clinical examination of the musculoskeletal system
TRANSCRIPT
Clinical Examination of the MusculoskeletalSystem
CLINICAL EXAMINATION OF THEMUSCULOSKELETAL SYSTEM
RICHARD LEBERT AND KELLY OULD
Clinical Examination of the Musculoskeletal System by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike4.0 International License, except where otherwise noted.
CONTENTS
Introduction 1
Part I. Neurological Assessment
1. Cranial Nerve Function 3
2. Upper Limb Neurological Examination 6
3. Lower Limb Neurological Examination 9
4. Full Motor, Sensory, and Reflex Examination 12
5. Proprioception 13
6. Manual Muscle Testing 14
Part II. Headaches and Migraines
7. Outcome Measures for Headaches and Migraines 17
8. Bone & Soft Tissue Palpation for Headaches and Migraines 18
9. Cervical Flexion-Rotation Test 19
Part III. Temporomandibular Joint Assessment
10. Outcome Measures for Temporomandibular Disorders 21
11. Bone & Soft Tissue Palpation for Temporomandibular Disorders 22
12. Jaw Reflex Test 23
13. Chvostek Test 24
14. Three Knuckle Test 25
Part IV. Cervical Spine Assessment
15. Outcome Measures for The Cervical Spine 27
16. Bone & Soft Tissue Palpation for The Cervical Spine 28
17. Vertebral Artery Test 29
18. Spurling’s Test 30
19. Cervical Distraction Test 31
20. Cervical Compression Test 32
21. Scalene Cramp Test 33
22. Adson’s Test 34
23. Halstead Maneuver OR Reverse Adson’s Test OR Wright’s Test OR Hyperabduction Test 35
24. Costoclavicular Test (Military Brace) 36
25. Upper Limb Neurodynamic Tests 37
Part V. Shoulder Assessment
26. Outcome Measures for The Shoulder 40
27. Bone & Soft Tissue Palpation for The Shoulder 41
28. Apprehension Test OR Crank Test 42
29. Hawkins Kennedy Impingement Test 43
30. Acromioclavicular Shear Test 44
31. Speed’s Test 45
32. Yergason’s Test 46
33. Empty Can (Supraspinatus) Test 47
34. Drop Arm Test OR Codman’s Test 48
35. Apley’s Scratch Test 49
36. Sulcus Sign Test 50
37. Neer’s Test 51
38. Roo’s Test (EAST) 52
39. SLAP Lesion Cluster 53
40. Load & Shift - Anterior 54
41. Scapular Retraction Test 55
42. Crossbody Adduction Test (Acromioclavicular Crossover) 56
43. Posterior Capsule Tightness 57
44. Serratus Anterior Strength Test (Punch Out) 58
45. Jerk Test (Posteroinferior Labral Tear) 59
46. O’Brien Test (Active Compression Test) 60
47. Lift-off Sign 61
48. Abdominal Compression Test (Belly Press or Napoleon Test) 62
49. Painful Arc Test 63
Part VI. Elbow Assessment
50. Outcome Measures for The Elbow 65
51. Bone & Soft Tissue Palpation for The Elbow 66
52. Elbow Valgus and Varus Stress Tests 67
53. Moving Valgus Stress Test of the Elbow 69
54. Cozen’s Test 70
55. Mill’s Test 71
56. Medial Epicondylitis Test (Golfers Elbow) 72
57. Tinel's Sign's at the Elbow (Cubital Tunnel Syndrome) 73
58. Pronator Teres Syndrome Test 74
59. Elbow Flexion Test 75
Part VII. Forearm, Wrist, and Hand Assessment
60. Outcome Measures for The Forearm, Wrist, and Hand 77
61. Bone & Soft Tissue Palpation for The Forearm, Wrist, and Hand 78
62. Finklestein’s Test 79
63. Sweater Finger Sign 80
64. Carpal Compression Test 81
65. Phalen’s Test 82
66. Allen's Test 83
67. Murphy’s Sign 84
68. Tinel’s Sign - Median Nerve 85
69. Hoffman’s Sign 86
70. Froment's Sign (Pinch Grip Test) 87
71. Triangular Fibrocartilage Complex (TFCC) Load 88
Part VIII. Thoracolumbar Spine and Pelvis Assessment
72. Outcome Measures for The Thoracolumbar Spine and Pelvis 90
73. Bone & Soft Tissue Palpation for The Thoracolumbar Spine and Pelvis 91
74. Craig's Test 92
75. Gaenslen’s Test 93
76. Gillet’s Test 94
77. Kemp’s Test OR Lower Quadrant Test 95
78. Kernig/Brudzinski Test 96
79. Rebound Tenderness (McBurney’s Point) 97
80. Piriformis Test OR FAIR Test 98
81. Cluster of Laslett (Sacroiliac Joint Pain Provocation) 99
82. Sacroiliac Compression (Squish) Test 100
83. Sacroiliac Distraction (Gap) Test 101
84. Thigh Thrust Test 102
85. Sacral Thrust Test 103
86. Slump Test 104
87. True Leg Length Measurement 106
88. Valsalva Maneuver 107
89. Well Leg Raise 108
90. Straight Leg Raise (Lasègue's sign) or Bragard's Test 109
91. Bowstring Maneuver 111
92. Supine-to-sit (Long Sitting) 112
93. Hoover Test 113
94. Prone Gap (Hibb's) Test 114
95. Pheasant Test (Lumbar Instability Test) 115
96. Nachlas (Prone Knee Bend) Test 116
97. Yeoman's Test 117
Part IX. Hip Assessment
98. Outcome Measures for The Hip 119
99. Bone & Soft Tissue Palpation for The Hip 120
100. FABER (Patrick’s) Test 121
101. FADDIR (Flexion-Adduction-Internal Rotation) Test 122
102. Trendelenburg Sign 123
103. Thomas Test 124
104. Ely’s Test 125
105. Ober’s Test 126
106. 90-90 Straight Leg Test 128
107. Piriformis Strength Test (Pace Maneuver) 129
108. Hip Quadrant Test (Scouring Test) 130
Part X. Knee Assessment
109. Outcome Measures for The Knee 132
110. Bone & Soft Tissue Palpation for The Knee 133
111. Bounce Home Test 134
112. Apley's Test 135
113. McMurry’s "Click" Test 137
114. Valgus Stress Test (Medial Collateral Ligament) 138
115. Varus Stress Test (Lateral Collateral Ligament) 140
116. Noble’s Compression 142
117. Lachman’s Test 143
118. Anterior Drawer Test 144
119. Posterior Drawer Test 145
120. Posterior Sag Sign (Gravity Drawer Test) 146
121. Coronary Ligament Stress Test 147
122. Patellar Grind Test (Clarke’s Sign) 148
123. Thessaly Test 149
124. Bragard’s Sign 150
125. Mediopatellar Plica Test (Hughston Plica Test) 151
126. Plica “Stutter” Test 152
127. Brush Test (Minor Effusion, Stroke, OR Wipe Test) 153
128. Ballotable Patella (Major Effusion or Patellar Tap Test) 154
129. Fluctuation Test 155
130. Waldron’s Test 156
131. McConnell Patellofemoral Knee Test 157
132. Q-Angle 158
133. Patellar Apprehension Test 159
134. Patellar Deep Tendon Reflex 160
Part XI. Lower Leg, Ankle, and Foot Assessment
135. Outcome Measures for The Lower Leg, Ankle, and Foot 162
136. Bone & Soft Tissue Palpation for The Lower Leg, Ankle, and Foot 163
137. Functional/Structural Pes Planus Test 164
138. Talar Tilt Test 165
139. Anterior Drawer of the Ankle 166
140. Calcaneocuboid Stress Test 167
141. Calcaneofibular Stress Test 168
142. Talofibular Ligament Stress Test (Anterior & Posterior) 169
143. Deltoid Ligament Stress Test 171
144. Dorsiflexion External Rotation Stress Test (Kleiger Test) 172
145. The Syndesmosis Squeeze Test 173
146. Toe/Heel Walking 174
147. Thompson’s Test 175
148. Tinel’s Sign at Tarsal Tunnel 176
149. Tinel's Sign - Anterior Tarsal Tunnel 177
150. Morton’s Neuroma Test (Metatarsal Squeeze Test) 178
151. Homan’s Sign 179
152. Babinski Test/Reflex 180
References and Resources 181
Acknowledgement 184
This Book Is A Living Document
This is an Open Educational Resource (OER) for commonly used orthopedic tests and outcome measurements. Thisresource is a living document that will be periodically updated to ensure current best practices are in place. In addition,it will be monitored and updated throughout the life cycle, based off Paul Hibbits Learning & Technology DevelopmentProcess Model and it will be updated and systematically edited for clarity and flow.
Note: This resource is not and should be taken as medical advice, it is educational content for health care professionalsand students.
PART I
NEUROLOGICAL ASSESSMENT
Neurological Assessment
• Cranial Nerve Function• Upper Limb Neurological Examination• Lower Limb Neurological Examination• Full Motor, Sensory, and Reflex Examination• Proprioception• Manual Muscle Testing
1.
CRANIAL NERVE FUNCTION
Cranial Nerve Function
Number Mnemonic Cranial Nerve Function (S/M/B) Mnemonic
I On Olfactory Smell (S) Some
II On Optic Vision (S) Say
III On Oculomotor Eye Movements (M) Marry
IV They Trochlear Eye Movements (M) Money
V Traveled Trigeminal Sensory/motor – face (B) But
VI And Abducens Eye movements (M) My
VII Found Facial Motor-face, Taste (B) Brother
VIII Voldemort Vestibulocochlear(Auditory) Hearing/Balance (S) Says
IX Guarding Glossopharyngeal Motor – throat Taste (B) Big
X Very Vagus Motor/sensory –viscera (autonomic) (B) Bucks
XI Ancient Accessory Motor-head &neck (M) Mean
XII Horcruxes Hypoglossal Motor-lower throat (M) More
4 | CRANIAL NERVE FUNCTION
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CRANIAL NERVE FUNCTION | 5
2.
