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Table of contents

DO THE CORE CERVICAL ORTHOPAEDIC EXAMINATION AND TEST FOR FACET JOINT IRRITATION................................................................................................................................................................3

DO THE CORE LUMBAR SPINE EXAMINATION ON A PAIN-FOCUSED PATIENT. TEST THE INTEGRITY OF THE L4 NERVE ROOT.................................................................................................................7

DO THE CERVICAL ORTHOPEDIC EXAMINATION, CHECK FOR CERVICOGENIC DORSALGIA AND DIFFERENTIAL DIAGNOSIS CERVICOGENIC VERTIGO FROM VESTIBULOCOCHLEAR CAUSES.......................................................................................................................................................................11

DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR SI JOINT SYNDROME................16

DO THE CORE LUMBAR SPINE EXAMINATION AND RULE OUT ANKYLOSING SPONDYLITIS. TEST THE INTEGRITY OF L5 NERVE ROOT....................................................................................................21

DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND CHECK FOR NERVE ROOT TENSION SIGNS ON A PATIENT YOU ARE SUSPECTING C5 CERVICAL RADICULOPATHY..............24

DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX LUMBAR FACET JOINT IRRITATION FROM THORACOLUMBAR SYNDROME. TEST THE INTEGRITY OF L5 NERVE ROOT...........................................................................................................................................................................29

DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND DDX CERVICAL SPRAIN VERSUS CERVICAL STRAIN. TEST THE INTEGRITY OF C6 NERVE ROOT............................................................32

DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX PIRIFORMIS SYNDROME FROM SI SYNDROME.............................................................................................................................................37

DO CORE LUMBAR ORTHOPEDIC EXAMINATION AND DO A FULL NEUROLOGICAL AND VASCULAR EXAMINATION OF THE LOWER LIMB.......................................................................................42

DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR TOCS. TEST THE INTEGRITY OF THE T1 NERVE ROOT...............................................................................................................47

DO THE LUMBAR ORTHOPEDIC EXAMINATION AND RULE OUT NERVE ROOT TENSION SIGNS IN THE LOWER LIMBS. TEST THE INTEGRITY OF THE S1 NERVE.........................................................52

DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT MENINGEAL IRRITATION. TEST THE INTEGRITY OF C7 NERVE ROOT..........................................................................55

DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR A LUMBAR DISC HERNIATION. TEST THE INTEGRITY OF SI NERVE ROOT.....................................................................................................60

DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR CERVICAL DISC HERNIATION. TEST THE INTEGRITY OF C6 NERVE ROOT........................................................................63

DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT VERTROBASILAR INSUFFICIENCY. TEST THE INTEGRITY OF C7 NERVE ROOT..................................................................68

DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE THORACIC SPINE AND CHECK FOR SCOLIOSIS.................................................................................................................................................................73


DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR LABRAL TEARS.........................................................................................................................................................................76

DO THE CORE EXMINATION OF THE KNEE AND CHECK FOR A MENISCAL TEAR...........................79

DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT PATELLOFEMORAL SYNDROMES.............................................................................................................................................................82

DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND CHECK FOR AN ACL TEAR......85

DO THE CORE ORTHOPEDIC EXAMINATION OF THE WRIST AND HAND............................................88

DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE FOOT AND ANKLE.....................................90

DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR BICIPITAL TENDONITIS.............................................................................................................................................................91

DO A CORE EXAMINATION OF THE HIP AND EXPLAIN THE DIFFERENCE BETWEEN BARLOW’S AND ORTOLANI’S TESTS......................................................................................................................................94

DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE TMJ................................................................96

DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR POSTERIOR SHOULDER INSTABILITY.....................................................................................................................................98

DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE ELBOW........................................................101

DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND RULE OUT AN ANTERIOR SHOULDER INSTABILITY...................................................................................................................................103

DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT A PLICA..................106


DO THE CORE CERVICAL ORTHOPAEDIC EXAMINATION AND TEST FOR FACET JOINT IRRITATION.Core tests:1. Observation – general, postural

a. facial expression à indicator of pain perceptionb. head and neck posture: torticollis, Klippel-Feil Syndrome (webbing of neck), anterior

head carriage, the stiff neck look, level of mastoidsc. shoulder levels: traps, levator scapulae, winging of scapulaed. muscle spasm or any atrophy: spasm of SCM or atrophy of deltoide. swelling/masses

2. Vertebrobasilar testing – must be done before any cervical adjustmentsHoule à positive is vertigo, dizziness, nausea, and nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites.

3. Neurological testing of cervical nerve roots – reflex, sensory, motor examinationC5 C6 C7 C8 T1

Motor Shoulder abduction

Wrist extension Wrist flexion and finger extension

Finger flexion (curl fingers)

Finger abduction and adduction

Sensation Lateral arm Lateral forearm, thumb and index finger

Middle finger Medial forearm, ring and small finger

Medial arm

Reflex Biceps Brachioradialis triceps

4. Cervical ROM testingFlexion: 45 à 60Extension: 45 à 75Rotation: 70 à 90Lateral flexion: 20à45

Note any crepitus. Pain on resisted ROM but little during passive ROM indicates muscular pain (strain).Pain on passive ROM but not on resisted is articular or ligamentous pain (sprain)Pain on all types of ROM is a combination of muscular and ligamentous pain

5. Cervical compression tests (neutral) – local cervical pain on ipsilateral side. May be posterior joint irritation.

6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain.

7. Soft tissue palpation Scalenes Suboccipitals


Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process

8. Motion palpation and joint plan analysis. Assess the end feel of a joint to differentiate a muscular fixation versus an articular fixation.

Lower cervical motion palpationMotion Contact hand Control hand Normal AbnormalFlexion Thumb on

articular pillar; index finger wrapped around TVP of segment below

On patient’s forehead. Patient’s head and neck is flexed and returned to neutral.

Articular pillar will glide anterior and superior

Articular pillar fails to go anterior and superior

Lateral flexion Three-finger contact on lateral aspect of TVPs.

On patient’s top of head. Lateral flexes head and neck towards contact hand, and returns to neutral

TVPs approximate a smooth ‘C’ curve is appreciated

A break in the ‘C’ curve may indicate DJD in joints of Luschka or possible scaleni/intertransverarii hypertonicity

Spinous deviation

Thumb contact against two adjacent spinouses.

On top of patient’s head. Lateral flexes head towards contact hand and returns to neutral

Spinous process deviates to convexity.

Loss of spinous deviation and/or spinous reversal (possible contralateral SS and/or splenius involvement)

Anterior rotation Three-fingered contact on three adjacent articular pillars, control hand on patient’s forehead.

Rotates face away from contact hand and returned to neutral.

Articular pillars move anterior in a stair stepping motion.

Restricted end feel with lack of anterior motion. Possible small cervical rotators

Posterior rotation Patient leans back against doctor as contact with 2-3 fingers placed over anterior aspect of TVPs

On patient’s head or chin. Guides face towards contact while contact hand pulls posterior and superior

TVPs move posteriorly allowing a slight “give”

Restricted end feel to the posterior motion and fullness under fingers or joint (possible scalenii)


Upper Cervical motion palpationMotion Contact finger Control fingers Normal AbnormalJawjut Middle finger on

anterior of C1a. index on

ramus of mandible

b. ring finger on mastoid

c. thumb on top of head

Patient’s head is pushed down and slightly anterior

Space between TVP and mandible increases, allowing a “give”

a. space does not open, extension restriction (rectus capitus anterior)

b. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)

Rotation Middle finger on anterior of C1 TVP

a. index on ramus of mandible



Head is rotated to each side

Space between C1 TVP and mandible increase on contralateral side

Space between C1 and mandible does not increase (contralateral superior oblique)

Lateral flexion of occiput on C1

Middle finger on superior aspect of C1 TVP



c. thumb on top of head.

Head is laterally flexed to each side

Occiput approximates C1 TVP and separates on contralateral side.

A. Restricted end feel

B. Lack of lateral flexion (contralateral rectus capitus lateral)

Lateral flexion of C1 on C2

Middle finger on inferior aspect of C1 TVP




Head is laterally

C1 TVP approximates on C2 TVP ipsilaterally and then separates contralaterally

Restricted end feel ipsilateral joint and a lack of separation on contralateral side (contralateral intertransversarii)


flexed to each side

Rotation of C1 on C2

Contact index finger on posterolateral aspect of C1 TVP and thumb on C2 spinous.

On forehead.Head is rotated away from contacts

First 25 degrees C1 TVP rotates anterior, then C2 spinous rotates to the same side

C2 spinous and C1 TVP do not separates (inferior oblique ipsilaterally)

Occiput-Atlas-Axis flexion

a. index finger on occiput rim, tubercle

b. 3rd finger on space (post of C1)

c. 4th finger on C2 spinous

On forehead.Head is flexed.

Spaces between fingers increase

a. posterior tubercle with occiput (possible rectus capitus minor)

b. C2 spinous rides up with occiput (rectus capitus major)

Semispinalis Capitus stretch (ipsilateral)

a. thumb on occiput rim just lateral to midline

b. index finger hooked around anterior aspect of C2

On forehead.Head and neck is flexed and challenged with contact

Springy end feel and give

Restricted end feel, lack of flexion of occiput

Splenius capitis stretch (ipsilateral)

a. 2-3 fingers on posterior of mastoid.

On forehead.Head is flexed and rotated (face away from the contact) and challenged with contact


Restricted end feel, lack of flexion and rotation of occiput


DO THE CORE LUMBAR SPINE EXAMINATION ON A PAIN-FOCUSED PATIENT. TEST THE INTEGRITY OF THE L4 NERVE ROOTCore1. Observation

a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg). Exaggerations.

b. disc stance – flattened lumbar lordosis, flexed hip and knee of side of sciaticac. antalgic posture (side of sciatica?)d. plumb linee. muscle spasm – bilateral or unilateral?f. Anatomical landmarks – shoulders, iliac crests, gluteal folds, popliteal creasesg. Lower extremities – pes planus, pronation at ankle, genu valgum, varum, recurvatum

2. Neurological examination:a. reflex, sensory and motor testing

Reflex Sensory MotorL4 Patellar Medial calf and medial

side of footTibialis anterior (ankle inversion)

L5 No reflex or medial hamstring tendon

Lateral leg and dorsum of foot including web of big toe (divided by crest of tibia)

Extensor digitorum longus, extensor hallucis longus, walk on heels

S1 Achilles Lateral malleolus, lateral and plantar surfaces of foot

Peroneus longus and brevis (ankle eversion), gastrocnemius (plantar flexion), walk on toes

b. plantar reflex – normally down goingc. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to

walk on toes may indicate S1 root compressiond. muscle girth testing

3. Gait analysis

4. Lumbar ROM testing Forward flexion 40 – 60 degrees à dramatic refusal may be suggestive of a non-

organic problem Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees

Forward flexion may be limited by facet joint dysfunction, SI dysfunction, muscle spasm or hip joint pathology

Extension may be limited due to inflamed posterior apophyseal joints, disc herniation, myofascial syndromes, spondylolisthesis


Limitations in lateral bending suggest lumbar facet dysfunction or local muscle spasm

5. Standing Kemp’s test

6. Non-organic testinga. simulation tests – axial loading, trochanteric rotationb. distraction tests – sitting SLR

7. Straight leg raise

8. Crossed SLR test

9. Muscle stretch testsa. SLRb. Fabere’s – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet

joint – may indicate tight adductors, intrinsic hip problem, an irritated SI or L/S facet joint

c. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris) – Supine. Examiner approximates patient’s knee to his chest. If the opposite thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris)

d. Psoas palpatione. Ely’s – prone. Examiner approximates heel to buttock. May indicate a contracture of the

rectus femoris or psoas, hip or SI lesion, or traction femoral nerve so that the patient experiences radicular symptoms from an irritated L2, L3, L4 nerve root.

