229
SYSTEMATIC REVIEW
Diagnostic Accuracy of Clinical Tests for Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis Marwan Alqunaee, RCSI, Rose Galvin, BSc (Physio), PhD, Tom Fahey, MD, FRCGP ABSTRACT. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil 2012;93:229-36. Objective: To examine the accuracy of clinical tests for diagnosing subacromial impingement syndrome (SIS). Data Sources: A systematic literature search was conducted in January 2011 to identify all studies that examined the diagnostic accuracy of clinical tests for SIS. The following search engines were used: Cochrane Library, EMBASE, Science Direct, and PubMed. Study Selection: Two reviewers screened all articles. We included prospective or retrospective cohort studies that examined individuals with a painful shoulder, reported any clinical test for SIS, and used arthroscopy or open surgery as the reference standard. The search strategy yielded 1338 articles of which 1307 publications were excluded based on title/abstract. Sixteen of the remaining 31 articles were included. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were followed to conduct this review. Data Extraction: The number of true positives, false positives, true negatives, and false negatives for each clinical test were extracted from relevant studies, and a 2⫻2 table was constructed. Studies were combined using a bivariate randomeffects model. Heterogeneity was assessed using the variance of logit-transformed sensitivity and specificity. Data Synthesis: Ten studies with 1684 patients are included in the meta-analysis. The Hawkins-Kennedy test, Neer’s sign, and empty can test are shown to be more useful for ruling out rather than ruling in SIS, with greater pooled sensitivity estimates (range, .69 –.78) than specificity (range, .57–.62). A negative Neer’s sign reduces the probability of SIS from 45% to 14%. The drop arm test and lift-off test have higher pooled specificities (range, .92–.97) than sensitivities (range, .21–.42), indicating that they are more useful for ruling in SIS if the test is positive.
From the HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland. Supported by the Health Research Board (HRB) of Ireland through the HRB Centre for Primary Care Research (grant no. HRC/2007/1). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Rose Galvin, BSc (Physio), PhD, HRB Centre for Primary Care Research, Dept of General Practice, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Republic of Ireland, e-mail:
[email protected]. 0003-9993/12/9302-00341$36.00/0 doi:10.1016/j.apmr.2011.08.035
Conclusions: This systematic review quantifies the diagnostic accuracy of 5 clinical tests for SIS, in particular the lift-off test. Accurate diagnosis of SIS in clinical practice may serve to improve appropriate treatment and management of individuals with shoulder complaints. Key Words: Meta-analysis; Rehabilitation; Sensitivity and specificity; Subacromial impingement syndrome. © 2012 by the American Congress of Rehabilitation Medicine
HOULDER PAIN IS the third most common musculoskS eletal consultation in primary care, and second most common cause of referrals to orthopedic and sports medicine clin-
ics.1,2 The differential diagnosis of conditions that cause shoulder pain is a challenging and complex area of musculoskeletal practice. Subacromial impingement syndrome (SIS) is the most frequent cause of shoulder pain. SIS is a clinical syndrome that indicates pain and pathology relating to the subacromial bursa and rotator cuff tendons within the subacromial space. The 3 stages of SIS are subacromial bursitis, partial-thickness and full-thickness rotator cuff tears.3 The cause of SIS is considered to be multifactorial, with both extrinsic and intrinsic factors involved in its pathogenesis.4 The primary factors relating to the intrinsic theory are muscle overload and weakness, shoulder overuse and repetitive tissue microtrauma, and degeneration of the rotator cuff. The key elements of the extrinsic hypothesis are shape of the acromion, glenohumeral instability, altered scapulothoracic rhythm, os acromiale, and degeneration of the acromioclavicular joint.5,6 Clinicians have traditionally relied on a clinical examination comprising a subjective history and physical examination, followed by various clinical tests to diagnose SIS. Numerous clinical tests have been described to evaluate the presence of impingement syndrome and to determine the integrity of the individual components of the rotator cuff.7 These tests can be broadly classified as impingement or pain provocation tests and rotator cuff strength tests. Impingement tests are designed to reproduce symptoms or pain by compressing the greater tuberosity against the acromion.8,9 Rotator cuff strength tests assess the integrity of the individual rotator cuff tendons and their respective musculotendinous units. Table 1 contains the comList of Abbreviations CI LR PRISMA QUADAS ROC SIS
