Physical examination tests in the acute phase of shoulder injuries with negative radiographs: a diagnostic accuracy study

Key Points

1. No pain with resisted abduction, the ability to abduct >90 degrees, no weakness with the small finger test, and no weakness of external rotation were helpful to rule out full-thickness rotator cuff tears.
2. Caution, as these findings only produce a moderate ability to help rule out full-thickness rotator cuff tears, and the shifts are imprecise.

BACKGROUND AND OBJECTIVE

The evidence supporting shoulder physical examination tests has been considered insufficient in reviews and meta-analyses. Rotator cuff tears may easily be missed in patients with acute shoulder trauma, as these individuals are often discharged when skeletal imaging is negative. However, rotator cuff pathologies are often found on follow-up consultation (1).

It has also been suggested that diagnostic tests be employed by emergency room physicians on patients who were not referred to a specialist (2). One primary reason for this is the fact that approximately half of shoulder injuries in an emergency department are soft tissue injuries and being able to accurately diagnose a rotator cuff pathology is important for patient care (3).

The aim of the present study was to assess the accuracy in predicting or ruling out acute rotator cuff tears in the first-line health care.

Rotator cuff tears may easily be missed in patients with acute shoulder trauma, as these individuals are often discharged when skeletal imaging is negative.

The inability to abduct more than 90 degrees and weakness in external rotation are more useful to help rule out full-thickness rotator cuff tears when the findings of the tests are negative.

METHODS

A prospective diagnostic accuracy study was conducted at a combined primary care walk-in clinic and secondary care orthopedic emergency department.

Participants:

• 120 consecutive patients aged ≥ 40 years (median age of 55 years; 51% female) with acute shoulder trauma (67% were falls from their own height), negative plain radiographs, and follow-up ≤ 21 days (mean of 12 days).

Inclusion Criteria:

• Age ≥ 40 years

• Oslo resident

• Acute injury with concomitant onset of symptoms

• International Classification of Diseases (ICD-10) S4-diagnosis (Injuries to the shoulder and upper arm) except the middle and distal third of the humerus and related soft tissues

• Negative plain X-rays for signs of acute injury or successfully reduced glenohumeral dislocation without fracture.

Exclusion Criteria:

• Injury of both shoulders

• Other injuries affecting shoulder symptoms or function

• Previous surgery on one of the shoulders during the last 6 months

• Known rotator cuff tear on imaging

• Neck-/shoulder problems or generalized joint-/muscle pain during the last 3 months before the injury

Assessments:

• Thirteen physical examination tests and clinical signs were performed for both the injured and uninjured shoulder (see Video 1).

VIDEO 1 – PHYSICAL EXAMINATION TESTS

RESULTS

• A full-thickness rotator cuff tear was diagnosed in 38 (32%) patients, and 46 (38%) had a rotator cuff tear and/or occult fracture at its insertion.

• The patients with rotator cuff tear were older than those without a tear (median age 67 years and 51 years, respectively, p < 0.001), but there was no gender disparity (53% and 51% females, respectively).

• The inability to actively abduct the arm above 90° had the highest diagnostic odds ratio (DOR) for a single test of 12.9.

• Pretest to post-test probability shifts

  • Positive test shifted from 41% to 67%, but only a small shift in probability based on the likelihood ratio (4).
  • Negative test shifted from 41% to 14%, but also only a small shift (4).

• Pain on resisted abduction had the highest sensitivity of 91%, demonstrating a moderate shift in pre-(38%) to post-test probability (9%) (4) to help rule out a full-thickness rotator cuff tear when the test was negative in this study.

• The test combination of inability to abduct >90 degrees + small finger test:

  • Small ability (4) to help rule in the diagnosis of full full-thickness tears when the tests are positive.
  • Moderate ability (4) to help rule out a full-thickness tear when the tests are negative.

• The test combination of inability to abduct >90 degrees + weakness in external rotation:

  • Small ability (4) to help rule in the diagnosis of full-thickness tears when the tests are positive.
  • Moderate ability (4) to help rule out a full-thickness tear when the tests are negative.

LIMITATIONS

• The findings were limited to patients ≥ 40 years and early follow-up. Therefore, it is unclear whether these measures have applicability to younger patients or those with insidious/delayed onset of symptoms.

• Few isolated subscapularis tears (n = 2); therefore, findings are unable to validate subscapularis-specific maneuvers.

• Greater than 50% of eligible patients excluded (mostly chronic shoulder/neck pain); may overestimate accuracy.

CLINICAL IMPLICATIONS

The authors suggest that the inability to abduct more than 90 degrees and weakness in external rotation are effective in diagnosing full-thickness tears of the upper rotator cuff and assessing the integrity of its insertion.

My interpretation would be that these tests are more useful to help rule out full-thickness rotator cuff tears when the findings of the tests are negative (versus helpful to rule in when the test findings are positive). In brief, these tests are more effective at excluding a full-thickness rotator cuff tear than diagnosing it.

With diagnostic accuracy studies, it is important to determine the clinical utility of measures examined (magnitude of the shift in testing and the precision of such a shift). In this study, the largest magnitude of probability shift was a moderate shift for the following (all to help rule out full-thickness tears when the tests were negative):

• Negative findings with pain on resisted abduction (thus no pain with this test).

• Negative findings with the test combination of inability to abduct >90 degrees + small finger test.

• Negative findings with the test combination of inability to abduct >90 degrees + weakness in external rotation.

• Most tests in this study demonstrated poor precision (limited confidence of shift in magnitude).

+STUDY REFERENCE

Enger M, Schmidt M, Nordsletten L, Moosmayer S, Pripp A, Melhuus K, Brox J (2025) Physical examination tests in the acute phase of shoulder injuries with negative radiographs: a diagnostic accuracy study. BMC Musculoskelet Disord, 26(1), 546 (published Online First: 20250603)

SUPPORTING REFERENCE

1. Sørensen AK, Bak K, Krarup AL, et al. Acute rotator cuff tear: do we miss the early diagnosis? A prospective study showing a high incidence of rotator cuff tears after shoulder trauma. J Shoulder Elbow Surg 2007;16(2):174-80 [published Online First: 20061213]
2. Hanchard NC, Lenza M, Handoll HH, et al. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev 2013;2013(4):Cd007427 [published Online First: 20130430]
3. Enger M, Skjaker SA, Melhuus K, et al. Shoulder injuries from birth to old age: A 1-year prospective study of 3031 shoulder injuries in an urban population. Injury 2018;49(7):1324-29 [published Online First: 20180522]
4. Jaeschke R, Guyatt GH, Sackett DL. Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? JAMA 1994;271(9):703-7 [published Online First: 1994/03/02]