Novel Physical Examination Techniques Identify Rotator Cuff Tears Missed by Static Tests
Key findings
- This study assessed the ability of two new dynamic maneuvers, designed by Scott D. Martin, MD, of the Massachusetts General Hospital Sports Medicine Center, to detect rotator cuff pathology in patients with negative results on static tests
- Magnetic resonance arthrography, used as the comparator, revealed 27 supraspinatus full-thickness tears (FTTs)—all missed by static tests
- The dynamic isotonic manipulation examination (DIME) was highly sensitive for supraspinatus FTTs, approximately 93%–100%; the negative predictive value was 95%–100%
- The unopposed active abduction test had specificity of 100% and positive predictive value of 100% for detecting supraspinatus pathology of any kind
- If DIME is negative, FTT is adequately ruled out and the clinician can comfortably forego ordering an MRI; if DIME is positive, the clinician may decide to order MRI
No single physical examination (PE) maneuver reliably diagnoses full-thickness tears (FTTs) of the supraspinatus tendon, the most commonly torn rotator cuff tendon. For some patients with negative findings on a traditional rotator cuff exam, clinicians may continue to suspect FTT if the patient has severe pain, a suggestive history or another factor.
Subscribe to the latest updates from Orthopaedics Advances in Motion
Scott D. Martin, MD, director of the Joint Preservation Service within the Department of Orthopaedics Sports Medicine Center at Massachusetts General Hospital, recently designed two dynamic PE maneuvers for use as second-line screening tests in that scenario. In the Journal of Shoulder and Elbow Surgery, Dr. Martin, sports medicine research fellows Paul F. Abraham, MD, Mark R. Nazal, MD, MPH, Noah J. Quinlan, MD, and Kyle Alpaugh, MD, and research assistants Nathan H. Varady, MD, MBA, and Stephen M. Gillinov report that both maneuvers are highly useful for guiding decision-making about ordering MRI.
Study Methods
The study subjects were 171 patients with clinical suspicion of rotator cuff disease, with an average age of 52 and an average symptom duration of 10.8 months. None had pain or weakness on the full can or empty can tests, weakness or inability to lift the hand from the sacrum, or pain or weakness on external or internal rotation.
Each subject underwent two new maneuvers:
Dynamic isotonic manipulation examination (DIME)—The patient's arm is placed in maximal abduction, with the palm facing down. The examiner applies a constant force to the dorsal aspect of the wrist, perpendicular to the arm. The patient is asked to maximally resist this force, while the examiner forces the arm into adduction over a smooth, five-second arc. For this study, a handheld dynamometer/inclinometer was placed on the dorsal side of the wrist to measure the applied force.
Unopposed active abduction test (UAAT)—The patient is asked to stand with the affected arm at their side and abduct slowly in the coronal plane, with the palm facing down. If the patient reports pain at any point through the abduction arc, the angle at which pain is first reported is noted. The maneuver is repeated in the scapular plane, 30° of forward flexion from the coronal plane. For this study, the active abduction range of motion was measured with the inclinometer.
Following the office visit where these two maneuvers were performed, all participants underwent magnetic resonance arthrography (MRA), the gold standard for diagnosing rotator cuff pathology.
MRA Results
MRA revealed 27 FTTs—all missed by static tests. Most were medium-sized or larger, highlighting the importance of prompt diagnosis, as these tears have high rates of tear progression.
There were 12 focal FTTs/full-thickness perforations, 52 partial-thickness tears, 17 ''frayed'' tendons, 37 cases of tendinopathy and 26 cases without supraspinatus pathology.
DIME Results
- Coronal plane—The presence of pain had a sensitivity of 96%, specificity of 17% and negative predictive value (NPV) of 96% for detecting supraspinatus FTTs
- Scapular plane—The presence of pain had a sensitivity of 93%, specificity of 26% and NPV of 95%
- Use of dynamometer in the coronal plane—Strength ≤86.0 N had a sensitivity of 100%, specificity of 11% and NPV of 100%
- Use of dynamometer in the scapular plane—Strength ≤86.0 N had a sensitivity of 96%, specificity of 15% and NPV of 96%
UAAT Results
Pain starting at an angle ≤90° had a sensitivity of 27%, specificity of 100% and positive predictive value of 100% for detecting supraspinatus pathology of any kind (tearing, fraying or tendinopathy).
Guidance for Clinicians
If DIME results are negative, the clinician can be relatively confident that the patient does not have a supraspinatus FTT because negative results of highly sensitive tests effectively rule out disease. The specificity figures for DIME may seem low, but they reflect the test's performance when every other test has failed to rule out FTT.
Pain during DIME was nearly as sensitive for FTTs as DIME strength measurements were (96% vs. 100%). Therefore, DIME has great utility, even for clinicians without dynamometers.
When performing the UAAT, clinicians are likely to be able to identify a 90° angle without using an inclinometer, making this test useful for examination via videoconference.
view original journal article Subscription may be required
Learn more about the Sports Medicine Service at Mass General
Refer a patient to the Sports Medicine Service at Mass General