Physiotherapy Clinical Examination Guide

Welcome to the Clinical Examination Guide

This guide supports physiotherapy students in developing a structured and evidence-informed approach to clinical examination. It combines regional examination procedures, movement assessment, strength and length testing, and selected special tests with available diagnostic values.

The purpose of the guide is not to provide a fixed checklist, but to support clinical reasoning. Findings from the physical examination should always be interpreted in relation to the patient’s history, symptom behaviour, functional limitations, irritability, and comparison with the contralateral side.

Clinical examination is also part of a broader biopsychosocial assessment. Pain, movement, disability, and recovery are influenced not only by tissue-related factors, but also by psychological, social, contextual, and lifestyle factors. The physical examination can therefore help identify relevant impairments, but it should never be separated from the person’s goals, beliefs, concerns, daily activities, and participation.

Using the guide

Special tests can help refine clinical hypotheses by increasing or decreasing the likelihood of specific pathologies. However, no test should be interpreted on its own. Sensitivity and specificity values are useful only when they are considered within the broader clinical picture.

Use the menu to navigate between anatomical regions, the search bar to locate tests or pathologies, and the filter options to explore diagnostic values. The guide is intended to help you ask better clinical questions, choose relevant tests, and interpret findings more carefully.

Red Flags & Referral

Clinical examination should always begin with awareness of possible serious pathology. Most musculoskeletal complaints are not caused by serious disease, but physiotherapists must be able to recognise findings that may require medical assessment before continuing with routine examination or treatment.

Red flags are signs or symptoms that may indicate serious underlying pathology. They are not diagnoses and should not be interpreted in isolation. A single red flag may be non-specific, but combinations of findings, worsening symptoms, unusual presentation, or clear mismatch between symptoms and mechanical behaviour should increase clinical concern.

When to Consider Referral

Consider referral or urgent medical assessment when the patient presents with findings such as significant trauma, suspected fracture, unexplained weight loss, fever or signs of infection, history of cancer with new or unexplained pain, severe or worsening night pain, progressive neurological deficit, bowel or bladder dysfunction, saddle anaesthesia, unexplained vascular symptoms, or severe non-mechanical pain.

Interpreting Red Flags

Red flags should always be interpreted in relation to the full clinical picture: age, history, symptom behaviour, irritability, mechanism of onset, general health, neurological status, and the patient’s own concerns.

When serious pathology cannot be reasonably excluded, the priority is not to complete the musculoskeletal examination, but to ensure appropriate medical follow-up.

Clinical Reasoning Note

The presence of a red flag does not automatically mean that serious pathology is present. However, it should change the level of clinical caution. The more the findings cluster together, worsen over time, or do not fit a typical musculoskeletal pattern, the more important it becomes to pause, reconsider the working hypothesis, and seek appropriate medical input.

The Osteokinematic Examination

The osteokinematic examination is divided into two parts: the Active Function Examination (AFE) and the Passive Function Examination (PFE). During the AFE, the patient performs the movement independently after instruction from the therapist. During the PFE, the therapist performs the movement with the patient, often involving fixation. This allows for counteracting compensation and allows for a better assessment of the actual range of motion of the joint.

For both the lower and upper extremities, always begin with the Active Function Examination before proceeding to the passive examination. Expected ranges of motion are standard values, but deviations do not automatically indicate pathology. Comparing findings for the left and right sides is particularly important, as is the occurrence of recognisable symptoms.

Active Function Examination (AFE)

During the AFE the patient performs movements independently. The therapist observes and records the following:

Range of motion (ROM) — how far the movement can be performed
Quality of movement — fluency, symmetry, and control
Crepitations or other sounds — audible or palpable phenomena
Patient findings — pain, discomfort, or other sensations reported during movement

Passive Function Examination (PFE)

During the PFE the therapist performs the movement with the patient. Fixation is used to counteract compensatory movement and to isolate the joint being examined. The therapist observes and feels the following:

Range of motion (ROM)
End-feel — the quality of the resistance at the end of the available range
Crepitations or other sounds
Ability to be moved — willingness or capacity of the joint to be guided through range
Patient findings — pain or other symptoms during passive movement

The tables for each region include the expected end-of-motion sensations. Deviations from these could indicate pathology, but comparing the contralateral side remains essential.

End-Feel Classification

End-feel is the quality of resistance felt by the examiner at the end of the available passive range of motion. Deviations from the expected end-feel at a given joint are clinically significant and should be noted.

Soft Soft tissues of the body touch each other, preventing the movement from continuing. Normal example: knee flexion (soft tissue approximation).

Hard The movement comes to an end and it feels as if one bone is touching another — bone on bone. Normal example: elbow extension.

Tight Non-contractile tissue structures such as the joint capsule and ligaments prevent the movement from continuing. The most common normal end-feel.

Elastic Contractile tissues stretch and prevent the movement from continuing. Normal example: hip extension with knee flexed (rectus femoris).

Empty As a therapist, you think you could continue the movement, but the patient is experiencing too many complaints, making it irresponsible to continue. Always indicates pathology. Apprehension — a patient's protective fear response or sense of impending instability — can also produce an empty end-feel.

Purpose of the General Examination Phases

After completing the active and passive examination of joint function, the physical therapist proceeds to the assessment of strength and length of the contractile tissues. This step is not an isolated procedure, but a logical continuation of the clinical reasoning process.

