Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement

  • Review
  • Diagnostic

Authors


Abstract

Background

Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting.

Objectives

To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.

Search methods

We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English.

Selection criteria

We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials.

Data collection and analysis

Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed.

Main results

We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.

The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition.

Authors' conclusions

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.

Résumé scientifique

Tests physiques du syndrome de conflit sous-acromial et des lésions locales des bourses séreuses, du tendon ou du bourrelet marginal pouvant l'accompagner

Contexte

Le syndrome de conflit sous-acromial est une cause fréquente de douleur de l'épaule. Les mécanismes du syndrome de conflit sous-acromial peuvent agir au niveau sous-acromial (sous l'arche acromio-coracoïdienne) ou au niveau interne (au sein de l'articulation de l'épaule), et un nombre de pathologies secondaires peuvent y être associées. Elles comprennent par exemple la bursite sous-acromiale/tendinite calcifiante des courts rotateurs de l'épaule (inflammation de la partie sous-acromiale des bourses séreuses, de la partie sous-deltoïde, ou des deux), les tendinopathies ou les déchirures touchant la coiffe des rotateurs ou le tendon de la longue portion du biceps, et les lésions du bourrelet glénoïdien. Un diagnostic précis fondé sur des tests physiques devrait faciliter l'optimisation précoce de l'approche de prise en charge clinique. La plupart des gens souffrant de douleur de l'épaule sont diagnostiqués et pris en charge dans le contexte de médecine générale.

Objectifs

Évaluer la précision diagnostique des tests physiques du syndrome de conflit sous-acromial (au niveau sous-acromial ou interne) ou des lésions locales des bourses séreuses, de la coiffe des rotateurs ou du bourrelet glénoïdien pouvant accompagner le syndrome de conflit sous-acromial, chez les personnes dont les symptômes et/ou les antécédents suggèrent l'un de ces troubles.

Stratégie de recherche documentaire

Nous avons effectué des recherches dans les bases de données électroniques pour identifier des études primaires en deux étapes. Au cours de la première étape, nous avons consulté MEDLINE, EMBASE, CINAHL, AMED et DARE (toutes de leur origine jusqu'à novembre 2005). Au cours de la seconde étape, nous avons consulté MEDLINE, EMBASE et AMED (de 2005 jusqu'au 15 février 2010). Les recherches ont été limitées aux articles écrits en anglais.

Critères de sélection

Nous avons considéré pour inclusion les études portant sur la précision des tests diagnostiques ayant directement comparé la précision d'un ou plusieurs tests d'indice physiques du syndrome de conflit sous-acromial par rapport à celle d'un test de référence dans un contexte clinique. Nous avons considéré les études portant sur la précision des tests diagnostiques ayant un schéma d'étude croisé ou de cohorte (études rétrospectives ou prospectives), les études cas-témoins et les essais contrôlés randomisés.

Recueil et analyse des données

Deux groupes de deux auteurs de la revue ont, indépendamment, sélectionné les études, évalué la qualité méthodologique des études à l'aide de l'outil QUADAS, et extrait des données dans un formulaire prévu à cet effet, en notant les caractéristiques des patients (y compris le contexte de médecine générale), le schéma de l'étude, les tests d'indice et la référence, et les tableaux de diagnostic de 2 x 2. Nous avons présenté des données sur les sensibilités et les spécificités avec des intervalles de confiance (IC) à 95 % pour les tests d'indice. Aucune méta-analyse n'a été effectuée.

Résultats principaux

Nous avons inclus dans la revue 33 études impliquant 4002 épaules pour un total de 3852 patients. Bien que 28 études étaient prospectives, la qualité des études était pourtant généralement médiocre. Elles reflétaient principalement l'utilisation de la chirurgie en tant que test de référence dans la plupart des études, aussi nous avons considéré que toutes les études sauf deux ne répondaient pas aux critères permettant d'avoir un spectre représentatif de patients. Toutefois, même ces deux études n'ont recruté qu'une partie des patients dans le contexte de médecine générale.

Les troubles ciblés qui ont été évalués dans les 33 études ont été regroupés dans cinq catégories principales : syndrome de conflit sous-acromial ou interne, tendinopathie ou déchirures de la coiffe des rotateurs, tendinopathie ou déchirures de la longue portion du biceps, lésions du bourrelet glénoïdien et multiples troubles ciblés indifférenciés. La majorité des études ont utilisé la chirurgie arthroscopique comme standard de référence. Huit études ont utilisé des références qui étaient potentiellement applicables au contexte de médecine générale (anesthésie locale, une étude ; ultrasons, trois études) ou au contexte de médecine ambulatoire (imagerie par résonance magnétique, quatre études). Une étude a utilisé toute une série de références, certaines étant applicables au contexte de médecine générale ou au contexte de médecine ambulatoire. Dans deux de ces études, la référence utilisée était acceptable pour identifier le trouble ciblé, mais dans six autres études, elle ne l'était que partiellement. Les études ont évalué de nombreux tests d'indice standard, modifiés ou combinés, et 14 nouveaux tests d'indice. Il y avait 170 combinaisons de tests d'indice/troubles cibles, mais six cas seulement où un test d'indice quelconque a été utilisé et interprété de la même manière dans deux études. Deux études seulement portant sur un test modifié « modified empty can test » de la déchirure de l'épaisseur entière de la coiffe des rotateurs, et deux études portant sur un test modifié d'instabilité antérieure « modified anterior slide test » des lésions SLAP de type II (du bourrelet glénoïdien supérieur et de l'insertion du long biceps), étaient cliniquement homogènes. Compte tenu du nombre limité des études, il n'a pas été possible d'effectuer les méta-analyses. Les estimations de sensibilité et de spécificité de chaque étude sont présentées sur des Forest plots (graphiques en forêt) pour les 170 combinaisons de tests d'indice/troubles cibles regroupées en fonction du trouble cible.

Conclusions des auteurs

Il n'y a pas suffisamment d'éléments probants pour justifier la sélection de tests physiques du syndrome de conflit sous-acromial, et des lésions locales des bourses séreuses, du tendon ou du bourrelet glénoïdien pouvant accompagner le syndrome de conflit sous-acromial, dans le contexte de médecine générale. La grande partie de la littérature a révélé une diversité extrême dans les performances et l'interprétation des tests, qui empêche toute synthèse des preuves et/ou toute applicabilité clinique.

Plain language summary

Physical tests for shoulder impingement in primary care

Impingement (or pinching) of soft-tissues in or around the shoulder is a common cause of pain and is often linked to tissue damage in and around the joint. If doctors and therapists could identify impingement and associated damage using simple, physical tests, it would help them to inform on the best treatment approach at an early stage. We were particularly interested in the primary (community) care setting, because this is where most shoulder pain is diagnosed and managed. We reviewed original research papers for evidence on the accuracy of physical tests for shoulder impingement or associated damage, in people whose symptoms and/or history suggest any of these disorders. To find the research papers, we searched the main electronic databases of medical and allied literature up to 2010. Two review authors screened assessed the quality of each research paper and extracted important information. If multiple research papers reported using the same test for the same condition, we intended to combine their results to gain a more precise estimate of the test's accuracy. We included 33 research papers. These related to studies of 4002 shoulders in 3852 patients. None of the studies exclusively looked at patients from primary care, though two recruited some of their patients from primary care. The majority of studies used arthroscopic surgery as the reference standard. There were 170 different target condition/index test combinations but only six instances where the same test was used in the same way, and for the same reason, in two studies. For this reason combining results was not appropriate. We concluded that there is insufficient evidence upon which to base selection of physical tests for shoulder impingement, and potentially related conditions, in primary care.

Résumé simplifié

Tests physiques du syndrome de conflit sous-acromial dans un cadre de médecine générale

Le conflit sous-acromial (ou pincement) des tissus mous dans et autour de l'épaule est une cause fréquente de douleur et est souvent associé à des lésions tissulaires dans et autour de l'articulation. Si les médecins et les thérapeutes pouvaient identifier le conflit sous-acromial et les lésions qui y sont associées en utilisant des tests physiques simples, ils seraient en mesure d'orienter la meilleure approche de traitement à un stade précoce. Nous étions plus particulièrement intéressés par le contexte de médecine générale (dans les communautés), parce que c'est à ce niveau que la plupart des douleurs de l'épaule sont diagnostiquées et prises ne charge. Nous avons examiné les articles de recherche d'origine pour trouver des preuves sur la précision des tests physiques du syndrome de conflit sous-acromial ou des lésions qui y sont associées, chez les personnes dont les symptômes et/ou les antécédents suggèrent l'un de ces troubles. Pour trouver les articles de recherche, nous avons effectué des recherches dans les principales bases de données électroniques de la littérature médicale et alliée jusqu'en 2010. Deux auteurs de la revue ont sélectionné les articles, évalué la qualité de chaque article de recherche et extrait des données importantes. Si de multiples articles de recherche rendaient compte de données en utilisant le même test pour le même trouble, nous avions décidé de combiner leurs résultats afin d'obtenir une estimation plus précise de la précision du test. Nous avons inclus 33 articles de recherche. Ils concernaient des études portant sur 4002 épaules chez 3852 patients. Aucune des études n'a exclusivement examiné les patients issus d'un contexte de médecine générale, même si deux ont recruté certains de leurs patients dans un contexte de médecine générale. La majorité des études ont utilisé la chirurgie arthroscopique comme référence. Il y avait 170 différentes combinaisons de tests d'indice/troubles cibles mais six cas seulement où le même test a été utilisé de la même manière, et pour la même raison, dans deux études. Pour cette raison, il n'a pas été possible de combiner les résultats. Nous en avons conclu qu'il n'y avait pas suffisamment d'éléments probants pour justifier la sélection de tests physiques du syndrome de conflit sous-acromial, et des troubles potentiellement liés, dans un cadre de médecine générale.

Notes de traduction

Traduit par: French Cochrane Centre 17th May, 2013
Traduction financée par: Pour la France : Minist�re de la Sant�. Pour le Canada : Instituts de recherche en sant� du Canada, minist�re de la Sant� du Qu�bec, Fonds de recherche de Qu�bec-Sant� et Institut national d'excellence en sant� et en services sociaux.

Laienverständliche Zusammenfassung

Körperliche Tests für Schulter-Impingements in der Primärversorgung

Ein Impingement (bzw. eine Einklemmung) der Weichteile in oder um die Schulter herum ist eine häufige Ursache von Schmerzen und steht oft in Verbindung mit Gewebeschäden in und um das Gelenk herum. Wenn Ärzte und Therapeuten ein Impingement und damit verbundene Schäden durch einfache körperliche Tests identifizieren könnten, würde ihnen das die Beratung über den besten Behandlungsansatz in einem frühen Stadium erleichtern. Wir waren insbesondere an der Primärversorgung (damit ist im allgemeinen die (haus-) ärztliche Grundversorgung in Abgrenzung zur sekundären Versorgung durch Spezialisten gemeint) interessiert, weil dort Schulterschmerzen überwiegend diagnostiziert und versorgt werden. Wir haben originale Forschungsberichte bezüglich der Evidenz (des wissenschaftlichen Belegs) zur Genauigkeit körperlicher Tests für ein Schulter-Impingement oder mit einem solchen verbundene Schäden bei Menschen, deren Symptome und/oder Vorgeschichte eine dieser Störungsbilder vermuten lässt, begutachtet. Um die Forschungsberichte ausfindig zu machen, durchsuchten wir die wichtigsten medizinischen und (Medizin-) verwandten elektronischen Literaturdatenbanken bis 2010. Zwei Review-Autoren überprüften den Einschluss jedes Forschungsberichts, bewerteten die Qualität und entnahmen wesentliche Informationen. Für den Fall, dass mehrere Forschungsberichte die Verwendung desselben Test für dasselbe Beschwerdebild angaben, beabsichtigten wir die statistische (rechnerische) Zusammenfassung ihrer Ergebnisse, um eine genauere Schätzung der Genauigkeit des Tests zu erhalten. Wir schlossen 33 Forschungsarbeiten ein. Diese bezogen sich auf 4002 Schultern von 3852 Patienten. Keine der Studien betrachtete ausschließlich Patienten aus der Primärversorgung, allerdings schlossen zwei Studien einige Patienten aus der Primärversorgung ein. Der Großteil der Studien verwendete einen arthroskopischen Eingriff als Referenzstandard (d.h. als Vergleichsuntersuchung, anhand derer die Genauigkeit des interessierenden körperlichen Tests ermittelt wurde). Es gab 170 verschiedene Kombinationen von Ziel-Störungsbildern/Index-Tests (interessierenden körperlichen Tests), aber nur sechs Fälle, in denen derselbe Test in der gleichen Weise, und zwei Fälle, in denen er aus demselben Grund angewandt wurde. Daher war eine statistische Zusammenfassung der Ergebnisse unangemessen. Wir folgerten, dass es unzureichende Evidenz als Grundlage für die Auswahl körperlicher Tests für Schulterimpingements und möglicherweise mit solchen verbundenen Störungsbildern in der Primäversorgung gibt.

Anmerkungen zur Übersetzung

C. Braun, M. Lohkamp und N. Jahnke, Koordination durch Cochrane Schweiz

Laički sažetak

Fizički testovi za dijagnosticiranje sindroma sraza ramena u primarnoj medicinskoj skrbi

Sindrom sraza ramena (engl. shoulder impingement) čest je uzrok boli u ramenu i povezuje se sa oštećenjima tkiva unutar i oko zgloba. Ako bi se sindrom sraza i pridružena oštećenja mogla otkriti koristeći jednostavne fizičke testove, liječenje bi moglo započeti u ranoj fazi bolesti. Autore Cochrane sustavnog pregleda su zanimali uvjeti u obiteljskih liječnika, zato što se tu prepoznaje i liječi najviše slučajeva boli u ramenu. Pregledane su originalne studije o preciznosti fizičkih testova za sindrom sraza ramena i pridruženih oštećenja u osoba čiji simptomi i/ili povijest bolesti upućuju na postojanje tih poremećaja. Za pronalazak studija koristile su se glavne elektroničke baze podataka medicinske i druga relevantna literatura objavljena zaključno do 2010. godine. Dva autora studije procijenili su kvalitetu studija i analizirali važne podatke. U slučaju višestrukih studija koje koriste isti test za isto stanje procijenjena je ukupna preciznost testa. Uključene su 33 studije, u kojima su prikazani podatci o 4002 pregledanih ramena u 3852 pacijenta. Studije nisu isključivo pratile pacijente iz ordinacija obiteljskih liječnika, iako su u 2 studije takvi pacijenti činili dio uključenih ispitanika. Većina studija je kao kontrolu za usporedbu koristila artroskopiju. Analizirano je 170 različitih kombinacija stanja i testa, ali su se u samo 6 studija koristile na isti način i za ista stanja. Zbog ovih razloga nije bilo primjereno statistički zbirno analizirati sve podatke. Autori sustavnog pregleda zaključuju da ne postoje dokazi koji potvrđuju efikasnost korištenje fizičkih testova za sindrom sraza ramena i sličnih stanja u obiteljskoj skrbi.

Bilješke prijevoda

Hrvatski Cochrane
Preveli: Lara Lalić i Zvonimir Križanac
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Background

Target condition being diagnosed

Shoulder pain and dysfunction are common in the general population. A systematic review reported point prevalences for shoulder pain ranging from 7% to 26% with some indication that prevalence increases with age (Luime 2004a). Data from the US National Ambulatory Medical Care Survey (NAMCS) 1993 to 2000 indicate that one per cent of all office visits to physicians are for shoulder pain, and that a quarter of these visits are to primary care physicians (Wofford 2005). Moreover, shoulder pain has little tendency to resolve quickly or completely; according to a Dutch study, one half of all sufferers still report problems a year after their initial consultation (Van der Heijden 1997).

Shoulder pain and dysfunction may result from various aetiologies and pathologies. A common cause is impingement (pinching), which causes ‘catching’ or aching pain without appreciable joint stiffness, and which has a number of subtypes.

Impingement was originally characterised by Neer and Welsh (Neer 1977) as pinching of the soft-tissue structures between the humerus (upper arm bone) and the bone-and-ligament coraco-acromial arch of the scapula (shoulder blade) on movement. These structures include the contents of the so-called subacromial outlet: the ‘rotator cuff’ of muscles and tendons that surrounds the shoulder joint and the large lubricating sac (the subacromial bursa) that overlies it; and also the biceps tendon, which arches over the humerus, deep to the rotator cuff and within the shoulder joint itself. Neer 1977 proposed a continuum of impingement severity, from irritation of the bursa and cuff (normally due to overuse, and reversible by conservative management) to full thickness tears of the cuff. It has since been theorised that any abnormal reduction in the subacromial outlet’s volume (e.g. by bone shape, soft-tissue thickening, posture or minor joint instability) may predispose to, contribute to, perpetuate or aggravate this train of events (discussed by Hanchard 2004).

It is increasingly recognised that other forms of impingement exist which, in distinction from subacromial outlet impingement, involve pinching of intra-articular (internal joint) structures at the extremes of movement. The socket’s rim (the glenoid rim), its fibrocartilage extension (the glenoid labrum), and the deep surface of the rotator cuff are all at risk from this internal impingement mechanism, which may be subcategorised as anterosuperior or posterosuperior glenoid impingement (respectively affecting the front and back of the shoulder joint). It is unclear to what extent internal impingement is limited to athletes, and whether instability is a prerequisite (Jobe 1996).

Sometimes, primary partial thickness tears occur inside the substance of the rotator cuff, possibly due to internal shear stress (Fukuda 2003). Such tears also have the potential to cause impingement pain (Fukuda 2003; Uchiyama 2010).

Index test(s)

When a person presents with a history and symptoms suggestive of shoulder impingement, the clinician performs a series of physical (non-invasive) tests that aim to establish the diagnosis, and inform treatment and prognosis. Such tests may include the 'painful arc' test, intended to identify impingement in general terms (Cyriax 1982); tests to identify subacromial impingement (e.g. Neer 1977) or internal impingement (e.g. Meister 2004); tests to differentiate subacromial from internal impingement (Zaslav 2001); tests to diagnose rotator cuff involvement, including tears (e.g. Gerber 1991a; Gerber 1996; Hertel 1996a), or biceps tendon involvement (e.g. Yergason 1931); or tests to diagnose glenoid labrum tears (e.g. Kim 2001; Liu 1996b; O'Brien 1998a). These tests are described in Table 1, and include tests that were identified in studies included in this review. See Table 2 for explanations of terms used in Table 1 and elsewhere. Sometimes, local anaesthetic is injected into or around the subacromial bursa on the premise that negation of a previously positive (painful) physical test for subacromial outlet impingement will confirm and localise the diagnosis (Neer 1977). While not encompassing local anaesthesia per se, we will consider it for inclusion in this review when it is used in this special adjunctive mode. (Some studies of diagnostic accuracy may use local anaesthesia as a reference test rather than an index test, as considered below.)

Table 1. Index tests for impingement and secondary disorders
Tests intended to identify impingement in general
Test Reference Specified pre-requisites Technique Definition of positive response Specific implication of a positive response, according to the author(s)
Painful arc test Cyriax 1982NoneThe patient actively elevates, then lowers, the shoulder through abduction.Onset and offset of pain during elevation, during lowering, or both. Subacromial impingement; calcific tendonitis; pain secondary to shoulder joint instability; or internal impingement (involving the deep aspect of the rotator cuff or the LHB tendon)
Tests intended to identify subacromial impingement
Test Reference Specified pre-requisites Technique Definition of positive response Specific implication of a positive response, according to the author(s)
Hawkins' test Hawkins 1980NoneThe upright patient's arm is passively positioned in 90° of flexion at shoulder and elbow. The tester then forcibly medially rotates the patient's shoulder.Reproduction of the patient's pain Subacromial impingement
Neer's sign Neer 1977; Neer 1983 (Neer 1972a, sometimes cited, does not give a clear account of this test)NoneThe tester forcibly elevates the sitting patient's arm through scaption, preventing scapular movement by pressing down on the clavicle and acromion with the other hand.Pain constitutes a positive Neer's sign. Subacromial Impingement and 'many other shoulder conditions, including stiffness (partial frozen shoulder), instability (e.g. anterior subluxation), arthritis, calcium deposits, and bone lesions'.
Neer's test Neer 1977; Neer 1983NoneThe tester forcibly flexes the sitting patient's arm, preventing scapular movement by pressing down on the clavicle and acromion with the other hand (*Neer's sign). The patient is given an injection of 10 ml, 1% xylocaine beneath the anterior acromion before the manoeuvre is repeated.A positive *Neer's sign which is abolished by the injection is termed a positive Neer's test. Subacromial impingement
'Yocum's (impingement) test' Leroux 1995 and Naredo 2002 cite Yocum 1983: apparently a misconception (see under technique).NoneYocum did not describe a novel impingement test in the article cited (but see comment relating to the *empty can test, further in this table). Leroux 1995 and Naredo 2002 may have misinterpreted a photograph depicting Hawkins' test. According to Naredo 2002, the patient places the hand of the affected arm on his or her other shoulder and, keeping the point of the affected shoulder down, raises the elbow of the same limb.Reproduction of the patient's pain Subacromial impingement
Tests intended to identify internal impingement
Test Reference Specified pre-requisites Technique Definition of positive response Specific implication of a positive response, according to the author(s)
Anterior apprehension test at 90° for pain Krishnan 2004NoneThe test may be performed with the patient sitting or supine. In the latter position the test may be termed the fulcrum test. With the elbow flexed 90, the patient's shoulder is positioned in 90° abduction and full lateral rotation. (As distinct from the version of this test described by Jobe 1989, no anterior pressure is applied to the humeral head (see below).Pain is considered a positive result Internal impingement
Anterior apprehension test at 90° for pain Jobe 1989NoneThe supine patient's shoulder is placed in in 90° abduction and full lateral rotation, with the elbow flexed 90°. Maintaining this position, the tester applies an anterior pressure to the posterior aspect of the humeral head.Pain but no apprehension. (Note that Rowe 1981 described a test which, apart from the patient being in sitting, was performed comparably to that presented here. However, Rowe's test, which was for subluxation, required that both pain and apprehension be present for a positive result.)Pain associated with anterior subluxation. Since the original description of this test, this pain has more specifically been ascribed to posterosuperior glenoid impingement (Jobe 1995, Jobe 1996).
Anterior release test Gross 1997NoneThe patient lies supine, affected shoulder over the edge of the examination couch. The shoulder is passively abducted to 90° while the tester applies a posteriorly directed force to the humeral head. Maintaining this force, the tester brings the arm into full lateral rotation. Then the posteriorly directed force is released.Sudden pain, an increase in pain or reproduction of symptoms [on release]Primarilrily occult instability; but the authors link this to posterosuperior glenoid impingement.
Modified relocation test for postero-superior glenoid impingement Hamner 2000NoneThe patient liessupine. The shoulder is held by the tester in full lateral rotation and positioned at each of 90°, 100° and 120° of abduction. In each of these positions the tester applies a force to the patient's upper humerus, first directed anteriorly, then posteriorlyPain on the anteriorly directed force which is relieved by the posteriorly directed force Internal impingement
Posterior impingement test Meister 2004NoneThe supine patient's shoulder is placed into 90°-110° degrees of abduction and 10°-15° extension.  Full lateral rotation is then added.Pain felt deeply within the posterior aspect of the shoulder joint Posterior glenoid impingement and concomitant tear of the internal surface of the rotator cuff, of the posterior glenoid labrum, or both.
Relocation test for pain Jobe 1989Positive apprehension testThis is an extension of the apprehension test for pain at 90°, which it immediately follows. With the patient's arm still abducted and laterally rotated, posterior pressure is applied to the humeral head.The pain of the apprehension test is relieved. While posterior pressure is maintained, reduced pain may allow greater lateral rotation.Pain associated with anterior subluxation. Since the original description of this test, this pain has more specifically been ascribed to posterosuperior glenoid impingement (Jobe 1995, Jobe 1996).
Tests intended to differentiate between subacromial and internal impingement
Test Reference Specified pre-requisites Technique Definition of positive response Specific implication of a positive response, according to the author(s)
Internal rotation resistance strength test Zaslav 2001Positive Neer's signThe patient and tester stand, the tester to the rear. The patient's elbow is flexed to about 90°, and the shoulder positioned at 90° abduction and 80°lateral rotation. In this position, lateral- and medial rotation are manually, isometrically resisted. Lateral rotation is strong. Medial rotation is weak. Internal impingement. The converse is a 'negative' finding, and signifies subacromial outlet impingement
Tests intended to diagnose rotator cuff tears or tendinosis
Test Reference Specified pre-requisites Technique Definition of positive response Specific implication of a positive response, according to the author(s)
Bear-hug test Barth 2006aNoneThe patient places the palm of the affected limb, fingers extended, on the opposite shoulder. The patient is asked to hold this position, while the tester, by applying a force perpendicular to the forearm, attempts to laterally rotate the shoulder.The patient is unable to hold the hand in contact with the shoulder, or is > 20% weaker than on the unaffected side.Tear of subscapularis
Belly-press test Gerber 1996Inadequate range of motion to perform the *lift-off test (see below)The patient, in a sitting position, presses against the abdomen with the palm of the hand while trying to keep the shoulder in full medial rotation.Full medial rotation cannot be maintained. The patient feels weak and the shoulder drops back into extension. The patient tries to exert pressure by extending the elbow and flexing the wrist.Weakness of subscapularis, implying a partial or complete tear
Drop arm test Codman 1934NoneThis test was not clearly described in its primary source. By convention, it is applied in the plane of abduction, with the patient's arm placed passively above 90° by the tester; the support is removed, and the patient attempts to lower the arm actively.The patient is unable to actively lower the arm under control beyond the horizontal, and it drops to his or her side.Tear of supraspinatus
Drop sign Hertel 1996aNormal passive range of movement at the shoulder is required: capsular contracture (hypomobility) or ruptured subscapularis (hypermobility) might cause false -ve and false +ve results, respectively. The authors suggest proceeding to this test if the external rotation lag sign is positive.The patient sits. The tester stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder elevated to 90° in the plane of the scapula, then laterally rotates the shoulder to just short of full range. The tester continues to support the elbow while releasing the wrist and asking the patient to maintain the lifted-off position.The patient cannot maintain the position and there is a 'drop' or 'lag', which is recorded to the nearest 5°.Tear of postero-superior rotator cuff, particularly infraspinatus, or neuropathy. The authors suggest that the value of the test is in assessing involvement of infraspinatus having established the presence of a poster-superior cuff tear using the external rotation lag sign.
Empty can test (Jobe's test, supraspinatus test). Note that Yocum 1983 described the same test (minus the preliminary deltoid component) in the same year, apparently derived from the same studies at the Centinela Hospital Medical Centre Biomechanics Laboratory, California. Thus the empty can test has also been termed 'Yocum's test' (REF and see separate entry for *'Yocum's impingement test' above). Jobe 1982 is often cited as the source of this test, but the manoeuvre described in that report was a strengthening exercise, not a diagnostic test. Jobe 1983NoneThere are two stages. Preliminarily, the tester evaluates the deltoid, with the patient's arm at 90° of abduction and neutral rotation. To evaluate supraspinatus, the arm is then moved into medial rotation (thumb pointing down) and 90° of scaption, where the patient is asked to isometrically resist a downward pressure applied by the tester.Pain or weakness on testing supraspinatus Supraspinatus impingement (pain) or tear (weakness)
External rotation lag sign Hertel 1996aNormal passive range of movement at the shoulder is required: capsular contracture (hypomobility) or ruptured subscapularis (hypermobility) might cause false -ve and false +ve results, respectively.The patient sits. The tester stands behind the patient, supports the arm with the elbow flexed to 90° and the shoulder in 20° of elevation (in the plane of the scapula), then laterally rotates the shoulder to 5° short of full range. The tester asks the patient to maintain the lateral rotation and, while continuing to support the elbow, releases the wrist.An angular 'drop' or 'lag', which is recorded to the nearest 5°Tear of supraspinatus ± infraspinatus. A 15° lag or greater signifies a complete tear of both or a neuropathy
Full can test Kelly 1996NoneThe patient sits, arm laterally rotated (thumb pointing up) and in 90° of scaption. The patient is then asked to isometrically resist a downward pressure applied on the arm by the tester.Weakness (the test was described in the context of strength assessment, not pain-provocative testing). However, by convention, the test is often interpreted as for the *empty can test. Supraspinatus dysfunction
Gum-turn test Gumina 2008aNoneStarting in the *empty can test position, the patient traces a 20-cm wide spiral drawn on the wall, from centre to periphery and back 10 times, resting for one minute, then repeating the procedure.The test is positive if weakness or pain prevent completion. (For positive results, the number of turns completed were recorded, but it is unclear how these data were used. Results were compared with the contralateral arm but, again, it is unclear how these data were used.) Postero-superior rotator cuff tear
Internal rotation lag sign.
(Also see *lift-off test, Gerber 1991a; and *lift-off test, Gerber 1996.)
Hertel 1996aAdequate range of medial rotation. If this is not available, the belly press test (see above) should be used.The patient sits. The tester, standing to the rear, brings the patient's hand behind the back and flexes the elbow to 90°, so that the back of the hand rests on the spine at waist level. Gripping the patient's wrist, the tester then lifts the back of the hand clear of the spine until the shoulder is in almost full medial rotation. The tester, who continues to support the elbow but releases the wrist, asking the patient to actively maintain this position.A lag occurs, the magnitude of which is recorded to the nearest 5°.'An obvious drop of the hand may occur with large tears. A slight lag indicates a partial tear of the cranial part of the subscapularis tendon.'
Lift-off test.
(Also see *internal rotation lag sign, Hertel 1996a, and *lift-off test, Gerber 1996.)
Gerber 1991aAdequate passive range of medial rotation. Active medial rotation not inhibited by pain.The arm is brought passively behind the patient's body into medial rotation, such that the hand rests against the spine at waist level, palm backwards. The patient attempts to lift the hand off his or her back.Inability to lift the hand off the backTear of subscapularis

Lift-off test.

(Also see *internal rotation lag sign, Hertel 1996a, and *lift-off test, Gerber 1991a.)

