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D
PHOTOGRAPHIC MANuAL OF
REGIONAL ORTHOPAEDIC
AND NEUROLOGICAL TESTS
FO U R T H
EDITIO N
•
THIS PAGE INTENTIONALLY
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D
PHOTOGRAPHIC MANuAL OF
REGIONAL ORTHOPAEDIC
AND NEUROLOGICAL TESTS
FOURTH
EDITION
JOSEPH]' CIPRIANO, D.C.
Atlanta, Georgia
�� liPPINCOTT WILLIAMS
•
A
&
WILKINS
Wolters Kluwer Company
Philadelphia
•
Baltimore
•
New York
•
London
Buenos Aires · Hong Kong . Sydney · Tokyo
Editor: Peter]. Darcy
Managing Editor: Linda S. Napora
Marketing Manager: Paul Jarecha
Production Editor: Jennifer Ajello
Designer: Armen Kojoyian
Compositor: Graphic World
Printer: Maple Vail Book Manufacturing Group
Copyright © 2003 Lippincott Williams & Wilkins
351 West Camden Street
Baltimore, MD 21201
530 Walnut Street
Philadelphia, PA 19106
All rights reserved. This book is protected by copyright. No part of this book may be repro­
duced in any form or by any means, including photocopying, or utilized by any information
storage and retrieval system without written permiSSion from the copyright owner.
The publisher is not responsible (as a matter of product liability, negligence, or otherwise)
for any injury resulting from any material contained herein. This publication contains infor­
mation relating to general principles of medical care that should not be construed as spe­
cific instructions for individual patients. Manufacturers' product information and package in­
serts should be reviewed for current information, including contraindications, dosages, and
precautions.
Printed in the United States of America
First Edition, 1985
Second Edition, 1991
Third Edition, 1997
Library of Congress Cataloging-in-Publication Data
Cipriano, Joseph ].
Photographic manual of regional orthopaedic and neurological tests
/ Joseph].
Cipriano.-4th ed.
p. cm.
Includes index.
ISBN 0-7817-3552-1
1. Physical orthopedic tests-Atlases. 2. Neurologic examination-Atlases. I. Title.
RD734.5.P58 C57 2003
617.3-dc21
2002072497
The publishers have made every effort to trace the copyright holders for borrowed mate­
rial. If they have inadvertently overlooked any, they will be pleased to make the neces­
sary arrangements at the first opportunity.
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02 03 04 05 06
1 2 3 4 5 6 7 8 9 10
To
Jenny, my loving wife,
Maria, my encouraging mother, and
in memory of Vincent, my Father,
who gave me the courage to follow my dreams.
Without their love, encouragement, compassion,
and courage this manual would not exist.
D
PREFACE
After four editions and nearly 20 years from the beginning of Photographic Manual of Regional
Orthopaedic and Neurological Tests, I have come to realize that when information is presented in a
logical and concise way, readers will master it quickly. For this reason, the format of this manual has
remained the same over four editions, successfully providing instruction for the clinician or student
of orthopaedics and neurology in the proper performance and evaluation of physical orthopaedic
and neurological tests. The tests are categorized in terms of anatomical applications and subcatego­
rized in terms of diagnostic entities. This arrangement assists the clinician and student in evaluat­
ing various orthopaedic and neurological conditions.
The 4'h edition continues to be user-friendly. Each test is accompanied by appropriate photo­
graphs that illustrate the performance of the test. Where applicable, anatomic illustrations provide
enhanced clarity of concept.
All of the information for each test is on one page or two facing pages
so the user can view all of the information without turning the page.
This new edition includes approximately 30 new tests with 90 new photographs and 20 new
anatomical illustrations. Two new features are: Clinical Description, a brief clinical description for
each diagnostic entity, and Suggested Imaging P rocedures, suggested diagnostic imaging for each
condition; these feature are presented in a convenient, easy-to-see format. In addition, there is a
Sensitivity/Reliability Scale
Sensitivity/Reliability Scale I , I I I , I , I. The tests are rated based on the biomechanics
o
1
2
3
4
of the movement that produces the desired outcome of each test, and the Sensitivity/Reliability scale
rating provides a logical order for selecting tests more efficiently by indicating the more sensitive/
reliable tests first.
This 4'h edition will keep readers abreast of new physical orthopaedic and neurological testing
while learning and using the classic and standard tests more efficiently. I believe this material will
enhance your clinical skills. Ultimately, the benefit will be the enhanced well-being of the patients
who have sought our help.
Joseph J. Cipriano, D.C.
vi
D
ACKNOWLEDGMENTS
I thank the following people for their contributions to this book:
J. Randazzo, nc., Mark E. White, D.C. and Warren T. Jahn, Sr., nc., EA.C.O-their technical re­
view of the manuscript and suggestions have been greatly appreciated.
Mark DelSantro , Steve Hite, Dr. L.E Jernigan and Michelle Larson-their expertise is evident in
the photographs that enhance the accuracy of this text.
Anthony Conticelli, John Michie, Barry Silverstein, Joseph Castellana, Mark E. White and Lucas
Wells-their time and professionalism as models have my gratitude.
Lydia V. Kibiuk-her fine artwork and 20 additional illustrations continue to enhance the read­
ers' comprehension of anatomy throughout the book.
Steven P. Weiniger, D.C.-his experience and professionalism are evident in his significant chap­
ter on postural assessment
Pete Darcy, Linda Napora, and Jenn Ajello at Lippincott Williams & Wilkins-their patience and
support have been constant during the publication process.
VII
D
CONTENTS
Vi
P REFACE
ACKNOWLEDGMENTS
1
CLINICAL ASSESSMENT
P ROTOCOL
4
2
History
Observation/Inspection
4
Palpation
4
Range ofMotion Evaluation
5
Special Physical, Orthopaedic, and
8
Neurological Testing
Diagnostic Imaging and other Specialized
Structural Testing
9
Functional Testing
13
General References
14
2
Space-Occupying Lesions
80
Cervical Neurological Compression and
82
Irritation
Vll
POSTURAL ASSESSMENT
C5
C6
C7
C8
Tl
5
15
Why Posture Is Important
16
Architectural vs Adaptive Postural
Changes: Body Types, Injury, and
Habit
16
Posture Evaluation: Methods and
19
Observations
Posture Types
25
Postural Syndromes
26
Other Postural Distortions, Adaptations,
and Pathologies
28
CERVICAL ORTHOPAEDIC
TESTS
39
Cervical Orthopaedic Examination Flow
40
Chart
Cervical Palpation
41
Cervical Range ofMotion
47
Cervical Resistive Isometric Muscle
Testing
52
Vertebrobasilar Circulation
56
Assessment
Subclavian Artery Compromise
68
Cervical Fractures
72
viii
96
98
100
102
104
SHOULDER ORTHOPAEDIC
TESTS
106
Shoulder Orthopaedic Examination
107
Flow Chart
Shoulder Palpation
108
116
Shoulder Range of Motion
Tendinitis (Supraspinatus)
122
Tendinitis (Bicipital)
125
Bursitis
129
Anterior Glenohumeral
Instability
132
Posterior Glenohumeral
Instability
139
Multidirectional Shoulder
Instability
142
Biceps Tendon Instability
150
Thoracic Outlet Syndrome
155
Brachial Plexus Irritation
161
by Steven P. Weiniger, DC
3
CERVICAL NERVE ROOT
92
LESIONS
6
ELBOW ORTHOPAEDIC
167
TESTS
Elbow Orthopaedic Examination
Flow Chart
168
Elbow Palpation
169
Elbow Range of Motion
177
Lateral Epicondylitis
(Tennis Elbow)
180
Medial Epicondylitis
(Golfer's Elbow)
184
Ligamentous Instability
185
CONTENTS
L4
L5
Sl
Neuropathy/Compression
Syndromes
188
7
WRIST ORTHOPAEDIC
193
TESTS
12
Wrist Orthopaedic Examination
194
Flow Chart
Wrist Palpation
195
Wrist Range of Motion
201
205
Carpal Tunnel Syndrome
210
Ulnar Tunnel Syndrome
211
Stenosing Tenosynovitis
Carpal Instability
212
8
HAND ORTHOPAEDIC TESTS
13
215
14
LUMBAR NERVE ROOT
294
LESIONS
T1� L1, L2, L3
295
L2, L3, L4
301
SACROILIAC ORTHOPAEDIC
TESTS
312
HIP JOINT ORTHOPAEDIC
326
TESTS
KNEE ORTHOPAEDIC TESTS
354
Knee Orthopaedic Examination
355
Flow Chart
Palpation
356
Knee Range of Motion
367
Meniscus Instability
369
Plica Tests
378
Ligamentous Instability
381
Patellofemoral Dysfunction
391
Knee Joint Effusion
394
LUMBAR ORTHOPAEDIC
250
TESTS
Lumbar Orthopaedic Examination
Flow Chart
251
Palpation
252
Lumbar Range of Motion
258
Joint Dysfunction Tests
261
265
Lumbar Fractures
Lumbar Nerve Root and Sciatic Nerve
Irritation/Compression Tests
266
Space-Occupying Lesions
285
Differential Diagnosis: Lumbar vs
Sacroiliac Involvement
288
11
309
Hip Joint Orthopaedic Examination
Flow Chart
327
Palpation
328
Hip Range ofMotion
334
Congenital Hip Dysplasia
340
Hip Fractures
343
Hip Contracture Tests
344
General Hip Joint Lesions
349
THORACIC ORTHOPAEDIC
TESTS
228
Thoracic Orthopaedic Examination
Flow Chart
229
Palpation
230
Posterior Aspect
232
Thoracic Range of Motion
237
Scoliosis/Kyphosis Screening
240
243
Thoracic Fractures
245
Nerve Root Lesions
Costovertebral Joint Ankylosis
248
10
303
305
Sacroiliac Orthopaedic Examination
Flow Chart
313
Palpation
314
Sacroiliac Sprain
316
General Sacroiliac Joint Lesions
322
Hand Palpation
216
Joint Instability
220
Joint Capsule Tests
222
Tendon Instability
224
9
IX
15
ANKLE ORTHOPAEDIC
397
TESTS
Ankle Orthopaedic Examination
398
Flow Chart
Palpation
399
409
Ankle Range of Motion
Ligamentous Instability
413
Tarsal Tunnel Syndrome
417
Achilles Tendon Rupture
419
16
MISCELLANEOUS ORTHOPAEDIC
422
TESTS
Peripheral Arterial Insufficiency
Deep Vein Thrombosis
425
Symptom Magnification
Assessment
426
423
X
CONTENTS
Meningeal Irritation and
430
Inflammation
Leg Measurements
433
17
CRANIAL NERVES
18
464
Pathological Upper Extremity
465
Reflexes
Pathological Lower Extremity
469
Reflexes
Superficial Cutaneous Reflexes
435
Olfactory Nerve (I)
437
Optic Nerve (II)
438
Ophthalmoscopic Examination
441
Oculomotor, Trochlear, and Abducens
Nerves (III, IV, VI)
443
Trigeminal Nerve ( V)
446
Facial Nerve
449
Auditory Nerve ( VIII)
452
Glossopharyngeal and Vagus Nerves
(Ix, X)
458
Spinal Accessory Nerve (XI)
461
Hypoglossal Nerve (XII)
462
REFLEXES
19
CEREBELLAR FUNCTION
477
TESTS
Upper Extremity
Lower Extremity
INDEX
478
483
474
--------�rn�-CLINICAL ASSESSMENT PROTOCOL
PATIENT HISTORY
SPECI AL PHYSICAL, ORTHOPAEDIC,
2
Closed-Ended History
O pen-Ended History
AND NEUROLO GIC TESTING
3
8
Physical Examination Precautions
3
Sensitivity/Reliability Rating Scale
OBSERVATI ON/INSPECTION
Skin
DI AGNOSTIC IM AGING AND O THER
4
Subcutaneous Soft Tissue
Bony Structure
SPECI ALIZED STRUCTURAL TESTING
4
Plain Film Radiology
4
9
Computed Tomography
PALPATION
Skin
4
10
Magnetic Resonance I maging
4
Myelography
Subcutaneous Soft Tissue
Pulse
9
4
Skeletal Scintigraphy
4
11
12
13
5
Bony Structures
FUNCTIONAL TESTING
5
Electroencephalography
R ANGE OF MO TION EVALUATION
Passive Range of Motion
Active Range of Motion
Resisted Range of Motion
5
Electromyography
13
13
13
Somatosensory Evoked Potential
5
Suggested Diagnostic Imaging
7
7
13
13
9
2
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
A thorough understanding of anatomic and biomechanical principles provides the foundation for
accurate evaluation of orthopaedic and related neurologic conditions. Knowledge of these princi­
ples is required to understand the relationship between structure and function and the role it plays
in assessing orthopaedic and neurologic dysfunction. The examiner must also be familiar with
anatomic and biomechanical variants that may be normal to a particular patient.
This text deals primarily with physical examination procedures, which are an integral part of any
orthopaedic or related neurologic examination. Complete assessment is not limited to physical ex­
amination; it includes other standard procedures, such as plain film radiography, computed tomog­
raphy (CT), and magnetic resonance imaging (MRI). The clinician must perform the appropriate
protocol to evaluate the patient's condition.
This chapter discusses the appropriate protocol for evaluating orthopaedic and related neuro­
logic problems. These procedures, when followed properly, allow the clinician to assemble parts of
a puzzle so that he or she can visualize the picture, in this case, the patient's condition. Each piece of
the puzzle is analogous to the information gathered by each particular procedure in the clinical as­
sessment protocol. The clinical assessment protocol is shown in Box 1- 1.
Clinical Assessment Protocol
Patient history
Inspection/observation
Palpation
Range of motion
•
Orthopaedic and
neurologic testing
Diagnostic imaging
Functional testing
During the clinical assessment, it is necessary to document findings. The most common method
to record the outcome of the assessment is through a problem-oriented records method that uses a
SOAP (subjective, objective, assessment, plan) note format (Box 1-2).
SOAP Notes
Subjective
Objective
Assessment
Plan
The subjective portion is evaluated by taking the patient's
history.
The objective portion is evaluated by observation and special
tests that measure an objective component.
The assessment is based on the compilation of the
subjective and objective findings and the examination.
The plan may include further testing and/or treatment options.
The clinical assessment protocol is a comprehensive, organized, and reproducible system. This
protocol is an essential tool for evaluating musculoskeletal and neurologic disorders.
PATIENT HISTORY
A complete history is one of the most important aspects of the clinical assessment protocol. A com­
plete and thorough history is invaluable in assessing the patient's condition. At times, a history alone
may lead to a proper diagnosis. The examiner should place emphasis on the aspect of the patient's
history with the greatest clinical significance. Although concentrating on the area of greatest clini­
cal significance, the examiner must not forget to acquire all of the patient's history, whether or not
it seems relevant at the time. There may come a time during the clinical assessment that the infor­
mation that seemed irrelevant is quite useful.
History may also help to determine the personality type of the patient and his or her ability or
willingness to follow directions. Patients who have a history of using an inordinate number of cli-
CHAPTER 1
CLINICAL ASSESSMENT PROTOCOL
3
nicians for the same disorder and receiving little or no help from them may be unwilling or unable
to perform certain functions to better their condition.
It is important that the examiner keep the patient focused on the problem and discourage wan­
dering from the presenting condition. To achieve a good history it is essential to listen carefully to
the patient's concerns about his or her problem and the expectations for diagnosis and treatment.
When acquiring information from the patient the examiner must not lead the patient into answer­
ing questions, such as, "Is this movement painful?" Instead the examiner should say something like,
"What do you feel with this movement?"
This history should concentrate on, but not be limited to, the patient's chief complaint, past his­
tory, family history, occupational history, and social history. History taking should be accomplished
in two steps:
Closed-Ended History
The first step is a closed-ended question and answer format in which the patient answers direct,
pointed questions. This step can be accomplished in a written form that the patient fills out.
Open-Ended History
After the closed-ended history is complete, the patient and examiner should engage in an open di­
alog to discuss the patient's condition. A closed-ended history may lead the examiner to the patient's
problem but may not address the patient's fears or concerns regarding this condition. The patient
may also have other problems either directly or indirectly related to the presenting complaint that
may not be addressed by a closed-ended history.
An open-ended history may take on a discussion format in which the examiner and patient ask
questions of each other. In this way, the examiner acquires extra needed information about the pa­
tient and the patient's complaint. All aspects of the patient's complaint should be explored and eval­
uated to its fullest. The examiner should develop a good rapport with the patient, keeping the pa­
tient focused on the presenting problem and discouraging irrelevant topics. The pneumonic
OPQRST (onset, provoking or palliative concerns, quality of pain, radiating, site and severity, time)
may be incorporated into this evaluation (Box 1-3).
OPQRST
•
•
•
•
•
·
Mnemonic
Onset of complaint
Provoking or palliative concerns
Quality of pain
Radiating to a particular area
Site and severity of complaint
Time frame of complaint
Once the examiner has determined all aspects of the presenting complaint, it is time to focus on
the history. Has the patient had prior problems with this or any other complaint? This information
may assist with both assessment of the problem and insight on how to treat the problem.
Family history can give a clue about the patient's propensity of inheriting familial diseases. A sig­
nificant number of neurologic problems and many orthopaedic problems can be traced to family
members.
Occupational and social histories are also important because they may lead to a factor causing
the patient's problem, such as an overuse syndrome. They can also help to determine whether the
patient's condition will respond more favorably if the patient refrains from performing certain work
or social functions. For example, lifting, bending, and playing tennis or golf may be contraindicated.
The patient may also need to be retrained for other types of work.
II
4
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
OBSERVATION/INSPECTION
Observe the patient for general appearance and functional status. Note the body type, such as slim,
obese, short, or tall, and postural deviations for general appearance, gait, muscle guarding, com­
pensatory or substitute movements, and assistive devices for functional status.
Inspection should be divided into three layers: skin, subcutaneous soft tissue, and bony struc­
ture. Each layer has its own special characteristics for determining underlying pathology or dys­
function.
Skin
Skin assessment should begin with common and obvious findings, such as bruising, scarring, and
evidence of trauma or surgery. Then look for changes in color, either from vascular changes accom­
panying inflammation or from vascular deficiency, such as pallor or cyanosis. Large, brownish, pig­
mented areas and/or hairy regions, especially on or near the spine, may indicate a bony defect such
as spina bifida. Changes in texture may accompany reflex sympathetic dystrophies. Open wounds
should be evaluated for either traumatic or insidious origin, which may accompany diabetes.
Subcutaneous Soft Tissue
Subcutaneous soft tissue abnormalities usually involve either inflammation and swelling or atrophy.
When evaluating for an increase in size, attempt to identify edema, articular effusion, muscle hy­
pertrophy, or other hypertrophic changes. Also note any nodules, lymph nodes, or cysts. Establish
any inflammation by comparing bilateral symmetry for the torso and circumferential measurements
for the extremities.
Bony Structure
Bony structure should be evaluated, especially when the patient presents with a functional abnor­
mality, such as a gait deviance or an altered range of motion. Bony inspection in the spine should
focus on items such as scoliosis, pelvic tilt, and shoulder height. Note and possibly measure malfor­
mations in the extremities that may be congenital or traumatic. Two examples of congenital mal­
formations are genu varus and genu valgus. Traumatic malformations include a healed Colles' frac­
ture with residual angulation. All bony structures should be visually assessed for abnormalities and
documented.
PALPATION
Palpate the patient in conjunction with inspection; the structures being inspected are the same ones
that should be palpated. The layers are the same for palpation as for inspection, skin, subcutaneous
soft tissue, and bony structures.
When palpating the skin, begin with a light touch, especially if nerve pressure is suspected. Pres­
sure on a nerve may result in dysesthesia, which may feel like an exaggerated burning sensation to
the patient.
Skin
Evaluate skin temperature first. High skin temperature may indicate an underlying inflammatory
process. Low skin temperature may indicate a vascular deficiency. Also, evaluate skin mobility for
adhesions, especially after surgery or trauma.
Subcutaneous Soft Tissue
The subcutaneous soft tissue consists of fat, fascia, tendons, muscles, ligaments, joint capsules,
nerves, and blood vessels. Palpate these structures with more pressure than for skin. Tenderness is a
subjective complaint that should be noted. It may be caused by (a) injury; (b) pathology that corre­
lates directly to the tenderness, such as tenderness at the supraspinatus ligament for supraspinatus
CHAPTER 1
CLINICAL ASSESSMENT PROTOCOL
5
tendinitis; or (c) a referred component, such as tenderness in the buttock area from a lumbar injury
or pathology. Determine tenderness by applying pressure to the area and grade it according to the
patient's response (Box 1-4).
Evaluate swelling or edema according to its origin. Determine if the inflammation is intra­
articular or extra-articular. In intra-articular effusion, the fluid is confined to the joint capsule. In
extra-articular effusion, the fluid is in the surrounding tissues. Various palpation techniques are dis­
cussed in detail in the chapters on specific areas of the body.
Tenderness Grading Scale
Grade
Grade
Grade
Grade
I
II
III
IV
Patient complains of pain.
Patient complains of pain and winces.
Patient winces and withdraws the joint.
Patient will not allow palpation of the joint.
There are different types of swelling or edema, according to onset and palpation feel. If swelling
occurs immediately after an injury and feels hard and warm, the swelling contains blood. If the
swelling occurs 8 to 24 hours after an injury and feels boggy or spongy, the swelling contains syno­
vial fluid. If the swelling feels tough and dry, it is most likely a callus. If the feeling is thickened or
leathery, it is most likely chronic swelling. If the swelling or edema is soft and fluctuating, it is most
likely acute. If the feeling is hard, it is most likely bone. If the feeling is thick and slow moving, it is
most likely pitting edema.
Pulse
Pulse amplitude in certain arteries is important. It is used to assess the vascular integrity of an area
and plays an integral part in certain tests for thoracic outlet syndrome, arterial insufficiency, and
vertebrobasilar compromise.
Bony Structures
Bony structure palpation is critical for the detection of alignment problems, such as dislocations,
luxations, subluxations, and fractures. When you palpate bony structures, you must also identify the
ligaments and tendons that attach to those structures. Tenderness is a major finding in bony palpa­
tion. It may indicate periosteoligamentous sprain. It also may indicate fracture. Bony enlargements
usually are associated with healing of fractures and degenerative joint disease.
RANGE OF MOTION EVALUATION
Range of motion evaluation is not only a measurement of function but also an important part of
biomechanical analysis. Range of motion is evaluated for three separate types of functions: passive
motion, active motion, and resisted motion.
Passive Range of Motion
In passive motion, the examiner moves the body part for the patient without the patient's help. It
can yield a significant amount of information about the underlying pathology. The goal obviously
depends on which joint is being tested and what pathology or injury is suspected. In evaluating such
motion, first note whether the movement is normal, increased, or decreased and in which planes.
Second, note any pain. Classically, pain on passive range of motion indicates a capsular or ligamen­
tous lesion on the side of movement and/or a muscle lesion on the opposite side of movement. Var­
ious other problems may be detected, depending on the degree of mobility and pain. Six possible
variations of range of motion pain are shown in Box 1-5.
II
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
6
Six Range of Motion and Pain Variations
1. Normal mobility with no pain
indicates a normal joint with no lesion.
may indicate a minor sprain of a ligament
2. Normal mobility with pain elicited
or capsular lesion.
3. Hypomobility with no pain
may indicate an adhesion of a particular tested
structure.
4. Hypomobility with pain elicited
5.
6.
may indicate an acute sprain of a ligament or
capsular lesion. When an injury is severe, hypomobility and pain may also be
a sign of muscle spasm caused by guarding or by muscle strain opposite the
side of movement.
Hypermobility with no pain suggests a complete tear of a structure with no
fibers intact where pain can be elicited. It may also be normal if other joints
in the absence of trauma are also hypermobile.
Hypermobility with pain elicited indicates a partial tear with some fibers still
intact. Normal pressure by the weight of structure that is attached to the
ligament or capsule is being exerted. This pressure on the intact fibers can
elicit pain.
After you determine the degree of passive range of motion and evaluate for pain, evaluate for an
end feel. To determine end feel, passively move the joint to the end of its range of motion and then
apply slight overpressure to the joint. The quality of the feeling that this elicits is the end feel, as­
sessed as either normal (physiologic) or abnormal (pathologic) (Table 1-1).
TABLE 1-1
END FEEL EVALUATION
Category
Normal Physiologic End Feels
Abnormal Pathologic End Feels
Hard
Abrupt hard to stop movement
when bone contacts bone
Example: passive elbow extension.
Olecranon process contracts
the olecranon fossa
When two body surfaces come
together, a soft compression of
tissue is felt.
Example: Passive elbow flexion.
Anterior aspect of the
forearm approximates the
biceps muscle.
A firm or spongy sensation that
has some give when a muscle,
ligament, or tendon is
stretched.
Example: Passive wrist flexion,
passive external shoulder
rotation.
Abrupt stopping movement before
normal expected passive movement.
Example: Cervical flexion hard end feel
due to severe degenerative joint disease.
Soft
Firm
Springy, block
Empty
A soft boggy sensation resulting from
synovitis or soft tissue edema.
Example: Ligamentous sprain.
A firm springy sensation to movement
with a slight amount of give in
capsular joints.
Example: Frozen shoulder.
Rebound effect with limited motion;
usually in joints with a meniscus.
Example: Torn meniscus.
An empty feel in a joint with severe pain
when passively moved. The movement
cannot be performed because of the pain.
Example: Fracture, subacromial bursitis,
neoplasm, joint inflammation.
CHAPTER 1
CLINICAL ASSESSMENT PROTOCOL
7
Active Range of Motion
Active range of motion evaluates the physical function of a body part. This type of range will yield
general information regarding the patient's general ability and willingness to use the part. If a
patient is asked to move a joint through a full arc of movement and cannot, it is impossible to dis­
tinguish whether the loss of function is caused by pain, weakness caused by a neurologic motor dys­
function, stiffness, or the conscious unwillingness of the patient to perform the full function. There­
fore, the assessment value of active range of motion in and of itself is vague and limited. Active
motion is a basic test for the integrity of the muscle or muscles used in the action and the nerve sup­
ply attached to the muscle. Obviously, the integrity of the joint being tested must be intact to eval­
uate muscular or neurologic dysfunction. This integrity is best evaluated by passive range of motion.
When evaluating active motion, note the degree of motion in the tested plane as well as any pain
associated with the movement. The pain should be correlated with the movement, such as pain in
the full arc or only in the extreme range of motion. Crepitus should also be noted when performing
active range of motion. Crepitus is a crackling sound that usually indicates a roughening of joint
surfaces or increased friction between a tendon and its sheath (caused by swelling or roughening).
Joint range of motion should be measured and recorded by commonly accepted reproducible
means. To measure the range of motion of the spine, the most accurate instrument is the incli­
nometer (Fig. 1- 1). This instrument measures angular displacement relative to gravity as opposed to
arcs. The reason for inclinometer measurement of the spine is that the spine is composed of multi­
ple joints that function in unison to produce movement. A device that measures arcs, such as a go­
niometer (Fig. 1-2), cannot distinguish the difference between sacral flexion and lumbar flexion in
the lower back when the patient is bending forward. In this particular instance, the inclinometer can
distinguish between true lumbar flexion and sacral or hip flexion (see inclinometer range of motion
in Chapters 3, 9, and 10). Goniometers are best suited to measure extremity range of motion.
Figure ,-,
Figure '-2
Resisted Range of Motion
Resisted range of motion is useful in assessing musculotendinous and neurologic structures. It is
primarily used to test neurologic function (see nerve root lesions). The tests are graded 5 to 0, a scale
that has been adopted by the American Academy of Orthopaedic Surgeons (Box 1-6).
Musculotendinous injuries are generally more painful than they are weak. Neurologic lesions are
generally more weak than they are painful. The four general pain-related reactions to resisted range
of motion testing are listed in Box 1-7.
D
8
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Muscle Grading Scale
5
4
3
2
1
o
Complete range of motion against gravity with full resistance
Complete range of motion against gravity with some resistance
Complete range of motion against gravity
Complete range of motion with gravity eliminated (movement
in the horizontal plane)
Evidence of slight contractility
No evidence of contractility
Resistant Range of Motion Reactions
1.
2.
3.
4.
Strong with no pain elicited is normal and not indicative
of any lesions.
Strong with pain elicited may indicate a minor lesion of the
muscle or tendon.
Weak and painless may indicate a neurologic lesion, which must
be evaluated with the previous chart. It may also indicate a
complete rupture of a tendon or muscle because there are no
fibers intact from which pain can be elicited.
Weak and painful may indicate a partial rupture of a muscle or
tendon because intact fibers may be stressed to produce pain.
Fracture, neoplasm, and acute inflammation are also possibilities.
SPECIAL PHYSICAL, ORTHOPAEDIC, AND NEUROLOGIC TESTING
Special physical, orthopaedic, and neurologic testing is designed to place functional stress on iso­
lated tissue structures in terms of the underlying pathology. Positive physical testing is not diag­
nostic in itself but rather a biomechanical assessment to be used as part of a complete clinical
evaluation.
Before performing certain special tests, you must ascertain that they will not be detrimental to
the patient's condition. Box 1-8 lists the conditions for which care must be taken when performing
either range of motion testing or special physical orthopaedic and neurologic testing.
Physical Examination Precautions
Dislocation
Unhealed fracture
Myositis ossificans/ ectopic ossification
Joint infection
Marked osteoporosis
Bony ankylosis
Newly united fracture
After surgery
If it is determined that special physical testing may indeed harm the patient, structural and/or
functional testing, such as radiography, CT, MRI, or electromyography (EMG), should be employed
before any physical testing.
The subsequent chapters contain a collection of special physical orthopaedic and neurologic
tests organized anatomically and subcategorized by diagnostic entity. This system is best suited for
expedient evaluation of musculoskeletal and orthopaedic neurologic conditions. Each test illustrates
and discusses the procedures for correct performance of the test. Each test is accompanied by an ex­
planation that indicates the positive indicators for that test and what they may mean in terms of an
underlying pathology or injury. Biomechanical considerations that may not be evident in the clas­
sical interpretation of a particular test are also explored.
CHAPTER 1
CLINICAL ASSESSMENT PROTOCOL
9
Sensitivity/Reliability Scale
I have chosen to add a sensitivity/reliability scale to each of the tests described in this text. For each
diagnosis presented, there are multiple tests. Some of those tests are more sensitivelreliable than oth­
ers. I have attempted to rate each test based on the biomechanics of the movement to isolate the af­
fected structures. The scale is numbered from 0 to 4, with 1 to 2 being poorly sensitivelreliable, 2 to
3 being moderately sensitivelreliable and 3 to 4 being very sensitivelreliable. Those tests that are very
sensitivelreliable should be performed first. This will help in evaluating the patient's condition more
expeditiously.
DIAGNOSTIC IMAGING AND OTHER SPECIALIZED
STRUCTURAL TESTING
Diagnostic imaging or structural testing entails the use of specialized equipment to visualize certain
anatomic structures. The most common diagnostic imaging procedures include plain film radiology
(x-ray), CT), MRI), and skeletal scintigraphy (bone scan). Each type of structural test may be best
suited to visualize various structures in specific ways.
Plain Film Radiology
Plain film radiology dates to 1895, and its fundamentals are still used in practice today. X-rays are a
form of radiant energy that have a short wavelength and can penetrate many substances (Fig. 1-3).
The x-ray is produced by bombarding a tungsten target with an electron beam in an x-ray tube.
Plain film radiography demonstrates five basic densities: air, fat, subcutaneous tissue, bone, and
metal. Anatomic structures are seen on radiographs as outlines in whole or as part of different tis­
sue densities. These differences in densities are the key to determining the normal or pathologic state
of tissues shown on radiographic film. Bone is the best-seen tissue on plain film radiography.
Figure 1-3
10
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Computed Tomography
Computed tomography is a cross-sectional imaging technique that uses x-ray as its energy (Fig.
1-4). A computer is used to reconstruct a cross-sectional image from measurements of x-ray trans­
mission. Most CT units allow for a slice thickness between 1 and 10 mm and are generally limited
to the axial plane. CT is best used for bone detail and demonstration of calcifications. Intervertebral
disc defects may also be visualized on CT, but not as well as with MRI.
Figure 1-4
CHAPTER 1
CLINICAL ASSESSMENT PROTOCOL
11
Magnetic Resonance Imaging
MRl is also a cross-sectional imaging technique (Fig. 1-5). It uses magnetic fields and radio waves
instead of x-rays to produce its images. MRI is based on the ability of the body to absorb and emit
radio waves when the body is in a strong magnetic field. The absorption and release of this energy
is different and detectable in each individual type of tissue. Hence, MRI is invaluable in contrasting
soft tissue structures in many planes without the use of ionizing radiation. It poorly demonstrates
bone density detail or calcifications; this is the advantage of CT. MRI is superior in visualizing an in­
tervertebral disc or other soft tissue structure for pathology.
Patients with any metallic implants or metal fragments (e.g., cardiac pacemakers, insulin
pumps, vascular clips, skin staples, bullets, or shrapnel) are advised not to undergo MRI because of
the strong magnetic field emitted by the scanner. This field may move or dislodge metallic implants
or objects in an individual whose body is being scanned.
Figure 1-5
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12
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Myelography
Myelography introduces a small amount of water-soluble contrast medium into the subarachnoid
space (Fig. 1-6). Standard x-ray films of the spine are then taken to evaluate and defects of the spinal
canal, such as spinal stenosis, spinal cord lesions, and dural tears.
Figure 1-6
CHAPTER 1
CLINICAL ASSESSMENT PROTOCOL
13
Skeletal Scintigraphy
Skeletal scintigraphy, or bone scan, uses an intravenous radiopharmaceutical, technetium-99m,
which is attracted to osteoblastic activity in bone tissue and is detected by a gamma camera (Fig.