confidence interval likelihood ratio preferred reporting items for systematic reviews and meta-analyses quality assessment of diagnostic accuracy studies receiver operating characteristic subacromial impingement syndrome
Arch Phys Med Rehabil Vol 93, February 2012
230
SUBACROMIAL IMPINGEMENT SYNDROME, Alqunaee Table 1: Clinical Tests Used in the Diagnosis of SIS Shoulder Pathology
Muscle Function
Clinical Test
SIS Supraspinatus tear
Not applicable Initiates arm abduction
Infraspinatus and teres minor tear
Lateral rotation of arm and adduction. Medial rotation of the arm and adduction
Subscapularis tear
mon clinical tests that are used to assist in the diagnosis of SIS. A recent review10 examined the diagnostic accuracy of clinical tests for different shoulder pathologies, including SIS. However, the included studies used various reference standards in the diagnosis. The aim of this systematic review and metaanalysis is to determine the diagnostic accuracy of common clinical tests to detect SIS.
Neer’s sign, Hawkins-Kennedy test, horizontal adduction test Empty can test, full can test, drop arm test, painful arc test, supraspinatus palpation, resisted abduction Resisted external rotation (infraspinatus test), external rotation lag sign, Patte’s test, Hornblower’s sign Bear-hug test, belly-press test/Napoleon test, belly-off test, lift-off test, internal rotation lag sign, internal rotation strength test
METHODS Search Strategy The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for the reporting of systematic review and meta-analysis were followed to conduct this
Fig 1. PRISMA flow diagram of the studies.
Arch Phys Med Rehabil Vol 93, February 2012
231
SUBACROMIAL IMPINGEMENT SYNDROME, Alqunaee
review.11 A literature search was conducted in January 2011 and included the following search engines: the Cochrane Library, EMBASE, Science Direct, and PubMed. The databases were searched using a combination of key words and Medical Subject Headings of the National Library of Medicine designed to identify index tests, the diagnostic accuracy set, and the target condition. The following key words were included: “physical examination” OR “clinical examination” OR “routine diagnostic tests” OR “diagnostic tests, routine” AND “shoulder” OR “shoulder pain” OR “shoulder impingement syndrome” OR “bursitis” OR “tendinopathy” OR “rotator cuff” AND “sensitivity and specificity” OR “sensitivity” AND “specificity” OR sensitiv* (text word) OR “diagnosis.” Checking references of the relevant articles and searching Google
Scholar supplemented the search. No restrictions were placed on language. Study Selection Studies were included if they met the following inclusion criteria: 1. Study design: Prospective or retrospective cohort studies 2. Patient population: Adult patients (age ⬎16y) with a painful shoulder 3. Explanatory variables: Any index test contained in table 1 reported 4. Setting of care: Inpatient and outpatient settings 5. Reference test: Arthroscopy or open surgery; findings include the presence of an enlarged or fibrotic-appearing
Table 2: Characteristics of Included Studies Study 18
Barth
No. of Patients
68
Mean Age, y (Range/SD)
45.1⫾14.7 (16–76)
Fowler24
101
Hertel25
100
51 (16–79)
Holtby29
50
50 (24–79)
Leroux31
55
51 (24–77)
45 85 130
NR 40 (16–72) 46.8 (19–85)
55
40.6
Lyons19 MacDonald26 Malhi32
Michener27
40.8⫾14.6
Murrell30 Nanda7
400 50
Park28
552
NR
Scheibel21
60
55.3
Walch22
54
66 (47–80)
Wolf20 Zaslav23
109 115
51.2 (29–86) 44 (17–76)
NR 52 (29–79)
Clinical Test
Lift-off; belly-press; bearhug; Napoleon Hawkins-Kennedy; empty can; Speed’s test; O’Brien’s; apprehension; Gerber’s External rotation lag sign; drop arm sign; internal rotation lag sign Empty can Neer’s; Hawkins-Kennedy; Yocum; empty can; Patte; lift-off Rent test Hawkins-Kennedy; Neer’s Hawkins-Kennedy; Neer’s; painful arc; subacromial crepitus Hawkins-Kennedy; Neer’s; painful arc; empty can; external rotation resistance test Drop arm; O’Brien’s sign Painful arc; Hawkins-Kennedy; Neer’s; drop arm; empty can; infraspinatus strength; lift-off; Yergason’s; Speed’s Neer’s; Hawkins-Kennedy; painful arc sign; empty can; Speed’s; crossbody adduction; drop arm; infraspinatus Lift-off; internal rotation lag test; Napoleon; belly-off sign Hornblower’s; dropping sign Rent test Internal rotation resistance strength test
Reference Test
SIS Stage
Setting and Country
Arthroscopy
SIS 1–3
Orthopedic clinic, U.S.
