Download Orthopedic Tests Booklet

Clinical Assessment
Orthopedic and Neurological Tests
Gene Desepoli. LMT, D.C.
Descriptions of the Common Orthopedic Tests
Neck/Cervical Spine
Ranges of motion:
Flexion
Extension
Lateral flexion
Rotation
45
45
45
60-80
An orthopedic, as well as a neurological evaluation of the cervical spine is based on the fact that
pathology in the cervical spine such as a herniated disc, is frequently reflected to the upper extremity
via the brachial plexus (C5-T1) which is the innervation to the entire extremity. When signs and
symptoms involve the upper extremity, one must be sure to evaluate the cervical spine first before
evaluating the integrity of the brachial plexus. In fact, symptoms may be referred to the hand from the
elbow, shoulder and the cervical spine. The possible causes of referred pain to the hand may
included a) herniated cervical disc b) osteoarthritis c) cervical spondylosis and d) thoracic outlet
syndromes.
Brachial Plexus Tension Test
Purpose:
To detect nerve root compression.
Position:
Patient lies supine
Procedure:
The patient slowly abducts and externally rotates the shoulder just to the
point of pain. The forearm is then supinated and the wrist if flexed, while you are
supporting the shoulder and forearm.
Positive:
The test is positive if the patient's symptoms are reproduced or increased.
Shoulder Abduction Test (Bakody's Sign)
Purpose:
To assess for nerve root irritation due to cervical foraminal compression.
Position:
Patient is seated.
Procedure:
The patient with cervical radicular pain is instructed to place their hand on top of their
head with the elbow at head level.
Positive:
The reduction or elimination of radicular pain is a positive sign.
Significance: This signifies a nerve root irritation due to foraminal compression
Note:
The Reverse Bakody's Sign is an increase in pain while performing the test, which is
significant for thoracic outlet syndrome (stretches the neurovascular bundle and compresses
between the clavicle and the first rib, similar to Wright's test) or for the presence of a dural
root adhesion.
Cervical Distraction Test
pure distraction
Purpose:
A test designed to identify nerve root compression/foraminal encroachment or a
musculo-ligamentous problem.
Position:
The patient is seated.
Procedure:
Place one hand under the patient's chin and the other under the occiput. Lift the head
slowly to distract it.
Positive:
A positive test is the elimination or the reduction of pain.
The patient with cervical and or radicular pain gets relief when traction is applied to
the head. Relief of pain signifies a nerve root compression due to foraminal
Note:
encroachment. However, a patient with musculo-ligamentous injury or dural adhesions
may experience increased pain with distraction.
The are two ways to perform this test:
1. distract from neutral (passive)
2. have the patient actively rotate the head until radicular pain is produced, followed
by passive traction. The examiner then distracts with the hands behind the
mastoids and pulls upwards.
Also note that muscle spasm will result in local pain.
Distraction Test
Purpose:
Position:
Procedure:
Positive:
Signifies:
To detect nerve root compression from foraminal encroachment or from a disc lesion.
The patient is seated.
The patient actively rotates his head until radicular pain is produced. Then, from the neutral
position, you apply a strong traction and assists the patient in rotating the head to the
point that had previously caused pain. A variation of this test is to simply distract the head
from the neutral position.
Decreased pain at the rotation position that had originally produced pain.
Reduction in pain may signify and relieve foraminal compression or a facet capsulitis. Increased pain may be caused by muscle spasm.
Rotation Cervical Compression Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect foraminal compression.
The patient is seated.
Rotate the head toward the side being examined and exert a strong downward pressure
on the head.
The exacerbation of cervical and/or radicular pain.
Pain is caused by narrowing of the intervertebral foramina.
Hyperextension Cervical Compression Test
Purpose:
To detect foraminal compression.
Position:
The patient is seated.
Procedure:
The patient performs passive hyperextension of the head/neck followed by your strong
downward pressure on the head.
Positive:
The exacerbation of cervical and/or radicular pain.
Analysis:
Pain is caused by narrowing of the intervertebral foramina.
Foraminal Compression Test
Purpose:
To detect nerve root compression due to foraminal encroachment.
Position:
You are standing behind the seated patient whose head is in the neutral position.
Procedure:
The patient rotates her head toward the side of pain and then you apply a strong
downward pressure to the top of the patient's head. The test is repeated with
pressure on the head in the neutral position.
Positive:
The test is positive if pain is increased in the neck or arm.
Analysis:
The downward pressure approximates the vertebrae, thus the pedicles which are the
superior and inferior boundaries of the IVF, shortens the IVF.
If the pain radiates as far as the wrists or fingers, it is indicative of a cervical
disc lesion.
Radiating (radicular) pain indicates nerve root compression due to foraminal
encroachment.
Jackson's Compression Test
Purpose:
To detect nerve root compression due to foraminal encroachment.
Position:
The examiner is standing behind the seated patient.
Procedure:
Instruct the patient to laterally flex the head (to approximate the shoulder) on the effected
side. Clasp your hands over the patient's head and exerts strong downward pressure.
The test is repeated on the opposite side as well.
Positive:
The test is positive if cervical or radiating pain is experienced into the arm toward the flexed
side.
Shoulder Abduction Test
Purpose:
To identify extra-dural compression, such as a herniated disc, epidural pain compression
or nerve root compression most commonly at C5 or C6.
Position:
The patient is in a sitting or a lying position.
Procedure:
The patient's arm is abducted actively or passively so that the hand or forearm of the
patient
rests on their head.
Positive:
The test is positive if there is a decrease in symptoms.
Shoulder Depression Test
Purpose:
To detect nerve root adhesions or dural sleeve adhesions
Position:
Patient is lying supine.
Procedure:
Stand at the head of the table and perform 3 steps:
1. apply downward pressure to the shoulder of the effected side
2. laterally flex the head to the opposite side
3. rotate the head to the opposite side
Positive:
Radiating pain produced or aggravated by the first maneuver and confirmed/worsened
by the succeeding steps signifies a positive test.
Note:
Some sources state that pain on the side being tested is a positive sign.
Valsalva Maneuver
Purpose:
To detect a space-occupying lesion in the cervical spine, such as a herniated disc or an
osteophyte
Position:
The patent is seated.
Procedure:
Instruct the patient to take a deep breath and to "bear down," as if they are having a bowel
movement. (The patient can also place a thumb in their mouth and simulate blowing up their
hand like a balloon.)
Positive:
The test is positive if the symptoms are reproduced (radicular pain) or increased upon
straining. Ask the patient to localizes the source of pain if present.
Analysis:
This test increases intrathoracic pressure. Local pain would signify a space-occupying
lesion, such as a tumor, osteophyte or a disc herniation.
Note:
This test is for cervical problems. Milgram's is the test for lumbar and spinal disc pain. Dejerine's Sign is a related test, but for lumbar disc pathology and includes coughing and
sneezing.
Note:
Intrathecal pressure tests include Dejerine's, Valsalva, Milgram's and Nafzinger's and signify
space-occupying lesions. A prolapsed disc will give a negative result on these tests.
Dejerine's Test adds coughing or sneezing to the Valsalva maneuver. 6
Maximal Foraminal Compression Test (Maximal Cervical/Rotatory Compression Test)
Purpose:
Position:
Procedure:
Analysis:
To detect nerve root impingement
The patient is seated.
The patient actively laterally bends the head to bring the ear to the shoulder on the
affected side, and then rotates the head to bring the chin to the same shoulder.
Ipsilateral radicular pain
These movements significantly narrow the intervertebral foramina. This test may be
performed passively.
Extension Compression Test Cip 48 graphic
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
To assess for
The patient is seated. Ask the patient to extend his head approximately 30 degrees.
Place downward pressure on the extended head.
An increase in cervical and/or radicular symptoms may indicate a disc lesion.
Flexion of the head/neck places pressure on the disc and causes the posterior aspect of the
disc to bulge. Some books state that this maneuver causes the disc to bulge anteriorly,
removing a posterior bulge, and taking pressure off of the nerve roots.
The apophyseal joints may be irrtated with this maneuver causing local cervical pain.
Upper extremity pain with this maneuver may be due to its decreasing of the intervertebral
foramina size.
Flexion Compression Test Cip 49 graphic
Purpose:
Positive:
Analysis:
the
disc
Note:
The patient is seated. Ask the patient to flex his head and neck.
Place downward pressure on the flexed head.
An increase in cervical and/or radicular symptoms may indicate a disc lesion.
Flexion of the head/neck places pressure on the disc and causes the posterior aspect of
to bulge
A decrease in (scleratogenous) pain with flexion may signify an apophyseal joint lesion.
Soto-Hall Test
Purpose:
Position:
Procedure:
Positive:
Signifies:
Analysis:
Note:
Cip 42 graphic
To check for possible spinous or body fractures or for ligamentous disease.
The patient is supine.
Apply downward pressure to the sternum and then flex the patient's chin to his chest.
A positive test will cause localized pain in the cervical or cervico-thoracic region.
A positive finding may indicate an anterior vertebral body collapse (bony compression) or a
ligamentous problem.
Pain is usually elicited at the level of the lesion due to the tightening of the posterior
interspinous ligament at all levels.
Used to diagnose and localize bony disease in the cervical spine, especially compression
fractures. If the patient flexes both knees, suspect meningeal irritation.
Spurling's Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect nerve root irritation due to disc disease or cervical spondylosis.
The examiner stands behind the seated patient.
Maximally rotate and laterally flex the patient's neck to the same side and then hyperextend it.
Then, apply a downward blow to your hand, which you have placed on top of the patient's
head.
A significant increase of any combination of neck, shoulder or arm pain when the blow is
delivered.
This test stimulates nerve root irritation or other pain-sensitive tissue related to disc disease or
cervical spondylosis.
O'Donohue Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
Note:
To determine if the source of pain is from either contractile or non-contractile tissue.
The patient is seated.
The examiner and patient put the cervical spine through various active and then passive
ranges of motion. (The patient actively moves the part against resistance, then the examiner
passively moves the part through a full range of motion.)
The presence of pain
Pain during passive range of motion indicates a ligamentous problem (sprain).
Pain during active range of motion indicates a musculo-tendinous problem (strain or
tendonitis ).
This test can be used for any joint to determine the source of pain, from active/contractile
tissue or from passive, inert tissue.
Swallowing Test
Purpose:
Procedure:
Position:
Positive:
Note:
To determine the presence of a bony or soft-tissue mass anterior to the cervical spine.
The patient is seated.
The patient is instructed to swallow.
Difficulty swallowing or pain upon swallowing.
Several causes include tumors, osteophytes, a large disc protrusion. hematoma, cranial nerve
lesion and DISH (diffuse idiopathic skeletal hyperostosis which is calcification of the anterior
longitudinal ligament. The is the most common cause of dysphagia and exists in 5-7% of the
populatioin, males greater than females and in diabetecs.
Include x-rays of these conditions
Neurovascular Compression Syndromes
Allen's Test
Purpose:
Procedure:
Position:
Positive:
Note:
Cip 144 graphic
To detect occlusions in either the radial or ulnar arteries.
The patient is seated with the forearms supinated and resting on the thighs.