Gerber 1996Adequate range of internal rotation. If this is not available, the *belly-press test should be used instead.The arm is brought passively behind the patient's body into full internal rotation. The hand, palm facing backwards, is at waist level but not in contact with the spine. The patient attempts to maintain this position. (This description differs slightly from that above, despite apparently relating to the same patient sample, but tallies with the internal rotation lag sign.)(a) The patient cannot maintain the position: the hand drops back to the body and cannot be actively lifted off without elbow extension; or (b) the patient is weak, so that the hand drops back more than 5°, but not all the way to the spine.Tear of subscapularis. No information is given on differential interpretation of (a) and (b).
Lift-off test with force Kelly 1996Adequate medial rotation. If this is not available, the *belly press test should be used instead.As above, except the patient is asked to maintain the lift-off position against manually applied resistance.Weakness (the test was described in the context of strength assessment, not pain-provocative testing). Subscapularis dysfunction
Napoleon test Schwamborn 1999 [German] Burkhart 2002NoneThis is a modification of the belly-press test. The patient adopts a Napoleonic pose, palm on abdomen and with the elbow positioned laterally Burkhart 2002 refined the test's interpretation thus. A negative (normal) result is where the patient can press against the abdomen without wrist flexion. A positive result is an inability to press against the abdomen without wrist flexion to 90°. Intermediate results may occur.    Subscapularis tear (positive result) or partial tear (intermediate result)
Passive horizontal adduction (scarf test) Cyriax 1982NoneThe patient's arm is passively horizontally adducted across the chest.PainLesions of the ACJ, but also of the lower part of the tendon of subscapularis
Patte's test Patte 1987 [French], Leroux 1995NoneWith the arm supported in 90° of scaption, the patient is asked to laterally rotate maximally against the tester's isometric resistance. The starting position in terms of the degree of rotation was not specified.There are three possible responses: (A) strong and painless; (B) normal ability to resist despite pain; and (C) inability to resist, with gradual lowering of the forearm. (C) is subcategorised as follows: (1) decreased resistance compared to the other side, allowing the tester to lower the forearm; (2) the patient can perform the test against gravity but is cannot resist the pressure applied by the tester; and (3) the patient cannot perform the test against gravity.(1) Normal; (2) simple tendinitis of infraspinatus; (3) ruptured infraspinatus tendon. The score 1-3 'has been claimed to increase in parallel with the severity of muscle atrophy and the size of the tear'.
Rent test (transdeltoid palpation) Codman 1934NoneThe tester draws the upright patient's shoulder into extension, palpating anterior to the acromion.There is a tender depression (rent) anterior to the acromion and, just distal to this, an eminence.A rent represents a full thickness tear of supraspinatus; the associated eminence is the greater tuberosity, and possibly a stump of supraspinatus' attachment distal to the tear. If portions of the adjacent rotator cuff tendons are torn, the tenderness, eminence and rent may be a little internal or external to the mid-point of the insertion of supraspinatusitself.
Resisted abduction Cyriax 1982NoneThe patient stands, arm at side, and is asked to abduct the arm maximally against the tester's isometric resistance, which is applied at the elbow.Pain or weakness (either or both) Supraspinatus lesion. (1) pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy.
Resisted lateral rotation from neutral rotation Cyriax 1982NoneThe patient stands, elbow at side and flexed to 90°, shoulder in neutral rotation. He or she is then asked to laterally rotate the shoulder maximally against the tester's isometric resistance, which is applied at the wrist.Pain or weakness (either or both) Infraspinatus or (less likely) teres minor lesion. (1) pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy.
Resisted medial rotation from neutral rotation Cyriax 1982NoneThe patient stands, elbow at side and flexed to 90°, shoulder in neutral rotation. He or she is then asked to medially rotate the shoulder maximally against the tester's isometric resistance, which is applied at the wrist.Pain or weakness (either or both)Lesion of subscapularis or another medial rotator. (1) Pain: minor lesion; (2) painful weakness: partial tear; (3) painless weakness: complete tear or neuropathy.
Whipple test Savoie 2001NoneThe patient horizontally adducts the straight arm, so that the hand, palm down is in front of the unaffected shoulder. In this position the tester applies a downwards force at the wrist, which the patient isometrically resists.No details of interpretation were given.Tear of anterior supraspinatus
Tests intended to diagnose LHB tears or tendinosis
Gilcreest's test (Gilcreest's palm up test) Gilcreest 1936NoneThe patient elevates the arms in full lateral rotation, holding a weight (e.g. 5 lb dumbbells) in each hand. The tester palpates the LHB while the patient, maintaining full lateral rotation, lowers both arms through abduction. Occasionally
the vibrations produced by the snap may be visible in the LHB.
When the arms reach an angle of from 110° to 90°
degrees, a definite snap may be audible and/or palpable, and a sharp pain is elicited both in the shoulder and in the region of the
bicipital groove.
Recurrent dislocation of LHB tendon. Since used in a modified form for LHB tendinitis (Naredo 2002).
Speed's test Crenshaw 1966NoneThe patient flexes his or her shoulder against isotonic resistance with the elbow extended and the forearm supinated.Pain localised to the bicipital grooveDegenerative changes of the LHB, or synovitis of its tendon sheath. Recently the test has also been applied to the diagnosis of SLAP lesions (see below).
Upper cut test Kibler 2009NoneThe patient, elbow at the side and flexed to 90°, palm upwards and with the shoulder in neutral rotation, is asked to make a fist. The tester, with a hand placed over the fist, applies isotonic resistance as the patient attempts to rapidly bring the hand up towards the chin, in the manner of a boxing upper cut.  Pain or a painful pop over the anterior portion of the involved shoulder during the resisted movement is interpreted as a positive result. LHB or SLAP lesions (see below)
Yergason' test  (supination sign) Yergason 1931NoneThe patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the tester's resistance.Pain localised to the bicipital groove.Degenerative changes of the LHB, or synovitis of its tendon sheath. Recently, the test has also been applied to the diagnosis of SLAP lesions (see below).
Tests intended to diagnose tears of the glenoid labrum
Test Reference Specified pre-requisites Technique Definition of positive response Specific implication of a positive response, according to the author(s)
Active compression test O'Brien 1998aNoneThe patient, who is standing, flexes his or her shoulder to 90°, then adducts 10-15° and medially rotates fully. The elbow remains extended throughout. The tester stands behind the patient and applies a uniform downward force to the arm. This is repeated in full lateral rotationPain on the 1st manoeuvre, reduced or eliminated on the 2nd SLAP lesion
Anterior slide test Kibler 1995aNone

The patient sits or stands, hands on hips and thumbs pointing posteriorly. One of the tester’s hands is placed across the top of the shoulder from behind, with the last segment

of the index finger extending over the anterior aspect of the acromion at the shoulder joint. The tester’s other hand is placed behind the elbow, and a forward and slightly superiorly directed force is applied to the elbow and upper arm. The patient is asked to push back against this force.

Pain localised to the front of the shoulder under the tester’s hand, and/or a pop or click in the same area, or reproduction of the symptoms felt during overhead activityUnstable SLAP lesion
Biceps load II test Kim 2001NoneThe patient lies supine. The tester gently grips his or her wrist and elbow, elevating the shoulder to 120° and laterally rotating it fully. The patient's forearm is supinated, and elbow flexed to 90°. The patient is now asked to flex his or her elbow against the tester'sisometric resistance.    Pain provoked by resisted elbow flexion. SLAP lesion
Biceps tension test Snyder 1990aNoneProbably as for *Speed’s test, but whether resistance is isometric or isotonic was not made clearNot definedUnstable SLAP lesion
Compression-rotation test Snyder 1990aNoneThe patient lies supine, shoulder abducted to 90° and elbow flexed to 90°. The tester holds the patient’s wrist with one hand, while cradling the elbow with the other. The tester then applies a compression force along the line of the humerus while rotating the shoulder, in an attempt to trap the torn labrum.Palpable catching & snapping, analogous to that felt during a positive McMurray’s test for a torn meniscus at the kneeUnstable SLAP lesion
Crank test Liu 1996cNoneThe patient lies supine. The tester, holding the patient's arm and wrist, forward flexes the shoulder fully (c.f. the entry below) and, while axially loading the shoulder through the humerus, rotates it medially and laterally.Clicking, apprehension or both (c.f. the entry below).Tear of the glenoid labrum
Crank test Liu 1996bNoneThe patient sits or lies (the lying variant is stated to be the more sensitive test: c.f. the entry above) with the elbow flexed 90° and the shoulder elevated 160° in the plane of the scapula (c.f. the entry above). The tester compresses the joint along the line of the humerus with one hand, while fully rotating the shoulder in either direction with the other.Pain, usually during lateral rotation, with or without a click; or reproduction of symptoms (usually pain or a sensation of catching: c.f. the entry above).Tear of the glenoid labrum. Interpretation is confused by the discrepancies with the entry above, but also by the recommendation, here, to conduct the test in sitting as well as in supine, especially since, ‘frequently, a positive crank test in the upright position will also be positive in the supine position’. If the supine test is more accurate, the rationale for additionally testing in sitting is unclear
Modified dynamic labral shear Kibler 2009NoneThe patient stands. The elbow is flexed and the shoulder elevated to above 90° of scaption, then externally rotated to the point of tightness. The shoulder is then guided into maximal horizontal abduction. The tester then applies a shear load by maintaining external rotation and horizontal abduction while lowering the arm to 60° of scaption. Reportedly, this differs from the test described by O’Driscoll (no further citation information given) in that the arm is not placed into maximal horizontal abduction until it is elevated above 120°. (Reportedly, in pilot testing this modification was found to reduce the high number of false positive tests due to pain through the whole motion.)Reproduction of the pain and/or a painful click or catch along the posterior joint line between 120° and 90° of scaption is interpreted as a positive result. SLAP lesion
Pain provocation test Mimori 1999aNoneThe sitting patient’s shoulder is passively abducted to between 90 & 100° & fully externally rotated. With the patient’s elbow flexed to 90°, his or her forearm is fully pronated, then supinated, by the tester.Pain, greater in the pronated positionUnstable SLAP lesion
Palpation for bicipital groove tenderness Morgan 1998aNoneDeep pressure applied to the bicipital groove on the symptomatic and (for comparison) the asymptomatic armPain elicited by deep pressure on the symptomatic arm, compared to no pain on the asymptomatic arm SLAP lesion
Passive compression test Kim 2007bNoneThe patient is in side-lying, affected arm uppermost. The tester places one hand over the acromion, using the other to cradle the elbow, which is flexed to 90°. The shoulder is abducted to 30° and laterally rotated. The tester then applies a compressive force through the axis of the humerus while drawing the shoulder into extension.Pain or a painful click SLAP lesion
Passive distraction test Rubin 2002NoneThe patient lies supine with the shoulder off the examining
table. The arm is elevated "in the plane of the trunk" with the elbow extended, and the forearm held in neutral or slight supination. The forearm is then gently
pronated without rotating the humerus.
Pain. If asked, the patient will frequently indicate
with accuracy the anterior or posterior location of the
lesion.
SLAP lesion
SLAPprehension test Berg 1998aNoneThe arm of the seated or standing patient is horizontally adducted across the chest with the elbow extended and the shoulder medially rotated. The test is repeated with the shoulder laterally rotated.‘SLAPprehension’ (meaning unclear), pain which may be referred to the bicipital groove, and sometimes an audible or palpable click. Repeating the manoeuvre in lateral rotation must be less painful, or the test is negative or indeterminate.Unstable SLAP lesion
Speed's test Crenshaw 1966NoneThe patient flexes his or her shoulder against isotonic resistance with the elbow extended and the forearm supinated.PainOriginally developed to diagnose LHB lesions (see above), the test has recently also been applied to the diagnosis of SLAP lesions.
Upper cut test Kibler 2009NoneThe patient, elbow at the side and flexed to 90°, palm upwards and with the shoulder in neutral rotation, is asked to make a fist. The tester, with a hand placed over the fist, applies isotonic resistance as the patient attempts to rapidly bring the hand up towards the chin, in the manner of a boxing upper cut.  Pain or a painful pop over the anterior portion of the involved shoulder during the resisted movement is interpreted as a positive result. SLAP orLHB lesions (see above)
Yergason' test,  Supination sign Yergason 1931NoneThe patient's elbow is flexed to 90° and the forearm pronated. The patient then actively supinates against the tester's resistance.Pain localised to the bicipital groove.Originally developed to diagnose biceps lesions (see above), the test has recently also been applied to the diagnosis of SLAP lesions.
Table 2. Glossary. Terms marked * have their own entries
  1. Snyder 1990a

    Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6(4):274-9.

Abduction. Sideways movement of a limb away from the body, as in flapping the arms. The opposite of *adduction. The range of abduction is measured from the arm-at-side position (0°).

Adduction. Movement of a limb towards the midline of the body. The opposite of *abduction.

Accuracy. Formally, the proportion of all cases correctly identified by the test. Estimated as (TP+TN)/(TP+FP+FN+TN).

ACJ. See ACROMIOCLAVICULAR JOINT.

Acromioclavicular joint. The joint between the outer end of the *clavicle and the *acromion.

Acromion. A bony process that projects from the *scapula and forms the point of the shoulder. It lies above the shoulder joint.

Anterior. Towards the front. The opposite of *posterior.

Arthrography. A diagnostic technique in which X-rays are taken after injection of a contrast material into a joint.

Biceps. See LONG HEAD OF BICEPS.

Bicipital groove. A groove on the front of the upper *humerus that accommodates the Tendon of the *long head of biceps.

Bursa. A lubricating sac. Bursae are often found where ligaments, muscles, tendons or bones rub together.

Bursal-side. Pertaining to the outer (superficial) aspect of the *rotator cuff: the aspect adjacent to the *subacromial-subdeltoid bursa.

Bursography. A diagnostic technique in which X-rays are taken after injection of a contrast material into a *bursa.

Calcific tendonitis. An inflammation of tendon characterised by deposition of calcium within the tendon’s substance. The tendon of *supraspinatus is commonly affected in this way.

Clavicle. The collarbone.

Cranial. Towards the head.

Caudal. Away from the head.

Deltoid. The muscle which gives rise to the rounded contour of the shoulder. Its major function, in concert with *supraspinatus, is to *abduct the shoulder.

Distal. The direction away from the body.

Elevate. To move upwards. At the shoulder, elevation may be through *flexion, *abduction or in the *plane of the scapula. In each case the range of the movement is measured from the arm-at-side position (0°).

Extend. See EXTENSION.

Extension. In general terms, straightening a joint to lengthen a limb. The opposite of *flexion. At the shoulder, it denotes movement backwards. The range of shoulder extension is measured from the arm-at-side position (0°).

External rotation. See LATERAL ROTATION.

False Negative (FN). The cases which a test incorrectly classifies as not having a disease.

False Positive (FP). The cases which a test incorrectly classifies as having a disease.

Flex. See FLEXION.

Flexion. In general terms, bending a joint to shorten a limb (as in bending the arm up at the elbow).The opposite of *extension. At the shoulder it denotes movement forwards. The range of shoulder flexion is measured from the arm-at-side position (0°).

FN. See FALSE NEGATIVE.

FP. See FALSE POSITIVE.

Glenoid. The socket of the shoulder joint.

Glenoid labrum. A fibrocartilage (gristly) extension of the *glenoid rim that deepens the socket of the shoulder joint.

Gold standard. A reputedly optimal *reference standard.

Greater tuberosity. A protuberance on the upper *humerus to which *supraspinatus attaches.

Horizontal abduction. The movement in which the arm is positioned parallel to the ground and brought backwards. The opposite of *horizontal adduction.

Horizontal adduction. The movement in which the arm is positioned parallel to the ground and brought forwards. The opposite of *horizontal abduction.

Humerus. The upper arm bone.

Humeral head. The rounded upper part of the *humerus, which forms the ball of the shoulder joint.

Impingement. Pinching. This causes ‘catching’ or aching pain without appreciable joint stiffness, and may lead to local inflammation and tissue damage. Subcategories include *internal impingement, *subacromial outlet impingement.

Index test. The test undergoing evaluation against a *reference standard.

Inferior. Relating to the lower portion of a structure. Opposite of *superior.

Inferiorly. Downwards. Opposite of *superiorly.

Infraspinatus. See ROTATOR CUFF.

Internal rotation. See MEDIAL ROTATION.

Internal impingement. Pinching of structures inside the shoulder joint at the extremes of movement. The *glenoid rim, the *glenoid labrum and the deep surface of the *rotator cuff are vulnerable to this type of *impingement, and may be affected singly or in combination.

Isometric resistance. Tester-applied resistance that prevents an attempted movement.

Isotonic resistance. Tester-applied resistance that allows an attempted movement

Joint-side. Pertaining to the inner (deep) aspect of the *rotator cuff: the aspect adjacent to the shoulder joint.

Labrum. See GLENOID LABRUM.

Lateral. Away from the midline of the body. The opposite of *medial.

*Lateral rotation. At the shoulder this denotes a twisting movement as in unfolding the arms. The opposite of *medial rotation.

Lesion. An area of tissue damage.

LHB. See LONG HEAD OF BICEPS.

Long head of biceps (LHB). The portion of the biceps that arises inside the shoulder joint. The tendon arches over the *humerus to pass into the arm.

LR̶̶-. See NEGATIVE LIKELIHOOD RATIO.

LR+. See POSITIVE LIKELIHOOD RATIO.

Magnetic resonance arthrography (MRA). *MRI following injection of a contrast material into a joint.

Magnetic resonance Imaging (MRI). A non-invasive diagnostic technique. Tissues' differing responses in a strong electromagnetic field are analysed by computer and translated into an accurate anatomical image.

Medial. Towards the midline of the body. The opposite of *lateral.

Medial rotation. At the shoulder, a twisting movement as in folding the arms or bringing the hand behind the back. The opposite of *medial rotation.

MRA. See MAGNETIC RESONANCE ARTHROGRAPHY.

MRI. See MAGNETIC RESONANCE IMAGING.

Negative likelihood ratio (LR-). The ratio between the probability of a negative test result when the disease is present, and the probability of a negative test result when the disease is absent; estimated as (1-Sn)/Sp.

Negative predictive value. The probability that the disease is absent when the test is negative; estimated as TN/(FN+TN).

Neuropathy. A disorder of a nerve that may result in muscle weakness.

Neutral rotation. A position of neither *lateral nor *medial rotation.

Plane of the scapula. A plane of shoulder movement between *flexion/*extension and *abduction/*adduction.

Posterior. Towards the back. The opposite of *anterior.

Positive likelihood ratio (LR+). The ratio between the probability of a positive test result when the disease is present, and the probability of a positive test result when the disease is absent; estimated as Sn/(1-Sp).

Positive predictive value (PPV). The probability that the disease is present when the test is positive; estimated as TP/(TP+FP).

PPV. See POSITIVE PREDICTIVE VALUE.

Pronation. The movement of the forearm that, in relaxed standing, would bring the palm to face backwards.

Prone. Lying face downwards.

Proximal. The direction towards the body.

Reference standard. A highly accurate method of diagnosis. It provides a benchmark against which other methods are judged.

Rheumatoid disease. A systemic disease, one manifestation of which is inflammation of joints.

Rotator cuff. A musculotendinous cuff that surrounds and blends with the shoulder joint, contributing to stability as well as producing movements. It comprises four overlapping units: supraspinatus, which lies on top of the joint and produces *abduction is the most commonly damaged; infraspinatus lies behind the joint, produces *lateral rotation and is the second most commonly damaged; subscapularis lies in front of the joint, produces *medial rotation and is damaged comparatively rarely. The fourth unit, teres minor, lies below *infraspinatus. It is relatively unimportant.

SA-SD *bursa. See SUBACROMIAL-SUBDELTOID BURSA.

Scaption. *Elevation of the arm in the *plane of the scapula.

Scapula. Shoulder blade.

Scapular. Relating to the *scapula.

Sensitivity (Sn). The proportion of cases with the disease that are correctly identified by the *index test i.e. the true positive rate; estimated as TP/(TP+FN).

SIS. See SUBACROMIAL IMPINGEMENT SYNDROME.

SLAP lesion (Superior Labrum Anterior to Posterior *lesion). A tear in the upper part of the *glenoid labrum that extends forwards and backwards (Snyder 1990a; see Footnotes). It may result from *internal impingement.

Sn. See SENSITIVITY.

Sp. See SPECIFICITY.

Specificity (Sp). The proportion of cases without the disease that are correctly identified by the *index test i.e. the true negative rate; estimated as TN/(FP+TN).

Subacromial impingement. Pinching of the *subacromial-subdeltoid bursa, the *rotator cuff, the *long head of biceps, or a combination of these, between the *humerus and the *acromion.

Subacromial impingement syndrome. A collection of signs and symptoms considered characteristic of *subacromial impingement.

Subacromial-subdeltoid *bursa. A palm-sized *bursa centred deep to the anterolateral tip of the *acromion. Extending *distally - under the *deltoid - as well as *proximally, and being superficial to the tendons of the *rotator cuff, it facilitates movement at the shoulder.

Subacromial outlet impingement. See SUBACROMIAL IMPINGEMENT.

Subluxation. A loss of joint congruity lesser in degree than in dislocation.

Subscapularis. See ROTATOR CUFF.

Superior. Relating to the upper portion of a structure. Opposite of *inferior.

Superiorly. Upwards. Opposite of *inferiorly.

Supination. The movement of the forearm that, in relaxed standing, brings the palm to face forwards.

Supine. Lying flat with face upwards.

Supraspinatus. See ROTATOR CUFF.

Synovitis. Inflammation of *synovium.

Synovium. Slippery tissue that lines joints, bursae and the sheaths that surround some tendons, such as the *long head of biceps.

Systemic. Body-wide, as opposed to local.

Tendon Sheath. See SYNOVIUM.

Teres minor. See ROTATOR CUFF.

Tendinitis. Inflammation affecting a tendon.

Tendinosis. Degenerative changes affecting a tendon.

TN. See TRUE NEGATIVE.
TP. See TRUE POSITIVE.

True Negative (TN). The cases which a test correctly identifies as not having a disease.

True Positive (TP). The cases which a test correctly identifies as having a disease.

Ultrasonography. A non-invasive diagnostic technique in which high- frequency sound waves are bounced from the tissues in order to form images of the body's internal structures.

Xylocaine. A local anaesthetic.

The attraction of physical tests is that they can be used at any stage in the patient’s care pathway and in any setting. They are non-invasive (apart from optional, adjunctive local anaesthesia), convenient, quick, and yield immediate results. Their aim of replicating pain or functional deficits lends them implicit relevance to patients’ symptoms whereas, by contrast, lesions detected by imaging or at open surgery may actually be asymptomatic (Dinnes 2003; MacDonald 2000a; Milgrom 1995; Sher 1995). Furthermore, they involve no cost additional to that of a clinical consultation.

Physical tests involve clinical and interpretative skills, and results have been shown to differ with testers’ expertise (Hanchard 2005). This has implications for the generalisation of results relating to test performance from individual studies. Given this, we will summarise data on variability in test results reported by the included studies, whether this is between individuals, across settings, or both.

Alternative test(s)

Other tests, usually conducted subsequently and in secondary care settings by specialists, include ultrasonography, arthrography, bursography, magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA). Those considered as potential reference standards for this review are described in Table 3. Some of these tests are invasive and none is completely valid (Dinnes 2003). Specifically, the generally accepted gold standard of diagnosis, direct observation at open or arthroscopic ('keyhole') surgery (Table 3), is not completely valid because tears within the substance of the rotator cuff are not directly visible (Fukuda 2003) and conversely, visible tears may be asymptomatic (Dinnes 2003; MacDonald 2000a; Milgrom 1995; Sher 1995). Surgery carries a risk of complications (Blumenthal 2003; Boardman 1999; Borgeat 2001), and is not applicable in the primary care setting where the majority of consultations and treatment prescriptions occur. Moreover, approximately 70% of patients with shoulder impingement respond to conservative treatment (Morrison 1997a) and so those having surgery cannot be considered representative (spectrum bias).

Table 3. Reference tests for impingement and secondary disorders
TestDefinitionAdequate reference standard for:Qualifications
Open surgery A diagnostic 'gold' standard. An invasive procedure during the course of which the interior of the shoulder joint and subacromial-subdeltoid bursa may be directly visualised through an open incision.

(1) Subacromial impingement.

(2) Subacromial-subdeltoid bursitis.

(3) Bursal side rotator cuff tears.

(4) Full thickness rotator cuff tears. 

(1) Tears of the rotator cuff's internal substance and joint side may be missed, as may SLAP lesions and disorders of the LHB.

(2) Rotator cuff tears may be missed if obscured e.g. by inflammation.

(3) Not applicable to primary care.

Arthroscopy A diagnostic 'gold' standard. A 'keyhole' surgical procedure, in which the interior of the shoulder joint and subacromial-subdeltoid bursa may be visualised through a flexible fibre-optic tube.

(1) Subacromial-subdeltoid bursitis.

(2) Subacromial impingement.

(3) Anterosuperior glenoid impingement.

(4) Posterosuperior glenoid impingement.

(5) Bursal side rotator cuff tears.

(6) Full thickness rotator cuff tears.

(7) Joint side rotator cuff tears.

(8) Disorders of LHB.

(9) SLAP lesions.

 

(1) There is a technical and interpretive learning curve.

(2) Tears of the rotator cuff's internal substance may be missed.

(3) Rotator cuff tears may be missed if obscured, e.g. by inflammation.

(4) Not applicable to primary care.

UltrasonographyA non-invasive diagnostic technique in which high-frequency sound waves are bounced (reflected) from the tissues in order to form images of the body's internal structures.(1) Full thickness rotator cuff tears.  

(1) Technique and interpretation are highly operator-dependent. The presence/absence of data/material confirming accuracy in individual diagnostic studies should be taken into account.

(2) SLAP lesions cannot be visualised using ultrasound.

Magnetic Resonance Imaging (MRI)A non-invasive diagnostic technique. Tissues’ differing responses in a strong electromagnetic field are analysed by computer and translated into an accurate anatomical image.(1) Full thickness rotator cuff tears.   This applies in settings (such as general primary care) where there is likely to be a low incidence of this disorder.
ArthrographyA diagnostic technique in which X-rays are taken after injection of a fluid contrast material into a joint.

(1) Joint side rotator cuff tears.

(2) Full thickness rotator cuff tears.   

 
Magnetic Resonance Arthrography (MRA)A combination of Magnetic Resonance Imaging (MRI) and arthrography. An MRI scan is done after injection of contrast material into a joint.

(1) Joint side rotator cuff tears.

(2) Full thickness rotator cuff tears.

(3) SLAP lesions.

 
BursographyA diagnostic technique in which X-rays are taken after injection of a contrast material into a bursa.(1) Bursal side rotator cuff tears. 
Local anaesthesiaA minimally invasive procedure in which a local anaesthetic is injected, usually into the subacromial space (this is the second part of Neer's impingement test) and the effect on signs and/or symptoms noted. (1) Subacromial outlet impingement.(1) Correct interpretation is dependent on the injection's accuracy. 'Guided' injection, using fluoroscopy or ultrasound, is therefore preferable to 'blind' injection technique.

The reference tests are also affected by clinical and interpretation skills. Varying degrees of ‘operator dependence’ apply to the imaging techniques, among which ultrasonography is the most susceptible. Surgery is also operator dependent; evaluations using videotaped arthroscopies have demonstrated disappointing agreement between surgeons as to the presence, absence and extent of pathology (Mohtadi 2004). As with the index tests (above), we will therefore summarise data reported by the included studies on the variability of the alternative reference tests.

Rationale

In a systematic review of interventions for shoulder pain, Green et al (Green 2003) observed that diverse and often conflicting diagnostic labelling hampered interpretation of the literature. Our review should help in this regard. In addition, timely diagnosis of impingement and the underlying structural deficits should enable rationalisation of patients’ diagnostic pathways, as well as informing their management and prognosis.

At the inception of this review, we identified two relevant systematic reviews in this area. Dinnes et al (Dinnes 2003) reviewed diagnostic tests for shoulder pain due to soft tissue disorders, including cohort studies of physical tests, ultrasound, MRI or MRA in patients suspected of having soft tissue disorders (search date October 2001). Though they reported inclusion of 'clinical impingement syndrome', Dinnes et al's primary emphasis was on the detection of rotator cuff tears. Tests for disorders of the glenoid labrum were specifically excluded. Conversely, a systematic review by Luime et al (Luime 2004b) concentrated on clinical diagnostic studies of tests for glenoid labral tears and shoulder joint instability (reported search dates '2001' for CINAHL and EMBASE, and '2003' for MEDLINE). Our own review, as well as conducting an updated search for studies of clinical examination, extends the definition of shoulder impingement, as described above. The mutually distinct nature of tests for impingement and instability (despite the potential interrelationships between the two conditions) has enabled the review to focus on the former. Our review also differs from the others in placing emphasis on the primary care setting (while not excluding secondary or tertiary care) as most people with shoulder pain are diagnosed and managed in this setting (Broadhurst 2004). From the primary care perspective, patients studied at a later stage in the referral pathway or undergoing more than minimally invasive reference tests are not representative, and this issue of applicability is explicit in the quality assessment of included studies.   

Objectives

To evaluate the diagnostic accuracy of physical tests, applied singly or in combination, for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders.

We also examined the physical tests according to whether they were intended to:

  • identify impingement in general (or differentiate it from other causes of shoulder pain, e.g. 'frozen shoulder')

  • subcategorise impingement as subacromial outlet impingement (impingement under the acromion process) or internal impingement (impingement within the shoulder joint)

  • diagnose lesions of bursa, tendon or glenoid labrum that may be associated with impingement

  • form part of a diagnostic package or process and, if so, according to the stages at which they may apply.

Investigation of sources of heterogeneity

We planned to investigate the following potential sources of heterogeneity.

  • Study population: older general population; young athletic population; other well defined groups e.g. wheelchair users or swimmers (see the Differences between protocol and review)

  • Stage of clinical care: primary (generally in the community setting), secondary (referral following preliminary screening) or tertiary (referral to a specialist centre)

  • Study design: cross sectional (or cohort) versus case-control; retrospective versus prospective design

  • Type of reference test. This will vary according to the target condition and setting, but generally surgery versus non-invasive imaging will be considered (seeTable 3)

  • Aspects of study conduct, specifically: blinding and reporting of uninterpretable or intermediate results.

Methods

Criteria for considering studies for this review

Types of studies

We considered diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials. In particular, we noted whether the cases and controls in case-control studies were highly selected or acceptably representative of the patient population normally tested by the index test(s). We considered, but decided against, excluding cohort studies with an excessively long period between the index and reference test. We defined this as a period that, on average, equals or exceeds the reported mean duration of symptoms, or one month (whichever is shorter). We excluded studies that were reported only in abstract form.