Arthroscopy
SIS 1–3
Sports medicine clinic, UK
Arthroscopy
SIS 1–3
Orthopedic clinic, Switzerland
Arthroscopy or surgery Surgery
SIS 1–2 SIS 3 SIS 1–3
Orthopedic clinic, Canada Orthopedic clinic, France
Arthroscopy Arthroscopy Arthroscopy
SIS 2–3 SIS 1–3 SIS 1–3
Outpatient medical clinic, UK University hospital, Canada Orthopedic clinic, UK
Arthroscopy
SIS 1
Orthopedic clinic, U.S.
Arthroscopy Arthroscopy
SIS 2–3 SIS 1–3
Orthopedic clinic, Australia Orthopedic clinic, UK
Arthroscopy
SIS 1–3
Orthopedic clinic, U.S.
Arthroscopy
SIS 2–3
Musculoskeletal clinic, Germany
Arthroscopy
SIS 2–3
Orthopedic clinic, France.
Arthroscopy Arthroscopy
SIS 1–3
Medical center, U.S. Orthopedic clinic, U.S.
Abbreviations: NR, not reported; UK, United Kingdom; U.S., United States.
Arch Phys Med Rehabil Vol 93, February 2012
232
SUBACROMIAL IMPINGEMENT SYNDROME, Alqunaee
bursa (stage 1 of SIS), as well as partial or full rotator cuff tears (stages 2 and 3 of SIS, respectively). Studies that included the same data set for more than 1 publication were included once in the meta-analysis. Two reviewers (M.A., R.G.) read the titles and/or abstracts of the identified references and eliminated irrelevant studies. Studies that were considered eligible for inclusion were read fully in duplicate, and both reviewers independently determined their suitability for inclusion to the study. Disagreements were managed by consensus. Data Extraction The number of true positives, false positives, true negatives, and false negatives for each clinical test were extracted from each of the studies, and a 2⫻2 table was constructed. Discrepancies were resolved by discussion between the 2 reviewers (M.A., R.G.). Authors were contacted to provide further information when there was insufficient detail in an article to construct a 2⫻2 table. Quality Assessment The methodological quality of selected studies was assessed using the quality assessment of diagnostic accuracy studies (QUADAS) tool, a validated tool for the quality assessment of diagnostic accuracy studies.12 The QUADAS tool was modified to exclude question 13 (were uninterpretable/intermediate test results reported?) because it was irrelevant in the context of this review. Two independent reviewers (M.A., R.G.) applied the QUADAS tool to the articles included in the study, and differences in assessment were resolved by discussion. Data Synthesis and Analysis We used Stata version 10.1,a particularly the metandi commands, for all statistical analyses. We have used this methodology in previous studies13,14 of this nature. We applied the bivariate random-effects model to estimate summary estimates of sensitivity and specificity and their corresponding 95% confidence intervals (CIs). This approach was applied because it preserves the 2-dimensional nature of the original data and takes into account both study size and heterogeneity beyond chance between studies.15 It is not possible to
calculate pooled estimates using the bivariate model with less than 4 studies. Individual and summary estimates of sensitivity and specificity for each clinical test were plotted in a receiver operating characteristic (ROC) graph, plotting the test’s sensitivity (true positive) on the y axis against 1 minus specificity (false negative) on the x axis. We also plotted the 95% confidence region and the 95% prediction region around the pooled estimates to illustrate the precision with which the pooled values were estimated (confidence ellipse around the mean value). The 95% confidence contour around the summary estimate of sensitivity and specificity may be considered as a 2-dimensional confidence interval. The