Clinical examination is the bedrock of diagnosis in musculoskeletal (MSK) medicine. It enables the clinician to both assemble information and to interpret the findings in order to assist in identifying the nature and stage of the patient’s disease or injury, determine the need for further investigations, provide a prognosis, guide treatment and measure outcome. Its big advantage is that it can be used at any stage in the patient’s management and reproduction of the symptoms provides not only immediate feedback but also reassuring evidence, to both clinician and patient, that the source of the pain has been identified. Physical tests are quick and convenient to perform and, in the hands of a skilled practitioner, facilitate appropriate and cost-effective intervention.

The proliferation of additional or special tests used in MSK examination over the years has left the clinician with a vast array of physical tests at his or her disposal. All clinicians know that isolating the lesion and planning effective intervention is not about performing lots of tests for the sake of it, but instead selecting the most appropriate examination procedures as part of the clinical reasoning process. With so many tests in the clinical domain, combined with uncertainty concerning their accuracy and reliability, it can be hard for clinicians to determine whether or not the tests they have chosen are in fact providing them with the information they need. In addition, because tests involve both clinical and interpretative skills, results may differ with the level of the tester’s technical expertise, thereby limiting the generalization of results produced from individual studies.

Special tests are usually incorporated into the physical examination once a thorough history has been taken and clinicians can use this information to guide the selection of examination procedures. A familiarity with the core elements of the physical examination is therefore essential before incorporating special tests that can be more challenging to perform and interpret. These tests are often misreported, poorly evaluated or simply overlooked, leaving clinicians uncertain about their application and value. Most of us have had the experience of being confounded when a learned colleague expresses disbelief at our omission from the patient examination of the ‘grabem-pullem-and-twistem’ test – the one perfect test guaranteed to diagnose the particular condition facing you! Having familiarized yourself with this manoeuvre and used it in practice, it is sometimes not too long before you are questioning its value and wondering whether it is any more helpful than any other test you might have used. So, how do we decide which tests are actually worth using and which ones should be discarded?

As clinicians who treat patients on a daily basis, we decided to dig a bit deeper and look at the evidence base for as many additional or special tests as we could. As our primary aim was to produce a useful guide for clinicians, we selected tests which were either in common use, had supporting evidence or which we and our colleagues working in a particular specialty deemed helpful.

By gathering the tests in one place, describing the technique in detail, presenting the evidence and mixing in clinical tips and expert opinion, we hope in this book to inform your selection of special tests, enable you to reproduce the manoeuvres reliably and interpret the results meaningfully.

As you will see, there is a format which is repeated for each test; we explain the background to each section below.

Where we found several names for the same test we have listed the less well known names in the ‘also known as’ (aka) section. The use of eponyms in this area of medicine is commonplace and we have continued the tradition by using them in cases where the test is best known by this name. Inevitably, there are instances of regional and professional differences in the name given to a particular test and we have had to make a judgement in one or two cases. There has been debate about the relative merits of using eponyms (Matteson & Woywodt 2007, Whitworth 2007), but since their use is ingrained in medical practice, in our view it would be perverse to refer to the tests in any other way.