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Most Clinical Tests Cannot Accurately Diagnose Rotator Cuff Pathology a Systematic Review

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Interrater reliability of physical test tests in the astute stage of shoulder injuries

  • Martine Enger1,2,
  • Are Hugo Pripp3,
  • Lars Nordslettenane,2,
  • Stefan Moosmayer4,
  • Knut Melhuusi &
  • Jens Ivar Brox2,v

BMC Musculoskeletal Disorders volume 22, Article number:770 (2021) Cite this article

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Abstruse

Background

The physical examination is one of the cornerstones of the diagnostic process in patients with acute shoulder injuries. The discriminative backdrop of a given examination test depend both on its validity and reliability. The aim of the nowadays study was to assess the interrater reliability of 13 physical exam manoeuvres for astute rotator gage tears in patients with acute soft tissue shoulder injuries.

Methods

In a large walk-in orthopaedic emergency department, 120 consecutive patients ≥40 years of age were included in a diagnostic study. Patients who had follow-up within 3 weeks of an acute shoulder injury without fracture on radiographs were eligible. Four emergency department physicians participated as examiners. In a subset of 48 patients, the concrete examination tests were performed past two physicians, randomly chosen past their piece of work rotation. The physicians were blinded to the findings of each other and the results of the ultrasound screening. The interrater reliability was assessed by Cohen's kappa, intraclass correlation coefficient (ICC), standard mistake of measurement (SEM) and Bland-Altman plots depending on whether the exam examination result was registered as a binary, ordered categorical or continuous numerical variable.

Results

The median age was 55.5 years, 46% were female. Twenty-seven percent had a rotator cuff full-thickness tear on ultrasound screening; all but ane involved the supraspinatus tendon. Cohen's kappa for binary tests ranged from excellent to fair. Excellent agreement (kappa > 0.8) was plant for the inability to abduct in a higher place 90° and abduction strength. External rotation force expressed substantial agreement (kappa 0.7). The lowest scores were registered for Hawkins` test and the external rotation lag sign (kappa 0.25 and 0.forty, respectively). The ICCs for active range of abduction and external rotation were 0.93 (0.88–0.96) and 0.84 (0.72–0.91), whereas the SEM was 15 and 9, respectively.

Conclusions

The results signal that exam manoeuvres assessing abduction and external rotation range of motion and strength are more reliable than manoeuvres assessing hurting in patients in the acute phase of traumatic shoulder injury. The poor understanding observed is likely to limit the validity in the nowadays setting of ii commonly used tests.

Trial registration

The Norwegian Regional Ideals Committee South East (2015/195).

Peer Review reports

Background

A careful history and a systematic clinical exam are cornerstones for the evaluation of patients with shoulder hurting [1]. The diagnostic value of the clinical examination depends upon the skills of the examiner and the reliability and validity of the clinical tests. Previous studies and reviews take to a large degree focused on the validity of physical test tests, and reviews have concluded that there is insufficient evidence upon which to make clinical recommendations [2,3,four,5,half-dozen].

1 possible reason for the limited diagnostic accuracy observed, would be that the intra- and interrater reliability and agreement of tests were low. At that place is still a paucity of loftier quality studies addressing this issue [v, 7, eight]. Furthermore, Lange'southward review and meta-assay in 2016 pointed to the heterogeneity of reliability measurements hindering proper synthesis of the data [8]. Interrater reliability of the Cyriax based clinical tests has previously been reported to exist good to excellent [9, 10], simply a recent evaluation of these tests in full general practice institute poor to moderate interrater agreement [11]. This discrepancy may depend on the selection of tests and examiners, too as the methodology of the studies.

The accurateness of clinical shoulder tests in diagnosing rotator cuff disorders has been investigated in numerous studies [v, 6, 12, xiii]. However, a common feature of most of these studies is that experienced examiners, oftentimes with shoulder disorders as their specialty or field of interest, performed the tests. We wished to evaluate the tests when performed by physicians exterior of the 3rd health care system, where about patients are.

