Hawkins-Kennedy Test Research Articles

Subacromial Tenoxicam Injection in the Treatment of Impingement Syndrome

Objectives:As subacromial bursa injection is widely used for pain relief and functional improvements in patients with periarticular shoulder disorder, we aimed to present our results of subacromial tenoxicam injection in the treatment of impingement syndrome.Methods:Patients presented to the Department of Orthopaedics and Traumatology, Istanbul Medipol University with the primary complaints of shoulder pain from January 2012 to June 2013 were selected. Those who met the following inclusion criteria were finally considered: 1) who had a clinical sign of a painful arc and positive in Hawkins test and/or Neer impingement sign; 2) who had a precise rotator cuff injury including partial cuff tears, or subacromial bursitis detected during ultrasonography or MRI. The exclusion criteria were as follows: 1) who underwent shoulder surgery; 2) who had full thickness rotator cuff rupture; 3) who had hemiplegic shoulder pain; and 4) who displayed any suspected fracture on X-ray or had a recent shoulder trauma; 5) who showed limited active ROM and stiffness due to adhesive capsulitis. Thirty one shoulders out of thirty patients were treated with subacromial tenoxicam injection. Ten of them were left shoulders. Fifteen of the patients were women.. Patients had a mean age of 51.6 (30-73). Patients were evaluated 4 times. Before the first injection, 1 week after the first injection, 2 weeks after the second injection and 3 weeks after the third injection. In every injection 20 mg tenoxicam was performed.Results:In order to relieve the pain; two patients were given only one injection, thirteen patients were given two injections and “3 injections protocol” were done to fifteen patients. The mean pre- and posttreatment VAS scores were 7.9 (between, 7-9) and 2.7 (between, 2-4) points respectively. The average pre and posttreatment DASH scores were 59.41 (between, 45-80) and 14 (between, 8.3-25.8) points respectively. The mean pre and posttreatment range of motion were 106.1 (between, 80-130 and 170i7 (between, 140-180) degrees respectively. Differences between all pre- and post-treatment parameters were statistically significant (p<0.05).Conclusion:Tenoxicam is a cheap NSAID and an analgesic of the oxicam class, is closely related to proxicam, and has a long half-life, which enables it to be administrated once daily. It also readily penetrates the synovial fluid and intraarticular intravenous administration provides superior postoperative analgesic benefits. Tenoxicam also has the ability to prevent adhesion formation. Besides it has no detrimental effect on cartilage structure. It can be safely administrated intraarticularly. Given the positive therapeutic effects of subacromial tenoxicam injection, it can be used as an alternative treatment option.

A preoperative scoring system to select patients for arthroscopic subacromial decompression

This study investigated the clinical and radiographic factors that influence outcome after arthroscopic subacromial decompression (ASAD) for shoulder impingement syndrome. The goal was to develop a new preoperative scoring system to identify patients who would have a prompt and sustained benefit from ASAD. We prospectively reviewed 112 consecutive patients with impingement syndrome who subsequently underwent ASAD. The Oxford Shoulder Score (OSS) was recorded preoperatively and 3 and 12months postoperatively. A statistically significant improvement in OSS at 3 months after surgery was considered a good outcome. The variables associated with good outcome were shoulder pain with overhead activities, persistent symptoms for more than 6 months, symptoms persistent despite a 3-month course of supervised physiotherapy, consistently positive Hawkins test result, radiologic changes of impingement on both acromion and humerus in the subacromial region, and improvement for more than 1 week after a steroid injection. These 6 criteria were combined into a single score for this study, termed the preoperative score (PrOS). Sixty-two patients who had been symptomatic for 1 year with a preoperative score of 5 to 6 showed significant improvement in OSS at 3 months after surgery (P<.001). Thirty-eight patients with a score 3 to 4 had no statistically significant improvement in OSS at 3months but had a further slight improvement at 1 year. Twelve patients with a score of ≤2 had no significant improvement in OSS at 3months or 1year. This scoring system can identify patients who would have a prompt benefit from ASAD. The impact of surgery in patients with a PrOS of ≤4 points is questionable.

