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Orthopedic special tests have traditionally been used to support diagnosis by identifying specific structures that are dysfunctional, pathological, or lacking structural integrity. The purpose of these tests is to confirm findings from the clinical examination and provide a preliminary diagnosis¹.

Special tests are usually performed following a thorough clinical evaluation of the shoulder, including patient history, mechanism of injury, clinical observation, palpation of bony and soft tissue structures, assessment of active and passive range of motion, joint mobility, neurological examination, muscle testing, and functional assessment².

A positive test, with reproduction of pain or weakness, has often been considered diagnostic.

Evidence

Although orthopedic special tests are widely used, both narrative and systematic reviews, as well as research studies, have consistently questioned their value in accurately identifying the structures involved in a patient’s symptoms.

Several studies have concluded that special tests alone cannot confirm a specific pathology with sufficient certainty to guide clinical decision-making²³.

“It is not possible to establish a definitive diagnosis based on clinical tests alone.”⁴

According to Magee¹, many special tests—especially those assessing labral injuries—demonstrate low sensitivity and specificity. Therefore, combinations of tests, often referred to as test clusters or clinical prediction rules, are considered more reliable. Even so, these tests are not necessarily definitive¹.

Despite extensive research on shoulder special tests, Hegedus et al.⁵ point out that much of the evidence is of low to moderate quality⁶⁷. Even high-quality studies reveal that tests have limited diagnostic properties and their utility may vary between clinical settings and examiners.

“At present, it is almost universally unclear whether the commonly used tests in clinical shoulder examination are actually useful for differential diagnosis of shoulder pathologies.”⁶

“No single physical examination test for the shoulder can be unequivocally recommended to establish a pathoanatomic diagnosis.”⁷

While combinations of tests have shown improved diagnostic accuracy, these test clusters are often misapplied in clinical practice⁵⁶⁷. Hegedus et al.⁵ identified six test clusters with the strongest likelihood ratios, based on studies with high methodological quality assessed by the QUADAS tool. They argue that studies with QUADAS scores ≤ 10 have significant methodological weaknesses, making results less reliable outside of the studied populations.

Use for symptom change assessment

Orthopedic special tests may still be valuable for reproducing symptoms and for test-retest evaluation following therapeutic interventions, helping clinicians assess changes in a patient’s symptoms over time.

Diagnostic tests for the shoulder

Assessment	Pathology	Special tests
Instability and capsular tests	Inferior instability of the GH joint due to laxity of the superior capsule	Sulcus Sign
	Instability of the GH joint due to anterior and posterior capsular laxity	Load and Shift Test
	Anterior instability of the GH joint due to anterior-inferior capsular laxity	Apprehension Test, Jobe’s Relocation Test
	Posterior instability of the GH joint due to posterior capsular laxity	Posterior Drawer Test (Norwood Stress Test)
Acromioclavicular and labral tests	AC joint and SLAP lesions	Active Compression Test (O’Brien’s Test)
	AC joint	Paxino’s Test
	SLAP lesion	Crank Test, Biceps Load I & II, Clunk Test
Impingement tests	Subacromial impingement	Neer’s Test, Hawkins-Kennedy Test, Painful Arc, Yocum’s Test
Rotator cuff tests	Supraspinatus tear	Drop Arm Test (Codman’s), Empty Can Test, Full Can Test
	Supraspinatus & infraspinatus tear, impingement	External Rotation Lag Sign
	Subscapularis tear	Internal Rotation Lag Sign, Lift-Off Test (Gerber’s), Belly Press Test, Belly-Off Test, Bear Hug Test
	Infraspinatus tear and subacromial impingement	Infraspinatus Test
	Teres minor & infraspinatus tear	Hornblower’s Sign
Biceps brachii tests	Biceps tendon pathology or SLAP lesion	Yergason’s Test
	Biceps tendinopathy or superior labrum lesion	Speed’s Test

Clinical relevance

• Orthopedic special tests have limited diagnostic value when used in isolation.

• Combinations of tests may improve diagnostic confidence, but results must always be interpreted within the context of a comprehensive clinical examination.

• Test clusters with the strongest evidence should be prioritized in practice.

• Sensitivity and specificity vary widely between tests, influencing their utility in confirming or ruling out specific shoulder pathologies.

Conclusion

While orthopedic special tests can be useful for assessing shoulder symptoms, their standalone diagnostic value is limited. The combination of tests may enhance accuracy, but findings should always be interpreted alongside a thorough clinical evaluation.

References

1. Magee, D. Shoulder. Chapter 5 In: Orthopedic Physical Assessment. Elsevier, 2014

2. Biederwolf NE. A proposed evidence-based shoulder special testing examination algorithm: clinical utility based on a systematic review of the literature. International Journal of Sports Physical Therapy. 2013 Aug;8(4):427.

3. Lewis J, McCreesh K, Roy JS, Ginn K. Rotator cuff tendinopathy: navigating the diagnosis-management conundrum. Journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):923-37.

4. 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.

5. Hegedus EJ, Cook C, Lewis J, Wright A, Park JY. Combining orthopedic special tests to improve diagnosis of shoulder pathology. Physical Therapy in Sport. 2015 May 1;16(2):87-92.

6. 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. British journal of sports medicine. 2008 Feb 1;42(2):80-92.

7. 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. British journal of sports medicine. 2012 Nov 1;46(14):964-78.

8. 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.

9. Tennent TD, Beach WR, Meyers JF. A Review of the Special Tests Associated with Shoulder Examination: Part I: The Rotator Cuff Tests. The American Journal of Sports Medicine. 2003;31(1):154-160.

10. ­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. The American Journal of Sports Medicine. 2003;31(2):301-307.

11. Jain NB, Wilcox RB III, Katz JN. and Higgins LD. Clinical Examination of the Rotator Cuff. PM&R. 2013; 5(1): 45-56.

12. 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.

13. Wallmann HW. Overview of shoulder orthopedic special tests. Home Health Care Management & Practice. 2010 Aug;22(5):364-6.

14. 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.