Special Manuevers

I’m in family nurse practitioner school and the course I’m currently taking is physical assessment techniques. I’m going through ortho right now and diagnostic tests are being discussed in the text related to primary care orthopedic complaints ie., shoudler pain, knee pain, back pain etc. Most of the maneuvers I am required to learn are backed up according to the text with good sensitivity and specificity for diagnosis of the pathology they claim to screen for with citations to the meta analyses validating these tests. What I have learned from barbell medicine’s content makes me skeptical of tests that rely on reproducing pain or really any other test that a clinician can manually perform. Are these types of tests bull shit? Do they have clinical value? I have to suspend what I have learned here in order to fully digest and learn the reductionist techniques discussed in the text and was wondering if these tests really possess the validity the authors claim. If these tests have no diagnostic value than when would one know when additional work up and imaging were warranted?

Are these types of tests bull shit? Do they have clinical value?

I don’t think it would be appropriate for us to make broad, sweeping claims about such tests as there is variability among them. Specific examples would facilitate discussion.

If these tests have no diagnostic value than when would one know when additional work up and imaging were warranted?

This depends on the potential diagnoses in question. The purpose of testing in order to make a diagnosis is to inform specific management plans. If you have a test that purports to distinguish between two diagnostic entities that ultimately have the exact same clinical management, then we would argue that the test isn’t especially useful. Unless the diagnosis itself changes your management of the patient, the label applied to the patient’s case probably isn’t worth much concern.

I’m sure Mike and Derek will have more to say here.

Great questions. I’m in agreement with Ausitn.

I usually reflect on how many tests we have that are named after someone when thinking about this topic…perhaps it is the name that leads one to think special rather than the test itself - which would likely explain why we have so many orthopedic tests.

Anyways - you are right for being skeptical. There are articles pushing back on the idea of special tests in the MSK context:

It Is Time to Put Special Tests for Rotator Cuff–Related Shoulder Pain out to Pasture

Orthopaedic special tests and diagnostic accuracy studies: house wine served in very cheap containers - this excerpt summarizes my opinion on the topic well:

“House wine is the abstruse alcoholic drink sold by restaurants to thirsty, unquestioning individuals who are looking for the path of least resistance. House wine is easily accessible, simplifies an oft-complex process and ‘feels’ like its highbrow cousins. House wine is alluring to sellers of wine because it appeals to the masses and is profitable. House wine meets a need; but its packaging (usually a box) is generally looked down upon by discerning consumers since it signals lack of quality. Unfortunately, orthopedic special tests are the house wine of the research community and diagnostic accuracy studies are the cheap containers in which they are served.”

Superficially these tests sound great, but rarely are necessary or lead to meaningful difference in usual management. However, they are often rationalized as a gateway into unnecessary future investigations, like imaging, and unnecessary interventions.

If you give us some specific case context then I can probably provide more specific insight. I can say, generally speaking, I will test ligamentous stability in post trauma situations. A clinical context that comes to mind would be if I’m suspicious of an ACL rupture then I will likely perform anterior drawer and a Lachman’s then image depending on how much my suspicion is increased and patient is leaning towards surgical intervention for a specific return to activity level.