title: Reliability of forced internal rotation and active internal rotation to assess lateral instability of the biceps pulley.
abstract: OBJECTIVE
  the aim of this study was to investigate the relationship between positive painful forced internal rotation (FIR) and lateral pulley instability in the presence of a pre-diagnosed posterosuperior cuff tear. The same investigation was conducted for painful active internal rotation (AIR).
  
  
  METHODS
  a multicenter prospective study was conducted in a series of patients scheduled to undergo arthroscopic posterosuperior cuff repair. Pain was assessed using a visual analog scale (VAS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) was administered. The VAS score at rest, DASH score, and presence/absence of pain on FIR and AIR were recorded and their relationships with lesions of the lateral pulley, cuff tear patterns and shape of lesions were analyzed.
  
  
  RESULTS
  the study population consisted of 115 patients (mean age: 55.1 years) recruited from 12 centers. The dominant arm was affected in 72 cases (62.6%). The average anteroposterior extension of the lesion was 1.61 cm. The mean preoperative VAS and DASH scores were 6.1 and 41.8, respectively. FIR and AIR were positive in 94 (81.7%) and 85 (73.9%) cases, respectively. The lateral pulley was compromised in 50 cases (43.4%). Cuff tears were partial articular in 35 patients (30.4%), complete in 61 (53%), and partial bursal in 19 (16.5%). No statistical correlation between positive FIR or AIR and lateral pulley lesions was detected. Positive FIR and AIR were statistically associated with complete lesions. Negative FIR was associated with the presence of partial articular tears.
  
  
  CONCLUSIONS
  painful FIR in the presence of a postero-superior cuff tear does not indicate lateral pulley instability. When a cuff tear is suspected, positive FIR and AIR are suggestive of full-thickness tear patterns while a negative FIR suggests a partial articular lesion.
  
  
  METHODS
  level I, validating cohort study with good reference standards.
authors.affiliation: IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Arrigoni
authors.affiliation: IRCCS Istituto Clinico Humanitas, Rozzano, Italy.
authors.forename: Giacomo Delle
authors.initials: GD
authors.lastname: Rose
authors.affiliation: IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: D'Ambrosi
authors.affiliation: Policlinico Militare di Roma Celio, Italy.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Rotundo
authors.affiliation: Policlinico Militare di Roma Celio, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Campagna
authors.affiliation: Maria Cecilia Hospital, Cotignola, Ravenna, Italy.
authors.forename: Piergiorgio
authors.initials: P
authors.lastname: Pirani
authors.affiliation: Maria Cecilia Hospital, Cotignola, Ravenna, Italy.
authors.forename: Manlio
authors.initials: M
authors.lastname: Panascì
authors.affiliation: Istituto Clinico Città di Brescia, Italy.
authors.forename: Dario
authors.initials: D
authors.lastname: Petriccioli
authors.affiliation: Istituto Clinico Città di Brescia, Italy.
authors.forename: Celeste
authors.initials: C
authors.lastname: Bertone
authors.affiliation: Casa di Cura Villa Valeria, Rome, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Grasso
authors.affiliation: Casa di Cura Villa Valeria, Rome, Italy.
authors.forename: Carmine
authors.initials: C
authors.lastname: Latte
authors.affiliation: Ospedale Orlandi, Bussolengo, Verona, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Costa
authors.affiliation: Ospedale Orlandi, Bussolengo, Verona, Italy.
authors.forename: Gino
authors.initials: G
authors.lastname: Viola
authors.affiliation: University of Bari, Italy.
authors.forename: Silvana
authors.initials: S
authors.lastname: DE Giorgi
authors.affiliation: Policlinico di Bari, Italy.
authors.forename: Antonello
authors.initials: A
authors.lastname: Panella
authors.affiliation: IRCCS Istituto Clinico Humanitas, Rozzano, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Padua
authors.affiliation: Clinica Lami, Perugia, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Beccarini
authors.affiliation: Clinica Lami, Perugia, Italy.
authors.forename: Barbara
authors.initials: B
authors.lastname: Salcher
authors.affiliation: Ospedale Valdelsa, Poggibonsi, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Olivieri
authors.affiliation: Ospedale Valdelsa, Poggibonsi, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Mugnaini
authors.affiliation: Casa di Cura Città di Udine, Udine, Italy.
authors.forename: Antonello
authors.initials: A
authors.lastname: Pannone
authors.affiliation: Casa di Cura Città di Udine, Udine, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Ceoldo
authors.affiliation: Campus Bio-Medico University, Rome, Italy.
authors.forename: Umile Giuseppe
authors.initials: UG
authors.lastname: Longo
authors.affiliation: Campus Bio-Medico University, Rome, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Denaro
authors.affiliation: Università degli Studi del Molise, Campobasso, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Cerciello
authors.affiliation: Università degli Studi del Molise, Campobasso, Italy.
authors.forename: Alfredo Schiavone
authors.initials: AS
authors.lastname: Panni
authors.affiliation: Ospedale Sacro Cuore Don Calabria, Negrar, Verona, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Avanzi
authors.affiliation: Ospedale Sacro Cuore Don Calabria, Negrar, Verona, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Zorzi
authors.affiliation: IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
authors.forename: Vincenza
authors.initials: V
authors.lastname: Ragone
authors.affiliation: IRCCS Istituto Clinico Humanitas, Rozzano, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Castagna
authors.affiliation: IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Randelli
keywords: biceps pulley; clinical test; diagnostic accuracy; internal rotation; shoulder arthroscopy