Author(s): McCasey Smith, MD, MS, Rekha Swamy
Originally published: September 20, 2013 Last updated: March 20, 2025
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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

Any special exam performed is dependent on the patient’s chief complaint, history of present illness, social history, and relevant information about functional deficits present and context of injury, ensuring a thorough physical exam is performed. Prior to any specialized musculoskeletal examinations, it is recommended to begin with an examination consisting of observation, palpation, and manipulation – testing range of motion (ROM), reflexes, strength, sensations, and gait.

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 MSK Exams Table

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.

Special tests are supplemental to the clinical decision-making process and the use individual tests alone remain controversial with limited accuracy and reliability. A multi-faceted approach is recommended by using multiple tests to isolate the structural pathology. Some sets of tests for certain injuries have been shown to be more sensitive and specific than others.

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.
  • There is a lack of standardization in regard to clinical methods and approaches to musculoskeletal disorders as employment of special tests is highly variable based on examiner
  • Variability in patient’s presentation can make the use of special tests challenging such as mobility, body habitus, age, and severity of injury influence results
  • 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.

Adapting the Physical Examination in the Pediatric and Disabled Population

The musculoskeletal examination may be adapted for the pediatric population as tolerance to maneuvers and common pathology may differ from their adult counterparts.  A screening examination, pGALS (pediatric Gait, Arms, Legs, Spine), is recommended for pediatric patients.  This includes the following maneuvers15

  • Observe standing
  • Observe walking
  • Hold hands in front
  • Turn hands over; make a fist
  • Pinch index finger and thumb together
  • Touch the tips of the fingers
  • Squeeze the metacarpal-phalangeal joints for tenderness
  • Put hands together palm to palm and back to back
  • Reach up, “touch the sky”
  • Put hands behind neck
  • Try and touch ear to the shoulder
  • Put three fingers in the mouth
  • Palpate for knee effusion
  • Active range of motion of the knee
  • Passive range of movement of the hip
  • Bend and touch the toes

When performing specialized maneuvers, pediatric joints may demonstrate more range of motion or mobility.  It is important to pay special attention to the pediatric patient’s comfort throughout the examination.  For disabled patients, specialized maneuvers may not be able to be performed with normal positioning.  Special attention should be made to modify physical examination maneuvers with the intent to stress the region with similar biomechanical principles.

References

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  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.
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  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.
  11. Karbach LE, Elfar J. Elbow Instability: Anatomy, Biomechanics, Diagnostic Maneuvers, and Testing. J Hand Surg Am. 2017 Feb;42(2):118-126. doi: 10.1016/j.jhsa.2016.11.025. PMID: 28160902; PMCID: PMC5821063.
  12. Manske RC, Prohaska D. Physical examination and imaging of the acute multiple ligament knee injury. N Am J Sports Phys Ther. 2008 Nov;3(4):191-7. PMID: 21509120; PMCID: PMC2953340.
  13. Karanasios S, Korakakis V, Moutzouri M, Drakonaki E, Koci K, Pantazopoulou V, Tsepis E, Gioftsos G. Diagnostic accuracy of examination tests for lateral elbow tendinopathy (LET) – A systematic review. J Hand Ther. 2022 Oct-Dec;35(4):541-551. doi: 10.1016/j.jht.2021.02.002. Epub 2021 Feb 27. PMID: 33814224.
  14.   MacDermid, Joy C, and Jean Wessel. “Clinical diagnosis of carpal tunnel syndrome: a systematic review.” Journal of hand therapy : official journal of the American Society of Hand Therapists vol. 17,2 (2004): 309-19. doi:10.1197/j.jht.2004.02.015
  15. Foster, H.E., Jandial, S. pGALS – paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatr Rheumatol11, 44 (2013). https://doi.org/10.1186/1546-0096-11-44

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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, Vincent Lee, DO, Rohini Singh, DO, Deepthi Ganta, MD. Specialized Musculoskeletal Examination. 9/23/2021

Author Disclosure

McCasey Smith, MD, MS
Nothing to Disclose

Rekha Swamy
Nothing to Disclose