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Evidence summaries

Diagnostic Tests for the Assessment of Shoulder Pain

Clinical assessment by specialist appears to be accurate in ruling out rotator cuff tears. Either ultrasound or MRI can be used to detect the tears, and ultrasound appears to be the more cost-effective choice. Level of evidence: "B"

A technology assessment report 1 studied the effectiveness and cost-effectiveness of diagnostic methods for soft tissue shoulder disorders. Ten studies focused on the clinical assessment of shoulder pain. Individual tests were either good at ruling out rotator cuff tears (high sensitivity) or at ruling in such disorders when positive (high specificity). Because of small sample sizes the evidence was not conclusive. Pooled results from four studies for overall sensitivity and specificity of clinical examination were 0.90 (95% CI 0.87 to 0.93) and 0.54 (0.47 to 0.61), respectively. Ultrasound was assessed in 38 studies. Ultrasound was most accurate when used for the detection of full-thickness tears, although results were heterogeneous: pooled sensitivity 0.87 (0.84 to 0.89) and specificity 0.96 (0.94 to 0.97). Sensitivity was lower for detection of partial-thickness tears (0.67, 95% CI 0.61 to 0.73). Magnetic resonance imaging (MRI) was investigated in 29 studies. For full-thickness tears, pooled sensitivities and specificities were high (0.89, 95% CI 0.86 to 0.92 and 0.93, 95% CI 0.91 to 0.95, respectively). There were six studies on magnetic resonance artrography (MRA). However, there design varied considerably between studies making conclusions difficult. MRA may perform better than MRI or ultrasound but this potential benefit must be set against the invasiveness and potential discomfort to the patient. Conclusions: The authors conclude that clinical examination by specialists can rule out the presence of rotator cuff tear, and that either ultrasound or MRI can be used for detection of full-thickness tears. Given the large difference in costs, ultrasound is the more cost-effective test to use in specialist hospitals.

    References

    • Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003;7(29).

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