The aim of the nowadays report was to explore the interrater reliability of physical examination shoulder tests aiming to diagnose acute rotator gage lesions in patients with previously healthy shoulders who had sustained an astute soft tissue shoulder injury.

Patients and methods

Patients

The nowadays study is a subset of a diagnostic accuracy study of 120 patients 40 years or older, who had follow-up at the Department of Orthopaedic Emergency, Oslo University Hospital within three weeks of an astute shoulder injury. The facility is a combined primary and secondary care emergency department admitting non-referred patients. The department's treatment algorithm recommends follow-up for patients with at least one of the following: hurting intensity of 4 or more at rest or during activity on a numeric rating calibration from nix to ten (worst pain), abduction active range of motility reduced by > 30° or external rotation active range of motion reduced by > 20° (additional file ane). Inclusion criteria were acute soft tissue shoulder injury or successfully reduced glenohumeral dislocation with a concomitant onset of symptoms and no fracture on manifestly radiographs. Exclusion criteria were injury of both shoulders, previous shoulder surgery during last vi months, known rotator gage tear on imaging, ongoing neck−/shoulder problems and other serious disease. One hundred and 20 sequent patients were included, of which 48 were examined by two physicians and included in the present study (Fig. 1). The 48 included patients were randomly selected past the department'due south work rotation: during the inclusion period of the present study, a 2nd examiner performed the tests in improver to the first if at least two of the four participating physicians were present at the facility.

Fig. 1
figure 1

Flow of participants

Full size paradigm

Age, gender and injury mechanism were recorded. The patients filled in the Oxford Shoulder Score (OSS) ranging from 0 (virtually severe symptoms) to 48 (least symptoms) at inclusion.

The report was approved by the Norwegian Regional Ethics Committee South Eastward (2015/195) and performed in accord with the Helsinki proclamation. Written informed consent was obtained from all participants. The study was registered in ClinicalTrials.gov with ID: NCT02644564.

Clinical tests

Four physicians, none of whom were specializing in shoulder disorders, performed the clinical tests. They had from 1.5 to vi years of experience at Department of Orthopaedic Emergency. The physicians were given xxx min didactics and written information on the testing procedures (boosted file 2). They were blinded to the findings of each other and to the ultrasound screening which was the reference standard. The second author who performed the ultrasound screening, had undergone formal training and had performed iv–6 scans per week for 1.5 years when the report started. The ultrasound screening was performed according to a standard protocol [xiv, 15]. In 53 of the 120 patients of the cohort, MRI was performed. There was disagreement between the MRI and the ultrasound regarding the target condition full-thickness tear in 2 cases (4%).

The ultrasound and physical examination test results were recorded in structured questionnaires also every bit in the patient records. The patients were independently examined past ii of the iv physicians at the first follow-upwardly consultation when inclusion took place. They had clinical information available by the inclusion criteria and were besides informed as to whether the patient had sustained a glenohumeral dislocation. The examiners did not read the electronic patient record notes from the master visit, as previous examination results might influence the interpretation of the tests. The fourth dimension interval between the two assessors was less than 1 h.

The target condition that the physical examination tests aimed to detect was acute rotator gage full-thickness tears. Occult fractures of the tendon insertion were included in the target condition, as a concrete exam test could not be expected to discriminate between an avulsion of the tendon insertion and a tear of the tendon itself [16]. An occult fracture was defined every bit a fracture that could not exist identified on the primary plain radiographs by the physician in charge or by the skeletal radiologist [17]. The tests used were chosen considering of the accuracy reported in articles, reviews and meta-analyses [six, thirteen, eighteen,xix,20,21,22,23], the probability of patients being able to execute the tests in an acute setting, likewise as the feasibility of the tests in emergency departments and general practice.

