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Rheumatology Advance Access originally published online on March 27, 2008
Rheumatology 2008 47(5):679-683; doi:10.1093/rheumatology/ken101
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© The Author 2008. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Accuracy of physical examination in subacromial impingement syndrome

L. Silva1, J. L. Andréu1, P. Muñoz1, M. Pastrana2, I. Millán3, J. Sanz1, C. Barbadillo1 and M. Fernández-Castro1

1Department of Rheumatology, 2Department of Imaging and 3Department of Biostatistics, Hospital Universitario Puerta de Hierro, Madrid, Spain.

Correspondence to: J. L. Andreu, Servicio de Reumatología, Hospital Universitario Puerta de Hierro, San Martín de Porres 4, Madrid 28035, Spain. E-mail: jlandreu{at}arrakis.es


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 References
 
Objective. Shoulder pain is a common complaint, frequently caused by subacromial impingement syndrome (SIS). There are a number of physical examination (PE) manoeuvres that explore the subacromial space. MRI provides an accurate anatomic image of the subacromial space, being the current gold standard in the diagnosis of SIS. The aim of this study is to evaluate the accuracy of the PE in the diagnosis of SIS and/or subacromial–subdeltoid bursitis (SSB) confirmed by MRI.

Methods. Consecutive outpatients with an episode of shoulder pain were prospectively included in the study. They were examined by a rheumatologist and, within 3 days, an MRI was done. Sensitivity, specificity, positive and negative predictive values, and accuracy of PE manoeuvres were calculated using a 2 x 2 table.

Results. Fourteen males and 16 females were included. All the tests exhibited acceptable sensitivity. As a result Yocum manoeuvre was considered the most sensitive and most accurate for SIS. With regard to SSB, the Gerber test was the most sensitive. The majority of the PE manoeuvres showed low specificity.

Conclusions. Most PE manoeuvres identify reasonably well subacromial impingement of the shoulder, although, in general, they have low specificity. The Yocum test has the best sensitivity and precision. Our data suggest that imaging techniques should be recommended to better define shoulder lesions.

KEY WORDS: Painful shoulder, Subacromial impingement syndrome, Subacromial–subdeltoid bursitis, Clinical evaluation, MRI


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 References
 
Shoulder pain is a common presenting complaint for patients of all ages. Subacromial impingement syndrome (SIS) is the most common disorder of the shoulder. It comprises a spectrum of subacromial space lesions including partial thickness rotator cuff tears, rotator cuff tendinosis, calcified tendinitis and subacromial bursitis. It is generally assumed that they arise from the repetitive or excessive contact of the rotator cuff tendons with other anatomic structures in the shoulder, and usually result in functional loss and disability [1–3].

SIS leads to progressive oedema, fibrosis and consequent tears in the rotator cuff muscles. As described by Neer [4, 5] and Birtane et al. [6], SIS is categorized in three stages: Stage 1 is characterized by oedema and haemorrhage. In Stage 2, cuff fibrosis is evident, with thickening and partial cuff tearing. Stage 3 involves the specific findings of full thickness tendon tears, bony changes and tendon ruptures.

The assessment of a patient with shoulder pain is usually complicated due to the wide variety of possible aetiologies, and the difficulty to palpate many of the structures that cause pain. The physical examination (PE) for rotator cuff disease remains important for the clinical assessment of patients who present with shoulder pain or weakness. To know the utility of the different examination tests for SIS and other disorders of the shoulder is relevant for those who treat patients with symptoms of rotator cuff disease [7, 8]. On the other hand, currently, MRI is considered an excellent non-invasive tool for the diagnosis of shoulder lesions. MRI is indeed a highly sensitive technique [6].

Some previous studies have analysed the utility of the different clinical tests in the diagnosis of shoulder disorders. Comparisons between PE and different imaging techniques have been done, surgery being the most commonly used gold standard [8–11]. Nevertheless, although MRI is frequently used nowadays for the diagnosis of musculoskeletal disorders, the PE of the painful shoulder has hardly ever been compared with MRI. Çalis et al. [11] investigated the diagnostic value of clinical tests in SIS diagnosis confirmed by the subacromial injection test, but they also compared the clinical findings with the MRI findings. Since this kind of study is rarely available, and the MRI is widely accepted as a reliable imaging technique for shoulder disorder diagnosis, we performed this study to try to confirm their findings and define as to which clinical tests were the best diagnostic tools for SIS confirmed by MRI.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 References
 
