The Most Special Test

Special orthopaedic tests are used by clinicians in the assessment of those with suspected MSK pain or injury. There are a mind-boggling number of these tests, covering all areas of the body usually named after the surgeon who invented it. They are believed to diagnose MSK structures that maybe damaged or sensitive. However, it’s time to look at these ‘special’ tests differently and start to realise that perhaps many ‘special’ tests are not that ‘special’.

There is no doubting that a full, detailed, and thorough physical exam is essential when assessing someone with pain or injury, and sometimes using special orthopaedic tests are part of this. However, these special tests are often relied upon too easily, too readily, and trusted too implicitly to confirm a diagnosis when they often can not and do not.

The shoulder arguably has more special tests than any other area, and they are believed too ‘diagnose’ all manner of pathologies. At my last count, there were well over 200 tests for shoulder pain and this continues to grow as more and more are dreamt up. However, despite common assumption and still being widely taught, many special tests don’t and can’t do what they claim they can do.

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 can 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 therefore is more specific for biceps tendon pathology is also not true (ref).
Screen Shot 2017-08-26 at 13.28.14
And this is not unique to shoulder special tests, it 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 just not so (ref)… etc etc ad infinitum.

Special tests simply do not isolate specific tissues or structures, therefore when pain is reproduced during these 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 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 eg… “Ok Mrs Miggins I need to assess your Rotator Cuff now, this may hurt a little bit when I do this…” talk about priming painful expectations!

However, this is not to say that all special tests are completely useless, for example I do not know a clinician who would not do a Lachmans after a suspected ACL rupture or Hoffmans or Babinski tests for suspected cervical mylopathy, we just have to recognise their limitations, and stop calling them special.

Personally I think they should be called pain provocation tests, and although most pain provocation tests are not very special or 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 than positive pain provocation.

I often like to tell the patient what its not even when I can be certain about what it is!

It must also be remembered that the physical exam is always shaped and influenced by the patient’s 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 a Lachmans ACL laxity test 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 during 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 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, mean, unkind or even uncaring, however, I find it is really useful to observe a patients response and wiliness to do the one thing they don’t want to do. It allows me to gauge their function, pain, fear, anxiety, apprehension 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.

As always thanks for reading
Adam

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  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. 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”.

  3. 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?

  4. 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?

  5. 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.

  6. 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.

  7. 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

  8. 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

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. 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

  14. 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