Download SHOULDER

Sara Cohen
SHOULDER
Surface anatomy
Ecchymosis: a sign of fracture or musculotendinous injury
Edema: sign of infection or inflammation BUT may not be visible in glenohumeral jt due
to thickness of deltoid.
Clavicle: Most commonly fractured long bone in the body!
--Most fractures occur in middle 1/3
--The sternocleidomastoid muscle connects the proximal clavicle and adjacent sternum
with the mastoid process of the skull
Sternoclavicular jt: Lies at proximal end of clavicle
--Surprisingly, a lot of motion occurs here, especially during shoulder abduction
--If swollen? Think of fracture of medial clavicle, dislocation of joint, infection (if red
too), or arthritis
--Posterior dislocation causes respiratory distress
Acromioclavicular jt: Lies at the distal end of the clavicle
--strong ligaments prevent displacement
--There are SIX types of (Rockwood) injuries to the AC joint.
Acromion: That long flat part of the scapula that articulates with the clavicle
--Origin for middle deltoid muscle
--Lateral edge is palpable but rarely visible because the humeral head extends laterally
and the whole thing is covered by the deltoid
--You get to see the lateral edge in anterior dislocation of the shoulder OR if you have
deltoid atrophy (axillary n injury perhaps?)
Coracoid process: Origin for short head of biceps and coracobrachialis and insertion for
pec minor
--only seen in: very thin patients OR patients with deltoid atrophy OR posteriorly
dislocated shoulder
Pectoralis Major: One of the three most prominent muscles when shoulder viewed
anteriorly (the other two are the deltoid and the biceps brachii)
--origin: sternum, clavicle, and ribs
--inserts on proximal humerus
--actions: adductor, flexor, and internal rotator of the arm
--innervation: lateral and medial pectoral nerves
--rupture is pretty unlikely but more common now with so much weight training
--It is relatively common for the pec major to be congenitally unilaterally absent. I
wonder what that looks like.
Sara Cohen
Deltoid: gives shoulder its contour
--origin: anteriorly, along clavicle and AC jt
--insertion: lateral aspect of the humerus (deltoid tubercle)
--actions: abduction, flexion, extension
--innervation: axillary nerve
--deltoid tendonitis is pretty rare so if you notice pain at the insertion point, it’s likely to
be REFERRED PAIN from the rotator cuff
Subacromial bursa: deep to acromion and deltoid
--Can become inflamed in RA and cause swelling in the anterior shoulder
Biceps Brachii: most prominent muscle of anterior arm (duh)
--actions: flexor of elbow, supinator of forearm, SOME shoulder flexion
--has two heads
--long head: originates at superior glenoid labrum
--short head: originates at coracoid process
--innervated by musculocutaneous nerve
--rupture of LONG head is common and causes the muscle belly to bunch up when elbow
is flexed and sort of looks like Popeye’s arm  called a POPEYE DEFORMITY
Quiz Questions:
1. What is the most fractured long bone in the body?
2. When can sternoclavicular joint dislocation be dangerous?
3. What are the three most prominent muscles of the anterior shoulder and arm?
What is their innervation and function?
4. What is a Popeye deformity?
Triceps Brachii: primary extensor of the elbow
--innervation: radial nerve
--THREE heads: medial and lateral heads arise from humerus
--long head arises from glenoid and is a site of tendonitis in athletes that throw a lot
Scapula:
--most visible part is the spine, which terminates in the acromion process
--supraspinatus muscle fills superior fossa
--infraspinatus muscle and teres minor mucle fill inferior fossa
--spine is insertion site of trapezius
--winging of the scapula: protrusion of medial border of scapula, results from weakness
of serratus anterior (most common), rhomboids, or trapezius
--lateral border of scapula is covered by latissimus dorsi
--superior border is covered by trapezius and supraspinatus
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Trapezius:
--C-spine pain often referred to upper trapezius and patient thinks he has upper shoulder
pain
--Helps stabilize, lift, and retract the scapula
--innervated by XIth cranial nerve
Levator Scapula: raises superior angle of the scapula
Supraspinatus:
--inserts on greater tuberosity of the humerus
--difficult to detect atrophy because it’s covered by trapezius
--atrophy occurs with rotator cuff tear or less commonly suprascapular nerve palsy (due
to impingement)
Infraspinatus:
--inserts on greater tuberosity of humerus
--atrophied in rotator cuff tear or suprascapular nerve entrapment
--If only the infraspinatus is atrophied, the suprascapular nerve was entrapped at the
spinoglenoid notch
Serratus anterior:
--innervation: long thoracic nerve
--injury results in winging of scapula
Questions:
1. Weakness of which three muscles causes winging of the scapula?
2. Where does tendonitis commonly occur in athletes that throw a lot?
3. Which muscles are atrophied in suprascapular nerve palsy?
Alignment
--differences between shoulders may occur normally
--Sprengel’s deformity: congenital deformity in which involved scapula is smaller and
carried higher than on the uninvolved side
--lateral scapular slide: in athletes, soft tissue contracture draws scapula of dominant
shoulder away from midline
--measure inferior tip of dominant scapula to midline: if >1.5cm greater than nondominant, this is associated with posterior shoulder pain and anterior impingement
symptoms
ROM
--assess AROM first before PROM
--abduction and forward flexion usually consistent between individuals
Abduction:
--usually to at least 160 degrees
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--observe posteriorly if possible
--with a damaged rotator cuff, patient will unconsciously “shrug” shoulders to increase
abduction
--painful arc syndrome: pain starts when abducted arm approaches shoulder level and
decreases when full abduction is reached suggests impingement or torn rotator cuff
--passive abduction: if greatly exceeds active abduction, suspect torn rotator cuff
Forward flexion:
--may be limited with arthritis, adhesive capsulitis, or rotator cuff tears
--rotator cuff impingement is more likely to limit abduction than forward flexion
External Rotation:
--can either be measured with arm at side or with 90 degrees abduction
--normal external rotation varies from 45 to 90 degrees
--massive posterior rotator cuff tears greatly limit external rotation, such that the patient
may not be able to get the arm even to neutral
--external rotation at 90 degrees abduction: more functionally relevant (throwing
motion!), normal rotation is 90 degrees or more (20 degrees greater on dominant side)
--trunk motion may be used to compensate for lack of ability to externally rotate
--if there is anterior shoulder instability, an externally rotated abducted arm puts patient at
risk for subluxation or dislocation
Internal Rotation:
--internal rotation at 90 degrees abduction: 30-45 degrees
--Apley scratch test: ask patient to reach behind to mid-back as high as possible,
measures full internal rotation  reach to T7 in women, T9 in men, two levels higher
with non-dominant limb
--internal rotation is first motion lost in adhesive capsulitis and last regained
Adduction:
--swing arm across trunk with elbow straight
--normal adduction is 30 degrees
--can also test by forward flexing shoulder 90 degrees, then reaching across body and try
to place hand on opposite shoulder or past (should at least be able to cup opposite
shoulder)
--limited in patients with AC jt pathology
Extension:
--ranges from 40-60 degrees
--not always tested in routine exam because not frequently used in daily activities
--scapular retraction: observed when shoulders are pulled back and scapulae approach
each other
--scapular protraction: observed when patient hunches and scapulae are pulled away from
each other
--snapping scapula syndrome: a palpable/audible grating during retraction and protraction
Sara Cohen
Question:
1. What is a painful arc symptomatic of?
2. Where can the average woman reach with an Apley scratch test? The average
man?
3. What is the first motion lost in adhesive capsulitis?
4. What is snapping scapula syndrome?
PALPATION
Acromioclavicular joint:
--can identify mild joint injury
--can have painless enlargement due to asymptomatic osteophytes
Sternoclavicular jt:
--palpate 1.5-2cm lateral to midline of sternal notch
Long head biceps tendon:
--biceps tendonitis can cause anterior shoulder pain
--long head typically affected where it passes underneath the acromion and enters
intertubercular groove (usually faces anterior when shoulder is 10 degrees internally
rotated, 1-4cm distal to anterior acromion)
Biceps:
--can sometimes palpate a tear
--myositis ossificans can occur in biceps or brachialis after a contusion  usually
associated with a feeling of warmth and firmness in the affected muscle
Pectoralis major:
--ask patient to press palms together and follow muscle as it tapers to a flat tendon in the
axilla  if there is a tear, discontinuity is detected
Posterior shoulder:
--pain is likely to be referred from the C-spine and cannot be distinguished by tenderness
to palpation (or presence of trigger points)
--soft spot: 1 cm medial to posterolateral corner of acromion and 2cm inferior, soft spot is
1.5 cm in diameter (identifies superior portion of glenohumeral joint)
--soft spot is a useful landmark for injection of glenohumeral joint
Brachial artery:
--pulsations can be felt in groove between biceps and triceps, close to the axilla
--median and ulnar nerves travel with the artery, but cannot be palpated
IMPINGEMENT SYNDROME
--rotator cuff tendons: supraspinatus, infraspinatus, subscapularis, and teres minor
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--impingement results when one of these tendons (most likely supraspinatus) or the
subacromial bursa is compressed between the greater tubercle of the humeral head and
the lateral edge of the acromion
--impingement is common, but impingement SYNDROME occurs only when pain is
chronic and interferes with daily activities
--classic sign: shoulder pain located on outer deltoid when reaching overhead
Causes:
--glenohumeral instability: usually from rotator cuff weakness, results in superior
subluxation of humeral head and therefore narrowing of subacromial space
--scapular instability
--narrow acromion or osteophyte formation
Presentation: gradual onset of shoulder pain when reaching overhead, difficulty sleeping
on affected side
Diagnosis: usually by physical exam
Physical Exam:
--pain with abduction, flexion, and internal rotation
--subacromial tenderness
--normal ROM
--no weakness
-- Neer impingement test: one hand is placed on the acromion and one hand grasps the
proximal forearm. The patient is asked to relax the shoulder. The arm is carefully raised
(without the help of the patient) while simultaneously preventing the patient from
shrugging. Note whether the patient guards by shrugging as the maneuver is performed:
 Pain at 90 degrees is consistent with mild impingement.
 Pain at 60 to 70 degrees is consistent with moderate impingement.
 Pain at 45 degrees or below is consistent with severe impingement.
--Hawkins impingement test: the clinician stabilizes the shoulder with one hand and with
the other flexes the shoulder 90 degrees and, with the patient's elbow bent at 90 degrees,
internally rotates the shoulder. This brings the greater tubercle into greater contact with
the undersurface of the acromion. Shoulder pain elicited by internal rotation represents a
positive test for impingement.
