title: A proposed evidence-based shoulder special testing examination algorithm: clinical utility based on a systematic review of the literature.
abstract: OBJECTIVE
  Attaining the highest possible level of diagnostic statistical probability assists the practitioner in making an optimal differential diagnosis between or among pathological conditions. The purpose of this manuscript is to accomplish two things. The first is to identify orthopedic shoulder physical examination special tests with the best clinical utility statistics to ease the diagnostic process through usage of an examination algorithm. The second is to expedite the diagnostic process by guiding the practitioner to select only the special tests that are necessary based on pattern recognition of common pathological conditions.
  
  
  METHODS
  Systematic review of the literature identified the statistical clinical utility of common shoulder special tests used in physical examination, either singularly or in clusters. Quality assessment and statistical parameters were designed for inclusion criteria to determine diagnostic data for special test selection for the proposed algorithm.
  
  
  RESULTS
  In the proposed shoulder examination algorithm, 15 of 26 special tests achieved the proposed statistical diagnostic threshold parameters for clinical utility. Achievement of proposed statistical diagnostic threshold parameters was accomplished for 6 pathological shoulder conditions; while 3 pathological shoulder conditions did not achieve these criteria.
  
  
  CONCLUSIONS
  Large, randomized controlled trials that include patient history and all facets of the physical examination are lacking in the literature. Should diagnostic physical examination testing become more accurate, it is very possible that improved research can be accomplished, in order to establish clinical practice guidelines to help guide examination and treatment, patient management, and improve patient outcomes.
  
  
  METHODS
  1A.
authors.affiliation: Ideal Physical Therapy, Phoenix, AZ, USA.
authors.forename: Nicklaus E
authors.initials: NE
authors.lastname: Biederwolf
keywords: Differential diagnosis; evidence-based practice; orthopedic special tests; shoulder