Characteristics of Shoulder Impingement in the Recreational Weight-Training Population

Despite reports implicating subacromial impingement syndrome (SIS) as an etiologic source of shoulder pain among weight-training (WT) participants, a paucity of case-controlled evidence exists to support this premise. The purpose of this study was to determine whether WT participants present with characteristics of SIS. Additionally, we investigated the role of exercise selection among those identified as having SIS. Seventy-seven (154 shoulders) men (mean age, 28) were recruited, including 46 individuals who engaged in WT a minimum of 2 days per week; and 31 controls with no history of WT participation. Before testing, participants completed a questionnaire summarizing their training patterns. On completing questionnaire, 2 previously validated tests used to identify SIS were performed on both groups and included the painful arc sign and Hawkins-Kennedy test. When clustered, these tests have a positive likelihood ratio of 5.0 for identifying SIS when compared with diagnostic gold standards. Analysis identified significant between-group differences in the combined presence of a positive painful arc and Hawkins-Kennedy (p < 0.001) test. A significant association existed between clinical characteristics of SIS (p ≤ 0.004) and both lateral deltoid raises and upright rows above 90°. Conversely, a significant inverse association was found between external rotator strengthening and characteristics of SIS. Results suggest that WT participants may be predisposed to SIS. Avoiding performance of lateral deltoid raises and upright rows beyond an angle of 90° and efforts to strengthen the external rotators may serve as a useful means to mitigate characteristics associated with SIS.

Impact of outpatient clinic ultrasound imaging in the diagnosis and treatment for shoulder impingement: a randomized prospective study

The use of musculoskeletal ultrasonography (MSUS) in guiding subdeltoid injection has been shown to improve outcome up to 6 weeks in a few small studies. A recent meta-analysis identified the need for further studies with longer-term outcome and larger sample size. This randomized prospective study assessed whether clinic-based MSUS can significantly improve diagnostic accuracy in shoulder pain and whether MSUS-guided shoulder injection results in improved long-term outcomes. One hundred consecutive patients with 125 painful shoulders were recruited. Patients were randomized to receive either sonographic assessment with consequent palpation-guided injection (Group 1, n = 66) or sonographic assessment with a MSUS-guided injection of 40 mg of methylprednisolone acetate (Group 2, n = 59). A blinded rheumatologist (ADF) performed clinical assessments at baseline, 6 and 12 weeks including shoulder function tests (SFTs) (Hawkins-Kennedy test, supraspinatus tendon tenderness), physician global assessment (PGA) and patient visual analogue scores (VAS) for pain (0-10). Eighty patients with 90 symptomatic shoulders completed 12-week follow-up. Twenty patients, 11 (20 shoulders) from the palpation-guided group and 9 (15 shoulders) from the MSUS-guided group, were excluded at 6 weeks either due to requirement for repeat injection or due to surgical referral. Mean age for patients was 57.7 years, and 65 % patients were female; mean shoulder pain duration was 18 weeks (range 14-22 weeks). SFTs, patient VAS and PGA scores for pain improved significantly from baseline in both groups with significantly greater improvements in the MSUS-guided group (44 shoulders) compared to the palpation-guided group (46 shoulders) in all parameters at 6 (p < 0.01) and 12 weeks (p < 0.05). The use of MSUS in guiding subdeltoid injection has been shown to improve outcome up to 6 weeks in a few small studies. A recent meta-analysis identified the need for further studies with longer-term outcome and larger sample size.

AB0665 Relationship between clinical and ultrasonographic changes in patients with shoulder pain

BackgroundThe shoulder is one of the most common application of musculoskeletal ultrasound due to the high incidence of rotator cuff disorders related to increasing aging and sporting activities (1) Muskuloskeletal...

