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., 2011Sihvonen 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., 2020Lin 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.

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