title: Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance.
abstract: Physical examination tests of the shoulder (PETS) are clinical examination maneuvers designed to aid the assessment of shoulder complaints. Despite more than 180 PETS described in the literature, evidence of their validity and usefulness in diagnosing the shoulder is questioned.
  
  
  
  This meta-analysis aims to use diagnostic odds ratio (DOR) to evaluate how much PETS shift overall probability and to rank the test performance of single PETS in order to aid the clinician's choice of which tests to use. This study adheres to the principles outlined in the Cochrane guidelines and the PRISMA statement. A fixed effect model was used to assess the overall diagnostic validity of PETS by pooling DOR for different PETS with similar biomechanical rationale when possible. Single PETS were assessed and ranked by DOR. Clinical performance was assessed by sensitivity, specificity, accuracy and likelihood ratio.
  
  
  
  Six thousand nine-hundred abstracts and 202 full-text articles were assessed for eligibility; 20 articles were eligible and data from 11 articles could be included in the meta-analysis. All PETS for SLAP (superior labral anterior posterior) lesions pooled gave a DOR of 1.38 [1.13, 1.69]. The Supraspinatus test for any full thickness rotator cuff tear obtained the highest DOR of 9.24 (sensitivity was 0.74, specificity 0.77). Compression-Rotation test obtained the highest DOR (6.36) among single PETS for SLAP lesions (sensitivity 0.43, specificity 0.89) and Hawkins test obtained the highest DOR (2.86) for impingement syndrome (sensitivity 0.58, specificity 0.67). No single PETS showed superior clinical test performance.
  
  
  
  The clinical performance of single PETS is limited. However, when the different PETS for SLAP lesions were pooled, we found a statistical significant change in post-test probability indicating an overall statistical validity. We suggest that clinicians choose their PETS among those with the highest pooled DOR and to assess validity to their own specific clinical settings, review the inclusion criteria of the included primary studies. We further propose that future studies on the validity of PETS use randomized research designs rather than the accuracy design relying less on well-established gold standard reference tests and efficient treatment options.
authors.affiliation: Department Physical Medicine and Rehabilitation, St.Olavs University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway. Sigmund.Gismervik@ntnu.no.|Department of Public Health and General Practice, Norwegian University of Science and Technology, P.B. 8905 MTFS, 7491, Trondheim, Norway. Sigmund.Gismervik@ntnu.no.
authors.forename: Sigmund Ø
authors.initials: SØ
authors.lastname: Gismervik
authors.affiliation: Institute of Neuromedicine, Faculty of Medicine, Norwegian University of Science and Technology, P.B 8905 MTFS, 7491, Trondheim, Norway.|Department of Orthopedic Surgery, Trondheim University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway.
authors.forename: Jon O
authors.initials: JO
authors.lastname: Drogset
authors.affiliation: Department Physical Medicine and Rehabilitation, St.Olavs University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway.
authors.forename: Fredrik
authors.initials: F
authors.lastname: Granviken
authors.affiliation: Department Physical Medicine and Rehabilitation, St.Olavs University Hospital, P.B. 3250 Sluppen, NO-7006, Trondheim, Norway.
authors.forename: Magne
authors.initials: M
authors.lastname: Rø
authors.affiliation: Department of Clinical Medicine, Neuromuscular Diseases Research Group, UiT The Arctic University of Norway, N-9037, Tromsø, Norway.|Unicare Medical Rehabilitation Centre, Hokksund, Norway.
authors.forename: Gunnar
authors.initials: G
authors.lastname: Leivseth
mesh_terms: D006801:Humans; D010808:Physical Examination / Q000379:methods / Q000592:standards*; D019534:Shoulder Impingement Syndrome / Q000175:diagnosis* / Q000503:physiopathology; D020069:Shoulder Pain / Q000175:diagnosis* / Q000503:physiopathology
keywords: Clinical test; Diagnosis; Meta-analysis; Physical examination; Rotator cuff tear; SLAP (superior labral anterior posterior) lesion; Shoulder; Shoulder pain; Subacromial impingement; Systematic review