Zusammenhang zwischen Schulter-Impingement-Syndrom und Defiziten in der Schlägerkopfgeschwindigkeit bei leistungsstarken Amateurgolfspielern

Joint structure damages due to overstrain often occur even in commonly not injury-prone golfing. Triggered by the golf swing's repetitive movement pattern and technique deficits of the player these structural damages are most likely to affect the lumbar spine as well as shoulder and elbow joint. As a synonym for shoulder impingement symptoms in golfers the term golf shoulder has been established in medical terminology. Despite this fact, currently there exist no studies addressing the relation between shoulder impingement syndrome and club head velocity. The aim of this study was to highlight the relation between club head velocity deficits of high-performance amateur golfers and persisting shoulder impingement syndrome. All of the 31 high-performance amateur golfers included in this study were male, active tournament players and right hander. Each golfer was examined for shoulder impingement syndrome using the Neer test, the Hawkins-Kennedy test, the painful arc and the functional test of the M. infraspinatus. Based on the test results the participants were allocated to an impingement group or a non-impingement group. Additionally, each golfer's club head velocity was determined. Between the two groups a significant difference concerning the club head velocity has been reported. A persisting shoulder impingement syndrome can have a negative effect on club head velocity. In many shoulder studies predominantly the influence of pathological muscular balance alterations (myofascial dysfunction) is not taken into consideration.

Shoulder pain in primary care: diagnostic accuracy of clinical examination tests for non-traumatic acromioclavicular joint pain

BackgroundDespite numerous methodological flaws in previous study designs and the lack of validation in primary care populations, clinical tests for identifying acromioclavicular joint (ACJ) pain are widely utilised without concern for such issues. The aim of this study was to estimate the diagnostic accuracy of traditional ACJ tests and to compare their accuracy with other clinical examination features for identifying a predominant ACJ pain source in a primary care cohort.MethodsConsecutive patients with shoulder pain were recruited prospectively from primary health care clinics. Following a standardised clinical examination and diagnostic injection into the subacromial bursa, all participants received a fluoroscopically guided diagnostic block of 1% lidocaine hydrochloride (XylocaineTM) into the ACJ. Diagnostic accuracy statistics including sensitivity, specificity, predictive values, positive and negative likelihood ratios (LR+ and LR-) were calculated for traditional ACJ tests (Active Compression/O’Brien’s test, cross-body adduction, localised ACJ tenderness and Hawkins-Kennedy test), and for individual and combinations of clinical examination variables that were associated with a positive anaesthetic response (PAR) (P≤0.05) defined as 80% or more reduction in post-injection pain intensity during provocative clinical tests.ResultsTwenty two of 153 participants (14%) reported an 80% PAR. None of the traditional ACJ tests were associated with an 80% PAR (P<0.05) and combinations of traditional tests were not able to discriminate between a PAR and a negative anaesthetic response (AUC 0.507; 95% CI: 0.366, 0.647; P>0.05). Five clinical examination variables (repetitive mechanism of pain onset, no referred pain below the elbow, thickened or swollen ACJ, no symptom provocation during passive glenohumeral abduction and external rotation) were associated with an 80% PAR (P<0.05) and demonstrated an ability to accurately discriminate between an PAR and NAR (AUC 0.791; 95% CI 0.702, 0.880; P<0.001). Less than two positive clinical features resulted in 96% sensitivity (95% CI 0.78, 0.99) and a LR- 0.09 (95% CI 0.02, 0.41) and four positive clinical features resulted in 95% specificity (95% CI 0.90, 0.98) and a LR+ of 4.98 (95% CI 1.69, 13.84).ConclusionsIn this cohort of primary care patients with predominantly subacute or chronic ACJ pain of non-traumatic onset, traditional ACJ tests were of limited diagnostic value. Combinations of other history and physical examination findings were able to more accurately identify injection-confirmed ACJ pain in this cohort.