First palpate and occlude the radial and ulnar arteries. Ask the patient to open and close his
or her fingers rapidly for about 10 seconds to cause palmar blanching. Pressure is then
released from either the radial or ulnar artery, and the rapidity with which the hand regains
color is noted.
The test is repeated with release of the other artery.
A failure or a delay of more than 10 seconds for the blood to return may indicate a possible
occlusion of the corresponding (non-occluded) artery. This signifies a diminished or
absent
communication between the superficial ulnar arch and deep ulnar arch. Be sure to
compare the other wrist.
Allen's test should be done before performing either Adson's, Eden's or Wright's tests.
Adson's Test (Scalenus Anticus Syndrome or Cervical Rib Syndrome) subclavian artery
Cip 106 + graphic
Purpose:
Procedure:
Position:
Positive:
Note:
The detection of thoracic outlet syndrome or for the presence of a cervical rib.
The patient is seated and the radial pulse is palpated.
Hold the patient's arm in slight extension and palpate the radial pulse. Ask the patient to
rotate and then extend the head toward the involved side. A deep breath-hold is then
taken by the patient.
A decrease or an elimination of the radial pulse and/or duplication of the patient's symptoms
indicates a thoracic outlet (scalenius anticus) syndrome. Be sure to compare the well side to
rule out false positive findings.
If the above test is negative, turn the head to the opposite side (Modified Adson's Test) and
look for the same results. This "Modified Adson's Maneuver" tests obstruction by the scalene
anterior???(medius) muscle or from a cervical rib.
Costoclavicluar Test
Purpose:
Position
Procedure:
Positive:
Analysis:
Cip 107 + graphic
To detect costoclavicular syndrome.
The patient is standing and the examiner monitors the radial pulse.
The patient actively forces the shoulders backward and downward and then flexes the chin to
his chest.
A positive test is the presence of any of the following:
1. decrease or absence of the pulse
2. upper limb radicular pain
3. ichemic color changes, such as pallor or blanching
4. paresthesia.
This test confirms neurovascular compression of the subclavian artery and the brachial
plexus between the clavicle and the first rib.
Eden's Test
Purpose:
Position:
Procedure:
Positive:
Note:
Analysis:
To detect neurovascular compression.
The patient is seated.
Establish a radial pulse and then ask the patient to retract the shoulders. Then, place
downward pressure on the retracted shoulders, and observe for a change in the amplitude
of the pulse
A decrease in the pulse or an increase in radicular symptoms.
A positive finding may be due to several causes: an elongated C7 transverse process,
a cervical
rib, a displaced or healed fracture or a dislocation of the clavicle or first rib. Shoulder retraction causes the clavicle to approximate the first rib
Wright's Hyperabduction Test Cip 108 + graphic
Purpose:
Position:
Procedure:
Positive:
Note:
Significance:
To detect hyperabduction or pectoralis minor syndrome
The patient is seated while the examiner monitors the radial pulse.
Hyperabduct (and extend) the arm.
The syndrome is present if there is an alteration or obliteration of the pulse or duplication of
the patient's symptoms upon hyperabduction.
Perform Allen's Test first to assure arterial patency before the test is begun.
Many people have a normal obliteration of the pulse upon abduction without having this
syndrome. It is necessary to check the opposite side and if obliteration of the pulse is
present on the asymptomatic side as well, the test is negative.
Compression of the axillary artery between the pectoralis minor and/or the coracoid process
Traction Test for Cervical Rib
Purpose:
Position:
Procedure:
Positive:
Note:
Significance:
Cip 109 graphic
To detect the presence of a cervical rib.
The patient is seated while the examiner monitors the radial pulse.
While maintaining the pulse, apply inferior traction to the patient's arm.
A positive test is the reduction or absence of a radial pulse unilaterally.
A bilateral decrease may be considered normal.
A positive test signifies a cervical rib on the side of the decreased pulse.
Brachial Plexus Stretch Test
Purpose:
Position:
Procedure:
Positive:
Note:
Analysis:
To detect brachial plexus irritation.
The patient is seated.
Ask the patient to laterally flex his head opposite to the affected side and to extend his
shoulder and elbow.
Pain and/or paresthesia along the course of the brachial plexus.
Irritation to the plexus will cause paresthesis and/or pain along the plexus distribution.
Pain and paresthesia on the same side as lateral flexion may indicate a nerve root problem. This test stretches the brachial plexus opposite to the side of lateral flexion.
Halstead Maneuver
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect a neurovascular compression syndrome.
The patient is seated.
Establish a radial pulse on the patient and then, with your other hand, apply downward
traction on the patient's arm. Ask the patient to hyperextend the head. Repeat on the other
arm.
Pain and/or paresthesia in the neck/arm.
Traction on the arm compresses the brachial plexus and axillary artery over the first rib. Extension of the neck tightens the scalene muscles.
A decreased pulse may indicate a cervical rib.
An upper extremity radicular component indicates scalene anterior compression.
10
Intermittant Claudication Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
Roo's Test Purpose:
Position:
The patient is standing.
Procedure:
With both arms in the air, the patient pumps the hands for 30 seconds. Positive:
Positive is pain and or the inability to maintain the pumping arm elevation. Analysis:
Neurovascular compromise from the first rib and/or clavicle subluxation.
Shoulder Region
Ranges of Motion
Flexion
Extension
Abduction
90
45-60
180
Adduction
45
Internal rotation
60
External rotation
60
Abbot-Saunders Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect for subluxation of the bicipital tendon from the intertubercular groove.
The patient is seated.
Abduct and externally rotate, then slowly lowers the arm to the patient's side.
A palpable or audible click at the bicipital groove.
Indicates a subluxation or dislocation of the bicipital tendon.
Anterior Apprehension Test (for Anterior Shoulder Dislocation)
Purpose:
Position:
Procedure:
Positive:
Analysis:
To determine whether a patient has a history of chronic anterior shoulder dislocations.
The patient is seated.
Slowly abducts and externally rotate the patient's arm while the elbow is flexed 90
degrees. Gently begin to push the humerus from posterior to anterior.
The test is positive if the patient becomes apprehensive (observe the face) and resists
further motion.
As the test is named, you should look for apprehension on the patient's face.
Posterior Apprehension Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect posterior glenohumeral instability.
The patient is supine.
Flex the patient's shoulder to 90 degrees and then internally rotate it. Apply downward
pressure on the patient's elbow
Local pain/discomfort and a look of apprehension on the patient's face. This test stresses the posterior rotator cuff and posterior joint capsule.
The patient may also state that he is feeling a similar sensation as when he previously
dislocated the shoulder.
Shoulder Anterior Drawer Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect anterior instability of the glenohumeral joint.
The patient is supine.
Hold the patient's and in your axilla. Grasp the posterior scapula with your fingers while
positioning your thumb on the coracoid process. Draw the humerus forward with the hand
holding the arm.
Clicking or an abnormal amount of movement as compared to the other side.
This test evaluates the integrity of the anterior rotator cuff
Codman's Drop Arm Test
Purpose:
A test designed to determine the presence of a torn rotator cuff, usually the supraspinatus.
Position:
The patient is seated or standing.
Procedure:
Abducts the patient's shoulder to 90,0 and then instruct the patient to slowly lower the arm
Positive:
Analysis:
back to their side.
The patient is unable to lower the arm slowly to the side in the same arc of movement or has
severe pain when attempting to so, or the arm drops suddenly. Also, observe for hunching of
the shoulder.
A rotator cuff tear will prevent lowering of the shoulder.
Impingement Test
Purpose:
A test designed to identify inflammation of tissues within the subacromial space. Position:
The patient is seated.
Procedure:
Move the patient's upper extremity into internal rotation and horizontal adduction.
Positive:
The presence of pain yields a positive test.
Analysis:
This maneuver' is thought to decrease the space between the head of the humerus and
acromion process.
Hawkin's Test for Shoulder Impingement
Purpose:
To determine supraspinatus tendonitis from impingement within the coraco-acromial arch.
Position:
The patient is seated.
Procedure:
Bring the patient's arm into 90 degrees of flexion with the elbow bent 90 degrees.
Then force the arm into internal rotation.
Positive:
Pain under the coraco-acromial arch signifies a positive test.
Analysis:
This maneuver forces the supraspinatus tendon against the anterior surface of the
coracromial ligament.
Speed's Test (Biceps' Test)
Purpose:
To determine whether bicipital tendonitis is present.
Position:
The patient is seated
Procedure:
The forearm is supinated and the elbow is fully extended with the shoulder flexed 45
degrees, the patient tries to flex the forearm against resistance applied by the examiner.
Positive:
The test is positive if the patient reports increased pain in the area of the bicipital groove.
Supraspinatus Test
Purpose:
To identify a tendonitis of the supraspinatus muscle.
Position:
The patient is seated
Procedure:
Position the patient's upper limbs horizontally 30 degrees anterior to the frontal plane and in
internal rotation. Apply a downward force on the patient's limbs.
Positive:
The test is positive if pain (and weakness) are present on the involved side.
Analysis:
Weakness may suggest a partial tear of the tendon. A strong, painful contraction suggests
tendonitis.
Inferior Sulcus Sign
Purpose:
To test for global instability of the glenohumeral joint.
Position:
The patient is seated.
Procedure:
Stand beside the patient with the patient's arms hanging at his side. Apply inferior traction to
the shoulder by pulling down on the elbow.
Positive:
A positive test is when there is a noticeable inferior slide of the humeral head or where there
is a
marked increase in the space between the humeral head and acromion.
Biceps Tendon Stability Test Cip graphic 103
Purpose:
Position:
Procedure:
To detect instability of the biceps' tendon and/or bicipital tendonitis.?????
The patient is seated.
Ask the patient to flex the elbow. Grab the patient's wrist and ask him to continue flexion
while you internally and externally rotate the arm against resistance.
Pain localized at the intertubercular groove.
Positive:
Yergason's Test Cip p.103 graphic
Purpose:
Position:
Procedure:
Positive:
Analysis:
To determine biceps tendon instability and/or biceps tendonitis.
The patient is seated and the elbow is flexed to 90 degrees.
Palpate the bicipital groove with one hand and clasp the patient's fist with the other.
The patient then attempts elbow flexion against resistance as you both internally
and then externally rotates the patient's arm while maintaining resistance.
Pain in the area of the bicipital groove, with an audible snap or click as the tendon slips out of
the groove. Pain itself may signify tendonitis of the long head of the biceps.
The test may be done with one hand pulling down on the patient's elbow with the free hand
palpating over the bicipital groove, feeling for a subluxation of the tendon in the groove.
Dugas Test Purpose:
Position:
Procedure:
Positive:
Analysis:
The detection of a shoulder dislocation. The patient is seated.
Instruct the patient with a shoulder injury to place the palm of the suspected side hand on the
opposite shoulder and then to move their elbow toward the chest.
The patient cannot perform the maneuver due to pain or limitation
Dislocation may cause a physical limitation and prevent this test from being performed.
Hamilton Ruler Test
Purpose:
Position:
Procedure:
Positive:
To assess for shoulder dislocation.
The patient is seated or standing.
Place a straight-edge/ruler along the lateral arm touching from the lateral epicondyle to
the
deltoid.
