standing patient forward flexed the arm to 90 degrees with the elbow in full extension and then adducted the arm 10 degrees to 15 degrees medial to the sagittal plane of the body and internally rotated it so that the thumb pointed downward. The examiner, standing behind the patient, applied a uniform downward force to the arm. With the arm in the same position, the palm was then fully supinated and the maneuver was repeated. The test was considered positive if pain was elicited during the first maneuver, and was reduced or eliminated with the second. Pain localized to the acromioclavicular joint or "on top" was diagnostic of acromioclavicular joint abnormality, whereas pain or painful clicking described as "inside" the shoulder was considered indicative of labral abnormality. A prospective study was performed on 318 patients to determine the sensitivity, specificity, and positive and negative predictive values of the test. Fifty-three of 56 patients whose preoperative examinations indicated a labral tear had confirmed labral tears that were repaired at surgery. Fifty-five of 62 patients who had pain in the acromioclavicular joint and whose preoperative examinations indicated abnormalities in the joint had positive clinical, operative, or radiographic evidence of acromioclavicular injury. There were no false-negative results in either group. With the increasing use of shoulder arthroscopy, diagnosis of glenoid labral lesions has become increasingly common. However, a physical examination maneuver that would allow a definitive clinical diagnosis of a glenoid labral tear, and more specifically a SLAP lesion, has been elusive. This study correlated the results of commonly used examination maneuvers with findings at shoulder arthroscopy. The working hypothesis was that 7 commonly used clinical tests, alone or in logical combinations, would provide diagnoses with reliability greater than the accepted standards for magnetic resonance imaging arthrography; i.e., greater than 95% sensitivity and specificity.
                Consecutive sample, sensitivity-specificity study.
                Sixty shoulders undergoing arthroscopy for a variety of pathologies were examined before surgery. All subjects submitted to the Speed test, an anterior apprehension maneuver, Yergason test, O'Brien test, Jobe relocation test, the crank test, and a test for tenderness of the bicipital groove. The examination results were compared with surgical findings and analyzed for sensitivity and specificity in the diagnosis of SLAP lesions and other glenoid labral tears.
                The results of the O'Brien test (63% sensitive, 73% specific) and Jobe relocation test (44% sensitive, 87% specific) were statistically correlated with presence of a tear in the labrum and the apprehension test approached statistical significance. Performing all 3 tests and accepting a positive result for any of them increased the statistical value, although the sensitivity and specificity were still disappointingly low (72% and 73%, respectively). The other 4 tests were not found to be useful for labral tears, and none of the tests or combinations were statistically valid for specific detection of a SLAP lesion.
                Clinical testing is useful in strengthening a diagnosis of a glenoid labral lesion, but the sensitivity and specificity are relatively low. Thus a decision to proceed with surgery should not be based on clinical examination alone. The purpose of this report is to describe the biceps load test II for evaluating the superior labral anterior and posterior (SLAP) lesions.
                This is a double-blind study in consecutive data, which includes diagnostic accuracy of a test using sensitivity, specificity, and interexaminer reliability.
                In the supine position, the arm is elevated to 120 degrees and externally rotated to its maximal point, with the elbow in the 90 degrees flexion and the forearm in the supinated position. The patient is asked to flex the elbow while resisting the elbow flexion by the examiner. The test is considered positive if the patient complains of pain during the resisted elbow flexion. The test is negative if pain is not elicited or if the pre-existing pain during the elevation and external rotation of the arm is unchanged or diminished by the resisted elbow flexion. A prospective study was performed in 127 patients to evaluate the diagnostic accuracy for the biceps load test II. Two independent examiners were assigned to perform the new diagnostic test. The results of the tests were confirmed during the arthroscopic examination.
                A positive test result in 38 subjects correlated with a SLAP lesion in 35 patients and an intact biceps-superior labrum in 3 patients. A negative test result in 89 patients correlated with an intact superior labrum complex in 85 patients, whereas 4 patients with a negative test result had a type II SLAP lesion. The biceps load test II had a sensitivity of 89.7%, a specificity of 96.9%, a positive-predictive value of 92.1%, a negative-predictive value of 95.5%, and a kappa coefficient of 0.815. The abduction and external rotation of the shoulder during the test changes the relative direction of the biceps fiber in a position of oblique angle to the posterosuperior labrum. The resisted contraction of the biceps increases the pain generated on the superior labrum that is already peeled off the glenoid margin in the abducted and externally rotated position.