main axis of the 95% confidence region represents the correlation between sensitivity and specificity (threshold effect). The 95% prediction region displays a 2-dimensional SD of the individual studies included in the analysis. The area of the 95% prediction region beyond the 95% confidence region reflects significant between-study variation (heterogeneity).16 We evaluated heterogeneity visually using the summary ROC plots and statistically by using the variance of logittransformed sensitivity and specificity, with smaller values indicating less heterogeneity among studies. We used Bayes’ theorem to estimate the posttest probability of SIS, by multiplying the pretest odds by the likelihood ratio (LR), where pretest odds are calculated by dividing the pretest probability by (1 – pretest probability), and the posttest probability equals posttest odds divided by (1 ⫹ posttest odds).17 To estimate the prevalence (pretest probability) of the condition in the studies included in our review, we used the following formula: (true positives ⫹ false negatives)/ (true positives ⫹ false positives ⫹ false negatives ⫹ true negatives). RESULTS Study Identification A flow diagram of the search strategy is presented in figure 1. Two researchers screened all potential articles. The search strategy yielded 1338 articles, of which 1307 publications were excluded based on their title or abstract. Sixteen of the remain-
Table 3: Description of the Clinical Tests Included in the Meta-Analysis Clinical Test
Neer’s sign
Hawkins-Kennedy test
Empty can test (supraspinatus)
Drop arm sign
Lift-off test
Description
The examiner stabilizes the scapula and asks the patient to forward flex the arm until he reports pain or until full elevation is reached.31,32 The examiner places the arm in 90° of forward flexion and then gently internally rotates the arm. The endpoint for internal rotation is either when the patient feels pain or when the rotation of the scapula is felt or observed by the examiner. The test is positive when the patient experience pain during the maneuver.33 The examiner asks the patient to elevate and internally rotate the arm with thumbs pointing downwards in the scapular plane. The elbow should be fully extended. In this position the examiner applies downward pressure on the upper surface of the arm.34,35 The patient fully elevates the arm and then slowly reverses the motion in the same arc. If the arm is dropped suddenly or the patient has severe pain, the test is considered to be positive.36 The patient internally rotates the shoulder, placing the hand on the ipsilateral buttock. He is then asked to lift the hand off the buttock against resistance. A tear in the subscapularis muscle produces weakness of this action.37
Arch Phys Med Rehabil Vol 93, February 2012
Endpoint Sign
Pain
Pain
Weakness
Pain or weakness
Weakness
233
SUBACROMIAL IMPINGEMENT SYNDROME, Alqunaee
Table 5: Summary Estimates of Positive and Negative LRs Using a Bivariate Random-Effects Model Clinical Test
LR⫹
95% CI
–LR
95% CI
Hawkins-Kennedy test Neer’s sign Empty can test Drop arm test Lift-off test
1.70 1.86 1.81 2.62 16.47
1.29–2.26 1.49–2.31 1.16–2.83 1.60–4.30 1.46–185.61
.46 .37 .50 .86 .59
.27–.78 .25–.55 .40–.63 .79–.94 .37–.97
Quality Assessment The overall summary of the quality assessment is illustrated in figure 2. The methodological quality of the studies included ranges from moderate to good. The primary concerns with methodological quality relate to the time delay between the clinical test and the reference test, and it is unclear in many studies whether the assessors were blinded to the outcome of index and reference tests.
