Overview and Description
Specialized musculoskeletal tests
- Examine the structural integrity of joints, muscles, and tendons
- Assess joint stability, strength, and provoke pain from damaged and inflamed musculoskeletal structures
- May elicit a painful response from damage to adjacent joint-associated structures (bones, muscles, tendons, ligaments, joint capsules, labra, and synovia)
- Should always be performed within the context of a complete history and physical exam, including mechanism of injury, psychosocial history, and functional impairments
A complete review of all these tests is beyond the scope of this article. This review emphasizes commonly cited tests for cervical, shoulder, pelvis and hip disorders, as these are areas of greatest clinical complexity where combinations of special tests may be more accurate.
Relevance to Clinical Practice
Patient is standing in anatomical position for all tests unless otherwise stated. The authors’ decision to include specific tests was primarily based on frequency cited in the literature, validity and clinical utility. Blank boxes indicate an absence of specificity/sensitivity data.
There is no imaging “gold standard” for sensitivity and specificity for SI joint pathology, so these tests are compared to the ability of anesthetic injections to block pain symptoms.
Cutting Edge/ Unique Concepts/ Emerging Issues
Accuracy, reproducibility, and validity of individual tests are controversial, although combinations of tests are likely to be more accurate. Individual tests probably detect pain from more than one pathoanatomical structure; therefore, multiple tests performed in the context of an overall examination are more useful than relying on a single test to diagnose a specific structural pathology. Comparison with contralateral side or limb may also be helpful. Three or more positive tests for SI pathology improves predictive power compared to intra-articular injection tests. Evaluation of combinations of specific musculoskeletal tests for improved diagnostic accuracy and validity is an emerging area of research.
Gaps in Knowledge/ Evidence Base
Wide ranges of values for sensitivities and specificities reflect problems with quality and standardization.
Quality of studies can be problematic because:
- Blinded studies are rare.
- Few studies use appropriate comparison groups.
- Acuity, severity, and age of populations tested affect findings.
- Recruitment bias in surgical populations that are preselected for likely pathology.
- Use of different musculoskeletal test criteria to determine a positive test (e.g., any pain, localized pain, weakness)
- Lack of standardized physical examinations and variations in test maneuvers.
- Sensitivity and specificity are based on different validating criteria (imaging, surgical findings, response to injections). There is no gold standard because structural abnormalities noted on imaging studies may not correlate with physical exam findings, and the validity of joint injections is uncertain since adjacent structures may also be inadvertently anesthetized.
- Interpretation of specialized musculoskeletal tests depends on proper technique, skill, experience, and clinical judgement.
- While use of multiple provocative tests is probably more predictive of pathology, the exact combination and number of provocative musculoskeletal tests to improve diagnostic accuracy remains unclear.
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Original Version of the Topic
Robert A. Lavin, MD, Ryan K. Murphy, DO. Specialized musculoskeletal examination. 9/20/2013.
Previous Revision(s) of the Topic
Robert A. Lavin, MD. Specialized musculoskeletal examination. 3/24/2017.
Laura Gruber, MD
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Vincent Lee, DO
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Rohini Singh, DO
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