Radiography:
--shoulder X-rays usually normal in first episode of impingement
--in patients with recurrent or persistent symptoms, X-ray may show: calcification in
tendons, high riding humeral head, erosive changes in greater tubercle
--MRI to rule out tear
--MR arthroscopy can be used if partial tear is suspected and MRI is negative
Treatment:
--Acute: NSAIDs, ice, avoid repetitive or overhead shoulder motions
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--chronic: physical therapy for flexibility and strengthening exercises combined with joint
mobilization for minimum of 6 weeks
--subacromial steroid injections
--referral to orthopedic surgeon if other modalities fail
Muscle Testing
--keep in mind that it’s rarely possible to test one muscle in isolation
Scapula stabilizers: serratus anterior, rhomboids, and trapezius
Serratus anterior:
--inserts on medial border of scapula
--weakness manifests as winging of scapula
--innervated by long thoracic nerve, which is subject to injury during weight lifting and
other sports
--classic test for winging: ask patient to perform a modified pushup against the wall
Rhomboids:
--responsible for retraction of scapulae on thorax, covered by trapezius
--test by retracting scapula (ask patient to pull shoulders back)
--innervation by the dorsal scapular nerve, which is rarely injured in isolation
Trapezius:
--when weak, scapula may be more lateral than normal with some winging
--test by asking patient to shrug shoulders
Rotator cuff: not only rotates but also stabilizes humeral head in glenoid fossa during
abduction -> made up of supraspinatus, infraspinatus, subscapularis, and teres minor
Supraspinatus:
--lies deep to traps in supraspinatus fossa
--where tear or impingement usually begins
--evaluation by Jobe test (supraspinatus isolation test = empty beer can test): Abduct arms
to 90 degrees with elbows extended. Bring arms 30 degrees anterior. Internally rotate
arms so that thumbs are pointing down. Patient is asked to push toward ceiling while
examiner pushes down.
Infraspinatus:
--isolated weakness may be caused by injury to suprascapular nerve at spinoglenoid notch
--is tested with teres minor
--evaluation: Place arms tightly at sides with elbows flexed to 90 degrees. Patient
externally rotates arms while examiner provides resistance.
Teres Minor:
--tested with infraspinatus
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--only involved in massive rotator cuff tears
--innervated by axillary nerve, but any injury to this nerve would should mostly loss of
deltoid
Subscapularis:
--tested by subscapularis liftoff test (will discuss later)
--can be tested by having patient press hand against abdomen while examiner tries to lift
it off
--innervated by upper and lower subscapular nerves
Humeral Adductor/Internal Rotators: Pectoralis major, latissimus dorsi
Pectoralis major:
--adducts and internally rotates arm
--assess by asking patient to compress hands together in front of chest with elbows and
shoulders flexed
--during this isometric contraction, the muscle can be seen, and palpated where it crosses
the anterior axilla (most common place for a rupture)
--if ruptured, muscle belly will bunch up abnormally
Latissimus dorsi:
--large internal rotator and extender of the arm
--test: Flex shoulder forward to 90 degrees with elbow flexed. Internally rotate and
extend arm as if attempting to climb a ladder.
--innervated by thoracodorsal nerve
Humeral Abductors: deltoid
Deltoid:
--principle abductor of arm, assisted by rotator cuff (which stabilizes)
--axillary nerve innervation; axillary is at greatest risk during shoulder trauma, esp
dislocation
--there are three heads: posterior head extends shoulder, middle head abducts, anterior
head flexes
--it’s pretty obvious how to examine these three functions
Sensation testing:
--axillary nerve: sensation to area over lateral deltoid (“shoulder patch”)
--musculocutaneous nerve: sometimes injured at shoulder, sensory branch is lateral
cutaneous nerve of the forearm, which supplies sensation to lateral forearm
Questions:
1. What muscles stabilize the scapula?
2. What muscles make up the rotator cuff?
3. How do you test for scapular winging?
4. How do you evaluate the supraspinatus?
Sara Cohen
SPECIAL TESTS
Rotator cuff disorders
--Neer impingement sign: examiner passively flexes shoulder to point of maximal
forward flexion while stabilizing scapula -> pain is positive for impingement or tear if
pain is reproduced
--can increase sensitivity by flexing elbow and internally rotating shoulder first
--Neer impingement test: repeat above after injecting local anesthetic into subacromial
bursa -> test is positive if pain is now eliminated
--Hawkins impingement reinforcement test: forward flex shoulder 90 degrees with
forearm parallel to floor, then examiner internally rotates shoulder -> pain is positive for
rotator cuff or subacromial bursa pathology
--droparm test: used when passive abduction greatly exceeds active, examiner abducts
arm maximally and then asks patient to slowly lower arm back to side -> positive is when
patient loses control of arm and it falls suddenly to side, usually indicative of large rotator
cuff tear or axillary nerve palsy
AC Joint Injury
--Passive cross-chest adduction: examiner passively brings patient’s arm into maximal
cross-chest adduction -> reproduces pain in AC joint injury or arthritis
SLAP lesions: Superior Labrum Anterior to Posterior -> tear of superior glenoid labrum
extending anteriorly and/or posteriorly
--O’Brien test: forward flex shoulder 90 degrees with elbow extended and bring arm
additional 15 degrees toward midline, then maximally internally rotate shoulder so thumb
points down. The patient is asked to resist a downward force supplied by examiner.
Then repeat with thumbs up. Test is positive if patient has pain thumbs down that is
improved with thumbs up.
*pain on top of the shoulder implicates AC joint
*pain deep in the shoulder implicates an injury to the glenoid labrum
--biceps load test: used to identify SLAP lesions with anterior instability. Patient place
supine and arm placed in abduction and external rotation. Once patient starts feeling
apprehensive, arm is stabilized in this position with the elbow flexed 90 degrees and the
forearm supinated. The patient is then asked to flex elbow against resistance. -> positive
for SLAP is an increase in apprehension or discomfort
Stability Testing
--apprehension test (crank test): classic test for anterior instability, easiest in supine
position. Patient relaxes and shoulder is placed in 90 degrees abduction and slight
extension with the elbow flexed. Examiner externally rotates arm, simulating the most
common position of subluxation or dislocation. Positive is if patient becomes
apprehensive or if shoulder is dislocated (which is not desirable).
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--jerk test: for posterior instability. Performed in supine, relaxed patient. Shoulder is
forward flexed 90 degrees with the elbow flexed and examiner applies a posteriorly
directed force at the elbow, attending to push the humeral head out the back of the
glenoid fossa. A jerk or jump may be felt as the humeral head dislocates.
Biceps tendon
--Speed test: most sensitive for provoking biceps tendon pain. Ask patient to put
shoulder in 90 degree forward flexed position with elbow fully extended and forearm
supinated. -> positive is pain with this maneuver
--Yergason’s test: patient places arm at side with elbow flexed 90 degrees and forearm
pronated. Examiner grasps patient’s hand and asks the patient to attempt to
simultaneously flex the elbow and supinate the forearm while examiner resists -> positive
for pain represents biceps tendonitis or instability.
Thoracic Outlet Syndrome
--compression of neurovascular structures as they exit the thorax above the first rib
--may cause pain and paresthesias in the arm and shoulder
--Adson’s test: Patient’s arm is abducted 30 degrees at the shoulder and maximally
extended. The examiner grasps patients wrist, positioning fingers to palpate radial pulse.
Patient turns head toward affected shoulder or takes a deep breath -> change in pulse
suggests TOS, especially if symptoms are reproduced
*called Wright’s maneuver if shoulder is abducted to 90 degrees and fully externally
rotated
--Roos test: Patient abducts shoulder 90 degrees while flexing elbow 90. Patient is then
asked to open and close hand 15 times. Numbness, cramping, weakness, or inability to
complete test suggests TOS.
Knee
--two interconnecting joints: patellofemoral and tibiofemoral
--TF jt is inherently unstable, heavily dependent on its ligaments
--patella is largest sesamoid bone in the body (sesamoid = ossicle that forms in a tendon),
acting as a fulcrum that increases the mechanical advantage of the quadriceps
Inspection
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Patella:
--thin layer of tendon bursa and SQ tissue lies between the patella and the skin
--patella accentuated by depression or sulcus on both sides
--when excess fluid is present in the knee, these sulci fill up and the prominence of the
patella is reduced
--bipartite patella: manifested as a protruding prominence at the supralateral aspect of the
patella
--patella magna: when osteophytes around edges of patella create an enlarged appearance
Prepatellar bursa:
--prepatellar bursitis: SQ egg-like swelling anterior to the patella, usually soft and fluidfilled, erythema, warmth
--bursa = 5 cm in diameter
--chronic thickening or nodule formation can be seen or palpated in a bursa that has been
inflamed in the past
Extensor mechanism:
--patella + quadriceps + associated tendinous structures
--quadriceps: rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius
--quadriceps tendon: common tendon of insertion of rectus femoris and vastus
intermedius, with additional contributions from the two other vasti
--VL muscle belly terminates 2cm proximal to the patella
--VM muscle extends further distally, almost into the patella
--distal prominence of VM is formed by more oblique fibers that are more transverse ->
called the vastus medialis obliquus and is thought to stabilize the patella against lateral
subluxation
Patellar tendon: distal to patella, broad fat band that connects patella to the tibia
Infrapatellar fat pad (Hoffa’s fat pad):
--bulges forward on both sides of the patellar tendon
--flexing knee causes fat pad to retract
--ganglion cysts occur in the fat pad -> firm nodular masses
Proximal tibia:
--patellar tendon inserts on bony prominence of tibial tubercle
--tibial tubercle enlarged in Osgood Schlatter disease, caused by abnormal bone
formation at distal patellar tendon
--subtle swelling at distal tip of patella in patellar tendonitis (jumper’s knee) and SindingLarsen-Johansson disease
-- tubercle of Gerdy: lateral and proximal to tibial tubercle
--pes anserinus: formed by confluence of sartorius, gracilis, and semitendinosus tendons,
inserts on tibia (not usually visible)
Medial Aspect of Knee:
--medial epicondyle: often detectable in the normal knee, terminating of the insertion of
the adductor muscles
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--medial collateral ligament (MCL): fibers originate on medial epicondyle and course
obliquely across medial joint line in an anterioinferior direction, inserting on the tibia
--Pelligrini-Stieda sign: calcific deposits on medial epicondyle, as seen radiographically
--medial joint line: anterior portion is visible as a subtle depression -> point where the
line disappears is the anterior edge of the MCL
--periarticular ostephytes can cause a visible ridge along medial joint line
Lateral Aspect of Knee:
--lateral epicondyle: more difficult to see than medial, proximal point of attachment of
lateral collateral ligament
--lateral collateral ligament (LCL): attaches distally at the fibular head, increased
prominence with varus stress (knee crossing)
--biceps tendon is sole hamstring on the lateral aspect of the knee and also inserts into the
fibular head
--iliotibial tract: thickening of fascia lata (deep fascia of thigh), contributes to stability of
lateral knee, inserts on tubercle of Gerdy (on proximal tibia)
--lateral joint line: usually not visible but may bulge with a chronic lateral meniscus tear
Posterior Aspect of Knee:
--popliteal fossa: gap between inferior hamstring and superior calf muscles that is
diamond-shaped -> formed by semimembranosus and semitendinosus medially, biceps
laterally
--common peroneal nerve can sometimes be identified just medial to biceps tendon.