                The biceps load test II is an effective diagnostic test for SLAP lesions. Although our understanding of superior labral anterior posterior lesions has grown, the physical diagnosis remains imperfect.
                Cohort study (diagnostic); Level of evidence, 2.
                To determine the most effective provocative maneuver with which to diagnose superior labral anterior posterior lesions.
                A series of 132 consecutive patients scheduled to undergo diagnostic shoulder arthroscopy were examined preoperatively over a 6-month period, and the final diagnosis in each case was made arthroscopically. The following assessments were included: active compression (O'Brien), anterior slide, pain provocation, crank, Jobe relocation, Hawkins, Neer, Speed, and Yergason tests.
                The most sensitive diagnostic tools for type II superior labral lesions were the active compression, Hawkins, Speed, Neer, and Jobe relocation tests. When type I and type II lesions were combined, the results were similar. However, none of the sensitive tests were specific for either type I or type II lesions.
                The authors' results contradict the current literature regarding provocative testing for both stable and unstable superior labral lesions. There is no single maneuver that can accurately diagnose superior labral anterior posterior lesions; arthroscopy remains the standard by which to diagnose such lesions. Tears of the superior labrum of the shoulder, anterior to posterior, are difficult to diagnose clinically.
                We examined whether the crank or O'Brien tests were reliable tools for detecting glenoid labral tears.
                Nonrandomized prospective study.
                Results of diagnostic shoulder arthroscopy were compared with those of the preoperative tests and magnetic resonance imaging for 65 patients who had symptoms of shoulder pain.
                The crank test result was positive in 29 patients (45%), and the O'Brien test was positive in 41 patients (63%). The crank test had a positive predictive value of 41%, was 56% specific, 46% sensitive, and had a negative predictive value of 61%. The O'Brien test had a positive predictive value of 34%, was 31% specific, 54% sensitive, and had a negative predictive value of 50%. Magnetic resonance imaging had a positive predictive value of 63%, was 92% specific, 42% sensitive, and had a negative predictive value of 83%.
                The O'Brien and crank tests were not sensitive clinical indicators for detecting glenoid labral tears and other tears of the anterior and posterior labrum. Results were often falsely positive for patients with other shoulder conditions, including impingement or rotator cuff tears. We studied 62 patients (40 men and 22 women) with an average age of 28 years over a 28-month period who presented with shoulder pain that was refractory to 3 months of conservative management. Patients with a prior glenohumeral dislocation or a rotator cuff tear were excluded. The "crank" test was performed with the arm elevated to 160 degrees in the scapular plane of the body, loaded axially along the humerus, and with maximal internal and external rotation. Although similar tests have been described, the crank test is a new examination previously unreported. Half of the patients (31) had a positive crank test. Arthroscopy performed on all 62 patients revealed glenoid labral tears in 32 patients. Two patients who had positive crank tests did not have labral tears but had partial-thickness, articular-side rotator cuff tears. The sensitivity of the crank test was 91%, the specificity was 93%, the positive predictive value was 94%, and the negative predictive value was 90%. With these data, the crank test fulfills the criteria as a single physical examination test that is highly accurate for the preoperative diagnosis of glenoid labral tears. Accordingly, expensive imaging modalities currently used in this patient population may be employed less in the future. The purpose of this report is to present a new provocative maneuver, the passive distraction test (PDT), as an examination tool to be used in the evaluation of patients thought to have a SLAP lesion and to compare its accuracy, precision, and reproducibility alone and in conjunction with previously published maneuvers.
                A retrospective analysis of 319 consecutive arthroscopies performed between May 2001 and November 2003 was performed. A total of 65 cases were excluded, 53 because of limitation of elevation to less than 150 degrees or pain in the starting test position and 12 who had previous shoulder procedures performed by the senior author, leaving 254 cases for review. A thorough history was obtained and a thorough physical examination performed with a focus on the involved shoulder including specific provocative maneuvers for the clinical diagnosis of a SLAP lesion. The active compression test, the anterior slide test, and the PDT were used to clinically diagnose a SLAP lesion. The results from the 3 provocative maneuvers were compared with the arthroscopic findings to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value of each test alone and in a logical combination.