The test is positive if the ruler can rest simultaneously on the acromial tip and the lateral
epicondyle of the humerus.
Dawbarn's Test Cip graphic p74, 92
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect subacromial bursitis.
The patient is seated.
Palpate and locate a point of tenderness just beneath the acromion process.
Maintaining that finger pressure on the painful area, you then passively abduct the arm
past 90 degrees.
The painful spot disappears under the finger of the examiner, when the arm is abducted. The reduction of pain is due to the deltoid muscle overlapping the palpation area, cushioning
the bursa.
Apley's Scratch Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To test the active range of motion of the shoulder.
The patient is seated.
The patient is instructed to
1. reach across the chest to touch the opposite shoulder
2. reach behind the head to touch the opposite superior angle of the opposite scapula
3. reach behind the back and touch the opposite inferior angle of the opposite scapula.
Exacerbation of the patient's pain.
Pain signifes a rotator cuff tendonitis (usually supraspinatus)
Shoulder Compression Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect thoracic outlet syndrome.
The patient is seated.
Apply a downward pressure on the patient's coracoid process with your hypothenar eminence.
A positive test occurs with the creation of neurovascular symptoms.
Signifies a thoracic outlet-type syndrome called "corcoid pressure syndrome."
Mazion's Shoulder Maneuver (Shoulder Rock Test)
Purpose:
Position:
Procedure:
Positive:
To assess for generalized shoulder pathology.
The patient is seated or standing.
The patient places the palm on the acromion of the opposite shoulder and then moves
the elbow
superiorly and inferiorly to create a rocking motion.
The appearance of shoulder pain signifies general shoulder pathology.
Supraspinatus Press Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To assess for a rotator cuff tear.
Patient is seated with he arms hanging limply at the side.
Exert strong thumb pressure toward the midline at the clavicular point above the
scapular
spine.
The production or increased shoulder pain.
Signifies a rotator cuff tear of the supraspinatus tendon.
Subacromial Push-Button Test
Purpose:
Position:
Procedure:
Positive:
Cip 91 graphic
To detect subacromial bursitis.
The patient is seated.
Apply pressure to the subacromial bursa area just below the acromion.
Localized pain indicates subacromial bursitis.
The Elbow Region
Ranges of Motion
Flexion
Extension
Supination
Pronation
135-150
0-5
90
90
Elbow Flexion Test Cip 136 + graphic
Purpose:
Position:
Procedure:
Positive:
To identify cubital tunnel syndrome.
The patient is seated.
The patient is asked to hold his or her elbow fully flexed for 5 minutes.
Tingling or paresthesia is felt in the ulnar nerve distribution of the forearm and hand.
Golfer's Elbow Test Cip 129 + graphic
Purpose:
Position:
Procedure:
Positive:
Analysis:
To identify the presence of inflammation in the area of the medial epicondyle.
The patient is seated.
The patient flexes the wrist against your resistance.
The test is positive if the patient complains of pain over the medial epicondyle.
The majority of wrist flexors originate at the common flexor tendon of the medial epicondyle.
Abduction Stress Test (Valgus Stress Test) Cip graphic 133
Purpose:
Position:
Procedure:
Positive:
To assess the integrity of the medial collateral ligament of the elbow.
The patient is seated or supine.
Hold the patient's arm to support both the elbow and wrist.
Test the medial collateral ligament by applying an abduction or valgus force to the
distal forearm with the patient's elbow held in 20 to 30 degrees of flexion.
The test is positive if pain or altered mobility is present.
Adduction Stress Test (Varus Stress Test) Cip graphic 131
Purpose:
Position:
Procedure:
Positive:
To assess the integrity of the lateral collateral ligament of the elbow.
The patient is seated or supine.
Hold the patient's arm to support both the elbow and wrist
Test the lateral collateral ligament by applying an adduction or varus force to the
distal forearm with the patient's elbow held in 20 to 30 degrees of flexion.
The test is positive if pain or altered mobility is present.
Cozen's Test Cip graphic 127
Purpose:
Position:
Procedure:
Positive:
To detect humeral lateral epicondylitis (amateur tennis elbow) and/or radiohumeral bursitis.
The patient is seated, standing or reclining with the elbow flexed 90 degrees.
The patient clenches the fist and while keeping the elbow stable and performs wrist
extension against your resistance.
Sharp, pinpoint pain at the lateral epicondyle.
Mill's Test Cip 128 graphic
Purpose:
To detect lateral epicondylitis and/or radiohumeral bursitis.
Position:
Procedure:
Positive:
The patient is seated or standing.
With the elbow fully extended, the patient makes a fist, flexes the wrist and then maximally
pronates the forearm.
Sharp tenderness and pain at the lateral elbow region.
Kaplan's Sign
Purpose:
Position:
Procedure:
Positive:
To detect lateral epicondylitis.
The patient is seated.
The patient holds the upper limb straight out with slight wrist extension. The patient's grip
strength is tested with a dynamometer. Repeat this procedure, but this time, firmly encircling
the patient's forearm with both hands placed approximately one or two inches just below the
elbow joint line.
Grip strength increases and lateral elbow pain is decreased with constriction of the forearm.
Tinel's Sign (of the Elbow)
Purpose:
Position:
Procedure:
Positive:
To detect the presence of ulnar nerve irritation.
The patient is seated.
Tap in the groove between the olecranon and the medial malleolus.
Hypersensitivity or a temporary, painful, tingling sensation in the distal distribution of the
ulnar nerve.
Ulnar Tunnel Triad
Purpose:
This consists of:
Indicates:
Cip 143 graphic
To detect ulnar nerve entrapment in the tunnel of Guyon.
1. Tenderness over the ulnar tunnel
2. Clawing of the ring finger
3. Hypothenar wasting
Ulnar nerve compression in the tunnel of Guyon
Froment's Sign (Froment's Paper Sign)
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect ulnar nerve palsy/damage.
Any.
A piece of paper is placed between the patient's thumb and index finger. Instruct the patient To
hold the paper between those two digits.
The patient flexes the interphalangeal joint of the thumb instead of merely bringing the two
digits together.
The patient flexes the thumb to compensate for paralysis of the adductor pollicis.
Pinch Grip Test
Cip 137 + graphic
Purpose:
To detect anterior interosseous nerve injury/entrapment.
Position:
The patient is sitting.
Procedure:
Ask the patient to place the thumb and index finger together as in pinching ..
Positive:
When the pads, rather than the tips of the fingers touch.
Note:
Analysis:
The anterior interosseous is a branch of the median nerve.
A positive test may signify entrapment by the two heads of the pronator teres muscle or
damage
to the anterior interosseous nerve.
Hand/Wrist Region
Ranges of Motion
Flexion
Extension
Ulnar deviation
Radial Deviation
80
70
30
20
Allen’s Test
Phalen's Test (Wrist Flexion Test; Median Nerve Compression Test; Reverse Prayer Sign)
Purpose:
Position:
Procedure:
Positive:
Analysis:
To determine the presence of carpal tunnel syndrome.
The patient is seated.
The patient maintains a position of maximal wrist flexion by holding the dorsal surface of
each wrist back-to-back for 30 seconds.
The test is positive if pain and/or paresthesia is present in the distribution of the median
nerve (3 ½ fingers).
This maneuver directly compresses the median nerve.
Reverse Phalen's Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect median nerve compression in the carpal tunnel.
The patient is seated.
Hold the patient's wrist in extension, and with your other thumb, put pressure into the carpal
tunnel.
Tingling in the lateral 3 ~ fingers
A positive test may be due to retinacular inflammation, anterior lunate dislocation, arthritic
changes or tenosynovitis of the flexor digitorum tendons.
Tight Retinacular Ligament Test
Purpose:
Position:
Procedure:
Positive:
To detect the presence of shortened retinacular ligaments or a tight DIP joint capsule.
The patient is seated.
Hold the patient's PIP joint in a fully extended position while attempting to flex the DIP joint.
If the DIP joint does not flex, the test is positive for either a contracted collateral ligament or
joint capsule. The test is positive for a tight retinacular (collateral) ligament and a normal joint
capsule if, when the PIP joint is flexed, the DIP joint flexes easily.
Tinel's Sign (at the Wrist)
Purpose:
Position:
Procedure:
Positive:
To determine the presence of carpal tunnel syndrome.
The patient is seated or supine with the elbow supinated.
Tap over the median nerve within the carpal tunnel of the wrist.
The test is positive if the patient reports exacerbation of symptoms and/or paresthesia over
the course of the median nerve distal to the lesion. (3 1/2 fingers)
-- hoppenfe/d illustration
Pinch Test Purpose:
To detect median nerve compression. Position:
The patient is seated.
Procedure:
Ask the patient to pinch a piece of paper between his thumb, index and middle fingers.
Attempt to pull it away as the patient resists.
Positive:
Decreased or no resistance to your pull, especially as compared to the other sided extremity.
Note:
The patient may experience numbness and/or cramping of the fingers in the mid palmar
region.
Analysis:
The lumbrical muscles are being tested and they are innervated by the median nerve.
Finklestein's Test
Purpose:
The detection of stensoing tenosynovitis.
Position:
The patient is seated or standing.
Procedure:
The patient makes a fist with the thumb wrapped inside the other fingers and then performs
ulnar deviation/adduction ..
Positive:
Significant pain located just distal to the radial styloid process.
Analysis:
Signifies DeQuervain's disease or stensoing tenosynovitis/tenovaginitis
The tendons that are stressed with this maneuver are the abductor pollicis longus and the
extensor pollicus brevis.
--hoppenfe/d illustration
Oriental Prayer Sign (Wartenberg's Oriental Prayer Sign)
Purpose:
???????????
Position:
??????????
Procedure:
The patient extends and adducts four fingers of each hand with the thumbs extended. In this
position hands are held in front of the patient's face, side by side in the same plane and the
thumbs and index fingers touching tip to tip.
Positive:
Note:
Paralysis of the abuctor pollicus brevis will not allow the thumbs to coincide when the index
fingers touch. Indicated median nerve palsy abductor pollics brevis palsy
Wartenburg's Sign
Purpose:
To detect ulnar nerve neuritis or damage.
Position:
The patient is sitting.
Procedure:
Ask the patient to place his hand on the table. After you passively abduct/spread his fingers, ask
him to actively bring them together again.
Positive:
The patient is unable to adduct the little finger to the rest of the hand.
Analysis:
If the little finger stays in significant abduction during normal hand movements it indicates
ulnar nerve palsy.
Bracelet Test
Purpose:
To assess for rheumatoid arthritis.
Position:
The patient is seated
Procedure:
Squeeze the lower ends of the radius and ulna.
Positive:
The appearance of sharp, acute forearm, wrist and hand pain.
2
Finsterer's Sign
Purpose:
Position:
Procedure:
Positive:
To detect an aseptic necrosis of the lunate bone (Kienbock's Disease).
Any.
Observe the patient grasping an object, making a fist or clenching the hand. You should see a
normal prominence of the third metacarpal on the dorsal surface of the hand.
Lack of the normal 3rd metacarpal prominence after performing a procedure above OR
When percussion of that third metacarpal elicits tenderness just distal to the center of the
wrist.
