title: Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review.
abstract: OBJECTIVE
  Rotator cuff disease (RCD) is the most common cause of shoulder pain seen by physicians.
  
  
  OBJECTIVE
  To perform a meta-analysis to identify the most accurate clinical examination findings for RCD.
  
  
  METHODS
  Structured search in MEDLINE, EMBASE, and CINAHL from their inception through May 2013.
  
  
  METHODS
  For inclusion, a study must have met the following criteria: (1) description of history taking, physical examination, or clinical tests concerning RCD; (2) detailing of sensitivity and specificity; (3) use of a reference standard with diagnostic criteria prespecified; (4) presentation of original data, or original data could be obtained from the authors; and (5) publication in a language mastered by one of the authors (Danish, Dutch, English, French, German, Norwegian, Spanish, Swedish).
  
  
  METHODS
  Likelihood ratios (LRs) of symptoms and signs of RCD or of a tear, compared with an acceptable reference standard; quality scores assigned using the Rational Clinical Examination score and bias evaluated with the Quality Assessment of Diagnostic Accuracy Studies tool.
  
  
  RESULTS
  Twenty-eight studies assessed the examination of referred patients by specialists. Only 5 studies reached Rational Clinical Examination quality scores of level 1-2. The studies with quality scores of level 1-2 included 30 to 203 shoulders with the prevalence of RCD ranging from 33% to 81%. Among pain provocation tests, a positive painful arc test result was the only finding with a positive LR greater than 2.0 for RCD (3.7 [95% CI, 1.9-7.0]), and a normal painful arc test result had the lowest negative LR (0.36 [95% CI, 0.23-0.54]). Among strength tests, a positive external rotation lag test (LR, 7.2 [95% CI, 1.7-31]) and internal rotation lag test (LR, 5.6 [95% CI, 2.6-12]) were the most accurate findings for full-thickness tears. A positive drop arm test result (LR, 3.3 [95% CI, 1.0-11]) might help identify patients with RCD. A normal internal rotation lag test result was most accurate for identifying patients without a full-thickness tear (LR, 0.04 [95% CI, 0.0-0.58]).
  
  
  CONCLUSIONS
  Because specialists performed all the clinical maneuvers for RCD in each of the included studies with no finding evaluated in more than 3 studies, the generalizability of the results to a nonreferred population is unknown. A positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting RCD, whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear.
authors: Department of Orthopaedic Surgery, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands. j.hermans@erasmusmc.nl
authors: Job
authors: J
authors: Hermans
authors: Jolanda J
authors: JJ
authors: Luime
authors: Duncan E
authors: DE
authors: Meuffels
authors: Max
authors: M
authors: Reijman
authors: David L
authors: DL
authors: Simel
authors: Sita M A
authors: SM
authors: Bierma-Zeinstra
mesh_terms: D006801:Humans; D008487:Medical History Taking; D010808:Physical Examination / Q000379:methods*; D012016:Reference Values; D012017:Referral and Consultation; D000070636:Rotator Cuff Injuries; D020069:Shoulder Pain / Q000209:etiology*; D014947:Wounds and Injuries / Q000150:complications / Q000175:diagnosis*