                Of 254 shoulder arthroscopies, 61 had a clinically significant SLAP lesion, for an incidence of 24%. The sensitivity and specificity for the PDT were 53% and 94%, respectively, with an NPV of 87% and positive predictive value of 72%. In combination, the PDT and the active compression test yielded an NPV of 90.5%.
                The PDT can be used alone or in combination to aid in the clinical evaluation and diagnosis of a SLAP lesion.
                Level IV, retrospective, diagnostic, sensitivity-specificity study. To determine whether the presence and extent of a tear of the rotator cuff could be predicted on the basis of a patient's history, physical examination, and radiographic findings, detailed data from the histories and physical examinations of 103 patients who were known to have a tear of the rotator cuff were correlated with the radiographic and operative findings on these patients. An age-matched control group of fifty-one patients who had similar symptoms, but whose arthrograms showed normal results, was used to establish a baseline incidence of ten specific radiographic findings in the shoulder. Two discrete groups of patients who had a tear of the rotator cuff were identified. Twenty-eight patients (27 per cent) had a tear of a single tendon; the histories and the physical and radiographic findings in this group were consistent with a symptomatic local mechanical-impingement process in the shoulder. Sixty (80 per cent) of the seventy-five patients in the other group had a history of acute trauma to a shoulder. The patients in this second group were older and were non-athletic, and had not previously had symptoms that were severe enough to need treatment. These patients were subsequently found to have a complete tear of more than one of the tendons of the rotator cuff. Multiple radiographic findings in the shoulder and other coexisting orthopaedic conditions also were more common in these patients. In this group, we believe that acute trauma in a shoulder that had chronic degenerative changes, rather than localized mechanical impingement, caused the tendons to rupture. The study was an open randomized controlled trial to compare the outcome at 8 weeks with two different modalities in the treatment of 'Frozen shoulder'. Clinical cases with painful limitation of movement of shoulder were randomized to receive physical therapies alone versus physical therapies and shoulder arthrography with intra-articular steroid in a sequential randomization process. Cases suspected of having a concomitant illness and has potential to cause secondary frozen shoulder were excluded, such as, history of trauma to shoulder over the last 6 months, symptomatic clinical cervical degenerative diseases, and causes in and around the shoulder (infective and non-infective). Physical Therapies provided to all patients were therapeutic exercises, transcutaneous electrical nerve stimulation (TENS) and infra-red radiation (IRR). Outcome measures were improvement of pain on a Visual Analogue Scale (VAS) score and range of motion measured by Goniometer at 8 weeks. Patients were followed weekly for 8 weeks and outcome parameters were recorded on every evaluation. The baseline range of motion in the two groups was comparable. At 8 weeks a statistically significant difference in outcome were observed in the two groups. The chi-square means difference of improvement in range of motion for abduction was p <0.00 and for external rotation was p <0. 00. The pain reduction on VAS score was not significant in the two groups (p <0. 40). In the present small series, the distension arthrography with intra-articular (IA) steroid plus physical therapy was superior over physical therapy alone in the functional improvement of the frozen shoulder. Further studies with larger sample size are required to confirm the observations. The purpose of this study was to evaluate the sensitivity, specificity, negative and positive predictive values, and accuracy of the shoulder relocation test in 100 patients who underwent shoulder surgery. Based on operative data and examination under anesthesia, the diagnoses were grouped into six categories: anterior instability (without cuff disease), posterior instability, rotator cuff disease (without associated anterior instability), acromioclavicular disorder, osteoarthrosis, and instability of the biceps tendon. The test was performed on the day of surgery by placing the arm in a position of 90 degrees of humerothoracic abduction and 90 degrees of external rotation (90 degrees/90 degrees). Patient responses of pain and apprehension (considered separately) were assessed in this position both with and without application of an anterior force to the proximal humerus. The relocation test assessed diminution of pain and apprehension after application of a posteriorly directed force to the proximal humerus relative to the position of 90 degrees/90 degrees alone and to the position of an anterior force being applied to the proximal humerus. Overall, 63 patients reported pain with 90 degrees/90 degrees; 74 reported pain when an anterior force to the proximal humerus was applied: the anterior instability group alone had 46 and 63 reports of pain, respectively; the rotator cuff group alone had 82 and 88 reports of pain, respectively. The only positive responses for apprehension were in the anterior instability group, of which 63% had apprehension with 90 degrees/90 degrees alone and 74 had apprehension when an anterior humeral force was applied.(ABSTRACT TRUNCATED AT 250 WORDS) To investigate the reliability and diagnostic accuracy of individual tests and combination of tests for subacromial impingement syndrome (SAIS).
