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Questions and Answers
What is the positive likelihood ratio (LR) for weakness during the dropping sign test indicating a supraspinatus rotator cuff tear or bicipital tendinitis?
Which clinical test is specifically positive for detecting a subscapularis disorder?
What is the specificity of the External Rotation Lag Test for supraspinatus and infraspinatus disorders?
During the External Rotation Resistance Test, what is indicated by pain or weakness in a patient?
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What is the positive likelihood ratio for inability to maintain external rotation in the External Rotation Lag Test?
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What does a positive Neer impingement test indicate?
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What angle of shoulder abduction corresponds to a painful arc indicating subacromial impingement?
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What is the specificity of the Hawkins impingement sign?
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What does a positive Yocum test suggest?
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What is the positive likelihood ratio (LR) for the drop arm test?
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What is the likelihood ratio (LR) for 3 or more positive findings in detecting rotator cuff disease (RCD)?
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Which test has the highest positive likelihood ratio for diagnosing rotator cuff tears?
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In patients referred to shoulder specialists, what is the probability of RCD if the painful arc test is positive?
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What is the recommended first-line imaging modality for nearly all shoulder pathology?
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Which of the following tests is NOT recommended as part of the routine assessment for RCD?
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What does a finding of fewer than 3 positive tests indicate in terms of likelihood ratio for RCD?
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At what age does the population prevalence of RCD begin to increase significantly?
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What is the probability of rotator cuff disease in patients older than 70 years?
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What finding can be visualized through the use of plain X rays in relation to rotator cuff tears?
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Which combination of findings on shoulder tests is associated with the highest likelihood ratio for RCD?
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Study Notes
Acromioclavicular Joint Tenderness
- Acromioclavicular (AC) joint tenderness has low likelihood ratios (LRs) for diagnosis.
- Sensitivity is 75%, specificity is 61%.
Neer Impingement Sign
- Used to assess subacromial impingement/rotator cuff tendinitis.
- Shoulder is flexed maximally overhead.
- Positive test: pain is reproduced with full passive shoulder flexion.
- Sensitivity: 79%, Specificity: 53%
- Positive LR: 1.0 - 1.6, Negative LR: 0.60
Painful Arc of Abduction
- Shoulder pain between 60° and 120° is a positive finding for subacromial impingement/rotator cuff tendinitis.
- Positive LR: 3.7, Negative LR: 0.36
- Sensitivity: 71%, Specificity: 81%
Hawkins Impingement Sign
- Assesses supraspinatus impingement/rotator cuff tendinitis.
- Shoulder flexed 90 degrees, elbow flexed 90 degrees.
- Shoulder internally rotated to impinge the greater tuberosity on the acromion.
- Positive test: pain is reproduced.
- Sensitivity: 79%, Specificity: 59%
- Positive LR: 1.5
- When both Hawkins and Neer signs are absent, negative LR is 0.1
Passive Abduction
- Examiner passively abducts shoulder to full abduction.
- Positive test: pain is reproduced, indicating supraspinatus impingement/rotator cuff tendinitis.
- Sensitivity: 74%, Specificity: 10%
- Positive LR: 0.82, Negative LR: 2.6
Yocum Test
- Assesses rotator cuff or subacromial bursal impingement.
- Patient flexes elbow and places hand on contralateral shoulder.
- Patient elevates elbow without raising ipsilateral shoulder.
- Pain is a positive finding.
- Positive LR: 1.3, Negative LR: 0.53
- Sensitivity: 79%, Specificity: 40%
Drop Arm Test
- Assesses supraspinatus rotator cuff tear or bicipital tendinitis
- Arm passively abducted to 90 degrees, then lowered slowly.
- Positive test: immediate pain and inability to lower arm slowly.
- Positive LR: 3.3, Negative LR: 0.82
- Sensitivity: 24%, Specificity: 93%
Dropping Sign
- Assesses infraspinatus involvement (tear/RCD).
- Shoulder abducted 90 degrees, elbow flexed 90 degrees, externally rotated.
- Examiner resists external rotation.
- Pain or weakness is a positive finding.
- Positive LR: 3.2, Negative LR: 0.35
- Sensitivity: 73%, Specificity: 77%
External Rotation Lag Test
- Assesses supraspinatus and infraspinatus disorders.
- Inability to maintain external rotation is positive.
- Positive LR: 7.2
- Sensitivity: 47%, Specificity: 94%
Internal Rotation Lag Test
- Assesses subscapularis disorders.
- Inability to hold the hand in internal rotation is positive.
- Positive LR: 5.6 - 6.2
- Negative LR: 0.04
- Sensitivity: 97%, Specificity: 83%
Gerber Lift Off Test
- Assesses subscapularis disorders.
- Starting position is the same as the internal rotation lag test.
- Examiner resists as patient lifts hand away from back.
