Diagnostic value of patient characteristics, history, and six clinical tests for traumatic anterior shoulder instability

doi:10.1016/j.jse.2013.05.006

Journal of Shoulder and Elbow Surgery

Volume 22, Issue 10, October 2013, Pages 1310-1319

https://doi.org/10.1016/j.jse.2013.05.006 Get rights and content

Background

It is unknown which combination of patient information and clinical tests might be optimal for the diagnosis of traumatic anterior shoulder instability. This study aimed to determine the diagnostic value of individual clinical tests and to develop a prediction model that combined patient characteristics, history, and clinical tests for diagnosis of traumatic anterior shoulder instability.

Materials and methods

This prospective cohort study included 169 consecutive patients with shoulder complaints who were examined at an orthopaedic outpatient clinic. One experienced clinician conducted 25 clinical tests; of these, 6 were considered to be specific for testing of traumatic anterior shoulder instability (apprehension, relocation, release, anterior drawer, load and shift, and hyperabduction tests). Magnetic resonance arthrography was used to determine the final diagnosis. A prediction model was developed by logistic regression analysis.

Results

In this cohort, 60 patients (36%) were diagnosed with anterior shoulder instability on the basis of magnetic resonance arthrography. The overall accuracy of individual clinical tests was 80.5% to 86.4%. Age, previous shoulder dislocation, sudden onset of complaints, and the release test were important predictors for the diagnosis of traumatic anterior shoulder instability. The prediction model demonstrated high discriminative ability (AUC 0.95).

Conclusion

Individual clinical shoulder tests provide good diagnostic accuracy. Young age, history of shoulder dislocation, sudden onset of complaints, and positive result of the release test were the most important predictors for traumatic anterior shoulder instability.

Section snippets

Patients

This prospective cohort study included new patients with shoulder complaints recruited consecutively between February 2009 and June 2012 at the orthopaedic outpatient clinic. Exclusion criteria were fractures, frozen shoulder, arthritis, and problems with reading and understanding the Dutch language. Institutional approval was obtained by our local Ethics Committee, and written, signed, informed consent was obtained from all participants.

Data collection

One experienced orthopaedic surgeon (W.J.W.) performed

Patients

The flow chart of the selection process for the study population is presented in Figure 1. The study included 174 patients with shoulder complaints. One patient had bilateral complaints; thus, 175 shoulders were included. Each patient underwent the standardized testing protocol. Six patients were subsequently excluded; 1 patient went to another hospital because of our waiting list, and 5 patients refused to undergo MRA. Thus, 169 (97%) shoulders were analyzed. Twelve (7%) patients did not

Discussion

This study evaluated the value of individual clinical tests for diagnosis of traumatic anterior shoulder instability. In addition, we developed a prediction model that combined patient characteristics, history, and clinical tests. We found that the patient information was of paramount importance in establishing the diagnosis of traumatic anterior shoulder instability. The individual clinical tests had good diagnostic value, with an overall accuracy that varied between 80.5% and 86.4%. In

Conclusion

We hypothesized that clinical evaluation might improve with a prediction model that combines patient characteristics, history, and clinical tests for the diagnosis of traumatic anterior shoulder instability. In this cohort study, we found that the individual clinical tests for traumatic anterior shoulder instability provided good diagnostic value. Moreover, we developed a prediction model that provided improved diagnostic value, with an AUC of 0.95. Young age, history of shoulder dislocation,

Acknowledgment

We thank Ms. M. Boekhorst for assistance in collecting study data and V.P.M. van der Hulst for assistance as a second radiologist. We also thank the European Society for Surgery of the Shoulder and the Elbow for a research grant (2009 SECEC/ESSSE), the Anna Foundation for a research grant (2009 Research Grant), and the Marti-Keuning Eckhardt Foundation for financial support.

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

References (45)

T. Berendes et al.
Validation of the Dutch version of the Oxford Shoulder Score
J Shoulder Elbow Surg
(2010)
T.S. Ellenbecker et al.
Intrarater and interrater reliability of a manual technique to assess anterior humeral head translation of the glenohumeral joint
J Shoulder Elbow Surg
(2002)
D.L. Patrick et al.
Patient-reported outcomes to support medical product labeling claims: FDA perspective
Value Health
(2007)
E.W. Steyerberg et al.
Stepwise selection in small data sets: a simulation study of bias in logistic regression analysis
J Clin Epidemiol
(1999)
C.-Y. Tian et al.
The added value of ABER position for the detection and classification of anteroinferior labroligamentous lesions in MR arthrography of the shoulder
Eur J Radiol
(2013)
A. Tzannes et al.
An assessment of the interexaminer reliability of tests for shoulder instability
J Shoulder Elbow Surg
(2004)
D.A. van Kampen et al.
Validation of the Dutch version of the Simple Shoulder Test
J Shoulder Elbow Surg
(2012)
G. Ambler et al.
Simplifying a prognostic model: a simulation study based on clinical data
Stat Med
(2002)
M. Bhandari et al.
User's guide to the surgical literature: how to use an article about a diagnostic test
J Bone Joint Surg Am
(2003)
W. David et al.
Applied logistic regression
(2013)

J. Dawson et al.

The assessment of shoulder instability. The development and validation of a questionnaire

J Bone Joint Surg Br

(1999)

J. Dawson et al.

Questionnaire on the perceptions of patients about shoulder surgery

J Bone Joint Surg Br

(1996)

A.J. Farber et al.