1-7). Vigorous osteoblastic activity, such as healing fractures and pathologic conditions, stimulate
skeletal blood flow and bone repair. In turn, more of the radiopharmaceutical attaches to the area,
marking the increased activity for evaluation. Bone scans are best suited for undetectable fractures
on x-ray and arthropathies, such as early degenerative changes in joints, osteomyelitis, bony dys­
plasias, primary bone tumors, and metastatic malignancy.
Figure 1-7
FUNCTIONAL TESTING
Functional testing for musculoskeletal and neurologic pathology entails testing neurologic function
by assessing electrical activity of specific neurologic structures, such as electroencephalography
(EEG), EMG, and somatosensory evoked potential studies (SSEP).
Electroencephalography
EEG records the electrical activity of the brain through the skull by surface electrodes. Abnormal
electrical activity may indicate cerebral pathology, such as epilepsy, inflammatory encephalopathies,
infarction, trauma, or tumor, that may not be detectable by structural testing.
Electromyography
EMG measures the electrical activity of contracting muscles and is recorded either via surface elec­
trodes or through needles inserted directly into the muscle itself. The surface electrodes record and
average the activity from many motor units, whereas needle EMG can detect the activity from a sin­
gle motor unit. The recordings are used to detect the cause of muscle weakness. They are also use­
ful in detecting neuropathies, denervation, and entrapment syndromes.
Somatosensory Evoked Potential
SSEP studies measure electrical activity from a distal nerve to a more proximal point on the nerve,
spinal cord, or brain stem. A stimulus is given peripherally, and responses are recorded and averaged
proximal to the stimulated area. The purpose of the test is to determine and quantify nerve, cord, or
brain stem lesions. It is used most commonly to detect trauma, tumors, and demyelinating diseases
of the nervous system.
Suggested Diagnostic Imaging
Each chapter contains a suggested diagnostic imaging section for each diagnostic entity. These sug­
gestions start from the most basic diagnostic imaging and move on to more advanced testing pro­
cedures. If diagnostic imaging is needed, the clinician should start with the most basic tests and
14
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
move forward based on the outcome of those first tests. Secondly, the clinician should not advance
to other diagnostic tests if the results of the basic diagnostic imaging reveal that injury may result
from further testing, such as flexion/extension plain film radiography to the cervical spine if insta­
bility is noted on static scout films. Remember that there is no substitution for a complete history
and physical examination and that the suggested diagnostic imaging sections are just that­
"suggested:' based on the history and examination of the presenting patient.
SUMMARY
The examining clinician should employ the techniques discussed in this chapter to assess the pa­
tient's condition. Not all segments of the clinical assessment protocol need be employed for each pa­
tient and complaint. History, inspection, palpation, range of motion, and physical testing are core
requirements. Whether to use diagnostic imaging and functional testing is based on the outcomes
of the core requirements and the clinical judgment and experience of the examiner.
General References
1. Adams
JC,
Hamblen
DL.
1 1 th
Edinburgh:
Outline of
Or­
1 2. Hertling
D,
Kessler
RM.
Management
of
Churchill
Common Musculoskeletal Disorders: Physical
2. American Academy of Orthopaedic Surgeons.
Philadelphia: Lippincott Williams & Wilkins,
thopaedics.
ed.
T herapy Principles
Livingstone, 1 990.
T he Clinical Measurement of Joint Motion.
Chicago: American Academy of Orthopaedic
and History Taking.
7th
ed.
Philadelphia:
Lippincott Williams & Wilkins, 1 999.
HM.
Musculoskeletal
2nd
ed.
Baltimore:
Lippincott
Williams & Wilkins, 2000.
ed.
1996.
13. Hoppenfeld S. Physical Examination of the
Medicine. London: Butterworth, 1 983.
Vol 1. Diagnosis of Soft T issue Lesions. 8th ed.
1 5. Krejci V P. Koch muscle and tendon injuries.
Chicago: Year Book, 1 979.
3rd ed. Philadelphia: WB Saunders, 1 997.
Methods for the Health Professional. Reston,
VA: Reston, 1 985.
1 8. Mooney V. Where is the Pain Coming From?
London: Bailliere Tindall, 1 982.
7. Dambro MR, Griffith JA. Griffith's 5 Minute
Baltimore:
Williams & Wilkins, 1 993.
1 7. Minor MAD, Minor SD. Patient Evaluation
6. Cyriax J. Textbook of Orthopaedic Medicine.
Consult.
Century-Crofts, 1 976.
1 4. Kendall FP, McCreary EK, Provance PG. Mus­
1 6. Magee DJ. Orthopaedic physical assessment.
5. Corrigan B, Maitland GD. Practical Orthopaedic
Clinical
3rd
cles: Testing and Function. 4th ed. Baltimore:
Assessment:
Joint Range of Motion and Manual Muscle
Strength.
Methods.
Spine and Extremities. New York: Appleton­
Surgeons, 1 994.
3. Bates B. Bates' Guide to Physical Examination
4. Clarkson
and
Williams
&
Wilkins, 1 997.
8. Endow Aj, Swisher SN. Interviewing and Pa­
tient Care. New York: Oxford University, 1 992.
9. French S. History Taking in Physiotherapy As­
sessment. Physiotherapy 1 988;74: 1 58- 1 60.
1 0. Greenstein GM. Clinical Assessment of Muscu­
loskeletal Disorders. St. Louis: Mosby, 1 997.
Spine 1 989;1 2:8:754-759.
1 9. Nordin M, Frankel VH. Basic biomechanics of
the musculoskeletal system. 3rd ed. Philadel­
phia: Lippincott Williams & Wilkins, 200 1 .
20. Post M . Physical Examination o f the Muscu­
loskeletal System. Chicago: Year Book, �987.
2 1 . Salter RE. Textbook of disorders and injuries of
the musculoskeletal system. 3rd ed. Baltimore:
Williams & Wilkins, 1999.
1 1 . Hawkins RJ. An Organized Approach to Muscu­
22. Starkey C, Ryan J. Evaluation of Orthopedic
loskeletal Examination and History Taking.
and Athletic Injuries. Philadelphia. FA Davis,
St. Louis: Mosby, 1995.
1 996.
--------�rn�-POSTURAL ASSESSMENT
II
Steven P. Weiniger, DC*
WHY POSTURE IS IMPORTAN T
16
ARCHITE CTURAL VERSUS ADAPTIVE
POSTURAL CHANGES: BODY TYPES,
INJURY, AND HABIT 16
POSTURE EVALUATION : METHODS AND
OBSERVATIONS 19
Posterior View Evaluation 21
Lateral View 22
A nteroposterior/Front View 24
POSTURE TYPES
25
POSTURAL SYNDRO MES
26
OTHER POSTURAL DISTORTIONS,
ADAPTATIONS, AND PATHOLOGIES
Forward Head Posture 28
Head Tilt and/or Rotation 30
U nlevel Shoulders 30
28
Scapula Winging 32
Scapula Rotation 32
Round Shoulders/Internal Rotation of the
Upper Extremity 33
Lateral Spinal Deviation/Scoliosis 33
Lateral Pelvic Tilt/Abdominal
A symmetry 34
A nterior or Posterior Pelvic Tilt 35
Abdomen Protrusion 36
Knock Knees: Genu Valga 36
*Private practice in Conyers, Georgia; founder, BodyZone.com.
15
16
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
WHY POSTURE IS IMPORTANT
Posture is how a body balances. If a body doesn't balance, it falls down. To analyze posture it
is necessary to observe how the body is balancing. Posture is more than muscles and bones. The
spine, with its ligaments intact but devoid of muscles, is an extremely unstable structure. Mus­
cles and their complex neuromuscular control are required (a) to provide stability of the trunk
in a given posture and (b) to produce movement during physiologic activity (1). The motor sys­
tem and the nervous system function as one entity (2). Therefore, postural analysis is an as­
sessment of the function of the motor system (bones, muscles, and ligaments) and the nervous
system's control of the motor system.
Postural observations are organic; that is, they deal with the whole organism. Unlike most or­
thopaedic or neurologic tests, which focus on identifying the specific nature of an injury, illness, or
other clinical problem, a postural evaluation looks at the whole person and attempts to assess the
relative contributions of myriad postural observations. Posture comprises an accumulation of adap­
tations and compensations from injuries and habits to allow the body to balance and function
effectively.
An individual's neutral posture occurs when the brain and nervous system use information
from three sources to balance the body in space when standing, sitting, or moving:
Eyes: We see what is level.
Ears: The vestibular apparatus gives the brain information about the relative position and mo­
tion of each inner ear.
Muscles and joints: Proprioceptors in the muscles, ligaments, and tendons tell the brain how
hard each is being stressed.
The brain integrates the information it receives to balance the body.
ARCHITECTURAL VERSUS ADAPTIVE POSTURAL CHANGES:
BODY TY PES, INJURY, AND HABIT
Postural compensations and adaptations can be both a cause and an effect of a clinical problem. Or­
thopedic problems frequently cause a postural change, which in turn worsens the orthopaedic prob­
lem. Asymptomatic postural problems can cause undue mechanical stress, predisposing an individ­
ual to either injury or chronic mechanical stress syndrome.
There is no one "normal" posture. An ideal posture is used as a reference point, but rarely does
a patient have "perfect posture." Since the posture is how the body balances, the ideal posture for an
individual distributes the forces of gravity for balanced muscle function. Joints should move in their
mid range so as to minimize undue stress and strain on ligaments at the joint's end range of motion
and fully distribute stress on the joint surfaces. A biomechanically efficient posture is maximally ef­
fective in that individual's activities of daily living and avoids injury.
People come in various shapes and sizes and live unique lives, and their postures differ ac­
cordingly (Fig. 2-1). An individual learns during childhood to balance the body's unique archi­
tecture. The child's habits affect his or her posture. Good habits can create a strong and stable
posture. Bad habits can train the body for poor posture and instability. Excessive sitting, carry­
ing a heavy backpack, slumping, or poor sleeping position trains the body to a folded-forward
posture. Habitual one-sided activities, such as carrying a heavy purse, sitting on a wallet, or fac­
ing sidewise to view a poorly placed computer monitor train the body to be asymmetrical from
left to right.
CHAPTER 2
POSTURAL ASSESSMENT
17
II
Figure 2-1. Posture varies b y individual body type, history o f injury, and habits.
Poor posture creates adaptive patterns of body motion. Poor posture and body motion stress the
musculoskeletal system, resulting in premature joint wear and susceptibility to injury. Studies show
that sports injuries correlate with deviations of body mechanics (3). The incidence of injury in ath­
letes has been linked to postural distortions associated with the site of injury, and those with more
than two types of injury have significantly worse postural symmetry.
The human bipedal posture is extremely effective and "the most economical of antigravity
mechanisms once the upright posture is attained" (4). However, when there is an illness or injury,
the body adapts and moves differently. The body must balance, so the posture adapts to changes in
muscle and joint motion and resting positions. Overstressed muscles strengthen and favored mus­
cles weaken.
Posture and body motion are like a fold in a piece of paper. Once folded, the paper will bend
along the fold when it is stressed. Similarly, once posture and body motion change to compensate
for poor habits or injury, the body continues to assume the same uneven resting posture and follows
the same adaptive pattern of motion. Biomechanically speaking, this adaptive posture is almost al­
ways inefficient. Mother was right about molding good posture in a child by standing straight with
head and shoulders back.
Clinically, a postural change begins a cascade of compensating causes and effects. Subjectively,
the patient usually believes he or she is standing straight and balanced, even if a visual inspection
shows otherwise. If the brain believes the body is balanced when it is not, posture adaptations cause
uneven stress and predisposition to future injury. Over a lifetime, people's history of injury, daily ac­
tivities, and habits shape their unique posture.
18
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Spinal distortions occur in all directions of three-dimensional space and are more than a sum
of the front, back, and side views of the spine. When viewed from above, the helical nature of spinal
adaptations becomes apparent (Fig. 2-2) (1). However, according to White and Panjabi (1), present
knowledge and technology do not allow effective evaluation of helical adaptations. Nonetheless,
posture analysis can provide valuable clinical information that must be correlated with a patient's
history and reported symptoms.
Figure 2-2. Helical spine adaptation.
CHAPTER 2
POSTURAL ASSESSMENT
19
POSTURE EVALUATION: METHODS AND OBSERVATIONS
A suggested posture evaluation mindset is to think of the body as a stack of children's blocks (Fig.
2-3). When the blocks are all balanced, the stack is stable. But when one is out of place, the stack
wobbles. To balance a stack of blocks, you put the second block on top of the first. When you place
the third block on the second, it can be only as stable as the second. Placing a forth block requires
stability of the blocks below, and so on. This bottom-to-top arrangement is how human beings balance. That is why shoulder corrections tend to follow correction of lateral pelvic tilt, but the reverse
does not necessarily occur.
Figure 2-3. Unbalanced posture
creates instability.
•
20
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Additionally, in posture analysis and clinical treatment, it is important to determine whether a
muscle is weak or inhibited. A weak muscle is unused because it is unstressed and should therefore
be strengthened with exercise. An inhibited muscle is not used because its antagonist is being adap­
tively overused. The neurologic reciprocal inhibition of a muscle by its antagonist results in overde­
velopment of the muscles most used in posture and underdevelopment of their antagonists (2).
Clinically, the goal is to identify the most important fault in the kinetic chain. Since postural
analysis can be diagnostic and possibly suggest therapeutic actions, it is imperative to differentiate
between actions and reactions. Unbalanced postures have compensating reactions. When observing
the posture, the examiner should note any inconsistencies or imbalances, both from left to right and
from front to back. Mentally integrate the patient's complaint and history with the mechanics of the
body's balance. Palpation can help differentiate longstanding adaptive muscle hypertrophy (unilat­
erally tight muscles without significant reactive pain on palpation) from acute muscle spasm (with
reactive pain on palpation).
Prior to postural evaluation, the examiner should obtain all pertinent history, including a de­
scription of symptoms, fractures, injuries, congenital abnormalities, and the patient's dominant
hand. It is important to note any gross structural asymmetries, scoliosis, or other condition that cre­
ates imbalance.
The patient should be as minimally clothed as possible so that the examiner may clearly visual­
ize the contours, bony prominences, and other anatomical landmarks from the front (anteroposte­
rior [AP] view), back (posteroanterior [PAl view) and sides (left and right lateral views) (Fig. 2-4).
The patient should be told to stand straight and look straight ahead. The patient who adopts a
rigid standing straight posture (i.e. bilateral shoulder or abdominal tightening on assuming a
straight posture) should be told to relax and assume a comfortable position. Patients will try to as­
sume a "good" posture, so to observe a true resting posture it is important not to coach patients by
asking them to straighten up what is misaligned.
If there is poor alignment of the feet and the torso or if both feet are not facing at the same an­
gie, instruct the patient to march in place for five steps. A postural distortion is indicated if the feet
and torso are still misaligned.
Figure 2-4. Posture should be viewed from the front. back. left side. and right side.
CHAPTER 2
POSTURAL ASSESSMENT
21
Posterior View Evaluation
In a balanced posture, the body appears equal from left to right. A vertical plumb line over the cen­
ter of the body (Fig. 2-5) should show alignment of the occipital protuberance; cervical, thoracic,
and lumbar spinous processes; coccyx:; and gluteal folds. The arms should hang equally from the
torso, with an equal and small amount of the palms visible. The space between the arms and the
body should be the same on both sides. The legs should appear equally abducted from the center­
line, and the backs of the knees should appear the same. The ankles and feet should display bilater­
ally symmetric alignment (e.g., no pronation or supination) and toe out. In balanced posture, the
following structures should be level and equal: tips of the mastoid processes, acromia, scapula, lower
margins of the 12th ribs, iliac crests, posterior superior iliac spines, and ischial tuberosities.
Lateral trunk
muscles
Quadratus lumborum
Internal oblique
External oblique
Hip abductors
Gluteus medius
Tensor fasciae
latae
Iliotibial tract
of fascia lata
Adductors
Everters
Peroneus
longus
and brevis
Inverters
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Figure 2-5. Ideal alignment, posterior view. (Modified with permission from Kendall FP.
McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Baltimore: Williams &
Wilkins, 1993:88.)
22
PHOTOGRAPHIC MANuAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Most people have a slight postural distortion because of left- or right-hand dominance. Right­
handed people tend to have a high right hip and a low right shoulder (Fig. 2-6). Left-handed ones
tend to have a high left hip and a low left shoulder. In addition, the normal AP spine has a slight
right convex thoracic curve, most likely due to an individual's left or right-handedness (1).
Figure 2-6. Right-handed
postural pattern.
Lateral View
The examiner should evaluate the patient from both sides. From the side view, a plumb line should
show alignment between the external auditory canal, acromion process of the shoulder, axillary line,
midpoint of the iliac crest, greater trochanter of the hip, lateral condyles of the femur, and tibia
slightly anterior to the lateral malleolus.
The head, chest, pelvis, and lower extremities should be in alignment and balanced. There
should be a normal cervical lordosis, thoracic kyphosis, and lumbar lordosis (Fig. 2-7). The head is
balanced when a horizontal line can be drawn from the occipital protuberance to the lower margin
of the zygomatic arch. In neutral posture the head should be above the shoulders, not forward. The
eyes have a strong tendency to seek level, so if there is postural distortion, the head position may tilt
forward or backward to compensate (Fig. 2-8).
CHAPTER 2
POSTURAL ASSESSMENT
23
•
Back extensors
Abdominals
Rectus abdominis
External oblique
Hip flexors
Psoas major
Iliacus
Hip extensors
Gluteus
maximus
Tensor fasciae
Hamstrings
latae
Rectus femoris
i?ftrc....==
..::
===.
Figure 2-7. Lateral posture alignment. (Modified with permission from
Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th
ed. Baltimore: Williams & Wilkins, 1993:83.)
Figure 2-8. Neutral posture (left), forward posture (center), and cervical retraction (right).
24
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
On a lateral view, the shoulder girdle and torso are balanced when a horizontal line can be
drawn from the medial end of the spine of the scapula to the head of the humerus and then to the
medial end of the clavicle. The scapulae should appear equal and lie symmetrically against the torso
(Fig. 2-9).
The pelvis is level and balanced when a horizontal line can be drawn from just below the ante­
rior superior iliac spine to the posterior superior iliac spine. Ideally, the anterior superior iliac spine
should be vertically aligned with the symphysis pubes (Fig. 2-9).
The lower extremities should be vertically aligned with the knee joints neutral (e.g., not locked
in hyperextension). The legs should be equally vertical and at a right angle to the sole of the foot
(Fig. 2-9).
Anteroposterior/Front View
Balanced posture should appear equal from left to right. A vertical plumb line over the center of the
body will show alignment of the bridge of the nose, center of the chin, episternal notch, xiphoid
process, umbilicus, and pubes. The arms should be hanging similarly, both palms at the side of the
thighs. Shoulder girdle symmetry is indicated if the hands show similar rotation and placement on
the body. The legs should appear equally abducted from the centerline, with the feet displaying bilat­
erally symmetric alignment (e.g., no pronation or supination) and toe out. The knees should be for­
ward and bilaterally symmetric in their alignment and orientation on the lower extremity (Fig. 2-10).
In balanced posture, anterior examination will show the following structures to be equal bilat­
erally and level: eyes, clavicles, lower margins of the ribcage, anterior superior iliac spines, femoral
trochanters, knees, and ankles.
Figure 2-9. Balanced
Figure 2-10. Posture
shoulder girdle and
balanced left to right.
torso.
CHAPTER 2
POSTURAL ASSESSMENT
25
POSTURE TY PES
A postural distortion is an adaptation, or change, in the way the body is balancing. This is ac­
companied by characteristic patterns of dysfunctional muscle tightness and weakness. Significant
clinical information can be deduced from observing and correlating different posture types and
distortions.
Kendall and Kendall's posture typing system categorizes posture types by lateral view into four
types: military, kypholordotic, swayback, and flat back (Fig. 2-11). Each posture type's characteris­
tic patterns of muscle overactivity and underactivity are shown, with tight muscles dark and weak
muscles lightly drawn. Observing head position (neutral or forward) and pelvic posture (neutral or
posterior) allows posture to be categorized into the four types. Table 2-1 correlates with the posture
types in Fig. 2-11 and summarizes the posture types and their associated patterns of muscle weak­
ness (Table 2-1).
Military Posture
Kypho-Lordotic Posture
Swayback Posture
Flatback Posture
Figure 2-11. Four posture types. (Modified with permission
from Kendall FP, McCreary EK, Provance PG. Muscles: Testing
and Function. 4th ed. Baltimore: Williams & Wilkins,
1993:84-87.)
II
I
26
TABLE
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
i-I
POSTURE TYPE CLASSIFICATION BY PELVIC TILT AND HEAD POSTURE
Neutral Head Postures
Posterior
Pelvic Tilt
Forward
Pelvic Tilt
Forward Head Postures
Military Posture
Kypholordotic Posture
Anterior body structure
Chest; pelvis if lordosis is
marked
Tight muscles
Low back
Hip flexors
Weak muscles
Anterior abdominals initially,
hamstrings lengthen, then
adaptively shorten
Anterior body structure
Head (forward head posture)
Abdomen
Tight muscles
Suboccipital neck extensors
Hip flexors
Serratus anterior
Pectorals
Upper trapezius (if scapulae are
abducted)
Weak muscles
Neck flexors
Upper thoracic spinae
External abdominal oblique
Mid and lower trap (if scapulae are
abducted)
Swayback Posture
Flat Back Posture
Anterior body structure
Pelvis or femur heads with
compensating long kyphosis
Tight muscles
Hamstrings
Internal abdominal obliques
Low back erector spinae
Same side TFL (if lateral pelvic
distortion)
Weak muscles
1 hip joint flexors
External abdominal obliques
Lower and mid trapezius
Deep neck flexors
Same side gluteus medius (if
lateral pelvic distortion)
Anterior body structure
Head
Tight muscles
Hamstrings
Abdominals
Weak muscles
1 joint hip flexors
POSTURAL SYNDROMES
The body moves in patterns of motion. Unbalanced overuse of the postural muscles (e.g., the mus­
cles used to maintain posture) is accompanied by weakening of the opposing antagonist muscles.
This weakening is due to lack of use and a neurologic reciprocal inhibition. This pattern of overuse
and weakening results in distinct postural syndromes. The upper crossed syndrome affects the head,
neck, and shoulders, while the lower crossed syndrome affects the lumbar spine and pelvis. They fre­
quently exist simultaneously and combine to create chronic musculoskeletal stress.
This upper crossed posture syndrome is the source of computer user's (and others in long-term
seated postures) complaint of chronic neck and shoulder tightness and pain. The upper crossed pos­
ture is characterized by rolled-in and forward shoulders with increased thoracic kyphosis, a forward
head posture, and loss of the cervical lordosis (Fig. 2-12). The tightness in anterior shoulder mus­
cles results in weak and inhibited infraspinatus, teres minor, rhomboids, and thoracic erector spinae
muscles. Neck, upper and middle back, and shoulder girdle muscles are shortened and tight from
overuse, while their antagonists are weak and stretched. Trigger points are frequently found in the
CHAPTER 2
POSTURAL ASSESSMENT
27
overused neck extensor muscles, the upper trapezius, and the levator scapulae muscles. The oppos­
ing longus colli, capitis, and lower trapezius muscles are weak (Table 2-2).
The lower crossed syndrome is the other modern postural pattern. The lower crossed posture is
characterized by an anterior pelvis and increased lumbar lordosis with tightness in the psoas and
lumbar erector spinae (Fig. 2-13). Sitting shortens the psoas and other hip flexor muscles when the
thigh is flexed. Long-term sitting at work and play, along with driving between the two, creates mus­
cle imbalance between these overused hip flexors and the underused hip extensors. The gluteus
maximus, the primary hip extensor, opposes the hip flexors and therefore becomes adaptively weak.
To maintain erect posture and balance, the lumbar erector spinae muscles compensate and extend
the spine, resulting in hypertonicity of the lumbar erector spinae and adaptive weakening of the op­
posing abdominal muscles. Also, the hip adductor muscles are frequently tight, with compensating
weakness of the gluteus medius and minimus muscles (Table 2-2).
UPPER CROSS
POSTURE
Tight-short
muscles
Tight-short
muscles
LOWER CROSS
POSTURE
Figure 2-12.
Upper cross posture
Figure 2-13.
Lower cross posture
Forward head
Anterior pelvis
Loss of cervical lordosis
Protruding abdomen
Shoulders rolled in and forward
Increased lumbar lordosis
Increased thoracic kyphosis
light-short muscles
Feet turned out
light-short muscles
Suboccipitals
Psoas
Pectorals, anterior shoulder
Lumbar erector spinae
Upper trapezius
Weak-long muscles
Hip adductor
Weak-long muscles
Mid, lower trapezius
Hip extensors, gluteus maximus
Serratus anterior
Abdominal
Gluteus medius, minimus
28
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
'
TABLEi -2
POSTURAL SIGNS OF UPPER AND LOWER C ROSSED SYNDROME
Postural Finding
Dysfunction
Upper crossed syndrome
Round shoulders
Forward-drawn head
CO-Cl hyperextension
Elevation of shoulders
Winging of scapulae
Shortened pectorals
Kyphotic upper thoracic spine
Shortened suboccipitals
Shortened upper trapezius, levator scapulae,
weak lower, middle trapezius
Weak serratus anterior
Lower crossed syndrome
Lumbar hyperlordosis
Anterior pelvic tilt
Protruding abdomen
Foot turned out
Hypertrophy of
thoracolumbar junction
Groove in iliotibial band
Shortened erector spinae
Weak gluteus maximus
Weak abdominals
Shortened piriformis
Hypermobile lumbosacral junction
Shortened tensor fascia latae
Adapted with permission from Liebenson C, ed. Rehabilitation of the Spine.
Baltimore: Williams & Wilkins, 1996:363-364.
OTHER POSTUR AL DISTORTIONS, ADAPTATIONS, AND
PATHOLOGIES
Because postural evaluation is a global evaluation of how the body balances, faults and postures
from one part of the kinetic chain can cause a compensating postural distortion in a different re­
gion. The overall posture is the sum of all distortions and resulting compensations necessary to al­
low the individual to balance and avoid painful positions and motions. In the interest of providing
a comprehensive summary, primarily local muscular involvements are detailed below. Also, a nor­
mal skeletal system without vertebral compression fractures or congenital abnormalities such as
hemivertebra is assumed.
Forward Head Posture
Forward head posture is probably the most common posture distortion (Fig. 2- 1 4). For every inch
that the head moves forward of neutral posture, the weight carried by the lower neck increases by
the additional weight of the entire head (Fig. 2-15). Many patients' symptoms of neck, shoulder, and
arm pain; headaches; and stress are associated with the faulty biomechanics of carrying the skull too
far forward of the torso. Observations associated with forward head posture include (a) external au­
ditory meatus anterior of the acromion and (b) sternocleidomastoideus usually hypertrophied.
Possible tight, overactive muscles: SCM and/or suboccipitals, anterior cervical flexors; upper
trapezius, levator scapulae, pectorals.
Possible weak, underactive muscles: Cervical extensors, lower and mid trapezius, serratus ante­
rior. Also possible deep neck flexors (longus colli) inhibition.
Clinical correlate: Palpate the suboccipitals when sitting and standing (Figs. 2-16 and 2-17). If
there is less tension when sitting, pelvic postural stress is contributing to the forward head posture.
CHAPTER 2
POSTURAL ASSESSMENT
29
s
1X
2X
3X
Figure 2-14. Forward
head posture.
Figure 2-15. For every inch the
head moves forward of neutral
posture, the weight carried by
the lower neck increases by the
additional weight of the entire
head. (Adapted from Liebenson
C, ed. Rehabilitation of the
Spine. Baltimore: Williams &
Wilkins, 1996:177.)
Figure 2-16. Palpation of the suboccipitals with the
Figure 2-17. Palpation of the suboccip­
subject seated.
itals with the subject standing.
30
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Head Tilt and/or Rotation
PA view: The line between tips of the mastoid processes is unlevel (Fig. 2-18). The occipital protu­
berance is to one side of a center line bisecting the pelvis and spine. The skull is not evenly bisected
by a centerline.
Possible tight, overactive muscles: Lateral neck flexors on the flexed side, scalene or intrinsic rota­
tor muscles on the opposite side of head rotation. Sternocleidomastoideus, upper trapezius.
Possible weak, underactive muscles: Lateral neck flexors on the opposite side of head flexion. In­
trinsic rotator muscles on the side of head rotation.
Unlevel Shoulders
Observations: The horizontal line between the acromia is not level. Shoulder imbalance is also ob­
served with thoracic scoliosis and hand dominance (Fig. 2- 1 9).
Possible tight overactive muscles: On the side of the high shoulder, upper trapezius and/or leva­
tor scapulae muscles; on the side of the low shoulder, lower trapezius and pectoralis minor muscles,
tight rhomboid and/or latissimus dorsi muscles.
Possible weak, underactive muscles: On the side of the high shoulder, lower and mid trapezius; on
the side of the low shoulder, upper trapezius.
Figure 2-18. Right head
Figure 2-19. High left
tilt and rotation.
shoulder.
CHAPTER 2
POSTURAL ASSESSMENT
31
Observation: The neck-shoulder line is not contoured normally (Fig. 2-20). A straightening of
the neck-shoulder line indicates a tight trapezius muscle. This is known as a gothic shoulders ap­
pearance because it looks like a Gothic church tower.
Observation: A double wave appearance at the lateral scapula at the insertion of the levator
scapula indicates tightness of the levator scapula (Fig. 2-21).
Figure 2-20. Elevated, or Gothic, shoulders. (Reprinted with
permission from Liebenson C, Chapman S. Cervico-Thoracic
Spine: Making a Rehabilitation Prescription, Tape 2. Baltimore:
William� & Wilkins, 1998, Fig 3.)
.
Figure 2-21. TIghtness of the levator scapula.
(Reprinted with permission from Liebenson C,
ed. Rehabilitation of the Spine. Baltimore:
Williams & Wilkins, 1996:108.)
II
32
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Scapula Winging
The medial borders of the scapulae are lifted posteriorly from the ribs.
Possible tight, overactive muscles: Rhomboid.
Possible weak, underactive muscles: serratus anterior.
Clinical correlate: Push-up test. Observe whether scapula winging increases when the person
does a pushup (Fig. 2-22).
Figure 2-22. Winged scapula. (Reprinted with permission from
Liebenson C, Chapman S. Cervico-Thoracic Spine: Making a
Rehabilitation Prescription, Tape 2. Baltimore: Williams &
Wilkins, 1998, Fig 2.)
Scapula Rotation
The scapula are unevenly centered on the torso. Usually one is abducted (more lateral from thoracic
spine midline) and one is adducted (more medial to the thoracic spine midline) (Fig. 2-23). Scapu­
lar rotation is also observed with thoracic scoliosis and hand dominance.
Possible tight, overactive muscles: Side of the abducted scapula: serratus anterior. Side of the ad­
ducted scapula: rhomboid.
Possible weak, underactive muscles: Side of the abducted scapula: rhomboid and middle trapez­
ius; side of the adducted scapula: pectoralis major or minor.
Figure 2-23. Right scapula abduction and
winging. (Reprinted with permission from
Liebenson C, ed. Rehabilitation of the Spine.
Baltimore: Williams & Wilkins, 1996:108.)
CHAPTER 2
POSTURAL ASSESSMENT
33
Round Shoulders/Internal Rotation of the Upper Extremity
In addition to having a rounded appearance of the shoulders, the back of the hands may be visible
on an anterior view as the thumbs point across the body instead of to the anterior. The palm of the
hands may be visible from the posterior (Fig. 2-24).
Possible tight, overactive muscles: Latissimus dorsi and/or pectorals.
Possible weak, underactive muscles: Mid trapezius.
Clinical correlate: Usually observed with forward head posture.
Figure 2-24. Round
shoulders with internal
rotation of the arms.
Lateral Spinal Deviation/Scoliosis
Scoliosis is a lateral curvature of the spine that may be acquired or congenital. Congenital scoliosis
is due to some architectural asymmetry, such as a wedge vertebra or other anatomic variant. Most
acquired scoliosis is idiopathic, or of unknown origin. Scoliosis evaluation, management, and treat­
ment continually progress but are still controversial. On visual evaluation, the spinous processes are
lateral to the midline of the trunk (Fig. 2-25).
Figure 2-25. Right thoracolumbar erector spinae
hypertrophy. (Reprinted with permission from
Liebenson C, ed. Rehabilitation of the Spine.
Baltimore: Williams & Wilkins, 1996:107.)
34
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Possible tight, overactive muscles: Shortened intrinsic paraspinal muscles on the side of concavity.
Possible weak, underactive muscles: Lengthened intrinsic paraspinal muscles on the side of con­
vexity.
Clinical correlate: Thoracolumbar erector spinae hypertrophy indicates a longstanding adaptive
change. Most AP spines have a slight right convex thoracic curve due to the individual's right-hand­
edness. It is important to rule out congenital abnormalities and factor in leg length discrepancies
and other distortions.
Lateral Pelvic Tilt!Abdominal Asymmetry
The horizontal line connecting the left and right iliac crests are unlevel (Fig. 2-26)
Possible tight, over-active muscles:
High side: PA-quadratus lumborum muscle; AP-abdominal obliques
Low side: hip adductor.
Possible weak/underactive muscles:
High side: gluteus maximus, abductor muscles
Low side: opposite side abdominal obliques.
Clinical correlates: Leg length discrepancies and other distortions are usually present. Trende­
lenburg test may be positive on the side of laterality. Scoliosis may be present.
