Examination of the LHBT in the clinical setting
(active compression test, anterior slide test, crank test,
and Speed test). They found that the anterior slide test
was statistically inferior to the 3 other tests; this can be
appreciated when looking at their ROC curves. In our
review, the curve for the anterior slide test resembles
the 3 others. This inconsistency may be explained by
the 3 studies included in our analysis that were pu-
blished after their review (22, 32, 33). After reviewing
the literature on the same research question, Walton et
al. (13) performed a meta-analysis for the OSTs that
have been evaluated at least 3 times in the literature.
They provided estimates of the pooled LR+ for, among
others, the active compression test (1.07), crank test
(1.51), and Speed test (1.12). Our pooled LR+ estima-
tes were 1.37 for the active compression test, 1.63 for
the crank test, and 1.24 for the Speed test. Our values
are slightly higher for the active compression test be-
cause we included 3 studies that have been published
after their work (26, 34, 35). Also, for the Speed test,
they incorporated Holtby & Razmjou’s (31) as well as
Bennet’s (36) studies in their analysis, which evaluates
not only SLAP lesions, but any LHBT pathology.
Strengths and weaknesses of the review
Strengths. First, this systematic review was based on
a rigorous search of the literature, which resulted in
the inclusion of 30 articles. Secondly, a recommended
appraisal tool was used to determine the risk of bias of
included studies. In addition, the statistics presented
in the included studies were double-checked by back-
calculating 2×2 tables. Where we observed discrepancy
between text and tables, or when values presented had
arithmetical errors, the study was excluded. Finally,
judicious use was made of meta-analysis’ tools: they
were used when there was a minimum of 4 primary
studies identified, as suggested by Sotiriadis et al. (20).
Weaknesses. In our protocol design, we chose to exclude
non-English or French studies, which may have led to
selection bias. There was one study in Persian and one
in Turkish languages that could have been eligible.
We also recognize the possibility of information bias
in the studies included. More specifically, as appraised
with QUADAS-2 instrument, there is a possibility of
misclassification due to spontaneous recovery or pro-
gression of disease. Of the 30 included studies, 9 had
an inadequate interval between index test and reference
standard. In the same vein, misclassification in the
primary studies due to inaccurate reference standard
is another possibility to consider. It was “unclear” if
the reference standard was likely to correctly classify
the target condition in 8 of the 30 included studies. For
instance, in order to assess the accuracy of OSTs in diag-
nosing tendinopathy, HRUS was the reference standard
in the only individual studies identified in the literature
487
(Fig. S4 1 ). Since the role of ultrasound in the diagnosis
of biceps tendinopathy is still poorly understood, this
area of uncertainty would need to be addressed before
a more definitive conclusion can be drawn (2).
Applicability of findings to the review question
From the findings of this systematic review, HRUS
had variable Sn and thus would be of lower interest as
a screening test. Nevertheless, it can be considered a
highly specific clinical tool for the diagnosis of disloca-
tion, rupture and tendinopathy of the LHBT; it can be
useful in ruling-in disease. Besides its effectiveness,
HRUS has several advantages over other imaging
modalities: there is no contraindication, it has high
spatial resolution, dynamic assessment is possible as
well as correlation of findings with patients’ symptoms.
Furthermore, it has been shown to be cost-effective in
specific situations, such as in the context of rotator cuff
disease (37), and proved to be a reliable method for the
measurement of the LHBT in healthy shoulders (38).
With regard to OSTs, the evidence was more limited
by the variability of the test accuracies across different
study settings. A promising screening test (high Sn) for
SLAP II–IV lesions is passive compression test, but
the test has been evaluated only by its originators. No
other test demonstrated high Sn. For ruling-in specific
diagnosis, several tests seem to be valuable. The anterior
slide test and biceps load II test had high Sp for diagno-
sing SLAP I–IV lesions. Passive compression test and
passive distraction test were highly specific for SLAP
II–IV lesions, but only the test’s originators assessed
their accuracies. For LHBT tendinopathy, Yergason’s
manoeuvre proved highly specific. For proximal LHBT
pathology except SLAP lesions, Heuter’s sign (one
study) and Yergason’s manoeuvre had high Sp.
Whereas no single clinical finding, either OSTs or
HRUS, is accurate enough to confirm diagnosis and
guide subsequent clinical decisions, it is appealing
for clinicians and researchers to improve diagnostic
accuracy by clustering clinical information. Further-
more, combining clinical findings more closely reflects
how clinicians make decision in practice. Combining
the more sensitive clinical information with the more
specific data could be quite helpful in improving our
ability to diagnose LHBT pathology. Future research
on the subject should focus on the development of
such clusters.
Conclusion
In order to rule in LHBT pathology, HRUS has proven
its diagnostic efficacy. However, evidence is lacking
to recommend its use for the purpose of ruling out pa
thology. There is insufficient evidence to recommend
individual OSTs. In the future, rigour in diagnostic test
J Rehabil Med 51, 2019