                A prospective, blinded study design.
                Orthopedic surgeon shoulder clinic.
                Patients with shoulder pain (n=55, mean age=40.6y).
                Patients were evaluated with 5 physical examination tests for SAIS: Neer, Hawkins-Kennedy, painful arc, empty can (Jobe), and external rotation resistance tests. Surgical diagnosis was the reference standard.
                Diagnostic accuracy calculated with a receiver operating characteristic (ROC) curve and sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR). A forward stepwise binary logistic regression analysis was used to determine the best test combination for SAIS. An ROC curve analysis was also used to determine the cut point of the number of tests discriminating between the presence and absence of SAIS. Kappa coefficients and percent agreement assessed interrater reliability.
                The ROC analyses revealed a significant area under the curve (AUC) (AUC=.67-.72, P<.05) for all tests, except for the Hawkins-Kennedy. The tests with a +LR greater than or equal to 2.0 were the painful arc (+LR=2.25; 95% CI, 1.33-3.81), empty can (+LR=3.90; 95% CI, 1.5-10.12), and the external rotation resistance tests (+LR=4.39; 95% CI, 1.74-11.07). Tests with -LR less than or equal to 0.50 were the painful arc (-LR=.38; 95% CI, .16-.90), external rotation resistance (-LR=.50; 95% CI, .28-.89), and Neer tests (-LR=.35; 95% CI, .12-.97). The regression analysis had no specific test combinations for confirming or ruling out SAIS. The ROC analysis was significant (AUC=.79, P=.001), with a cut point of 3 positive tests out of 5 tests. Reliability was moderate to substantial agreement (kappa=.45-.67) for the painful arc, empty can, and external rotation resistance tests and fair strength of agreement (kappa=.39-.40) for the Neer and Hawkins-Kennedy tests.
                The single tests of painful arc, external rotation resistance, and Neer are useful screening tests to rule out SAIS. The single tests of painful arc, external rotation resistance, and empty can are helpful to confirm SAIS. The reliability of all tests was acceptable for clinical use. Based on reliability and diagnostic accuracy, the single tests of the painful arc, external rotation resistance, and empty can have the best overall clinical utility. The cut point of 3 or more positive of 5 tests can confirm the diagnosis of SAIS, while less than 3 positive of 5 rules out SAIS. The aim of this study was to assess the diagnostic accuracy of a new clinical test for the diagnosis of subacromial impingement and full thickness postero-superior rotator cuff tears. One hundred and twenty patients who underwent arthroscopic treatment for acromioplasty or cuff repair were previously submitted to a new test of resistance. The test is performed in the standing position with the involved arm in 90 degrees abduction, 20 degrees -30 degrees anteposition and in external rotation (as for full-can test). Thus, the patient was invited to follow the way of a spiral drawn on a drawing sheet for 20 turns; 1 turn = from the centre to the end of the spiral and vice versa (spiral width = 20 cm). The test was considered positive when the patient was not able to conclude it due to strength decrease or to shoulder pain. Sensitivity, specificity, positive and negative predictive values as well as diagnostic accuracy were calculated for our test of resistance. The test resulted scarcely reliable as detector of subacromial impingement and not very reliable as detector of small tear. When the test is positive there is a high probability that a subacromial disease exists; instead, when it is negative there is a high probability that the patient has not a large or massive cuff tear. The resistance test (Gum-Turn test) adds to our armamentarium of physical examination signs in patients with painful shoulder and furnishes further information on possible dimensions of tendinous tear. The purpose of this study was to explore and describe reasons for variation in diagnostic accuracy of clinical tests using Yergason's and Speed's tests in predicting biceps tendon pathology and SLAP lesions. Shoulder arthroscopy was used as the gold standard.
                Prospective blinded study of consecutive patients with a wide spectrum of shoulder conditions.
                One hundred fifty-two subjects (65 women and 87 men) with complaints of shoulder pain were examined. Fifty subjects (16 women and 34 men) ranging in age from 24 to 79 years (mean age, 50 years; SD = 14.36) met the criteria for surgery. The validity of the Yergason's and Speed's tests was evaluated against findings at surgery.