UPPER LIMB NEUROLOGICAL EXAMINATION
Upper Limb Neurological Examination
Myotomes, Dermatomes and Reflexes of the Upper Limb
NerveRoot Motor Test Reflex Test Sensory Test
C1-C2 Neck flexion N/AC1 – Vertex (top) of the skull
C2 – Temple forehead and occiput
C3 Neck lateral flexion N/A Entire neck, posterior cheek, temporal area
C4 Shoulder elevation N/A Shoulder area, clavicular area, upper scapular area
C5 Shoulder abduction Biceps Lateral arm, pure sensation is a round patch on the lateral aspect of thedeltoid m.- the axillary nerve
C6 Elbow flexionand wrist extension Brachioradialis Lateral forearm, thumb, index, and half of the middle finger –
branches of the musculocutaneous nerve
C7 Elbow extensionand wrist flexion Triceps Middle finger – radial nerve
C8 Interossei musclesand finger flexor N/A Distal half of the ulnar side of the forearm, and the ring and little
fingers of the hand.
T1 Interossei – finger abductors N/A Medial side of the upper half of the forearm and lower part of the arm
UPPER LIMB NEUROLOGICAL EXAMINATION | 7
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8 | UPPER LIMB NEUROLOGICAL EXAMINATION
3.
LOWER LIMB NEUROLOGICAL EXAMINATION
Lower Limb Neurological Examination
Myotomes, Dermatomes and Reflexes of the Lower Limb
NerveRoot Motor Test Reflex Test Sensory Test
T12,L1,L2, L3 Iliopsoas N/A
L1 – upper anterior portion of the thigh immediately below theinguinal ligament;
L3 – anterior thigh, immediately above the knee cap;
L2 – runs between L1 & L3
L2, L3,L4 Quadriceps N/A (See L4)
L4 Tibialis Anterior PatellarL4 – Medial buttock, lateral thigh, medial leg over
ankle and somewhat the dorsum of the foot and great toe
L5Extensor Hallucis
Longus
L4-5 – Tibialis posterior tendon
L5-S1 –Semimembranosis tendon
Buttock, posterior and lateral thigh, lateral aspect of the leg,dorsum of the foot – toes 2-4
S1
S1) Peroneus longus& brevis muscles;
S2) Gastrocnemius &Soleus muscles
S1-2 – Achilles
tendon reflex
Lateral malleolus and the lateral side and plantar surface of thefoot
S2, 3, 4
These are theprincipal nervesupplies for thebladder, & theintrinsic mm. of thefoot
N/A Concentric rings around the anus with the innermost ring as S4-5, and the outermost ring as S2
10 | LOWER LIMB NEUROLOGICAL EXAMINATION
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4.
FULL MOTOR, SENSORY, AND REFLEXEXAMINATION
Motor, Sensory, and Reflex Examination
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5.
PROPRIOCEPTION
Proprioception
Use: To assess for proprioceptive loss.Procedure: Grasp client’s affected finger or toe and passively move into flexion/extension; ask client to identify whatposition it’s inFindings: Incorrect answer or hesitation before answering indicates loss.Note: If the test is positive, repeat using the next proximal joint
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6.
MANUAL MUSCLE TESTING
Manual Muscle Testing (MRC Scale)
Uses: Manual muscle testing is used to see if there is an injury or pathology causing muscle weakness.
Findings: Muscle testing involves testing muscles against the examiner’s resistance and grading the individuals strengthon a 0 to 5 scale:
Score Description
0 No contraction
1 Flicker or trace of contraction
2 Active movement, with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power
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MANUAL MUSCLE TESTING | 15
PART II
HEADACHES AND MIGRAINES
7.
OUTCOME MEASURES FOR HEADACHES ANDMIGRAINES
Outcome Measures for Headaches and Migraines
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient Specific Functional Scale• Headache Impact Test 6-item (HIT-6)• Migraine-Specific Quality of Life Questionnaire (MSQ v2.1)• Patient Perception of Migraine Questionnaire (PPMQ-R)• The Migraine Disability Assessment (MIDAS)• Headache Disability Index
8.
BONE & SOFT TISSUE PALPATION FORHEADACHES AND MIGRAINES
Bone & Soft Tissue Palpation for Headaches andMigraines
A selection of regional structures to keep in mind while assessing and treating patients suffering from headaches andmigraines may include:
• Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)• Levator Scapula• Longus Colli & Capitis• Rhomboid Minor and Major• Occipitofrontalis• Corrugator Supercilii• Sternocleidomastoid• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Temporomandibular Joint
◦ Medial Pterygoid◦ Temporalis◦ Masseter◦ Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)◦ Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)
9.
CERVICAL FLEXION-ROTATION TEST
Cervical Flexion-Rotation Test
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PART III
TEMPOROMANDIBULAR JOINTASSESSMENT
Temporomandibular Assessment
Orthopedic Special Tests
• Jaw Reflex Test• Three Finger Test OR Knuckle Test• Chvostek Test
10.
OUTCOME MEASURES FORTEMPOROMANDIBULAR DISORDERS
Outcome Measures for Temporomandibular Disorders
You may consider incorporating one or more of the following outcome measurements when assessing and monitoringpatient progress:
• Self-Rated Recovery Question• Patient-specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• Numeric Pain Rating Scale (NRS)• Jaw Functional Limitation (JFL‐8)• Mandibular Function Impairment Questionnaire (MFIQ)• Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD)• Neck Disability Index (NDI)
11.
BONE & SOFT TISSUE PALPATION FORTEMPOROMANDIBULAR DISORDERS
Bone & Soft Tissue Palpation for TemporomandibularDisorders
A selection of regional structures to keep in mind while assessing and treating patients suffering fromtemporomandibular disorders may include:
• Medial Pterygoid• Temporalis• Masseter• Sternocleidomastoid• Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)• Infrahyoids Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)
12.
JAW REFLEX TEST
Jaw Reflex Test
Use: To assess the reflex of the TMJ (this is a test for CN V).
Procedure: Client seated; mouth relaxed and open in the resting position; therapist places thumb on chin of client andtaps thumbnail with reflex hammer.
Findings: If reflex is present, the jaw will appear to close
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13.
CHVOSTEK TEST
Chvostek Test
Use: Determine whether there is a pathology involving CN VII (facial) (Bell’s Palsy).
Procedure: Client seated; therapist taps the parotid gland overlying the masseter muscle (this will be over the area of thefacial nerve).
Findings: Positive findings with result in twitching of the facial muscles.
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14.
THREE KNUCKLE TEST
Three Knuckle Test
Use: To assess active free range of motion of the jaw in depression
Procedure: Instruct client to open mouth and place the knuckle of the 2-4 digits of the non-dominant hand betweenfront teeth
Findings: Hypomobility of the temporomandibular joint is indicated if the client can get one or less knuckles betweenthe incisors
*Note: normal is 2-3 knuckles
PART IV
CERVICAL SPINE ASSESSMENT
Cervical Spine Assessment
Orthopedic Special Tests
• Vertebral Artery Test• Foraminal Compression Test OR Spurling’s Test• Cervical Distraction Test• Cervical Compression Test• Scalene Cramp Test• Adson’s Test• Halstead Maneuver OR Reverse Adson’s Test OR Wright’s Test OR Hyperabduction Test• Costoclavicular Test (Military Brace)• Upper Limb Tension Tests (1, 2, 3, & 4)
15.
OUTCOME MEASURES FOR THE CERVICALSPINE
Outcome Measures for The Cervical Spine
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient-specific Functional Scale• Neck Pain and Disability Scale• Neck Disability Index
16.
BONE & SOFT TISSUE PALPATION FOR THECERVICAL SPINE
Bone & Soft Tissue Palpation for The Cervical Spine
A selection of regional structures to keep in mind while assessing and treating patients suffering from neck pain mayinclude:
• Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)• Levator Scapula• Longus Colli & Capitis• Rhomboid Minor and Major• Occipitofrontalis• Corrugator Supercilii• Sternocleidomastoid• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Temporomandibular Joint
◦ Medial Pterygoid◦ Temporalis◦ Masseter◦ Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)◦ Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)
17.
VERTEBRAL ARTERY TEST
Vertebral Artery Test
Use: To assess for deficiency of circulation of the vertebral artery
Procedure: Client seated or supine; active or passive rotation & extension of neck; 30 sec.
Findings: Dizzy, nystagmus – rapid eye movement back and forth
*Note: if positive, return head quickly and smoothly to neutral; no further testing, refer to MD; techniques with neck insimilar positions should also be avoided
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18.
SPURLING’S TEST
Spurling’s Test
Use: To assess for compression of cervical nerve root or facet joint irritation.
Procedure: Client seated; actively place neck in extension, lateral flexion, & rotation to affected side; carefully applydownward pressure on client’s head; no need to do if client has symptoms already.
Findings: Radiating pain or other neurological signs/symptoms on affected side; pain distribution will indicate whichnerve root is involved; local pain is a positive test for the facet joint.
CI: If positive for vertebral artery, do not do this one.
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19.
CERVICAL DISTRACTION TEST
Cervical Distraction Test
Use: To relieve pressure on nerve roots especially after Spurling’s and Cervical Compression
Procedure: Seated/supine, grasp head at occiput, put head into neutral & slowly traction superiorly, hold for 30 seconds
Findings: If pain reduces, test is positive for reducing pressure on facets or nerve roots; presence of pain may indicateshort intrinsics
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20.
CERVICAL COMPRESSION TEST
Cervical Compression Test
Use: As with Spurling’s but used can be used when client cannot rotate or extend head
Procedure: Client seated with neck in neutral, therapist stands behind & carefully applies downward pressure on clientshead
Findings: Radiating pain or other neurological signs and symptoms on affected side; pain distribution will indicate nerveroot is involved; local pain indicate facet joint
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21.
