How to interpret orthopedic special tests

For physical therapists and other clinicians examining adults and adolescents: a special test changes the probability of a diagnosis by its likelihood ratio, applied to the patient’s pretest probability. Multiply pretest odds by the likelihood ratio, convert back to a probability, and check the study population before trusting any published figure.⁠^1,2

What do sensitivity and specificity mean for a special test?

Sensitivity is the share of people who have the condition and test positive; specificity is the share of people who do not have it and test negative.⁠² Both are measured against a reference standard, such as arthroscopy, arthrotomy or MRI in the anterior cruciate ligament (ACL) studies, so a test’s figures are only as good as the comparison behind them.⁠⁸

A diagnostic accuracy study’s results can be set out as a two-by-two table of true positives, false positives, true negatives and false negatives, as the meniscal meta-analysis did for each article and test.⁠⁹ The rows are the test result, the columns are the truth according to the reference standard, and the definitions of sensitivity and specificity follow from the cells.⁠²

Sensitivity and specificity describe the test in people whose diagnosis is already known. The clinician has the reverse problem: a result in hand and an unknown diagnosis. Likelihood ratios bridge the two, because they can be used to calculate the probability of the condition while adapting to different prior probabilities in different settings.⁠¹

Why can a sensitive test still fail to rule out a condition?

Because the power of a negative result to rule out depends on specificity as well as sensitivity, and low specificity weakens it.⁠² The straight leg raise shows the effect: in surgical populations its pooled sensitivity was 0.92, but its pooled specificity was 0.28.⁠¹⁰ Those figures give a negative likelihood ratio of about 0.29, which lowers the probability of disc herniation without coming close to the 0.1 usually treated as strong evidence for ruling out.⁠^1,10

How do you calculate likelihood ratios?

Divide sensitivity by (1 minus specificity) for the positive likelihood ratio, and divide (1 minus sensitivity) by specificity for the negative likelihood ratio.⁠² A likelihood ratio says how many times more or less likely a given result is in patients with the condition than in patients without it; above 1 the result points toward the condition, below 1 away from it.⁠¹

1. Write down the pair. Take sensitivity and specificity from the study whose population looks most like the patient, as decimals (0.81, not 81).
2. Positive likelihood ratio. LR+ = sensitivity / (1 − specificity). For a sensitivity of 0.81 and a specificity of 0.85, that is 0.81 / 0.15 = 5.4.
3. Negative likelihood ratio. LR− = (1 − sensitivity) / specificity. For the same pair, 0.19 / 0.85 = 0.22.
4. Read the size. The further a likelihood ratio is from 1, the stronger the evidence; above 10 and below 0.1 are generally considered strong evidence to rule in or rule out.⁠¹

The pair in the steps is the pooled Lachman test result from a 2022 bivariate meta-analysis of ACL tears without other ligament injury.⁠¹¹

What is a quick way to apply a likelihood ratio at the bedside?

Remember three anchors: a likelihood ratio of 2 raises the probability by about 15 points, 5 by about 30, and 10 by about 45.⁠³ McGee’s paper reports these estimates are accurate to within 10 points of the full calculation whenever the pretest probability lies between 10 and 90, with an average error of 4 points.⁠³ For results below 1, the same paper gives a decrease of about 15 points at 0.5, 30 at 0.2 and 45 at 0.1.⁠³

How do pretest and post-test probability work?

Convert the pretest probability to odds, multiply by the likelihood ratio, and convert the post-test odds back to a probability.⁠^1,2 Pretest odds are probability divided by (1 minus probability), post-test odds are pretest odds times the likelihood ratio, and post-test probability is post-test odds divided by (1 plus post-test odds).⁠²

The example’s sensitivity and specificity are the 2022 pooled Lachman values; the bedside check uses McGee’s table; the patient and the pretest estimate are invented inputs.⁠^3,11

Where does a pretest probability come from in a clinic?

It is the probability that the patient has the target condition before the test, so it starts from how common that condition is among patients like this one, then moves with the history and earlier findings.⁠² Each finding with its own likelihood ratio updates the estimate, which is why likelihood ratios work across settings where sensitivity, specificity or predictive values from a single study do not.⁠¹ Writing the estimate down before testing keeps the examination honest: the number recorded first is the one the test result revises.

When do SpPIn and SnNOut rule a diagnosis in or out?