10. SI provocation testa. SI compression test

11. Spinous tenderness

12. Soft tissue palpation

13. Motion palpation and joint play analysis (say only)Motion Contact finger Control fingers Normal AbnormalFlexion Three finger

contact on interspinous spaces

Patient is flexed and returned to neutral

Spinous processes separate.

No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous


ligamentsExtension Make a fist and

use a thumb contact on interspinous

Extended by lifting elbows and returned to neutral

Spinous processes will approximate

No approximation. Extension restriction of flexion malposition.

Lateral flexion Hook and push contact

Laterally flexed away from doctor and turned to neutral

Superior spinous will rotate to concavity.

Spinous will not rotate or reverse into convexity (sacrospinalis and/or multifidus)

Lateral flexion (spinous challenge)

Thumb contact on lateral aspect of 2 adjacent spinous

Laterally flexed away toward Doctor and returned to neutral

Springy end feel as disc is wedge open on contralateral side

Hard end feel, no lateral flexion:a. disc

protrusion/herniation

b. hypertonic intertransversarii QL.

Rotation Hook-push or thumb-push

Rotated toward Dr. and returned to neutral.

Spinous rotates away from superior finger

Spinous remains in midline and/or fails to rotate (multifidus)

Special test for Pain-focused patients –Waddell’s Tests1. Tenderness – light touch on the back causes pain or if deep tenderness spreads over large

areas of the body – test is positive.2. Simulation test – scored positive if 1 to 2 pounds of axial pressure applied to the head causes

back pain or leg pain or if gentle axial rotation of the pelvis and shoulders together, causes back pain.

3. Distraction test – patient is sitting as the heel is raised with one hand and the doctor’s other had palpates the dorsalis pedal pulse (leg extended and hip joint is flexed). Can be sciatic if leans back. Also can be nonorganic or functional disease if positive for supine SLR < 20 degrees but negative at sitting with hip flexed to 90 degrees (a.k.a. positive Flip test)

4. Regional disturbances – positive if non-neuroanatomic numbness in the absence of peripheral neuropathy, or if the patient demonstrates cogwheel weakness associated with extrapyramidal systemic disease

5. Over-reaction sign –patient uses excessive body language, gestures, moans and groans, sweats profusely, trembles.

Not a Waddell’s test but still for pain focused patient.1. Sham SLR: patient is in the seated position with straight legs and foot dorsiflexed. LBP à

pain amplification or non-organic lesion.


DO THE CERVICAL ORTHOPEDIC EXAMINATION, CHECK FOR CERVICOGENIC DORSALGIA AND DIFFERENTIAL DIAGNOSIS CERVICOGENIC VERTIGO FROM VESTIBULOCOCHLEAR CAUSES Core tests:1. Observation – general, postural



2. Vertebrobasilar testing Houle à positive is vertigo, dizziness, nausea, and nystagmus. It indicates possible stenosis or compression of the vertebral basilar or carotid artery at one of the seven sites.



Wrist extension

Wrist flexion and finger extension





Medial arm

Reflex Biceps Brachioradialis Triceps






7. Soft tissue palpation Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process


Lower cervical motion palpationMotion Contact hand Control hand Normal AbnormalFlexion Thumb on









Spinous deviation









Posterior rotation Patient leans back against doctor as contact with 2-3 fingers

On patient’s head or chin. Guides face towards contact while


Restricted end feel to the posterior motion and fullness


placed over anterior aspect of TVPs

contact hand pulls posterior and superior

under fingers or joint (possible scalenii)


anterior of C1d. index on

ramus of mandible

e. ring finger on mastoid

f. thumb on top of head



c. space does not open, extension restriction (rectus capitus anterior)

d. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)


d. index on ramus of mandible










f. thumb on top of head.



C. Restricted end feel

D. Lack of lateral flexion (contralateral rectus capitus lateral)





C1 TVP approximates on C2 TVP ipsilaterally and then separates

Restricted end feel ipsilateral joint and a lack of separation on contralateral side




contralaterally (contralateral intertransversarii)







d. index finger on occiput rim, tubercle

e. 3rd finger on space (post of C1)

f. 4th finger on C2 spinous



c. posterior tubercle with occiput (possible rectus capitus minor)

d. C2 spinous rides up with occiput (rectus capitus major)


c. thumb on occiput rim just lateral to midline

d. index finger hooked around anterior aspect of C2









Cervical dorsalgia testsa. In the seated position:

flexion and rotation deep palpation (facet rub) for referral PA spinous challenge lateral spinous challenge C6/7


interspinous challenge rub the ligamentb. In supine position:

skin rolling T2/3, T5/6 point testing T2,T5/6 digital pressure – tightness and tenderness on palpation dorsal spinous challenge lateral and PA

c. cervical doorbell test is done in the seated position. The examiner palpates the anterolateral aspect of the lower cervical spine. Maintain this mild to moderate pressure for 3 to 5 seconds. Be careful not to occlude the carotid artery. A positive sign is the reproduction or aggravation of pain in the patient’s interscapular region. May be a sign of cervicogenic dorsalgia, pressure over an irritated nerve root may cause radicular arm pain or pain in the interscapular region or hypertonic scalene muscles.

Cervicogenic vertigo from vestibulocochlear causesa. rotary chair test

Part one – patient sits on stool that rotates with eyes closed and shake head from side to side. Vertigo may be from vestibular nuclei or from the muscles and joints in the cervical spine.Part two – Have rotate head side from side as examine stands behind the patient and holds their head steady while the patient continues to rotate their body. If there is vertigo, it most likely originates form the tissues of the cervical spine. If there is no vertigo, it most likely originates from the vestibular nuclei.

b. VBI testingc. Romberg’s – patient stands with eyes closed. The position is held for 20 to 30 seconds. If

the body begins to sway excessively or the patient loses balance, the test is considered positive for an upper motor neuron lesion.

d. BPV test have patient sit near the middle of the table so that if lying down, head can be supported

off the table. The doctor holds the patient’s head (rotates and extends) and instructs the patient to fall back (reassure the patient you are maintaining contact. Hold in that position for 5 to 10 seconds. Look for nystagmus.

Caloric test. The examiner alternately applies hot and cold test tubes just behind the patient’s ears on the side of the head; each side is done in turn. A positive test is associated with the inducement of vertigo, which indicates inner ear problems.


DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR SI JOINT SYNDROME.Core1. Observation

a. gait limping, body type, facial expression, step defect (spondylolisthesis) and Minor’s sign (from sitting position, do they support by placing hand on healthy leg)



Reflex Sensory MotorL4 Patellar Medial calf and

medial side of footTibialis anterior (ankle inversion)








3. Gait analysis

4. Lumbar ROM testing Forward flexion 40 – 60 degrees Extension 20-35 degrees Lateral flexion 15-20 degrees Rotation 3 – 18 degrees.






6. Non-organic testingc. simulation tests – axial loading, trochanteric rotationd. distraction tests – sitting SLR


8. Crossed SLR test


joint – increased pain may indicate SI painc. Thomas – Supine. Examiner approximates patient’s knee to his chest. If the opposite

thigh raises from the table this may indicate a flexion contracture of the hip (psoas and/or rectus femoris)



10. SI provocation testa. SI compression test – indicates sacroiliac joint irritation



13. Motion palpation and joint play analysis (say only)

Lumbar spineMotion Contact finger Control fingers Normal AbnormalFlexion Three finger




No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or


interspinous ligaments

Extension Make a fist and use a thumb contact on interspinous












Hard end feel, no lateral flexion:c. disc


d. hypertonic intertransversarii QL.





SI joint evaluationMotion Contact finger Control fingers Normal Abnormal1. pelvic flexion on acetabulum

a. Index or middle finger under PSIS

b. Thumb contact on sacral apex

Stabilizes pelvis.Patient bends forward

Sacrospinalis and hamstrings elongate. Relatively sacrum will slightly extend/counternutate on the innominate

a. Lumbar spine will not flex (tight sacrospinalis)

b. Patient will flex knees (tight hamstrings)

c. Innominate fails to flex

d. No counternutation

2. pelvic lateral flexion

a. thumbs under PSIS

Hands firmly grasp pelvis. Patient laterally bends to each

Lumbar spine laterally flexes in a smooth C-curve with

a. Limited or no pelvic shift (tight abd/add)


side opposite thigh abduction and adduction elongation to allow a slight pelvic shift

b. Pelvic rotation (psoas)

c. PSIS elevates on opposite side (tight QL)

d. Limited lumbar lateral flexion

3. ilium flexion Thumbs contact under PSIS.

Doctor’s hands stabilize pelvis as patient stabilizes with hand against wall.Patient lifts leg as if climbing stairs

PSIS will move posterior and inferior

a. PSIS fails to move

b. As leg lowers will see psoas shimmer

4a. iliosacral motion

Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle

Patient stabilizes with hand against wall.Patient lifts leg contact lateral to S1 tubercle to 90 degrees.


a. PSIS fails to move

b. PSIS and sacral base move together posterior

4b. sacroiliac motion

Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle.

Patient stabilizes with hand against wall.Patient lifts leg contact contralateral to S1 tubercle to 90 degrees.

Sacrum moves posterior and inferior on the flexed innominate

Sacrum fails to move posterior and/or inferior

5. sacroischial motion

Thumb contact on sacral apex. Other thumb contact on soft tissue over posterior ischium

Patient stabilizes with hand against wall.Patient lifts leg on side of ischial contact to 90 degrees.

Ischium moves slightly anterior and lateral

a. Ischium fails to move anterior and lateral

b. Sacral apex moves with ischium.

SI joint syndrome


a. Gaenslen’s test – Patient is supine and bring knee to chest on unaffected side. The affected limb is off the table and hyperextended by the examiner with increasing force. Pain on hyperexteded side may indicate an SI lesion

b. Yeoman’s test – patient is prone as the examiner flexes the knee, extends the hip joint and applies pressure on ipsilateral PSIS. Increased pain may indicate an SI lesion

c. Hibb’s test – the examiner flexes the patient’s leg (prone) on his thigh to 90 degrees and then moves it laterally causing internal rotation of the hip joint. Increased pain may indicate a hip joint lesion, SI lesion or piriformis spasm


DO THE CORE LUMBAR SPINE EXAMINATION AND RULE OUT ANKYLOSING SPONDYLITIS. TEST THE INTEGRITY OF L5 NERVE ROOTCore1. Observation



2. Neurological examination:Reflex Sensory Motor

L4 Patellar Medial calf and medial side of foot

Tibialis anterior (ankle inversion)






a. plantar reflex – normally down goingb. heel/toe walking –inability to heal walk may indicate L5 root compression. Inability to

walk on toes may indicate S1 root compressionc. muscle girth testing

3. Gait analysis







6. Non-organic testinga. simulation tests – axial loading, trochanteric rotationb. distraction tests – sitting SLR


8. Crossed SLR test









13. Motion palpation and joint play analysis (say only)Lumbar spineMotion Contact finger Control fingers Normal AbnormalFlexion Three finger




No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or interspinous ligaments














Hard end feel, no lateral flexion:e. disc


f. hypertonic intertransversarii QL.





Special test:1. Trendelenburg test – Patient stands on one leg so that gluteus medius on supported side

contracts to elevate opposite side. If not, this may indicate L4 root lesion or hip disease.2. Schober’s test. Take out a tape measure and find the dimples of Venus (or the PSIS

bilaterally). Draw an imaginary line across the PSIS at the S2 level. Now place the 10 cm point of the tape measure at the S2 level. With the left hand fix the O point of the tape measure onto the spine, which should now be at about the L1 level. With the right hand, hold the tape measure loosely and find the 15 cm point which should be around the apex of the sacrum. Now as you ask the patient to forward flex, the inferior (right hand) allows the tape measure to slide between the fingers and the measurement should normally increase approximately 7 cm, from 15 cm to 22 cm. Any movement less than 3 cm is considered to be positive Schoeber’s test and is highly indicative of seronegative spondyloarthropathy.


DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND CHECK FOR NERVE ROOT TENSION SIGNS ON A PATIENT YOU ARE SUSPECTING C5 CERVICAL RADICULOPATHY.Core tests:1. Observation – general, postural



2. Vertebrobasilar testing Houle à positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites.








Medial arm









Lower Cervical motion palpationMotion Contact hand Control hand Normal AbnormalFlexion Thumb on









Spinous deviation









Posterior rotation Patient leans back against doctor as contact with 2-3 fingers placed over

On patient’s head or chin. Guides face towards contact while contact hand


Restricted end feel to the posterior motion and fullness under fingers or


anterior aspect of TVPs

pulls posterior and superior

joint (possible scalenii)


anterior of C1g. index on

ramus of mandible

h. ring finger on mastoid

i. thumb on top of head



e. space does not open, extension restriction (rectus capitus anterior)

f. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)


g. index on ramus of mandible


i. thumb on top of head








i. thumb on top of head.



E. Restricted end feel

F. Lack of lateral flexion (contralateral rectus capitus lateral)





i. thumb on top


Restricted end feel ipsilateral joint and a lack of separation on contralateral side (contralateral


of headHead is laterally flexed to each side

intertransversarii)







g. index finger on occiput rim, tubercle

h. 3rd finger on space (post of C1)

i. 4th finger on C2 spinous



e. posterior tubercle with occiput (possible rectus capitus minor)

f. C2 spinous rides up with occiput (rectus capitus major)


e. thumb on occiput rim just lateral to midline

f. index finger hooked around anterior aspect of C2









Special tests for nerve root irritation:1. compression tests

a. lateral cervical compression will close IVF on side of flexion. The appearance or aggravation of radicular pain, paresthesia, or numbness in the shoulder, or upper arm and in the forearm or hand may mean nerve root compression possibly due to cervical disc disease.


b. rotational cervical compression test is positive when there is appearance or aggravation of radicular pain, paresthesia, or numbness in the shoulder or upper arm and in the forearm or hand. This may be due to cervical disc disease

2. axial manual tract test is done supine. May decrease or dissipate radicular symptoms.3. shoulder abduction test is done in the sitting position with the patient’s hand lifted above his

or head and holds it there for 30 seconds. A positive is a decrease or disappearance of radicular symptom. May be due to nerve root compression possibly due to cervical disc disease.

4. cervical doorbell test is done in the seated position. The examiner palpates the anterolateral aspect of the lower cervical spine. Maintain this mild to moderate pressure for 3 to 5 seconds. Be careful not to occlude the carotid artery. A positive sign is the reproduction or aggravation of pain in the patient’s interscapular region. May be a sign of cervicogenic dorsalgia, pressure over an irritated nerve root may cause radicular arm pain or pain in the interscapular region or hypertonic scalene muscles.


DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX LUMBAR FACET JOINT IRRITATION FROM THORACOLUMBAR SYNDROME. TEST THE INTEGRITY OF L5 NERVE ROOT.Core1. Observation













3. Gait analysis






5. Standing Kemp’s test – aggravates an inflamed facet joint and/or disc herniation

6. Non-organic testinga. simulation tests – axial loading, trochanteric rotationc. distraction tests – sitting SLR


8. Crossed SLR test

9. Muscle stretch testsa. SLRb. Fabere’s – may indicate tight adductors, intrinsic hip plebe, an irritated SI or L/S facet













Extension Make a fist and use a thumb

Extended by lifting elbows

Spinous processes will

No approximation.


contact on interspinous

and returned to neutral

approximate Extension restriction of flexion malposition.









Hard end feel, no lateral flexion:g. disc


h. hypertonic intertransversarii QL.





Special tests for lumbar facet joint from thoracolumbar syndrome1. spinal percussion – the patient leans froward the examiner percusses each lumbar vertebrae

with a reflex hammer. Localized pain may indicate a facet syndrome or possible vertebral fracture.

2. Do skin roll3. Motion palpation4. Pain in hip and buttock


DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND DDX CERVICAL SPRAIN VERSUS CERVICAL STRAIN. TEST THE INTEGRITY OF C6 NERVE ROOT.Core tests:1. Observation – general, postural











Medial arm


















Spinous deviation









Posterior rotation Patient leans back against doctor as contact with 2-3 fingers placed over

On patient’s head or chin. Guides face towards contact while contact hand


Restricted end feel to the posterior motion and fullness under fingers or


anterior aspect of TVPs

pulls posterior and superior

joint (possible scalenii)


anterior of C1j. index on

ramus of mandible

k. ring finger on mastoid

l. thumb on top of head



g. space does not open, extension restriction (rectus capitus anterior)

h. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)


j. index on ramus of mandible


l. thumb on top of head








l. thumb on top of head.



G. Restricted end feel

H. Lack of lateral flexion (contralateral rectus capitus lateral)





l. thumb on top


Restricted end feel ipsilateral joint and a lack of separation on contralateral side (contralateral


of headHead is laterally flexed to each side

intertransversarii)







j. index finger on occiput rim, tubercle

k. 3rd finger on space (post of C1)

l. 4th finger on C2 spinous



g. posterior tubercle with occiput (possible rectus capitus minor)

h. C2 spinous rides up with occiput (rectus capitus major)


g. thumb on occiput rim just lateral to midline

h. index finger hooked around anterior aspect of C2









Special test for ddx of cervical strain versus sprain.After performing the active ranges of motion, put the cervical spine through passive ranges of motion then through resisted ranges of motion. All are done with the patient sitting.a. muscular pain (strain) – pain is elicited during resisted ROM or isometric contraction but

little pain during passive ROMb. articular or ligamentous pain (sprain) – pain is elicited during passive ROM but little pain

during isometric (resisted) contraction


c. combination – pain is elicited in all types of ranges of motion.


DO THE CORE LUMBAR ORTHOPEDIC EXAMINATION AND DDX PIRIFORMIS SYNDROME FROM SI SYNDROME.Core1. Observation




Reflex Sensory MotorL4 Patellar Medial calf and

medial side of footTibialis anterior (ankle inversion)








3. Gait analysis







6. Non-organic testinga. simulation tests – axial loading, trochanteric rotationb. distraction tests – sitting SLR while palpating pedal pulse


8. Crossed SLR test













No separation – flexion restriction, extension malposition may be due to shorted supraspinous and/or


interspinous ligaments













Hard end feel, no lateral flexion:i. disc


j. hypertonic intertransversarii QL.





SI joint evaluationMotion Contact finger Control fingers Normal Abnormal1. pelvic flexion on acetabulum

c. Index or middle finger under PSIS

d. Thumb contact on sacral apex

Stabilizes pelvis.Patient bends forward

Sacrospinalis and hamstrings elongate. Relatively sacrum will slightly extend/counternutate on the innominate

e. Lumbar spine will not flex (tight sacrospinalis)

f. Patient will flex knees (tight hamstrings)

g. Innominate fails to flex

h. No counternutation

2. pelvic lateral flexion

a. thumbs under PSIS

Hands firmly grasp pelvis. Patient laterally bends to each

Lumbar spine laterally flexes in a smooth C-curve with

e. Limited or no pelvic shift (tight abd/add)


side opposite thigh abduction and adduction elongation to allow a slight pelvic shift

f. Pelvic rotation (psoas)

g. PSIS elevates on opposite side (tight QL)

h. Limited lumbar lateral flexion

3. ilium flexion Thumbs contact under PSIS.

Doctor’s hands stabilize pelvis as patient stabilizes with hand against wall.Patient lifts leg as if climbing stairs


c. PSIS fails to move

d. As leg lowers will see psoas shimmer

4a. iliosacral motion

Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle

Patient stabilizes with hand against wall.Patient lifts leg contact lateral to S1 tubercle to 90 degrees.


c. PSIS fails to move

d. PSIS and sacral base move together posterior

4b. sacroiliac motion

Thumb contact under PSIS. Other thumb contact lateral to S1 tubercle.

Patient stabilizes with hand against wall.Patient lifts leg contact contralateral to S1 tubercle to 90 degrees.

Sacrum moves posterior and inferior on the flexed innominate

Sacrum fails to move posterior and/or inferior

5. sacroischial motion

Thumb contact on sacral apex. Other thumb contact on soft tissue over posterior ischium

Patient stabilizes with hand against wall.Patient lifts leg on side of ischial contact to 90 degrees.

Ischium moves slightly anterior and lateral

c. Ischium fails to move anterior and lateral

d. Sacral apex moves with ischium.

SI joint syndromea. Gaenslen’s test – Supine. Patient is supine and bring knee to chest on unaffected side. The

affected limb is off the table and hyperextended by the examiner with increasing force. Pain on hyperexteded side may indicate an SI lesion


b. Yeoman’s test – Prone. patient is prone as the examiner flexes the knee, extends the hip joint and applies pressure on ipsilateral PSIS. Increased pain may indicate an SI lesion

c. Hibb’s test – Prone. The examiner flexes the patient’s leg (prone) on his thigh to 90 degrees and then moves it laterally causing internal rotation of the hip joint. Increased pain may indicate a hip joint lesion, SI lesion or piriformis spasm.

d. Sciatic notch tenderness: Prone. Examiner should press with his/her thumb into the sciatic notch (2 inches lateral to mid-sacral level)-Reproduces or increases reported leg pain. Positive for nerve root tension or a trigger for piriformis.


DO CORE LUMBAR ORTHOPEDIC EXAMINATION AND DO A FULL NEUROLOGICAL AND VASCULAR EXAMINATION OF THE LOWER LIMB.Core1. Observation













3. Gait analysis









8. Crossed SLR test

















No approximation. Extension restriction of flexion


malposition.Lateral flexion Hook and push

contactLaterally flexed away from doctor and turned to neutral







Hard end feel, no lateral flexion:k. disc


l. hypertonic intertransversarii QL.





Special tests for peripheral vascular:Inspect both legs from the groin and buttocks to the feeta. note size, symmetry and any swelling

edema causes swelling that may obscure veins, tendons and bony prominences Measure legs at forefoot, smallest possible circumference above the ankle, the largest

circumference at the calf and the midthigh a measure distance above the patella with the knee extended. Compare one side with the other. A difference >1cm just above the ankle or 2 cm difference between calves suggests edema

b. venous pattern and any venous enlargement varicosities that are tortuous and dilated ask the patient to stand and inspect the saphenous system. The veins may be dilated and

tortuous.c. pigmentation, rashes, scarsd. color and texture of skin, color of nail beds and the distribution of hair on the lower legs, feet

and toes. thin and shiny in chronic arterial insufficiency thick and brown in chronic venous insufficiency ulcers at the toes (chronic arterial insufficiency) or sides of the medial ankle (chronic

venous insufficiency)e. palpation of peripheral pulses

Popliteal pulse-Patient’s knee is somewhat flexed. Place the fingertips of both hands so that they just meet in the midline behind the knees and press them deeply into the popliteal fossa. Exaggerated, widened pulse à aneurysm of popliteal artery. Primarily in men over 50. If absent à iliac, femoral or popliteal occlusion


Dorsalis pedis pulse-Feel the dorsum of the foot, just lateral to the extensor tendon of the great toe. A decreased or absent pulses with normal femoral and popliteal pulses suggest occlusive disease in the lower popliteal artery à diabetes mellitus

Posterior tibial pulse-Curve fingers behind and slightly below the medial malleolus of ankle. A sudden occlusion i.e. embolism or thrombosis à pain and numbness or tingling. Limb distal to occlusion becomes cold, pale and pulseless.

e. Palpation of Temperature – compare extremities. Note the temperature of the feet and legs with the backs of your fingers. Bilateral coldness – cold environment or anxiety. Unilateral coldness – arterial insufficiency, inadequate arterial circulation

f. Palpation of Edema. Press firmly but gently with your thumb for at least 5 seconds in the following locations:

a. over the dorsum of each footb. behind each medial malleolusc. over the shins

Look for pitting. Normally there is none. The severity of edema is graded on a 4-point scale, from slight to very marked.

Right-handed congestive heart failure first appears in the feet and legs Hypoalbuminemia – edema first appears in the loose subcutaneous tissues of the

eyelids Venous stasis secondary to obstruction or insufficiency – limited to the area of

blockage, often on a leg or on both legs or on an arm.g. Palpation for Phlebitis. The affected vein may be palpated as firm and cord-like. Test using

Homan’s sign. Palpate the groin just medial to the femoral pulse for tenderness of the femoral vein With the knee flexed and relaxed, palpate the calf. With your fingerpads, gently

compress the calf muscles against the tibia and search for any tenderness or cords. Homan’s sign – calf pain produced by sudden dorsiflexion of the patient’s foot with

the knee slightly flexed. Pain is provoked by muscular effort Phlebitis may lead to pulmonary embolismIf inspection of saphenous system indicated varicosities, palpate them for any signs of thrombophlebitis

h. Palpation of superficial inguinal nodes. Palpate both the horizontal group and vertical groups. Note their size, consistency and discreteness and note any tenderness. Nontender, discrete inguinal nodes up to 1cm or 2 cm in diameter are frequently palpable

in normal people. Lymphadenopathy – enlargement of nodes with or without tenderness

Special maneuvers1. Trendelenburg test (retrograde filling). This tests venous competency. Start with patient supine. Elevate on leg to 90 degrees to empty venous blood. Occlude great

saphenous vein in upper thigh by manual compression. Ask patient to stand and keep vein occluded and watch for venous filling in the leg Normally the saphenous vein fills from below taking about 35 s.

Rapid filling of superficial veins while the saphenous vein is occluded indicates incompetent valves in the communicating veins.


After the patient has stood for 20s, release the compression and look for any additional venous filling. Normally none. When both steps are normal a.k.a. negative-negative Positive-positive is abnormal Sudden additional filling of superficial veins after release of compression indicates

incompetent valves in the saphenous veins.


DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR TOCS. TEST THE INTEGRITY OF THE T1 NERVE ROOT.Core tests:1. Observation – general, postural



2. Vestrobrobasilar testing Houle à positive is vertigo, dizziness, nausea, nystagmus. It indicates possible stenosis or compression of the vertebral, basilar or carotid artery at one of the seven sites.








Medial arm


















Spinous deviation









Posterior rotation Patient leans back against doctor as contact with 2-3 fingers

On patient’s head or chin. Guides face towards contact while


Restricted end feel to the posterior motion and fullness


placed over anterior aspect of TVPs

contact hand pulls posterior and superior

under fingers or joint (possible scalenii)


anterior of C1m. index on

ramus of mandible

n. ring finger on mastoid

o. thumb on top of head



i. space does not open, extension restriction (rectus capitus anterior)

j. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)


m. index on ramus of mandible










o. thumb on top of head.



I. Restricted end feel

J. Lack of lateral flexion (contralateral rectus capitus lateral)





C1 TVP approximates on C2 TVP ipsilaterally and then separates

Restricted end feel ipsilateral joint and a lack of separation on contralateral side




contralaterally (contralateral intertransversarii)







m. index finger on occiput rim, tubercle

n. 3rd finger on space (post of C1)

o. 4th finger on C2 spinous



i. posterior tubercle with occiput (possible rectus capitus minor)

j. C2 spinous rides up with occiput (rectus capitus major)


i. thumb on occiput rim just lateral to midline

j. index finger hooked around anterior aspect of C2









Special tests for TOSTest Procedure Positive sign SignificanceEAST maneuver (elevated arm stress test)

Elevate arms 90 degrees in abduction externally, rotated position, with the shoulders and elbows

Gradual increase in pain beginning in the back of the neck and shoulders and progressing down the arm

Most reliable test for TOCS


braced back, similar to a military posture. The hands are opened and closed at a moderate speed for 3 minutes.

across the forearms into the hands. Paresthesias develop in the lower arm, forearm and fingers often causing the patients to be unable to complete the entire 3 minutes

Adson’s With the patient sitting, establish a radial pulse. Have the patient rotate the head and elevate the chin to the side being tested. Have them take a breath and hold it for as long as they can. Modified Adson’s requires the head turned in the opposite direction.

Decreased or absent radial pulse. Paresthesias or radiculopathy in the upper limb. Need both.

Compression of the neurovascular bundle in the costoclavicular space by the scalenus anterior muscle or the presence of a cervical rib.

Hyperabduction (Wright’s) With the patient in the sitting position, establish the radial pulse. Hyperabduct and slightly extend the arm while checking the pulse. Hold for 30 seconds.

Decrease or absence of the radial pulse. Paresthesias in upper limb.

Compression of the axillary artery by either the pectoralis minor muscle or the coracoid process

Costoclavicular (Eden’s) With the patient seated, establish a radial pulse. Take the patient’s shoulder posteriorly and inferiorly and have them flex their chin to their chest. Hold for 30 seconds.

Decrease or absence of the radial pulse. Paresthesia or radiculopathy in the upper extremity

Compression of the neurovascular bundle in the costoclavicular space due to a decrease in the space between the clavicle and the first rib.


DO THE LUMBAR ORTHOPEDIC EXAMINATION AND RULE OUT NERVE ROOT TENSION SIGNS IN THE LOWER LIMBS. TEST THE INTEGRITY OF THE S1 NERVE.Core1. Observation













3. Gait analysis









8. Crossed SLR test














Extension Make a fist and use a thumb contact on

Extended by lifting elbows and returned to


No approximation. Extension


interspinous neutral restriction of flexion malposition.









Hard end feel, no lateral flexion:m. disc


n. hypertonic intertransversarii QL.





Special tests for nerve root tension signsTest Procedure Positive SignificanceBraggard’s Supine. Examiner lowers the patient’s straight

leg about 5-10 degrees from the point of pain and dorsiflexes the patient’s foot.

Report pain Disc lesion, sciatic neuritis or spinal cord tumor

Bowstring Supine. Patient’s hip and knee are flexed but not to the point of pain. Examiner rests the patient’s leg on his shoulder and presses his thumbs into the popliteal fossa

Pain in low back, thigh or lower limb

Limited SLR is due to nerve root irritation

Femoral nerve stretch (Ely’s)

Prone. Examiner approximates the patient’s heel to his buttock.

An inability to complete this motion.Pain.

Tight rectus femoris or psoas. Hip or SI lesion. Radicular symptoms from an irritated L2, L3 or L4 nerve root

Sciatic notch tenderness

Prone. Examiner should press with his/her thumb into the sciatic notch (2 inches lateral to mid-sacral level)

Reproduces or increases reported leg pain.

Positive for nerve root tension.Trigger for piriformis.

DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT MENINGEAL IRRITATION. TEST THE INTEGRITY OF C7 NERVE ROOT.Core tests:1. Observation – general, postural











Middle finger

Medial forearm, ring and small finger

Medial arm








Lower Cervical motion palpation


Motion Contact hand Control hand Normal AbnormalFlexion Thumb on









Spinous deviation














anterior of C1p. index on

ramus of mandible

q. ring finger on mastoid

r. thumb on top of head


k. space does not open, extension restriction (rectus capitus anterior)



l. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)


p. index on ramus of mandible










r. thumb on top of head.



K. Restricted end feel

L. Lack of lateral flexion (contralateral rectus capitus lateral)








Restricted end feel ipsilateral joint and a lack of separation on contralateral side (contralateral intertransversarii)







p. index finger on occiput



k. posterior tubercle with


rim, tubercleq. 3rd finger on

space (post of C1)

r. 4th finger on C2 spinous

occiput (possible rectus capitus minor)

l. C2 spinous rides up with occiput (rectus capitus major)


k. thumb on occiput rim just lateral to midline

l. index finger hooked around anterior aspect of C2









Special test for meningeal irritation testsTest Procedure Positive SignificanceKernig’s a.k.a Leseague

Supine with hip and knee flexed to 90 degrees. Patient extends the leg being test

Inability to straighten and/or back pain

Meningeal irritation

Brudzinski’s Supine as examiner flexes the patent’s neck to the chest

Neck and low back pain with involuntary flexion of the knees and hips


L’Hermitte’s Sitting with legs extended on the table. Examiner passively flexes the patient’s head and hips simultaneously

Sharp pain or lightning bolt down the spine and into the upper or lower limb



DO THE CORE LUMBAR SPINE EXAMINATION AND CHECK FOR A LUMBAR DISC HERNIATION. TEST THE INTEGRITY OF SI NERVE ROOT.Core1. Observation













3. Gait analysis









8. Crossed SLR test

















No approximation. Extension restriction of flexion


malposition.Lateral flexion Hook and push

contactLaterally flexed away from doctor and turned to neutral







Hard end feel, no lateral flexion:o. disc


p. hypertonic intertransversarii QL.





Special test for disc herniationSitting position

1. Valsalva’s test – may be due to space occupying lesion such as disc or tumor.2. Spinal percussion – local pain indicates a facet syndrome or possible vertebral

fracture. Radicular pain indicates possible disc lesionSupine position

1. SLR – radiating leg pain may indicate lumbar radiculopathy from a disc herniation.2. Crossed SLR – contralateral leg pain may be considered positive for a lumbar disc

herniation.3. Braggard’s – pain may be due to disc lesion, sciatic neuritis or spinal cord tumor.

Prone position1. Herron-pheasants’ test. Examiner approximates both the patient’s heels to the

buttocks and holds them in this position for a minute. Retest motor reflex. This position may irritate a disc bulge enough or spinal stenosis to cause alterations in a previously performed test.

2. Spinous tenderness. Pain may indicate facet joint irritation or discogenic disorder.


DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND TEST FOR CERVICAL DISC HERNIATION. TEST THE INTEGRITY OF C6 NERVE ROOT.Core tests:1. Observation – general, postural




3. Neurological testing of cervical nerve roots – reflex, sensory, motor examination Grip strength weakness Dermatomal paresthesias, loss of sensation Diminished motor power (3-4 out of 5) Diminished to absent deep tendon reflexes

C5 C6 C7 C8 T1Motor Shoulder

abductionWrist extension Wrist flexion

and finger extension





Medial arm






6. Cervical Kemp’s test (extend and rotate) – local pain on ipsilateral. May be posterior joint irritation due to a cervical facet joint sprain. positive

7. Soft tissue palpation –paraspinal muscle spasm/hypertonicity Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process











Spinous deviation















anterior of C1s. index on

ramus of mandible

t. ring finger on mastoid

u. thumb on top of head



m. space does not open, extension restriction (rectus capitus anterior)

n. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)


s. index on ramus of mandible








s. index on ramus of mandible


u. thumb on top of head.



M. Restricted end feel

N. Lack of lateral flexion (contralateral rectus capitus lateral)

Lateral flexion of Middle finger on s. index on C1 TVP Restricted end


C1 on C2 inferior aspect of C1 TVP

ramus of mandible




approximates on C2 TVP ipsilaterally and then separates contralaterally

feel ipsilateral joint and a lack of separation on contralateral side (contralateral intertransversarii)







s. index finger on occiput rim, tubercle

t. 3rd finger on space (post of C1)

u. 4th finger on C2 spinous



m. posterior tubercle with occiput (possible rectus capitus minor)

n. C2 spinous rides up with occiput (rectus capitus major)


m. thumb on occiput rim just lateral to midline

n. index finger hooked around anterior aspect of C2









Special tests:Test Procedure Positive Significance


Soto-Hall test Supine. Passively flex the neck to the chest while applying pressure over the sternum

Localized cervical pain

Nonspecific. May be osseous, ligamentous, muscular, discal or space occupying lesion

Valsalva Sitting. Increased pain in the cervical spine area

May be disc bulge, tumor

Naffziger’s test Sitting or supine. Examiner gently bilaterally compresses the jugular veins for approximately 10 s. patient’s face will flush

Pain in the cervical spine

Disc herniation


DO THE CORE CERVICAL ORTHOPEDIC EXAMINATION AND RULE OUT VERTROBASILAR INSUFFICIENCY. TEST THE INTEGRITY OF C7 NERVE ROOT.Core tests:1. Observation – general, postural










Middle finger

Medial forearm, ring and small finger

Medial arm








Scalenes Suboccipitals Trapezius Levator scapulae Posterior cervical muscle group SCM Mastoid process











Spinous deviation









Posterior rotation Patient leans back against doctor as contact with 2-3 fingers placed over anterior aspect of

On patient’s head or chin. Guides face towards contact while contact hand pulls posterior


Restricted end feel to the posterior motion and fullness under fingers or joint (possible


TVPs and superior scalenii)


anterior of C1v. index on

ramus of mandible

w. ring finger on mastoid

x. thumb on top of head



o. space does not open, extension restriction (rectus capitus anterior)

p. space does not increase, flexion restriction with restricted end feel (OCS, OCI, RCPM, RCPM)


v. index on ramus of mandible










x. thumb on top of head.



O. Restricted end feel

P. Lack of lateral flexion (contralateral rectus capitus lateral)







Restricted end feel ipsilateral joint and a lack of separation on contralateral side (contralateral intertransversarii



)







v. index finger on occiput rim, tubercle

w. 3rd finger on space (post of C1)

x. 4th finger on C2 spinous



o. posterior tubercle with occiput (possible rectus capitus minor)

p. C2 spinous rides up with occiput (rectus capitus major)


o. thumb on occiput rim just lateral to midline

p. index finger hooked around anterior aspect of C2









Special test for vertebrobasilar insufficiency.Test Procedure Positive SignificanceHoule’s Prone with head off

the table, extended and rotated for 40-60 seconds

Vertigo, dizziness, nausea, nystagmus

Indicative of possible stenosis or compression of vertebral, basilar or carotid artery


Hautant’s Seated with eyes closed. Arms extend outward in front of them with palms up and instruct the patient to extend and rotate their head to one side for 40 to 60 seconds

Vertigo, dizziness, nausea, nystagmus and/or dropping of unilateral arm

Indicative of possible stenosis or compression of vertebral, basilar or carotid artery

Auscultation of carotid arteries

Auscultate carotid arteries

Bruits Possible occlusion

Blood pressure Take blood pressure Difference of 10 mmHg between the two systolic blood pressures

Subclavian artery stenosis or occlusion

Patient questionnaire Ask about signs and symptoms of VBI to identify risk factors

Get consent


DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE THORACIC SPINE AND CHECK FOR SCOLIOSIS.1. Observations – general state of health, stature, habitus and sexual development. Observations

should be made with reference to set anatomical landmarks. Observe from posterior, anterior and lateral views both in standing and sitting positions Inspect skin for any lesions (anatomical site, arrangement, type and colour): tinea

vesicolour, vesicles, scales, moles, surgical scares, café au lait spots, hairy patches Note breathing rate and rhythm (normal is 8-16 breaths/minutes in an adult and up to 44

breaths, minute in an infant. Note are of complaint and be aware of possible underlying visceral disease Note any obvious or acquired deformities – pectus carinatum, pectus excavatum, barrel

chest Note functional or structural scoliosis – unilateral scapular elevation in

Sprengel’s/Klippel-Fiel’s deformities, increased thoracic kyphosis as in Scheuermann’s disease or ankylosing spondylitis, increased thoracic kyphosis due to thoracic vertebral body fractures (Dowager’s Hump, Gibbus deformity)

6. Neurological examinationTest Procedure FindingsDeep tendon reflexes None for thoracic but do patellar

and Achilles reflexesHyperreflexia à upper motor lesion

Abdominal reflex Stroke each quadrant. Upper quadrant is innervated by T7 to T10 and lower by T10 to T12

Lack of reflex à upper motor lesion

Plantar reflex Stroke bottom of foot Fanning à pyramidal tract lesionBeevor’s sign Patient does an abdominal crunch

as you look for umbilical deviationMove cephalad à bilateral T10 to T12 lesionMoves caudad à bilateral T7 to T10 lesionMoves cephalad and laterally à contralateral unilateral T10 to T12 lesion Moves caudad and laterally à contralateral unilateral T7 to T10 nerve root lesion

Sensation Soft touch and pinprick over T1 to T12 dermatomes

Inability à lesion

Vibration Test over medial malleoli and ASIS

Upper motor neuron lesion

2. Ranges of motion – to be done active, passive, resistedForward flexion 20 to 45 degrees Rib humping, side of deviationsExtension 25 to 45 degrees > 2.5 cm decreaseLateral flexion 20 to 40 degrees Look for unwindingRotation 35-50 degrees Done in forward flexed standing position


Done seated to see whether there is irritation of the costovertebral joints

Resisted ranges of motion are best done seated and active ranges should be repeated in the seated position to check for flexibility of scoliotic curves

3. To be done seatedTest Procedure FindingsSlump test (sitting dural stretch test)

Patient slumps to flex spine and shoulders sag forward, the head is held erect.No symptoms – Dr. flexes head forward and applies overpressureNo symptoms – leg is extendedNo symptoms, foot is dorsiflexed

Possible impingement of dura, spinal cord or nerve roots

T1 nerve stretch Patient abduct arm to 90° and flexes elbow to 90° with forearm pronated à no symptoms.The patient then places hand behind the neck.

Ipsilateral scapular or arm pain may indicate T1 nerve root lesion or ulnar nerve lesion

T2 nerve stretch Patient flexes arm to 90° and then adducts arm across chest while rotating head in opposite direction

Ipsilateral arm pain may indicate a lesion

Kemp’s test Patient rotates and extends upper body while Dr. applies a small amount of pressure to the ipsilateral shoulder

Pain in thoracic may indicate an irritated facet joint

Chest expansion Tape measure is placed at level of 4th intercostal space à patient exhales and measured à patient inhales and measured

Normal: difference of 3 to 7.5 cm.< 3cm may indicate ankylosing spondylitis

Passive scapular approximation test

Examiner passively approximates the scapulae by lifting the shoulder up and backwards

Reproduction of pain in the scapular area is indicative of T1 or T2 nerve root lesion

Cervical doorbell test Palpate with index finger the anterolateral aspect of the lower cervical spine on one side at a time

Reproduction or aggravation of mid-thoracic pain the patient’s interscapular region suggesting cervicogenic dorsalgia

Valsalva’s maneuver Patient bears down or blow with their lips sealed around their thumb

Increased pain in the thoracic spine area may indicate a space occupying lesion

Kerning’s Patient lies supine with the hip and knee flexed to 90 degrees and extend leg being tested

Inability to straighten the leg and/or back painà meningeal irritation

Brudzinki’s With the patient supine, the examiner flexes the patient’s neck to their chest

Neck and low back or involuntary flexion of knees and hip à meningeal irritation


L’hermitte’s Patient is sitting with their legs extended on the table. Head passively flexed and hips

Sharp lightning bolt down spine and into limbs à meningeal irritation

4. To be done supineTest Procedure FindingsSLR Knee extended, raise patient’s leg Reproduction of thoracic spine

pain may indicate a space occupying lesion of the thoracic

Soto Hall test Passively flex the neck to the chest while applying pressure over the sternum

Localized pain may indicate an osseous, ligamentous, muscular, discal or space occupying lesion

Sternal compression Dr. exerts pressure downwards over the sternum

Rib pain along the lateral margins may suggest a possible rib fracture

True leg length test Measure distance from the ASIS to the medial malleoli of the ankles

>2.5 cm differences may cause a functional scoliosis

Beevor’s sign See neurological review

5. To be done proneTest Procedure FindingSpinal percussion Percuss each spinous process Localized pain may indicate

possible fractured vertebrae.Pain may indicate ligamentous sprain, muscular strain or disc lesion

Skin rolling Skin is rolled paraspinally over the thoracic spin

Localized pain indicate muscular trigger points

7. Palpation Do superficial and deep palpation over the sternum, ribs, costal cartilage, clavicle and

scapulae Do motion palpation Pain along costochondral margins may be suggestive of costochondritis


DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR LABRAL TEARS1. Observationa. Anteriorly

Are head and neck in the midlines? No à problem with the cervical spine or upper trapezius

Look for step deformity over the lateral shoulder between the acromion and humeral head à AC dislocation. If deformity appears with long axis traction to arm à multidirectional instability leading to inferior subluxation of the GH joint a.k.a. SULCUS sign.

Is the deltoid muscle round or flat? Flat à anterior dislocation of GH joint or paralysis of the muscle.

Look at bumps and alignment i.e. clavicle or sternum Height of shoulder. Dominant side will be lower than the non-dominant side, due to

capsular and ligamentous stretching BUT the dominant side will be more muscularb. Posteriorly

Note bony and soft tissue contours Winging of the scapula Sprengel’s deformity – congenitally high or undescending scapula Suprascapular fossa for tonicity of supraspinatus Infrascapular fossa for tonicity of infraspinatus and teres minor Kyphosis or scoliosis of thoracic spine Alignment of neck

2. Active movements *** do C-spine ****Range of motion Motion (°) FindingsForward flexion 160 to 180Abduction 160 to 180Lateral rotation 80 to 90 Most restricted in frozen

capsular shoulderMedial rotation 60 to 100Extension 50 to 60Adduction 50 to 75Horizontal adduction/abductionCircumduction Scapulohumeral rhythm is 1:2 ratio – look for shoulder hiking sign Any painful arc? 60 to 120 – rotator cuff tear; 120 to 180 – AC joint problem Is clavicle moving Apley’s scratch test: do extension/adduction/medial rotation Then do

flexion/abduction/lateral rotation

3. passive movementDo supine with the shoulder girdle to be examined by side of table. If there are restrictions, note the end feel, muscular spasm or hypertonicity, and capsular pattern (lateral rotation/abduction, medial rotation)


abduction medial and lateral rotation flexion locking test quadrant test

4. resisted isometric movements abduction – supraspinatus, (deltoid)

painful arc – lesion superficial at tenoperiosteal junction pain of full passive elevation, lesion deep to tenoperiosteal junction no painful arc, no pain on full elevation – lesion at musculo-tendinous junction

adduction – pectoralis major, latissimus dorsi, 2 teres to differentiate – bring arm first forwards than backward against resistance. If

forward hurts, the pectoralis is at fault. If backward hurts If backward hurts, 3 other muscles – teres major (medial rotation), teres minor

(lateral rotation), teres major and latissimus dorsi cannot be differentiated Weakness of adduction is found in severe cervical 7th root palsy due to weakness of

latissimus dorsi muscle Lateral rotation – infraspinatus, teres minor

Lateral rotation alone – infraspinatus Lateral rotation and adduction – teres minor Painful arc with infraspinatus, lesion distal and superficial fibers of tendon If lateral rotation plus infraspinatus – lesion distal and superficial fibers of tendon

Medial rotation – subscapularis, pectoralis major, latissimus dorsi, teres major. The last three are adductors.

If painful arc – lesion at uppermost part of tenoperiosteal junction If pain on passive adduction across front of chest, proximal aspect of tendon

Resisted forward flexion – deltoid (ant fibers), pectoralis (clavicular fibres), coracobrachialis Most often coracobrachialis

Resisted extension – deltoid (post fibres), 2 teres, latissimus dorsi, pectoralis major Resisted flexion and supination at the elbow – biceps brachii, brachioradialis, brachialis

Pain – usually long head of biceps brachii Resisted extension at elbow – triceps, anconeus

5. Specific tests Yergason’s – bicipital tendonitis Speed’s test – bicipital tendonitis Drop arm test – tear in rotator cuff Ludington’s test – rupture of long head of biceps Empty can supraspinatus test – tear in supraspinatus Neer impingement sign – overuse injury or biceps tendon Hawkin’s Kennedy Impingement test – supraspinatus tendonitis Lift off sign – subscapularis

6. Anterior shoulder test


a. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases –

anterior instability

7. Posterior shoulder testa. Posterior apprehension test. Patient is supine as the doctor flexes patient shoulder in sagittal

plane to 90 degrees. Posterior force on patient’s elbow while adducting and medially rotating while doctor has one hand on the elbow and one to stabilize the scapula. Positive test is apprehension on patient’s face or pain production

8. Test for acromioclavicular injurya. horizontal adduction compression test: patient is seated, abduct arm to 90 degrees then

horizontally adduct to full range. Pain occurs in AC joint before full adduction is reached

9. Joint play movementsa. backward glide of the humerusb. forward glide of the humerusc. lateral distraction of the humerusd. backward glide of the humerus in abductione. lateral distraction of the humerus in abductionf. scapular lift

Special tests for labral tears:1. Clunk test: patient is supine as examiner has one hand under the shoulder at humeral head.

Examiner’s other hand holds humerus above the elbow. Examiner fully abducts arm over patient’s head. Examiner then pushes anteriorly with hand under humeral head and with other hand, rotates, humerus into lateral rotation. Positive – clunk or grinding indicate labrum tear

2. Compression rotation test: Patient is supine as examiner grasps arm, flexes elbow, with arm abducted to about 30 degrees. Examiner pushes or compresses humerus in glenoid by pushing up on elbow while rotating humerus medially and laterally. Stabilize acromion with medial hand. If snapping or catching sensation felt, positive for labral tests (coracohumeral)


DO THE CORE EXMINATION OF THE KNEE AND CHECK FOR A MENISCAL TEARCore testsDone standing1. postural observationa. anterior: genu valgum/varum, bayonet sign, squinting patella (patella facing inward and

increased femoral anteversion/tibial torsionb. lateral: genu recurvatum (hyperextended – 15 degrees)c. posterior – popliteal fossa – baker’s cysts2. squatting – look for patellofemoral tracking problem3. duck waddling – pain upon walking in the squatted position i.e. meniscal tear4. Kneeling – pain may be prepatellar bursitis, patellofemoral arthralgia, meniscal/capsular5. Gait – observe6. Effusion – observation and palpation

Done sitting1. lateral postural observation

a. knee flexed at 45 degrees – normal patella, patella baja, patella alta (camel sign), tender tibial tuberosity

b. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter3. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line

up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury

Done supine1. Effusion2. Knee ranges of motion (active and passive)

Flexion – 0 to 135 degrees Extension – 0 to –15 degrees Medial rotation of tibia on the femur – 10 to 30 degrees Lateral rotation of tibia on the femur – 10 to 40 degrees

3. passive medial and lateral motion of the patella4. joint line tenderness – with the knee in 90 degrees of flexion (foot flat on table) apply thumb

pressure in the medial and lateral joint line. Joint line tenderness is highly sensitive for a meniscal tear.

5. Valgus stress – the knee is fully extended with a valgus stress applied, focussed at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for medial collateral ligament injury and/or capsular ligament injury

6. Varus stress – the knee is fully extended and a varus stress is applied, focused at the knee joint. Significant pain and/or gapping at the medial knee is a positive sign for lateral collateral ligament injury and/or capsular ligament injury (30 degrees of flexion)

7. Hyperextension test - the knee is fully extended, the foot is grasped at the heel and raise, flexing the legs at the hips. Significant hyperextension of the knees (> 15 degrees) is a positive sign for laxity of the cruciate ligaments and/or arcuate complex. Inability to fully the knee 20 to 30 degrees may indicate a loose body or meniscal tear.


8. Bounce home test – the patient’s foot is cupped in the examiner’s hand and the patient’s knee is passively allowed to extend from full flexion. If extension is not complete or has a rubbery end feel, this is a positive sign for a possible torn meniscus, displaced meniscal flap, loose body, articular damage or torn ACL.

9. Posterior sag sign – the patient is supine with the hip flexed to 45 degrees and the knee to 90 degrees. In this position, the tibia will drop back or sag back on the femur if the posterior cruciate ligament is torn.

10. Anterior drawer test – with the hip flexed 45 degrees and the knee flexed 90 degrees, the patient’s foot is heel on the table the examiner’s body with the examiner sitting on the patient’s forefoot. The examiner’s hands are then placed around the proximal tibia and the tibia is then drawn forward on the femur. The test is positive fi the tibia moves forward on the femur, more than 0.5 cm indicating injury to the anterior cruciate ligament.

11. Posterior drawer test – same position as above except the tibia is pushed backward on the femur. The test is positive if the tibia moves backwards on the femur more than 0.5 cm, indicating injury to the posterior cruciate ligament

12. Lachman’s test – patient lies in a supine position and the examiner holds the patient’s knee between full extension and 30 degrees of flexion. The patient’s femur is stabilized with one of the examiner’s hands while the proximal aspect of the tibia is movement forward with the other hand. A positive sign is a mushy or soft end feel when the tibia is moved forward on the femur (anterior cruciate ligament).

13. McMurray’s testa. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral

rotation. The knee is extended slowly while applying a valgus force. A click in the region of the medial joint line à medial meniscus lesion.

b. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line à medial meniscus lesion.

14. Noble compression test – the patient lies in a supine position and the examiner flexes the knee to 90 degrees, accompanied by hip flexion. Pressure is then applied 1 to 2 cm proximal to the lateral femoral epicondyle with the thumb. While the pressure is maintained, the patient’s knee is passively extended. This is a positive test if at about 30 degrees of flexion, the patient complains of severe pain under the examiner’s thumb à iliotibial band syndrome.

Special tests:1. Steinmann’s test – starting with the knee flexed to 90 degrees forced external rotation gives

pain on the medial joint line. Conversely, internal rotation gives lateral joint pain. The test is formed with varying degrees of knee flexion. When joint line moves posteriorly with increasing degrees of flexion, it tends to distinguish meniscal pathology from injury of capsular ligaments.

2. Anderson’s medial-lateral grind test – with the patient lying supine, the examiner grasps the tibia firmly with one hand and the index finger and thumb of the opposite hand are placed over the anterior joint line. A valgus stress is applied as the knees is flexed to 45 degrees and a varus stress is applied as it is extended. This produces a circular motion and should be repeated with progressive stress. A longitudinal or flap tear of the meniscus produces a distinct grinding sensation at the joint line whereas a complex tear produces prolonged grinding (meniscus tear)


To be done prone1. Apley’s grind test – patient is prone, the knee is flexed 90 degrees and the joint is compressed

while rotating the tibia internally and externally. Positive test is knee pain à meniscal tear2. Apley’s distraction test – the knee is flexed to 90 degrees and the patient’s thigh is then

anchored to the table by the examiner’s knee. The examiner then medially and laterally rotates the tibia combined with distraction, noting any restriction or discomfort. A positive sign is pain and the lesion is probably ligamentous à meniscal tear

Soft tissue palpationa. quads and tendonb. VMOc. Hamstring musclesd. ITBe. Popliteus


DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT PATELLOFEMORAL SYNDROMES

Core testsDone standing1. postural observation

a. anterior: genu valgum/varum, bayonet sign, squinting patella (patella facing inward and increased femoral anteversion/tibial torsion

b. lateral: genu recurvatum (hyperextended – 15 degrees)c. posterior – popliteal fossa – baker’s cysts

2. squatting – look for patellofemoral tracking problem3. Kneeling – pain may be prepatellar bursitis, patellofemoral arthralgia, meniscal/capsular4. Gait – observe5. Effusion – observation and palpation



b. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter2. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury.













12. McMurray’s testc. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral


d. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line à medial meniscus lesion.


Special tests done supine1. Resisted knee extension – pain – retropatellar inflammation could indicate patellofemoral

arthralgia2. Compression test – with the knee in extension, the patella is compressed in the

patellofemoral groove. Repeat the test with 30 degrees knee flexion. The test is positive if patellar pain is produced at both locations. It may indicate patellofemoral lesion, malalignment, and/or chondromalacia patella

3. Apprehension test – the patient’s quadriceps re relaxes and knee flexed to 30 degrees while the examiner carefully and slowly pushes the patella laterally. A positive test is when the patient contracts the quadriceps muscles to bring the patella back into line as he/she feels as if it is going to dislocate. This is a test for dislocation of the patella.

4. Clarke’s sign – the examiner presses down slightly proximal to the upper pole of the patella with the web of the hand as the patient lies relaxed with the knee extended. The patient is then asked to contract the quadriceps muscles while the examiner pushes down. If the pain causes retropatellar pain and the patient cannot hold a contraction, the test is considered positive à chondromalacia patellae


Soft tissue palpationc. quads and tendond. VMOe. Hamstring musclesf. ITBg. Popliteus


DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND CHECK FOR AN ACL TEARCore testsDone standing1. postural observation



2. squatting – look for patellofemoral tracking problem3. Gait – observe4. Effusion – observation and palpation



b. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter2. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury








8. Bounce home test – the patient’s foot is cupped in the examiner’s hand and the patient’s knee is passively allowed to extend from full flexion. If extension is not complete or has a rubbery


end feel, this is a positive sign for a possible torn meniscus, displaced meniscal flap, loose body, articular damage or torn ACL.




12. Lachman’s test – patient lies in a supine position and the examiner holds the patient’s knee between full extension and 30 degrees of flexion. The patient’s femur is stabilized with one of the examiner’s hands while the proximal aspect of the femur is movement forward with the other hand. A positive sign is a mushy or soft end feel when the tibia is moved forward on the femur (anterior cruciate ligament).

13. McMurray’s testa. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral


b. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line à medial meniscus lesion.


Special tests done supine1. Slocum test

a. set as anterior drawer test, but the foot is first placed in 30 degrees medial rotation and the examiner draws the tibia forward. If excessive movement occurs it indicates an anterolateral rotary instability with possible injury to the anterior cruciate ligament and the lateral collateral ligament

b. set as anterior drawer test, but the foot is placed in 15 degrees lateral rotation and the examiner draws the tibia forward. If excessive movement occurs it indicates an anteromedial rotary instability with possible injury to the anterior cruciate ligament and the medial collateral ligament.

2. Lateral Pivot shift maneuver – hip is flexed to 20 degrees. The examiner holds the patient’s foot with one hand while the other hand flexes the knee by placing it behind the fibula. The examiner then applies a valgus stress to the knee as it is flexed to 30 to 40 degrees and varus stress to ankle, while maintaining a medial rotation of the tibia. it is positive if the tibia


reduces or jogs backward and the patient may feel as if it were giving way. This is for anterolateral rotary instability – anterior cruciate ligament.



DO THE CORE ORTHOPEDIC EXAMINATION OF THE WRIST AND HAND1. observation and palpationa. general – vasomotor changes, hypertrophy of one or more fingers, ulcerations, temperature or

color changesb. palmar aspect – muscle wasting of thenar eminence (median), first dorsal interosseous

muscle (C7) and hypothenar eminence (ulnar nerve)c. dorsum of hand – localized swelling, effusion and synovial thickening, Heberden’s nodes,

Bouchard’s nodes, spoon shaped or clubbed fingernails

2. Ranges of motion – active and passive and resisteda. pronation of the forearmb. supination of the forearmc. wrist abductiond. wrist adductione. wrist flexionf. wrist extensiong. finger flexionh. finger extensioni. finger abductionj. finger adductionk. thumb flexionl. thumb extensionm. thumb abductionn. thumb adductiono. opposition of little finger and thumb

Capsular patternsCapsular pattern PainDistal radioulnar joint Full ROM with pain at the extremes of

supination and pronationWrist Equal limitation of flexion and extensionMCP and ICP Flexion more limited than extension

Special orthopedic tests1. Finkelstein’s test – the patient makes a fist with the thumb tucked inside the other fingers.

The examiner stabilizes the lower forearm and with the other hand gently forces the wrist into ulnar deviation. Pain over the radial styloid process – stenosing tenosynovitis (de quervain’s disease)

2. Tinel’s sign at the wrist – the examiner taps over the median nerve at the wrist. Positive distal tingling in the thumb, index, middle and lateral half of ring finger à carpal tunnel syndrome

3. Phalen’s test – the patient puts the backs of both hands together and holds the wrists in forced flexion for one minute. Positive is numbness and tingling along the median nerve distribution in the hand à median nerve entrapment


4. Froment’s sign – the patient attempts to grasp a piece of paper between the thumb and index paper. The examiner attempts to pull the paper away. Positive: the terminal phalanx of the thumb will flex because of paralysis of the adductor pollicus muscle à ulnar nerve

5. Allen’s test – the patient is asked to open and close the hand several times as quickly as possible and then squeeze the hand tightly. The examiner’s thumb and index finger are placed over the radial and ulnar arteries. The patient then opens the hand while pressure is maintained over the arteries. One artery is tested by releasing the pressure over the artery to see if the hand flushes. Then the other artery is tested in a similar fashion. Positive: the hand does not flush when pressure is release à reduced patency of the tested artery

6. Bunnel-Littler test – the MCP joint is held slightly extended the examiner passively moves the PIP joint into flexion, if possible. Positive: the PIP is not able to be flexed.

Do dermatomes and cutaneous distribution.


DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE FOOT AND ANKLE

1. Inspection – compare weight-bearing with non-weight-bearing. Look for: pes planus, supination/pronation, bumps, exostoses, forefoot splaying, swelling/pitting edema, toe deformities, Achilles tendon deviation, tibial varum

2. Check for muscle bulk, arches, wear pattern on shoes, hips, knees, tibia, fick angle, gait, include heel and toe walking and inner and outer border walking

3. ROM (active, passive and resisted) Dorsiflexion Plantar flexion Inversion Eversion Forefoot abduction Forefoot adduction Supination Pronation

Orthopedic tests1. anterior drawer2. talar tilt – patient sitting, supine or side lying. Stabilize the tibia and fibular, introduce

inversion to the talus. Positive: excessive motion indicates torn anterior talofibular and calcaneofibular ligaments.

3. Eversion test – same setup as talar tilt, but introduce eversion. Positive: excessive motion indicates a torn deltoid ligament.

4. Kleiger test – patient is sitting and introduce forefoot abduction. Positive test – excessive motion and indicates a torn deltoid ligament.

5. Homan’s sign – patient supine and introduced dorsiflexion of the ankle. Positive test – pain in the calf and indicates deep vein thrombophlebitis

6. Thompson test – patient prone or kneeling and squeeze the calf. Positive test is lack of plantar flexion and indicates a torn Achilles tendon

7. Forefoot neuroma – squeeze the forefoot. Positive test indicates a neuroma8. Plantar fascia tenderness – palpate the anteroinferior portion of the calcaneous for tenderness.

Pain is usually indicative of plantar fasciitis.


DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR BICIPITAL TENDONITIS1. Observationa. Anteriorly







2. Active movements ***do C-spine***Range of motion Motion (°) FindingsForward flexion 160 to 180Abduction 160 to 180Lateral rotation 80 to 90 Most restricted in frozen

capsular shoulderMedial rotation 60 to 100Extension 50 to 60Adduction 50 to 75Horizontal adduction/abductionCircumduction

Scapulohumeral rhythm is 1:2 ration – look for shoulder hiking sign Any painful arc? 60 to 120 – rotator cuff tear; 120 to 180 – AC joint problem Is clavicle moving Apley’s scratch test: do extension/adduction/medial rotation Then do


3. passive movement


Do supine with the shoulder girdle to be examined by side of table. If there are restrictions, note the end feel, muscular spasm or hypertonicity, and capsular pattern (lateral rotation/abduction, medial rotation) abduction medial and lateral rotation flexion locking test quadrant test















6. Anterior shoulder testa. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate

patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases –






9. Joint play movementsA . backward glide of the humerusb. forward glide of the humerusc. lateral distraction of the humerusd. backward glide of the humerus in abductione. lateral distraction of the humerus in abductionf. general movement of the scapula upon thorax


DO A CORE EXAMINATION OF THE HIP AND EXPLAIN THE DIFFERENCE BETWEEN BARLOW’S AND ORTOLANI’S TESTS.Do standing1. Postural observationa. anterior – note any abnormality of the bony and soft tissue contours, swelling in the hip joint

is difficult to detect, excessive femoral anteversion (toeing in), femoral retroversion (toeing out)

b. lateral – abnormal contour of buttock, hip flexion deformity, increased lumbar lordosis (iliopsoas contracture)

c. posterior – check bony and soft tissue contours, iliac crest height, PSIS

2. Trendelenburg test – pelvis on suspended side drops instead of rising. This indicates either a weak gluteus medius or an unstable hip on the weight-bearing side.

3. Gait analysis – antalgic limp, trendelenburg gait, OA (will not extend hip, no toe off)

4. Squatting – decrease flexibility

Do supine1. HIP ranges in of motion –active and passivea. flexionb. extensionc. adductiond. abductione. lateral rotationf. medial rotation

2. resisted isometric movements of the hipa. flexion – hip and knee are flexed at 90 degreesb. extension – hip is flexed minimallyc. adductiond. abductione. lateral rotationf. medial rotationg. knee flexion – knee is flexed at 90 degrees and hip is flexed at 45 degreesh. knee extension – knee is flexed at 60 degrees and hip is flexed at 30 degrees

3. True leg length – measure from ASIS to ipsilateral medial malleolus. 1 to 1.5 cm may be normal but may still cause symptoms

4. apparent leg length – measurements from umbilicus to the medial malleolus. A difference in leg length may indicate an iliopsoas

5. Thomas test – iliopsoas contracture and rectus femoris contracture


6. Patrick’s fabere – if the test leg remains above the opposite straight leg, it may indicate a hip joint dysfunction, a sacroiliac joint dysfunction, an iliopsoas spasm or an adductor spasm.

7. Noble compression test – done supine

Do side lying1. Ober’s test – the patient is in the sidelying position with the lower leg flexed at the hip and

knee for stability. The examiner then passively abducts and extends the patient’s upper leg with the knee straight. The examiner then lowers the upper limb. It is a positive sign for tensor fascia lata contracture if the test leg remains abducted and does not fall to the table.

Do prone1. Hip ranges of motion – extension (0 to 30 degrees)2. Ely’s (femoral nerve stretch) test – the examiner passively flexes the patient’s knee while

lying prone. A positive sign for rectus femoris contracture is anterior thigh pain or the patient’s ipsilateral hip will spontaneously flex. Severe anterior thigh pain upon knee flexion may be indicative of L3 nerve root irritation. The test is repeated on the other side.