Figure 2·26. Pelvic unleveling. (Reprinted with permission from
Liebenson C, Chapman S. Lumbar Spine: Making a Rehabilitation
Prescription, Tape 1. Baltimore: Williams & Wilkins, 1998, Fig 5.l
CHAPTER 2
POSTURAL ASSESSMENT
35
Anterior or Posterior Pelvic Tilt
Neutral and stable pelvic position is the range of possible stable positions, which are the base upon
which spinal posture rests. The anterior superior spines of the innominates should be vertically
aligned with the symphysis pubes. On a lateral view, the waist line (or belt line) should be level to
tilting slightly forward with a normal anterior lumbar lordosis providing stable posture.
Anterior pelvis: The pelvis tilts forward, with an associated increased lumbar lordosis (Figs.
2-27 and 2-28).
Possible tight, overactive muscles: Psoas, lumbar erector spinae.
Possible weak, underactive muscles: Gluteus maximus; abdominals.
Posterior Pelvis: (Fig. 2-29) There is a flattened lumbar curve with the pelvis tilting posteriorly
or slightly forward of level.
Possible tight, overactive muscles: Hamstrings, abdominals, low back erector spinae.
PossibLe weak, underactive muscles: Hip flexors, quadriceps.
Figure 2-27. Anterior pelvic tilt. (Reprinted with permission from
Liebenson C, Chapman S. Lumbar Spine: Making a Rehabilitation
Prescription, Tape 1. Baltimore: Williams & Wilkins, 1998, Fig 4.'
Figure 2-28. Anterior
Figure 2-29. Posterior
pelvic tilt.
pelvic tilt.
•
36
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Abdomen Protrusion (Figs. 2-30 and 2-31)
Possible associated findings: Lateral buttock flattening in the lateral or superior quadrant.
Possible tight, overactive muscles: Erector spinae, iliopsoas.
Possible weak, underactive muscles: Gluteus maximus, abdominals.
Clinical correlate: Because of the marked anterior pelvic tilt usually associated with abdominal
protrusion, weakness and limited range of motion on hip extension and hip abduction are common.
Figure 2·30. Abdominal
Figure 2·31. Abdominal
protrusion.
protrusion in pregnancy.
Knock Knees: Genu Valga (Fig. 2-32)
Associated observations:
Pronation
Prominence of iliotibial tract
Observation: Lateral deviation of the patellae.
Possible tight, overactive muscles: TFL
Possible weak underactive muscles: Adductors, sartorius
Clinical correlate: Correlate with wear patterns of shoes
CHAPTER 2
POSTURAL ASSESSMENT
37
•
Figure 2-32. Knock-knees (genu valga). (Reprinted with permission from
Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th
ed. Baltimore: Williams & Wilkins, 1993:97.)
,
\
\
,. J.:?," //��?_)
ii
\
_____
Figure 2-33. Bowlegs (genu vara). (Reprinted with permission from Kendall
FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed.
Baltimore: Williams & Wilkins , 1993:97.)
38
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Observation: Bowleg (genu vara) (Fig. 2-33).
Possible weak underactive muscles: Weak hip rotators.
Observation: Pronation of the feet (Figs. 2-34 and 2-35)
Possible tight, overactive muscles: Soleus (on the right).
Possible weak underactive muscles: Anterior tibialis, Gluteus medius and maximus.
Clinical correlate: Flat feet.
Figure 2-34. Pronation of the foot. (Reprinted with
permission from Liebenson C. Chapman S. Lumbar Spine:
Making a Rehabilitation Prescription, Tape 1. Baltimore:
Williams & Wilkins, 1998, Fig 1.)
Figure 2-35. Pronation with soleus tightness on
the right. (Reprinted with permission from
Liebenson C, ed. Rehabilitation of the Spine.
Baltimore: Williams & Wilkins, 1996:107.)
References
1. White AA, Panjabi MM. Clinical Biomechanics
General References
Kendall FP, McCreary EK, Provance PG. Muscles:
of the Spine. 2nd ed. Philadelphia: JB Lippincott,
Testing and Function. 4th ed. Baltimore: Williams &
1990:58,86-91,116,162.
Wilkins, 1993:20,70-119,354-356.
2. Janda V. Functional Pathology of the Motor Sys­
tem Seminars. Atlanta: 1999; Greenville, SC:
2000; Prague: 2000.
3. Watson J. Relationship between injuries & body
mechanics in soccer and rugby players. Sports
Med Physical Fitn 1995;35:289-294.
4. Basmajian IV, De Luca DJ. Muscles Alive. 5th ed.
Baltimore: Williams & Wilkins, 1985:255, 414,
P71,328.
Janda v. Functional Pathology of the Motor System
Seminars.
Atlanta:
1999;
Greenville,
SC:
2000;
Prague: 2000.
Jull G, Janda V, Muscles and motor control in low
back pain. In: Twomey L T , Taylor JR, eds. Physical
T herapy for the Low Back. Clinics in Physical T her­
apy. New York: Churchill Livingstone,1987.
Liebenson C, ed. Rehabilitation of the Spine. Balti­
more: Williams & Wilkins,1996
------�rn�---CERVICAL ORTHOPAEDIC TESTS
SUBCLAVIAN ARTERY
CERVICAL ORTHO PAEDIC
EXAMINATION FLOW CHART
40
DIFFERENTIAL DIAGNOSIS: STRAIN
41
ANTERIOR ASPECT
70
VERSUS SPRAIN
Sternocleidomastoid Muscle
41
72
CERVICAL FRACTURES
43
Supraclavicular Fossa
73
Spinal Percussion Test
44
POSTERIOR ASPECT
Soto-Hall Test
44
Trapezius Muscle
Rust's Sign
Cervical Intrinsic Musculature
Spinous Process/Facet Joints
74
75
45
46
CERVICAL RANGE OF MOTION
47
48
77
Alar L igament Stress Test
79
Valsalva's Maneuver
51
Dejerine's Sign
CERVICAL RESISTI VE ISOMETRIC
MUSCLE TESTING
Swallowing Test
80
81
81
52
CERVICAL NEUROLOGICAL
52
82
COMPRESSION AND IRRITATION
53
Extension
80
SPACE-OCCUPYING LESIONS
50
L ateral Flexion
82
Foraminal C ompression Test
54
L ateral Flexion
Rotation
83
Jackson's C ompression Test
55
84
E xtension C ompression Test
VERTEBROBASILAR CIRCULATION
ASSESSMENT
56
Maigne's Test
85
86
Maximal Foraminal C ompression
Vertebrobasilar Artery Functional
Maneuver
Flexion C ompression Test
Spurling's Test
59
B arre-Lieou Sign
60
Test
87
L'hermitte's Sign
61
88
Shoulder Depression Test
Vertebral Artery (C ervical Quadrant)
Test
78
Transverse L igament Stress Test
49
E xtension
Flexion
76
CERVICAL INSTABILITY
Sharp-P urser Test
Rotation
70
O 'Donoghue's Maneuver
42
Carotid A rteries
Flexion
68
G eorge's Screening Procedure
41
CERVICAL PAL PATION
68
COMPROMISE
62
Distraction Test
89
89
Shoulder Abduction Test (B akody's
Dekleyn's Test
63
Hautant's Test
64
Underburg's Test
Sign)
90
64
Hallpike's Maneuver
66
39
Cervical Orthopaedic Examination
�
o
t
Cervical spine pain
Cervical pain
with upper extremity
and dizziness
pain/paresthesia
compromise
Foraminal compression test
maneuver
Jackson compression test
Flexion/extension
compression test
8arre-Lieou sign
(+)
(-)
Shoulder depression test
Peripheral
Maigne's test
vascular
Dekleyn's test
compromise
Distraction test
Hautant's test
Underburg's test
Shoulder abduction test
(+)
Adson's test
Costoclavicular test
Cervical
Wright's test
vascular
Traction test
compromise
Halstead Maneuver
( -)
Strain
Refer for
or
neurological
Sprain
evaluation
Subluxation
Dislocation
Osseus defects
Space-occupying
lesions
Diagnostic imaging
(x-ray) (MRI)
(CT scan)
(+)
Foraminal encroachment
Discogenic spondylosis
Disc defect
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
41
CERVICAL PALPATION
Anterior Aspect
Sternocleidomastoid Muscle
DESCRIPTIVE ANATOMY
The sternocleidomastoid muscle extends from the mastoid process of the temporal bone down to
the clavicle and sternum ( Fig. 3-1). It divides the neck into anterior and posterior triangles. Its ac­
tion is to flex the head to the same side and rotate it to the opposite side. Both muscles acting to­
gether flex the neck forward.
PROCEDURE
Instruct the patient to turn the head to one side. Pinch the muscle on the side of head rotation be­
tween your thumb and forefinger, traveling from the clavicle upward to the mastoid ( Fig. 3-2). Com­
pare each muscle bilaterally, noting any inflammation, tenderness, and palpable bands. Palpable
bands are hyperirritable spots within a taut band of skeletal muscle or fascia. Rate tenderness based
on tenderness rating scale (Box 3-1).
Inflammation and tenderness secondary to trauma usually are associated with cervical acceler­
ation and deceleration (CAD) types of injuries. Torticollis may also cause local inflammation and
tenderness. Palpable bands may indicate a myofascial trigger point. These trigger points may be
caused by overuse, trauma, or chilling. They may also indicate arthritic joints or emotional distress.
Internal and --17f-\\!i!!\--+
external-----J'frH1I+r++-+-!l"-
Omohyoid
artery and vein
'-----v----'
Sternum
Figure
Figure
3-1
3-2
Tenderness Grading Scale
Grade I
Mild tenderness to moderate palpation
Grade III
Severe tenderness with withdrawal
Grade II
Grade IV
Mild tenderness with grimace and flinch to moderate palpation
Severe tenderness with withdrawal from nonnoxious stimuli
II
42
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Carotid Arteries
DESCRIPTIVE ANATOMY
The carotid arteries lie lateral to the trachea and medial to the sternocleidomastoid muscle. These
arteries branch to form the internal and external carotid arteries, which supply blood to the brain
(see Fig. 3-1).
PROCEDURE
With your first and second digits, lightly press on the carotid artery against the transverse process of
the cervical vertebra ( Fig. 3-3). Palpate each artery individually and assess amplitude equality. A dif­
ference in the strength of the pulses may indicate carotid artery stenosis or compression. If carotid
artery stenosis or compression is suspected, auscultate the carotid arteries for bruits and evaluate the
vertebrobasilar circulation.
Figure
3-3
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
43
Supraclavicular Fossa
DESCRIPTIVE ANATOMY
The supraclavicular fossa is superior to the clavicle. It contains the omohyoid fascia, the lymph
nodes, and the pressure point for the subclavian artery. It is usually a smooth, contoured depression
(Fig. 3- 1 ).
PROCEDURE
Palpate each fossa for swelling, tenderness, and any abnormal bony or soft tissue masses ( Fig. 3-4).
Pain and tenderness associated with swelling secondary to trauma may indicate a fractured clavicle
or a separated acromioclavicular joint. Abnormal bony tissue may indicate a cervical rib, which may
cause neurological or vascular symptoms in the upper extremity. If an extra rib is suspected, evalu­
ate for thoracic outlet syndrome (see Chapter 5) . An abnormal soft tissue mass may indicate lymph
adenopathy or a tumor.
Figure
3-4
II
44
PHOTOGRAPHIC MANuAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Posterior Aspect
Trapezius Muscle
DESCRIPTIVE ANATOMY
The trapezius muscle is a large, triangular muscle that extends from the occiput and spinous
processes of the cervical and thoracic vertebra to the acromion process of the clavicle and spine of
the scapula ( Fig. 3-5). Its superior fibers elevate the shoulders; the middle fibers retract the scapula;
and the inferior fibers depress the scapula and lower the shoulders.
PROCEDURE
Palpate each muscle from the superior aspect just below the occiput downward, continuing to the su­
perior aspect of the spine of the scapula, then lateral to the acromion process (Fig. 3-6). From the
inferior, palpate from the spinous processes of the thoracic vertebra lateral and superior toward the
acromion process ( Fig. 3-7).
Inflammation and tenderness secondary to trauma may indicate muscle spasm caused by
torn muscle fibers associated with edema. Inflammation and tenderness that are not trauma re­
lated may indicate fibrosis of muscle tissue or fibromyalgia. Assess it according to the tender­
ness rating scale (see Box 3-1) . Palpable bands indicate myofascial trigger points that may be
caused by overuse, overload, trauma, or chilling. These palpable bands may also indicate arthritic
joints or emotional distress.
Semispinalis
Longissimus
Figure 3-6
Figure
3-5
Figure 3-7
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
45
Cervical Intrinsic Musculature
DESCRIPTIVE ANATOMY
The palpable intrinsic spinal muscles in the cervical spine consist of splenius capitis and cervi­
cis, longissimus cervicis, and semispinalis cervicis. These layered muscles are used for the main­
tenance of posture and movements of the cervical spine. The superficial layer consists of the
splenius capitis and cervicis, and the intermediate layer consists of the longissimus and semispinalis cervicis. These muscles stretch from the base of the occiput to the upper aspect of the
thoracic spine ( Fig. 3-5) . The deep muscles on the cervical spine at best are difficult to palpate
and are not discussed here.
PROCEDURE
Palpate the superficial layer by moving the fingers in a transverse fashion over the belly of the
muscle with the cervical spine in slight extension ( Fig. 3-8). Note any abnormal tone, tender­
ness, or palpable bands. Palpate the intermediate layer with the fingertips directly adjacent to
the spinous processes, also with the cervical spine in slight extension ( Fig. 3-9). Note any ab­
normal tone, tenderness, or palpable bands. Rate the layers according to the tenderness rating
scale (Box 3-1). Any abnormal tone or tenderness may indicate an inflammatory process in the
muscle, such as muscle strain, myofascitis, or fibromyalgia. Palpable bands indicate myofascial
trigger points, which may be caused by overuse, overload, trauma, or chilling. They may also
indicate arthritic joints or emotional distress.
Figure
3-8
Figure
3-9
II
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
46
Spinous Process/Facet Joints
DESCRIPTIVE ANATOMY
The C1, or atlas, vertebra has a posterior arch rather than a spinous process that is difficult at
best to palpate. The C2 to C7 vertebrae have relatively prominent spinous processes that are
easily palpable. Slightly lateral to the spinous processes lie the facet joints. Each facet joint is
composed of a posterior inferior articular process and a posterior superior articular process from
congruent vertebra ( Fig. 3- 1 0).
PROCEDURE
With the patient seated and head slightly flexed, palpate each spinous process individually with
your index and/or middle finger, noting any pain and/or tenderness ( Fig. 3-11). Also, evaluate
each spinous process as you move the cervical spine in flexion and extension to determine hy­
pomobility versus hypermobility ( Fig. 3 - 1 2).
Again, with the patient's head slightly flexed, using your thumb and index finger, palpate
the facet joints bilaterally both in a static position ( Fig. 3-l3) and in a flexed position while
performing extension movements ( Fig. 3- 1 4). Tenderness at the spinous and/or facet joint indi­
cates an inflammatory process at that site. The inflammation is usually secondary to subluxa­
tion or trauma, that is, hyperflexion or hyperextension injury. Crepitus on movement may in­
dicate degenerative joint disease.
Posterior
inferior
articular
process
Atlas (Cl)
Figure
3-11
Figure
3-12
Posterior
superior
articular
process
Spinous
process
Facet
joint
Figure
3-10
C5
C6
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
47
II
Figure
3-13
Figure
3-14
CERVICAL RANGE OF MOTION
Cervical range of motion should be evaluated only after taking a proper and thorough history to
rule out any indication that these movements will adversely affect the patient. Severe trauma caus­
ing a fracture or dislocation or cervical vascular compromise should be ruled out before perform­
ing these movements. You should not only note limited motion in the cervical spine but also any
pain along with its location and character. The most painful movements should be performed last
so that no residual pain is carried over from the previous movement. Crepitus should also be noted
upon movement; it may indicate degenerative changes in the cervical spine.
Spinal range of motion is measured using inclinometers, with the patient performing the move­
ments actively and passively. The inclinometer is the preferred instrument for measuring spinal
range of motion because it measures angular displacement relative to gravity. For continuity of re­
porting and for evaluating patient compliance, the movements should be performed three times.
The three measureme nts must be within SOor 1 0% of each other for a valid reporting criterion. The
full arc of motion is paramount to the evaluation of range of motion in the cervical spine. Adding
the opposing measurements to determine the full arc of movement is the most objective way to as­
sess cervical spine movement. For example, the patient carries the head in 10° of flexion, which for
this person is the neutral position. When you measure cervical flexion on this individual, cervical
flexion may be reduced 10° from average. If you then measure extension, you may possibly have an
increase of 10°. This increase may be caused by the 10° flexion angle, which is the neutral position
for that patient. If you take each measurement individually, you have a deficit movement in flexion
and an increase in movement in extension. If you add both movements, you see that the full arc is
within normal limits.
48
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Flexion: Inclinometer Method (1,2)
With the patient seated and the cervical spine in the neutral position, place one inclinometer over
the Tl spinous process in the sagittal plane. Place the second inclinometer at the superior aspect of
the occiput, also in the sagittal plane ( Fig. 3 - 1 5). Zero out both inclinometers. Instruct the patient
to flex the head forward and record both angles ( Fig. 3- 1 6). Subtract the Tl inclination from the oc­
cipital inclination to obtain the active cervical flexion angle.
NORMAL RANGE
Normal range is 50° or greater from the neutral or 0 position for active movement.
Figure
3-15
Figure
3-16
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
49
Extension: Inclinometer Method (1,2)
With the patient seated and the cervical spine in the neutral position, place one inclinometer slightly
lateral to the Tl spinous process in the sagittal plane. Place the second inclinometer at the superior
aspect of the occiput, also in the sagittal plane ( Fig. 3 - 1 7) . Zero out both inclinometers. Instruct the
patient to extend the head backward and record both inclinations ( Fig. 3 - 1 8 ) . Subtract the Tl incli­
nation from the occipital inclination to obtain the active cervical extension angle.
NORMAL RANGE
The normal range is 60° or greater from the neutral or 0 position for active movement and 1 l 00for
full arc of active flexion and extension. The normal range of passive flexion and extension varies as
follows (3):
Age
Degrees
20-29
30-49
> 50
151 ± 1 7
1 4 1 ± 35
1 29 ± 14
Figure
3-17
Figure
3-18
II
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
50
L ateral Flexion: Inclinometer Method (1, 2)
With the patient seated and the cervical spine in the neutral position, place one inclinometer flat on
the T1 spinous process in the coronal plane. Place the second inclinometer at the superior aspect of
the occiput, also in the coronal plane (Fig. 3-19). Zero out both inclinometers. Instruct the patient
to flex the head to one side and record both inclinations (Fig. 3-20). Subtract the Tl inclination from
the occipital inclination to obtain the active cervical lateral flexion angle. Repeat with flexion to the
opposite side.
NORMAL RANGE
The normal range is 45° or greater from the neutral or 0 position for active movement and 90° for
full arc of active right and left lateral flexion. The full arc of passive right and left lateral flexion varies
as follows (3) :
Age
Degrees
20-29
30-49
> 50
101 ± 1 1
93 ± 1 3
80 ± 17
Figure
3-19
Figure
3-20
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
51
Rotation: Inclinometer Method (1,2)
With the patient supine, place the inclinometer at the crown of the head in the transverse plane
(Fig. 3-21). Zero out the inclinometer. Instruct the patient to rotate the head to one side, and then
record your findings ( Fig. 3-22). Repeat the procedure with the patient's head rotated to the oppo­
site side.
NORMAL RANGE
Normal range is 80° or greater from the neutral or 0 position for active movement. The full arc of ac­
tive right and left rotation is 160°. The full arc of passive right and left rotation varies as follows (3):
Age
Deg rees
20-29
30-49
> 50
183 ± 11
172 ± 13
155 ± 15
Figure
3-21
Figure 3-22
1.1
52
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
CERVICAL RESISTIVE ISOMETRIC MUSCLE TESTING
The same movements can also be tested for resistive strength. Contra indications such as fracture, dis­
location, and cervical vascular compromise must be considered before testing for resistive strength.
Resistive isometric muscle testing is performed to evaluate muscle strength or muscle state.
Weakness of a particular muscle or muscle group may indicate neurological dysfunction in the
nerves supplying the affected muscles. Pain of a particular muscle or muscle group during resistive
isometric muscle testing may indicate muscle dysfunction, such as a muscle strain.
Each of the following movements includes a chart that indicates the muscles that make the
movement and the nerve supply to each muscle. The clinician evaluates each movement according
to muscle strength; grade is based on the muscle grading scale adopted by the American Academy
of Orthopaedic Surgeons (Box 3-2).
Muscle Grading Scale
5
4
Complete range of motion against gravity with full resistance
Complete range of motion against gravity with some resistance
3
Complete range of motion against gravity
2
1
Complete range of motion with the gravity eliminated
Evidence of slight contractility; no joint motion
o
No evidence of contractility
Flexion
With the patient seated and in the neutral position, instruct him or her to flex the head forward against
your resistance, making sure that there is no patient movement and only muscle contraction (Fig.
3-23).
Muscles
Nerve Supply
l.
C2-Cs
C4-Cs
C3-C8
C6-C8
Accessory, C2
2.
3.
4.
5.
Longus colli
Scalenus anterior
Scalenus medius
Scalenus posterior
Sternocleidomastoid
Figure
3-23
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
53
Extension
With the patient seated and in the neutral position, instruct him or her to extend the head backward
against your resistance, making sure that there is no patient movement and only muscle contraction
( Fig. 3-24).
Muscles
Nerve Supply
I.
2.
3.
4.
5.
6.
7.
B.
9.
10.
II.
12.
C6,C7,CB
C1-C6,C7,CB
C6-CB
C3-C4
C6,C7,CB
C6,CB
C1-C6,C7,CB
C1-CB
C3,C4
C1
C1-CB
C1-CB
Splenius cervicis
Semispinalis cervicis
Longissimus cervicis
Levator scapulae
Iliocostalis cervicis
Spinalis cervicis
Multifidus
Interspinalis cervicis
Trapezius (Upper)
Rectus capitis posterior major
Rotatores breves
Rotatores longi
Figure
3-24
•
54
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
L ateral Flexion
With the patient seated and in the neutral position, instruct him or her to bend the head to one side
against your resistance, making sure that there is no patient movement and only muscle contraction
( Fig. 3-25). This action should be performed bilaterally.
Muscles
Nerve Supply
1.
2.
3.
4.
5.
6.
7.
S.
9.
10.
11.
12.
13.
14.
C3-C4
C4-C6
C6-CS
C6-CS
CI-CS
CI-CS
CI-CS
C3-CS
C2
Cl
CI-CS
CI-CS
C2-C6
C3-C4
Levator scapulae
Splenius cervicis
Iliocostalis cervicis
Longissimus cervicis
Semispinalis cervicis
Multifidus
Intertransversarii
Scaleni
Sternocleidomastoideus
Obliquus capitis inferior
Rotatores breves
Rotatores longi
Longus colli
Trapezius
Figure
3-25
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
55
Rotation
With the patient seated and in the neutral position, instruct him or her to rotate the head to one side
against your resistance, making sure that there is no patient movement and only muscle contraction
( Fig. 3-26). This action should be performed bilaterally.
Muscles
Nerve Supply
Moves Face to Same Side
l . Levator scapulae
2. Splenius cervicis
3. Iliocostalis cervicis
4. Longissimus cervicis
5. Intertransversarii
6. Obliquus capitis inferior
7. Rotatores breves
B. Rotatores longi
Moves Face to Opposite Side
l . Multifidus
2. Scaleni
3. Sternocleidomastoideus
C3-C4
C4-C6
C6-CB
C6-CB
CI-CB
Cl
CI-CB
CI-CB
CI-CB
C3-CB
C2
RATIONALE
Pain on resistive isometric contraction may indicate a musculotendinous strain of one or more of
the muscles involved in the action. Weakness may indicate a neurological disruption to the muscle
or muscles involved in the action.
Figure
3-26
II
56
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
VERTEBROBASILAR CIRCULATION ASSESSMENT
CLINICAL DESCRIPTION
Vascular insufficiency may be aggravated by positional change in the cervical spine. Assessment of
vertebrobasilar circulation must be done if cervical adjustment or manipulation is to be performed.
Absolute contraindications and risks of cervical adjustment or manipulation can be minimized sig­
nificantly, even though reportedly small, with proper diagnostic evaluation. These risks and con­
traindications may be predicted in some cases by functional or provocative testing and by adequate
history (familial history of stroke or cardiovascular disease, hypertension, smoking, cervical spondy­
losis or arthrosis, bleeding disorders, medication, and/or anatomic anomaly or pathology) . Vascular
accidents may still occur with no evidence of vascular insufficiency, deficit, and negative provocative
procedures. Box 3-3 lists the eight most common predispositions associated with cerebrovascular
accidents.
Predispositions to Cerebrovascular Accidents
Headaches, migraine
Dizziness
Sudden severe head or neck pain
Hypertensive
Cigarette smoking
Oral contraceptives
Obesity
Diabetes
All of the following tests incorporate a positional change in the cervical spine. The rotation as­
pect of this change is the common denominator of all the following tests. Rotation of CI on C2 be­
tween 30° and 45° compresses the vertebral artery at the atlantoaxial junction on the opposite side
of head rotation, reducing blood flow to the basilar artery ( Fig. 3-27) (4,5) . In the normal patient,
this diminution of blood flow caused by positional change of the cervical spine does not cause any
neurological symptoms, such as dizziness, nausea, tinnitus, faintness, or nystagmus. This lack of
symptoms is a result of the normal flow of collateral circulation by the opposite vertebral artery,
common carotid arteries, and a communicating cerebral arterial circle (Circle of Willis) ( Fig. 3-28) .
Rotational instability i n the upper cervical spine caused by trauma, arterial artery disease,
and/or degenerative joint disease in the cervical spine may lead to a mechanical reduction of blood
flow to an area, causing neurological symptoms. This reduction of blood flow may be such that the
collateral circulation is not sufficient to sustain normal function to the brain. Therefore, when you
positionally stress a vessel in the cervical spine, you are testing the integrity of the collateral circula­
tion supplied to the area, which is normally supplied by the vessel being stressed.
)
,). /,($
;<
II
Basilar
artery
"�
Compression of
vertebral artery
reduces blood flow
to basilar artery
Vertebral artery
Figure
3-27
.- _ _
o W
__
_
S
_
-../ Anterior
cerebral a.
Ant. communicating a.
Middle
cerebral a.
Posterior
communicating a.
Basilar artery
Posterior
cerebral a.
--WH'ft,��+-=�
:-----+_ Basilar a.
�--+- Ant. info
cerebellar a.
Vertebral a.
Vertebral artery
----t---21m��
Common carotid a. L
__
--
Figure
3-28
.- .
57
58
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Assessment of the vertebrobasilar circulation by provocative or functional testing stresses seven
areas of possible compression. These areas are as follows ( Fig. 3-29):
1. Between Cl and C2 transverse processes, where the vertebral arteries are relatively fixed at the
Cl and C2 transverse foramina
2. C2 to C3 at the level of the superior articular facet of C3 on the ipsilateral side to head rota­
tion
3. The Cl transverse process and the internal carotid artery
4. The atlanto-occipital aperture by the posterior arch of Atlas and the rim of foramen magnum
or anteriorly at the atlanto-occipital joint capsule and posteriorly at atlanto-occipital mem­
brane.
5. C4 to Cs or Cs to C6 levels because of arthrosis of the joints of the uncovertebral joints with
compression on the ipsilateral side to head rotation
6. At the transverse foramina of the atlas or axis between the obliquus capitis inferior and in­
tertransversarii during rotatory movements
7. Before entering the C6 transverse process by the longus colli muscle or by tissue communi­
cating between the longus colli and scalenus anterior muscles
Most compression and/or damage is reported at the first four sites.
Skull
Foramen
Internal
carotid
involving C1
:;�
;d r:::=�����
Vertebral-HL.lb
artery
__
_
Arthrosis
Osteophyte
Figure
3-29
CHAPTER 3
CERV1CAL ORTHOPAEDIC TESTS
59
Allow a lO-second interval between tests to ensure that there are no latent symptoms. If symp­
toms are reproduced, there is no need to progress to any other cervical vascular provocative tests.
The most common clinical signs and symptoms exhibited in cerebrovascular episodes are presented
in the box below.
Clinical Signs and Symptoms of Cerebrovascular Episodes
Vertigo, dizziness, giddiness, light-headedness
Drop attacks, loss of consciousness
Diplopia
Dysarthria
Dysphagia
Ataxia of gait
Nausea, vomiting
Numbness on one side of the face
Nystagmus
Sensitivity/Reliability Scale
Barre-Lieou Sign (6)
I
o
PROCEDURE
I
1
I
2
I
3
I
I
With the patient seated, instruct him or her to rotate the head to one side and then the other
(Fig. 3-30).
RATIONALE
Rotating the head causes compression of the vertebral artery opposite the side of head rotation ( Fig.
3-27). Therefore, you are testing the patency of the vertebral artery on the same side of head rota­
tion. Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive
test. This sign indicates buckling vertebral artery syndrome. Also, consideration must be given to the
patency of the carotid arteries and a communicating cerebral arterial circle.
Figure
3-30
60
PHOTOGRAPH1C MANUAL OF REG10NAL ORTHOPAED1C AND NEUROLOG1CAL TESTS
Sensitivity/Reliability Scale
Vertebrobasilar Artery Functional Maneuver (7)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, palpate and auscultate the carotid ( Fig. 3-3 1 )and subclavian arteries ( Fig.
3-32) for pulsations or bruits. When auscultating, instruct the patient to hold his or her breath. If
neither artery is palpable, instruct the patient to rotate and hyperextend the head to one side and
then the other ( Fig. 3-33). If pulsations or bruits are present, do not perform the rotation and hy­
perextension portion of the test.
RATIONALE
If pulsations or bruits are present at the carotid or subclavian arteries, this test is considered posi­
tive. It may indicate a compression or stenosing of the carotid or subclavian arteries. The rotation
and hyperextension portion of the test places a motion-induced compression on the vertebral artery
opposite the side of head rotation ( Fig. 3-27) . Vertigo, dizziness, visual blurring, nausea, faintness,
and nystagmus are all signs of a positive test. A positive result indicates vertebral or basilar artery
stenosis or compression at one of the seven sites discussed earlier in the chapter. Consideration must
also be given to the patency of the carotid arteries and a communicating cerebral arterial circle.
NOTE
Vertebrobasilar artery functional maneuver and George's screening procedure are both subsections
of George's Cerebrovascular Craniocervical Functional Test.
Figure
3·31
Figure
3-32
CHAPTER 3
61
CERVICAL ORTHOPAEDIC TESTS
•
Figure
3-33
Sensitivity/Reliability Scale
Maigne's Test (8)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, instruct the patient to extend and rotate the head and hold that position for
15 to 40 seconds ( Fig. 3-34). Repeat the test with the patient's head rotated to the opposite side.
RATIONALE
Rotation and extension of the head place a motion-induced compression on the vertebral artery on
the opposite side of head rotation ( Fig. 3-27). Vertigo, dizziness, visual blurring, nausea, faintness,
and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery
stenosis or compression at one of the seven sites discussed at the beginning of this section. Consid­
eration must also be given to the patency of the carotid arteries and a communicating cerebral ar­
terial circle.
Figure
3-34
62
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Vertebral Artery (Cervical Quadrant) Test (9)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine and the patient's head off the table, the examiner passively hyperextends and
laterally flexes the head and holds this position for 30 seconds ( Fig. 3-35). Repeat with the head lat­
erally flexed to the opposite side.
RATIONALE
Lateral flexion and hyperextension of the head place a slight motion-induced compression on the
vertebral artery on the same side of lateral head flexion. Vertigo, dizziness, visual blurring, nausea,
faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or
carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this sec­
tion. Consideration must also be given to the patency of the carotid arteries and a communicating
cerebral arterial circle.
Figure 3-35
CHAPTER 3
Dekleyn's Test (10, 11)
CERVICAL ORTHOPAEDIC TESTS
63
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
2
I
3
I
4
With the patient supine and the patient's head off the table, instruct the patient to hyperextend and
rotate the head and hold for 1 5 to 40 seconds ( Fig. 3-36). Repeat with the head rotated and extended
to the opposite side.
RATIONALE
Rotation and hyperextension of the head place a motion-induced compression on the vertebral ar­
teries on the opposite side of head rotation ( Fig. 3-27). Vertigo, dizziness, visual blurring, nausea,
faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or
carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this sec­
tion. Consideration must also be given to the patency of the carotid arteries and a communicating
cerebral arterial circle.
Figure 3-36
II
64
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Hautant's Test (12)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
I
3
4
With the patient seated and the patient's eyes closed, instruct the patient to extend the arms to the
front with palms up. Instruct the patient to extend and rotate the head to one side ( Fig. 3-37). Re­
peat with the head rotated and extended to the opposite side.
RATIONALE
A patient with stenosis or compression to the vertebral, basilar, or subclavian arteries without suffi­
cient collateral circulation will tend to lose balance, drop the arms, and pronate the hands. If this oc­
curs, suspect a vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites
discussed at the beginning of this section.
Figure
Underburg's Test
PROCEDURE
3-37
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
I
4
With the patient standing, instruct him or her to close the eyes and look for difficulty in equilibrium
( Fig. 3-38) . Next, instruct the patient to stretch out the arms and supinate the hands ( Fig.
3-39). Look for difficulty in equilibrium and drifting or pronating of the arms. Then instruct the pa­
tient to march in place ( Fig. 3-40). Next, instruct the patient to extend and rotate the head while
continuing to march in place ( Fig. 3-41) . Repeat with the patient's head rotated and extended to the
opposite side.
