Abstract
Background
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Clinical examination of the shoulder joint has gained attention in recent years as clinicians aim to practice with an evidence-based and accurate clinical examination of the biceps tendon. There is an increased desire for proper diagnosis while simultaneously minimizing costly imaging procedures and unnecessary procedures. Thus, the purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing and subsequently treating long head of biceps (LHB) pathology.
Methods
A literature review of level one and two diagnostic studies was conducted to extract characteristics of clinical tests for LHB pathology through a systematic review of Pubmed, Medline, Ovid and Cochrane Review databases. Tests were combined in series and parallel to determine final sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pre-test probability. The gold-standard for diagnosis in all studies included was arthroscopy or arthrotomy.
Results
Seven studies regarding LHB clinical diagnostic testing met inclusion criteria. The optimal testing modality was use of the uppercut test combined with the tenderness to palpation of the biceps tendon test. This combination achieved a sensitivity of 88.4% when performed in parallel and a specificity of 93.8% when performed in series. These tests used in combination optimize post-test probability accuracy greater than any single individual test; adding a third test decreases accuracy.
Conclusion
Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of long head of the biceps pathology as compared to diagnostic arthroscopy (The PEC exam). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A quick reference guide is provided to use in the clinical setting.
Level of Evidence: II – Systematic Review and Meta-Analysis
Key Words: biceps tendon; long head; physical examination; pathology; diagnosis; shoulder examination
Introduction
The physical examination is a requisite and inexpensive component to medical diagnosis. The shoulder examination, in particular, encompasses a myriad of special provocative maneuvers, displaying a wide range of sensitivities and specificities pertaining to diagnostic accuracy. Accurate understanding from the correct sequence of maneuvers or tests increases diagnostic yield.
In the modern era, clinical diagnosis heavily relies on imaging modalities including ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), arthrography, and arthroscopy to diagnose shoulder pathology21,33. Current gold standard diagnostic testing options have limitations. MRI has poor statistical characteristics for diagnostic accuracy as it very reader and technician dependent, adds both direct and indirect costs, and may be less accurate than the physical exam37. Diagnostic arthroscopy is successful in diagnosing intra-articular pathology, but is limited in visualization for extra-articular pathology, is costly, and increases patient risk37. Increased use of diagnostic imaging contributes to rising health care costs14,30,32,38. According to the Centers for Medicare and Medicaid Services (CMS), diagnostic imaging costs are significant, accounting for up to 40% of overall healthcare expenditure increases over the past 10 years25. Advanced imaging techniques result in not only higher direct costs, but may increase indirect costs and jeopardize outcomes36,39.
As the healthcare landscape transitions to cost minimization and value-based healthcare delivery, the development of an efficient, cost-effective, shoulder examination is desired. Shoulder examinations have poor sensitivity and/or specificity that makes diagnosing certain pathologies difficult4,28,30,33. Thus, evaluating the long head of the biceps brachii tendon (LHB) pathology with high-yield examination maneuvers can aid physicians through increasing the accuracy of shoulder diagnoses and aid in surgical decision making.
Previously published studies focused on the following questions: whether physical examination special tests correlate with surgical findings; whether imaging correlates with surgical findings; and whether physical exam tests are accurate enough to diagnose pathology effectively5,9,10,26,28,29,33. Currently, there is a need to develop new algorithms to provide shoulder practitioners with a practical but comprehensive evidence-based approach to diagnose LHB pathology during an office visit and to further reduce the need for diagnostic imaging20,22,34.
The purpose of this study was to perform a systematic review and a secondary sensitivity analysis based on pre-formed likelihood scenarios based on the history of present illness (HPI) past medical history (PMH), and epidemiology to provide clinicians a practical, evidence-based clinical (P.E.C) physical examination algorithm to accurately diagnose patients with LHB pathology. Specific objectives were to: compile the peak performing physical exam tests extracted from level I and II studies within the English literature; synthesizing the most accurate test combination; develop a clinical algorithm to provide quantify LHB diagnostic accuracy; and create a diagnostic accuracy reference guide.
Materials and Methods
A systematic literature review with the terms “proximal”, “biceps”, “clinical” and “examination” in the Medline database through the Pubmed, Medline, Ovid and Cochrane Review databases was completed in May 2015. The searches included the use of Boolean operators such as “AND” and “OR”. The databases were scrutinized independently by three authors.