Myofascial Pain Syndrome: Trigger Points

SUMMARY The aim of this observational study from Spain was to determine the prevalence of mechanical hypersensitivity and active and latent trigger points [TrPs] in elite swimmers with and without unilateral shoulder pain. Seventeen elite swimmers with and 18 without shoulder pain were included, while 15 elite athletes acted as matched controls. The subjects were assessed for pressure pain thresholds [PPT] and the presence of active and latent TrPs in the levator scapulae, sternocleidomastoid, upper trapezius, infraspinatus, subscapularis and scalene muscles. The PPT was also assessed over the tibialis muscle. Subjects were included when aged between 18 and 30 years of age and swimming more than 6 h per week. The subjects with shoulder pain had these complaints for more than 3 months. Pain was described as pain felt in the shoulder or arm with an intensity of at least 4 on an 11-point numerical pain rating scale. They had to report a positive Neer test and Hawkins-Kennedy test at physical examination. Subjects were excluded with a history of shoulder or neck surgery, fracture of the shoulder region, bilateral shoulder symptoms, cervical radiculopathy, previous steroid injections or any type of physical intervention within the last year. The age-matched controls were right-handed elite athletes without shoulder complaints and with a negative Neer test and Hawkins-Kennedy test and the abovementioned exclusion criteria were used. A mechanical pressure algometer was used to establish PPT, which was defined as the minimal amount of pressure needed to elicit pain. The PPT was measured at predefined points within the muscles. The TrPs were explored by a blinded assessor with more than 8 years of experience in TrPs diagnosis following the guidelines described by Simons et al. (1) and by Gerwin et al. (2). The TrPs were considered active, when local and referred pain PPTs were significant reduced in the swimmers with shoulder pain group compared with the healthy controls in all muscles, but not when compared to the swimmers without shoulder pain group. Furthermore, much higher numbers of active and latent TrPs were found in swimmers with and without shoulder pain compared to healthy athletes.

Scapular-focused treatment in patients with shoulder impingement syndrome: a randomized clinical trial

The purpose of this clinical trial is to compare the effectiveness of a scapular-focused treatment with a control therapy in patients with shoulder impingement syndrome. Therefore, a randomized clinical trial with a blinded assessor was used in 22 patients with shoulder impingement syndrome. The primary outcome measures included self-reported shoulder disability and pain. Next, patients were evaluated regarding scapular positioning and shoulder muscle strength. The scapular-focused treatment included stretching and scapular motor control training. The control therapy included stretching, muscle friction, and eccentric rotator cuff training. Main outcome measures were the shoulder disability questionnaire, diagnostic tests for shoulder impingement syndrome, clinical tests for scapular positioning, shoulder pain (visual analog scale; VAS), and muscle strength. A large clinically important treatment effect in favor of scapular motor control training was found in self-reported disability (Cohen's d = 0.93, p = 0.025), and a moderate to large clinically important improvement in pain during the Neer test, Hawkins test, and empty can test (Cohen's d 0.76, 1.04, and 0.92, respectively). In addition, the experimental group demonstrated a moderate (Cohen's d = 0.67) improvement in self-experienced pain at rest (VAS), whereas the control group did not change. The effects were maintained at three months follow-up.

Arthroscopic subacromial decompression is effective in selected patients with shoulder impingement syndrome

A total of 92 patients with symptoms for over six months due to subacromial impingement of the shoulder, who were being treated with physiotherapy, were included in this study. While continuing with physiotherapy they waited a further six months for surgery. They were divided into three groups based on the following four clinical and radiological criteria: temporary benefit following steroid injection, pain in the mid-arc of abduction, a consistently positive Hawkins test and radiological evidence of impingement. Group A fulfilled all four criteria, group B three criteria and group C two criteria. A total of nine patients improved while waiting for surgery and were excluded, leaving 83 who underwent arthroscopic subacromial decompression (SAD). The new Oxford shoulder score was recorded pre-operatively and at three and 12 months post-operatively. A total of 51 patients (group A) had a significant improvement in the mean shoulder score from 18 (13 to 22) pre-operatively to 38 (35 to 42) at three months (p < 0.001). The mean score in this group was significantly better than in group B (21 patients) and C (11 patients) at this time. At one year patients in all groups showed improvement in scores, but patients in group A had a higher mean score (p = 0.01). At one year patients in groups A and B did better than those in group C (p = 0.01). Arthroscopic SAD is a beneficial intervention in selected patients. The four criteria could help identify patients in whom it is likely to be most effective.

