A Proposed Evidence Based Shoulder Special Testing Examination Algorithm: Adaptation of a Reference Standard Nicklaus Biederwolf, PT,DPT,OCS,CSCS Regis University Manual Therapy Fellowship Phoenix Orthopedic Manual Therapy September 2, 2010

Reference Standard: George Davies’ Special Testing Algorithm1 Based on the work of George Davies, PT, DPT, Med, SCS, ATC, LAT, CSCS, FAPTA Professor Emeritus of the University of Wisconsin at La Crosse Professor at Armstrong State University in Savannah, GA Currently practices at Coastal Therapy in Savannah Georgia and Gundersen Lutheran Sports Medicine in La Crosse, WI

Reference Standard: George Davies’ Special Testing Algorithm1 Testing algorithm is based on “Critical Pathways” Pattern recognition based on clusters of signs and symptoms, subjective data, and empirical data Implicates a specific group of special testing for a specific pathology Statistics of notice are shown in GREEN if they are of particularly good utility and RED if they are of questionable clinical usage.

Proposed Evidence-Based Examination Algorithm for Chosen Tests Testing for a specific condition is only indicated based on an individual’s cluster of subjective data, history, signs, and symptoms. Pre-Test Probability is estimated at 50% for each condition based on above findings; post-test probability is calculated for chosen tests. Statistics of notice are shown in GREEN if of particularly good utility and RED if of questionable clinical usage. Testing is continued until a treatment threshold (or referral threshold) of 80% post-test probability is achieved (unless otherwise stated).

Likelihood Ratios Positive Likelihood Ratio: Sensitivity/(1-Specificity) Shifts Pre-Test Probability in a direction that favors the existence of a disorder. Negative Likelihood Ratio: (1-Sensitivity)/Specificity Shifts Pre-Test Probability in a direction that favors the absence of a disorder.

Post-Test Probability Pre-Test Probability=50% With use of a nonogram, +LR or –LR can be used to determine Post-Test Probability.

Likelihood Ratio Interpretation +LR -LR Interpretation >10 <0.1 Large Probability Shifts 5-10 0.1-0.2 Moderate Probability Shifts 2-5 0.2-0.5 Small Probability Shifts 1-2 0.5-1.0 Minimally Alter Probability

Reference Standard: George Davies’ Special Testing Algorithm1

Davies’ Algorithm: MDI Screening1 Critical Pathway: Performed on all patients to assess GH stability. Test Applicable Finding(s) Sp Sn +LR -LR Sulcus Sign at 0° 2 Identification of sulcus .89 .31 2.8 .78 Sulcus Sign at 90° ABD NR Anterior Load and Shift3 Grade of Laxity (Trace, I, II, III) .54 2.5 .59 Posterior Load and Shift3 1.00 0.00 1.7 .99

Proposed Screening Test Testing Indication: Perform on all patients (if able) to rule in or rule out both intra-articular pathology and RTC pathology. Test Applicable Finding(s) Sp Sn +LR -LR Test of Zaslav (IR Resisted Strength Test)4 In 90° ABD and 80° ER, if IR MMT<< ER MMT test is positive for intra-articular pathology. If IR MMT>>ER MMT test is positive for RTC involvement. .96 .86 22.0 .13 Post-Test probability for ruling in and ruling out both intra-articular pathology and RTC pathology are both respectively 91.6% and 6.1%.

Test of Zaslav4

Test of Zaslav4 Operational definition of RTC pathology: Findings that included a thickened or inflamed subacromial bursa, erosions on the CA ligament and undersurface of the acromion, and bursal side partial or full thickness RTC tears.4 Operational definition of Intra-Articular pathology: Findings that included anterior glenoid erosion or labral tears, middle GH ligament tearing, articular-sided RTC partial tears, posterior labral lesions, and SLAP lesions.4

Proposed Evidence-Based Examination Algorithm for Chosen Tests

Applicable Finding(s) Davies’ Algorithm: SLAP Lesions1 Critical Pathway: Macrotraumatic injury, history of eccentric deceleration activities, pain complaint is “deep” or “in” the shoulder, sensations of locking, clicking, or clunking. Test Applicable Finding(s) Sp Sn +LR -LR Compression Rotation5 Pain or click elicited .76 .24 1.0 Anterior Slide Test6 .92 .78 9.75 Posterior Slide Test NR Speed’s Test7,8 Pain deep in the shoulder .75-.87 .09-.32 1.28-1.29 .91-.98 O’Brien’s Test8,5,7,9,10 Pain or click elicited (part I), then reduced (part II) .31-.98 .54-1.0 .78-50 0.0-1.48

Applicable Finding(s) Proposed SLAP Lesion Tests Testing Indication: Intra-articular pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms. Test Applicable Finding(s) Sp Sn +LR -LR Biceps Load Test I11 Apprehension in ER or pain with resisted bicep contraction .97 .90 30 .10 Biceps Load Test II12 Pain with resisted bicep contraction Pain Provocation Test of Mimori13 Positive if pain is more severe in pronated position 1.0 10.0 0.0 Post-Test probabilities are respectively 93.75%, 93.75%, 83.3% for positive tests, and 4.8%, 4.8%, and 0.0% for negative tests.

