22 Orthopedic Physical Examination
Orthopedic Physical Examination
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
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
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816. doi:10.3174/ajnr.A4173
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
Kaizik, M. A., Hancock, M. J., & Herbert, R. D. (2019). DiTA: a database of diagnostic test accuracy studies for physiotherapists. Journal of physiotherapy, 65(3), 119–120. doi:10.1016/j.jphys.2019.05.006
Koulidis, K., Veremis, Y., Anderson, C., Heneghan, N.R. (2019). Diagnostic accuracy of upperlimb neurodynamic tests for the assessment of peripheral neuropathic pain: A systematic review. Musculoskelet Sci Pract. Apr;40:21-33. doi:10.1016/j.msksp.2019.01.001.
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
Maher, C. G., O’Keeffe, M., Buchbinder, R., & Harris, I. A. (2019). Musculoskeletal healthcare: Have we over-egged the pudding?. International journal of rheumatic diseases, 22(11), 1957–1960. doi:10.1111/1756-185X.13710
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
Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. The New England journal of medicine, 369(26), 2515–2524. doi:10.1056/NEJMoa1305189
Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., … FIDELITY (Finnish Degenerative Meniscal Lesion Study) Investigators (2018). Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial. Annals of the rheumatic diseases, 77(2), 188–195. doi:10.1136/annrheumdis-2017-211172
Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit Up Straight”: Time to Re-evaluate. The Journal of orthopaedic and sports physical therapy, 49(8), 562–564. doi:10.2519/jospt.2019.0610
Sleijser-Koehorst, M., Bijker, L., Cuijpers, P., Scholten-Peeters, G., & Coppieters, M. W. (2019). Preferred self-administered questionnaires to assess fear of movement, coping, self-efficacy, and catastrophizing in patients with musculoskeletal pain-A modified Delphi study. Pain, 160(3), 600–606. doi:10.1097/j.pain.0000000000001441
Swain, C., Pan, F., Owen, P. J., Schmidt, H., & Belavy, D. L. (2020). No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. Journal of biomechanics, 102, 109312. https://doi.org/10.1016/j.jbiomech.2019.08.006
Wideman, T. H., Edwards, R. R., Walton, D. M., Martel, M. O., Hudon, A., & Seminowicz, D. A. (2019). The Multimodal Assessment Model of Pain: A Novel Framework for Further Integrating the Subjective Pain Experience Within Research and Practice. The Clinical journal of pain, 35(3), 212–221. doi:10.1097/AJP.0000000000000670