                The surgical findings related to biceps pathology and SLAP lesions were as follows: 2 bicipital tendonitis, both associated with significant rotator cuff pathology; 10 biceps partial tears; and 2 complete ruptures. Fifteen patients had SLAP lesion type I, 12 type II, and 1 type IV. The sensitivity, specificity, and positive and negative predictive values were 43%, 79%, 60%, and 65% for Yergason's test and 32%, 75%, 50%, and 58% for Speed's test, respectively. The likelihood ratios were 1.28 and 0.91 for Speed's test and 2.05 and 0.72 for Yergason's test. These ratios were provided to assist clinicians in calculating the probability of biceps pathology and SLAP lesions for a single patient with a different history-specific prevalence of having the pathology.
                Although Speed's and Yergason's tests are moderately specific, they do not generate a large change in the post-test probability and are unlikely to make a significant change in the pretest diagnosis. Clinicians should understand that clinical examination tests do not perform consistently and have variable predictive values in different patient populations and settings.
                Level I diagnostic study: testing of previously developed criteria in a series of consecutive patients (using surgery as gold standard). Pain is the most common symptom of patients with rotator cuff tendinopathy, but little is known about the relationship between the site of pain and the site of cuff pathologic lesions. Also, accuracies of physical examinations used to locate a tear by assessing the muscle strength seem to be affected by the threshold for muscle weakness, but no studies have been reported regarding the efficacies of physical examinations in reference to their threshold.
                Pain location is useful in locating a tear site. Efficacies of physical examinations to evaluate the function of the cuff muscles depend on the threshold for muscle weakness.
                Case series; Level of evidence, 4.
                The authors retrospectively reviewed the clinical charts of 160 shoulders of 149 patients (mean age, 53 years) with either rotator cuff tears (140 shoulders) or cuff tendinitis (20 shoulders). The location of pain was recorded on a standardized form with 6 different areas. The diagnostic accuracies of the following tests were assessed with various thresholds for muscle weakness: supraspinatus test, the external rotation strength test, and the lift-off test.
                Lateral and anterior portions of the shoulder were the most common sites of pain regardless of existence of tear or tear location. The supraspinatus test was most accurate when it was assessed to have positive results with the muscle strength less than manual muscle testing grade 5, whereas the lift-off test was most accurate with a threshold less than grade 3. The external rotation strength test was most accurate with a threshold of less than grade 4+.
                The authors conclude that pain location is not useful in locating the site of a tear, whereas the physical examinations aiming to locate the tear site are clinically useful when assessed to have positive results with appropriate threshold for muscle weakness. Subacromial impingement syndrome (SIS) is a frequent cause of shoulder pain. The aim of this study was to investigate the diagnostic values of clinical diagnostic tests, in patients with SIS.
                72 female, 48 male patients with shoulder pain were included in the study. Five had bilateral shoulder pain, so 125 painful shoulders were evaluated. Details were recorded about the patients' ages and sexes, as well as characteristics of pain and related problems. Detailed physical examination and routine laboratory tests were performed. Conventional radiography and subsequent magnetic resonance imaging of the shoulder region of all patients were performed. Patients were divided into two groups according to the results of subacromial injection test, a reference standard test for SIS. Test positive patients constituted SIS group and test negative patients the non-SIS group. Sensitivity, specificity, accuracy, positive and negative predictive values of some clinical diagnostic tests such as Neer, Hawkins, horizontal adduction, painful arc, drop arm, Yergason and Speed tests for SIS were determined by using 2 x 2 table.
                The most sensitive diagnostic tests were found to be Hawkins test (92.1%), Neer test (88.7%) and horizontal adduction test (82.0%). Tests with highest specificity were drop arm test (97.2%), Yergason test (86.1%) and painful arc test (80.5%) consecutively.
                The highly sensitive tests seem to have low specificity values and the highly specific ones to have low sensitivity values. Although this finding suggests that these diagnostic tests are insufficient for certain diagnosis, it is suggested they play an important part in clinical evaluation. A randomized clinical study was conducted to compare the outcome between double-bundle (DB) and single-bundle (SB) anterior cruciate ligament (ACL) reconstructions with 4-strand semitendinosus tendon (ST).