RATIONALE
Marching in place increases the heart rate, which increases the rate of blood flow through the sus­
pected vessels. Extension and rotation of the head place a motion-induced compression on the ver­
tebral arteries on the opposite side of head rotation (see Fig. 3-27). Vertigo, dizziness, visual blur­
ring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral,
basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning
of this section. Consideration must also be given to the patency of the carotid arteries and a com­
municating cerebral arterial circle.
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
65
II
Figure
3-38
Figure
3-40
Figure
3-39
Figure
3-41
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
66
Hallpike's Maneuver
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Have the patient lie supine with the head extending off the examination table. Support the patient's
head and move it into extension ( Fig. 3-42) . Then rotate and laterally flex the head to one side ( Fig.
3-43) and hold for 15 to 45 seconds looking for nystagmus or other neurological signs. Repeat the
test to the opposite side. Finally, slowly release the head and allow it to hang free in hyperextension
( Fig. 3-44).
RATIONALE
Rotation hyperextension and lateral flexion of the head place a motion-induced compression on the
vertebral arteries on the opposite side of head rotation (see Fig. 3-27) . Vertigo, dizziness, visual blur­
ring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral,
basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning
of this section. Consideration must also be given to the patency of the carotid arteries and a com­
municating cerebral arterial circle.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Plain film cervical radiography
AP open mouth
AP lower cervical, upper thoracic
Neutral lateral cervical
Oblique views
Vertebral and carotid ultrasound
Magnetic resonance angiogram
Cerebral angiogram
Figure 3-42
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
67
II
Figure
3-43
Figure
3-44
68
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
SUBCLAVIAN ARTERY COMPROMISE
DESCRIPTION
The subclavian arteries arch superiorly and posteriorly, grooving the pleura and the lungs. They
then pass inferiorly behind the midpoint of the clavicle. They are crossed anteriorly by the scalenus
anterior muscles ( Fig. 3-45). Compromise of the subclavian artery may be produced by atheroscle­
rosis, muscle dysfunction, or a space-occupying lesion. The following conditions may compromise
the subclavian artery: (a) sclerotic plaque on the walls of the artery, (b) spasm of the scalenus ante­
rior muscle, and (c) superior pulmonary sulcus tumor ( Pancoast's tumor).
CUNlCAL SIGNS AND SYMPTOMS
•
•
•
•
Upper extremity pain
Cold upper extremity
Upper extremity claudication
Supraclavicular pain
Anterior scalene
muscles
Clavicle
Pleural groove
Subclavian
artery
Figure
3-45
George's Screening Procedure (7)
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
I
I
4
With the patient seated, take the patient's blood pressure bilaterally and record the findings ( Fig.
3-46). Determine the character of the patient's radial pulse bilaterally ( Fig. 3-47).
RATIONALE
A difference of 10 mm Hg between the two systolic blood pressures and a feeble or absent radial
pulse suggests subclavian artery stenosis on the side of the feeble or absent pulse.
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
69
NOTE
If the test is negative, place a stethoscope over the supraclavicular fossa and auscultate the subcla­
vian artery for bruits ( Fig. 3-48 ). If bruits are present, suspect subclavian artery stenosis or com­
pression.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Figure
II
Plain film radiography
AP Lower cervical, thoracic
AP open mouth
Neutral lateral cervical
PA chest
Apical lordotic view
AP shoulder
Vascular ultrasound
Magnetic resonance angiogram
3-46
Figure
Figure
3-48
3-47
70
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
DIFFERENTIAL DIAGNOSIS: STRAIN VERSUS SPRAIN
CLINICAL DESCRIPTION
Cervical strain is an irritation and spasm of the muscles of the cervical spine with or without par­
tial muscle fiber tearing (see Cervical Resistive Isometric Muscle Testing, earlier in the chapter). Cer­
vical sprain is a wrenching of the joints of the cervical spine with partial tearing of its ligaments.
Traumatic injuries such as cervical acceleration-deceleration injuries produce strain and sprain in­
juries. Other traumatic and nontraumatic conditions, such as athletic injuries, overuse, overstretch­
ing, overcontraction against resistance, and a direct blow, usually produce a muscular condition that
may indicate sprain. Strains are categorized by degree of muscle tissue damage ( Box 3-4). Sprains
are categorized by degree of ligament damage (Box 3-4).
CLINICAL SIGNS AND SYMPTOMS OF STRAIN VERSUS SPRAIN
•
•
•
•
•
Cervical and upper back pain
Cervical and upper back stiffness
Cervical and upper trapezius tightness
Reduced cervical range of motion
Cervical and upper trapezius spasm
Categories of Strains and Sprains
Degree of Strain
1. Mild: Slight disruption of muscle fibers with no appreciable hemorrhage and minimal
amounts of swelling and edema
2. Moderate: Laceration of muscle fibers with an appreciable amount of hemorrhage into
the surrounding tissues and a moderate amount of swelling and edema
3. Severe: Complete disruption of the muscle tendon unit, possibly with tearing of the
tendon from the bone or a rupture of the muscle through its belly
Degree of Sprain
1. Mild: Slight tears of a few ligamentous fibers
2. Moderate: More severe tearing of ligamentous fibers but not complete separation of
the ligament
3. Severe: Complete tearing of a ligament from its attachments
4. Avulsion: A ligament that attaches to a bone is pulled loose with a fragment of that bone
O'Donoghue's Maneuver (13)
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
With the patient seated, put the cervical spine through resisted range of motion ( Fig. 3-49) , then
through passive range of motion ( Fig. 3-50) . See sections on Cervical Range of Motion and Cervi­
cal Resistive Isometric Muscle Testing in this chapter.
RATIONALE
Pain during resisted range of motion or isometric muscle contraction signifies muscle strain (see re­
sistive range of motion for muscles involved) . Pain during passive range of motion may indicate a
sprain of any of these ligaments: alar ligaments, transverse ligament, supraspinous ligament, inter­
spinous ligament, ligamentum flavum, articular capsule, intertransverse ligaments, posterior longi­
tudinal ligament, and anterior longitudinal ligament ( Fig. 3-51) .
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
71
NOTE
This maneuver can be applied to any joint or series of joints to determine ligamentous or muscular
involvement. Since resistive range of motion mainly stresses muscles and passive range of motion
mainly stresses ligaments, you should be able to determine between strain and sprain or a combi­
nation thereof.
•
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
•
Plain film radiography
AP lower cervical, upper thoracic
AP open mouth
Neutral lateral cervical
Cervical flexion/extension views·
Cervical lateral flexion views·
Figure
Figure 3-49
Figure
3-50
3-51
Alar ligament
(�,.\\Il,;t:I1-
__
-Transverse ligament
_
Anterior
longitudinal
ligament
iim�tt----_ Posterior
longitudinal
ligament
�7i1liI1l1lII1W�t±:::;:::::=- Ligamentum
flavum
�J;���H---�
,!&�-.,tItt��--
__
Interspinous
ligament
Articular
capsule
sPinous
�:3����m�I---supra
ligament
1
U
'Based on outcome of the cervical AP, open-mouth, and neutral lateral radiographs and if movement will not
adversely affect the patient.
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
72
CERVICAL FRACTURES
CLINICAL DESCRIPTION
Cervical fractures due to trauma are classified as either disrupting or not disrupting the spinal canal
and as either stable or unstable. Fractures, dislocations, and fracture dislocations of the cervical
spine are often the result of either a sudden and forceful flexion of the head and neck or a severe ax­
ial force, such as an object falling on the top of the head. The main concern with cervical fractures
is compression or transection of the spinal cord. Compression of any part of the central nervous sys­
tem for 3 to 5 minutes results in death of nervous tissue, particularly nerve cells.
Care must be taken if you suspect a cervical fracture. Radiographs of the affected area should be
performed prior to any cervical movement. Fractures may be caused by a motor vehicle accident,
falling, athletic injuries, or falling objects. Some of the common cervical fractures are spinous
process fracture, vertebral body compression fracture, posterior arch of Atlas fracture, odontoid
fractures, and burst fracture, a compound fracture anterior and posterior to the lateral masses. Most
cervical fractures that cause severe disability are most likely evaluated in an emergency situation.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
Severe cervical pain
Patient stabilizing the head
Little or no cervical motion
Severe cervical muscle spasm
Upper extremity neurological dysfunction (see Chapter 4 )
Lower extremity neurological dysfunction (see Chapter 11)
CHAPTER 3
Spinal Percussion Test (13, 14)
CERVICAL ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
73
I
1
I
2
I
3
I
4
With the patient sitting and the head slightly flexed, percuss the spinous process ( Fig. 3-52) and as­
sociated musculature ( Fig. 3-53) of each of the cervical vertebrae with a neurological reflex hammer.
Rationale
Evidence of local pain may indicate a fractured vertebra with no neurological compromise. Evidence
of radicular pain may indicate a fractured vertebra with neurological compromise or a disc lesion
with neurological compromise. If a fracture is suspected, a full cervical radiography series is indi­
cated. If radicular pain is elicited, assess which neurological level is affected (see Chapter 4).
NOTE
This test is not specific; other conditions also elicit a positive pain response. A ligamentous sprain
elicits a positive sign on percussion of the spinous processes. Percussing the paraspinal musculature
elicits a positive sign for muscular strain.
Figure 3-52
Figure 3-53
II
74
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sensitivity/Reliability Scale
Soto-Hall Test (15)
I
o
PROCEDURE
I
1
I
2
I
3
I
I
With the patient supine, press on the patient's sternum with one hand. With the other hand, pas­
sively flex the patient's neck to the chest ( Fig. 3-54).
RATIONALE
Evidence of local pain may indicate ligament, muscular, osseous pathology or injury, or cervical cord
disease. This test is nonspecific; it merely isolates the cervical spine in passive flexion. If the patient
reports radicular symptoms in the upper extremity on passive flexion, suspect a disc defect. When
the cervical spine is flexed forward, the intervertebral disc is compressed at the anterior and
stretched at the posterior ( Fig. 3-55). The dura is also in traction at the posterior. If the patient has
a posterior disc defect, this movement may exacerbate the defect, resulting in spinal cord or nerve
root compression.
Figure 3-54
Disc compressed
anteriorly
Disc bulges posteriorly
Figure 3-55
CHAPTER 3
75
CERVICAL ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
Rust's Sign
I
o
PROCEDURE
I
1
I
2
I
3
I
4
A patient with severe injury to the upper cervical spine will grasp the head with both hands to sup­
port the weight of the head on the cervical spine ( Fig. 3-56). The supine patient will support the
head while attempting to rise.
RATIONALE
The patient with a severe upper cervical injury, such as severe muscular strain, ligamentous insta­
bility, posterior disc defect, upper cervical fracture, or dislocation, is subject to guarded movements,
including stabilization of the head with slight traction to reduce the pain.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP lower cervical, upper thoracic
AP open mouth
Neutral lateral cervical
Cervical flexion/extension viewsb
Computed tomography
Myelography
Figure
3-56
bBased on outcome of the cervical AP, open-mouth, and neutral lateral radiographs and if movement will not
adversely affect the patient.
•
76
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
CERVICAL INSTABILITY
CLINICAL DESCRIPTION
Cervical instability, like fracture, is usually associated with trauma to the head and cervical spine. If
the instability is not to due to a fracture, it may be due to a torn or stretched ligament of the atlanto­
occipital joint and/or the atlantoaxial joints ( Fig. 3-57), which may cause a subluxation or disloca­
tion of either of those joints. If cervical instability is suspected, the main concern is compression or
transection of the cervical spinal cord. Cervical spinal cord compression may lead to severe neuro­
logical problems, and cervical spinal cord transection may lead to death. Most severe cervical spinal
cord injuries are evaluated in an emergency department.
The following tests attempt to evaluate stability of the atlanto-occipital and atlantoaxial joints
and their associated ligaments. The ligaments being tested are the alar and the transverse. Radio­
graphs of the cervical spine should be obtained before these tests are performed because of the pos­
sibility of cervical instability, which may lead to neurological deficit. Because of the nature of un­
stable cervical injuries, the following tests must be performed with extreme caution.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
Severe cervical pain
Patient stabilizing the head
Little or no cervical motion
Severe cervical muscle spasm
Upper extremity neurological dysfunction (see Chapter 4 )
Lower extremity neurological dysfunction (see Chapter 1 1 )
Alar ligaments
Alar ligaments damaged
Transverse
ligament
damaged
Figure
3-57
CHAPTER 3
CERVICAL ORTHOPAEDIC TESTS
77
Sensitivity/Reliability Scale
Sharp-Purser Test (16)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With a patient seated, the examiner places one hand over the patient's forehead and the thumb of
the opposite hand over the spinous process of C2 for stabilization ( Fig. 3-58). Instruct the patient to
flex the head slowly as you apply a posterior pressure with the palm of your hand ( Fig. 3-59). A positive test is indicated if you feel the head slide backward during the movement.
RATIONALE
In an anterior Atlas subluxation due to severe trauma the Atlas is anterior to the axis with alar or
transverse ligament damage. A backward slide indicates that the subluxation of the Atlas on axis has
been reduced, and the slide may be accompanied by a "clunk." The subluxation may be caused by a
stretched or torn alar or transverse ligament ( Fig. 3-60).
Figure
Figure
3-58
Alar ligaments
Alar ligaments damaged
Axis
remains stationary
Figure
3-60
3-59
Transverse
ligament
damaged
IJI
78
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Transverse Ligament Stress Test (1 7, 1 8)
Sensitivity/Reliability Scale
I
a
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, support the occiput with the palms of both hands and the third, fourth, and
fifth fingers. Place the index fingers of both hands between the occiput and C2 at the posterior arch
or Atlas, which is not palpable ( Fig. 3-6 1 ) . Carefully lift the head and Cl off the table, not allowing
any flexion or extension of the cervical spine. ( Fig. 3-62 ) . Hold this position for 1 0 to 20 seconds.
RATIONALE
Lifting the head and Cl off the table places motion-induced posterior traction on the transverse lig­
ament by the odontoid process. This movement should be limited by a transverse ligament. If the
transverse ligament is torn or stretched, compression of the spinal cord by this anterior shear may
occur. Possible signs include a soft end feel, muscle spasm, dizziness, nausea, paresthesia of the lip,
face or limbs, nystagmus or a lump sensation in the throat. This indicates a hypermobile atlantoaxial
articulation.
Figure
3-61
Figure
3-62
CHAPTER 3
Alar Ligament Stress Test ( 1 7, 1 8)
CERVICAL ORTHOPAEDIC TESTS
79
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, grasp the head with one hand. With the opposite hand grasp C2 with a
pinch grip around the spinous process and lamina ( Fig. 3-63 ) . Attempt a shear side-to-side move­
ment of the head against the axis ( Fig. 3-64). There should be a minimal amount of lateral motion
with a strong capsular end feel.
RATIONALE
The alar ligaments extend from the odontoid process to the lateral margins of the foramen magnum.
These ligaments limit side-to-side movement of the skull on the axis. Excessive side-to-side move­
ment indicates a stretched or torn alar ligament or ligaments.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Figure
Plain film radiography
AP lower cervical, upper thoracic
AP open mouth
Neutral lateral cervical
Cervical flexion/extension views'
Cervical lateral flexion views'
AP open-mouth rotational views'
Computed tomography
Myelography
Magnetic resonance imaging
3-63
Figure
3-64
'Based on outcome of the cervical AP, open-mouth, and neutral lateral radiographs and if movement will not
adversely affect the patient.
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
80
SPACE-OCCUPYING LESIONS
CLINICAL DESCRIPTION
Space-occupying lesions in and around the cervical spine may have any of various origins. Some
masses, such as posterior disc defects, posterior osteophytes, tumors, and displaced fractures, are
within the spinal canal. The same types of masses outside of the spinal canal include anterior disc
defects, anterior osteophytes, tumors, and displaced fractures. Space-occupying lesions within the
spinal canal may cause neurological deficit. Most of these masses are identified by various imaging
studies. The following tests attempt to distinguish between masses within and outside of the spinal
canal. If the suspected mass is within the spinal canal and is causing neurological dysfunction, the
examiner should evaluate for neurological deficit based on the outcome of the tests in this section.
The diagnostic imaging studies listed at the end of this section are imperative for determining the
location and type of mass.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
Cervical pain
Upper extremity neurological symptoms
Lower extremity neurological symptoms
Vals alva's m aneuver (19)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, instruct him or her to bear down as if defecating but concentrating the bulk
of the stress at the cervical region ( Fig. 3-65 ) . Ask the patient if he or she feels any increased pain,
and if so, have the patient point to its location. This test is subjective and requires an accurate re­
sponse from the patient.
RATIONALE
This test increases intrathecal pressure in the entire spine, but the patient should be able to localize
the stress to the cervical spine. Local pain secondary to the increased pressure may indicate a space­
occupying lesion (e.g., disc defect, mass, osteophyte) in the cervical canal or foramen.
Figure
3-65
CHAPTER 3
Dejerine's Sign
CERVICAL ORTHOPAEDIC TESTS
81
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, instruct the patient to cough, sneeze, and bear down as if defecating ( Valsalva's
maneuver).
RATIONALE
Pain, either local or radiating to the shoulders or upper extremities after either of these actions, in­
dicates an increase in the intrathecal pressure. This pain may be caused by a space-occupying lesion,
such as a disc defect, osteophyte, or mass.
Swallowing Test (19)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the seated patient to swallow ( Fig. 3-66).
RATIONALE
Pain upon swallowing usually indicates esophageal or pharyngeal injury, dysfunction, or pathology.
Pain upon swallowing has orthopaedic significance. Because of the proximity of the esophagus to
the anterior longitudinal ligament in the cervical spine, anterior pathology of the cervical spine,
such as anterior disc defect, osteophyte, mass, or muscle spasm, may compress or irritate the esoph­
agus and cause pain upon swallowing.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP lower cervical, upper thoracic
AP open mouth
Neutral lateral cervical
Cervical oblique views
Lateral extension view (for retropharyngeal mass)
Computed tomography
Cervical magnetic resonance imaging
Figure
3-66
•
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
82
CERVICAL NEUROLO GICAL COMPRESSION AND IRRITATION
CLINICAL DESCRIPTION
Compression and irritation of the neurological structures in the cervical spine involve mainly the
spinal cord and nerve roots. Compression of these structures may be caused by disc defects, osteo­
phytes, degenerative joint disease, tumors, or fractures. Most of the tests in this section are provoca­
tive, that is, they aggravate the compression if present. If neurological compression is suspected, the
examiner should evaluate for neurological deficit as described in Chapter 4. After performing these
tests and evaluating for neurological deficit, select the appropriate imaging procedures for the sus­
pected condition.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Cervical pain
Upper extremity radicular pain
Loss of upper extremity sensation
Loss of upper extremity reflexes
Loss of upper extremity muscle strength
Foraminal Compression Test (20-22)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated and the patient's head in the neural position, exert strong downward pres­
sure on the head ( Fig. 3-67). Repeat the test with the head rotated bilaterally (Fig. 3-68) .
RATIONALE
When downward pressure is applied to the head, the following biomechanical actions take place: ( a)
narrowing of the intervertebral foramina, (b) compression of the apophyseal joints in the cervical
spine, and (c) compression of the intervertebral discs in the cervical spine. Local pain may indicate
foraminal encroachment without nerve root pressure or apophyseal capsulitis. Radicular pain may in­
dicate pressure on a nerve root by a decrease in the foraminal interval (foraminal encroachment) or by
a disc defect. If nerve root involvement is suspected, evaluate the neurological level (see Chapter 4).
Figure
3-67
Figure
3-68
CHAPTER 3
Jackson's Compression Test (23)
CERVICAL ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
83
I
1
I
2
I
3
I
4
With the patient seated, laterally flex the neck and exert strong downward pressure on the head. Per­
form this test bilaterally ( Fig. 3-69).
RATIONALE
With the neck laterally flexed and downward pressure applied, the following biomechanical actions
take place: (a) narrowing of the intervertebral foramina on the side of lateral bending, (b) com­
pression of the facet joints on the side of lateral bending, and (c) compression of the intervertebral
discs in the cervical spine.
Local pain may indicate foraminal encroachment without nerve root pressure or apophyseal
joint pathology. Radicular pain may indicate pressure on a nerve root by a decrease in the forami­
nal interval (foraminal encroachment) or a disc defect. If nerve root involvement is suspected, eval­
uate the neurological level (see Chapter 4).
Figure
3-69
III
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
84
Sensitivity/Reliability Scale
Extension Compression Test (24)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, instruct the patient to extend the head approximately 30°. Then place down­
ward pressure on the patient's head ( Fig. 3-70).
RATIONALE
When pressure is applied to the patient's head with the cervical spine in extension, the cervical in­
tervertebral disc space is decreased posteriorly and increased vertically and anteriorly, with an in­
creased load on the posterior apophyseal joints ( Fig. 3-7 1 ) . If the patient's symptoms decrease, sus­
pect a posterolateral disc defect because of the anterior and vertical displacement of discal material
away from the nerve root or spinal cord. Downward pressure on the head also compresses the pos­
terior apophyseal joints, which, if irritated, can cause local cervical pain.
An increase in upper extremity radicular symptoms may indicate pathology in the interverte­
bral foramina, such as an osteophyte or mass or a degenerating cervical intervertebral disc. This is
possible because the pressure on the head decreases the intervertebral foraminal interval.
Disc
bulges
anteriorly
IF.::=::tt-----+-_ Disc space
compressed
posteriorly
Figure
3-70
Figure
3-71
CHAPTER 3
85
CERVICAL ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
Flexion Compression Test (24)
I
o
PROCEDURE
I
1
I
2
I
3
I
With the patient seated, instruct the patient to flex the head forward. Then place downward pres­
sure on the patient's head ( Fig. 3-72).
RATIONALE
When the patient flexes the head forward under pressure, the intervertebral disc is compressed an­
teriorly and the load is placed on the intervertebral elise. This pressure also causes the posterior as­
pect of the disc to bulge posteriorly ( Fig. 3-73). An increase in cervical and/or radicular symptoms
may indicate a discal defect. Flexion of the cervical spine and compression on the head also reduces
the load on the posterior apophyseal joints. A decrease in localized scleratogenous pain may indicate
apophyseal joint injury or pathology.
Figure
3-72
Flexion
forward
.
Load
I
-----r-....
j
Disc bulges
posteriorly
Figure 3-73
III
86
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sensitivity/Reliability Scale
Spurling's Test (20)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Laterally flex the seated patient's head and gradually apply strong downward pressure ( Fig. 3-74). If
pain is elicited, the test is considered positive; do not continue with the next procedure. If no pain is
elicited, put the patient's head to a neutral position and deliver a vertical blow to the uppermost por­
tion of the patient's head ( Fig. 3-75).
RATIONALE
Local pain may indicate facet joint involvement, either from the strong downward pressure on the
head or from the vertical blow to the head. Radicular pain may indicate foraminal encroachment,
degenerating cervical intervertebral disc, or disc defect with nerve root pressure. This test may also
indicate a lateral disc defect.
Figure 3-74
Figure
3-75
CHAPTER 3
Maximal Foraminal Compression Test
CERVICAL ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
87
I
1
I
I
2
I
I
3
I
I
4
Instruct the seated patient to approximate the chin to the shoulder and extend the neck. Perform
this test bilaterally ( Fig. 3-76).
RATIONALE
Rotation of the head and hyperextension of the neck causes the following biomechanical actions: (a)
narrowing of the intervertebral foramina on the side of head rotation; (b) compression of the facet
joints on the side of head rotation; and (c) compression of the intervertebral discs in the cervical
spine. Pain on the side of head rotation with a radicular component may indicate nerve root com­
pression caused by pathology such as an osteophyte or mass or decreased interval in the foramina,.
Local pain with no radicular component may indicate apophyseal joint pathology on the side of
head rotation and neck extension. Pain on the opposite side of head rotation indicates muscular
strain or ligament sprain.
If nerve root compression is suspected, evaluate the neurological level (see Chapter 4 ) .
Figure
3-76
II
88
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sensitivity/Reliability Scale
L'hermitte's Sign (25,26)
I
o
PROCEDURE
I
,
I
2
I
3
I
With the patient seated, passively flex the patient's chin to the chest (Fig. 3-77).
RATIONALE
When the cervical spine is flexed forward, the spinal cord and its coverings are under traction at the
posterior, and the intervertebral disc is compressed at the anterior and bulges at the posterior ( Fig.
3-78). If the patient has a posterior disc defect, this movement may exacerbate the defect, resulting
in spinal cord or nerve root compression. Cervical cord disease, meningitis, osteophytes, and masses
may cause local and/or radicular pain into the upper and/or lower extremities. A sudden electrical
tingling felt in the spine and/or extremities during neck flexion may indicate cervical myelopathy or
multiple sclerosis.
Figure 3-77
Flexion
forward
/
-�
Traction on
spinal cord
Disc bulges
posteriorly
Figure 3-78
CHAPTER 3
Shoulder Depression Test (23)
CERVICAL ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
89
I
1
I
2
I
3
I
4
With the patient seated, place downward pressure on the shoulder while laterally flexing the patient's
head to the opposite side ( Fig. 3-79).
RATIONALE
When pressure is applied to the shoulder and the head is slightly flexed to the opposite side, the mus­
cles, ligaments, nerve roots, nerve root coverings, and brachial plexus are stretched and the clavicle
is depressed, approximating the first rib. Local pain on the side being tested indicates shortening of
the muscles, muscular adhesions, muscle spasm, or ligamentous injury. Radicular pain may indicate
compression of the neurovascular bundle, adhesion of the dural sleeve, or thoracic outlet syndrome.
On the opposite side, the foraminal interval is decreased, the apophyseal joints are compressed, and
the intervertebral disc is compressed. If pain is elicited on the side opposite the one being tested, it
may indicate a pathological decrease in the foraminal interval, facet pathology, or disc defect.
Figure
3-79
Sensitivity/Reliability Scale
Distraction Test (19)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, grasp beneath the mastoid processes and press up on the patient's head. This
removes the weight of the patient's head on the neck ( Fig. 3-80).
RATIONALE
When the head is pulJed upward, the cervical muscles, ligaments, and apophyseal joint capsules are
stretched. If local pain increases, suspect muscle strain, spasm, ligamentous sprain, or facet capsuli­
tis. Also, when the head is pulled upward, the interforaminal and intervertebral interval increase. Re­
lief of local or radicular pain indicates either foraminal encroachment or a disc defect.
Figure 3-80
•
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
90
Shoulder Abduction Test (Bakody's Sign) (27)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the seated patient to abduct the arm and place the hand on top of the head (Fig. 3-8 1 ).
RATIONALE
Placing the hand above the head elevates the suprascapular nerve, reducing the traction on the lower
trunk of the brachial plexus. This procedure reduces the traction on a compressed nerve. A decrease
in or relief of the patient's symptoms indicates a cervical extradural compression problem, such as
a herniated disc, epidural vein compression, or nerve root compression, usually in the C5-C6 area.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Plain film radiography
AP lower cervical, upper thoracic
AP open mouth
Neutral lateral cervical
Cervical oblique views
Cervical magnetic resonance imaging
Computed tomography
Myelography
Figure
3-81
CHAPTER 3
1 . American Medical Association. Guides to the
evaluation of permanent impairment. 5th ed.
Chicago: American Medical Association, 2000.
2. American Academy of Orthopaedic Surgeons.
The clinical measurement of joint motion.
Chicago: American Association of Orthopaedic
Surgery, 1 994.
3. Dvorak 1, Antinnes JA, Panjabi M, et al. Age and
gender normal motion of the cervical spine.
Spine 1 992; 1 7(suppl l 0 ) :S393-S398.
4. Okawara S, Nibbelink D. Vertebral artery occlu­
sion following hyperextension and rotation of
the head. Stroke 1 974;5;640-643.
AA,
91
20. Spurling RG, Scoville WB. Lateral rupture of the
References
5. White
CERVlCAL ORTHOPAEDIC TESTS
Panjabi
MM.
Clinical
biome­
chanics of the spine, 2nd ed. Philadelphia: JB
Lippincott, 1 990.
6. Barre JA. Le syndrome sympathique cervical
posterieur. Rev Neurol 1 926;33:248-249.
7. George PE, Silverstein HT, Wallace H , et al.
Identification of the high risk pre-stroke pa­
cervical IVDs-a common cause of shoulder and
arm pain. Surg Gynecol Obstet 1 944;78:350-358.
2 1 . Harris NM. Cervical spine dysfunction. GP
1 967;32(4):78-88.
22. Depalma A, Rothman RH. The Intervertebral
Disc. Philadelphia: WB Saunders, 1 970:88.
23. Jackson R. The Cervical Syndrome. 3rd ed.
St. Louis: Mosby, 1 985.
24. Gerard 1, Kleinfeld S. Orthopaedic testing. New
York: Churchill Livingstone, 1 993.
25. L'hermitte J. Etude de la commotion de la
moella. Rev Neurol (Paris), 1 :2 1 0, 1 933.
26. L'hermitte J, Bollak P, Nicholas M . Les douleurs
a type de decharge electrique dans la sclerose en
plaques. Un cas forme sensitive de la sclerose
multiple. Rev Neurol (Paris).
27. Davidson RI, Dunn E1, Metzmater IN. The
shoulder abduction test in the diagnosis of
radicular pain in cervical extradural compres­
sive monoradiculopathies. Spine 1 98 1 ;6:44 1 .
tient. J Chiropractic 1 98 1 ; 1 5:26-28.
8. Maigne R. Orthopaedic medicine. A new ap­
proach to vertebral manipulations. Springfield,
IL: Charles C Thomas, 1972: 1 55.
9. Maitland GD. Vertebral Manipulation. London,
Butterworths, 1 973.
10. deKleyn A, Versteegh e. Ober verschiendene
Formen von
Meniere's
Syndrom.
Deutsche
Ztschr 1933; 1 3 2 : 1 57.
1 1 . deKleyn A, Nieuwenhuyse P. Schwindelandfaelle
und Nystagmus bei einer bestimmten Stellung
des Kopfes. Acta Otolaryng 1 927; 1 1 :555.
12. Lewis CB, Knotz NA. Orthopedic Assessment
and Treatment of the Geriatric Patient. St. Louis:
Mosby, 1 993.
13. O'Donoghue D. Treatment of injuries to ath­
letes. 4th ed. Philadelphia: WB Saunders, 1 984.
1 4. Turek SL. Orthopaedics. 3rd ed. Philadelphia:
JB Lippincott, 1 977.
15. Soto-Hall R, Haldeman K. A useful diagnostic
sign in vertebral injuries. Surg Gynecol Obstet
827-8 3 1 .
1 6. Magee DJ. Orthopedic Physical Assessment. 3rd
ed. Philadelphia: WB Saunders, 1 997.
General References
Clarkson H M . Musculoskeletal Assessment: Joint
Range of Motiond Manual Muscle Strength. 2nd ed.
Baltimore: Lippincott Williams & Wilkins, 2000.
Cyriax J. Textbook of Orthopaedic Medicine. Vol. 1 .
Diagnosis o f Soft Tissue Lesions. London: Bailliere
Tindall, 1 983.
Edwards Be. Combined movements in the cervical
spine (C2-C7 ) : their value in examination and tech­
nique choice. Aust J Physiother 1 980;26: 1 65 .
Foreman S M , Croft Ae. Whiplash Injuries: The Cer­
vical Acceleration/Deceleration Syndrome. 3rd ed.
Baltimore: Lippincott Williams & Wilkins, 2002.
Kapandji IA. The Physiology of Joints. Vol. 3 . The
Trunk
and
the Vertebral
Column.
New York:
Churchill Livingstone, 1 974.
Naffzinger HC, Grant WT. Neuritis of the brachial
plexus mechanical in origin: the scalenus syndrome.
Clin Orthop 1 967;5 1 :7.
Neviaser JS. Musculoskeletal disorders of the shoul­
1 7. Pettman E. Stress test of the craniovertebral
der region causing cervicobrachial pain: differential
joints. In Boyling JD, Palastanga N, eds. Grieve's
diagnosis and treatment. Surg Clin North Am
Modern Manual Therapy: The Vertebral Col­
1 963;43: 1 703.
umn. 2nd ed. Edinburgh: Churchill Livingstone,
Nichols H M . Anatomic structures of the thoracic
1994.
18. Meadows JJ, Magee DJ. An overview of dizziness
and vertigo for the orthopedic manual therapist.
In Boyling JD, Palastanga N, eds. Grieve's Mod­
ern Manual Therapy: The Vertebral Column.
outlet. Clin Orthop 1 967;5 1 : 1 7.
Norkin CC, Levangie PK. Joint Structure and Func­
tion: A Comprehensive Analysis. Philadelphia: FA
Davis, 1983.
2nd ed. Edinburgh: Churchill Livingstone, 1 994.
Terrett AGJ. Importance and interpretation of tests
19. Hoppenfeld S. Physical examination of the
designed to predict susceptibility to neurocircula­
spine and extremities. New York: Appleton­
tory accidents from manipulation. J Aust Chiropr
Century-Crofts, 1 976: 1 27.
Assoc 1 983; 1 3 (2 ) :29-34.