Participants

Patients of any age and in any clinical setting with pain, dysfunction or both suspected to be due to shoulder impingement of any type (see Target conditions), whether subacromial, internal or secondary to rotator cuff disease, and with or without rotator cuff tears. Excluded were studies evaluating physical (index) tests under anaesthesia, or intra- or post-operatively. We also excluded studies that focused solely on pain due to acromioclavicular joint (ACJ) disorders; or that focused primarily on shoulder joint instability, fracture, acute or recurrent shoulder dislocation, or systemic disease (e.g. rheumatoid disease). Subsequent to the protocol we excluded studies with highly selected populations, such as overhead throwing athletes.

After evaluation of a patient’s history, physical tests are normally the first stage in the diagnosis of shoulder impingement. However, the applicability of one physical test may be conditional upon the result of another (e.g. Zaslav 2001), and this was taken into account.

Index tests

Physical tests used singly or in combination to identify shoulder impingement, such as the painful arc test (Cyriax 1982); to classify shoulder impingements, e.g. Neer’s test (Neer 1977; Neer 1983), the modified relocation test (Hamner 2000), the internal rotation resistance strength test (Zaslav 2001); or to diagnose localised conditions that may accompany impingement, e.g. Yergason’s test (Yergason 1931), the lift off test (Gerber 1991a; Gerber 1996; Hertel 1996a), the crank test (Liu 1996b), the active compression test (O'Brien 1998a) and the biceps load II test (Kim 2001) (see Table 1).

Ideally, articles for inclusion should have described a physical test, or reference a source that did so, in sufficient detail to enable its replication, and clearly indicate what constituted a positive index test result. Those that did not were included only if they provided sufficient information to be of clinical value. Studies reporting the collective diagnostic accuracy of a series of tests were considered, providing each component, and its manner of inclusion, were adequately described. Generic terms such as 'physical examination', as used to denote an unspecified combination of physical tests, led to exclusion unless further details were obtained from authors.

Target conditions

Subacromial or internal impingement of the shoulder and the localised conditions that may accompany these classifications, namely bursitis, rotator cuff tears, glenoid labrum tears, and inflammation or rupture of the biceps tendon.

Instability may underlie impingement, but tests of instability were only included if they were intended to demonstrate associated impingement pain, as in the modified relocation test (Hamner 2000), as opposed to instability per se. Similarly, tests for ACJ disorders were only included if, like the active compression test (O'Brien 1998a), they had a component intended to reproduce impingement pain.

Reference standards

In the absence of a definitive reference standard, surgery, whether open or arthroscopic, is generally regarded as the best available. We additionally considered ultrasound, which may be conducted in the primary care setting, and magnetic resonance imaging, magnetic resonance arthrography, subacromial local anaesthesia, arthrography and bursography, all of which may have more general applicability than surgery. These additional ‘reference’ tests are defined in Table 3. Their validity varies according to context, and are discussed case by case (see Table 3).

Search methods for identification of studies

Electronic searches

The search for studies was carried out in two stages (up to November 2005; 2005 to February 2010)

In the first stage, we searched MEDLINE (1966 to 14 November 2005), EMBASE (1974 to 14 November 2005), CINAHL (1982 to 14 November 2005) and AMED (Allied and Complementary Medicine Database) (1985 to 14 November 2005). We developed a sensitive search strategy (Appendix 1) as recommended in Chapter 5 and Appendix 5.4 of the Handbook (de Vet 2005). We also searched DARE (Database of Abstracts of Reviews of Effectiveness, The Cochrane Library) (1995 to 14 November 2005). While we recognise the potential association between language restriction and selection bias, pragmatic considerations required that the searches were restricted to articles written in the English language.

In the second stage, we searched MEDLINE, EMBASE and AMED (CINAHL had been removed to a separate search platform) from 2005 to 15 February 2010 (Appendix 2).

Searching other resources

We checked the reference lists of all relevant retrieved articles of primary diagnostic studies and systematic reviews.

Data collection and analysis

Selection of studies

Assisted by a pro-forma stating the review inclusion criteria, two review authors (NH and HH) independently screened the results of the electronic searches for the first batch (up to November 2005); and one review author (HH) screened the results of the second batch. Throughout, benefit of doubt was given for the assessment of study eligibility. After obtaining full text articles, two pairs of review authors (NH and HH; NH and ML) independently performed study selection. Disagreements were resolved by discussion between three review authors (NH, HH and ML).

Data extraction and management

We designed a review-specific data collection form (Whiting 2005a) and piloted it on three studies of diagnostic accuracy that focused on physical tests for shoulder instability (a condition outside the scope of the present review). Pairs of review authors (NH and HH; NH and ML) independently extracted all key study and participant information and data from the included studies without masking of trial authors and other identifying information. All disagreements were resolved by consensus.

We extracted the diagnostic 2 x 2 table data (number of true positives, false positives, false negatives, and true negatives) from the publications. If these were not available we attempted to reconstruct the 2 x 2 table(s) from summary estimates (Whiting 2005b). Studies presenting insufficient data for construction of 2 x 2 tables were excluded from the review.

We contacted authors mainly in regard to the availability of trial reports and more rarely identification of index tests and where there were minor and isolated discrepancies impeding the construction of 2 x 2 tables.

Discrepancies in 2 x 2 tables due to rounding errors were a common finding. A rule was devised whereby data were considered for inclusion only where the discrepancies in the back-calculated 2 x 2 table did not exceed 10% in any cells. Studies with multiple discrepant analyses were excluded. Where incorrectly reported summary statistics (borderline discrepancies in sensitivity or specificity not attributable to rounding error; or positive predictive value, negative predictive value or accuracy) were identified in included studies, this was highlighted as a cause for concern.

Assessment of methodological quality

At the same time as data collection, pairs of review authors (NH and HH; NH and ML) independently assessed study quality using all items of the QUADAS form (Whiting 2003), tailored to the review. Prior to the protocol, we had already undertaken a preliminary piloting exercise to establish a coding manual setting out review-specific criteria (see Appendix 3). Disagreements were resolved by consensus.

Statistical analysis and data synthesis

For each index test, we plotted the observed sensitivities and specificities (with 95% confidence intervals) on forest plots for visual examination of variation in test accuracy across studies.

We planned to perform meta-analysis using hierarchical models if adequate data were available. However, due to the limited number of studies included for each test, meta-analysis was not possible and so descriptive analyses were undertaken.

Investigations of heterogeneity

We planned to use meta-regression (by adding covariates to the hierarchical models) or subgroup analyses to explore the effect of potential sources of heterogeneity, such as the type of reference standard, on sensitivity and specificity. However, due to the limited number of studies available for each test, this was not possible.

Results

Results of the search

We screened 3127 records from the first stage of the search and 1888 from the second stage (see Appendix 2). We obtained over 400 full text articles, some (numbers not fully documented) prompted by our scrutiny of references lists of reviews and primary studies. Of the 205 potentially eligible studies, 162 were excluded, 10 await classification, and 33 were included. The study flow diagram is shown in Figure 1.

Figure 1.

Flow diagram.

Included studies

The Characteristics of included studies table gives details of the 33 studies, which evaluated a total of 4002 shoulders in 3852 patients. Apart from five studies (Castoldi 2009; Itoi 2006; Norwood 1989; Oh 2008 and Schlechter 2009), all were prospective. Fourteen (42%) were conducted in the USA. The remainder took place in Canada (Holtby 2004a; Holtby 2004b; MacDonald 2000; Razmjou 2004), South Korea (Kim 2001; Kim 2006; Kim 2007b; Oh 2008), Italy (Castoldi 2009; Gumina 2008; Iagnocco 2003), Denmark (Frost 1999; Suder 1994), Japan (Itoi 1999; Itoi 2006), Spain (Naredo 2002), Switzerland (Hertel 1996), Turkey (Calis 2000) and the UK (Miller 2008b).

Most of the studies were set in secondary or tertiary care, and only a few used reference standards that would be applicable to primary care, the intended focus of this review, or to the hospital outpatient setting. These were Calis 2000 (local anaesthesia, MRI); Iagnocco 2003, Miller 2008b, Naredo 2002 (ultrasonography); Frost 1999, Itoi 1999, Kim 2006 (MRI); and O'Brien 1998 (radiography and MRI, but also arthroscopic and open surgery, in various unspecified combinations). Apart from O'Brien 1998, previously mentioned, four studies (Castoldi 2009; Hertel 1996; Razmjou 2004; Speer 1994) used a mixture of arthroscopic and open surgery. The remainder, comprising 20 (61%) studies, used arthroscopic surgery alone.

Studies were grouped according to their target condition (see Table 4).

Table 4. Summary of target conditions, studies, and patients/shoulders
  1. *LHB/labral pathology; LHB/SLAP lesions; SA-SD bursitis/bursal-side degeneration of supraspinatus; and SIS/rotator cuff tendinitis or tear.

Target conditionStudiesShoulders/patients
Subacromial or internal impingement5471/466
Rotator cuff tendinopathy or tears182477/2337
LHB tendinopathy or tears3660/557
Glenoid labral lesions111245/1236
Multiple undifferentiated target conditions*4201/200
Subacromial impingement

Five studies (Calis 2000; Gumina 2008; Iagnocco 2003; MacDonald 2000; Naredo 2002) evaluated tests for subacromial impingement explicitly, or SA-SD bursitis, which we considered synonymous, on a total of 889 shoulders in 781 patients (see Table 5 for overview). One of these studies, Calis 2000, evaluated tests not only for subacromial bursitis but also, using dynamic ultrasonography as a reference standard, for subacromial impingement as an observable event in real time.

Table 5. Summary: studies of tests for subacromial and internal impingement
  1. Modified interpretation 1: criteria for a positive test result not as described in the primary source
    Modified interpretation 2: target condition of test not as described in the primary source

    A: Isolated absolute discrepancy of 1% to <5% - a suspected or confirmed typographical error
    B: Isolated absolute discrepancy of 5% to <10% - a suspected or confirmed typographical error
    C: Isolated discrepancy of 10% or more - a suspected or confirmed typographical error

    D: Multiple absolute discrepancies of which the greatest is 1% to <5%  
    E: Multiple absolute discrepancies of which the greatest is 5% to <10%
    F: Multiple absolute discrepancies of which the greatest is 10% or more

    ?: 2 X 2 table not reported and cannot be deduced with certainty.
    NR: Summary statistics not reported

Study ID Shoulders (patients, if different) Specific target condition Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) Discrepancies between reported and back-calculated summary statistics (Sn, Sp, PPV, NPV or accuracy)
Yes No
Subacromial impingement
Calis 2000125 (120)SIS

● Combination: ALL 7 +ve

● Drop arm test (modified interpretation 2)

● Hawkins' test (standard)

● Neer's sign (standard)

● Painful arc test (standard)

● Passive horizontal adduction (modified interpretation)

● Speed's test (modified interpretation 2)

● Yergason's test (modified interpretation 2)

D 
Gumina 2008120SIS● Gum-Turn test (novel)E 
MacDonald 200085SA-SD bursitis● Hawkins' test (standard) No
● Neer's sign (modified procedure)
● Hawkins' test OR Neer's sign (modified procedure)
● Hawkins' test AND Neer's sign (modified procedure)
Naredo 200231SA-SD bursitis● Combination: Hawkins’ test, Neer's sign, 'Yocum's (impingement) test' (overall criterion for +ve result not stated) No
Subacromial impingement in real time (dynamic ultrasonography)
Differentiating subacromial from internal impingement
Zaslav 2001110Subacromial versus internal impingement● Internal rotation resistance strength test (novel) No
Internal impingement
NoneNone    
Internal impingement

No studies evaluated tests for internal impingement in isolation.

Subacromial versus internal impingement

One study (Zaslav 2001) of 110 shoulders in 110 patients evaluated a test to differentiate subacromial from internal impingement (see Table 5 for overview).

Rotator cuff tendinopathy or tears

Eighteen studies (Barth 2006; Calis 2000; Castoldi 2009; Frost 1999; Gumina 2008; Hertel 1996; Holtby 2004b; Iagnocco 2003; Itoi 1999; Itoi 2006; Kim 2006; MacDonald 2000; Miller 2008b; Naredo 2002; Norwood 1989; Speer 1994; Suder 1994; Wolf 2001) evaluated tests for rotator cuff tendinopathy or tears on a total of 2477 shoulders in 2337 patients (see Table 6 for overview).

Table 6. Summary: studies of tests for rotator cuff tears or tendinopathy
  1. Modified interpretation 1: criteria for a positive test result not as described in the primary source
    Modified interpretation 2: target condition of test not as described in the primary source

    A: Isolated absolute discrepancy of 1% to <5% - a suspected or confirmed typographical error
    B: Isolated absolute discrepancy of 5% to <10% - a suspected or confirmed typographical error
    C: Isolated discrepancy of 10% or more - a suspected or confirmed typographical error

    D: Multiple absolute discrepancies of which the greatest is 1% to <5%  
    E: Multiple absolute discrepancies of which the greatest is 5% to <10%
    F: Multiple absolute discrepancies of which the greatest is 10% or more

    ?: 2 X 2 table not reported and cannot be deduced with certainty.
    NR: Summary statistics not reported

Study ID Shoulders
(patients, if different)
Specific target condition Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) Discrepancies between reported and back-calculated summary statistics (Sn, Sp, PPV, NPV or accuracy)
Yes No
Barth 200668Subscapularis, any tear of

● Bear-hug test (novel)

● Belly-press test (modified procedure)

● Lift-off test (Gerber 1991a: modified interpretation 1)

● Napoleon test (Burkhart 2002: standard)

 No
Subscapularis, complete tear of
Subscapularis, partial tear of
Castoldi 2009395 (390)Supraspinatus, FTT of, full-width● External rotation lag sign (standard) No 
Supraspinatus, PTT of, isolated
Calis 2000125 (120)Supraspinatus, FTT of

● Drop arm test (standard)

● Hawkins' test (modified interpretation 2)

● Neer's sign (modified interpretation 2)

● Painful arc test (modified interpretation 2)

● Passive horizontal adduction (modified interpretation 2)

● Speed's test (modified interpretation 2)

● Yergason's test (modified interpretation 2)

F 
Frost 199973Supraspinatus, FTT, degeneration or tendinitis of● Hawkins' test (modified procedure, modified interpretation 2)NRNR
Supraspinatus, FTT or degeneration of
Supraspinatus, FTT of
Gumina 2008120Rotator cuff, postero-superior, FTT of● Gum-Turn test (novel)E 
Rotator cuff, postero-superior, supraspinatus AND infraspinatus, FTT of
Supraspinatus, FTT of
Hertel 1996100Rotator cuff, postero-superior FTT or PTT of

● Drop sign (novel)

● Empty can test for weakness ± pain (modified interpretation 2)

● External rotation lag sign (novel)

C 
Subscapularis, any tear of

● Internal rotation lag sign (novel)

● Lift-off test (Gerber 1991a: probably standard)

Holtby 2004b50Supraspinatus, PTT or tendinitis of● Empty can test for pain WITHOUT weakness (standard)  No
Supraspinatus, FTT of● Empty can test for weakness ± pain (standard)
Rotator cuff, large or massive FTT of● Empty can test for weakness ± pain (modified interpretation 2)
Iagnocco 2003528 (425)Supraspinatus, any disease of, including calcification● Empty can test (no reference or details given)NRNR 
Infraspinatus, any disease of, including calcification● Resisted lateral rotation from neutral rotation (no reference or details given)
Subscapularis, any disease of, including calcification● Resisted medial rotation from neutral rotation (no reference or details given)
Itoi 1999143 (136)Supraspinatus, FTT of

● Empty can test for pain ± weakness (modified interpretation 1)

● Empty can test for pain AND/OR weakness (modified interpretation 1)

● Empy can test for weakness ± pain (standard)

● Full can test for pain ± weakness (modified interpretation 1)

● Full can test for pain AND/OR weakness (modified interpretation 1)

● Full can test for weakness ± pain (standard)

 No 
Itoi 2006160 (149)Supraspinatus FTT or PTT of

● Empty can test for pain ± weakness (modified interpretation 1)

● Empty can test for weakness ± pain (standard)

● Empty can test for weakness < grade 3 ± pain (modified interpretation 1)

● Full can test for pain ± weakness (modified interpretation 1)

● Full can test for weakness ± pain (standard)

● Full can test for weakness < grade 3 ± pain (modified interpretation 1)

B 
Infraspinatus, FTT or PTT of● Resisted external rotation from neutral rotation for weakness < grade 3 (modified interpretation 1)
Subscapularis, any tear of● Lift-off test with force for weakness < grade 2 ± pain (Gerber 1991a: modified procedure; modified interpretation 1)
Kim 2006200Rotator cuff, FTT or PTT of

● Empty can test for pain ± weakness (modified interpretation 1,2)

● Empty can test for pain OR weakness (ONE ONLY) (modified interpretation 1,2)

● Empty can test for pain AND weakness (BOTH) (modified interpretation 1,2)

● Empty can test for weakness ± pain (modified interpretation 2)

● Full can test for pain ± weakness (modified interpretation 1,2)

● Full can test for pain OR weakness (ONE ONLY) (modified interpretation 1,2)

● Full can test for pain AND weakness (BOTH) (modified interpretation 1,2)

● Full can test for weakness ± pain (modified interpretation 2)

B 
Rotator cuff, FTT of
MacDonald 200085Rotator cuff, FTT or PTT of

● Combination: Hawkins' test (modified interpretation 2) OR Neer's sign (modified procedure, modified interpretation 2) +ve

● Combination: Hawkins' test (modified interpretation 2) AND Neer's sign (modified procedure, modified interpretation 2) +ve

● Hawkins' test (modified interpretation 2)

● Neer’s sign (modified procedure, modified interpretation 2)

C 
Miller 2008b46 (37)Rotator cuff, postero-superior, FTT of

● Drop sign (modified interpretation 2)

● External rotation lag sign (modified interpretation 2)

A 
Subscapularis, FTT of● Internal rotation lag sign (modified interpretation 2)

Naredo 2002

 

31Supraspinatus, FTT, PTT or tendinitis of● Empty can test for pain AND/OR weakness (standard) E 
Infraspinatus, FTT, PTT or tendinitis of● Patte’s test for pain AND/OR weakness (Leroux 1995: standard)
Subscapularis, any tear or tendinitis of● Combination: lift-off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described); resisted medial rotation from neutral rotation. Overall criterion for +ve result not given.
Supraspinatus, FTT or PTT of● Empty can test for weakness ± pain (standard)
Infraspinatus, FTT or PTT of● Patte’s test for weakness ± pain (Leroux 1995: standard)
Subscapularis, any tear of● Combination: lift-off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described), resisted medial rotation from neutral rotation. Overall criteria for +ve result not given.
Supraspinatus, tendinitis of● Empty can test for pain WITHOUT weakness (standard)
Infraspinatus, tendinitis of● Patte’s test for pain WITHOUT weakness (Leroux 1995: standard)
Subscapularis, tendinitis of● Combination: lift-off test (Gerber 1991a cited, but Gerber 1996/Hertel 1996a described, modified interpretation 2), resisted medial rotation from neutral rotation. Overall criterion for +ve result not given.
Norwood 1989103Rotator cuff, FTT of, multiple- versus single-tendon● Active abduction to < 90° (novel)NRNR

Speer 1994

 

100Rotator cuff, any disease of

● Relocation test for pain (Jobe 1989: modified procedure)

● Relocation test for pain (Jobe 1989: standard)

 No

Suder 1994

 

31Rotator cuff, FTT or PTT of

● 'Impingement sign' (no reference or details given)

● 'Impingement test' (no reference or details given)

NRNR
Rotator cuff, FTT of

● 'Impingement sign' (no reference or details given)

● 'Impingement test' (no reference or details given)

Rotator cuff, PTT of

● 'Impingement sign' (no reference or details given)

● 'Impingement test' (no reference or details given)

Wolf 2001

 

119Rotator cuff, FTT of● Rent test (standard) No
LHB (long head of biceps) tendon tendinopathy or tears

Three studies (Iagnocco 2003; Kibler 2009; Naredo 2002) evaluated tests for LHB tendon tendinopathy or tears on a total of 660 shoulders in 557 patients (see Table 7 for overview).

Table 7. Summary: studies of tests for LHB tears or tendinopathy
  1. Modified interpretation 1: criteria for a positive test result not as described in the primary source
    Modified interpretation 2: target condition of test not as described in the primary source

    A: Isolated absolute discrepancy of 1% to <5% - a suspected or confirmed typographical error
    B: Isolated absolute discrepancy of 5% to <10% - a suspected or confirmed typographical error
    C: Isolated discrepancy of 10% or more - a suspected or confirmed typographical error

    D: Multiple absolute discrepancies of which the greatest is 1% to <5%  
    E: Multiple absolute discrepancies of which the greatest is 5% to <10%
    F: Multiple absolute discrepancies of which the greatest is 10% or more

    ?: 2 X 2 table not reported and cannot be deduced with certainty.
    NR: Summary statistics not reported

Study ID Shoulders
(patients, if different)
Specific target condition Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) Discrepancies between reported and back-calculated summary statistics (Sn, Sp, PPV, NPV or accuracy)
Yes No
Iagnocco 2003528 (425)LHB, any lesion of● Speed's test (standard)NRNR
Kibler 2009101LHB, any lesion of

● Active compression test (modified interpretation 2)

● Anterior slide test (modified procedure, modified interpretation 1,2)

● Bear-hug test (modified interpretation 1,2)

● Belly-press test (modified interpretation 2)

● Modified dynamic labral shear (novel)

● Speed's test (modified procedure)

● Upper cut test (novel)

● Yergason's test (modified procedure)

E 
Naredo 200231LHB, any lesion of● Combination: Yergason's test (standard), Gilcreest's palm up test (modified procedure, modified interpretation 1,2). Criteria for +ve result not given. No
Glenoid labral lesions

Eleven studies (Guanche 2003; Kibler 2009; Kim 2001; Kim 2007b; Liu 1996b; O'Brien 1998; Oh 2008; Parentis 2006; Schlechter 2009; Stetson 2002; Suder 1994) evaluated tests for glenoid labral lesions on a total of 1245 shoulders in 1236 patients (see Table 8 for overview).

Table 8. Summary: studies of tests for labral lesions
  1. Modified interpretation 1: criteria for a positive test result not as described in the primary source
    Modified interpretation 2: target condition of test not as described in the primary source

    A: Isolated absolute discrepancy of 1% to <5% - a suspected or confirmed typographical error
    B: Isolated absolute discrepancy of 5% to <10% - a suspected or confirmed typographical error
    C: Isolated discrepancy of 10% or more - a suspected or confirmed typographical error

    D: Multiple absolute discrepancies of which the greatest is 1% to <5%  
    E: Multiple absolute discrepancies of which the greatest is 5% to <10%
    F: Multiple absolute discrepancies of which the greatest is 10% or more

    ?: 2 X 2 table not reported and cannot be deduced with certainty.
    NR: Summary statistics not reported

Study ID Shoulders (patients, if different) Specific target condition Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) Discrepancies between reported and back-calculated summary statistics (Sn, Sp, PPV, NPV or accuracy)
Yes No
Guanche 200360 (59)Labrum, any SLAP lesion of

● Active compression test (modified procedure, modified interpretation 2: 2 x 2 table not calculable for this test)

● Anterior apprehension test at 90° for pain (Krishnan 2004: modified interpretation 2)

● Anterior release test described as in Gross 1997 with modified interpretation 2, but erroneously labelled as Jobe's relocation test.

● Crank test (Liu 1996b: modified procedure, modified interpretation 2)

● Palpation for bicipital groove tenderness (standard)

● Speed's test (modified interpretation 1,2)

● Yergason's test (modified interpretation 1,2)

 No
Kibler 2009101Labrum, any SLAP lesion of

● Active compression test (modified interpretation 2)

● Anterior slide test (modified procedure, modified interpretation 1, 2)

● Bear-hug test (modified interpretation 1,2)

● Belly-press test (modified interpretation 2)

● Modified dynamic labral shear (novel)

● Speed's test (modified procedure, modified interpretation 2)

● Upper cut test (novel)

● Yergason's test (modified procedure, modified interpretation 2)

E 
Kim 2001127Labrum, type II SLAP lesion of● Biceps load II test (novel) No
Kim 2007b61Labrum, any SLAP lesion of● Passive compression test (novel) No
Labrum, type II-IV SLAP lesion of● Passive compression test (novel, modified interpretation 2)
Liu 1996b62Labrum, any tear of● Crank test (novel) No
O'Brien 1998206Labrum any tear of● Active compression test (novel) No
Oh 2008146Labrum, type II SLAP lesion of

● Active compression test (modified interpretation 2)

● Anterior apprehension test at 90° for pain OR apprehension (Rowe 1981: modified interpretation 1,2)

● Anterior slide test (modified interpretation 2)

● Biceps load II test (standard)

● Compression-rotation test (modified interpretation 2)

● Palpation for bicipital groove tenderness (modified interpretation 2)

● Relocation test for pain OR apprehension (modified interpretation 2)

● Speed's test (modified procedure, modified interpretation 1,2)

● Whipple test (modified interpretation 2)

● Yergason's test (modified interpretation 2)

E 
Parentis 2006132Labrum, type II SLAP lesion of

● Active compression test (modified interpretation 1,2)

● Anterior slide test (modified interpretation 2)

● Crank test (Liu 1996b: modified procedure, modified interpretation 2)

● Hawkins' test (modified procedure, modified interpretation 2)

● Neer's sign (modified procedure, modified interpretation 2)

● Pain provocation test (modified interpretation 2)

● Modified relocation test for posterosuperior glenoid impingement (modified interpretation 2) mislabelled as Jobe's relocation test

● Speed's test (modified interpretation 1,2)

● Yergason's test (modified interpretation 1,2)

A 
Schlechter 2009254 (246)Labrum, type II-IV SLAP lesion of

● Active compression test (modified interpretation 2)

● Anterior slide test (modified procedure)

● Combination: active compression test (modified interpretation 2) OR passive distraction test (standard)

● Passive distraction test (standard)

E 
Stetson 200265Labrum, any tear of

● Active compression test (modified interpretation 1)

● Crank test (standard)

 No
Suder 199431Labrum, any tear of

● 'Impingement sign' (no reference or details given)

● 'Impingement test' (no reference or details given)

NRNR
Multiple, undifferentiated target conditions

Four studies evaluated tests for multiple, undifferentiated target conditions. These were Bennett 1998 (LHB/labral pathology; 46 shoulders in 45 patients), Holtby 2004a (LHB/SLAP lesions; 50 shoulders in 50 patients), Michener 2009 (SA-SD bursitis/bursal-side degeneration of supraspinatus; 55 shoulders in 55 patients) and Razmjou 2004 (subacromial impingement syndrome/rotator cuff tendinitis or tear; 50 shoulders in 50 patients) (see Table 9 for overview).

Table 9. Summary: studies of tests for multiple, undifferentiated target conditions
  1. Modified interpretation 1: criteria for a positive test result not as described in the primary source
    Modified interpretation 2: target condition of test not as described in the primary source

    A: Isolated absolute discrepancy of 1% to <5% - a suspected or confirmed typographical error
    B: Isolated absolute discrepancy of 5% to <10% - a suspected or confirmed typographical error
    C: Isolated discrepancy of 10% or more - a suspected or confirmed typographical error

    D: Multiple absolute discrepancies of which the greatest is 1% to <5%  
    E: Multiple absolute discrepancies of which the greatest is 5% to <10%
    F: Multiple absolute discrepancies of which the greatest is 10% or more

    ?: 2 X 2 table not reported and cannot be deduced with certainty.
    NR: Summary statistics not reported

Study ID Shoulders (patients, if different) Specific target condition Index test name, provenance (where clarification is required) and manner of use compared to original description (standard/ modified procedure/modified interpretation) Discrepancies between reported and back-calculated summary statistics (Sn, Sp, PPV, NPV or accuracy)
Yes No
Bennett 199846 (45)LHB tendinitis/LHB avulsion/SLAP lesion, any● Speed's test (modified procedure, modified interpretation 1)C 
Holtby 2004a50LHB lesion, any/SLAP lesion, any● Speed's test (modified procedure, modified interpretation 1, 2) No
● Yergason's test (modified interpretation 1, 2)
Michener 200955SA-SD bursitis/ bursal-side degeneration of supraspinatus (but patients with PTT or FTT inter alia were not excluded)● Empty can test (modified interpretation 2) No
● Hawkins' test (standard)
● Neer's sign (modified procedure)
● Painful arc test (standard)
● Resisted lateral rotation from neutral rotation for weakness ± pain (modified interpretation 1,2)
● 3 or more tests +ve
Razmjou 200450SIS/rotator cuff tendinitis or tear● Hawkins' test (modified interpretation 2) No
● Neer's sign (modified interpretation 2)

Excluded studies

The reasons for excluding, usually from inspection of the full text article, 162 studies are given in the Characteristics of excluded studies. Table 10 shows the trials grouped by their primary reason. The main and often listed as the sole reason for exclusion was that the study was not a diagnostic test accuracy study. Of the 104 studies for which this was the case, 11 were systematic reviews without reporting of results from an associated primary study. Three studies were not reported in full and it appears unlikely that this will ever be the case. The rest were confirmed diagnostic test accuracy studies. Of these, five were not of physical tests and eight did not study a target condition of this review. Twenty-one trials studied a highly selected population, either in terms of a high risk population (e.g. overhead throwing athletes as in Hamner 2000), previous injury (e.g. anterior shoulder dislocation), 100% prevalence of a condition by intent (e.g. all had SLAP lesions in Berg 1998) or a highly selected population by exclusion of key conditions (e.g. Liu 1996a). Two studies were excluded because special equipment (a hand held dynamometer) was used and four studies were excluded because the reference test was unacceptable (e.g. MRI was used as a reference standard for impingement in Silva 2008). In seven studies there was unclear reporting of physical tests, testing and/or the population. Lastly, eight studies were excluded because of the lack, incompleteness or gross inconsistency of reported data.