Clinical assessment of three common tests for traumatic anterior shoulder instability

J Bone Joint Surg Am

(2006)

E.M. Fowler et al.

Clinical and arthroscopic findings in recreationally active patients

Sports Med Arthrosc Rehabil Ther Technol

(2010)

O.J. Gagey et al.

The hyperabduction test

J Bone Joint Surg Br

(2001)

C. Gerber et al.

Clinical assessment of instability of the shoulder. With special reference to anterior and posterior drawer tests

J Bone Joint Surg Br

(1984)

M.L. Gross et al.

Anterior release test. A new test for occult shoulder instability

Clin Orthop Relat Res

(1997)

J.J. Halma et al.

Interdisciplinary inter-observer agreement and accuracy of MR imaging of the shoulder with arthroscopic correlation

Arch Orthop Trauma Surg

(2012)

F.E. Harrell et al.

Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors

Stat Med

(1996)

E.J. Hegedus

Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests

Br J Sports Med

(2012)

E.J. Hegedus et al.

Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests

Br J Sports Med

(2007)

L. Hovelius et al.

Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. A prospective twenty-five-year follow-up

J Bone Joint Surg

(2008)

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The results are graded as 0, minimal displacement; 1, translation to glenoid rim; 2, translation over glenoid rim with spontaneous relocation; and 3, translation over glenoid rim without spontaneous relocation. The specificity has been found to be 90% to 100% and sensitivity up to 71%.33 The anterior drawer test is performed by shifting the humeral head anteriorly on the glenoid fossa and is considered positive if the patient experiences a sense instability with affected shoulder compared with the contralateral shoulder.
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The investigation of Hill-Sachs and bony Bankart lesions continues to evolve. Patients with large bone lesions can present with a positive apprehension test even at ranges below 45° of abduction and external rotation of the shoulder. Modern concepts, such as glenoid track and quantification of glenoid bone loss, have been increasingly applied to shoulder instability. The objective of this study was to assess the correlation of the glenoid track and glenoid bone loss on the apprehension test conducted at 0°, 45°, and 90° of shoulder abduction.
Ninety-four shoulders of 90 patients with anterior glenohumeral instability were retrospectively assessed. The apprehension test was performed at 0°, 45°, and 90° of shoulder abduction. Computed tomography, magnetic resonance imaging, or magnetic resonance arthrogram scans were performed to calculate the glenoid track and glenoid bone loss. A descriptive analysis, an association analysis, and a logistic regression analysis were used in this study. Logistic regression analysis was used to assess the influence of glenoid track and glenoid bone loss when the apprehension test was positive in lower degrees of abduction.
A positive apprehension test at 0°, 45°, and 90° of abduction revealed significant association with off-track lesions, glenoid bone losses greater than 13.5%, and bipolar bone lesions. Shoulders classified as off-track were 36.4 times more likely to test positive at 0°, 45°, and 90° than on-track shoulders. The logistic regression analysis revealed that the positive apprehension test at 0°, 45°, and 90° of abduction seems to be more influenced by off-track lesions than by glenoid bone loss greater than the 13.5% threshold.
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Ixodes ricinus (L.) (Acari: Ixodidae) is a major vector for the transmission of several important human pathogens. The aim of the present study was to evaluate the in vitro efficacy of different concentrations of essential oils (Eos) on I. ricinus tick nymphs. Oils were obtained from the leaves of three plants native to Libya: white wormwood (Artemisia herba alba Asso), marjoram (Origanum majorana L.) and Arâr (Juniperus phoenicea L., English common name Phoenician juniper). Assays were done using the “open filter paper method”. Two concentrations from each oil, 0.5 and 1 μl/cm, were tested. The acaricidal effect was measured in terms of the lethal concentrations (LC₅₀, LC₉₅) and lethal time (LT₅₀, LT₉₅). Mortality rates were obtained by counting the surviving nymphs every 30 min for the first five hours and then at 24, 48 and 72 h. A mortality of 100% was recorded at the higher concentration of oils (1 μl/cm²) from A. herba alba and J. phoenicea at the first 2 h of exposure. Exposure to O. majorana led to 100% mortality on the third day (72 h), and this effect decreased noticeably with 0.5 μl/cm² oil at the same exposure time. However, 50% of ticks showed a paralysis effect and less movement after 2 h. The LC₅₀ of mortality was reached within the first 24 h of exposure time at 0.5 μl/cm² of O. majorana, which produced 60% tick's mortality. Chemical composition of the essential oils was elucidated by gas chromatography–mass spectrometry analyses. These results suggest that essential oils deserve further investigation as components of alternative approaches for I. ricinus tick control.
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Shoulder instability is a common problem in the young athletic population. While it is more frequently reported in male athletes relative to female athletes, the female athletic population sustains unique pathologies that need to be recognized and treated carefully based on the patient's history, physical examination, imaging, and desired level of return to play. Shoulder instability can present in the anterior direction, in the posterior direction, or can be multidirectional. Each pattern of instability presents with unique mechanisms of injury and treatment algorithms. A thorough understanding of shoulder anatomy and biomechanics is essential in successfully treating this patient population.
Estimation of Location and Extent of Labral Tear Based on Preoperative Range of Motion in Patients Undergoing Arthroscopic Stabilization for Anterior Shoulder Instability
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To determine whether range of motion (ROM) varies with the location and extent of labral tear seen in patients undergoing arthroscopic anterior shoulder stabilization.
Consecutive patients undergoing arthroscopic anterior shoulder stabilization who were enrolled in the Multicenter Orthopaedic Outcomes Network Shoulder Instability database underwent a preoperative physical examination and intraoperative examination under anesthesia in which ROM was recorded. Intraoperatively, the location and extent of the labral tear was recorded using conventional clock-face coordinates. Patients were grouped by combinations of quadrants involved in the labral tear (G1-G7): G1 = anterior only, G2 = anterior + inferior, G3 = anterior + inferior + posterior, G4 = all quadrants, G5 = superior + anterior, G6 = superior + anterior + inferior, and G7 = posterior + superior + anterior. Statistical analyses were performed with the Kruskal–Wallis rank-sum test. When P < .05, a post-hoc Dunn’s test was performed. For categorical variables, the χ² test was performed. We performed a series of bivariate negative binomial regression models testing pairwise combinations of ROM parameters predicting the count of labral tear locations (possible: 0-5) within each quadrant.
A total of 467 patients were included, with 13 (2.8%) in G1, 221 (47.3%) in G2, 40 (8.6%) in G3, 51 (10.9%) in G4, 18 (3.9%) in G5, 121 (25.9%) in G6, and 3 (0.6%) in G7. Multiple statistically significant differences were noted in ROM, specifically active internal rotation at side (IRS) (P = .005), active abduction (P = .02), passive IRS (P = .02), and passive external rotation in abduction (P = .0007). Regression modeling revealed a positive correlation between passive abduction and predicted count of labral tear locations in the superior quadrant and between passive IRS and predicted count of labral tear location in the inferior quadrant.
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II, prospective comparative study.