--medial hamstring: tendons of semitendonosus and semimembranosus
--lateral hamstring: tendon of biceps femoris
--Baker’s cyst: in adults, usually secondary to intraarticular pathology, such as meniscus
tear or arthritis, appear as generalized fullness of popliteal fossa
Alignment
--physiological valgus alignment: for knees to touch, femur and tibia must be in mild
valgus (7 degrees in women, 5 degrees in men) since hips are further apart than knees
--genu valgum: ankles still apart when knees together, caused by angular deformity
following fracture, arthritic erosion of lateral compartment, or congenital
--genu varum: knees still separated when feet and ankles are in contact. If small, femur
and tibia may still be in valgus alignment but just less than usual. Causes include
congenital, angular deformity from fractures, severe lateral ligament injuries, and arthritic
erosion and collapse of medial compartment of knee
--windswept deformity: occurs in osteoarthritis due to loss of medial joint space -> genu
varus in arthritic knee and excess valgus in unaffected knee
Patellar Alignment:
--kneecaps normally face directly forward
--squinting patellae: kneecaps angled towards each other, may be associated with
patellofemoral pain, may be caused by increased external tibial torsion
--out-facing patella: less common, may be seen in people with habitual subluxation or
dislocation of kneecaps
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--Q angle: measure of overall patella alignment, the angle between a line from the
anterior superior iliac spine to the center of the patella and a liner from the center of the
patella through the center of the tibial tubercle -> 15 degrees is normal (17 women, 14
men)
--increased Q angle: associated with a tendency toward patellofemoral pain
--tubercle-sulcus angle: variation of Q angle that eliminates effect of femoral rotation, for
detecting abnormal lateral displacement of tibial tubercle
--patella alta: high riding patella, produced by a long patellar tendon or patellar tendon
rupture -> increased risk of patellar instability
--patella baja: low riding patella, usually secondary to trauma
--to assess patella height, patient sits with knees flexed to 90 degrees over table -> patella
alta faces ceiling (baja more difficult to detect)
Gait
--Varus thrust: knee collapses into a position of increased varus as the opposite foot is
lifted off the ground -> caused by advanced OA with erosion of medial joint space
--varus recurvatum thrust: knee is thrust into varus and hyperextension -> usually caused
by lateral ligament laxity
--valgus thrust: knee collapses into valgus as opposite foot is lifted off ground -> less
common than varus
--antalgic gait: alternating slow and quick steps as patient reduces stance phase on
affected limb -> nonspecific
--stiff knee gait: one knee kept in full extension while walking -> caused by pain that
only occurs when knee is flexed or from weak quadriceps
--flexed knee gait: a flexion contracture as small as 5 degrees may cause a limp, foot
strikes ground in a foot-flat position -> jerky, up and down motion
Range of Motion
Extension:
--first assessed with patient supine, passively -> examiner raises patient’s feet in air,
holding medial malleoli together
--knees should extend to at least neutral, but usually 10 degrees or less
--genu recurvatum: knee hyperextension
--flexion contracture: occurs if one knee does not extend as far as the other -> may be due
to pain, swelling, arthritis, or mechanical block
--pathological hyperextension may be due to trauma or posterior ligament injury
--prone hanging test: patient lies prone with lower limbs from knee down projecting
beyond the end of the examining table -> measure heel height difference to assess for
flexion contractures (each cm corresponds to 1 degree of contracture)
--active extension: when active extension is less than passive, an extension lag is present
-> usually due to quadriceps weakness or patellofemoral pain, although patients with
sciatica or tight hamstrings may also have this problem
Flexion:
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--ask supine patient to flex knee as far as possible -> should be able to get the heel close
to the ipsilateral buttock, or even touching it (130-150 degrees)
--flexion of 110 degrees is necessary for stairs and other daily activities
--measure heel to buttock distance
--loss of flexion due to effusion, arthritic pain, or patellofemoral pain
--if passive flexion produces pain localized to one joint line, it may be a sign of ipsilateral
meniscal tear
Palpation
Patella:
--patella facet tenderness is a common finding in patellofemoral pain -> ask pt to lie
supine with legs full extended and relaxed, examiner shifts patella medially to expose
medial facet and pushes upward on facet with other hand -> discomfort is positive
*repeat with lateral facet
--in excessive lateral pressure syndrome, very little lateral glide is possible and
tenderness is localized to the lateral patellofemoral ligament (a tight band about 1 cm
wide connecting the lateral border of the patella to the lateral epicondyle)
--medial patellar plica: can sometimes cause anteromedial knee pain, palpated as a
fibrous band running between patella and medial femoral condyle
--tenderness of the anterior patella itself may be due to a nondisplaced fracture
Extensor Mechanism:
--in quadriceps tendon rupture, examiner may be able to palpate a gap and tenderness
during straight leg raise
--palpate patellar tendon during straight leg raise to assess for rupture
--Jumper’s knee: includes proximal patellar tendonitis*, distal patellar tendonitis, and
quadriceps tendonitis -> examiner should feel spongy crepitant sensation when firmly
palpating this area
Medial Joint Line:
--ask patient to flex knee 90 degrees
--tenderness is suspicious for meniscus tear or OA
--if tenderness is anterior only, this is more nonspecific
--tenderness where MCL crosses medial meniscus may be due to either structure (if
valgus laxity -> MCL is responsible)
Semimembranosus tendon:
--tendonitis usually associated with tenderness at insertion of muscle into tibia
Lateral joint Line:
--flexion of the knee makes it easier to palpate
--tenderness suspicious for lateral meniscus tear or OA
--small lateral meniscus cysts may be palpable as firm swellings at posterolateral joint
line
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Lateral Collateral Ligament
--palpated by asking patient to cross legs into a figure-4 position -> between lateral
epicondyle and head of fibula
Iliotibial Band
--common site of tenderness in runners and other athletes
--iliotibial band tendonitis: tenderness is maximal where iliotibial band crosses the lateral
epicondyle
Biceps tendon:
--occasional cause of lateral knee pain
--tendonitis: tenderness in distal biceps tendon near fibular head
Posterior aspect of the knee:
--fullness of popliteal fossa suggest a Baker’s cyst
--pulsations of popliteal artery can be felt with knee flexed
Muscle testing:
Quadriceps:
--provides primary extensor force
--patient instructed to maximally extend knee while examiner forces it into flexion
--patellofemoral pain may produce the impression of weak quadriceps
--atrophy is a common nonspecific finding in painful knee injury
--injury to femoral nerve also causes atrophy
--measure circumference: 10-15 cm proximal to patella -> differences of 1 cm or more
are indicative of atrophy
Hamstrings:
--provides primary flexion force
--measure with patient prone -> patient instructed to flex knee and maintain it against the
examiner’s force
--innervated by sciatic nerve
Sensation:
--most commonly injured nerve about the knee is the infrapatellar branch of the
saphenous nerve (infrapatellar nerve) -> runs across the knee just inferior to patella
--infrapatellar nerve usually transected by longitudinal incision on anterior knee ->
anesthesia immediately lateral to the incision
SPECIAL TESTS
Effusion:
--caused by excess synovial fluid, blood, or pus
Sara Cohen
--visible fluid wave: compress hollows on both sides of the knee cap simultaneously,
which forces the fluid into the suprapatellar pouch -> then compress pouch and watch if
fluid returns to hollows (good for a small effusion)
--palpable fluid wave: compress hollows with one hand and compress suprapatellar
pouch with other hand -> with an effusion, examinder should feel fluid pushing on
thumb and fingers of first hand (useful for larger effusion or obese patient)
--extraarticular soft tissue swelling is more diffuse and fusiform
--ballotable patella sign: in a supine patient, a large effusion lifts patella off femoral
trochlea. Examiner pushes patella posteriorly with 2 or 3 fingers using a quick, sharp
motion and feel for impact.
Stability tests:
--Valgus stress test: assesses integrity of MCL. Patient lies supine while examiner raises
lower limb off table at ankle with knee extended. Apply gentle inward force at the knee
and outward force at the ankle. Look and feel for separation of femur and tibia on medial
side of knee.
--MCL laxity grades:
*I: injury without elongation -> tender and swollen but no laxity
*II: elongation of ligament without disruption ->increased laxity to valgus stress
but with firm endpoint
*III: loss of all structural integrity -> no firm endpoint to laxity
--Varus stress test: assess LCL complex. Similar to valgus, but examiner applies outward
force at knee and inward force at ankle, feeling for separation. In slight flexion, a normal
separation of 3-5mm is felt between tibia and femur.
Anterior Laxity: sign of injury to ACL
--Anterior drawer sign: patient supine with knee bent 90 degrees. Examiner sits at end of
table with his thigh against patient’s toes. Grasp tibia below joint line and pull forward
with both hands. Normal forward movement is a few mm.
*limitations: may be difficult to flex knee 90 degrees with injury, hamstrings may mask
abnormal anterior translation
--Lachmann’s test: Knee in 20-30 degrees of flexion. Grasp lower leg with one hand,
placing thumb over tibial tubercle and other fingers around calf. Other hand grasps thigh
just above patella. Thumb of upper hand presses against femur through quads tendon
while other fingers wrap around thigh. Once patient is relaxed, examiner pulls on tibia
while pushing back on femur with other hand.
Pivot shift Phenomenon
--mild physiologic pivot shift may occur in absence of knee injury in patients with greater
than avg anterior knee laxity, but it is usually an indication of complete ACL rupture or
elongation
--classic pivot shift test: lift lower limb of table by foot and internally rotates it (knee
should be in full extension)  this will cause femur to fall posteriorly. Place palm of
other hand on lateral aspect of proximal leg just below knee and gently apply valgus
stress and flex knee. At 20-30 degrees, anteriorly subluxed tibia will reduce into normal
position, resulting in a visible “jump”.