Only when the test’s likelihood ratio is actually strong in a population like the patient’s; the mnemonics are shortcuts, not proof.⁠² SnNOut stands for high sensitivity, negative result, rules out; SpPIn for high specificity, positive result, rules in.⁠²

Pewsner and colleagues give three reasons for caution. Studies quoted as showing SpPIn or SnNOut properties may suffer from spectrum bias, partial verification bias or incorporation bias; some are too small to estimate accuracy precisely; and a test’s power to rule out is reduced by low specificity, as its power to rule in depends on sensitivity too.⁠² They recommend calculating post-test probabilities with 95% confidence intervals before relying on a test as SpPIn or SnNOut.⁠²

The pivot shift test illustrates the point. A 2006 meta-analysis pooled its specificity at 98% and its sensitivity at 24%.⁠⁸ That gives a positive likelihood ratio of about 12, strong enough to rule an ACL tear in, and a negative likelihood ratio of about 0.78, which barely moves the probability: a negative pivot shift says almost nothing.⁠^1,8

Why does a highly specific test not help when it is negative?

Because a negative result’s likelihood ratio is (1 minus sensitivity) divided by specificity, and a test that misses most true cases keeps that ratio close to 1 however specific it is.⁠² The prone Lachman study reached the same conclusion for its own test: with a specificity of 97% and a sensitivity of 70%, its authors wrote that the test should not be used as the sole criterion to rule out an ACL tear.⁠¹²

Why does clustering special tests improve diagnostic accuracy?

Because a combination can capture more of the clinical picture than any single item, and some studies report clusters that outperform each of their parts.⁠^4,13 In 82 patients with suspected cervical radiculopathy or carpal tunnel syndrome, Wainner and colleagues identified a four-item cluster with a positive likelihood ratio point estimate of 30.3, more useful for indicating radiculopathy than any single item.⁠⁴ The authors also noted that every likelihood ratio’s confidence interval was wide and called for the cluster to be validated.⁠⁴

For the shoulder, Park and colleagues found that the Hawkins-Kennedy sign, the painful arc and the infraspinatus muscle test together gave the best post-test probability, 95%, for any degree of impingement syndrome.⁠¹³ The 2012 shoulder meta-analysis was more guarded: combinations of shoulder tests gave better accuracy, but only marginally, and no single shoulder test could be recommended to make a pathognomonic diagnosis.⁠¹⁴

How should a clinician use a published test cluster?

Use it exactly as the study defined it, with the same items, the same rule for a positive cluster and a population like the one studied, and treat it as provisional until a second study confirms it.⁠^4,14 A combination’s accuracy belongs to that combination: the 2015 Thessaly study, for example, reported its own figures for the Thessaly and McMurray tests together, a sensitivity of 53% and a specificity of 62%.⁠⁷

How do you judge a diagnostic accuracy study with QUADAS-2?

Rate it in QUADAS-2’s four domains, patient selection, index test, reference standard, and flow and timing, for risk of bias, and rate the first three for concerns about applicability to the question at hand.⁠⁵ Signaling questions under each domain help the reader judge bias.⁠⁵ The 2012 shoulder review, for one, used QUADAS-2 to critique each new paper it added.⁠¹⁴

Why do published figures for the same test disagree so much?

Because studies differ in who they enroll, how they perform the test, what they use as truth and how they pool results.⁠^2,15 Five patterns recur in the studies cited on this page:

• Population. The Thessaly test at 20 degrees reached diagnostic accuracy of 94% for medial and 96% for lateral tears in a study that included asymptomatic volunteers, then a sensitivity of 64% and a specificity of 53% in 593 patients referred for arthroscopy.⁠^6,7
• Examiner and setting. In the same study, the Thessaly test gave a sensitivity of 0.66 and a specificity of 0.39 for primary care clinicians, and 0.62 and 0.55 for musculoskeletal clinicians.⁠¹⁶
• Acuity and anesthesia. For acute complete ACL tears, the pivot shift’s sensitivity was 0.28 in the office and 0.73 under anesthesia.⁠¹⁷ The anterior drawer performed well in chronic but not acute conditions in an earlier review.⁠⁸
• Reference standard. The cervical provocative test review found no study with an optimal reference standard, and the lack of a standard way to perform Spurling’s test made its studies impossible to compare.⁠¹⁵ MRI, a common reference, had a specificity of only 0.53 against arthroscopy in one meniscal subgroup.⁠¹⁶
• Analysis method. A 2022 bivariate meta-analysis argued that earlier pooling methods overestimated accuracy, and put the Lachman test at a sensitivity of 81% and a specificity of 85%.⁠¹¹

How sensitive and specific are common special tests?

