Transcript Current Trends in Surgery for Articular Defects of the Knee

A Proposed Evidence Based
Shoulder Special Testing
Examination Algorithm:
Adaptation of a Reference
Standard
Nicklaus Biederwolf, PT,DPT,OCS,CSCS
Regis University Manual Therapy Fellowship
Phoenix Orthopedic Manual Therapy
September 2, 2010
Reference Standard: George
Davies’ Special Testing Algorithm1
• Based on the work of George Davies, PT, DPT, Med, SCS,
ATC, LAT, CSCS, FAPTA
• Professor Emeritus of the University of Wisconsin at La
Crosse
• Professor at Armstrong State University in Savannah, GA
• Currently practices at Coastal Therapy in Savannah
Georgia and Gundersen Lutheran Sports Medicine in La
Crosse, WI
Reference Standard: George
Davies’ Special Testing Algorithm1
• Testing algorithm is based on “Critical
Pathways”
– Pattern recognition based on clusters of signs
and symptoms, subjective data, and empirical
data
– Implicates a specific group of special testing
for a specific pathology
– Statistics of notice are shown in GREEN if they
are of particularly good utility and RED if they
are of questionable clinical usage.
Proposed Evidence-Based
Examination Algorithm for Chosen
Tests
• Testing for a specific condition is only indicated based on
an individual’s cluster of subjective data, history, signs,
and symptoms.
• Pre-Test Probability is estimated at 50% for each
condition based on above findings; post-test probability
is calculated for chosen tests.
• Statistics of notice are shown in GREEN if of particularly
good utility and RED if of questionable clinical usage.
• Testing is continued until a treatment threshold (or
referral threshold) of 80% post-test probability is
achieved (unless otherwise stated).
Likelihood Ratios
• Positive Likelihood Ratio:
– Sensitivity/(1-Specificity)
– Shifts Pre-Test Probability in a direction that
favors the existence of a disorder.
• Negative Likelihood Ratio:
– (1-Sensitivity)/Specificity
– Shifts Pre-Test Probability in a direction that
favors the absence of a disorder.
Post-Test Probability
• Pre-Test Probability=50%
– With use of a nonogram,
+LR or –LR can be used
to determine Post-Test
Probability.
Likelihood Ratio Interpretation
+LR
-LR
Interpretation
>10
<0.1
5-10
0.1-0.2
2-5
0.2-0.5
1-2
0.5-1.0
Large Probability
Shifts
Moderate
Probability Shifts
Small Probability
Shifts
Minimally Alter
Probability
Reference Standard: George
Davies’ Special Testing Algorithm1
MDI Screening on All Patients
RTC Pathology
(Impingement Syndrome, RTC Tears, Internal Impingement)
Labral Pathology and Instability
(Anterior Instability, Posterior Instability, SLAP Lesions,
and Bankart Lesions)
Other (AC Joint Lesions, LHB Tendinopathy)
Davies’ Algorithm: MDI Screening1
• Critical Pathway: Performed on all patients to
assess GH stability.
Test
Sp
Sn
Identification of sulcus
.89
Sulcus Sign at 90° ABD
Identification of sulcus
Anterior Load and Shift3
Posterior Load and
Shift3
Sulcus Sign at 0°
Applicable Finding(s)
2
+LR
-LR
.31
2.8
.78
NR
NR
NR
NR
Grade of Laxity (Trace, I, II, III)
.78
.54
2.5
.59
Grade of Laxity (Trace, I, II, III)
1.00
0.00
1.7
.99
Proposed Screening Test
• Testing Indication: Perform on all patients (if able) to
rule in or rule out both intra-articular pathology and RTC
pathology.
Test
Test of Zaslav (IR
Resisted Strength Test)4
Applicable Finding(s)
Sp
Sn
In 90° ABD and 80° ER, if IR MMT<< .96
ER MMT test is positive for intraarticular pathology. If IR MMT>>ER
MMT test is positive for RTC
involvement.
.86
+LR
-LR
22.0
.13
Post-Test probability for ruling in and ruling out both intra-articular
pathology and RTC pathology are both respectively 91.6% and 6.1%.
