Treating Long Head of Biceps (LHB) Pathology

Treating Long Head of Biceps (LHB) Pathology AbstractBackgroundClinical psychometric ladder of the elevate joint has gained attention in recent years as clinicians aim to practice with an evidence-based and accurate clinical testination of the biceps muscle. There is an increased craving for proper examine while simultaneously minimizing represently resourcefulness procedures and unnecessary procedures. Thus, the purpose of this study is to create a decision channelise compend that enables the culture of a clinical algorithmic rule for diagnosing and subsequently treating long head of biceps (LHB) pathology.MethodsA literature review of take aim one and twain diagnostic studies was conducted to distil characteristics of clinical tests for LHB pathology through a systematic review of Pubmed, Medline, Ovid and Cochrane Review informationbases. Tests were feature in serial publication and jibe to determine final sensitivities and specificities, and positive and nega tive likeliness ratios were determined for each combination using a subjective pre-test probability. The bullion- model for diagnosis in all studies include was arthroscopy or arthrotomy.ResultsSeven studies regarding LHB clinical diagnostic interrogatory met inclusion criteria. The optimal interrogation modality was use of the upper golf shot test combined with the tenderness to tactual exploration of the biceps muscularity 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 apply in combination optimize post-test probability truth greater than any single individual test adding a deuce-ace test decreases truth.ConclusionPerforming the uppercut test and biceps groove tenderness to palpation test together has the highest sensitivity and specificity of known physical inquirys maneuvers to aid in the diagnosis of long head of the biceps pathology as comp atomic number 18d to diagno stic arthroscopy (The PEC exam). A decision tree analysis aides in the PEC exam diagnostic true statement post interrogation based on the ordinal scale pre-test probability. A quick case guide is provided to use in the clinical setting. direct of Evidence II dogmatic Review and Meta-AnalysisKey Words biceps tendon long head physical examination pathology diagnosis raise examinationIntroductionThe physical examination is a requisite and inexpensive component to medical diagnosis. The shoulder examination, in particular, encompasses a myriad of supernumerary provocative maneuvers, displaying a wide range of sensitivities and specificities pertaining to diagnostic accuracy. right 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 rapport imaging (MRI), computed tomography (CT), arthrography, and arthroscopy to diagnose shoulder p athology21,33. Current gold standard diagnostic testing options have limitations. MRI has poor statistical characteristics for diagnostic accuracy as it real reader and technician dependent, adds twain direct and indirect damages, and may be less accurate than the physical exam37. symptomatic arthroscopy is successful in diagnosing intra-articular pathology, but is limited in visualization for extra-articular pathology, is costly, and increases long-suffering risk37. Increased use of diagnostic imaging contributes to rising health conduct 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 yield in not only higher direct costs, but may increase indirect costs and jeopardize egresscomes36,39.As the healthcare landscape transitions to cost minimization and rate-based healthcare deli very, the development of an efficient, cost-effective, shoulder examination is desired. get up 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 change magnitude the accuracy of shoulder diagnoses and aid in surgical decision making.Previously published studies think on the following questions whether physical examination modified tests correlate with surgical decisions 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, in that location is a consider 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 but reduce the need for diagnostic im aging20,22,34.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 take I and II studies within the English literature synthesizing the about accurate test combination develop a clinical algorithm to provide quantify LHB diagnostic accuracy and create a diagnostic accuracy reference guide.Materials and MethodsA 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 include the use of Boolean operators such as AND and OR. The databases were scrutinized self-sustainingly by three authors.Inclusion criteria include 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 quality 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 additively taxd to identify additional articles for inclusion. relevant 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 surplus 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 authorisation 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 delimit 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 un liable(predicate) 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 consummation was identified (named the PEC exam). A decision tree analys is was certain to determine the PEC exam diagnostic accuracy post testing based on the ordinal scale pre-test probability. A table was created as a bare(a) reference guide to use in the clinical setting.ResultsThe initial electronic database search retrieved 2,112 unique articles, with 28 obtained from a manual search of reference lists. Of these, 2051 studies were establish 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 Speeds, Yergasons, bicipital groove tenderness, uppercut, bear credit crunch, belly sign on, OBriens, and an esthetic 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 Yergasons tests demonstrated the lower spectrum of sensitivity (31%, 41% respectively). The belly press and OBriens 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 possible practical application for in-office transport 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 sound judgements determined two physical exam tests improv ed 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 Speeds, Yergasons 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).DiscussionLHB pathology is an progressively 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 style 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. finical 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 diag nostic 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 sure thing 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 efficie ncy18,22,23,37. 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. irrelevant past studies, we incorporate d 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 receipts 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 M RI may be a more appropriate diagnostic modality for surgical candidates or patients with indecisive 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 medicate 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 return in four orthopedic surgeons who attended a formal training course to identify and size snap on the rotator shock through US. In the later training period, results showed positive predictive value improving by 16%27. An additional study by Roy and coll eagues 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 author 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. impact). 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 create verbally 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 presently 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.ConclusionPerforming 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). 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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 presen t. 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