The tests performed in the scope of this study are presented in Tabular array ane. Range of motion and strength were assessed clinically without the use of goniometers or dynamometers equally they are not in common utilize in emergency departments and principal health care. In accordance with the department's routine, abduction to a higher place 90° and maximal external rotation were not performed at first follow-upwards in patients with glenohumeral dislocation. These patients were not included in the reliability assay of the relevant tests (inability to abduct > 90°, painful arc, external rotation active range of movement (AROM) reduction and lag sign).

Tabular array 1 Physical examination tests assessed for astute rotator cuff total-thickness tear in soft tissue shoulder injuries

Full size table

Statistics

A sample size of 48 was comparable with other relevant studies and institute acceptable [24,25,26,27]. To evaluate interrater reliability for dichotomous variables, Cohen'south kappa was used [28]. Kappa statistics expresses the degree of agreement between ii raters corrected for take chances agreement [29]. A value of − 1 represents accented disagreement, a value of 0 no agreement above chance, and a value of 1 absolute agreement. At that place is no value of k that can exist regarded every bit a universal indicator of proficient agreement, and individual estimation is recommended. Previous studies accept considered values ≤0.4 as fair to poor, from 0.41–0.lx as moderate, 0.61–0.lxxx substantial and values greater than 0.fourscore as excellent or about perfect [30]. Linear weighted kappa was used for the ordered categorical variable internal rotation active range of motion that had four categories (Table 1).

To let for a more diverse interpretation of agreement we also calculated the percentage of absolute agreement by dividing the number of cases in which both raters agreed with the total number of cases.

For continuous numerical variables (degrees of external rotation and abduction) the intraclass correlation coefficient (ICC (ane,ane); one-style random, single measures in SPSS) and standard error of measurement (SEM) were calculated. Under the weather of the present written report with a sample of more than xxx heterogeneous patients and more than than iii raters, ICC values from 0.5 to 0.75 propose moderate reliability, 0.75 to 0.9 good, and to a higher place 0.ix fantabulous reliability [27]. For the SEM, the standard divergence (SD) of the measurements (subjects) were estimated by first calculating the mean of the SD of the starting time and second raters` results. The SEM was then calculated every bit the SD x √(i-ICC).

Bland-Altman plots were used to assess the hateful deviation and the limits of agreement betwixt raters [31]. Heteroscedasticity was examined by visual inspection of the plots, whereas linear regression assay was performed to control for proportional bias of the continuous variables.

We compared the demographic information of the subset examined by two physicians with the residuum in the principal study using the Chi-square and Isle of mann-Whitney-U-test.

IBM SPSS Statistics Version 23 was used for all analyses autonomously for SEM for which Version 26 was used.

Results

A full of 48 patients were included in this assay. The median age was 55.5 years (interquartile range (IQR) 46–64) and 46% were female. The age and sex distribution was not different from the other 72 patients of the primary study. The mean number of days from the blow to inclusion and examination was 12 (SD, three.iv), and 85% were injured due to falls. The mean Oxford Shoulder Score was 27.5 (SD, 8.7) at inclusion.

The proportion of patients with a total-thickness rotator gage tear was 27% (north = thirteen) and besides not different from the main study. All merely one tear involved the supraspinatus, and in 5 cases the tear extended into the superior portion of the subscapularis tendon. There was one isolated superior full-thickness subscapularis tendon tear, only no total-thickness, full-width tears. Furthermore, viii patients (17%) had sustained a glenohumeral dislocation, whereas 25 were classified equally contusions or sprains. The remaining patients had occult fractures (due north = 4), sternoclavicular dislocation (due north = i) or a tear of the long head of the biceps (n = one). Four patients had two diagnoses.

The valid number of comparisons is presented in Table 2. Six patients that had a contempo shoulder dislocation were prohibited by department protocol to housebreak > 90°. Those that abducted to 90° were therefore excluded from the analysis of the inability to abduct > 90° and the painful arc tests, as they could potentially exist interpreted as faux positives. The observed range of motion extended from 0 to 180 degrees for abduction, and from 0 to 90 degrees for external rotation.