Patient selection and study design
Consecutive adult (≥18-yr old) outpatients with a new-onset episode of shoulder pain, referred to our rheumatology clinic from primary care physicians and from the emergency room between January and June 2006, were prospectively included in the study. Sample size was not formally calculated. Patients with history of shoulder trauma or surgery, inflammatory rheumatic diseases, painful cervical motion or other musculoskeletal problems of an upper limb were excluded. Patients’ demographic characteristics, with respect to age and gender, and the date of onset of shoulder symptoms were recorded. A detailed PE including active and passive range of motion and seven manoeuvres for SIS was performed by the same rheumatologist (L.S.). Within 3 days of the PE, an MRI of the painful shoulder was carried out and evaluated by a radiologist who had experience on skeletal system, unaware of the patient's history or the PE findings. The study was approved by the ethical committee of our institution and a signed informed consent was obtained according to the Declaration of Helsinki.

PE
First, active and passive ranges of motion were evaluated. For active abduction, the patient is asked to bring his arm up as high as he can and is asked what he feels. For passive abduction, the examiner pushes the patient's arm up as high as possible and notes whether full abduction is obtainable, if it hurts and if active and passive abduction correspond in range or not. A painful passive abduction is considered as a positive test [12]. In addition, the PE included seven clinical tests for SIS. All these tests were performed with the patient standing and in an established order.

The first test was the Neer impingement sign. For this manoeuvre, the examiner stands behind the patient. While scapular rotation is prevented with one hand, the patient's arm is forwarded flexed by the other hand reducing the space between the greater tuberosity and the anteroinferior aspect of the acromion until the patient reports pain or full flexion is reached. The test is positive if the patient feels pain before the full flexion of the arm is achieved [4, 5].

For the Hawkins test, the examiner stands facing the patient and flexes the arm up to 90° with the elbow in 90° flexion and then gently changes to internal rotation. If pain occurs, then the test is positive [13].

In the Yocum manoeuvre, the arm is forced to adduction and the elbow is flexed until the hand is over the contralateral shoulder. Then the patient raises the elbow without moving the shoulder. The test is considered to be positive if the patient has pain during the manoeuvre [14].

The fourth test was the Jobe manoeuvre. In this test, the patient places both arms in 90° abduction in the scapular plane, angled forward 30°, and in internal rotation, with the thumbs pointing towards the floor. The examiner pushes the patient's arms down while he tries to maintain the position. If the patient cannot do this and the arm drops with pain, the test is considered positive [15].

In the fifth test, the Patte manoeuvre, the patient places his arm in the plane of the scapula with the elbow in 90° flexion and is asked to push his hand to the back. It allows the examiner to evaluate strength and pain in external rotation [9].

In Gerber's lift-off test, the patient is asked to place the hand against the back at the level of the waist with the elbow in 90° flexion. The examiner pulls the hand to about 5–10 cm from the back while maintaining the 90° bend in the elbow. The patient is then asked to hold the position without the examiner's help. The test is considered positive if the hand cannot be lifted off the back without feeling the pain [16].

Finally, the patient was asked to do a resisted abduction of the arm. For this manoeuvre, the patient pushes his elbow externally as hard as he can; the examiner holds the elbow so strongly that the shoulder joint does not move. It was considered positive when the patient experienced the pain. The test was also useful to note strength [12].

MRI evaluation
All the patients except one that suffered from claustrophobia underwent an MRI (Siemens Avanto 1.5 T Shoulder Array Coil, Siemens Medical Systems, Erlangen, Germany) of the painful shoulder within 3 days after the PE. The patients were placed in a supine position. The protocol included coronal oblique, sagittal and axial planes. Axial gradient echo (MEDIC 3D) should extend from the top of the acromioclavicular joint to the inferior glenoid margin. Coronal oblique spin-echo T1-weighted (443/12) and turbo spin-echo T2-weighted (3400/99) fat-suppressed images were performed parallel to the supraspinatus tendon. Sagittal oblique proton density (2150/38) fat-suppressed images were oriented parallel to the glenoid cavity. A section of thickness 1.5–4 mm was used, with high resolution (320–512) matrix. The total examination time did not exceed 20 min.

