Michael and John Doherty. 144 pages. London: Wolfe Publishing; 1992.

The predominantly hospital-based nature of medical school and resident training programs has long denied students of medicine exposure to the real problems faced by practitioners. These students have not been sensitized to the need to become facile with the recognition of rheumatologic-musculoskeletal disease. Education in the techniques of rheumatologic examination has generally been inadequate, which perhaps reflects the limited coverage of the topic in most general physical diagnosis texts. An addendum is definitely needed, and the Doherty's manual provides a readable, excellently illustrated approach to physical diagnosis of musculoskeletal complaints.

Full reading of the text provides an excellent basis for screening evaluations, with few exceptions, and the exceptions may simply reflect trans-Atlantic differences in perspectives and approach. The "screening history" does not appear adequate for American patients, for whom it seems necessary to ask questions about each joint in greater detail. The "screening examination" of the shoulder, wrist, and knee is somewhat limited, although the chapters on examination of the individual joints are excellent. Although failure of the wrist examination section to recommend evaluation of the midcarpal joint may be simply a matter of perspective, the description of knee "bulge sign" evaluation and the illustration of fibromyalgia trigger points suggest that trans-Atlantic differences do exist. The traditional orthopedic assessment techniques are well presented, as are the neurologic concepts. Another philosophical issue relates to compression tests for neuroforamen impingement. Many who deal with rheumatoid arthritis recommend that movement of the patient's neck be evaluated through active, rather than passive, testing and recommend avoidance of such compression testing.

As philosophy and preconceived notions often determine attitudes, this appears to be an excellent reference work for orthopedic, rehabilitation, rheumatology, and neurology residents and fellows. Although the presented screening examination is probably too limited for internal or family medicine residents, a full reading would certainly provide useful insights. I am uncertain of the role of a "free-standing" text (limited to rheumatologic examination) for medical students, but I would like to see its inclusion (with slight modifications, as above) into a general physical diagnosis textbook for that market.