Sara Cohen
--jerk test: begin with knee flexed and watch tibia sublux and knee is passively extended
Posterior Laxity
--rupture of PCL is necessary for increase in posterior laxity
--posterior drawer test: starting position the same as with anterior drawer -> if PCL is
torn, a “dropback phenomenon” occurs in which gravity causes the tibia to sublux
posteriorly (patella looks more prominent and tibial tubercle looks less prominent), then
push posterior on prox tibia with both hands
*a firm endpoint is usually felt
--Godfrey’s test: patient’s legs held in 90/90 position with both the knees and the hips
flexed to 90 degrees. Look for dropback phenomenon.
Patellofemoral Joint:
--passive patellar grind test: Patient is supine as examiner presses patella against the
femur with the palm of one hand while passively flexing the knee with the other.
Positive -> crunching sensation
--active patellar grind test: Patient sits with knee flexed over side of table. Examiner
places hand on patient’s patella and asks patient to actively extend knee, feeling for
crepitus.
--patellar glide test: measures passive patellar mobility. Patient lies supine with knees
extended and quadriceps relaxed. Examiner pushes patella first medially, then laterally.
Glide should be about 1cm in each direction.
--Fairbanks apprehension test: simulates episode of patellar instability. Patient is supine
and relaxed while examiner gasps limb at ankle and abducts it enough to allow knee to
flex over side of table. Perform lateral patella glide while slowly flexing patient’s knee
with other hand -> creates apprehension
Meniscal tests:
--Childress test: Patient asked to walk in a deep squat. When uninvolved limb is lifted to
step forward, all the body weight compresses the symptomatic knee -> pain localized to
joint line of the involved meniscus.
*with patellofemoral pain, pain is localized to retropatellar region
*with effusion, pain is localized to popliteal fossa
--McMurray’s test: supine patient flexes involved knee as far as possible. To test medial
meniscus, examiner grasps the hindfoot and externally rotates foot while placing a varus
stress at knee to compress medial meniscus. Knee is then passively extended while
examiner palpates medial joint line -> positive is medial joint line pain
*opposite maneuver tests for lateral meniscus tear
LUMBAR SPINE
Inspection:
Sara Cohen
--paraspinous muscles: most superficial column of paraspinous muscles is known as
erector spinae (or sacrospinalis)
--erector spinae: multifidus (medial), longissimus, and iliocostalis (lat)
--verify that line between iliac crests is parallel to the floor
--if a pelvic obliquity is found, it may be the result of a deformity within the spine such as
scoliosis or an anomalous vertebra, or possibly from a leg length discrepancy.
--list: an abrupt planar shift of the spine to one side, typically occurring in the lumbar
spine, usually reversible and related to pain/muscle spasm
--scoliosis: a helical abnormality involving abnormal vertebral rotation along the axis of
the spine
--primary scoliosis: an actual structural abnormality of the spine
--secondary scoliosis: curvature represents a compensatory adaptation of a normal spine
to an extrinsic factor such as muscle spasm or pelvic obliquity (placing books under
shorter limb should cause scoliosis to disappear unless it is longstanding)
--lumbar lipoma, abnormal hair patch, or port wine stain may be associated with spina
bifida or myelomeningocele
--café au lait spots and nodular skin swellings may indicate neurofibromatosis, which
causes secondary deformity of the spine
--step-off deformity: caused by severe spondylolisthesis
*normally the tips of the lumbar spinous processes protrude posteriorly the same
amount, producing a smooth hollow in the lumbar spine
*with severe spondylolisthesis, an abrupt displacement or step-off can be seen
(most common at L5-S1)
--hyperlordosis (swayback): results in increased prominence of the buttocks, usually
associated with flexion contractures of the hips
--decreased lumbar lordosis: often a temporary, reversible deformity related to pain and
associated muscle spasm – associated with spondylolysis and ankylosing spondylitis
--lumbar flatback: rigid lumbar spine in which normal lordosis has been completely lost > results from compression fractures or advanced disc degeneration or spinal fusion
--gibbus: sharp, angular kyphotic deformity noticed by protruding spinous process at
apex -> classically associated with tuberculosis of the spine which destroys anterior
vertebral body
Gait
--sciatica patient may walk with hip more extended and knee more flexed in order to put
less tension on nerve
--antalgic gait: putting as little weight as possible on affected side and quickly
transferring weight to unaffected side
--heel walking: tests strength of ankle DF -> L4 innervated tibialis anterior
--toe walking: requires S1 innervated gastrosoleus muscle group
Range of Motion
Flexion
--ask patient to bend straight forward at the waist as far as possible
Sara Cohen
--flexion avgs 80-90 degrees
--hernation of L4-5 and L5-S1 associated with painful, limited flexion
--scoliosis and lumbar list accentuated by flexion
--much of back flexion is due to hip flexion -> can observe if flexion is lumbar by
checking for changes in curvature
Extension
--ask patient to lean backwards as far as possible
--normal extension is 20-30 degrees
--since extension narrows diameter of spinal canal, patients with abnormal narrowing
tend to avoid extension (e.g. spinal stenosis, post-traumatic deformities, tumors)
--extension may also be painful in disorders of posterior elements of the vertebrae:
spondylolysis, tumors of posterior elements, and degenerative arthritis of posterior facet
joints
Lateral bending
--ask patient to lean as far as possible to each side while examiner stabilizes pelvis with a
hand on each iliac crest
--normal is 20-30 degrees
--patients with herniated discs may avoid bending toward the side of the herniation
--if muscles on side toward which patient is bending do not soften, this is evidence that
they are in spasm
Rotation
--ask patient to rotate or twist in each direction as far as possible while examiner
stabilizes pelvis
--normal is 30-40 degrees
Palpation
--palpate tips of spinous processes, which are linked by the supraspinous and interspinous
ligaments
--conditions that may cause tenderness at one vertebral level: sprain, disruption of
posterior ligaments, fracture or tumor of posterior elements
--step-off may be palpated in the case of spondylolisthesis
--on either side of spinous processes are erector spinae muscles (multifidus, longissimus,
iliocostalis) -> may appear more prominent with muscle spasm, which may be a
reflection of muscle injury or pain (unilateral muscle spasm may cause reactive scoliosis)
--trigger points are tender nodules within paraspinous muscles -> reaction to a painful
stimulus in paraspinous muscles or a sign of fibromyalgia
--posterior facet joints of lumbar spine are located deep to paraspinous muscles, just
lateral to spinous processes -> localized tenderness over these joints may be caused by
facet joint arthritis or painful facet joint syndrome
--examination of the lower spine should include the sacroiliac joint, the posterior pelvis,
the hip, and the thigh
Sara Cohen
Manipulation
--flexion of the spine is powered mostly by rectus abdominis -> assess by having patient
perform a crunch
--extension of spine powered by erector spinae -> assess by lifting chest off table while
prone
Neurologic Examination
Sensory Examination
--L1: anterior prox thigh near inguinal ligament
--L2: over antermedial thigh, midway to patella
--L3: just medial to patella
--L4: just prox to medial malleolus
--L5: just prox to 1st web space
--S1: posterolateral aspect of heel
--S2: center of popliteal fossa
--S3, S4, S5: perineal area
Motor Examination
--disk herniation affects the nerve root from the lower disk since that is the one that exits
between the vertebra
--most disk herniations at L4-L5, L5-S1*, and L3-L4
--L1 and L2 Nerve Roots: supply iliopsoas muscle, the primary hip flexor
--L3: assessed by evaluating quadriceps strength, even though quads are also innervated
by L2 and L4 -> test knee extension
--L4: evaluate by testing tibialis anterior -> test dorsiflexion
--L5: test extensor hallucis longus -> great toe extension
*can also test extensor digitorum longus or gluteus medius (hip abduction)
--S1: plantar flexion (gastrocsoleus) and eversion of ankle (peroneus longus and brevis)
as well as extensors of hip -> can screen by asking patient to toe walk
*can also test gluteus maximus (hip extension)
--S2, S3, S4: principle nerve supply for bladder and intrinsic muscles of the feet, motor
function tested by performing a rectal exam and feeling for firm resistance and voluntary
contraction
Reflexes
--Patellar tendon reflex is primarily L4 with some L3 contribution -> enhanced by having
patient hook fingers together and pull isometrically
--Tibialis Posterior Reflex (L5): examiner holds patient’s foot in eversion and DF and
strikes the posterior tibial tendon just below the medial malleolus -> slight plantar flexion
inversion response noted
--Medial hamstring reflex (L5): patient place prone and examiner’s thumb is placed on
the semitendinosus tendon in the popliteal fossa with knee flexed -> knee flexion is
positive
--Achilles tendon reflex (S1): reinforced by asking patient to kneel on examination table
with feet projecting past the end
Sara Cohen
--if reflexes are brisk, should also test for ankle clonus or Babinski
Nerve Tension Tests
--most important peripheral nerves deriving from lumbar and sacral nerve roots are
femoral and sciatic nerves
--femoral nerve (L2, L3, L4) runs down anteromedial aspect of thigh
--sciatic nerve (L4-S3) runs down posterior thigh
--Straight-leg raise test: patient lies supine as one foot is slowly lifted off table with knee
extended, stretching L5 and S1 nerve roots 2-6mm -> 70-90 degrees should be possible
without severe pain
*sciatica: angle reduced and patient reports pain shooting down posterior thigh,
often into lower leg -> suggests L5, S1 lesion
*pain beyond 70 degrees flexion is associated with deformation of sciatic nerve
beyond the spine
*test very sensitive but nonspecific
--Crossed straight-leg raise: if performing straight-leg raise on contralateral side
reproduces sciatica, this is very specific for sciatica
--Lasegue’s Test: after straight-leg raise elicits pain, DF foot -> if this exacerbates pain,
then diagnosis of sciatica is strengthened
--bowstring sign: after straight-leg raise, flex knee to alleviate pain. If pressure in
popliteal fossa brings back pain, this implies sciatica
--Slump test: straight-leg raise while seated, slumping, with neck flexed
--Femoral nerve stretch test: assesses compression of L2-L4 nerve roots. Patient placed
prone with knee flexed to 90 degrees. Hip then passively extended by lifting thigh off
examining table. Reproduction of pain implies femoral nerve compression.
Special Tests
--Single leg hyperextension test: more specific test for spondylolysis. Patient stands in
straddle position with one lower limb extended behind the other. Patient then instructed
to lean back as far as possible as examiner assists patient in achieving maximal
hyperextension without falling. Alternate limbs. In spondylolysis, hyperextension
exacerbates pain and is more severe when affected side limb is extended.
--Valsalva maneuver: increases intrathecal pressure and therefore exacerbates pain that is
due to spinal cord pressure.