Palpation tests versus impingement tests in Neer stage I and II subacromial impingement syndrome

Using sonographic findings to test the diagnostic accuracy of impingement versus tendon palpation tests in Neer stage I and II subacromial impingement syndrome cases and examine their clinical potential. Neer and Hawkins impingement tests and rotator cuff tendon palpation tests followed by bilateral shoulder sonography were conducted on 69 patients with a clinical diagnosis of unilateral subacromial impingement. The Neer and Hawkins tests had 74 and 62% accuracy (sensitivity 80 and 67%, and specificity 52 and 47%, respectively) in comparison to 79 and 62% accuracy rates for supraspinatus and biceps tendon palpation tests (sensitivity 92 and 41%, and specificity 41 and 48%, respectively). Overall, the palpation tests scored better than impingement tests in the diagnosis of Neer stage I and II subacromial impingement syndrome. No tendinosis or tear was noted in patients with negative findings in the supraspinatus palpation tests (sensitivity 100%, specificity 21%). Palpation tests for supraspinatus and biceps tendons have a slightly higher accuracy than the impingement tests, and if tenderness does not exist then supraspinatus tendinopathy can be ruled out. These findings warrant the use of palpation tests in a routine physical examination for tendinopathy. I.

February 2012 Letters to the Editor-in-Chief

February 2012 Letters to the Editor-in-Chief

Diagnostic accuracy of clinical tests for subacromial impingement syndrome (SIS): A systematic review and meta-analysis

BackgroundShoulder complaints are the third most common cause of musculoskeletal problems. Subacromial impingement syndrome (SIS) is the most frequent cause of shoulder pain. SIS is a clinical syndrome that indicates...

Minor or occult shoulder instability: an intra-articular pathology presenting with extra-articular subacromial impingement symptoms

Disruption in the balance of shoulder stability can produce a widely varied spectrum of clinical symptoms, ranging from minor shoulder instability to frank shoulder dislocation, followed by recurrent instability. In this study, a series of patients suffering from minor shoulder instability, all with clinical signs of preoperative subacromial impingement associated with instability, were treated. The shoulder instability alone was addressed, with the aim of eliminating the clinical symptoms of subacromial impingement and pain. In this study, 20 patients with minor shoulder instability, presenting with subacromial impingement symptoms, underwent arthroscopic treatment to address capsule-labral pathology. All patients underwent a preoperative assessment by one independent physiotherapist, using Constant and WOSI scores, as well as the Castagna test, on both the affected and non-affected sides. The Hawkins test and subacromial pain in 90° of abduction and internal rotation were also evaluated. All patients followed the same rehabilitation protocol by a second physiotherapist. All patients were followed up at 6, 12 and 24 months postoperatively by the same independent physiotherapist. We observed that 20/20 patients had a positive Hawkins sign at >20° of internal rotation preoperatively, while 4/19 had a positive Hawkins sign--all with less pain--at the 24-month follow-up (P < 0.0001). Moreover, 20/20 had a positive Castagna test preoperatively, while 1/20 had a positive Castagna test at the 24-month follow-up. In terms of shoulder scores, at 24 months, the Constant score had improved from a median value of 70 (51-91) preoperatively to a median value of 91 (86-100). The median WOSI score was 48.3 (12.7-78.6) preoperatively and improved to 84.9 (39.5-98.5) at 24 months postoperatively. Minor shoulder instability is an intra-articular pathology presenting with extra-articular subacromial impingement symptoms. By treating the intra-articular pathology, the extra-articular symptoms can be relieved in the vast majority of patients.

Clinical Presentation and Follow-up of Isolated SLAP Lesions of the Shoulder (SS-04)

