Shoulder Special Tests
Original Editor- Naomi O'Reilly Top Contributors - Kim Jackson, Manisha Shrestha, Caroline Stone, Shoko Otsuka, Naomi O'Reilly, Rucha Gadgil, Tarina van der Stockt, Vidya Acharya, Lucinda hampton, Jess Bell and Alexandra Stead
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 at the end of clinical examination, following subjective history, clinical observation, palpation, range of motion (ROM) assessment, assessment of passive arthokinematic and accessory joint mobility, neurological assessment, and manual muscle testing.[2] Reproduction of pain and weakness during special tests may be considered clinically diagnostic.[2] Orthopaedic special tests may be used to test and retest following therapeutic interventions to assess for any change in symptoms.
Testing Clusters and Clinical Prediction Rules
Current recommended testing clusters can be found below. Note that testing clusters may include findings such as age, or subjective reports. Positive tests in each cluster increase the likelihood of each diagnosis.[3]
| Pathology | Testing Cluster(s)/Clinical Prediction Rules |
|---|---|
| Superior Labral Anterior to Posterior (SLAP) Tear | |
| Labral Tear | |
| Supraspinatus Tendinopathy/Tear |
|
| Rotator Cuff Tear | |
| Subacromial Impingement | |
| Subscapularis Tear/Tendinopathy |
|
| Anterior Instability |
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][5] Special tests are unable to assess and implicate specific structures or pathology with a high degree of confidence and certainty, which should be considered in clinical decision making.[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.[3][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.[3][6][4] Even in high quality studies, shoulder special tests display limited sensitivity or specificity, which may vary between clinicians and clinical practice environments.[6][3] Common tests used in clinical examination lack clarity in whether or not they are useful in differentially diagnosing shoulder pathology.[4]
Clustering orthopaedic special tests together has been shown to improve diagnostic accuracy in both research and clinical practice.[6][4][3] 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[3]. 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.[3]
Clinical Relevance
As individual shoulder special tests demonstrate low sensitivity and specificity when used in isolation, testing clusters should be used clinically to guide diagnosis.[7] Clinicians should interpret test outcomes within the broader context of clinical assessment, including patient history and examination findings, as definitive diagnosis with clinical tests currently in use is not possible.[8] Clustering tests improves diagnostic confidence, though diagnosis is not definitive through special tests alone.[8]
Summary of Shoulder Special Tests
A general summary of special tests for the shoulder can be found below.
| Assessment | Special Test | Pathology |
|---|---|---|
| Instability / Capsular | 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[9]
SLAP lesion[4] | ||
| Posterior instability of GH joint due to laxity of the posterior capsule[9] | ||
| Acromioclavicular and Labral | AC joint pathology[10]
SLAP lesions[4] | |
| AC joint pathology[10] | ||
|
SLAP lesion[9][11] | |
| Impingement | Subacromial impingement | |
| Rotator Cuff | Supraspinatus tear | |
| Supraspinatus and infraspinatus tear
Shoulder impingement | ||
| Subscapularis tear | ||
| Infraspinatus tear
Subacromial impingement | ||
| Teres Minor and Infraspinatus tear | ||
| Biceps Brachii | Biceps tendon pathology
SLAP lesion[9] | |
| Biceps tendinopathy
Superior labral tears |
Conclusion
Shoulder special tests have low sensitivity and specificity when used in isolation, and a singular test cannot be used to provide a definitive diagnosis.[7][2] Clustering of tests into clinical prediction rules helps improve sensitivity and specificity of special tests, and improves confidence in diagnosis.[3] As a result, shoulder special tests should always be used in clusters to improve accuracy.
References
- ↑ 1.0 1.1 1.2 1.3 Magee, D. Shoulder. Chapter 5 In: Orthopedic Physical Assessment. Elsevier, 2014
- ↑ 2.0 2.1 2.2 2.3 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.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 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.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 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.
- ↑ 5.0 5.1 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.
- ↑ 6.0 6.1 6.2 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.
- ↑ 7.0 7.1 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.
- ↑ 8.0 8.1 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.
- ↑ 9.0 9.1 9.2 9.3 9.4 9.5 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.
- ↑ 10.0 10.1 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.
- ↑ 11.0 11.1 11.2 11.3 Wallmann HW. Overview of shoulder orthopedic special tests. Home Health Care Manag Pract. 2010 Aug;22(5):364-6.
- ↑ 12.0 12.1 12.2 12.3 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.
- ↑ 13.0 13.1 13.2 13.3 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.