                We divided 68 patients with unilateral ACL injury into 2 groups according to their birth date, and they were followed up in person for a mean of 25 months (range, 18 to 41 months). Each group of 34 patients underwent either DB or SB ACL reconstruction using 4-strand ST with EndoButton femoral fixation (Smith & Nephew Endoscopy, Andover, MA) and anchor staple tibial fixation. There was no difference between the 2 groups with regard to age at surgery, sex, follow-up period, period before surgery, combined meniscus injuries, and athletic activity level. All patients followed the same postoperative program. They were evaluated using manual knee laxity tests, instrumented anterior laxity measurements (KT-1000 arthrometer [MEDmetric, San Diego, CA]), knee extension and flexion strength testing, and so on. General knee condition was evaluated by use of the Lysholm knee score and subjective rating scale.
                There were no significant differences between the 2 groups with regard to range of motion, thigh girth, muscle strength, and Lysholm score. Manual knee laxity testing revealed that negative Lachman and pivot-shift test results were found in more patients in the DB group than in the SB group. KT measurements averaged 2.4 mm in the SB group and 1.4 mm in the DB group, which was statistically significantly different. Statistical analysis showed no significant difference regarding all of the modified International Knee Documentation Committee-categorized data between the 2 groups.
                This randomized controlled trial indicated that DB ACL reconstruction via 4-strand ST is superior to the SB technique with regard to anterior and rotational stability; however, it fails to show any subjective difference.
                Level I, prospective randomized controlled clinical study. We assessed the relative value of lag signs for the evaluation of rotator cuff rupture in a prospective study of 100 consecutive painful shoulders with impingement syndrome, stages 1 to 3. Lag signs were compared with the Jobe and lift-off signs. Three tests were designed to assess the main components of the rotator cuff: the external rotation lag sign (ERLS) for the supraspinatus and the infraspinatus tendons, the drop sign for the infraspinatus, and the internal rotation lag sign (IRLS) for the subscapularis tendon. For assessment of the supraspinatus and infraspinatus the ERLS was less sensitive but more specific than the jobe sign. The drop sign was the least sensitive but was as specific as the ERLS. Partial ruptures of the supraspinatus remained concealed to the ERLS. For assessment of the subscapularis the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS. The magnitude of the lag correlated with the size of the rupture for both the ERLS and the IRLS. Clinical testing for lag signs was efficient, reproducible, and reliable. In patients with little or no restriction of motion it enhanced the accuracy of clinical diagnosis in rotator cuff lesions. The purpose of this study was to assess the diagnostic accuracy of the Neer and Hawkins impingement signs for the diagnosis of subacromial bursitis or rotator cuff pathosis. Eighty-five consecutive patients undergoing shoulder arthroscopy by a single surgeon were documented prospectively for the positive and negative clinical and arthroscopic pathologic findings. The Neer sign was found to have a sensitivity of 75% for the appearance suggestive of subacromial bursitis; this compared with 92% for the Hawkins sign. For rotator cuff tearing, the sensitivity of the Neer sign was 85% and the sensitivity of the Hawkins sign was 88%. Specificity and positive predictive values for the two tests were low, being not much higher than pretest probability. The two tests had a high negative predictive value (96% for bursitis, 90% for rotator cuff tearing) when they were combined. The results are compared with those reported in the literature. We conclude that the Neer and Hawkins signs are sensitive for appearances suggestive of subacromial bursitis and rotator cuff partial or complete tearing with a high negative predictive value. However, they lack specificity in comparison with arthroscopic findings. Patients commonly develop shoulder disability and reduction in quality of life (QOL) following neck dissection surgery. There is a lack of studies investigating the impact of preventative rehabilitation to prevent shoulder disability in this population. An exploratory trial was undertaken to investigate this gap in the head and neck cancer literature. Thirty-two subjects were randomly assigned to either one of two groups: early physiotherapy for a period of 3 months following surgery and current routine inpatient care and advice. Blinded measurement of shoulder function and QOL were recorded pre-operatively and at 1 year following surgery. No difference was found using between-group analysis (Mann-Whitney U-Test) for any outcome measures observed. Descriptive data analysis suggests that subjects receiving early physiotherapy had a perception of increased physical well-being when compared with subjects receiving routine care. There may be some clinical significance that subjects receiving a course of physiotherapy did appear to rate their physical well-being higher than those subjects not undergoing rehabilitation. Further research to investigate the preventative effects of physiotherapy on this population should consider the use of head and neck cancer-specific outcome measurement of both shoulder disability and QOL.
