Test library › Strongest tests
The strongest special tests to rule in and rule out
Of the musculoskeletal examination tests in the library, these are the ones whose published figures make them strong: an LR+ of 10 or more (a positive makes the diagnosis much more likely) or an LR− of 0.1 or less (a negative makes it very unlikely). Ranked by likelihood ratio, with no caution on their pages.
Strongest to rule in: a positive result counts
| Test | For | LR+ | From 30%, after a positive |
|---|---|---|---|
| Surprise / anterior release test | Anterior instability | 58.6 | 96% |
| Apprehension test | Anterior instability | 20.2 | 90% |
| Hook test | Distal biceps rupture | 15.71 | 87% |
| Thompson (Simmonds) test | Achilles tendon rupture | 13.71 | 85% |
| Pivot shift test | ACL rupture | 10.7 | 82% |
| Relocation test | Anterior instability | 10.4 | 82% |
Strongest to rule out: a negative result counts
| Test | For | LR− | From 30%, after a negative |
|---|---|---|---|
| Moving valgus stress test | UCL injury | 0.02 | under 1% |
| Thompson (Simmonds) test | Achilles tendon rupture | 0.04 | 2% |
| Elbow extension test | Any elbow fracture after injury | 0.06 | 3% |
| Long stride walking test | Ischiofemoral impingement | 0.07 | 3% |
The last column shows the probability after the result if you thought the diagnosis was 30% likely before testing, calculated from the likelihood ratio. For any other starting estimate, use the probability calculator.
Strong figures, but read the caution first
These tests also reach those figures, but their pages carry a caution, or a note that the figures are not yet confirmed against the full paper (for example a small study, a study at high risk of bias, or the book not counting them as reliable in that direction), so they are left out of the rankings above.
Rule in: 30-second single-leg stance test for gluteal tendinopathy (lateral hip pain); Arm squeeze test for cervical radiculopathy versus shoulder pain; Inverted supinator sign for cervical myelopathy; Pelvic compression test (lateral femoral cutaneous nerve) for meralgia paraesthetica; Resisted external derotation test for gluteal tendinopathy (lateral hip pain); Supine sign (severe pain lying flat) for acute vertebral compression fracture.
Rule out: 30-second single-leg stance test for gluteal tendinopathy (lateral hip pain); Anterolateral impingement test (palpation + dorsiflexion) for anterior (anterolateral) ankle impingement; Arm squeeze test for cervical radiculopathy versus shoulder pain; Modified web-space tenderness test (thumb-pad palpation) for Morton's neuroma; Patellar apprehension test (reversed dynamic version) for lateral patellar instability; Patellar-pubic percussion test for occult hip fracture after trauma; WHAT test (wrist hyperflexion + abduction of the thumb) for De Quervain's tenosynovitis.
Reading the rankings
A test can be strong in one direction and weak in the other: a high LR+ says nothing about what a negative result means. The figures come from different studies and patient groups, many of them surgical or specialist populations where the condition is more common than in a first-contact clinic, so treat the order as a guide, not a league table. Tests for the same problem are rarely independent, so do not multiply their figures together. Most of these figures come from a single study, so a lower-ranked test backed by more research can be the safer choice.
Each test page gives sensitivity, specificity, what a positive and a negative result mean, any caution, and the source.
Get the book for how to do and read each test
These pages give the published figures. Rule It In, Rule It Out adds how to do each test, what counts as positive, how to read the result, and, where studied, whether combining tests helps.
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One study, one test, once a month
Rule It In is a free evidence letter for musculoskeletal clinicians: one recent study explained, one examination test with its real numbers. From Trokos, publisher of Rule It In, Rule It Out.
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