Introduction There is no definitive clinical sign or symptom which is diagnostic for a superior labral anterior to posterior (SLAP) tear of the shoulder. The purpose of our research is to conduct a retrospective review of isolated SLAP lesions of the shoulder to determine if there are any specific signs, symptoms, or mechanism of injury which are diagnostic for SLAP lesions and the clinical results of operative treatment. Methods In a review of 2,375 shoulder arthroscopies, 140 SLAP lesions were identified, 23 of which had no other intra-articular or subacromial pathology. At the time of diagnostic arthroscopy, there were 19 type II, one type III, two type IV, and one complex type II/III SLAP lesion. There was no other intra-articular or subacromial pathology found including partial or complete rotator cuff tears. Results The mechanism of injury was a fall on an outstretched arm in seven patients, a direct blow to the shoulder in four patients, glenohumeral subluxation or dislocation in two patients, pain while lifting a heavy object in two patients, traction injury in two patients, and an insidious onset in one patient. Five patients experienced an acute onset of pain with overhead sporting activities. The most common complaint was pain and pain with overhead activities in all 23 patients. All patients complained of some sort of painful mechanical-like symptoms in their shoulder which caused pain. The majority of patients mimicked impingement-like symptoms with 12/23 (52%) had a positive Neer test, 8/23(35%) had a positive Hawkins test but all had a normal bursoscopy examination at the time of arthroscopy. All type II SLAP lesions were repaired with a suture anchor technique. The type III and type IV SLAP lesions were debrided. The complex type II and III SLAP lesion was debrided and repaired with a suture anchor technique. Average follow-up was 3.8 years. Using the UCLA shoulder Rating Scale, 17 (74%) had a good or excellent result, 3 (13%) had a fair result, and 2 (8.5%) had a poor result. Conclusion SLAP lesions may mimic impingement, rotator cuff pathology, or anterior instability. The subacromial space should always be evaluated at the time of surgery to make sure there is no evidence of subacromial impingement. In our study, all patients with isolated SLAP lesions had pain and pain with overhead activities and had complaints of painful mechanical-like symptoms in their shoulders but had a normal subacromial space. Treatment with suture anchors gave good or excellent results in 74% of patients.

Interexaminer reliability of orthopaedic special tests used in the assessment of shoulder pain

Orthopaedic special tests (OST) are commonly used in the assessment of the painful shoulder to assist to rule-in or rule-out specific pathology. A small number of tests with high levels of diagnostic accuracy have been identified but interexaminer reliability data is variable or lacking. The aim of this study was to determine the interexaminer reliability of a group of OST with demonstrated diagnostic accuracy at primary care level. Forty consecutive subjects with shoulder pain were recruited. Six tests were performed by two examiners (physiotherapists) on the same day. Tests included the active compression test, Hawkins–Kennedy test, drop-arm test, crank test, Kim test and belly-press test. ‘Fair’ reliability (kappa 0.36–0.38) was observed for the active compression test (labral pathology), Hawkins–Kennedy test and crank test. Prevalence of positive agreements was low for the active compression test (acromioclavicular joint), drop-arm test, Kim test and belly-press test. Prevalence and bias adjusted kappa (PABAK) values indicated ‘substantial’ reliability (0.65–0.78) for these tests. The active compression test (acromioclavicular joint), belly-press tests (observation and weakness), Kim test and drop-arm test demonstrate acceptable levels of interexaminer reliability in a group of patients with sub-acute and chronic shoulder conditions.

Tests of Homoscedasticity, Normality, and Missing Completely at Random for Incomplete Multivariate Data

Test of homogeneity of covariances (or homoscedasticity) among several groups has many applications in statistical analysis. In the context of incomplete data analysis, tests of homoscedasticity among groups of cases with identical missing data patterns have been proposed to test whether data are missing completely at random (MCAR). These tests of MCAR require large sample sizes n and/or large group sample sizes n(i), and they usually fail when applied to non-normal data. Hawkins (1981) proposed a test of multivariate normality and homoscedasticity that is an exact test for complete data when n(i) are small. This paper proposes a modification of this test for complete data to improve its performance, and extends its application to test of homoscedasticity and MCAR when data are multivariate normal and incomplete. Moreover, it is shown that the statistic used in the Hawkins test in conjunction with a nonparametric k-sample test can be used to obtain a nonparametric test of homoscedasticity that works well for both normal and non-normal data. It is explained how a combination of the proposed normal-theory Hawkins test and the nonparametric test can be employed to test for homoscedasticity, MCAR, and multivariate normality. Simulation studies show that the newly proposed tests generally outperform their existing competitors in terms of Type I error rejection rates. Also, a power study of the proposed tests indicates good power. The proposed methods use appropriate missing data imputations to impute missing data. Methods of multiple imputation are described and one of the methods is employed to confirm the result of our single imputation methods. Examples are provided where multiple imputation enables one to identify a group or groups whose covariance matrices differ from the majority of other groups.

