Table Of ContentSpecial Tests in
Musculoskeletal Examination
www.specialtests.org
Commissioning Editor: Rita Demetriou-Swanwick
Development Editor: Veronika Watkins
Project Manager: Vijayakumar Sekar
Designer/Design Direction: Kirsteen Wright
Illustration Manager: Bruce Hogarth
Special Tests in
Musculoskeletal
Examination
An evidence-based
guide for clinicians
Written by
Paul Hattam MSc MCSP FSOM
Director and Principal Physiotherapist,
The Physios, Sheffield, UK
Alison Smeatham MSc MCSP FSOM
Extended Scope Practitioner, Royal Devon
and Exeter Hospital, Exeter, UK
Edinburgh London New York Oxford Philadelphia
St Louis Sydney Toronto 2010
First published 2010, © Elsevier Limited. All rights reserved.
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ISBN 978-0-7020-3025-3
B ritish Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
L ibrary of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
N otice
Neither the Publisher nor the Authors assume any responsibility for
any loss or injury and/or damage to persons or property arising out
of or related to any use of the material contained in this book. It is the
responsibility of the treating practitioner, relying on independent
expertise and knowledge of the patient, to determine the best treatment
and method of application for the patient.
The Publisher
Printed in China
DeDication
For Jean Barbara Smeatham 1937–2008
Faith, hope and love.
vi
About the Authors
Paul Hattam and Alison Smeatham are physiotherapists with a
special interest in musculoskeletal medicine, having accumulated
many years of experience treating patients both in the National
Health Service and in private practice. They were among the first
extended scope physiotherapists (ESPs) to establish orthopaedic
triage in primary care during the 1990s, a model that was subse-
quently evaluated and reproduced throughout the UK. They com-
pleted a musculoskeletal master’s programme in 2002/3 and retain
a keen interest in research in their area of specialty. Both tutor reg-
ularly on postgraduate courses for doctors and physiotherapists
in musculoskeletal medicine as well as being actively involved in
educational programmes closer to their homes. Paul now leads the
team at The Physios (www.thephysios.com) in Sheffield, UK, while
Alison works as an ESP with the specialist hip team at the Princess
Elizabeth Orthopaedic Centre in Exeter, UK.
vii
Acknowledgements
The authors would like to thank everyone who helped us see this
project through to completion. As is often the case, the size of an
undertaking only becomes evident once you have started it and
the encouragement we received from our families, friends and col-
leagues was always welcome and helped to spur us on.
We benefited enormously from the collective wisdom of a
number of medical and physiotherapy colleagues from across the
UK and are particularly grateful to the following: Jill Gillespie,
Margaret Rees, Chris Blundell, and the hip and knee surgeons and
ESPs at Princess Elizabeth Orthopaedic Centre and Devon PCT for
their contributions. We appreciated the free exchange of informa-
tion and ideas with our teaching colleagues Elaine Atkins, Jill Kerr
and Emily Goodlad, even though they managed to pip us to the
post and submit the manuscript for their book first.
Nigel Hanchard contributed to the labral, tendon and impinge-
ment tests at the shoulder. As lead author of the Cochrane proto-
type diagnostic review on this topic (in development), and of the
Chartered Society of Physiotherapy’s clinical guidelines on shoulder
impingement, his familiarity with the evidence base provided a rich
resource of which we made good use. Nigel also made welcome
suggestions for the introductory chapter, all of which were very
valuable.
We would like to thank Gordon Smith who, despite agreeing to
completely unreasonable deadlines, painstakingly proof read each
section and provided correction and challenge in equal measure. We
were also very grateful for the fresh pair of eyes willingly provided
by Joy Hattam at the final proof reading stage. Our model for the
photographs, Alison Crewesmith, was good humoured throughout
a very long day and Ant Clifford had the eye to make the photos
clear and visually appealing. Space to spread out and edit the book
was generously provided by Lindsay Jackson at EEF, Sheffield.
Thanks to everyone at Elsevier, particularly Heidi Harrison
for her initial enthusiasm that helped to launch the idea and to
Veronika Watkins and Rita Demetriou-Swanwick for their endless
patience and guidance during the writing and final editing stages.
viii
Acknowledgements ix
Paul thanks
Time away researching and writing the book inevitably meant an
increased burden on my colleagues and I would like to thank every-
one at The Physios for their encouragement and support. My family
have exhibited patience beyond measure and I am hugely grateful
to my wife, Alison, for taking everything perfectly in her stride and
helping me keep things in perspective, as well as retaining a keen
sense of humour throughout. The same can be said for Rachael,
James and Naomi who happily got on with life while Dad tapped
away on the computer. You’re amazing!
Alison thanks
I would like to thank friends and colleagues who managed to
remain interested and enthusiastic about this project over many
cups of tea and glasses of wine. My family, and in particular Mum
and Dad, continued to provide unwavering encouragement and
support even when much more important events were taking place
and my love and gratitude goes to them and to David, Karen, Tom,
Rosie, Irene and Terry.
Foreword
Paul Hattam and Alison Smeatham are long-time teaching col-
leagues of mine. From their first musings that a new text was
needed to acknowledge and examine the growing bank of addi-
tional tests for peripheral lesions, I have been so excited to see their
book in print knowing that they would create this clear, concise
and highly readable resource drawn from a rigorous and objective
trawl through the available evidence. They have wisely recruited
the opinion of other experts too though, acknowledging that many
tests are chiefly derived from empirical practice and should not be
discarded without due consideration for clinical experience. As we
might expect, many of the tests do not enjoy a strong, consistent
evidence base to support their application and not surprisingly, it is
the expert opinion that draws the eye to guide practice.
I have read this book because I wanted to learn from it and I
have already found it to be a valuable resource. The initial ‘About
the book’ section sets the scene for the rest of the book, providing
generic ‘ground rules’ for how to apply the tests and an explana-
tion of how the literature was searched and the evidence appraised
and interpreted. ‘Likelihood ratios’, combining sensitivity and spe-
cificity, are justified as the best statistics to assess the clinical use-
fulness of the diagnostic tests they have presented. The tests are
described simply and clearly and are accompanied by concise, ref-
erenced discussion to provide context; focussing on the tests them-
selves as opposed to the pathology of specific lesions. In this respect
a gap has been plugged since that tends to sit outside the remit of
other texts in musculoskeletal medicine; even those dedicated to
assessment.
The book includes tests I haven’t come across, tests I’d forgot-
ten and tests I’ve always been slightly confused about. The authors’
determination to unravel the complex and to keep to the facts is
both welcome and reassuring and the simple device of beginning
each test with an ‘also known as’ (aka) list defuses the confusion
where many of the tests described in the literature exist under sev-
eral different names. In this they have exposed their awareness of
just who their reader is – a busy clinician with the nous and will
to read more – but with so little time. The authors have struck an
