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1. Shoulder special tests should be viewed as pain provocation tests, rather than tools to arrive at specific diagnoses.
2. Current evidence does not support using special tests to inform patients of structural involvement and pain etiology when evaluating shoulder pain.
3. A comprehensive clinical exam should still include the utilization of special tests to recreate symptoms, quantify levels of pain, establish benchmarks, and inform the plan of care.

BACKGROUND AND OBJECTIVE
Rotator cuff-related diagnoses account for over a third of all shoulder pain, however the methods by which clinicians arrive at these diagnoses may be dubious (1). Previous systematic reviews have shown shoulder special tests offer greater utility when clustered together and should be reserved for identifying the degree and severity of symptoms, rather than pathology itself (2).

In this viewpoint paper, the authors discuss the alarmingly low validity of shoulder special tests in their ability to identify the structural and pathological source of pain.

METHODS
The most common way to investigate the validity of a clinical test is to compare it to a previously established gold standard. Validating shoulder special tests is near impossible due to the and asymptomatic shoulders (3). Only full thickness rotator cuff tears and glenohumeral osteoarthritis have been shown to have a higher incidence in symptomatic shoulders. The incidence of asymptomatic labral tears and partial thickness rotator cuff tears is far too high to use any single test or image to determine the exact source of pain, diagnose, and establish a plan of care.

RESULTS
The discussion of why the use of special tests persists has universal application across many facets of clinical practice. It is said that health- related research can take decades to be fully incorporated. Experienced clinicians may be slow to adopt new methods due to lack of exposure and the investment involved with change, students are taught by older clinicians early in their developmental process, and both academic and governing bodies typically move slowly in evolving their curriculum and licensure

Rotator cuff-related diagnoses account for over a third of all shoulder pain.

low reliability of their reference standard, the MRI. Studies have shown a high prevalence of abnormalities on MRIs of both symptomatic

It is clear special tests should not be used to provide a definitive structural diagnosis or inform a surgical or more invasive plan of care.

examination. Furthermore, current medical standards and patient expectations oftentimes place undue pressure on clinicians to identify a specific structural source of pain.

When a clinician is presented with a patient who is a strong candidate for conservative management, they should be able to reassure them of the high probability that their outcome will be favorable, while concurrently providing education on the uncertainty and lack of utility in producing specific structural diagnoses. Alongside a gradual increase in exposure and reduction in symptom presentation, experienced clinicians should be able to build patient confidence and foster self-efficacy without distilling their symptoms down to a structural diagnosis.

The simplicity of a definitive diagnosis can be alluring. It reduces uncertainty during a clinical exam, and it can actually help patients feel relieved in the short term. This can backfire, however. Some patients will continually associate their pain with said structural diagnosis and not understand how their pain can resolve if the structural pathology has not.

LIMITATIONS
The authors of this paper clearly sought to take a stance against special tests, and they accomplished their goal. They offer one perspective into the nuance of this topic when they mention that if special tests are used, their interpretation should relate only to the reproduction of symptoms, and not the structure associated with the symptoms. This paper would have been more informative if the authors offered a deeper look into how special tests can actually be used. However, previous systematic reviews have already done a satisfactory job of framing special tests in the way in which they should be used, without overstating their utility.

CLINICAL IMPLICATIONS
There are over 70 special tests for the shoulder, and many of them still do have clinical utility. The majority are focused on assessing active ROM, passive ROM, strength, and movement or positional intolerances. These variables are important to evaluate in every assessment, regardless of body part. Many of the shoulder special tests have significant overlap with more typical exam procedures, bringing into question how ‘special’ they really are. A strong argument can be made, however, to include clusters of special tests to assist clinicians in determining the degree and severity of pain, as well as aggravating and alleviating factors.

Special tests can help to quickly reproduce pain and establish movement/positional intolerances to work towards. They assist in narrowing the scope of the exam. They were formulated through pattern recognition and typical patient presentation (3). After being studied extensively, it is clear special tests should not be used to provide a definitive structural diagnosis or inform a surgical or more invasive plan of care. Many of them have failed to hold up to their intended purpose.

Clinical decision making and patient education should be informed by an extensive interview and history, a screen for more serious pathologies, the results of functional outcome measures, and a physical exam that includes ROM, strength, and the identification of impairments. Clinicians can still use special tests responsibly as long as other important components of the examination are not forgotten about.