The most special test…

Special orthopedic tests are commonly used by clinicians in the assessment of those with musculoskeletal pain or injury. There is a mind boggling number of these tests, usually named after the clinician who invented it, covering all areas of the body, and proposed to help diagnose many different injuries and pathologies. However, it’s time to look differently at these special tests and start to realise that many special tests are not special.

There is no doubt that a good physical exam is essential when assessing someone with suspected musculoskeletal pain or injury, and there is no doubt that sometimes using special orthopedic tests have a role in this physical exam. However, in my opinion, these special tests are used too often, relied upon too much, and believed to confirm a diagnosis when they don’t.

The shoulder arguably has the most special tests that are believed to ‘diagnose’ all manner of shoulder problems. There are well over 200 special tests for shoulder pain described in the literature and this continues to grow as more and more are dreamt up. However, despite common belief and it still being widely taught, many special tests can’t do what they claim they can do, which is isolate one structure or tissue and stress it significantly more than another.

For example, the belief that the ’empty can’ special test stresses the Supraspinatus tendon more than the ‘full can’ special test is not actually true, in fact, both positions do not stress ANY part of the rotator cuff more than any of the other surrounding shoulder muscles (see figure below ref). Also the belief that pain on the ‘Speeds’ or ‘Yergasons’ special tests isolates the long head of biceps from the other surrounding shoulder tissues and is more specific for long head of biceps tendon pathology is also not true (ref).

Screen Shot 2017-08-26 at 13.28.14

And this is not just unique to the shoulder special tests. This is also the same for many other special tests in many other areas. For example, the belief that pain during the ‘McMurrays’ special test stresses and strains the knee meniscus alone is not so (ref). The belief that pain on the ‘Spurlings’ special test or during the ‘upper limb tension’ special tests only indicates neural compression or tension is not so (ref).

Special tests just do not isolate a specific tissue or structure, therefore when pain is reproduced during these special tests all they tell you is that pain is reproduced not what the source is. That’s even if there is mechanical ‘source’ for the pain at all. Sometimes, I think pain can be reproduced in patients during these tests simply due to expectations of it going to hurt, especially when I hear a clinician explain to the patient what the purpose of this special test is for… “Ok Mrs Briggs this may hurt a bit when i do this…” talk about priming painful expectations!

Anyway, this is not to say all special tests are completely useless, we just have to recognise their limitations, and stop calling them special. Personally I think they should be called pain provocation tests instead, and although most pain provocation tests are not very specific, that is they can not rule in a particular tissue, structure, or pathology, they tend to be more sensitive, that is they are better at ruling out a tissue, structure, or pathology. I think negative pain provocation testing is far more useful in some examinations than positive pain provocation.

It must also be remembered that the physical exam is always shaped and influenced by the patients history. For example someone with knee pain who tells you they heard a loud pop and sudden pain after turning and twisting suddenly, is going to have a different exam than someone who tells you of knee pain building gradually when they walk more. You are probably only going to do ACL laxity testing on one of these patients. The history always shapes your exam. You will NOT do all the same tests on all the patients you see.

However, there is an exception to this rule, there is actually one ‘special’ test I do with every patient I see at the beginning of every physical exam regardless of where their problem is, or what I suspect the pathology is or is not. This is the ‘most special orthopaedic test’ and it is one I think every clinician should do.

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I ask every patient I see what is THE most painful, fearful, difficult thing for them to do. Once they tell me what this is, my most special orthopaedic test’ is to get them to do the one thing they just told me they don’t want to do.

This may seem unconventional, harsh, even unkind or uncaring, after all a patient has just told you something they can’t or don’t want to do and you go ask them to do it without any assessment or treatment first! However, I find it really useful to start all physical assessments observing the patient doing the one thing they don’t want to do. It allows me to gage their function, pain, fear, anxiety, apprehension etc etc all in one simple quick test before I go on to look at other things.

It truly is the most special of all the special tests… Give it a try, but please just don’t call it the ‘Meakins’ special test… unless of course you want too ;o) 

As always thanks for reading

Adam

16 thoughts on “The most special test…

  1. Spot on, as usual, Adam. Reminds me of assessing PIVMs in manual therapy. What about those staples of PT: manual muscle testing and goniometry. I always giggle when I see that a patient has “53 degrees of knee flexion”.

  2. What about the patient’s story? Is the exam more informative than the history? Once you’ve asked what is the MOST painful thing aren’t you more than halfway to knowing what is wrong?

  3. Chris Littlewood talks about this on his course – I hardly utilise any of the so called ‘special tests’ of the shoulder. It’s time we spread the word to our orthopaedic friends.

  4. Hey Adam, thanks for the blog!

    What sort of process do you usually go through to find your abstracts? Wouldn’t mind getting in the habit of reading through a few during my morning tea.

    Cheers,

    Matt

    • Hi Matt, I use a few search engines and keywords to sift through new research published and then send you email links. I find PubMed do a good email service as well as QXMD. Hope this helps.

      Cheers Adam

  5. This is taught by the MACP as a “functional demo”, which also allows you to try and modify the painful movement though muscle recruitment, postural modification or manual therapy to guide treatment.

  6. So why are we still teaching these ‘special tests’ at university and post graduate level. Isn’t there a belief that if we are taught something early on as a student it stays with us through out our career. Maybe we should be looking at what is taught and adjust it accordingly, keeping students up to date with evidence based medicine.

  7. Hey Adam
    You always bring clarity to the “as clear as muddy water” I appreciate your writing and podcast
    I hear your voice in the clinic

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