Inclusion criteria included studies that were focused on physical examination tests and compared to the diagnostic gold standard from Level I and II studies published in scientific journals. Exclusion criteria were: non-English, non-full text, level III of evidence or lower, related to superior labrum anterior to posterior (SLAP) lesions, investigated rheumatoid arthritis patients, or did not compare tests to a validated gold standard. The validated gold standard utilized for all studies and systematic reviews included were diagnostic arthroscopy or arthrotomy to confirm anatomical findings. Relevant studies were independently assessed, and conflicting studies were included only if there were consensus amongst the authors. References of included studies were additionally evaluated to identify additional articles for inclusion. Applicable data was extracted by reverse calculation where the information desired was not directly stated.
Using PRISMA guidelines for systematic reviews (Fig. 1), our original search retrieved 2,086 studies from Pubmed, Medline, Ovid and Cochrane Review databases. Twenty-eight additional records were included through a review of references from each article included in the systematic review. After duplicates were removed, the initial search yielded 2,112 studies. Subsequently, 1,689 studies were removed for irrelevant titles or abstracts, and an additional 362 were excluded because they were not in English. Lastly, the remaining 63 articles were assessed for eligibility; 14 were excluded for non-full text, 22 were excluded for not being level I or II study, and 18 were excluded for non-relevant data.
The data extracted was summarized and analyzed according to the statistical methods described by Eusebi et al. focusing on test specificity, sensitivity, positive predictive value and negative predictive value12.
Next, clinical tests were combined to assess improved diagnostic accuracy. The clinical tests were applied both in parallel and in series. The first approach in parallel analysis, consists of two special tests performed in theory at approximately the same time. The parallel analysis can interpret the findings in an “and” or “or” technique. When a parallel analysis is performed in an “or” technique, the overall sensitivity of the two tests is greater than the sensitivity of either special test alone. This parallel analysis allows for two opportunities to observe the potential pathology. If both tests are negative then it is considered a “negative” finding in the algorithm and rule out the pathology, but if just one of the two special tests is positive then it is not considered a “negative” result in parallel analysis.
The second approach in series analysis, consists of two special tests performed; however, the overall “negative” or “positive” finding depends on the outcomes of both special tests. By utilizing two special tests in an “and” technique in series, the specificity for both tests is higher than for either test alone. If both special tests are positive, then it is considered a “positive” result. If either special test is negative, then the in series analysis cannot be considered a “positive” result.
In order to calculate the post-test diagnostic probability of LHB diagnosis, we performed calculations for each test with four pre-test probability options. Pre-test probability is defined as the probability of a patient having the target disorder before a diagnostic test result is known. Therefore, pre-test probability is based on patient history, subjective complaints, epidemiologic probability and the medical opinion of the provider ordering the test. The ordinal scale created has four different probabilities: very unlikely 0.2 (20%); unlikely 0.4 (40%); likely 0.6 (60%); and very likely 0.8 (80%).
The physical exam test combination with the optimal test performance was identified (named the PEC exam). A decision tree analysis was developed to determine the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A table was created as a simple reference guide to use in the clinical setting.
Results
The initial electronic database search retrieved 2,112 unique articles, with 28 obtained from a manual search of reference lists. Of these, 2051 studies were found unrelated to the topic of interest based titles and abstract review, resulting in 63 full-text articles evaluated according to selection criteria. Fifty-four articles were excluded for the following: full-text unavailable (N=14), not a Level I/II study (N=22), and irrelevant data after full-text review (N=18). Seven relevant (N = 7) articles were identified through the systematic review and scrutinized (Supplementary Table S1).
From the reviewed articles, special tests and modalities evaluated included Speed’s, Yergason’s, bicipital groove tenderness, uppercut, bear hug, belly press, O’Brien’s, and anesthetic injection. Statistical characteristics for each test are documented in (Supplementary Table S2). The bear hug and uppercut special tests demonstrated the highest sensitivity for the physical examination special maneuvers (79%, 73% respectively), whereas the belly press and Yergason’s tests demonstrated the lower spectrum of sensitivity (31%, 41% respectively). The belly press and O’Brien’s special tests demonstrated the highest special test specificities (85%, 84% respectively), whereas the bear hug and bicipital groove tenderness tests showed the lowest specificities (60%, 72% respectively). Diagnostic ultrasound, used as a reference and also included to study as a potential application for in-office point of service testing, demonstrated the highest sensitivity and specificity of all statistical characteristics revealed through the review (Sensitivity – 88%, Specificity – 98%).