SCALENE CRAMP TEST
Scalene Cramp Test
Use: To reproduce pain of active scalene triggerpoints
Procedure: Client seated; Rotate head to affected side and pull chin inferiorly to the supraclavicular fossa
Findings: Positive findings is pain referred pattern for the scalene muscles
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22.
ADSON’S TEST
Adson’s Test
Use: To test for thoracic outlet syndrome caused by scalenes anticus tightness
Procedure: Straight arm, palpate radial pulse, extend arm and have client look over same side shoulder and hold breath
Findings: Positive finding is decreased radial pulse or a recreation of the clients signs and symptoms
Contraindication/Precautions: If unable to get full range of motion of the shoulder in the ranges required
Note: Holding breath activates the scalenes muscles which will further shorten/tighten them and make the signs andsymptoms easer to produce
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23.
HALSTEAD MANEUVER OR REVERSE ADSON’STEST OR WRIGHT’S TEST ORHYPERABDUCTION TEST
Halstead Maneuver OR Reverse Adson’s Test OR Wright’sTest OR Hyperabduction Test
Use: To test for thoracic outlet syndrome caused by pectoralis minor tightness.
Procedure: Straight arm, palpate radial pulse, abduct shoulder to >90 degrees with extension.
Findings: Positive findings is a decreased radial pulse or a recreation of the client’s signs and symptoms.
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24.
COSTOCLAVICULAR TEST (MILITARY BRACE)
Costoclavicular Test (Military Brace)
Use: To test for thoracic outlet syndrome caused by compression of the neurovascular bundle between the clavicle and1st rib
Procedure: Straight arm, palpate radial pulse, passively depress and retract shoulder
Findings: Positive finding is decrease radial pulse or a recreation of signs and symptoms
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25.
UPPER LIMB NEURODYNAMIC TESTS
Upper Limb Neurodynamic Tests (1,2,3,4)
Upper Limb Neurodynamic Tests (Koulidis et al., 2019)
1 2 3 4 5 6
ULNT –Median (1)
Shoulder girdlestabilization
Shoulderabduction
Wrist/fingerextension
Forearmsupination
Shoulder externalrotation
Elbowextension
ULNT –Median (2)
Shoulder girdledepression
Elbowextension
Shoulder externalrotation
Forearmsupination
Wrist/fingerextension
Shoulderabduction
ULNT –Radial (3)
Shoulder girdledepression
Elbowextension
Shoulder internalrotation
Forearmpronation
Wrist/fingerflexion
Shoulderabduction
ULNT –Ulnar (4)
Wrist/fingerextension
Forearmpronation Elbow flexion Shoulder external
rotationShoulder girdledepression
Shoulderabduction
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38 | UPPER LIMB NEURODYNAMIC TESTS
PART V
SHOULDER ASSESSMENT
Shoulder Assessment
Orthopedic Special Tests
• Apprehension Test OR Crank Test• Hawkins Kennedy Impingement Test• Acromioclavicular Shear Test• Speed’s Test• Yergason’s Test• Empty Can (Supraspinatus) Test• Drop Arm Test OR Codman’s Test• Apley’s Scratch Test• Sulcus Sign Test• Neer’s Test• Roo’s Test (EAST)• Slap Lesion Cluster• Load & Shift – Anterior• Scapular Retraction• AC Crossbody Adduction Test (Acromioclavicular Crossover)• Posterior Capsule Tightness• Serratus Anterior Strength Test (Punch Out)• Jerk Test (Posteroinferior Labral Tear)• Scapular Load Test• O’Brien Test (Active Compression Test)• Lift-off Sign• Abdominal Compression Test (Belly Press or Napoleon Test)• Painful Arc Test
26.
OUTCOME MEASURES FOR THE SHOULDER
Outcome Measures for The Shoulder
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient-specific Functional Scale• DASH Outcome Measure• Upper Extremity Functional Index• Western Ontario Rotator Cuff (WORC) Index
27.
BONE & SOFT TISSUE PALPATION FOR THESHOULDER
Bone & Soft Tissue Palpation for The Shoulder
A selection of regional structures to keep in mind while assessing and treating patients suffering from shoulder pain mayinclude:
• Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)• Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)• The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)• Deltoid Muscle Group (anterior, middle, posterior)• Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus• External Obliques, Internal Obliques, and Transverse Abdominal• Thoracolumbar Fascia, Latissimus Dorsi and Teres Major• Quadratus Lumborum
28.
APPREHENSION TEST OR CRANK TEST
Apprehension Test OR Crank Test
Use: To an in assess a previous dislocation in chronic.Procedure 1: Active Free – Client supine, abduct, extend, laterally rotate arm.Procedure 2: Passive Relax – Client supine, abduct, extend, laterally rotate arm.
Findings: Positive finding is apprehension or an unwillingness to move arm into position of injury.
Note: If active free is positive, do not perform passive relax and instead do active resisted of muscle crossing theglenohumeral joint. If active free is negative, progress to passive relaxed if passive relaxed is negative, carefully challengethe joint. In the anterior direction to further assess the integrity.
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29.
HAWKINS KENNEDY IMPINGEMENT TEST
Hawkins Kennedy Impingement Test
Use: To assess for supraspinatus tendinopathy
Procedure: Stabilize the scapula, passively abduct the shoulder to 90 degrees, flex the shoulder to 30 degrees, flex theelbow to 90 degrees, and internally rotate the shoulder
Findings: Positive finding is pain in shoulder
Note: Test may be performed in different degrees of forward flexion or horizontal adduction
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30.
ACROMIOCLAVICULAR SHEAR TEST
Acromioclavicular Shear Test
Use: To assess integrity of the acromioclavicular joint
Procedure: Cup clavicle and spine of scapula, apply pressure
Findings: Positive finding is pain or abnormal movement of the acromioclavicularjoint.
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31.
SPEED’S TEST
Speed’s Test
Use: To assess for biceps tendinitis
Procedure: Flex shoulder 60 degrees, palm up, resist flexion
Findings: Positive finding is pain over the tendon on resistance; weakness
Note: More effective test for biceps tendon pathology
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32.
YERGASON’S TEST
Yergason’s Test
Use: To assess the stability of the biceps tendon in the bicipital groove by the transverse humeral ligament or bicepstendinitis
Procedure: Elbow 90 degrees of flexion, supinate and externally rotate against resistance
Findings: Positive finding is pain and the sensation of the biceps popping out of the groove
Note: This test is not as effective as Speed’s for testing the biceps tendon due to limited movement of the tendon in thistest
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33.
EMPTY CAN (SUPRASPINATUS) TEST
Empty Can (Supraspinatus) Test
Use: To test for weakness/tear of supraspinatus muscle.
Procedure: Abduct, internally rotate, resist.
Findings: Positive finding is weakness or pain indicating a tear in the supraspinatus muscle or tendon, or neuropathy ofthe suprascapular nerve.
Note: Test horizontal range.
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34.
DROP ARM TEST OR CODMAN’S TEST
Drop Arm Test OR Codman’s Test
Use: To assess for a tear in the rotator cuff
Procedure: Abduct arm, lower slowly
Findings: Positive finding is pain when trying to return arm to side or inability to do so in a controlled manner
Note: Supraspinatus most common for rotator cuff injuries
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35.
APLEY’S SCRATCH TEST
Apley’s Scratch Test
Use: To assess for combined movement at the shoulder
Procedure: Client attempts to reach each hand behind back on opposite sides (one over, one under)
Findings: Positive finding is limitation in movement
Note: As this is a combination of movements, the therapist needs to determine which individual movements arerestricted and which are not
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36.
SULCUS SIGN TEST
Sulcus Sign Test
Use: To test for inferior instability of the glenohumeral joint
Procedure: Palpate head of Humerus, pull inferiorly just below elbow joint
Findings: Positive finding is gap between the inferior margin of the acromion and the humeral head; can be measuredand further graded (+1=less than 1 cm, +2=1-2cm, +3=more than 2cm)
Note: Shoulder should be tested in more than one position
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37.
NEER’S TEST
Neer’s Test
Use: To assess for overuse injury of the supraspinatus and sometimes biceps
Procedure: Thumbs up, flex shoulders through full range
Findings: Positive finding is pain in shoulder
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38.
ROO’S TEST (EAST)
Roo’s Test (EAST)
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39.
SLAP LESION CLUSTER
SLAP Lesion Cluster
Test clustering is a systematic process of grouping special tests together to facilitate clinical decision making. SLAP lesioncluster two test used to assess for SLAP Lesions, the tests are:
• Active Compression Test• Passive Distraction Test
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40.
LOAD & SHIFT - ANTERIOR
Load & Shift – Anterior
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41.
SCAPULAR RETRACTION TEST
Scapular Retraction Test
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42.
CROSSBODY ADDUCTION TEST(ACROMIOCLAVICULAR CROSSOVER)
Crossbody Adduction Test (Acromioclavicular Crossover)
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43.
POSTERIOR CAPSULE TIGHTNESS
Posterior Capsule Tightness
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44.
SERRATUS ANTERIOR STRENGTH TEST(PUNCH OUT)
Serratus Anterior Strength Test (Punch Out)
Use: To assess strength of serratus anterior muscle.
Procedure: “Wall push-ups”, 5-10 times
Findings: Winging of the scapula indicates weakness in this muscle or long thoracic neuropathy
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45.
JERK TEST (POSTEROINFERIOR LABRAL TEAR)
Jerk Test (Posteroinferior Labral Tear)
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46.
O’BRIEN TEST (ACTIVE COMPRESSION TEST)
O’Brien Test (Active Compression Test)
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47.