--Waddell’s nonorganic signs: alert examiner to possibility of nonorganic pathology ->
nonanatomic tenderness (disproportionate pain), simulation sign (exaggerated response to
axial compression), distraction sign (straight-leg raise response varies if patient is sitting
or lying down), regional sensory or motor disturbance (nonphysiological motor or
sensory deficits), overreaction (inappropriately theatrical response to gentle examination)
C-spine and T-spine
Surface Anatomy
--inion: definite bump where C-spine joins occiput at base of skull
Sara Cohen
--spinous processes start at inion and go down to sacrum
Vertebra prominens:
--one large spinous process that stands out at the cervicothoracic junction
--identifies the spinous process of C7
--more prominent with neck flexion
Trapezius
--most superficial and easily identifiable of posterior neck muscles
--originates at occiput and C7 through T12 and inserts laterally on clavicle, acromion and
scapular spine
--deep to trap is transversocostal muscles (splenius capitis, splenius cervicis, iliocostalis
cervicis, longissimus cervicis), deeper is the transversospinal group
Sprengel’s deformity:
--congenital
--one of scapulae remains fixed proximally in a tightly contracted position
List:
--pure planar shift to one side in the cornonal plane
--may be caused by pain, muscle spasm, or certain anomalies
--most common in lumbar spine
Scoliosis:
--curve in the coronal plane is combined with abnormal rotation of the vertebrae in the
transverse plane
--can detect subtle scoliosis by looking at rib prominence -> more prominent on convex
side of curve
--rib prominence is emphasized by bending forward
--if scoliosis extends into C-spine, asymm twisting of the neck (torticollis) may be
present
Cervical lordosis:
--reduction in lordosis is assoc with C-spine pain
--dramatic reduction seen in ankylosing spondylitis
--sniffing position: face of patient appears to be thrust out anteriorly
Thoracic kyphosis:
--normal is 21-33 degrees
--increased kyphosis can be caused by Scheuermann’s disease (wedge-shaped vertebral
bodies), ankylosing spondylitis,
Sternum:
--sternal notch at confluence of the two SCM muscles, typically located at the level of T3
and T4 vertebral bodies
--pectus excavatum: abnormally concave sternum
Sara Cohen
--pectus carinatus: abnormally convex sternum
Gait
--injury to posterior cord causes a loss of proprioception, which results in uncertainty ->
shuffling gait or slap foot gait (can also be seen in other neurologic disorders
--broad-based (halting) gait is seen when stenosis of C-spine causes cord compression ->
balancing difficulties during single leg stance
Range of Motion
C-spine:
--first support T-spine by having patient sit in a straight-backed chair that extends to the
midscapular level
--midrange pain is typically due to instability of the structure being moved (such as in
DDD)
--Flexion: ask patient to touch chin to chest -> patient should be able to make contact or
come very close (can measure distance)
--Extension: patient asked to tilt head back and look at ceiling -> face should be parallel
with ceiling -> reduced in degen arthritis or fixed deformity
--lateral rotation: patient asked to rotate chin laterally toward each shoulder -> normal is
60-90 degrees (50% of rotation occurs betw C1 and C2)
--lateral bending: ask patient to attempt to touch each ear to ipsilateral shoulder ->
calculate either the distance between shoulder and ear or angle of face with vertical
T-spine:
--permits little motion -> small amount of flexion and extension
--seat patient in straight-backed chair to eliminate lumbopelvic motion
--patient asked to flex and then extend spine
--flexion and extension limited in ankylosing spondylitis (AS) -> can detect by measuring
change in length of spine between flexion and extension
--modified Schober test: quantifies lumbosacral flexion by marking a point 10cm above
and 5cm below the LS junction in the extended spine -> measure when standing and
when maximally flexed -> distance should increase about 6 cm
--can also test for AS by measuring amount of chest expansion possible by measuring
difference between inhaled and exhaled circumference
Palpation
--used to identify a subtle deformity or malalignment
--may detect paraspinous muscle spasm
--may reveal point tenderness
Posterior Aspect:
--palpation begins at inion, located at base of skull
--first identifiable spinous process is C2
--evaluate for tenderness and alignment
Sara Cohen
--nuchal ligament connects the cervical spinous processes from skull to C7
--posterior facet joints are 2cm lateral to the midline -> firmer palpation needed
--evaluate posterior cervical musculature, consisting of upper trapezius and underlying
intrinsic neck muscles
--injuries to T-spine less common due to rib stabilization
Anterior aspect:
--hyoid: horseshoe-shaped bone just caudal to angle of mandible at level of C3 vertebral
body
--thyroid cartilage: just inferior to hyoid bone, forms Adam’s apple -> located at C4, C5
--cricoid cartilage: inferior to thyroid cartilage, located at C6
Muscle Testing
--sternocleidomastoid (SCM) muscles function as cervical rotators and flexors
(innervated by spinal accessory nerve)
--test given SCM by placing palm of hand on opposite side of face as patient attempts to
rotate head
--test flexion (also SCM) by placing a palm against patient’s forehead as patient attempts
to flex neck
--extension of C-spine is by posterior intrinsic neck muscles and upper trapezius -> test
by placing resisting hand on patient’s occiput while they extend neck
--lateral bending of neck powered by scalene muscles
Sensory Neurologic Exam
--test for light touch as a screening tool
--radicular sensory loss: injury to a specific nerve root
--nonradicular sensory loss: suggest peripheral injury
--glove or stocking sensory loss: diabetic peripheral neuropathy, reflex sympathetic
dystrophy, nonorganic disorders
--sharp-dull discrimination used to confirm light touch exam
--vibration: test over bony prominences -> ask patient to report when vibration stops ->
assoc with injury to posterior columns of spinal cord or peripheral nerves
--proprioception: also a sign of posterior column dysfunction -> assoc with aging, injury,
or cerebellar dysfunction
--2-point discrimination: should be able to distinguish 5mm at fingertips
--C4: lateral neck
--C5: middle deltoid
--C6: dorsum of 1st web space
--C7: dorsum of middle finger
--C8: little finger
--T1: medial arm at elbow
--T2: uppermedial arm adjacent to axilla
--T10: umbilicus
Motor Exam
Sara Cohen
C5:
--best assessed by testing deltoid -> abduction
--also contributes to biceps brachii
C6:
--innervates biceps and wrist extensors
--C5-6 most commonly involved in herniations, so C6 radiculopathy is most common
C7:
--test wrist flexors or long finger extensors
--also innervates triceps brachii
C8:
--test long digital flexors
T1:
--test strength of interosseous muscles -> abduction of fingers
--can test 1st dorsal interosseous alone by testing abduction of index finger -> can also
watch for contraction of muscle
--can test finger adduction by placing a card between pt’s long and index fingers and
attempting to withdraw it (should be difficult)
Long Thoracic Nerve Roots:
--not normally assessed
--Beevor’s sign: tests for asymmetric loss of thoracic root motor function -> patient asked
to do a half sit-up with knees flexed and arms behind head -> umbilicus will deviate
toward normal side
Reflex Examination
--biceps tendon reflex: used to assess C5 nerve root (but there is also a contribution from
C6) -> grasp patient’s arm at elbow, placing examiner’s thumb at biceps tendon and
lightly tap on thumb with reflex hammer
--brachioradialis reflex: used to assess C6 -> support forearm in a neutral position, then
tap radial aspect of forearm about 4-8cm prox to radial styloid -> may cause a quick
upward motion of the forearm
--triceps reflex: used to assess C7 -> assess with arm at 90 degrees shoulder abduction
and elbow flexion -> tap arm just prox to olecranon
--plantar reflex: abnormal is Babinski sign, where toes immediately dorsiflex when
plantar surface of foot is stroked
--clonus: sign of upper motor neuron lesion -> assess by forcefully pushing foot into
dorsiflexion, producing a rhythmic involuntary motion -> more than two beats of clonus
is abnormal
--cervical spinal stenosis produces LMN signs at level of lesion and UMN signs distal to
the lesion
Sara Cohen
--abdominal muscle reflexes: used as a method of screening for thoracic spinal cord
compression -> patient positioned supine and handle of reflex hammer is gently stroked
across abdomen in a radial manner beginning at the umbilicus -> umbilicus should move
in direction of quadrant being stroked
Special Tests
Axial Compression Test:
--should not perform when a nerve root compression with a motor deficit is suspected or
detected
--stand behind patient who is seated with C-spine neutral, place both hands at crown of
patient’s head and compress downward gently
--record symptoms
Spurling’s Test:
--used of examiner is suspicious of a lateralizing pathology, such as a disk prolapse
--neck is extended and rotated toward involved side prior to axial compression
--diminishes dimensions of foramen through which nerve root exits, exacerbating
symptoms
--in younger people, radicular pain usually due to nerve root compression from
intervertebral disk prolapse
--in older people, radicular pain is usually due to foraminal stenosis from disk degen and
secondary facet hypertrophy
Lhermitte’s Maneuver:
--ask patient to maximally flex cervical and thoracic spine
--positive Lhermitte’s: paresthesias in multiple extremities or trunk
--indicative of spinal stenosis w/ cord compression
Lower Leg, Foot, and Ankle
--28 bones and 57 articulations
--inspect feet during gait, standing, and in nonweightbearing position
Surface Anatomy
Anterior Aspect
Toes:
--prox and distal phalanx
--PIP and DIP joints
--transverse skin crease indentifiable over dorsum of IP joint of great toe and DIP joint of
other toes
Sara Cohen
--heloma durum (hard corns): thickened skin over dorsum of IP joints, reflect friction
between the toe and the top of the shoe
--toenails have rich capillary supply
--lunula: crescent at the base of toenails
--subungual hematoma: maroon or black discoloration visible at base of toenail, sequela
of a direct blow to toe or recurrent pressure (malignant melanoma also looks this way)
--chronic fungal infections produce deformities of toenails, including ridging, thickening,
and yellow-orange discoloration
--paronychia: infection around base or sides of toenail, often associated with an ingrown
toenail
Foot:
--metatarsophalangeal joints
--OA of 1st MTP joint is common and may be associated with a visible ridge of
osteophytes on dorsum of foot
--bunion: large bump on medial aspect of 1st MTP, produced by accretion of bone on
medial aspect of head of 1st metatarsal
*an adventitial bursa makes up a signif portion of bunion
*usually associated with hallux valgus
--bunionette (tailor’s bunion): bunion over lateral aspect of head of 5th metatarsal, usually
related to tight footwear
--Lisfranc’s joint (tarsometatarsal joint): where prox ends of 5 metatarsals articulate with
3 cuneiforms medially and cuboid laterally -> not normally visible unless there are