Table 10. Reasons for excluded trials
  1. DTA = Diagnostic test accuracy, N = number of studies

Main reasonNDetails
Not DTA study93Not shown
Not DTA study. Systematic review only11 Beaudreuil 2009; Calvert 2009; Dessaur 2008; Hegedus 2008; Hughes 2008; Jones 2007; Luime 2004; Meserve 2009; Munro 2009; Pugh 2009; Walton 2008
Abstract only / no published full report3 Ansara 2006; Morrissey 2005; Sileo 2006
Not DTA study of physical tests5 Birtane 2001; Cullen 2007; El Dalati 2005; Jee 2001; O'Connor 2005
Not DTA study of included condition8 Chronopoulos 2004; Kim 2004b; Kim 2005 (all not impingement); Kim 2007a (rheumatoid disease); Lafosse 2007 (timing of surgery); Lewis 2007 (not impingement); Odom 2001; Walton 2004 (not impingement)
Highly selected population - sports / lesion9

Berbig 1999

(post traumatic dislocation); Brasseur 2004 (veteran tennis players); Hamner 2000 (overhead throwing athletes); Kibler 2006a (athletes); Kim 1999 (all post anterior dislocation); Meister 2004 (all overhead athletes); Mimori 1999(throwing injuries); Myers 2005 (all athletes); Walsworth 2008 (military)

Highly selected pop: 100% prevalence or by exclusion12 Berg 1998 (slap); Burkhart 2000 (slap), Burkhart 2002 (rotator cuff); Fukuda 1996 (rotator cuff); Gschwend 1988 (no disease negative; no specificity); Liu 1996a (tears removed); Lyons 1992 (all RCT - tear size study); Morgan 1998 (slap); Pandya 2008 (slap); Read 1998 (100% prevalence by exclusion); Rhee 2005a (all slap); Watson 1989 (all subacromial impingement - no specificity)
Special equipment used2 McCabe 2005; Osbahr 2006
Unsatisfactory / unacceptable reference test / control: 44 Gerber 1991; Lo 2004; Scheibel 2005 (control); Silva 2008 (MRI for impingement)
Unclear reporting of tests, testing and/or population7 Adolfsson 1991; Ardic 2006; Malhi 2005; Miller 2008a; Murrell 2001; Norregaard 2002; Wnorowski 1997
Lack of, incomplete or grossly inconsistent data:8 Ebinger 2008; Fodor 2009; Leroux 1995 (very large discrepancies); Litaker 2000 (large discrepancies); Polimeni 2003 (no data); Rowan 2007 (no test-specific data); Sandenbergh 2006 (no 2 x 2); Sorensen 2007 (data presentation)

Studies awaiting classification

Ten studies await classification. The reasons are given in the Characteristics of studies awaiting classification. The reports for eight of these studies (Gill 2007; Jia 2008; Jia 2009; Kim 2003a; Kim 2003b; Kim 2004a; McFarland 2002; Park 2005), which apparently draw on the same clinical database, demonstrate substantial threats to validity. Verification is especially warranted in view of these studies' large patient numbers and potentially influential nature. The remaining two studies (Kelly 2010; Nanda 2008) presented insufficient data for adequate analysis.

Methodological quality of included studies

The methodological quality tables in the Characteristics of included studies give details of the results of the methodological quality assessment based on the 14 items of the QUADAS tool and using the coding manual set out in Appendix 3. In these tables, the results are expressed in terms of the methodological quality ('high', 'low' or 'unclear'). relating respectively to the review author's judgements ('yes', 'no', 'unclear'). Figure 2 summarises the judgements on each of the 14 methodological quality items for each included study.

Figure 2.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study. Coding: + = 'Yes'; - = 'No'; ? = unclear.

Figure 3 presents a graph showing the percentages of each of the three judgements for each quality item across all included studies. Some observations on these are given below.

Representative spectrum?: Mainly reflecting the use of surgery as a reference test, it is noteworthy that all but two studies (Calis 2000; Miller 2008b) were judged as not meeting the criteria for having a representative spectrum of patients. The reference tests in Calis 2000 were subacromial local anaesthetic injection and MRI, and ultrasound in Miller 2008b. However, the setting was mixed primary, secondary and tertiary in Calis 2000 and probably secondary in Miller 2008b and thus both were rated as having unclear risk of spectrum bias.

Selection criteria described?: The patient selection criteria were clearly described in seven studies and described but insufficiently clearly so in four others. The majority of studies (22 studies), however, gave a very limited description of their selection criteria.

Figure 3.

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Acceptable reference standard?: While 26 studies were considered to have an acceptable reference standard, the reference tests were sub-optimal (meriting an 'unclear' rating) in six studies (Calis 2000; Iagnocco 2003; Itoi 1999; Miller 2008b; Naredo 2002; O'Brien 1998). While not covered in our coding scheme for this item, Kim 2006 was given a 'No' rating for this item, which reflected the very unsatisfactory nature of the application of the two reference tests in this study.

Acceptable delay between tests?: Six studies met the criteria for an acceptable time period between the performance of the index and reference tests but in the majority (21) of studies there was insufficient information to judge this. The interval between the index and reference test was inappropriately long in six studies (Holtby 2004a; Holtby 2004b; Kim 2007b; Michener 2009; Norwood 1989; Razmjou 2004) putting them at risk of disease progression bias.

Partial verification avoided?: This was avoided in all studies except three studies (Bennett 1998; Frost 1999; O'Brien 1998) that were considered at high risk of partial verification bias.

Differential verification bias avoided?: Just two studies (Kim 2006; O'Brien 1998) were considered to be a high risk of differential verification bias.

Incorporation avoided?: Schlechter 2009 alone was considered to be a high risk of incorporation bias. In Schlechter 2009, the pathology found at surgery was "matched [to] the history, clinical presentation and symptoms".

Sufficient description of index tests?: All except Suder 1994 were judged as giving sufficient details to permit replication of the index test(s). Lack of sufficient details of the index tests generally resulted in exclusion of studies but we judged that the two tests, which were neither referenced nor described, in Suder 1994 were almost certainly the Neer's sign and Neer's test.

Sufficient description of reference test?: It was considered that sufficient details were given to replicate the reference test(s) in 20 studies but not in the other 13 studies, where often very limited or no detail was provided.

Index test results blinded?: There was a clear statement of blinding of the index tests in 15 studies and sufficient indication to merit an 'unclear' risk of test review bias in 10 prospective studies where the index test(s) clearly preceded the reference test. The other eight studies were judged to be an high risk of test review bias.

Reference tests blinded?: There was a clear statement of blinding of the reference test in 10 studies and sufficient indication that the reference test had been conducted independently in a further two studies (thus given an 'unclear' risk of bias rating). However, the lack of blinding in the remaining 21 studies meant that there was high risk of diagnostic review bias as foreknowledge of the index test result(s) may have influenced the interpretation of the reference test results.

Relevant clinical information?: Appropriate demographical and historical data were judged as being available when index tests were being interpreted in 26 studies; there being insufficient information to judge this in a further four studies. Such data were not available for interpreting the index tests in three studies (Frost 1999; Kim 2001; Kim 2007b).

Uninterpretable results reported?: Based on an assessment of the study design, recruitment and participant flow, 13 studies were judged to have fulfilled the criteria for this item and a further 17 studies may have done so but provided insufficient information to be certain. We judged that three studies (Frost 1999; Itoi 1999; O'Brien 1998) were at high risk of bias for this item.

Withdrawals explained?: Again, based on an assessment of the study design, recruitment and participant flow, 13 studies were judged to have had no withdrawals or to have accounted for these. In 10 studies there was insufficient information to be certain of this and in the remaining 10 studies, withdrawals were possible but either not reported or considered.

Findings

Overview of analyses and target condition/index test combinations

The complexity of the evidence is illustrated by the large number (170) of target condition/index test combinations. These were grouped by five main target conditions: subacromial or internal impingement; rotator cuff tendinopathy or tear; tendinopathy of the long head of biceps; glenoid labral lesions; and undifferentiated target conditions. The five main target conditions, which are also shown in Table 4, are exploded in Table 5 to Table 9. There were numerous standard, modified (see below) or combination index tests, and 14 novel index tests (tests being evaluated for the first time in the report in question, and originated by the authors of the report). The latter included the internal rotation resistance strength test for differentiating subacromial from internal impingement; active abduction, the drop sign, the external rotation lag sign, the Gum-Turn test and the internal rotation lag sign for rotator cuff tears; the upper cut test for LHB (long head of biceps) or labral lesions; and the active compression test, the biceps load II test, the crank test, modified dynamic labral shear, the passive compression test and the passive distraction test for labral lesions.

Subacromial and internal impingement (five studies)

The sensitivity and specificity estimates from each study for the tests of subacromial and internal impingement are shown in forest plots in Figure 4.

Figure 4.

Subacromial and internal impingement

Four studies evaluated 13 standard, modified or combination tests for subacromial impingement. The standard tests were Hawkins’ test, Neer’s sign and the painful arc test. The modified tests were Neer’s sign, passive horizontal adduction, Speed’s test and Yergason’s test. There were three combination tests, which comprised: all of seven specific tests (see Calis 2000 in Table 5); Hawkins’ test or Neer’s sign; and Hawkins’ test and Neer’s sign. The sensitivity estimates ranged from 5% (95% CI 1% to 11%) for the combination of seven tests to 96% (95% CI 79% to 100%) for the combination of Hawkins’ test or Neer’s sign. The specificity estimates ranged from 26% (95% CI 13% to 43%) for the standard Hawkins’ test in Calis 2000 to 99% (95% CI 93% to 100%) for the Gum-Turn test. Only one test was performed and interpreted similarly in two studies. This was the standard Hawkins’ test, but different and possibly incomparable reference standards were used (Calis 2000; MacDonald 2000).

One study evaluated the novel external rotation resistance strength test to differentiate subacromial from internal impingement and gave a sensitivity of 88% (95% CI 70% to 98%) and specificity of 96% (95% CI 90% to 99%).

No study evaluated any test for internal impingement.

Rotator cuff tendinopathy or tears (18 studies)

Non-specific disease of the 'rotator cuff' (five studies)

The sensitivity and specificity estimates from each study for the tests of non-specific disease of the 'rotator cuff' are shown in forest plots in Figure 5.

Figure 5.

Rotator cuff tendinopathy or tears - non-specific disease of the 'rotator cuff'

One study evaluated two tests for diseases of the 'rotator cuff', without attempting to discriminate between these diseases. The tests were a standard (Jobe 1989) and a modified relocation test for pain with sensitivities of 44% (95% CI 27% to 62%) and 56% (95% CI 38% to 73%), and specificities of 67% (95% CI 54% to 78%) and 47% (95% CI 35% to 60%) respectively. 

Three studies evaluated 14 standard, modified or combination tests for tears of the 'rotator cuff' without attempting to discriminate between full thickness tears (FTT) and PTT. The same test was not performed and interpreted similarly in any two studies. The standard test was the full can test. The modified tests included four variants of the empty can test, three variants of the full can test, Hawkins’ test and Neer's sign. There were two combination tests: Hawkins’ test or Neer’s sign; and Hawkins’ test and Neer’s sign. Two tests, an ‘impingement sign’ and an ‘impingement test’ were insufficiently defined to be categorised. The sensitivities ranged from 0% (95% CI 0% to 34%) for the undefined ‘impingement test’ to 88% for a modified Hawkins' test and the combination of Hawkins’ test or Neer’s sign (95% CI 68% to 97% in both instances). The specificities ranged from 38% (95% CI 26% to 51%) for the combination of Hawkins’ test or Neer’s sign to 96% (95% CI 78% to 100%) for the undefined ‘impingement test’.

One study evaluated a modified empty can test for partial thickness tears (PTT) or tendinitis of the 'rotator cuff' without attempting to discriminate between these diseases and gave a sensitivity of 62% (95% CI 41% to 80%) and specificity of 54% (95% CI 33% to 74%).

Specific diseases of the 'rotator cuff' (five studies)

The sensitivity and specificity estimates from each study for the tests of specific diseases of the 'rotator cuff' are shown in forest plots in Figure 6.

Figure 6.

Rotator cuff tendinopathy or tears - specific disease of the 'rotator cuff'

Four studies evaluated one or more of 11 standard or modified tests for FTT of the 'rotator cuff'. The standard test was the rent test. The modified tests were the empty can test (four variants) and the full can test (four variants). Two tests, an ‘impingement sign’ and an ‘impingement test’ were insufficiently defined to be categorised. The sensitivity estimates ranged from 0% (95% CI 0% to 71%) for the undefined ‘impingement test’ to 100% (95% CI 29% to 100%) for the undefined ‘impingement sign’. The specificity estimates ranged from 43% (95% CI 35% to 52%) for a variant of the empty can test to 97% for an undefined ‘impingement test’ and the rent test (95% CI 82% to 100% and 89% to 100% respectively). There was one instance of a test being performed and interpreted similarly in two studies. This was a modified empty can test (Holtby 2004b; Kim 2006).

One study evaluated a modified empty can test for massive or large FTT of the 'rotator cuff' with a sensitivity of 100% (95% CI 29% to 100%) and a specificity of 70% (95% CI 55% to 83%).

One study evaluated two tests for PTT of the 'rotator cuff'. These were an undefined ‘impingement sign’ and an undefined ‘impingement test’. The sensitivity estimates were 67% (95% CI 22% to 96%) for the undefined ‘impingement sign’ and 0% (95% CI 0% to 36%). The specificity estimates were 65% (95% CI 44% to 83%) and 96% (95% CI 80% to 100%) respectively.  

One study evaluated a novel active abduction range test to discriminate between single- and multiple-tendon FTT of the 'rotator cuff' with a sensitivity of 84% (95% CI 74% to 92%) and a specificity of 77% (95% CI 56% to 91%).

Non-specific disease of the 'posterosuperior rotator cuff' (two studies)

The sensitivity and specificity estimates from each study for the tests of non-specific disease of the 'posterosuperior rotator cuff' are shown in forest plots in Figure 7.

Figure 7.

Rotator cuff tendinopathy or tears: non-specific disease of the 'posterosuperior rotator cuff'

One study evaluated the novel Gum-Turn test for non-specific disease of the 'posterosuperior rotator cuff' (affecting supraspinatus AND infraspinatus) with a sensitivity of 90% (95% CI 70% to 99%) and a specificity of 98% (95% CI 93% to 100%).

One study evaluated three novel or modified tests for tears of the 'posterosuperior rotator cuff' without attempting to discriminate between FTT and PTT. The novel tests were the drop sign and the external rotation lag sign. The modified test was the empty can test. The sensitivity estimates ranged from 21% (95% CI 11% to 33%) for the novel drop sign to 84% (95% CI 73% to 92%) for the modified empty can test. The specificity estimates ranged from 58% (95% CI 37% to 78%) for the modified empty can test to 100% for the novel drop sign and novel external rotation lag sign (95% CI 86% to 100% in both instances).

Specific diseases of the 'posterosuperior rotator cuff' (two studies)

The sensitivity and specificity estimates from each study for the tests of specific diseases of the 'posterosuperior rotator cuff' are shown in forest plots in Figure 8 .

Figure 8.

Rotator cuff tendinopathy or tears: specific disease of the 'posterosuperior rotator cuff'.

Two studies evaluated three novel or modified tests for FTT of the 'posterosuperior rotator cuff'. The novel test was the Gum-Turn test. The modified tests were the drop sign and the external rotation lag sign. The sensitivity estimates ranged from 47% (95% CI 21% to 73%) for the modified external rotation lag sign to 73% (95% CI 45% to 92%) for the modified drop sign. The specificity estimates ranged from 77% (95% CI 59% to 90%) for the modified drop sign to 98% (95% CI 88% to 100%) for the Gum-Turn test.

Non-specific disease of supraspinatus (four studies)

The sensitivity and specificity estimates from each study for the tests of non-specific disease of the supraspinatus are shown in forest plots in Figure 9.

Figure 9.

Rotator cuff tendinopathy or tears: non-specific disease of supraspinatus

One study evaluated an undefined empty can test for diseases (calcification included) of supraspinatus without attempting to discriminate between these, with a sensitivity of 94% (95% CI 91% to 97%) and a specificity of 39% (95% CI 32% to 46%).

One study evaluated a modified Hawkins’ test for FTT, degeneration or tendinitis of supraspinatus without attempting to discriminate between these, with a sensitivity of 59% (95% CI 42% to 74%) and a specificity of 44% (95% CI 27% to 62%).

One study evaluated the standard empty can test for FTT, PTT or tendinitis of supraspinatus without attempting to discriminate between these, with a sensitivity of 96% (95% CI 79% to 100%) and a specificity of 50% (95% CI 1% to 99%).

One study evaluated a modified Hawkins’ test for FTT or degeneration of supraspinatus without attempting to discriminate between these, with a sensitivity of 66% (95% CI 47% to 81%) and a specificity estimate of 49% (95% CI 33% to 65%).

Two studies evaluated six standard or modified tests for FTT or PTT of supraspinatus, without attempting to discriminate between these diseases. The standard tests were the empty can test and the full can test. The modified tests were the empty can test (two variants) and the full can test (two variants). The estimates of sensitivity ranged from 6% (95% CI 3% to 12%) for a modified full can test to 87% (95% CI 80% to 92%) for a standard empty can test, and the specificity estimates ranged from 40% (95% CI 23% to 59%) for a modified empty can test to 100% for a standard empty can test, a modified empty can test, and a modified full can test (95% CI 78% to 100%; 88% to 100% and 88% to 100% respectively). One test was performed and interpreted similarly in both studies. This was the standard empty can test (Itoi 2006; Naredo 2002).  

Specific diseases of supraspinatus (six studies)

The sensitivity and specificity estimates from each study for the tests of specific diseases of the supraspinatus are shown in forest plots in Figure 10.

Figure 10.

Rotator cuff tendinopathy or tears: specific disease of supraspinatus.

Four studies evaluated 15 novel, standard or modified tests for FTT of supraspinatus. There were no instances of the same test being performed and interpreted similarly in two or more studies. The novel test was the Gum-Turn test. The standard tests were the drop arm test, the empty can test and the full can test. The modified tests were the empty can test, the full can test and Hawkins’ test (two variants each), and Neer’s sign, the painful arc test, passive horizontal adduction, Speed’s test and Yergason’s test (one variant each). The sensitivity estimates ranged from 11% (95% CI 1% to 35%) for modified passive horizontal adduction to 100% (81% to 100%) for a modified Hawkins' test. The specificity estimates ranged from 28% (95% CI: 20% to 38%) for both the modified passive horizontal adduction and the modified Neer’s sign to 100% (95% CI 97% to 100%) for the standard drop arm test.

One study evaluated the standard external rotation lag sign for full-width, FTT of supraspinatus, with a sensitivity of 56% (95% CI 38% to 74%) and a specificity of 98% (95% to 100%).

One study evaluated the standard external rotation lag sign for isolated PTT of supraspinatus, with a sensitivity of 12% (95% CI 5% to 23%) and a specificity of 98% (95% CI 95% to 100%).

One study evaluated the standard empty can test for tendinitis of supraspinatus, with a sensitivity of 72% (95% CI 47% to 90%) and a specificity of 38% (95% CI 14% to 68%).

Disease of infraspinatus (three studies)

The sensitivity and specificity estimates from each study for the tests of disease of infraspinatus are shown in forest plots in Figure 11.

Figure 11.

Rotator cuff tendinopathy or tears: disease of infraspinatus

One study evaluated undefined resisted lateral rotation from neutral rotation for diseases of infraspinatus (calcification included) without attempting to discriminate between these, with a sensitivity of 94% (95% CI 87% to 98%) and a specificity of 95% (95% CI 92% to 96%).

One study evaluated the standard Patte’s test for identifying and discriminating between tears and tendinitis of infraspinatus, with a sensitivity of 71% (95% CI 42% to 92%) and a specificity of 88% (95% CI 64% to 99%).

One study evaluated the standard Patte’s test and another study evaluated modified resisted lateral rotation from neutral rotation for tears of infraspinatus. In neither case was there an attempt to differentiate between FTT and PTT. The sensitivity estimates were 36% (95% CI 11% to 69%) for the standard Patte’s test and 84% (95% CI 74% to 91%) for resisted lateral rotation; and the specificity estimates were 95% (95% CI 75% to 100%) and 53% (95% CI 41 to 64%) respectively.

One study evaluated the standard Patte’s test for infraspinatus tendinitis with a sensitivity of 57% (95% CI 18% to 90%) and a specificity of 71% (95% CI 49% to 87%).

Non-specific disease of subscapularis (five studies)

The sensitivity and specificity estimates from each study for the tests of non-specific disease of subscapularis are shown in forest plots in Figure 12.

Figure 12.

Rotator cuff tendinopathy or tears: non-specific disease of subscapularis

One study evaluated undefined resisted medial rotation from neutral rotation for diseases of subscapularis (calcification included) without attempting to discriminate between these, with a sensitivity of 96% (95% CI 78% to 100%) and a specificity of 99% (95% CI 97% to 100%).

One study evaluated an incompletely defined combination of the lift-off test and resisted medial rotation from neutral rotation for any tear or tendinitis of subscapularis without attempting to differentiate between these diseases, with a sensitivity of 50% (95% CI 21% to 79%) and a specificity of 84% (95% CI 60% to 79%).

Four studies evaluated eight novel, standard, modified or combination tests for tears of subscapularis, without attempting to discriminate between types of tears. There were no instances of a test being performed and interpreted similarly in two or more studies. The novel tests were the bear-hug test and the internal rotation lag sign. The standard tests were the belly-press test, the lift-off test and the Napoleon test. The modified tests were the lift-off test and the lift-off with force. The combination test, which was incompletely defined, comprised the lift-off test and resisted medial rotation from neutral rotation. The sensitivity estimates ranged from 18% (95% CI 4% to 43%) for the modified lift-off test to 97% (95% CI 82% to 100%) for the internal rotation lag sign. The specificity estimates ranged from 59% (95% CI 50% to 67%) for the modified lift-off test with force to 100% for the standard lift-off test and the modified lift-off test (95% CI 86% to 100% and 92% to 100% respectively).

Specific diseases of subscapularis (three studies)

The sensitivity and specificity estimates from each study for the tests of specific diseases of subscapularis are shown in forest plots in Figure 13.

Figure 13.

Rotator cuff tendinopathy or tears: specific disease of subscapularis

One study evaluated four novel, standard or modified tests for a complete tear of subscapularis. The novel test was the bear-hug test. The standard test was the Napoleon test. The modified tests were the belly-press test and the lift-off test. The sensitivity estimates ranged from 67% (95% CI: 9% to 99%) for the modified lift-off test to 100% for the novel bear-hug test, the standard Napoleon test and the modified belly-press test (95% CI 29 to 100% in each instance). The specificity estimates ranged from 80% (95% CI 68% to 89%) for the novel bear-hug test to 98% (95% CI 91% to 100%) for the modified lift-off test. 

One study evaluated a modified internal rotation lag sign for FTT of subscapularis, with a sensitivity of 47% (95% CI 21% to 73%) and specificity of 94% (95% CI 79% to 99%).

One study evaluated four novel, standard or modified tests for a partial tear of subscapularis. The novel test was the bear-hug test. The standard test was the Napoleon test. The modified tests were the belly-press test and the lift-off test. The sensitivity estimates ranged from 7% (95% CI 0% to 34%) for the modified lift-off test to 53% (95% CI 28% to 77%) for the novel bear-hug test, and the specificity estimates ranged from 92% (95% CI 80% to 98%) for the novel bear-hug test to 100% (95% CI 92% to 100%) for the modified lift-off test.

One study evaluated an incompletely defined combination comprising the lift-off test and resisted medial rotation from neutral rotation for subscapularis tendinitis, with a sensitivity of 50% (95% CI 12% to 88%) and a specificity of 88% (95% CI 69% to 97%).

LHB tendinopathy or tears (three studies)

The sensitivity and specificity estimates from each study for the tests of LHB tendinopathy or tears are shown in forest plots in Figure 14.

Figure 14.

LHB tear or tendinitis

Three studies evaluated 10 novel, standard, modified or combination tests for LHB tears or tendinosis without attempting to differentiate between these diseases. There were no instances of a test being performed and interpreted similarly in two or more studies. The novel tests were modified dynamic labral shear and the upper-cut test. The standard tests were Speed’s test, the active compression test and the belly-press test. The modified tests were the anterior slide test, the bear-hug test, Speed’s test and Yergason’s test. The combination test comprised Yergason’s test and Gilcreest’s test but was incompletely defined. The sensitivity estimates ranged from 17% (95% CI 6% to 36%) for the novel modified dynamic labral shear to 87% (95% CI 82% to 91%) for the standard Speed’s test. The specificity estimates ranged from 53% (95% CI 41% to 65%) for the novel modified dynamic labral shear to 85% (95% CI 74% to 92%) for the standard belly-press test.

Labral lesions (11 studies)

Non-specific labral lesions (four studies)

The sensitivity and specificity estimates from each study for the tests of non-specific labral lesions are shown in forest plots in Figure 15.

Figure 15.

Glenoid labral lesion: non-specific labral lesion

Four studies evaluated five novel/standard or modified tests for labral lesions without attempting to discriminate between these lesions. The novel/standard tests were the active compression test and the crank test. The novel/standard crank test was performed and interpreted similarly in both studies, but the results were heterogeneous. The modified test was the active compression test. Two tests, an ‘impingement sign’ and an ‘impingement test’ were insufficiently defined to be classified. The sensitivity estimates ranged from 0% (95% CI 0% to 71%) for the undefined ‘impingement test’ to 100% (95% CI 93 to 100%) for the novel active compression test. The specificity estimates ranged from 31% (95% CI 17% to 48%) for the modified active compression test to 98% (95% CI 94% to 100%) for the novel active compression test.    

Non-specific SLAP lesions (three studies)

The sensitivity and specificity estimates from each study for the tests of non-specific SLAP lesions are shown in forest plots in Figure 16.

Figure 16.

Glenoid labral lesions: non-specific SLAP lesion

Three studies evaluated 15 novel or modified tests. There were no instances of a test being performed and interpreted similarly in two or more studies. The novel tests were modified dynamic labral shear, the passive compression test and the upper cut test. The modified tests were the active compression test, the anterior apprehension test at 90°, the anterior release test, the anterior slide test, the bear-hug test, the belly-press test, the crank test and palpation for bicipital groove tenderness (one variant each) and Speed’s test and Yergason’s test (two variants each). The sensitivity estimates ranged from 9% (95% CI 2% to 24%) for a modified Speed’s test to 82% (95% CI 65% to 93%) for the novel passive compression test. The specificity estimates ranged from 32% (95% CI 20% to 46%) for the modified bear-hug test to 98% (95% CI 90% to 100%) for the novel modified dynamic labral shear.

Type II-IV SLAP lesions (two studies)

The sensitivity and specificity estimates from each study for the tests of type II-IV SLAP lesions are shown in forest plots in Figure 17.

Figure 17.

Glenoid labral lesions: type II-IV SLAP lesion

Two studies evaluated five novel, standard, modified or combination tests for type II-IV SLAP lesions without attempting to differentiate between these types. None of the tests was performed and interpreted similarly in both studies. The novel test was the passive compression test. The standard test was the passive distraction test. The modified tests were the anterior slide test and the active compression test (one variant each). The combination test comprised the active compression test or the passive distraction test. The sensitivity estimates ranged from 21% (95% CI 12% to 34%) for the modified anterior slide test to 89% (95% CI 72% to 98%) for the novel passive compression test. The specificity estimates ranged from 82% (95% CI 65% to 93%) for the novel passive compression test to 98% (95% CI 95% to 99%) for the modified anterior slide test.

Type II SLAP lesions (three studies)

The sensitivity and specificity estimates from each study for the tests of type II SLAP lesions are shown in forest plots in Figure 18.

Figure 18.

Glenoid labral lesions: type II SLAP lesion

Three studies evaluated 18 novel/standard or modified tests for type II SLAP lesions. The novel/standard test was the biceps load II test. The modified tests were the active compression test, Speed’s test and Yergason’s (two variants each) and the anterior slide test, the compression-rotation test, the crank test, Hawkins’ test, the modified relocation test for postero-superior glenoid impingement, Neer’s sign, the pain provocation test, the relocation test for pain or apprehension and Whipple’s test (one variant each). The sensitivity estimates ranged from 9% (95% CI 1% to 28%) for the modified crank test to 90% (95% CI 76% to 97%) for the novel/standard biceps load II test. The specificity estimates ranged from 30% (95% CI 22% to 40%) for the modified Hawkins’ test to 97% (95% CI 90% to 99%) for the novel/standard biceps load II test.

Two tests were performed and interpreted similarly in two studies. These were the novel/standard biceps load II test by Kim 2001 and Oh 2008 and the modified anterior slide test by Oh 2008 and Parentis 2006.

Tests for multiple target conditions: undifferentiated (four studies)

The sensitivity and specificity estimates from each study for the tests of undifferentiated multiple target conditions are shown in forest plots in Figure 19.

Figure 19.

Non-specific

One study evaluated a modified Speed’s test for LHB tendinitis or avulsion or any SLAP lesion without attempting to differentiate between these, with a sensitivity of 90% (95% CI 55% to 100%) and a specificity of 14% (95% CI 5% to 29%).

One study evaluated a modified Speed’s test and a modified Yergason’s test for any LHB lesion, a type II or a type IV SLAP lesion without attempting to distinguish between these diseases, with a sensitivity of 32% (95% CI 14% to 55%) for the modified Speed’s test and 43% (95% CI 22% to 66%) for the modified Yergason’s test; and specificity estimates of 75% (95% CI 55% to 89%) and 79% (95% CI 59% to 92%) respectively.

One study evaluated six standard, modified or combination tests for SA-SD bursitis or bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability, without attempting to distinguish between these diseases. The standard tests were Hawkins’ test and the painful arc test. The modified tests were the empty can test, Neer’s test and resisted lateral rotation from neutral rotation. The combination test comprised all the foregoing, of which three were required to be positive. The sensitivity estimates ranged from 50% (95% CI 25% to 75%) for the modified empty can test to 81% (95% CI: 54% to 96%) for the modified Neer’s test. The specificity estimates ranged from 54% (95% CI 37% to 70%) for the modified Neer’s test to 90% (95% CI 73% to 98%) for the standard painful arc test.

One study evaluated two modified tests, Hawkins’ test and Neer’s sign, for SIS or rotator cuff tendinitis or tear without attempting to discriminate between these diseases, with a sensitivity of 43% (95% CI 28 to 59%) for the modified Hawkins’ test and 50% (95% CI 35 to 65%) for the modified Neer's sign; and specificity estimates of 67% (95% CI 22% to 96%) and 50% (95% CI 12% to 88%) respectively.

Between-tester reliability

Kappa coefficients were reported as 0.815 for the biceps load II test (Kim 2001); 0.39 (95% CI 0.12 to 0.65) for the empty can test (Michener 2009); respectively 0.47 (0.22 to 0.72) and 0.29 (0.180 to 0.398) for Hawkins’ test (Michener 2009; Razmjou 2004); respectively 0.40 (0.13 to 0.67) and 0.506 (0.366 to 0.645) for Neer's test (Michener 2009; Razmjou 2004); 0.45 (0.18 to 0.72) for the painful arc test (Michener 2009); 0.771 for the passive compression test (Kim 2007b); 0.67 (0.40 to 0.94) for resisted lateral rotation from neutral rotation (Michener 2009).

