A systematic review 1 evaluated the evidence for the effectiveness and cost-effectiveness of the newer diagnostic imaging tests as an addition to clinical examination and patient history for the diagnosis of soft tissue shoulder disorders. Studies were identified that evaluated clinical examination, ultrasound, magnetic resonance imaging (MRI), or magnetic resonance arthrography (MRA) in patients suspected of having soft tissue shoulder disorders. Outcomes assessed were clinical impingement syndrome or rotator cuff tear (full, partial or any). Only cohort studies were included.
In the included studies, the prevalence of rotator cuff disorders was generally high, partial verification of patients was common and in many cases patients who were selected retrospectively because they had undergone the reference test. Sample sizes were generally very small. Reference tests were often inappropriate with many studies using arthrography alone, despite problems with its sensitivity. For clinical assessment, 10 cohort studies were found that examined either the accuracy of individual tests or clinical examination as a whole: individual tests were either good at ruling out rotator cuff tears when negative (high sensitivity) or at ruling in such disorders when positive (high specificity), but small sample sizes meant that there was no conclusive evidence.
The results suggest that clinical examination by specialists can rule out the presence of a rotator cuff tear, and that either MRI or ultrasound could equally be used for detection of full-thickness rotator cuff tears, although ultrasound may be better at picking up partial tears. Ultrasound also may be more cost-effective in a specialist hospital setting for identification of full-thickness tears.
A systematic review 2 including 9 studies with a total of 1 020 subjects was abstracted in DARE. No data on the accuracy of history items were identified. Twenty clinical tests were evaluated in 6 studies. No test was evaluated in more than one study.
The dropping sign and Hornblower's sign had high sensitivity and specificity (greater than 0.90) for non-operable tears of the m. teres minor or m. infraspinatus. The internal rotation lag sign had high sensitivity and specificity (greater than 0.90) for partial or full tears of the m. supraspinatus and/or m. infraspinatus. The impingement sign and tests of Neer, Hawkin, Speed, Patte, and Jobe (both tests) had high sensitivity values, but low specificity. Conversely, the drop sign, external rotation less than 70 degrees, the lift-off test and external rotation lag sign had high reported specificity and low sensitivity. Low values for both sensitivity and specificity were reported for weakness with elevation, weakness with external rotation, elevation less than 170 degrees and infraspinatus muscular atrophy.
Information gain for the presence of a rotator cuff tear was limited. The only tests for which the change from pre- to post-test probability was calculated to be greater than 0.30 were the dropping sign, Hornblower's sign, the internal rotation lag sign and the external rotation lag sign.
Comment: The quality of evidence is downgraded by imprecise results (limited study size for each comparison).
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