Internal Rotation Lag Sign: Difference between revisions
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== Technique  ==
== Technique  ==


Patient is seated with examiner behind patient. The affected arm is brought into maximal internal rotation behind the back (dorsum of patients hand against the lumbar region). Examiner controls patient's arm at the elbow and wrist/hand which is passively brought into 20 degrees of extension taking the forearm and hand away from the back. Instruct patient to actively maintain this position as examiner releases the wrist but maintains support at the elbow. A lag is indicative of a subscapularis tendon tear.<ref name="Hertel">[http://www.ncbi.nlm.nih.gov/pubmed/8872929 Hertel R, Balmer FT, Lombert SM, Gerber C.  Lag signs in the diagnosis of rotator cuff rupture.  J Shoulder Elbow Surg.  1996 Jul-Aug:5(4):307-313]</ref><ref name="Miller">[http://www.ncbi.nlm.nih.gov/pubmed/18503815 Miller CA, Forrester GA, Lewis JS.  The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff:  a preliminary investigation.  Arch Phys Med Rehabil.  2008 Jun:89(6):1162-8]</ref><ref name="Magosch">[http://www.ncbi.nlm.nih.gov/pubmed/16226652 Magosch SM, Pritsch M, Lichtenberg S, Habemeyer P.  The belly-off sign:  a new clinical diagnostic sign for subscapularis lesions.  Arthroscopy: 2005 Oct:21(10):1229-35]</ref><ref name="Cleland">Cleland J.  Orthopaedic Clincial Examination:  An Evidence Based Approach for Physical Therapists:  Philadelphia:  Saunders - Elsevier.  2007</ref><ref name="Magee">Magee, DJ.&amp;nbsp; Orthopedic Physical Assessment:&amp; St. Louis:&amp; Saunders - Elsevier:&amp; (4th Ed.)</ref> Hertel, et. al.<ref name="Hertel" /> describe the magnitude of the lag in 5 degree intervals with an obvious drop indicating large or massive tear and a smaller lag revealing a partial tear.  
# Patient is seated with examiner standing behind the patient.  
# The affected arm is brought into maximal internal rotation behind the back (dorsum of patients hand against the lumbar region).  
# Examiner controls patient's arm at the elbow and wrist/hand which is passively brought into 20 degrees of extension, taking the forearm and hand away from the back.  
# The patient is instructed to actively maintain this position, as the examiner releases the wrist but maintains support at the elbow.  


Please note that the Internal Rotation Lag Sign (IRLS) is also described by Magee<ref name="Magee" /> as the "'''subscaplaris '''or '''medial rotation''' '<nowiki/>'''spring back' '''or '<nowiki/>'''lag test'''' in addtion to the "'''modified lift-off test'''".  
A lag is indicative of a subscapularis tendon tear. <ref name="Hertel">Hertel R, Balmer FT, Lombert SM, Gerber C. [http://www.ncbi.nlm.nih.gov/pubmed/8872929 Lag signs in the diagnosis of rotator cuff rupture.] Journal of Shoulder and Elbow Surgery. 1996 Jul-Aug:5(4):307-313.</ref><ref name="Miller">Miller CA, Forrester GA, Lewis JS. [http://www.ncbi.nlm.nih.gov/pubmed/18503815 The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff:  a preliminary investigation.] Archives of Physical and Medical Rehabilitation.  2008 Jun:89(6):1162-1168.</ref><ref name="Magosch">Magosch SM, Pritsch M, Lichtenberg S, Habemeyer P. [http://www.ncbi.nlm.nih.gov/pubmed/16226652 The belly-off sign: a new clinical diagnostic sign for subscapularis lesions.]  Arthroscopy: 2005 Oct:21(10):1229-1235.</ref><ref name="Cleland">Cleland J.  Orthopaedic Clincial Examination:  An Evidence Based Approach for Physical Therapists:  Philadelphia:  Saunders - Elsevier.  2007</ref><ref name="Magee">Magee, DJ.&amp;nbsp; Orthopedic Physical Assessment:&amp; St. Louis:&amp; Saunders - Elsevier:&amp; (4th Ed.)</ref>
 
Hertel, et. al. describe the magnitude of the lag in 5 degree increments with an obvious drop indicating a large or massive tear, and a smaller lag revealing a partial tear. <ref name="Hertel" />
 
Please note that the Internal Rotation Lag Sign (IRLS) is also described by Magee as the "'''subscaplaris '''or '''medial rotation''' '<nowiki/>'''spring back' '''or '<nowiki/>'''lag test'''' in addition to the "'''modified lift-off test'''". <ref name="Magee" />


{{#ev:youtube|3pzE4Uptx6o|300}}<ref>CRTechnologies. Internal Rotation Lag Sign - Shoulder Test. Available from: http://www.youtube.com/watch?v=3pzE4Uptx6o, last accessed 8 December 2009</ref>
{{#ev:youtube|3pzE4Uptx6o|300}}<ref>CRTechnologies. Internal Rotation Lag Sign - Shoulder Test. Available from: http://www.youtube.com/watch?v=3pzE4Uptx6o, last accessed 8 December 2009</ref>
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== Evidence  ==
== Evidence  ==


Hertel, et. al.<ref name="Hertel" /> (also cited in Cleland<ref name="Cleland" /> report Sensitivity (Sn) .97, Specificity (Sp) .96, positive Liklihood ratio (LR+) 24.3, and negative Liklihood Ratio (LR-) of .03 for the IRLS.  
Hertel, et. al.<ref name="Hertel" /> (also cited in Cleland) <ref name="Cleland" /> report Sensitivity (Sn) .97, Specificity (Sp) .96, positive Likelihood ratio (LR+) 24.3, and negative Likelihood Ratio (LR-) of .03 for the IRLS.  