LIFT-OFF SIGN
Lift-off Sign
Use: To test for weakness/tear of the subscapularis tendon/muscle
Procedure: Place hand in small of back and lift off
Findings: Positive finding is client cannot lift the hand away from the back; abnormal motion of the scapula mayindicate scapular instability
Note: Test performed once actively and if client can do it, therapist adds load to push the hand toward the back; if clientshand is medially rotated as far as possible and the hand moves towards the back, it’s called a subscapularis “spring back”or lag test
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48.
ABDOMINAL COMPRESSION TEST (BELLYPRESS OR NAPOLEON TEST)
Abdominal Compression Test (Belly Press or NapoleonTest)
Use: To assess the subscapularis muscle.
Procedure: The patient pushes into the abdomen (medial rotation of the shoulder).
Findings: Pain or limited strength of the subscapularis muscle.
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49.
PAINFUL ARC TEST
Painful Arc Test
Use: To assess for impingement of the supraspinatus tendon or sub-acromial bursa.
Procedure: Standing, abduct Humerus.
Findings: Positive finding is pain starting at 60-70 degrees of abduction which eases off at 120 degrees (AC joint ifpainful after 120 degrees).
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PART VI
ELBOW ASSESSMENT
Elbow Assessment
Orthopedic Special Tests
• Elbow Valgus and Varus Stress Tests• Moving Valgus Stress Test of the Elbow• Cozen’s Test• Mill’s Test• Medial Epicondylitis Test (Reverse Mill’s/Golfers Elbow)• Tinel’s Sign’s at the Elbow (Cubital Tunnel Syndrome)• Pronator Teres Syndrome Test• Elbow Flexion Test
50.
OUTCOME MEASURES FOR THE ELBOW
Outcome Measures for The Elbow
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient-specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• Patient-Rated Elbow Evaluation (PREE)• Patient-Rated Tennis Elbow Evaluation (PRTEE)• DASH Outcome Measure• Upper Extremity Functional Index
51.
BONE & SOFT TISSUE PALPATION FOR THEELBOW
Bone & Soft Tissue Palpation for The Elbow
A selection of regional structures to keep in mind while assessing and treating patients suffering from elbow pain mayinclude:
• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)• Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)• The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)• Anterior Interosseous Membrane• Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor
carpi ulnaris)• Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor
carpi ulnaris)• Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)
52.
ELBOW VALGUS AND VARUS STRESS TESTS
Elbow Valgus and Varus Stress Tests
Elbow Varus Stress Test
Use: Test for varus lateral collateral ligament (LCL) instability at the elbow
Procedure: Elbow flexed, slight supination, support forearm, gapping in/out to assess ligament
Findings: Positive finding is pain, decreased mobility, laxity as compared with the unaffected side
Elbow Valgus Instability Stress Test
Use: Test for medial collateral ligament (MCL) instability at the elbow
Procedure: Elbow flexed, slight supination, support forearm, gapping in/out to assess ligament
Findings: Positive finding is pain, decreased mobility, laxity as compared with the unaffected side
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68 | ELBOW VALGUS AND VARUS STRESS TESTS
53.
MOVING VALGUS STRESS TEST OF THE ELBOW
Moving Valgus Stress Test of the Elbow
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54.
COZEN’S TEST
Cozen’s Test
Use: To assess for lateral epicondylitis
Procedure: Elbow flexed, resist wrist extension in different positions
Findings: Positive finding is pain at the common extensor tendon and weakness
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55.
MILL’S TEST
Mill’s Test
Use: To assess for tendinopathy of the common extensor tendon (lateral epicondyle)
Procedure: Flex wrist, extend elbow
Findings: Positive finding is pain local to the common extensor tendon
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56.
MEDIAL EPICONDYLITIS TEST (GOLFERSELBOW)
Medial Epicondylitis Test (Reverse Mill’s/Golfers Elbow)
Use: To assess for medial epicondylitis.
Procedure: Extend elbow, resist flexion of the wrist.
Findings: Positive finding is pain at the common flexor tendon and weakness.
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57.
TINEL'S SIGN'S AT THE ELBOW (CUBITALTUNNEL SYNDROME)
Tinel’s Sign at the Elbow (Cubital Tunnel Syndrome)
Use: To assess for nerve compression or regeneration of a peripheral nerve
Procedure: Flex elbow 45 degrees, tap nerve in-between olecranon process and medial epicondyle
Findings: Positve finding is paresthesia or tingling along the distribution of the nerve distal to where the nerve is tapped,or paresthesia/tingling at the most distal point where the nerve has regenerated
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58.
PRONATOR TERES SYNDROME TEST
Pronator Teres Syndrome Test
Use: To determine if the pronator teres muscle is impinging the median nerve
Procedure: Flex elbow 90 degrees, handshake, resist pronation while extending elbow
Findings: Positive finding is tingling or paresthesia along median nerve distribution in the hand/forearm
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59.
ELBOW FLEXION TEST
Elbow Flexion Test
Use: To determine if a cubital tunnel syndrome(impinging the ulnar nerve) is present.
Procedure: Depress shoulder, elbow flexed, wrist extension (what gesture).
Findings: Positive sign is tingling or paresthesia in the distribution of the ulnar nerve (in the forearm/hand).
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PART VII
FOREARM, WRIST, AND HANDASSESSMENT
Forearm, Wrist, and Hand Assessment
Orthopedic Special Tests
• Finklestein’s Test• Sweater Finger Sign• Carpal Compression Test• Phalen’s Test• Allen Test• Murphy’s Sign• Tinel’s Sign – Median Nerve• Hoffman’s Sign• Froment’s Sign (Pinch Grip Test)• Triangular Fibrocartilage Complex (TFCC) Load
60.
OUTCOME MEASURES FOR THE FOREARM,WRIST, AND HAND
Outcome Measures for The Forearm, Wrist, and Hand
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient Specific Functional Scale (PSFS)• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• DASH Outcome Measure• CTS-6 Evaluation Tool• Kamath and Stothard Questionnaire• Katz and Stirrat Hand Symptom Diagram• Upper Extremity Functional Index• Brigham and Women’s Carpal Tunnel Questionnaire• Boston Carpal Tunnel Questionnaire (BCTQ)• Patient-Rated Wrist Evaluation (PRWE)• Patient-Rated Wrist/Hand Evaluation (PRWHE)
61.
BONE & SOFT TISSUE PALPATION FOR THEFOREARM, WRIST, AND HAND
Bone & Soft Tissue Palpation for The Forearm, Wrist, andHand
A selection of regional structures to keep in mind while assessing and treating patients suffering from wrist or hand painmay include:
• The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)• Anterior Interosseous Membrane• Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor
carpi ulnaris)• Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor
carpi ulnaris)• Palmar Aponeurosis & Transverse Carpal Ligament• Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)• Lumbricals
62.
FINKLESTEIN’S TEST
Finklestein’s Test
Use: To assess for D’equervan’s Tenosynovitis
Procedure: Client seated; client to make a fist with thumb inside; therapist stabilize forearm with one hand and ulnardeviate wrist with the other; or client can perform this motion actively
Findings: Pain along the radial aspect of the wrist – Abductor pollicus longus and Extensor pollicus brevis muscles areinvolved in this tenosynovitis
*Note: Test can be painful even if tendonitis not present; make sure assess both side
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63.
SWEATER FINGER SIGN
Sweater Finger Sign
Use: To test for rupture of the flexor digitorum profundus tendon.
Procedure: Client is asked to make a fist. Therapist is looking to see if the distal phalanx of one of the fingers doesn’tflex.
Findings: If the distal phalanx of one of the fingers does not flex, it means that there has been a rupture of the flexordigitorum profundus tendon.
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64.
CARPAL COMPRESSION TEST
Carpal Compression Test
Use: To assess for compression of the Median nerve.
Procedure: Examiner holds the supinated wrist in both hands and applies pressure with both thumbs to the carpaltunnel/medial nerve for 30 seconds.
Findings: Reproduction of client symptoms is considered positive for carpal tunnel syndrome.
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65.
PHALEN’S TEST
Phalen’s Test
Use: To assess for compression of the Median nerve, as in carpal tunnel syndrome
Procedure: Client seated; client places dorsum of hands together with pressure; forearms in horizontal position; holdfor one minute
Findings: Tingling and pain. In the thumb, index, middle, and lateral half of ring fingers is + finding
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66.
ALLEN'S TEST
Allen’s Test
Use: Assess for patency of radial and ulnar arteries
Procedure: Client to open/close hand several times & then squeeze hand tightly. Therapist places thumb and indexfinger over radial/ulnar arteries; client opens hand & therapist releases pressure over one artery at a time
Findings: This test determines which artery provides the major blood supply to the hand.A slow or no fill of the handby blood means that the artery may be blocked
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67.
MURPHY’S SIGN
Murphy’s Sign
Use: Assesses for Lunate dislocation
Procedure: Ask client to make a fist. Therapist to note orientation of MCP joints.
Findings: If 3rd MC is level with the 2nd and 4th, this indicates a Lunate dislocation.
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68.
TINEL’S SIGN - MEDIAN NERVE
Tinel’s Sign – Median Nerve
Use: To assess for nerve compression or regeneration of a peripheral nerve.
Procedure: Tap nerve over wrist where median nerve is located.
Findings: Positive sign is paresthesia or tingling along the distribution of the nerve distal to where the nerve is tapped,or paresthesia/tingling at the most distal point where the nerve has regenerated.
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69.
HOFFMAN’S SIGN
Hoffman’s Sign
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70.
FROMENT'S SIGN (PINCH GRIP TEST)
Froment’s Sign (Pinch Grip Test)
Use: Assesses for an Ulnar nerve lesion
Procedure: Client to grasp a piece of paper between the thumb and lateral aspect of index finger. Therapist to try andpull paper away.
Findings: Thumb will flex to keep paper in place due to weakness or paralysis of Abductor pollicus (supplied by ulnarnerve – Flexor pollicus is median)
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71.
