Shoulder Special Tests
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Introduction
Orthopaedic Special Tests are used to assist in the diagnostic process by implicating specific tissue structures that are either dysfunctional, pathological, or lack structural integrity, confirming the findings from the physical assessment, and providing a tentative diagnosis.[1] Special testing is generally performed following a full examination of the shoulder. Examination should include patient history, mechanism of injury, clinical observation, bony and soft tissue palpation, assessment of active and passive movements, assessment of passive arthokinematic / accessory joint mobility, neurological assessment, manual muscle testing, and functional assessments.[2] Reproduction of pain and weakness during special tests is considered clinically diagnostic. Orthopaedic special tests may be used to test and retest following therapeutic interventions to assess for any change in symptoms.
Evidence
Although orthopaedic special tests are commonly used, research findings have consistently questioned the value of these procedures as a method of implicating the structures associated with presenting symptoms.[2][3] The capability of these tests to assess and implicate specific pathology as the source of symptoms cannot be achieved with the certainty and confidence required to meaningfully inform clinical decision making. [3]
Individual shoulder special tests when used in isolation demonstrate low sensitivity and specificity.[4] Clinicians are advised to interpret test outcomes in the context of a thorough clinical assessment, including patient history and examination findings, as definitive diagnosis with clinical tests currently in use is not possible.[5] Clustering tests may improve diagnostic confidence but remains imperfect. [5]
Many of these special tests, in particular those involving the labrum, have not shown high sensitivity or specificity.[1] As a result, combinations of tests or test clusters, often referred to as clinical prediction rules, are considered more useful.[6][1] Even in these cases, the tests are not necessarily definitive.[1] While there has been a large amount of research on orthopaedic special tests for the shoulder, much of it is of low to moderate quality.[6][7][8] Even in high quality studies, shoulder special tests display limited solid diagnostic metrics, sensitivity or specificity, and are likely to vary greatly in the hands of different clinicians and in varying clinical practice environments.[7][6] Common tests used in clinical examination lack clarity in whether or not they are useful in differentially diagnosing shoulder pathology.[8]
While clustering orthopaedic special tests together has been shown to improve diagnostic accuracy in both research and clinical practice, clusters are often used incorrectly.[7][8][6] There are 6 best clusters, with best defined as those combinations of tests with the strongest likelihood ratios from research with the highest quality, judged through use of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) document with a score of > 10[6]. Any studies whose QUADAS is 10 or less may have design faults which make the likelihood ratios questionable, and not repeatable in outside of that study.[6] The following table summarises the best clusters based on current evidence:
Summary of Shoulder Special Tests
[8][9][10][11][12][13][14][15].
| Assessment | Pathology Category | Special Test |
|---|---|---|
| Instability / Capsular Tests | Inferior instability of GH joint due to laxity of the superior capsule | |
| Instability of GH joint due to laxity of the anterior and posterior capsule | ||
| Anterior instability of GH joint due to laxity of the anterior-inferior capsule | ||
| Posterior instability of GH joint due to laxity of the posterior capsule | ||
| Acromioclavicular and Labral Assessments | AC joint and SLAP lesions | |
| AC joint | ||
| SLAP lesion |
| |
| Impingement Tests | Subacromial impingement | |
| Rotator Cuff Assessments | Rotator cuff tear (Supraspinatus) | |
| Rotator cuff tear (Supraspinatus and infraspinatus muscles) and shoulder impingement | ||
| Rotator cuff tear (Subscapularis) | ||
| Rotator cuff tear (Infraspinatus) and subacromial impingement | ||
| Rotator cuff tear (Teres Minor and Infraspinatus muscles) | ||
| Biceps Brachii Assessments | Biceps tendon pathology or SLAP lesion | |
| Biceps tendinopathy or Superior labral tears |
References
- ↑ 1.0 1.1 1.2 1.3 Magee, D. Shoulder. Chapter 5 In: Orthopedic Physical Assessment. Elsevier, 2014
- ↑ 2.0 2.1 Biederwolf NE. A proposed evidence-based shoulder special testing examination algorithm: clinical utility based on a systematic review of the literature. Int J Sports Phys Ther. 2013 Aug;8(4):427.
- ↑ 3.0 3.1 Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. J Orthop Sports Phys Ther. 2015 Nov;45(11):923-37.
- ↑ Salamh P, Lewis J. It is time to put special tests for rotator cuff–related shoulder pain out to pasture. J Orthop Sports Phys Ther. 2020 May;50(5):222-5.
- ↑ 5.0 5.1 Lewis JS, Tennent TD. How Effective are our Diagnostic Tests for Rotator Cuff Pathology. Evidence Based Sports Medicine. 2nd Edition. BMJ Books. Blackwell Publishing. 2007.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Hegedus EJ, Cook C, Lewis J, Wright A, Park JY. Combining orthopedic special tests to improve diagnosis of shoulder pathology. Phys Ther Sport. 2015 May 1;16(2):87-92.
- ↑ 7.0 7.1 7.2 Hegedus EJ, Goode A, Campbell S, Morin A, Tamaddoni M, Moorman CT, Cook C. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008 Feb 1;42(2):80-92.
- ↑ 8.0 8.1 8.2 8.3 Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. 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 Nov 1;46(14):964-78.
- ↑ Krill MK, Rosas S, Kwon K, Dakkak A, Nwachukwu BU, McCormick F. A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review. Phys Sportsmed. 2018;46(1):98-104.
- ↑ Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with Shoulder Examination: Part I: The Rotator Cuff Tests. Am J Sports Med. 2003;31(1):154-160.
- ↑ Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with Shoulder Examination: Part II: Laxity, Instability, and Superior Labral Anterior and Posterior (SLAP) Lesions. Am J Sports Med. 2003;31(2):301-307.
- ↑ Jain NB, Wilcox RB III, Katz JN, Higgins LD. Clinical Examination of the Rotator Cuff. PM R. 2013; 5(1): 45-56.
- ↑ Dakkak A, Krill MK, Krill ML, Nwachukwu B, McCormick F. Evidence-Based Physical Examination for the Diagnosis of Subscapularis Tears: A Systematic Review. Sports Health. 2021;13(1):78-84.
- ↑ Wallmann HW. Overview of shoulder orthopedic special tests. Home Health Care Manag Pract. 2010 Aug;22(5):364-6.
- ↑ Jain NB, Luz J, Higgins LD, et al. The Diagnostic Accuracy of Special Tests for Rotator Cuff Tear: The ROW Cohort Study. Am J Phys Med Rehabil. 2017;96(3):176-183.