osteophytes
--tendon of EHL roughly parallels shaft of 1st metatarsal -> landmark for locating dorsalis
pedis artery
Ankle:
--medial and lateral malleoli
--lateral malleoli is 15 degrees posterior
--tibialis anterior (anterior tibial) tendon is the largest and most medial tendon to cross
the ankle joint -> almost always visible, esp with DF of foot
--lateral is EHL and EDL tendons
--peroneus tertius tendon runs along the lateral border of the EDL tendons
Lower Leg:
--anterior crest of tibia seen as a subtle longitudinal ridge that arises above ankle joint
--lateral to tibial crest is anterior compartment muscles (tibialis anterior and toe
extensors)
Lateral Aspect
Foot and Ankle:
--fat pad distal to lateral malleolus, over sinus tarsaae of subtalar joint and EDB muscle
--tendon of peroneus brevis curves around posterior border of lateral malleolus
Sara Cohen
--sural nerve courses distally in the leg along lateral border of Achilles tendon and curves
around lateral malleolus into foot
Lower Leg:
--posterior contour of calf is made up of gastrocnemius and soleus muscles
Posterior Aspect
Foot:
--plantar fat pad, which cushions the calcaneus during weightbearing, is seen bulging
toward examiner
--superiorly, calcaneal tuberosity is visible
*abnormally increased prominence is known as Haglund’s deformity, manifested
by a visible bump -> sometimes caused a pump bump because it is aggravated by shoe
pressure
--retrocalcaneal bursa between distal Achilles tendon and superior portion of calcaneal
tuberosity
Ankle:
--Achilles tendonitis and rupture usually occurs 2-3cm proximal to tendon’s insertion
--if rupture, there is more diffuse swelling throughout visible length of tendon
Calf:
--outlines of medial and lateral gastroc may be visible if pt is asked performed toe raise
--look for calf atrophy
Medial Aspect
--medial longitudinal arch: concavity produced by medial border of foot
--pes cavus: high arch
--pes planus: low arch
--accessory navicular or bicornuate navicular may be present
Plantar Aspect
--areas of thickened skin reflect weightbearing pattern of the foot, commonly occur along
lateral foot and underneath metatarsal heads
--intractable plantar keratosis: frequently painful accumulations of callused skin that can
form beneath the metatarsal heads -> usually secondary to deformities of the toes
--hammer toe deformity: hyperextension of MTP joint PFs metatarsal head and pulls the
metatarsal fat pad distally, leaving only skin and thin SQ tissue between metatarsal head
and the ground -> causes a protective callus known as an intractable plantar keratosis
--hyperkeratosis (callus): thickening of stratum corneum of the skin
--corns (helomas): when hyperkeratosis are thick and isolated
--helomas subdivided into: heloma durum (hard corn) and heloma molle (soft corn)
Sara Cohen
--heloma durum: collection of dense compacted keratotic tissue, usually found over
pressure areas of toes, esp dorsolateral aspect of 5th toe
--heloma molle: usually located deep in webspaces between the toes, where it forms
pressure of an adjacent toe against an osteophyte or prominence of a phalange
--plantar warts are a few mm in diameter and cause considerable pain if they form
beneath the metatarsal heads or calcaneal tuberosity
--tinea pedis (athlete’s foot): most common rash on feet -> causes a characteristic peeling
of skin between toes and a dry red scaly appearance
Alignment
Great toe:
--should point directly forward
--hallux valgus: most common abnormality of great toe -> valgus deformity in 1st MTP
joint, which causes great toe to deviate away from the midline (may even overlap second
toe)
--bunion: may be associated with hallux valgus, refers to accumulation of bone and
thickened soft tissue on medial aspect of the first metatarsal head
--splayfoot: metatarsals spread broadly during weightbearing
--metatarsaus primus varus: first metatarsal that angles excessively toward the midline
--hallus varus: usually a complication of surgery to correct hallus valgus
Lesser toes:
--hammer toe: usually involves a single digit, consists of hyperextension of MTP and
distal IP joints combined with hyperflexion of PIP joint
*callus often develops on the dorsal aspect of the PIP joint due to friction from
top of shoe
--claw toe deformity: both proximal and distal IP joints are held in flexion and multiple
toes are usually involved -> widespread clawing may signify a neurologic disorder such
as Charcot-Marie-Tooth or an adaptive change from longstanding rupture of Achilles
tendon
--mallet toe: usually applied to digit with an isolated flexion deformity of DIP joint, often
produces a callus on tip of involved toe
--major factor in all these deformities is thought to be ill-fitting footwear
Foot:
--forefoot abductus: forefoot appears laterally deviated in relation to hindfoot, usually
associated with pronation of the forefoot -> can occur with flatfoot or midfoot fracture
--forefoot adduction: medial deviation of forefoot -> may be result of clubfoot or
skewfoot deformity
Lower leg:
--tibia vara: bowed tibia -> may be result of malunited fracture, metabolic disorders
(rickets), or congenital abnormalities
Arch:
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--assess alignment and integrity of medial longitudinal arch
--apex usually about 1cm
--pes cavus: high arch, usually bilateral
*idiopathic or assoc with congenital anomaly, muscle imbalance, or CharcotMarie-Tooth
--pes planus: when medial arch is minimal or entirely absent
*genetic or assoc with Achilles reupture, posterior tibial tendon rupture, or RA
--rocker bottom feet: foot has convex appearance, usually due to Charcot arthropathy
(diabetes)
Hindfoot:
--midline of heel should be 5-10 degrees of valgus in relation to midline of the calf
--excessive valgus may be due to calcaneus fracture, arthritis, Charcot arthropathy, or
severe pes planus
--varus of heel assoc with malunited fx of calcaneus or ankle
--too-many-toes sign: ability to see >2 toes from posterior perspective, assoc with
posterior tibial tendon injury (or isolated pes planus)
--windlass effect: forced DF of MTP joints during toe raises tightens plantar fascia,
normally producing an involuntary inversion of the heel and accentuation of medial
longitudinal arch -> may be abnormal due to stiffness or injury to post tibial tendon
Gait
--heel strike: heel hits ground with foot supinated
--stance phase: planted leg internally rotates, heel everts, and foot pronates
--toe-off: leg externally rotates, heel inverts, longitudinal arch rises, and foot supinates
Antalgic Gait:
--self-protective adaptation to pain generated during stance phase of gait
--stance phase is shorter on affected limb
Short Leg Gait:
--develops in response to leg length discrepancy
--lateral shift to the affected side with the pelvis tilting downward toward the same side
--hip hiking on unaffected side: raising pelvis on the unaffected side during swing phase
to allow longer leg to clear ground
Drop Foot (Steppage) Gait:
--used by patient with weak or paralyzed ankle DF
--possible causes: lumbar radic, peroneal nerve palsy, tibialis anterior rupture
Stiff 1st MTP Joint:
--compensates by supinating entire foot and walking predominantly on lateral border
during stance phase
Equinus Contracture:
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--loss of normal ankle DF
--may have steppage gait or may externally rotate involved limb to decrease DF
necessary for stance phase
Range of Motion
Ankle Dorsiflexion:
--normal: about 20 degrees
--loss of DF may be due to contracture of posterior structures, loss of ankle syndesmosis
flexibility, impingement of anterior soft tissue or osteophytes
--equinus: ankle that can’t DF to neutral
Ankle Plantar Flexion:
--normal: about 50 degrees
--loss of PF due to anterior capsular contracture following trauma or posterior joint
impingement (from chronic ankle instability or trauma to a prominent pocessus trigonum
or os trigonum)
Subtalar Joint Inversion and Eversion:
--eversion: 20 degrees
--inversion: 40 degrees
--severe restriction of subtalar motion in child or adolescent -> tarsal coalition
--severe restriction of subtalar motion in an adult -> sequela of hindfoot fx
Forefoot abduction and adduction:
--about 5 degrees
--Very hard to measure accurately
Great toe:
--motion occurs through MTP joint and IP joint
--passive extension in 1st MTP: 70 degrees
--passive flexion in 1st MTP: 45 degrees
--hallux rigidus: restriction of motion in 1st MTP jt
Lesser Toes:
--3 jts: MTP, PIP, DIP
--loss of motion common following fracture or with hammer toe, claw toe, or mallet toe
deformities
Muscle Testing
--ability to walk on toes is a good general indicator of strength of ankle plantar flexors
(gastrocsoleus)
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--heel walking is a good general test of ankle DF (tibialis anterior)
--strength of inversion of foot (tibialis posterior) assessed by asking patient to walk on
lateral borders of feet
--strength of eversion (peronei) assessed by asking patient to walk on medial borders of
feet
Ankle DF and Toe Extensors:
--tibialis anterior: place ankle in max DF while supporting patient’s heel with one hand as
examiner plantarflexes ankle
--tibialis anterior assisted by EHL, EDL, and peroneus tertius
--deep peroneal nerve: innervates all ankle DFers -> injury causes footdrop
--common peroneal nerve: weakens DF and also weakens peroneus longus and brevis
--causes of extensor hallucis longus weakness: lumbar radiculopathy v. peroneal nerve
palsy
Ankle PF and Toe Flexors:
--ask patient to maximally PF ankle
--toe walking more sensitive because the weight is greater
--causes: lumbar radiculopathy, prior Achilles tendon rupture, and sciatic or tibial nerve
injury
--flexor hallucis longus and flexor digitorum longus: tested together because they have
tendinous cross-connections that make isolated testing difficult
Evertors of Foot:
--strength supplied primarily by peroneus brevis, assisted by peroneus longus (superficial
peroneal nerve)
--weakness due to tendonitis, instability of peroneal tendons, or Charcot-Marie-Tooth
--peroneus longus difficult to test in isolation -> also functions as PF of 1st metatarsal so
may test this function
Invertors of Foot:
--function primarily of tibialis posterior (with tib ant, FDL, FHL)
--innervated by tibial nerve (except tibialis ant, innervated by deep peroneal nerve)
--test by pushing laterally against the medial border of 1st metatarsal while foot is in
inversion
--can test tibialis posterior by asking patient to rise up on toes and watch heels invert as
they rise off the ground
Sensation
--sural nerve: test lateral border of ankle and foot
--deep peroneal nerve: supplies 1st web space
--superficial peroneal nerve: supplies most of rest of dorsum of foot
--saphenous nerve: most of medial leg, usually extending down to ankle
--posterior tibial nerve: plantar aspect of heel and foot
--numbness of individual digital nerve can develop with Morton’s neuroma
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Special Tests
Anterior drawer test:
--assesses anterior talofibular ligament
--allow lower limb to hang off side of table, grasp leg prox to ankle joint. Then grasp
heel with free hand and pull forward while pushing posteriorly on the leg.