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: Received grants: European Society for Surgery of the Shoulder and the Elbow (2009 SECEC/ESSSE Research Grant); Anna Foundation (2009 Research Grant), number: 09/078; Marti-Keuning Eckhardt Foundation (2009 Research Grant).

: Institutional review board (IRB): METC, OLVG Hospital, Amsterdam, The Netherlands. Ethical approval was obtained by the Ethics Committee.

View full text

ShoulderDiagnostic value of patient characteristics, history, and six clinical tests for traumatic anterior shoulder instability

Background

Materials and methods

Results

Conclusion

Section snippets

Patients

Data collection

Patients

Discussion

Conclusion

Acknowledgment

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Value Health

J Clin Epidemiol

Eur J Radiol

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Simplifying a prognostic model: a simulation study based on clinical data

Stat Med

User's guide to the surgical literature: how to use an article about a diagnostic test

J Bone Joint Surg Am

Applied logistic regression

The assessment of shoulder instability. The development and validation of a questionnaire

J Bone Joint Surg Br

Questionnaire on the perceptions of patients about shoulder surgery

J Bone Joint Surg Br

Clinical assessment of three common tests for traumatic anterior shoulder instability

J Bone Joint Surg Am

Clinical and arthroscopic findings in recreationally active patients

Sports Med Arthrosc Rehabil Ther Technol

The hyperabduction test

J Bone Joint Surg Br

Clinical assessment of instability of the shoulder. With special reference to anterior and posterior drawer tests

J Bone Joint Surg Br

Anterior release test. A new test for occult shoulder instability

Clin Orthop Relat Res

Interdisciplinary inter-observer agreement and accuracy of MR imaging of the shoulder with arthroscopic correlation

Arch Orthop Trauma Surg

Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors

Stat Med

Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests

Br J Sports Med

Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests

Br J Sports Med

Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger. A prospective twenty-five-year follow-up

J Bone Joint Surg

Shoulder
Diagnostic value of patient characteristics, history, and six clinical tests for traumatic anterior shoulder instability