jej dua przydatno w diagnostyce blu stawu opatkowo - ramiennego wynika z niedoskonaoci badania przedmiotowego w ocenie tej patologii . i ultrasonograficznego o wysokiej rozdzielczoci , wykonywanych u pacjentw z blem stawu opatkowo - ramiennego . kryteria wyczenia : zamania w obrbie stawu opatkowo - ramiennego , przebyte operacje stawu opatkowo - ramiennego oraz iniekcje dostawowe w tym stawie w cigu ostatniego miesica . wykonujcy standardowe badanie fizykalne stawu opatkowo - ramiennego klinicyci nie mieli dostpu do wynikw bada ultrasonograficznych a ultrasonografici  do wynikw bada fizykalnych . test ciasnoty hawkinsa i kennedy'ego stosowany w diagnostyce patologii cigna minia nadgrzebieniowego wykaza najwiksz czuo ( 0,86 ) , a test minia nadgrzebieniowego jobe'a najwiksz swoisto ( 0,55 ) . w ocenie zmian cigna minia podopatkowego test uniesienia koczyny od poladka gerbera wykaza czuo 1 , podczas gdy test ucisku brzucha  belly press oporowy test minia podgrzebieniowego wykaza wysok czuo ( 0,90 ) i swoisto ( 0,74 ) . wszystkie testy stosowane w patologiach stawu barkowo - obojczykowego ( test bolesnego uku , test uciskowy stawu barkowo - obojczykowego , test skrzyowanego przywodzenia ) cechoway si wysok wraliwoci ( 0,96 , 0,99 , 0,96 ) . w przypadku patologii cigna gowy dugiej minia dwugowego ramienia , test doni zwrconej ku grze wykaza najwysz czuo ( 0,47 ) , a test yergasona najwysz wraliwo ( 0,88 ) . znajomo czuoci i swoistoci poszczeglnych testw jest niezbdna do waciwej interpretacji badania fizykalnego stawu opatkowo - ramiennego . shoulder disorders constitute the third most common musculoskeletal presentation in the general practice and they can lead to absenteeism from work , inability to perform social activities and serious economic hardship for affected individuals and their families . in 1995 , 4.2 million days of sick leave were attributed to disorders of the upper limb and neck area in the uk . because shoulder disorders can develop into chronic conditions , it is essential to identify the exact pathology to select the most appropriate treatment . shoulder pain can originate in various structures of the shoulder joint or in affected periarticular structures . however , with clinical examination alone often an exact diagnosis can not be made . the high resolution ultrasonography ( hrus ) provides a non - painful , noninvasive , cost - efficient and fast imaging technique which is increasingly used to evaluate patients with musculoskeletal disorders . up to now , there are only few studies addressing the correlation between clinical and hrus examination findings of the painful shoulder , although the application of hrus is well established in the examination of the musculoskeletal system . in our study sensitivity and specificity of most common clinical tests for the assessment of a painful shoulder between august and december 2012 , 100 adult patients referred for evaluation of unilateral shoulder pain were included in the study , either in the rheumatology department of the university hospital of zurich or the sonography institute bethanien in zurich . exclusion criteria were shoulder fractures , prior shoulder joint surgery and prior shoulder injection ( local anesthetics or steroids ) in the past month . approval of the local ethics review board zurich was obtained and all patients had to sign an informed consent . the study was performed according to good clinical practice and carried out in compliance with the helsinki declaration . the hrus examination was conducted according to the guidelines of the swiss society of ultrasound medicine ( sgum , musculoskeletal section ) which are compatible with the musculoskeletal ultrasound technical guidelines from the european society of musculoskeletal radiology ( essr ) and the guidelines of the european league against rheumatism ( eular ) . the diagnostic criteria for hrus findings are listed in table 1 and figure 1 shows several examples of hrus pathologies of the shoulder . examples of hrus pathologies of the shoulder 