The table gives each test’s published sensitivity and specificity, the likelihood ratios that follow from them, and the population the figures came from.⁠^9,11,14 Likelihood ratios marked "calc." are calculated from the published pair with the formulas above; those marked "rep." are the study’s own.⁠²

Three rows need a second reading. The Lachman test’s pooled figures were higher, a sensitivity of 85% and a specificity of 94%, in a 2006 meta-analysis whose studies were heterogeneous.⁠⁸ The straight leg raise’s specificity in the Cochrane review ranged from 0.10 to 1.00 across studies, and studies using imaging showed poorer sensitivity.⁠¹⁰ In the slump study, the straight leg raise had a sensitivity of 0.52 and a specificity of 0.89, the reverse pattern of the surgical pooled estimate.⁠¹⁹

Do these figures apply to adolescent and older patients?

Only as far as the study populations reach, so check each study’s ages before applying a figure.⁠^12,20 The two prone and standard Lachman endpoint studies, for example, enrolled patients aged 16 to 57 and 20 to 64.⁠^12,20 For meniscal tears, age and a past history of osteoarthritis predicted the MRI diagnosis for primary care clinicians, while no physical test did in the multivariate models.⁠¹⁶

How should a clinician document special test results?

Record the test by name and variant, the side, what counted as positive, the comparison with the other side, and the result, then state the clinical impression the findings support.⁠^15,20 Naming the variant matters because studies of the same named test differ in how it is performed; the Spurling’s test studies, for one, used versions with and without neck extension and rotation.⁠¹⁵ Testing the uninvolved side first gives the baseline against which the involved side is judged.⁠²⁰

What belongs in the impression after a cluster of tests?

The diagnosis the findings support and how strongly, worded as a probability judgment rather than a certainty, with the findings that argue against it.⁠² Pewsner and colleagues warn that assuming a diagnosis is ruled in or out with confidence, when it cannot be, could seriously affect patients; an impression such as "findings consistent with an ACL tear; referral to orthopedics" keeps the uncertainty visible.⁠²

How do special tests fit with history and imaging in diagnosis?

As one part of a comprehensive examination that starts with the history; the shoulder review concluded its findings support exactly that.⁠¹⁴ The meniscal review reached the same view from the other side: no single physical examination test appeared to accurately diagnose a torn meniscus, and it called for a clinical prediction rule.⁠⁹

Imaging is not a perfect answer key. In the HTA meniscal study, MRI had a sensitivity of 1.0 but a specificity of 0.53 against arthroscopy in the subgroup that went on to surgery.⁠¹⁶ A special test validated against MRI inherits MRI’s errors, which is one reason the reference standard is its own QUADAS-2 domain.⁠⁵

For patients who need a clinic after the examination, the orthopedic conditions hub and the ACL reconstruction guide for adults are written for them, and the Lachman test reference gives the full technique behind the first row of the table. The clinical resources library collects the other measurement and examination references.