TRIANGULAR FIBROCARTILAGE COMPLEX(TFCC) LOAD
Triangular Fibrocartilage Complex (TFCC) Load
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PART VIII
THORACOLUMBAR SPINE AND PELVISASSESSMENT
Thoracolumbar Spine and Pelvis Assessment
Orthopedic Special Tests
• Craig’s Test• Gaenslen’s Test• Gillet’s Test• Kemp’s Test OR Lower Quadrant Test• Kernig/Brudzinski Test• Rebound Tenderness (McBurney’s Point)• Piriformis Test OR FAIR Test• Cluster of Laslett (Sacroiliac Joint Pain Provocation)• Sacroiliac Compression (Squish) Test• Sacroiliac Distraction (Gap) Test• Thigh Thrust Test• Sacral Thrust Test• Slump Test• True Leg Length Measurement• Valsalva Maneuver• Well Leg Raise• Straight Leg Raise (Lasègue’s sign) or Bragard’s Test• Bowstring Maneuver• Supine-to-sit (Long Sitting)• Hoover Test• Prone Gap (Hibb’s) Test• Pheasant Test (Lumbar Instability Test)• Nachlas (Prone Knee Bend) Test• Yeomen’s Test
72.
OUTCOME MEASURES FOR THETHORACOLUMBAR SPINE AND PELVIS
Outcome Measures for The Thoracolumbar Spine andPelvis
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient-specific Functional Scale• Oswestry Disability Index• Roland-Morris Disability Questionnaire• STarT Back Screening Tool (SBST)
73.
BONE & SOFT TISSUE PALPATION FOR THETHORACOLUMBAR SPINE AND PELVIS
Bone & Soft Tissue Palpation for The ThoracolumbarSpine and Pelvis
A selection of regional structures to keep in mind while assessing and treating patients suffering from lumbopelvic painmay include:
• Erector Spinae (iliocostalis, longissimus, spinalis)• Quadratus Lumborum• Multifidus• Thoracolumbar Fascia and Latissimus Dorsi• Muscles of The Abdomen (external obliques, internal obliques, transverse abdominis, and rectus abdominis)• Iliopsoas (iliacus and psoas major)• External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior,
and quadratus femoris)• Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)• Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)
74.
CRAIG'S TEST
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75.
GAENSLEN’S TEST
Gaenslen’s Test
Use: To test for sacroiliac joint or hip dysfunction
Procedure:
1. Client in sideline; unaffected hip/knee to be flexed to chest & client to hold; standing behind, stabilize the hipwith one hand while hyperextending the leg at the hip with the other
2. Client supine; unaffected hip and knee flexed; therapist beside client; take affected leg and bring over side of table;stabilize opposite hip and challenge affected hip into extension
Findings: Pain in the sacroiliac joint or hip means that dysfunction is present
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76.
GILLET’S TEST
Gillet’s Test
Use: To assess the mobility of the sacroiliac joint
Procedure: Client to stand & place hands against wall for stability; stand behind client & observe levels of posteriorsuperior iliac spine (PSIS); place one thumb on PSIS & other on S2; ask client to flex hip/knee; repeat on other side
Findings: Thumb of affected side moves superiorly as hip flexes or does not move at all; normal movement is indicatedif thumb on PSIS moves inferiorly as hip flexes
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77.
KEMP’S TEST OR LOWER QUADRANT TEST
Kemp’s Test OR Lower Quadrant Test
Use: To assess for nerve root compression or facet joint irritation in the lumbar spine
Procedure: Client standing; instruct client to: Slowly extend, latterly bend and rotate the thoracolumbar spine to theaffected side…place hand on back of thigh and slide down
Findings: Local pain is positive for facet joint irritation; radiating pain down affected leg is positive for nerve root.
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78.
KERNIG/BRUDZINSKI TEST
Kernig/Brudzinski Test
Use: To assess for pain caused by dural irritation, nerve root, or menigeal involvement.
Procedure: Client supine; client to flex head to chest (Brudzinski) and indicate if pain; then client to flex hip (Kernig)with knee in extension.
Findings: Pain at level of lesion and along the spine with referral to the affected limb; when pain present, client will flexknee involuntarily which will decrease stretch on dural tube and therefore decrease pain.
Note: The (passive) neck flexion part may also be referred to as Soto-Hal.
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79.
REBOUND TENDERNESS (MCBURNEY’S POINT)
Rebound Tenderness (McBurney’s Point)
Use: To assess for possibility of appendicitis
Procedure: Client supine, knees/hips flexed; therapist applies slow pressure over McBurney’s point & then quicklyreleases
Findings: Severe pain when pressure is released usually in presence of low grade fever and nausea indicates possibleappendicitis and requires referral
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80.
PIRIFORMIS TEST OR FAIR TEST
Piriformis Test OR FAIR Test
Use: To assess the length of piriformis
Procedure 1: Client prone, knees together; flex knees to 90 ̊; allow feet to fall out from midline as far as possible
Findings: Affected or short Piriformis will present as the leg staying closer to the midline relative to the other.
Procedure 2: Client side-lying with affected leg uppermost; keeping body from moving forward/back, ask client to flexhip & knee and drop knee toward the table.
Findings: Short Piriformis will prevent knee from dropping to the level of the table
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81.
CLUSTER OF LASLETT (SACROILIAC JOINT PAINPROVOCATION)
Cluster of Laslett (Sacroiliac Joint Pain Provocation)
Test clustering is a systematic process of grouping special tests together to facilitate clinical decision making. The Clusterof Laslett is a group of four test used for sacroiliac joint pain, the four tests are:
• Sacroiliac Distraction (Gap) Test• Thigh Thrust Test• Sacroiliac Compression (Squish) Test• Sacral Thrust Test
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82.
SACROILIAC COMPRESSION (SQUISH) TEST
Sacroiliac Compression (Squish) Test
Use: To stress test the posterior sacroiliac ligaments.
Procedure: Client supine; place hands on lateral aspect of anterior superior iliac spine (ASIS) & apply pressure towardsthe midline (can also be performed in side lying).
Findings: Pain local to the sacroiliac joint indicates a posterior sacroiliac ligament sprain.
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83.
SACROILIAC DISTRACTION (GAP) TEST
Sacroiliac Distraction (Gap) Test
Use: To stress test the anterior sacroiliac ligaments.
Procedure: Client supine; place hands on medial aspect of anterior superior iliac spine (ASIS) in a cross arm fashion &apply pressure inferiorly & laterally.
Findings: Unilateral gluteal or posterior leg pain which indicates and anterior sacroiliac ligament sprain.
Note: Careful not to painfully compress the soft tissue medially and anteriorly to ASIS.
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84.
THIGH THRUST TEST
Thigh Thrust Test
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85.
SACRAL THRUST TEST
Sacral Thrust Test
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86.
SLUMP TEST
Slump Test
Use: To detect problem with movement of the spinal cord
Procedure: Client seated; ask client to slump thoracolumbar spine fully with head erect, is there signs and symptoms?if not -flex head to chest –if no signs and symptoms; therapist to extend one unaffected knee and dorsiflex ankle; thenrepeat with other leg
Findings: Pain along the spine at the level of the lesion and/or referral to a limb is positive finding
1 2 3 4 5
Slump Hands behind back Thoracic flexion Extend one knee Dorsiflex foot Cervical flexion
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SLUMP TEST | 105
87.
TRUE LEG LENGTH MEASUREMENT
True Leg Length Measurement
Use: Identifies leg length discrepancy.
Procedure: First place one end of the measuring tape over the anterior superior iliac spine (ASIS), then place the otherover the medial malleolus. Compare side to side.
Finding: If one leg measures longer than the other there is a leg length discrepancy.
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88.
VALSALVA MANEUVER
Valsalva Maneuver
Use: To assess for space-occupying lesion (herniated disc, tumour) which increases pressure within the spinal cord.
Procedure: Client seated & instructed to take a breath & bear down/or put thumb in mouth, make a seal & blow as ifblowing up a balloon.
Findings: Positive finding is pain local to the site of lesion or radiates in a dermatomal pattern (pain may also bereproduced with cough or sneeze).
Contraindication: Use test cautiously with cardiovascular disorders –will decrease blood flow to heart and increaseblood pressure.
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89.
WELL LEG RAISE
Well Leg Raise
Use: To help assess possible cause of low back painProcedure: Client supine; unaffected leg is lifted toward 80-90 ̊ of hip flexion
Findings: Pain on the opposite side indicates a space occupying lesion such as herniated disc between 30-70 degrees, painat end range = hamstrings or sacroiliac joint
Note: Test causes stretch of ipsilateral & contralateral nerve root
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90.
STRAIGHT LEG RAISE (LASÈGUE'S SIGN) ORBRAGARD'S TEST
Straight Leg Raise (Lasègue’s sign) or Bragard’s Test
Use: To help determine cause of low back pain.
Procedure: Client supine; leg extended; passive flexion at hip until client complains of pain or tightness; leg taken out ofpainful range and Braggard’s performed.
Findings:
• Pain in posterior thigh = tight/short hamstrings.• Pain down posterior leg to foot, and with Braggard’s = Sciatic nerve involvement Pain after 70 ̊ = Joint pain from
SI/Lumbar.• Pain in opposite leg = Space occupying lesion or disc herniation (WLR).
Note: A unilateral straight leg raise is full at 70 degree.
1 2 3 4
StraightLeg Raise
Supineposition
Raise the legwith the kneeextended
If pain radiates when the angle of theleg is between 30 and 70 degrees(positive)
Increased pain on dorsiflexion of the patient’sfoot increases sensitivity of the test
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110 | STRAIGHT LEG RAISE (LASÈGUE'S SIGN) OR BRAGARD'S TEST
91.
BOWSTRING MANEUVER
Bowstring Maneuver
Use: To determine if pain related to sciatic nerve involvement
Procedure: Client supine; place client heel of testing leg on therapist shoulder, knee bent; strum sciatic nerve in poplitealfossa
Findings: Positive fining is pain which is related to pressure or tension on the sciatic nerve.