II
--------�GO�-CERVICAL NERVE ROOT LESIONS
C5
96
Motor
Reflex
96
Deltoid Muscle
Biceps Muscle
Reflex
Sensory
C6
Triceps Reflex
Sensory
96
C8
97
97
Palmar Interossei
Reflex
98
Sensory
98
Tl
99
99
104
Groups
Sensory
100
100
Wrist Flexor Group
100
Finger Extensor Group
92
103
104
Motor
Reflex
Triceps Muscle
103
103
Finger Abductor and Adductor
99
100
Motor
102
98
Brachioradialis Reflex
C7
102
Finger Abductor Group
Biceps Muscle
Sensory
102
Finger Flexor Group
Wrist Extensor Group
Reflex
102
Motor
98
Motor
101
101
97
97
Biceps Reflex
101
101
104
104
104
CHAPTER 4
CERVICAL NERVE ROOT LESIONS
93
The cervical spine consists of eight pairs of spinal nerves. Each spinal nerve consists of a dorsal root
(sensory component) and a ventral root (motor component). These nerve roots emerge from the
spinal column through lateral intervertebral foramina. The first four cervical nerves collectively
form the cervical plexus. The second four nerves, together with the first thoracic nerve, form the
brachial plexus (Fig. 4-1).
D
Figure 4-1
If a nerve root lesion is suspected, you must evaluate three clinical aspects of the neurological
examination: sensory, motor, and reflex dysfunction. Sensory testing attempts to delineate the seg­
mental cutaneous innervation to the skin. It is done with a sterile or disposable Neurotip or pin­
wheel in specific dermatomal patterns.
Two dermatomal maps are provided. Figure 4-2 is based on the body areas of intact sensation
when roots above and below an isolated root were interrupted; sensation loss when one or more
continuous roots were interrupted; or the pattern of herpetic rash and hypersensitivity when there
is isolated root involvement. Figure 4-3 is based on the hyposensitivity to pin scratch in various root
lesions and is consistent with electrical skin resistance studies showing axial dermatomes extending
to the distal extremities. This pattern is useful in evaluating paresthesias and hyperesthesias second­
ary to root irritation. This is the pattern this chapter delineates to evaluate sensory root dysfunction.
A fair amount of segmental overlap exists; therefore, a single unilateral lesion may affect more than
one dermatomal level.
Motor function is evaluated by testing the muscle strength of specific muscles innervated by a
particular nerve root or roots using the muscle grading chart adopted by the American Academy of
Orthopaedic Surgeons (Box 4-1). The reflex arc is tested by evaluating the superficial stretch reflex
associated with the particular nerve root. These arcs are graded by the Wexler Scale (Box 4-2).
The clinical presentation of nerve root lesions depends on two i:nportant factors: location and
severity of the injury or pathology. These two factors together determine the injury's clinical pre­
sentation. The possibilities are endless, ranging from no clinical presentation or slight clinical man­
ifestation, such as slight loss of sensation and pain, to total denervation with loss of total function
to the structures innervated by that nerve root (motor, reflex, and sensory).
\0
...
'"0
:r:
0
...,
0
C"l
C2
C3
�
/I','
:r:
n
C4
�
rz
C5
T2
�� T4
�
�
0
."
;:0
'"
C"l
(3
Z
:>r
0
q
:r:
0
�
'"
0
n
rz0
z
'"
c::
;0
0
if
L3
5
\ un
C"l
n
:>r
+-+---- L4
>-l
1\ I
'"
...,
en
en
�---- L5 ------�
-\------81
J
��
,(11�
Figure 4-2. Adapted with permission from Haymaker and Woodall.
Figure 4-3. Reprinted with permission from Keegan
Peripheral Nerve Injuries. 2nd ed. Philadelphia: WB Saunders, 1954.
1943;102:4:409-439.
JJ,
Garrett
ED.
Anat Record
CHAPTER 4
CERVlCAL NERVE ROOT LESIONS
95
Muscle Grading Chart
5
4
Complete range of motion against gravity with full resistance
Complete range of motion against gravity with some resistance
3
Complete range of motion against gravity
2
Complete range of motion with gravity eliminated
1
Evidence of slight contractility, no joint motion
o
No evidence of contractility
Wexler Scale
o
+1
No response
+2
Normal
+3
+4
Hyperreflexia
+5
Hyperreflexia with sustained clonus
Hyporeflexia
Hyperreflexia with transient clonus
Each nerve root has its own sensory distribution, muscle test or tests, and a stretch reflex; these
are grouped to facilitate the identification of the suspected level.
The clinical evaluation is not made solely on one aspect of the neurological package but is in­
stead determined by the combination of history, inspection, palpation, the three individual tests
(motor, reflex, and sensory) and appropriate diagnostic imaging and/or functional neurological
testing, such as electromyography. Furthermore, the injury or pathology under evaluation may not
necessarily be affecting a nerve root, but it may be affecting the brachial plexus, a trunk of that
plexus, or a named nerve. Depending on the severity and location of the injury or pathology, vari­
ous combinations of neurological dysfunction may be elicited.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
Cervical pain
Upper extremity paresthesia
Diminution or loss of upper extremity sensation
Diminution or loss of upper extremity reflexes
Decrease or loss of muscle strength
Atrophic upper extremity lesions
95
96
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
C5
The C5 nerve root exits the spinal canal between the C4 and C5 vertebrae and may be affected by
.
the C4 intervertebral disc (Fig. 4-4).
Figure 4-4
Motor
Sensitivity/Reliability Scale
I
Deltoid Muscle (C5 Axillary Nerve Innervation)
o
I
1
I
2
I
3
I
4
PROCEDURE
Stand behind the seated patient and place your hand at the lateral aspect of the elbow. Instruct the
patient to abduct the arm against resistance (Fig. 4-5). Grade the strength according to the muscle
grading chart. Perform this test bilaterally and compare each side.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C5 nerve root, upper trunk
of the brachial plexus, or the axillary nerve. A weak or strained deltoid muscle may be suspected if
the sensory and reflex portions of the C5 neurological package are intact.
Figure 4-5
CHAPTER 4
97
CERVICAL NERVE ROOT LESIONS
Biceps Muscle (CS, C6 Musculocutaneous Nerve Innervation)
PROCEDURE
With the patient in the seated position and the forearm flexed, stabilize the patient's elbow with one
hand and grasp the anterior aspect of the patient's wrist with your opposite hand. Instruct the pa­
tient to flex the forearm against resistance (Fig. 4-6). Grade the strength according to the muscle
grading chart and compare each side.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C5 or C6 nerve roots, upper
trunk of the brachial plexus, or musculocutaneous nerve. A weak or strained biceps muscle may be
suspected if the sensory and reflex portions of the C5 neurological package are intact.
Figure 4-6
Retlex
Sensitivity/Reliability Scale
I
Biceps Reflex (CS, C6 Musculocutaneous Nerve Innervation)
o
I
1
I
2
I
3
I
4
PROCEDURE
Place the patient's arm across your opposite arm with your thumb on the biceps tendon. Strike your
thumb with the narrow end of the reflex hammer (Fig. 4-7). The biceps muscle should contract
slightly under your thumb. Grade your response according to the reflex chart and evaluate bilaterally.
RATIONALE
Hyporeflexia may indicate a C5, C6 nerve root deficit. Loss of reflex may indicate an interruption of
the reflex arc (lower motor neuron lesion). Hyperreflexia may indicate an upper motor neuron lesion.
Figure 4-7
Sensory
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With a pin, stroke the lateral aspect of the arm (Fig. 4-8).
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the C5 nerve root or the axillary nerve.
Figure 4-8
98
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
C6
The C6 nerve root exits the spinal canal between the CS and C6 vertebrae and may be affected by
the CS intervertebral disc (Fig. 4-9).
Figure 4-9
Motor
Sensitivity/Reliability Scale
I
Biceps Muscle (CS, C6 Musculocutaneous Nerve Innervation)
o
I
1
I
2
I
3
I
4
See Figure 4-6 and accompanying text.
Wrist Extensor Group: Extensor Carpi Radialis, Longus, and Brevis (C6, C7 Radial
Nerve Innervation)
PROCEDURE
With the patient seated, stabilize the patient's forearm by grasping the elbow with your hand. In­
struct the patient to make a fist, and dorsiflex the wrist (Fig. 4-10). With your opposite hand, grasp
the patient's fist and attempt to force the wrist into flexion as the patient resists (Fig. 4-11). Evalu­
ate according to the muscle grading chart and compare bilaterally.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C6 or C7 nerve root. A weak
or strained wrist extensor may be suspected if the sensory and reflex portions of the C6 and C7 neu­
rological packages are intact.
Figure 4-10
Figure 4-11
CHAPTER 4
99
CERVICAL NERVE ROOT LESIONS
Reflex
Sensitivity/Reliability Scale
I
Brachioradialis Reflex (CS, C6 Radial Nerve Innervation)
o
I
1
I
2
I
3
I
4
PROCEDURE
Place the patient's arm across your opposite arm and tap the brachioradialis tendon at the distal aspect
of the forearm with the neurological reflex hammer (Fig. 4-12). The brachioradialis muscle should
contract slightly on your arm. Grade the response according to the reflex chart and evaluate bilaterally.
RATIONALE
Hyporeflexia may indicate a nerve root deficit. Loss of reflex may indicate an interruption of the re­
flex arc (lower motor neuron lesion). Hyperreflexia may indicate an upper motor neuron lesion.
Figure 4-12
Sensory
PROCEDURE
With a pin, stroke the lateral aspect of the forearm, thumb, and index finger (Fig. 4-13).
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the C6 nerve root or the musculocu­
taneous nerve.
Figure 4-13
C7
The C7 nerve root exits the spinal canal between the C6 and C7 vertebrae and may be affected by
the C6 intervertebral disc (Fig. 4-14).
Figure 4-14
Motor
Sensitivity/Reliability Scale
I
Triceps Muscle (C7 Radial Nerve Innervation)
o
I
1
I
2
I
3
I
4
PROCEDURE
With the patient supine, flex the shoulder and elbow to 90°. Grasp the proximal aspect of the arm
to stabilize the extremity. With your opposite hand, grasp the patient's wrist and ask the patient to
extend the forearm against your resistance (Fig. 4-15). Grade the strength according to the muscle
grading chart and compare bilaterally.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C7 nerve root or radial nerve.
A weak or strained triceps muscle may be suspected if the sensory and reflex portions of the C7 neu­
rological package are intact.
Figure 4-15
Wrist Flexor Group: Flexor Carpi Radialis
(C7 Median Nerve Innervation) and Flexor Carpi Ulnaris
(CB Ulnar Nerve Innervation)
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
PROCEDURE
With the patient seated, stabilize the patient's forearm by grasping the forearm with your hand. In­
struct the patient to make a fist and flex the wrist. With your opposite hand, grasp the patient's fist
and attempt to force the wrist into extension as the patient resists (Fig. 4-16). Grade according to
the muscle grading chart and compare bilaterally.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C7 or C8 nerve root. A weak
or strained wrist flexor may be suspected if the sensory and reflex portions of the C7 and C8 neu­
rological packages are intact.
Figure 4-16
Finger Extensor Group: Extensor Digitorum Communis,
Extensor Digiti Indids, Extensor Digiti Minimi
(C7 Radial Nerve Innervation)
Sensitivity/Reliability Scale
I
I
o
1
I
2
I
I
3
4
PROCEDURE
With the patient's wrist in the neutral position, grasp the wrist with your hand. Have the patient ex­
tend the metacarpophalangeal joints and flex the proximal and distal interphalangeal joints (Fig.
4-17). Place your hand on the distal aspect of the proximal phalanges and attempt to force the
metacarpophalangeal joints into flexion as the patient resists (Fig. 4-1S). Grade according to the
muscle grading chart and evaluate bilaterally.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C7 or CS nerve root. A weak
or strained finger extensor may be suspected if the sensory and reflex portions of the C7 and
CS neurological packages are intact.
Figure 4-17
Figure 4-18
--...,.-..,
Reflex
Sensitivity/Reliability Scale
I
o
Triceps Reflex (C7 Radial Nerve Innervation)
I
I
1
I
2
I
3
I
PROCEDURE
Flex the patient's arm across your opposite arm and tap the triceps tendon at the olecranon fossa
with the neurological reflex hammer (Fig. 4-19). The triceps muscle should contract slightly. Grade
your response according to the reflex chart and evaluate bilaterally.
RATIONALE
Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an
interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an
upper motor neuron lesion.
Figure 4-19
Sensory
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
With a pin, stroke the palmar surface of the middle finger (Fig. 4-20).
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the C7 nerve root or the radial nerve.
Figure 4-20
102
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
C8
The C8 nerve root exits the spinal canal between the C7 and T1 vertebrae and may be affected by
the C7 intervertebral disc (Fig. 4-21).
Figure 4-21
Motor
Sensitivity/Reliability Scale
I
o
Finger Flexor Group: Flexor Digitorum Superficialis
(C7, CB Median Nerve Innervation) and Flexor Digitorum
Profundus (C7, CB Median and Ulnar Nerve Innervation)
I
1
I
2
I
3
I
4
PROCEDURE
Grasp the seated patient's wrist with one hand to stabilize the hand. Curl your fingers into the pa­
tient's fist and attempt to pull the fingers out of flexion as the patient resists (Fig. 4-22). Grade ac­
cording to the muscle grading chart and compare bilaterally.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C8 nerve root. A weak or
strained finger flexor group muscle may be suspected if the sensory portion of the C8 neurological
package is intact.
Figure 4-22
Finger Abductor Group: Dorsal Interossei, Abductor Digiti Minimi
(CB, T1 Ulnar Nerve Innervation)
PROCEDURE
Instruct the patient to pronate the hand and abduct the fingers. Take each pair of fingers and pinch
them together as the patient resists (Fig. 4-23). Grade your findings according to the muscle grad­
ing chart and compare bilaterally.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C8 or Tl nerve root. A weak
or strained finger abductor may be suspected if the sensory portion of the C8 and Tl neurological
packages is intact.
Figure 4-23
CHAPTER 4
103
CERVICAL NERVE ROOT LESIONS
Palmar Interossei (C8, Tl Ulnar Nerve Innervation)
PROCEDURE
With the patient's hand pronated, have the patient adduct all the fingers. The examiner is to grasp
each pair of the patient's fingers and attempt to pull them apart against patient resistance (Fig.
4-24). Grade according to the muscle grading chart and compare bilaterally.
RATIONALE
A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C8 or Tl nerve root. A weak
or strained finger adductor may be suspected if the sensory portion of the C8 and Tl neurological
packages is intact.
Figure 4-24
Retlex
None
Sensitivity/Reliability Scale
Sensory
I
o
I
1
I
2
I
I
3
I
4
PROCEDURE
With a pin, stroke the palmar surface of the last two digits and the ulnar aspect of the forearm
(Fig. 4-25).
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the C8 nerve root or the ulnar nerve.
Figure 4-25
104
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Tl
The Tl nerve root exits the spinal canal between the Tl and T2 vertebrae and may be affected by the
Tl intervertebral disc (Fig. 4-26).
Motor
Figure 4-26
Finger Abductor and Adductor Groups
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
See C8 Neurological Level
Reflex
None
Sensory
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
With a pin, stroke the medial proximal aspect of the arm and forearm (Fig. 4-27).
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the Tl nerve root or the medial
brachial cutaneous nerve.
SUGGESTED IMAGING AND FUNCTIONAL TEsTING
•
•
•
Cervical magnetic resonance imaging
Electromyography
Somatosensory evoked potential
Figure 4-27
CHAPTER 4
CERVICAL NERVE ROOT LESIONS
lOS
General References
Bronisch FW. The Clinically Important Reflexes.
Kendall FP, McCreary EK, Provance PG. Muscles:
New York: Grune & Stratton, 1952.
Testing and Function. 4th ed. Baltimore: Williams &
Chusid JG. Correlative Neuroanatomy and Func­
Wilkins, 1994.
tional Neurology. 17th ed. Los Altos, CA: Lange,
Mancall E. Essentials of the Neurologic Examina­
1976.
tion. 2nd ed. Philadelphia: FA Davis , 1981.
Dejong RN. T he Neurologic Examination. 4th ed.
Parsons N. Color Atlas of Clinical Neurology.
Hagerstown, MD: Harper & Row, 1979.
Chicago: Year Book, 1989.
Hoppenfeld S. Physical Examination of the Spine
VanAllen MW, Rodnitzky RL. Pictorial Manual of
and Extremities. New
Neurologic Tests. 2nd ed. Chicago: Year Book, 1981.
Croft, 1976:127.
York:
Appleton-Century­
III
�
--------�rn�-SHOULDER ORTHOPAEDIC TESTS
SHOULDER ORTHOPAEDIC EXAMINATION
107
FLOW CHART
108
SHOULDER PAL PATION
Acromioclavicular Joints
108
Posterior D rawer Test
109
110
142
INSTABILITY
113
142
Feagin Test
114
Posterior Aspect
Rowe Test for Multidirectional
114
144
Sulcus Sign
116
SHOULDER RANGE OF MOTION
116
117
118
External Rotation
119
120
Adduction
121
122
Abbott-Saunders Test
B URSITIS
Ludington's Test
123
TENDINITIS (BICIPITAL )
Test
125
129
131
Wright's Test
158
Traction Test
159
Halstead's Maneuver
157
160
B RACHIAL PLEXUS IRRITATION
B rachial Plexus Stretch Test
ANTERIOR GLENOHUMERAL
Bik.ele's Sign
132
Anterior Apprehension Test
163
T innel's Sign (for B rachial Plexus
133
Prone Anterior Instability Test
161
161
162
B rachial Plexus Tension Test
132
155
155
Costoclavicular Test
128
Subacromial Push-B utton Sign
106
153
Adson's Test
127
Anterior D rawer Test
152
152
THORACIC OUTLET SY NDROME
129
INSTABILITY
150
Transverse Humeral L igament
124
126
D aw barn's Test
149
150
Yergason's Test
123
Neer Impingement Sign
148
148
BICEPS TENDON INSTABILITY
122
Hawkins-Kennedy Impingement
L ippman's Test
147
Supraspinatus Test
Apley Scratch Test
Gilchrest's Sign
146
D rop Arm Test
Supraspinatus Tendinitis Test
Speed's Test
145
Clunk Test
ROTATOR CUFF INSTABILITY
TENDINITIS (SUPRASPINAT US)
Test
LAB RAL TEARS
Anterior Slide Test
Internal Rotation
Abduction
143
Instability
115
Extension
141
MULTIDIRECTIONAL SHOULDER
D eltoid Muscle
Flexion
140
Norwood Stress Test
Push-Pull Test
112
Trapezius
140
III
B icipital Groove
Scapula
139
Posterior Apprehension Test
Subacromial (Subdeltoid) B ursa
B iceps
139
INSTABILITY
Clavicle, Sternoclavicular and
Rotator Cuff
138
POSTERIOR GLENOHUMERAL
108
Anterior Aspect
137
Fulcrum Test
D ugas Test
134
Andrews Anterior Instability Test
135
Rowe Test for Anterior Instability
137
L esions)
172
Shoulder Orthopaedic Examination
�
I NOra I
lTl
Range of motion
(active)
(passive)
Range of motion
(active)
(Passive)
+(+)
Anterior
drawer test
Anterior
apprehension
test
Rockwood test
Rowe test
Fulcrum test
Dugas test
I
t (+)
Radiology
t (+)
I
Anterior
glenohumeral
instability
Shoulder pain
with upper extremity
pain/paresthesia
I
(
-
)
J ( +)
Adhesive
capsulitis
t
(+
active)
I
Posterior
apprehension
test
Posterior drawer
test
Push-pull test
t (+)
Posterior
glenohumeral
instability
Supraspinatus
tendinitis test
Apley scratch
test
Speed's test
t
(+)
Supraspinatus
tendinitis
(
-
)
(
-
)
r-----
(+)
[!��i � ,
ti
I
t (+)
Tendon instability
(-) I
Hawkins-Mennedy
test
Lippman's test
(
-H
I
I
Brachial plexus
irritation
·HThoracic
outlet
syndrome
Brachial plexus
stretch test
Tinel's sign
t ( +)
Drop arm test
Biceps tendon
stability test
Yergason's test
Abbott-Saunders test
Ludington's test
Transverse humeral
ligament test
I
Subacromial
push-button
sign
Dawbarn's test
Adson's test
Costoclavicular test
Wright's test
Traction test
Halstead maneuver
I
(J
?:
-0
--l
m
;<l
\Jl
C/J
J:
o
C
c­
o
m
;<l
o
::j
J:
o
�o
n
....,
m
en
;;l
o
'-I
108
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
SHOULDER PALPATION
Anterior Aspect
Clavicle and Sternoclavicular and Acromioclavicular Joints
DESCRIPTIVE ANATOMY
The clavicle is slightly anterior and inferior to the top of the shoulder. The sternoclavicular joint,
which attaches the clavicle to the sternum, lies at the medial end of the clavicle. The acromioclavic­
ular joint, which is lateral, attaches the clavicle to the acromion process of the scapula (Fig. 5-1).
PROCEDURE
With your fingertips, palpate the length of the clavicle from the medial aspect at the sternoclavicu­
lar joint to the lateral aspect at the acromioclavicular joint (Fig. 5-2). Note any abnormal tenderness
or bumps along the length of the clavicle that indicate a fracture secondary to recent trauma or a
healed fracture with callus formation. Compare the clavicles for symmetry and placement. Next,
palpate the sternoclavicular joint (Fig. 5-3) and acromioclavicular joint (Fig. 5-4) for tenderness
with your index and middle fingers. If the affected clavicle and associated joint are more anterior,
posterior, or superior than the other, suspect a subluxation or dislocation of the clavicle at the af­
fected joint. Flexing and extending the shoulder during acromioclavicular joint palpation may re­
veal crepitus (Fig. 5-5). Crepitus is secondary to joint inflammation, such as osteoarthritis.
Acromioclavicular
joint
Coracoid
process
(Subdeltoid)
Subacromial
bursa
Deltoid
muscle---f-lil
Long head
of biceps --+-+i-4++-'-r--*"
tendon
Humerus --+--'1\'
Figure 5-1
Figure 5-2
Figure 5-3
Figure 5-4
Figure 5-5
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
109
Subacromial (Subdeltoid) Bursa
DESCRIPTIVE ANATOMY
The subacromial portion of the bursa is a fluid-filled sac that extends over the supraspinatus tendon
and beneath the acromion process. The subdeltoid portion, beneath the deltoid m uscle, (Fig. 5-6)
separates the deltoid muscle from the rotator cuff.
PROCEDURE
With one hand, extend the patient's arm. With your opposite hand, palpate for tenderness, masses,
and thickening of both subacromial (Fig. 5-7) and subdeltoid (Fig. 5-8) portions of the bursa. Sus­
pect subacromial or subdeltoid bursitis if the bursa is tender. Tenderness may also be associated with
restriction of motion and crepitus of the shoulder, especially in abduction and forward flexion.
Acromioclavicular
ligament
Coracoid
process
Sternoclavicular
(Subdeltoid)
Subacromial
bursa
Deltoid
muscle
Long head
of biceps
tendon
Humerus
la
Figure 5-6
1
Figure 5-7
J
Figure 5-8
110
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Rotator Cuff
DESCRIPTIVE ANATOMY
The rotator cuff is composed of four muscles, three that are palpable and one that is not. The three
palpable muscles are the supraspinatus, which lies above the spine of the scapula and whose tendon
lies under the acromion process; the infraspinatus, which lies inferior to the supraspinatus; and the
teres minor, which is inferior to the infraspinatus (Figs. 5-9 and 5-10) The fourth muscle is the sub­
scapularis, which is under the scapula and is difficult to palpate. The rotator cuff holds the humerus
in the glenoid cavity and blends with the articular capsule to provide dynamic stabilization.
PROCEDURE
Sitting behind the patient, grasp the patient's arm and extend it backward 20°. With your other
hand, palpate inferior to the anterior border of the acromion process (Fig. 5-11). Note any tender­
ness, swelling, nodular masses, or gaps in the cuff. Tendinitis, tears, abnormal calcium deposits, and
degeneration in the cuff may elicit tenderness and pain upon palpation. A palpable gap may indi­
cate a ruptured tendon.
(Shoulder Joint)
Acromioclavicular ligament
Clavicle
Rotator cuff (posterior view):
CD Supraspinatus m.
Acromion process 7"""--"'....
Supraspinatus m.---:I'-#'--,.;;.'
-
process
Infraspinatus m.
Teres minor m.
Scapula
® Infraspinatus @ Teres minor
muscle
muscle
Figure 5-9
Figure 5-10
Figure 5-11
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
III
Bicipital Groove
DESCRIPTIVE ANATOMY
The bicipital groove is anterior and medial to the greater tuberosity of the humerus. The tendon of
the long head of the biceps muscle and its synovial sheath lie in its groove. The transverse humeral
ligament holds the tendon in place (Fig. 5-12).
PROCEDURE
With one hand, locate the inferior tip of the acromion process, then move inferiorly to the greater
tuberosity of the humerus. With your other hand, grasp the patient's arm and externally rotate it
(Fig. 5-13). You will feel the bicipital groove slip under your fingers. Note any tenderness, which may
indicate tenosynovitis of the bicipital tendon and its sheath. Also note any excessive movement of
the tendon in its groove; it may indicate a predisposition of the tendon to dislocate out of the bicip­
ital groove or a torn or ruptured transverse humeral ligament.
Bicipital
groove
Transverse
humeral--+--f-t
ligament
Biceps
tendon
Biceps _L..lL-"-'I"
brachii
muscle
Figure 5-12
Figure 5-13
112
PHOTOGRAPHIC MANUAL O F REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Biceps Muscle
DESCRIPTIVE ANATOMY
The biceps muscle has two heads that originate from different areas. The long head originates from
the tuberosity above the glenoid cavity, and the short head originates from the coracoid process of
the scapula. They both insert into the bicipital tuberosity of the radius (Fig. 5-12).
PROCEDURE
With the patient's elbow flexed to 90°, begin palpating distally from the bicipital tuberosity of the ra­
dius upward to the bicipital groove (Fig. 5-14). Note any tenderness, spasm, or muscle mass. Tender­
ness at the proximal end may indicate tenosynovitis of the biceps tendon. Tenderness at the belly of
the muscle may indicate muscle strain or an active trigger point. If a curling of the muscle secondary
to overload is evident at the mid arm, suspect a rupture of the biceps tendon from its origin.
Figure 5-14
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
113
Deltoid Muscle
DESCRIPTIVE ANATOMY
The deltoid muscle originates from the clavicle and acromion process of the scapula and inserts into
the deltoid tuberosity of the humerus (Fig. 5-15). The three parts of the fibers are the anterior, mid­
dle, and posterior. This muscle is capable of acting in parts or as a whole. The anterior part flexes
and medially rotates the humerus. The middle part abducts the humerus. The posterior part extends
and laterally rotates the humerus.
PROCEDURE
Begin palpation of the anterior portion of the deltoid muscle from the acromion process inferiorly
(Fig. 5-16), then from the lateral aspect of the shoulder (again inferiorly) for the middle part of the
deltoid muscle (Fig. 5-17). Finally, palpate the posterior aspect of the deltoid muscle from the supe­
rior aspect to the inferior aspect with the patient's shoulder extended (Fig. 5-18). Note any tender­
ness or taut muscle fibers. Tenderness at the lateral aspect of the deltoid is associated with subdel­
toid bursitis. Tenderness at the anterior aspect of the deltoid may be associated with pathology or
injury in the bicipital groove, because the anterior aspect of the deltoid muscle covers the groove and
its tendon. General tenderness may indicate a strain or active trigger point of the deltoid muscle sec­
ondary to overuse, overload, trauma, or chilling.
Figure 5-15
Anterior
fibers
Deltoid
m. -f+r.�
Middle
fibers
Posterior
fibers
Figure 5-16
Figure 5-17
Figure 5-18
114
PHOTOGRAPHIC MANUAL O F REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Posterior Aspect
Scapula
DESCRIPTIVE ANATOMY
The scapula lies between T2 and T7. It has three borders, medial, lateral, and superior. It also has a
sharp ridge that extends from the acromion process, which is the spine of the scapula (Fig. 5-19).
PROCEDURE
Starting with the medial border of the scapula, palpate all three borders, noting any tenderness (Figs.
5-20-5-22). Next, palpate the spine of the scapula, noting any tenderness and/or abnormality (Fig.
5-23). Finally, palpate the posterior surfaces above the spine of the scapula for the supraspinatus
muscle (Fig. 5-24) and below the spine for the infraspinatus muscle (Fig. 5-25). Note any tender­
ness, palpable bands, atrophy, or spasm. Palpable bands in the supraspinatus and infraspinatus mus­
cle may indicate a myofascial syndrome caused by overuse, overload trauma, or chilling. Atrophy
may indicate a disruption of the nerve supply to the suspected muscle.
Superior border
Coracoid
Acromion
process
Lateral border
(Posterior View)
Figure 5-19
I
,
Figure 5-20
Figure 5-21
Figure 5-22
Figure 5-23
Figure 5-24
Figure 5-25
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
lIS
Trapezius Muscle
DESCRIPTIVE ANATOMY
The trapezius muscle originates from the occiput, ligamentum nuchae, and spine of C7 to T12 ver­
tebra. It inserts into the acromion process and spine of the scapula (Fig. 5-26). The trapezius con­
tains three sets of fibers that perform different actions. The superior fibers elevate the shoulders; the
middle fibers retract the scapula; and the inferior fibers depress the scapula and lower the shoulders.
PROCEDURE
Begin at the origin at the base of the occiput, palpating superior fibers inferior toward the spine of the
scapula (Fig. 5-27). Then, from the spine of the scapula, palpate the middle (Fig. 5-28) and inferior
(Fig. 5-29) fibers down toward the T l 2 spinous process. Note any tenderness, spasm, palpable bands,
or asymmetry of the muscles. Tenderness and spasm may be present secondary to hyperextension or
hyperflexion injuries. Tight palpable bands may be secondary to active myofascial trigger points. Ac­
cording to Travell, myofascial trigger points in muscle are activated directly by trauma, overuse, over­
load, or chilling. They are activated indirectly by visceral disease, arthritis, and emotional distress.
Figure 5-26
Semispinalis
cervicis m.
Wf-�"'-+ Longissimus
cervicis m.
-""':::"....",..--- Splenius capitus m.
\r----....:..,,---S plenius cervicis m.
Deltoid m.-H"r.'H--'
Figure 5-27
Figure 5-28
Figure 5-29
•
116
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
SHOULDER RANGE OF MOTION
Flexion (1,2)
With the patient seated, place the goniometer in the sagittal plane at the level of the glenohumeral
joint (Fig. 5-30). Instruct the patient to elevate the arm forward while following it with one arm of
the goniometer (Fig. 5-31).
NORMAL RANGE
Normal range is 1670 ± 5.70 from the 0 or neutral position.
Note: This expressed degree of motion probably did not permit enough external rotation and
abduction to achieve 1800 of flexion described by others.
Muscles
Nerve Supply
1.
2.
3.
4.
Axillary
Lateral pectoral
Musculocutaneous
Musculocutaneous
Anterior deltoid
Pectoralis major
Coracobrachialis
Biceps
Figure 5-30
Figure 5-31
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
117
Extension (1,2)
With the patient seated, place the goniometer in the sagittal plane at the level of the glenohumeral
joint (Fig. 5-32). Instruct the patient to elevate the arm backward while following it with one arm
of the goniometer (Fig. 5-33).
NORMAL RANGE
Normal range is 620 :t 9.50 from the 0 or neutral position.
Muscles
Nerve Supply
l. Posterior Deltoid
2. Teres major, minor
3. Latissimus dorsi
4. Pectoralis major
5. Triceps
Axillary
Subscapular
Thoracodorsal
Lateral Pectoral
Radial
Figure 5-32
Figure 5-33
118
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Internal Rotation (1,2)
Have the seated patient abduct the arm to 90° and flex the elbow to 90°. This is the 0 or neutral po­
sition for rotation of the shoulder. Place the goniometer in the sagittal plane with the center at the
lateral aspect of the elbow (Fig. 5-34). Instruct the patient to rotate the shoulder inward by moving
the forearm so that the palm of the hand faces posteriorly, and follow the forearm with one arm of
the goniometer (Fig. 5-35).
NORMAL RANGE
Normal range is 69° ± 5 6° from the 0 or neutral position.
.
Muscles
Nerve Supply
1.
2.
3.
4.
5.
Lateral Pectoral
Axillary
Thoracodorsal
Subscapular
Subscapular
Pectoralis major
Anterior deltoid
Latissimus dorsi
Teres major
Subscapularis
Figure 5-34
Figure 5-35
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
119
External Rotation (1,2)
Have the seated patient abduct the arm to 90° and flex the elbow to 90°. This is the 0 or neutral po­
sition for rotation of the shoulder. Place the goniometer in the sagittal plane with the center at the
lateral aspect of the elbow (Fig. 5-36). Instruct the patient to rotate the shoulder outward by mov­
ing the forearm so that the palm of the hand faces anteriorly, and follow the forearm with one arm
of the goniometer (Fig. 5-37).
NORMAL RANGE
Normal range is 1 04° :±: 8.5° from the 0 or neutral position.
Muscles
Nerve Supply
1. Infraspinatus
2. Posterior deltoid
3. Teres minor
Suprascapular
Axillary
Axillary
Figure 5-36
Figure 5-37
120
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Abduction (1,2)
With the patient seated, place the goniometer in the coronal plane with the center at the level of the
glenohumeral joint (Fig. 5-38). Instruct the patient to raise the arm laterally. Follow it with one arm
of the goniometer (Fig. 5-39).
NORMAL RANGE
Normal range is 1 840 ± 70 from the 0 or neutral position.
Muscles
Nerve Supply
1.
2.
3.
4.
5.
6.
Axillary
Suprascapular
Suprascapular
Suprascapular
Axillary
Musculocutaneous
Deltoid
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
Biceps brachii, long head
Figure 5-38
Figure 5-39
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
121
Adduction
With the patient seated, place the goniometer in the coronal plane with the center at the level of the
glenohumeral joint (Fig. 5-40). Instruct the patient to raise the arm medially. Follow it with one arm
of the goniometer (Fig. 5-41).