--watch for anterior motion of the talus (at least 3-5 mm difference between sides)
--normal: talus moves forward a few mm and then stops with firm endpoint
Inversion Stress Test (varus stress test):
--assesses calcaneofibular ligament
--grasp patient’s forefoot with one hand and maximally DF ankle to place calcaneofibular
ligament under tension and lock subtalar jt, then grasp calcaneus with opposite hand and
attempt to invert heel
--if ligament is compromised, talus will rock into inversion
Peroneal Tendon Instability Test:
--seeks to reproduce subluxation or dislocation of peroneal tendons ant to lat malleolus
--patient instructed to rotate ankle and foot clockwise then counterclockwise starting in
DF while examiner palpates posterior border of lateral malleolus with two fingers
--normal: tendons move slightly anteriorly as they tense but remain behind malleolus
--abnormal: tendons begin to sublux over malleolus and may even dislocate
Thompson’s Test
--confirms diagnosis of Achilles tendon rupture
--place pt prone on examination table with both feet dangling off edge -> examiner
should see swelling and ecchymosis and can palpate a gap in the tendon
--with tendon rupture, foot comes to rest in a more DF position (normal: slight PF)
--test: grasp pt’s calf with hand and gently squeeze muscle -> normally the foot should
passively plantarflex
--rupture -> no movement of foot
First Metatarsal Rise Test:
--supplementary test for posterior tibial tendon dysfunction
--patient stands and faces away from examiner; examiner grasps pt’s lower leg and
externally rotates it -> heel assumes a varus position
--if there is posterior tibial tendon dysfunction, first metatarsal rises off ground with this
manipulation
Morton’s Test:
--adjunctive test for detection of interdigital neuromas
--grasp head of 1st and 5th metatarsals and compresses them together (or move them up
and down in opposite directions -> reproduction of pain is suggestive of a neuroma
--Mulder’s click: palpable click when compressing metatarsal heads, caused by neuroma
being forced plantarly
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Dorsiflexion-Eversion Test:
--elicits symptoms of tarsal tunnel syndrome
--place ankle in maximal DF and eversion while also DFing MTP jts
--tibial nerve is maximally stretched through tarsal tunnel in this position and should
reproduce symptoms
Pelvis, Hip, and Thigh
--ilium, ischium, and pubis fuse to become the pelvic bone
--right and left pelvic bones join anteriorly at pubic symphysis and join sacrum
posteriorly at sacroiliac joints to form a closed ring
--serves as a stable central base for human locomotion
--hip: femoral head, most proximal aspect of femur, and the acetabulum (a socket located
in the center of the lateral surface of the pelvis)
Inspection
Anterior Aspect
Pelvis:
--iliac crest: arching superior margin of the ilium, lying immediately beneath the
abdominal fold at the waist
--anterior superior iliac spine: anterior terminus of the iliac crest, serves as site of origin
of the inguinal ligament and sartorius muscle
--inguinal ligament: a fibrous band that traverses the anterior pelvis and inserts just lateral
to the public symphysis on a small prominence of the pubis known as the pubic tubercle
*serves as the insertion for some of the abdominal muscles
*fascia envelops round ligament in women and spermatic cord in men
--lateral femoral cutaneous nerve: exits pelvis and enters anterolat thigh about 2cm
medial to ASIS, which is where nerve may be compressed by tight clothing -> meralgia
paresthetica
--further medially is femoral nerve, artery, and vein (most medial), which pass deep to
the inguinal ligament as they enter the anterior thigh -> then pass through femoral
triangle
--femoral triangle: boundaries are inguinal ligament, sartorius (lateral), and adductor
longus (medial)
--tensor fascia lata: superficial muscle that arises from anterior portion of iliac crest and
inserts into fascia lata of lateral thigh
--anterior inferior iliac spine: lies just medial and inferior to ASIS, not normally visible
because it is obscured by the sartorius
*origin for portion of rectus femoris (only component of quads that arises superior
to hip joint
--pubis: medial portion of each pelvic bone
--pubic symphysis: where two pubic bones join together in a fibrocartilaginous jt
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Hip Joint:
--located 2 cm lateral and 2cm distal to point where femoral pulse is palpable
--point arising from hip pathology located at this point and often described as “groin
pain”
Thigh:
--rectus femoris: arises partly from AIIS and partly from anterior hip capsule
--vastus intermedius: located deep to the rectus femoris and is not separately visible
--vastus medialis and vastus lateralis fill out lateral contour of anterior thigh
--adductor longus: originates from pubis and inserts on linea aspera of femur
--gracilis: arises from pubis and runs length of medial thigh until insertion on the tibia
Lateral Aspect
Pelvis and Hip:
--Nelaton’s line: imaginary line drawn from posterior superior iliac spine to ASIS
--gluteus medius: arises from superior portion of iliac wing and inserts on greater
trochanter
--tensor fascia lata: arises from anterior iliac crest and constitutes anterior border of
lateral aspect of hip
--gluteus maximus: arises from posterior ilium and adjacent sacrum
Thigh:
--vastus lateralis and biceps femoris constitute anterior and posterior contours of thigh
respectively
--greater trochanter is most prominent bony landmark, which provides leverage for
gluteus medius and gluteus minimus -> abduct femur and prevent drooping of pelvis
when opposite limb is lifted
--trochanteric bursa: lies between fascia lata and greater trochanter
Posterior Aspect
Pelvis and Hip:
--dominated by iliac crest
--PSIS overhangs sacroiliac joint
--sacrum: triangular depression between the two great prominences created by gluteus
maximus
--ischial tuberosity: constitutes inferiormost portion of pelvis, palpable in inferior medial
buttock, deep to gluteus maximus, serves as origin for hamstrings
--short external rotators that arise from pelvis and insert on greater trochanter: piriformis,
superior gemellus, obturator internus, inferior gemellus
*tendonitis in these structures can be a source of posterior hip pain
*piriformis may compress sciatic nerve
--gluteal fold: transverse crease that forms at junction of buttock and posterior thigh
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Thigh:
--visible muscle consists of three hamstring muscles: biceps femoris, semimembranosus,
and semitendinosus
--biceps femoris (lateral hamstring): originates from ischial tuberosity and prox femur
and inserts on fibular head
--semimembranosus and semitendinosus (medial hamstrings): originate on ischial
tuberiosity
Medial Aspect
Thigh:
--bordered by vastus medialis and sartorius anteriorly, by hamstrings posteriorly
--adductor magnus: originates from ischial tuberosity and inferior pubic ramus and inserts
on femur in two places -> bulkiest of adductors
--adductor longus: arises from anterior pubis near pubic symphysis and inserts on linea
aspera -> most visible
--gracilis: originates on medial pubis and inserts on tibia, where (with sartorius and adj
semitendinosus tendons) it forms pes anserinus
Alignment
Leg Length Discrepancy
--pelvic obliquity: usually results from LLD, so is a good starting point. 2 sides of pelvis
should be level when patient is standing -> check by placing hands on each of patient’s
iliac crests -> line should be parallel to floor
--true leg length discrepancy: actual length of 2 lower limbs (measured from femoral
heads to plantar surface of feet) is different
*can be caused by varus or valgus deformities of femoral neck, congenital
anomalies of femur or tibia
--functional leg length discrepancy: lower limbs are identical in length, but other factors
(eg contractures) cause one limb to function as if it were shorter or longer
*can be caused by contractures, posttraumatic deformities of pelvis, abduction or
adduction contractures of hip or flexion contracture of knee
--direct measurement: measure from ASIS to medial malleolus; differences of <5mm are
difficult to assess
--check for function LLD by measuring from umbilicus to tip of each medial malleolus
--Block method: place blocks or books under shorter limb of standing patient until pelvic
obliquity is eliminated
--Visual method: patient lies supine on table while examiner aligns patient as straight as
possible and compare position of medial malleoli
--abduction contracture: tightness of hip abductor muscles prevents hip from being
adducted to neutral -> involved limb is functionally long because pelvis drops ->place lift
on uninvolved side
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--adduction contracture: tightness prevents hip from being abducted to a neutral position > functionally short -> place lift on involved side
--femoral length discrepancy: patient lies on table with hips and knees flexed to 90
degrees -> if femoral discrepancy, knees are at different heights
--tibial length discrepancy: patient positioned prone with knees flexed to 90 degrees,
check high of soles of feet
--flexion contracture of hips: patient compensates with hyperlordosis of spine
Rotational Malalignment
--resting position:
*if there is posterior dislocation of hip, hip has a flexed and internally rotated
position
*if there is anterior dislocation or fracture, hip has an externally rotated position
--when standing in relaxed position, feet should normally point outward 10-20 degrees
--in-toeing: internal rotation of lower limb
--out-toeing: external rotation of lower limb
--version of the femoral neck: angle that the femoral neck makes in relation to the coronal
plane of the femur (normal = 8-15 degrees of anteversion)
*increased femoral anteversion -> in-toeing, unless this is compensated for by
incr external rotation of tibia
*decr femoral anteversion (retroversion) ->out-toeing (found in ballet dancers)
--Craig’s test: measures femoral anteversion; patient prone on table with knee flexed 90
degrees -> examiner palpates lateral prominence of greater trochanter with one hand
while controlling rotation of the limb with the other -> rotate limb until lateral
prominence of greater trochanter is maximal -> angle between axis of tibia and the
vertical is an approx of femoral anteversion
--tibial torsion: 20 degrees of external tibial torsion is normal
*measure by having pt lie prone with needs flexed 90 degrees and tibias held
vertical -> estimate the ankle that the foot makes with the axis of the thigh
--in-toeing may also be assoc with forefoot adductus or incompletely corrected clubfoot
Gait
Adductor muscle function:
--gluteus medius and minimus muscles counteract the tendency of the pelvis to fall
toward opposite side during gait
--muscles must pull with a force approx twice the patient’s upper body weight
--a compressive force of 3x the upper body weight is transmitted across weight-bearing
femoral head with each step
Trendelenburg’s Gaait:
--if gluteus medius and minimus are weak, pelvis drops toward floor when pt is bearing
wt on weak limb
--exaggerated up and down motion of pelvis during gait
Abductor limp:
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--seen with very weak hip abductors
--pt leans over toward side of weightbearing limb to bring center of gravity closer to the
femoral head
--side to side shifting of the upper body during gait
--may also be seen in a patient with a painful hip joint and normal abductors to decrease
compressive force on painful hip