Fig 2. Methodological quality of the included studies.
ing 31 articles met the inclusion criteria and were selected for inclusion in the review.7,18-32 Study Description Table 2 summarizes the characteristics of the included studies. The 16 studies include 2390 patients and were carried out in orthopedic or musculoskeletal outpatient clinics. Five studies were carried out in the United States,18,20,23,27,28 4 in the United Kingdom,7,19,24,32 2 in Canada,26,29 2 in France,22,31 1 in Germany,21 1 in Switzerland,25 and 1 in Australia.30 All publications are in English. Surgical diagnosis is the reference standard in all studies included. The included studies range in size from 4519 to 552 patients.28 Twenty-one different clinical tests were conducted to examine the integrity of the rotator cuff. The most common clinical tests reported in the studies for determining subacromial impingement are the Neer’s sign, reported in 6 studies,7,26-28,31,32 and the Hawkins-Kennedy test, conducted in 7 studies.7,24,26-28,31,32 The Jobe/ empty can test was performed in 7 studies and determines the integrity of the supraspinatus muscle.7,24,25,27-29,31 The lift-off test examines the integrity of the subscapularis muscle and was conducted in 6 studies.7,18,21,24,25,31 The “drop arm” sign examines the integrity of infraspinatus and was reported in 4 studies.7,25,28,30 A description of these tests is detailed in table 3. Ten studies with 1684 patients are included in the meta-analysis.
Diagnostic Test Accuracy of 5 Clinical Tests The pooled sensitivities and specificities and the respective variance of the logit-transformed sensitivity and specificity for each clinical test are presented in table 4. Furthermore, the summary estimates of positive and negative LRs are shown in table 5. All the clinical tests are identified as having useful diagnostic value, as their CIs do not cross the line of no effect. A positive Hawkins-Kennedy test, Neer’s sign, and empty can test are found to increase the probability of SIS. However, the Neer’s sign has the highest pooled sensitivity of .78 (95% CI, .68 –.87), indicating that a negative Neer’s sign is useful to “rule out” SIS. With the use of Bayes’ theorem, a negative Neer’s sign decreases the probability of SIS from 45% to 14%. The lift-off test appears to have the highest diagnostic utility (LR⫹, 16.47), with a pooled specificity of .97 (95% CI, .79 –1) and sensitivity of .42 (95% CI, .19 –.69). This indicates that a positive lift-off test is more useful at “ruling in” SIS. However, the pretest probability of the condition is high. Therefore, with the use of Bayes’ theorem, a positive lift-off test only increases the probability of SIS from 82% to 93%. The individual and summary estimates of sensitivity and specificity, the 95% CI region, and the 95% prediction region for each clinical test are presented in an ROC graph in figure 3. The 95% CI remains large for the lift-off test, indicating that there is greater precision for the pooled estimates of the other tests. The 95% prediction region (amount of variation between studies) is also wide for most of the clinical tests, as reflected in the large values for the variance of logit-transformed sensitivity and specificity.