Sources

1. Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios (BMJ 2004;329(7458):168-169; DOI 10.1136/bmj.329.7458.168; PMID 15258077; PMC478236; full text as shown on PubMed Central). Checked October 30, 2026.
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   “Each test result has its own likelihood ratio, which summarises how many times more (or less) likely patients with the disease are to have that particular result than patients without the disease.”; “A likelihood ratio greater than 1 indicates that the test result is associated with the presence of the disease, whereas a likelihood ratio less than 1 indicates that the test result is associated with the absence of disease.”; “Likelihood ratios above 10 and below 0.1 are considered to provide strong evidence to rule in or rule out diagnoses respectively in most circumstances.”; “The post-test odds that the patient has the disease are estimated by multiplying the pretest odds by the likelihood ratio.”; “Likelihood ratios provide a solution as they can be used to calculate the probability of abnormality, while adapting for varying prior probabilities of the chance of abnormality from different contexts.”.
2. Pewsner D, Battaglia M, Minder C, Marx A, Bucher HC, Egger M. Ruling a diagnosis in or out with “SpPIn” and “SnNOut”: a note of caution (BMJ 2004;329(7459):209-213; DOI 10.1136/bmj.329.7459.209; PMID 15271832; PMC487735; full text as shown on PubMed Central). Checked October 30, 2026.
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   “Sensitivity —The proportion of people with the disease who are correctly identified by a positive test result (“true positive rate”)”; “Specificity —The proportion of people free of the disease who are correctly identified by a negative test result (“true negative rate”)”; “Likelihood ratio of a positive test result (LR +)—The ratio of the true positive rate to the false positive rate: sensitivity/(1-specificity)”; “Likelihood ratio of a negative test result (LR -)—The ratio of the false negative to the true negative rate: (1-sensitivity)/specificity”; “Pretest probability (prevalence) —The probability that an individual has the target disorder before the test is carried out”; “Pretest odds —The odds that an individual has the target disease before the test is carried out (pretest probability/[1-pretest probability])”; “Post-test odds —The odds that a patient has the target disease after being tested (pretest odds×LR)”; “Two mnemonics that capture the properties of such tests have been coined: SnNOut (high sensitivity, negative, rules out) and SpPIn (high specificity, positive, rules in).”; “Studies quoted as showing SpPIn or SnNOut properties may be affected by spectrum bias, partial verification bias, or incorporation bias. Others may be too small to define test characteristics with sufficient precision”; “The power of a test to rule a diagnosis out does not depend exclusively on its sensitivity, as suggested by the SnNOut rule, but is reduced by low specificity. Similarly, the power to rule in depends on both specificity and sensitivity”; “post-test probabilities (with 95% confidence intervals) should be calculated when evaluating potential SnNOut or SpPIn tests”; “Assuming that a diagnosis can be ruled in or out with confidence, when in reality it cannot, could have serious consequences for patients”; “Positive predictive value (PPV) —The proportion of individuals with positive test results who have the target condition. This equals the post-test probability given a positive test result”.
3. McGee S. Simplifying likelihood ratios (J Gen Intern Med 2002;17(8):646-649; DOI 10.1046/j.1525-1497.2002.10750.x; PMID 12213147; PMC1495095; full text as shown on PubMed Central). Checked October 30, 2026.
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   “An LR of 2 increases probability 15%, one of 5 increases it 30%, and one of 10 increases it 45%.”; “Just as the LR of 2.0 increases probability 15%, its inverse, 0.5, decreases probability 15%. Similarly, an LR of 0.2 (the inverse of 5) decreases probability 30%, and a LR of 0.1 (the inverse of 10) decreases it 45%.”; “Although this method is inaccurate for pretest probabilities less than 10% or greater than 90%”; “these estimates are accurate to within 10% of the calculated answer for all pretest probabilities between 10% and 90%. The average error is only 4%.”.
4. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy (Spine 2003;28(1):52-62; DOI 10.1097/00007632-200301010-00014; PMID 12544957; abstract as shown on Europe PMC). Checked October 30, 2026.
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   “The study involved 82 patients.”; “Patients with suspected cervical radiculopathy or carpal tunnel syndrome received standardized electrophysiologic examination of the symptomatic upper quarter followed by a standardized clinical examination by physical therapist examiners blinded to diagnosis.”; “A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3. The 95% confidence intervals for all likelihood ratio point estimates in this study were wide.”; “the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item.”; “Further investigation is required both to validate the test item cluster and to improve point estimate precision.”.
5. Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeflang MM, Sterne JA, Bossuyt PM; QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies (Ann Intern Med 2011;155(8):529-536; DOI 10.7326/0003-4819-155-8-201110180-00009; PMID 22007046; abstract as shown on Europe PMC). Checked October 30, 2026.
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   “This tool comprises 4 domains: patient selection, index test, reference standard, and flow and timing.”; “Each domain is assessed in terms of risk of bias, and the first 3 domains are also assessed in terms of concerns regarding applicability.”; “Signalling questions are included to help judge risk of bias.”.
6. Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears (J Bone Joint Surg Am 2005;87(5):955-962; DOI 10.2106/JBJS.D.02338; PMID 15866956; abstract as shown on Europe PMC). Checked October 30, 2026.
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   “Two hundred and thirteen symptomatic patients with knee injuries who were examined clinically, had magnetic resonance imaging studies performed, and underwent arthroscopic surgery and 197 asymptomatic volunteers”; “The Thessaly test at 20 degrees of knee flexion had a high diagnostic accuracy rate of 94% in the detection of tears of the medial meniscus and 96% in the detection of tears of the lateral meniscus”.
7. Goossens P, Keijsers E, van Geenen RJ, Zijta A, van den Broek M, Verhagen AP, Scholten-Peeters GG. Validity of the Thessaly test in evaluating meniscal tears compared with arthroscopy: a diagnostic accuracy study (J Orthop Sports Phys Ther 2015;45(1):18-24; DOI 10.2519/jospt.2015.5215; PMID 25420009; abstract as shown on Europe PMC). Checked October 30, 2026.
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   “Patients with suspected meniscal tears, referred to a hospital for arthroscopic surgery, were eligible.”; “A total of 593 patients were included, of whom 493 (83%) had a meniscal tear, as determined by the arthroscopic examination.”; “The Thessaly test had a sensitivity of 64% (95% confidence interval [CI]: 60%, 68%), specificity of 53% (95% CI: 43%, 63%)”; “positive and negative likelihood ratios of 1.37 (95% CI: 1.10, 1.70) and 0.68 (95% CI: 0.59, 0.78), respectively.”; “The results of the Thessaly test alone or combined with the McMurray test do not seem useful to determine the presence or absence of meniscal tears.”; “The combination of positive Thessaly and McMurray tests showed a sensitivity of 53% and specificity of 62%.”.
8. Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis (J Orthop Sports Phys Ther 2006;36(5):267-288; DOI 10.2519/jospt.2006.2011; PMID 16715828; abstract as shown on Europe PMC). Checked October 30, 2026.
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   “compared the performance of the clinical examination of the knee with a reference standard, such as arthroscopy, arthrotomy, or MRI”; “Twenty-eight studies that assessed the accuracy of clinical tests for diagnosing ACL ruptures met the inclusion criteria. Study results were, however, heterogeneous.”; “The Lachman test is the most valid test to determine ACL tears, showing a pooled sensitivity of 85% (95% confidence interval [CI], 83-87) and a pooled specificity of 94% (95% CI, 92-95).”; “The pivot shift test is very specific, namely 98% (95% CI, 96-99), but has a poor sensitivity of 24% (95% CI, 21-27).”; “The anterior drawer test shows good sensitivity and specificity in chronic conditions, respectively 92% (95% CI, 88-95) and 91% (95% CI, 87-94), but not in acute conditions.”; “In case of suspected ACL injury it is recommended to perform the Lachman test. Because the pivot shift test is very specific both in acute as well as in chronic conditions, it is recommended to perform the pivot shift test as well.”.
9. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis (J Orthop Sports Phys Ther 2007;37(9):541-550; DOI 10.2519/jospt.2007.2560; PMID 17939613; abstract as shown on Europe PMC). Checked October 30, 2026.
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   “Eighteen studies qualified for the final analyses.”; “We retrieved data regarding true positives, false positives, true negatives, and false negatives to create 2-by-2 tables for each article and test.”; “Pooled sensitivity and specificity were 70% and 71% for McMurray’s, 60% and 70% for Apley’s, and 63% and 77% for joint line tenderness.”; “Large between-study differences could not be explained by prevalence, study quality, or how well an index test was described.”; “No single physical examination test appears to accurately diagnose a torn tibial meniscus”; “the development of a clinical prediction rule to aid clinicians in the diagnosis of a torn tibial meniscus”.