Low Back / Pelvis
Motor unit
Boundaries of the ivf: pedicle, facets, body disc
What can cause compression on a nerve:
Short pedicles
Facet
hypertrophy Disc
degeneration
Disc protrusion
Bony spurs
Facet trauma/ swelling of capsular ligaments
Ligamentum flavum hypertrophy
Most: most common cause in cervical region - lushka joints (on body)
Most common cause in the lumbar region is from disc protrusion.
Ranges of Motion:
Flexion
Extension
Lateral flexion
Rotation
80
30
35
40
Valsalva/Oejerine's Hopp 260
Straight Leg Raising Test (SLR)
Cip graphic 207
Purpose:
A test designed to identify sciatic nerve root compression / disc compression.
Position:
The patient is supine.
Area Tested: Low back (L 1 to S2).
Procedure:
Attempt to raises the patient's leg via the heel while maintaining the knee in
extension. Stop when the patient complains of low back or leg pain (and not hamstring
tightness).
Positive:
Pain in the gluteal or radicular pain in the posterior thigh region.
Analysis:
The angle of flexion of the hip joint at which pain occurs as well as the location and level of
pain are recorded.
Pain at 30° indicates a probable ipsilateral SI joint problem (no sciatic traction occurs)
Pain at
30-60° is a probable lumbosacral joint problem.
Pain at 60-90° is a probable lumbar (L1-L4) or contralateral SI joint problem.
Mechanism: Tractioning of the sciatic nerve and reduction of the normal lumbar lordosis.
Note;
Pain before 15 degrees (before the nerve roots are stretched is called Demianoff's Sign. Pain at 80 degrees (maximal pull on the 5th lumbar nerve root) may indicate an L4-L5 lesion. Posterior thigh pain alone may indicate tight hamstrings.
Localized low back pain may indicate a disc lesion.
False positives might be present from tight hamstrings, but this shouldn't give radicular pain.
Analysis:
Back pain suggests a central herniation and leg pain suggests a lateral disc protrusion.
The test is repeated for both sides.
1) If the pain returns after iliac stabilization, it is positive for sciatica.
2) If no pain after iliac stabilization, then it is positive for a lumbar lesion.
Fixation of the pelvis prevents stretching of the sacrolumbar muscles, but doesn't
prevent
stretching of the sciatic nerve and permits raising of the leg to an angle of 90
degrees,
unless it is due to sciatica.
3) Angle interpretation: 10 degrees - sacroiliac lesion
50 degrees - lumbosacral lesion 70 degrees -- lumbar lesion
Lasegue's Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect sciatica.
The patient is supine.
With the knee flexed to 90,0 flex the patient's hip to approximately 90.0
Then, slowly extend the knee
Pain is present when the thigh is flexed and the knee is extended and
no pain was present with thigh flexion when the knee was in the flexed position.
Knee flexion alleviates tension on the sciatic nerve and nerve roots, so from the
Note:
initial
position, no pain should occur.
This test has become synonymous with the Straight Leg Raise Test (SLR) although they are
two different tests.
Braggard's Sign
Purpose:
Note:
Position:
Procedure:
Positive:
Analysis:
To confirm the diagnosis of sciatica.
This test is a continuation of the SLR test.
The patient is supine.
Slowly raise the leg at the heel, keeping the knee joint extended until the patient
complains of pain (SLR). Then, lower the leg until the pain is eliminated. At that level,
dorsiflex the foot to see if pain returns.
An increase in radicular pain.
Dorsiflexion with leg-raising will traction and cause pain in the irritated sciatic nerve. Pain can also be produced by a disc lesion, spinal irritation, subluxation or tumor. If the
leg is able to be raised to a 90 degree angle with no pain, the test is negative (true also for
Goldthwait, Lasegue's, Well Leg and Fajerstajn's tests.
Bilateral Leg Lowering Test
Purpose:
Position:
Procedure:
Positive:
To detect a lumbar disc lesion.
The patient is supine.
Stand at the foot of the examining table. The patient is asked to raise both legs together to
approximately a 45 degree angle. The patient is asked to maintain that position as you are
prepared
to catch the legs.
If the legs drop to the table or if significant pain is elicited, then the test is positive for a
lumbar disc lesion or for erector spinae muscle contracture casing pain.
Deyerle's Sciatic Tension Test (Popliteal Press Test)
Purpose:
Position:
Procedure:
Positive:
Analysis:
To confirm the presence of sciatica.
The patient is seated.
Extend the affected knee to the point of pain. Then the knee is slightly flexed and strong
digital pressure is applied to the popliteal fossa.
The test is positive if radicular symptoms are increased.
Popliteal pressure puts tension on the sciatic nerve.
Buckling Sign
Purpose:
To detect sciatic radiculopathy.
Position:
The patient is supine.
Procedure:
Perform a straight leg raise.
Positive:
Pain causing flexing/buckling of the knee is a positive response.
Analysis:
The knee goes into flexion to reduce traction on the sciatic nerve.
Sicard' Sign
Purpose:
To assess for sciatic radiculopathy.
Position:
The patient is supine.
Procedure:
Positive:
Note:
Raise the leg's as in the SLR to a point just short of pain, then dorsiflex the big toe.
The appearance of sciatic pain when the big toe is dorsiflexed.
This is the second least aggressive sciatic test.
Turyn's Sign
Purpose:
Position:
Procedure:
Positive:
Note:
To assess for sciatic radiculopathy.
The patient is supine.
Dorsiflex the big toe (in a patient who has complained of sciatica).
Gluteal and/or radicular pain along the course of the sciatic nerve.
This is the least aggressive disc test. If it is positive, it indicates a more sever sciatic lesion.
Fajersztajn's Test (Well Leg Raising Test; Contralateral Braggard's Test) Cip graphic 213
Purpose:
To confirm the presence of a ruptured disc in a patient with sciatica ..
Position:
The patient is supine.
Procedure:
Perform a SLR on the unaffected limb until it causes or increases pain on the opposite side.
Once pain is elicited, lower the leg 5° until the pain stops. Then, dorsiflex the foot to see if
pain returns to the affected leg.
Positive:
The test is positive if pain is caused in the affected leg.
Analysis:
Pain down the affected (opposite-sided) leg indicates a postero-medial disc herniation.
If L leg raise causes R leg pain = medial disc protrusion.
If L leg raise causes L leg pain = lateral disc protrusion. (SLR) Note:
Kemp's Test should be performed next to confirm the findings. Adding dorsiflexion further tractions the sciatic nerve.
This test is done if the Well Leg Raise Test is positive.
Bechterew's Test (Seated Lasegue's Test; Petrin's Flip Test)
"leaning backward"
Purpose:
The diagnosis of sciatica due to a disc herniation.
Position:
The patient is seated with the legs hanging over the table.
Procedure:
The patient extends one leg at a time (the good leg first) and then both together.
Positive:
The test is positive if any of the three movements cause either:
1) inability to perform the test due to low back or radicular pain.
2) inability to perform the test by leaning backward because of pain.
Analysis:
This is the equivalent of the Straight Leg Raise Test (Lasegue's).
Note:
Pain down the affected leg when the well leg is extended indicates a postrero-medial disc
pathology. If this test is done passively, it is called the Petrin's Flip Test.
Kemp's Test Cip graphic 219,233
Purpose:
To detect a disc herniation.
Position:
The patient can be seated or standing.
Procedure:
Stabalize the pelvis and then bend the patient obliquely backward (into rotation
and
extension) to one side and then the other.
Positive:
Radiating pain down the leg is a positive test for disc protrusion.
Note:
Local lumbar pain is not a positive test and signifies facet irritation or muscle spasm.
Analysis:
Posteromedial disc = pain occurring when bending toward the uninvolved side. Posterolateral disc = pain occurring when bending to the involved side.
Note:
There a 4 possible sites of disc protrusion:
If R rotation causes L leg pain = left medial disc If R rotation causes R leg pain = right lateral disc If the disc is medial to the nerve root
- the patient leans into the side of compression to get relief
and
- Kemp's Test will be positive when leaning away.
If the disc is lateral to the nerve root
- the patient leans away from the pain to get relief
- Kemp's Test will be positive when leaning toward the lesion.
If the disc is centrally positioned:
- the patient will resist leaning to either side and stays centered.
- They may also experience bilateral leg pain/symptoms.
Milgram's Test (Bilateral Leg Raising Test)
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
The diagnosis of a space-occupying lesion or disc protrusion.
The patient is supine.
The patient raises both heels to bring them 2-3 inches off the table.
Pain upon attempting the maneuver or the inability to hold the legs up due to pain.
Pain is due to a space-occupying lesion within or outside of the spinal cord sheath.
This test should be performed along with Dejerine's and Valsalva's.
This test raises subarachnoid pressure, and if the patient can hold the legs elevated for a
considerable amount of time without pain, intrathecal pathology can be ruled out. Inability
without pain is due to abdominal weakness.
Bowstring Test (Popliteal Pressure Sign)
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
To detect nerve root compression.
The patient is supine.
Place the affected leg on your shoulder while sitting on the table. Then elevates the leg to
the point of pain and then lowers it 5 degrees. Next, slightly flex the knee and apply firm
pressure, first to the hamstrings and second into the popliteal fossa.
The reproduction of radicular pain indicating nerve root compression (from a disc). Local pain in the popliteal region is not a significant finding.
This test is pathognomonic for nerve root compression from a disc lesion.
This is an extremely useful test for the diagnosis of a ruptured intervertebral disc!
Lindner's Test
Purpose:
Position:
Procedure:
Positive:
Note:
c-shape
To detect lumbar nerve root compression.
The patient is supine with the examiner standing at the head of the table.
With a hand cupped under the occiput, force the head, neck and thoracic regions of
the spine into a large c-shaped curve.
The appearance or exacerbation of radicular pain.
This is an excellent test for low back nerve root compression (some say for a
posterolateral disc).
Sharp diffuse pain may indicate meningeal irritation.
Minor's Sign
Purpose:
A method of observing a patient rise from a seated position.
Position:
Procedure:
Positive:
Analysis:
The patient is initially seated and asked to stand.
The patient needs to support themself in order to rise (they hold the chair or climb their
hands up their well-sided thigh while keeping their knee on the affected side flexed. This sign is commonly present in people with sciatica.
Flexion of the affected leg relieves the pain/pressure of sciatica.
Astrom's Suspension Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
To further evaluate for a sciatic disc lesion.
The patient is standing and is asked to suspend himself from the arms.
Percuss the patient's lumbar spine with a fist in the suspected painful area.
The patient experiences buttock or leg pain without suspension/traction and the elimination of
pain after suspension/traction is applied.
Suspension by the hands produces enough traction to cause retraction of the herniated
portion of the disc and eliminates pressure upon the nerve roots causing sciatica.
This test can predict the success of traction therapy for the patient.
Adam's Sign
Purpose:
Position:
Procedure:
Positive:
Note:
To observe for a posterolateral disc rupture.
The patient is standing.
The patient is asked to flex forward.
Flexion is the most restricted motion due to pain and rotation should be the east
restricted/painful. Extension may be as limited as flexion, but not greater.
Flexion is the position that will aggravate a posterolateral disc herniation the most.
