Treating Long Head of Biceps (LHB) Pathology

Treating Long Head of Biceps (LHB) Pathology AbstractBackgroundclinical query of the raise joint has gained attention in recent age as clinicians aim to practice with an evidence- base and accurate clinical enquiry of the biceps sinew. thither is an change magnitude desire for proper diagnose while simultaneously minimizing dearly-won resourcefulness procedures and unnecessary procedures. Thus, the purpose of this have is to create a closing tree analysis that enables the development of a clinical algorithmic rule for assholevass and subsequently treating gigantic decimal point of biceps (LHB) pathology.MethodsA literature look backward of take one and two symptomatic studies was conducted to extract characteristics of clinical scrutinys for LHB pathology finished a taxonomic check up on of Pubmed, Medline, Ovid and Cochrane reexamination entropybases. Tests were combined in serial publication and collimate to determine final sensitivities and specificities , and compulsive and proscribe likelihood ratios were determined for e real(prenominal) combination using a subjective pre- try on opportunity. The gold- pattern for diagnosing in tot on the wholey studies include was arthroscopy or arthrotomy.ResultsSeven studies regarding LHB clinical symptomatic laddering met inclusion body criteria. The optimal examen modality was practice of the uppercut trial combined with the spunk to palpation of the biceps muscularity test. This combination achieved a esthesia of 88.4% when serveed in jibe and a specificity of 93.8% when performed in serial publication. These tests spendd in combination optimize post-test luck true statement greater than any single psyche test adding a third test decreases accuracy.ConclusionPerforming the uppercut test and biceps groove adhesion to palpation test together has the highest sensibility and specificity of cognize forcible interrogationinations maneuvers to help oneself in the diag nosis of long power point of the biceps pathology as equalityd to diagnostic arthroscopy (The PEC exam). A decision tree analysis maintenancees in the PEC exam diagnostic accuracy post testing found on the no. outperform pre-test chance. A quick origin guide is provided to handling in the clinical setting.Level of Evidence II Systematic Review and Meta-AnalysisKey speech communication biceps sinew long head material examination pathology diagnosis berm examinationIntroductionThe corporal examination is a requisite and chintzy component to medical examination diagnosis. The get up joint examination, in particular, encompasses a myriad of modified provocative maneuvers, displaying a wide range of sensitivities and specificities pertaining to diagnostic accuracy. Accurate spirit from the correct sequence of maneuvers or tests increases diagnostic yield.In the modern era, clinical diagnosis heavily relies on image modalities including ultrasound (US), magnetised re verberance imaging (MRI), computed tomography (CT), arthrography, and arthroscopy to make get up 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 some(prenominal) direct and confirmatory be, and whitethorn be less accurate than the physiological exam37. diagnostic arthroscopy is prospering in diagnosing intra-articular pathology, besides is limited in visualization for extra-articular pathology, is costly, and increases uncomplaining risk37. Increased use of diagnostic imaging contributes to rising health anxiety costs14,30,32,38. According to the Centers for Medic argon and Medicaid Services (CMS), diagnostic imaging costs are significant, explanation for up to 40% of boilersuit health care expenditure increases over the chivalric 10 years25. Advanced imaging techniques result in non scarce higher direct costs, but whitet horn increase indirect costs and jeopardize outcomes36,39.As the health care landscape transitions to cost minimization and value-based healthcare delivery, the development of an efficient, cost-effective, elevate examination is desired. articulatio humeri examinations have poor sensitiveness and/or specificity that makes diagnosing certain pathologies knotty4,28,30,33. 