|Year : 2019 | Volume
| Issue : 1 | Page : 91-96
The diagnostic value of the combination of clinical tests for the diagnosis of supraspinatus tendon tears
Sameer Haveri, RB Uppin, Kiran Patil
Department of Orthopaedics, KLE Academy of Higher Education and Research, JN Medical College and Hospital, Belagavi, Karnataka, India
|Date of Web Publication||18-Jan-2019|
Dr. Sameer Haveri
Department of Orthopaedics, KLE Academy of Higher Education and Research, JN Medical College and Hospital, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
CONTEXT: A large number of special tests have been described to examine the shoulder. It is unknown which combination of clinical tests might be optimal for the diagnosis of rotator cuff tears.
AIMS OF OUR STUDY: To estimate the diagnostic accuracy of history and clinical tests and to find out which combination of clinical tests is best in diagnosing supraspinatus tendon tears.
SETTINGS AND DESIGN: Diagnostic test accuracy study.
METHODOLOGY: One hundred and thirty-four patients with shoulder pain were evaluated with history-taking and clinical tests and magnetic resonance imaging of the shoulder.
STATISTICAL ANALYSES: Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratios were calculated with a 2 × 2 table.
RESULTS: The combination of Neer test, painful arc test, and full can test yielded 100% sensitivity and 100% specificity in diagnosing supraspinatus tears of any type.
CONCLUSIONS: Our study shows that individual clinical tests have moderate diagnostic value for the diagnosis of supraspinatus tears. Diagnostic value improves significantly when clinical tests are combined together. Neer test, painful arc test, and full can test form the best combination in diagnosing supraspinatus tears of any type.
Keywords: Clinical tests, diagnostic accuracy, magnetic resonance imaging, supraspinatus tendon tears
|How to cite this article:|
Haveri S, Uppin R B, Patil K. The diagnostic value of the combination of clinical tests for the diagnosis of supraspinatus tendon tears. Indian J Health Sci Biomed Res 2019;12:91-6
|How to cite this URL:|
Haveri S, Uppin R B, Patil K. The diagnostic value of the combination of clinical tests for the diagnosis of supraspinatus tendon tears. Indian J Health Sci Biomed Res [serial online] 2019 [cited 2020 Jan 27];12:91-6. Available from: http://www.ijournalhs.org/text.asp?2019/12/1/91/250391
| Introduction|| |
Rotator cuff tears are the common cause of shoulder pain and dysfunction., The prevalence of rotator cuff tears is 5%–39%. Clinical tests should be used selectively and tailored to the clinical condition suspected., Recent meta-analysis showed that data were lacking to support most clinical tests used for diagnosing rotator cuff tears, and there is a need for high-quality studies to test the diagnostic performance of parameters from patient history and physical examinations.,, The study was done to estimate the diagnostic accuracy of clinical tests and to find out which combination of clinical tests is best in diagnosing supraspinatus tendon tears.
| Methodology|| |
This prospective study was conducted in the orthopedic department of our hospital from June 2015 to August 2017.
Patients presenting with shoulder pain of age above 18 years of either sex was included in the study. Patients with shoulder fractures, frozen shoulder, arthritis, bilateral shoulder pain, previous dislocation shoulder, and instability were excluded. Ethical clearance has been taken from ethical committee before conducting the study.
Unaffected opposite shoulder joint was taken as control in our study.
Diagnostic test acuuracy study design.
Calculating the sample size
The targeted study population consists of all patients who satisfy the criteria for inclusion and are not disqualified by one or more of the exclusion criteria. The included patients were a consecutive series of patients presenting at the study center. No randomization was done. The sample size was calculated assuming a sensitivity and specificity of at least 0.85, the confidence interval of 95% with a width of 0.1 and an effect size of 0.5, leading to sample size of 70 patients with the power of 0.9.
The patients of shoulder pain were evaluated by history and clinical examination. The examiner was blinded to the imaging analyses. Subsequently, all patients underwent X-ray of the shoulder and magnetic resonance imaging (MRI) of the involved shoulder as a reference standard for the final diagnosis, which was done on the same day [Figure 1].
Relevant clinical information
Appropriate demographical and historical data were recorded.
Routine clinical examination of the shoulder was performed, and then, clinical tests were selected for evaluation in the study [Table 1].,, Blood tests and other investigations were done.
Plain X-ray films of the shoulder were useful to rule out other causes of shoulder pain, such as osteoarthritis (of glenohumeral joint and acromioclavicular joint) and calcific tendinitis. Changes seen on plain films that are consistent with rotator cuff disease include acromial spurs, decreased space between the humerus and acromion, and sclerosis and cystic changes in the greater tuberosity.