NORMAL RANGE
Normal range is 75° or greater from the 0 or neutral position.
NOTE
Adduction is a composite movement of flexion and adduction. Most sources do not measure com­
posite movements. I consider it a clinically important movement and think it should be measured.
Muscles
Nerve Supply
1 . Pectoralis major
2. Latissimus dorsi
3. Teres major
4. Subscapularis
Lateral pectoral
Thoracodorsal
Subscapular
Subscapular
Figure 5-40
•
Figure 5-41
122
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
TENDINITIS (SUPRASPINATUS)
CLINICAL DESCRIPTION
Supraspinatus tendinitis is a common inflammatory condition of the shoulder that causes anterior
shoulder pain. This inflammatory condition may be caused by trauma, overuse (especially overhead
movements), or faulty body mechanics during athletic activity, such as pitching or bowling.
Especially in abduction, the patient has painful passive range of motion and limited active range
of motion and is apprehensive while performing these movements. The painful arc is usually be­
tween 60° and 90° of abduction. During this range the greater tuberosity passes under the acromion
and the coracoacromial ligament. Pain and anterior spasm of the shoulder may indicate a moder­
ately inflamed swollen tendon. If the irritation of the tendon continues, calcific deposits may de­
velop and lead to calcific tendinitis.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
Anterolateral shoulder pain
Pain sleeping on the affected side
Stiffness
Catching of the shoulder during use
Pain on active and passive range of motion
Local tenderness
Supraspinatus Tendinitis Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient seated, instruct him to abduct the arm to 90° with the arm between abduction and
forward flexion. Instruct the patient to abduct the arm against resistance (Fig. 5-42).
RATIONALE
Resisting shoulder abduction stresses mainly the deltoid muscle and the supraspinatus muscle and
tendon. Pain and/or weakness over the insertion of the supraspinatus tendon may indicate degen­
erative tendinitis or a tear of the supraspinatus tendon. Pain over the deltoid muscle may indicate a
strained deltoid muscle.
Figure 5-42
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
l23
Sensitivity/Reliability Scale
Apley Scratch Test (3)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the seated patient to place the hand on the side of the affected shoulder behind the head and
touch the opposite superior angle of the scapula (Fig. 5-43). Then instruct the patient to place the
hand behind the back and attempt to touch the opposite inferior angle of the scapula (Fig. 5-44).
RATIONALE
Actively attempting to touch the opposite superior and inferior aspect of the scapula places stress on
the tendons of the rotator cuff. Exacerbation of the patient's pain indicates degenerative tendinitis
of one of the tendons of the rotator cuff, usually the supraspinatus tendon.
•
Figure 5-44
Figure 5-43
Hawkins-Kennedy Impingement Test (4)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient standing, flex the shoulder forward to 90°, then force the shoulder in an internal
rotation without resistance by the patient (Fig. 5-45).
RATIONALE
This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial
ligament. Local pain indicates supraspinatus tendinitis.
Figure 5-45
124
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Neer Impingement Sign (5)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, grasp the patient's wrist and passively move the shoulder through forward
flexion (Fig. 5-46).
RATIONALE
Moving the shoulder through forward flexion jams the greater tuberosity of the humerus against the
anterior inferior border of the acromion. Shoulder pain and a look of apprehension on the patient's
face indicate a positive sign. This indicates an overuse injury to the supraspinatus muscle or some­
times to the biceps tendon.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Ultrasonography
Magnetic resonance imaging
Figure 5-46
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
125
TENDINITIS (BICIPITAL)
CLINICAL DESCRIPTION
The biceps brachii has two heads, the long and the short. The long head originates from the supe­
rior lip of the glenoid fossa, proceeds laterally, and angles 90° at the bicipital groove on the superior
aspect of the humeral head. It is the affected tendon in bicipital tendinitis (Fig. 5-47). Bicipital ten­
dinitis is a chronic condition of shoulder pain with tenderness over the bicipital groove (see Fig.
5-51). Most cases are associated with lesions such as synovitis of the surrounding capsule, adhesive
capsulitis, osteophytes in the area of the bicipital groove, or rotator cuff tears. True isolated bicipital
tendinitis allows a full free range of passive movement.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
Anterior shoulder pain
Pain on palpation of the bicipital groove
Pain on active and passive elbow flexion and extension
Long head of
bicep s brachii
tendon m
groove of
humeral head
Figure 5-47
126
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Speed's Test (3,6)
Sensitivity/Reliability Scale
I
a
PROCEDURE
I
1
I
2
I
3
I
With the patient's elbow completely extended, supinated, and the shoulder flexed forward to 45°,
place your fingers on the bicipital groove and your opposite hand on the patient's wrist (Fig. 5-48).
Instruct the patient to elevate the arm forward against your resistance (Fig. 5-49).
RATIONALE
This test stresses the biceps tendon in the bicipital groove. Pain or tenderness in the bicipital groove
indicates bicipital tendinitis.
Figure 5-48
Figure 5-49
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
Lippman's Test (6)
127
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the sitting patient to flex the elbow to 90°. Stabilize the elbow with one hand, and with your
other hand palpate the biceps tendon and move it from side to side in the bicipital groove (Fig. 5-50).
RATIONALE
Moving the biceps tendon manually in the bicipital groove stresses the tendon and transverse
humeral ligament. Pain indicates bicipital tendinitis. Apprehension may indicate a propensity for
subluxation or dislocation of the biceps tendon out of the bicipital groove or a ruptured transverse
humeral ligament (Fig. 5-51).
II
Figure 5-50
Figure 5-51
128
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Gilchrest's Sign (7)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
Instruct the standing patient to grasp a 5- to 7-lb weight and lift it overhead (Fig. 5-52). Next, instruct
the patient to rotate the shoulder externally and the lower the arm slowly to the side (Fig. 5-53).
RATIONALE
This test is similar to the Abbott-Saunders test, but it is not passive, and it requires the use of a
weight. Abduction and external rotation of the shoulder stress the biceps tendon against the trans­
verse humeral ligament. Pain and/or discomfort in the bicipital groove indicates bicipital tendinitis.
An audible snap may indicate a subluxation or dislocation of the biceps tendon out of the bicipital
groove, which may be due to a lax or ruptured transverse humeral ligament or a congenitally shal­
low bicipital groove.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Ultrasonography
Magnetic resonance imaging
Figure 5-52
Figure 5-53
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
129
BURSITIS
CLINICAL DESCRIPTION
The subacromial bursa overlies the rotator cuff tendons and is continuous with the subdeltoid bursa
(see Fig. 5-55). Isolated subacromial or subdeltoid bursitis is rare. Usually the bursitis is associated
with tendinitis of the adjacent supraspinatus tendon. Anatomically the inner synovial wall of the
subdeltoid bursa is the outer wall of the supraspinatus tendon, so if there is inflammation in one of
those structures, there is inflammation of the other. Some of the most common causes of bursitis
are trauma, overuse, repeated multiple minor traumas, and improper executed activity.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
II
Anterolateral shoulder pain
Pain sleeping on the affected side
Stiffness
"Catching" of the shoulder during use
Pain on active and passive range of motion
Local tenderness
Subacromial Push-Button Sign
Sensitivity/Reliability Scale
I
o
PROCEDURE
With the patient seated, apply pressure to the subacromial bursa (Fig. 5-54).
Figure 5-54
I
1
I
2
I
3
I
4
130
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
RATIONALE
Pressure to the subacromial bursa will irritate an already inflamed bursa. Local pain suggests in­
flammation of the subacromial bursa or bursitis (Fig. 5-55).
Subacromial bursa
Acromion
Deltoid
muscle
Figure 5-55
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
Dawbarn's Test (6)
131
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, apply pressure just below the acromion process on the side being tested.
Note any pain or tenderness (Fig. 5-56). Then, abduct the patient's arm past 90°, maintaining pres­
sure on the spot below the acromion (Fig. 5-57).
RATIONALE
The spot below the acromion is the palpable portion of the subacromial bursa. Pain and/or tender­
ness at that location may indicate inflammation of the bursa or bursitis. When the arm is abducted,
the deltoid muscle will cover that spot below the acromion. Covering that spot reduces pressure on
the bursa, decreasing the tenderness if the bursa is inflamed. A decrease in the tenderness to that
point indicates subacromial bursitis (Fig. 5-58).
Figure 5-57
Figure 5-56
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Ultrasonography
Magnetic resonance imaging
Figure 5-58
View from above
Subdeltoid
bursa
•
132
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
ANTERIOR GLENOHUMERAL INSTABILITY
CLINICAL DESCRIPTION
Anterior shoulder instability is the major cause of shoulder dislocations. This is attributed to
anatomic weakness on the anterior structures of the glenohumeral joint: the anterior capsule, gleno­
humeral ligaments, rotator cuff tendons, and glenoid labrum. There are three types of anterior dis­
locations, based on the direction of dislocation: subclavicular, subcoracoid and subglenoid. The sub­
coracoid is the most common. The most common cause of shoulder dislocation is a fall on an
outstretched arm.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Painful arc (if dislocated)
Feeling of shoulder slippage
Apprehension on movement
Crepitus on movement
Increased shoulder girth (if dislocated)
Anterior Drawer Test (8)
Sensitivity/Reliability Scale
I
a
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, place his or her hand in your axilla. With your opposite hand, grasp the
posterior scapula with your fingers and place your thumb over the coracoid process (Fig. 5-59). Us­
ing the arm that is holding the patient's hand, grasp the posterior aspect of the patient's arm and
draw the humerus forward (Fig. 5-60).
RATIONALE
Attempting to move the humerus forward while stabilizing the scapula tests the integrity of the an­
terior portion of the rotator cuff, which holds the humerus into the glenoid cavity. A click and/or an
abnormal amount of movement compared with the normal side indicates anterior instability of the
glenohumeral joint.
Figure 5-59
Figure 5-60
CHAPTER 5
Anterior Apprehension Test (3)
SHOULDER ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
133
I
I
1
I
2
I
3
I
I
Stand behind the seated patient. Abduct the affected arm to 90° and externally rotate it slowly while
stabilizing the posterior aspect of the shoulder with the opposite hand (Fig. 5-61).
RATIONALE
Local pain indicates a chronic anterior shoulder dislocation. This test is called apprehension because
it is intended to elicit a look of apprehension on the patient's face. The patient may also state that
the test feels the same as when the shoulder was dislocated.
External rotation of the arm predisposes the humerus to dislocate anteriorly. This test forces external rotation to dislocate the humerus anteriorly from the glenoid fossa. If the rotator cuff musdes, joint capsule, and glenoid fossa are sound, the patient should have no pain or apprehension
when this test is performed. It tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.
Figure 5-61
II
134
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Prone Anterior Instability Test (9)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient prone, grasp the patient's forearm, abduct the arm to 90°, with the elbow flexed to
90° (Fig.5-62). Place your other hand over the humeral head and push it forward (Fig. 5-63).
RATIONALE
This is an attempt to dislocate the head of the humerus anteriorly. Anterior shoulder pain or a re­
production of the patient's symptoms indicate a positive test. This procedure tests the integrity of
the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.
Figure 5-62
Figure 5-63
CHAPTER 5
Andrews Anterior Instability Test (9)
PROCEDURE
135
SHOULDER ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
With the patient supine, grasp the patient's distal humerus, abduct the shoulder to 130°, and exter­
nally rotate it to 90° (Fig. 5-64). With your opposite hand grasp the humeral head from the poste­
rior and push it anterior (Fig. 5-65).
RATIONALE
This is an attempt to dislocate the head of the humerus anteriorly. Anterior shoulder pain or a re­
production of the patient's symptoms indicate a positive test. This procedure tests the integrity of
the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum. If a
labral tear is present, a clunk may be heard.
Figure 5-64
Figure 5-65
•
136
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Rockwood Test (10)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
This test is a variation of the anterior apprehension test. With the patient seated, externally rotate
the shoulder with the arm in the neutral position (Fig. 5-66). Repeat the test with the arm at 45° of
abduction (Fig. 5-67), then at 90° of abduction (Fig. 5-68), then at 120° of abduction (Fig. 5-69).
RATIONALE
The patient must show marked apprehension at 90° with pain. At 0° there is rarely any apprehen­
sion. At 45° and 120° there should be more pain with slight apprehension. The patient may say that
it felt the same as when the shoulder was previously dislocated. This procedure tests the integrity of
the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.
Figure 5-66
Figure 5-67
Figure 5-68
Figure 5-69
CHAPTER 5
Rowe Test for Anterior Instability (11)
Sensitivity/Reliability Scale
I
I
I
1
o
PROCEDURE
137
SHOULDER ORTHOPAEDIC TESTS
I
2
I
4
Instruct the seated patient to place the hand on the side of the affected shoulder behind the head.
Then, place your clenched fist against the posterior humeral head and push anteriorly, using your
opposite hand to extend the patient's arm (Fig. 5-70).
RATIONALE
The examiner is attempting to dislocate the patient's glenohumeral joint anteriorly. A look of ap­
prehension indicates a positive test. The patient may also may say that it felt the same as when the
shoulder was previously dislocated. This procedure tests the integrity of the inferior glenohumeral
ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.
Figure 5-70
Fulcrum Test (12)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine and the arm abducted to 90°, place your hand under the glenohumeral joint
and externally rotate the patient's arm over the hand (Fig. 5-71).
RATIONALE
This is an attempt to dislocate the head of the humerus anteriorly. A look of apprehension with pain
is a positive sign. The patient may say that it felt the same as when the shoulder was previously dis­
located. This procedure also tests the integrity of the inferior glenohumeral ligament, anterior cap­
sule, rotator cuff tendons, and glenoid labrum. A congenitally shallow glenoid fossa may also pre­
dispose the shoulder to dislocation.
Figure 5-71
•
138
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Dugas Test (13,14)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, instruct him or her to touch the opposite shoulder and bring the elbow to
the chest wall (Fig. 5-72).
RATIONALE
Inability to touch the opposite shoulder because of pain indicates an anterior dislocation of the
humeral head out of the glenoid cavity. This dislocation is usually caused by forced external rota­
tion when the arm is abducted. When the humerus is dislocated anteriorly, a characteristic sign is a
prominent acromion process.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Axillary shoulder radiograph
Tangential shoulder radiograph
Computed tomographic (CT) arthrography
Figure 5-72
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
139
POSTERIOR GLENOHUMERAL INSTABILITY
CLINICAL DESCRIPTION
Posterior glenohumeral dislocation is seen in only 5% to 10% of shoulder dislocations. In this type
of dislocation the head of the humerus dislocates posteriorly and is found behind the scapula. This
is usually caused by trauma to the anterior aspect of the shoulder that drives a forceful backward
movement of the humeral head. Instability of the rotator cuff and/or the posterior joint capsule may
predispose the joint to posterior dislocation.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Painful arc (if dislocated)
Feeling of shoulder slippage
Apprehension on movement
Crepitus on movement
Increased shoulder girth (if dislocated)
Posterior Apprehension Test (6)
•
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, forwardly flex and internally rotate his or her shoulder. With your hand,
apply posterior pressure on the elbow (Fig. 5-73).
RATIONALE
This test attempts to dislocate the shoulder posteriorly and stresses the rotator cuff and posterior
joint capsule. Local pain or discomfort and a look of apprehension on the patient's face indicates
chronic posterior shoulder instability. The patient may say that it felt the same as when the shoul­
der was previously dislocated. The mechanism of injury is commonly a position of forced adduc­
tion with internal rotation in some degree of elevation.
Figure 5-73
140
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Posterior Drawer Test (15)
Sensitivity/Reliability Scale
I
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
4
With the patient supine, grasp the patient's forearm, flex the patient's elbow, and abduct and flex the
shoulder. With your opposite hand, stabilize the scapula with your index and middle finger on the
spine of the scapula and your thumb on the coracoid process (Fig. 5-74). Rotate the forearm inter­
nally and flex the shoulder forward, taking the thumb of your other hand off the coracoid and forc­
ing the humerus posteriorly (Fig. 5-75).
RATIONALE
This is an attempt to dislocate the shoulder posteriorly, stressing the rotator cuff and joint capsule.
Local pain and a look of apprehension are the signs of a positive test. This test stresses the rotator
cuff and the posterior joint capsule.
Figure 5-74
Figure 5-75
Norwood Stress Test (16,17)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, instruct the patient to abduct the shoulder to 90°, externally rotate it to 90°,
and flex the elbow to 90°. With one hand, stabilize the scapula while palpating the posterior aspect
of the humeral head (Fig. 5-76). With your opposite hand, grasp the elbow, bringing the shoulder
into forward flexion and forcing the elbow posteriorly (Fig. 5-77).
RATIONALE
This test is an attempt to dislocate the shoulder posteriorly, stressing the rotator cuff and the poste­
rior joint capsule. A positive test is indicated by the humeral head slipping posteriorly out of the
glenoid fossa. When the arm is returned to the starting position, the humeral head should reduce.
A clicking sound may accompany the reduction.
Figure 5-76
Figure 5-77
CHAPTER 5
141
SHOULDER ORTHOPAEDIC TESTS
Push-Pull Test (12)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, grasp the patient's wrist and abduct the arm to 90° and forward flex it to
30° forward (Fig. 5-78). With your opposite hand, grasp the arm near the humeral head, pull up on
the wrist, and push down on the arm (Fig. 5-79).
RATIONALE
In the normal patient, up to 50% of translation is considered a negative test. More than 50% trans­
lation and a look of apprehension indicate a positive test. This test is also an attempt to dislocate the
shoulder posteriorly. It stresses the rotator cuff and posterior joint capsule.
•
SUGGESTED DIAGNOSTIC iMAGING
•
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Axillary shoulder radiograph
Tangential shoulder radiograph
CT arthrography
-­
Figure 5-78
Figure 5-79
142
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
MULTIDIRECTIONAL SHOULDER INSTABILITY
CLINICAL DESCRIPTION
Multidirectional shoulder instability is a combination of anterior and posterior shoulder instability.
The following tests are attempts to dislocate the shoulder in multiple directions. The different in­
stabilities are described in the sections on the anterior and posterior shoulder instabilities.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Painful arc (if dislocated)
Feeling of shoulder slippage
Apprehension on movement
Crepitus on movement
Increased shoulder girth (if dislocated)
Feagin Test (10)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient standing, instruct the patient to abduct the arm and place the hand on your shoul­
der (Fig. 5-80). With both hands, grasp the patient's humerus next to the humeral head and exert
downward and forward pressure (Fig. 5-8 1).
RATIONALE
A look of apprehension on the patient's face signifies a positive test. This indicates an anterior infe­
rior shoulder instability. This test is an attempt to dislocate the shoulder anteriorly and inferiorly. It
tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and
glenoid labrum.
Figure 5-80
Figure 5-81
CHAP TER 5
143
SHOULDER ORTHOPAEDIC TESTS
Rowe Test for Multidirectional Instability (11)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
To test for inferior instability, have the patient stand bending forward 45°. Grasp the shoulder with
the index and middle finger over the posterior humeral head and the thumb at the anterior humeral
head. With your opposite hand, grasp the patient's elbow and pull down on the arm (Fig. 5-82). To
test for anterior instability, push the humeral head forward from behind with your thumb and ex­
tend the patient's arm 20° to 30° (Fig. 5-83). To test for posterior instability, push the humeral head
posteriorly from the anterior with your index and middle fingers with the patient's shoulder flexed
20° to 30° (Fig. 5-84).
RATIONALE
This test is an attempt to dislocate the humeral head out of the glenoid fossa in various directions.
A look of apprehension and/or local discomfort on the patient's face is a positive sign. This test
stresses the glenohumeral ligament, rotator cuff tendons, and the joint capsule.
Figure 5-82
Figure 5-83
Figure 5-84
•
144
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sulcus Sign (18)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, instruct the patient to flex the elbow to 90° with the shoulder in the neutral
position for rotation (Fig. 5-85). Grasp the patient's wrist with one hand, pressing down on the fore­
arm with the other hand (Fig. 5-86).
RATIONALE
Pressing down on the forearm with the patient's shoulder in the neutral position is an attempt to
dislocate the shoulder inferiorly. A sulcus at the anterolateral aspect of the shoulder indicates an in­
ferior shoulder instability. The sulcus is graded according to its size. A + 1 sulcus indicates less than
l cm. A + 2 sulcus indicates 1 to 2 cm. A +3 sulcus indicates more than 2 cm.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Axillary shoulder radiograph
Tangential shoulder radiograph
CT arthrography
Figure 5-85
Figure 5-86
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
145
LABRAL TEARS
CLINICAL DESCRIPTION
The edge of the glenoid fossa is surrounded by a fibrocartilage rim called the glenoid labrum. The
superior portion of the labrum blends with the tendon of the long head of the biceps muscle (Fig.
5-87). This fibrocartilage rim adds depth to the glenoid fossa and helps to hold the humerus in
place. Tearing of any part of the labrum predisposes dislocation of the humerus out of the glenoid
cavity in the direction of the tear. These tears are relatively common to throwing athletes.
Glenoid fossa
Biceps brachii
tendon
(long head)
Head of
humerus
Glenoid
labrum
Biceps brachii muscle
Figure 5-87
II
146
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Clunk Test (6)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine the examiner places one hand over the posterior aspect of the humeral head.
With the opposite hand the examiner grasps the elbow and fully abducts the shoulder (Fig. 5-88).
The examiner then pushes anteriorly with the hand over the humeral head and externally rotates the
shoulder with the opposite hand (Fig. 5-89).
RATIONALE
Anterior pressure to the humeral head with external rotation of the shoulder attempts to dislocate
the shoulder anteriorly. A clunk or grinding sound indicates a positive test which suggests an ante­
rior tear of the glenoid labrum.
Figure 5-88
Figure 5-89
CHAPTER 5
147
SHOULDER ORTHOPAEDIC TESTS
Anterior Slide Test (18,19)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, instruct the patient to place the hands on the waist with the thumbs poste­
rior (Fig. 5-90). With one hand, stabilize the scapula and clavicle. With the opposite hand, grasp the
humerus and place anterior superior force to the shoulder (Fig. 5-9 1 ).
RATIONALE
Anterior and superior force to the shoulder may dislocate the shoulder anteriorly and superiorly. If
a pop or crack is noted and the patient complains of pain to the anterosuperior aspect of the shoul­
der, this indicates a superior or anterior tear of the glenoid labrum.
II
Figure 5-90
Figure 5-91
148
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
ROTATOR CUFF INSTABILITY
CLINICAL DESCRIPTION
Rotator cuff instability involves partial or complete tearing of one of the tendons of the rotator cuff.
Usually the supraspinatus tendon is involved, but it may involve the adjacent subscapularis or in­
fraspinatus tendon. Incomplete tears in younger adults are usually due to microtrauma. In older
adults, diminishing blood supply may cause the tendons to become frail and tear. Complete tears are
usually due to sudden severe strain caused by a fall or overexertion. Incomplete tears usually clini­
cally resemble supraspinatus tendinitis. In complete tears the patient cannot abduct the arm, and
any attempt to do so is followed by severe pain.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
•
Severe anterior lateral shoulder pain
Pain when sleeping on the affected side
Stiffness
"Catching" of the shoulder during use
Pain on active and passive range of motion
Localized tenderness
Unable to abduct shoulder
Drop Arm Test (2)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, abduct the arm past 90° (Fig. 5-92). Instruct the patient to lower the arm
slowly (Fig. 5-93).
RATIONALE
If the patient cannot lower the arm slowly or if it drops suddenly, this indicates a rotator cuff tear,
usually of the supraspinatus. The supraspinatus muscle acts as an abductor of the arm and holds the
head of the humerus in place. A tear of the supraspinatus tendon causes unsteadiness of the
humerus in abduction, causing it to drop suddenly.
Figure 5-92
Figure 5-93
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
Supraspinatus Test (20)
149
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
With the patient either sitting or standing, instruct the patient to abduct the shoulder to 90°. Grasp
the patient's arm and press down against resistance by the patient (Fig. 5-94). Next, instruct the pa­
tient to rotate the shoulders internally so that the thumb faces downward. Again, press down on the
arm against resistance by the patient (Fig. 5-95).
RATIONALE
Resistance to abduction stresses the supraspinatus muscle and tendon. Weakness or pain may indi­
cate a tear of the supraspinatus muscle or tendon. Weakness may also indicate suprascapular neu­
ropathy.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Axillary shoulder radiograph
CT arthrography
Magnetic resonance imaging (MRI)
Figure 5-94
Figure 5-95
II
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
150
BICEPS TENDON INSTABILITY
CLINICAL DESCRIPTION
The biceps brachii has two heads: long and short. The long head originates from the superior lip of
the glenoid fossa and proceeds laterally and angles 90° at the bicipital groove. It is held in the bicip­
ital groove by the transverse humeral ligament (see Fig. 5-98). A shallow bicipital groove or lax or
ruptured transverse humeral ligament may snap the biceps tendon into and out of the bicipital
groove, causing anterior shoulder pain with point tenderness at the bicipital groove. This painful
snap may also indicate a tear of the biceps tendon. A bicipital tendon tear is followed by swelling and
ecchymosis near the bicipital groove and a characteristic bulging of the belly of the biceps muscle
near the antecubital fossa (Popeye sign).
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Anterior shoulder pain
Stiffness
Pain on active and passive range of motion
Localized tenderness
Bulging of bicep muscle (complete tear)
Yergason's Test (21)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated and the elbow flexed to 90°, stabilize the patient's elbow with one hand (Fig.
5-96). With your opposite hand, grasp the patient's wrist and have the patient externally rotate the
shoulder and supinate the forearm against your resistance (Fig. 5-97).
Figure 5-96
Figure 5-97
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
151
RATIONALE
Resisted supination of the forearm and external rotation of the shoulder stress the bicipital tendon
and the transverse humeral ligament. Local pain and/or tenderness in the bicipital tendon indicates
an inflammation of the biceps tendon or tendinitis. If the tendon pops out of the bicipital groove,
suspect a lax or ruptured transverse humeral ligament or a congenital shallow bicipital groove caus­
ing the tendon to subluxate (Fig. 5-98).
groove
Transverse
humeral--+-f+,m
ligament
Biceps --+--'
tendon
Biceps ---,rn-r"r , ,
brachii
muscle
Figure 5-98
1.1
152
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Abbott-Saunders Test (22)
Sensitivity/Reliability Scale
I
I
a
PROCEDURE
I
,
I
2
I
3
4
With the patient seated, abduct and maximally rotate the patient's arm externally (Fig. 5-99), then
lower the arm to the patient's side while palpating the bicipital groove with your opposite hand (Fig.
5-100).
RATIONALE
Abduction and external rotation of the shoulder stress the biceps tendon against the transverse
humeral ligament. A palpable or audible click at the bicipital groove indicates a subluxation or dis­
location of the biceps tendon out of the groove caused by a lax or ruptured transverse humeral lig­
ament or congenitally shallow bicipital groove.
Figure 5-99
Figure 5-100
Ludington's Test (6)
Sensitivity/Reliability Scale
I
a
PROCEDURE
I
I
,
I
I
2
I
I
3
I
I
4
Instruct the patient to clasp both hands on top of the head, interlocking the fingers, (Fig. 5- 10 1) and
alternately contract and relax the biceps muscle while you palpate the biceps tendon (Fig. 5- 1 02).
RATIONALE
Placing the hands on the head supports the upper limb and allows relaxation of the biceps muscle.
If the biceps tendon on the affected side is not contracting and palpable, suspect a rupture of the
long head of the biceps tendon.
Figure 5-101
Figure 5-102
CHAPTER 5
1 53
SHOULDER ORTHOPAEDIC TESTS
Transverse Humeral Ligament Test (6)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
I
2
I
3
I
4
With the patient seated, grasp the patient's wrist. Abduct the shoulder to 90° and internally rotate it
with one hand. With your opposite hand, palpate the bicipital groove (Fig. 5-103). Then externally
rotate the shoulder (Fig. 5- 1 04).
II
Figure 5-103
Figure 5-104
154
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
RATIONALE
External rotation of the shoulder moves the biceps tendon in the bicipital groove. If you feel the
bicipital tendon snap in and out of the bicipital groove, suspect a torn or lax transverse humeral lig­
ament or shallow bicipital groove (Fig. 5-105).
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Anteroposterior shoulder radiographs
Neutral position
Internal rotation
External rotation
Axillary
CT arthrography
MRI
Figure 5-105
CHAPTER 5
1 55
SHOULDER ORTHOPAEDIC TESTS
THORACIC OUTLET SYNDROME
CLINICAL DESCRIPTION
Thoracic outlet syndrome is a group of signs and symptoms that result from compression of the
subclavian vessels and brachial plexus at the superior aperture of the thorax. It may be caused by
trauma, repetitive motions, overuse, and some systemic diseases, such as diabetes and thyroid dis­
ease. Patients may complain of neck and shoulder pain with numbness and tingling affecting the en­
tire upper extremity. The ulnar side of the limb is predominantly involved. Using the affected ex­
tremity in an overhead or elevated position is difficult.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
•
II
Upper extremity pain
Upper extremity paresthesias
Grip weakness
Upper extremity edema
Upper extremity coldness
Excessive dryness of arm or hand
Excessive sweating of arm or hand
Adson's Test (23-25)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, establish the amplitude of the radial pulse (Fig. 5- 1 06). Compare the am­
plitude bilaterally. Instruct the patient to take a deep breath and sustain it while he or she rotates the
head and elevates the chin to the side being tested (Fig. 5-107). If the test is negative, have the pa­
tient rotate and elevate the chin to the opposite side (Fig. 5- 108).
Figure 5-1 06
Figure 5-107
Figure 5-108
156
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
RATIONALE
Rotation and extension of the head compress the subclavian artery and brachial plexus. A decrease
or absence of the amplitude of the radial pulse indicates a compression of the vascular component
of the neurovascular bundle (subclavian artery) by a spastic or hypertrophied scalenus anterior
muscle, on a cervical rib, or a mass, such as a Pancoast tumor. Paresthesias or radiculopathy in the
upper extremity indicates compression of the neural component of the neurovascular bundle
(brachial plexus) (Fig. 5-109).
Scalenus middle
muscle
Axillary
artery
Figure 5-109
CHAPTER 5
157
SHOULDER ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
Costoclavicular Test (26-28)
I
o
I
1
I
2
I
3
I
4
PROCEDURE
With the patient seated, establish a radial pulse (Fig. 5-110). Instruct the patient to force the shoul­
ders posteriorly and have the patient flex the chin to the chest (Fig. 5-111).
RATIONALE
Forcing the shoulders posteriorly decreases the space between the clavicle and first rib. The neu­
rovascular bundle (brachial plexus, axillary artery) and the axillary vein run through a narrow cleft
beneath the clavicle and on top of the first rib.
Decrease or absence of the amplitude of the radial pulse indicates a compression to the vascu­
lar component of the neurovascular bundle. This compression is caused by a decrease in the space
between the clavicle and the first rib. This decrease may be caused by a recent or healed fracture to
the clavicle or first rib with or without callus formation, dislocation of the medial aspect of the clav­
icle, or a spastic or hypertrophied subclavius muscle. Paresthesias or radiculopathy in the upper ex­
tremity indicates compression to the brachial plexus or compression of the axillary vein (Fig. 5- 1 12).
Compression of the brachial plexus is usually localized to a nerve root or peripheral nerve distribu­
tion. Compression of the axillary vein typically presents as diffuse radicular vascular discomfort not
localized to a nerve root or peripheral nerve distribution.
Figure 5-1 1 0
Figure 5-112
Figure 5-111
•
1 58
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Wright's Test (29, 30)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, establish the character of the radial pulse (Fig. 5-1 13). Hyperabduct the arm
and take the pulse again (Fig. 5-114).
RATIONALE
The axillary artery, vein, and three cords of the brachial plexus pass under the pectoralis minor mus­
cle on the coracoid process. Abduction of the arm to 1800 stretches these structures around the ten­
don of the pectoralis minor muscle and the coracoid process. Decrease or absence of the amplitude
of the radial pulse indicates compression of the axillary artery either by a spastic or hypertrophied
pectoralis minor muscle or by a deformed or hypertrophied coracoid process (Fig. 5-115).
Figure 5-11 3
Figure 5-114
Figure 5-11 5
CHAPTER 5
Traction Test (31 )
SHOULDER ORTHOPAEDIC TESTS
1 59
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, establish a radial pulse (Fig. 5-116) . While maintaining the pulse, extend
and apply traction to the arm (Fig. 5-1l7).
RATIONALE
Traction and extension of the arm pulls the subclavian artery over the first rib. A decreased or oblit­
erated pulse is not diagnostic; however, when the test is repeated on the opposite side and reveals no
change, the test indicates a subluxated or malpositioned first rib or a cervical rib on the side of the
decreased or obliterated pulse.
II
Figure 5-116
Figure 5-1 1 7
160
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Halstead Maneuver (6)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient seated, find the radial pulse and note the amplitude (Fig. 5-118). With your oppo­
site hand, pull on the patient's arm and ask the patient to hyperextend the neck (Fig. 5-119). Repeat
the test on opposite arm.
RATIONALE
Traction pressure on the arm pulls the neurovascular bundle (brachial plexus and axillary artery)
over the first rib. Extension of the neck tightens the scalene muscles. A decreased or obliterated pulse
amplitude indicates a cervical rib, subluxation, or malposition of the first rib. An upper extremity
radicular component indicates compression of the brachial plexus by the scalenus anterior muscle
(See Fig. 5-109).