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 elevate canvasss and aid in surgical decision making.Previously published studies focused on the following questions whether physical examination modified tests correlate with surgical determinations 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, thither is a conduct to develop new algorithms to provide raise practitioners wi th a practical but comprehensive evidence-based approach to diagnose LHB pathology during an attitude visit and to further reduce the need for diagnostic imaging20,22,34.The purpose of this check was to perform a imperious review and a secondary sensitivity analysis based on pre-formed likelihood scenarios based on the storey 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 uncomplainings with LHB pathology. ad hoc objectives were to compile the peak performing physical exam tests extracted from level I and II studies within the incline literature synthesizing the most(prenominal) accurate test combination develop a clinical algorithm to provide limit LHB diagnostic accuracy and create a diagnostic accuracy elongation guide.Materials and MethodsA musical arrangementatic literature review with the terms proximal, biceps, clinical and examination in the Medline entropybase through the Pubmed, Medline, Ovid and Cochrane Review databases was completed in may 2015. The seekes include the use of Boolean operators such as AND and OR. The databases were scrutinized independently by trinity 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 trim back, associate to hypernym labrum anterior to poop (SLAP) lesions, investigated rheumatoid arthritis patients, or did not compare tests to a validated gold standard. The validated gold standard apply for all studies and authoritative reviews included were diagnostic arthroscopy or arthrotomy to confirm anatomical reference point findings. Relevant studies were independently assessed, and conflicting studies were included alone if there were con sensus amongst the authors. References of included studies were superfluously evaluated to identify supererogatory articles for inclusion. Applicable data was extracted by about-face 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. afterward 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 an d analyzed according to the statistical methods draw 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(prenominal) in latitude and in series. The first approach in repeat analysis, consists of two particular tests performed in theory at approximately the very(prenominal) time. The duplicate analysis can interpret the findings in an and or or technique. When a mate 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 emf pathology. If both tests are negative then(prenominal) it is copeed a negative finding in the algorithm and detect out the pathology, but if just one of the two special tests is positive then it is not considered a negativ e 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 outrank 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 head 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 numbe r scale created has four antithetical 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 procedure was set (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.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 arrange 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(prenominal) full-text review (N=18). Seven relevant (N = 7) articles wer e 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 hug, abdomen press, OBriens, and anesthetic barb. Statistical characteristics for each test are documented in (Supplementary Table S2). The bear hug and uppercut special tests controvertd 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 potential performance for in-office point of service testin g, 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 lessen 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 dec ision 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 increasingly recognized source of shoulder pain and functional impairment in symptomatic patients. Physicians are faced with diagnostic challenges payable 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 scarce 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, joined with pre-test probability assignments can now provide clinicians diagnostic trustfulness 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 duplicatable 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 ripe(p) 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 pre valence, HPI and PMH, the pre-test probability likelihood of long head bicep pathology was appointed. If the pre-test probability was in a higher place 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 a(prenominal) 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 n on-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 change 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 tenonitis, 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 uppe rcut 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 review article 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 