Background/Purpose: High resolution ultrasonography (HRUS) is a non-painful and non-invasive imaging technique which is increasingly used for evaluating patients with musculoskeletal disorders. In particular, HRUS is useful for an assessment of shoulder pain causes, as clinical examination often does not allow an exact diagnosis. The aim of this study was to establish the role of HRUS in the diagnosis of shoulder problems as well as to form an evidence base for clinical interpretation of most common clinical tests of the painful shoulder.

Methods: Non-interventional observational study of 100 adult patients suffering from unilateral shoulder pain. Exclusion criteria were shoulder fractures, prior shoulder joint surgery and prior shoulder injections (local anesthetics or steroids) in the past month. The HRUS examination was performed according to the guidelines of the Swiss Society of Ultrasound in Medicine (SGUM, musculoskeletal section). The clinical tests were: bursitis sign, Jobe’s test, painful arc, drop arm sign, Hawkins and Kennedy impingement tests, lift off test, belly press test, m. infraspinatus test, acromioclavicular (AC) joint tenderness, Abbott-Saunders test, palm up test, Yergason test and Hueter sign. The physicians performing clinical and HRUS examination were blinded to each other. In the statistical analysis HRUS findings were used as the gold standard.

Results: In the HRUS examination pathologies of the bursa subacromialis were found in 87 %, of the m. supraspinatus tendon in 67 %, of the AC joint in 24 %, of the long biceps tendon in 20 %, of the m. subscapularis tendon in 11 %, of the m. infraspinatus tendon in 10 % and of the m. pectoralis major tendon in 1 % of all cases.

In order to detect pathology of the m. supraspinatus tendon, the Hawkins Kennedy impingement tests showed the highest sensitivity (0.86) whereas the Jobe’s test showed the highest specificity (0.55). To identify m. subscapularis tendon pathology the lift off test showed a sensitivity of 1, whereas the belly press test showed the higher specificity (0.72) as the lift off test (0.55). The m. infraspinatus test showed a high sensitivity (0.90) and specificity (0.74). All three AC tests (painful arc II^a, AC joint tenderness^b, cross body action^c) showed low sensitivities (^a0.25, ^b0.38, ^c0.38) but high specificities (^a0.96, ^b0.99, ^c0.96). To evaluate the long biceps tendon the palm up test showed the highest sensitivity (0.47), the Yergason test showed the highest specificity (0.88).

Conclusion: Knowledge of sensitivity and specificity of various clinical tests is important for the interpretation of clinical examination test results and the identification of cases in which further imaging procedures are necessary to make a distinct diagnosis. Thus, clinical test results should be confirmed by HRUS examination, which allows a reliable differentiation of the various pathologies leading to a painful shoulder.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/correlation-of-findings-in-clinical-and-high-resolution-ultrasonography-examinations-of-the-painful-shoulder/