Shoulder special tests are currently a hot topic of debate in the PT world. They are a staple in PT school, residency, and even fellowship education, but over the past several years there have been more and more people questioning how special they actually are.
We understand that there are many causes of shoulder pain and we are becoming aware that special tests are not specific enough to determine the painful tissue. There have been studies now that even refute MRI as the “Gold Standard”. 123 people with unilateral shoulder pain underwent bilateral shoulder MRI and found there were as many abnormalities in the symptomatic shoulder as there were in the pain-free shoulder(1). This makes it difficult to show that abnormalities on imaging can explain the true source of pain.
I have put a much greater emphasis on the subjective portion of my evaluation as I have gained more experience and have gotten better at pattern recognition. Listening to the patient's symptoms and history results in gaining a lot of great information, which should lead you to several hypothesis prior to even starting the objective exam. One thing that I have learned through residency and fellowship education is that your job is to either rule in or rule out your hypothesis during the objective exam so that you are not performing every test under the sun and have more questions than answers when you are done.
Understanding the patient's symptoms in regards to severity and irritability plays a big factor in how aggressive I am with my exam and what special tests/provocation tests that I actually perform. If an athlete comes in with a hot/painful shoulder, anything that I have them do will most likely re-create their pain. I view special testing as more of a test-retest/asterisk sign over the course of treatment. For example, if an athlete comes in with the MD diagnosis of “shoulder impingement” and they have pain with overhead and across-body motions, I will use a Hawkins-Kennedy or Neers impingement sign as their asterisk to help determine the effectiveness of my treatment. Once they have a negative exam on the table, it helps give me a better understanding of how hard we can push the athlete with their training, as well as take off any restrictions they might have had in the weight room or practice.
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;50(5):222-225. doi:10.2519/jospt.2020.0606