SUGGESTED DIAGNOSTIC IMAGING
•
•
Plain film radiography
Posteroanterior chest ( if apical mass is suspect)
Apical lordotic view
Electrodiagnostic study
Figure 5-118
Figure 5-119
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
161
BRACHIAL PLEXUS IRRITATION
CLINICAL DESCRIPTION
Irritation of the brachial plexus may be due to various factors, such as a cervical rib, severe upper
traction of the arm, fractured clavicle, or pulmonary apical mass. Any of these irritations may cause
upper extremity radicular symptoms. Most of the following tests are upper limb tension signs that
are equivalent to the straight leg raising test for lumbar radiculopathy. These tests are attempts to
stress the neurological structures in the upper limb to determine neurological irritation; they stress
all of the structures in the upper extremities but are used here for reproduction of the neurological
signs reported by the patient.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
II
Upper extremity radicular pain
Upper extremity paresthesias
Grip weakness
Brachial Plexus Stretch Test
Sensitivity/Reliability Scale
I
a
PROCEDURE
I
I
,
I
I
2
I
I
3
I
I
4
With the patient seated, instruct the patient to laterally flex the head opposite the affected side and
extend the shoulder and elbow (Fig. 5- 120).
RATIONALE
This test is similar to a straight leg raising test for the upper extremity. This test stretches the brachial
plexus opposite the side of lateral head flexion. Any damage to the plexus will cause pain and/or
paresthesia along the distribution of the brachial plexus. Pain and paresthesia on the side of lateral
bending may indicate a nerve root problem. Local cervical pain on the side of lateral bending may in­
dicate a cervical facet joint problem because the facets are compressed on the side of lateral bending.
Figure 5-120
1 62
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Bikele's Sign (32)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
With the patient seated, instruct him or her to abduct the shoulder to 90° and extend it as far as pos­
sible with the elbow fully flexed (Fig. 5-12 1 ). Instruct the patient to extend the elbow fully (Fig. 5-122).
RATIONALE
Abduction and extension of the shoulder place a motion-induced distraction on the brachial plexus.
Adding the motion of elbow extension produces maximum distraction of the brachial plexus. If this
movement is met with resistance and/or increases radicular pain to the upper extremity, this may
indicate brachial plexus neuritis, nerve root irritation, or meningeal irritation of the covering of the
cervical nerve roots.
Figure 5-121
Figure 5-122
CHAPTER 5
Brachial Plexus Tension Test (32)
SHOULDER ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
163
I
,
I
2
I
3
I
With the patient seated and the arms in the neutral position, grasp the patient's arms and passively
abduct it to the end point of joint play or to the point of pain (Fig. 5- 123). Tell the patient to rotate
the arms externally and maintain that position while you support the arm (Fig. 5-124). Finally, in­
struct the patient to flex the elbows so that the hand is behind the patient's head (Fig. 5-125).
RATIONALE
Abduction and external rotation of the shoulder with elbow flexion provide maximum stretch to the
brachial plexus and the C8 to T l nerve roots. Reproduction of the patient's symptoms suggests
brachial plexus irritation. If the irritation is at the level of the nerve roots, radicular symptoms may
also be reproduced.
Figure 5-123
Figure 5-124
Figure 5-125
�
�
1 64
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Tinnel's Sign (for Brachial Plexus Lesions) (33)
Sensitivity/Reliability Scale
I
a
PROCEDURE
I
1
I I I
2
3
I
4
With the patient seated and the head laterally flexed, tap along the trunks of the brachial plexus with
your index finger (Fig. 5-126).
RATIONALE
Local pain may indicate a cervical plexus lesion. A tingling sensation in the distribution of one of
the trunks may indicate compression or neuroma of one or more of the trunks of the brachial
plexus.
SUGGESTED DIAGNOSTIC TESTS
•
Electrodiagnostic studies
Figure 5-126
CHAPTER 5
SHOULDER ORTHOPAEDIC TESTS
165
20. Jobe FW, Moynes DR. Delineation of diagnos­
References
1 . American Academy of Orthopaedic Surgeons.
The Clinical Measurement of Joint Motion.
Chicago: American Academy of Orthopaedic
Surgeons, 1 995.
2. Boons DC, Azen SP. Normal range of motion of
joints in male subjects. J Bone Joint Surg Am
tic criteria and rehabilitation program for rota­
tor cuff injuries. Am J Sports Med 1 982; 1 0 :
3336-3339.
2 1 . Yergason RM. Supination sign. J Bone Joint
Surg 1 93 1 ; 1 3: 1 60.
22. Abbott LC, Saunders lB. Acute traumatic dislo­
cation of tendon of long head of biceps brachii:
1 979;61 :756-759.
3. Hoppenfeld S. Physical Examination of the
report of cases with operative findings. Surgery
Spine and Extremities. New York: Appleton­
Century-Crofts, 1 976; 1 27.
23. Adson AW. Cervical ribs: symptoms, differential
diagnosis and indications for section of the in­
4. Hawkins Rj, Kennedy Je. Impingement syn­
drome in athletics. Am J Sports Med 1 980;
8: 1 5 1- 1 63.
5. Neer CS, Welsh RP. The shoulder in sports. Or­
thop Clin North Am 1 977;8: 583-59 1 .
6 . MaGee DJ. Orthopedic Physical Assessment.
2nd ed. Philadelphia: WB Saunders, 1 992.
7. Post M. Physical Examination of the Muscu­
loskeletal System. Chicago: Year Book, 1 987.
8. Gerber C, Maitland GD. Practical Orthopedic
Medicine. London: Butterworths, 1 969.
9. Andrews JA, Timmerman LA, Wilks KE. Athletic
Inj uries of the Shoulder. New York: McGraw­
Hill, 1 995.
10. Rockwood CA. Subluxations and dislocations
about the shoulder. In: Rockwood CA, Green
DP, eds. Fractures in adults- I . Philadelphia: J B
Lippincott, 1 985.
1 1 . Rowe CR. Dislocations of the shoulder. In:
Rowe CR, ed. The Shoulder. Vol 1. Edinburgh:
Churchill Livingstone, 1 988.
1 2. Matsen FA, Thomas SC, Rockwood CA. Gleno­
humeral instability. In: Rockwood CA, Matsen FA,
eds. The Shoulder. Philadelphia: WB Saunders,
1 990.
1 3 . Jahn WT. Standardization of orthopaedic test­
ing of the upper extremity. J Manip Physiol
Ther 1 98 1 ;4(2).
14. Stimson BBA. A Manual of Fractures and Dislo­
cations. 2nd ed. Philadelphia: Lea & Febiger,
1 946.
1 5 . Gerber C, Ganz R. Clinical assessment of insta­
bility of the shoulder. J Bone Joint Surg
1 984;66B:55 1-556.
16. Norwood LA, Terry Ge. Shoulder posterior and
subluxation. An1 J Sports Med 1 984; 1 2:25-30.
17. Cofield RH, Irving JE Evaluation and classifica­
tion
of shoulder
instability.
Clin
Orthop
1 987;223: 32-43.
18. Kibler WB. Clinical Examination of the Shoul­
der. In Pettrone A, ed. Atl1letic Injuries of the
Shoulder. New York: McGraw-Hill, 1 995.
19. Kibler WB. Specificity and sensitivity of the an­
terior slide test in throwing athletes with supe­
rior glenoid labral tears. Arthroscopy 1 995; 1 1 :
296-300.
1 939;6:8 1 7-840.
sertion of the scalenus anticus muscle. J Coli Int
Surg 1 95 1 ; 1 06:546.
24. Adson AW, Coffey JR. Cervical rib. Ann Surg
1 927;85:839-857.
25. Lord JR, Rosati LM, eds. Thoracic-Outlet Syn­
dromes. New Jersey, ClBA Pharmaceutical,
1 97 1 ;2 1 ( 2 ) :9- 1 0 .
2 6 . Falconer MA, Li FWP. Resection of first rib i n
costoclavicular compression of the brachial
plexus. Lancet 1 962;59( 1 ):63.
27. Falconer MA, Weddel G . Costoclavicular com­
pression of the subclavian artery and vein: rela­
tion to scalene anticus syndrome.
1 943;2:542.
Lancet
28. Devay AD. Costoclavicular compression
of
brachial plexus and subclavian vessels. Lancet
1 945;2 : 1 65 .
29. Wright JS. The neurovascular syndrome pro­
duced by hyperabduction of the arms. Am
Heart J 1 945;29( 1 ) .
30. Wright JS. Vascular diseases in clinical practice.
2nd ed. Chicago: Year Book, 1 952.
3 1 . McRae R. Clinical Orthopedic Examination.
New York: Churchill Livingstone, 1 976.
32. Evans Re. Illustrated Essentials i n Orthopedic
Physical Assessment. 2nd ed. St. Louis: Mosby
200 1 .
33. Landi A, Copeland S . Value o f the Tinel sign in
brachial plexus lesions. Ann Roy Coli Surg Eng
1 979;6 1 :470-47 1 .
General References
Cailliet R. Shoulder pain. Philadelphia: FA Davis,
1 966.
Cipriano J. Calcific tendinitis vs. chronic bursitis in
shoulder joint
pathology.
Today's
Chiropractic
1 986; 1 4 ( 4): 1 5- 1 6.
Cyriax J. Textbook of Orthopaedic Medicine. Vol. 1 .
Diagnosis o f Soft Tissue Lesions. London: Bailliere
Tindall, 1 982.
De Palma AF, Flannery GE Acute anterior disloca­
tions of the shoulder. J Sports Med Phys Fitness
1 973;1 :6- 1 5.
•
166
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROWGICAL TESTS
Kapandji IA. The Physiology of the Joints. Vol 1. Up­
per Limb. New York: Churchill Livingstone, 1 970.
Post M, Silver R, Singh M. Rotator cuff tear: diagno­
sis and treatment. Clin Orthop 1 983; 1 73:78.
Neviaser JS. Musculoskeletal disorders of the shoul­
Yocum LA. Assessing the shoulder: history, physical
der region causing cervicobrachial pain: differential
diagnosis and treatment. Surg Clin North Am
1 963;43: 1 703.
examination, differential diagnosis, special tests
used. Clin Sports Med 1983;2:28 1 .
------���--ELBOW ORTHOPAEDIC TESTS
ELBOW ORT HOPAEDIC EXAMINATION
168
FLOW CHART
LATERAL EPICONDYLITIS (TENNIS
ELBOW)
180
180
Cozen's Test
169
ELBOW PALPATION
169
Medial Aspect
MEDIAL EPICONDYLITIS (GOLFER'S
Medial Epicondyle and Attached
170
Tendons
ELBOW)
Ulnar Collateral Ligament
171
Lateral Epicondyle and Wrist Extensor
172
Tendons
Radial Collateral Ligament and Annular
173
Ligament
Olecranon Process and Bursa
175
Triceps Muscle
ELBOW R ANGE OF MOTION
Adduction Stress Test
185
Abduction Stress Test
187
174
SYNDROMES
185
188
T inel's Sign
188
189
Elbow Flexion Test
176
Cubital Fossa
LIGAMEN T OUS INST ABILIT Y
Wartenberg's Sign
176
Anterior Aspect
184
NEUROPATHYICOMPRESSION
174
Posterior Aspect
184
Golfer's Elbow Test
172
Lateral Aspect
Pinch Grip Test
190
191
177
177
Extension
Supination
Pronation
183
Kaplan's Sign
169
Ulnar Nerve
Flexion
182
Mill's Test
178
178
179
167
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
168
Elbow Orthopaedic Examination
�
History
Elbow pain
with history
of overuse
Elbow pain
with history
of trauma
Range of Motion
(active)
(passive)
Palpation
t+
Cozen's test
Mili's test
+(+)
Elbow pain
with no history
of overuse
Range of Motion
(active)
(passive)
+(+)
Range of Motion
(active)
(passive)
I
t+
Palpation
t +)
I
Radiology
+(+)
Traumatic
bursitis
fracture
+
I (- ,
r
-,
)
Golfer's elbow
test
I
+(+)
Medial
epicondylitis
I
+(+)
Neuritis/Neuroma
t
I
Adduction
stress test
Abduction
stress test
I
t+
Ligamentous
instability
-)
Nerve conduction
studies
Rheumatoid
arthritis
I (-)
(
t
Tinel's sign
Waterburg's sign
Elbow flexion test
Pinch grip test
+(+)
I
(
+(+)
+
Elbow pain
with radiation
to the hand
t
I
Radiology
Lateral
epicondylitis
I
I
I
I
CHAPTER 6
ELBOW ORTHOPAEDIC TESTS
169
ELBOW PALPATION
Medial Aspect
Ulnar Nerve
DESCRlPTIVE ANATOMY
The ulnar nerve is a branch of the medial cord of the brachial plexus. It passes in the groove between
the medial epicondyle and the olecranon fossa (Fig.
6-1).
PROCEDURE
With your index finger, palpate the groove between the medial epicondyle and the olecranon
process. Notice whether the nerve is tender to palpation or thickened (Fig.
6-2).
This can indicate
nerve compression or scar tissue on the nerve leading to paresthesia into the forearm and/or loss of
interosseous muscle strength.
Lateral cord
HWf��-==r-- Posterior cord
v-Jf-\\----"-=1:-:-=:::;- Medial cord
Humerus
Musculocutaneous
nerve
Fossa olecrani
Medial epicondyle
Radius --+-++HJI
Figure 6-'
Figure 6-2
}
.
Brachial
plexus
170
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Medial Epicondyle and Attached Tendons
DESCRIPTIVE ANATOMY
The medial epicondyle is a relatively large protuberance at the medial distal end of the humerus. At­
tached to the condyle are the wrist flexor and pronator group muscles. This group consists of the
pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. All of these muscles
originate from the medial epicondyle as a common tendon (Fig.
6-3).
PROCEDURE
With the elbow flexed to
90°, palpate the epicondyle and its tendons with your index finger; look for
6-4). This may indicate a strain of one or
tenderness, inflammation, and temperature elevation (Fig.
more of the previously mentioned tendons or an inflammation of the medial epicondyle caused by
various activities, such as golf or tennis.
--4--1--- Humerus
Medial
epicondyle
.�d:o--"'}�I--- Pronator teres m.
'\\\-'-t--+-- Flexor carpi radialis
-'lWl1--+--- Palmaris longus
�-+---- Flexor carpi ulnaris
Figure 6-3
Figure 6-4
CHAPTER 6
ELBOW ORTHOPAEDIC TESTS
17 1
Ulnar Collateral Ligament
DESCRIPTIVE ANATOMY
The ulnar collateral ligament attaches the medial epicondyle to the medial aspect of the ulna at the
trochanteric notch (Fig.
6-5) and stabilizes the humeroulnar articulation medially.
PROCEDURE
With your index finger, palpate the area of the ulnar collateral ligament (Fig.
6-6).
Ordinarily it is
not palpable. You should check for tenderness, which may indicate a sprain caused by forced valgus
stress.
Medial View
Vi.
-(1I--Humerus
Interosseous
membrane
Annular
ligament
Articular
capsule
Ulnar
collateral
ligament
Figure 6-5
Figure 6-6
172
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Lateral Aspect
Lateral Epicondyle and Wrist Extensor Tendons
DESCRlPTIVE ANATOMY
The lateral epicondyle is a relatively large protuberance at the lateral distal end of the humerus. At­
tached to the condyle is the common extensor tendon. From this tendon arise the carpi radialis bre­
vis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. The brachioradialis and
extensor carpi radialis longus and brevis are attached superior to the lateral epicondyle at the supra­
condylar ridge (Fig.
6-7).
PROCEDURE
With the patient's elbow flexed to
90°, palpate the lateral epicondyle and supracondylar ridge with
6-8). Note any tenderness, inflammation, and temperature ele­
your index and middle fingers (Fig.
vation at either location. These signs may indicate an inflammation of the lateral epicondyle (epi­
condylitis) or a strain of the extensor tendons of the wrist.
��-r-Lateral
epicondyle
Olecranon
process
Brachioradialis
Common --�--���
exterior
tendon
group
A..JWI.-E
-t--- xtensor carpi radialis longus
Extensor carpi radialis brevis
Extensor digitorum
DLJHiHtfljI/- E xtensor digiti minimi
Extensor carpi ulnaris
Figure 6-7
Figure 6-8
CHAPTER 6
ELBOW ORTHOPAEDIC TESTS
173
Radial Collateral Ligament and Annular Ligament
DESCRIPTIVE ANATOMY
Radial collateral ligament and annular ligaments are thick structures that extend from the lateral
epicondyle of the humerus to the annular ligament and lateral aspect of the ulnar. The annular lig­
ament encircles the radial head (Fig.
6-9). The radial collateral ligament stabilizes the humeroulnar
articulation laterally.
PROCEDURE
With your index and middle fingers, palpate the area of the radial collateral ligament from the lat­
eral epicondyle to the annular ligament (Fig.
6-10).
Check for tenderness, which may indicate a
sprain caused by forced varus stress.
Lateral view
Humerus
Annular
ligament
A rticular ..,..--h---::1'-:l-i
capsule
Radial collateral ligament
Figure 6-9
Figure 6-10
Ulnar collateral ligament
Interosseous
membrane
174
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Posterior Aspect
Olecranon Process and Bursa
DESCRIPTIVE ANATOMY
The olecranon process is posterior to the elbow at the proximal end of the ulnar. It is covered by the
olecranon bursa, which is not normally palpable (Fig.
6-11).
PROCEDURE
With the patient's elbow flexed to
90°, palpate the olecranon process and bursa for tenderness, in­
6-12). A thick, boggy feeling may indicate olecranon
flammation, and increased temperature (Fig.
bursitis. Check the posterior aspect of the olecranon border for rheumatoid nodules, which indicate
rheumatoid arthritis.
--'K1r---'\;---- Humerus ---\+-
-',yt-�+-----lr-- Olecranon
process
Olecranon
bursa
Figure 6-11
Figure 6-12
CHAPTER 6
ELBOW ORTHOPAEDlC TESTS
175
Triceps Muscle
DESCRIPTIVE ANATOMY
The triceps muscle has three heads; the long head crosses both the glenohumeral joint and the el­
bow joint, and it inserts into the olecranon process (Fig.
6-13).
PROCEDURE
With the patient's elbow slightly flexed, have the patient lean on a table. This will facilitate the pal­
pation of the muscle. With your thumb and index finger, palpate the length of the muscle down to
the olecranon process, looking for any tenderness or defects secondary to trauma (Fig.
6-14). This
may indicate a strain or active trigger points of the triceps muscle. A hard mass may indicate myosi­
tis ossificans secondary to repeated trauma.
!---;H--I--\-- Glenohumeral joint
/-t\---+- Long
head
U\lMll-\H\Il-lr-t- Lateral
Triceps
brachii muscle
head
Scapuli
/lIMa-+-- Medial
head
Brachioradialis m.
Medial--I---tt-.
epicondyle
of elbow
joint
Extensor carpi radialis longus
Extensor carpi radialis brevis
Extensor digitorum
Flexor----11HHII
carpi
ulnaris
Figure 6-13
Extensor digiti minimi
Extensor carpi ulnaris
Figure 6-14
176
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Anterior Aspect
Cubital Fossa
loCATION
The cubital fossa is the triangular space bordered by the brachioradialis laterally and the pronator
teres medially. The base is an imaginary line between the two epicondyles. The structures that pass
between the fossa are the biceps tendon, brachial artery, median nerve, and musculocutaneous nerve
(Fig.
6-15).
PROCEDURE
With the patient's elbow slightly flexed and the patient resisting flexion, palpate the cubital fossa
with your index finger, looking for the biceps tendon, which lies medial to the brachioradialis mus­
cle (Fig.
6-16). Tenderness may indicate a strain in the musculotendinous junction. A ruptured ten­
don is not palpable in the fossa, and a bulbous gathering of muscle is evident in the upper arm.
Cubital fossa
CD
Median nerve
®
Brachial artery
Lateral
epicondyle
®
Musculocutaneous
nerve
@
Biceps brachii
tendon
Medial epicondyle
Pronator teres m.
Brachioradialis m.
Figure 6-15
Figure 6-16
CHAPTER 6
ELBOW ORTHOPAEDIC TESTS
177
ELBOW RANGE OF MOTION
Flexion (1)
With the patient seated, elbow extended, place the goniometer in the sagittal plane with the center
at the elbow joint (Fig.
6-17). This is the neutral position for the elbow joint for flexion and exten­
sion. Instruct the patient to flex the arm as far as possible while following the forearm with one arm
of the goniometer (Fig.
6-18).
NORMAL RANGE
Normal range is 1410
::t:: 4.90 or greater from the 0
Muscles
1.
2.
3.
4.
5.
or neutral position
(2).
Nerve Supply
Brachialis
Musculocutaneous
Biceps brachii
Musculocutaneous
Brachioradialis
Radial
Pronator teres
Median
Flexor carpi ulnaris
Ulnar
Figure 6-17
Figure 6-1 8
•
178
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Extension (1)
With the elbow in full extension, place the goniometer in the sagittal plane with the center at the el­
bow joint. Instruct the patient to extend the elbow further while following the forearm with one arm
of the goniometer (Fig.
6-19).
NORMAL RANGE
Normal range is
0.3°
±
2.0° from full extension (2).
Nerve Supply
Muscles
1.
2.
Triceps
Radial
Anconeus
Radial
Figure 6-19
Supination (1)
With the patient's elbow in
coronal plane (Fig.
90° of flexion and the thumb facing upward, place the goniometer in the
6-20). This is the neutral position for supination and pronation. Instruct the pa­
tient to rotate the thumb outward while you follow the thumb with one arm of the goniometer (Fig.
6-21).
NORMAL RANGE
Normal range is
81° ± 4° or more from the 0
Muscles
1.
2.
or neutral position
Nerve Supply
Supinator
Radial
Biceps brachii
Musculocutaneous
Figure 6-20
Figure 6-21
(2).
CHAPTER 6
ELBOW ORTHOPAEDIC TESTS
179
Pronation (1)
With the patient's elbow in
90° of flexion and the thumb facing upward, place the goniometer in the
coronal plane (Fig.
Instruct the patient to rotate the thumb inward while you follow the
6-22).
thumb with one arm of the goniometer (Fig.
6-23).
NORMAL RANGE
Normal range is
75°
:::'::
6.3°
Muscles
1.
2.
3.
or greater from the
0 or
neutral position
(2).
Nerve Supply
Pronator quadratus
Median
Pronator teres
Median
Flexor carpi radialis
Median
II
Figure 6-22
Figure 6-23
180
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
LAT ERAL EPICONDYLITIS (T ENNIS ELBOW)
CLINICAL DESCRIPTION
Lateral epicondylitis is a repetitive injury of the common extensor tendon at the lateral epicondyle
of the humerus. Repetitive actions include lifting, hammering, and tight gripping with repeated im­
pact during sports activities. This injury causes microtearing and microavulsion at the origin of the
extensor carpi radialis tendon. Secondary inflammation develops at the epicondyle after this me­
chanical injury. Symptoms persist because of constant traction and movement of the wrist and
hand.
CLINICAL SIGNS AND SYMPTOMS
•
•
Local lateral elbow pain
Weakness of the forearm
Cozen's Test (3)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient seated, stabilize the patient's forearm. Instruct the patient to make a fist and extend
it (Fig.
6-24). Then force the extended wrist into flexion against resistance (Fig. 6-25).
Figure 6-24
CHAPTER 6
ELBOW ORTHOPAEDIC TESTS
181
RATIONALE
The tendons that extend the wrist are attached to the lateral epicondyle (Fig.
6-26).
They are the ex­
tensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris.
If the condyle itself or the common extensor tendons that attach to it are inflamed, then forcing the
extended wrist into flexion can reproduce irritation to the lateral epicondyle and its attaching ten­
dons. If pain is elicited at the lateral epicondyle, suspect inflammation of the lateral epicondyle (epi­
condylitis).
Posterior view
Common
extensor
tendon
Extensor digiti minimi
(b)
.J,...\\\-\W,\- I=xtem>or carpi ulnaris (c)
}
Common extensor
tendon group
/�
Figure 6-26
182
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Mill's Test (4)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
With the patient seated, instruct the patient to pronate the arm and flex the wrist. Then instruct him
or her to supinate the arm against resistance (Fig.
6-27).
RATIONALE
The tendon of the supinator muscle, which supinates the wrist, is attached to the lateral epicondyle.
If the condyle itself or the tendon of the supinator that attaches to the condyle is inflamed, resisting
supination of the wrist may reproduce irritation to the lateral epicondyle and its attaching tendons.
If pain is elicited at the lateral epicondyle, suspect inflammation of the lateral epicondyle (epi­
condylitis).
Figure 6-27
CHAPTER 6
ELBOW ORTHOPAEDIC TESTS
Kaplan's Sign (5)
183
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient in the seated position and the elbow slightly flexed, instruct the patient to grip a
dynamometer and record the findings (Fig.
patient's epicondyles (Fig.
6-28). Next, place a tennis elbow brace slightly below the
6-29). Again, instruct the patient to grip the dynamometer and record the
findings.
RATIONALE
Gripping the dynamometer unsupported increases the traction on the common extensor tendon at
the lateral epicondyles, which causes pain and produces weakness of the hand and forearm. When a
support is placed distal to the epicondyle, pain is reduced and strength is increased because traction
to the common extensor tendon is relieved.
SUGGESTED DIAGNOSTIC IMAGING
Plajn film raruography
AP elbow view
Lateral elbow view
Figure 6-28
Figure 6-29
184
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
MEDIAL EPICONDYLITIS (GOLFER'S ELBOW)
CLINICAL DESCRIPTION
Medial epicondylitis is a repetitive injury of the common flexor tendon at the medial epicondyle of
the humerus. Repetitive actions include lifting, hammering, and tight gripping with repetitive im­
pact during sports activities. This injury causes microtearing and microavulsion at the origin of the
flexor carpi radialis tendon. Secondary inflammation develops at the epicondyle after this mechan­
ical injury. Symptoms persist due to constant traction and movement of the wrist and hand.
CLINICAL SIGNS AND SYMPTOMS
•
•
Local medial elbow pain
Weakness of the forearm
Golfer's Elbow Test (6)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Tell the seated patient to extend the elbow and supinate the hand. Instruct the patient to flex the
wrist against resistance (Fig.
6-30).
RATIONALE
The tendons that flex the wrist, the flexor carpi radialis and flexor carpi ulnaris, are attached to the
medial epicondyle (Fig.
6-31).
If the condyle itself or the common flexor tendons that attach to it
are inflamed, resisting wrist flexion may reproduce irritation to the medial epicondyle and its at­
taching tendons. If pain is elicited at the medial epicondyle, suspect inflammation of the medial epi­
condyle (epicondylitis).
Medial epicondyle
SUGGESTED DIAGNOSTIC IMAGING
-4-+-- Humerus
Plain film radiography
AP elbow view
Lateral elbow view
�O!C--7f--+- Pronator teres m
WH-+-- Flexor carpi radialis
r\'iIl--t-- Palmaris longus
Flexor carpi ulnaris
Figure 6-30
Figure 6-31
CHAPTER 6
185
ELBOW ORTHOPAEDIC TESTS
LIGA MENTOUS INSTABILITY
CLINICAL DESCRIPTION
Ligamentous instability at the elbow is relatively uncommon. The radial collateral ligament at the lat­
eral aspect of the elbow and the ulnar collateral ligament at the medial aspect of the elbow are af­
fected. This injury may be due to forced elbow hyperextension, forced abduction of the extended arm,
or forced adduction of the extended arm. Forced adduction of the extended arm will damage the ra­
clial collateral ligament. Forced abduction of the extended arm will damage the ulnar collateral liga­
ment. Severe instability may include an avulsion fracture or a complete dislocation of the elbow.
CLINICAL SIGNS AND SYMPTOMS
•
•
Medial or lateral elbow pain
Local swelling
Adduction Stress Test (7)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient sitting, stabilize the medial arm and place adduction pressure on the patient's lat­
eral forearm (Fig.
6-32).
RATIONALE
Placing adduction pressure on the lateral forearm applies stress to the radial collateral ligament (Fig.
6-33). Gapping and pain indicate radial collateral ligament instability.
Figure 6-32
186
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Ulnar
collateral
ligament
-+-f-Ulna
Lateral view
Figure 6-33
CHAPTER 6
Abduction Stress Test (7)
Sensitivity/Reliability Scale
I
o
PROCEDURE
187
ELBOW ORTHOPAEDIC TESTS
I
I
1
I
I
2
I
I
3
I
I
4
With the patient sitting, stabilize the lateral arm and place abduction pressure on the medial fore­
arm (Fig.
6-34).
RATIONALE
Placing an abduction pressure on the medial forearm applies stress to the ulnar collateral ligament.
Gapping and pain indicate ulnar collateral ligament instability.
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiography
AP elbow view
Lateral elbow view
•
•
Computed tomography
Magnetic resonance imaging
Figure 6-34
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
188
NEUROPATHY/COMPR ESSION SYNDROMES
CUNCAL DESCRIPTION
Neuropathy and compression syndromes of the elbow are peripheral neurological disorders caused
by trauma, overuse, arthritis, or postural considerations. These disorders may cause paresthesia and
weakness to the forearm and/or hand. The nerve most affected is the ulnar nerve. The sites of com­
pression or entrapment may include the groove between the olecranon process and medial epi­
condyle or the cubital tunnel (Fig.
6-35).
CLINICAL SIGNS AND SYMPTOMS
Forearm and/or hand paresthesia
•
Forearm and/or hand weakness
•
Tinel's Sign (8)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, tap the ulnar nerve in the groove between the olecranon process and the
medial epicondyle with a neurological reflex hammer (Fig.
6-36).
The ulnar nerve passes in this
groove.
RATIONALE
This test is designed to elicit pain caused by a neuritis or neuroma of the ulnar nerve. Pain indicates
a positive test. The nerve can become damaged in the following ways:
1.
2.
3.
4.
Excessive use or repetitive injuries or trauma of the elbow
Arthritis of the elbow joint
Cubital tunnel compression, between the heads of the flexor carpi ulnaris muscle
Postural habits that compress the nerve, such as sleeping with elbows flexed and hands un­
der head
5.
Recurrent nerve subluxations or dislocations
Medial epicondyle
Cubital tunnel
Ulnar nerve
Olecranon process
Figure 6-35
Figure 6-36
CHAPTER 6
189
ELBOW ORTHOPAEDIC TESTS
Wartenberg's Sign (9)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the seated patient to place the hand on the table. Passively spread the patient's fingers (Fig.
6-37). Instruct the patient
to bring the fingers together (Fig.
6-38).
RATIONALE
The ulnar nerve controls abduction of the fingers. Inability to abduct the little finger to the rest of
the hand indicates ulnar nerve neuritis (Fig.
6-39).
Figure 6-38
Figure 6-37
Figure 6-39
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
190
Elbow Flexion Test (10)
Sensitivity/Reliability Scale
I
o
PROCEDURE
Instruct the seated patient to flex the elbow completely for
5
minutes (Fig.
I
1
I
2
I
3
I
4
6-40).
RATIONALE
Flexion of the elbow may compress the ulnar nerve in the cubital tunnel. Paresthesia along the me­
dial aspect of the forearm and hand may indicate compression of the ulnar nerve in the cubital tun­
nel (cubital tunnel syndrome) (Fig.
6-41).
It can also be trapped between the heads of the flexor
carpi ulnaris or by scar tissue in the ulnar groove.
Figure 6-40
Sites of Ulnar Nerve Compression
Two heads of
FCU (flexor
carpi ulnaris)
Figure 6-41
nerve
tunnel
process
Ligament of
Struthers
CHAPTER 6
191
ELBOW ORTHOPAEDIC TESTS
Pinch Grip Test (11)
Sensitivity/Reliability Scale
I
I
1
PROCEDURE
Instruct the patient to pinch the tips of the index finger and thumb together (Fig.
I
2
I
3
I
6-42).
RATIONALE
Normally the pinch is tip to tip. The test is positive if the pulps of the thumb and index finger touch
(Fig.
6-43). This result is caused by an injury to the anterior interosseous nerve,
which is a branch
of the median nerve. It may also indicate an entrapment syndrome of the anterior osseous nerve be­
tween the two heads of the pronator teres muscle (Fig.
6-44).
SUGGESTED DIAGNOSTIC AND FUNCTIONAL TESTING
•
Electrodiagnostic studies
Humerus ---\----fl-J'--
Entrapped
nerve
Heads of
pronator
teres m.
��t----i���
Figure 6-42
Radius --+----f-'-
Ulna
Figure 6-44
Figure 6-43
--t----,HH-.��'If'+-.r
192
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
References
1. American Academy of Orthopaedic Surgeons.
The Clinical Measurement of Joint Motion.
Chicago: American Academy of Orthopaedic
Surgeons, 1994.
2. Boone DC, Azen SP. Normal range of motion in
male subjects. J Bone Joint Surg 1979;61A:
756-759.
3. Lucas GL. Examination of the Hand. Spring­
field, IL: Charles C. Thomas, 1972.
4. Mills GP. The treatment of tennis elbow. Br Med
J 1928;1:12-13.
5. Kaplan EB. Treatment of tennis elbow by dener­
vation. J Bone Joint Surg 1959;41A:147.
6. McRae R. Clinical Orthopedic Examination.
New York: Churchill Livingstone, 1976;41.
7. Hoppenfeld S. Physical examination of the
spine and extremities. New York: Appleton­
Century-Crofts, 1976;127.
8. Tinel J. Nerve wounds; symptomatology of pe­
ripheral nerve lesions caused by war wounds.
Joll CA, ed, Rothwell F, trans. New York:
W illiam Wood, 1918.
9. Volz RC, Morrey BF. The physical examination
of the elbow. In: Morrey BF, ed. The Elbow and
Its Disorder. Philadelphia: WB Saunders, 1986.
10. Magee DJ. Orthopedic Physical Assessment.
2nd ed. Philadelphia: WB Saunders, 1992.
