An Update to Hegedus' Systematic Review on Orthopaedic Tests for the Shoulder

Study Title: Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests
Authors: E. Hegedus
Journal: British Journal of Sports Medicine
Date: October 2012
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Summary:

• Although high quality open access journal articles aren't common - yet - they still do occur. This systematic review with meta-analysis by Hegedus is one such paper for example, and is one that is essentially an updated version of his 2008 review. With a surplus of orthopaedic tests for the shoulder and an equally great number of review papers investigating such tests, it can be very simple for clinicians who a) take a less than adequate history and b) are unfamiliar with the accuracy of the arsenal of tests to fall into the trap of utilizing inappropriate tests for given clinical presentations.
• Hegedus' review provides us with an update of his original article, based on the fact that since his original article was published, not only have new studies been published, but also the methodologies behind systematic reviews and meta-analyses have been updated as well.
• Without going into great detail, the protocol used in this review was that of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The original paper examined studies from 1966-October, 2006 while this paper confined it's Medline and CINAHL search to November, 2006-February, 2012. Additionally, EMBASE and the Cochrane Library were added as databases as well. 2x2 tables were used for meta-analysis and quality was assesed via the QUADAS-2 tool.
• In total, 32 new studies addressing diagnostic accuracy were revealed in this new time frame with 12 of these studies added 13 new tests to the literature. And the majority of these tests pertained to the diagnosis of SLAP tears. What this updated paper adds to the literature include the following:

• Biceps Load II seems to be less diagnostic for SLAP lesions
• The belly-off and modified belly press tests may add to subscapularis tendinopathy diagnosis
• The olecranon-manubrium percussion test may be useful in traumatic cases for requiring imaging
• The passive compression test may be helpful in diagnosing a SLAP lesion
• The modified dynamic labral shear test may be helpful for SLAP lesions
• The lateral Jobe test for diagnosing rotator cuff tears
• The passive distraction test may assis in ruling in a SLAP tear if possible

• With the information provided above, it is still very reasonable to assume that rather than clarifying the application of orthopaedic testing for the shoulder, we may be no further from a practicality standpoint. I, myself, firmly believe that although there are numerous tests for the shoulder, a detailed clinical history combined with a good understanding of the mechanisms behind shoulder pathologies hold more value than the testing itself. Essentially, orthopaedic tests should confirm or deny your differentials but your differentials will always be based on your investigative and listening skills, as well as your understanding of the body (and mind).
• So with that said, I want to leave you with a snippet of an email discussion I had several months back with a colleague of mine who is an orthopaedic surgeon that specializes in the upper extremity.

"Sorry, but I won't be much help with the biceps/slap debate.  My own personal view is that all the tests are pretty useless and I've not found much predictive value with any of them.  Most of them put the arm in significant flexion or adduction and these are essentially the impingement or AC compression testing positions, so I feel they overlap siginificantly with eliciting the much more common cuff and AC pathology.  I also refuse to do multiple tests to evaluate the same structure, I pick the one that is the best (even if it's the best of a bunch of bad tests).  So for superior labrum I do the crank test, because it is past the painful arc and mimics the peel back meneuvre that we do intra-operatively to visualize an unstable II slap if it's there.  

Combine that diagnostic dilema with the fact that most slap repairs either don't heal or cause significant stiffness and essentially I only repair slaps in combination with a pan labral injury during instability surgery.  Final caveat though is that I definitely don't have a very young sportsy practice, so maybe others are seeing the real deal, for me it's all hocus pocus."
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Hegedus, E. (2012). Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. British Journal of Sports Medicine, vol 46; 964-978
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