Note: If seated, test is called Sciatic tension test
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92.
SUPINE-TO-SIT (LONG SITTING)
Supine-to-sit (Long Sitting)
Use: Assesses for a functional leg length discrepancy due to pelvic dysfunction
Procedure: Client supine with knees extended; compare levels of both malleoli and make sure level; instruct client to situp & note if one limb appears to move proximal relative to the other leg
Findings: If one leg moves farther up/proximal relative to the other, there is a functional leg length difference due to apelvic rotation or torsion. Spasm of the lumbar muscles may also be the cause.
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93.
HOOVER TEST
Hoover Test
Use: To assess for malingering (exaggerating symptoms for personal gain)
Procedure: Client supine; therapist places hands under heels of feet; ask client to lift one leg; test bilaterally
Findings: If client does not lift leg/attempt or therapist does not feel pressure under the other heel, the client is likelynot trying
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94.
PRONE GAP (HIBB'S) TEST
Prone Gap (Hibb’s) Test
Use: To stress test the posterior sacroiliac ligaments.
Procedure: Client prone; therapist stabilizes clients pelvis; clients knee is flexed to 90 ̊ and hip is rotated medially as far aspossible. Therapist to palpate the sacroiliac joint on the same side, at the very end of rotation. Repeat on the other side.
Findings: Therapist to note the amount of movement and the quality of movement on each side (looking for hyper/hypomobility and movement will possibly cause discomfort in the posterior sacroiliac ligaments as they are being stressedin the event of injury/sprain.
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95.
PHEASANT TEST (LUMBAR INSTABILITY TEST)
Pheasant Test (Lumbar Instability Test)
Use: To test for unstable spinal segments in the lumbar spine.
Procedure: Client prone; therapist to apply gentle pressure to the lumbar spine; with other hand, passively flex clientsknees to buttocks.
Findings: Pain in the leg indicates an unstable spinal segment and is considered a positive finding.
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96.
NACHLAS (PRONE KNEE BEND) TEST
Nachlas (Prone Knee Bend) Test
Use: Primarily to assess for neurological dysfunction in the lumbar, but also assesses tight quadriceps.
Procedure: Client prone; therapist passively flexes knee as much as possible to the buttock; maintain for 45-60 secondsTherapist should make sure hip is not rotating during test.
Findings: Unilateral pain in lumbar area may indicate a L2 or L3 nerve root lesion; test also stretches the femoral nerve;pain in anterior thigh = tight quadriceps.
Note: If client cannot fully flex knee, extend hip with knee flexed as much as possibleAdditional Note: May also be called femoral nerve stretch test or Reversed Lasègue
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97.
YEOMAN'S TEST
Yeoman’s Test
Use: To assess for lumbar joint dysfunction.
Procedure: Client prone; therapist stabilizes pelvis on testing side & extends each hip in turn with knees extended, andthen flexed.
Findings: Pain in lumbar spine during both parts of the test.
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PART IX
HIP ASSESSMENT
Hip Assessment
Orthopedic Special Tests
• FABER (Flexion-Abduction-External Rotation) Test (Patrick’s Test)• FADDIR (Flexion-Adduction-Internal Rotation) Test• Trendelenburg Sign• Thomas Test• Ely’s Test• Ober’s Test• 90-90 Straight Leg Test• Piriformis Strength Test (Pace Maneuver)• Hip Quadrant Test (Scouring Test)
98.
OUTCOME MEASURES FOR THE HIP
Outcome Measures for The Hip
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient Specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• The Western Ontario and McMaster Universities Arthritis Index (WOMAC)• Lower Extremity Functional Scale (LEFS)
99.
BONE & SOFT TISSUE PALPATION FOR THE HIP
Bone & Soft Tissue Palpation for The Hip
A selection of regional structures to keep in mind while assessing and treating patients suffering from hip pain mayinclude:
• Iliopsoas (iliacus and psoas major)• Hip Adductors (adductor brevis, adductor longus, adductor magnus, pectineus, gracilis)• External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior,
and quadratus femoris)• Quadricep Muscles (rectus femoris, vastus lateralis, vastus mediali, vastus intermedius)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)• Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)• Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus• Quadratus Lumborum• Thoracolumbar Fascia & Latissimus Dorsi
100.
FABER (PATRICK’S) TEST
FABER (Patrick’s) Test
Use: To assess the hip and psoas muscle.
Procedure:Part 1: Client supine with legs extended; put foot of affected side on the knee of unaffected side –“4”.Findings: If affected knee remains above unaffected then possible hip pathology or psoas spasm, adductor.
Part 2: Stabilize the unaffected anterior superior iliac spine & with other hand, gently push down on the medial aspectof the knee.Findings: Pain local to the sacroiliac joint indicating sacroiliac dysfunction.
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101.
FADDIR (FLEXION-ADDUCTION-INTERNALROTATION) TEST
FADDIR (Flexion-Adduction-Internal Rotation) Test
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102.
TRENDELENBURG SIGN
Trendelenburg Sign
Use: Assesses for weak gluteus medius
Procedure: Client standing; stand behind client & instruct them tot stand on the affected leg; observe the non-weightbearing side of the pelvis
Findings: Pelvis on non-weightbearing side will drop or stay level indicating a weak hip abductor, mainly gluteusmedius. The pelvis should raise slightly if negative
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103.
THOMAS TEST
Thomas Test
Use: To assess for shortness or contracture of the hip flexors.
Procedure 1 (Thomas Flexion): Client supine with hips & knees flexed; while maintaining the unaffected hip & kneein flexion, have client lower the affected leg into extension as far as it will go; watch for amount of flexion at hip & makesure that lumbar is flat.Findings: If the posterior knee will not touch the table then hip flexors are short.
Procedure 2 (Rectus Femoris Contracture Test): Same as procedure #1, only client is at end of table which will allowthe therapist to see what the knee is doing in addition to the hip.Findings: As above, plus looking for the knee to extend which would indicate rectus femoris shortness.
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104.
ELY’S TEST
Ely’s Test
Use: Assesses for rectus femoris shortness
Procedure: Client prone; flex the affected knee toward the buttocks; make sure leg does not abduct; observe the pelvis
Findings: If pelvis on affected side flexes as the knee is being flexed, indicates short rectus femoris
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105.
OBER’S TEST
Ober’s Test
Use: Assess for iliotibial band and tensor fascia latae shortness.
Procedure 1: Client sideline edge of table with affected leg superior; client to flex unaffected leg; stand behind client &stabilize pelvis at lateral ilium with one arm/hand; with other hand, passively abduct & extend femur with knee flexed &allow the leg to lower without rotation.
Findings: If leg remains strongly abducted; indicates a short tensor fascia latae. There is also stress placed on the femoralnerve and if this is involved, neurological signs will be present. Pain over the Greater Trochanter indicates bursitis.
Procedure 2: Same as procedure #1, but keep knee extended and lower leg without rotation (This places less stress onthe knee and reduces interference from a short rectus femoris).
Findings: If leg remains strongly abducted, indicates a short iliotibial band and tensor fascia latae as greater stress isplaced on the iliotibial band with the knee extended.
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OBER’S TEST | 127
106.
90-90 STRAIGHT LEG TEST
90-90 Straight Leg Test
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107.
PIRIFORMIS STRENGTH TEST (PACEMANEUVER)
Piriformis Strength Test (Pace Maneuver)
Use: To assess the strength of piriformis muscle.
Procedure: Client prone with knee flexed to 90 ̊; stabilize opposite pelvis; move foot of testing leg across the midline sothat the femur is externally rotated; client to hold; therapist to apply pressure to medial ankle in lateral direction.
Pace Maneuver: Seated: Knees together, hands on lateral knees, abduct against resistance.
Findings: Client is unable to hold position, or resist pressure indicating weakness of piriformis and other lateral rotators.
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108.
HIP QUADRANT TEST (SCOURING TEST)
Hip Quadrant Test (Scouring Test)
Use: Assess joint capsule tightness or other pathology of the hip.
Procedure: Client supine; flex and adduct affected hip so that knee is facing opposite shoulder; move the hip through anarc into abduction & feel quality of mvmt. through range.
Findings: An early, leathery end feel, crepitus or jerky movement & pain or apprehension indicates capsular tightness,other pathology, or osteophyte formation.
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PART X
KNEE ASSESSMENT
Knee Assessment
Orthopedic Special Tests
• Bounce Home• Apley’s Test (Compression/Distraction)• McMurry’s Test• Valgus Stress Test (Medial Collateral Ligament)• Varus Stress Test (Lateral Collateral Ligament)• Noble’s Compression• Lachman’s Test• Anterior Drawer Test• Posterior Drawer Test• Posterior Sag Sign (Gravity Drawer Test)• Coronary Ligament Stress Test• Patellar Grind Test (Clarke’s Sign)• Thessaly Test• Bragard’s Sign• Mediopatellar Plica Test (Hughston Plica Test)• Plica “Stutter” Test• Ballotable Patella (Major Effusion or Patellar Tap Test)• Brush Test (Minor Effusion, Stroke, OR Wipe Test)• Fluctuation Test• Waldron’s Test• McConnell Patellofemoral Knee Test• Q-Angle• Patellar Apprehension Test• Patellar Deep Tendon Reflex
109.
OUTCOME MEASURES FOR THE KNEE
Outcome Measures for The Knee
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient Specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• The Western Ontario and McMaster Universities Arthritis Index (WOMAC)• Lower Extremity Functional Scale (LEFS)
110.
