Evidenzbasierter Ansatz zur Schulteruntersuchung bei subakromialer Bursitis und Rotatorenmanschettenrissen: eine systematische Übersichtsarbeit und Metaanalyse

Summary

Background

Shoulder pain is one of the most common musculoskeletal symptoms in physiotherapy, after lower back and knee pain. The annual incidence ranges between 8–62 per 1000 person-years [1], with up to 50 percent of all patients experiencing shoulder pain for the first time reporting persistent symptoms even 6 months after their onset. This results in high costs for the health and social security systems, particularly due to work-related absences caused by pain and functional impairments [2].

The most common diagnoses for shoulder pain include subacromial pain syndrome (SAPS) and rotator cuff tear (RCT). More than 100 different physical tests aiming to reproduce specific symptoms and provide clues to the pathogenesis are available for clinical diagnosis [3]. A targeted diagnostic approach is intended to make it easier for therapists to plan treatment so that treatment objectives can be achieved faster and more effectively. However, previous studies show that the clinical performance of most shoulder tests is limited and that performing tests alone is not sufficient for diagnosis [4] [5].

Objective

The objective of the study by Zhao et al. (2024) was to provide an up-to-date and comprehensive overview of the diagnostic significance of clinical shoulder tests for SAPS or RCT. The systematic assessment of the validity of the tests is intended to improve clinical decision-making and enhance diagnostic accuracy in physiotherapy practice.

Methods

For the systematic literature search, the scientific databases PubMed, Ovid MEDLINE, Embase and Cochrane Library were searched for relevant publications with publication dates between January 1, 1980, and March 15, 2024. The research was based on a clearly defined PICO question: For patients who are being examined due to shoulder complaints, can physical examination reliably and reproducibly help to identify patients who may have subacromial pain syndrome or a rotator cuff tear? The selection and evaluation of studies was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) scheme. Two independent authors first reviewed titles and abstracts and then conducted a full-text analysis. Included were prospective cohort studies, case series and case-control studies in which a physical examination had been performed prior to imaging. All studies in which the examiners were not blinded were excluded.

The following diagnostic test quality parameters were determined as part of the meta-analysis: sensitivity, specificity, positive likelihood ratio (LR+) and negative likelihood ratio (LR-), as well as diagnostic odds ratio (DOR) as a measure of overall quality.

Results

A total of 20 studies involving 3438 patients met the inclusion criteria. A total of 13 clinical shoulder tests were examined, including: Neer Test, Hawkins Test, Painful Arc Test, Drop Arm Sign, Yergason’s Test, Jobe’s Test, Patte’s Test, Lift-off Test, External Rotation Lag Sign, Internal Rotation Lag Sign, Bear Hug Test.

Results on RTC diagnosis: 

The test with the highest diagnostic value was the External Rotation Lag Sign in 90 degrees of abduction with a diagnostic odds ratio of 12.7 (95 % CI: 3.7–43.9; p < 0.0001). Another test of high diagnostic quality was the Internal Rotation Lag Sign, with a diagnostic odds ratio of 7.0 (95 % CI: 3.0–16.6, p < 0.0001). Although some of the other tests also showed statistically significant DOR values, they did not achieve high levels of diagnostic value.

Results on SAPS diagnosis: 

No single test of high diagnostic value for clinical practice could be identified for the examination of SAPS.

Conclusions

The results provide new insights for the physical examination of the shoulder joint in cases of suspected RCT or SAPS. For the examination of RCT, the External Rotation Lag Sign in 90-degree abduction with a diagnostic odds ratio of 12.7 and the Internal Rotation Lag Sign with a diagnostic odds ratio of 7.0 appear to have high diagnostic value for everyday practice.

In addition, the External Rotation Lag Sign at zero degrees of abduction, Jobe Test, Hawkins Test and Bear Hug Test show significant diagnostic accuracy, but it is considerably lower and therefore of less clinical value.

For the examination of SAPS, the results of the current meta-analysis coincide with those of previous studies, which show that the diagnostic accuracy of orthopedic tests such as the Painful Arc for examining SAPS is insufficient [5]. This study was unable to identify any test with a high diagnostic accuracy for this clinical picture, which shows that these tests should be used by therapists in a very differentiated manner.

Publikationsverlauf

Artikel online veröffentlicht:
08. Dezember 2025

• Literatur

• 1 Lucas J, van Doorn P, Hegedus E. et al. A systematic review of the global prevalence and incidence of shoulder pain. BMC Musculoskelet Disord 2022; 23: 1073
• 2 Virta L, Joranger P, Brox JI. et al. Costs of shoulder pain and resource use in primary health care: a cost-of-illness study in Sweden. BMC Musculoskelet Disord 2012; 13: 17
• 3 McFarland EG. Examination of the Shoulder: The Complete Guide. Stuttgart: Thieme; 2006
• 4 Gismervik SØ, Drogset JO, Granviken F. et al. Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC 2017; 18: 41
• 5 Diercks R, Bron C, Dorrestijn O. Dutch Orthopaedic Association, Hrsg.. et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop 2014; 85: 314-322
• 6 Park SW, Chen YT, Thompson L. et al. No relationship between the acromiohumeral distance and pain in adults with subacromial pain syndrome: a systematic review and meta-analysis. Sci Rep 2020; 10: 20611
• 7 Hertel R, Ballmer FT, Lombert SM. et al. Lag signs in the diagnosis of rotator cuff rupture. J Shoulder & Elbow Surg 1996; 5: 307-313
• 8 Paavola M, Kanto K, Ranstam J. et al. Finnish Shoulder Impingement Arthroscopy Controlled Trial (FIMPACT) Investigators. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. Br J Sports Med 2021; 55: 99-107