The SIS was graded by an experienced radiologist according to Zlatkin's MRI stages of SIS [17], as follows: Stage 0: tendon morphology and signal intensity normal; Stage 1: increased signal intensity in the tendon without any thinning irregularity or discontinuity; Stage 2: increased signal intensity with irregularity and thinning of the tendon; and Stage 3: complete disruption of the supraspinatus tendon. Patients with Stage 1–3 MRI findings were accepted as MRI-positive cases for SIS. The presence of subacromial–subdeltoid bursitis (SSB) was also recorded.

Statistical analysis
Statistical Package for Social Sciences 15.0 software for Windows was used for all statistical analyses. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), accuracy, and positive likelihood ratio (LR = sensitivity/1–specificity) of each manoeuvre to detect SIS and SSB were calculated using a 2 x 2 table. The CIs for the LRs were constructed using the iterative method of Gart and Nam.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 References
 
Patients
Of the 30 patients enrolled, 14 (46.66%) were males and 16 were females (53.33%). The average age of the whole patient group was found to be 54.87 ± 13.8 (range: 24–82). Median duration of symptoms was 97.5 days (range: 9–738).

Clinical results
PE findings were compared with the MRI findings. Clinical findings are listed in Table 1. No single manoeuvre was positive in all the cases. Whereas passive abduction was positive in 80% of the shoulders, Yocum and Jobe manoeuvres were negative in more than a quarter of the patients. The Neer impingement sign and Hawkins test, two manoeuvres designed to detect SIS, were negative in 30% of the patients. All the tests were positive in more than a half of the patients.


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  		TABLE 1. Clinical findings in the 30 patients

 
MRI findings
Twenty-nine patients underwent an MRI. Once the PE was done, Patient 16 did not complete the MRI exploration due to claustrophobia that he had not complained of previously. Of the 29 patients, 19 (65.5%) showed MRI signs of SIS and 15 (51.7%) showed SSB.

Correlation between clinical and MRI findings
Table 2 shows the sensitivity, specificity, PPV, NPV, accuracy and LR of the different PE manoeuvres in the detection of SIS. Sensitivity was reasonably good for all the clinical tests (all of them above 58%) but the specificity was very low, with values between 10% and 60%. The Yocum manoeuvre was the most sensitive, followed by the Hawkins and Jobe manoeuvres. The Patte manoeuvre had the best PPV (73.3%) and Yocum's was the most accurate (65.5%).


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  		TABLE 2. PE findings in MRI-confirmed SIS

 
Table 3 shows the values for SSB. In this case, all the sensitivities were above 73%. Once again, specificities were very low. The Gerber manoeuvre obtained the best PPV and accuracy.


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  		TABLE 3. PE findings in MRI-confirmed SSB

 
We wondered if any combination of manoeuvres could improve the diagnostic value of the PE. The performances of the 28 combinations of two diagnostic tests for SIS and SSB are shown in Table 4. Noteworthy, the combination of Geber and Patte tests had an LR of 10.27 for the detection of SSB. We also calculated the LR of the combinations of more than two tests, but none of them improved the LR significantly (data not shown).


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  		TABLE 4. Performance of the 28 different combinations of two tests

 

   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
References
 
Shoulder disorders are very common in rheumatology clinics, usually presenting with similar symptoms, which makes the differential diagnosis quite difficult. Besides, narrowing the aetiology of shoulder pain can be even more complex as a number of conditions often co-exist in older individuals [1]. PE, although having a great importance, may not be sufficient for appropriate diagnosis [11]. This circumstance, added to the excellent soft tissue contrast assessment provided by MRI, had resulted in an increased number of indications for MRI in the past few years [18].

The SIS is a clinical syndrome that indicates a pathological process between the roof and floor of the subacromial space. It commonly results from abrasion of the rotator cuff and the subacromial bursa secondary to compression of these structures between the humeral head and the acromion, the coracoacromial ligament, or the acromioclavicular joint [19, 20]. In 1972, Neer [4] described the condition of subacromial impingement as the elicitation of pain in the external region of the deltoid when, in the standing position, the affected extremity is forcibly elevated, while the scapula is stabilized. This manoeuvre is supposed to pinch the supraspinatus tendon between the humeral head and the anteroinferior aspect of the acromion [20]. The final stage of the impingement is the degeneration and rupture of the supraspinatus tendon [3].