BONE & SOFT TISSUE PALPATION FOR THEKNEE
Bone & Soft Tissue Palpation for The Knee
A selection of regional structures to keep in mind while assessing and treating patients suffering from knee pain mayinclude:
• Hip Adductors (adductor brevis, adductor longus, adductor magnus, pectineus, gracilis)• Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)• Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)• Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus
tertius)• Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)• Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior,
popliteus)• Proximal Tibiofibular Joint• Ankle Joint (talocrural joint, subtalar joint and inferior tibiofibular joint)
111.
BOUNCE HOME TEST
Bounce Home Test
Use: Assesses meniscal tearing
Procedure: Client supine with knee flexed & heel cupped in therapist hand; knee is passively allowed to extend
Findings: Incomplete extension or springy block end feel indicates that likely a torn meniscus is blocking movement
Note: Caution when letting leg fall into full extension quickly if knees are hyperextended to begin with, will beuncomfortable
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112.
APLEY'S TEST
Apley’s Test
Apley’s Distraction Test
Use: Assesses integrity of collateral ligaments of the knee
Procedure: Client prone, knee flexed to 90º; therapist stabilizes thigh with knee, & wraps hands around distal end oftibia; pull tibia superiorly & apply internal and external rotation
Findings: Medial aspect pain= MCL; Lateral aspect pain = LCL
Apley’s Compression Test
Use: Assesses for meniscal damage
Procedure: Client prone, knee flexed to 90º; place one hand on foot, other on tibia; compress knee into table, theninternal/external rotate tibia
Findings: Medial aspect joint line pain = medial menisus; lateral aspect joint line pain = lateral meniscus
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136 | APLEY'S TEST
113.
MCMURRY’S "CLICK" TEST
McMurry’s “Click” Test
Use: Assesses for meniscal damage (& somewhat the MCL)
Procedure: Client supine, knee/hip flexed; cup hand over knee with fingers/thumb over joint line with one hand; withother hand, grasp heel; slowly extend knee while placing various stresses at knee to check both menisci
Findings: An audible click, catching, and pain during extension of the knee
• Medial = external rotation of tibia with valgus stress• Lateral = internal rotation of tibia with varus stress
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114.
VALGUS STRESS TEST (MEDIAL COLLATERALLIGAMENT)
Valgus Stress Test
Use: To assess the integrity of the medial collateral ligament & other structures preventing medial instability of the knee
Procedure: Client supine; stabilize tibia in slight lateral rotation while applying a valgus stress at the knee; repeat withknee in slight flexion
Findings: Tibia will move away from the femur (medially) excessively. Pain is also an indicator.
• Knee extended: MCL, ACL, PCL or joint capsule may have been damaged• Knee flexed: MCL, PCL, or joint capsule may have been damage
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VALGUS STRESS TEST (MEDIAL COLLATERAL LIGAMENT) | 139
115.
VARUS STRESS TEST (LATERAL COLLATERALLIGAMENT)
Varus Stress Test (Lateral Collateral Ligament)
Use: To assess the integrity of the lateral collateral ligament & other structures preventing lateral instability of the knee.
Procedure: Client supine; stabilize tibia in neutral while applying a varus stress at the knee; perform again with kneeslightly flexed.
Findings: Tibia will move away from femur (laterally), excessively. Pain is also an indicator.
• Knee extended: LCL, ACL, PCL, ITB, Lateral Gastrocnemius, joint capsule or biceps femoris tendon may havebeen damaged.
• Knee flexed: LCL, ITB, Biceps femoris tendon or joint capsule may have been damaged.
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VARUS STRESS TEST (LATERAL COLLATERAL LIGAMENT) | 141
116.
NOBLE’S COMPRESSION
Noble’s Compression
Use: To assess for iliotibial band friction syndrome
Procedure: Client supine, knee flexed to 90º. Firmly compress Iiliotibial band approx. 2 cm proximal to lateral femoralcondyle. While maintaining pressure, client is to slowly extend knee.
Findings: Pain over lateral epicondyle at approx. 30º of knee extension indicates Iiliotibial friction syndrome
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117.
LACHMAN’S TEST
Lachman’s Test
Use: To assess the integrity of the ACL (considered more accurate test than Draw)
Procedure: Client supine, knee flexed to 30º; this is the position where the ACL play major role; stabilize femur withone hand while proximal end of tibia is moved forward with the other
Findings: Pain and excessive anterior movement of the tibia indicates damage to the ACL
Note: See Magee for variations and pick one that best suits you and allows you to perform the test competently
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118.
ANTERIOR DRAWER TEST
Anterior Drawer Test
Use: Assess integrity of the anterior stability of the knee.
Procedure: Client supine, hip/knee flexed; therapist stabilize foot, places hands behind tibia and draws it forward.
Findings: Excessive forward movement of tibia with pain indicates that the ACL, Joint capsule, MCL may have beendamaged.
Note: If there is an audible snap or palpable jerk (Finochietto’s jumping sign) when the tibia is pulled forward and thetibia moves with it, a meniscus lesion may be accompanying the torn anterior cruciate ligament.
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119.
POSTERIOR DRAWER TEST
Posterior Drawer Test
Use: Assesses integrity of posterior stability of the knee
Procedure: Client supine, hip/knee flexed; therapist stabilize foot, places hands on anterior portion of tibia and pushesposteriorly
Findings: Excessive posterior movement of tibia with pain indicates that the PCL, ACL may have been damage
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120.
POSTERIOR SAG SIGN (GRAVITY DRAWER TEST)
Posterior Sag Sign (Gravity Drawer Test)
Use: To assess integrity of the posterior cruciate ligament.
Procedure: Client supine with hip/knees flexed; observe profile of knees from side of table.
Findings: The affected tibia sags posteriorly compared to the unaffected side which indicates a torn PCL.
Note: The PCL should be tested for a posterior sag before the ACL is tested to rule out false-positive test for an ACLinjury.
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121.
CORONARY LIGAMENT STRESS TEST
Coronary Ligament Stress Test
Use: Assesses integrity of coronary ligament.
Procedure: Client seated, knee flexed to 90 ̊; therapist passively externally rotates tibia on femur.
Findings: Pain on external rotation of tibia is positive for coronary ligament sprain.
Note: Sprain of this ligament will show no pain with a valgus stress test.
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122.
PATELLAR GRIND TEST (CLARKE’S SIGN)
Patellar Grind Test (Clarke’s Sign)
Use: To assess for patellofemoral syndrome
Procedure: Client supine, knees extended, compress patella posteriorly & inferiorly; instruct client to contractquadriceps
Findings: If apprehension, pain, & crepitus are present, test is positive
Note: If too much force is used, may be discomfort anyway; use gradual pressure
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123.
THESSALY TEST
Thessaly Test
Use: To evaluate for meniscal damage.
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124.
BRAGARD’S SIGN
Bragard’s Sign
Use: Assesses for meniscal tearing.Procedure: Client supine, knee/hip flexed; externally rotate tibia while extending knee; stabilize femur to preventmovement.Findings: Pain along the medial aspect of joint line = medial meniscus; pain along lat. aspect of joint line when testperformed with internal rotation = lateral meniscus.
125.
MEDIOPATELLAR PLICA TEST (HUGHSTONPLICA TEST)
Mediopatellar Plica Test (Hughston Plica Test)
Use: To assess for a mediopatellar plica as source of knee pain.Procedure: Client supine; knee flexed by therapist to 30 ̊ and then moves the patella medially, pinching the plicabetween the edge of the patella and the femoral condyle.Findings: Pain in area where plica is pinched.
126.
PLICA “STUTTER” TEST
Plica “Stutter” Test
Use: To identify the presence of a plica.Procedure: Client seated; knee flexed to 90 ̊. Therapist places one finger over the patella to palpate while client slowlyextends the knee.Findings: The patella stutters or jumps somewhere between 60 ̊ and 45 ̊ during an otherwise smooth movement.Note: Can only do this if no joint swelling is present.
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127.
BRUSH TEST (MINOR EFFUSION, STROKE, ORWIPE TEST)
Brush Test (Minor Effusion, Stroke, OR Wipe Test)
Use: To assess for minor effusion at the knee.
Procedure: Client supine; affected knee in extension; therapist to slowly brush effusion upwards from medial aspect ofknee with one hand several times, then with the other hand, strokes down the lateral aspect of the knee.
Findings: If present, a wave of fluid will pass to the medial aspect of the knee and bulge just distally to the medial portionof the patella. It may take several seconds to appear.
Note: If major or minor tests positive, refer for immediate medical attention.
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128.
BALLOTABLE PATELLA (MAJOR EFFUSION ORPATELLAR TAP TEST)
Ballotable Patella (Major Effusion or Patellar Tap Test)
Use: To assess for major effusion at the knee.Procedure: Client supine, affected knee in extension; compress patella down into condyles of femur and release.Findings: Patella clicks down onto femur & rebounds to floating position.
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129.
FLUCTUATION TEST
Fluctuation Test
Use: To assess for significant knee effusion.Procedure: Client supine; therapist places palm of one hand over the suprapatellar pouch and the palm of the otherhand anterior to the joint. Therapist will press down with one hand and then the other.Findings: The therapist can feel the fluid fluctuate under the hands and move from one hand to the other.
130.
WALDRON’S TEST
Waldron’s Test
Use: To assess for patellofemoral syndrome.Procedure: Client standing; therapist in front; client does a few slow deep knee bends while therapist palpates patella.Findings: Pain, crepitus & poor tracking of the patella are present indicating patellofemoral syndrome symptoms.
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131.
MCCONNELL PATELLOFEMORAL KNEE TEST
McConnell Patellofemoral Knee Test
Use: To assess for patellofemoral tracking problems
Procedure: Client seated with femur externally rotated; client to isometrically contract quadriceps at: 120, 90, 60, 30,0; hold each 10 sec.; If pain produced at any degrees tested, knee is passively returned to full extension; therapist to thensupport clients leg and push patella medially; maintain this position while placing leg back into the angle of pain; clientis again asked to contract quadriceps
Findings: If pain is decreased when returned to the painful position with medial pressure on the patella, the pain isconsidered to be patellofemoral in origin
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132.