10. van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain (Cochrane Database Syst Rev 2010;(2):CD007431; DOI 10.1002/14651858.CD007431.pub2; PMID 20166095; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “Only one study was carried out in a primary care population.”; “In surgical populations, characterized by a high prevalence of disc herniation (58% to 98%), the SLR showed high sensitivity (pooled estimate 0.92, 95% CI: 0.87 to 0.95) with widely varying specificity (0.10 to 1.00, pooled estimate 0.28, 95% CI: 0.18 to 0.40).”; “Results of studies using imaging showed more heterogeneity and poorer sensitivity.”; “In the one primary care study, most tests showed higher specificity and lower sensitivity compared to other settings.”.
11. Sokal PA, Norris R, Maddox TW, Oldershaw RA. The diagnostic accuracy of clinical tests for anterior cruciate ligament tears are comparable but the Lachman test has been previously overestimated: a systematic review and meta-analysis (Knee Surg Sports Traumatol Arthrosc 2022;30(10):3287-3303; DOI 10.1007/s00167-022-06898-4; PMID 35150292; PMC9464183; full text as shown on PubMed Central). Checked October 30, 2026.
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    “The aim of this study was to report the diagnostic accuracy of clinical tests for anterior cruciate ligament tears (partial and complete) without concomitant knee ligament injury.”; “Meta-analyses have also been performed using methods that do not account for the non-independence of sensitivity and specificity, potentially overestimating diagnostic accuracy.”; “anterior drawer test 83% [95% CI, 77–88] and 85% [95% CI, 64–95]; Lachman test 81% [95% CI, 73–87] and 85% [95% CI, 73–92]; pivot shift test 55% [95% CI, 47–62] and 94% [95% CI, 88–97]”; “complete tears 68% [95% CI, 54–79] and 79% [95% CI, 51–93]; post-acute injuries 70% [95% CI, 57–80] and 77% [95% CI, 53–91]”; “The diagnostic accuracy of the Lachman test, particularly in post-acute presentations and for complete tears, is lower than previously reported.”; “The pivot shift and Lever sign were the best tests overall for ruling in or ruling out an anterior cruciate ligament tear, respectively.”; “Further research is required to establish more accurate estimates for the Lachman test in acute presentations and partial ligament tears using bivariate analysis.”.
12. Mulligan EP, Harwell JL, Robertson WJ. Reliability and diagnostic accuracy of the Lachman test performed in a prone position (J Orthop Sports Phys Ther 2011;41(10):749-757; DOI 10.2519/jospt.2011.3761; PMID 21891874; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “An alternative position for evaluating the integrity of the ACL has been proposed as a means for examiners with smaller hands to adequately stabilize the thigh of a larger individual”; “Direct arthroscopic visualization and a consensus of clinical findings, including joint arthrometry and magnetic resonance imaging, were used as the reference standards.”; “Fifty-two consecutive patients with a complaint of knee pain were independently evaluated in a prone position for the status of their ACL by 2 physical therapists”; “The 31 men and 21 women ranged in age from 16 to 57 (mean ± SD, 34.3 ± 4.2) years”; “The agreement between examiners was 90%, with a kappa coefficient of 0.81.”; “The sensitivity of the prone Lachman test was 70% and the specificity was 97%, resulting in a positive likelihood ratio of 20.17 and a negative likelihood ratio of 0.32.”; “the test should not be used as the sole criterion to rule out the presence of the injury.”.
13. Park HB, Yokota A, Gill HS, El Rassi G, McFarland EG. Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome (J Bone Joint Surg Am 2005;87(7):1446-1455; DOI 10.2106/JBJS.D.02335; PMID 15995110; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “The combination of the Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for any degree of impingement syndrome.”; “The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests.”.
14. Hegedus EJ, Goode AP, Cook CE, Michener L, Myer CA, Myer DM, Wright AA. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests (Br J Sports Med 2012;46(14):964-978; DOI 10.1136/bjsports-2012-091066; PMID 22773322; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “The Quality Assessment of Diagnostic Accuracy Studies, version 2 (QUADAS 2) tool was used to critique the quality of each new paper.”; “For subacromial impingement, the meta-analysis revealed that the pooled sensitivity and specificity for the Neer test was 72% and 60%, respectively, for the Hawkins-Kennedy test was 79% and 59%, respectively, and for the painful arc was 53% and 76%, respectively.”; “Based on data from the original 2008 review and this update, the use of any single ShPE test to make a pathognomonic diagnosis cannot be unequivocally recommended.”; “Combinations of ShPE tests provide better accuracy, but marginally so.”; “These findings seem to provide support for stressing a comprehensive clinical examination including history and physical examination.”; “Where appropriate, data from the prior review and this review were combined to perform meta-analysis using the updated hierarchical summary receiver operating characteristic and bivariate models.”.