Summary of findings

Summary of findings. Summary of results table
SettingMost people with shoulder pain symptomatic of impingements and related pathologies are diagnosed and managed in the primary care setting.
Index testsPhysical tests used single or in combination to identify shoulder impingement and related pathologies.
Reference standardWhile a definitive reference standard is lacking, surgery, whether open or arthroscopic, is generally regarded as the nest available. Non-invasive contenders include ultrasound and magnetic resonance imaging (MRI).
ImportanceAccurate diagnosis using readily applied, convenient, low-cost physical tests would enable appropriate and well-timed management of these common causes of shoulder pain.
StudiesIndex were 33 studies including 4002 shoulders in 3852 patients. These incorporated numerous standard, modified or combinations of index tests and 14 novel index tests.
Quality concernsAlthough 28 studies were prospective, study quality was generally poor. All but two studies failed to meet the criteria for having a representative spectrum of patients.
Data analysisThe studies tested 170 target condition/index test combinations, with only six instances of any index test being performed and interpreted similarly in two studies. Meta-analysis of the latter was inappropriate, however.
Target condition Subcategory of target condition, if applicable Studies Shoulders/patients Tests or variants evaluated
Subacromial and internal impingementSubacromial impingement5361/35613
subacromial versus Internal impingement1110/1101
Internal impingement000
Rotator cuff tendinopathy or tearsNon-specific disease of the 'rotator cuff'5466/46617
Specific diseases of the 'rotator cuff'5503/50315
Non-specific disease of the 'posterosuperior rotator cuff'2220/2204
Specific disease of the 'posterosuperior rotator cuff'2166/1573
Non-specific disease of supraspinatus4792/67811
Specific disease of supraspinatus6887/87018
Disease of infraspinatus3719/6055
Non-specific disease of subscapularis5887/77310
Specific disease of subscapularis3145/13610
LHB tendinopathy or tears 3660/55710
Glenoid labral lesionsNon-specific labral lesions4364/3645
Non-specific SLAP lesions3222/22115
Type II-IV SLAP lesions2315/3075
Type II SLAP lesions3405/40518
Multiple, undifferentiated target conditionsLHB/labral pathology; LHB/SLAP lesions; SA-SD bursitis/bursal-side degeneration of supraspinatus; and SIS/rotator cuff tendinitis or tear.4201/20010

Discussion

We set out to identify and review studies evaluating the diagnostic accuracy of defined physical tests, whether applied singly or in combination, for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders. Our particular focus was primary care (while not excluding secondary or tertiary care, especially in the hospital outpatient setting). 

Summary of main results

See Summary of findings . The 33 included studies, of 4002 shoulders in 3852 patients, incorporated numerous standard, modified, or combination index tests and 14 novel index tests. In consequence they embodied 170 target condition/index test combinations, with only six instances of any index test being performed and interpreted similarly in two studies. However, only two studies of a modified empty can test for FTT of the rotator cuff (Holtby 2004b; Kim 2006) and a modified anterior slide test for type II SLAP lesions (Kim 2001; Oh 2008) were clinically homogenous.

Variations in index tests’ provenance, procedure and interpretation

The provenance given for index tests was diverse. Primary sources for at least one index test were cited in 20 studies (Barth 2006; Calis 2000; Castoldi 2009; Guanche 2003; Hertel 1996; Holtby 2004a; Itoi 1999; Itoi 2006; Kibler 2009; MacDonald 2000; Michener 2009; Miller 2008b; Naredo 2002; Oh 2008; Parentis 2006; Razmjou 2004; Schlechter 2009; Speer 1994; Stetson 2002; Wolf 2001); secondary/tertiary sources in eight (Bennett 1998; Calis 2000; Guanche 2003; Iagnocco 2003; Kibler 2009; Michener 2009; Naredo 2002; Oh 2008); and none in six (Frost 1999; Kim 2006; Norwood 1989; Oh 2008; Parentis 2006; Suder 1994). In two studies (studies reporting novel tests were not included in this) neither a reference nor a description of the index tests was offered (Norwood 1989; Suder 1994). We identified some misattributions, most commonly of the empty can test to Jobe 1982 (Holtby 2004b; Hertel 1996; Itoi 1999; Itoi 2006; Michener 2009). Neer’s sign was misattributed to Neer 1972a, a report which gave no clear account of this index test, by Razmjou 2004. Speed’s test was incorrectly referenced by Oh 2008. In one instance, a figure depicting Hawkins’ test was apparently misinterpreted as a novel test, Yocum’s test (Naredo 2002).   

Some studies cited index tests' primary sources as well as providing a description, often revealing substantive, apparently unintentional inconsistencies in procedures, criteria for positive results, or both. This applied to the active compression test (Guanche 2003), the anterior release test (Guanche 2003), the anterior slide test (Kibler 2009; Schlechter 2009), the belly press test (Barth 2006), the crank test (Guanche 2003), the drop sign (Miller 2008b), Hawkins’ test (Parentis 2006), Neer’s sign (MacDonald 2000; Michener 2009; Parentis 2006), the palm up test (Naredo 2002), Yergason’s test (Guanche 2003; Kibler 2009). There were also three instances in which the originators of index tests described the method of performance and interpretation differently across reports: the anterior slide test (Kibler 1995a; Kibler 2009), the crank test (Liu 1996a; Liu 1996b) and the lift-off test (Gerber 1991; Gerber 1996). In two of these instances, (Liu 1996a and Liu 1996b; Gerber 1991 and Gerber 1996), the differing descriptions apparently related to the same patient samples, revealing internal inconsistencies.

Whether intentional or unintentional, variations in index tests' procedure or interpretation were prevalent, such that, as observed above, there were only six instances of any index test being performed and interpreted (in terms of criteria for, and implications of, a positive result) similarly in two studies; and no instances of three studies or more using any one test similarly.

As previously stated, 14 of the tests identified - a surprisingly large proportion - were novel, and we were particularly interested to explore their provenance. The justifications given included synthesis of empirical evidence from other studies (the internal rotation resistance strength test), application of biomechanical principles (the biceps load II test, the drop sign, the external rotation lag sign, the internal rotation lag sign, the passive compression test), or mechanisms of pain-provocation described by patients (the active compression test and the upper-cut test). Some tests appear to have been developed on a trial and error basis: active abduction, which was developed retrospectively from routinely collected data; the modified dynamic labral shear, which was adapted from an existing test; and the passive distraction test, the postulated mechanism of which was confirmed arthroscopically. For two tests (the crank test, the Gum-Turn test), no clear justification was reported.

Arithmetical discrepancies

Arithmetical discrepancies in reported statistics, over and above those attributable to rounding error, were prevalent. In three studies, substantial discrepancies in the 2 x 2 tables, as back-calculated from reported sensitivity and/or specificity, warranted exclusion (Ebinger 2008; Fodor 2009; Litaker 2000). Seven studies presented multiple but smaller errors of this type, multiple errors associated with other summary statistics, or both (Bennett 1998; Hertel 1996; Itoi 2006; Kim 2006; MacDonald 2000; Miller 2008b; Parentis 2006).

We adopted a policy of excluding studies in which, allowing for the possibility of an isolated typographical/transcription error, back-calculation of 2 x 2 tables from the reported sensitivity and specificity demonstrated greater-than 10% discrepancies in any cell (which was not attributable to unit-of-analysis issues). We excluded three studies (Ebinger 2008; Fodor 2009; Litaker 2000) on this basis.

Many of the remainder presented with errors which were either too small to warrant study exclusion or which related to summary statistics other than sensitivity or specificity. We divided these errors into two categories: isolated discrepancies within study reports which (extending the benefit of doubt) we attributed to typographical errors, or confirmed as such by communication with the authors; and multiple discrepancies within a report, which we attributed to miscalculation. Seven studies (Bennett 1998; Hertel 1996; Itoi 2006; Kim 2006; MacDonald 2000; Miller 2008b; Parentis 2006) fell within the former category and six within the latter (Calis 2000; Gumina 2008; Kibler 2009; Naredo 2002; Oh 2008; Schlechter 2009). We subcategorised each type of error according to its absolute magnitude in reported percentage terms: see Table 5.  

Tests' potential to inform diagnoses

Sensitivity and specificity are test properties, and not directly applicable at the interface between clinician and patient. Useful statistics in this context are the positive and negative likelihood ratio (LR+, LR-). The LR+ may be defined as true positive rate/false positive rate = sensitivity/(1-specificity), and the LR- as false negative rate/true negative rate = (1-sensitivity)/specificity. These statistics facilitate a Bayesian approach, which is intuitive to clinicians (Gill 2005), enabling estimation of the likelihood of a target condition post-test when the pre-test probability of the condition is known, by means of a nomogram (Jaeschke 1994). We had intended to tabulate LR+ and LR- data to optimise the clinical utility of our review. However, in the light of our findings, we decided that this step would overplay the evidence. For the most part, this evidence derives from small, methodologically compromised, single studies; often conducted by tests' originators, with negative implications for reproducibility. Over and above these considerations is the fact that few of the results, and none from methodologically and arithmetically robust studies, are directly applicable to primary care.

Between-tester agreement

Few studies addressed this aspect, although it is fundamental to the validity of clinical tests. Agreement is best evaluated using the kappa coefficient, since this takes account of the fact that agreements may occur by chance. The coefficient ranges from 0 to 1, and interpretation has been recommended as follows by Altman 1991: less than 0.20 = poor; 0.21 to 0.40 = fair; 0.41 to 0.60 = moderate; 0.61 to 0.80 = good; 0.81 to 1 = very good. By these criteria, and based on point estimates, very good between-rater agreement was achieved for only one test, the biceps load II test (Kim 2001). Good agreement was obtained for the passive compression test (Kim 2007b) and resisted lateral rotation from neutral rotation (Michener 2009). Agreement for the painful arc test was moderate (Michener 2009), while that for Neer's test was fair to moderate (Michener 2009; Razmjou 2004). For the empty can test (Michener 2009) and Hawkins' test (Michener 2009; Razmjou 2004), agreement was only fair.

Calis 2000 reported interobserver reliability for their battery of index tests of 'above 98%', but gave no breakdown and presumably did not account for chance agreement in their calculations. Miller 2008b stated that ‘to ensure test quality, the clinical tests were practiced on five separate occasions with an orthopaedic surgeon with a special interest in shoulders on a separate subgroup of subjects’, but no statistical analysis was presented. In Naredo 2002, two rheumatologists performed independent assessments, then established clinical diagnoses by consensus. Finally, although evaluation of reproducibility was mentioned in the abstract of Schlechter 2009, this aspect was not addressed in the report.

Comparison with other systematic reviews

We identified 12 other systematic reviews and one non-systematic review which overlapped with aspects of ours. Two addressed multiple shoulder pathologies. These were Dinnes 2003, which covered impingement syndrome and rotator cuff tears (FTT, PTT or any) but excluded labral disorders and Hegedus 2008a, which had no exclusions. One systematic review (Alqunaee 2012) was nominally specific to subacromial impingement syndrome, but encompassed rotator cuff pathology tears (i.e. stage II and III impingement, according to the criteria of Neer 1977). Three (Beaudreuil 2009a; Hughes 2008a; Longo 2011) addressed rotator cuff disease. One, Munro 2009a, addressed labral disease. Disproportionately, considering the relatively low prevalence of this condition, six reviews (Dessaur 2008a; Calvert 2009a; Jones 2007a; Luime 2004b; Meserve 2009a; Walton 2008a) focused on SLAP lesions. Table 11 summarises these reviews and compares their main conclusions to our own.

Table 11. Summary of systematic reviews
#  Target condition Study ID Search period Included studies N Main conclusions Notes and comments
1Any Hegedus 2008a1966 to  October 200645999

Conclusion 1

'There is a lack of clarity with regard to whether common orthopaedic special tests are useful in differentially diagnosing pathologies of the shoulder'

General

• Included studies with highly selected populations.

• Pooled some clinically heterogeneous data.

Re conclusion 1

• Our conclusions broadly agree.

2Impingement, Any tear, FTT, PTT Dinnes 20031985 to October 2001101235

Conclusion 1

'Few tests provided convincing evidence of the presence or absence of disease ... [Although] individual tests did perform well in the study by [Hertel 1996] ... the sample size was small and CIs were very wide'.

The internal rotation lag sign also had a very low negative LR ... Other tests demonstrating high positive and negative LRs were the rent test and internal rotation resistance strength test.'

Conclusion 2

'In four studies [Litaker 2000; Lyons 1992; MacDonald 2000; Read 1998], negative LRs were sufficiently low to confirm that disease is absent in those with a negative diagnosis'.

Conclusion 3

'The results suggest that [generic] clinical examination by specialists can rule out the presence of a rotator cuff tear'.

Re conclusion 1

• Our conclusions broadly agree.

• We excluded three (Litaker 2000; Lyons 1992; Read 1998) of the four studies underpinning this conclusion on clinical or methodological grounds.

Re conclusion 2

• We excluded those studies evaluating generic examination.

3SIS Alqunaee 2012to January 2011162390

Conclusion 1

'The Hawkins-Kennedy test, Neer's sign and empty can test are ... more useful for ruling out rather than ruling in SIS.'

Conclusion 2

'The drop arm test and lift-off test ... are more useful for ruling in SIS if the test is positive.'

General

• Pooled some clinically heterogeneous data.

• Included several studies which we excluded on clinical or methodological grounds (Leroux 1995; Lyons 1992; Malhi 2005; Murrell 2001; Scheibel 2005; Walch 1998) or categorised as 'awaiting classification' pending clarification (Nanda 2008; Park 2005).

• Included one study which post-dated our search (Fowler 2010), but which concerned a selected population.

Re conclusion 1

• Our conclusions partially agree. We suggest cautious interpretation, as the point estimates are small, the 95% CIs wide, and the pooled data clinically heterogeneous.

Re conclusion 2

• The pooled point estimate for the drop arm test is small. That for the lift-off test is large, but the 95% CIs are wide. Again, the pooled data are clinically heterogeneous.

4Rotator cuff disease Beaudreuil 2009ato June 200692116 See notes and comments

General

• A descriptive review with transliteration of data from the primary studies and no quality assessment.

• The conclusions are not contentious.

5Rotator cuff disease Hughes 2008aJanuary 1966 to April 2007132010

Conclusion 1

One test, the rent test in Wolf 2001, is identified with LR+ >10 and LR - < 0.1; but a contradictory result in Lyons 1992 is noted.

Conclusion 2

Other tests with LR+ > 10 or LR- < 0.1 are listed.

Conclusion 3

Hertel 1996 was excluded on the grounds of arithmetical discrepancies.

 

Re conclusion 1

• We agree, but excluded Lyons 1992 on clinical grounds.

Re conclusion 2

• We excluded four studies underpinning these conclusions on clinical or methodological grounds (Ardic 2006; Leroux 1995; Lyons 1992; Murrell 2001) and categorised one (Park 2005) as 'awaiting classification' pending clarification.

Re conclusion 3

• Our back-calculations identified only one discrepancy in Hertel 1996, which we attributed to a typographical error.

 6Rotator cuff disease Longo 2011Not reportedNot reportedNot reported See notes and comments.

General

• Included for completeness, but not a systematic review

 7Labral disease Munro 2009a1995 to June 200715Numbers reported by test, not by study.

Conclusion 1

The biceps load II and internal rotation resistance strength tests were identified as having large LR+ and moderate LR-, based on single studies of good quality.

General

• Pooled some clinically heterogeneous data.

Re conclusion 1

• Our conclusions are broadly agree.

8SLAP Calvert 2009aJanuary 1970 to June 200415Unclear

Conclusion 1

'The current literature being used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful.'

Conclusion 2

'There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion.'

General

• Included studies with highly selected populations.

Re conclusion 1

• While sharing concerns as to the validity of much of the diagnostic test accuracy literature, we consider this an over generalisation.

Re conclusion 2

• We distinguish 'limited or contradictory evidence for accuracy' from 'evidence of inaccuracy', and place a number of tests former category.

9SLAP Dessaur 2008a 1996 to 2006172148

Conclusion  1

'It appears that no single test is sensitive or specific enough to to determine the presence of a SLAP lesion accurately'.

General

• Included studies with highly selected populations.

Re conclusion 1

• We distinguish between 'limited or contradictory evidence for accuracy' from 'evidence of inaccuracy', and place a number of tests in the former category.

10SLAP  Jones 2007a January 1 1966 to July 1 2006122260

Conclusion 1

'SLAP-specific physical examination results cannot be used as the sole basis of a diagnosis of a SLAP lesion.'

General

• A descriptive review with transliteration of data from the primary studies and limited quality assessment.

• Included studies with highly selected populations.

Re conclusion 1

• Given the current state of knowledge, we agree with this conclusion.

11SLAP Luime 2004b1966 to 2003171901

Conclusion 1

'Most promising [tests] for establishing labral tears are currently the biceps load I [not relevant to this review] and II, pain provocation of Mimori, and the internal rotation resistance strength tests.'  

General

• Included studies with highly selected populations.

Re conclusion 1

• We agree regarding the biceps load II and internal rotation resistance strength tests. However, in the population relevant to the present review, the pain provocation test did not perform well.

12SLAP Meserve 2009a 1966 to June 20076777

Conclusion 1

The anterior slide test is a poor test for predicting the presence of a labral lesion in the shoulder.

Conclusion 2 Active compression, crank, and Speed tests are more optimal choices.

Conclusion 3 Clinicians should choose the active compression test first, crank second and Speed test third when a labral lesion is suspected.

General

• Included studies with highly selected populations.

• Pooled some clinically heterogeneous data.

Re conclusion 1

• Based on the results of Schlechter 2009 (notwithstanding that this study was prone to arithmetical error), which post-dated the search of Meserve 2009a, we cannot unconditionally agree.

Re conclusions 2 & 3

• Based on current knowledge, we agree concerning the active compression test.

• In relatively unselected populations, we found the crank test inferior to biceps load II for ruling in labral tears; and LRs for Speed's test did not suggest that it would be clinically useful.

13SLAP Walton 2008aTo May 20067Numbers reported by test, not by study.

Conclusion 1 'Yergason's test is the only [test] that shows a significant ability to influence clinical decision making, based on the results of the current analysis.

Conclusion 2 'Methodologic inadequacies in the reporting of the publications are common, and caution must be exercised when drawing inferences from the results of these studies.'

General

• Included studies with highly selected populations.

• There was limited quality assessment.

• Pooled some clinically heterogeneous data.

Re conclusion 1

• In relatively unselected populations, LRs for Yergason's test did not suggest that it would be clinically useful.

Re point 2

• We agree.

Our own review differs from the remainder, except Dinnes 2003, in terms of its emphasis on relatively unselected populations such as might be encountered in primary care. We took this approach because it is in primary care that people with these problems are screened and, for most diagnoses, managed. We decided not exclude secondary or tertiary care, based in part upon the (correct) pragmatic assumption that few studies would use reference standards directly applicable to primary care. Extrapolation from the secondary and tertiary settings to primary care should be undertaken with caution, however. In primary care, patients will have travelled less far down the screening pathway, disease is likely to be less severe, and the expertise of clinicians conducting and interpreting the physical tests may be less. These aspects would tend to reduce diagnostic test accuracy. On the other hand, our results do have applicability to relatively unselected populations (in terms of occupation and sporting activity) in secondary and tertiary care.

Our review also differs in terms of its scope. We considered that shoulder impingements and those painful conditions that may be related to impingements present a coherent class of pathologies which would resonate with clinicians. Although we recognise that this class of pathologies may overlap with others (laxities and instabilities, capsular and acromio-clavicular conditions), we omitted these in order to maintain focus and optimise the utility of an already large review. We believe that we have achieved an appropriate compromise.

Strengths and weaknesses of the review

Strengths of the review

This review has a number of strengths, principal among which are the following.

Search strategy

Our search strategy was comprehensive.

Definition of physical tests

As an integral part of the review, we have described the performance and interpretation of physical tests, by reference, wherever possible, to the primary sources (Table 1). We have also been careful to evince the detail of index tests from the included studies.

Comparisons revealed that modifications in the procedures and/or interpretation of tests, sometimes intentional and sometimes not, are highly prevalent in the literature. Unclear is the extent to which a test's performance may be changed in terms of the starting position, the plane and range of movement, inclusion or exclusion of passive, active and resisted components, and the forcefulness of application, before it must be regarded as a different test. Our alertness to such procedural modifications, and modifications of interpretation (the criteria for a positive response, the implications of a positive response, or both) has enabled us to avoid pooling data which on superficial inspection seem suitable, but which are actually clinically heterogeneous; and has brought to light numerous internal inconsistencies.

Back-calculations

We double-checked the summary statistics presented in the included studies for each target condition/index test combination, back-calculating 2 x 2 tables. That we observed such a high frequency of arithmetical errors, some so serious as to warrant study exclusion (Ebinger 2008; Fodor 2009; Litaker 2000) and others sufficiently serious to cast doubt on the safety of results (Calis 2000; Gumina 2008; Kibler 2009; Naredo 2002; Oh 2008; Schlechter 2009), emphasises the inadvisability of uncritically accepting reported values.

Non-blinding of reviewers

Perhaps counter-intuitively, we consider non-blinding of reviewers to study authors was a strength of this review, because it facilitated identification of inconsistencies across multiple publications.

Weaknesses of the review

As predicted in our protocol, non-English literature was not included because of resource limitations, although we are aware that this may have led to selection bias. However, at minimum, very good quality and complete technical translations are required and even then some key subtleties (such as in population and test performance) may be missed. In practice, due to obscure presentation of data in much of the primary literature, extraction even in the English-language frequently presented a considerable challenge. This emphasizes the unfeasibility of extracting data with similar stringency from literature in other languages

While our search strategy was comprehensive, specialist feedback at editorial review highlighted that a greater use of subject headings in the database searches for the conditions under investigation and terms found in diagnostic test accuracy filters terms would have been desirable. Specialist feedback also suggested other databases and pointed to various grey literature sources such as MEDION (database of systematic reviews of diagnostic studies). We cannot say how many studies may have been missed through these potential deficiencies in our search strategy but reflect that our search through the reference lists of other reviews did not reveal any relevant omissions.

We recognise the possible inclusion of a large number of studies with an unacceptable delay between the index and reference tests, which we defined as an interval exceeding either the average duration of symptoms or one month (whichever was the shorter), as a potential source of bias. Specifically, there is a possibility of misclassification due to spontaneous recovery or progression of disease. Of the 33 trials included, 22 provided no details of the interval between the index and reference test. Only seven trials would have met the acceptable delay criterion, had it been a condition for inclusion. These were Calis 2000 (no delay assumed), Guanche 2003 (immediate), Iagnocco 2003 (a few days' delay), Miller 2008b (no delay), Naredo 2002 (≤ 1 week), Oh 2008 (mean delay 1 day), and Speer 1994 (index and reference tests were on the same day). The other four trials providing data would not have met the inclusion criterion. These were Holtby 2004a, Holtby 2004b (mean delay 23 weeks); Michener 2009 (mean 2.6 months); and Razmjou 2004 (mean 23 weeks). Given that the majority of studies did not report on the delay between the index and reference tests, our decision to include these and other studies with longer than desirable delays between index and reference tests was  pragmatic, and necessitated by the evidence.

Applicability of findings to the review question

In the light of limitations of the primary evidence, the practical diagnostic advice that may be offered to the primary care clinician faced with an impingement-related disorder can only be very tentative. A first step may be to screen for those conditions, such as glenoid labral lesions and large rotator cuff tears, which are most likely to warrant surgical opinion, so that a timely referral made be made; even if the immediate plan, perhaps while the patient is on a waiting list, is to implement a trial of conservative treatment. Identifying the best tests for screening purposes, and thus ruling out these diseases, involves consideration of the reported sensitivity, but also the precision of the point estimate and the methodological quality of the reporting study (or studies). Taking these factors into account, the most promising screening test for glenoid labral lesions was the passive compression test (Kim 2007b) with a sensitivity of 89% (95% CI 72% to 98%). But the test was novel and the evaluation was by its originators, and firm conclusions as to its usefulness must await independent verification. For full thickness tears of the rotator cuff, the posterosuperior rotator cuff in general, supraspinatus or infraspinatus there were no strong candidate tests. Thus the decision whether to refer may rest upon patients’ response to conservative intervention. For any tear of subscapularis, the sensitivity of the internal rotation lag sign was very high (97% (95% CI 82% to 100%)), although the evaluation was by the test’s originators (Hertel 1996) and, as with the passive compression test for labral lesions, independent verification would be highly desirable.        

The degree to which specific localization of lesions (and thus tests with high specificity) is necessary depends upon the therapeutic approach. For example, a diagnosis of impingement is sufficient to implement a programme of exercises which aims to centre the humeral head in the glenoid. On the other hand, administration of localized massage such as deep transverse friction (Cyriax 1984) would call for a tendon-specific diagnosis. In fact, there were no strong candidates for diagnosing impingement per se, and it may be that greater emphasis should be placed on making this diagnosis by excluding other main causes of shoulder pain such as frozen shoulder. Regarding specific rotator cuff tendons, resisted lateral rotation from neutral rotation, a conventional test for any disease of infraspinatus, had not only very high specificity (95% (95% CI 92% to 96%)) but also high sensitivity (94% (95% CI 87% to 98%)); likewise resisted medial rotation from neutral rotation, with a specificity of 99% (95% CI 97% to 100%)) and sensitivity of 96% (95% CI 78% to 100%) (Iagnocco 2003). There was no test which appeared to be equivalently useful for ruling in any disease of supraspinatus, but the empty can test appeared very useful for ruling it out (Iagnocco 2003; Naredo 2002) with sensitivities of 94% (95% CI 91% to 97%)) and 96% (95%CI 79% to100%) for an undefined test and a standard test, respectively.

Assessments of diagnostic test accuracy are only meaningful for tests which are replicable in different target users' hands. Thus between-tester reliability is a critical consideration. Few of the included studies (Calis 2000; Kim 2001; Michener 2009; Razmjou 2004) addressed this aspect, however. It is noteworthy that the sole test on which there was 'very good' agreement was novel, and reported by its originators, whom one would expect to be highly proficient in its application and interpretation. Likewise, of the two tests for which there was 'good' agreement, one was a novel test, and reported by its originators.

Authors' conclusions

Implications for practice

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. Our discussion has given an indication of an approach that may be tentatively adopted; but it must be emphasized that this is very provisional.

Implications for research

Diagnostic test accuracy research should be approached with the same rigour as randomised controlled trials. Weak, often retrospective, designs, coupled with poor reporting, are prevalent; and it is cause for concern that not one of the 14 included studies published between 2004 and the present make explicit reference to STARD, the Standards for Reporting Studies of Diagnostic Accuracy, which were simultaneously published in seven journals in 2003 (Bossuyt 2003) and have been published in eight journals since. Editors should make compliance with these standards obligatory for diagnostic test accuracy research.

Another critical issue is the non-standard way in which tests are performed and interpreted across studies since (despite the large number of studies in the field) this hinders synthesis of the evidence and/or clinical applicability. Where possible, trialists should revisit the primary source in order to ensure that their perception of the test complies with the original description, because the descriptions in many secondary or tertiary sources, both 'how to do it' literature and reports of diagnostic test accuracy studies, are idiosyncratic.

Especially useful for primary care would be studies independently verifying the screening capabilities of the passive compression test for any labral lesion and the internal rotation lag sign for any tear of subscapularis, and to identify simple, accurate screening tests for full thickness tears of the rotator cuff, the posterosuperior rotator cuff in general, supraspinatus and infraspinatus. A test specific to subacromial impingement syndrome is still elusive, as is a test specific to any disease of the supraspinatus; and studies verifying the diagnostic accuracy of resisted lateral and medial rotation for any disease of infraspinatus and subscapularis are required.

Finally, investigators should consider conducting formal reliability studies within the context of, or alongside, diagnostic test accuracy studies: this important aspect is often overlooked.

Acknowledgements

We are grateful to the following for helpful feedback about the review: Lotty Hooft, James Robertson and Cathie Sherrington. We thank Lindsey Elstub and Joanne Elliott for their editorial help and support during the preparation of the review. We are grateful to Amy Kavanagh for obtaining copies of dozens of study reports and for some data entry of reference citations and trial characteristics.

We thank Riekie de Vet for her helpful comments on the first drafts of the review protocol and to her and Danielle van der Windt for sharing their protocol with us. We thank Riekie de Vet and Lesley Gillespie for their support during the editorial review process. We thank the following for helpful feedback at editorial review: Riekie de Vet, Bill Gillespie, Lesley Gillespie, Petra Macaskill, Rob Scholten and Janet Wale.

Data

Presented below are all the data for all of the tests entered into the review.