Table 2 Inter-observer reliability of physical examination tests in patients diagnosed as acute soft tissue shoulder injury

Total size table

We observed splendid interrater understanding for the abduction strength test, substantial and moderate for external rotation strength assessed conventionally and by the small finger test, respectively. The internal rotation lag sign was categorized as positive in ii patients by the beginning assessors, whereas the 2d assessors categorized it every bit not possible to perform (Table 2). At that place was full agreement between the first and second assessors regarding the remaining negative tests. No reliability values could be calculated for the internal rotation lag sign performed anteriorly to the torso, equally at that place was no positive finding registered past the 2nd assessors. There was almost perfect understanding between the examiners for the inability to abduct > 90°, deduced from the registered number of degrees of abduction (Table 2), whereas understanding was substantial for registering a loss of external rotation ≥20° compared to the uninjured side. For abduction AROM the ICC (ICC (1,ane); 1-way random, single measures) conviction interval suggested skillful to excellent reliability, and for external rotation AROM moderate to excellent reliability (Table iii). Agreement of the continuous variables was farther explored by quantifying the mean divergence between the first and second assessor and the limits of agreement in Bland Altman plots (Figs. 2 and three). The linear regression analyses did not betoken proportional bias. At that place was no obvious sign of heteroscedasticity in external rotation AROM (Fig. 3), but there could exist a tendency for a narrower dispersion of values in abduction AROM at the high end of the spectre (Fig. 2).

Table 3 Reliability of continuous measurements

Full size tabular array

Fig. 2
figure 2

Bland Altman plot of degrees of active range of abduction. The horizontal lines represent the mean and ± 1.96 x SD of the difference between the first and 2d examiner. Six patients were not tested to maximum abduction due to recent glenohumeral dislocation. The largest marker represents 12 cases. The medium sized 4 and 3, respectively

Full size image

Fig. 3
figure 3

Bland Altman plot of degrees of active range of external rotation. The horizontal lines represent the mean and ± 1.96 x SD of the difference between the outset and second examiner. Eight patients were not tested for maximum external rotation due to contempo glenohumeral dislocation. The largest markers represent 3 cases, the medium sized ii

Full size prototype

Discussion

The main result of the present report is that clinical cess of active range of abduction and external rotation (expressed by the inability to abduct > 90° and external rotation reduced by ≥ xx° compared to uninjured side) and abduction and external rotation strength expressed best reliability amidst the included tests in patients in the acute phase of shoulder injury. According to Landis and Koch these results are classified as substantial to almost perfect [30]. There is however no universally agreed upon kappa value that indicates «adequate» agreement, and careful interpretation is equally ever necessary. Others have used kappa > 0.60 or accented agreement of 80% as indicative of adequate agreement in clinical tests of the shoulder [32].

Nosotros observed bang-up variation of interrater agreement betwixt tests; with kappa values ranging from 0.25 to 0.90. The tests with the two lowest scores nigh included aught in the confidence intervals (Table two). The internal rotation lag sign had a kappa value of one, but in that location were simply 6 patients with a subscapularis tear in the superior portion of the tendon and a strong predominance of negative tests. This result should therefore be interpreted with circumspection.

Accented values of degrees of active range of abduction and external rotation were registered by the examiners. In addition, we dichotomized the values into the inability to abduct higher up ninety° and reduction in external rotation ≥20° or more, every bit positive or negative tests. Interrater agreement was evaluated by ICCs and SEMs for assessment of the estimated number of degrees of agile range of motion. The results presented in Table three indicate moderate to excellent reliability. In a previous study assessing the reliability of active range of motion in an identical way merely performed by trained physical therapists, the ICC was 0.96 compared to 0.93 in our report, both excellent [32]. There could exist a tendency for a narrower dispersion of the difference between the examiners in the Bland-Altman plot when abduction got shut to normal (Fig. ii), indicating that heteroscedasticity may have been present. The kappa values were still excellent and good for the binary tests inability to housebreak above xc° and external rotation reduced by ≥twenty°, respectively (Table 2). The finding of a loftier degree of understanding between the physicians when information technology comes to estimating agile range of movement, is supported past a previous study on hip range of motion reporting loftier understanding between visual estimates and goniometer measurements with ICCs ranging from 0.fourscore to 0.88 [33].