Test of Zaslav4
Test of Zaslav4
• Operational definition of RTC pathology:
Findings that included a thickened or inflamed
subacromial bursa, erosions on the CA ligament
and undersurface of the acromion, and bursal
side partial or full thickness RTC tears.4
• Operational definition of Intra-Articular
pathology: Findings that included anterior
glenoid erosion or labral tears, middle GH
ligament tearing, articular-sided RTC partial
tears, posterior labral lesions, and SLAP lesions.4
Proposed Evidence-Based Examination
Algorithm for Chosen Tests
Screening:
Test of
Zaslav (IRRST)
If IR>>ER MMT:
RTC Pathology
(Impingement syndrome, RTC
tendinopathy, RTC tears)
Other:
AC Joint Lesions,LHBTendinopathy.
If ER>>IR MMT:
Intra-Articular
Pathology
(Anterior or posterior instability,
SLAP Lesions, Bankart Lesions,
Posteroinferior Labral Lesions, RTC
articular internal impingement)
Davies’ Algorithm: SLAP
Lesions1
• Critical Pathway: Macrotraumatic injury, history of eccentric
deceleration activities, pain complaint is “deep” or “in” the shoulder,
sensations of locking, clicking, or clunking.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Compression Rotation5
Pain or click elicited
.76
.24
1.0
1.0
Anterior Slide Test6
Pain or click elicited
.92
.78
9.75
.24
Posterior Slide Test
Pain or click elicited
NR
NR
NR
NR
Speed’s Test7,8
Pain deep in the shoulder
.75.87
.09.32
1.281.29
.91.98
O’Brien’s Test8,5,7,9,10
Pain or click elicited (part I), then
reduced (part II)
.31.98
.541.0
.7850
0.01.48
Proposed SLAP Lesion Tests
• Testing Indication: Intra-articular pathology per Zaslav’s
test (if able) and Davies’ critical pathway cluster of signs
and symptoms.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Biceps Load Test I11
Apprehension in ER or pain with
resisted bicep contraction
.97
.90
30
.10
Biceps Load Test II12
Pain with resisted bicep contraction
.97
.90
30
.10
Pain Provocation Test of
Mimori13
Positive if pain is more severe in
pronated position
.90
1.0
10.0
0.0
Post-Test probabilities are respectively 93.75%, 93.75%, 83.3%
for positive tests, and 4.8%, 4.8%, and 0.0% for negative
tests.
SLAP Lesion Testing
Biceps Load Test II12
Pain Provocation
Test of Mimori13
Davies’ Algorithm: LHB
Tendinopathy1
• Critical Pathway: History of eccentric deceleration
activities, LHB is TTP, complaints of pain are in the
anterior shoulder.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Yergason’s Test14
Pain is produced in the bicipital
groove
.86
.37
2.64
.73
Speed’s Test14
Pain is elicited
.56
.69
1.57
.55
*These currently appear to be the best statistical utility
tests we have for identification of LHB tendinopathy.
Post-Test probability with a + Yergason’s test is 56.8% (rule in) and
with a – Speed’s test is 21.6% (rule out). Treatment threshold
exception for lack of evidence is proposed to be both + tests.
Davies’ Algorithm: AC Joint
Lesions1
• Critical Pathway: Age >40, macrotrauma to superior shoulder in CKC
position, pain complaint is “on top” of the shoulder, AC joint is TTP,
pain with horizontal adduction.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
AC Shear Test
Pain localized to AC joint
NR
NR
NR
NR
O’Brien’s Test9,15
Pain localized to AC joint
.90.97
.161.0
1.633.3
0.0.93
Cross-Body Adduction
Test15
Pain localized to AC joint
.79
.77
3.67
.29
Proposed AC Joint Lesion Tests
• Testing Indicated: Per Davies’ critical pathway.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Cross-Body Adduction
Test15
Pain localized to AC joint
.79
.77
3.67
.29
AC Resisted Extension
Test15
Pain localized to AC joint
.10
.96
1.07
.40
O’Brien’s Test9
Pain localized to AC joint
.90.97
.161.0
1.633.3
0.0.93
Test Cluster15
Above three tests are positive
.97
.25
8.3
.77
Post-Test probability when all three tests are positive is
80.5%.