 a. shoulder lateral longitudinal view . no pathology . m. supraspinatus tendon ( star ) , humerus ( triangle ) . b. shoulder anterior transverse view . effusion ( star ) , synovial proliferation ( arrow ) . c. shoulder lateral longitudinal view . m. supraspinatus tendon ( star ) , calcification with distal ultrasound cancellation ( arrow ) . m. supraspinatus tendon ( star ) , partial thickness tear ( triangle ) . f. shoulder lateral longitudinal view . clavicula ( star ) , acromion ( plus sign ) , osteophyte ( triangle ) . h. shoulder anterior transversal view . long biceps tendon ( star ) , effusion ( arrow ) diagnostic criteria for hrus findings used in the study the hrus examination was performed by two expert sonographers , both medical doctors with several years of experience performing hrus examination of the musculoskeletal system . for hrus examination an esaote mylab50xvision with a linear 12 mhz transducer , respectively a philips hd 11 with a linear 1215 mhz transducer and a ge voluson e6 with a 514 mhz linear array transducer were used . the tests included in the clinical examination were : bursitis sign;jobe supraspinatus test;painful arc i and ii;drop arm test;hawkins and kennedy impingement test;gerber lift off test;belly press ( abdominal compression ) test;infraspinatus test;acromioclavicular ( ac ) joint tenderness;cross body adduction stress test;abbott - saunders test;palm up test (= speed bicepsor straight arm test);yergason test;hueter sign ( table 2 ) . jobe supraspinatus test ; painful arc i and ii ; hawkins and kennedy impingement test ; gerber lift off test ; belly press ( abdominal compression ) test ; acromioclavicular ( ac ) joint tenderness ; cross body adduction stress test ; abbott - saunders test ; palm up test (= speed bicepsor straight arm test ) ; hueter sign ( table 2 ) . . 
  assumed corresponding shoulder structure of the clinical tests neither the clinical examiner nor the hrus examiner had information about the history of the patients and both were blinded to the results of each other 's examinations . statistical calculations were done with ibm spss statistics 21 and microsoft excel 2010 . using hrus findings as the gold standard , the following diagnostic values were calculated : sensitivity , specificity , efficiency , positive predictive value , negative predictive value , positive likelihood coefficient , negative likelihood coefficient , youden index , empirical pearson 's correlation coefficient and uniweighted cohen 's  coefficient . empirical pearson 's correlation coefficient was used as an indicator of linear dependence between the two variables ( clinical examination test results and hrus examination findings respectively ) . in order to measure the correlation in terms of inter - rater agreement , the uniweighted cohen 's  coefficient was used . the median age of the patients included in the study was 54 , female was the predominant gender and the right shoulder was more affected than the left one ( cf . baseline characteristics of the subjects ( n = 100 ) hrus examination revealed a variety of pathologic findings ( cf . table 5 ) . pathologies of the subacromial bursa were found in 87% , of the m. supraspinatus tendon in 67% , of the ac joint in 24% , of the long biceps tendon in 20% , of the m. subscapularis tendon in 11% , of the m. infraspinatus tendon in 10% and of the m. pectoralis major tendon in 1% of the cases . the most frequent pathology of the rotator cuff ( m. supraspinatus , m. subscapularis and m. infraspinatus ) was tendon calcification ( 51% , 72% , and 60% of each tendon pathologies ) , besides tendon tear and tendinosis . tendon calcification occurred more frequent in females ( male / female = 0.32 ) and were found more frequently in patients older than 30 and generally correlated positively with age . sheath effusion was the predominant finding in the hrus examination of the long biceps tendon . patients older than 45 years showed more long biceps tendon pathologies than the younger and isolated ( no other pathologies at the shoulder except bursitis and ac joint pathologies ) long biceps tendon pathologies was more often seen in males ( male / female = 1.50 ) . hrus examination findings ( n = 100 ) table 6 gives an overview of the diagnostic values of clinical examinations compared with hrus examination findings ( any pathology ) . = correlation coefficient bursitis sign has a very low sensitivity ( 0.09 ) and a specificity of 1 . the m. supraspinatus tests ( jobe supraspinatus test , painful arc i and hawkins and kennedy impingement test ) show high sensitivities ( 0.81 , 0.83 , and 0.86 ) and low specificities ( 0.55 , 0.35 , and 0.45 ) for any pathology . as opposed to this , the drop arm test has a specificity of 1 and a low sensitivity ( 0.12 ) for any pathology of the rotator cuff . all m. supraspinatus tests have only moderate correlation as measured by the values of the empirical pearson 's correlation coefficient ( 0.36 , 0.20 , 0.33 , and 0.20 ) and only weak correlation as measured by the uniweighted cohen 's  coefficients ( 0.36 , 0.19 , 0.33 , and 0.08 ) . comparing the