15. Rubinstein SM, Pool JJ, van Tulder MW, Riphagen II, de Vet HC. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy (Eur Spine J 2007;16(3):307-319; DOI 10.1007/s00586-006-0225-6; PMID 17013656; PMC2200707; full text as shown on PubMed Central). Checked October 30, 2026.
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    “Only six studies met the inclusion criteria, which evaluated five provocative tests.”; “(2) no study used an optimal reference standard”; “Spurling’s—without neck extension”; “therefore, a meta-analysis was not conducted.”; “In general, the four studies which investigated Spurling’s test [ 51 , 59 , 62 , 63 ] demonstrated low to moderate sensitivity and high specificity”; “Shah [ 51 ] (no rotation) Operation (group 1) 20 5 0.90 (0.68–0.99) 1.00 (0.48–1.00)”; “Tong [ 59 ] (with contralateral rotation) EMG 20 172 0.30 (0.12–0.54) 0.93 (0.88–0.96)”; “Ibid MRI, no operation (group 2) 9 16 1.00 (0.66–1.00) b 0.94 (0.70–1.00) b”; “Viikari-Juntura [ 62 ] (with contralateral rotation) Myelography a 22 56 0.50 (0.28–0.72) 0.93 (0.83–0.98)”; “Wainner [ 63 ]; (Test part A) c (no cervical rotation) Needle EMG/NCS 19 63 0.50 (0.27–0.73) 0.86 (0.77–0.94)”; “Wainner [ 63 ]; (Test part B) c (with ipsilateral rotation) Needle EMG/NCS 19 63 0.50 (0.27–0.73) 0.74 (0.63–0.85)”; “the lack of test standardization (or performance), specifically Spurling’s test, made it impossible to compare sensitivity and specificity across studies.”; “a negative ULTT might be used to rule it out. However, the lack of evidence precludes any firm conclusions regarding their diagnostic value, especially when used in primary care.”.
16. Blyth M, Anthony I, Francq B, Brooksbank K, Downie P, Powell A, Jones B, MacLean A, McConnachie A, Norrie J. Diagnostic accuracy of the Thessaly test, standardised clinical history and other clinical examination tests (Apley’s, McMurray’s and joint line tenderness) for meniscal tears in comparison with magnetic resonance imaging diagnosis (Health Technol Assess 2015;19(62):1-62; DOI 10.3310/hta19620; PMID 26243431; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “The Thessaly test had a sensitivity of 0.66, a specificity of 0.39 and a diagnostic accuracy of 54% when utilised by primary care clinicians.”; “This compared with a sensitivity of 0.62, a specificity of 0.55 and diagnostic accuracy of 59% when used by musculoskeletal clinicians.”; “For primary care clinicians, age and past history of osteoarthritis were both significant predictors of MRI diagnosis of meniscal tears.”; “No physical tests were significant predictors of MRI diagnosis in our multivariate models.”; “The specificity of MRI diagnosis was tested in subgroup of patients who went on to have a knee arthroscopy and was found to be low [0.53 (95% confidence interval 0.28 to 0.77)], although the sensitivity was 1.0.”.
17. van Eck CF, van den Bekerom MP, Fu FH, Poolman RW, Kerkhoffs GM. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia (Knee Surg Sports Traumatol Arthrosc 2013;21(8):1895-1903; DOI 10.1007/s00167-012-2250-9; PMID 23085822; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “All cross-sectional and cohort studies comparing one or more physical examination tests for diagnosing acute complete ACL rupture to an accepted reference standard such as arthroscopy, arthrotomy and MRI were included.”; “Twenty studies were identified and included. The overall sensitivity of the Lachman test was 0.81 and the specificity 0.81; with anaesthesia, the sensitivity was 0.91 and the specificity 0.78.”; “For the anterior drawer test, the sensitivity was 0.38 and the specificity 0.81; with anaesthesia, the sensitivity was 0.63 and the specificity 0.91.”; “The sensitivity of the pivot shift test was 0.28 and the specificity 0.81; with anaesthesia, the sensitivity was 0.73 and the specificity 0.98.”; “In the office setting, the Lachman test has the highest sensitivity for diagnosing an acute, complete ACL rupture, while all three tests had comparable specificity.”.
18. Ackmann T, Schneider KN, Schorn D, Rickert C, Gosheger G, Liem D. Comparison of efficacy of supraspinatus tendon tears diagnostic tests: a prospective study on the “full-can,” the “empty-can,” and the “Whipple” tests (Musculoskelet Surg 2021;105(2):149-153; DOI 10.1007/s12306-019-00631-0; PMID 31691179; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “We examined 61 patients (26 women, 35 men) presenting for arthroscopic surgery with functional disability or persisting shoulder pain.”; “For full and partial supraspinatus tendon tears, the Whipple test showed a sensitivity of 88.6% and a specificity of 29.4%, whereas the empty-can test and the full-can test had sensitivities of 88.6% and 75.0%, and specificities of 58.8% and 47.1%, respectively.”.
19. Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation (J Clin Rheumatol 2008;14(2):87-91; DOI 10.1097/RHU.0b013e31816b2f99; PMID 18391677; abstract as shown on Europe PMC). Checked October 30, 2026.
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    “A prospective case control study of 75 patients with complaints suggestive of lumbar disc herniation was carried out in the outpatient clinics of the neurosurgery department of a state teaching hospital.”; “Thirty-eight patients had signs of herniation demonstrated by MRI.”; “The Slump test was found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniations. However, the SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83).”.
20. Mulligan EP, McGuffie DQ, Coyner K, Khazzam M. The reliability and diagnostic accuracy of assessing the translation endpoint during the Lachman test (Int J Sports Phys Ther 2015;10(1):52-61; PMID 25709863; PMC4325288; full text as shown on PubMed Central). Checked October 30, 2026.
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    “The Lachman test is characterized as the most direct and definitive evaluative technique used to determine the status of the ACL and is best performed prior to the onset of the patient’s pain, swelling, and guarding.”; “Traditionally, a grade of A is given when the endpoint is perceived to be “firm” while a grade of B is given if the endpoint is felt to be soft, absent, or ill‐defined.”; “A firm endpoint in the presence of increased translation may represent a partial tear or a tear of the ACL’s posterolateral bundle.”; “Callaghan et al 12 suggest that an absent or soft endpoint indicates the lack of anterior restraint, whereas a firm endpoint signifies a normal ACL.”; “17 of the 45 patients had a torn ACL.”; “This classification was determined prior to testing for a pivot shift so as to not bias the findings of the examiners.”; “For all patients the uninvolved knee was evaluated first in order to establish a baseline by which the contralateral knee could be judged.”; “This is an important element of the evaluative process particularly in cases where there is significant inherent laxity of the uninvolved extremity.”; “The general “rule of thumb” for interpreting ligamentous stability is to place more value on the quality of motion and endpoint distinctiveness as compared to the amount of laxity present.”; “When analyzed by discipline, physical therapists had an intertester kappa coefficient range of 0.02 to 0.69 with 53‐84% agreement.”; “suspicion of posterior cruciate ligament (PCL) involvement”; “PCL injury evaluation was conducted via visual and palpatory assessment of a tibial sag sign with knee flexed at 90 degrees.”; “If the tibial plateau did not appear to be at least one centimeter (cm) anterior to the femoral condyle, a quadriceps active drawer test was applied to rule in PCL injury.”; “The palpatory loss of the tibia‐femur step‐off relationship has been shown to be a sensitive (0.90) and specific (0.99) means by which to detect the presence of a PCL injury.”; “The quadriceps active drawer test is performed by the patient gently contracting the quadriceps with the knee flexed at 90° and foot stabilized on the treatment plinth.”; “The specificity of this maneuver has been reported to be 96% and the sensitivity 53%.”; “record the millimeters of anterior translation at 15, 20, and 30 pounds (6.8, 9.1, and 13.6 kg) of force”; “The test was performed with the patient lying supine on a firm examination table and the knee flexed to 20‐30 degrees. Care was taken to ensure the both knees were in the same degree of flexion during the physical examination procedure.”; “The examiner’s upper hand stabilized the unsupported distal thigh, while the lower hand, with the thumb on the anterior joint line, and the fingers feeling to ensure that the hamstrings were relaxed, pulled the tibia forward with approximately 30 lbs of force.”; “I < 5 mm translation II 5 – 10 mm translation III > 10 mm translation”; “Forty‐five consecutive patients with a complaint of knee pain were independently evaluated for the endpoint classification during a Lachman test by two physical therapists before any other diagnostic assessment.”; “The 21 men and 24 women ranged in age from 20 to 64 years”; “The agreement between examiners on A versus B endpoint classification was 91% with a kappa coefficient of 0.72. In contrast, classification agreement based on the translational amount had an agreement of 65% with a weighted kappa coefficient of 0.52.”; “The sensitivity of the endpoint grade alone was 0.81 with perfect specificity resulting in a positive likelihood ratio of 6.2 and a negative likelihood ratio of 0.19.”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is a reference on reading diagnostic accuracy research for licensed clinicians, and it does not replace the clinician’s own examination and judgment. Published accuracy figures come from the study populations named beside them and may not match a given patient.