A large percentage of my current caseload consists of shoulder pain. Often these referrals come from family practice physicians or other generalists who utilize physical therapy as a conservative precursor to an orthopedic physician. As a link in this referral chain, I look at early establishment of a appropriate rehab prognosis to be an essential function of my job.
Physical therapists are not diagnosticians, but the use of clinical diagnostic testing can give us some indication of the patients potential to respond to conservative care. A 2005 article in the Journal of Bone and Joint Surgery attempts to determine which of the numerous clinical tests of rotator cuff disease has the most clinical utility. The tests were investigated to determine their utility in assessing three degrees of rotator cuff pathology: bursitis, partial-thickness rotator cuff tear, and full-thickness rotator cuff tear. The following eight clinical tests were examined:
- Neer impingement sign
- Hawkins-Kennedy impingement sign
- Painful-arc sign
- Supraspinatus muscle strength test
- Infraspinatus muscle strength test
- Speed test
- Cross-body adduction sign
- Drop-arm sign
The authors found that sensitivity, specificity, PPV, NPV, and overall accuracy of each test showed considerable variability. The combination of Hawkins-Kennedy sign, painful arc sign, and infraspinatus muscle strength test yielded a 95% post-test probability for any type of impingement syndrome. Full thickness rotator cuff tears were found with a 91% post-test probability using a combination of the drop-arm test, painful arc sign, and infraspinatus test.
Studies such as the one cited above lend support to the notion that batteries of tests are capable of adding tremendous strength to a clinical exam for a physical therapist. Future research in our profession could look into how patients fitting into one of the three degrees of rotator cuff disease respond to various modes of physical therapy.
Park, H.B. (2005). Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. The Journal of Bone and Joint Surgery, 87(7), 1446-1455. DOI: 10.2106/JBJS.D.02335
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Great post Rod. This goes along with the relatively recent article published in AJSM on clinical tests for SLAP lesions. Those authors also found that it was a combination of tests that gave the greatest SN and SP for detection of SLAP lesions.
ReplyDeleteSad part is that for a lowly clinician like me, the articles are just a tease as I don't have the personal fortune to afford yearly subscriptions to the many journals related to PT care and treatment.
Thanks for the feedback Jason. Always great to hear from you.
ReplyDeleteRod,
ReplyDeleteI don't have access to the full text article either, so perhaps you can answer a few questions.
Do all three tests need to be positive to achieve the post-test probability, or is it some combination of the three? I also ahve the same question about the diagnosis of rotator cuff tears.
Thanks for you help, and nice work with the blog.
Jess. Sorry for the delay in responding to your question. After reviewing the article again, all three tests need to be positive as defined by the operational definitions to reach this level of probability.
ReplyDeleteThere are definitely some weakness of the study the authors acknowledge that might make it difficult to generalize across all populations we see in the clinic.
If you email or PM on rehab edge, I can send you a copy of the full article. Let me know if that would help. Take care.