In series and in parallel assessments determined two physical exam tests improved test performance over any single test. Performing more than two physical examination tests decreased diagnostic accuracy. The uppercut test combined with the tenderness to palpation of the LHB test provided the highest physical examination accuracy for diagnosing pathology at the proximal biceps. This combination has a parallel testing sensitivity of 88.3% and a series specificity of 93.3%. We characterize this as the PEC exam. Additional combinations, including diagnostic ultrasound, are reported in (Supplementary Table S3). The uppercut test and diagnostic ultrasound in parallel revealed the highest sensitivity (97%). Each of the Speed’s, Yergason’s and upper cut tests paired with diagnostic ultrasound all achieved the highest specificity (100%).
A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability (Fig. 2). A quick reference guide is provided to use in the clinical setting (Fig. 3).
Discussion
LHB pathology is an increasingly recognized generator of shoulder pain and functional impairment in symptomatic patients. Physicians are faced with diagnostic challenges due to non-specific clinical presentations and lack of direction based on physical exam findings. As such, the purpose of this study was to perform a decision-tree analysis to create a clinical algorithm to diagnose biceps pathology with increased accuracy compared to previously reported diagnostic examinations 8,11,15-17,19,22,24. This was achieved by conducting a systematic literature review including only level I and II studies. Special test sensitivities and specificities were combined in series and parallel. Analysis showed that the uppercut test combined with tenderness to palpation of the LHB within the bicipital groove provided the highest accuracy physical exam tests for diagnosing pathology at the proximal biceps. Application of this PEC exam, coupled with pre-test probability assignments can now provide clinicians diagnostic confidence in the office. In equivocal cases, point of care ultrasound examination can further improve diagnostic accuracy2,31. Applying the PEC algorithm provides a simple, efficient and reproducible physical examination protocol for shoulder clinicians yielding an accurate diagnosis in the clinic. Now, with the calculated accuracy reference guide available, a clinician may rely on the office-based diagnosis with improved certainty and may consider forgoing advanced imaging, thereby avoiding additional cost, treatment delays and possible patient risk.
In order to cover an array of clinical scenarios, we used a pretest probability range of 20-80% at 20% increments according to the likelihood of pathology. After addressing the disease prevalence, HPI and PMH, the pre-test probability likelihood of long head bicep pathology was appointed. If the pre-test probability was above 90% or below 10%, we then assume there is no need to perform additional testing with acceptance of a 10% error rate.
Combination of physical examination techniques demonstrated that the uppercut test combined with tenderness to palpation of the LHB provided the highest accuracy for diagnosing pathology at the proximal biceps. This combination has a parallel testing sensitivity of 88.3% and a series specificity of 93.3% (Supplementary Table S3). The values of the test used in series and in parallel were definitive and overpowered the value of the pre-test probability assessment in many clinical scenarios. This adds credibility to a reproducible, simplified two-step P.E.C. examination without the need for additional maneuvers to be performed. Furthermore, we feel that the application of the PEC test is generalizable to non-shoulder specialists, facilitating both increased utilization and diagnostic accuracy of LHB disease.
Many studies have explored the accuracy of physical examination and special test maneuvers in diagnosing LHB pathology with limited conclusions regarding its efficiency18,22,23,37. However, our study is unique in that it additionally produces a diagnostic tool, both enabling accurate point of care diagnosis of LHB injury and minimizing the need for advanced imaging.
The value of the P.E.C. examination corroborates with current clinical recommendations. In 2009, Churgay et al. stated that bicipital groove point tenderness is the most common isolated finding during physical examination of patients with biceps tendinitis, and that ultrasonography is the best modality for evaluating isolated biceps tendinopathy extra-articularly3,6. With regards to diagnostic accuracy and fluidity of exam, our study revealed that the best maneuver combination for diagnosing biceps pathology are the uppercut test and tenderness to palpation. Incidentally, our study has also concluded that use of ultrasound after equivocal physical examination findings improves the sensitivity and specificity of all evaluated test combinations. Unlike past studies, we incorporated a diagnostic algorithm to aid efficient shoulder examination and to increase physician confidence in biceps tendon diagnosis.