                © 2010 Blackwell Publishing Ltd. A positive Speed's test result is usually thought to suggest inflammation or lesions related to the biceps/labral complex. The specificity, sensitivity, and positive and negative predictive values are determined for the Speed's test. A prospective study design was developed for all patients with shoulder pain who presented between October 1, 1994 and February 28, 1995. The clinical results of the Speed's test were correlated with biceps/labral pathology by direct arthroscopic visualization. A neuroprobe is used to pull the biceps tendon into the articular portion of the glenohumeral joint so as to visualize the biceps tendon at the level of the bicipital groove. Forty-six shoulders in 45 patients, 31 men (average age, 53 years; range, 16 to 76 years) and 14 women (average age, 64 years; range, 30 to 80 years) with 26 dominant and 20 nondominant extremities were operated on during this time interval. The clinical evaluation showed that the speed's test was positive in 40 shoulders. Biceps/labral complex pathology was present in 10 of these patients. A specificity of 13.8%, a sensitivity of 90%, a positive predictive value of 23%, and a negative predictive value of 83% were calculated. Thus, it is concluded that the Speed's test is a nonspecific but sensitive test for macroscopic biceps/labral pathology. This clinical examination is positive with a various number of other pathological shoulder problems. This prospective study introduces a new sign to differentiate between outlet impingement and non-outlet (intra-articular) causes of shoulder pain in patients with positive impingement sign: the internal rotation resistance strength test (IRRST). It was hypothesized that positive test results are predictive of non-outlet impingement, whereas negative test results confirm outlet impingement. A prospective comparison between IRRST and arthroscopic findings of 115 consecutive patients showed the test to be highly accurate in differentiating between these two diagnoses (positive predictive value 88%, negative predictive value 96%, sensitivity 88%, specificity 96%, and accuracy 94.5%). The IRRST, in conjunction with impingement and apprehension signs, adds to our armamentarium of tests that distinguish between subacromial outlet impingement and intra-articular forms of pathology. Forty-two patients with subacromial impingement syndrome entered a randomized prospective study comparing open anterior acromioplasty with a physiotherapy regime. The criterion for a successful outcome of treatment was a reduction of the initial pain score of more than 50% using the visual analogue scale (VAS) technique. The evaluation was performed by an independent observer. At the 6-month follow-up, treatment in the surgical group had been successful in 12/21 (57%) patients versus 6/18 (33%) in the physiotherapy group. A one-year evaluation revealed 16/21 (76%) "successes" in the surgical group. A direct and unbiased comparison with the physiotherapy group was not possible at one year, since 13 patients chose surgery after initial physiotherapy. However, in "an intention to treat" analysis outcome at one year was significantly better in those randomized to surgery. We found two standardized, composite, active movements--the "Pour out of a Pot" manoeuvre requiring the emptying of a pot of water, and the "Hand in Neck" manoeuvre--to be of predictive value for the outcome of surgery. When combining three pain-related variables into a criterion for prediction of success, a sensitivity of 78% (p < 0.02) and a specificity of 90% (p < 0.03) were attained. We advance the hypothesis that pain in the impingement syndrome is mainly elicited by comparison of the subacromial bursa. In some patients a traction-responsive pain generator in the supraspinatus tendon may be present as well. The purpose of this study was to determine the clinical usefulness of the full can and empty can tests for determining the presence of a torn supraspinatus tendon. The two tests were performed in 143 shoulders of 136 consecutive patients. In each test, the muscle strength was determined by manual muscle testing, and the presence of pain during the maneuver was recorded. We interpreted the tests as positive when there was 1) pain, 2) muscle weakness, or 3) pain or muscle weakness or both. Shoulders were examined by high-resolution magnetic resonance imaging with 95% accuracy for full-thickness rotator cuff tears. There were 35 shoulders with full-thickness tears of the supraspinatus tendon. The accuracy of the tests was the greatest when muscle weakness was interpreted as indicating a torn supraspinatus tendon in both the full can test (75% accurate) and the empty can test (70% accurate). However, there was no significant difference between the accuracy of the tests when this criterion was used. Pain was observed in 62 shoulders (43%) during the full can test and in 71 shoulders (50%) during the empty can test, but the difference was not statistically significant. Muscle weakness should be interpreted as indicative of supraspinatus tendon tear. Using this indicator, both tests are equivalent in terms of accuracy, but considering pain provocation, the full can test may be more beneficial in the clinical setting. After biopsy confirmation of breast carcinoma, women who were scheduled to undergo a modified radical mastectomy had demographic data collected, goniometric measurements of shoulder flexion and abduction, and functional