Davies’ Algorithm: Impingement
Syndrome1
• Critical Pathway: Age >40, history of overhead activities, recent
unaccustomed overuse of arm, painful arc of abduction, pain with
overhead activities, pain complaints in lateral shoulder, pain at night,
compensatory shoulder shrug sign.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Neer Test14,16,17
Positive if pain reproduced
.31.48
.75.89
1.291.44
.35.52
Hawkins-Kennedy
Test14,16,17
Positive if pain reproduced
.25.44
.87.92
1.231.64
.18.32
Coracoid Impingement
Test
Positive if pain reproduced
NR
NR
NR
NR
Horizontal Adduction
Test17
Positive if pain reproduced
.28
.82
1.14
.64
Proposed Impingement
Syndrome Tests
• Testing Indication: RTC pathology per Zaslav’s test (if able) and
Davies’ critical pathway cluster of signs and symptoms.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Hawkins-Kennedy
Test14,16,17
Positive if pain reproduced
.25.44
.87.92
1.231.64
.18.32
Infraspinatus MMT18
Positive if weak and/or painful
.81
.74
3.89
.32
Painful Arc Sign18
Positive if painful arc reproduced
.81
.74
3.89
.32
Test of Zaslav4
In 90° ABD and 80° ER, if IR MMT<
ER test is positive for intra-articular
pathology. If IR MMT>ER MMT test is
positive for RTC involvement.
.96
.86
22.0
.13
Post-Test probability for the TIC of the first three tests is 95.5% if all 3 are positive, and
91.0% if 2 of 3 are positive (based on reported TIC of 10.56 for 3 + tests and 5.03 for 2
+ tests)18. Post-Test probability for a positive and negative Test of Zaslav are 91.6% and
6.1% to rule in and rule out impingement, respectively.
Davies’ Algorithm: RTC Tears1
• Critical Pathway: Age >40, macrotraumatic injury with major
functional disabilities, idiopathic onset of major functional
disabilities, painful arc of abduction, dull constant ache in shoulder,
pain complaints in lateral shoulder, pain at night, compensatory
shoulder shrug sign.
Test
Applicable Finding(s)
Sp
External Rotation Lag
Inability to hold shoulder in ER
Sign for Supraspinatus17
1.00
External Rotation Lag
Sign @ 90/90 (Drop
Sign) for Supraspinatus
and Infraspinatus17
Inability to arm in place
Internal Rotation Lag
Sign for Subscapularis17
Inability to actively IR shoulder
Sn
+LR
-LR
.70
NA
.30
1.00
.36
NA
.64
.96
.97
24.3
.03
Proposed Tests for RTC Tears
• Testing Indication: RTC pathology per Zaslav’s test (if
able) and Davies’ critical pathway cluster of signs and
symptoms.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
External Rotation Lag
Inability to hold shoulder in ER
Sign for Supraspinatus17
1.00
.70
NA
.30
Dropping Sign @ 90°
ABD and 45° ER for
Infraspinatus19
Inability to arm in place
1.00
1.00
NA
0.0
Hornblower’s Sign for
Teres Minor19
Inability to externally rotate to
“Hornblower” position
.93
1.00
14.29
0.0
Internal Rotation Lag
Sign for Subscapularis17
Inability to actively IR shoulder
.96
.97
24.3
.03
Post-Test probabilities are respectively (+)~100% and (-)13.0%, (+)~100% and (-)~0.0%,
(+)87.7% and (-)~0.0%, (+)92.4% and (-)1.48%.
Davies’ Algorithm: Anterior
Instability1
• Critical Pathway: Macrotrauma (especially in ABD and ER), repetitive
microtrauma (overhead activities), history of recurrent
subluxations/dislocations, complaints of “dead arm” syndrome,
sensations of weakness.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Apprehension Test20
Apprehension to test position
.99
.53
53
.47
Anterior Relocation
Test21
Anterior pain is positive for anterior
microinstability
.44
.54
.96
1.05
Proposed Anterior Instability
Tests
• Testing Indication: Intra-articular pathology per Zaslav’s
test (if able) and Davies’ critical pathway cluster of signs
and symptoms.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Apprehension Test20
Apprehension to test position
.99
.53
53
.47
Anterior Release Test
(also known as Surprise
Test) 21,22
Pain or apprehension when posterior
relocation is removed
.89.99
.64.92
8.3664.0
.09.36
Post-Test probabilities are respectively 96.4% and, at worst,
80.7%.
Davies’ Algorithm: Internal
Impingement Syndrome1
• Critical Pathway: Specific pain inferior to the postero-lateral
acromion, pain in the cocking phase of the throwing motion.
