Author(s): Laura Gruber, MD, Vincent Lee, DO, Rohini Singh, DO, Deepthi Ganta, MD
Originally published: September 20, 2013 Last updated: September 23, 2021
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Overview and Description

Specialized musculoskeletal tests

  1. Examine the structural integrity of joints, muscles, and tendons
  2. Assess joint stability, strength, and provoke pain from damaged and inflamed musculoskeletal structures
  3. May elicit a painful response from damage to adjacent joint-associated structures (bones, muscles, tendons, ligaments, joint capsules, labra, and synovia)
  4. 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.

Specialized-Musculoskeletal-Examination-Table-of-Patient-TestsDownload

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:

  1. Blinded studies are rare.
  2. Few studies use appropriate comparison groups.
  3. Acuity, severity, and age of populations tested affect findings.
  4. Recruitment bias in surgical populations that are preselected for likely pathology.
  5. Use of different musculoskeletal test criteria to determine a positive test (e.g., any pain, localized pain, weakness)
  6. Lack of standardized physical examinations and variations in test maneuvers.
  7. 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.
  8. Interpretation of specialized musculoskeletal tests depends on proper technique, skill, experience, and clinical judgement.
  9. 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.

References

  1. Cifu, D. X. Braddom’s Physical Medicine and Rehabilitation. 6th ed. Philadelphia, PA: Elsevier; 2020: 18-26.
  2. Magee, DJ. Manske, RC. Orthopedic Physical Assessment. 7th ed. St. Louis, MO: Elsevier; 2021.
  3. Ghasemi M,Golabchi K,Mousavi SA,Asadi B,Rezvani M,Shaygannejad V,Salari M. The value of provocative tests in diagnosis of cervical radiculopathy. J Res Med Sci. 2013;18:S35-8.
  4. Malanga GA, Landes P, Nadler SF. Provocative tests in cervical spine examination: historical basis and scientific analyses. Pain Physician, 2003;6:199-205.
  5. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42:80-92.
  6. Hegedus EJ. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br. J Sports Med. 2012;46:964-969.
  7. Michener LA, Walsworth MK, Doukas WC, Murphy KP. Reliability and diagnostic accuracy of 5 physical examination tests and combination of tests for subacromial impingement. Arch Phys Med Rehabil. 2009;90(11):1898-903.
  8. Szadek KM, van der Wurff P, van Tulder MW, et al. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. Journal of Pain. 2009;10:354-368.
  9. Jackson JL, O’Malley PG, Kroenke K. Evaluation of acute knee pain in primary care. Ann Intern Med. 2003;139:575-588.
  10. Hing W, White S, Reid D, et al. Validity of the McMurray’s test and modified versions of the test: a systematic literature review. J Man & Manip Ther. 2009;17:22-35.

Bibliography

Frontera WR, Silver JK, eds. Essentials of Physical Medicine and Rehabilitation. Philadelphia, PA: Hanley & Belfus; 2002:85, 263-265.

Hansen HC, Mckenzie-Brown AM, Cohen SP, et al. Sacroiliac joint interventions: a systematic review. Pain Physician. 2007;10:165-184.

Hughes PC, Taylor NF, Green RA. Most clinical tests cannot accurately diagnose rotator cuff pathology: a systematic review. Australian Journal of Physiotherapy. 2008;54:159-170.

Jain NB, Wilcox RB III, Katz JN, et al. Clinical examination of the rotator cuff. PM&R. 2013;5:45-56.

Khare S, Seth D. Lhermitte’s Sign: The Current Status. Ann Indian Acad Neurol. 2015;18:154-6.

Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SM. Does this patient with shoulder pain have rotator cuff disease?: The Rational Clinical Examination systematic review. JAMA. 2013;310(8):837-47.

Lurie JD. What diagnostic tests are useful for low back pain? Best Practice & Research Clinical Rheumatology. 2005;19:557-575.

Malanga GA, Andrus S, Nadler SF, et al. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil. 2003;84:592-603.

Meserve BB, Cleland JA, Boucher CT. A meta-analysis examining clinical test utilities for assessing meniscal injury. Clin Rehabil. 2008;22:143-161.

Ombregt L, Bisschop P, ter Veer HJ, et al, eds. A System of Orthopaedic Medicine. London,UK: WB Saunders;1999:595-611, 697-700, 816-821.

Sarwark JF. Essentials of Musculoskeletal Care. 4th ed. Rosemont, IL: American Medical Association; 2010.

Solomon DH, Simel DL, Bates DW, et al. Does this patient have a torn meniscus or ligament of the knee? JAMA. 2001;386:1610-1620.

van Kampen DA, van den Berg T, van der Woude HJ, Castelein RM, Scholtes VA, Terwee CB, Willems WJ. The diagnostic value of the combination of patient characteristics, history, and clinical shoulder tests for the diagnosis of rotator cuff tear. J Orthop Surg Res. 2014;9:70-78.

Vleeming A, Monney V, Dorman T, et al, eds. Movement, Stability & Low Back Pain: The Essential Role of the Pelvis. New York, NY: Churchill Livingstone; 1997:288-292.

Warfield CA, Bajwa ZH. Principles & Practice of Pain Medicine. 2nd ed. New York, NY: McGraw Hill; 2004:283-284.

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.

Author Disclosure

Laura Gruber, MD
Nothing to Disclose

Vincent Lee, DO
Nothing to Disclose

Rohini Singh, DO
Nothing to Disclose

Deepthi Ganta, MD
Nothing to Disclose