The Hawkins` test for impingement may be a hard test to perform and translate in the astute setting where a considerable number of patients experience hurting at top of the arm to shoulder level. This is illustrated by the lowest level of agreement of the present study, but even so fair co-ordinate to the Landis and Koch interpretation [xxx]. Cadogan and co-workers written report like fair values [24]. In Lange'due south systematic review and meta-analysis extensive heterogeneity was observed for the Hawkins` test, and the results indicated an overall kappa value of 0.47 (moderate) [8].

There are several possible explanations to the variation in reliability among the tests in the nowadays written report. The most obvious is that for some tests more than others, the same signs and symptoms may be interpreted differently by dissimilar physicians. Second, the patient may experience a training result resulting in a discrepancy between the findings of the first and second assessors. A patient having experienced pain may be more hesitant during the second testing, or unable to perform too as the get-go fourth dimension. Conversely, patients who perform the test without much pain may button their limit farther the next time. Third, it is possible that providing more than training of the physicians than what was offered in the nowadays study could accept improved reliability. The generalizability to emergency departments and principal wellness care would on the other manus have decreased, as the physicians would have been trained to be more like to shoulder specialists than first line physicians.

In spite of the diversity, there was a trend for tests estimating range of motion and strength to have superior reliability to tests interpreting pain (resisted abduction pain, Hawkins` examination). This is in keeping with the results from a contempo written report reporting that for resisted external rotation; muscle weakness alone had better diagnostic validity for the detection of infraspinatus tears than pain or muscles weakness and/or pain [34].

Of the tests for which kappa values were calculated, v tests expressed substantial or excellent inter-rater reliability, whereas 5 expressed moderate reliability. The latter is not surprising in the light of the reliability reported in other clinical evaluations. A recent report examined interrater agreement for radiographic evaluation of glenohumeral osteoarthritis and institute moderate kappa values of about 0.5 in experienced radiologists [35], whereas some other ii recent studies of shoulder examination techniques reported great diversity of the kappa values and broad confidence intervals [11, 29]. In the present written report, several tests had wide confidence intervals, specially the belly-press test and the external rotation lag sign. The tests expressing the all-time kappa values also had narrower confidence intervals.

Ane of the strengths of the nowadays study is that it provides data with external validity to facilities both in hospitals and primary care that admit the majority of acute shoulder injuries. The included patients were not referred, and the four physicians performing the tests were not shoulder specialists. Several authors have pointed out the lack of data on the performance of shoulder tests from such a setting, as nigh previous studies have involved referred patients examined by specialists [5, 12, 13].

The study has some limitations. Showtime, intrarater reliability was not studied. Patients with acute shoulder injuries may feel changes in symptoms, making it necessary to go along the time interval between tests brusk. To adequately blind the md to patients they examined hours earlier would have been challenging. Due to the methodological difficulties, only one of 18 studies in a recent review of the reliability of concrete examination tests for shoulder pathologies reported intrarater reliability [eight]. 2d, every bit in other reliability studies examining shoulder tests, the confidence intervals were quite wide [7, 8, xi]. A higher number of included patients could possibly accept reduced the confidence intervals. Finally, only six patients had full-thickness tears of the subscapularis, all limited to the superior portion of the tendon. The examination results related to the subscapularis tendon should therefore be interpreted with caution.

Conclusions

Kappa values were splendid for the inability to abduct > 90° and abduction forcefulness and substantial for external rotation strength. There was a tendency for tests assessing pain to exist less reliable than tests assessing range of motion and strength. Commonly used tests like the external rotation lag sign and Hawkins` test expressed the lowest kappa values of the included tests. Leaving these tests out from the examination in the acute phase of shoulder injury should be considered.

