Shoulder Instablity - RCE Synopsis


Question: Does This Patient Have an Instability of the Shoulder or a Labrum Lesion?

Original Citation: Luime et al. Does this patient have an instability of the shoulder or a labrum lesion? JAMA 2004; 292: 1989

Bottom Line

• For shoulder instability the relocation test (+LR 6.5, -LR 0.18 ) and the anterior release test (+LR 8.3, -LR 0.09 ) are best for establishing the diagnosis

• For labral tears the biceps load I and II tests (+LR 26 & 29, -LR 0.09 & 0.11),and the internal rotation resistance strength tests (+LR 25, - LR 0.12 ) are best for ruling in the diagnosis. The pain provocation test of Mimori is best for ruling out the diagnosis (-LR 0.03 )

• Many of the physical exam techniques described are relatively new and thus have not been validated in further studies

• Studies were conducted in orthopaedics offices, so the prevalence of shoulder instability in this population of patients higher than in the general population

SORT Grade of Recommendation: B Meta-analysis of limited quality studies

Comments/Hints/Suggestions

An excellent overview of the shoulder exam with illustrations is given on the aafp website:

www.aafp.org/afp/20000515/3079.html (Woodward et al. The Painful Shoulder: Part I Clinical Evaluation. American Family Physician. 2000; 61(10): 3079-3089)

If patient is willing to undergo surgery, optimal management is referral to orthopaedic surgeon as surgery/arthroscopy is often diagnostic and therapeutic.

Prevalence

Incidence of shoulder dislocation in the general population is 1.7%. There is no scientific literature regarding the incidence or prevalence of subluxation. In the studies of patients reporting to an orthopaedic surgeon with shoulder pain, the prevalence of instability and labral lesions ranged from 15-100%

Accuracy of Exam

Signs

Positive LR

(95 % CI)

Negative LR

(95% CI)

Sensitivity

Specificity

Instability

Relocation Test

6.5 (3.0-14.0)

0.18 (0.07-0.45)

0.85

0.87

Anterior Release test

8.3 (3.6-19.0)

0.09 (0.03-0.27)

0.92

0.89

Labral Tear

Biceps Load I

29.0 (7.3-115.0)

0.09 (0.01-0.58)

0.83

0.98

Biceps Load II

26.0 (8.6-80.0)

0.11 (0.04-0.28)

0.90

0.96

Pain Provocation test of Mimori

7.2 (1.6-32.0)

0.03 (0.00-0.47)

1.00

0.90

Internal Rotation Resistance Strength test

25.0 (8.1-76.0)

0.12 (0.04-0.35)

0.88

0.96


Description of how exams were done or of prediction rules

Tests for Instability:

1. Relocation Test- With patient lying supine, the shoulder is abducted to 90 degrees, externally rotated 90 degrees, with elbow having 90 degrees of flexion. The examiner applies posterior pressure to the humeral head, with a positive test providing relief of pain.

2. Anterior release test: Perform like the relocation test, then quickly release the posterior pressure being applied to the humeral head. A positive test results when there is pain or the patient expresses apprehension.

Tests for Labral tears:

1. Biceps load Test I: With the patient lying supine, the shoulder is abducted to 90 degrees with maximal external rotation and the elbow is placed in 90 degrees of flexion. The patient resists lateral force applied to the forearm by the examiner. A positive test results in the patient having increased pain.

2. Biceps load Test II: Same as biceps load test I, with the exception that the shoulder is abducted 120 degrees instead of 90 degrees.

3. Pain provocation test of Mimori: With patient seated upright or standing, the shoulder is abducted to 90 degrees with the elbow flexed to 90 degrees. The patient’s forearm is maximally supinated. A positive test occurs when the patient expresses increasing pain when the examiner moves the forearm from maximum supination to maximum pronation.

4. Internal rotation resistance strength test: With patient seated upright or standing, the shoulder is abducted to 90 degrees with the elbow flexed to 90 degrees and the shoulder externally rotation to 80 degrees. The patient is then asked to resist internal and external rotation forces applied by the examiner. A positive test is when the patient shows normal strength when resisting external rotation but decreased strength when resisting internal rotation.

Precision

No kappa statistics were given.

Study’s description

Inclusion Criteria: Descriptions of clinical tests for instability or intra-articular pathology of the shoulder, use of a reference/gold standard, detailing of sensitivity and specificity, publication in English, Dutch, or German. Exclusion criteria included diagnosis of fibromyalgia or systemic disorders such as fractures, tumors, rheumatoid arthritis, or stroke.