In addition to enhancing diagnostic accuracy, development of a value-based clinical decision pathway may play a small, but essential role in the improvement of the current state of the healthcare system. High-yield, algorithm-derived examination like our proposed sequence further alleviate the number of follow-up visits needed until diagnosis, which often delay expedient care delivery35,39. Moreover, simplified diagnostic algorithms may also result in cost reduction and decreased iatrogenic injury associated with unnecessary advanced imaging studies. A shoulder examination that provides accurate diagnosis provides multiple advantages that benefits both physicians and the healthcare system with the ultimate goal of improving patient outcomes. However, it is important to note that clinical decisions should be tailored to patient clinical presentation, and that MRI may be a more appropriate diagnostic modality for surgical candidates or patients with inconclusive preliminary workup.
These findings provide evidence towards the current trend in orthopedic surgery education as more national conferences and residency programs are increasing musculoskeletal ultrasound (US) courses incorporated into their curriculums. Accordingly, the American Medical Association for Sports Medicine has endorsed increased integration of sports US into sports medicine fellowship curriculums13. Studies have proposed that proficient level diagnostic skills may be quickly obtained by the inexperienced orthopedist with an established examination protocol1. Murphy et al. conducted a study investigating diagnostic improvement in four orthopedic surgeons who attended a formal training course to identify and size tears on the rotator cuff through US. In the later training period, results showed positive predictive value improving by 16%27. An additional study by Roy and colleagues also demonstrated improved diagnostic accuracy of US irrespective of whether a trained radiologist, sonographer or orthopedic surgeon operated the device32. US requires further studies to evaluate its cost effectiveness compared to advanced imaging techniques like MRI or arthroscopy, but an algorithm(Fig. 3) may provide a simple evidence-based decision analysis for physicians to rely on when considering LHB as the major source of pain.
This study, however, also has its limitations. Foremost, a majority of the studies included in our data collection did not solely focus on LHB pathology. True positives may have included superior labrum, anterior to posterior (SLAP) lesions within the diagnosis of biceps pathology. Studies may have also incorporated biceps pathology into other diagnostic categories (e.g. “impingement”). Therefore, it was difficult to find studies which solely focused on diagnostic accuracy of LHB pathology. Additionally, only level I or II studies were considered for diagnosis, which routinely compare diagnostic testing algorithm (DTA) to the gold standard of diagnosis. Unfortunately, there is no clearly defined arthroscopic findings for diagnosis of LHB pathology. To aid in any study misinterpretations due to inaccurate language translations, only articles originally written in English were evaluated, and only published articles were included. This may have introduced both publication and/or selection bias. A method to eliminate some of these potential biases would be to perform a truly systematic review and meta-analysis combining results from multiple studies; however, even this can be hindered by bias with the lack of currently published methods for meta-analyses evaluating diagnostic testing. Another future direction for this study may be to further evaluate the accuracy of new special tests described to evaluate long head of the biceps pathology, specifically the uppercut test. Currently the uppercut test has only been described and analyzed in a single level I or II study that we utilized for our algorithm24. Further validation testing for this specific test may be warranted.
Conclusion
Performing the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical examinations maneuvers to aid in the diagnosis of long head of the biceps pathology as compared to diagnostic arthroscopy (The PEC exam). A decision tree analysis aides in the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A quick reference guide is provided to use in the clinical setting.
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Figure and Table Legends
Figure 1: PRISMA Systemic Review Flow Diagram: This figure displays the process and rationale behind why studies were omitted from the systemic review.
Figure 2: (A) Diagnostic Combination to Rule in Pathology: These findings demonstrate that the combination of tests that best help rule out pathology are the TTP + Uppercut test when performed in series. If both tests are negative in a scenario with a low pre-test probability (i.e. prevalence), then there is a very small chance of pathology being present. TTP = Tenderness to palpation (of the long head of the biceps within the bicipital groove); Diamond = TTP + Uppercut in series, square = TTP + Speeds in Series, triangle = TTP + Yergasons in Series
(B) Diagnostic Combination to Rule Out Pathology: These findings demonstrate that the combination of TTP + upper