Test
Anterior Relocation Test
Applicable Finding(s)
Posterior pain is positive for internal
impingement syndrome.1
Sp
NR
Sn
NR
+LR
-LR
NR
NR
*This is the only known suggested test for internal impingement
syndrome. It is hypothesized, however, that positive impingement
testing and a positive Test of Zaslav for an intra-articular lesion may
suggest internal impingement syndrome.
Treatment Threshold exception for lack of evidence: All above subjective
and objective findings.
Davies’ Algorithm: Posterior
Instability1
• Critical Pathway: Macrotrauma, blunt force to anterior shoulder,
volitional subluxator.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Jerk Test23
Sharp pain and/or click/clunk
.98
.73
36.5
.28
Posterior Glide Test
Subluxation/Dislocation over glenoid
rim
NR
NR
NR
NR
Posterior Glide Test II
Subluxation/Dislocation over glenoid
rim
NR
NR
NR
NR
Proposed Tests for Posteroinferior
Laxity and Labral Lesions
• Testing Indication: Intra-articular pathology per Zaslav’s
test (if able) and Davies’ critical pathway cluster of signs
and symptoms.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Jerk Test23
Sharp pain and/or click/clunk
.98
.73
36.5
.28
Kim Test23
Sharp pain and/or click/clunk
.94
.80
13.3
.21
Post-Test probability for the Jerk and Kim tests are respectively 94.8% and 86.9%.
The Kim Test23
A) With the patient in a sitting position with the arm in 90° of abduction, the examiner
holds the elbow and lateral aspect of the proximal arm, and a strong axial loading force
is applied. B) While the arm is elevated another 45° diagonally upward, downward and
backward force is applied to the proximal arm. A sudden onset of posterior shoulder
pain indicates a positive test result, regardless of accompanying posterior clunk of the
humeral head. During the test, it is important to apply a firm axial compression force to
the glenoid surface by the humeral head.
Davies’ Algorithm: Bankart
Lesions1
• Critical Pathway: Macrotrauma, anterior/inferior subluxation or
dislocation, history of recurrent subluxations/dislocations, “deep”
pain in the shoulder, complaints of clicking/clunking or locking.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Clunk Test
Pain, clicking, or clunking elicited
NR
NR
NR
NR
Clunk Test II (Anterior
Pain, clicking, or clunking elicited
NR
NR
NR
NR
Crank Test5,7,10,13,24
Pain is elicited
.561.00
.40.91
1.013
.10.96
(Anterior/inferior GH
scouring in maximal
scaption)
relocation in multiple
anterior/inferior positions)
Proposed Tests for Bankart
Lesions
• Testing Indication: Intra-articular pathology per Zaslav’s
test (if able) and Davies’ critical pathway cluster of signs
and symptoms.
Test
Applicable Finding(s)
Sp
Sn
+LR
-LR
Clunk Test
Pain, clicking, or clunking elicited
NR
NR
NR
NR
Crank Test5,7,10,13,24
Pain or clicking is elicited
.561.00
.40.91
1.013
.10.96
(Anterior/inferior GH
scouring in maximal
scaption)*
*Though no studies have been performed on the Clunk Test, I believe
it has a high enough level of construct validity to be considered for
use in examination.
Post-Test probability of the Crank test is 86.7% at best and 33.3% at worst. Proposed
treatment threshold are + findings in both tests, and a click/clunk in either.
Proposed Evidence-Based Shoulder
Special Testing Examination
Algorithm
RTC Pathology
Intra-Articular Pathology
Miscellaneous
•Test of Zaslav (IR MMT >> ER MMT)
•Test of Zaslav (ER MMT >> IR MMT)
•Test of Zaslav inconclusive
RTC Impingement
SLAP Lesions
AC Joint Lesion
•Hawkins-Kennedy Test
•Infraspinatus MMT
•Painful Arc Sign
•Biceps Load Test I
•Biceps Load Test II
•Pain Provocation Test of Mimori
•Cross-Body Adduction
•AC Resisted Extension
•O’Brien’s Test
RTC Tears
Bankart Lesions
LHB Tendinopathy
•ER Lag Sign
•Dropping Sign
•Hornblower’s Sign
•IR Lag Sign
•Clunk Test
•Crank Test
•Yergason’s Test
•Speed’s Test
Posteroinferior Capsulolabral
Laxity and Labral Lesions
RTC Internal
Impingement
•Kim Test
•Jerk Test
•Anterior Relocation Test
Anterior Instability
•Apprehension Test
•Anterior Release Test
Questions?
• Email: [email protected]
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