Table 4: Summary Estimates of Sensitivity and Specificity Using a Bivariate Random-Effects Model Clinical Test
No. of Studies
No. of Patients
Pooled Sensitivity
95% CI
Variance Logit (Sensitivity)
Pooled Specificity
95% CI
Variance Logit (Specificity)
Hawkins-Kennedy test Neer’s sign Empty can test Drop arm test Lift-off test
6 5 6 5 4
1029 1127 695 1213 267
.74 .78 .69 .21 .42
.57–.85 .68–.87 .54–.81 .14–.30 .19–.69
0.63 0.13 0.52 0.19 1.12
.57 .58 .62 .92 .97
.46–.67 .47–.68 .38–.81 .86–.96 .79–1
0.20 0.08 1.30 0.20 2.32
Arch Phys Med Rehabil Vol 93, February 2012
234
0
Sensitivity .4 .6 0
0
.2
.2
.2
Sensitivity .4 .6
Sensitivity .4 .6
.8
.8
.8
1
1
1
SUBACROMIAL IMPINGEMENT SYNDROME, Alqunaee
1 1
.8
.6 .4 1-Specificity
Summary point 95% confidence region
.2
.8
.6 .4 1-Specificity
0
Study estimate HSROC curve 95% prediction region
HSROC curve 95% prediction region
AUC=0.67 (0.63-0.71)
0
1
.8
.4 .6 1-Specificity
Study estimate HSROC curve 95% prediction region
AUC=0.69 (0.65-0.73)
.2
0
Summary point 95% confidence region AUC=0.71 (0.67-0.75)
EMPTY CAN
NEER’S
0
0
.2
.2
Sensitivity .4 .6
Sensitivity .4 .6
.8
.8
1
1
HAWKINS-KENNEDY
.2
Summary point 95% confidence region
1
.8
.6 .4 1-Specificity
Study estimate HSROC curve 95% prediction region
.2
0
Summary point 95% confidence region AUC=0.55 (0.50-0.59)
DROP ARM
1
.8
.4 .6 1-Specificity
Study estimate HSROC curve 95% prediction region
.2
0
Summary point 95% confidence region AUC=0.85 (0.82-0.88)
LIFT-OFF TEST
Fig 3. ROC graphs with 95% confidence region and 95% prediction region for each clinical test. Abbreviations: AUC, area under the curve; HSROC, Hierarchical Summary Receiver Operating Characteristic.
DISCUSSION Statement of Principal Findings We assessed the discriminative value of 5 clinical tests suggestive of SIS when assessed against the surgical reference standard. The Hawkins-Kennedy test, the Neer’s sign, and the empty can test, have higher sensitivities than specificities. Therefore, patients are more likely not to have SIS when these 3 tests are negative. In contrast, the drop arm test and the lift-off test have higher specificities, indicating that when the clinical test is positive, SIS is more likely to be present. The lift-off test has the highest diagnostic utility (⫹LR, 16.7) and provides strong evidence to rule in SIS when the test is positive. This is the first systematic review to examine the diagnostic accuracy of these common clinical tests, with a surgical diagnosis as the reference standard. Indirect imaging methods including magnetic resonance imaging, diagnostic ultrasound, and double-contrast arthrography have also been used as criterion reference standards in diagnostic accuracy studies; however, these methods have varying degrees of accuracy for evaluating shoulder pathology.8 We excluded 12 studies that used these alternative reference standards. We considered pooling the results of the clinical tests in these studies to facilitate a comparison of different reference tests; however, a metaArch Phys Med Rehabil Vol 93, February 2012
analysis was not possible because pooled estimates cannot be calculated using the bivariate model when there are less than 4 studies. Current Context and Future Research Directions Patients with shoulder pain are commonly seen by general practitioners and by physiotherapists in private practice clinics. No studies in this review have investigated the diagnostic accuracy of clinical tests in a primary care setting. The studies included investigated the diagnostic accuracy of SIS and rotator cuff integrity tests in specialist clinics where different clinicians including medical practitioners, rheumatologists, and orthopedic surgeons conduct the clinical examination of patients. There is a need for future prospective cohort studies in primary care settings to investigate the diagnostic utility of these clinical tests. In addition, it is important to consider the methodological quality of the studies included in the review. The time between performing the clinical test and the surgical reference standard is generally poorly reported, and in studies where it is reported, the time lag varies from days to months. Future studies should minimize the time delay between the index and reference test to reduce the possibility of a change in the pathology of SIS. In addition, it is not clear in many of the studies whether the surgeon performing the arthroscopy was blinded to the clinical tests. Furthermore, the effect of examiner
SUBACROMIAL IMPINGEMENT SYNDROME, Alqunaee