Table Tests. Data tables by test
TestNo. of studiesNo. of participants
1 Target condition: SIS. Index test: combination of ALL 7 tests +ve (see table 7).1125
2 Target condition: SIS. Index test: combination of Hawkins' test AND Neer's sign (modified procedure) +ve.185
3 Target condition: SIS. Index test: combination of Hawkins' test OR Neer's sign (modified procedure) +ve.185
4 Target condition: SIS. Index test: drop arm test (modified interpretation).1125
5 Target condition: SIS. Index test: Gum-turn test (novel)1120
6 Target condition: SIS. Index test:. Hawkins' test (standard).2210
7 Target condition: SIS. Index test: Neer's sign (standard).1125
8 Target condition: SIS. Index test: Neer's sign (modified procedure).185
9 Target condition: SIS. Index test: painful arc test (standard).1125
10 Target condition: SIS. Index test: passive horizontal adduction (modified interpretation).1125
11 Target condition: SIS. Index test: Speed's test (modified interpretation).1125
12 Target condition: SIS. Index test: Yergason's test (modified interpretation).1125
13 Target condition: SIS (SA-SD bursitis). Index test: combination of Hawkins' test, Neer's sign, 'Yocum's (impingement) test' (overall criterion for +ve result not given).131
14 Target condition: SIS versus internal impingement, differentiation. Index test: internal rotation resistance strength test (novel).1110
15 Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: standard).1100
16 Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: modified procedure).1100
17 Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) OR Neer's sign (modified procedure, modified interpretation) +ve.185
18 Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) AND Neer's sign (modified procedure,modified interpretation) +ve.185
19 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation).1200
20 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation).1200
21 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation).1200
22 Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation).1200
23 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation).1202
24 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation).1200
25 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation).1200
26 Target condition: rotator cuff, FTT or PTT of. Index test: full can test for weakness ± pain (standard).1200
27 Target condition: rotator cuff, FTT or PTT of. Index test: Hawkins' test (modified interpretation).185
28 Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement sign' (no reference or details given).132
29 Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement test' (no reference or details given).132
30 Target condition: rotator cuff, FTT or PTT of. Index test: Neer's sign (modified procedure, modified interpretation).185
31 Target condition: rotator cuff, PTT or tendinitis of. Index test: empty can test for pain WITHOUT weakness (modified interpretation).150
32 Target condition: rotator cuff, FTT of. Index test: empty can test for pain ± weakness (modified interpretation).1200
33 Target condition: rotator cuff, FTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation).1200
34 Target condition: rotator cuff, FTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation).1200
35 Target condition: rotator cuff, FTT of. Index test: empty can test for weakness ± pain (modified interpretation).2250
36 Target condition: rotator cuff, FTT of. Index test: full can test for pain ± weakness (modified interpretation).1200
37 Target condition: rotator cuff, FTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation).1200
38 Target condition: rotator cuff, FTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation).1200
39 Target condition: rotator cuff, FTT of. Index test: full can test for weakness ± pain (modified interpretation).1200
40 Target condition: rotator cuff, FTT of. Index test: 'impingement sign' (no reference or details given).132
41 Target condition: rotator cuff, FTT of. Index test: 'impingement test' (no reference or details given).132
42 Target condition: rotator cuff, FTT of. Index test: rent test (standard).1109
43 Target condition: rotator cuff, FTT of, massive or large. Index test: empty can test for weakness ± pain (modified interpretation).150
44 Target condition: rotator cuff, PTT of. Index test: 'Impingement sign' (no reference or details given).132
45 Target condition: rotator cuff, PTT of. Index test: 'Impingement test' (no reference or details given).132
46 Target condition: rotator cuff, postero-superior (supraspinatus AND infraspinatus), FTT of. Index test: Gum-turn test (novel).1120
47 Target condition: rotator cuff, postero-superior, FTT or PTT of. Index test: drop sign (novel).187
48 Target condition: rotator cuff, postero-superior, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation).187
49 Target condition: rotator cuff, postero-superior, FTT or PTT of. Index test: external rotation lag sign (novel).187
50 Target condition: rotator cuff, postero-superior, FTT of. Index test: drop sign (modified interpretation).146
51 Target condition: rotator cuff, postero-superior, FTT of. Index test: external rotation lag sign (modified interpretation).146
52 Target condition: rotator cuff, postero-superior, FTT of. Index test: Gum-turn test (novel).1120
53 Target condition: rotator cuff, FTT, multiple- versus single-tendon. Index test: active abduction range (novel).196
54 Target condition: supraspinatus, any disease of, including calcification. Index test: empty can test (no reference or details given).1528
55 Target condition: supraspinatus, FTT, degeneration or tendinitis,of. Index test: Hawkins' test (modified procedure, modified interpretation).173
56 Target condition: supraspinatus, FTT, PTT or tendinitis,of. Index test: empty can test for pain AND/OR weakness (standard).126
57 Target condition: supraspinatus, FTT or degeneration of. Index test: Hawkins' test (modified procedure, modified interpretation).173
58 Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation).1160
59 Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness ± pain (standard).2191
60 Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness (< grade 3) ± pain.(modified interpretation)1160
61 Target condition: supraspinatus, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation).1160
62 Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness (< grade 3) ± pain (modified interpretation).1160
63 Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness ± pain (standard).1160
64 Target condition: supraspinatus, FTT of. Index test: drop arm test (standard).1125
65 Target condition: supraspinatus, FTT of. Index test: empty can test for pain ± weakness (modified interpretation).1143
66 Target condition: supraspinatus, FTT of. Index test: empty can test for pain AND/OR weakness (modified interpretation).1143
67 Target condition: supraspinatus, FTT of. Index test: empty can test for weakness ± pain (standard).1143
68 Target condition: supraspinatus, FTT of. Index test: full can test for pain ± weakness (modified interpretation).1143
69 Target condition: supraspinatus, FTT of. Index test: full can test for pain AND/OR weakness (modified interpretation).1143
70 Target condition: supraspinatus, FTT of. Index test: full can test for weakness ± pain (standard).1143
71 Target condition: supraspinatus, FTT of. Index test: Gum-turn test (novel).1120
72 Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified interpretation).1125
73 Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified procedure, modified interpretation).173
74 Target condition: supraspinatus, FTT of. Index test: Neer's sign (modified interpretation).1125
75 Target condition: supraspinatus, FTT of. Index test: painful arc test (modified interpretation).1125
76 Target condition: supraspinatus, FTT of. Index test: passive horizontal adduction (standard).1125
77 Target condition: supraspinatus, FTT of. Index test: Speed's test (modified interpretation).1125
78 Target condition: supraspinatus, FTT of. Index test: Yergason's test (modified interpretation).1125
79 Target condition: supraspinatus, FTT of, full-width. Index test: external rotation lag sign (standard).1189
80 Target condition: supraspinatus, isolated PTT of. Index test: external rotation lag sign (standard).1222
81 Target condition: supraspinatus, tendinitis of. Index test: empty can test for pain WITHOUT weakness (standard).131
82 Target condition: infraspinatus, any disease of, including calcification. Index test: resisted lateral rotation from neutral rotation (no reference or details given).1528
83 Target condition: infraspinatus, FTT, PPT or tendinitis,of. Index test: Patte's test for pain AND/OR weakness (standard).131
84 Target condition: infraspinatus, FTT or PTT of. Index test: Patte's test for weakness ± pain (standard).131
85 Target condition: infraspinatus, FTT or PTT of. Index test: resisted lateral rotation from neutral rotation for weakness < grade 3 ± pain (modified interpretation).1160
86 Target condition: infraspinatus, tendinitis of. Index test: Patte's test for pain WITHOUT weakness (standard).131
87 Target condition: subscapularis, any disease of, including calcification. Index test: resisted medial rotation from neutral rotation (no reference or details given).1528
88 Target condition: subscapularis, any tear or tendinitis of. Index test: combination of lift-off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given).131
89 Target condition: subscapularis, any tear of. Index test: bear-hug test (novel)168
90 Target condition: subscapularis, any tear of. Index test: belly-press test (standard)168
91 Target condition: subscapularis, any tear of. Index test: internal rotation lag sign (novel).153
92 Target condition: subscapularis, any tear of. Index test: lift-off test (Gerber 1991: modified interpretation).163
93 Target condition: subscapularis, any tear of. Index test: lift-off test (Gerber 1991: probably standard)153
94 Target condition: subscapularis, any tear of. Index test: Napoleon test (Burkhart 2002: standard).168
95 Target condition: subscapularis, any tear of. Index test:: lift-off test with force for weakness < grade 2 ± pain (modified procedure, modified interpretation).1159
96 Target condition: subscapularis, any tear of. Index test: combination of lift-off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given).131
97 Target condition: subscapularis, complete tear of. Index test: bear-hug test (novel).168
98 Target condition: subscapularis, complete tear of. Index test: belly-press test (modified procedure).168
99 Target condition: subscapularis, complete tear of. Index test: lift-off test (Gerber 1991: modified interpretation).163
100 Target condition: subscapularis, complete tear of. Index test: Napoleon test (Burkhart 2002: standard).168
101 Target condition: subscapularis, FTT of. Index test: internal rotation lag sign (modified interpretation).146
102 Target condition: subscapularis, partial tear of. Index test: bear-hug test (novel).165
103 Target condition: subscapularis, partial tear of. Index test: belly-press test (modified procedure).165
104 Target condition: subscapularis, partial tear of. Index test: lift-off test (Gerber 1991: modified interpretation).160
105 Target condition: subscapularis, partial tear of. Index test: Napoleon test (Burkhart 2002: standard).165
106 Target condition: subscapularis, tendinitis of. Index test: combination of lift-off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given).131
107 Target condition: LHB, tear or tendinitis of. Index test: Speed's test (standard).1528
108 Target condition: LHB, tear or tendinitis of. Index test: active compression test (standard)1101
109 Target condition: LHB, tear or tendinitis of. Index test: anterior slide test (modified procedure, modified interpretation).1101
110 Target condition: LHB, tear or tendinitis of. Index test: bear-hug test (modified interpretation)1101
111 Target condition: LHB, tear or tendinitis of. Index test: belly-press test (standard)1101
112 Target condition: LHB, tear or tendinitis of. Index test: modified dynamic labral shear (novel)1101
113 Target condition: LHB, tear or tendinitis of. Index test: Speed's test (modified procedure)1101
114 Target condition: LHB, tear or tendinitis of. Index test: upper-cut test (novel)1101
115 Target condition: LHB, tear or tendinitis of. Index test: Yergason's test (modified procedure)1101
116 Target condition: LHB, tear or tendinitis of. Index test: combination of Yergason's test and Gilcreest's test (modified procedure, modified interpretation).(Overall criterion for +ve result not given.)131
117 Target condition: labrum, any tear of. Index test: active compression test (novel).1206
118 Target condition: labrum, any tear of. Index test: active compression test (modified interpretation).165
119 Target condition: labrum, any tear,of. Index test: crank test (novel/standard).2127
120 Target condition: labrum, any tear,of. Index test: 'impingement sign' (no reference or details given).132
121 Target condition: labrum, any tear,of. Index test: 'impingement test' (no reference or details given).132
122 Target condition: labrum, any SLAP lesion of. Index test: active compression test (modified interpretation).1101
123 Target condition: labrum, any SLAP lesion of. Index test: anterior apprehension test at 90° for pain (Krishnan 2004: modified interpretation).160
124 Target condition: labrum, any SLAP lesion,of. Index test: anterior release test (Gross 1997: modified interpretation).160
125 Target condition: labrum, any SLAP lesion of. Index test: anterior slide test (modified procedure, modified interpretation).1101
126 Target condition: labrum, any SLAP lesion of. Index test: bear-hug test (modified interpretation).1101
127 Target condition: labrum, any SLAP lesion of. Index test: belly-press test (modified interpretation).1101
128 Target condition: labrum, any SLAP lesion of. Index test: crank test (Liu 1996b: modified procedure, modified interpretation).160
129 Target condition: labrum, any SLAP lesion of. Index test: modified dynamic labral shear (novel).1101
130 Target condition: labrum, any SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation).160
131 Target condition: labrum, any SLAP lesion of. Index test: passive compression test (novel).161
132 Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation).1101
133 Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified interpretation).160
134 Target condition: labrum, any SLAP lesion of. Index test: upper cut test (novel).1101
135 Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified interpretation).160
136 Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified procedure, modified interpretation).1101
137 Target condition: labrum, type II-IV SLAP lesion of. Index test: active compression test (modified interpretation).1254
138 Target condition: labrum, type II-IV SLAP lesion of. Index test: anterior slide test (modified procedure).1254
139 Target condition: labrum, type II-IV SLAP lesion of. Index test: combination of active compression test (modified interpretation) OR passive distraction test (standard).1254
140 Target condition: labrum, type II-IV SLAP lesion of. Index test: passive compression test (novel, modified interpretation).161
141 Target condition: labrum, type II-IV SLAP lesion of. Index test: passive distraction test (standard).1254
142 Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 2).1146
143 Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 1,2).1132
144 Target condition: labrum, type II SLAP lesion of. Index test: anterior apprehension test at 90° for pain OR apprehension (Rowe 1981: modified interpretation).1146
145 Target condition: labrum, type II SLAP lesion of. Index test: anterior slide test (modified interpretation).2278
146 Target condition: labrum, type II SLAP lesion of. Index test: biceps load test II (novel/standard).2273
147 Target condition: labrum, type II SLAP lesion of. Index test: compression-rotation test (modified interpretation).1146
148 Target condition: labrum, type II SLAP lesion of. Index test: crank test (modified procedure, modified interpretation).1132
149 Target condition: labrum, type II SLAP lesion of. Index test: Hawkins' test (modified procedure, modified interpretation).1132
150 Target condition: labrum, type II SLAP lesion of. Index test: modified relocation test for posterosuperior glenoid impingement (modified interpretation).1132
151 Target condition: labrum, type II SLAP lesion of. Index test: Neer's sign (modified procedure, modified interpretation).1132
152 Target condition: labrum, type II SLAP lesion of. Index test: pain provocation test (modified interpretation).1132
153 Target condition: labrum, type II SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation).1146
154 Target condition: labrum, type II SLAP lesion of. Index test: relocation test for pain OR apprehension (modified interpretation).1146
155 Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified interpretation).1132
156 Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation).1146
157 Target condition: labrum, type II SLAP lesion of. Index test: Whipple's test (modified interpretation).1146
158 Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 2).1146
159 Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 1,2).1132
160 Target condition: multiple (LHB tendinitis/LHB avulsion/SLAP lesion, any). Index test: Speed's test (modified procedure, modified interpretation 1).146
161 Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Speed's test (modified procedure, modified interpretation 1,2).150
162 Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Yergason's test (modified interpretation 1,2).149
163 Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Empty can test (modified interpretation).155
164 Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Hawkins' test (standard).155
165 Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Neer's sign (modified procedure).155
166 Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: painful arc test (standard).145
167 Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability) Index test: resisted lateral rotation from neutral rotation for weakness ± pain (modified interpretation 1,2).155
168 Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: combination of 3 or more tests +ve (see table 11).155
169 Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Hawkins' test (modified interpretation).150
170 Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Neer's sign (modified interpretation).150
Test 1.

Target condition: SIS. Index test: combination of ALL 7 tests +ve (see table 7)..

Test 2.

Target condition: SIS. Index test: combination of Hawkins' test AND Neer's sign (modified procedure) +ve..

Test 3.

Target condition: SIS. Index test: combination of Hawkins' test OR Neer's sign (modified procedure) +ve..

Test 4.

Target condition: SIS. Index test: drop arm test (modified interpretation)..

Test 5.

Target condition: SIS. Index test: Gum-turn test (novel).

Test 6.

Target condition: SIS. Index test:. Hawkins' test (standard)..

Test 7.

Target condition: SIS. Index test: Neer's sign (standard)..

Test 8.

Target condition: SIS. Index test: Neer's sign (modified procedure)..

Test 9.

Target condition: SIS. Index test: painful arc test (standard)..

Test 10.

Target condition: SIS. Index test: passive horizontal adduction (modified interpretation)..

Test 11.

Target condition: SIS. Index test: Speed's test (modified interpretation)..

Test 12.

Target condition: SIS. Index test: Yergason's test (modified interpretation)..

Test 13.

Target condition: SIS (SA-SD bursitis). Index test: combination of Hawkins' test, Neer's sign, 'Yocum's (impingement) test' (overall criterion for +ve result not given)..

Test 14.

Target condition: SIS versus internal impingement, differentiation. Index test: internal rotation resistance strength test (novel)..

Test 15.

Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: standard)..

Test 16.

Target condition: rotator cuff, any disease of. Index test: relocation test for pain (Jobe 1989: modified procedure)..

Test 17.

Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) OR Neer's sign (modified procedure, modified interpretation) +ve..

Test 18.

Target condition: rotator cuff, FTT or PTT of. Index test: combination of Hawkins' test (modified interpretation) AND Neer's sign (modified procedure,modified interpretation) +ve..

Test 19.

Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation)..

Test 20.

Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation)..

Test 21.

Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation)..

Test 22.

Target condition: rotator cuff, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation)..

Test 23.

Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation)..

Test 24.

Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation)..

Test 25.

Target condition: rotator cuff, FTT or PTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation)..

Test 26.

Target condition: rotator cuff, FTT or PTT of. Index test: full can test for weakness ± pain (standard)..

Test 27.

Target condition: rotator cuff, FTT or PTT of. Index test: Hawkins' test (modified interpretation)..

Test 28.

Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement sign' (no reference or details given)..

Test 29.

Target condition: rotator cuff, FTT or PTT of. Index test: 'Impingement test' (no reference or details given)..

Test 30.

Target condition: rotator cuff, FTT or PTT of. Index test: Neer's sign (modified procedure, modified interpretation)..

Test 31.

Target condition: rotator cuff, PTT or tendinitis of. Index test: empty can test for pain WITHOUT weakness (modified interpretation)..

Test 32.

Target condition: rotator cuff, FTT of. Index test: empty can test for pain ± weakness (modified interpretation)..

Test 33.

Target condition: rotator cuff, FTT of. Index test: empty can test for pain OR weakness (ONE ONLY) (modified interpretation)..

Test 34.

Target condition: rotator cuff, FTT of. Index test: empty can test for pain AND weakness (BOTH) (modified interpretation)..

Test 35.

Target condition: rotator cuff, FTT of. Index test: empty can test for weakness ± pain (modified interpretation)..

Test 36.

Target condition: rotator cuff, FTT of. Index test: full can test for pain ± weakness (modified interpretation)..

Test 37.

Target condition: rotator cuff, FTT of. Index test: full can test for pain OR weakness (ONE ONLY) (modified interpretation)..

Test 38.

Target condition: rotator cuff, FTT of. Index test: full can test for pain AND weakness (BOTH) (modified interpretation)..

Test 39.

Target condition: rotator cuff, FTT of. Index test: full can test for weakness ± pain (modified interpretation)..

Test 40.

Target condition: rotator cuff, FTT of. Index test: 'impingement sign' (no reference or details given)..

Test 41.

Target condition: rotator cuff, FTT of. Index test: 'impingement test' (no reference or details given)..

Test 42.

Target condition: rotator cuff, FTT of. Index test: rent test (standard)..

Test 43.

Target condition: rotator cuff, FTT of, massive or large. Index test: empty can test for weakness ± pain (modified interpretation)..

Test 44.

Target condition: rotator cuff, PTT of. Index test: 'Impingement sign' (no reference or details given)..

Test 45.

Target condition: rotator cuff, PTT of. Index test: 'Impingement test' (no reference or details given)..

Test 46.

Target condition: rotator cuff, postero-superior (supraspinatus AND infraspinatus), FTT of. Index test: Gum-turn test (novel)..

Test 47.

Target condition: rotator cuff, postero-superior, FTT or PTT of. Index test: drop sign (novel)..

Test 48.

Target condition: rotator cuff, postero-superior, FTT or PTT of. Index test: empty can test for weakness ± pain (modified interpretation)..

Test 49.

Target condition: rotator cuff, postero-superior, FTT or PTT of. Index test: external rotation lag sign (novel)..

Test 50.

Target condition: rotator cuff, postero-superior, FTT of. Index test: drop sign (modified interpretation)..

Test 51.

Target condition: rotator cuff, postero-superior, FTT of. Index test: external rotation lag sign (modified interpretation)..

Test 52.

Target condition: rotator cuff, postero-superior, FTT of. Index test: Gum-turn test (novel)..

Test 53.

Target condition: rotator cuff, FTT, multiple- versus single-tendon. Index test: active abduction range (novel)..

Test 54.

Target condition: supraspinatus, any disease of, including calcification. Index test: empty can test (no reference or details given)..

Test 55.

Target condition: supraspinatus, FTT, degeneration or tendinitis,of. Index test: Hawkins' test (modified procedure, modified interpretation)..

Test 56.

Target condition: supraspinatus, FTT, PTT or tendinitis,of. Index test: empty can test for pain AND/OR weakness (standard)..

Test 57.

Target condition: supraspinatus, FTT or degeneration of. Index test: Hawkins' test (modified procedure, modified interpretation)..

Test 58.

Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for pain ± weakness (modified interpretation)..

Test 59.

Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness ± pain (standard)..

Test 60.

Target condition: supraspinatus, FTT or PTT of. Index test: empty can test for weakness (< grade 3) ± pain.(modified interpretation).

Test 61.

Target condition: supraspinatus, FTT or PTT of. Index test: full can test for pain ± weakness (modified interpretation)..

Test 62.

Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness (< grade 3) ± pain (modified interpretation)..

Test 63.

Target condition: supraspinatus, FTT or PTT of. Index test: full can test for weakness ± pain (standard)..

Test 64.

Target condition: supraspinatus, FTT of. Index test: drop arm test (standard)..

Test 65.

Target condition: supraspinatus, FTT of. Index test: empty can test for pain ± weakness (modified interpretation)..

Test 66.

Target condition: supraspinatus, FTT of. Index test: empty can test for pain AND/OR weakness (modified interpretation)..

Test 67.

Target condition: supraspinatus, FTT of. Index test: empty can test for weakness ± pain (standard)..

Test 68.

Target condition: supraspinatus, FTT of. Index test: full can test for pain ± weakness (modified interpretation)..

Test 69.

Target condition: supraspinatus, FTT of. Index test: full can test for pain AND/OR weakness (modified interpretation)..

Test 70.

Target condition: supraspinatus, FTT of. Index test: full can test for weakness ± pain (standard)..

Test 71.

Target condition: supraspinatus, FTT of. Index test: Gum-turn test (novel)..

Test 72.

Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified interpretation)..

Test 73.

Target condition: supraspinatus, FTT of. Index test: Hawkins' test (modified procedure, modified interpretation)..

Test 74.

Target condition: supraspinatus, FTT of. Index test: Neer's sign (modified interpretation)..

Test 75.

Target condition: supraspinatus, FTT of. Index test: painful arc test (modified interpretation)..

Test 76.

Target condition: supraspinatus, FTT of. Index test: passive horizontal adduction (standard)..

Test 77.

Target condition: supraspinatus, FTT of. Index test: Speed's test (modified interpretation)..

Test 78.

Target condition: supraspinatus, FTT of. Index test: Yergason's test (modified interpretation)..

Test 79.

Target condition: supraspinatus, FTT of, full-width. Index test: external rotation lag sign (standard)..

Test 80.

Target condition: supraspinatus, isolated PTT of. Index test: external rotation lag sign (standard)..

Test 81.

Target condition: supraspinatus, tendinitis of. Index test: empty can test for pain WITHOUT weakness (standard)..

Test 82.

Target condition: infraspinatus, any disease of, including calcification. Index test: resisted lateral rotation from neutral rotation (no reference or details given)..

Test 83.

Target condition: infraspinatus, FTT, PPT or tendinitis,of. Index test: Patte's test for pain AND/OR weakness (standard)..

Test 84.

Target condition: infraspinatus, FTT or PTT of. Index test: Patte's test for weakness ± pain (standard)..

Test 85.

Target condition: infraspinatus, FTT or PTT of. Index test: resisted lateral rotation from neutral rotation for weakness < grade 3 ± pain (modified interpretation)..

Test 86.

Target condition: infraspinatus, tendinitis of. Index test: Patte's test for pain WITHOUT weakness (standard)..

Test 87.

Target condition: subscapularis, any disease of, including calcification. Index test: resisted medial rotation from neutral rotation (no reference or details given)..

Test 88.

Target condition: subscapularis, any tear or tendinitis of. Index test: combination of lift-off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given)..

Test 89.

Target condition: subscapularis, any tear of. Index test: bear-hug test (novel).

Test 90.

Target condition: subscapularis, any tear of. Index test: belly-press test (standard).

Test 91.

Target condition: subscapularis, any tear of. Index test: internal rotation lag sign (novel)..

Test 92.

Target condition: subscapularis, any tear of. Index test: lift-off test (Gerber 1991: modified interpretation)..

Test 93.

Target condition: subscapularis, any tear of. Index test: lift-off test (Gerber 1991: probably standard).

Test 94.

Target condition: subscapularis, any tear of. Index test: Napoleon test (Burkhart 2002: standard)..

Test 95.

Target condition: subscapularis, any tear of. Index test:: lift-off test with force for weakness < grade 2 ± pain (modified procedure, modified interpretation)..

Test 96.

Target condition: subscapularis, any tear of. Index test: combination of lift-off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given)..

Test 97.

Target condition: subscapularis, complete tear of. Index test: bear-hug test (novel)..

Test 98.

Target condition: subscapularis, complete tear of. Index test: belly-press test (modified procedure)..

Test 99.

Target condition: subscapularis, complete tear of. Index test: lift-off test (Gerber 1991: modified interpretation)..

Test 100.

Target condition: subscapularis, complete tear of. Index test: Napoleon test (Burkhart 2002: standard)..

Test 101.

Target condition: subscapularis, FTT of. Index test: internal rotation lag sign (modified interpretation)..

Test 102.

Target condition: subscapularis, partial tear of. Index test: bear-hug test (novel)..

Test 103.

Target condition: subscapularis, partial tear of. Index test: belly-press test (modified procedure)..

Test 104.

Target condition: subscapularis, partial tear of. Index test: lift-off test (Gerber 1991: modified interpretation)..

Test 105.

Target condition: subscapularis, partial tear of. Index test: Napoleon test (Burkhart 2002: standard)..

Test 106.

Target condition: subscapularis, tendinitis of. Index test: combination of lift-off test and resisted medial rotation from neutral rotation (overall criterion for +ve result not given)..

Test 107.

Target condition: LHB, tear or tendinitis of. Index test: Speed's test (standard)..

Test 108.

Target condition: LHB, tear or tendinitis of. Index test: active compression test (standard).

Test 109.

Target condition: LHB, tear or tendinitis of. Index test: anterior slide test (modified procedure, modified interpretation)..

Test 110.

Target condition: LHB, tear or tendinitis of. Index test: bear-hug test (modified interpretation).

Test 111.

Target condition: LHB, tear or tendinitis of. Index test: belly-press test (standard).

Test 112.

Target condition: LHB, tear or tendinitis of. Index test: modified dynamic labral shear (novel).

Test 113.

Target condition: LHB, tear or tendinitis of. Index test: Speed's test (modified procedure).

Test 114.

Target condition: LHB, tear or tendinitis of. Index test: upper-cut test (novel).

Test 115.

Target condition: LHB, tear or tendinitis of. Index test: Yergason's test (modified procedure).

Test 116.

Target condition: LHB, tear or tendinitis of. Index test: combination of Yergason's test and Gilcreest's test (modified procedure, modified interpretation).(Overall criterion for +ve result not given.).

Test 117.

Target condition: labrum, any tear of. Index test: active compression test (novel)..

Test 118.

Target condition: labrum, any tear of. Index test: active compression test (modified interpretation)..

Test 119.

Target condition: labrum, any tear,of. Index test: crank test (novel/standard)..

Test 120.

Target condition: labrum, any tear,of. Index test: 'impingement sign' (no reference or details given)..

Test 121.

Target condition: labrum, any tear,of. Index test: 'impingement test' (no reference or details given)..

Test 122.

Target condition: labrum, any SLAP lesion of. Index test: active compression test (modified interpretation)..

Test 123.

Target condition: labrum, any SLAP lesion of. Index test: anterior apprehension test at 90° for pain (Krishnan 2004: modified interpretation)..

Test 124.

Target condition: labrum, any SLAP lesion,of. Index test: anterior release test (Gross 1997: modified interpretation)..

Test 125.

Target condition: labrum, any SLAP lesion of. Index test: anterior slide test (modified procedure, modified interpretation)..

Test 126.

Target condition: labrum, any SLAP lesion of. Index test: bear-hug test (modified interpretation)..

Test 127.

Target condition: labrum, any SLAP lesion of. Index test: belly-press test (modified interpretation)..

Test 128.

Target condition: labrum, any SLAP lesion of. Index test: crank test (Liu 1996b: modified procedure, modified interpretation)..

Test 129.

Target condition: labrum, any SLAP lesion of. Index test: modified dynamic labral shear (novel)..

Test 130.

Target condition: labrum, any SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation)..

Test 131.

Target condition: labrum, any SLAP lesion of. Index test: passive compression test (novel)..

Test 132.

Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation)..

Test 133.

Target condition: labrum, any SLAP lesion of. Index test: Speed's test (modified interpretation)..

Test 134.

Target condition: labrum, any SLAP lesion of. Index test: upper cut test (novel)..

Test 135.

Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified interpretation)..

Test 136.

Target condition: labrum, any SLAP lesion of. Index test: Yergason's test (modified procedure, modified interpretation)..

Test 137.

Target condition: labrum, type II-IV SLAP lesion of. Index test: active compression test (modified interpretation)..

Test 138.

Target condition: labrum, type II-IV SLAP lesion of. Index test: anterior slide test (modified procedure)..

Test 139.

Target condition: labrum, type II-IV SLAP lesion of. Index test: combination of active compression test (modified interpretation) OR passive distraction test (standard)..

Test 140.

Target condition: labrum, type II-IV SLAP lesion of. Index test: passive compression test (novel, modified interpretation)..

Test 141.

Target condition: labrum, type II-IV SLAP lesion of. Index test: passive distraction test (standard)..

Test 142.

Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 2)..

Test 143.

Target condition: labrum, type II SLAP lesion of. Index test: active compression test (modified interpretation 1,2)..

Test 144.

Target condition: labrum, type II SLAP lesion of. Index test: anterior apprehension test at 90° for pain OR apprehension (Rowe 1981: modified interpretation)..

Test 145.

Target condition: labrum, type II SLAP lesion of. Index test: anterior slide test (modified interpretation)..

Test 146.

Target condition: labrum, type II SLAP lesion of. Index test: biceps load test II (novel/standard)..

Test 147.

Target condition: labrum, type II SLAP lesion of. Index test: compression-rotation test (modified interpretation)..

Test 148.

Target condition: labrum, type II SLAP lesion of. Index test: crank test (modified procedure, modified interpretation)..

Test 149.

Target condition: labrum, type II SLAP lesion of. Index test: Hawkins' test (modified procedure, modified interpretation)..

Test 150.

Target condition: labrum, type II SLAP lesion of. Index test: modified relocation test for posterosuperior glenoid impingement (modified interpretation)..

Test 151.

Target condition: labrum, type II SLAP lesion of. Index test: Neer's sign (modified procedure, modified interpretation)..

Test 152.

Target condition: labrum, type II SLAP lesion of. Index test: pain provocation test (modified interpretation)..

Test 153.

Target condition: labrum, type II SLAP lesion of. Index test: palpation for bicipital groove tenderness (modified interpretation)..

Test 154.

Target condition: labrum, type II SLAP lesion of. Index test: relocation test for pain OR apprehension (modified interpretation)..

Test 155.

Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified interpretation)..

Test 156.

Target condition: labrum, type II SLAP lesion of. Index test: Speed's test (modified procedure, modified interpretation)..

Test 157.

Target condition: labrum, type II SLAP lesion of. Index test: Whipple's test (modified interpretation)..

Test 158.

Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 2)..

Test 159.

Target condition: labrum, type II SLAP lesion of. Index test: Yergason's test (modified interpretation 1,2)..

