Physical Examination

Clinical Signs

Low Back

Straight Leg raise• One of the Simplest and most effective

tests of nerve root irritation• Compare with bent knee• Elevate and measure angle in degrees

Purpose• To provoke a dural or root sign • Positive Response• Extra-segmental reference of pain

(dural) • Segmental reference of pain (root) • Technique• Patient supine • Flex hip while maintaining knee

extension • Amplify response by dorsiflexing ankle

and/or flexing neck • Comments• This test is biased toward the lower

part of the lumbo-sacral plexus (L4 - S1)

• A crossed leg (opposite leg) response may indicate disk bulge medial to the opposite side root

• . 

Lasegue Sign

• Variation of Straight leg raise

• Flex hip first with bent knee and then straighten knee or…

• Dorsiflex ankle with straight leg elevation to elicit increased pain

Patrick’s Test

• Sacroiliac Testing

Cervical Examination• The foraminal compression test or Spurling test is

performed by extending the neck and rotating the head and then applying downward pressure on the head. The test is considered positive if pain radiates into the limb ipsilateral to the side that the head is rotated to. The Spurling test has been found to very specific, but not sensitive, in diagnosing acute radiculopathy.

• Manual cervical distraction can be used as a physical examination test. With the patient in a supine position, gentle manual distraction often greatly reduces the neck and limb symptoms in patients with radiculopathy.

• Lhermitte sign is performed by flexing the neck and asking the patient about symptoms of an electric shock–like sensation radiating down the spine, and in some patients, into the extremities. This has been found in patients with cervical cord involvement, cervical spondylosis, and also in patients with tumor and multiple sclerosis (MS).

Shoulder Examination

• Apley Scratch Test

• A test for rotator cuff stability

• Looking for assymmetry between shoulders

Neer Impingement Sign• is tested by having the patient place

his hand on the unaffected shoulder and gradually forward flexing the shoulder;    - impingement sign is elicited w/ pt seated and the examiner standing;    - scapular rotation is prevented w/ one hand while other hand raises arm in forced foward elevation            causing greater tuberosity to impinge against the acromion;    - raise the arm somewhere between flexion and abduction;    - this maneuver produces pain in pts w/ impingement lesions of all stages (as well as partial frozen shoulder, instability, arthritis ect.)    - if this motion is painful at 90 degrees of forward flexion it is a positive sign for impingement (primary impingement sign);          - pain during abduction of the arm to 80 deg and internal rotation is a secondary impingement sign;

Hawkins and Kennedy• Hawkins and

Kennedy described a second impingement sign in which the arm is flexed forward 90 degrees and then forcibly internally rotated, jamming the supraspinatus tendon against the anterior edge of the coracoacromial ligament to produce pain.

Apprehension Test/Relocation Test

Supraspinatus Test• Hold arms to side as if

holding cans bilaterally – Empty Cans test (original test)

• Wrists pronated as if emptying cans

– Full Cans Test • Wrists supinated as if holding

cans upright • May be more specific for

Supraspinatus impingement

• Hold arm abducted at 50 degrees against resistance

Supraspinatus examination ("empty can" test). The patient attempts to elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward.

Infraspinatus/Teres Minor Test• Infraspinatus/

teres minor examination. The patient attempts to externally rotate the arms against resistance while the arms are at the sides and the elbows are flexed to 90 degrees

Cross Arm Test

• Cross-arm test for acromioclavicular joint disorder. The patient elevates the affected arm to 90 degrees, then actively adducts it

Yergason test

• Yergason test for biceps tendon instability or tendonitis. The patient's elbow is flexed to 90 degrees, and the examiner resists the patient's active attempts to supinate the arm and flex the elbow.

Speed’s Maneuver

• Forward flex the shoulder against resistance while maintaining the elbow in extension and the forearm in supination. Pain or tenderness in the bicipital groove in dicates bicipital tendinitis.

Sulcus Test• With the patient's arm in a

neutral position, the examiner pulls downward on the elbow or wrist while observing the shoulder area for a sulcus or depression lateral or inferior to the acromion. The presence of a depression indicates inferior translation of the humerus and suggests inferior glenohumeral instability

Scarfs Test

• For AC Joint Pathology

The Knee

Lachman Sign• ACL - Lachman Test• • The patient is in the supine position,

with the knee flexed at 20 to 30 degrees.

• Grasp the femur in one hand and the tibia in the other, and examine the anteroposterior motion of the knee by displacing the tibia on the femur.

• Grade the motion from 0 to 4+(1+, 5mm; 2+, 10mm; 3+, 15mm; 4+, 20mm).

• In addition, examine the endpoint of the ligament and grade it as firm, marginal, or stiff. A soft endpoint is usually indicative of a positive ACL tear.

PCL - Posterior Drawer Test (Posterior Sag Sign)

• Have the patient lie supine with knee at 90 degrees of flexion. Determine the neutral position by comparing its resting position with the normal knee.

• If the PCL is disrupted, the tibia will sag posteriorly.

• The patient's foot is placed between examiner's legs while the palms of the hands are used to push the tibia posteriorly.

• The stability can be seen from the lateral view of the knee and the posterior displacement may be evaluated by palpating with the thumb at the joint line.

MCL - Valgus Stress Test• With the patient in the supine

position, place the knee at 20 to 30 degrees of flexion with the thigh supported.

• Stabilize the femur and palpate the medial joint line with one hand.

• Place the other hand on the distal tibia - Place the joint surface in the starting position and abduct the tibia on the femur, restricting axial rotation.

• Estimate the medial joint space and evaluate the stiffness of motion.

• Laxity is graded on a 1 to 4 scale: 1+, 5mm of medial joint space opening with a firm but abnormal endpoint; 2+, 10mm medial opening with a soft endpoint; 3+ (15mm) and 4+ (20mm) may be indicative of an assosiated cruciate ligament injury and must be carefully examined

LCL - Varus Stress Test • Place the patient in the supine

position, with the knee at 20 to 30 degrees of flexion with the thigh supported.

• Stabilize the femur and palpate the lateral joint line with one hand.

• Place the other hand on the distal tibia - begin with the joint in the starting position and adduct the tibia on the fumur, restricting axial rotation.

• Estimate the joint space and evaluate the stiffness of motion.

• Grading is similar to that described above for the valgus stress test.

McMurray Test • Have the patient lie

supine with the knee completely flexed.

• Medially rotate the tibia: if there is a loose fragment of the lateral meniscus, this action will cause a snap accompanied by pain.

• Laterally rotate the tibia: if there is a loose fragment of the medial meniscus, this action will cause a snap accompanied by pain