training and experience on the outcome of the clinical test needs to be considered. In the current systematic review, we examined the most commonly used clinical tests and their accuracy as diagnostic tools for SIS. Night pain, crepitus, and pain and weakness with overhead movement are commonly reported symptoms of patients with SIS.4 Very few studies have investigated the value of historical and subjective features from a clinical examination for SIS and rotator cuff tears. It may be useful to examine the diagnostic usefulness of signs and symptoms in future studies of this nature. Clinical Implications The diagnosis of shoulder pathology is a challenging and complex process. The signs and symptoms associated with most pathologies affecting the structures of the shoulder, especially those linked to SIS, are very similar. Furthermore, patients may have a combination of SIS pathologies such as a rotator cuff tear and subacromial bursitis. Current international guidelines recommend that an accurate diagnosis of painful and disabling SIS will ultimately guide the treatment and management options of the patient.33,34 The guidelines suggest that clinical tests such as the Neer’s sign, Hawkins-Kennedy test, and drop arm test may be helpful as part of the clinical examination. In our systematic review, the summary estimates of the positive LRs for the Hawkins-Kennedy test, Neer’s test, empty can test, and drop arm test provide limited diagnostic information and should be interpreted with caution. However, our meta-analysis indicated that the lift-off test has the highest diagnostic utility, particularly for ruling in the condition when the test is positive. It is also imperative that clinicians are aware of the correct management of individuals with SIS to optimize recovery and minimize residual impairment. The guidelines recommend that individuals with mild to moderate SIS (subacromial bursitis and partial-thickness rotator cuff tear) carry out a supervised exercise rehabilitation program by a recognized treatment provider such as a physiotherapist.34 It is also advised that patients with end-stage SIS (full-thickness rotator cuff tear) or extensive structural damage to the rotator cuff be referred for urgent surgical review. An early diagnosis of full-thickness tear is particularly important in those patients who are active and “physiologically young,” to inform the surgical management of such patients.34 Study Limitations We acknowledge that this review has limitations. We were unable to extract data from some studies, particularly the older articles19,31; therefore, these studies were not included in the meta-analysis. In addition, the variety in the clinical tests performed in the different studies meant that not all studies were included in the meta-analysis. Furthermore, variability of diagnostic accuracy estimates across studies is high. This may be due to a number of factors including age, sex, occupation, underlying conditions, and recreational activities. It is known that the prevalence of SIS differs across age groups and sex.4 In addition, research shows that the severity and underlying cause of the SIS may affect the diagnostic accuracy of the individual clinical tests. In our review, only 1 study28 investigated clinical tests for all 3 stages of pathology of SIS, from subacromial bursitis to full-thickness rotator cuff tears. CONCLUSIONS Accurate diagnosis of SIS is a challenge to clinicians, and the diagnostic accuracy of some of the clinical tests used in
235
clinical practice needs to be considered in the context of the overall patient assessment. The lift-off test provides strong evidence to rule in SIS when the test is positive. Accurate clinical diagnosis of SIS may serve to reduce the number of unnecessary referrals to surgery, physiotherapy, or both, thus saving time and costs for both the patient and the health system. References 1. Urwin M, Symmons D, Allison T. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Ann Rheum Dis 1998;57:649-55. 2. Butcher J, Zukowski C, Brannen S, et al. Patient profile, referral sources, and consultant utilization in a primary care sports medicine clinic. J Fam Pract 1996;43:556-60. 3. Van der Windt D, Koes B, De Jong B, Bouter L. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis 1995;54:959-64. 4. Harvey H. The diagnosis of subacromial impingement syndrome and associated pathology in the primary care setting. Aukland: Auckland University of Technology; 2009. 