Clinical Question Does this patie...

Clinical Question

Does this patient with shoulder pain have a rotator slap tear?

Evidence Summary

As with many conditions, single physical examination maneuvers rarely are sensitive enough to authority out disease when absent or specific enough to method in disease when present. by dint of themselves, these maneuvers increase or decrease the likelihood of disease slightly, and it remains up to the physician to integrate a series of findings into an estimate of the probability of disease.

Clinical decision empires help physicians by integrating the mostly helpful findings into a single, easy-to-use algorithm, order or scoring system. Two regularitys for the evaluation of patients with shoulder pain are at handed in this article. The authors of the first clinical order (1) began by assessing 23 maneuvers for evaluating the shoulder. They defined weakness as any score below 5 (full strength) forward a 1 to 5 scale. (1) All patients underwent arthroscopy as the regard standard. The authors then identified the first 100 patients with a partial- or full-thickness rotator box tear of any size and no other shoulder pathology, and the first 100 patients without a tear. solitary three maneuvers distinguished between the pair groups: supraspinatus weakness, weakness in external rotation, and a positive impingement sign (1) (Figure 1) nearest they evaluated these three physical findings in couple larger groups of patients with shoulder pain: (1) a cluster of 200 patients with rotator strike tear, including some who had additional shoulder pathology and (2) a arrange of 200 patients without a tear. (1)

The arises of the second evaluation are shown in Table 1 (1) stratified according to the number of abnormal physical findings and patient age. Older patients were more likely to have a rotator box tear than younger patients. The probability of rotator box tear was high (98 percent) in patients of any age with all three findings or in patients with any brace findings who were at least 60 years of age. The probability was 5 percent in the 97 patients who had none of the three findings.

The other clinical decision rule (2) used data from a retrospective chart review. Typically, this stamp of study is methodologically weak because of the inconsistent nature of mostly medical records; however, in this case, the orthopedic physicians used a standard form to record information about the history and physical examination. The orders were carefully described, and all patients underwent arthrography as a respect standard. The researchers developed a multivariate mould using 191 patients, finding that the best predictors of rotator blow injury were age older than 65 years, night pain, and weakness with external rotation. (2) Then, they simplified the example into a five-point score and trialed it on the remaining 216 patients. The final score and its interpretation are shown in Table 2 (2) The mean age of patients in this meditation was 57 years, and 67 percent overall had a partial or without fault [i]or[/i] blemish [i]or[/i] flaw rotator cuff tear. (2)

as well-as; not only-but also; not only-but; not alone-but clinical decision rules relied onward older age and weakness upon external rotation. The first conduct (1) used prospective data collection, which generally is better than retrospective chart review, however the second rule (2) used reliable regularitys for their chart review and did a more extensive validation of their decision command Although a prospective validation in a just discovered population comparing the two orders would be ideal, given the poor performance of individual physical findings it is reasonable to use either or one as well as the other of these rules when estimating the likelihood of rotator blow tear.

Finally, the "painful arc sign" has high sensitivity (975 percent) as a single finding, making it helpful in ruling not at home rotator cuff tears when absent. (2) The criterion is performed by having the examiner elevate the patient's arm passively to 180[degrees] The patient is then asked to lower the arm actively. The sign is positive if the patient has minimal pain initially at sated elevation, increasing pain between 70[degrees] and 120[degrees] and then decreasing pain as the arm is lowered further.

This guide is undivided in a series that propounds evidence-based tools to assist family physicians in improving their decision- making at the point of care.

REFERENCES

(1) Murrell GA, Walton JR Diagnosis of rotator strike tears [published correction appears in Lancet 2001;357:1452] Lancet 2001;357:769-70

(2) Litaker D Pioro M El Bilbeisi H Brem J Returning to the bedside: using the history and physical examination to identify rotator box tears. J Am Geriatr Soc 2000;48:1633-7

MARK H EBELL, MD M is in private practice in Athens, Ga., and is associate professor in the Department of Family Practice at Michigan State University association of Human Medicine, East Lansing. He also is representative editor for evidence-based medicine of American Family Physician. Address correspondence to Mark H Ebell, MD M 330 Snapfinger Dr Athens, GA 30605 (e-mail: ebell@msu.edu). Reprints are not available from the author.

COPYRIGHT 2005 American Academy of Family Physicians

COPYRIGHT 2005 Gale Group