This is not Adam's test for scoliosis
This sign is present in the low back patient who's most restricted and painful position is
the Adam's Position: flexion of the entire spine.
Hyperextension Test for the Low Back
Purpose:
Position:
Procedure:
Positive:
Note:
To localize the source of low back pain and/or to evaluate the level of facet irritation.
The patient is prone with the ankles at the sides.
Ask the patient to perform a hyperextension of the thoracolumbar spine, while stabilizing the
ankles. The level of pain is noted and signifies the level at which facet irritation exists.
Pain
This test aids in localizing the site of a lumbar lesion.
Double Leg Raise Test a differential
Purpose:
Position:
Procedure:
Positive:
Note:
To differentiate for lumbosacral involvement
The patient is supine.
Perform a SLR on each leg separately and then, on both legs together
The angle at which the patient feels pain is compared.
The test is positive when lifting both legs together produces pain at an earlier angle
than when lifting each leg separately.
This test is highly accurate and is specific for a lumbosacral lesion!
Heel Walk Test
Purpose:
To assess for a L5 nerve root lesion.
Position:
Procedure:
Positive:
Significance:
Note:
The patient is standing.
Ask the patient to walk on their heels for several steps.
Inability to perform the test due to pain or weakness along with low back pain.
L5 nerve lesion.
Correlate these finding along with sensory and reflex testing.
Toe Walk Test
Purpose:
Position:
Procedure:
Positive:
Significance:
Note:
To assess for a nerve root lesion.
The patient is standing.
Ask the patient to walk on their toes for several steps.
Inability to perform the test due to pain or weakness along with low back pain.
S1 nerve lesion.
Correlate these finding along with sensory and reflex testing.
Differentiating between Lumbar and Sacroiliac Involvement
Goldthwait's Test
Purpose:
Position:
Procedure:
Note:
Analysis:
a differential test
The differential diagnosis of sacroiliac vs. lumbar vs. lumbosacral involvement.
The patient is supine.
Palpate the lumbar interspinous segments, then slowly raises the affected limb to
a 90 degree angle.
The onset of pain is correlated with the area moving at the time to determine the site of
pathology. Look for subluxation, sprain, arthtitis or disc involvement.
Pain before lumbar or lumbosacral movement = ipsilateral SI jointlligamant problem
Pain atlafter lumbar or lumbosacral movement =Iumbosacral or contralateral SI joint problem
If the pain begins when either leg is raised to the same height, the lesion is lumbosacral.
If the leg on the less involved side can be raised to a much higher level without producing
pain, then the SI joint on the side of the complaint is involved.
Radiating pain is indicative of sciatic radiculopathy at the following levels for the
following degrees:
0-30 degrees Sacroiliac lesion
30-60 degrees Lumbosacral lesion
60-90 degrees L 1-L4 disc lesion
Supported Forward Bending Test (Supported Flexion Test; Belt-Test)
Purpose:
Position:
Procedure:
Analysis:
Note:
a differential
To differentiate between a lumbar, lumbosacral or a SI joint lesion.
The patient is standing.
The patient is asked to bend forward from the waist to the point of pain. Make a mental note
at where that occurs. The test is repeated. This time, reach behind and stabilizes the pelvis
by supporting the ASIS's, as well as by bringing her hips against the sacrum.
If the pain disappears with support it signifies a SI joint problem. A sacroiliac problem will
only elicit pain when the pelvis is not immobilized
If the pain is still present, then the lumbar spine is the source of the pathology.
A lumbar problem will be painful in both cases.
Nachlas' Heel to Buttock a differential
Purpose:
To differentiate a lesion of the lumbosacral or sacroiliac joint and also femoral neuralgia.
Position:
Procedure:
Positive:
Analysis:
Note:
The patient is prone.
.
Stabilize the pelvis and flex the ipsilateral heel to the ipsilateral buttock.
The test is positive when the patient experiences pain in the lumbosacral or sacroiliac region
or along the course of the nerves that run from these joints (mainly the sciatic nerve or femoral
cutaneous nerve).
The ASIS is pulled downward when traction is applied through the rectus femoris muscle.
The torsion stress is then applied to the ipsilateral SI joint. The stress will eventually be transmitted to the lumbosacral or the contralateral sacroiliac joint.
If pain is occurs along the course of the femoral nerve, it's called the Femoral Nerve
Stretch Test.
Pain in the lumbar region implicates a lumbar disc lesion.
Pain in the buttock implies a sacroiliac lesion.
Hip Joint
Ranges of Motion:
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
120
30
45
25
35
45
-- Comment on femoral anteversion
Fabere Test (Patrick Test; Figure 4 Test)
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect hip joint and/or sacroiliac joint irritation.
The patient is supine.
Place the suspected leg's lateral malleolus over the patella of the other limb and
then press down on the knee (into the table).
Pain other than from stretching indicates a hip or sacroiliac joint lesion, depending on the
location of the pain.
The leg is moved into the positions of flexion, abduction, external rotation and extension,
hence the name "FABERE."
Lewin Standing Test
Purpose:
Position:
Procedure:
Positive:
To detect hamstring spasm or tightness.
The patient is standing.
Stabilize the pelvis with one hand and sharply pull the knee on that side into extension.
Repeat on the opposite side by bracing the shoulder against the patient's sacrum and pulling
both knees sharply into extension.
Pain when the knee or knees are pulled into extension followed by either or both knees
snapping back into flexion.
LaGuerre's Sign/Test "fabere in the air"
Purpose:
Position:
Procedure:
Positive:
Significance:
Analysis:
To diagnose hip joint lesions.
The patient is supine.
Flex the affected thigh and knee 90.0 Then abduct and externally rotate the thigh (the foot is
moved inward). The femur can also be pushed/directed in towards the acetabulum
Pain in the hip joint.
Confirms the presence of a non-specific hip lesion, such as psoas muscle irritation or a
sacroiliac lesion (if pain is found at the SI joint on the same side or for hip pathology.)
This action forces the head of the femur against the anterior hip capsule. There should be
No lumbar or lumbosacral pain or involvement with this maneuver.
Thomas Test
Purpose:
Position:
Procedure:
To assess for hip flexion contracture and/or iliopsoas tightness.
The patient is supine.
The patient's knee is fully brought (actively or passively) to the chest and secured in that
position. Observe the position of the knee/leg of the opposite limb.
Positive:
A positive test is present when the opposite knee is involuntarily raised off the table.
Analysis:
A positive test signifies iliopsoas muscle tightness/contracture. If the leg extends as well, it
signifies quadriceps tightness. As the thigh if flexed, slack is taken from the sacroiliac joint
to the lumbar spine to the opposite sacroiliac joint, eventually reaching the opposite sided
iliopsoas muscle.
Note:
Be sure to fully flex the well-sided limb against the chest to take out all the slack.
There should normally be enough elongation of the psoas to allow the leg/knee to remain
resting on the table.
-- rectus femoris and tff observation????
Piriformis Stretch Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect a piriformis muscle lesion.
The patient is supine.
Flex the patient's hip and knee to 90 degrees and the internally rotate and adduct the femur.
Pain or reproduction of symptoms indicates a piriformis muscle lesion.
Also look for decreased range of motion as compared to the opposite side to detect muscle
shortening.
Trendelenberg Test
Purpose:
Position:
Procedure:
Positive:
Note:
To determine weakness or paralysis of the hip abductors.
The patient is standing.
Stand behind the patient with both hands lightly on top of both iliac crests.
The patient is asked to stand on one foot and to raise the knee (thigh flexion) to the level
of
their hip. Note any changes in the height of the iliac crest on the side of the leg being raised.
The test is repeated for the hip on the opposite side.
If the pelvis/iliac crest drops on the same side that the knee was raised, this indicates a
weakness of the contralateral hip abductors (gluteus medius and minim us).
A positive test may also be found with coax vara, coax valga, congenital hip dislocations and
nerve damage.
Demianoff's Test
Purpose:
Position:
Procedure:
Positive:
Note:
To assess for lumbar muscle (iliocostalis lumborum) spasm.
The patient is supine.
Perform a straight leg raise on the patient.
Lumbar pain which prevents> 15 degrees of flexion
The pain may be due to overstretching of the tight IL muscles.
Dejerine's Triad
Purpose:
Position:
Procedure:
Positive:
Note:
To detect a space-occupying lesion: disc, tumor or osteophyte.
The patient is sitting.
Asks the patient to cough, sneeze or to strain (Valsalva Maneuver).
The sign is present (positive) when coughing, sneezing or straining at the stool causes
low back and/or radicular pain.
This is a good test for identifying disc protrusions. The above actions increase cerebrospinal fluid
pressure, as well as tensing the paraspinal muscles which causes pain at the site of the lesion
Lewin Punch Test (Gluteal Punch Test)
Purpose:
Position:
Procedure:
Positive:
To detect a probable disc herniation.
The patient is standing.
Punch the buttock on the side of the pain, then punch the opposite buttock.
Pain is referred to the back when the buttock is punched on the affected side and there is no
reaction when punched on the unaffected side.
Smith-Peterson Test (similar to Goldthwait's)
Purpose:
Position:
Procedure:
Positive:
Analysis:
Differential:
Note:
a differential test
To differentiate between a sacroiliac or lumboscaral lesion.
The patient is supine.
Palapte for movement in the lumbar spine, while performing a SLR on the well side.
The appearance or exacerbation of pain
If the pain occurs before lumbosacral movement, a SI lesion is suspected.
If the pain occurs after lumbosacral movement, either a lumbosacral or sacroiliac lesion is
suspected.
With a sacroiliac lesion, the contralateral leg can be raised higher before causing pain.
With a lumbosacral lesion, pain should start when both legs are bought to the same level.
If pain occurs after greater than 60 degrees of flexion, it signifies a contralatral SI joint lesion.
If pain occurs down the opposite leg this may signify a media lumbar disc lesion.
Lasegue Rebound Test (Drop Lasegue Test)
Purpose:
Position:
Procedure:
Positive;
NOTE:
To detect psoas spasm or irritation, or lumbar disc pathology.
The patient is supine.
Perform a SLR to the point of pain or muscle resistance, then suddenly drop the
leg, without warning into a pillow or into your other hand.
Aggravation of the backache and sciatic pain and increased low back muscle spasms
This test is good for detecting psoas spasm or irritation, and may also indicate a lumbar disc
pathology.
Anvil Test
Purpose:
Position:
Procedure;
Positive;
Note:
To detect hip pathology or femoral fracture. The patient is supine.
Tap the inferior aspect of the calcaneus with your fist. Local thigh pain
If pain localizes to the thigh, suspect a femoral fracture or hip joint pathology. If pain localizes to the leg, suspect a tibia or a fibula fracture.
If pain localizes to the calcaneus, suspect a calcaneal fracture.
Erichsen's Sign
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
To detect a sacroiliac lesion
The patient is lying prone.
Introduce strong sharp thrusts bilaterally from the ilia toward the midline
(sacroiliac joints) in order to forcibly move both crests toward the sacrum.
Sacroiliac pain.
Pain will be felt in sacroiliac disease but not with hip joint disease, as the
force is transmitted superior to the hip joints.
This test differentiates sacroiliac from hip joint pathology.