Reference standard–magnetic resonance imaging
Experienced radiologist who was blinded from clinical test results reported the MRI. MRI gives a great deal of anatomic information and usually is considered the gold standard for imaging cuff disease. The normal rotator cuff tendon is of low signal on T1- and T2-weighted images. Partial-thickness rotator cuff tears most commonly appear as interruption of the normal cuff contour, resulting in a cuff defect filled with fluid signal. Full-thickness tears were seen as defect has fluid-like signal and might also see tendon retraction.,,
Data analyses/statistical analyses
Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio, and negative likelihood ratios were calculated with a 2 × 2 table.
| Results|| |
One hundred and thirty-four (134) patients were collected. Thirty-four patients were excluded as per inclusion and exclusion criteria. Effective sample size was (134–34) 100. [Table 2] shows patient's demographic characteristics. Sixty-seven patients were diagnosed with supraspinatus tendon tears. Males were affected more commonly. Right shoulder has higher incidence of supraspinatus tendon tears. [Table 3] shows different types of rotator cuff tears and their frequency. Incidence of supraspinatus tears was higher as compared to other tendons and partial tears were more common. [Table 4] and [Table 5] show various MRI diagnoses and their frequencies. Partial tear of supraspinatus tendon was the most common diagnosis. Twenty-four patients had other diagnosis [Table 5] and nine patients had normal shoulder on MRI.
The highest incidence of supraspinatus tendon tears was seen in the age group above 50–60 years, which was clinically significant (P = 0.009). Night pain has showed the highest sensitivity. Weakness and smoking have highest specificities [Table 6].
Painful arc test has highest sensitivity of 96%. Palpation test, external rotation at 0°, and drop arm test have highest specificity of 100%, 100%, and 97%, respectively. Drop arm test has positive likelihood ratio of 11, suggesting that it is very useful test in ruling in the disease. Diagnostic values of individual tests and combination of tests are presented in [Table 7] and [Table 8].
| Discussion|| |
This study evaluates diagnostic values of individual patient's characteristics, symptoms, and clinical tests in supraspinatus tendon tears. The prevalence of supraspinatus tendon tears in our study is 67%; in other studies, it is 40%.,
According to Murrell and Walton and van Kampen et al., rotator cuff tear prediction increases with increasing age. Our study also showed increased incidence of cuff tear in 51–60 years of age group. In our study, age above 50.5 years has very significant correlation (P = 0.009) with supraspinatus tendon tears. Night pain has sensitivity of 89% in the study by van Kampen et al., while our study showed similar result (89%). Further, radiation of pain and patients taking analgesics showed high sensitivities of 73% and 78%, respectively. Weakness has 34% sensitivity and 55% specificity in the study by van Kampen et al., while our study had sensitivity of 40% and specificity of 88% for weakness.
Sensitivity of clinical tests ranged from 6% to 96%. Painful arc test showed highest sensitivity of 96%, which was also reported in study by Park et al. Hawkins test had highest sensitivity of 95.2%.
Specificity of clinical tests ranged from 21% to 100%. Palpation test and external rotation test at 0° showed highest specificity and PPV of 100%. Drop arm test had specificity of 97%. Park et al. showed that infraspinatus muscle test had highest specificity of 75% and highest PPV of 90.6% for rotator cuff disease of any type. Drop arm test had highest specificity of 100%. In the study by Wolf and Agrawal, the transdeltoid palpation test was found to have a sensitivity of 95.7%, a specificity of 96.8%, a PPV of 95.7%, a NPV of 96.8%, and an overall accuracy of 96.3%.
The present study (2018), Ardic et al., Kim et al., Caliş et al., and Itoi et al. have MRI as reference standard. Barth et al., Itoi et al., Park et al., and MacDonald et al. have arthroscopy as reference standard. Holtby and Razmjou, Murrell and Walton, and Leroux et al. have operation as reference standard. Study designs with operation and arthroscopy as reference standard are invasive and can induce verification bias because only patients who require surgery were tested with reference standard.
According to Murrell and Walton, when all three tests are positive (supraspinatus weakness, weakness in external rotation, and impingement) or if two tests were positive and patient's age is >60 years, there is 98% chance of having the rotator cuff tear. Combined absence of these features excludes the diagnosis. According to Park et al., Hawkins test, painful arc test, and weakness in external rotation form the best combination in diagnosing overall impingement syndrome. According to Ardic et al. and McDonald et al., combination of Hawkins test and/or Neer test was diagnostically inaccurate. According to our study (2018), Neer test, painful arc test, and full can test form the best combination in diagnosing supraspinatus tears of any type. Individual clinical tests do not have higher sensitivity, specificity, PPV, NPV, positive likelihood ratio, and negative likelihood ratio all together, hence requiring combination of clinical tests and/or prediction model. The present study confirms that combination of clinical tests improves the diagnostic value for supraspinatus tears.