evaluation of the ipsilateral shoulder performed, and upper extremity circumferential measurements at five levels determined. Patients were then randomly assigned either to a group that received immediate postoperative physical therapy or to one that did not. Results represent the combination of data from a pilot study and this subsequent study following appropriate statistical analysis. Sixty-four women in the treatment group showed a statistically significant increase in shoulder range of motion in both abduction and flexion as compared to 51 women who received no physical therapy. The treated group also had fewer problems with five of the six upper extremity functional tasks that were assessed. There were no significant differences between the groups for length of hospital stay, postoperative complications, or upper extremity edema. The authors conclude that early physical therapy intervention makes a significant contribution to return to normal function without increasing the incidence of postoperative complications or prolonging hospital stay. To examine the association between supraspinatus pathology and clinical sign of impingement, 42 workers with and 31 age-matched workers without signs of subacromial impingement had their shoulder examined by magnetic resonance imaging. All subjects were selected from an epidemiologic study evaluating the risk of shoulder impingement syndrome in relation to ergonomic exposure. Physical examination was conducted according to the same protocol and included assessment of shoulder function. Magnetic resonance images were evaluated in a blinded manner with regard to clinical status and age. Twenty-two (55%) subjects in the impingement group and 16 (52%) subjects in the control group had a pathologic supraspinatus tendon (odds ratio 1.13 [95% confidence interval 0.45 to 2.88]). The prevalence of supraspinatus pathology increased from 32% in the youngest to 48% in the middle and 72% in the oldest age group. The results of this study indicate that supraspinatus pathology is related to age rather than to clinical sign of impingement. We conducted a prospective randomised study of anatomical single-bundle (A-SB group) versus double-bundle (A-DB group) anterior cruciate ligament (ACL) reconstruction using the hamstrings tendons. Twenty patients with unilateral ACL deficiency were randomised into two groups. We created the bone tunnels at the position of the original insertion of the anteromedial bundle footprint and posterolateral bundle footprint in the A-DB group and at the central position between these two bundles in the A-SB group. All of the patients were tested before ACL reconstruction and one year after surgery. The KT-1000 measurements, isokinetic muscle peak torque and heel-height difference were evaluated and the general knee condition was assessed by Lysholm score. For pre- and postoperative stability assessment, we used the six-degrees-of-freedom of knee kinematic measurement system using an electromagnetic device (the EMS) for quantitative assessment during the Lachman test and the pivot shift test. There were no significant differences in the KT-1000 measurements, isokinetic muscle peak torque, heel-height difference, and Lysholm score at one-year follow-up between these two groups. The EMS data showed there were significant differences in the acceleration of the pivot shift test between the operated knee and the contralateral normal knees in the A-SB group. In conclusion, clinical outcomes were equally good in both groups. However, the EMS data showed the anatomical double-bundle ACL reconstruction tended to be biomechanically superior to the single-bundle reconstruction. Double-bundle ACL reconstruction popularity is increasing with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published.
                The aim of this study was to prospectively compare the clinical results of single- and double-bundle ACL reconstruction.
                Randomized controlled clinical trial; Level of evidence, 1.
                Seventy patients with a chronic unilateral ACL rupture who underwent arthroscopically assisted ACL reconstruction using a hamstring graft were randomized to receive a single- (SB) or double-bundle (DB) reconstruction. Both groups were comparable with regard to preoperative data. A double-incision surgical technique was adopted in both groups. The graft was fixed by looping the hamstring tendons around a bony (DB) or a metallic (SB) bridge on the tibial side and with interference screws reinforced with a staple on the femur. The same rehabilitation protocol was adopted. Outcome assessment was performed by a blinded, independent observer using the visual analog scale (VAS) score, the new International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation.
                All the patients reached a minimum follow-up of 2 years. No differences between the 2 groups were observed in terms of KOOS and IKDC subjective score. A statistically significant difference in favor of the DB group was found with the VAS (P < .03). The objective IKDC final scores showed statistically significantly more "normal knees" in the DB group than in the SB group (P = .03). There was 1 stability failure in the DB group and 3 in the SB group. The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08).
                In the 2-year minimum follow-up, DB ACL reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed.
There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.