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. 2017 Aug;26(8):1484-1492.
doi: 10.1016/j.jse.2017.03.002. Epub 2017 May 4.

A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps

Samuel Rosas  1 , Michael K Krill  2 , Kelms Amoo-Achampong  3 , KiHyun Kwon  4 , Benedict U Nwachukwu  5 , Frank McCormick  6
Affiliations

A practical, evidence-based, comprehensive (PEC) physical examination for diagnosing pathology of the long head of the biceps

Samuel Rosas et al. J Shoulder Elbow Surg. 2017 Aug.

Abstract

Background: Clinical examination of the shoulder joint has gained attention as clinicians aim to use an evidence-based examination of the biceps tendon, with the desire for a proper diagnosis while minimizing costly imaging procedures. The purpose of this study is to create a decision tree analysis that enables the development of a clinical algorithm for diagnosing long head of biceps (LHB) pathology.

Methods: A literature review of Level I and II 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 sensitivities and specificities, and positive and negative likelihood ratios were determined for each combination using a subjective pretest probability. The "gold standard" for diagnosis in all included studies was arthroscopy or arthrotomy.

Results: 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.

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 LHB pathology compared with diagnostic arthroscopy (practical, evidence-based, comprehensive examination). A decision tree analysis aides in the practical, evidence-based, comprehensive examination diagnostic accuracy post-testing based on the ordinal scale pretest probability.

Keywords: Biceps tendon; diagnosis; long head; pathology; physical examination; shoulder examination.

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Figures

Figure 1
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. This figure displays the process and rationale behind why studies were omitted from the systemic review.
Figure 2
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 tenderness to palpation (TTP) of the long head of the biceps within the bicipital groove plus the uppercut test when performed in series. If both tests are negative in a scenario with a low pretest probability (ie, prevalence), then there is a very small chance of pathology being present (diamond, TTP + uppercut in series; square, TTP + Speed’s in series; triangle, TTP + Yergason’s in series). (B) Diagnostic combination to rule out pathology: These findings demonstrate that the combination of TTP + uppercut test in parallel allows us to diagnose the presence of pathology even when the pretest probability (ie, prevalence) is small. When there is a high pretest probability, the combination of the 2 tests provide similar results (diamond, TTP + uppercut in parallel; square, TTP + Speed’s in parallel; triangle, TTP + Yergason’s in parallel). CI, confidence interval.
Figure 2
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 tenderness to palpation (TTP) of the long head of the biceps within the bicipital groove plus the uppercut test when performed in series. If both tests are negative in a scenario with a low pretest probability (ie, prevalence), then there is a very small chance of pathology being present (diamond, TTP + uppercut in series; square, TTP + Speed’s in series; triangle, TTP + Yergason’s in series). (B) Diagnostic combination to rule out pathology: These findings demonstrate that the combination of TTP + uppercut test in parallel allows us to diagnose the presence of pathology even when the pretest probability (ie, prevalence) is small. When there is a high pretest probability, the combination of the 2 tests provide similar results (diamond, TTP + uppercut in parallel; square, TTP + Speed’s in parallel; triangle, TTP + Yergason’s in parallel). CI, confidence interval.
Figure 3
Figure 3
Practical, evidence-based, comprehensive (PEC) biceps algorithm in (A) parallel and (B) in series.
See this image and copyright information in PMC

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