Test 160.

Target condition: multiple (LHB tendinitis/LHB avulsion/SLAP lesion, any). Index test: Speed's test (modified procedure, modified interpretation 1)..

Test 161.

Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Speed's test (modified procedure, modified interpretation 1,2)..

Test 162.

Target condition: multiple (LHB lesion, any/type II or IV SLAP lesion). Index test: Yergason's test (modified interpretation 1,2)..

Test 163.

Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Empty can test (modified interpretation)..

Test 164.

Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Hawkins' test (standard)..

Test 165.

Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: Neer's sign (modified procedure)..

Test 166.

Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: painful arc test (standard)..

Test 167.

Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability) Index test: resisted lateral rotation from neutral rotation for weakness ± pain (modified interpretation 1,2)..

Test 168.

Target condition: multiple (SA-SD bursitis/bursal side degeneration of supraspinatus ± other pathology of tendon or labrum ± instability). Index test: combination of 3 or more tests +ve (see table 11)..

Test 169.

Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Hawkins' test (modified interpretation)..

Test 170.

Target condition: multiple (SIS/rotator cuff tendinitis or tear). Index test: Neer's sign (modified interpretation)..

Appendices

Appendix 1. Search strategy for MEDLINE, EMBASE, CINAHL and AMED (OVID Web format): to November 2005

Index tests
Diagnostic tests of interest
  General terms associated with diagnostic tests
Diagnos$.mp. 
2Examin$.mp. 
3Man?euv$.mp. 
4Sign$.mp. 
5Test$.mp. 
6or / 1-5
  Named diagnostic tests
7Active compression.mp. 
8(Anterior adj (release or slide or apprehension)).mp. 
9(Biceps adj (load or tension)).mp. 
10Bicipital groove.mp. 
11Compression rotation.mp. 
12Crank.mp. 
13Drop arm.mp. 
14Empty can.mp. 
15External rotation.mp.
16External rotation lag.mp. 
17Full can.mp. 
18Gerber$.mp. 
19Hawkins.mp. 
20Hawkins Kennedy$.mp. 
21Impingement$.mp. 
22Infraspinatus.mp. 
23Internal rotation.mp. 
24Internal rotation resistance strength.mp. 
25IRRST.mp. 
26Jobe$.mp. 
27Lag.mp. 
28Lift off.mp. 
29Mimori$.mp. 
30Modified relocation.mp. 
31Neer$.mp. 
32O'Brien$.mp. 
33Pain provocation.mp. 
34Painful arc.mp. 
35Patte$.mp. 
36Physical.mp. 
37Posterior impingement.mp. 
38Relocation.mp. 
39Rent.mp. 
40Rotator cuff.mp. 
41SLAP.mp. 
42Snyder$.mp. 
43SLAPPrehension.mp. 
44Speed$.mp. 
45Subscapularis.mp.
46Yergason$.mp. 
47Yocum$.mp. 
48Zaslav$.mp. 
49Or / 7-48
  General terms associated with diagnostic tests combined with named diagnostic tests (and /)
50and / 6,49
Conditions of interest
51Arc.mp. 
52Bursitis.mp. 
53Impingement$.mp. 
54Lesion$.mp. 
55Patholog$.mp. 
56Tear$.mp. 
57Tend#nitis.mp. 
58Or / 51-57
  Structures at risk
59Biceps.mp.
60Bicipital.mp. 
61Glenoid.mp. 
62Infraspinatus.mp.
63Intraarticular.mp.
64Labr$.mp. 
65Rotator cuff.mp. 
66SA SD.mp. 
67Shoulder.mp. 
68Subacromial.mp. 
69Subdeltoid.mp. 
70Subscapular$.mp. 
71Subcoracoid.mp. 
72SLAP.mp.
73Teres minor.mp.
74Or / 59-73
  Classes of disorder combined with structures at risk (and / )
75and / 58,74
Authors of eponymous tests
76Crenshaw A$.au.
77Gerber C.au.
78Hawkins R.au.
79Jobe C$.au.
80Mimori K.au.
81Neer C$.au.
82O'Brien S$.au.
83Patte D.au.
84Snyder S$.au.
85Yergason R$.au.
86Yocum L$.au.
87Zaslav K$.au.
88Or / 76-87
  Authors combined with classes of disorder (and / )
89and / 88,58
  Authors combined with classes of disorder or structures at risk (and / )
90and / 88,74
  Authors combined with classes of disorder or structures at risk (or / )
91Or / 89,90
Diagnostic tests of interest combined with conditions of interest (and/)
92and / 50,75
Synthesis
93or / 91-92
94limit 93 to English language
95remove duplicates from 94

 

Appendix 2. Search strategy for MEDLINE, EMBASE and AMED (OVID Web format): 2005 to February 2010

Search Strategy run 15/02/2012:

--------------------------------------------------------------------------------
1 Diagnos$.mp. (3120783)
2 Examin$.mp. (2921664)
3 Man?euv$.mp. (35699)
4 Sign$.mp. (6361696)
5 Test$.mp. (3682306)
6  or/1-5 (11970722)
7  Active compression.mp. (312)
8  (Anterior adj (release or slide or apprehension)).mp. (368)
9  (Biceps adj (load or tension)).mp. (25)
10 Bicipital groove.mp. (187)
11 Compression rotation.mp. (41)
12  Crank.mp. (1153)
13 Drop arm.mp. (15)
14 Empty can.mp. (128)
15 External rotation.mp. (5940)
16 External rotation lag.mp. (16)
17 Full can.mp. (2648)
18 Gerber$.mp. (432)
19 Hawkins.mp. (566)
20 Hawkins Kennedy$.mp. (18)
21 Impingement$.mp. (7596)
22 Infraspinatus.mp. (1793)
23 Internal rotation.mp. (3969)
24 Internal rotation resistance strength.mp. (3)
25 IRRST.mp. (1)
26 Jobe$.mp. (150)
27 Lag.mp. (39297)
28 Lift off.mp. (662)
29 Mimori$.mp. (17)
30 Modified relocation.mp. (2)
31 Neer$.mp. (1309)
32 O'Brien$.mp. (1052)
33 Pain provocation.mp. (318)
34 Painful arc.mp. (81)
35 Patte$.mp. (1269379)
36 Physical.mp. (798454)
37 Posterior impingement.mp. (86)
38 Relocation.mp. (5150)
39 Rent.mp. (853)
40 Rotator cuff.mp. (10385)
41 SLAP.mp. (887)
42 Snyder$.mp. (1231)
43 SLAPPrehension.mp. (3)
44 Speed$.mp. (133045)
45 Subscapularis.mp. (1571)
46 Yergason$.mp. (24)
47 Yocum$.mp. (35)
48 Zaslav$.mp. (23)
49 or/7-48 (2202477)
50 and/6,49 (1286501)
51 Arc.mp. (20009)
52 Bursitis.mp. (4827)
53 Impingement$.mp. (7596)
54 Lesion$.mp. (915638)
55 Patholog$.mp. (790962)
56 Tear$.mp. (47604)
57 Tend#nitis.mp. (6231)
58 or/51-57 (1673209)
59 Biceps.mp. (12979)
60 Bicipital.mp. (613)
61 Glenoid.mp. (4590)
62 Infraspinatus.mp. (1793)
63 Intraarticular.mp. (9261)
64 Labr$.mp. (8170)
65 Rotator cuff.mp. (10385)
66 SA SD.mp. (25)
67 Shoulder.mp. (69932)
68 Subacromial.mp. (2381)
69 Subdeltoid.mp. (254)
70 Subscapular$.mp. (4647)
71 Subcoracoid.mp. (165)
72 SLAP.mp. (887)
73 Teres minor.mp. (366)
74 or/59-73 (100979)
75 and/58,74 (21410)
76 Crenshaw A$.au. (110)
77 Gerber C.au. (467)
78 Hawkins R.au. (336)
79 Jobe C$.au. (51)
80 Mimori K.au. (344)
81 Neer C$.au. (67)
82 O'Brien S$.au. (3422)
83 Patte D.au. (136)
84 Snyder S$.au. (2886)
85 Yergason R$.au. (0)
86 Yocum L$.au. (43)
87 Zaslav K$.au. (9)
88 or/76-87 (7870)
89 and/58,88 (657)
90 and/74,88 (628)
91 or/89-90 (968)
92 and/50,75 (8459)
93 or/91-92 (9221)
94 limit 93 to english language (7748)
95 limit 94 to yr="2005 -Current" (3000)
97 remove duplicates from 96 (1888)

Appendix 3. Quality assessment tool* and coding manual

*Adapted from Whiting (2003), Cochrane Diagnostic Reviewers Handbook version 0.3 (2005)

1. Was the spectrum of patients representative of the patients who will receive the test in practice? [To define spectrum bias]

Though clinical examination can be applied at all stages, our target population is the relatively unselected one in a primary care setting. This level of care may involve self-referral to a physiotherapist or, more usually, consultation with a general medical practitioner and possible cross-referral to a physiotherapist (often located in the community) or for imaging tests.

Clearly defined patient populations are unlikely in retrospective studies (Bossuyt 2003; van der Schouw 1995: see Footnotes for citations). 

Yes (Y)(a) The setting was primary care AND (b) the population was unselected but defined by age and gender AND (c) the reference test was non- or minimally invasive (physical tests plus local anaesthesia, ultrasound, MRI) AND (d) there was diagnostic uncertainty AND (e) the study was prospective and (f) recruitment was consecutive
No (N)

General factors

(a) There was no diagnostic uncertainty i.e. the study compared diseased- with healthy subjects (case-control study) OR (b) the study was not prospective OR (c) recruitment was not consecutive

Review-specific factors

(a) The setting was secondary or tertiary care OR (b) the population was clearly selected OR (c) the reference test was more than minimally invasive (surgery, arthroscopy, arthrography, MRA, CT)

Unclear (?)Insufficient information

2. Were selection criteria clearly described?

This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but considered important in the present context, in which pain may arise from a number of conditions other than the target condition.

Y(a) The selection criteria were clearly described (e.g. pain in the shoulder/ deltoid region, painful arc of motion, pain on overhead activities contributing to a clinical suspicion of impingement) AND (b) the exclusion criteria were clearly described (e.g. referred pain, gross restriction of movement, inflammatory disease, fracture)
N(a) The selection criteria were undescribed/ very unclearly described (e.g. “shoulder pain”) OR (b) the exclusion criteria were undescribed/ very unclearly described
?(a) The selection criteria were described AND (b) the exclusion criteria were described BUT (c) the description of the selection criteria was not completely clear (e.g. an unqualified statement such as, “patients with suspected impingement”) OR (d) the description of the exclusion criteria was not completely clear

3. Is the reference standard likely to correctly classify the target condition?

The generally recognised ‘gold’ standards are inapplicable to primary care. In general, the diagnostic tests that are applicable to primary care are less likely to correctly classify the target conditions. There two exceptions:  

    1. Since structural abnormalities of the rotator cuff are common in asymptomatic shoulders (MacDonald 2000; Milgrom 1995; Sher 1995), subacromial local anaesthesia may be more relevant to the symptoms of subacromial outlet impingement than diagnostic imaging, arthroscopy or open surgery (Dinnes 2003). However, since the site of anaesthesia would be critical, only subacromial bursal injections performed under guidance (fluoroscopic or ultrasonographic) will be accepted as a satisfactory reference test.

    2. Based on data from eight primary studies (N = 687) that used arthroscopy and/or open surgery as reference standards for full thickness rotator cuff tears in low-prevalence samples (range 3 to 37%; mean 25% (16.32 to 33.68%)), MRI had a pooled sensitivity of 0.90 (0.84 to 0.94) and specificity of 0.95 (0.92 to 0.96) (Dinnes 2003). On these grounds, MRI appears sufficiently accurate for use as a reference test for full thickness rotator cuff tears in settings (such as general primary care) where there is likely to be a low prevalence of this disorder

YThe reference standard was (a) arthroscopy OR (b) surgery OR (c) a combination of these OR (d) local anaesthesia of the subacromial bursa by guided injection OR (e) the target condition was full thickness rotator cuff tears in a sample with a likely low prevalence of this condition and the reference standard was MRI
NNot applicable
?The reference standard was (a) arthrography OR (b) subacromial local anaesthesia by ‘blind’ injection OR (c) MRA OR (d) MRI, except as defined above OR (e) ultrasonography

4. Is the time period between the reference standard and index test short enough to be reasonably sure that the target condition did not change between the two tests? [To identify disease progression bias]

 The acceptable interval would vary according to the average duration of symptoms.

YThe average interval was < (a) the average duration of symptoms OR (b) 1 month (whichever was the shorter)   
NThe conditions for ‘Y’ were expressly not met
?Insufficient information
5. Did the whole sample, or a random selection of the sample, receive verification using a reference standard? [To identify partial verification bias]
Y(a) All patients were accounted for as having undergone a reference test OR (b) a randomly selected sample of patients underwent a reference test. (Score ‘Y’ even if different reference tests were used)
N(a) Not all patients were accounted for as having undergone a reference test OR (b) a non-random selection of patients underwent a reference test
?Insufficient information
6. Did patients receive the same reference standard regardless of the index test result? [To identify differential verification bias]
Y(a) All patients underwent the same reference test OR (b) patients underwent different reference tests, but these were probably equivalent (e.g. arthroscopy and open surgery)
NPatients underwent different reference tests, which were probably not equivalent (e.g. arthrography and surgery)
?Insufficient information
7. Was the reference standard independent of the index test? [To identify incorporation bias]
YSelf explanatory
NSelf explanatory
?Self explanatory

8. Was the execution of the index test described in sufficient detail to permit replication of the test?

This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but included here because minor technical variations may affect physical tests’ outcomes, and interpretation may not be straightforward.

Y(a) A clear, detailed description was given enabling replication and interpretation OR (b) a reference was given to an adequate source of this information
N(a) The description lacked sufficient clarity to enable replication or interpretation AND (b) no reference was given to an adequate source of this information
?Not applicable

9. Was the execution of the reference standard described in sufficient detail to permit its replication?

This criterion is omitted from the Cochrane Diagnostic Reviewers’ Handbook (Cochrane Diagnostic Review Group 2005) but included here because the reference tests’ interpretation is ultimately subjective.

Y(a) A clear, detailed description was given enabling replication and interpretation OR (b) a reference was given to an adequate source of this information
N(a) The description lacked sufficient clarity to enable replication or interpretation AND (b) no reference was given to an adequate source of this information
?Not applicable

10. Were the index test results interpreted without knowledge of the results of the reference standard? [To identify test review bias?]

Clinical examination is highly subjective, and retrospective interpretation is a potential concern.

YThere was a clear statement of blinding
NThere does not appear to have been blinding
?The study was prospective and it is unclear whether there was blinding, but the index test preceded the reference standard. This does not apply to retrospective studies, in which both tests are likely to have been re-interpreted at the same time (Whiting 2003). In the absence of a clear statement of blinding, retrospective studies should be scored ‘N’

11. Were the reference standard results interpreted without knowledge of the results of the index test? [To identify diagnostic review bias]

Since the clinical relevance of some arthroscopic and surgical findings (e.g. glenoid labral lesions, rotator cuff fraying and even rotator cuff tears) is uncertain, and interpretation of the other reference tests is subjective, foreknowledge of the index test result has potential to influence interpretation.

YThere was a clear statement of blinding
NThere does not appear to have been blinding
?The reference test was stated to have been conducted “independently”

12. Were the same clinical data available when test results were interpreted as would be available when the test is used in practice?

Patients’ demographic (age/ sex) and historical data would normally be available when physical test results are interpreted.

YDemographic and historical data were available when index test/s was/were interpreted
NDemographic or historical data were not available when index test/s was/were interpreted
?Insufficient information
13. Were uninterpretable/ intermediate test results reported?
Y(a) The study was prospective AND (b) recruitment was consecutive AND (c) test results were reported for all initially included patients
N(a) Recruitment was not consecutive OR (b) test results were not reported for all initially included patients
?(a) Insufficient information OR (b) the study was not prospective (due to inconsistent reporting in clinical records, uninterpretable/ intermediate test results are sometimes not identified in retrospective studies (van der Schouw 1995))
14. Were withdrawals from the study explained?
Y(a) The study was prospective AND (b) recruitment was consecutive AND (c) withdrawals were reported AND (d) withdrawals were explained (ideally by a flow chart)
N(a) The study was not prospective OR (b) recruitment was not consecutive (unexplained non-recruitment equating to unreported/explained withdrawal) OR (c) withdrawals did not appear to have been reported OR (d) withdrawals were unexplained
?Insufficient information

Footnotes

Bossuyt 2003

Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, et al. The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Annals of Internal Medicine 2003;138(1):W1-12.

van der Schouw 1995  

van der Schouw YT, Van Dijk R, Verbeek AL. Problems in selecting the adequate patient population from existing data files for assessment studies of new diagnostic tests. Journal of Clinical Epidemiology 1995;48(3):417-22.

What's new

DateEventDescription
3 September 2014AmendedRepublished (September 2014) to include a Plain Language Summary.

Contributions of authors

Nigel Hanchard co-ordinated the production of the protocol and produced the first drafts at all stages of its development. All drafts were critically reviewed by Helen Handoll.

Nigel Hanchard co-ordinated the production of the review, screened search results, retrieved papers, performed study selection, designed the data extraction form, appraised quality and extracted data of all the included studies, wrote to authors for additional information, collated the review data, entered data into RevMan, analysed the data, interpreted the results, provided a clinical perspective, and drafted most of the writing of the review.

Mario Lenza screened search results, retrieved papers, performed study selection, appraised quality and extracted data of half of the included studies, gave key input into discussions on the structuring of the review, interpreted the results, provided a clinical perspective, and provided feedback on draft versions of the review.

Helen Handoll screened search results, retrieved papers, performed study selection, appraised quality and extracted data of half of the included studies, gave key input into discussions on the structuring of the review, interpreted the results, gave general advice, drafted select sections of the review and provided feedback on draft versions of the review.

Yemisi Takwoingi provided key input and feedback on review structure, data analysis and statistical methods, provided a methodological perspective, and gave feedback on draft versions of the review.

Nigel Hanchard is the guarantor of the review.

Declarations of interest

None known. Nigel Hanchard has recently completed a study on the diagnostic accuracy of physical tests for subacromial and internal shoulder impingement. The ‘reference’ test was ultrasound guided injection of local anaesthetic into the subacromial bursa and shoulder joint.

Sources of support

Internal sources

  • University of Teesside, Middlesbrough, UK.

External sources

  • Department of Health, UK.

Differences between protocol and review

Subsequent to the protocol we excluded studies with highly selected populations, such as overhead throwing athletes.

We did not contact all authors as planned in respect of missing key information such as 2 x 2 table data, study participant numbers and application of blinding. This is because we judged it unlikely that a request would be successful in obtaining reliable data. We left eight studies apparently drawing on the same database in Studies awaiting classification as it would require a major effort by ourselves and the study authors to clarify statistical and procedural inconsistencies in these studies.

Discrepancies in 2 x 2 tables due to rounding errors were a common finding. A rule was devised for the inclusion of data from studies with minor discrepancies in their 2 x 2 tables (Data extraction and management).

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Barth 2006

Clinical features and settings

Inclusion criteria [1] Arthroscopy
Exclusion criteria [1] Previous surgery on shoulder, [2] shoulder scheduled for capsular release and lysis of adhesions

Duration of symptoms Not reported
Previous treatments Not reported (although previous surgery on the shoulder was an exclusion)
Care setting Secondary or tertiary care

ParticipantsUSA (01-03/2004)
68 shoulders in 68 patients (72% male), mean age 45 years (SD 15, range 16-76)
Study designProspective, consecutive, cross sectional study
Target condition and reference standard(s)

Subscapularis tears, [1] any, [2] full, [3] partial
Arthroscopy

Procedure The patient was in the lateral decubitus position, with 5-10 lbs of balanced suspension with the arm in 20-30° abduction and 20° flexion. A senior author (SSB) undertook a complete arthroscopic examination  of the shoulder joint and subacromial space through a standard posterior portal. Subscapularis was evaluated with a 30° and a 70° arthroscope with an arthroscopy pump maintaining pressure at 60mmHg. The subscapularis insertion and its footprint were readily visualised by abduction and internal rotation (reference given to Lo 2003).   

Interpretation An area of ‘bare footprint’ indicated a partial or complete subscapularis lesion. The size of this lesion was assessed by measuring the superior-to-inferior length of bare footprint. This was then converted to a percentage of the complete insertion length by dividing it by 2.5cm (the mean superior-to-inferior length of subscapularis footprint).
Interval between index and reference test Not reported
Tester(s) An orthopaedic surgeon specializing in arthroscopic surgery and reconstructive procedures of the shoulder
Prevalence 29% (any subscapularis tears), 26% (partial thickness subscapularis tears in subgroup with complete tears excluded: see Note 1) 4.4% (complete subscapularis tears)

Index and comparator tests

Lift-off test (modified interpretation 1)

Referenced to the primary source (Gerber 1991a) and described

Procedure As in the primary source

Interpretation As in the primary source except that, in addition to inability to lift the hand off the back, the ability to do so only by extending the shoulder or elbow was also considered positive.

Belly-press test (modified procedure)

Referenced to the primary source (Gerber 1996) and described

Procedure As in the primary source except that, reportedly, the test was performed with 'the arm at the side'. The test was originally depicted in slight shoulder abduction (Gerber 1996). An addition in this study was use of a digital tensiometer for bilateral comparisons of force. Resistance was applied perpendicular to the distal forearm via a padded sling.

Interpretation As in the primary source, the test was considered positive if the patient utilised elbow or shoulder extension. In addition, force was measured and compared to the other shoulder.

Napoleon test (standard)

Referenced to Schwamborn 1999, the German language primary source, and Burkhart 2002, who refined the test's interpretation. The test was also described.

Procedure The patient was required to adopt a Napoleonic pose, palm on abdomen. 

Interpretation A negative (normal) result was where the patient could press against the abdomen without flexing the wrist. A positive result was defined as inability to push against the abdomen without flexing the wrist to 90°. An intermediate result, which has been correlated with partial tears of subscapularis Burkhart 2002, was also recorded as positive.   

Bear-hug test (novel)

This was a novel test.

Procedure The patient placed the palm of the affected limb on the opposite shoulder, fingers extended. He or she was then required to sustain the position while the tester applied an external rotation force perpendicular to the forearm. An electronic digital tensiometer was used to measure force via a padded sling applied just proximal to the wrist.

Interpretation The test was considered positive if the patient was unable to position the arm, or demonstrated more than a 20% strength deficit compared to the other side. 

Tester(s) No information given. However the testers' expertise at the bear hug test, which they originated, would be expected to be high.

Follow-up Adverse events None mentioned
Notes

Note 1 This sub-grouping presupposes that full thickness tears have been identified and excluded. However,

a. this subgroup may be more representative of the primary care population than the study group as a whole; and

b. the increasing availability of diagnostic ultrasound raises the possibility that FTT may indeed be excluded, even in the primary care setting.

2 x 2 tables and summary statistics

Were 2 x 2 tables reported? No

If applicable, could 2 x 2 tables be back-calculated? Yes

Were the reported summary statistics confirmed as accurate? Yes

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was secondary or tertiary care and the reference test (arthroscopy) was more than minimally invasive.
Selection criteria described?
All tests
NoOnly a broad outline was given.
Acceptable reference standard?
All tests
YesArthroscopy
Acceptable delay between tests?
All tests
UnclearInsufficient information
Partial verification avoided?
All tests
YesAll patients were accounted for as having undergone the reference test.
Differential verification avoided?
All tests
YesAll patients underwent the same reference test.
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
Yes 
Index test results blinded?
All tests
UnclearThe study was prospective and it is unclear whether there was blinding, but the index test preceded the reference standard.
Reference standard results blinded?
All tests
NoThere does not appear to have been blinding.
Relevant clinical information?
All tests
UnclearThe index tests were conducted on patients already listed for arthroscopy.
Uninterpretable results reported?
All tests
YesThe study was prospective, recruitment was consecutive and (with the exception of the lift-off test), results were reported for all initially included patients.
Withdrawals explained?
All tests
YesExcept in relation to the lift-off test

Bennett 1998

Clinical features and settings Inclusion criteria [1] Shoulder pain, [2] arthroscopy (implied)
Exclusion criteria None reported
Duration of symptoms Not reported
Previous treatments Not reported
Care setting Secondary or tertiary care
ParticipantsUSA (1/10/1994-28/2/1995).
46 shoulders in 45 patients (67% male), mean age 56 years (SD not reported, range 16-80)
Study designProspective, cross-sectional study. The statement, "In light of the results of this series, patients not entered into the study who responded to conservative treatment may have had positive Speed test findings" implies non-consecutiveness in terms of surgery.
Target condition and reference standard(s)[1] Intra-articular LHB tendon/labral injury or macroscopic bicipital groove and/or LHB tendon inflammation at the level of the groove
Arthroscopy
Procedure The beach-chair position was used. By flexing the elbow (and elevating the shoulder), tension was released on the LHB tendon, thus allowing the LHB tendon at the level of the bicipital groove to be directly visualized in the intra-articular portion of the glenohumeral joint (Figure given). Visual examination of the tendon at the level of the bicipital groove for inflammation and/or fraying was facilitated by placing a neuroprobe into and through the anterior portal and placing it just under the superior glenohumeral ligament and then over the LHB tendon. The application of a caudal force to the tendon with a neuroprobe levers the nonarticular portion of the LHB tendon an additional 3 to 4 cm into the glenohumeral joint (Figure given). The normal intra-articular portion of the LHB tendon was also evaluated for inflammation, fraying, avulsion, or SLAP lesions.
Interpretation Any macroscopic inflammation and/or tearing of the LHB tendon at any level, evidence of any type of SLAP lesion (these are undefined), or a complete avulsion of the LHB tendon were considered positive results.
Interval between index and reference test Not reported
Tester(s) No information given
Prevalence 22% (LHB tendon/labral injury)
Index and comparator tests

Speed's test (modified procedure, modified interpretation 1)
Referenced to a secondary source (van Moppes 1995) and described:

Procedure A downward pressure was applied to the upper extremity with the shoulder elevated 90°, full supination of the forearm, and the elbow extended. (This interpretation of the test as an isometric technique appears to differ to that of Crenshaw 1966, who cited a personal communication with the test’s originator. They wrote, 'it is performed by having the patient flex his shoulder (elevate it anteriorly) against resistance.')  
Interpretation 'Pain experienced in the anterior shoulder of the patient when pressure is applied' and 'pain in the proximal portion of the shoulder during the application of a downward force applied to the arm' were variously stated to indicate a positive Speed's test result. (According to Crenshaw 1966, 'the test is positive when pain is localized to the bicipital groove'.)
Tester(s) No information given

Follow-up Adverse events None mentioned
Notes

Note 1 There is an error in table 3. The contents of the lower two cells are transposed.

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? Yes

If applicable, could 2 x 2 tables be back-calculated? N/A

Were the reported summary statistics confirmed as accurate? There was a borderline discrepancy in specificity, but the other summary statistics were confirmed as accurate.

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was secondary or tertiary care and the reference test (arthroscopy) was more than minimally invasive.
Selection criteria described?
All tests
NoVery unspecific description: patients with shoulder pain and listed for arthroscopy
Acceptable reference standard?
All tests
YesArthroscopy
Acceptable delay between tests?
All tests
UnclearInsufficient information
Partial verification avoided?
All tests
NoThe test was applied to some patients who were treated conservatively.
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
YesThough poorly reported
Sufficient description of reference test?
All tests
YesGenerally very clear though SLAP lesions were undefined
Index test results blinded?
All tests
UnclearThere is no statement of blinding, but the study was prospective.
Reference standard results blinded?
All tests
NoThere does not appear to have been blinding.
Relevant clinical information?
All tests
YesProbably
Uninterpretable results reported?
All tests
UnclearInsufficient information - probably not consecutive recruitment (see comments in Study design above)
Withdrawals explained?
All tests
UnclearInsufficient information (see comments in Study design above)

Calis 2000

Clinical features and settings Inclusion criteria [1] Shoulder pain, [2] aged 18-70, [3] standard radiographic assessment
Exclusion criteria [1] Inflammatory or systemic diseases, [2] acute traumatic conditions, [3] postoperative conditions, [4] neck or elbow disorders
Duration of symptoms Not reported, but specified to be equivalent for the groups with and without impingement
Previous treatments Not reported
Care setting Mixed: primary, secondary and tertiary
ParticipantsTurkey (period not reported)
125 shoulders in 120 patients (40% male), mean age 52 years (SD not reported, range not reported)
Study designProspective, cross-sectional study: unclear whether recruitment was consecutive
Target condition and reference standard(s)

[1] Subacromial impingement syndrome, [2] complete disruption of supraspinatus tendon

Reassessment following blind subacromial local anaesthetic injection
Procedure 1% lidocaine was injected under the acromion by an anterior approach 'by experienced hands'. Using the ACJ and the anterior edge of the acromion as landmarks, the aim was to place the needle tip directly below the anterior edge of the acromion. Gentle longitudinal traction through the arm was used to facilitate needle entry.

Interpretation Marked relief of pain and almost total improvement in passive or active ROM after 30 minutes was interpreted as positive, provided that there were no calcific lesions on adjuvant X-rays.

MRI

Procedure Not reported

Interpretation Used Zlatkin stages (reference given to Zlatkin 1989), with stage 1 defined as increased signal intensity in the tendon without any thinning, irregularity or discontinuity, stage 2 as increased signal intensity with irregularity and thinning in the tendon, and stage 3 as complete disruption of the supraspinatus tendon.

Interval between index and reference test Not reported, but the X-ray and MRI appear to have preceded the index tests, and the injection test was presumably immediately afterwards.
Tester(s) Subacromial injection test was performed by 'experienced hands'; MRI by a radiologist with experience on the skeletal system, especially shoulder imaging
Prevalence 70% (subacromial impingement syndrome); 17% (complete disruption of supraspinatus tendon)

Index and comparator tests

Tests were referenced to primary and/or secondary sources and described. All were conducted/interpreted as standard.

Neer's sign, Hawkins' test, passive horizontal adduction

painful arc test, drop arm test, Yergason's test

Speed's test (all standard)

Tester(s) Two physicians with four and eight years' experience in shoulder management

Follow-up Adverse events None mentioned
Notes

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? No

If applicable, could 2 x 2 tables be back-calculated? Yes

Were the reported summary statistics confirmed as accurate? No. There were borderline discrepancies between most reported sensitivities, specificities and other summary statistics and those derived from back-calculated 2 x 2 tables.

