Introduction

Shoulder injures are common with older patients and can be quite disabling. The rotator cuff surrounds the shoulder joint and is composed of four muscle tendons, which join with a fibrous capsule covering the joint. Tearing the cuff is a serious injury that causes severe pain and can limit the ability to raise the arm. It may require corrective surgery.

Commonly, diagnosis of a rotator cuff tear (RCT) often necessitates expensive, intrusive arthrography or arthroscopic exploration of the injured area. Double contrast arthrography, which involves x-rays after injection of a dye into the shoulder joint, has been considered the "gold standard" for the diagnosis of RCT. Other newer methods of diagnosis such as ultrasound or magnetic resonance imagery (MRI) can be useful, but also have drawbacks. Reading ultrasounds can be difficult, and MRI is expensive and sometimes uncomfortable for the patient. Recently, physicians have compared the results of these established methods of diagnosis with a new approach involving analysis of the patient's history and a bedside physical examination protocol. This technique of diagnosis proved highly effective and efficient.

A study of patients with suspected RCT using bedside diagnostics

Older adults often complain of shoulder pain. This pain may be a symptom of a simple soft tissue injury or may be more serious, involving the rotator cuff. Simple soft tissue injuries are generally easily treated with conservative therapy (painkillers, physiotherapy and specific exercises), while more serious injuries often necessitate surgical repair. Determining the extent and type of injury can be difficult. The physicians hoped to establish a series of easy physical examinations and analysis of patient history to quickly and inexpensively differentiate patients who have RCT.

The physicians examined records from 448 patients (average age 57, 63% men) to see whether an analysis of a patient's history and a series of bedside physical examinations could provide a reliable, non-intrusive and inexpensive diagnosis for RCT. They compared the findings with those from more intrusive and/or expensive methods, such as MRI or arthroscopy.

Study findings

A series of ten elements in a history and clinical examination were identified, and this led to a 5-point scoring system. These elements were based on movement or rotation of the patient's arm and the resulting pain or weakness, and other pain such as night pain. Night pain and rotational weakness were the most useful diagnostic elements.

The results were compared to the diagnostic findings from arthrography. Statistically speaking, the examination protocol had a highly predictive value (93%). The 5-point system allowed the scientists to determine those patients who had a high probability of RCT (scores of 4 or 5), those who should have confirmatory testing (MRI) because of uncertainty (scores of 2-3), and those who did not require further diagnostic evaluation (scores of 0-1).

The authors of this report stress that although the protocol is very useful and accurate it requires experience and practice. They suggest further testing with patients who have a very low likelihood of actually having RCT.

In conclusion, this study has shown that a return to a bedside diagnostic method, using this new scoring system, can be used to avoid costly and difficult examinations, and also may benefit the patient by promoting direct contact with the doctor at the bedside.