A more recent study by Miller, et. al.<ref name="Miller" /> report Sn 1.0, Sp .84, LR+ 6.2, LR- 0.0 with Positive Predictive Value (PPV) 28% and Negative Predictive Value (NPV) of 100 for the IRLS. These values are compared to diagnostic ultrasound which has been found to be comparable with arthroscopy for diagnosing RTC tears<ref name="Miller" />.&nbsp; However, they summarize that clinical diagnosis of ''full-thickness tears of the rotator cuff cannot be conclusively reached using one or more of the lag signs''<ref name="Miller" />. The other lag signs investigated in this study are the drop sign and external rotation lag sign (ERLS). <br>
A more recent study by Miller, et. al. report Sn 1.0, Sp .84, LR+ 6.2, LR- 0.0 with Positive Predictive Value (PPV) 28% and Negative Predictive Value (NPV) of 100 for the IRLS. These values are compared to diagnostic ultrasound which has been found to be comparable with arthroscopy for diagnosing RTC tears.&nbsp;However, they summarize that clinical diagnosis of ''full-thickness tears of the rotator cuff cannot be conclusively reached using one or more of the lag signs''. The other lag signs investigated in this study are the drop sign and external rotation lag sign (ERLS). <ref name="Miller" /><br>


== References  ==
== References  ==

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Purpose[edit | edit source]

To test for rotator cuff tears of the Subscapularis tendon.

Technique[edit | edit source]

  1. Patient is seated with examiner standing behind the patient.
  2. The affected arm is brought into maximal internal rotation behind the back (dorsum of patients hand against the lumbar region).
  3. Examiner controls patient's arm at the elbow and wrist/hand which is passively brought into 20 degrees of extension, taking the forearm and hand away from the back.
  4. The patient is instructed to actively maintain this position, as the examiner releases the wrist but maintains support at the elbow.

A lag is indicative of a subscapularis tendon tear. [1][2][3][4][5]

Hertel, et. al. describe the magnitude of the lag in 5 degree increments with an obvious drop indicating a large or massive tear, and a smaller lag revealing a partial tear. [1]

Please note that the Internal Rotation Lag Sign (IRLS) is also described by Magee as the "subscaplaris or medial rotation 'spring back' or 'lag test' in addition to the "modified lift-off test". [5]

[6]

Evidence[edit | edit source]

Hertel, et. al.[1] (also cited in Cleland) [4] report Sensitivity (Sn) .97, Specificity (Sp) .96, positive Likelihood ratio (LR+) 24.3, and negative Likelihood Ratio (LR-) of .03 for the IRLS.

A more recent study by Miller, et. al. report Sn 1.0, Sp .84, LR+ 6.2, LR- 0.0 with Positive Predictive Value (PPV) 28% and Negative Predictive Value (NPV) of 100 for the IRLS. These values are compared to diagnostic ultrasound which has been found to be comparable with arthroscopy for diagnosing RTC tears. However, they summarize that clinical diagnosis of full-thickness tears of the rotator cuff cannot be conclusively reached using one or more of the lag signs. The other lag signs investigated in this study are the drop sign and external rotation lag sign (ERLS). [2]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Hertel R, Balmer FT, Lombert SM, Gerber C. Lag signs in the diagnosis of rotator cuff rupture. Journal of Shoulder and Elbow Surgery. 1996 Jul-Aug:5(4):307-313.
  2. ↑ 2.0 2.1 Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation. Archives of Physical and Medical Rehabilitation. 2008 Jun:89(6):1162-1168.
  3. ↑ Magosch SM, Pritsch M, Lichtenberg S, Habemeyer P. The belly-off sign: a new clinical diagnostic sign for subscapularis lesions. Arthroscopy: 2005 Oct:21(10):1229-1235.
  4. ↑ 4.0 4.1 Cleland J. Orthopaedic Clincial Examination: An Evidence Based Approach for Physical Therapists: Philadelphia: Saunders - Elsevier. 2007
  5. ↑ 5.0 5.1 Magee, DJ.&nbsp; Orthopedic Physical Assessment:& St. Louis:& Saunders - Elsevier:& (4th Ed.)
  6. ↑ CRTechnologies. Internal Rotation Lag Sign - Shoulder Test. Available from: http://www.youtube.com/watch?v=3pzE4Uptx6o, last accessed 8 December 2009
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