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Ann Rheum Dis. 1999 May; 58(5): 272–277.
PMCID: PMC1752887

Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement


OBJECTIVES—To assess the interobserver agreement on the diagnostic classification of shoulder disorders, based on history taking and physical examination, and to identify the determinants of diagnostic disagreement.
METHODS—Consecutive eligible patients with shoulder pain were recruited in various health care settings in the Netherlands. After history taking, two physiotherapists independently performed a physical examination and subsequently the shoulder complaints were classified into one of six diagnostic categories: capsular syndrome (for example, capsulitis, arthritis), acute bursitis, acromioclavicular syndrome, subacromial syndrome (for example, tendinitis, chronic bursitis), rest group (for example, unclear clinical picture, extrinsic causes) and mixed clinical picture. To quantify the interobserver agreement Cohen's κ was calculated. Multivariate logistic regression analysis was applied to determine which clinical characteristics were determinants of diagnostic disagreement.
RESULTS—The study population consisted of 201 patients with varying severity and duration of complaints. The κ for the classification of shoulder disorders was 0.45 (95% confidence intervals (CI) 0.37, 0.54). Diagnostic disagreement was associated with bilateral involvement (odds ratio (OR) 1.9; 95% CI 1.0, 3.7), chronic complaints (OR 2.0; 95% CI 1.1, 3.7), and severe pain (OR 2.7; 95% CI 1.3, 5.3).
CONCLUSIONS—Only moderate agreement was found on the classification of shoulder disorders, which implies that differentiation between the various categories of shoulder disorders is complicated. Especially patients with high pain severity, chronic complaints and bilateral involvement represent a diagnostic challenge for clinicians. As diagnostic classification is a guide for treatment decisions, unsatisfactory reproducibility might affect treatment outcome. To improve the reproducibility, more insight into the reproducibility of clinical findings and the value of additional diagnostic procedures is needed.

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Selected References

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  • Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. Primary Care Rheumatology Society Shoulder Study Group. BMJ. 1996 Sep 7;313(7057):601–602. [PMC free article] [PubMed]
  • van der Windt DA, Koes BW, Boeke AJ, Devillé W, De Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract. 1996 Sep;46(410):519–523. [PMC free article] [PubMed]
  • Vecchio PC, Kavanagh RT, Hazleman BL, King RH. Community survey of shoulder disorders in the elderly to assess the natural history and effects of treatment. Ann Rheum Dis. 1995 Feb;54(2):152–154. [PMC free article] [PubMed]
  • Chard MD, Sattelle LM, Hazleman BL. The long-term outcome of rotator cuff tendinitis--a review study. Br J Rheumatol. 1988 Oct;27(5):385–389. [PubMed]
  • Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ. 1998 Jan 31;316(7128):354–360. [PMC free article] [PubMed]
  • Neviaser RJ. Painful conditions affecting the shoulder. Clin Orthop Relat Res. 1983 Mar;(173):63–69. [PubMed]
  • Neer CS., 2nd Impingement lesions. Clin Orthop Relat Res. 1983 Mar;(173):70–77. [PubMed]
  • Uhthoff HK, Sarkar K. An algorithm for shoulder pain caused by soft-tissue disorders. Clin Orthop Relat Res. 1990 May;(254):121–127. [PubMed]
  • Uhthoff HK, Sarkar K. Classification and definition of tendinopathies. Clin Sports Med. 1991 Oct;10(4):707–720. [PubMed]
  • Hedtmann A, Fett H. Die sogenannte Periarthropathia humeroscapularis--Klassifizierung und Analyse anhand von 1266 Fällen. Z Orthop Ihre Grenzgeb. 1989 Nov-Dec;127(6):643–649. [PubMed]
  • Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoulder: can consultants agree? Br J Rheumatol. 1996 Nov;35(11):1172–1174. [PubMed]
  • Pellecchia GL, Paolino J, Connell J. Intertester reliability of the cyriax evaluation in assessing patients with shoulder pain. J Orthop Sports Phys Ther. 1996 Jan;23(1):34–38. [PubMed]
  • ZUNG WW. A SELF-RATING DEPRESSION SCALE. Arch Gen Psychiatry. 1965 Jan;12:63–70. [PubMed]
  • Scheier MF, Carver CS. Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychol. 1985;4(3):219–247. [PubMed]
  • Brennan P, Silman A. Statistical methods for assessing observer variability in clinical measures. BMJ. 1992 Jun 6;304(6840):1491–1494. [PMC free article] [PubMed]
  • Miller ME, Hui SL, Tierney WM. Validation techniques for logistic regression models. Stat Med. 1991 Aug;10(8):1213–1226. [PubMed]
  • Balich SM, Sheley RC, Brown TR, Sauser DD, Quinn SF. MR imaging of the rotator cuff tendon: interobserver agreement and analysis of interpretive errors. Radiology. 1997 Jul;204(1):191–194. [PubMed]
  • Croft P. The epidemiology of pain: the more you have, the more you get. Ann Rheum Dis. 1996 Dec;55(12):859–860. [PMC free article] [PubMed]
  • Larson HM, O'Connor FG, Nirschl RP. Shoulder pain: the role of diagnostic injections. Am Fam Physician. 1996 Apr;53(5):1637–1647. [PubMed]
  • Grechenig W, Clement HG, Schatz B, Grechenig M. Stellenwert der Sonographie am Stütz- und Bewegungsapparat--unter besonderer Berücksichtigung von Strahlenbelastung und Kostenreduktion. Biomed Tech (Berl) 1997 May;42(5):132–137. [PubMed]
  • Tsao LY, Mirowitz SA. MR imaging of the shoulder. Imaging techniques, diagnostic pitfalls, and normal variants. Magn Reson Imaging Clin N Am. 1997 Nov;5(4):683–704. [PubMed]
  • Fritz RC, Stoller DW. MR imaging of the rotator cuff. Magn Reson Imaging Clin N Am. 1997 Nov;5(4):735–754. [PubMed]
  • Deutsch AL, Klein MA, Mink JH, Mandelbaum BR. MR imaging of miscellaneous disorders of the shoulder. Magn Reson Imaging Clin N Am. 1997 Nov;5(4):881–895. [PubMed]
  • Winters JC, Groenier KH, Sobel JS, Arendzen HH, Meyboom-de Jongh B. Classification of shoulder complaints in general practice by means of cluster analysis. Arch Phys Med Rehabil. 1997 Dec;78(12):1369–1374. [PubMed]

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