Friday, September 20, 2013

Rotator cuff disease - clinical signs

Does This Patient With Shoulder Pain Have Rotator Cuff Disease? The Rational Clinical Examination Systematic Review

These authors remind us that rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians. They performed a meta-analysis to identify the most accurate clinical examination
findings for RCD. They located 28 studies that assessed the examination of referred patients by specialists. Only 5 of the studies reached Rational Clinical Examination quality scores of level 1-2. These included from 30 to 203 shoulders with the prevalence of RCD ranging from 33%to 81%. 

They found that among pain provocation tests, a positive painful arc test result was the only finding with a positive likelihood ratio (LR) greater than 2.0 for RCD (3.7 [95%CI, 1.9-7.0]) and a
normal painful arc test result had the lowest negative LR (0.36 [95%CI, 0.23-0.54]). 

Among strength tests, they found that a positive external rotation lag test (LR, 7.2 [95%CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95%CI, 2.6-12]) were the most accurate findings for full-thickness
tears.  A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95%CI, 0.0-0.58]). 

We observe that the tricky thing about cuff disease is that, addition to pain, it can present with (1) weakness (usually on supraspinatus testing, but also on infraspinatus and subscapularis testing), (2) subacromial crepitance on active or passive motion of the shoulder, (3) stiffness (limitation of range of motion, especially internal rotation), and (4) instability.

Our examination for patients suspected of having cuff problems is shown here.

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