sensitivity of the m. supraspinatus tests ( jobe supraspinatus test , painful arc i , drop arm test , and hawkins and kennedy impingement test ) versus the grade of tendon tear [ partial thickness ( + ) , intramural ( + + ) , and full thickness ( + + + ) ] , it was observed , that the higher the tendon tear grade , the higher the sensitivity was . only in the case of the hawkins and kennedy impingement test the sensitivity of detecting partial thickness tendon tears was higher ( 0.80 ) than the sensitivity of detecting full thickness tendon tears ( 0.71 ) . the drop arm test showed a high specificity ( 0.98 ) and sensitivity ( 0.86 ) for detecting full thickness supraspinatus tendon rupture . the hawkins and kennedy impingement test showed a high sensitivity ( 0.86 ) and a specificity of 1 to detect a supraspinatus tendon rupture . to detect m. subscapularis tendon pathology the gerber lift off test has a sensitivity of 1 , the belly press test a high specificity ( 0.73 ) . the infraspinatus test showed a high sensitivity ( 0.90 ) and specificity ( 0.74 ) . forty - one hundredths is the empirical pearson 's correlation coefficient and 0.33 the uniweighted cohen 's  coefficient . all m. supraspinatus tests ( jobe supraspinatus test , painful arc i , hawkins and kennedy impingement test , drop arm test ) provided high sensitivities ( 0.91 , 0.86 , 1 , 0.86 ) and low specificities ( 0.43 , 0.17 , 0.15 , 0.17 ) , in order to detect tendon calcification . the other rotator cuff tests ( gerber lift off test , belly press test and infraspinatus test ) show low sensitivities ( 0.41 , 0.39 , and 0.46 ) and high specificities ( 1 , 0.91 , and 0.96 ) . patients aged 55 to 59 years have significantly more often a partial thickness rupture than other patient groups and regarding people older than 65 years there is a significant accumulation of full thickness rupture . all three ac joint tests ( painful arc ii , ac joint tenderness , cross body adduction stress test ) show low sensitivities ( 0.25 , 0.38 and 0.38 ) and high specificities ( 0.96 , 0.99 and 0.96 ) . ac osteophytes are in 9 out of total 13 cases ( 69% ) associated with pathologies in the rotator cuff , either tendon tear or tendinosis or both . to examine the long biceps tendon both tests ( palm up test and yergason test ) have a high specificity ( 0.75 and 0.88 ) and a low sensitivity ( 0.47 and 0.32 ) . the abbott - saunders test shows a sensitivity of 1 and a high specificity ( 0.99 ) in order to detect a long biceps tendon subluxation . the hueter sign has a low sensitivity ( 0.05 ) and a specificity of 1 to identify a long biceps tendon tear . in 18 out of total 20 patients ( 90% ) with at least one long biceps tendon pathology ( tendon sheath effusion , tendinosis , tendon subluxation or tendon rupture ) a concomitant tendon tear of one or multiple rotator cuff tendons was noticed . the study of naredo et al . showed that with the clinical tests performed in the study an exact diagnosis of the underlying shoulder pathology could not be made . found in his study that the sonographic examination has a higher sensitivity and specificity than the clinical examination . therefore , in our study the primary goal was to find out if the clinical tests are useful for detection of the location of the shoulder pathology and in a second step to examine whether some of the tests are specific for distinct pathologies . furthermore in this study the clinical examination was more detailed and included a larger number of patients than in the study of naredo et al . hrus is an inexpensive , non - painful , non - invasive and fast method for a real - time and dynamic examination of the shoulder . the accuracy is comparable to mri examination to evaluate superficial tendons and soft tissues with a high degree of resolution , including the rotator cuff and muscles , and concomitant pathology of the long biceps tendon , ac joint , and bursa subacromialis . furthermore hr us is not limited by mri contraindications , such as patient 's body habitus , claustrophobia , inability to lie flat , or implanted devices not compatible with the magnetized environment in a mri . for this reasons hrus however , there exist occasions in which hrus is inferior to mri examination of the shoulder . for instance if labral and ligamentous injuries are suspected , or when underlying osseous pathology is a concern . scheel et al . evaluated in the study interobserver reliability of rheumatologists performing musculoskeletal ultrasonography : results from a eular  train the trainers course an interobserve r