Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

May 2020

Study Title:

It Is Time to Put ‘Special Tests’ for Rotator Cuff Related Shoulder Pain Out to Pasture


Salamh P & Lewis J

Author's Affiliations:

Krannert School of Physical Therapy, University of Indianapolis, USA; London Central Community Healthcare National Health Services Trust, London, UK; Department of Physical Therapy and Rehabilitation, Qatar University, Qatar.

Publication Information:

Journal of Orthopedic and Sports Physical Therapy 2020; 50(5): 219-279.

Background Information:

Numerous orthopedic testing procedures (otherwise known as ‘special tests’) have been developed in an effort to establish a tissue-specific diagnosis for rotator cuff-related shoulder pain (RCRSP) (1). Clinical conditions that are placed in this category include rotator cuff-related shoulder pain, subacromial impingement syndrome, rotator cuff tendinopathy, bursa pathology and atraumatic partial/full thickness rotator cuff tears (2). These authors sought to outline and critique the current use and validity of RCRSP orthopedic tests and provide specific recommendations for how clinicians might consider using these special tests in practice.


The validity of a special (or, orthopedic) test is determined by its ability to test the phenomenon it is purported to assess, compared to a reference standard. Unfortunately, validating shoulder orthopedic tests to identify structural causes of pain is quite difficult, because imaging regularly detects abnormalities in shoulder anatomy in asymptomatic individuals. This is exemplified by MRI studies finding similar abnormalities in both shoulders of patients with unilateral shoulder pain. (3) Studies such as these challenge whether imaging modalities such as MRI and ultrasound are truly good reference comparisons for shoulder special testing procedures; as such, determining the validity of special tests for RCRSP is not possible at this time.

Additionally, special tests rely on the assumption that a specific structure can be loaded in isolation, and that pain produced with a positive finding originates in the ‘isolated’ structure being tested. However, anatomical and histological investigations (4) have shown that rotator cuff tendons have intimate functional and anatomical connections with capsular, ligamentous and bursal tissues. This fact is exemplified by a study demonstrating that the ‘Empty Can’ and ‘Full Can’ tests, which are assumed to load the supraspinatus individually, actually recruit 9 and 8 shoulder muscles, respectively (5). Bearing this in mind, how can clinicians expect to load rotator cuff muscles or tendons individually? Is this even necessary in the context of evaluating the whole region?

The authors offer 4 reasons why clinicians continue to utilize special tests in spite of poor validity:
  1. Clinicians are obsessed with identifying a single and simple structural cause for symptoms.
  2. Time constraints and little access to new research limit seasoned clinicians from implementing new knowledge into practice.
  3. Students are dogmatically taught special tests in school (sound familiar?) and must display competency in these tests to graduate.
  4. Students and junior clinicians regularly observe seasoned clinicians, which perpetuates clinical practice behaviours generationally.

Clinical Application & Conclusions:

The authors argue that use and teaching of RCRSP special tests be discontinued until a valid reference standard associated with the patient’s pain experience can be identified. Special tests should no longer be used to inform patients of the source of their symptoms in surgical and non-surgical practice. The authors posit that if these tests are used, interpretation should only be related to symptom reproduction, without definitive emphasis on a specific pathological structure.

The following recommendations for clinical practice were proposed:

While conducting a structured interview, clinicians should seek to identify changes in loading history that might support the clinical hypothesis of RCRSP. It is also necessary to determine how these symptoms impact the patient’s life by understanding their fears, beliefs, expectations and valued activities. (Reviewer’s note: The ICE Questions are often helpful here, and include: the patient’s Impressions about their problem; their Concerns about treatment and recovery and; Expectations for treatment and recovery.)

Clinicians should additionally seek to identify relevant psychosocial and lifestyle factors, current activity levels, medications, supplements used, co-morbidities and risk factors for rotator cuff pathology (i.e. age, diabetes and overhead activities). Screening for ‘red flags’ is also extremely important.