accurat e diagnosis provides nonuple 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 orthopaedic surgery education as more national conferences and residency programs are increasing musculoskeletal ultrasound (US) courses incorporated into their curriculums. Accordingly, the American health check Association for Sports Medicine has endorsed increased integration of sports US into sports medicinal drug caller 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 i nvestigating diagnostic improvement in four orthopedic operating surgeons who attended a formal schooling course to identify and size of it tears on the rotator box 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 study 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 wi thin 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 distinctly defined arthroscopic findings for diagnosis of LHB pathology. To aid in any study misinterpretations ascribable 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 curre ntly 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). 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.References1. Amoo-Achampong K, Nwachukwu B U, McCormick F. An orthopedists guide to shoulder ultrasound a systematic review of examination protocols. Phys Sportsmed. 2016 Aug 221-10. inside 10.1080/00913847.2016.12222242. Ardic F, Kahraman Y, Kacar M, Kahraman MC, Findikoglu G, Yorgancioglu ZR. Shoulder impingement syndrome relationships among clinical, functional, and radiologic findings. Am J Phys Med Rehabil. 2006 Jan 185(1)53-60. doi10.1097/01.phm.0000297449.72296.3d3. Armstrong A, Teefey SA, Wu T, Clark AM, Middleton WD, Yamaguchi K, et al. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder cubitus Surg. 2006 Jan-Feb15(1)7-11. doi10.1016/j.jse.2005.04.0084. Arrigoni P, Ragone V, DAmbrosi RI, Denard P,Randelli F, Banfi G, et al. Improving the accuracy of the preoperative diagnosis of long head of the biceps pathology the biceps resisted flexion test. Joints. 2014 Jul 82(2)54-8. doi10.11138/jts/2014.2.2.0545. Bennett WF. Specificity of the Speeds test arthroscopic techniq ue for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy. 1998 Nov-Dec14(8)789-96. No doi6. Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 2009 Sep 180(5)470-6.7. Chu K. An introduction to sensitivity, specificity, predictive values and likelihood ratios. Emergency Medicine Australasia. 1999 Sep 811(3)175-81. doi10.1046/j.1442-2026.1999.00041.x8. subgenus Chen HS, Lin SH, Hsu YH, Chen SC, Kang JH. A comparison of physical examinations with musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis. Ultrasound Med Biol. 2011 Sep 3037(9)1392-8. doi10.1016/j.ultrasmedbio.2011.05.8429. Cohen SB, Valko C, Zoga A, Dodson CC, Ciccotti MG. Posteromedial elbow impingement magnetic rapport imaging findings in overhead throwing athletes and results of arthroscopic treatment. Arthroscopy. 2011 Oct 3127(10)1364-70. doi10.1016/j.arthro.2011.06.01210. Dinnes J, Loveman E, McIntyre L, Waugh N. The effectivenes s of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders a systematic review. wellness Technol Assess. 20037(29)iii, 1-166. doi10.3310/hta729011. Dubrow SA, Streit JJ, Shishani Y, Robbin MR, Gobezie R. Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI. Open Access J Sports Med. 2014 Apr 28581-7. doi10.2147/OAJSM.S5822512. Eusebi P. Diagnostic accuracy measures. Cerebrovasc Dis. 2013 Oct 1636(4)267-72. doi10.1159/00035386313. Finnoff JT, Berkoff D, Brennan F, DiFiori J, manse MM, Harmon K, et al.. American Medical Society for Sports Medicine recommended sports ultrasound curriculum for sports medicine fellowships. Br J Sports Med. 2015 Feb49(3)145-50. doi10.1136/bjsports-2014-09422014. Freeman R, Khanna S, Ricketts D. Inappropriate requests for magnetic resonance scans of the shoulder. Int Orthop. 2013 Nov37(11)2181-4. doi10.1007/s00264-013-1968-415. Gazzillo GP, Finnoff JT, Hall MM, Sayeed YA, Smith J. true statement of palpating the long head of the biceps tendon an ultrasonographic study. PM R. 2011 Nov3(11)1035-40. doi10.1016/j.pmrj.2011.02.02216. Gill HS, El Rassi G, Bahk MS, Castillo RC, McFarland EG. sensual examination for partial(p) tears of the biceps tendon. Am J Sports Med. 2007 Aug35(8)1334-40. doi10.1177/036354650730005817. Gilmer BB, DeMers AM, Guerrero D, Reid JB, Lubowitz JH, Guttmann D. Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis. Arthroscopy. 2015 Jan31(1)29-34. doi10.1016/j.arthro.2014.07.02518. Hanchard NC, Lenza M, Handoll HH, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev. 2013 Apr 30(4)CD007427. doi 10.1002/14651858.CD007427.pub219. Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y. Accuracy of the biceps tendon sheath injection ultrasound- guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg. 2011 Oct20(7)1069-73. doi10.1016/j.jse.2011.04.00420. Hegedus EJ. Physical Examination of the Shoulder and Elbow with a Focus on orthopedical Special Tests. In Park JY, editor. Sports Injuries to the Shoulder and Elbow. Heidelberg Springer. 2015. p. 35-44. (ISBN No. 978-3-642-41794-8. doi10.1007/978-3-642-41795-521. Hegedus EJ, limit C, Lewis J, Wright A, Park JY. Combining orthopedic special tests to improve diagnosis of shoulder pathology. Phys Ther Sport. 2015 May16(2)87-92. doi10.1016/j.ptsp.2017.08.00122. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, et al.. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012 Nov46(14)964-78. doi10.1136/bjsports-2012-09106623. Jordan RW, Saithna A. Physical examination tests and imaging studies based on art hroscopic assessment of the long head of biceps tendon are invalid. human knee Surg Sports Traumatol Arthrosc. 2015 Nov 26 Epub ahead of print. doi10.1007/s00167-015-3862-724. Kibler BW, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of tralatitious and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009 Sep37(9)1840-7. doi10.1177/036354650933250525. Health explosive charge Spending and the Medicare Program. Medicare Payment Advisory Commission. Washington DC 2011. p.1-207.26. Momenzadeh OR, Gerami MH, Sefidbakht S, Dehghani S. Assessment of correlation between MRI and arthroscopic pathologic findings in the shoulder joint. Arch dress up Jt Surg. 2015 Oct3(4)286-90.27. Murphy RJ, Daines MT, Carr AJ, Rees JL. An independent learning method for orthopaedic surgeons performing shoulder ultrasound to identify full-thickness tears of the rotator cuff. J Bone Joint Surg Am. 2013 Feb 695(3)266-72. doi10.2106/JBJS.K.0070628. Naredo E, Aguado P, De Miguel E, Uson J, Mayordomo L, Gijon-Banos J, et al. Painful shoulder comparison of physical examination and ultrasonographic findings. Ann genus Rheum Dis. 2002 Feb61(2)132-6. doi10.1136/ard.61.2.13229. -str AJ, Richards CA, Tytherleigh-Strong G, Bearcroft PW, Prevost AT, Speed CA, et al. Validation of clinical examination versus magnetic resonance imaging and arthroscopy for the detection of rotator cuff lesions. Clin Rheumatol. 2013 Sep32(9)1283-91. doi10.1007/s10067-013-2260-030. Razmjou H, Fournier-Gosselin S, Christakis M, Pennings A, ElMaraghy A, Holtby R. Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders comparison with arthroscopy. J Shoulder Elbow Surg. 2016 Jan25(1)38-44. doi10.1016/j.jse.2015.06.02031. Read JW, Perko M. Shoulder ultrasound diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow S urg. 1998 May-Jun7(3)264-71. doi10.1016/S1058-2746(98)90055-632. Roy JS, Bran C, Leblond J, Desmeules F, Dionne CE, MacDermid JC, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders a systematic review and meta-analysis. Br J Sports Med. 2015 Oct49(20)1316-28. doi10.1136/bjsports-2014-09414833. Sandrey MA. Special physical examination tests for superior labrum anterior-posterior shoulder tears an examination of clinical usefulness. J Athl Train. 2013 Nov-Dec48(6)856-8. doi10.4085/1062-6050-48.3.1434. Sciascia AD, Spigelman T, Kibler WB, Uhl TL. frequency of use of clinical shoulder examination tests by experienced shoulder surgeons. J Athl Train. 2012 Jul-Aug47(4)457-66. doi10.4085/1062-6050-47.4.0935. Seagger R, Bunker T, Hamer P. Surgeon-operated ultrasonography in a one-stop shoulder clinic. Ann R Coll Surg Engl. 2011 Oct93(7)528-31. doi10.1308/147870811X1313760845493936. Skendzel JG, Jacobson JA, Carpenter JE, Miller BS. Long head of biceps brachii tendon evaluation accuracy of preoperative ultrasound. AJR Am J Roentgenol. 2011 Oct197(4)942-8. doi10.2214/AJR.10.501237. Taylor SA, Khair MM, Gulotta LV, Pearle AD, Baret NJ, Newman AM, et al. Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex. Arthroscopy. 2015 Feb31(2)215-24. doi10.1016/j.arthro.2014.10.01738. Voigt JD, Mosier M, Huber B. In-office diagnostic arthroscopy for knee and shoulder intra-articular injuries its potential impact on cost savings in the United States. BMC Health Serv Res. 2014 May 514203. doi10.1186/1472-6963-14-20339. Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC. Demographic trends in arthroscopic SLAP repair in the United States. Am J Sports Med. 2012 May40(5)1144-7. doi10.1177/0363546512436944Figure and Table LegendsFigure 1 PRISMA Systemic Review Flow Diagram This figure displays the process and rationale behind wherefore studies were omitted from the systemic revi ew.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