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The Rational Clinical Examination |

Does This Patient With Shoulder Pain Have Rotator Cuff Disease?  The Rational Clinical Examination Systematic Review

Job Hermans, MD, MSc1; Jolanda J. Luime, PhD2; Duncan E. Meuffels, MD, PhD1; Max Reijman, PhD1; David L. Simel, MD, MHS3; Sita M. A. Bierma-Zeinstra, PhD1,4
[+] Author Affiliations
1Department of Orthopaedic Surgery, Erasmus MC University Medical Centre Rotterdam, Rotterdam, the Netherlands
2Department of Rheumatology, Erasmus MC University Medical Centre Rotterdam
3Department of Internal Medicine, Durham Veterans Affairs Medical Center and Duke University, Durham, North Carolina
4Department of General Practice, Erasmus MC University Medical Centre Rotterdam
JAMA. 2013;310(8):837-847. doi:10.1001/jama.2013.276187.
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Importance  Rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians.

Objective  To perform a meta-analysis to identify the most accurate clinical examination findings for RCD.

Data Sources  Structured search in MEDLINE, EMBASE, and CINAHL from their inception through May 2013.

Study Selection  For inclusion, a study must have met the following criteria: (1) description of history taking, physical examination, or clinical tests concerning RCD; (2) detailing of sensitivity and specificity; (3) use of a reference standard with diagnostic criteria prespecified; (4) presentation of original data, or original data could be obtained from the authors; and (5) publication in a language mastered by one of the authors (Danish, Dutch, English, French, German, Norwegian, Spanish, Swedish).

Main Outcomes and Measures  Likelihood ratios (LRs) of symptoms and signs of RCD or of a tear, compared with an acceptable reference standard; quality scores assigned using the Rational Clinical Examination score and bias evaluated with the Quality Assessment of Diagnostic Accuracy Studies tool.

Results  Twenty-eight studies assessed the examination of referred patients by specialists. Only 5 studies reached Rational Clinical Examination quality scores of level 1-2.The studies with quality scores of level 1-2 included 30 to 203 shoulders with the prevalence of RCD ranging from 33% to 81%. Among pain provocation tests, a positive painful arc test result was the only finding with a positive LR greater than 2.0 for RCD (3.7 [95% CI, 1.9-7.0]), and a normal painful arc test result had the lowest negative LR (0.36 [95% CI, 0.23-0.54]). Among strength tests, a positive external rotation lag test (LR, 7.2 [95% CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95% CI, 2.6-12]) were the most accurate findings for full-thickness tears. A positive drop arm test result (LR, 3.3 [95% CI, 1.0-11]) might help identify patients with RCD. A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95% CI, 0.0-0.58]).

Conclusions and Relevance  Because specialists performed all the clinical maneuvers for RCD in each of the included studies with no finding evaluated in more than 3 studies, the generalizability of the results to a nonreferred population is unknown. A positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting RCD, whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear.

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Figure 1.
Musculoskeletal Anatomy of the Shoulder and Range of Motion Created by the Rotator Cuff Muscles
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Figure 2.
Recommended Clinical Tests for the Evaluation of Rotator Cuff Disease

A, The positive result of the painful arc test, a pain provocation test, is characteristic shoulder pain during abduction of the arm between 60° and 120°, suggesting a subacromial impingement syndrome or rotator cuff disorder due to compression of the rotator cuff muscles and subacromial bursa between the humeral head, acromion, or coracoid process. B, Strength tests assess muscle function of a specific rotator cuff muscle, producing weakness, pain, or both, especially when the patient has a partial rotator cuff tear. During such tests, the patient either moves the arm toward a certain position or maintains a certain position of the arm or shoulder against gravity. The internal rotation lag test evaluates the subscapularis muscle. The external rotation lag test assesses both the supraspinatus and infraspinatus muscles. The drop arm test assesses the integrity of the supraspinatus muscle. A positive test result is an immediate drop of the arm accompanied by pain. C, The external rotation resistance test is a composite test of the infraspinatus muscle. The test is positive when the patient experiences either pain or weakness during the maneuver.

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