New Era in Orthopedic Special Tests for the Shoulder

Recently, I was invited to co-author an article on combining special tests to arrive at a diagnosis of shoulder pathology (PT in Sport, 2014). While authoring a publication is always exciting, the most energizing part of the request was the topic. The word “combining” signifies a welcome shift in practitioner mentality, the recognition that orthopedic special tests are of little use alone and must be combined to have a diagnostic impact.

Embracing Special Test Combinations

State-of-the-art clinical practice encompasses an understanding of sensitivity, specificity, and likelihood ratios and using these metrics to rule in or rule out diagnoses. Most clinicians have realized that a single test doesn’t reflect clinical practice and is insufficient to make a diagnosis. Many have embraced that combining tests is a must and a good clinical practice, whereas simply taking one’s favorite individual tests and using them one after the other is not the answer.

Many tests detect the same pathology clouding the diagnostic picture or reproduce pain in almost all every patient creating false positive results. The best known combinations from the highest quality literature are outlined below along with suggestions of potentially better combinations.

New Research

Practitioners interested in the highest level of evidence currently available will note new research in 3 areas:

• Labral tears (Guanche and Jones, 2003)
• Traumatic anterior instability (Farber et al, 2006)
• Rotator cuff tears (Litaker et al, 2000; Park et al, 2005)

All of these studies are of high quality, but some words of caution are needed.

Labral Tears

Guanche and Jones (2003) examined labral tears using test clusters consisting of the relocation test, the apprehension test, and the active compression test – none of which are individually the best tests for labral tears.

Suggestion: Better tests would be the passive compression and the modified dynamic labral shear.

Traumatic Anterior Instability

Farber et al (2006) suggest that the apprehension and relocation tests are not bad choices.

Suggestion: Do clinicians really need special tests to determine whether a patient has had a traumatic anterior dislocation, or might patient history give a bigger diagnostic clue?

Rotator Cuff Tears

Litaker et al (2000) and Park et al (2005) take the most valuable information from the total examination process and add special tests to this information to improve diagnostic accuracy. For example, valuable information from history, like older age, is combined with findings of weakness in external rotation and special tests, like the drop arm and the painful arc, to produce high positive likelihood ratios and low negative likelihood ratios. In other words, as information from a comprehensive examination is coupled with special tests, we get closer to the ideal, which is that a positive test cluster correctly diagnoses pathology while a negative test cluster rules out pathology.

Suggestion: For patients under the age of 60, the external and internal rotation lag sign may be most appropriate.

The Next Step

Clinical examination has come a long way in the past 20 years. The use of sensitivity, specificity, and likelihood ratios has become commonplace. Further, clinicians realized the limitations of orthopedic tests and began to examine combinations of tests. The next step is to understand how to effectively use the best diagnostic tests in a comprehensive physical examination.