Pain Provocation Test of Mimori13 SLAP Lesion Testing Biceps Load Test II12 Pain Provocation Test of Mimori13

Applicable Finding(s) Davies’ Algorithm: LHB Tendinopathy1 Critical Pathway: History of eccentric deceleration activities, LHB is TTP, complaints of pain are in the anterior shoulder. Test Applicable Finding(s) Sp Sn +LR -LR Yergason’s Test14 Pain is produced in the bicipital groove .86 .37 2.64 .73 Speed’s Test14 Pain is elicited .56 .69 1.57 .55 *These currently appear to be the best statistical utility tests we have for identification of LHB tendinopathy. Post-Test probability with a + Yergason’s test is 56.8% (rule in) and with a – Speed’s test is 21.6% (rule out). Treatment threshold exception for lack of evidence is proposed to be both + tests.

Applicable Finding(s) Davies’ Algorithm: AC Joint Lesions1 Critical Pathway: Age >40, macrotrauma to superior shoulder in CKC position, pain complaint is “on top” of the shoulder, AC joint is TTP, pain with horizontal adduction. Test Applicable Finding(s) Sp Sn +LR -LR AC Shear Test Pain localized to AC joint NR O’Brien’s Test9,15 .90-.97 .16-1.0 1.6-33.3 0.0-.93 Cross-Body Adduction Test15 .79 .77 3.67 .29

Applicable Finding(s) Proposed AC Joint Lesion Tests Testing Indicated: Per Davies’ critical pathway. Test Applicable Finding(s) Sp Sn +LR -LR Cross-Body Adduction Test15 Pain localized to AC joint .79 .77 3.67 .29 AC Resisted Extension Test15 .10 .96 1.07 .40 O’Brien’s Test9 .90-.97 .16-1.0 1.6-33.3 0.0-.93 Test Cluster15 Above three tests are positive .97 .25 8.3 Post-Test probability when all three tests are positive is 80.5%.

Applicable Finding(s) Davies’ Algorithm: Impingement Syndrome1 Critical Pathway: Age >40, history of overhead activities, recent unaccustomed overuse of arm, painful arc of abduction, pain with overhead activities, pain complaints in lateral shoulder, pain at night, compensatory shoulder shrug sign. Test Applicable Finding(s) Sp Sn +LR -LR Neer Test14,16,17 Positive if pain reproduced .31-.48 .75-.89 1.29-1.44 .35-.52 Hawkins-Kennedy Test14,16,17 .25-.44 .87-.92 1.23-1.64 .18-.32 Coracoid Impingement Test NR Horizontal Adduction Test17 .28 .82 1.14 .64

Applicable Finding(s) Proposed Impingement Syndrome Tests Testing Indication: RTC pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms. Test Applicable Finding(s) Sp Sn +LR -LR Hawkins-Kennedy Test14,16,17 Positive if pain reproduced .25-.44 .87-.92 1.23-1.64 .18-.32 Infraspinatus MMT18 Positive if weak and/or painful .81 .74 3.89 .32 Painful Arc Sign18 Positive if painful arc reproduced Test of Zaslav4 In 90° ABD and 80° ER, if IR MMT< ER test is positive for intra-articular pathology. If IR MMT>ER MMT test is positive for RTC involvement. .96 .86 22.0 .13 Post-Test probability for the TIC of the first three tests is 95.5% if all 3 are positive, and 91.0% if 2 of 3 are positive (based on reported TIC of 10.56 for 3 + tests and 5.03 for 2 + tests)18. Post-Test probability for a positive and negative Test of Zaslav are 91.6% and 6.1% to rule in and rule out impingement, respectively.