Hip Abduction Stress Test
?same as Sacroiliac Resisted Abduction Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
To detect sacroiliac lesions.
The patient is lying on the well side.
The patient abducts the affected leg and holds it in abduction. You then apply pressure to
return the hip to the initial position while the patient resists.
Pain in the pelvic area.
This test is fairly accurate in detecting sacroiliac joint lesions even in the presence of
concurrent hip joint pathology.
Pinpoint pain at the greater trochanter may signify a tendonitis of the hip abductors (gluteus
medius/minimus)
Adam's Position Cip graphic 185
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
The evaluation of a functional scoliosis.
The patient can be seated, standing or kneeling.
Observe the position of the spinous processes as the patient bends forward.
The disappearance of the spinal scoliosis.
With a functional scoliosis, the spinal curve should disappear upon flexion. With a structural
scoliosis, the curve will remain.
Obviously, this test is done on someone with a visible scoliosis.
Sacroiliac Tests
Gaensalen's Test
Purpose:
Position:
Procedure:
Positive:
Note:
The determination of sacroiliac involvement.
The patient is supine with the involved side near the edge of the examining table.
Have the patient hold their (uninvolved) flexed knee and thigh against their abdomen.
Gradually extend the involved leg off the table. Apply downward pressure against both the
clasped knee and the knee at the extended hip.
Exacerbation of pain at the sacroiliac joint/pelvis.
This test is contraindicated in children, geriatrics and pregnant patients.
The validity of this test is compromised with hip and knee lesions and with adhesions of the
upper lumbar nerve roots.
Anterior Innominate Test
Purpose:
To detect forward displacement of the ilium in a patient with low back or sacroiliac pain.
Position:
The patient is standing with the painful extremity placed 2-3 feet forward.
Procedure:
The patient bends the upper trunk acutely over the forward foot so as to place all their weight
onto that forward leg as they raise the back foot off the floor.
Positive:
The exacerbation or worsening of lower trunk pain on the posterior side leg.
Analysis:
The ilium may be anterior in relation to the sacrum.
Lewin-Gaensalen's Test
Purpose:
To detect a sacroiliac lesion.
Position:
The patient lies on their side with the involved side up and the downside thigh and knee
flexed with their hands clasping the knee.
Procedure:
The examiner stands behind the patient, stabilizing the hip with one hand and slowly
hyperextends the affected leg with the other hand.
Positive:
Pain in the sacroiliac joint.
Note:
This test is used when Gaensalen's is contraindicated, as with pregnancy.
Side-lying Iliac Compression Test
Purpose:
To identify the presence of a sacroiliac lesion.
Position:
The patient lies on their side.
Procedure:
Stand over the patient and apply a strong downward pressure over the most superior part of
the iliac crest.
Positive:
The test is positive if the patient's painful symptoms in the sacroiliac, gluteal or crural
regions are reproduced.
Note:
This test is contraindicated in children, geriatrics and pregnant patients.
Hibb's Test Purpose:
Position:
Procedure:
Positive:
Note:
a differential test
To determine sacroiliac joint involvement. The patient is prone.
Stand on the opposite side of the table for the limb being tested and stabilize the pelvis closest to
you. Reach across the body and flex that leg 90.0 Then, internally rotate the
femur (by pushing
the flexed leg away from you) to move it into internal rotation
Pain at the pelvis indicates a sacroiliac lesion; pain in the hip indicates a hip joint lesion.
A sacroiliac lesion is can be suspected, assuming there is no hip joint pathology.
This test can be used to differentiate hip joint from SI joint pathology!
Yeoman's Test Cip graphic 252
Purpose:
Position:
Procedure:
Positive;
Note:
To determine sacroiliac joint involvement.
The patient is prone.
Place downward pressure on the suspected SI joint. With the other hand, maximally flex
the
knee and hyperextend the thigh.
Deep sacroiliac pain signifies a sprain of the anterior sacroiliac ligaments.
Lumbar pain would signify lumbar pathology.
Sacroiliac Stretch Test
Purpose:
Position:
Procedure:
Positive:
Note:
To assess for anterior sacroiliac ligament strain.
The patient is supine.
With your crossed, press downward and laterally on the ASIS of each ilium.
Deep unilateral pain (gluteal or crural) indicates an anterior sacroiliac ligament sprain.
Lumbosacral pain is a negative finding as is sacral pain.
Sacroiliac Resisted Abduction Test
Purpose:
Position:
Procedure:
Positive;
Note:
To assess for anterior sacroiliac ligament strain.
The patient is side-lying with the suspected side up and the down-side knee flexed for
stability.
Therapist resists the patient's attempt to abduct the limb. (the patient's leg is straight
with the knee extended)
Pain in the sacroiliac joint indicates a sacroiliac joint sprain.
Pain in the hip may signify a hip join tlesion.
Gillis' Test
Purpose:
Position:
Procedure:
Positive:
To determine sacroiliac joint involvement.
The patient is prone.
Stand opposite to the side of the lesion and place the palm of one hand over the
SI joint of the unaffected side to fix the sacrum with the fingertips fanning over the affected SI
joint. The other hand is placed under the thigh and that thigh is hyperextended.
The pain that the patient complained of is aggravated over the affected SI joint.
Pelvic Rock Test (Iliac Compression Test)
Purpose:
Position:
Procedure:
Positive:
To detect pathology of the sacroiliac joint.
The patient is side-lying.
The ASIS and lateral iliac crest of the pelvis are located and then you apply a force
designed to compress the joint into the table. The test is repeated with the patient lying
on the other side as well.
Increased pain in the area of the sacroiliac joint.
Hyperextension Test for the Hip
Purpose:
Position:
Procedure:
To detect inflammation or adhesions of the 3rd or 4th lumbar nerve roots.
The patient is prone.
Place one hand over the posterior iliac bone of the suspected side. Apply downward
Pressure and stabilize the pelvis. The other hand is used to slowly extend the affected side
Positive:
hip with the knee in slight flexion.
The test is only positive if the patient experiences radiating pain down the anterior thigh.
34
Ely Hell to Buttock Test (Heel to Opposite Buttock)
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect pathology of the hip joint.
The patient is prone.
Flex the knee and bring the heel to the contralateral buttock
Then, hyperextend the thigh from this position.
Any significant hip lesion will make this test impossible to perform.
There are 4 possibilities and symptoms:
1. femoral nerve irritation
2. iliopsoas irritation which will limit thigh extension.
3. lumbar nerve root (disc) irritation will give femoral radicular pain.
4. lumbar nerve root adhesion will yield upper lumbar discomfort
Ely's Sign (heel to buttock)
Purpose:
Position:
Procedure:
Positive:
To detect rectus femoris and/or tensor fascia lata or iliotibial band contracture.
The patient is prone.
Flex the knee toward the buttock on the same side.
The sign is present when the pelvis rises up off the table and the thigh goes into abduction.
Phelp's Test
Purpose:
Position:
Procedure:
Positive:
To detect contracture of the gracilis muscle.
The patient is prone with the knees extended.
The thighs are maximally abducted, using pain and resistance as a guide. Then flex the
patient's knees bilaterally to a right angle and notes if this maneuver allows more hip
abduction.
The test is positive if knee flexion allows greater hip abduction and knee extension
decreases hip abduction.
Knee Region
Ranges of Motion:
Flexion
Extension
Internal rotation
External rotation
135
0-10
5 (passive)
5 (passive)
Ober's Test
Purpose:
Position:
Procedure:
Positive;
Analysis:
Note:
To detect tensor fascia lata or iliotibial band contractures (a shortened, tight iliotibial band).
The patient is side-lying with the affected side up. The knee of the down-side leg is flexed.
Stabilize the pelvis at the lateral iliac crest with one hand. Hold under the knee (which is flexed 90°)
and then abduct and extend that thigh. When the hip is fully extended, allow the limb to fall to the
table into adduction.
A positive test is when the leg remains in the abducted position or fails to drop slowly.
Normally, the leg will descend to the table.
If the limb doesn't drop, it indicates that the iliotibial band is shortened and tight.
A contracture of the iliotibial band can be palpated between the iliac crest and the anterior aspect
of the greater trochanter.
Valgus (Abduction) Stress Test
Purpose:
Position:
Procedure:
Positive:
Note:
Analysis:
The detection of medial instability/medial collateral ligament damage of the knee
The patient is supine.
Apply a stress to the patient's outer knee (to open the inner side of the joint) while stabilizing the
ankle. The test is first done with the knee fully extended, and then repeated with the knee in 20-300
of flexion.
Excess movement of the tibia away from the femur indicates a positive test.
A positive test with the knee flexed is indicative of damage to the medial collateral ligament.
Positive finding with the knee fully extended indicates a major disruption of the knee
ligaments.
Flexing the knee 30° is a more accurate test for both abduction and adduction stress tests.
The knee joint is more vulnerable to torsional stress in the flexed position.
Varus (Adduction) Stress Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
The detection of lateral instability and/or medial collateral ligament damage of the knee.
The patient is supine.
Apply a varus stress to the patient's inner knee (to open the outside of the joint) while Stabilizing
the ankle. The test is done first with the knee in full extension and then repeated with the knee in
20-300 of flexion.
Excess movement of the tibia away from the femur indicates a positive test.
A positive test with the knee extended suggests a major disruption of knee ligaments. A positive test with the knee in flexion suggests
Flexing the knee 30° is a more accurate test for both abduction and adduction stress tests
as it eliminates capsular involvement.
If Rotation is used
Macintosh/Slochum Test for rotatory instability.
=
Apley's Distraction Test (collateral ligaments)
Purpose:
Position:
Procedure:
Positive
Analysis:
Note:
To evaluate collateral ligament damage of the knee.
The patient is prone and the knee is flexed to 90 degrees.
Flex the patient's knee to 90.0 Stabilize the distal femur with your knee to keep it from being
lifted off of the table. The apply an upward distraction to the tibia while internally and
externally rotating it.
If pain or clicking occurs, it implicates a ligamentous injury of the knee.
Lateral knee pain signifies a lateral collateral ligament injury.
Medial knee pain signifies a medial collateral ligament injury.
The calcaneus will point to the side of the ligament being tested.
If pain is relieved with this test, it confirms the compression test for ligament damage.
Anterior/Posterior Drawer Sign (ACLlPCL)
Purpose:
Position:
Procedure:
Positive:
Analysis:
Cip graphic 319,320
To detect anterior and posterior instability of the knee (ACUPCL damage)
The patient is supine, the thigh is flexed 45 degrees and the knee is flexed 90 degrees with the
foot flat on the table. The examiner sits lightly on the foot to stabilize it.
Pull forward on the proximal tibia and then push it backward, observing for the
motion present. Repeat this motion with the foot internally rotated 30 degrees and externally rotated
15 degrees (Slochum's Test). Do both sides for comparison.
The test is positive if there is excessive anterior or posterior movement or gapping of the tibia with
respect to the femur, indicating an anterior cruciate ligament or posterior cruciate ligament
injury/tear.
Increased anterior mobility (with foot in neutral) = anterior cruciate ligament damage.
Increased posterior mobility (with foot in neutral) = posterior cruciate ligament damage. With no
abnormal movement, but acute pain from the joint's center
partial rupture of the respective
anterior or posterior cruciate ligament.
