Special Tests: Clues, Not Conclusions

There are few joints as fascinating, frustrating, and wonderfully unpredictable as the shoulder. If you’ve treated enough of them, you already know: every shoulder tells a story, and almost none of the stories match the textbook.

One client wakes up one morning unable to reach the top shelf. Another swears the pain started when they “just grabbed the seatbelt.” Someone else complains of a deep ache in the arm, but insists the shoulder is “fine.”

This is where special tests can help.
They are not the whole assessment. They are not a diagnosis.
They are simply tools — a way to gather clues.

Special tests apply controlled stress to a specific structure in the shoulder (a tendon, ligament, capsule, or muscle) to see whether the client’s familiar pain is reproduced. In the best cases, the test shines a spotlight on the tissue involved. In the worst cases, it adds noise to an already noisy situation. The skill lies not in performing the test, but in interpreting the information in context.

Why we use special tests

Special tests become useful only after listening to the client’s story, watching how they move, and feeling how the shoulder responds under your hands. A special test is like asking the shoulder a very specific question: Is this where the problem lives?

When we use them well, they help us narrow the field.
When we use them blindly, they simply create confusion.

A lot of therapists — especially newer ones — rush to special tests too early. They jump into the testing battery before the bigger picture is clear. But a test without a working hypothesis is just pressing and hoping. You’ll get much more value from special tests when you already have a theory and you use the test to confirm or challenge that theory.

Why there are so many tests (and why every therapist has favourites)

Once you’ve been in clinical practice for a while, you start to develop your own “playlist” of tests. Not because one school taught you better ones than another, but because certain tests make more sense in your hands and give you clearer information.

A physio might favour tests that isolate a specific tendon.
A manual therapist might choose tests that combine movement and palpation.
An athletic trainer working sidelines wants tests that are fast and decisive.

None of them are wrong.

Shoulder special tests aren’t a strict formula — they are a language.
Each therapist becomes fluent in the parts of the language that feel natural.

That’s why two therapists can assess the same client and use different tests — and still arrive at a similar treatment plan.

The strengths (and the honest limitations)

The great advantage of special tests is how efficiently they give direction. A good test can reveal:

• whether a structure is sensitive under load

• which movements reproduce the pain

• whether the shoulder feels stable or threatened

However — and this is important — a positive test does not diagnose pathology. A painful supraspinatus test doesn’t mean the tendon is torn. A positive impingement test doesn’t automatically make it “impingement syndrome.” It simply tells you that when you challenge that structure, the client feels their familiar pain.

Pain is information, not a verdict.

Special tests should guide your thinking, not replace it.

Pattern recognition > memorising tests

If you learn every shoulder test but you don’t learn how to think like a clinician, the tests are useless.

The magic lies in pattern recognition:

• Pain during active elevation — followed by pain on a specific special test

• Limited external rotation — followed by a positive stability test

• Weakness without pain — referral for imaging

When those pieces line up, you gain clarity.

And when they don’t line up?
That’s a clue too.

Sometimes the shoulder tests “negative” across the board, yet the client is in agony. That’s when we step back and think bigger.

Maybe it’s a rib issue.
Maybe it’s cervical referral.
Maybe it’s not a shoulder problem at all.

When to treat and when to refer

Special tests help determine whether a shoulder is appropriate for conservative care.

A shoulder that is painful yet reasonably strong usually responds well to manual therapy, trigger point release, and progressive exercise. On the other hand, sudden weakness without pain — especially after trauma — deserves a medical referral.

In plain language:

• Pain with strength = treat

• Weakness without pain = refer

Our scope is to support recovery, not to diagnose structural damage.

Bringing it to life: Rebecca Tyler’s “go-to” tests

In the video we’re adding to this blog, shoulder specialist Rebecca Tyler Ost (SMT, PT) walks through several of her personal go-to tests — the ones she actually uses in real practice with real clients.

She doesn’t demonstrate every test in the orthopedic manual.
She demonstrates the ones that help her answer meaningful questions:

• Is the cuff involved?

• Does the shoulder feel stable?

• Is impingement likely?

• Should we treat, or should we investigate further?

Rebecca has assessed thousands of shoulders, and like most experienced clinicians, she doesn’t rely on tests that create noise — only the ones that create clarity.

If you want to go deeper

If this topic grabs you and you want to learn shoulder assessment and treatment in a structured, clinically usable way, Rebecca teaches a full 8-hour online CE course:

Treating the Complex Shoulder
(assessment, special tests, manual treatment, and rehab progression)
https://nielasher.com/products/nat-treating-the-complex-shoulder-8-hrs

In that course, she goes far beyond special tests — she teaches how to think like a shoulder clinician, build a treatment plan, and confidently progress clients out of pain.

Final thought

Special tests are not the assessment.
They are part of the assessment.

Your greatest tools will always be:

• Your listening

• Your hands

• Your clinical reasoning

When used thoughtfully, special tests don’t tell you what’s wrong with the shoulder — they help you understand what to do next. And that’s what clients need most.