Applicable Finding(s) Davies’ Algorithm: RTC Tears1 Critical Pathway: Age >40, macrotraumatic injury with major functional disabilities, idiopathic onset of major functional disabilities, painful arc of abduction, dull constant ache in shoulder, pain complaints in lateral shoulder, pain at night, compensatory shoulder shrug sign. Test Applicable Finding(s) Sp Sn +LR -LR External Rotation Lag Sign for Supraspinatus17 Inability to hold shoulder in ER 1.00 .70 NA .30 External Rotation Lag Sign @ 90/90 (Drop Sign) for Supraspinatus and Infraspinatus17 Inability to arm in place .36 .64 Internal Rotation Lag Sign for Subscapularis17 Inability to actively IR shoulder .96 .97 24.3 .03

Applicable Finding(s) Proposed Tests for RTC Tears Testing Indication: RTC pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms. Test Applicable Finding(s) Sp Sn +LR -LR External Rotation Lag Sign for Supraspinatus17 Inability to hold shoulder in ER 1.00 .70 NA .30 Dropping Sign @ 90° ABD and 45° ER for Infraspinatus19 Inability to arm in place 0.0 Hornblower’s Sign for Teres Minor19 Inability to externally rotate to “Hornblower” position .93 14.29 Internal Rotation Lag Sign for Subscapularis17 Inability to actively IR shoulder .96 .97 24.3 .03 Post-Test probabilities are respectively (+)~100% and (-)13.0%, (+)~100% and (-)~0.0%, (+)87.7% and (-)~0.0%, (+)92.4% and (-)1.48%.

Applicable Finding(s) Davies’ Algorithm: Anterior Instability1 Critical Pathway: Macrotrauma (especially in ABD and ER), repetitive microtrauma (overhead activities), history of recurrent subluxations/dislocations, complaints of “dead arm” syndrome, sensations of weakness. Test Applicable Finding(s) Sp Sn +LR -LR Apprehension Test20 Apprehension to test position .99 .53 53 .47 Anterior Relocation Test21 Anterior pain is positive for anterior microinstability .44 .54 .96 1.05

Applicable Finding(s) Proposed Anterior Instability Tests Testing Indication: Intra-articular pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms. Test Applicable Finding(s) Sp Sn +LR -LR Apprehension Test20 Apprehension to test position .99 .53 53 .47 Anterior Release Test (also known as Surprise Test) 21,22 Pain or apprehension when posterior relocation is removed .89-.99 .64-.92 8.36-64.0 .09-.36 Post-Test probabilities are respectively 96.4% and, at worst, 80.7%.

Applicable Finding(s) Davies’ Algorithm: Internal Impingement Syndrome1 Critical Pathway: Specific pain inferior to the postero-lateral acromion, pain in the cocking phase of the throwing motion. Test Applicable Finding(s) Sp Sn +LR -LR Anterior Relocation Test Posterior pain is positive for internal impingement syndrome.1 NR *This is the only known suggested test for internal impingement syndrome. It is hypothesized, however, that positive impingement testing and a positive Test of Zaslav for an intra-articular lesion may suggest internal impingement syndrome. Treatment Threshold exception for lack of evidence: All above subjective and objective findings.

Applicable Finding(s) Davies’ Algorithm: Posterior Instability1 Critical Pathway: Macrotrauma, blunt force to anterior shoulder, volitional subluxator. Test Applicable Finding(s) Sp Sn +LR -LR Jerk Test23 Sharp pain and/or click/clunk .98 .73 36.5 .28 Posterior Glide Test Subluxation/Dislocation over glenoid rim NR Posterior Glide Test II

Applicable Finding(s) Proposed Tests for Posteroinferior Laxity and Labral Lesions Testing Indication: Intra-articular pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms. Test Applicable Finding(s) Sp Sn +LR -LR Jerk Test23 Sharp pain and/or click/clunk .98 .73 36.5 .28 Kim Test23 .94 .80 13.3 .21 Post-Test probability for the Jerk and Kim tests are respectively 94.8% and 86.9%.

The Kim Test23 A) With the patient in a sitting position with the arm in 90° of abduction, the examiner holds the elbow and lateral aspect of the proximal arm, and a strong axial loading force is applied. B) While the arm is elevated another 45° diagonally upward, downward and backward force is applied to the proximal arm. A sudden onset of posterior shoulder pain indicates a positive test result, regardless of accompanying posterior clunk of the humeral head. During the test, it is important to apply a firm axial compression force to the glenoid surface by the humeral head.

Applicable Finding(s) Davies’ Algorithm: Bankart Lesions1 Critical Pathway: Macrotrauma, anterior/inferior subluxation or dislocation, history of recurrent subluxations/dislocations, “deep” pain in the shoulder, complaints of clicking/clunking or locking. Test Applicable Finding(s) Sp Sn +LR -LR Clunk Test (Anterior/inferior GH scouring in maximal scaption) Pain, clicking, or clunking elicited NR Clunk Test II (Anterior relocation in multiple anterior/inferior positions) Crank Test5,7,10,13,24 Pain is elicited .56-1.00 .40-.91 1.0-13 .10-.96

Applicable Finding(s) Proposed Tests for Bankart Lesions Testing Indication: Intra-articular pathology per Zaslav’s test (if able) and Davies’ critical pathway cluster of signs and symptoms. Test Applicable Finding(s) Sp Sn +LR -LR Clunk Test (Anterior/inferior GH scouring in maximal scaption)* Pain, clicking, or clunking elicited NR Crank Test5,7,10,13,24 Pain or clicking is elicited .56-1.00 .40-.91 1.0-13 .10-.96 *Though no studies have been performed on the Clunk Test, I believe it has a high enough level of construct validity to be considered for use in examination. Post-Test probability of the Crank test is 86.7% at best and 33.3% at worst. Proposed treatment threshold are + findings in both tests, and a click/clunk in either.