Anterior displacement with the foot internally rotated
lateral and posteromedial
ligament
damage ( + Slochum's)
Anterior displacement with the foot externally rotated
medial capsular ligament damage (+
Slochum's)
=
=
=
-- orthopedic book illustration (orange one)
Slochum Test
See "Anterior/Posterior Drawer Test"
Position:
Purpose:
To detect rotatory instability of the knee.
Position:
The patient is supine with the hip flexed 45 degrees and the knee flexed 90 degrees with you sitting
lightly on the foot for stabilization.
Procedure:
An anterior drawer test is performed on the tibia in each of two positions.
In the first position, the leg is placed in 30 degrees of internal rotation to tighten the lateral and
posterolateral ligaments. In the second position, the leg is placed in 15 degrees of external
rotation.
This allows forward and outward movement of he medial tibia if the medial
ligaments are damaged.
Note:
The test is graded according to the amount of laxity present:
+
>+ ½ " of movement
++
>+ ½ to ¾ of movement
+++
>+ ¾” of movement
Mcintosh Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect anterolateral instability of the knee.
The patient is supine.
Support the heel with one hand and the other hand is placed laterally over the proximal tibia.
Your proximal hand applies a valgus stress and internally rotates the tibia as the knee is
gradually moved from full extension into flexion.
At approximately 30-40 degrees of flexion a sudden jump and palpable clunk will be present at
the lateral tibial plateau which has subluxated anteriorly during the first 5 to 15 degrees of
flexion suddenly reduces.
This test is dependant upon an intact ilio-tibial band which becomes very taut at the point of
reduction and glides posteriorly to the transverse axis of rotation and thus pulls the
tibial
plateau into reduction with a jumping sensation.
Lachman Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect anterior cruciate ligament damage of the knee.
The patient is supine.
The knee is in 30 degrees of flexion. Grasp the patient's thigh with one hand to stabilize it.
with the opposite hand, grasp the tibia and pull it forward.
A soft end-feel and excess forward translation of the tibia indicates a torn ACL.
This is the most reliable test for anterior cruciate damage, as the knee doesn't require 90
degrees of flexion as with the anterior drawer test. This test is similar to the anterior drawer
test except that the knee is flexed 30 degrees and the drawer maneuver is attempted while the
thigh is stabilized on the table.
Reverse Lachman Test
Purpose:
Position:
Procedure:
Positive:
To detect posterior cruciate ligament damage of the knee.
The patient is prone.
The knee is flexed 30 degrees. Stabilize the posterior thigh with one hand. With the other
hand, grasp the tibia and push it in a posterior direction.
A soft end-feel and excess posterior translation of the tibia indicates a torn PCL.
Knee Flexion Stress Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect any knee flexion limitation.
The patient is supine.
Raise the affected knee with one hand while holding the ankle with the other. As the knee is
flexed, gently push it to the patient's chest as the other hand brings the heel to the patient's
buttock, attempting maximal flexion.
Inability to perform the maneuver due to pain or discomfort.
Normally, the knee can be flexed so that the heel touches the buttock without pain.
Tests for Meniscal Tears
Childress Duck Waddle Test
Purpose:
Position:
Procedure:
Positive:
Note:
To assess for a medial or lateral meniscus injury.
The patient is standing.
A full squat is attempted by the patient after the legs are placed in maximal internal rotation
and then repeated with the legs in maximal external rotation.
Pain and/or the inability to fully flex the knee with or without a clicking sound. A medial meniscus tear exists if there is pain on internal rotation.
A lateral meniscus tear exists if there is pain on external rotation.
Meniscal problems are potentially serious. The meniscus may fold over on itself.
Be careful with conservative treatment.
With meniscal tears, both active and passive ranges of motion may be limited.
McMurray's Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect medial meniscus damage/displacement.
The patient is supine.
Palpate the joint line with your thumb and index finger. Hold the foot or heel, the knee is
then
flexed to approximately 45 degrees. Then, the examiner externally rotates the knee while
that knee is extended. This is followed by re-flexing the knee so that internal rotation during
extension can be performed.
A palpable or audible click or popping with pain at the medial joint line.
Most positive responses occur within the last 30 degrees of flexion.
When rotation of the knee during extension produces the same findings on the lateral joint
line, lateral meniscal damage is suspected.
Wilson's Sign
Purpose:
Position:
Procedure:
Positive:
To detect osteochondritis of the knee.
The patient is seated with the lower leg in a dependant position.
Flex the knee to 90° and then maximally internally rotate the leg. While maintaining
the internal rotation, slowly extend the knee. At approximately 30 degrees of flexion, the
patient may complain of pain over the anterior aspect of the medial femoral condyle. The
pain is relieved at this point with external rotation of the leg.
Relief of pain when external rotation is performed.
Apley's Compression Test (Apley's Grinding Test)
Purpose:
Position:
Procedure:
Positive:
Note:
To detect meniscal irritation or damage.
The patient is prone and the knee is flexed to 90°
Apply a compressive force through the tibia via the heel and then rotate the tibia back and
forth into internal and external rotation. (you may also palpate the knee joint line with the
other hand, feeling for crepitation.)
The test is positive if the patient reports pain at the knee or the examiner feels crepitation.
Signifies a meniscal injury on the side that the patent experiences pain.
Medial knee pain correlates to a medial meniscus injury.
Lateral knee pain correlates to a lateral meniscus injury.
Modified Helfet's Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect a meniscal tear.
The patient is seated with he foot on the floor. Make note of the tibial tuberosity's position
in relation to the midline.
Passively extend the patient's leg and re-evaluate the position of the tibial tuberosity.
Lack of tibial rotation, as evidenced by tibial tuberosity position, during knee extension may signify a meniscal tear which is blocking tibial rotation.
The tibia normally externally rotates during knee extension (screw home mechanism).
Payr's Sign Purpose:
Position:
Procedure:
Procedure:
Positive:
To detect a lesion of the posterior horn of the medial meniscus.
The patient is in a Turkish sitting position (feet and ankles crossed). Apply downward pressure on the knee joint.
Pain on the medial side of the knee joint.
Bounce Home Test (Spring Test)
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect generalized knee pathology (effusion, meniscal tear).
The patient is supine.
Hold the patient's heel with one hand and support the calf with the other. The
knee is positioned into a relaxed slight flexion, and then allowed to fall or "bounce home" into
extension.
The lack of a sharp bounce.
Pain on full extension might indicate a smaller meniscus tear or general knee pathology. The normal knee will fall crisply into extension followed by a rebound.
This test is similar to the Knee Drop test, which is done with the patient prone.
Patellar Apprehension Test
Purpose:
Position:
Procedure:
Positive:
Note:
To identify chronic lateral dislocation of the patella.
The patient lies supine with the knee resting in full extension.
Aattempt to move the patella laterally.
If the patient looks apprehensive and tries to contract the quadriceps muscle to bring the
patella back to neutral, the test is positive ..
A positive test signifies a chronic tendency toward lateral patella dislocation.
Tests for Chondromalacia Patellae I Patellofemoral Pain
Syndrome
Note: Pain behind the patella upon walking up steps or uphill may be due to vastus medialis weakness
which permits lateral patella tracking. Vastus medialis is the first muscle to weaken or strengthen of the
quadriceps group. Treatment therefore, is to rehabilitate this muscle with exercise tubing/resistance.
Patella Grinding Test (Fouchet's Sign; Perkin's Sign)
Purpose:
To detect chondromalacia patella or retropatella arthritis.
Position:
Procedure:
Positive:
Note:
The patient sits with the knee fully extended and supported on a table.
Move the patella medially and laterally after applying a downward pressure to it.
Crepitus under the patella would indicate a positive test as would pain in the knee upon
downward pressure (Fouchet's Sign) or pain upon medial and lateral movement with strong
pressure (Perkin's Sign).
The patient can also be supine.
Patellofemoral Grind Test (Clarke's Sign)
Purpose:
Position:
Procedure:
Positive:
Note:
Analysis:
To detect for chondromalacia patella.
The patient is supine.
Push the patella inferiorly with the web of your hand. The patient is asked to contract
the quadriceps.
Crepitation and/or pain
Signifies loss of the integrity of the patello-femoral articulation. Be sure to test both sides. There may be some degree of pain, even in normal subjects.
This test examines for roughening or pitting of the articular surfaces of the patella and
femoral condyles. (chondromalacia)
Q-Angle Measurement
Purpose:
Position:
Procedure:
Positive:
Analysis:
Note:
To detect the probability of the patella maltracking.
The patient is supine.
Measure the angle created by two intersecting lines. The first line runs through the long axis Of
the femur (ASIS to the center of the patella) and the second line runs through the center of the
patella tendon. (some books regard the second line as the long axis of the tibia).
A measurement of greater than 10 degrees in males and greater than 15 degrees in females is a
positive measurement.
An increased Q-angle signifies an increased predisposition to patellofemoral syndrome or
lateral patella tracking.
A goniometer can be used for an accurate measurement.
Patella Tap Test (Patella Ballotment Test)
Purpose:
Position:
Procedure:
Positive:
Note:
To detect fluid or effusion within the knee.
The patient is supine.
Compress the suprapatellar pouch from superior to inferior and forces any fluid into the
retro-patellar region.
If there is enough fluid, the patella will lift away from the femoral condyles. Also, a quick
gentle thrust with the thumb or thenar eminence will push the patella back against the
condyles, resulting in a significant palpable tap.
Signifies effusion within the knee.
Tests for Generalized Knee Pathology
Knee Drop Test
Purpose:
Position:
Procedure:
Positive:
Note:
To detect a generalized knee lesion.
The patient is prone.
Cup your hand and places it below the affected knee to raise it off the table, as your other
hand partially flexes the knee. Allow the knee to drop to the table on its own.
Failure of the knee to drop and rebound.
Signifies a general knee lesion and an extension limitation.
This test is similar to the Bounce Home Test, which is done with the patient supine.
Flamingo Test
Purpose:
To detect general joint pathology.
Position:
The patient is standing.
Procedure:
Ask the patient to hop on leg, thereby increasing stress into the foot, knee, hip, pubic
symphysis and sacroiliac joints.
Positive:
Increased pain in any of these joints.
Analysis:
Pain following trauma may indicate a fracture. Pain at the hip may signify trochanteric
bursitis. Pain in any of the aforementioned joints may indicate an inflammatory process.
Actual Leg Length
Purpose:
To measure the actual leg length.
Position:
The patient is standing.
Procedure:
Measure each limb from the ASIS to the floor.
Positive:
A difference between both limbs would indicate an anatomical short leg.
Apparent Leg Length
Purpose:
To determine the functional length of each extremity.
Position:
The patient is supine.
Procedure:
Measure from the umbilicus to the apex of the medial malleolus on each extremity.
Analysis:
An abduction contracture causes apparent lengthening of the limb.
An adduction contracture causes apparent shortening because of the pelvis is tilting
sideways to make the legs parallel and the heel of the shorter side cannot be placed on the
ground when the legs are parallel.
Allis Test Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect an anatomical difference and/or a hip dislocation.
The patient is supine with both knees flexed to 90° and the feet are placed flat on the table
with both malleoli together.