Reviewer’s note on psychosocial factors: while important, we must remember two things about this topic: 1) Psychosocial factors and distress are inherent to the pain experience and cannot be separated from any other biological and social causes. Patients often seek care because there is some emotional experience tied to their pain. Emotions make pain a salient (important) experience. The existence of the Biopsychosocial framework does not mean that individual treatments or patient experiences can/should be siloed. Additionally, while exploring this topic clinically, it often helps to remind the patient that you do not think they are crazy, making their pain up or that their pain is ‘all in their head.’ Patients often fear that this line of questioning is more an accusation rather than an exploration of their personal experience of pain, so reassurance is key; 2) Refer the patient to a mental health professional for co-treatment should you detect clinically relevant psychopathology such as generalized anxiety, depression, PTSD, kinesiophobia or clinically relevant distress. Keep in mind, that physical treatment modalities are helpful in the treatment of pain disorders and that psychoemotional therapies can provide added benefit in a well-chosen patient.

Part of a comprehensive assessment is administration of general functional disability questionnaires, shoulder specific questionnaires and psychosocial questionnaires.

Clinical examination should include neurological screening if deemed appropriate, exclusion of referred pain sources, active and passive ROM, strength testing and the response to changes in load on muscle-tendon units. With specific regard to strength testing, clinicians should also evaluate repetitions to pain and/or fatigue. Physical assessments should be performed bilaterally for comparison. Finally, lower limb and trunk testing should be performed. The authors caution us to understand that nociception is not necessary for the experience of pain. Reviewer’s note: While this is true in controlled experimental settings and can be a factor in some real-life clinical scenarios, we must understand multiple things here: 1) We cannot clinically measure nociception in humans directly and; 2) While pain perception can be elicited in the absence of nociception, we must assume that some activation of the nociceptive apparatus is present the vast majority of the time. What is unknown is the volume of nociceptive stimulation at any given time, and also how much the nociceptive stimuli contribute to that patient’s pain experience. Remember, that pain perception is created through a combination of biomedical, psychoemotional and social constructs. Just because psychoemotional and social constructs are genuinely and fundamentally important to the individual pain experience, does not mean that biological inputs such as nociception do not matter. How much of the pain experience is sourced from nociception directly is currently immeasurable and uncertain.

Treatment starts by educating the patient about their condition and different management options. This must be a shared decision-making experience that incorporates potential harms, and alternative treatment options. The authors advised aiming to encourage low-risk, high-value, evidence-informed care. If the shared decision is to trial non-surgical care, graduated rehabilitation progressions for at least 3-months with activity modification is indicated, with the goal of exceeding the patient’s functional expectations. Clinicians are advised to include all functional activities in rehab, open and closed chain exercise, precision exercise and chaotic (real life) activities. Lifestyle issues such as smoking, nutrition sleep and stress must be addressed, as they are potent pain amplifiers. Finally, patients and clinicians alike must appreciate that there is no cure for rotator cuff injuries, and that attention to lifestyle and full body exercise/activity need to be performed and incrementally increased with no specific end-date.

If the desired outcomes are not achieved or if the condition worsens, patients and clinicians should consider other management options after potential harms and benefits have been discussed and understood.

Study Methods:

This article is a clinical viewpoint and as such no statistical analysis was conducted and no description of methodology was provided.

Study Strengths / Weaknesses:

Strengths: This was a clinical viewpoint from one of the foremost world experts on this topic. They support a whole-person perspective on the management of rotator cuff disorders, which is in line with the recommendations for the clinical management of other pain conditions.

Weaknesses: While only a clinical viewpoint, this article would have been strengthened by a more robust synthesis of the literature proving that special tests are not helpful in the precise diagnosis of RCRSP. The article is only lightly referenced for making such claims as to remove ‘special tests’ from the figurative clinical toolbox.

Additional References:

  1. Cook CE, Hegedus, E.J. Orthopedic Physical Examination Tests: An Evidence-Based Approach. 2nd ed. Upper Saddle River, New Jersey: Pearson; 2013.
  2. Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. 217 (1532-2769 (Electronic)).
  3. Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg 2019.10.1016/j.jse.2019.04.001.
  4. Clark JM, Harryman DT, 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg (Am) 1992; 74(5): 713-725.
  5. Brownson RC, Kreuter MW, Arrington BA, True WR. Translating scientific discoveries into public health action: how can schools of public health move us forward? Public Health Rep 2006; 121(1): 97-103.