Proposed Evidence-Based Shoulder Special Testing Examination Algorithm RTC Pathology Test of Zaslav (IR MMT >> ER MMT) RTC Impingement Hawkins-Kennedy Test Infraspinatus MMT Painful Arc Sign RTC Tears ER Lag Sign Dropping Sign Hornblower’s Sign IR Lag Sign Intra-Articular Pathology Test of Zaslav (ER MMT >> IR MMT) SLAP Lesions Biceps Load Test I Biceps Load Test II Pain Provocation Test of Mimori Bankart Lesions Clunk Test Crank Test Posteroinferior Capsulolabral Laxity and Labral Lesions Kim Test Jerk Test Anterior Instability Apprehension Test Anterior Release Test Miscellaneous Test of Zaslav inconclusive AC Joint Lesion Cross-Body Adduction AC Resisted Extension O’Brien’s Test LHB Tendinopathy Yergason’s Test Speed’s Test RTC Internal Impingement Anterior Relocation Test

Questions? Email: nikbieds@yahoo.com

REFERENCES Davies, GJ. Musculoskeletal Evaluation and Treatment of the Upper Extremity: Course packet from PT 644. La Crosse, WI: University of Wisconsin at La Crosse, Spring Semester 2003. Liu SH, Henry MH, Nuccion S, Shapiro MS, Dorey F. Diagnosis of glenoid labral tears. A comparison between MRI and clinical examinations. Am J Sports Med. 1996;24:149-154. T’Jonk et al. The relationship between clinical shoulder tests and the findings in arthroscopic examination. Geneeskunde Sport. 2001;34:15-34. Zaslav KR. Internal rotations strength resistance test: a new diagnostic test to differentiaite intra-articular pathology from outlet (Neer) impingement syndrome in the shoulder. J Shoulder Elbow Surg. 2001;10:23-27. McFarland EF, Kim TK, Savino RM. Clinical Assessment of three common tests for SLAP lesions. Am J Sports Med. 2002;19:517-523. Kibler WB. Specificity and sensitivity of the anterior slide test in throwing athletes with superior glendoid labral tears. Arthroscopy. 1995;11:296-300. Guanche CA, Jones DC. Clinical testing for tears of the glenoid labrum. Arthroscopy. 1998;26:610-613. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy. 2004;20:231-236. O’Brien Sj, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med. 1998;26:610-613. Stetson WB, Templin K. The Crank Test, the O’Brien test, and routine MRI scans in the diagnosis of labral tears. Am J Sports Med. 2002;30:806-809.

Kim SH et al. Biceps load test II: a clinical test for SLAP lesions of the shoulder. Arthroscopy. 2001;17:160-164. Mimori K et al. A new pain provocation test for superior labral tears of the shoulder. Am J Sports Med. 1999;27:137-142. Calis M et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis. 2000;59:44-49. Chronopoulos et al. Diagnostic value of physical tests for isolated chronic acromioclavicular lesion. Am J Sports Med. 2004;32:655-661. MacDonald et al. An analysis of the diagnostic accuracy of the Hawkins and Neer subacromial impingement signs. J Shoulder Elbow Surg. 2000;9:299-301. Leroux Jl et al. Diagnostic value of the clinical tests for shoulder impingement syndrome. Rev Rheum Engl Ed. 1995;62:423-428. Hertel R et al. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg. 1996;5:307-313. Kim et al. Diagnostic Accuracy of Clinical Tests for the Different Degrees of Subacromial Impingement Syndrome. J Bone Joint Surg. 2005;7:1446-1455. Walch G et al. The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator cuff tears. J Bone Joint Surg. 1998;80:624-628. Lo et al. An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder instability. Am J Sports Med. 2004;32:301-307. Speer et al. An evaluation of the shoulder relocation test. Am J Sports Med. 1994;22:177-183. Gross ML, Distefano MC. Anterior release test. A new test for occult shoulder instability. Clin Orthop. 1997;339:105-108. Kim SH et al. The Kim Test: A novel test for posteroinferior labral lesions of the shoulder-A comparison to the Jerk test. Am J Sports Med. 2005;33:1188-1192. Liu SH et al. A prospective evaluation of a new physical examination in predicting glenoid labral tears. Am J Sports Med. 1996;24:721-725.