Q-ANGLE
Q-Angle
Use: To determine if client will be prone to patellar tracking problems.Findings: Normal is 13 ̊ for males and 18 ̊ for females when the knee is straight.
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133.
PATELLAR APPREHENSION TEST
Patellar Apprehension Test
Use: To assess if patella is likely to laterally dislocate
Procedure: Client supine, knee extension; with thumbs on medial aspect of patella, slowly move patella laterally; observeclient
Findings: Client may attempt to move away or have look of apprehension on face
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134.
PATELLAR DEEP TENDON REFLEX
Patellar Deep Tendon Reflex (L3/L4 myotome)
Procedure: Flex the leg at the knee and hip. Hold the leg under the knee and then strike the patellar tendon and watchfor quadriceps contraction.
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PART XI
LOWER LEG, ANKLE, AND FOOTASSESSMENT
Lower Leg, Ankle, and Foot Assessment
Orthopedic Special Tests
• Functional/Structural Pes Planus Test• Talar Tilt Test• Anterior Drawer of the Ankle• Calcaneocuboid Stress Test• Calcaneofibular Stress Test• Talofibular Ligament Stress Test (Anterior & Posterior)• Deltoid Ligament Stress Test• Dorsiflexion External Rotation Stress Test (Kleiger Test)• The Syndesmosis Squeeze Test• Thompson’s Test• Toe/Heel Walking• Tinel’s Sign – Tarsal Tunnel• Tinel’s Sign – Anterior Tarsal Tunnel• Morton’s Neuroma Test (Metatarsal Squeeze Test)• Homan’s Sign• Babinski’s Test/Reflex
135.
OUTCOME MEASURES FOR THE LOWER LEG,ANKLE, AND FOOT
Outcome Measures for The Lower Leg, Ankle, and Foot
Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:
• Self-Rated Recovery Question• Patient Specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• Lower Extremity Functional Scale (LEFS)• Foot and Ankle Ability Measure• Foot and Ankle Disability Index
136.
BONE & SOFT TISSUE PALPATION FOR THELOWER LEG, ANKLE, AND FOOT
Bone & Soft Tissue Palpation for The Lower Leg, Ankle,and Foot
A selection of regional structures to keep in mind while assessing and treating patients suffering from lower leg, ankle, orfoot pain may include:
• Plantar Fascia• Lumbricals• Adductor Hallucis• Flexor Hallucis Brevis• Metatarsals & Interossei• Peroneals (peroneus longus, peroneus brevis)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)• Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus
tertius)• Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)• Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior,
popliteus)• Ankle Joint (the talocrural joint, subtalar joint and the inferior tibiofibular joint)
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FUNCTIONAL/STRUCTURAL PES PLANUSTEST
Functional/Structural Pes Planus Test
Use: To assess if pes planus is functional, or structural.
Procedure: Client standing; observe medial longitudinal arch; client to raise on toes – observe; client to sit so non-weightbearing – observe.
Findings: When client raises on toes or when non-weight bearing, arch will return if functional. If arch does not returnor does not present itself in seated or toe raise, test is likely + for structural pes planus.
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TALAR TILT TEST
Talar Tilt Test
Use: To test for tearing of the calcaneofibular ligament (CFL)
Procedure: Client supine or sidelying; flex client knee to relax and place ankle in anatomical position; therapist to tilttalus into adduction (calcaneofibular) and abduction (deltoid).
Findings: Pain and increased mobility compared to the unaffected limb.
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ANTERIOR DRAWER OF THE ANKLE
Anterior Drawer of the Ankle
Use: To assess integrity of anterior talofibular ligament (ATFL)
Procedure: Client supine, knees extension; therapist stabilizes tib/fib with one hand; the other hand cups calcaneus &places ankle in 20 ̊ of plantar flexion with slight distraction, & pulls ant.
Findings: Excessive movement in the anterior direction with a possible clunk sound indicates ligament laxity or possiblerupture
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CALCANEOCUBOID STRESS TEST
Calcaneocuboid Stress Test
Use: To assess integrity of the calcaneocuboid ligament
Procedure: One hand cups calcaneus, the other is placed over lat. aspect of the foot; therapist will supinate & adduct theforefoot with overpressure at end
Findings: Pain and hypermobility local to tested ligament
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141.
CALCANEOFIBULAR STRESS TEST
Calcaneofibular Stress Test
Use: To assess integrity of the calcaneofibular ligament
Procedure: One hand, stabilize the tib/fib; with other hand cup calcaneus & invert the hindfoot with overpressure atend
Findings: Pain and hypermobility local to tested ligamentNote:Keep ankle in neutral during test
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142.
TALOFIBULAR LIGAMENT STRESS TEST(ANTERIOR & POSTERIOR)
Talofibular Ligament Stress Test (Anterior & Posterior)
Anterior Talofibular Stress Test
Use: To assess the integrity of the anterior talofibular ligament
Procedure: Client seated or supine; therapist grasps tibia with one hand & other hand is over dorsum of foot; therapistwill then plantarflex, adduct, & invert ankle with overpressure at end
Findings: Pain local to this ligament, & excessive movement in mild-moderate subacute hypermobility or false negativedue to muscle spasm if rupture chronic ligament rupture will be hypermobile without pain
Posterior Talofibular Stress Test
Use: To assess integrity of the posterior talofibular ligament
Procedure: Position as above; therapist grasps lateral Tib/fib with one hand & other cups calcaneus; therapist willdorsiflex, invert, & adduct ankle with overpressure at end
Findings: Pain local to this ligament, & excessive movement in mild-moderate subacute hypermobility or false negativedue to spasm if rupture chronic ligament rupture will be hypermobile without pain
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170 | TALOFIBULAR LIGAMENT STRESS TEST (ANTERIOR & POSTERIOR)
143.
DELTOID LIGAMENT STRESS TEST
Deltoid Ligament Stress Test
Use: To assess the integrity of the deltoid ligament
Procedure: This ligament has three parts and each should be tested.
1. One hand stabilizes tib/fib & other is over dorsum of foot; eversion, plantar flexion with overpressure is performed2. One hand cups calcaneus & other is over dorsum of foot; eversion of hindfoot with overpressure3. One hand cups cancaneus& other is over sole of foot; eversion & dorsiflexion with overpressure
Findings: Pain over hypermobility local to the affected fibres; muscle spasm may also be present
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DORSIFLEXION EXTERNAL ROTATION STRESSTEST (KLEIGER TEST)
Dorsiflexion External Rotation Stress Test (Kleiger Test)
Use: To identify a tear or rupture of the deltoid ligament or high ankle sprain (syndesmosis Injury)
Procedure: Client seated with knee flexed to 90°and foot not weight-bearing; therapist grasps foot and rotates it laterally.
Findings: Pain medially and laterally with possible palpation of the talus displacing from the medial malleolus
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145.
THE SYNDESMOSIS SQUEEZE TEST
The Syndesmosis Squeeze Test
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TOE/HEEL WALKING
Toe/Heel Walking
Use: Part of neurological testing for the lower extremity.
Procedure: Client to walk across the room on their toes, then return walking on their heels.
Findings: Heel walking is assessing tibialis anterior = L4/5; Toe walking is assessing gastrocnemius/soleus = S1/2.
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THOMPSON’S TEST
Thompson’s Test
Use: To assess for third degree strain or rupture of the Achilles tendon
Procedure: Client prone, ankles over table; therapist squeezes the posterior calf muscles; (can be done standing)
Findings: If ankle does not plantarflex, the test is positive for rupture of Achilles
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TINEL’S SIGN AT TARSAL TUNNEL
Tinel’s Sign at Tarsal Tunnel
Use: To detect peripheral neuropathy of the tibial nerve
Procedure: Locate the tarsal tunnel (posterior to the medial malleolus) and tap over the nerve
Findings: Paraesthesia over medial ankle and arch of the foot
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TINEL'S SIGN - ANTERIOR TARSAL TUNNEL
TINEL’S SIGN – ANTERIOR TARSAL TUNNEL
Use: To assess for neuropathy of the deep peroneal nerve
Procedure: Tap nerve over the proximal dorsum of the foot
Findings: Paraesthesia in the deep peroneal nerve distribution
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150.
MORTON’S NEUROMA TEST (METATARSALSQUEEZE TEST)
Morton’s Neuroma Test (Metatarsal Squeeze Test)
Use: To assess for presence of Morton’s neuroma
Procedure: Client supine; therapist places lateral & medial aspect of the foot between their palms & squeezes
Findings: Positive finding is sharp pain at the location of the neuroma. Pain is worsened by activity
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HOMAN’S SIGN
Homan’s Sign
Use: To assess for deep vein thrombosis
Procedure: Client supine/seated, affected knee extended; therapist to passively dorsiflex client’s ankle
Findings: Pain deep to the calf. May also find heat/tenderness local to deep vein thrombosis (DVT). Dorsalis pedis pulsemay also be diminished & affected leg swollen/pale.
Note: Tenderness or heat local to the thrombophlebitis upon palpation. The dorsalis pedis pulse is diminished or absentand the affected leg is swollen and has pallor. Refer out if positive
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BABINSKI TEST/REFLEX
Babinski Test/Reflex
Use: To assess for upper motor nerve (UMN) lesion
Procedure: Client supine; therapist to run pointed object along plantar aspect of client’s foot (heel –toe)
Findings: Extension of the big toe and abduction of the other toes is positive (flexion withdrawal due to ticklishness orhypersensitivity can be confounding factors).
Note: Test will be positive in infants and will usually be negative after 5-7 months
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ACKNOWLEDGEMENT
Acknowledgement goes to Alex Kidd and Andrew Clapperton at Humber College for graciously sharing theirassessment resource. Additional acknowledgement goes out to the staff at Physiotutors for their extensive research andcontent related to assessment.