agreement . using modified  index for majority agreement the agreement was estimated to be 0.76 for the shoulder which was described as good . . found a high agre ement ( 92% ) between the observers in the diagnosis of rotator cuff partial and full thickness tear . on the opposite naredo et al . found a low inter observer agreement (  = 0.5 ) for the diagnosis of shoulder tendon lesions it is believed that the interobserver variabilities are low due to lacking standardization of us scanning techniques and definitions of different pathological us lesions . in this study the hrus examinators had clear definitions of both . looking at previous studies , the diagnostic values of the m. supraspinatus tests for determining the location of the rotator cuff lesion are similar to this study . used surgery as th e gold standard ; the sensitivity and specificity of jobe supraspinatus test for detecting tendon lesions was 0.86 and 0.50 , respectively . the lacking specificity of the jobe supraspinatus test may be explained by the fact that a present pathology of the long biceps tendon , the adjacent rotator cuff tendons or a neuropathy of the suprascapular nerve result in a false - positive test result . the sensitivity and specificity of painful arc i calculated by park et al . was 0.71 and 0.47 al so using surgery as the gold standard . a positive painful arc can be the result of complete or incomplete rotator cuff tears , swelling and inflammation as a result of bursitis and abnormality of the margin of the acromion . for detecting subacromial impingement the drop arm test showed a sensitivity of 0.04 and a specificity of 1 , calculated by cali et al . using surgery as the gold standard . in the study of macdonald et al . the sensitivity and s pecificity of hawkins and kennedy impingement test were 0.88 and 0.43 again using surgery as the gold standard . these two tests are not suitable for any m. supraspinatus pathologies but the drop arm test is an ideal test for detecting full thickness supraspinatus tendon rupture . in patients in which a tendon rupture is suspected , the hawkins and kennedy impingement tests are highly sensitive and specific for supraspinatus tendon tear . regarding the sensitivity of 1 but low specificity ( 0.55 ) of the gerber lift off test and the high specificity ( 0.72 ) of the belly press test , the gerber lift off test is suitable as screening test and the belly press test may serve as a confirmatory test for m. subscapularis tendon pathology . regarding other studies , gerber and krushell calculated a sensitivi ty of 0.98 for the gerber lift off test and barth et al . calculated a specifici ty of 0.98 for the belly press test . these values suggest that the belly press test may be valuable as a confirmatory test for subscapularis muscle tear after a positive gerber lift off test result . the infraspinatus test showed a high sensitivity and specificity . in the study of walch et al . the diagnostic values of the external rotation lag sign , which is an alteration of the infraspinatus test , were calculated using surgery as the gold standard . a sensitivity and specificity of each 0.98 to detect m. infraspinatus muscle tear was shown . therefore the alteration of the infraspinatus test may be diagnostic of an infraspinatus muscle tear . in this study , it is shown that patients , aged 55 to 59 years , have significantly more often a partial thickness rupture than other patient groups . regarding people older than 65 years , there is a significant accumulation of total thickness rupture . tendon ruptures in older individuals are more often full thickness tears , traumatic ruptures in younger individuals are mainly partialthickness tears . tendon calcification was the most frequently detected pathology of the rotator cuff ( 42% of all cases ) . female was the predominantly affected gender ( male / female = 0.32 ) , as has been reported previously . however , a further ex planation for this female predominance has not yet been worked out . with regard to location , the m. supraspinatus tests have high sensitivities and the m. subscapularis and m. infraspinatus tests have high specificities to detect calcification in their corresponding tendon . a positive power doppler signal was shown to correlate with symptomatic tendon calcifications . in our study the hrus examination findings of ac osteophytes with consequent rotator cuff pathologies as tendon tear and tendinosis are correlated with the according test results : only in 4 cases out of total 13 ( 30% ) ac osteophytes occurred without tendinosis and tear . therefore in cases with ac osteophytes rotator cuff tendon tears or tendinosis should be suspected as ac osteophytes can mechanically damage the rotator cuff . as with ac osteophytes , a strong correlation between long biceps tendon pathology and rotator cuff tears was found . eighteen out of 20 patients ( 90% ) with biceps pathologies showed one or multiple rotator cuff tears . in cases of rotator cuff incompetence the bicipital tendon acting as a humeral head depressor has to compensate for the ruptured rotator cuff . also , the presence of a complete rotator cuff tear exposes the intra - articular portion of the bicipital tendon to the overlying acromion and further impingement . therefore if a pathologic long biceps tendon is observed one should carefully look for a rotator cuff pathology . all three ac test results ( painful arc ii , ac joint tenderness , cross body adduction stress test ) showed low sensitivities ( 0.25 , 0.38 and 0.38 ) . this can be explained by the fact that the main pathologic findings in the ac joint detectable by hrus ; joint space narrowing and osteophytes can be asymptomatic . found for the yergason test a sensitivity of 0.43 and a specificity of 0.79 , for the palm up test a sensitivity of 0.32 and a specificity of 0.75 using surgery as the gold standard . the palm up test includes the anterior part of the deltoid muscle as well as the m. supraspinatus , m. subscapularis and upper part of the major pectoralis muscle in its movement . the yergason test involves a supination movement of the forearm which can also be performed by the m. supinator . pathologies of the rotator cuff with concomitant subacromial bursitis often lead to a long biceps tendon sheath effusion , because the subacromial bursa communicates with the long biceps tendon sheath when a full thickness tear is present . the fact that males ( male / female = 1.50 ) and older patients showed more isolated long biceps tendon pathologies is in agreement with other studies . long biceps tendon tears occur more often in patients 4060 years of age and in male patients in general . in the elderly degenerative tendon changes this study shows that knowledge of sensitivity and specificity of various clinical tests is important for the interpretation of clinical examination results and the identification of cases , for which further imaging procedures are necessary to make distinct diagnosis . only few clinical tests are sensitive and specific enough to allow a diagnosis without further imaging . if a rotator cuff rupture is suspected , the hawkins kennedy impingement test is diagnostic for m. supraspinatus tendon rupture . regarding m. subscapularis tendon pathology , the gerber lift off test is suitable as screening test and the belly press test serve as a confirmatory test .
objectivehigh resolution ultrasonography is a non - painful and non - invasive imaging technique which is useful for the assessment of shoulder pain causes , as clinical examination often does not allow an exact diagnosis . 
 the aim of this study was to compare the findings of clinical examination and high resolution ultrasonography in patients presenting with painful shoulder.methodsnon-interventional observational study of 100 adult patients suffering from unilateral shoulder pain . 
 exclusion criteria were shoulder fractures , prior shoulder joint surgery and shoulder injections in the past month . 
 the physicians performing the most common clinical shoulder examinations were blinded to the results of the high resolution ultrasonography and vice versa.resultsin order to detect pathology of the m. supraspinatus tendon , the hawkins and kennedy impingement test showed the highest sensitivity ( 0.86 ) whereas the jobe supraspinatus test showed the highest specificity ( 0.55 ) . to identify m. subscapularis tendon pathology the gerber lift off 
 test showed a sensitivity of 1 , whereas the belly press test showed the higher specificity ( 0.72 ) . 
 the infraspinatus test showed a high sensitivity ( 0.90 ) and specificity ( 0.74 ) . 
 all ac tests ( painful arc iia , ac joint tendernessb , cross body adduction stress testc ) showed high specificities ( a0.96 , b0.99 , c0.96 ) . evaluating the long biceps tendon , 
 the palm up test showed the highest sensitivity ( 0.47 ) and the yergason test the highest specificity ( 0.88).conclusionknowledge of sensitivity and specificity of various clinical tests is important for the interpretation of clinical examination test results . high resolution ultrasonography is needed in most cases to establish a clear diagnosis .