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The Rational Clinical Examination
Clinician's Corner
October 27, 2004

Does This Patient Have an Instability of the Shoulder or a Labrum Lesion?

Author Affiliations

The Rational Clinical Examination Section Editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA.


Author Affiliations: The Netherlands Expert Centre for Work-related Musculoskeletal Disorders, Erasmus, University Medical Center Rotterdam (Mr Miedema, Dr Kuiper, and Ms Luime); Department of General Practice, Erasmus MC, University Medical Center Rotterdam (Ms Luime and Drs Verhagen and Koes); Department of Public Health, Erasmus MC, University Medical Center Rotterdam (Dr Burdorf); and Department of Orthopedics, Erasmus MC, University Medical Center Rotterdam (Dr Verhaar), Rotterdam, the Netherlands.

JAMA. 2004;292(16):1989-1999. doi:10.1001/jama.292.16.1989

Context History taking and clinical tests are commonly used to diagnose shoulder pain. Unclear is whether tests and history accurately diagnose instability or intra-articular pathology (IAP).

Objective To analyze the accuracy of clinical tests and history taking for shoulder instability or IAP.

Data Sources Relevant studies identified through PubMed, EMBASE, CINAHL, and bibliographies of known primary and review articles.

Study Selection Studies comparing the performance of history items or physical examination with a reference standard were included. Studies on fibromyalgia, fractures, or systemic disorders were excluded. Of 1449 articles, 35 were eligible, and 17 were selected.

Data Extraction Data were extracted on study population, clinical tests, reference tests, and outcome. The studies’ methodological quality (patient spectrum, verification, blinding, and replication) was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist.

Data Synthesis Six tests showed positive likelihood ratios (LRs) and confidence intervals (CIs). Tests favoring the diagnosis for establishing instability included: relocation (LR, 6.5; 95% CI, 3.0-14.0) and anterior release (LR, 8.3; 95% CI, 3.6-19). Tests showing promise for establishing labral lesions included: the biceps load I and II (LR, 29; 95% CI, 7.3-115.0 and LR, 26; 95% CI, 8.6-80.0), respectively, pain provocation of Mimori (LR, 7.2; 95% CI, 1.6-32.0), and internal rotation resistance strength (LR, 25; 95% CI, 8.1-76.0). The apprehension, clunk, release, load and shift, and sulcus sign tests proved less useful. Results should be cautiously interpreted because studies were completed in select populations in orthopedic practice, mostly assessed by the test designers, and evaluated in single studies only. No accuracy studies were found for history taking or for clinical tests in primary care.

Conclusions Shoulder complaints are frequently recurrent. Instability might cause some of these complaints. Best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests.