CERVICAL SPINE

Teerawong KasiolarnORTHOPEDIC TESTS

CERVICAL SPINEOrthopedic Tests Procedure Rationale

DiGeorges Test(Dekleyn’s Test)(63 C)

Pt supine & head off table, instruct pt to hyperextend & rotate the head & hold for 15-40 sec. Repeat w/ the head rotated & extended to the opposite side.

Rotation & hyperextension of head place a motion-induced compression on the vertebral arteries on the opposite side of the head rotation. Positive: Vertigo, dizziness, visual blurring, nausea, faintness, & nystagmus. This test indicates vertebral, basilar, or carotid artery stenosis or compression. Consideration must also be given to the patency of the carotid arteries & a communicating cerebral arterial circle.

Maigne’s Test(61 C)

Pt seated, instruct pt to extend & rotate head & hold 15-40 sec. Repeat the test w/ pt’s head rotated to opposite side.

This test places a motion-induced comprx on the vertebral a. on the opposite side of head rotation. Positive: vertigo, dizziness, visual blurring, nausea, fainting, & nystagmus. Ddx: vertebral, basilar, or carotid artery stenosis or compression

Hautant’s Test(64 C)

Pt seated & eyes closed: extend arms to the front w/ palms up + extend & rotate head to one side. Repeat w/ opposite side.

Pt w/ stenosis or compression to the vertebral, basilar, or subclavian aa. w/o sufficient collateral circulation will tend to lose balance, drop the arms, & pronate the hands.Ddx: vertebral, basilar, or carotid artery stenosis or compression

*Foraminal Compression Test(82 C)

Pt seated & head in neutral position, exert strong downward pressure on head. Repeat w/ head rotated bilaterally.

Downward pressure causes:• narrowing of intervertebral

foramina• comprx of apophyseal jts in

cervical spine• comprx of intervertebral discs in

cervical spineLocal pn foraminal encroachment w/o nerve root pressure or apophyseal capsulitis.Radicular pn pressure on nerve root by a decrease in foraminal interval (encroachment) or by a disc defect. If suspect nerve root involvement, eval neurological level.

Jackson’s Compression Test(83 C)

Pt seated, laterally flex the neck & exert strong downward pressure on head. Perform this test bilaterally

Laterally flexed & downward:• narrowing of intervertebral foramina on

the side of lateral bending• comprx of facet jts on the side of lateral

bending• comprx of intervertebral discs in

* NPLEXM = Magee, David. Orthopedic Physical Assessment, 4th Ed.C = Cipriano, Joseph. Photographic Manual of Regional Orthopedic & Neurological Tests, 4th Ed.

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cervical spineLocal pn foraminal encroachment w/o nerve root pressure or apophyseal joint pathology.Radicular pn pressure on nerve root by a decrease in foraminal interval (encroachment) or by a disc defect. If suspect nerve root involvement, eval neurological level.

Extension Compression Test(84 C)

Pt seated & extend head ~ 30º, then place downward pressure on pt’s head.

Downward pressure & extended head Cervical intervertebral disc space is decreased posteriorly & increased vertically & anteriorly, w/ an increased load on the posterior apophyseal jts. If ↓ Sx posterolateral disc defect b/c of anterior & vertical displacement of disc material away from nerve root/spinal cord.Downward pressure on head also compresses posterior apophyseal jts, which, if irritated, can cause local cervical pain. ↑ upper extremity radicular sxs:pathology in intervertebral foramina (e.g. osteophyte, mass, degenerative cervical intervertebral disc)

Flexion Compression Test(85 C)

Pt seated & flex head forward. Then, place downward pressure on pt’s head.

Intervertebral disc is compressed anteriorly & causes the posterior aspect of the disc to bulge posteriorly. ↑ cervical and/or radicular sxs: discal defect.The test also reduces the load on the posterior apophyseal jts. ↓ localized scleratogenous pain: apophyseal jt injury or pathology

*Cervical Distraction Test(89 C)

Pt seated, grasp beneath mastoid processes & press up on the pt’s head. This removes the wt of the pt’s head on the neck.

Cervical mm, ligg, & apophyseal jt capsules are stretched. And, interforaminal & intervertebral interval increase.↑ local pn: mm strain, spasm, lig sprain, or facet capsulitis. Relief of local/radicular pain: either foraminal encroachment or a disc defect.

*Spurling’s Test(86 C)

Laterally flex the seated pt’s head & gradually apply strong downward pressure. Positive: pain & do not continue w/ the next procedure. If no pain: put pt’s head to neutral position &

Local pain: facet jt involvementRadicular pain: foraminal encroachment, degenerating cervical intervertebral disc, or disc defect w/ nerve root pressure. This test may also indicate a lateral disc defect.


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deliver a vertical blow to the uppermost portion of pt’s head.

Maximum Foraminal Compression Test(87 C)

Instruct the seated pt to approximate the chin to shoulder & extend the neck. Perform this test bilaterally.

IV = Intervertebral

Rotated head & hyperextended neck: • narrowing of IV foramina on the

side of head rotation• comprx of facet jts on the side of

head rotation• comprx of IV discs in C-spinePain on the side of head rotation w/ radicular component: nerve root comprx (e.g. osteophyte, mass, ↓ interval in foramina. Local pain w/ no radicular component: apophyseal jt pathology on the side of head rotation & neck extension. Pain on opposite side of head rotation: muscular strain or ligament sprain

Spinal Percussion (w/ reflex hammer)(73 C)

Pt seated, head slightly flexed & percuss the spinous process & associated musculature of each of the cervical vertebrae w/ a reflex hammer

Local pain: fractured vertebra w/ no neurological compromiseRadicular pain: fractured vertebra w/ neurological compromise or a disc lesion w/ neurological compromiseIf suspect frx, a full cervical radiography series is indicated.Note: This test is not specific. A lig sprain + on percussion of SP. Muscular strain + on percussion of paraspinal mm.

*Nafziger’s Test(287 C)

Pt seated, compress jugular vv b/l, which lie ~ 1” lateral to tracheal cartilage. Hold comprx for 1 min.

The test raises the intrathecal pressure. The theca is the covering of the spinal cord, which consists of the pia mater, arachnoid mater & dura mater.Local pain in lumbar: space-occupying lesion, usually a disc protrusion or prolapseRadicular pain: nerve root involvement.

*Valsalva Test(285 C)

Instruct the seated pt to bear down as if straining at stool but concentrating the bulk of the stress at the lumbar region. Locate the pain if any. The test is subjective & requires an accurate response from pt.

The test increases intrathecal pressure. Local pain 2º to ↑ pressure: space-occupying lesion (e.g., disk defect, mass, osteophyte) in the lumbar canal or foramen.

*Shoulder Depression Test(89 C)

Pt seated, place downward pressure on shoulder while laterally flexing the pt’s head to opposite side.

Muscles, ligg, nerve roots, nerve root coverings, & brachial plexus are stretched & the clavicle is depressed, approximating the 1st rib.


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TOS = thoracic outlet syndromeLocal pain on the tested side: shortening of mm, muscular adhesions, mm spasm, ligg injuryRadicular pain: comprx of neurovascular bundle, adhesion of dural sleeve, or TOS. On opposite side, foraminal interval is decreased, apophyseal jts & IV disc are compressed.Pain on opp side: pathological decrease in foraminal interval, facet pathology, or disc defect.

SHOULDEROrthopedic Tests Procedure Rationale

*Doorbell Test(Lecture Note)

Push down on Erb’s pt (brachial plexus)

For TOS.Positive: radicular pain

*Wright’s Hyperabduction Test(158 C)

Pt seated & you stand behind. Establish the character of radial pulse. Hyperabduct the arm & take the pulse again.

The axillary artery, vein, & 3 cords of brachial plexus pass under pect minor m. on the coracoid process. Abduction of arm to 180º stretches these structures around the tendon of pect minor m. & coracoid process.↓ or absence of radial pulse: comprx of axillary artery (either by a spastic or hypertrophied pect minor m. or by a deformed or hypertrophied coracoid process.

*Adson’s Test(155 C)

*Reverse Adson’s Test(155 C)

Pt seated, establish the amplitude of radial pulse. Compare the amplitude b/l. Instruct pt to take a deep breath & sustain it while rotating the head & elevating the chin to the tested side. (Test anterior scalene)

If negative, have pt rotate & elevate the chin to opposite side. (Test middle scalene m)

Rotation & extension of head compress the subclavian artery & brachial plexus. Tight ant scalene or cervical rib problems in TOS. ↓ or absence of radial pulse: comprx of vascular component of neurovascular (subclavian a.) by a spastic or hypertrophied scalenus anterior m., on a cervical rib, or a mass (e.g. Pancoast tumor). Paresthesias or radiculopathy in the upper extremity: comprx of neural component of neurovascular bundle (brachial plexus)

Halstead’s Maneuver(160 C)

Pt seated, find the radial pulse & note amplitude. W/ your opposite hand, pull on the pt’s arm & ask pt to hyperextend neck. Repeat the test on opposite arm.

Traction pressure on the arm pulls the neurovascular bundle (brachial plexus & axillary a.) over the 1st rib. Extension of neck tightens the scalene muscles.↓ or obliterated pulse: cervical rib subluxation or malposition of 1st rib. Upper extremity radicular pain: comprx of brachial plexus by


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scalenus anterior m.

*Apley’s Scratch Test(123 C)

Pt seated, place the hand on the side of the affected shoulder behind the head & touch the opposite superior angle of the scapula. Then, place the hand behind the back & attempt to touch the opposite inferior angle of the scapula.

The test places stress on the tendons of rotator cuff – infraspinatus, teres minor & subscapularis.Supraspinatus tendons are tested w/ Supraspinatus Tendon Test & Drop Arm Test. Exacerbation of pain: degenerative tendinitis of one of the tendons of rotator cuff

*Drop Arm Test(148 C)

Pt seated, abduct the arm past 90º & lower the arm slowly.

Positive: cannot slowly lower the arm or drops suddenly rotator cuff tear, usually supraspinatus. The supraspinatus m. acts as an abductor of arm & holds head of humerus in place.

Costoclavicular Test(157 C)

Pt seated, establish a radial pulse. Instruct pt to force the shoulders posteriorly (retract shoulders) & flex the chin to the chest

TOS d/t clavicle or 1st rib impingemt. Forcing shoulders posteriorly decreases the space b/w the clavicle & 1st rib. The neurovascular bundle (brachial plexus, axillary a.) & axillary v. run through a narrow cleft beneath the clavicle & on top of 1st rib. Positive: ↓ or absence of radial pulse Comprx of brachial plexus or axillary vein: paresthesias or radiculopathy in the upper extremityComprx of brachial plexus: usually localized to a nerve root or peripheral nerve distributionComprx of axillary vein: typically diffuse radicular vascular discomfort, not localized to a nerve root or peripheral nerve distribution.

Anterior Shoulder Drawer Test(132 C)

Pt supine & place pt’s hand in your axilla. W/ your opposite hand, grasp the post scapula with your fingers & place your thumb over the coracoid process. Using the arm that is holding pt’s hand, grasp the post aspect of pt’s arm & draw the humerus forward

Moving humerus forward while stabilizing scapula tests the integrity of the ant portion of the rotator cuff, which holds humerus into the glenoid cavity. Positive: a click and/or an abnormal amt of mvmt compared w/ normal side ant instability of glenohumeral jt

Neer Impingement Sign(124 C)

Pt seated, grasp pt’s wrist & passively move the shoulder through forward flexion

This mvmt jams the greater tuberosity of humerus against the ant-inf border of acromion. Positive: shoulder pain or apprehension look on pt’s face d/t overuse injury to supraspinatus m. or


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sometimes to biceps tendon

Hawkins-Kenedy Impingement Test(123 C)

Pt standing, flex the shoulder forward to 90º, then force the shoulder in an internal rotation w/o resistance by pt

This mvmt pushes the supraspinatus tendon against the ant surface of the coracoacromial ligament. Positive: local pain supraspinatus tendinitis

*Impingment Test(Magee’s text p. 263)

Pt seated, take pt’s arm to 90º abduction & full lateral rotation (same position as Apprehension Test).

Testing anterior capsule:Placing humerus in 30º-40º abduction & 0º-10º flexion, followed by passive lat rotation to stress the ant capsule Testing posterior capsule:Placing humerus in 60º-70º abduction & 20º-30º flexion, followed by passive medial rotation to stress the post capsule.

If no hx of traumatic sublx or dislcx, the mvmt can cause ant translx of humerus, resulting in 2º impingement of rotator cuff. Positive: ↑ Sxs & anterior or posterior shoulder pain

*Anterior Apprehension Test(133 C)

Stand behind the seated pt. Abduct the affected arm to 90º & externally rotate it slowly while stabilizing the post aspect of shoulder w/ opp hand.

Ext rotation of arm predisposes the humerus to dislocate anteriorly. It tests the integrity of the inf glenohumeral lig, ant capsule, rotator cuff tendons, & glenoid labrum.Positive: apprehension look or local pain chronic ant shoulder dislocation

*Posterior Apprehension Test)(139 C)

Pt supine, forward flex & internally rotate pt’ shoulder. Then, you apply posterior pressure on the elbow.

MOI = Mechanism of Injury

This tests attempts to dislocate the shoulder posteriorly & stresses the rotator cuff & posterior jt capsule. Local pain or discomfort & apprehension look: chronic posterior shoulder instabilityMOI: commonly a position of forced adduction w/ internal rotation in some degree of elevation.

Supraspinatus Test(149 C)

Pt sitting/standing, abduct the shoulder to 90º. Grasp pt’s arm & press down against pt’s resistance. Next, instruct pt to rotate shoulder internally so that the thumb faces downward. Again, press down on the arm against pt’s resistance.

Resistance to abduction stresses the supraspinatus m. & tendon. Weakness or pain: tear of supraspinatus m./tendon or suprascapular neuropathy

*Yergason’s Test(150 C)

Pt seated & elbow flexed to 90º. Stabilize pt’s elbow w/ one hand. With your opposite hand, grasp pt’s wrist & have pt externally rotate the shoulder & supinate forearm against your resistance.

Resisted supination of forearm & external rotation of shoulder stress the bicipital tendon & transverse humeral ligament. Local pain in bicipital tendon: inflmx of biceps tendon or tendinitis.


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If tendon pops out of bicipital groove: a lax or ruptured transverse humeral ligament or a congenital shallow bicipital groove

Speed’s Test(126 C)

Pt seated & elbow completely extended, supinated, & the shoulder flexed forward to 45º. Place your fingers on the bicipital groove & your opposite hand on pt’s wrist. Instruct pt to elevate the arm forward against your resistance.

This test stresses the biceps tendon in the bicipital groove. Pain/tenderness in bicipital groove: bicipital tendinitis

*Lippman’s Test(127 C)

Pt seated & flex elbow to 90º. Stabilize the elbow w/ one hand & w/ your other hand palpate the biceps tendon & move it from side to side in the bicipital groove.

Moving the biceps tendon manually in the bicipital groove stresses the tendon & transverse humeral lig. Pain: bicipital tendinitis Apprehension: a propensity for subluxation or dislocation of the biceps tendon out of the bicipital groove or a ruptured transverse humeral ligament.

Subacromial Push-Button Sign(129 C)

Pt seated, apply pressure to the subacromial bursa.

Pressure to the subacromial bursa will irritate an already inflamed bursa.Local pain: subacromial bursitis.

Dawbarn’s Test(131 C)

Pt seated, apply pressure just below the acromion process on the tested side. Note any pain/tenderness. Then, abduct pt’s arm past 90º, maintaining pressure on the spot below acromion.

The spot below acromion is the palpable portion of subacromial bursa.Pain/tenderness: bursitis

When the arm is abducted, the deltoid m. will cover that spot below acromion, which reduces pressure on the bursa & ↓ pain in bursitis, which indicates subacromial bursitis.

ELBOW, WRIST & HANDOrthopedic Tests Procedure Rationale

*Cozen’s Test (Tennis)(180 C)

Pt seated & stabilize pt’s forearm. Instruct pt to make a fist & extend the wrist. Then, force the extended wrist into flexion against resistance.

The tendons that extend the wrist are attached to the lateral epicondyle. These include extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, & extensor carpi ulnaris. This test can reproduce irritation to the already inflamed lateral epicondyle or common extensor tendons. Pain at lateral epicondyle: lateral epicondylitis (Tennis’ Elbow)

Mill’s Test(182 C)

Pt seated, instruct pt to pronate the arm & flex the wrist. Then, instruct

Tendon of supinator m. is attached to lateral epicondyle. This test


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pt to supinate the arm against resistance.

reproduces irritation to the already inflamed lateral epicondyle & its attaching tendons. Pain: lateral epicondylitis

Pinch Grip Test(191 C)

Instruct pt to pinch the tips of the index finger & thumb together

Normally the pinch is tip to tip. Positive: the pulps of thumb & index finger touch – caused by an injury to the ant interosseous nerve, which is a branch of median nerve. It may indicate an entrapment synd of the ant osseous nerve b/w 2 heads of pronator teres muscle.

Golfer’s Elbow Test(184 C)

Pt seated, instruct pt to extend elbow & supinate the hand. Instruct pt to flex the wrist against resistance.

Tendons that flex the wrist (the flexor carpi radialis & flexor carpi ulnaris) are attached to the medial epicondyle. Pain: medial epicondylitis

*Ligamentous Stability Test (Varus Stress Test)(185 C)

Valgus Stress Test(187 C)

Adduction (Varus) Stress Test: Pt seated, stabilize the medial arm & place adduction pressure on pt’s lateral forearm.

Abduction (Valgus) Stress Test:Pt seated, stabilize the lateral arm & place abduction pressure on pt’s medial forearm.

Adduction Stress Test: Placing adduction pressure on the lateral forearm applies stress to the radial collateral ligament. Gapping & pain: radial collateral ligament instability Abduction Stress Test:Placing an abduction pressure on the medial forearm applies stress to the ulnar collateral ligament. Gapping & pain: ulnar collateral ligament instability

*Tinel’s Elbow Sign(188 C)

Pt seated, tap the ulnar nerve in the groove b/w olecranon process & medial epicondyle w/ reflex hammer.

This test is designed to elicit pain caused by neuritis or neuroma of ulnar nerve. Pain: positive test & the nerve can be damaged as follows:1. overuse or repetitive injury or trauma

of elbow2. arthritis of elbow jt3. cubital tunnel comprx, b/w the heads of

flexor carpi ulnaris m.4. postural habits that compress the nerve

(e.g. sleeping w/ elbows flexed & hands under head)

5. recurrent nerve subluxations or dislocations

Wartenberg’s Sign(189 C)

Instruct the seated pt to place the hand on table. Passively spread pt’s fingers. Instruct pt to bring the fingers together.

The ulnar nerve controls abduction of fingers. Ulnar nerve neuritis: inability to abduct the little finger to the rest of the hand

*Allen’s Test(Radial & Ulnar artery compression)(424 C)

Pt seated, occlude the radial & ulnar aa. w/ both thumbs. Then, instruct pt to open & close fist to express blood from the tissue. At that point,

Consecutively opening & closing fist decreases bld flow in the hand, causing blanching. When pressure on one of the aa. is released, the hand should fill w/


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instruct pt to open hand as you release the pressure to the radial a. Repeat the test w/ the pressure released to the ulnar a.

bld, which turns it a pinkish color, & the veins distend. Delay > 10 sec. to pinkish hand: ulnar/radial aa. insuff. The tested artery is the one not being manually occluded.

*Phalen’s Test(206 C)

Flex both wrists & approximate them to each other. Hold for 60 sec.

CTS = Carpal tunnel syndrome

When both wrists are flexed, the flexor retinaculum provides increased compression of the median nerve in the carpal tunnel.Positive: tingling in the hand along median nerve distribution (thumb, index, middle & lateral half of ring fingers)Ddx: CTS or comprx of median n. in carpal tunnel by inflmx of flexor retinaculum, ant dislocation of lunate bone, arthritic changes, or tenosynovitis of flexor digitorum tendons.

Reverse Phalen’s Test(207 C)

Pt seated, instruct pt to extend the affected wrist & have pt grip your hand. W/ your opposite thumb, press on the carpal tunnel.

This test further constricts the tunnel. Positive: tingling in the thumb, index, middle & lateral half of ring fingersDdx: CTS or comprx of median n. in carpal tunnel by inflmx of flexor retinaculum, ant dislocation of lunate bone, arthritic changes, or tenosynovitis of flexor digitorum tendons.

*Tinnel’s Wrist Sign(205 C)

Pt seated & hand supinated, stabilize the wrist w/ one hand. W/ your opposite hand, tap the palmar surface of wrist w/ a reflex hammer.

Positive: tingling in the hand along median nerve distribution (thumb, index, middle & lateral half of ring fingers)Ddx: CTS or comprx of median n. in carpal tunnel by inflmx of flexor retinaculum, ant dislocation of lunate bone, arthritic changes, or tenosynovitis of flexor digitorum tendons.

Tourniquet Test(209 C)

Wrap a sphygmomanometer cuff around the affected wrist & inflate it to just above the pt’s systolic bld pressure. Hold for 1-2 mins.

The inflated cuff induces mechanically increased pressure to the median nerve. Positive: tingling in the hand along median nerve distribution (thumb, index, middle & lateral half of ring fingers)Ddx: comprx of median n. in carpal tunnel by inflmx of flexor retinaculum, ant dislocation of lunate bone, arthritic changes, or tenosynovitis of flexor digitorum tendons.

*Finkelstein’s Test(211 C)

Pt seated, instruct pt to make a fist w/ the thumb across the palmar surface of the hand & to stress the wrist medially.

This test stresses the abductor pollicis longus & extensor pollicis brevis tendons. Positive: pain distal to the styloid


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process of the radius stenosing tenosynovitis of the abductor pollicis longus & extensor pollicis brevis tendons (de Quervain’s dz)

*Retinacular Test(223 C)

With the PIP jt in neutral position, passively attempt to flex the DIP jt. Repeat the test w/ PIP jt in the flexed position.

Tight collateral ligg or jt capsule: DIP jt does not flex w/ PIP jt in neutral positionNormal capsule but tight collateral ligg: DIP jt flexes easily when PIP jt is flexed

*Bunnel-Littler Test(222 C)

Instruct pt to extend the MCP jt slightly. Attempt to move the PIP jt into flexion. Repeat the test w/ MCP jt in flexion.

Tight intrinsic muscle or a contracture of jt capsule: PIP jt does not flex w/ MCP in slight extension. Tight intrinsic muscles: PIP jt fully flexes w/ MCP jt flexed.Positive test indicates inflmx process in fingers (e.g. osteoarthritis or rheumatoid arthritis)

THORACIC SPINEOrthopedic Tests Procedure Rationale

Inclinometer: Flexion(237 C)

Pt seated, place one inclinometer in the sagittal plane at T1 level & the other at T12 level. Zero out both inclinometers. Instruct pt to place hands on hips & to flex forward the thoracic spine. Record both inclinations & subtract the T12 from T1 inclination to arrive at the thoracic flexion angle.

Normal range: ≥ 50° from neutral or zero position

Muscles Nerve supplyRectus abdominous T6-T12External abdominal oblique

T7-T12

Internal abdominal oblique

T7-T12, L1

Inclinometer: Lateral Flexion(238 C)

Pt standing, place on inclinometer flat against T1 SP & the other flat against L1 SP. Zero out both inclinometers. Instruct pt to flex T-spine to one side & then the other & record findings. Subtract T1 inclination angle from T12 inclination angle to arrive at thoracic lateral flexion angle.

Normal range: 20°- 40° from neutral or zero position

Muscles Nerve supplyLateral Flexion to the Same SideIliocostalis thoracis T1-T12Longissimus thoracis T1-T12Intertransversarii T1-T12 Internal abdominal oblique

T1-T12, L1

External abdominal oblique

T7-T12

Quadratus lumborum T7-T12

Lateral Flexion to the Opposite SideSemispinalis thoracis T1-T12Multifidus T1-T12


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Rotators T1-T12External abdominal oblique

T7-T12

Transversus abdominis T7-T12, L1

Inclinometer: Rotation(239 C)

Pt seated, instruct pt to flex forward as far as possible, bracing w/ the arms. Inclinometers at T1 & T12 levels in coronal plane. Zero out both inclinometers. Instruct pt to rotate the trunk to one side; record both T1&T12 inclinations. Subtract T12 from T1 inclination to get the thoracic rotation angle. Perform this measurement w/ rotation to the opposite side.

Normal range: ≥ 30° from neutral or zero position

Muscles Nerve supplyRotation to the Same SideIliocostalis thoracis T1-T12Longissimus thoracis T1-T12Intertransversarii T1-T12 Internal abdominal oblique

T1-T12, L1

Rotation to the Opposite SideSemispinalis thoracis T1-T12Multifidus T1-T12Rotators T1-T12External abdominal oblique

T7-T12

Transversus abdominis T7-T12, L1

McZenzie’s Slide Glide Test(242 C)

Pt standing. Stand to one side of pt. W/ your shoulder, block the thoracic spine. W/ both hands, grasp pt’s pelvis & pull it toward you. Hold this position for 10-15 sec. Repeat this test to the opp side. If pt has evident scoliosis, the side toward which the spine curves should be tested first.

This test is performed on pts w/ symptomatic scoliosis. Blocking the shoulder & moving the pelvis stress the area of scoliosis. Positive: sx or pain increases on the affected side d/t scoliosis

Tuning Fork Test(Lecture Note)

Vibrate a 250-Hz tuning fork & place it on the affected ribs

Each rib is innervated w/ multiple sensory pain fibers in the surrounding periosteum. If fractured, vibration will cause exacerbation of these inflamed nerves. Positive: pain is reproduced from vibration of tuning fork rib fracture


Pt seated & bear down as if straining at stool but concentrating the stress at lumbar region. If increased pain, ask pt to point to it. The test is subjective & require an accurate response from pt.

This test increases intrathecal pressure. Local pain 2° to ↑ pressure: a space-occupying lesion (e.g. disk defect, mass, osteophyte) in lumbar canal or foramen

Brudzinski’s Sign(431 C)

Pt supine, flex pt’s neck to the chest Flexing the neck places traction on the dural sac & spinal cord. Flexing the knees reduces the traction on the spinal cord & meninges. Positive: pain at the level of irritation or pt flexes the knee meningeal irritation or nerve root involvement

*Kernig’s Test(430 C)

Pt supine, instruct pt to flex the hip & knee to 90° w/ the lower leg

W/ the hip & knee flexed, the sciatic nerve & dural sac are relaxed.


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parallel to table. The, instruct pt to extend knee on the tested side.

Extension of knee puts traction on the sciatic nerve, hence ultimately the dural sac or meninges. Positive: inability to straighten leg or pain meningeal irritation or nerve root involvement

Slump Test(511 Magee)

Sequence of pt’s postures:- pt sits erect on the edge of table

w/ hands behind the back- pt slumps L & T-spine while you

hold pt’s head in neutral- push down on pt’s shoulders

while pt holds head in neutral- pt flexes head- apply overpressure to pt’s C-spine- extend pt’s knee & dorsiflex foot- pt extends head- repeat the test w/ the other leg &

then both legs at the same timeNote: If sxs occur at any stage, stop the sequence.

This test checks if there is ↑ tension in neuromeningeal tract. Positive: increase in pt’s sxs or pain

Note: non-pathological responses- pain/discomfort in ~ T8-9

(50% of normal pts)- pain/discomfort behind

extended knee & hamstrings, symmetric restriction of knee extension & ankle dorsiflexion

- symmetric ↑ range of knee extension & ankle dorsiflexion on release of neck flexion

Sternal Compression Test(244 C)

Pt supine, push down on the sternum Pressure on the sternum compresses the lateral borders of the ribs.If a fracture is sustained at or near the lat border of ribs, the pressure on the sternum will cause the fracture to become more pronounced, increasing pain the area of fracture

Soto Hall Test(244 C)

Pt supine, assist pt in flexing the chin to the chest

Positive: local pain osseous, discal, or ligg pathology. If positive, perform tests for strain, sprain, fractures, & space-occupying lesions. Note: this test is nonspecific. It merely isolates the C & T-spine in passive flexion.

LUMBAR SPINEOrthopedic Tests Procedure Rationale

*Bragard’s Test(271 C)

Pt supine, raise pt’s leg to the point of leg pain. Lower the leg 5° & dorsiflex the foot. Same as Homan’s Sign (for DVT)

Test for lumbar radicular painThis procedure places traction pressure on the sciatic nerve. Pain w/ dorsiflexion of foot at 0-35°: extradural sciatic nerve irritationPain w/ dorsiflexion of foot at 35-70°:Irritation of sciatic n. roots from intradural problem, usually from an IV disc lesion.Dull posterior thigh pain: tight hamstring muscles

*Straight Leg Raise (266 C)

Pt supine, place & zero out an inclinometer at the tibial tuberosity & raise pt’s leg to the point of pain or 90°, whichever comes first.

Test for lumbar radicular painThis test stretches the sciatic nerve & spinal n. roots at L5 & S1-2 levels.Pain w/ hip flexion between:


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70-90°: lumbar jt pain35-70°: sciatic n. roots tense over the IV disc. If radicular pain begins at this level, suspect intradural lesion or IV disc pathology (disc herniation).0-35°: extradural problem (sciatic n. is relatively slack at this level)

*Lasègue’s Test(267 C)

Pt supine, flex pt’s hip w/ the leg flexed. Keeping the hip flexed & extend the leg.

Test for lumbar radicular painPositive for sciatic radiculopathy when:pain w/ hip flexed & leg extendedWhen both hip & leg are flexed, no tension on sciatic n. When hip flexed & knee extended, sciatic n. is stretched & if irritated, will cause leg pain.

*Fajersztajn’s Test (Well Leg Raise)(273 C)

Pt supine, raise the unaffected leg to 75° or to the point of leg pain & dorsiflex the foot. Like Braggard’s Test but to asymptomatic foot

Test for lumbar radicular painThis test causes ipsilateral & contralateral stretching of the nerve roots, pulling laterally on dural sac. Medial disc protrusion: ↑ pain on the affected leg, b/c an increase tension on the n. root opposite the side of hip flexionLateral disc protrusion: ↓ pain on the affected leg, b/c the n. root is pulled away from the disc.

*Bechterews Test(274 C)

Pt seated w/ legs hanging over the exam table. Instruct pt to extend one knee at a time alternatively. If no positive response is elicited, instruct pt to raise both legs together.

Test for lumbar radicular painW/ pt seated & leg flexed, the sciatic n. is slack. Extending the leg places traction pressure on the sciatic n. Positive: pt cannot perform b/c of radicular pain or can perform but leans back comprx to sciatic n. or lumbar n. roots, either intradurally or extradurally

*Kemp’s Test(282 C)

Pt seated, stabilize the PSIS w/ one hand. W/ your other hand, reach around to the front of pt & grasp the shoulder. Passively bend the dorsolumbar spine obliquely backward.

Test for lumbar radicular painWhen pt bends obliquely backward, the dural sac on the side of bending moves laterally. Lateral disc lesion: ↑ n. root tension over that disc lesion LBP, usually w/ radiculopathy on the side of oblique bendingOn the side opposite the oblique bending, the dural sac moves medially. Medial disc lesion: ↑ tension over the disc lesion LBP w/ radiculopathy on the side opposite the oblique bendingLumbar m. spasm or facet capsulitis:Local LBP w/ no radiculopathy

*Minor’s Sign(275 C)

Instruct the seated pt to stand Test for lumbar radicular painPt w/ sciatic radiculopathy will stand on the healthy side & keep the affected leg flexed to decrease tension on sciatic n., hence relieve pain.

Lidner’s Sign Pt supine, passively flex pt’s head. Test for lumbar radicular pain


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(283 C) Same rational as Brudzinski’s or Slump Test or Soto Hall Test.

This test stretches the dural sac. Reproduction of pt’s pain disc lesion at the pain level. Meningeal irritation: sharp, diffuse pain or involuntary hip flexion


Instruct the seated pt to bear down as if straining at stool but concentrating the bulk of the stress at the lumbar region. If pain, ask pt to point to it.

Test for Space-Occupying Lesion (SOL)This test increases intrathecal pressure which will exacerbate chord or nerve root comprx against an SOLLocal pain: SOL (disk defect, mass, osteophyte) in lumbar canal/foramen

*Milgram’s Test(286 C)

Instruct the supine pt to raise legs 2-3” above the table

Test for Space-Occupying Lesion (SOL)Pt should be able to perform this test for at least 30 sec. w/o LBP. Pain: SOL inside/out of spinal canal, esp. disc protrusionNote: pt w/ weak abd mm may not be able to perform this test.

*Hoover’s Sign(426 C)

Pt supine, instruct pt to lift the affected leg while you place one hand under the heel on the unaffected side.

Test for malingering LBPPositive: pt will not raise the affected leg & no posterior pressure on the unaffected heelIf pt is genuinely trying to raise the leg but cannot do so, you should feel pressure from the unaffected heel.

*Burn’s Bench Test(427 C)

Instruct pt to kneel on a chair & touch the floor w/ the fingers.

Test for malingering LBPPt w/ LBP can perform this test b/c no strenuous activity of the back is involved. Positive: pt cannot perform the test

*Nachlas Test(290 C)

Pt prone, approximate pt’s heel to the buttock on the same side

Test to differentiate lumbar & SI problemStretching the quadriceps mm causes the SI jt & lumbosacral jts to move inferiorlyButtock pain: SI lesionLumbosacral pain: lumbosacral lesionFlexing the leg to buttock stretches the quadriceps mm & the femoral n., which is the largest br of lumbar plexus (L2-4).Radicular pain into anterior thigh: comprx or irritation of L2-4 n. roots by an intradural lesion (e.g. disc defect, spur, mass), a lumbar plexus, or extradural lesion (piriformis m hypertrophy). Quadriceps muscle contracture: local pain at the anterior thigh & inability to touch the heel to buttock

*Sign of the Buttock (291 C)

Pt supine, perform a passive straight leg raising test. If you find restriction, flex the pt’s knee & see if hip flexion increases.

Differentiate lumbar & SI problemsNegative If hip flexion increases & pain worsens: lumbar spine lesion b/c there is full mvmt in SI jt w/ knee flexedPositive If hip flexion does not increase: SI jt lesion or inflm in buttock


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(e.g. bursitis, mass, or abscess)

Stork Standing Test(525 M)

Pt standing on one leg w/ the other leg making figure 4. Eyes open & then eyes closed.

Proprioception of lower extremity jtsPositive: losing balance w/ eyes open or closed

Spinal Percussion Test(265 C)

Pt seated & slightly bent forward, tap the spinal process & associated musculature of each of the lumbar vertebrae w/ a reflex hammer.

Local pain: a fractured vertebra w/ no neurological compromise. Radicular pain: a fractured vertebra w/ neurological compromise or possibly a disc defect w/ neurological compromise.

Segmental Instability Test(263 C)

Place the pt prone w/ the legs over the exam table & the feet resting on the floor. Press down on the lumbar spine. Next, instruct pt to lift the legs off the floor, & again press down on the lumbar spine

Test for jt dysfunctionWhen pt lifts the legs off the floor, the lumbar paravertebral muscle tightens, causing muscle guarding in the L-spine. Positive: pain when pressure is applied to the L-spine w/ the feet on the floor & pain disappears when the feet are off the floor & the paravertebral mm are tightened. Raising the feet off the floor allows the mechanical muscle guarding to protect the underlying lumbar instability, such as spondylolisthesis.

SACROILIAC JOINTOrthopedic Tests Procedure Rationale

March Test(lecture note)

Pt stands & holds onto a railing or desk for balance. Dr places thumb on PSIS of tested side & other thumb on a sacral tubercle. Have pt slowly flex the hip being tested, above 90°. Feel for motion relative to the PSIS & sacrum.

Test for Sacroiliac (SI) functionLimited ROM: SI restriction on that sidePosterior Inferior (PI) fixation: PSIS is fixed inferior, relative to the sacrum.Anterior Superior (AI) fixation: PSIS is fixed superior to the sacrum

*Gaenslen’s Test(317 C)

Pt supine & the affected side near the edge of table, instruct pt to approximate the knee to chest on the unaffected side. Then place downward pressure on the affected thigh until it is lower than the edge of the table.

Test for SI ligament sprainExtension of the leg stresses the SI jt & ant SI jt ligg on the side of leg extension. Pain on that side general SI lesion (e.g. ant SI lig sprain – iliofemoral, ischiofemoral) or inflm in SI jt

Yeoman’s Test(319 C)

Pt prone, grasp pt’s lower leg & passively flex the knee, then extend the hip.

Test for a sprain of the anterior SI lig or SI jt inflmExtension of thigh stresses the SI jt & ant SI jt ligg on the side of thigh extension. Pain on ipsilateral: sprain of ant SI jt ligg (iliofemoral or ischiofemoral lig); inflm or abscess in SI jtNote:This test also stresses the lower lumbar vertebra by slightly extending the lumbar spine. Lumbar pain (local /radiating) may indicate lumbar involvement.

*Hibb’s Test(322 C)

Pt prone, flex the pt’s leg to the buttock & move the leg outward,

This procedure causes a stressed internal rotation of the femoral head


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internally rotating the hip into the acetabular cavity & causes slight distrx on SI jt.Pain in SI jt: SI jt lesion (e.g. inflm or abscess in SI jt or sprain of SI ligg) Pain in hip jt: hip jt lesion

*Pelvic Rock Test(323 C)

Pt side-lying, exert a strong downward pressure on the ilium. Perform this test bilaterally.

Downward pressure on the ilium transfers a comprx pressure to the jt surfaces of the sacroiliac jts.Pain in either SI jt: SI jt lesion (inflm in jt surfaces on the affected side)

*Patrick Test (FABER)(349 C)

Pt supine, flex the leg & place the foot flat on the table. Grasp the femur & press it into the acetabular cavity. Next, cross pt’s leg to the opposite knee. Stabilize the opposite ASIS & press down on the knee of the hip that is being tested. Make a Figure 4!

Test for SI & acetabular dysfxFABER (flexion, abduction, external rotation)This test forces the femoral head into the acetabular cavity, giving maximal congruence to the articular surfaces. Hip pain: inflm in hip jtPain d/t trauma: fracture in acetabular cavity or femoral neck.Pain may also indicate avascular necrosis of femoral head.

LUMBAR NERVE ROOT LESIONS

Nerve Roots Motor Test Sensory Test ReflexT12, L1, L2, L3(298-300 C)

Note:These n. roots exit the spinal cord at their respective levels. The T12 & L1 n. roots can be affected by the IV disc at their respective levels or levels above them, depending on the size & laterality of the disc defect.

Iliopsoas muscleProcedure:Pt seated at edge of table, instruct pt to raise thigh off the table. Place your hand on pt’s knee & instruct pt to continue to raise the thigh against your resistance. Perform the test on the opposite thigh. Rationale:A grade 0-4 unilaterally may indicate a neurol deficit of T12,L1-3 nerve root. Suspect a weak or strained iliopsoas m if the sensory portion of T12,L1-3 neurol package is intact

Procedure:W/ a pin, stroke the dermatomal area corresponding to each nerve root & evaluate bilaterally.Rationale: Unilateral hypoesthesia may indicate a neurol deficit of the corresponding T12,L1-3 nerve root or the femoral nerve.

No reflex test

L2, L3, L4(301-302 C)

Note:These n. roots can be affected by the IV disc at their respective levels or levels above them, depending on the size & laterality of the disc defect.

Quadriceps muscle(L3, L4 Femoral Nerve)Procedure:Pt seated at edge of table, instruct pt to extend the knee. Place one hand on pt’s thigh for stabilization & place the other hand on pt’s leg. Exert pressure on the leg while instructing pt to A grade 0-4 unilaterally may indicate a neurol deficit of L2-4 nerve root or femoral n. Suspect a weak or strained quadriceps m if the sensory portion of L2-4 neurol package is intactresist flexion. Perform the test bilaterally. Rationale:A grade 0-4 unilaterally may indicate a neurol deficit of L1-4

Procedure:W/ a pin, stroke the dermatomal area corresponding to each nerve root & evaluate bilaterally.Rationale: Unilateral hypoesthesia may indicate a neurol deficit of the corresponding L2-4 nerve roots or the femoral nerve.

Patella reflex(primarily an L4 reflex w/ the L4 neurol level.


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Muscle Grading Chart5 Complete ROM against gravity w/ full resistance

4 Complete ROM against gravity w/ some resistance

3 Complete ROM against gravity

2 Complete ROM w/ gravity eliminated

1 Evidence of slight contractility; no joint motion

0 No evidence of contractility

Wexler Scale0 No response+1 Hyporeflexia+2 Normal+3 Hyperreflexia+4 Hyperreflexia w/ transient clonus+5 Hyperreflexia w/ sustained clonus


nerve root or femoral n. Suspect a weak or strained quadriceps m if the sensory portion of L2-4 neurol package is intact

L4(303-304 C)

Note:L4 exits the spinal canal b/w L4 & L5 vertebrae & is usually affected by the L3-4 intervertebral disc

Tibialis Anterior muscle(L4, L5 Deep Fibula Nerve)Procedure:Pt seated at edge of table, instruct pt to dorsiflex & invert the foot. Grasp pt’s ankle w/ one hand & foot w/ your other hand, and attempt to force the foot into plantar flexion & eversion against resistance by pt. Perform & evaluate bilaterally. Rationale:A grade 0-4 unilaterally may indicate a neurol deficit of L4 nerve root or the deep fibular nerve. A weak or strained tibialis anterior m may be suspected if the sensory & reflex portions of L4 neurol package are intact.

Procedure:W/ a pin, stroke the medial aspect of the leg & foot & evaluate bilaterally. Rationale: Unilateral hypoesthesia may indicate a neurol deficit of L4 nerve root.

Patella ReflexProcedure:Pt seated at edge of table, tab the infrapatellar tendon w/ reflex hammer.Rationale:Unilat hyporeflexia: nerve root deficit Unilat loss of reflex: interruption of reflex arc (LMN lesion)Unilat hyperreflexia: UMN lesion

L5(305-308 C)

Note:L5 exits the spinal canal b/w L5 & S1 vertebrae & is usually affected by the L4-5 intervertebral disc

Gluteus Medius muscle(L5, S1 Superior Gluteal Nerve)Procedure:Pt side-lying, instruct pt to abduct the superior leg. Place your hand on the lat aspect of pt’s knee & attempt to push the knee into adduction against pt resistance. Perform & evaluate bilaterally. Rationale:A grade 0-4 unilaterally may indicate a neurol deficit of L5 nerve root or the superior gluteal nerve. A weak or strained gluteus medius m may be suspected if the sensory & reflex portions of L5 neurol package are intact.

Procedure:W/ a pin, stroke the lateral leg & dorsum of foot. Evaluate bilaterally. Rationale: Unilateral hypoesthesia may indicate a neurol deficit of L5 nerve root.

Medial Hamstring ReflexProcedure:Pt prone, slightly flex the pt’s knee & place your thumb on the medial hamstring tendon. W/ reflex hammer, tap the medial hamstring tendon. Pt should slightly flex the knee.Rationale:Unilat hyporeflexia: nerve root deficit Unilat loss of reflex: interruption of reflex arc (LMN lesion)Unilat hyperreflexia: UMN lesion

S1(309-310 C)

Note:S1 exits the spinal canal through the 1st sacral foramen & is usually affected by the L5-S1 intervertebral disc

Peroneus Longus & Brevis m.(L5, S1 Superficial Fibular Nerve)Procedure:Pt seated at edge of table, stabilize the calcaneus w/ one hand & grasp the lat aspect of foot w/ your opp hand. Instruct pt to plantarflex & evert the foot against your resistance. Evaluate bilaterally. Rationale:A grade 0-4 unilaterally may indicate a neurol deficit of S1 nerve root or the superficial fibular nerve. A weak or strained peroneus longus and/or brevis m may be suspected if the sensory & reflex portions of S1 neurol package are intact.

Procedure:W/ a pin, stroke the lateral aspect of foot. Evaluate bilaterally. Rationale: Unilateral hypoesthesia may indicate a neurol deficit of S1 nerve root.

Achilles ReflexProcedure:Pt seated at edge of table, place slight dorsiflexion on the foot. W/ reflex hammer, tap the Achilles tendon. Pt should exhibit a slight plantar flexion of footRationale:Unilat hyporeflexia: nerve root deficit Unilat loss of reflex: interruption of reflex arc (LMN lesion)Unilat hyperreflexia: UMN lesion

HIP JOINTOrthopedic Tests Procedure Rationale


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*Thomas Test(344 C)

Pt supine, instruct pt to approximate each knee to the chest one at a time. Palpate the quadriceps mm on the unflexed leg.

Test for hip contracturePositive: if pt significantly flexes the opposite knee & tightness is palpated on the side of the involuntary flexed knee a hip flexion contractureIf no tightness in the rectus femoris muscle exists, the restriction may be at hip jt structure or jt capsule.

*Ely’s Test(346 C)

Pt prone, then grasp pt’s ankle & passively flex the knee to buttock

Test for hip contracturePositive: hip flexion on the same side that is flexed tight rectus femoris m. or iliopsoas mThis spontaneous flexion of hip reduces the traction pressure on the rectus femoris m. or iliopsoas induced by passive knee flexion.

*Ober’s Test(347 C)

Pt side-lying, abduct pt’s leg & then release it. Perform this test bilaterally.

Test for hip contractureThe tensor fasciae latae (TFL) & IT band abduct the hip. Positive: the leg fails to descend smoothly, suspect contracture of the TFL muscle or IT band.

Rectus Femoris Contracture Test(345 C)

Pt supine w/ the legs off the table & flexed to 90°. Instruct pt to flex the opposite knee to his chest & hold it. Palpate the quadriceps muscles of the leg that is flexed off the table for tightness. Note: Like the Thomas test except more specific to the rectus femoris portion of the quadricep femoris.

Test for hip contracturePositive: pt involuntarily extends the knee of the leg that is flexed off the table & tightness is palpated in that thigh hip flexion contractureNote:If there is no tightness in the rectus femoris m, the probable cause of restriction is at the hip jt structure or jt capsule.

*Patrick Test (FABER)(349 C)

Pt supine, flex the leg & place the foot flat on the table. Grasp the femur & press it into the acetabular cavity. Next, cross pt’s leg to the opposite knee. Stabilize the opposite ASIS & press down on the knee of the hip that is being tested. Make a Figure 4!

Test for SI & acetabular dysfxFABER (flexion, abduction, external rotation)This test forces the femoral head into the acetabular cavity, giving maximal congruence to the articular surfaces. Hip pain: inflm in hip jtPain d/t trauma: fracture in acetabular cavity or femoral neck.Pain may also indicate avascular necrosis of femoral head.

*Trendelenburg Test(350 C)

Pt standing, grasp pt’s waist & place your thumbs on the PSIS of each ilium. Next, instruct pt to flex one leg at a time.

Test for hip jt lesionsWhen pt is standing w/ one leg flexed, pt is supported by an intact hip jt w/ its associated ligg & mm on that side. Positive: pt cannot stand on one leg b/c of pain and/or b/c of the opposite pelvis falls or fails to raise. This


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result may indicate a weak gluteus medius m opposite the side of hip flexion, and it tests the integrity of hip jt & assoc musculature & ligg on the opposite side of hip flexion.

Laguerre’s Test(352 C)

Pt supine, flex the hip & knee to 90°. Rotate the thigh outward & the knee medially. Press down on the knee w/ one hand, and pull up on the ankle w/ the other hand.

Test for hip jt lesionsThis test externally forces the head of the femur into the acetabular cavity, stressing the anterior aspect of the jt capsule. This test may indicate an inflm in the acetabular jt (e.g. osteoarthritis)Pain 2° to trauma may indicate fracture of acetabular cavity or rim.

Allis Test(340 C)

Infant supine, flex the knees. Pt’s feet should approximate each other on the table.

Test for congenital hip dysplasiaPositive: difference in knee heights. Short knee on the affected side:Posterior displacement of femoral head or decreased tibial lengthLong knee on the affected side:Anterior displacement of femoral head or increased tibial length

*Ortolani’s Click Test(341 C)

Infant supine, grasp both thighs w/ your thumbs on lesser trochanters. Then flex & abduct thigh bilaterally.

Test for congenital hip dysplasiaPositive: palpable &/or audible clickThe click signifies a displacement of the femoral head in/out of acetabular cavity.

*Telescoping Sign(342 C)

Child supine, flex the suspected hip & knee to 90°. Next, grasp the thigh & push it posteriorly toward the table, then pull it anterior away from the table.

Test for congenital hip dysplasiaPositive: excessive mvmt or a click will occur if the child has a dislocated hip or a hip that has potential to dislocate. This excessive mvmt is called telescoping. Normally, little motion occurs when this action is performed.

Actual Leg Length (433 C)

Pt standing, take a tape measure & measure bilaterally from ASIS to the floor

This is a true measurement of pt’s lower extremity. Compare the measurements. Anatomical short leg: not equal in lengths (congenital or acquired). It is usually d/t fracture in the leg at or close to an epiphyseal growth plate and is more pronounced if it occurs d/r adolescence.

Apparent Leg Length(lecture note)

Pt supine, measure the distance b/w the umbilicus & the medial malleolus on each side.

Functional leg length difference: normal actual leg length but different apparent leg length (d/t unilat mm or ligg contracture, scoliosis, pelvic torsion, SI restriction)


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Anvil Test(343 C)

Pt supine, tap the inferior calcaneus w/ your fist w/ about 10 lbs of pressure.

Test for hip fracturesTapping the inferior calcaneus transfers quick, sharp compression-type blows to the hip jt (acetabulum). Positive: Local pain in hip jt after trauma a femoral head fracture or jt pathology Note:Local pain in thigh/leg 2° trauma femoral, tibial, or fibula fracture. Pain local to the calcaneus calcaneus fracture

Hamstring Contracture Test(lecture note)

Pt seated w/ one leg into “cross legged sitting” while extending the leg to be tested. Instruct pt to flex forward at hip & try to touch their toes.

Positive: cannot touch toes d/t hamstring contracture or tightness

Pubic Spring Test(lecture note)

Pt supine w/ knee extended. You place 2 fists, end to end, b/w pt’s knees & have pt squeeze.

You may hear an audible “pop” if jt is restricted. This puts distraction force on the symphysis jt

KNEEOrthopedic Tests Procedure Rationale

*Apley’s Compression Test(369 C)

Pt prone, flex one leg to 90°. Stabilize pt’s thigh w/ your knee. Grasp pt’s ankle & place downward pressure while you internally & externally rotate the flexed leg

Test for meniscus instabilityThe menisci, which are asymmetric fibrocartilaginous disks, separate the tibial condyles from the femoral condyles. When the knee is flexed, the meniscus distorts to maintain the congruence b/w tibial & femoral condyles. Positive: pain or crepitus on either side of the knee meniscus injury on that side

*McMurray’s Test(370 C)

Pt supine & flex the leg. Externally rotate the leg as you extend; internally rotate as you extend.

Test for meniscus instabilityFlexion & extension of knee distort the meniscus to maintain the congruence b/w tibial & femoral condyles. Flexing & extending the knee w/ int & ext rotation further stress the already distorted meniscus. Positive: palpable or audible click meniscus injury

*Bounce Home Test(371 C)

Pt supine, instruct pt to flex the leg. When the leg is flexed, cup your hand around the pt’s heel & instruct pt to relax mm & allow the knee to drop.

Test for meniscus instabilityExtension of knee entails medial rotation of the femur on the tibia. If the meniscus is injured, rotation of femur on the tibia may be blocked & pt cannot fully extend the knee.Positive: rubbery end feel on full extension or cannot extend the knee fully meniscus injury


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*Ant./Post. Drawer Sign(382 C)

Pt supine, flex the leg & place the foot on the table. Grasp behind the flexed knee & pull & push on the leg. The hamstring tendons must be relaxed for this test to be accurate.

Test for ligamentous instabilityIf > 5 mm tibial mvmt on femur when leg is pulled, injury/tear to one or more of the following structures:• anterior cruciate lig • posterolateral capsule• posteromedial capsule• med collateral lig (> 1cm mvmt)• iliotibial band• posterior oblique lig• arcuate-popliteus complex

If excessive mvmt when leg is pushed, injury to one or more of the following structures:• posterior cruciate lig• arcuate-popliteus complex• posterior oblique lig• anterior cruciate lig

*Lachman’s Test(385 C)

Pt supine & knee in 30° flexion, grasp pt’s thigh w/ one hand to stabilize it. W/ the opposite hand, grasp the tibia & pull it forward.

Test for ligamentous instabilityIf a softened feel & anterior translation of tibia is present when tibia is moved forward, then a tear of any of the following ligg is supect:• anterior cruciate lig• posterior oblique ligNote:This is the most reliable test for ant cruciate lig rupture b/c the knee does not need to flex to 90°, as w/ the ant drawer sign; less meniscal impgmt; & hamstrings are less likely to spasm

*Apley’s Distraction Test(388 C)

Pt prone, flex the leg to 90°. Stabilize the pt’s thigh w/ your knee. Pull on pt’s ankle while internally & externally rotating the leg.

Test for ligamentous instabilityDistraction of knee takes pressure off the meniscus & put strain on the medial & lateral collateral ligg. Positive: pain nonspecific lig injury or instability

*Adduction (Varum) Stress Test(389 C)

Pt supine, stabilize the medial thigh. Grasp the lower leg & push it medially. Also perform this test w/ the knee in 20°-30° of flexion

Medial Stability Rating ScaleGrade 0 No jt openingGrade 1+ < 0.5 cm jt openingGrade 2+ 0.5-1 cm jt openingGrade 3+ > 1 cm jt opening

Test for ligamentous instabilityIf tibia moves an excessive medial amt away from femur when knee is in full extension, there maybe a tear of any of the following ligg:• tibial collateral lig• posterior meniscofemoral lig• posterior medial capsule• anterior cruciate lig• posterior cruciate lig

If the foregoing is positive when the


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knee is flexed 20°-30°, any of the following ligg may be unstable:• tibial collateral lig• posterior meniscofemoral lig• posterior cruciate lig

*Abbduction (Valgum) Stress Test(390 C)

Pt supine, stabilize the lateral thigh. Grasp the lower leg & pull it laterally. Then perform this test in 20°-30° of flexion.