- Inability to lift hand away from back is a positive finding.
- Positive LR: 1.4 - 1.5
- Negative LR: 0.63 - 0.85
- Sensitivity: 34 - 68%, Specificity: 50 - 77%
External Rotation Resistance Test
- Assesses infraspinatus disorders.
- Pain or weakness during external rotation is positive.
- Positive LR: 2.6, Negative LR: 0.49
- Sensitivity: 63%, Specificity: 75%
Empty/Full Can Tests
- Assess supraspinatus muscle and tendon lesions, but can also engage other shoulder muscles.
- A study showed a positive LR of 2.9 for 3 or more positive findings (Hawkins, Neer, external rotation resistance, empty can, painful arc)
- Fewer than 3 positive findings conferred an LR of 0.34.
Rotator Cuff Disease (RCD) Interpretation
- Internal and external rotation lag tests and painful arc have the highest positive LRs for RCD and rotator cuff tears.
- Increased number of positive findings increase the likelihood of RCD.
- Absence of positive findings in more tests decreases the likelihood of RCD.
Rotator Cuff Disease (RCD) Testing Recommendations
- Single pain provocation test (painful arc)
- Three strength tests (internal rotation lag, external rotation lag, drop arm)
- One composite test (external rotation resistance)
Rotator Cuff Disease (RCD) Probability
- Positive painful arc test along with other positive findings suggests an LR of 3.7 or greater.
- Population prevalence of RCD increases with age (2.8%-15%).
- Probability of disease among individuals over 30 years is 9.6%, increasing to over 40% for those 70 and older.
- Among patients referred to shoulder specialists, the probability of RCD is much higher (>30%).
- Painful arc test in referred patients confers a more than 60% probability of disease.
- Absence of pain during painful arc test in a referred patient does not rule out RCD, with the probability of disease still as high as 13%.
Radiographic Imaging of RCD
- Plain film/X-ray is the first-line imaging modality for most shoulder pathologies.
- Useful for evaluating calcific tendinitis, arthritis, acute trauma, and osteolysis of the distal clavicle.
- Can visualize rotator cuff tears due to degenerative changes between the acromion and greater tuberosity.
- Certain views can show superior elevation of the humeral head in relation to the glenoid.
MRI
- First-line imaging modality for assessing joints, with superior soft tissue contrast.
- MR arthrography (MRA) is the gold standard for evaluating suspected labral tears or shoulder instability.
Shoulder Arthrogram
- Used to evaluate shoulder structures, including the axillary recess, on a conventional radiograph.
- Contrast material can demonstrate rupture within the rotator cuff.
- Can identify ligamentous and tendon injuries, loose bodies, cartilage/synovial abnormalities, loosening of joint prosthesis, and sinus tracts.
Prognosis of Shoulder Pain
- Periarticular disorders, such as impingement, may be self-limited and respond to rest, analgesics, and exercises.
- Impingement syndrome can be chronic and recurrent, progressing to rotator cuff tendinopathy, full-thickness tears, and osteoarthritis.
- Asymptomatic rotator cuff tears are common with age.
- Large tears can lead to loss of abduction, decreased strength, and reduced function.
- Referral to a specialist is recommended for larger tears.
Rotator Cuff Tear Prognosis
- Untreated supraspinatus tendonitis can progress to rotator cuff tears.
- Early changes may be subclinical, only presenting when the tear has been present for some time.
- A significant portion of rotator cuff defects enlarge and become symptomatic over time.
Acromioclavicular Joint Injury: Types
- Type I: AC ligament stretched or sprained, coracoclavicular ligament intact; treated conservatively
- Type II: AC ligament torn, coracoclavicular ligament stretched; treated conservatively
- Type III: AC and coracoclavicular ligaments torn, clavicle elevated above acromion, coracoclavicular distance increased 25-100% on X-ray; often managed non-operatively, but surgical intervention may be considered for significant displacement, laborers, athletes, cosmetic concerns, or lack of improvement with conservative treatment.
- Type IV: Distal clavicle posteriorly displaced into trapezius; usually managed surgically
- Type V: Superior displacement of clavicle greater than 100% compared to the contralateral side; usually managed surgically
- Type VI: Rare, inferior lateral displacement behind the coracobrachialis or biceps tendon; usually managed surgically.
Acromioclavicular Joint Injury: Management
- Type I and II injuries: managed conservatively with rest, ice, compression, and elevation (RICE) and a sling
- Type III, IV, V, and VI injuries: typically managed surgically and require referral to an orthopedic surgeon.
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Description
This quiz focuses on key diagnostic techniques for shoulder injuries, specifically related to the acromioclavicular joint and rotator cuff. You will explore various tests including the Neer Impingement Sign, Painful Arc of Abduction, and Hawkins Impingement Sign, along with their sensitivity and specificity. Test your understanding of these clinical assessments!