While joint examinations provide information about movement availability, joint integrity, and pain behaviour, they do not fully explain how the neuromuscular system contributes to observed limitations. Strength and muscle length testing clarify whether the contractile tissues are functioning adequately within the available range of motion and under load.

The purpose of the general examination phases is to narrow the diagnostic field and to identify potentially treatable components of the patient's presentation. Movement behaviour, symptom response, strength deficits, and changes in muscle length provide valuable clues about tissue involvement, load tolerance, and modifiable impairments. Only when this foundation is in place does specific testing become meaningful.

Why Perform Special Tests?

Special tests in physiotherapy are designed to include or exclude specific pathologies. Their value lies in their ability to modify the likelihood that a particular condition is present.

Some tests are characterised by high sensitivity. A highly sensitive test is useful for ruling out a pathology when the test result is negative — the SnNOUT rule. If such a test does not reproduce the expected findings, the likelihood that the condition is present becomes low.

Other tests have high specificity. These are most useful for ruling in a pathology when the test result is positive — the SpPIN rule. A positive result strongly suggests the presence of the condition being tested for. Ideally a test would be both highly sensitive and highly specific, but in clinical practice this combination is uncommon.

Special tests therefore serve as confirmatory or exclusionary tools rather than starting points. When used too early, without sufficient prior information, their results risk being misleading. When used appropriately, they refine clinical hypotheses, support decision-making, and contribute to a more precise working diagnosis.

Position of Tests in the Examination Sequence

The special tests included in this manual are organised by anatomical region. This overview does not represent an exhaustive collection of all available special tests. It is a deliberate selection of tests for which the strongest evidence is currently available.

In clinical practice, you may encounter or learn additional tests beyond those presented here. Such tests may have lower clinimetric values, meaning that conclusions drawn from them may be less robust. Research on diagnostic testing is continuously evolving and the selection of recommended tests may change accordingly.

The emphasis during class is on understanding when and why to use a specific test, rather than memorising test procedures alone. By embedding special testing within a logical examination sequence, physiotherapy assessment remains hypothesis-driven, efficient, and clinically meaningful.

Importantly, special test findings should never be interpreted in isolation. They must be integrated with the patient's history, general examination findings, symptom behaviour, and functional limitations.

Diagnostic Value Legend

Sensitivity and specificity values in this reference are colour-coded as follows:

≥ 0.80 High — strong diagnostic value; can meaningfully rule in or rule out

0.50–0.79 Moderate — some diagnostic contribution; interpret with caution

< 0.50 Low — limited diagnostic value; use only in combination

N/A Not available — test is included as best available clinical option

Strength Testing

After completing an active and passive examination of joint function, the physical therapist proceeds to the assessment of strength and length of the contractile tissues. This step is a logical continuation of the clinical reasoning process — not an isolated procedure.

The primary aim at this stage is not detailed muscle diagnosis, but functional screening. Assessment therefore begins with muscle groups rather than individual muscles. Testing muscle groups first allows the therapist to identify whether there is a functional deficit at all. If group testing reveals reduced strength, altered control, or unexpected symptoms, this provides a clear clinical indication to proceed with more specific, selective muscle testing. If no relevant findings emerge, further differentiation is often unnecessary and may not add clinical value.

Strength testing within this framework is performed isometrically. Isometric testing minimises joint movement, reduces mechanical stress on potentially irritable tissues, and allows for a controlled assessment of force generation. This makes it particularly suitable early in the examination process, especially when pain, instability, or uncertainty about tissue tolerance is present.

MRC Scale

Strength findings are documented using the Medical Research Council (MRC) scale, ranging from 0 to 5. The scale is used in its standard form.

Score	Description
0	No visible or palpable contraction
1	Visible or palpable contraction, but no movement
2	Active movement possible with gravity eliminated
3	Active movement against gravity, no additional resistance
4	Active movement against gravity and some resistance
5	Normal strength against full resistance

Riddoch et al, MRC, 1943 (revised 1976)

Length Testing

In addition to strength, muscle group length is assessed to gain insight into the extensibility of the contractile tissues. Length testing is not merely a mechanical measurement of range, but a clinical evaluation that integrates both objective and subjective information.

From a clinical perspective, the therapist observes whether the expected end range is reached and at what point in the range movement becomes limited. An early or unexpected end range may indicate increased muscle tone, adaptive shortening, or protective behaviour. Equally important is the patient's experience during the test.

Discomfort, pain, or tension occurring earlier than expected — or with disproportionate intensity — can be clinically relevant even if the absolute range appears acceptable. By combining observed movement behaviour with patient-reported sensations, muscle length testing provides information about tissue function, load tolerance, and symptom reproduction.

These findings help the therapist decide whether muscle length contributes meaningfully to the patient's problem and whether it should be addressed in treatment or further differentiated in examination.

Integration with the Examination Sequence

Strength and length testing should always be interpreted in the context of the broader examination. Key clinical questions at this stage:

Is the primary source of the complaint likely contractile or non-contractile tissue?
Are the symptoms more consistent with an intra-articular or extra-articular origin?
Do deficits in strength or length adequately explain the patient's functional limitations?
Can identified deficits be addressed directly through intervention, or do they require further differentiation?

These questions are not answered by special tests, but by the synthesis of information gathered in the preceding examination phases. Only when this foundation is in place does targeted special testing become meaningful.