How Can You Use Special Tests to Help Your Evaluations of the Shoulder?

When it comes to athletes, the decision often falls into your hands as a clinician whether to allow your athlete to return to their sport following a shoulder injury. Do you have set criteria you follow before releasing your athlete back to their sport? Are you 100% confident in the decisions you make? [1]

There is a limited number of guidelines to follow and not much evidence to support any particular process which places more responsibility on the clinician for their decisions.

It is recommended to use “an algorithm, defined as a process consisting of steps, each step depending on the outcome of the previous one. In clinical medicine, an algorithm is a step-by-step protocol for management of a healthcare problem.” [1]

With over 150 different special tests for the shoulder, as a clinician you might not be sure where to begin. Luckily, we have just the place for you to start! The “George J. Davies’ Algorithm for Special Tests of the Shoulder Examination” was created by George Davies, PT, DPT, MED, SCS, ATC, LAT, CSCS, PES, CSMS, FAPTA. He uses 29 out of the 158+ special tests to create an examination process you can follow before designing an exercise program.

Special tests are used during a physical examination by clinicians in physical therapy and orthopedics. The tests can be used to rule in or out whether a patient has a certain musculoskeletal problem. They are helpful in diagnosing orthopedic conditions and injuries.

Orthopedic special tests aim to make the diagnostic process more precise by implicating specific tissue structures that are dysfunctional, pathological, or lack structural integrity. Uses of special tests include confirming a tentative diagnosis, assisting in the differential diagnosis process, distinguishing between or among various potentially pathological tissues that may be symptomatic, and making sense of atypical objective and subjective patient signs and symptoms. Clinical diagnosis then leads the practitioner to establish a prognosis and select appropriate interventions, ultimately and ideally leading the patient to an optimal outcome. Special testing is generally performed following a full examination of the shoulder. [2]

Davies believes that special tests are necessary to provide a proper care plan to your patient. “I think the most important thing before you begin doing exercises, is to examine a patient’s shoulder. Then based on what is found during the exam, you design your exercise programs predicated on your exam findings,” he says, “I don’t know how you can treat a patient without doing a good clinical exam first to figure out the problem, the cause of the problem, and then start putting things together to figure out how to treat it.”

He emphasizes the importance of special tests on the shoulder for two reasons:

1. It is the most important thing to determine in designing an exercise program


2. The orthopedic competencies for OCS are changing.


• One of the major changes made is that the orthopedic competencies to become an OCS has place a greater importance on special tests.

Davies’ rule of three for passive tests are that you first start with a general idea, then implicate the structure, and finally corroborate your findings. By using multiple tests to corroborate, you are able to implicate involved structures.

In order to have a working theory as to why the patient is experiencing pain, the subjective and objective examination is extremely important. By only selecting the special tests that are necessary based on pattern recognition of common pathological conditions, clinicians may be able to quicken the process. [2]

“No one test is the best test!” Make sure to be thorough and correct in your findings by using multiple tests. In his algorithm, he makes sure that although he tests the shoulder stability in the front, back, top, and bottom while the patient is sitting in a safe and more stable position, he tests the front and back again while the patient is lying down with more provocative tests to corroborate the previous findings in the exam.

You will see that the “Crank Test” is one that is included in Davies’ algorithm. This test is more sensitive and specific than an MRI and only takes 10 seconds. When thinking about how valuable special tests can be in examining your patient, be sure to remember that!

The 29 special tests for the shoulder that are included in Davies’ algorithm are broken up into ten different test categories:

1. Stability Tests


• Start in a safe, more stable position


2. SLAP Tests


3. Long Head Biceps Tests


4. Acromio-Clavicular Tests


5. Rotator Cuff Impingement Tests


6. Partial/Full Thickness Rotator Cuff Tears


7. Anterior Instability Tests


• Macroinstability and Microinstability


• More provocative positions compared to #1 for corroboration


8. Internal Impingement Test


9. Posterior Instability Tests


• More provocative positions compared to #1 for corroboration


10. Bankart Tests

Davies has created a document available for clinicians to easily be able to recognize and perform the steps of the 29 special tests in his algorithm. It is arranged in 7 different columns that each represent a different piece of the exam.

1. First Column: Test category (algorithm)


2. Second Column: Critical pathways, clusters of signs & symptoms, or clinical decision making


3. Third Column: Which position the patient will be in during the tests


4. Fourth Column: Which tests to use


5. Fifth Column: Science behind the tests


• Sensitivity, Specificity, Likelihood Ratios, PPV, NPV


6. Sixth Column: Tissues that are being implicated


7. Seventh Column: Clinical reasoning for treatment predicated on the tests performed

The entire Davies' Algorithm of the Special Tests of the Shoulder are presented in Dr. Davies’ Continuing Education Courses. This is only one component of the courses which also include a 400+ page manual for examination and treatment of selected shoulder conditions.

Dr. George J. Davies is an internationally known speaker who has presented hundreds of conferences throughout the world on sports physical therapy, athletic training, shoulder, knee, open and closed kinetic chain topics, orthopaedics, rehabilitation and Isokinetics. Davies is a clinician, educator, speaker, researcher, author, editor and consultant. He has been involved in the clinical practice of sports physical therapy/athletic training, since he was a student athletic trainer, for over 53 years.

He has a passion for teaching and has been an educator for over 48 years in colleges and universities. For the past 45 years, he has been involved in teaching undergraduate and graduate physical therapy courses. Because Davies values education, after 30 years, he returned to school and completed his post-professional Doctor of Physical Therapy (DPT) at MGH Institute of Health Professions and graduated with highest honors.

Dr. Davies has been involved in many research projects that have been presented at numerous national conferences and published in various journals.

Davies was the original co-founder and co-editor of The Journal of Orthopaedic and Sports Physical Therapy for approximately 10 years and the co-founder and Associate Editor of Sports Health.

He served as the President of the Sports Physical Therapy Section-APTA from 1992-1998.

One of the reasons Davies is involved in sports physical therapy is because the former U.S. Marine from 50 years ago also likes to think he is an occasional athlete by participating in: running (over 35 years), marathons (sub-3 hours), ultra- marathons, triathlons , iron-man triathlon, and weight training. Davies has also been involved in the martial arts for over 25 years, earned a Black Belt in Karate and has been a sense´ for many years.

However, one of the accomplishments he is most proud of is that he is a cancer survivor and continues to participate in some of the above activities. [3]

Sources:

[1] https://www.researchgate.net/publication/313964954_The_Use_of_a_Functional_Testing_Algorithm_FTA_to_Make_Qualitative_and_Quantitative_Decisions_to_Return_Athletes_Back_to_Sports_Following_Shoulder_Injuries

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812837

[3] https://www.armstrong.edu/armstrong/2/rs-george-davies

[4] https://sites.google.com/a/GeorgiaSouthern.edu/george-j-davies