Returning to the bedside: Using the history and physical examination to identify rotator cuff tears

OBJECTIVES: To determine the value of elements of the bedside history and p hysical examination in predicting arthrography results in older patients wi th suspected rotator cuff tear (RCT). DESIGN: Retrospective chart review SETTING: Orthopedic practice limited to disorders of the shoulder PARTICIPANTS: 448 consecutive patients with suspected RCT referred for arth rography over a 4-year period MAIN OUTCOME MEASURE: Presence of partial or complete RCT on arthrogram RESULTS: 301 patients (67.2%) had evidence of complete or partial RCT. Clin ical findings in the univariate analysis most closely associated with rotat or cuff tear included infra- and supraspinatus atrophy (P < .001), weakness with either elevation (P < .001) or external rotation (P < .001), are of p ain (P = .004), and impingement sign (P = .01). Stepwise logistic regressio n based on a derivation dataset (n = 191) showed that weakness with externa l rotation (Adjusted Odds Ratio (AOR) 6.96 (3.09, 13.03)), age <greater tha n or equal to> 55 (AOR 4.05(2.47, 16.07)), and night pain (AOR 2.61 (1.004, 7.39)) best predicted the presence of RCT. A five-point scoring system dev eloped from this model was applied in the remaining patient sample (n = 214 ) to test validity. No significant differences in performance were noted us ing ROC curve comparison. Using likelihood ratios, a clinical score = 4 was superior in predicting RCT tu the diagnostic prediction of an expert clini cian. This score had specificity equivalent to magnetic resonance imaging o r ultrasonography in diagnosis of RCT. CONCLUSIONS: The presence of three simple features in the history and physi cal examination of the shoulder can identify RCT efficiently. This approach offers a valuable strategy to diagnosis at the bedside without compromisin g sensitivity or specificity.