Fracture of the Greater Tuberosity of the Humerus

The patient was a 27-year-old male pilot referred to a physical therapist for a suspected left acromioclavicular joint injury following a fall 3 weeks prior. Physical examination revealed decreased active shoulder flexion, decreased supraspinatus strength, and a positive Hawkins test. Radiographs were ordered and the anterior-posterior radiographic view showed an incomplete nondisplaced fracture in the superior aspect of the greater tuberosity. The patient was placed in a sling for 4 weeks and performed passive range-of-motion exercises to maintain shoulder mobility. Radiographs at 7 weeks following the injury revealed a healed greater tuberosity fracture. J Orthop Sports Phys Ther 2010;40(7):447. doi:10.2519/jospt.2010.0411

Clinical Value of Single Versus Composite Provocative Clinical Tests in the Assessment of Painful Shoulder

The aims of the present study were to investigate the clinical value of the provocative clinical tests and propose a composite index for the assessment of painful shoulder, using ultrasonography (US) as reference method. Two hundred three patients with painful shoulder underwent both clinical and US evaluations. The physical examination was carried out performing the Hawkins, Jobe, Patte, Gerber, and Speed tests. Each test was included in a composite index namely, SNAPSHOT (Simple Numeric Assessment of Pain by SHOulder Tests). The US examination was performed by a rheumatologist experienced in US and blinded to clinical findings. Sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratio of each clinical test were calculated. The receiver operating characteristic (ROC) curve analysis was used to assess the performance of the composite SNAPSHOT index. Sensitivity was low for the clinical diagnosis of all shoulder abnormalities. The highest sensitivity and smallest negative likelihood ratio were found for the Hawkins (63.88% and 0.50%) and Patte (62.21% and 0.52%) tests. Specificity was good for Speed (76.33%), Gerber (75.42%), and Patte (74.20%) tests. Patte and Speed tests were the most accurate (71.12% and 66.41%, respectively). The calculated area under the ROC curve related to the SNAPSHOT composite index was 0.881 +/- 0.026. With an optimal cut-off point of 3, the sensitivity and specificity were 75.8% and 87.5%, respectively. The results of the present study showed that SNAPSHOT is a feasible, informative and quantitative composite index for the assessment of painful shoulder in the clinical setting.

The value of physical tests for subacromial impingement syndrome: a study of diagnostic accuracy

Objective: To determine the diagnostic accuracy of commonly used physical tests for subacromial impingement syndrome, using ultrasound as the reference standard. Design: A cross-sectional study of 59 participants with chronic shoulder pain of more than four months duration with a referral for diagnostic ultrasound scanning were invited to participate in the study. Main measures: Thirty-four participants met the inclusion criteria and had an ultrasound scan followed immediately by application of the following tests: Neer’s sign, Hawkins and Kennedy test, painful arc of abduction, empty and full can tests, resisted isometric shoulder abduction and resisted isometric shoulder external rotation. Using the two-way contingency table method sensitivity, specificity, likelihood ratios and overall accuracy were calculated for each physical test. Results: Diagnostic values for each test varied considerably. The Hawkins and Kennedy test was the most accurate test for diagnosing any degree of subacromial impingement syndrome (71.0%). The most accurate tests for diagnosing subcategories of impingement were pain on resisted external rotation and weakness during the full can test (63.6%) for presence of subdeltoid fluid, pain on resisted external rotation (58.8%) for partial thickness tears and the painful arc test (62.1%) for full thickness tears. Conclusions: As the predictive values of these tests are shown to be variable in this study it indicates that the clinical tests identified have limited use in informing diagnosis. Emphasis on the management of dysfunction may be more appropriate rather than reliance on clinical tests with inconclusive sensitivity and specificity if ultrasound scanning is not available.