Orthopedic testing of the pediatric hip1. Ortolani’s sign – with the infant supine, the thighs are grasped so that the examiner has

his/her index and middle fingers over the greater trochanters. He/she then flexes the hips and with gentle traction the thighs are abducted and pressure is applied against the greater trochanters of the femur. If the examiner feels a “click”, “clunk”, or a “jerk”, the hips has reduced and is a positive test for Congenital Dislocation of the hip.

2. Barlow’s test – modification of Ortolani’s sign. Each hip is evaluated individually, while the other hand stabilizes the pelvis. The hip is taken into abduction while the examiner’s middle finger applies forward pressure behind the greater trochanter. If the femoral head slips forward into the acetabulum with click, clunk or jerk, the test is positive, indicating that the hip was dislocated. Then the examiner uses the thumb to apply pressure backward and outward on the inner thigh. If the femoral head slips out and reduces again, once the pressure is removed, it is a positive sign for an unstable hip. The hips is DISLOCATABLE, not DISLOCATED. The procedure is repeated for the other hip.

3. Galeazzi’s sign (Allis’ test) – the child lies in the supine position with the knees flexed to 90 degrees. If one knee is lower than the other it is a positive sign and may indicate a unilateral hip dislocation deformity.

4. Telescoping – the child lies supine and the examiner flexes the knee and hip to 90 degrees. The femur is pushed down into the table and then pulled up. In a normal hip little movement occurs. If a lot of relative movement occurs it is a positive sign for a possible dislocated hip.


DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE TMJHistory

Inspection Facial asymmetry, mastoid, lips, cheek Hypertrophy, hypertonicity of muscles of mastication Posterior cervical muscles, accessory muscles of respiration Hands – evidence of RA Assess speech Auditory acuity Swallowing

Posture Head carriage, head position, head tilt, head movement Resting position of the jaw Musculature of the head, neck, back, chest and leg Any tenderness to touch, trigger points or spasm

ROM: active, passive and resisted for Cervical spine Shoulder Thoracic spine Lumbar

Note: unleveling, scoliosis, kyphosis, leg length inequality

Mandibular gait Opening 40 to 60 mm, three knuckle test Closing – pain or double contact Lateral deviation 5-10 mm Ratios of opening: lateral deviation –1:4 normal, 1:3 extracapsular, 1:6 intracapsular Protrusion 5 mm Retrusion 3-4 mm

Palpation Joint tenderness to touch Crepitus, cracking, clicking Bruxomania Trigger points: lateral pterygoid, medial pterygoid, masseter, temporalis, SCM digastric Joint play and end feel

a. distraction inferolateral at 20 degrees at rest (extraoral) and at open (intraoral)b. lateral deviationc. posterosuperior (disc, RDT)


Resisted muscle tests:Opening Closing Protrusion Retrusion Lateral

deviationMasseter + +Temporalis + + +Med Ptery + + +Inf Later Ptery

+ + +

Digastric + +Sup lat Ptery + +

Percussion general – sharply close teeth – pain à periodontal disease specific – tap each tooth with a blunt instrument

Vapocoolant spray test

Cervical spine exam

Neurological exam


DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND CHECK FOR POSTERIOR SHOULDER INSTABILITY1. Observationa. Anteriorly







2. Active movements *** do C-spine ***Range of motion Motion (°) FindingsForward flexion 160 to 180Abduction 160 to 180Lateral rotation 80 to 90 Most restricted in frozen




3. passive movement


6. Anterior shoulder testa. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate

patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases –




b. load and shift test – patient sitting with arm resting on thigh. Examiner stands behind patient, stabilizes clavicle and scapula with one hand. With the other hand, examiner grasps the head of the humerus with the thumb over the posterior humeral head and fingers over anterior humeral head. The humerus is gently pushed in the glenoid fossa. The examiner then pushes the humeral pushes the humeral head anterior (anterior instability) and posterior (post instability). 25% of diameter of humeral head considered normal for anterior translation and 50% of diameter of humeral head considered normal for posterior translation.



9. Joint play movementsa. backward glide of the humerusb. forward glide of the humerusc. lateral distraction of the humerusd. caudal glidee. backward glide of the humerus in abductionf. lateral distraction of the humerus in abductiong. anteroposterior and cephalocaudal movement of the clavicle at the AC jointh. anteroposterior and cephalocaudal movement of the clavicle at the SC jointi. general movement of the scapula upon thorax


DO A THOROUGH ORTHOPEDIC EXAMINATION OF THE ELBOWObservation normal carrying angle 5 – 10 degrees in the male and 10 to 15 degrees swelling – general see approximately 70% of flexion; localized is olecranon bursitis normal bony and soft tissue contours – biceps tendon and contour normal functional position of the elbow

Palpation can be done sitting or lying supine, palpate the following structuresAnterior aspect Cubital fossa for biceps tendon and brachial artery)

Coronoid process and head of radius The relevant muscles

Medial aspect Medial epicondyle and common insertion of wrist flexor forearm pronator muscles (golfer’s)

Medial collateral ligament Ulnar nerve

Lateral aspect Lateral epicondyle and common extensor tendon (tennis) Lateral collateral ligament Annular ligament

Posterior aspect Olecranon process and olecranon bursa Triceps muscle

Range of motionActive Passive Resisted

Elbow flexion + + +Elbow extension + + +Supination of the forearm

+ + +

Pronation + + +Wrist flexion +Wrist extension +

Special orthopedic tests1. hyperextension/hyperflexion stress tests – the examiner tries to hyperextend/hyperflex the

patient'’ elbow. Positive: pain, limited motion or excessive motion2. valgus stress: the patient’s elbow is flexed a few degrees. With the superior hand, the

examiner cups the posterior aspect of the patient’s elbow. The other hand grasps the medial aspect of the patient’s wrist. With the superior hand acting as a fulcrum, the wrist is forced laterally. Pain and or laxity at the medial side à torn medial collateral ligament

3. varus stress – the patient’s elbow is flexed a few degrees. With his superior hand the examiner cups the posterior aspect of the patient’s wrist. With the superior hand acting as a fulcrum, the wrist is forced medially. Positive: pain and/or laxity at the lateral side of the elbow à torn lateral collateral ligament.

4. Cozen’s test – the patient flexes the elbow 90 degrees, pronates the forearm and extends the wrist. The examiner stabilizes the elbow (thumb placed on lateral epicondyle) with one hand


and with the other applies pressure to force the wrist into flexion. The patient tries to resist. Positive: pain at the lateral epicondyle à lateral epicondylitis.

5. Mill’s maneuver – the patient flexes the elbow 90 degrees, pronates the forearm, makes a fist and flexes the wrist. The examiner passively extends the elbow. Positive: pain at the lateral epicondyle à lateral epicondylitis

6. Golfer’s elbow test – while the examiner palpates the patient’s medial epicondyle, the patient’s forearm is supinated and the elbow and wrist are extended by the examiner. Positive: pain at the medial epicondyle à medial epicondylitis

7. Tinel’s sign – ulnar nerve is tapped. Positive: tingling sensation in the ulnar nerve distribution down the forearm and hand.

Reflexes and cutaneous distributionBiceps – C5Brachioradialis – C6Triceps – C7

Nerve compression around elbow jointNerve Syndrome CharacteristicsMedian nerve Pronator syndrome Resisted pronation of the extended

forearm stresses the pronator teres muscles

Resisted elbow flexion and forearm supination stresses the laceratus fibrosus

Resisted flexion of the long finger PIP joint stresses the flexor digitorum superficialis arch

Anterior interosseous nerve Pinch deformity Weakness of pronator quadratus – elbow

fully flexed to eliminate pronator teres, then resist pronation

Radial nerve Posterior interosseous nerve Resistance to supination Long finger extension resistance test

Ulnar nerve Compressed in cubital tunnel or between two heads of flex carp

Tine’s sign Maintain full elbow flexion and

pronation


DO THE CORE ORTHOPEDIC EXAMINATION OF THE SHOULDER AND RULE OUT AN ANTERIOR SHOULDER INSTABILITY1. Observationa. Anteriorly







2. Active movements *** Do C-spine***Range of motion Motion (°) FindingsForward flexion 160 to 180Abduction 160 to 180Lateral rotation 80 to 90 Most restricted in frozen




3. passive movement


6. Anterior shoulder testa. load and shift test: patient sitting with arm resting on thigh. Examiner stands behind patient,

stabilizes clavicle and scapula with one hand. With the other hand, examiner grasps the head of the humerus with the thumb over the posterior humeral head and fingers over anterior humeral head. The humerus is gently pushed in the glenoid fossa. The examiner then pushes the humeral pushes the humeral head anterior and posterior. 25% of diameter of humeral head considered normal for anterior translation and 50% of diameter of humeral head considered normal for posterior translation.

b. Apprehension test: Patient is supine with arm abducted to 90 degrees. Laterally rotate patient’s shoulder slowly. A look or feeling of apprehension and resistance to further movement represents a positive test. If positive, examiner applies a posterior pressure and apprehension and pain decreases –

anterior instabilityc. Rowe test: patient is supine with hand behind the head. Examiner places clenched fist

against posterior head of humerus and pushes while extending arm slightly. A look of apprehension is positive for anterior instability.





9. Joint play movementsa. backward glide of the humerusb. forward glide of the humerusc. lateral distraction of the humerusd. caudal glidee. backward glide of the humerus in abductionf. lateral distraction of the humerus in abductiong. anteroposterior and cephalocaudal movement of the clavicle at the AC jointh. anteroposterior and cephalocaudal movement of the clavicle at the SC jointi. general movement of the scapula upon thorax


DO THE CORE ORTHOPEDIC EXAMINATION OF THE KNEE AND RULE OUT A PLICACore testsDone standing1. postural observation



2. squatting – look for patellofemoral tracking problem3. Gait – observe4. Effusion – observation and palpation


c. knee flexed at 45 degrees – normal patella, patella baja, patella alta (camel sign), tender tibial tuberosity

d. knee at 90 degrees – enlarged tibial tuberosity i.e. Osgood-Schlatter2. Modified Helfet – extend knee from 90 degrees to 0. Normally the tibial tubercle should line up with the lateral border of the patella. If not, lateral rotation is blocked, indicating a possible meniscal or cruciate injury








8. Bounce home test – the patient’s foot is cupped in the examiner’s hand and the patient’s knee is passively allowed to extend from full flexion. If extension is not complete or has a rubbery


end feel, this is a positive sign for a possible torn meniscus, displaced meniscal flap, loose body, articular damage or torn ACL.





13. McMurray’s testc. lateral rotation – the hip and knee are maximally flexed and the tibia is placed in lateral


d. medial rotation – the hip and knee are maximally flexed and the tibia is placed in medial rotation. The knee is extended slowly while applying a varus force. A click in the region of the lateral joint line à medial meniscus lesion.


Special tests done supine15. Hughston plica test – patient’s knee is passively flexed and extended while palpating

medially for a popping16. Mediopatellar plica test – as the knee is flexed to 30 degrees, the patella is passively moved

medially. If pain is felt, it could be a symptomatic plica


documentc6

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