By Steven D. Waldman, M.D., J.D. Philadelphia, Saunders/Elsevier, 2010. Pages: 376. Price: $169.00.

The pain medicine literature contains a wealth of information regarding the proper algorithms, techniques, and treatments that practitioners in the field may use. However, there has been a dearth of concise evaluation methods. As the Achilles' heel of our discipline, diagnostics too often rely on either nonspecific and dated physical examination results or indiscriminate radiographic findings to arrive at a diagnosis by exclusion. What Waldman tries to accomplish through his book, Physical Diagnosis of Pain: An Atlas of Signs and Symptoms,  is to create a compilation of practical physical examination tools that we, as pain physicians, can use in our daily practices. As our field develops into a multidisciplinary specialty, with members of the anesthesiology, physiatry, neurology, and psychiatry disciplines, a book such as this one allows all members the proper diagnostic foothold regardless of their background.

Working cephalad to caudad, this book is arranged anatomically into 11 sections, each focusing on a region of the body (e.g ., spine, trunk, extremity, or appendage). Waldman succeeds masterfully. Each section begins with an introduction to functional anatomic features and then works systematically through the visual and tactile clues that each physician may expect to find with painful conditions of the previously mentioned features. Once achieved, Waldman takes cues from the physiatry and orthopedic literature in providing detailed explanations of the specific physical assessment necessary to test for a particular malady. For instance, in section 10 on the knee, Waldman begins by providing illustrative and photographic visuals of the joint and surrounding anatomic characteristics and then explains in subsequent chapters signs on inspection and palpation that should trigger diagnosis by the examining physician. At this point, he explains 24 different physical examination tests in depth, from the common Anterior Drawer Test for anterior cruciate ligament integrity to the atypical Reverse Pivot Shift Test of Jakob for posterial instability. Each test has an accompanying picture showing the examination being performed on a patient by a physician, and a supplemental DVD provides further videographic details for 21 of the more complicated maneuvers. To call this entire atlas comprehensive would be an understatement.

With any medical textbook, no matter how complete, there may always be shortcomings that can be improved on. As a pain practitioner, most complaints are related to problems arising within the spine. Although never easy to truly diagnose by physical examination or cover in a book without enlarging it to twice its current size, perhaps more emphasis on these problems would be beneficial and, thus, make the book more attractive to the pain physician. In addition, better coverage of differential diagnosis and the relevant tests to distinguish between maladies would be a benefit in future editions.

Following in the tradition of Hoppenfeld's Physical Examination of the Spine and Extremities ,1Waldman's Physical Diagnosis of Pain : An Atlas of Signs and Symptoms  may stand as a standard for the evaluation of pain for clinicians in the field. By thoroughly explaining the structure, inspection, and examination of the varied anatomic components, we are given a rationale for the pain and can, thus, tailor our therapies with a solid understanding of the problem at hand. Far too often as pain physicians, we may make diagnoses not by examination results but by the treatment itself in the hope that we are correct. With the help of Waldman's atlas, we will know we are correct.

MD Anderson Cancer Center, Houston, Texas.

Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton & Lange, 1976
Norwalk, CT
Appleton & Lange