Rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians.
To perform a meta-analysis to identify the most accurate clinical examination findings for
Structured search in MEDLINE, EMBASE, and CINAHL from their inception through May 2013.
For inclusion, a study must have met the following criteria: (1) description of history taking,
physical examination, or clinical tests concerning RCD; (2) detailing of sensitivity and
specificity; (3) use of a reference standard with diagnostic criteria prespecified; (4) presentation
of original data, or original data could be obtained from the authors; and (5) publication in a
language mastered by one of the authors (Danish, Dutch, English, French, German, Norwegian, Spanish,
Main Outcomes and Measures
Likelihood ratios (LRs) of symptoms and signs of RCD or of a tear, compared with an acceptable
reference standard; quality scores assigned using the Rational Clinical Examination score and bias
evaluated with the Quality Assessment of Diagnostic Accuracy Studies tool.
Twenty-eight studies assessed the examination of referred patients by specialists. Only 5 studies
reached Rational Clinical Examination quality scores of level 1-2.The studies with quality scores of
level 1-2 included 30 to 203 shoulders with the prevalence of RCD ranging from 33% to 81%. Among
pain provocation tests, a positive painful arc test result was the only finding with a positive 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, 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 positive drop arm test result (LR, 3.3 [95%
CI, 1.0-11]) might help identify patients with RCD. A normal internal rotation lag test result was
most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95% CI,
Conclusions and Relevance
Because specialists performed all the clinical maneuvers for RCD in each of the included studies
with no finding evaluated in more than 3 studies, the generalizability of the results to a
nonreferred population is unknown. A positive painful arc test result and a positive external
rotation resistance test result were the most accurate findings for detecting RCD, whereas the
presence of a positive lag test (external or internal rotation) result was most accurate for
diagnosis of a full-thickness rotator cuff tear.
Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SMA. Does This Patient With Shoulder Pain Have Rotator Cuff Disease? The Rational Clinical Examination Systematic Review. JAMA. 2013;310(8):837–847. doi:10.1001/jama.2013.276187
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