Clinical and arthroscopic findings in recreationally active patients

OBJECTIVE: To examine the diagnostic accuracy of standard clinical tests for the shoulder in recreational athletes with activity related pain. DESIGN: Cohort study with index test of clinical examination and reference standard of arthroscopy. SETTING: Sports Medicine clinic in Sheffield, U.K. PARTICIPANTS: 101 recreational athletes (82 male, 19 female; mean age 40.8 ± 14.6 years) over a six year period. INTERVENTIONS: Bilateral evaluation of movements of the shoulder followed by standardized shoulder tests, formulation of clinical diagnosis and shoulder arthroscopy conducted by the same surgeon. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, likelihood ratio for a positive test and over-all accuracy of clinical examination was examined retrospectively and compared with arthroscopy. RESULTS: Isolated pathology was rare, most patients (72%) having more than one injury recorded. O'Brien's clinical test had a mediocre sensitivity (64%) and over-all accuracy (54%) for diagnosing SLAP lesions. Hawkins test and Jobe's test had the highest but still not impressive over-all accuracy (67%) and sensitivity (67%) for rotator cuff pathology respectively. External and internal impingement tests showed similar levels of accuracy. When a positive test was observed in one of a combination of shoulder tests used for diagnosing SLAP lesions or rotator cuff disease, sensitivity increased substantially whilst specificity decreased. CONCLUSIONS: The diagnostic accuracy of isolated standard shoulder tests in recreational athletes was over-all very poor, potentially due to the majority of athletes (71%) having concomitant shoulder injuries. Most likely, this means that many of these injuries are missed in general practice and treatment is therefore delayed. Clinical examination of the shoulder should involve a combination of clinical tests in order to identify likely intra articular pathology which may warrant referral to specialist for surgery.