Assessment of the shoulder complex ACPA conference 9th April 2014 Stuart Calver MSc, Grad Dip Phys, MCSP
Contents • Key findings subjective exam • Shoulder exam video approx 10 mins • Diagnostic accuracy orthopaedic special tests and combination of tests • Stuart’s sub categorisation treatment approach
Referred pain • Nearly all shoulder structures are supplied by the C5 nerve root • Acromioclavicular joint is supplied by C4 thus refers pain to this segment • Watch out for Cloward’s areas
Diagnostic accuracy individual clinical tests • The use of any single ShPE test to make a pathognomonic diagnosis cannot be unequivocally recommended (Hedegus 2008 & 2012). • Many tests that have high sensitivity (Sn) have poor specificity (Sp) & visa versa, very few tests have Sn & Sp > 80% • Some tests such as apprehension test are beginning to stand the test of time. • Combinations of tests provide better accuracy but only marginally so.
Reliability of shoulder exam • Pellecchia et al (1996) 91% agreement; kappa=0.88 using Cyriax method of assessment, Cyriax’s schema patho-anatomical classification with nine possible categories. However sample size small n=21 & only 2 assessing therapists used. • Carter et al (2012) used 3 clinical syndromes; pattern 1: impingement, pattern 2: AC joint pain, pattern 3: 7 subcategories including OA, frozen shoulder, cuff tear & instability. 55 physiotherapists arranged in pairs. 80% agreement; kappa=0.66
Treatment based assessment • Unlikely that any test would not compress or stretch adjacent structures • Most orthopaedic tests have high sensitivity but low specificity or visa versa • Investigations used as gold standard (MRI, arthroscopy) have high levels of false positive & negative.