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3.3: Orthopedic Physical Examination

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    Most orthopedic special tests involve a degree of subjectivity and few are sensitive or specific enough to have clinical value on their own. Even when these tests are clustered there are issues with testing validity, this is because these tests are often good at reproducing pain but not great at telling us what structures the symptoms are coming from (Docking et al., 2016; Hegedus et al., 2017; Salamh & Lewis, 2020).

    The current use of clinical tests is focused on a black and white pathoanatomical diagnosis, this often does not determine the source of pain. Increasingly, research shows that attributing the experience of pain solely to poor posture, minor leg length discrepancies, vertebral misalignment and other structural abnormalities is an oversimplification of a complex process (Green et al., 2018).

    In some cases degenerative changes in the knee, shoulder, and spine are a normal part of normal aging and not associated with symptom presentation (Brinjikji et al., 2015; Culvenor et al., 2019; Farrell et al., 2019; Girish et al., 2011; Sihvonen et al., 2018). This disconnect between tissue damage seen on imaging and clinical presentation often creates confusion for both patients and clinicians. As a result, the medical community has moved on from a traditional biomechanical framework into a biopsychosocial framework (Lewis et al., 2020; Lin et al., 2020).

    All this does not mean we should give up on performing a physical examination of our patients, what it means is that we ought to gather information about patients’ limitations, course of pain, and prognostic factors (eg, coping style). This information is then blended with information gathered from a traditional clinical examination including special testing, neurological examination, mobility and/or muscle strength assessment.

    PhysioTutors: Special Tests Are Not So Special… and when to use them

    Key Takeaways

    Increasingly, research shows that attributing the experience of pain solely to poor posture, minor leg length discrepancies, vertebral misalignment and other structural abnormalities is an oversimplification of a complex process. The human body is not a simple structure, but rather a complex and adaptable network of overlapping systems. We must move from the myth of a simple biomechanical framework, or pathoanatomical model of trying to fix the structure, to understanding the complexity of a biopsychosocial framework and how all of the systems within the body interact to experience all types of pain.

    References and Sources

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    Caneiro, J. P., Roos, E. M., Barton, C. J., O’Sullivan, K., Kent, P., Lin, I., … O’Sullivan, P. (2020). It is time to move beyond ‘body region silos’ to manage musculoskeletal pain: five actions to change clinical practice. British journal of sports medicine, 54(8), 438–439. https://doi.org/10.1136/bjsports-2018-100488

    Cook, C. (2010). The lost art of the clinical examination: an overemphasis on clinical special tests. The Journal of manual & manipulative therapy, 18(1), 3–4. https://doi.org/10.1179/106698110X12595770849362

    Culvenor, A. G., Øiestad, B. E., Hart, H. F., Stefanik, J. J., Guermazi, A., & Crossley, K. M. (2019). Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. British journal of sports medicine, 53(20), 1268–1278. doi:10.1136/bjsports-2018-099257

    Docking, S. I., Cook, J., & Rio, E. (2016). The diagnostic dartboard: is the bullseye a correct pathoanatomical diagnosis or to guide treatment?. British journal of sports medicine, 50(16), 959–960. doi:10.1136/bjsports-2015-095484

    Farrell, S. F., Smith, A. D., Hancock, M. J., Webb, A. L., & Sterling, M. (2019). Cervical spine findings on MRI in people with neck pain compared with pain-free controls: A systematic review and meta-analysis. Journal of magnetic resonance imaging: JMRI, 49(6), 1638–1654. doi:10.1002/jmri.26567

    Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. AJR. American journal of roentgenology, 197(4), W713–W719. doi:10.2214/AJR.11.6971

    Green, B. N., Johnson, C. D., Haldeman, S., Griffith, E., Clay, M. B., Kane, E. J., … Nordin, M. (2018). A scoping review of biopsychosocial risk factors and co-morbidities for common spinal disorders. PloS one, 13(6), e0197987. doi:10.1371/journal.pone.0197987

    Hegedus, E. J., Wright, A. A., & Cook, C. (2017). Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers. British journal of sports medicine, 51(22), 1578–1579. doi:10.1136/bjsports-2017-097633

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    Lewis, J., & O’Sullivan, P. (2018). Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?. British journal of sports medicine, 52(24), 1543–1544. doi:10.1136/bjsports-2018-099198

    Lewis, J. S., Cook, C. E., Hoffmann, T. C., & O’Sullivan, P. (2020). The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice. The Journal of orthopaedic and sports physical therapy, 50(1), 1–4.

    Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., … O’Sullivan, P. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British journal of sports medicine, 54(2), 79–86. doi:10.1136/bjsports-2018-099878

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    Salamh, P., & Lewis, J. (2020). It Is Time to Put Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture. The Journal of orthopaedic and sports physical therapy, 50(5), 222–225. https://doi.org/10.2519/jospt.2020.0606

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    This page titled 3.3: Orthopedic Physical Examination is shared under a CC BY 4.0 license and was authored, remixed, and/or curated by Richard Lebert (eCampus Ontario) via source content that was edited to the style and standards of the LibreTexts platform.