5. Lewis JS. Rotator cuff tendinopathy and subacromial impingement syndrome: is it time for a new method of assessment? Br J Sports Med 2009;43:259-64. 6. Hyvonen P. The pathogenesis of subacromial impingement syndrome. Oulu: University of Oulu; 2003. 7. Nanda R, Gupta S, Kanapathipillai P, Liow R, Rangan A. An assessment of the inter examiner reliability of clinical tests for subacromial impingement and rotator cuff integrity. Eur J Orthop Surg Traumatol 2008;18:495-500. 8. Diehr S, Ison D, Jamieson B, Oh R. Clinical inquiries. What is the best way to diagnose a suspected rotator cuff tear? J Fam Pract 2006;55:621-4. 9. Bak K, Fauno P. Clinical findings in competitive swimmers with shoulder pain. Am J Sports Med 1997;25:254-60. 10. Hegedus E, Goode A, Campbell S, 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. 11. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA group. Preferred reporting items for systematic reviews and metaanalyses: the PRISMA statement. BMJ 2009;339:b2535. 12. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25. 13. Giesen L, Cousins G, Dimitrov B, van de Laar F, Fahey T. Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs. BMC Fam Pract 2010;11:78. 14. Cousins G, Hijazze S, van de Laar F, Fahey T. Diagnostic accuracy of the ID-Migraine: a systematic review and meta-analysis. Headache 2011;51:1140-48. 15. Reitsma J, Glas A, Rutjes A, Scholten R, Bossuyt P, Zwinderman A. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 2005;58:982-90. 16. Boland G, Dwamena B, Jagtiani S, et al. Characterization of adrenal masses by using FDG PET: a systematic review and meta-analysis of diagnostic test performance Radiology 2011;259: 117-26. 17. Deeks J, Altman D. Diagnostic tests 4: likelihood ratios. BMJ 2004;329:168-9. Arch Phys Med Rehabil Vol 93, February 2012
236
SUBACROMIAL IMPINGEMENT SYNDROME, Alqunaee
18. Barth J, Burkhart S, De Beer J. The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy 2006;22:1076-84. 19. Lyons A, Tomilson J. Clinical diagnosis of tears of the rotator cuff. J Bone Joint Surg Br 1992;74:414-5. 20. Wolf E, Agrawal V, Calif S. Transdeltoid palpation (the rent test) in the diagnosis of rotator cuff tears. J Shoulder Elbow Surg 2001;10:470-3. 21. Scheibel M, MAgosch P, Pritsch M, Lichtenberg S, Habermeyer P. The belly-off sign: a new clinical diagnostic sign for subscapularis lesions. Arthroscopy 2005;21:1229-35. 22. Walch G, Boulahia A, Calderone S, Robinson A. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone Joint Surg Br 1998;80:624-8. 23. Zaslav K. Internal rotation resistance strength test: a new diagnostic test to differentiate intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg 2001;10:23-7. 24. Fowler E, Horsley I, Rolf C. Clinical and arthroscopic findings in recreationally active patients. Sports Med Arthrosc Rehabil Ther Technol 2010;2:2. 25. Hertel R, Ballmer F, Lambert F, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 1996;5: 307-13. 26. MacDonald P, 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. 27. Michener L, Wasworth M, Doukas W, Murphy K. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil 2009;90:1898-903.
Arch Phys Med Rehabil Vol 93, February 2012
28. Park H, Yokota A, Gill H, El Rassi G, McFarland E. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome. J Bone Joint Surg Am 2005;87:1446-55. 29. 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. 30. Murrell G, Walton J. Diagnosis of rotator cuff tears. Lancet 2001;357:769-70. 31. Leroux J, Thomas E, Bonnel F, Blotman F. Diagnostic value of clinical tests for shoulder impingement syndrome. Rev Rhum Engl Ed 1995;62:423-8. 32. Malhi A, Khan R. Correlation between clinical diagnosis and arthroscopic findings of the shoulder. Postgrad Med J 2005;81: 657-9. 33. Reed Group. Rotator cuff tear. In: The medical disability advisor: workplace for guidelines for disability duration. 2009; Westminster: Reed Group. p 10. 34. Accident Compensation Corporation (ACC). The diagnosis and management of soft tissue shoulder injuries and related disorders. Available at: http://www.acc.co.nz/PRD_EXT_CSMP/groups/ external_communications/documents/guide/wcm001684.pdf. Accessed February 25, 2011. 35. Jobe F, Jobe C. Painful athletic injuries of the shoulder. Clin Orthop Relat Res 1983;173:117-24. 36. Codman EA. The shoulder. Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. 1934:123-77. 37. Gerber C, Krushell R. Islolated rupture of the tendon of subscapularis muscle. Bone joint Surg. 1991;73B:389-94. Supplier a. StataCorp, 4905 Lakeway Dr, College Station, TX 77845.