Pelvic Rotation:
--coronal pelvic rotation is normal, but is exaggerated in muscle weakness or hip arthritis
-> waddling appearance
--transverse plane pelvic rotation is normal
Flexion Contracture of hip:
--can cause increased lumbar lordosis or a forward-stooping posture
--short stride length
--excessive lumbar flexion and extension
Gluteus Maximus Lurch:
--weak gluteus maximus
--GM usually locks hip in extension as contralat limb is advanced
--if weak GM, pt may thrust pelvis forward and trunk backward, shifting center of gravity
posterior to hip
Range of Motion
ROM Pelvis
--2 types of motion associated with pelvis:
*motions between pelvic bones at pubic symphysis and SI joints (small motions)
*change in position of pelvis in space and in relation to body -> occurs at joints of
adjacent L-spine and hips
--flexion occurs when superior pelvis rotates posteriorly -> produced by flexion of Lspine combined with extension of hips
--extension occurs when superior pelvis rotates anteriorly -> produced by extension of Lspine combined with flexion of hips
--abnormal pelvic flexion and ext cause shortened stride length
ROM Hip
--Ball and socket jt
--3 movement pairs: flexion-extension, abduction-adduction, internal-external rotation
--must stabilize pelvis to distinguish from L-spine movement
Hip Flexion-Extension: Thomas Test
--used to assess true ROM of hip jt
--patient lies supine and flexes both hips until knees touch chest -> examiner locks knees
in this position so pelvis is in max flexion and L-spine can’t extend
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--release hip to be tested for extension: in normal patient, leg should touch examining
table
--to measure flexion, allow contralateral thigh to touch table while examined thigh in max
flexion -> measure angle between table and midline of thigh (normal > 110 degrees)
Hip Abduction-Adduction:
--may be assessed with hips extended or flexed
--test abduction while in extension: examiner stands at side of table facing supine pt ->
one hand grasps pt’s ankle and other hand on ASIS -> passively abduct pt’s LE away
from midline until first feel movement of pelvis -> angle betw thigh and midline is
maximal abduction (normal = 45 degrees)
--test adduction in extension: same as above except adduct as far as possible and feel for
pelvic motion (normal = 30 degrees)
--may also test abd-add in flexion by same maneuver with hip flexed with foot next to
contralateral knee
Hip Rotation:
--can be measured in flexion and extension but more important in extension b/c it affects
foot placement with ambulation
--loss of ext rotation in flexed position affects putting on shoes and cutting toenails
--rotation is first affected in hip arthritis -> groin pain with rotation
--hip rotation in extension: patient lies on table with hips and knees extended
*normally, hips should ext rotate ~30 degrees (SCFE or malunited hip fx causes
incr ext rotation at rest)
*grasp pt’s feet and use them to fully ext rotate LE’s at hip (normal = 45 deg),
then internally rotate feet (normal = 35 deg)
*incr int rot, decr ext rot: caused by incr femoral anteversion
*decr int rot, incr ext rot: caused by femoral retroversion, a sequela of SCFE or
developmental dysplasia
--hip rotation in flexion:
*while supine, grasp pt’s knee in one hand and foot in other hand. Flexing hip
and knee to 90 deg, rotate limb at hip (normal: 45 deg ext rot, 30 deg int rot)
*may measure while pt seated -> body wt stabilizes pelvis and prevents pelvic
rotation
*THA is contraindication to evaluation of hip rotation or abduction-adduction in
flexed position
Palpation
Anterior Ilium:
--ASIS: serves as Sartorius origin, common site of apophyseal avulsion fractures in
adolescents
--iliac crest: ant portion also common site of avulsion fx or iliac apopysitis
*tenderness in iliac crest after direct blow -> hip pointer (localized hematoma)
--AIIS: palpable only in lean individuals
--lateral femoral cutaneous nerve: passes under inguinal lig on way to ant thigh
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*compression -> meralgia paresthetica (dysesthesia in anterolat thigh)
*percussion may reproduce symptoms
Lesser trochanter:
--located on floor of femoral triangle deep to Sartorius
--cannot be felt in normal people
--tenderness of lesser trochanter in adolescents indic avulsion fx
--snapping hip syndrome: seen in dancers, caused by distal iliopsoas tendon
*hip extension produces pain in prox medial thigh
Pubis:
--superior pubic ramus at medial end of ant pelvis
--palp at superior margin of normal pubic hair growth
--pubic symphysitis: common in soccer players, caused by strong adductors
Neurovascular Structures:
--femoral artery passes under inguinal lig to ant thigh midway betw ASIS and pubic
symphysis
--femoral n lateral to artery
--femoral v and lymphatics medial to artery
Hip Joint:
--acetabulum and hip jt loc 2cm lateral and inferior to femoral pulse
--palpate for deep tenderness: arthritis, infection, SCFE, femoral neck fx
Quadriceps:
--subject to muscle contusions (direct blow) and strains (eccentric contraction)
--eval of contusion: gentle palpation identifies injury and assoc hematoma
*if warm, firm swelling, there is a risk of evolving myositis ossificans
--eval of strain: search for defect in muscle
*graded by restriction of prone knee flexion
Sartorius:
--injuries involve origin near the ASIS
--can be identified with lower limb in figure-4 position
--distally, difficult to distinguish from quads
Greater Trochanter:
--most prominent landmark of lateral hip and thigh
--greater trochanteric bursa: loc betw bony trochanter and overlying iliotibial tract ->
common site of painful inflammation
--trochanteric bursitis: tenderness directly over most prominent portion of trochanter
*may be associated with tightness of iliotibial tract (Ober’s test)
*gluteus medius tendonitis assoc with tenderness just superior to bony
prominence; piriformis tendonitis just posterior to prominence
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Posterior Ilium:
--PSIS: primary landmark for orientation and palpation
--sacroiliac jt: immediately deep, lateral, and inferior to PSIS -> tenderness caused by
injury, infection, or arthritis
Sciatic notch:
--midway between PSIS and ischial tuberosity (difficult to palpate)
--tenderness indicates sciatica
Sacrum/coccyx:
--tenderness of sacrum caused by fx, tumor, or infxn
--coccyodynia may be caused by overuse, fx, or disruption of one of jts
--rectal exam can confirm coccyx as site of pain
Ischium:
--ischial tuberosity loc at medial inf margin of gluteal prominence
--most easily palpated with patient lying supine and ipsilat hip flexed 45 deg
--tenderness may indicate avulsion fx
--weaver’s bottom: inflammation of bursa over ischial tuberosity from sitting on hard
surfaces
Piriformis:
--tendon inserts into piriformis fossa on post sup aspect of greater trochanter beneath inf
border of gluteus medius muscle
Gluteus maximus:
--tendon palp near gluteal fold at inf aspect of gluteus maximus
--tenderness here and a painful Yeoman’s test -> gluteus maximus tendonitis
Hamstrings:
--strain primarily occurs during eccentric contraction of muscle and may involve any
portion of muscle
--severe strain restricts passive straight-raise test and may produce a tripod sign
Tests for Joint Contractures:
Thomas’s Test: screening tool for loss of hip extension
Ober’s Test:
--test for contractures of iliotibial tract
--tightness may be associated with troch bursitis or snapping hip syndrome prox and IT
band tendonitis at the knee
--pt in lateral decubitus position with side to be tested facing up -> knee flexed 90 deg
and hip abducted 40 deg and extended to limit
--while stabilizing pelvis, gently adduct limb toward table -> should go past midline
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Ely’s test:
--test for contractures of rectus femoris muscle
--based on fact that rectus fem crosses hip and knee jts
--pt prone with knees extended -> passively flex knee
--involuntary flexion of hip is abnormal with this motion
Tripod sign:
--test for contractures of hamstrings
--pt sits on side of exam table with knees bent to 90 deg -> grasp pt’s ankle on side to be
tested and passively extend knee fully
--tight hamstrings -> invol extension of ipsilateral hip
--similar response with sciatic nerve irritation
Phelps’ test:
--test from contractures of gracilis muscle
--pt prone with knees extended -> examiner passively abducts hips to max degree
--flex pt’s knees and attempt to abduct hips further
--if hips can abduct further with knees flexed, gracilis contracture is present
Screening tests for Tendinitis
--have pt perform a resisted contraction of suspected muscle-tendon unit
--stretch suspected muscle-tendon unit to see if painful
Piriformis test
--piriformis: exits pelvis and inserts into post sup portion of greater troch
*external rotator of hip
*in 15% of pt’s, sciatic nerve passes thru piriformis (instead of distal)
--pt in lat decub position with side to be examined facing up
--hip flexed 45 deg with knee flexed 90 deg
--examiner stabilizes pelvis while pushing flexed knee toward the floor, internally
rotating hip -> stretches piriformis and causes pain if tendonitis
--if pain radiates, consider piriformis syndrome: entrapment of sciatic nerve in piriformis
Pelvic Stress Tests
Patrick’s Test (FABER test)
--Flexion-Abduction External Rotation (figure-4 position)
--pt supine on exam table and limb to be examined is guided into figure-4 position with
ipsilateral ankle resting on contralat thigh prox to knee
--examiner presses down on ipsil knee with one hand while providing counterpressure
with other hand on contralat ASIS -> stresses SI jt on tested side
--posterior hip pain with maneuver -> pathology of SI jt
--groin pain with maneuver -> arthritic hip
--iliopsoas sign: pain in figure-4 position
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Gaenslen’s test:
--stress test for SI jt
--pt supine on table with buttock to be examined projecting over side of table
--pt draws both knees up to chest
--Examiner stabilizes pt while ipsil thigh is allowed to drop off side of table, thus fully
extending hip -> stresses ipsil SI jt
Lateral Pelvic Compression Test:
--screening test for pathology of major jts of pelvic ring
--pt in lat decub position while examiner presses on iliac crest
--pain localized to either SI jt or pubic symphysis indicative of pathology
Anteroposterior Pelvic Compression Test:
--Compresses pelvis in anteropost plane
--press downward on pubic symphysis while pt lies supine
Pubic Symphysis Stress Test
--detect instability or pain assoc with injured or inflamed pubic symphysis
--pt lies supine while examiner has one hand on sup aspect of one pubic bone and one
hand on inf aspect of other pubic bone -> push hands toward each other and assess for
pain
Other Tests:
Stinchfield’s Test:
--screen for hip pathology: arthritis, fx, infection
--simulates normal walking forces
--ask supine pt to do active straight-leg raise with ipsil knee in extension -> pain means
pathology of hip jt
Fulcrum Test:
--helps in detection of stress fractures of femoral shaft
--pt sits on exam table while examiner places forearm beneath middle of pt’s thigh and
presses down on ipsil knee -> bending force across femoral shaft -> pain is positive
Trendelenburg’s Test
--screening for hip abductor muscle weakness (gluteus medius and gluteus minimus)
--examiner stands or sits behind standing pt while pt lifts each foot off ground (contralat
abductors are tested)
--weak abductors -> pelvis droops to unsupported side when foot is lifted