With the existing clinical impingement tests, a different anatomical structure is tested, but these tests often fail to take into account the different aetiologies of impingement syndrome [20]. In this study, we have examined the accuracy of a wide range of PE manoeuvres as diagnostic tools for SIS. Our results show that the PE manoeuvres of the shoulder have an acceptable accuracy in localizing the lesion in a painful shoulder, but they are not very accurate in defining the lesion compared with MRI diagnosis. We found that the majority of the tests for SIS and SSB have greater sensitivity than specificity. This finding is supported by other previous studies [8–11], and it is probably due to the fact that many of these PE manoeuvres can be positive in the presence of other shoulder conditions. In our study, the test found to be the most diagnostic for SIS was the Yocum test, since it obtained the best sensitivity and the best accuracy. Nevertheless, the Hawkins, Jobe and passive abduction tests resulted to be good diagnostic tools too. With regard to SSB, the Gerber manoeuvre was the most useful. As expected, the combination of several clinical tests improved the PPV significantly but decreased the sensitivity. This effect was even more obvious with the combination of three tests than with the combination of only two of them.

Other previous studies [8, 9, 11, 21, 22] have compared the PE with MRI or other imaging techniques such as ultrasonography (US) or arthroscopy in the diagnosis of painful shoulder.

As in our study, the Hawkins test also achieved good sensitivity in other studies [8, 11, 23]. In 2000, Çalis et al. [11] studied the diagnostic values of clinical tests in 120 patients with painful shoulder using the subacromial injection test as the reference standard for classifying patients with or without SIS. Besides the Hawkins test, they found the Neer and horizontal adduction tests to be quite good to determine the presence of SIS. In the study of Leroux et al. [9], the sensitivities of the Neer, Hawkins and Yocum signs were 89, 87 and 78%, respectively compared with intraoperatively observed anatomic lesions. Nevertheless, the Neer manoeuvre did not give as good results as the Yocum or Hawkins manoeuvres in our study, although it was useful too.

In another study, Park et al. [8] concluded that the severity of the impingement syndrome affected the diagnostic values of the clinical tests. They studied the utility of clinical tests for diagnosing bursitis alone, partial-thickness rotator cuff tears and full-thickness rotator cuff tears, using surgery (arthroscopy) as the reference standard. This was the first study evaluating the PE for the three different degrees of rotator cuff disease. Once again, in accordance with previous studies, the Hawkins and horizontal abduction tests achieved the best sensitivities for diagnosing SIS in general, and they were also among the best tests for each separate degree of disease. They also studied the diagnostic value of the combination of several manoeuvres, finding that the best combination of tests for SIS of any degree were the Hawkins sign, horizontal abduction and weakness in external rotation.

Naredo et al. [21] used high-frequency US to confirm the diagnosis of SIS. In this study, clinical assessment showed low accuracy in the diagnosis of periarticular shoulder lesions. With regard to the SIS, the PE sensitivity was 65% and PPV was 81.2%, but for SSB it only achieved a sensitivity of 42.8%, which is very low. They did not calculate the diagnostic values of each separated manoeuvre, but, since the global sensitivity of PE in the diagnosis of shoulder lesions was so low, they recommend the use of US as a regular tool in the study of the painful shoulder. We preferred to use MRI as the reference standard due to its widely reported value in the diagnosis of soft tissue lesions [18, 24–27], although it also should be considered that MRI is, in contrast to US, expensive, time consuming and not always available.

Other studies [2, 10, 28] have only evaluated Neer and Hawkins signs, since they are the most commonly used manoeuvres in diagnosing SIS. In this way, MacDonald et al. [10] assessed the accuracy of these two signs for the diagnosis of subacromial bursitis documented by arthroscopy. The sensitivity of Neer and Hawkins signs were 75 and 92%, respectively. Specificity and PPV for the two tests were low, being not much higher than pre-test probability.

In conclusion, the clinical evaluation of a patient with painful shoulder is a diagnostic challenge for the physician, since a number of different disorders may result in the same PE. Besides, SIS has different aetiologies, and, mostly in older individuals, different shoulder conditions may coexist. A negative test does not rule out rotator cuff and/or subacromial space disease, but we can state that a positive test correlates very well with the presence of shoulder pathology, although it can have a wide range of aetiologies. In this study, the Yocum test obtained the best sensitivity to diagnose SIS and the Gerber test to diagnose SSB. The Gerber and Patte tests represented the best combination of two diagnostic manoeuvres. Imaging techniques such as US or MRI, should be recommended to better define shoulder lesions.

Formula

Disclosure statement: The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 References
 

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Submitted 29 October 2007; revised version accepted 8 February 2008.
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