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Objective: To compile and critique research on the diagnostic accuracy of individual orthopaedic physical examination tests in a manner that would allow clinicians to judge whether these tests are valuable to their practice. Methods: A computer-assisted literature search of MEDLINE, CINAHL, and SPORTDiscus databases (1966( to October 2006 using keywords related to diagnostic accuracy of physical examination tests of the shoulder. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used to critique the quality of each paper. Meta-analysis through meta-regression of the diagnostic odds ratio (DOR) was performed on the Neer test for impingement, the Hawkins2Kennedy test for impingement, and the Speed test for superior labral pathology. Results: Forty-five studies were critiqued with only half demonstrating acceptable high quality and only two having adequate sample size. For impingement, the metaanalysis revealed that the pooled sensitivity and specificity for the Neer test was 79% and 53%, respectively, and for the Hawkins2Kennedy test was 79% and 59%, respectively. For superior labral (SLAP) tears, the summary sensitivity and specificity of the Speed test was 32% and 61%, respectively. Regarding orthopaedic special tests (OSTs) where meta-analysis was not possible either due to lack of sufficient studies or heterogeneity between studies, the list that demonstrates both high sensitivity and high specificity is short: hornblowers's sign and the external rotation lag sign for tears of the rotator cuff, biceps load II for superior labral anterior to posterior (SLAP) lesions, and apprehension, relocation and anterior release for anterior instability. Even these tests have been under-studied or are from lower quality studies or both. No tests for impingement or acromioclavicular (AC) joint pathology demonstrated significant diagnostic accuracy. Conclusion: Based on pooled data, the diagnostic accuracy of the Neer test for impingement, the Hawkins2Kennedy test for impingement and the Speed test for labral pathology is limited. There is a great need for large, prospective, well-designed studies that examine the diagnostic accuracy of the numerous physical examination tests of the shoulder. Currently, almost without exception, there is a lack of clarity with regard to whether common OSTs used in clinical examination are useful in differentially diagnosing pathologies of the shoulder.History and physical examination of patients with shoulder pain has traditionally been a cornerstone of the diagnostic process. Diagnosis based on physical findings is important to determine a treatment path and because the ability to correctly diagnose the source of shoulder pain can save the patient from further diagnostic tests that are more costly, painful or inconvenient. Physical examination tests or orthopaedic special tests (OSTs) have historically been an integral part of this process. However, despite the fact that studies on the diagnostic accuracy of OSTs in the shoulder have been published at an acce...

Objective To update our previously published systematic review and meta-analysis by subjecting the literature on shoulder physical examination (ShPE) to careful analysis in order to determine each tests clinical utility. Methods This review is an update of previous work, therefore the terms in the Medline and CINAHL search strategies remained the same with the exception that the search was confi ned to the dates November, 2006 through to February, 2012. The previous study dates were 1966 -October, 2006. Further, the original search was expanded, without date restrictions, to include two new databases: EMBASE and the Cochrane Library. The Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS 2) tool was used to critique the quality of each new paper. Where appropriate, data from the prior review and this review were combined to perform meta-analysis using the updated hierarchical summary receiver operating characteristic and bivariate models. Results Since the publication of the 2008 review, 32 additional studies were identifi ed and critiqued. For subacromial impingement, the meta-analysis revealed that the pooled sensitivity and specifi city for the Neer test was 72% and 60%, respectively, for the HawkinsKennedy test was 79% and 59%, respectively, and for the painful arc was 53% and 76%, respectively. Also from the meta-analysis, regarding superior labral anterior to posterior (SLAP) tears, the test with the best sensitivity (52%) was the relocation test; the test with the best specifi city (95%) was Yergason's test; and the test with the best positive likelihood ratio (2.81) was the compression-rotation test. Regarding new (to this series of reviews) ShPE tests, where meta-analysis was not possible because of lack of suffi cient studies or heterogeneity between studies, there are some individual tests that warrant further investigation. A highly specifi c test (specifi city >80%, LR+ ≥ 5.0) from a low bias study is the passive distraction test for a SLAP lesion. This test may rule in a SLAP lesion when positive. A sensitive test (sensitivity >80%, LR− ≤ 0.20) of note is the shoulder shrug sign, for stiffnessrelated disorders (osteoarthritis and adhesive capsulitis) as well as rotator cuff tendinopathy. There are six additional tests with higher sensitivities, specifi cities, or both but caution is urged since all of these tests have been studied only once and more than one ShPE test (ie, active compression, biceps load II) has been introduced with great diagnostic statistics only to have further research fail to replicate the results of the original authors. The belly-off and modifi ed belly press tests for subscapularis tendinopathy, bony apprehension test for bony instability, olecranon-manubrium percussion test for bony abnormality, passive compression for a SLAP lesion, and the lateral Jobe test for rotator cuff tear give reason for optimism since they demonstrated both high sensitivities and specifi cities reported in low bias studies. Finally, one additional test was studied in tw...

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