The Research Titans seem determined to knock Orthopedic special tests off their pedestal. Here I give my opinion on the latest article titled:
It Is Time to Put ‘Special Tests’ for Rotator Cuff Related Shoulder Pain Out to Pasture. (Salamh & Lewis 2020)
This means put them in a field to eat grass if you’re a farmer or forced to leave due to old age in the job market.
The article summarises early by asking three questions, designed to catch you out if you haven’t been reading shoulder research over the last few years. These are my abbreviated versions.
One: Can we clinically identify the structure causing pain?
Two: Can imaging identify the structure causing pain?
Three: Will structural surgery stop the symptoms?
Of course the Yes/No answer to these is NO based on the current research.
Here are few interesting statistics from the article.
In 123 people with unilateral shoulder pain who had bilateral MRI, there were as many abnormalities in the symptomatic shoulder as there were in the pain free shoulder (Barreto et al 2019). So they are not really abnormalities, just anatomical variants of normal – whatever that is?
While you can argue that a special test has good validity based on comparisons with MRI. So that it does test the structure you think your testing. The clinical validity stops here because it’s unlikely the structural issue is the clear cause of the pain. Pain and structure have never had a good relationship – even after lockdown.
So why do we keep using these special shoulder tests and why should we care.
The authors proposed the following.
Simplicity: Structure is simple. It’s this or it’s that! A nice clear yes/no test and specific diagnosis makes everyone happy.
Routine and Experience: It took us ages to learn all the special tests with their Jedi like terms and martial arts maneuverers. They cannot possibly be a waste of time! – Unfortunately, they can.
Teaching: We all had good and bad educators, it’s just fact that unnecessary special tests will continue to be taught for many years to come.
Key Point: Continuing to rely on ‘special’ test results and imaging to inform recommendations for often ineffectual but expensive surgical procedures in non-traumatic presentations will do more harm than good.
We need to let go of structure, but this is hard when we don’t have a tangible replacement.
Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic 189 resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow 190 Surg. 2019.10.1016/j.jse.2019.04.001
Reference: Salamh, P., & Lewis, J. (2020). It Is Time to Put “Special Tests” for Rotator Cuff Related Shoulder Pain Out to Pasture. Journal of Orthopaedic & Sports Physical Therapy, 1–11. doi:10.2519/jospt.2020.0606