Original Article
The Value of Clinical Tests in Acute Full-Thickness Tears of the Supraspinatus Tendon: Does a Subacromial Lidocaine Injection Help in the Clinical Diagnosis? A Prospective Study

https://doi.org/10.1016/j.arthro.2009.11.005Get rights and content

Purpose

Early repair of rotator cuff tears leads to superior results. To detect symptomatic full-thickness tears of the supraspinatus tendon at an early stage, we conducted a prospective study to evaluate the value of clinical examination with and without subacromial lidocaine within the first weeks after an acute injury to the shoulder.

Methods

Of 104 patients included in a prospective investigation, 52 patients were selected to evaluate the diagnostic accuracy of clinical tests in acute full-thickness tears of the supraspinatus tendon. Clinical tests and ultrasound examination were performed at a median of 13 days (range, 3 to 49 days) after the initial injury. The study group consisted of 29 patients (median age, 56 years [range, 39 to 75 years]) who all had an acute complete tear of the supraspinatus tendon verified by ultrasound and arthroscopy. The control group consisted of 23 patients who all had an intact tendon confirmed by ultrasound (median age, 38 years [range, 19 to 73 years]).

Results

The Hawkins sign (0.83) and the painful arc test (0.97) had high sensitivity but low specificity (0.23 and 0.05, respectively). The external rotation lag sign (ERLS) and the drop-arm test (DAT) had a sensitivity of 0.39 and 0.37, respectively, and specificity of 0.91 and 0.86, respectively, in diagnosing acute full-thickness tears of the rotator cuff. After a subacromial lidocaine injection, sensitivity of all lag sign tests was reduced, whereas specificity and likelihood ratios of the Jobe test, the ERLS, and the DAT improved. Active abduction was significantly reduced in the full-thickness tear group.

Conclusions

A positive lag sign (ERLS or DAT) is indicative of a full-thickness supraspinatus tear, but a negative lag sign does not preclude a tear. After a subacromial injection of lidocaine, the specificity improves whereas the sensitivity is reduced. Overall, in patients with suspected acute rotator cuff tear, clinical tests cannot stand alone in the evaluation the first weeks after an acute injury.

Level of Evidence

Level I, diagnostic study—testing of previously developed criteria in a series of consecutive patients (by use of arthroscopy and ultrasound as the gold standard).

Section snippets

Methods

From February 1998 until January 2001, a total of 104 patients who presented to the emergency department with an acute injury to a previously healthy shoulder were included in this prospective diagnostic investigation. The inclusion criteria are listed in Table 1. The flow diagram is shown in Fig 1.

Results

The Hawkins sign, Neer sign, Jobe test, and painful arc test had high sensitivity (0.83, 0.70, 0.74, and 0.97, respectively) but low specificity (0.23, 0.36, 0.61, and 0.05, respectively) for acute full-thickness supraspinatus tear (Table 4). The DAT, ERLS, IDS, and IRLS, on the contrary, showed low sensitivity (0.37, 0.39, 0.43, and 0.39, respectively) but high specificity (0.86, 0.91, 0.73, and 0.83, respectively) (Table 4). Specificity improved for all tests after SAL, whereas the

Discussion

The purpose of this study was to investigate the ability of clinical tests to detect acute complete ruptures of the supraspinatus tendon and, in addition, to evaluate whether administration of lidocaine in the subacromial space (SAL) would add to the clinical information. We found that the classical DAT and the Hertel lag signs (ERLS, IDS, and IRLS) had low sensitivity in this study with respect to cases of acute FTT of the supraspinatus tendon. The sensitivity dropped further after SAL,

Conclusions

A positive lag sign (ERLS or DAT) is indicative of a full-thickness supraspinatus tear. A negative lag sign does not preclude a tear. After an SAL, the specificity improves whereas the sensitivity is reduced. Overall, in patients with suspected acute rotator cuff tear, clinical tests cannot stand alone in the evaluation the first weeks after an acute injury.

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