Observe and compare the heights of the knees.
Unequal knee heights.
A positive test is reflected to the affected side. The test may indicate: 1. if the knee of the suspected limb is short:
posterior displacement of the femoral head or decreased tibial length. 2. if the knee of the suspected limb is long:
anterior displacement of the femoral head or increased tibial length
Dreyer Test
Purpose:
To detect a fracture of the patella.
Position:
Procedure:
Positive:
The patient is supine with the knees extended.
The patient attempts to perform a straight leg raise. If he is unable to do that, grasp firmly around
the knee joint to stabilize the quadriceps tendon.
The patient is only capable of performing a straight leg raise with quadriceps stabilization.
Ankle Region
Ranges of Motion
Dorsiflexion
Plantarflexion
Inversion
Eversion
20
50
5-10
5
Anterior/Posterior Foot Drawer Sign (Drawer's Foot Sign)
Purpose:
Position:
Procedure:
Positive:
Analysis:
Cip graphic 349
To detect instability of the anterior talofibular ligament.
The patient is supine or seated with the legs hanging off the table with the feet relaxed
slightly in plantar flexion.
Place one hand on the tibia near the ankle and the other hand under the calcaneus.
With the foot stabilized, push the tibia posteriorly and then pull it anteriorly.
The test is positive if the tibia slides anteriorly, signifying a posterior talofibular ligament tear or
The test is positive if the tibia slides posteriorly, signifying an anterior talofigular ligament tear.
Instability usually is secondary to a rupture or following a plantarflexion-inversion sprain.
Lateral Stability Test Cip graphic 350
Purpose:
Position:
Procedure:
Positive:
Note:
To detect a tear of the anterior talofibular ligament and/or calcaneofibular ligament.
The patient is supine or seated.
Grasp and passively invert the foot.
Increased gapping.
With the stability tests, the foot is moved.
Medial Stability Test Cip graphic 351
Purpose:
Position:
Procedure:
Positive:
To detect a tear of the anterior deltoid ligament.
The patient is supine or seated.
Grasp and passively evert the foot.
Increased gapping.
Tinel's Foot Sign
Purpose:
Position:
Procedure:
Positive:
Cip graphic 352
To detect tarsal tunnel syndrome.
The patient is supine or seated with the foot in the neutral position on a table.
Tap just posterior to the medial malleolus in the area of the posterior tibial nerve.
Paresthesia radiating down the foot.
Duchenne's Sign
Purpose:
Position:
Procedure:
Positive:
To detect a superficial peroneal nerve lesion.
The patient is supine.
The patient attempts to plantarflex the foot while the examiner applies resistance against the
head of the 1 st metatarsal.
A positive test is found when the medial side of the foot stays in dorsiflexion and lateral part
Analysis:
plantarflexes (foot inversion occurs).
Signifies paralysis of the peroneus longus de to a lesion of the superficial peroneal nerve at
or above the L4-L5-S 1 nerve roots.
Homan's Sign
Purpose:
Position:
Procedure:
Positive:
Analysis:
To assess for deep venous thrombophlebitis.
The patient is either supine or prone.
Dorsiflex the patient's ankle (pressure may be applied to the belly of the calf muscle with the
fingers.
Any sudden increase of pain in the calf or popliteal space is noted as a positive test. Signifies deep venous thrombophlebitis.
Talar Tilt
(Inversion Stress Test?)
Purpose:
Position: Procedure:
Positive:
Analysis:
A test designed to identify lesions of the calcaneofibular ligament.
The patient is sitting on a table with the leg in a dependant position and the knee flexed 90°.
With the foot in a neutral position, the talus is tilted medially.
The test is positive if the amount of inversion on the involved side is excessive.
Eversion Stress Test
Purpose:
Position:
Procedure:
Positive: Analysis: To determine stretch or tear of the deltoid ligament.
The patient is sitting on a table with the knee flexed to 90° and the foot in a neutral position.
The test is performed the same as with the Talar Tilt test, except the foot is tilted laterally
instead of medially.
The amount of tilt is compared to the uninjured side. An excessive amount of motion would
be a positive test.
This test and the talar tilt test are often performed bilaterally under x-ray exam to give a
comparison.
"Clunk" Test for Tibia-Fibula ligament sprain
Purpose:
Position:
Procedure:
Positive:
This detect a severe sprain of the anterior tibiofibular ligament.
The patient is seated or supine.
To perform this test, the distal tibia and fibula are stabilized with one hand and the calcaneus is
grasped with the other hand. The calcaneus is then moved in a side-to-side motion attempting
to contact the medial and lateral malleoli.
A positive test would be indicated by a "clunk" as the talus hits the malleolus on one side and
then the other.
Tests for a ruptured Achilles tendon
Thompson Test (Simmond's Test)
Purpose:
Position:
To detect rupture of the achilles tendon.
The patient is prone with the feet hanging over the table.
Procedure:
Positive:
Squeezes the affected side just below the widest part of the calf muscle and observe for a
slight plantarflexion of the ankle.
If a normal plantarflexion response is not elicited, an achilles tendon rupture is suspected.
Hoffa's Sign
Purpose:
Position:
Procedure:
Positive:
Note:
To detect a calcaneal avulsion fracture or for a ruptured achilles tendon.
The patient is prone with the feet hanging symmetrically off the table.
Palpate and move the achilles tendon of each leg.
One achilles tendon is less taut than the other.
A loose fragment may be seen and felt behind either malleolus.
Achilles Tap Test
Purpose:
Positon:
Procedure:
Positive:
Note:
To detect an achilles tendon rupture.
The patient is prone.
Tap the achilles tendon with a reflex hammer.
The exacerbation of pain and the loss of the plantar flexion of the foot.
This test assumes no neurological disturbance of the foot, as you may see a normal
plantarflexion response of the S1 reflex.
Metatarsal Tests
Metatarsal Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect metatarsalgia.
The patient is supine or seated with the legs extended on the table.
Place pressure against the plantar surface of digits 2 through 5 so that the
Metatarsophalangeal joints are accentuated (forced flexion).
Then, percuss each metatarsophalangeal joint with a reflex hammer.
Neuritic pain.
This test may detect metatarsalgia due to metatarsophalangeal joint inflammation.
Strunsky's Sign
Purpose:
Position:
Procedure:
Positive:
To detect inflammation of the anterior arch of the foot. (metatarsophalangeal joints)
The patient is supine.
Grasp and suddenly flexes the toes.
Lancinating pain or sudden passive toe flexion.
Compression Test
Note:
This test has two parts. First the tibia and fibula are squeezed together at the malleoli and
again at the midshaft and at the proximal ends of the bones. Referred pain back onto a spot
on the fibula or tibia would indicate a possible fracture (can also be used with ulnar/radius
fractures). The second part of the test checks for anterior tibio-fibular ligament sprain and
spreading of the joint mortise. To check for this injury the tibia and fibula are squeezed
together at the malleoli
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Analysis:
This maneuver may decrease or may not change the amount of pain the patient has in the area of the anterior
tibia-fibular ligament, but when pressure released, the mortisse will spread and the patient will report an
increase in their pain over the anterior tib-fib ligament.
Note:
Procedure:
Positive:
Percussion/"Thump" Test
Purpose:
This test checks for possible fracture in the ankle joint or in the tibia or fibula.
Position:
The patient is seated in the table with the leg in a dependant position and the ankle at 90
degrees.
Procedure:
Firmly percuss the heel with an open hand.
Positive:
Pain referred back to a specific spot on one of the bones of the ankle or the shaft of the tibia or fibula would indicate a possible fracture.
Note:
The test can also be performed on the following areas to check for fractures:
1. Phalanges/metacarpals/metatarsals:
with fingers (toes) extended, percuss the end of the distal phalanx of the
involved ray with your finger.
2. Spine: with the patient in forward flexion, percuss along the spinouses with your fist.
3. Patella: with the knee extended, percuss the medial and lateral borders of the patella
with your finger.
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Meningeal Irritation Tests
Kernig's Sign
Purpose:
Position:
Procedure:
Positive:
Note:
"K" kick
To detect meningeal irritation.
The patient is supine.
The patient is instructed to flex his thigh to 90° with the leg parallel to the floor. He is
then asked to straighten the leg (extend the knee)
Inability to straighten the leg or the presence of pain while straightening the leg.
Sciatica will also cause pain during this test.
This is the most reliable meningeal irritation test!
Brudzinsky's Sign
Purpose:
Position:
Procedure:
Positive:
Note:
To detect meningeal irritation.
The patient is supine.
Flex the patient's head to her chin.
The patient flexes both knees upon flexion of the spine.
The knee flexion relieves meningeal pressure.
Malingering Tests
Libman's Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
a man or a wimp?
To determine the pain threshold of the patient.
The patient is seated.
Place strong bilateral pressure on the mastoid processes.
The patient reports experiencing pain.
The patient has a low threshold for pain. The mastoids are relatively insensitive.
Lasegue's Sitting Test (Seated Lasegue's Test)
Purpose:
Position:
Procedure:
Positive:
Note:
To detect malingering or exaggeration of symptoms.
The patient is seated with the legs hanging over the table.
The patient is instructed to extend one leg at a time.
The person with sciatica will lean backward (due to pain) when the affected leg is extended
Suspect malingering if another test suggested sciatica due to the patient complaining of pain.
Observations
Neri's Bowing Sign
Purpose:
Position:
Procedure:
Positive:
Note:
To detect tight hamstrings.
The patient is standing.
The knee on the affected side is flexed as the patient bends forward. The test is then
repeated with both legs straight.
The sign is present when the patient can bend more with the knee flexed than when both knees are extended.
This sign is present with spasm of the hamstrings, but may also be found with sacroiliac, lumbar
and lumbosacral joint involvement. It is usually also present with lumbar
radiculopathy.
Murphy's Punch Test
Purpose:
Position:
Procedure:
Positive:
To detect kidney inflammation.
The patient can be seated of standing.
Apply several sharp blows with the edge of the hand to the patient's twelfth rib area at the
back.
Muscular rigidity and deep-seated tenderness or sharp pain that may radiate around the chest
wall.
Sternal Compression Test
Purpose:
Position:
Procedure:
Positive:
Analysis:
To detect rib fracture.
The patient is supine.
Exert downward pressure into the sternum.
Pain at the lateral border of the ribcage.
Signifies rib fracture.
Schepelman's Sign
Purpose:
Position:
Procedure:
Positive:
Note:
To assess for intercostals neuritis or pleural fibrosis.
The patient is seated.
The patient laterally flexes from the waist to each side.
Pain.
Pain on the concave side indicates intercostals neuritis.
Pain on the convex side indicates fibrous inflammation of the pleura.
Neurological Assessment
Medical hamstring reflex
With the patient's leg relaxed, sharply strike the tendon or belly of the medial hamstrings muscle. Look for flexion of the
knee or contraction of the muscle. Grade on a scale of 1 to 5.
Ankle jerk
With the [patient sitting, p[;lace a slight dorsiflexion stress on the ankle so as to stretch the achilles tendon. Sharply strike
the tendon withq reflex hammer. Look for plantarflexion of the foot or contraction of the gastroc/soleus.
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