ICC for estimating active range of abduction and external rotation were acceptable and like, merely relative to the range, improve for abduction than external rotation.

The present written report contributes to filling the knowledge gap regarding the reliability of shoulder tests. Equally tests that exercise not measure consistently cannot be accurate, the results of the present study indicate which concrete examination tests may be effective in detecting acute rotator cuff tears in patients during the acute phase of shoulder injury in the offset line setting. Effective physical examination tests may ameliorate the management of these patients both by providing a more reliable tool for the option of patients for advanced imaging, likewise as by providing the patient with a diagnosis and treatment program at an earlier stage.

Availability of data and materials

The dataset is available from the corresponding author upon reasonable request.

Abbreviations

AROM:

Active range of move

ICC:

Intraclass correlation coefficient

IQR:

interquartile range

OSS:

Oxford Shoulder Score

SD:

Standard deviation

SEM:

Standard error of measurement

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Acknowledgements

The authors would like to thank all patients that contributed to the written report. Nosotros are also very grateful to Øyvind Karlsen, Anniken Nyhus and Ingrid Oftebro who performed the concrete test tests, to Dominic Anthony Hoff for back up regarding the database and to Benthe J. Hansen for administrative back up.

Authors` contributions

MS, ME, LN, SM, KM and JIB conceived and designed the study. ME and MS recruited the patients. MS and 3 other medical doctors performed the physical test tests. ME performed the ultrasound screening. MS designed the database. ME entered the data. MS, AHP and ME conducted the statistical assay. MS drafted the first version of the manuscript; MS, ME and JIB the final version. AHP, LN, SM and KM revised the manuscript critically. JIB supervised the written report. All authors read and canonical the terminal manuscript.

Authors` information

MS is a medical md, PhD and trainee in orthopaedic surgery. ME and KM are senior consultants at Department of Orthopaedic Emergency, ME is a PhD candidate. AHP is a senior statistician. SM is an orthopaedic surgeon, PhD. 2 authors are professors, LN in Orthopaedic surgery and JIB in physical medicine.

Funding

This report was supported past Sophies Minde Ortopedi As, which is a non-commercial subsidiary company fully owned by Oslo University Hospital. Sophies Minde Ortopedi Every bit had no role in the data collection, data analysis or the preparation of or editing of the manuscript.

Author information

Affiliations

  1. Section of Orthopaedic Emergency, Sectionalisation of Orthopaedic Surgery, Oslo University Hospital, Postboks 4956 Nydalen, 0424, Oslo, Norway

    Malte Schmidt, Martine Enger, Lars Nordsletten & Knut Melhuus

  2. Plant of Clinical Medicine, University of Oslo, Oslo, Norway

    Martine Enger, Lars Nordsletten & Jens Ivar Brox

  3. Oslo Heart of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway

    Are Hugo Pripp

  4. Department of Orthopaedic Surgery, Martina Hansens Hospital, Sandvika, Norway

    Stefan Moosmayer

  5. Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway

    Jens Ivar Brox

Corresponding writer

Correspondence to Martine Enger.

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The study was approved by the Norwegian Regional Ethics Commission South East (2015/195) and performed in accordance with the Helsinki declaration. Written informed consent was obtained from all participants in the report.

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ME received grants from Sophies Minde Ortopedi Every bit. Sophies Minde Ortopedi As is a non-commercial subsidiary company of Oslo University Hospital. The other authors have declared no competing interests.

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Schmidt, M., Enger, M., Pripp, A.H. et al. Interrater reliability of physical examination tests in the acute phase of shoulder injuries. BMC Musculoskelet Disord 22, 770 (2021). https://doi.org/10.1186/s12891-021-04659-x

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Keywords

  • Reliability
  • Agreement
  • Physical examination test
  • Acute shoulder injury

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