1. Assessment of the shoulder complex
ACPA conference 9th April 2014
Stuart Calver MSc, Grad Dip Phys, MCSP

2. Contents Key findings subjective exam
Shoulder exam video approx 10 mins
Diagnostic accuracy orthopaedic special tests and combination of tests
Stuart’s sub categorisation treatment approach

3. Referred pain
Nearly all shoulder structures are supplied by the C5 nerve root
Acromioclavicular joint is supplied by C4 thus refers pain to this segment
Watch out for Cloward’s areas
Gerber et al 1998 hypertonic saline solution 15 times ACJ 10 healthy volunteers, 10 times subacromial space 9 healthy volunteers pain pattern described in slide.

4. Cloward’s areas

5. Shoulder assessment video

6. Diagnostic accuracy individual clinical tests
The use of any single ShPE test to make a pathognomonic diagnosis cannot be unequivocally recommended (Hedegus 2008 & 2012).
Many tests that have high sensitivity (Sn) have poor specificity (Sp) & visa versa, very few tests have Sn & Sp > 80%
Some tests such as apprehension test are beginning to stand the test of time.
Combinations of tests provide better accuracy but only marginally so.

7. Test Sensitivity Specificity +LR -LR
Hawkins Kennedy 80 56
1.79
0.47
Painful arc 53 76
2.25
0.62
O’Brien’s 67 37
1.06
0.89
Crank (labral tear)
57.3
72.6
2.44
0.51
Apprehension
65.6
95.4
17.21
0.39
Relocation
64.6
90.2
5.48
0.55
Benchmarks: Sn > 80%, Sp > 80%, +LR > 5.0, -LR > 2.0

8. Combination of tests Test combination Pathology Sensitivity
Specificity
+LR
-LR
Age>65, weakness ER & night pain
RC tear 49 95
9.84
0.54
Hawkins Kennedy, Neer, painful arc, empty can & resisted ER
Subacromial impingement ≥ 3 positive 75 74
2.93
0.34
Apprehension & relocation
Anterior instability 81 98
39.68
0.19
Labral tear 38 93
5.43
0.67
Passive distraction & O’Brien’s
SLAP 70 90
7.00
0.11
Benchmarks: Sn > 80%, Sp > 80%, +LR > 5.0, -LR > 2.0

9. Reliability of shoulder exam
Pellecchia et al (1996) 91% agreement; kappa=0.88 using Cyriax method of assessment, Cyriax’s schema patho-anatomical classification with nine possible categories. However sample size small n=21 & only 2 assessing therapists used.
Carter et al (2012) used 3 clinical syndromes; pattern 1: impingement, pattern 2: AC joint pain, pattern 3: 7 subcategories including OA, frozen shoulder, cuff tear & instability. 55 physiotherapists arranged in pairs. 80% agreement; kappa=0.66
Carter et al (2012) impingement pattern: painful arc, tenderness over greater tuberosity & able to abduct arm from side. ACJ pattern: pain on horizontal flexion, tender palpation ACJ & joint prominence.

10. Treatment based assessment
Unlikely that any test would not compress or stretch adjacent structures
Most orthopaedic tests have high sensitivity but low specificity or visa versa
Investigations used as gold standard (MRI, arthroscopy) have high levels of false positive & negative.

11. Sub categorisation treatment approach

12. Any Questions