Limitation of our study
(1) Small sample size of 100 patients, but we have ensured all patients have undergone rigid protocol. (2) Examiner was not blinded about history information of the patient, which might influence the test results. Bias was tried to be avoided by performing rigid fixed order of clinical tests. (3) We did not assess every clinical test for supraspinatus tear that was published. (4) Intra- and inter-observer reliability in conducting clinical tests and in interpreting of MRI results was not studied. (5) Fatigue component leading to positive result was not studied.
| Conclusions|| |
Our study shows that individual clinical tests were less accurate in diagnosing supraspinatus tendon tears as compared to combination tests. Diagnostic value improves significantly when clinical tests are combined together. Neer test, painful arc test, and full can test form the best combination in diagnosing supraspinatus tears of any type. This study is useful in low-income countries with limited access to MRI and to limit the number of MRI ordered.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barr KP. Rotator cuff disease. Phys Med Rehabil Clin N Am 2004;15:475-91.
Jain NB, Wilcox RB 3rd
, Katz JN, Higgins LD. Clinical examination of the rotator cuff. PM R 2013;5:45-56.
Longo UG, Berton A, Ahrens PM, Maffulli N, Denaro V. Clinical tests for the diagnosis of rotator cuff disease. Sports Med Arthrosc Rev 2011;19:266-78.
McFarland EG, Garzon-Muvdi J, Affonso J, Petersen SA. Examination of the shoulder for rotator cuff disease. In: Maffulli N, Furia J, editors. Rotator cuff disorders: Basic Science and Clinical Medicine. London: Jaypee Medical Publishers; 2012. p. 41-54.
Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SM, et al.
Does this patient with shoulder pain have rotator cuff disease? The rational clinical examination systematic review. JAMA 2013;310:837-47.
Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT 3rd
, et al.
Physical examination tests of the shoulder: A systematic review with meta-analysis of individual tests. Br J Sports Med 2008;42:80-92.
Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, et al.
Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med 2012;46:964-78.
Guyatt GH, Mills EJ, Elbourne D. In the era of systematic reviews, does the size of an individual trial still matter. PLoS Med 2008;5:e4.
Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane database of systemic reviews 2013.
Ellenbogen PH, Tashjian JH. RadiologyInfo: Reaching out to touch patients. J Am Coll Radiol 2007;4:809-15.
Awh MH, Stadnick ME. MRI challenge. Sports health- multidisciplinary approach. J Sports Health - A Multidisciplinary Approach 2009;1:180-3.
Murrell GA, Walton JR. Diagnosis of rotator cuff tears. Lancet 2001;357:769-70.
van Kampen DA, van den Berg T, van der Woude HJ, Castelein RM, Scholtes VA, Terwee CB, et al.
The diagnostic value of the combination of patient characteristics, history, and clinical shoulder tests for the diagnosis of rotator cuff tear. J Orthop Surg Res 2014;9:70.
Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am 2005;87:1446-55.
Wolf EM, Agrawal V. Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears. J Shoulder Elbow Surg 2001;10:470-3.
Ardic F, Kahraman Y, Kacar M, Kahraman MC, Findikoglu G, Yorgancioglu ZR, et al.
Shoulder impingement syndrome: Relationships between clinical, functional, and radiologic findings. Am J Phys Med Rehabil 2006;85:53-60.
Kim E, Jeong HJ, Lee KW, Song JS. Interpreting positive signs of the supraspinatus test in screening for torn rotator cuff. Acta Med Okayama 2006;60:223-8.
Caliş M, Akgün K, Birtane M, Karacan I, Caliş H, Tüzün F, et al.
Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis 2000;59:44-7.
Itoi E, Kido T, Sano A, Urayama M, Sato K. Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon? Am J Sports Med 1999;27:65-8.
Barth JR, Burkhart SS, De Beer JF. The bear-hug test: A new and sensitive test for diagnosing a subscapularis tear. Arthroscopy 2006;22:1076-84.
Itoi E, Minagawa H, Yamamoto N, Seki N, Abe H. Are pain location and physical examinations useful in locating a tear site of the rotator cuff? Am J Sports Med 2006;34:256-64.
MacDonald PB, Clark P, Sutherland K. An analysis of the diagnostic accuracy of the Hawkins and Neer Subacromial impingement signs. J Shoulder Elbow Surg 2000;9:299-301.
Holtby R, Razmjou H. Validity of the supraspinatus test as a single clinical test in diagnosing patients with rotator cuff pathology. J Orthop Sports Phys Ther 2004;34:194-200.
Leroux JL, Thomas E, Bonnel F, Blotman F. Diagnostic value of clinical tests for shoulder impingement syndrome. Rev Rhum Engl Ed 1995;62:423-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]