Test for ligamentous instabilityIf tibia moves an excessive amt away from femur when knee is in full extension, there maybe a tear of any of the following ligg:• fibular collateral lig• posterolateral lig• posterior cruciate lig• anterior cruciate ligIf the foregoing is positive when the knee is flexed 20°-30°, any of the following ligg may be unstable:• fibular collateral lig• posterolateral capsule• iliotibial band

*Patella Apprehension Test(392 C)

Pt supine, manually displace the patella laterally

Test for patellofemoral dysfunctionPositive: apprehension look or pain & a contrx of quadriceps m. chronic tendency to lateral patella dislocx

*Patella Grinding Test(391 C)

Pt supine, move the patella medially & laterally while pressing down

Test for patellofemoral dysfunctionPositive: pain chondromalacia patellae, retropatellar arthritis, chondral fracture, osteochondritis of patella, & prepatellar bursitis (pain over the patella)

Hughston Plica Test(380 C)

Pt supine, grasp pt’s leg. Flex & medially rotate the leg. W/ your opposite hand, move the patella medially w/ the heel of your hand & palpate the medial femoral condyle w/ the fingers of the same hand. Flex & extend the knee while feeling for popping of the plical band under your fingers.

Plica is an embryological remnant of the knee jt capsule present in some adults. It may become inflamed if it is caught b/w the femoral condyles & patella. It is important b/c it may mimic meniscus pathology. Positive: Popping under your fingers the plica is attached to the patella & may be inflamed.Note:The incidence of patella plica varies from 18-60% of the population, according to different authors.

*Patella Ballottement Test (Major Effusion)(394 C)

W/ one hand, encircle & press down on the sup aspect of patella. W/ the other hand, push the patella against femur w/ your finger

Test for knee jt effusionEffusion in and around the knee may be caused by trauma, infx, RA, gout, pseudogout, or degenerative jt dz. The fluid may contain blood, fat,


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Lateral Stability Rating ScaleGrade 0 No jt openingGrade 1+ < 0.5 cm jt openingGrade 2+ 0.5-1 cm jt openingGrade 3+ > 1 cm jt opening


lymphocytes, & crystals such as urate, pyrophosphate & oxalate.

If fluid is present in the knee, the patella will elevate when pressure is applied. When the patella is pushed down, it will strike the femur w/ a palpable tap.

*Stroke/Bulge Test(Minor Effusion)(395 C)

Pt supine, stroke the medial side of the patella up toward suprapatellar pouch 2-3 times w/ your fingers & simultaneously stroke the lateral aspect of patella inferior w/ your opposite hand.

Test for knee jt effusionPositive: If a wave of synovial fluid is present, it will concentrate to the inferior medial border of the patella; subsequently, the area will bulge.

LOWER LEG, ANKLE, & FOOTOrthopedic Tests Procedure Rationale

*Thompson’s Test(419 C)

Instruct the prone pt to flex the knee. Squeeze the calf mm against the tibia & fibula while pushing it superiorly.

Test for Achilles Tendon RuptureWhen the calf mm are squeezed, the gastrocnemius & soleus mm contract. These mm are attached to Achilles tendon, which in turn plantar-flexes the foot. Positive: contrx of the gastroc & soleus mm will not plantar flex the foot ruptured Achilles tendon

*Homan’s Sign(425 C)

Pt supine, dorsiflex the foot while squeezing the calf of that leg.

Test for Deep Vein ThrombosisDVT: clot formation in the deep peroneal & tibial veins of the calf.Sxs: claudication & pain (< walking)Dangerous if a clot dislodges as an embolism & causes a pulm infarctionC/I: massageDorsiflexing the foot places a dynamic stretch on the gastroc m & tension of the deep veins. The addition of squeezing the calf compresses the surrounding tissue against the thrombus, simulating a nociceptive response. Positive: Deep-seated pain at the posterior leg or calf DVT or thrombophlebitis

*Tibial Torsion Test(801 M)

Pt seated w/ knee flexed 90° & feet flat on the floor. Measure the axis of the knee in relation to the axis of the 2 maleoli from superior view. The angle axis should form an angle b/w 12°-18° (for adults) Test for tibial lateral rotation or “too many toes sign”:Pt standing & you look from the

Tibial Torsion: a lateral or medial rotation of the tibia in relation to the sagital plane of the body. It can either occur in conjuction w/ femoral torsion or be rotated in respect to the femur itself. Internal rotation often d/t femoral anteversion & seen in genu valgum. Normal Values of Lateral torsion:


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back side. If you can see more than 2.5 toes, there is excessive lateral tibial torsion.

Adults (12°-18°)Children (< 12°)

*Drawer’s Foot Sign(Anterior & Posterior Draw Test)(414 C)

Anterior Draw Test:Pt supine, stabilize the ankle by grasping the posterior aspect of foot. W/ your opposite hand, grasp anterior aspect of tibia & press posteriorly. Posterior Draw Test:Next, grasp the anterior aspect of the foot w/ one hand & the posterior aspect of the tibia w/ the other hand, and pull anteriorly.

Positive: Gapping d/t trauma when Pushing tibia posteriorly tear of anterior talofibular lig

Pulling tibia anteriorly tear of posterior talofibular lig

Lateral Stability Test(415 C)

Pt supine, grasp pt’s foot & passively invert it. (Passive Inversion)

Positive: pain, apprehension or jt gapping suspect a tear of the anterior talofibular &/or calcaneofibular lig

Medial Stability Test(416 C)

Pt supine, grasp pt’s foot & passively evert it.(Passive Eversion)

Positive: pain, apprehension or jt gapping suspect a tear of the deltoid liggDeltoid ligg (4):

1. anterior tibiotalar lig2. posterior tibiotalar lig3. tibiocalcanean lig4. tibionavicular lig

*Morton’s Neuroma Test(808 M)

Grasp the foot around the metatarsal heads & squeeze them together.

Morton’s Neuroma: forefoot pain, esp in middle-aged women; 15% B/L; caused by abnormal pressure on the plantar digital nerves, resulting in perineural fibrosis & myxoid degenx. Most common site is b/w 3rd & 4th metatarsals. This test compresses the contents of the intermetatarsal space Positive: pain neuroma, stress frx

*Test for Congenital (Rigid) or Acquired (Supple) Flat Feet(Lecture Note)

Pt standing on tiptoes & if the arch appears, it is an acquired flatfoot

Pes Planus = flat feetPes Cavus = High arches

Congenital (Rigid) Flat Foot:• calcaneus is in valgus & midtarsal

region is locked in pronation • accompanied by bony & soft tissue

changes • immobile foot jts Acquired Flat Foot: • hypermobile foot jts• less severe condition Acquired flatfoot: the arch appears w/ tiptoes

*Tinnel’s Foot Sign(418 C)

Tap the area over the posterior tibial nerve w/ a reflex hammer.

Test for Tarsal Tunnel SyndromeTTS is comprx of the posterior tibial nerve beneath the flexor retinaculum of the ankle. The nerve runs its course posterior to the medial maleolus.


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Positive: Paresthesias radiating to the foot irritation to the post tibial n., that may be d/t tarsal tunnel syndrome

Tourniquet Test(417 C)

Wrap a sphygmomanometer cuff around the affected ankle & inflate it to just above the pt’s systolic BP. Hold it for 1-2 mins.

Test for Tarsal Tunnel SyndromeComprx of the area by the cuff accentuates the narrowing of the tunnel, increasing pt’s pain. Positive: pain or existing pain is exacerbated TTS

*Talar Tilt Test(803 M)

Pt side-lying w/ knee slightly flexed & the foot relaxed in neutral position. Tilt the talus from side to side into adduction & abduction.

Adduction stresses calcaneofibular lig on lateral side, while abduction stresses the deltoid ligg on the medial side. Positive: pain or excessive jt opening calcaneofibular instability/sprain


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