Search Date: MEDLINE 1966-2003, EMBASE 1980-2001, and CINAHL (1982-2001)

Number Found and Reviewed: 130 abstracts were found that evaluated shoulder disorders and diagnostic outcome measurements. 35 articles that evaluated clinical tests were formally reviewed, with 17 articles meeting inclusion criteria.

Quality/Limitations: There were many limitations with studies used in the meta-analysis. There were small sample sizes (32-419 shoulders). In 12 out of 17 of the studies, the procedure for selecting patients was not described. In 11 of the studies, the time between the clinical exam (index test) and either arthroscopy or surgery (reference test) was unknown. In 16 of the studies, it was unclear if the physician performing the reference test was blinded from the results of the clinical exam (with the 17th study not blinded). In 15 of the studies, patients were selected from waiting lists for either shoulder surgery or arthroscopy (possible spectrum bias). There was also a high prevalence of shoulder instability and labrum tears, which prevents false positives and true negative from being detected. As a result, the studies will overestimate the sensitivity and underestimate the specificity when used to evaluate patients in areas with lower prevalence (ie- primary care physician offices).

Gold Standard: Arthroscopy or surgery

Updated SearchDate: May 16, 2007

Updated Medline search was conducted for articles from January 2004 thru May 2007. Two relevant articles were found.

Article #1: Farber, Adam et al. “Clinical Assessment of Three Common Tests for Traumatic Anterior Shoulder Instability. J Bone Joint Surg Am. 2006; 88: 1467-1474

Description: 363 patients underwent three physical examination tests (anterior drawer test, apprehension test, relocation test) followed by shoulder arthroscopy. 46 patients were found to have anterior shoulder instability on arthroscopy, with the remaining patients serving as controls.

Findings: For the apprehension test, the presence of apprehension showed a large positive likelihood ratio and good specificity (+ LR 20.2, - LR 0.29, Sensitivity 72%, Specificity 96%). In comparison, if the presence of pain as the definition of a positive test lowered these values (+ LR 1.13, -LR 0.90, Sensitivity 50%, Specificity 56%). For the relocation test, relief of apprehension showed a large positive likelihood ratio as well (+LR 10.35, -LR 0.20, Sensitivity 81%, Specificity 92%). As with the apprehension test, if relief of pain (instead of apprehension) was used as the criterion for a positive test, the + LR was lowered (+ LR 3.02, - LR 0.77, Sensitivity 30%, Specificity 90%). The anterior drawer test was not as helpful (only 87% of patients were able to tolerate the exam, and + LR was 0.97-3.57 depending on criterion for a positive test result).

Critique: Small number of patients (n= 46). The study group was significantly different from the control group in terms of age (study group was younger), trauma as etiology of injury (more common in study group), and patients involved in sports above the high-school level (more in study group). The study was not blinded as all physical exams and surgeries were performed by the senior author or under his supervision.

Level of Evidence: Grade B- Lower quality clinical trial

Fit: For the apprehension test, this article fits with the RCE article in that the test was very specific when apprehension (and not pain) was used as criteria for a positive test. For the relief test, the RCE article likewise noted similar results of sensitivity, specificity, and + LR when relief of apprehension was used. The anterior drawer test was not mentioned in the RCE.

Article #2: Jones, G. et al. “Clinical Assessment of Superior Glenoid Labral Lesions”. Clinical Orthopaedics and Related Research. 2007; 455:45-51

Description: A systematic review of the literature using Medline and Embase was used to evaluate various physical examination tests in the diagnosis SLAP lesions.

Findings: This review found that many SLAP detecting physical exam techniques were unable to reproduce the same results when repeated in independent studies. This is likely due to difference in physical exam techniques between the studies, including variable criteria for what constitutes a positive test. The patients were different between the studies in terms age and underlying shoulder pathology as well. Overall, it is felt that further investigation is needed to evaluate the reliability of these tests.

Critique: As mentioned above, differences in the patient populations between the studies made it difficult to assess the reproducibility of the tests. The patients also had a high prevalence of SLAP lesions, which makes it difficult to apply the results to the general population.

Level of Evidence: Grade B- review of lower quality clinical trial

Fit: 9 of the ll articles reviewed in this study were mentioned in the RCE exam article, with many of the same conclusions drawn. The RCE article mentioned four tests that were most effective at diagnosing labral tears. Three of these tests (the Biceps Load I, Biceps Load II, and pain provocation test of Mimori) were all included in this article with the same results that were presented in the RCE. The internal rotation resistance strength test was not mentioned.

Reviewed by: Mark Rowand, M Lee Chambliss Date May 22, 2007


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