Electronic Thesis and Dissertation Repository

Degree

Doctor of Philosophy

Program

Health and Rehabilitation Sciences

Supervisor(s)

Dr. Dianne Bryant

Abstract

Shoulder pain and disability can pose a diagnostic challenge for clinicians owing to the numerous etiologies than can exist and the potential for multiple disorders to co-exist. There are an abundance of physical examination maneuvers available to clinicians to utilize in their clinical decision making. Additionally the patient history may be an important diagnostic tool in patients with shoulder pathology. The evidence in support of most clinical tests is weak or absent and only a few studies have formally assessed the measurement properties of history findings. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers and patient reported history for shoulder pathology. We recruited consecutive shoulder patients who were referred to two tertiary orthopedic clinics. The patient first completed a questionnaire on the history of their pathology. The surgeon then took a thorough history and indicated his or her certainty about each possible diagnosis. The clinician performed the physical examination for diagnoses where uncertainty remained. We considered arthroscopy the reference standard for patients who underwent surgery and magnetic resonance imaging with arthrogram for patients who did not. We calculated the sensitivity, specificity, and likelihood ratios and investigated whether combinations of the top tests provided stronger predictions of the presence or absence of disease. Finally we assessed whether a tool could be developed from the history items that could be used for triaging patients. None of the tests were highly sensitive for rotator cuff or labral pathology. The physical examination and history agreed in 75% of cases. Of those that did not agree, the physical examination misdirected the diagnosis in 47% of our cases. In particular history items were strong predictors of anterior and posterior instability and subscapularis tears and were combined in a tool to be utilized for screening patients. In conclusion, no test in isolation is sufficient to diagnose a patient with rotator cuff disease or labral pathology. The patient reported history items were effective for diagnosing shoulder pathology and should be considered for use in a triaging instrument.


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