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The Rational Clinical Examination | Clinician's Corner

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

Jolanda J. Luime, MSc; Arianne P. Verhagen, PhD; Harald S. Miedema, MD; Judith I. Kuiper, PhD; Alex Burdorf, PhD; Jan A. N. Verhaar, PhD, MD; Bart W. Koes, PhD
JAMA. 2004;292(16):1989-1999. doi:10.1001/jama.292.16.1989.
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Context History taking and clinical tests are commonly used to diagnose shoulder pain. Unclear is whether tests and history accurately diagnose instability or intra-articular pathology (IAP).

Objective To analyze the accuracy of clinical tests and history taking for shoulder instability or IAP.

Data Sources Relevant studies identified through PubMed, EMBASE, CINAHL, and bibliographies of known primary and review articles.

Study Selection Studies comparing the performance of history items or physical examination with a reference standard were included. Studies on fibromyalgia, fractures, or systemic disorders were excluded. Of 1449 articles, 35 were eligible, and 17 were selected.

Data Extraction Data were extracted on study population, clinical tests, reference tests, and outcome. The studies’ methodological quality (patient spectrum, verification, blinding, and replication) was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist.

Data Synthesis Six tests showed positive likelihood ratios (LRs) and confidence intervals (CIs). Tests favoring the diagnosis for establishing instability included: relocation (LR, 6.5; 95% CI, 3.0-14.0) and anterior release (LR, 8.3; 95% CI, 3.6-19). Tests showing promise for establishing labral lesions included: the biceps load I and II (LR, 29; 95% CI, 7.3-115.0 and LR, 26; 95% CI, 8.6-80.0), respectively, pain provocation of Mimori (LR, 7.2; 95% CI, 1.6-32.0), and internal rotation resistance strength (LR, 25; 95% CI, 8.1-76.0). The apprehension, clunk, release, load and shift, and sulcus sign tests proved less useful. Results should be cautiously interpreted because studies were completed in select populations in orthopedic practice, mostly assessed by the test designers, and evaluated in single studies only. No accuracy studies were found for history taking or for clinical tests in primary care.

Conclusions Shoulder complaints are frequently recurrent. Instability might cause some of these complaints. Best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests.

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Figure 3. Clinical Tests to Evaluate Anterior Instability of the Shoulder
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A, Apprehension test, although of limited clinical value because of low specificity, is included as part of a sequence of tests for shoulder instability. It is conducted with the patient sitting or standing, with the arm placed in 90° abduction and 90° external rotation and the elbow flexed 90°. Pressure is applied to the posterior aspect of the humerus. B, Relocation test, performed to relieve symptoms (pain and apprehension) of instability, is conducted with the patient supine and the arm abducted to 90° and externally rotated to 90°. Downward (posterior) pressure is applied to the humeral head. C, The anterior release test is conducted in a similar manner as the relocation test, then the examiner’s hand is removed suddenly, releasing pressure on the humeral head.

Figure 2. Radiograph of Shoulder Luxation
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Figure 1. Anatomy of the Shoulder
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Figure 4. Clinical Tests for Labral Tears
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A, Biceps load test II is performed with the patient supine, the arm is placed in 120° abduction (90° abduction in biceps load test I), and the elbow is placed in 90° flexion. The patient is asked to resist the lateral force applied by the examiner. B, In the pain provocation test of Mimori, the arm is placed in 90° abduction, the elbow in 90° flexion, and the forearm in maximum supination. To provoke symptoms, the examiner moves the forearm into maximum pronation. C, Internal rotation resistance strength test (test of Zaslav) is conducted with the patient standing or sitting, the humerus in 90° abduction and 80° external rotation. The patient is asked to resist an external rotation force applied by the examiner, then to resist an applied internal rotation force.




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The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Original Article: Does This Patient Have an Instability of the Shoulder or a Labrum Lesion?