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
UnclearProportion of referred to self-referred not known
Selection criteria described?
All tests
Yes 
Acceptable reference standard?
All tests
UnclearBlind (unguided) injection reference test. MRI is acceptable for full thickness tears in low-prevalence samples. 
Acceptable delay between tests?
All tests
UnclearLikely, but no information given
Partial verification avoided?
All tests
Yes 
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
YesFor the physical tests the same procedures were used, but with or without local anaesthesia. 'Yes' for MRI.
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
YesInjection 'Yes', MRI 'No'
Index test results blinded?
All tests
UnclearIt is unclear whether there was blinding, but the study was prospective and the index tests preceded the injection aspect of the reference standard. (MRI appears to have preceded the index tests, however.)
Reference standard results blinded?
All tests
No 
Relevant clinical information?
All tests
UnclearNo information
Uninterpretable results reported?
All tests
UnclearUnclear
Withdrawals explained?
All tests
UnclearUnclear

Castoldi 2009

Clinical features and settings

Inclusion criteria [1] Painful shoulder, [2] having had arthroscopy or open surgery
Exclusion criteria [1] Acute traumatic conditions, [2] acute postoperative conditions, [3] fractures, [4] frozen shoulder with a great deficit of range of motion, [5] neurologic disorders (plexus injury), [6] notes unavailable

Duration of symptoms Not reported
Previous treatments Not reported
Care setting Secondary or tertiary care

Participants

Italy or Switzerland? (01/2004-06/2006)

395 shoulders in 390 patients (57% male), mean age 50 years (SD 16, range 16-89)

Study designRetrospective, consecutive, cross sectional study
Target condition and reference standard(s)

Supraspinatus tears: [1] FTT, full-width; [2] PTT, isolated

Arthroscopy or open surgery

Procedure No information

Interpretation “The size of any tear was estimated depending on the number of involved tendons. The topographic description of the tear was performed by dividing the sagittal plane of the rotator cuff in 7 zones. Partial nontransmural tears of the supraspinatus were allocated to a separate group.” 

Interval between index and reference test Not reported
Tester(s) No information given
Prevalence 29% (isolated partial thickness supraspinatus tears), 17% (full width, full thickness supraspinatus tears)

Index and comparator tests

External rotation lag sign (standard)

Referenced to the primary source (Hertel 1996a) and described

Procedure As in the primary source

Interpretation As in the primary source. Emphasis was placed on the need to make bilateral comparisons in order to identify small lags.

Tester(s) A 'single skilled examiner'. A co-author was the originator of the test.

Follow-up Adverse events None mentioned
Notes

Note 1 Table 1 reports 199 cuff tears plus 2 cuff tears with instability, making a total of 201 cuff tears (70 left, 131 right) in 395 shoulders. On this basis, 395 - 201 = 194 cuffs were intact. However in Table 2 the number of intact cuffs is reported as 157, and this is the value used in the diagnostic test accuracy calculations. No explanation is given for this discrepancy of 37 shoulders.

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? Yes. For isolated partial thickness tears of supraspinatus, only shoulders with that specific lesion (n = 65) or a normal cuff (n = 157) were given in the 2 x 2 table (total = 222). For isolated full width, full thickness tears of supraspinatus, only shoulders with that specific lesion (n = 32) or a normal cuff (n = 157) were included in the 2 x 2 table (total = 189). In relation to the latter target condition, this restrictive approach to inclusion limits the applicability of the results to the clinical setting, where intermediate cases would be encountered.

If applicable, could 2 x 2 tables be back-calculated? N/A

Were the reported summary statistics confirmed as accurate? Yes

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe study was retrospective. Also the reference test (arthroscopy or open surgery) was invasive.
Selection criteria described?
All tests
UnclearThe inclusion criteria were limited.
Acceptable reference standard?
All tests
YesProbably, though no procedural details were given
Acceptable delay between tests?
All tests
UnclearInsufficient information
Partial verification avoided?
All tests
Yes 
Differential verification avoided?
All tests
YesThe reference tests used were probably equivalent.
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
NoNo information was given on the procedure for the reference test.
Index test results blinded?
All tests
NoThe study was retrospective.
Reference standard results blinded?
All tests
NoVery unlikely, since the study was retrospective
Relevant clinical information?
All tests
Yes 
Uninterpretable results reported?
All tests
UnclearThe study was retrospective. Also see below.
Withdrawals explained?
All tests
NoThe study was retrospective and there are unexplained missing cases from the analysis

Frost 1999

Clinical features and settings Inclusion criteria Based on a questionnaire screening workers for shoulder symptoms; [1] cases, comprising individuals who had suffered > months' shoulder pain in the past year, and [2] controls, who had experienced no long lasting shoulder symptoms. Controls were age matched to cases.
Exclusion criteria [1] Claustrophobia, [2] size too large to fit in the MRI
Duration of symptoms 3 months in the past year for the cases
Previous treatments Not reported
Care setting The individuals recruited were not necessarily undergoing care
ParticipantsDenmark (period not reported).
From among 167 individuals who met the criteria for 'patients' and 110 who met the criteria for controls, 73 shoulders in 73 participants (81% male; mean age and range not reported) ultimately underwent the index and reference tests.
Study designProspective, case control study with non-consecutive recruitment
Target condition and reference standard(s)Supraspinatus: [1] FTT, degeneration or tendinitis; [2] FTT or degeneration; [3] FTT
MRI
Procedure This utilised 2 identical 1.5 Tesla Gyroscans and surface shoulder coils. The supine patient's arm was held in neutral. The scans were done in 3 sequences: a scout in the coronal plane was used to place the co-ordinates for the transverse scans of the area from the undersurface of the acromion to the lower glenoid margin. Coronal scans were performed in the plane parallel to the supraspinatus tendon. Scans were done with TR/msec/TE msec 1800/30 proton and 1800/90 T2-weighted sequences, slice thickness 4 mm, spacing 0.4 mm, matrix 266 X 256, field view 200 mm, and number of excitations 1.
Interpretation used criteria adapted from Zlatkin 1989, collapsing the possible diagnoses relating to supraspinatus pathologies into 4 categories.
Interval between index and reference test Not reported
Tester A radiologist whose level of expertise was not reported, but who was blinded to participants' age and clinical status.
Prevalence 53% (any supraspinatus lesions), 9.6% (full thickness tears)
Index and comparator tests Hawkins' test (modified procedure, modified interpretation 2)
Procedure With the arm in 90° of scaption [versus the standard starting position for Hawkins test, which is 90° of flexion], the shoulder was passively medially rotated.
Interpretation The test was considered positive if there was provocation or aggravation of pain at the anterolateral aspect of the shoulder.
Tester(s) 2 examiners from the Department of Occupational Medicine: no further information given
Follow-up Adverse events None mentioned
Notes

Note 1 The primary purpose of this study was not diagnostic, but to compare MRI appearances of supraspinatus in symptomatic subjects aged < and > 50 years, respectively, who had impingement against that in a control group of asymptomatic subjects of corresponding age without impingement. The results showed no difference in the prevalence of supraspinatus pathology between the impingement sign positive/ impingement sign negative groups (though full thickness tears were reported to be more common in the former) but a strong association with age. This emphasises the questionable suitability of MRI (and possibly, by corollary, ultrasound, arthroscopy and open surgery) as a reference standard in impingement related diagnostic studies. Note 2 From a diagnostic perspective, this study is weakened by its case control design. The small numbers within the subgroups 'tendonitis', 'degeneration' and 'full thickness tear' precluded their individual analysis.

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? No

If applicable, could 2 x 2 tables be back-calculated? Yes

Were the reported summary statistics confirmed as accurate? No summary diagnostic test accuracy statistics were reported.

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoCase control design. Community - not a care setting as such.
Selection criteria described?
All tests
NoVery unspecific description: 3 months' shoulder pain in the past year
Acceptable reference standard?
All tests
YesMRI: acceptable for full thickness tears
Acceptable delay between tests?
All tests
UnclearInsufficient information
Partial verification avoided?
All tests
NoA non-random selection of participants underwent a reference test
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
Yes 
Index test results blinded?
All tests
UnclearProbably, given the unambiguous nature of the index test
Reference standard results blinded?
All tests
Yes 
Relevant clinical information?
All tests
NoThere was blinding to the results of the questionnaires
Uninterpretable results reported?
All tests
NoRecruitment was not consecutive
Withdrawals explained?
All tests
No 

Guanche 2003

Clinical features and settings Inclusion criteria [1] Patients undergoing shoulder arthroscopy for a variety of activity related complaints, [2] complete physical examination immediately prior to surgery, [3] full range of motion attainable under anaesthesia and (4) failure to respond to previous conservative treatment.
Exclusion criteria Previous surgery on affected shoulder
Duration of symptoms Not reported
Previous treatments Non-operative care. The protocol for subacromial impingement was subacromial steroid injections (maximum of three) followed by physical therapy; that for suspected ACJ arthritis was steroid injection; and that for presumptive labral pathology was a course of progressive physical therapy and activity modification.
Care setting Secondary or tertiary care
ParticipantsUSA (period not reported).
60 shoulders in 59 patients (82% male); mean age 38 years (SD not reported, range 15-76).
Study designProspective, cross sectional study with consecutive recruitment
Target condition and reference standard(s)

[1] SLAP lesion (any)
Arthroscopy
Procedure The procedure described is internally inconsistent. Thus, with the patient in the beach-chair position, ‘in all cases the glenohumeral joint was first evaluated and the pathology addressed as appropriate. Subsequently the subacromial space was evaluated... and appropriate treatments were performed. Finally lesions of the glenohumeral joint were addressed.’

Interpretation Classification of SLAP lesions was according to Snyder 1990a. Labral lesions inferior to the 10 o’clock to 2 o’clock segment defined as SLAP were recorded as ‘labral tears’.
Interval between index and reference test The index tests were performed in the holding area of the operating theatre, immediately before administration of anaesthetic or narcotic agent.
Tester(s) No information given
Prevalence 55% (Types I-IV SLAP lesions)

Index and comparator tests

Active compression test (modified procedure, modified interpretation 2)

Procedure Referenced to primary source (O'Brien 1998a), but the illustration and caption indicated that the second part of the test was conducted with the shoulder in neutral rotation rather than full external rotation, and this differs from the test as originally described.

Interpretation As in the primary source, deep pain in the shoulder which was less in 'external' than internal rotation was considered positive. Questioning as to the site of pain was overlooked in 27 patients, reducing the data available for this test.

Anterior apprehension test at 90° for pain (modified interpretation 2)

Referenced to a chapter by Hawkins and Bokor in Rockwood and Matsen (1990) and faithfully described. (Rockwood and Matsen (1990) was unavailable to the review authors, but the description was compatible with that given in the third edition of that book (Krishnan 2004).)

Procedure The supine patient's arm was positioned in 90° abduction and full external rotation. (As distinct from the version of this test described by Jobe 1989, no anterior pressure was applied to the humeral head.)

Interpretation Pain was considered a positive result.

Palpation for bicipital groove tenderness (modified interpretation 2)

Procedure and Interpretation Tenderness was sought by palpation.

Crank test (modified procedure, modified interpretation 2)

Referenced to one of the primary sources (Liu 1996b) and described

Procedure Performed with the patient lying supine and the shoulder in full abduction. This differs from both of the definitions given by the originators of the test (Liu 1996c; Liu 1996b) - see further in this table.

Interpretation  Standard
Anterior release test (modified interpretation 2)

The authors reportedly evaluated the relocation test, which they referenced to Jobe et al (1990); but the manoeuvre illustrated is the anterior release test (Gross 1997).

Speed's test (modified interpretation 1,2)

Referenced to a tertiary source (Bennett 1998) which itself described the test incompletely, and illustrated.

Procedure The procedure appears to have been consistent with that in the primary source, but neither report specified the arc of movement through which the test was performed.

Interpretation As distinct from the primary source, pain was accepted as a positive result regardless of whether it was localized to the bicipital groove.

Yergason's test (modified interpretation 1,2)

Secondarily referenced to a chapter by Hawkins and Bokor in Rockwood and Matsen (1990) and illustrated.

Procedure As in the primary source (Yergason 1931) with the addition of ‘simultaneous [palpation] of the biceps tendon’. Rockwood and Matsen (1990) was unavailable to the review authors, but in the third edition of that book there is no mention of palpation as part of the test (Krishnan 2004).

Interpretation As in the primary source (Yergason 1931) with the additional requirement that ‘unusual’ pain in the biceps tendon be felt in order to signify a positive result. This qualification is not mentioned by Krishnan 2004.
Tester(s) All tests were performed by the first author, an orthopaedic surgeon.

Follow-up Adverse events None mentioned
Notes

Note 1 The references to ‘tears’ in the title and Table 3 of this article are misleading, because Type I SLAP lesions (which are not tears) are pooled with other types of SLAP lesion (which are tears) in the data analyses.

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? No

If applicable, could 2 x 2 tables be back-calculated? Yes, except for the active compression test (for which the numbers of disease positive and disease negative patients were not reported)

Were the reported summary statistics confirmed as accurate? Yes 

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was secondary or tertiary care and the reference test (arthroscopy) was more than minimally invasive.
Selection criteria described?
All tests
UnclearThe description was not completely clear.
Acceptable reference standard?
All tests
YesArthroscopy
Acceptable delay between tests?
All tests
YesThe index tests were performed immediately pre-operatively.
Partial verification avoided?
All tests
Yes 
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
YesBrief but referenced
Index test results blinded?
All tests
UnclearThere is no statement of blinding, but the study was prospective.
Reference standard results blinded?
All tests
NoThere does not appear to have been blinding.
Relevant clinical information?
All tests
Yes 
Uninterpretable results reported?
All tests
Yes 
Withdrawals explained?
All tests
Yes 

Gumina 2008

Clinical features and settings Inclusion criteria Diagnoses relating to shoulder pain and weakness (impingement syndrome and postero-superior cuff tears). It is unclear whether either or both were required for inclusion.
Exclusion criteria None reported
Duration of symptoms Not reported
Previous treatments Not reported
Care setting Secondary or tertiary care
ParticipantsItaly (period not reported).
120 shoulders in 120 patients (gender distribution not reported); mean age 64 years (SD not reported, range 46-79).
Study designUnclear whether prospective. Cross sectional study with consecutive inclusion.
Target condition and reference standard(s)

Subacromial impingement and full thickness postero-superior rotator cuff tears.
Arthroscopy
Procedure No information given

Interpretation No information given
Interval between index and reference test Not reported
Tester(s) No information given
Prevalence 38% (subacromial impingement), 62% (rotator cuff tears)

Index and comparator tests

Gum-Turn test

A novel test.

Procedure Starting in the empty can test position, the patient traced a 20 cm wide spiral drawn on the wall, from centre to periphery and back 10 times, resting for one minute, then repeating the procedure.

Interpretation The test was positive if weakness or pain prevented completion. For positive results, the number of turns completed was recorded, but it is unclear how these data were used. Results were compared with the contralateral arm but, again, it is unclear how these data were used.
Tester(s) Presumably expert, as the authors were the originators of the test

Follow-up Adverse events None mentioned
Notes

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? No

If applicable, could 2 x 2 tables be back-calculated? Yes

Were the reported summary statistics confirmed as accurate? No. Sensitivity was reported accurately throughout, but there were borderline discrepancies between some reported specificities and those derived from back-calculated 2 x 2 tables.

For numerous other summary statistics there were substantial discrepancies.

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was secondary or tertiary care and the reference test (arthroscopy) was more than minimally invasive.
Selection criteria described?
All tests
NoThe selection criteria were unclearly described and no exclusion criteria were reported.
Acceptable reference standard?
All tests
YesIn principle, though no procedural or interpretative details were given
Acceptable delay between tests?
All tests
UnclearNo information given
Partial verification avoided?
All tests
Yes 
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
YesAlthough it is unclear how the number of turns completed or comparison with the other arm were used, these issues do not appear critical to interpretation of the test.
Sufficient description of reference test?
All tests
NoNo information given
Index test results blinded?
All tests
NoThere is no statement of blinding and the study may not have been prospective.
Reference standard results blinded?
All tests
NoThere does not appear to have been blinding.
Relevant clinical information?
All tests
YesMost probably
Uninterpretable results reported?
All tests
UnclearThe study may not have been prospective.
Withdrawals explained?
All tests
NoThe study may not have been prospective.

Hertel 1996

Clinical features and settings Inclusion criteria [1] Unilateral subacromial impingement (Neer’s stage I-3), [2] subsequent open or arthroscopic rotator cuff exploration
Exclusion criteria Impaired passive range of glenohumeral motion
Duration of symptoms Not reported
Previous treatments Not reported
Care setting Unclear but likely to be tertiary care
ParticipantsBerne, Switzerland (03/1992-12/1993).
'100 consecutive patients' (74% male) with unilateral subacromial impingement syndrome (stages 1-3); but see further information in 'Index and comparator tests'. Median age 51 years (range 16-79)
Study designProspective, cross sectional study with consecutive recruitment
Target condition and reference standard(s)

Rotator cuff ruptures in 2, probably overlapping, groups: [1] ruptures affecting the supraspinatus and infraspinatus tendons and [2] ruptures affecting the subscapularis tendon.
Open surgery or arthroscopy
Procedure No information given

Interpretation Criterion for a positive result was “rotator cuff rupture”. No further details were given.
Interval between index and reference test Unclear
Tester(s) No details given
Prevalence 63% (lesions of any type involving the postero-superior rotator cuff), 29% (lesions of any type involving subscapularis)

Index and comparator tests

The empty can test and two novel tests, the external rotation lag sign (ERLS) (to assess the function of supraspinatus and infraspinatus) and the drop sign (to assess the posterosuperior rotator cuff), were evaluated in a subgroup (n = 87) found not to have subscapularis lesions in isolation. The lift-off sign (to assess the function of subscapularis) and a novel test, the internal rotation lag sign (IRLS) (to assess for cranial or large tears of subscapularis) were evaluated in a subgroup (n = 53) found not to have supraspinatus and/or infraspinatus lesions in isolation.

Procedure and interpretation The reference erroneously given for the empty can test is Jobe 1982, in which an isotonic manoeuvre was described for strengthening and testing strength. The manoeuvre described by Hertel 1996 is Jobe's isometric test for supraspinatus integrity, the primary source for which is Jobe 1983. In the context of Hertel 1996 it appears that weakness was taken as a positive result, which is compatible with the primary source. The lift-off sign is referenced to its primary source (Gerber 1991a) but not described further.
Tester(s) No details given though, apart from the empty can test, all of the tests evaluated had been originated by one of the study's authors

Follow-up Adverse events None mentioned
Notes

Note 1 The empty can test, ERLS, and drop sign were not reported for isolated subscapularis lesions (n = 13); the lift-off test and IRLS were not reported for lesions of supraspinatus +/- infraspinatus (n = 47). Note 2 There is an error in Table 1. The accuracy of the ERLS should read 67/87, not 37/87 as reported; and the accuracy of the drop sign should read 37/87, not 68/87 as reported.

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? No

If applicable, could 2 x 2 tables be back-calculated? Yes

Were the reported summary statistics confirmed as accurate? Yes

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was probably tertiary and the reference test (open surgery or arthroscopy) was more than minimally invasive.
Selection criteria described?
All tests
Yes 
Acceptable reference standard?
All tests
YesOpen surgery or arthroscopy
Acceptable delay between tests?
All tests
UnclearInsufficient information
Partial verification avoided?
All tests
YesAll patients underwent surgery
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
YesProbably, though there is no mention of how the lag was measured
Sufficient description of reference test?
All tests
NoNo details given
Index test results blinded?
All tests
UnclearThere is no statement of blinding and the analysis is structured towards presenting results with knowledge of the reference test results
Reference standard results blinded?
All tests
NoThere does not appear to have been blinding
Relevant clinical information?
All tests
YesProbably
Uninterpretable results reported?
All tests
Yes 
Withdrawals explained?
All tests
Yes 

Holtby 2004a

Clinical features and settings Inclusion criteria [1] Persistent pain and functional disability > 6 months, not responsive to adequate conservative treatment, with a positive impingement test confirmed with local anaesthetic or clinical or investigative signs of rotator cuff tears, labral or LHB lesions, [2] symptoms referred to the ACJ > 6 months with radiographic changes in the joint [3] symptomatic shoulder instabilities, [4] informed consent.
Exclusion criteria History of previous shoulder surgery or upper extremity fractures
Duration of symptoms Not reported
Previous treatments Not reported
Care setting Tertiary care
ParticipantsCanada (period not reported)
Patients complaining of shoulder pain, referred by family physicians or orthopaedic surgeons for assessment, and meeting the criteria for surgery.
50 shoulders in 50 patients (68% male); mean age 50 years (SD 14, range 24-79).
Study designProspective cross sectional study with consecutive recruitment
Target condition and reference standard(s)

LHB tendon pathology or SLAP lesions
Arthroscopy
Procedure Lateral position with arm suspended from a robot traction device with 12 lbs of weight. The arthroscope was inserted through the superior portal to inspect the articular surfaces, anterior and inferior labrum, LHB, and articular surface of the rotator cuff. 

Interpretation Criteria for a positive result were [1] LHB tendon fibrillation, adhesion in the bicipital groove, subluxation or dislocation, partial tear or complete rupture, [2] visualisation of type II or IV SLAP lesions. Types I and III SLAP lesions were not considered positive findings.
Interval between index and reference test Mean approximately 23 weeks
Tester(s) No details given
Prevalence 42-43% (LHB pathologies or SLAP type II or IV lesions)

Index and comparator tests

Speed's test
Referenced to Gilcreest 1936, which we have been unable to obtain, and described.

Procedure The examiner pressed downwards on the arm with the shoulder flexed to 90°, the forearm fully supinated and the elbow extended. (This interpretation of the test as an isometric technique appears to differ to that of Crenshaw 1966, who cited a personal communication with the test’s originator, and wrote, “it is performed by having the patient flex his shoulder (elevate it anteriorly) against resistance.”)

Interpretation Pain in the anterior shoulder or glenohumeral joint was considered a positive result. (According to Crenshaw 1966, 'the test is positive when pain is localized to the bicipital groove'.)

Yergason's test
Referenced to primary source (Yergason 1931) and described.

Procedure As in primary source

Interpretation As in the primary source, pain in the bicipital groove area was considered a positive result. Pain in the glenohumeral joint was also considered positive.
Tester(s) No information given

Follow-up Adverse events None mentioned
Notes

Note 1 MRI and X-rays taken beforehand were examined only after completion of the data collection form. Note 2 Same study population as Holtby 2004b and Razmjou 2004.

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? Yes

If applicable, could 2 x 2 tables be back-calculated? Yes

Were the reported summary statistics confirmed as accurate? Yes

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was tertiary care and the reference test (arthroscopy) was more than minimally invasive.
Selection criteria described?
All tests
Yes 
Acceptable reference standard?
All tests
YesArthroscopy
Acceptable delay between tests?
All tests
NoMean interval from examination to surgery approximately 23 weeks
Partial verification avoided?
All tests
Yes 
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
Yes 
Index test results blinded?
All tests
Yes 
Reference standard results blinded?
All tests
Yes 
Relevant clinical information?
All tests
YesMRI and X-rays taken beforehand were examined only after completion of the data collection form.
Uninterpretable results reported?
All tests
UnclearSee below
Withdrawals explained?
All tests
No[1] Some problems regarding handling of results for bicipital tendonitis; [2] 1 patient's data missing from the Yergason's test results.

Holtby 2004b

Clinical features and settings Inclusion criteria Undergoing surgery for at least one of: [1] persistent pain and functional disability for > 6 months, not responsive to adequate conservative intervention, and a positive impingement test, confirmed with local anaesthesia; [2] clinical signs of rotator cuff tears, labrum or LHB lesions; [3] symptoms referred to the ACJ lasting > 6 months, with visible radiographic changes in the joint, or [4] symptomatic shoulder instabilities
Exclusion criteria History of previous shoulder surgery or upper extremity fractures
Duration of symptoms 1 month to > 5 years
Previous treatments ‘Adequate conservative intervention’
Care setting Tertiary care
ParticipantsCanada (period not reported)
50 shoulders in 50 patients (68% male); mean age 50 years (SD 14, range 24-79)
Study designProspective, cross sectional study with consecutive recruitment
Target condition and reference standard(s)

Tendinitis and partial thickness rotator cuff tears, full thickness rotator cuff tears, large or massive full thickness rotator cuff tears
All patients were initially examined by arthroscopy , proceeding to open surgery if required for management of large or massive rotator cuff tears.

Procedure The bursal and articular aspects of the rotator cuff were inspected for inflammation, fraying, or tears.

Interpretation Tears were categorized as partial thickness or full thickness. Full details are given in an appendix.
Interval between index and reference test Mean 23 weeks (range 5 weeks to 11 months)
Tester(s) The orthopaedic surgeon
Prevalence 34% (full thickness supraspinatus tears)

Index and comparator tests

Jobe's empty can test

Procedure and interpretation The reference erroneously given for the empty can test is Jobe 1982, in which an isotonic manoeuvre was described for strengthening and testing strength. The primary source for the empty can test of supraspinatus' integrity is Jobe 1983. The Procedure described is compatible with the primary source, but Interpretation is broadened to the 'rotator cuff'.
Tester(s) Independent examinations were performed by two testers, an orthopaedic surgeon and a physical therapist (for assessment of reliability) but only the surgeon's findings were included in the analysis of test diagnostic performance.

Follow-up Adverse events None mentioned
Notes

Note 1 Same study population as Holtby 2004a and Razmjou 2004

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? Yes

If applicable, could 2 x 2 tables be back-calculated? N/A

Were the reported summary statistics confirmed as accurate? Yes

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was tertiary care and the reference test (arthroscopy) was more than minimally invasive.
Selection criteria described?
All tests
Yes 
Acceptable reference standard?
All tests
YesAthroscopy
Acceptable delay between tests?
All tests
NoMean interval from examination to surgery was approximately 23 weeks
Partial verification avoided?
All tests
Yes 
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
Yes 
Index test results blinded?
All tests
Yes 
Reference standard results blinded?
All tests
Yes 
Relevant clinical information?
All tests
Yes 
Uninterpretable results reported?
All tests
Yes 
Withdrawals explained?
All tests
Yes 

Iagnocco 2003

Clinical features and settings Inclusion criteria Patients referred to a rheumatology unit with shoulder pain
Exclusion criteria None reported
Duration of symptoms Mean 5.3 months (SD not reported, range 1-19 months)
Previous treatments Analgesics (n=182), NSAIDs (n=122)
Care setting Secondary care
Participants

Italy (period not reported)
528 shoulders in 425 patients (34% male, mean age 58 years, range 18-90 years) referred to rheumatology with painful shoulders (103 had bilateral involvement)

Subgroups [1] 228 had clinically diagnosed peri-articular disorders, [2] 13 rheumatoid arthritis, [3] 10 seronegative spondarthritis [4] 14 osteoarthritis, [5] 15 previous trauma, [6] 5 chondrocalcinosis, [7] 6 SLE, [8] 3 systemic sclerosis, [9] 131 not yet clinically diagnosed

Study designProspective, cross sectional study with consecutive recruitment.
Target condition and reference standard(s)[1] Pathological changes of LHB, supraspinatus, infraspinatus and subscapularis tendons and acromioclavicular joints, [2] calcifications. The SA-SD bursa and glenohumeral joint were also listed among structures evaluated ultrasonographically (see below), but were not included in calculations of diagnostic test accuracy.
Ultrasound
Procedure Examinations were repeated twice by each of 2 independent operators using 7.5 MHz linear transducers.
Interpretation Criteria for a positive result were hyperechoic areas with possible posterior shadows (calcifications); thinning, hypo-echoicity of tendons (partial rupture); thickening, hyperechoicity of tendons (tendinitis); hyperechoic discontinuity of tendons, non-visualisation of tendons (rupture); empty bicipital groove with identification of LHB tendon in the surrounding area (subluxation); hypo-anechoic area between LHB tendon and its sheath (tenosynovitis); hypo-anechoic fluid in bursae with > 2mm thickening (bursitis); effusion in or bony irregularities of the ACJ; effusion in the glenohumeral joint on transaxillary scan. References were given (was the procedure referenced too?).
Interval between index and reference test A 'few days'
Tester(s) 2 rheumatologists experienced in sonography
Prevalence 48% (changes in LHB tendon), 60% (changes in supraspinatus tendon), 17% (changes in infraspinatus tendon), 4.4% (changes in subscapularis tendon)
Index and comparator tests

A single general reference was given for all index tests (Dalton, 1998)

Speed's test for the LHB tendon

Procedure The examiner resisted flexion of the patient's shoulder, with the elbow extended and the forearm supinated. This is compatible with the primary source (Crenshaw 1966).

Interpretation No additional information given

Resisted abduction for supraspinatus

Procedure This test was performed with the arm abducted to 90°, flexed to 30° and internally rotated (i.e. empty can test ).

Interpretation No additional information given

Resisted lateral rotation (presumably from neutral rotation) for infraspinatus, and resisted medial rotation (presumably from neutral rotation) for subscapularis, were named but not described.
Tester(s) An experienced rheumatologist

Follow-up Adverse events None mentioned
Notes

2 x 2 tables and summarystatistics

Were 2 x 2 tables reported? No

If applicable, could 2 x 2 tables be back-calculated? Yes

Were the reported summary statistics confirmed as accurate? No. For all tests evaluated there were borderline discrepancies between the reported sensitivities and those derived from back-calculated 2 x 2 tables.

Table of Methodological Quality
ItemAuthors' judgementDescription
Representative spectrum?
All tests
NoThe setting was secondary care.
Selection criteria described?
All tests
No 
Acceptable reference standard?
All tests
UnclearUltrasonography
Acceptable delay between tests?
All tests
YesA 'few days'
Partial verification avoided?
All tests
Yes 
Differential verification avoided?
All tests
Yes 
Incorporation avoided?
All tests
Yes 
Sufficient description of index tests?
All tests
Yes 
Sufficient description of reference test?
All tests
Yes 
Index test results blinded?
All tests
Yes 
Reference standard results blinded?
All tests
UnclearThe reference test was conducted independently.
Relevant clinical information?
All tests
YesProbably
Uninterpretable results reported?
All tests
Yes 
Withdrawals explained?
All tests
Yes 

Itoi 1999

Clinical features and settings Inclusion criteria Various shoulder symptoms
Exclusion criteria None reported
Duration of symptoms Not reported
Previous treatments Not reported
Ca