11. W iens E, Lane S. The anterior interosseous
nerve syndrome. Can J Surg 1978;21:354.
General References
Boyd HB. Tennis elbow. J Bone Joint Surg Am
1973;55:1183-1187.
Cyriax J. Pathology and treatment of tennis elbow. J
Bone Joint Surg 1936;18:921.
Cyriax J. Textbook of Orthopaedic Medicine. Vol 1.
Diagnosis of soft tissue lesions. London: Bailliere
Tindall, 1982.
Kapandji IA. The physiology of the Joints. Vol 1. Up­
per Limb. New York: Churchill Livingstone, 1970.
McKee GK. Tennis elbow. Br Med J 1937;2:434.
MenneU JM. Joint Pain. Boston: Little, Brown, 1964.
Nagler W, Johnson E, Gardner R. The pain of tennis
elbow. Current Concepts Pain Analg, 1986.
Nirschl R, Pettrone F. Tennis elbow. J Bone Joint
Surg 1979;61A(6):836.
Post M. Physical examination of the musculoskele­
tal system. Chicago: Year Book, 1987.
Roles NC, Maudsley RH. Radial tunnel syndrome:
resistant tennis elbow as a nerve entrapment. J Bone
Joint Surg Br 1972;54:499.
--------�rn�-WRIST ORTHOPAEDIC TESTS
WRIST OR T HOPAEDIC EXAMINATION
194
FLOW CHAR T
Carpal Compression Test
195
Carpal Tunnel
196
Guyon's Canal
197
R adial and Ulnar Arteries
Pinch Test
198
208
209
Tourniquet Test
199
Posterior Aspect
207
R everse Phalen's Test
195
Flexor Tendons
206
Phalen's Test
195
205
205
T inel's Wrist Sign
WRIST PALPATION
Anterior Aspect
CARPAL TUNNEL SYNDROME
209
ULNAR TUNNEL SYNDROME
210
210
Ulnar Tunnel Triad
Ulnar Styloid P rocess and R adial
Tubercle
199
Extensor Tendons
STENOSING T ENOSYNOVITIS
200
WRIST R ANGE OF MOTION
Flexion
Extension
201
R adial Deviation
201
211
CARPAL INSTABILIT Y
212
Lunatotriquetral B allottement
202
Ulnar Deviation
Finkelstein's Test
•
211
Test
203
212
Watson's Test
213
204
193
194
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Wrist Orthopaedic Examination
�
History
Wrist pain
with history
of overuse
I
Wrist pain
with history
of trauma
Range of Motion
(active)
(passive)
t(+)
Range of Motion
(active)
(passive)
Lunatotriquetral
ballottement test
Watson test
t(+)
Nerve conduction
studies
(+)
I
I
I
(-)
Ulnar tunnel triad
J
(+)
Nerve conduction
studies
(+)
Ulnar tunnel
syndrome
I
Radiology
I
Rheumatoid arthritis
Degenerative joint disease
Fracture dislocation
Carpal instability
Tinel's wrist sign
Phalen's test
Reverse Phalen's test
Tourniquet test
Pinch test
-\
)
J(+)
( +)
(+)
Compression
neuropathies
(-
I
(-)
I
L
t
Finkelstein's test
l
1(+)
Stenosing
tenosynovitis
J
I
CHAPTER 7
WRIST ORTHOPAEDIC TESTS
195
WRIST PALPATION
Anterior Aspect
Flexor Tendons
DESCRIPTIVE ANATOMY
Six wrist and digit flexor tendons cross the wrist (Fig.
7-1):
Flexor carpi ulnaris
Palmaris longus
Flexor digitorum profundus
Flexor digitorum superficialis
Flexor pollicis longus
Flexor carpi radialis
PROCEDURE
Palpate each tendon just proximal to the flexor retinaculum, noting any tenderness or calcific de­
posits (Fig.
7-2). Tenderness may indicate tenosynovitis of the suspected flexor tendon.
•
NOTE
Small pealike swelling may appear at the anterior or posterior aspect of the wrist. These ganglia are
benign tenosynovial tumors and are usually symptom free but may become tender and painful when
distended.
{
Median
duo
Radial
trio
{
palmaris longus tendon
--==:��������S;;
Median nerve -
����������
rad
Flexor digitorum superficialis
tendons
����#I�����- Flexor digitorum profundus
tendons
Radial artery
UI
Flexor pollicus longus
tendon in radial brevis
UI
Palmar carpal ligament
Pronator quadratus muscle
Figure 7-'
Figure 7-2
�:��
'
Flexor carpi
}
ulnaris tendon
Ulna
Radius
Ulnar
trio
}
196
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Carpal Tunnel
DESCRIPTIVE ANATOMY
The carpal tunnel is deep to the palmaris longus at the anterior surface of the wrist. It is bound by
the pisiform and the hook of the hamate medially, the tubercle of the scaphoid and tubercle of the
trapezium laterally, the flexor retinaculum anteriorly, and the carpal bones posteriorly (Fig.
7-3). In­
side the tunnel lie the median nerve and the finger flexor tendons from the forearm to the hand. This
tunnel is a common site of compression neuropathy.
PROCEDURE
The actual tunnel and structures within the tunnel are not palpable. The borders of the tunnel
should be palpated for deformity and/or tenderness (Fig.
7-4). The area over the tunnel should be
palpated for increase in symptoms, such as numbness, tingling, pain, and weakness in the hand.
These symptoms may indicate carpal tunnel syndrome.
Compression
•• }
(9) Flexor tendons
Flexor
Median nerve
Carpal ligament
Figure 7-3
Figure 7-4
Pass through
carpal tunnel
CHAPTER 7
WRIST ORTHOPAEDIC TESTS
197
Guyon's Canal (Ulnar Tunnel)
DESCRIPTIVE ANATOMY
The tunnel, or canal, of Guyon is between the pisiform and the hook of the hamate. It contains the
ulnar nerve and artery (Fig.
7-5). It is also a common site of compression neuropathy.
PROCEDURE
The ulnar artery and nerve are not palpable in the tunnel. Palpating over the tunnel may increase
tenderness to the area and the symptoms to the ulnar distribution of the hand (Fig.
•
Palmar
carpal
ligament
7-6).
Palmar
carpal
ligament
&I
•
Ulnar n.
•
Ulnar artery
Palmaris
longus
tendon
Radius
Figure 7-5
Figure 7-6
198
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Radial and Ulnar Arteries
DESCRIPTIVE ANATOMY
The radial and ulnar arteries are the two branches of the brachial artery that supply the hand with
blood flow. The radial artery lies lateral at the anterior lateral aspect of the wrist, and the ulnar ar­
tery is at the anterior medial aspect of the wrist (Fig.
7-7).
PROCEDURE
Palpate each artery individually and determine the amplitude of both pulses bilaterally (Figs.
and
7-8
7-9). A decrease in amplitude may indicate a compression of the respective artery between the
elbow and the wrist if the brachial artery is palpated and not compromised. A common site of com­
pression of the ulnar artery is the tunnel of Guyon.
Radial--f-+Wf7
artery'
Ulnar artery'
Figure 7-7
Figure 7-8
Figure 7-9
CHAPTER 7
WRIST ORTHOPAEDIC TESTS
199
Posterior Aspect
Ulnar Styloid Process and Radial Tubercle
DESCRIPTIVE ANATOMY
The ulnar styloid process is at the posterior aspect of the wrist proximal to the fifth digit. The radial
tubercle is at the posterior aspect of the wrist proximal to the thumb (Fig.
7-10).
PROCEDURE
Palpate the ulnar styloid process and radial tubercle for tenderness, pain, swelling, or deformity
(Figs.
7-11 and 7-12). Pain at the radial tubercle following trauma may indicate a fracture, such as
Colles', a fracture of the distal radius with dorsal angulation. Pain at the ulnar styloid may be asso­
ciated with a distal ulnar fracture. Tenderness, swelling, or deformity at either site may indicate
rheumatoid arthritis.
•
Fifth
digit
Ulnar 1¥���r->-4--f�
styloid
process
Figure 7-10
Figure 7-11
Figure 7-12
200
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Extensor Tendons
DESCRIPTIVE ANATOMY
There are six fibro-osseous tunnels at the posterior aspect of the wrist. The extensor tendons to the
hand pass through these tunnels, which are bound by the extensor retinaculum superficially and are
lined with a synovial sheath. From the thumb laterally, these are the tunnels and their respective ten­
dons (Fig.
7-13):
Tunnell
Adductor pollicis longus, extensor pollicis brevis
Tunnel 2
Extensor carpi radialis longus and brevis
Tunnel 3
Extensor pollicis longus
Tunnel 4
Extensor digitorum and extensor indexes
TunnelS
Extensor digiti minimi
Tunnel
Extensor carpi ulnaris
6
PROCEDURE
Support the patient's hand with your fingers while palpating the wrist with both your thumbs (Fig.
7-14). Note any crepitus or restriction of movement. Crepitus may indicate tenosynovitis of one of
the extensor tendons.
NOTE
A small pealike swelling may appear at the anterior or posterior aspect of the wrist. These are be­
nign tenosynovial tumors and are usually symptom free but may become tender and painful when
distended.
CD
{
®
{
®
Extensor carpi
radialis brevis
Extensor
pollicus
longus
@
Extensor
digitorum and
extensor indicis
Extensor carpi
radialis longus
®
Extensor
digiti
Extensor
pollicus brevis
®
Adductor
pollicus longus
Extensor
carpi
ulnaris
Radius
Figure 7-13
Figure 7-14
Ulna
CHAPTER 7
WRIST ORTHOPAEDIC TESTS
201
Wrist Range of Motion
Flexion (1)
With the patient's wrist in the neutral position, place the goniometer in the sagittal plane with the
center at the ulnar styloid process (Fig.
7-15). Instruct the patient to flex the wrist downward, and
7-16).
follow the hand with one arm of the goniometer (Fig.
NORMAL RANGE
Normal range is 75 ::!::
7.60 or greater from the 0 or neutral position (2).
Muscles
Nerve Supply
Flexor carpi radialis
Median
Flexor carpi ulnaris
Ulnar
Figure 7-15
Figure 7-16
202
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Extension (1)
With the patient's wrist in the neutral position, place the goniometer in the sagittal plane with the
center at the ulnar styloid process (Fig.
7-17). Instruct the patient to extend the wrist backward while
7-18).
you follow the hand with one arm of the goniometer (Fig.
NORMAL RANGE
Normal range is
74 ± 7.60 or greater from the 0 or neutral position (2).
Muscles
Nerve Supply
Extensor carpi radialis longus
Radial
Extensor carpi radialis brevis
Radial
Extensor carpi ulnaris
Radial
Figure 7-17
Figure 7-18
CHAPTER 7
WRJST ORTHOPAEDIC TESTS
203
Ulnar Deviation (1)
With the patient's wrist in the neutral position and the hand supinated, place the goniometer in the
coronal plane with the center at the radial-ulnar junction (Fig.
7-19). Instruct the patient to deviate
7-20).
the wrist medially, and follow the hand with one arm of the goniometer (Fig.
NORMAL RANGE
Normal range is 35 :±: 3.80 or greater from the
Muscles
Nerve Supply
Flexor carpi ulnaris
Ulnar
Extensor carpi ulnaris
Radial
0 or neutral position (2).
•
Figure 7-19
Figure 7-20
204
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Radial Deviation (1)
With the patient's wrist in the neutral position and the hand supinated, place the goniometer in the
coronal plane with the center at the radial-ulnar junction (Fig.
7-21). Instruct the patient to deviate
7-22).
the wrist laterally, and follow the hand with one arm of the goniometer (Fig.
Normal Range
Normal range is 21
± 4° or greater from the 0 or neutral position (2).
Nerve Supply
Muscles
Extensor carpi radialis
Median
Extensor carpi radialis longus
Radial
Abductor pollicis longus
Radial
Extensor pollicis brevis
Radial
Figure 7-21
Figure 7-22
CHAPTER 7
WRIST ORTHOPAEDIC TESTS
205
CARPAL TUNNEL SYNDROME
DESCRIPTION
Carpal tunnel syndrome is a compression neuropathy of the median nerve. Compression occurs un­
der the flexor retinaculum at the wrist. The stage of the condition from sensory loss to motor loss
with atrophy correlates directly with a degree of compression and the chronicity of the symptoms.
Most cases present at an early stage with intermittent sensory symptoms only.
CLINICAl SIGNS AND SYMPTOMS
•
•
•
Loss of sensation of the tips of the first three fingers
Hand and wrist pain
Weakness of grip
Tinel's Wrist Sign (3)
Sensitivity/Reliability Scale
I
I
o
PROCEDURE
I
1
I
I
2
I
I
3
I
I
4
With the patient's hand supinated, stabilize the wrist with one hand. With your opposite hand, tap
the palmar surface of the wrist with a neurological reflex hammer (Fig. 7-23).
RATIONAlE
Tingling in the hand along the distribution of the median nerve (thumb, index finger, middle fin­
ger, and medial half of the ring finger) indicates carpal tunnel syndrome, a compression of the me­
dian nerve by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone,
arthritic changes, or tenosynovitis of the flexor digitorum tendons (see Fig. 7-25).
Figure 7-23
206
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Phalen's Test (4,5)
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
PROCEDURE
Flex both wrists and approximate them to each other. Hold for
60 seconds (Fig. 7-24).
RATIONALE
When both wrists are flexed, the flexor retinaculum provides increased compression of the medial
nerve in the carpal tunnel. Tingling in the hand along the distribution of the median nerve (thumb,
index finger, middle finger, and medial half of the ring finger) indicates compression of the median
nerve in the carpal tunnel (Fig.
7-25) by inflammation of the flexor retinaculum, anterior disloca­
tion of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.
Figure
Figure
7-24
7-25
���I-H--r- Tendons
-\!--;Me!
;.>--!ffi+-- OIEIn nerve
Pressured area
Flexor retinaculum
Synovial sheath
Compressed nerve
Test for carpal tunnel syndrome
CHAPTER 7
Reverse Phalen's Test (6)
207
WRIST ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
I
4
PROCEDURE
Instruct the patient to extend the affected wrist and have the patient grip your hand. With your op­
posite thumb, press on the carpal tunnel (Fig. 7-26).
RATIONALE
Extending the hand and applying pressure to the carpal tunnel further constricts the tunnel. Tin­
gling in the thumb, index finger, and lateral half of the ring finger may indicate compression of the
medial nerve in the carpal tunnel by inflammation of the flexor retinaculum, anterior dislocation of
the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.
IfJI
Figure 7-26
208
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Carpal Compression Test (7)
PROCEDURE
Sensitivity/Reliability Scale
I
I
I
1
I
I
2
I
I
3
I
I
4
With the patient's wrist and hand extended, grasp the patient's wrist with both hands and place di­
rect pressure with both thumbs over the median nerve in the carpal tunnel for up to 30 seconds (Fig.
7-27).
RATIONALE
Placing a mechanical pressure over the carpal tunnel increases pressure to the median nerve. Tin­
gling in the hand along the distribution of the median nerve (thumb, index finger, middle finger,
and medial half of the ring finger), indicates compression of the median nerve in the carpal tunnel
by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic
changes, or tenosynovitis of the flexor digitorum tendons.
Figure
7-27
CHAPTER 7
Tourniquet Test (8)
209
WRIST ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
I
3
I
Wrap a sphygmomanometer cuff around the affected wrist and inflate it to just above the patient's
systolic blood pressure. Hold for
1 to 2 minutes (Fig. 7-28).
RATIONALE
The inflated sphygmomanometer cuff induces mechanically increased pressure to the median nerve.
Tingling in the hand along the distribution of the median nerve (thumb, index finger, middle fin­
ger, and medial half of the ring finger) indicates compression of the median nerve in the carpal tun­
nel by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic
changes, or tenosynovitis of the flexor digitorum tendons.
•
Figure 7-28
Pinch Test (9)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
I
4
Instruct the patient to pinch a piece of paper between the thumb, index, and middle fingers while
you attempt to pull it away (Fig.
7-29).
RATIONALE
The median nerve innervates the lumbrical muscles, which are used to pinch the piece of paper.
With compression of the median nerve, the patient may have numbness and/or cramping of the fin­
gers or mid palm region within
1 minute.
SUGGESTED DIAGNOSTIC AND FUNCTIONAL TESTING
•
•
Magnetic resonance imaging
Electromyography
Figure 7-29
210
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
ULNAR TUNNEL SYNDROME
DESCRIPTION
The ulnar nerve travels through the tunnel of Guyon and innervates the muscles to the little and ring
fingers. Ulnar tunnel syndrome is a compression neuropathy of the ulnar nerve. Compression oc­
curs at the tunnel of Guyon at the wrist (see Fig.
7-5). The stage of the condition from sensory loss
to motor loss with atrophy correlates directly with a degree of compression and the chronicity of the
symptoms. Most cases present at an early stage with intermittent sensory symptoms only.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Pain over the little and ring finger
Weakness of grip
Difficulty with finger spreading
Claw hand
Ulnar Tunnel Triad
PROCEDURE
Inspect and palpate the patient's wrist, looking for tenderness over the ulnar tunnel, clawing of the
ring finger, and hypothenar wasting (Fig.
7-30).
RATIONALE
All three of these signs are indicative of ulnar nerve compression possibly in the tunnel of Guyon.
SUGGESTED DIAGNOSTIC AND FUNCTIONAl TESTING
•
•
Magnetic resonance imaging
Electromyography
Figure 7-30
CHAPTER 7
WRIST ORTHOPAEDIC TESTS
211
STENOSING TENOSYNOVITIS
DESCRIPTION
Stenosing tenosynovitis in the wrist affects the tendon and sheath of the abductor pollicis longus
and the extensor pollicis brevis (Fig.
7-31). It is also termed de Quervain's or Hoffman's disease.
Swelling of the tendons and thickening of the sheaths that the tendons pass through, is due to an
overuse condition of the wrist and thumb.
CLINICAl SIGNS AND SYMPTOMS
•
•
•
Painful wrist and thumb during movement
Swelling over the radial styloid
Tendons and sheath tender to palpation
Metacarpal I
•
Extensor pollicus
brevis tendon
Figure 7-31
Finkelstein's Test (10)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
I
2
Instruct the patient to make a fist with the thumb across the palmar surface of the hand (Fig.
and to stress the wrist medially (Fig.
I
3
I
I
4
7-32)
7-33).
RATIONALE
Making a fist and stressing it medially stress the abductor pollicis longus and extensor pollicis bre­
vis tendons. Pain distal to the styloid process of the radius indicates stenosing tenosynovitis of the
abductor pollicis longus and extensor pollicis brevis tendons (de Quervain's disease).
SUGGESTED DIAGNOSTIC IMAGING
•
•
Magnetic resonance imaging
CT arthrography
Figure 7-32
Figure 7-33
212
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
CARPAL INSTABILITY
DESCRIPTION
Carpal instability or the propensity for carpal bone dislocation or fracture is due to trauma, overuse
injury, or rheumatoid arthritis. The ligaments of the wrist permit little movement of the intercarpal
joints. Trauma may sprain the ligaments, which may subluxate one or more of the carpal bones. Se­
vere trauma may cause an incomplete fracture or chondral fracture. Rheumatoid arthritis may cause
weakening of the intercarpal ligaments, permitting the propensity for dislocation or subluxation of
the one or more of the carpal bones.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
Wrist pain
Apprehension on movement
Crepitus on Movement
Lunatotriquetral Ballottement Test (11)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With one hand, grasp the triquetrum on the affected side with your thumb and index finger. With
your opposite hand, grasp the lunate, also with the thumb and index finger (Fig.
7-34). Move the lu­
nate anteriorly and posteriorly, noting any pain, laxity, or crepitus.
RATIONALE
The lunate and triquetrum are held together by a fibrous articular capsule and by dorsal, palmar,
and interosseous ligaments. The lunate is the most commonly dislocated of the carpal bones. Most
of the time it dislocates anteriorly and affects the radiolunate and the ligaments between the lunate
and the triquetrum. Pain, laxity, or crepitus indicates instability of the lunatotriquetral articulation,
causing a propensity of the lunate to subluxate or dislocate. This instability may lead to carpal tun­
nel syndrome, medial nerve palsy, flexor tendon constriction, or progressive avascular necrosis of the
lunate.
Figure 7-34
CHAPTER 7
Watson's Test (11)
213
WRIST ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With one hand, stabilize the radius and the ulna. With the opposite hand, grasp the scaphoid, mov­
ing it anteriorly and posteriorly (Fig.
7-35).
RATIONALE
The scaphoid is prone to subluxate or dislocate with hyperextension trauma. Pain, laxity, or crepi­
tus indicates an instability of the scaphoid with propensity to subluxate or dislocate.
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiography
AP wrist view
Lateral wrist view
Scaphoid view
Clenched fist view
•
Figure
7-35
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
214
General References
References
1. American Academy of Orthopaedic Surgeons.
de Quervain F. Clinical surgical diagnosis for stu­
The Clinical Measurement of Joint Motion.
dents and practitioners. 4th ed. Snowman J, trans.
Chicago: American Academy of Orthopaedic
New York: William Wood, 1913.
Surgeons, 1994.
2. Boone DC, Azen SP. Normal range of motion in
male subjects. J Bone Joint Surg 1979;61A:
756-759.
3. Tinel J. Nerve Wounds: Symptomatology of Pe­
Ditmars OM, Houin HP. Carpal tunnel syndrome.
Hand Clin 1986;2:525-532.
Green DP. Carpal dislocations. In: Operative Hand
Surgery. New York: Churchill Livingstone, 1982.
ripheral Nerve Lesions Caused by War Wounds.
Hoppenfeld S. Physical Examination of the Spine
Jol! CA, ed, Rothwell F, trans. New York:
and Extremities.
W illiam Wood, 1918.
Crofts, 1976;127.
4. Phalen GS. The carpal tunnel syndrome: 17
years experience in diagnosis and treatment of
654
hands.
J
Bone
Joint
Surg
1966;48A:
211-228.
5. American Society for Surgery of the Hand. The
Hand: Examination and Diagnosis. Aurora, CO,
1978.
6. Post M. Physical examination of the muscu­
loskeletal system. Chicago: Year Book, 1987.
7. Durken JA. A new diagnostic test for carpal tun­
nel syndrome. J Bone Joint Surg AmI991;73:
535-538.
8. McRae R. Clinical Orthopedic Examination.
New York: Churchill Livingstone, 1977.
9. Ditmars OM, Houin HP. Carpal tunnel syn­
drome. Hand Clin 1986;2:723-737.
10. F inkelstein H. Stenosing tenosynovitis at the ra­
dial
styloid
process.
J
Bone
Joint
Surg
1930;12:509.
11. Taleisnik J. Carpal instability. J Bone Joint Surg
1988;70A:1262-1268.
New York: Appleton-Century­
Kapandji lA. The Physiology of the Joints. Vol. l.
Upper Limb. New York: Churchill Livingstone,
1970.
Stevenson TM. Carpal tunnel syndrome. Proc R Soc
Med 1966;59:824.
Thompson WAL, Koppel! HP. Peripheral entrap­
ment neuropathies of the upper extremities. N Engl
J Med 1959;260:1261.
Wadsworth CT. Wrist and hand examination and
interpretation. J Orthop Sports Phys Ther 1983;
5:108.
------�oo�--HAND ORTHOPAEDIC TESTS
HAND PALPATION
Anterior Aspect
216
216
216
T henar Eminence
Hypothenar Eminence
Posterior Aspect
JOINT CAPSULE T ESTS
222
Bunnel-Littler Test
222
Test For T ight Retinacular
Ligaments
217
223
218
Extensor Tendons
TENDON INSTABILITY
218
Metacarpals and Phalanges
219
Profundus Test
224
224
Flexor and Extensor Pollicis Longus
JOINT INSTABILITY
Test
220
Varus and Valgus Stress Test
220
Thumb Ulnar Collateral Ligament Laxity
Test
225
Extensor Digitorum Communis
Test
226
221
215
216
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
HAND PALPATION
Anterior Aspect
Thenar Eminence
DESCRIPTIVE ANATOMY
The thenar eminence lies at the lateral aspect of the hand with the palm facing out. It comprises
three muscles that move the thumb: abductor pollicis brevis, opponens pollicis, and flexor pollicis
brevis. These muscles are innervated by a branch of the recurrent median nerve (Fig. 8-1). Severe,
prolonged compression of the median nerve in the carpal tunnel may cause the muscles of the
thenar eminence to atrophy.
PROCEDURE
Palpate the thenar eminence from the base of the thumb medial to the central aspect of the hand at
the base of the carpal bones, then inferior and lateral to the base of the forefinger (Fig. 8-2). Look
for hypertrophy or atrophy in comparison with the opposite hand. If atrophy or wasting is accom­
panied by pain and paresthesia along the medial nerve distribution, suspect compression of the me­
dial nerve in the carpal tunnel.
Muscles of thenar eminence:
Hypothenar eminence:
Opponens digiti minimi
Flexor pollicis brevis m.
Opponens poliicis m.
Abductor poliicis brevis m.
Flexor digitorum minimi
Abductor digiti minimi m.
Pisifom
Figure 8-1
Figure 8-2
rrent median nerve
CHAPTER 8
HAND ORTHOPAEDIC TESTS
217
Hypothenar Eminence
DESCRIPTIVE ANATOMY
The hypothenar eminence lies at the anterior aspect of the hand from the base of the little finger to
the medial aspect of the hand, ending at the pisiform (Fig. 8-1). This eminence contains the abduc­
tor digiti minimi, opponens digiti minimi, and flexor digiti minimi. These muscles are supplied by
the deep branch of the ulnar nerve. Severe, prolonged compression of the nerve either in Guyon's
tunnel or more proximally in the extremity may cause wasting of the hypothenar eminence.
PROCEDURE
Palpate the length of the thenar eminence from the base of the little finger to the base of the pisi­
form (Fig. 8-3). Look for hypertrophy or atrophy in comparison with the opposite hand. Wasting of
the hypothenar eminence may indicate a compression of the ulnar nerve either in the tunnel of
Guyon or more proximally in the extremity.
Figure 8-3
218
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Posterior Aspect
Extensor Tendons
DESCRIPTIVE ANATOMY
The posterior aspect of the hand contains an intricate system of ligaments, fascial bands, and
tendons-the extensor mechanism. This mechanism provides active extension to the fingers and
contributes to the stabilization of the hand and digits. The extrinsic extensor tendons run along the
entire length of the posterior aspect of the hand to each digit (Fig. 8-4). The tendons can be affected
by trauma, which can strain or rupture them, and by rheumatoid arthritis, which can displace them.
PROCEDURE
With the patient's fingers and wrists extended, palpate the length of each tendon of the extensor dig­
ito rum communis from the base of the wrist to the proximal phalanx (Fig. 8-5). Note any tender­
ness, cysts, displacement, or loss of continuity of any of the individual tendons. Tenderness and dis­
placement indicate rheumatoid arthritis. Loss of continuity secondary to trauma with loss of digit
extension may indicate a ruptured extensor tendon. Small, easily palpable pealike cysts may develop
between the second and third metacarpal bones.
Extensors of Thumb:
Abductor pullicis longus
Extensor pullicis brevis
Extensor pullicis longus
Extensor radius tendon
Figure 8-4
Figure 8-5
CHAPTER 8
HAND ORTHOPAEDIC TESTS
219
Metacarpals and Phalanges
DESCRIPTIVE ANATOMY
The metacarpal bones and phalanges are held together by a series of ligaments and joint capsules
that supply stability to the joints (Fig. 8-6). The metacarpal and phalangeal bones are easily palpa­
ble from the posterior aspect of the hand. They are susceptible to traumatic fractures. The joints may
become inflamed and are a common site for rheumatoid arthritis.
PROCEDURE
Palpate each individual digit and metacarpal bone (Fig. 8-7). Look for tenderness, swelling, temper­
ature differences, and bony nodules. Tenderness and swelling following trauma may indicate a frac­
ture. Swelling around a joint capsule may indicate an inflammatory process, such as rheumatoid
arthritis. Bony nodules (Heberden's nodes) on the posterior and lateral surfaces of the distal inter­
phalangeal joints may indicate osteoarthritis.
Distal Phalanges
{
{
Middle Phalanges
Proximal phalanges
Deep transverse
metacarpal ligaments
{
Metacarpal bones -!-----"'<h-T-.cl--Hc-h:-I--'-f-.
Carpal bones
{
Figure 8-6
Figure 8-7
f(t/!!1R-+--Joint
capsule
220
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
JOINT INSTABILITY
DESCRIPTION
The interphalangeal joints are the most common site of joint injuries to the hand. The injuries range
from simple sprain to partial collateral ligament injury to dislocation to fracture-dislocation. Joint
stability is maintained by the collateral ligaments in combination with the volar plate, which pro­
duces a three-sided box around the joints (Fig. 8-8). The most commonly affected joints are the in­
dex and little finger. Joint instability is usually due to dislocation.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
Joint pain
Joint swelling
Joint deformity
Varus and Valgus Stress Test (1)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
I
I
3
With a pinch grip, grasp the joint (either a distal or proximal interphalangeal joint) with one hand.
With your opposite hand, pinch-grip the adjoining bone and apply varus (Fig. 8-9) and valgus (Fig.
8-10) stress to the joint.
RATIONALE
These procedures test the integrity of the collateral ligaments and the capsule surrounding the
joints. If pain is elicited, suspect a capsule sprain, subluxation, or dislocation. Laxity may indicate a
tear to the joint capsule or collateral ligaments of the joint secondary to trauma.
Collateral ligament
Interphalangeal joint
��-7 Collateral ligaments
Figure 8-8
Figure 8-9
Figure 8-10
CHAPTER 8
HAND ORTHOPAEDIC TESTS
Thumb Ulnar Collateral Ligament Laxity Test (2)
Sensitivity/Reliability Scale
I
o
PROCEDURE
221
I
1
I
2
I
3
I
4
With the carpometacarpal joint in extension, stabilize the metacarpal with a pinch grip. With your
opposite hand, grasp the proximal phalanx (also with a pinch grip) and push the phalanx radially
(Fig. 8-11). Repeat the test with the metacarpophalangeal joint fully flexed (Fig. 8-12).
RATIONALE
When the thumb is fully extended, it normally has 6° of laxity. If laxity is greater than 6° or as much
as 30°, the ulnar lateral collateral ligament and volar plate are damaged. If the joint is lax in full flex­
ion, the ulnar collateral ligament is damaged. If there is no laxity in flexion, the ligament is intact. If
there is no laxity in full flexion and more than 30° of laxity in full extension, the damage is limited
to the volar plate.
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiography
Posteroanterior hand view
Oblique hand view
Lateral hand view
Figure 8-11
Figure 8-12
222
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
JOINT CAPSULE TESTS
Flexibility and stability of the interphalangeal joints are a function of the joint capsules. If these cap­
sules are tight, they may have decreased joint motion; if loose, they may have increased joint mo­
tion. Decreased joint motion may also be caused by limitations in the intrinsic muscles of the hand
or tight collateral ligaments. These processes may be caused by rheumatoid arthritis or osteoarthri­
tis of the hands.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Joint pain
Joint swelling
Joint deformity
Limited joint motion
Bunnel-Littler Test (3)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the patient to extend the metacarpophalangeal joint slightly. Attempt to move the proximal
interphalangeal joint into flexion (Fig. 8-13). Repeat the test with the metacarpophalangeal joint in
flexion (Fig. 8-14).
RATIONALE
If the proximal interphalangeal joint does not flex with the metacarpophalangeal joint in slight ex­
tension, there is a tight intrinsic muscle or a contracture of the joint capsule. If the proximal inter­
phalangeal joint fully flexes with the metacarpophalangeal joint flexed, the intrinsic muscles are
tight. A positive test indicates an inflammatory process in the fingers, such as osteoarthritis or
rheumatoid arthritis.
Figure 8-13
Figure 8-14
CHAPTER 8
Test for Tight Retinacular Ligaments
Sensitivity/Reliability Scale
I
o
PROCEDURE
223
HAND ORTHOPAEDIC TESTS
I
1
I
2
I
3
I
I
With the proximal interphalangeal joint in the neutral position, passively attempt to flex the distal
interphalangeal joint (Fig. 8-15). Repeat the test with the proximal interphalangeal joint in the flexed
position (Fig. 8-16).
RATIONALE
If the distal interphalangeal joint does not flex with the proximal interphalangeal joint in the neu­
tral position, the collateral ligaments or joint capsule is tight. If the distal interphalangeal joint flexes
easily when the proximal interphalangeal joint is flexed, the collateral ligaments are tight and the
capsule is normal.
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiography
Posteroanterior hand view
Oblique hand view
Lateral hand view
Figure 8-15
Figure 8-16
224
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
TENDON INSTABILITY
Tendon instability or rupture or may be caused by vascular impairment, tenosynovitis, overstretch,
or trauma. Trauma may affect the forearm, wrist, or hand. Trauma to the forearm may injure one of
more of the long tendons, such as the flexor digitorum profundus and extensor digitorum, which
originates in the forearm and flexes and extends all of the joints in the fingers.
CLINICAL SIGNS AND SYMPTOMS
•
•
Forearm, wrist, or hand pain
Limited or absent joint motion
Profundus Test (3)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
Instruct the patient to flex the suspected distal phalanx while you stabilize the proximal phalanx
(Fig. 8-17).
RATIONALE
Inability to flex the distal phalanx indicates a divided flexor digitorum profundus tendon.
Figure 8-17
CHAPTER 8
Flexor and Extensor Pollicis Longus Test (4)
HAND ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
225
I
I
1
I
2
I
3
I
4
Stabilize the proximal phalanx of the thumb. Instruct the patient to flex (Fig. 8-18) and extend the
distal phalanx (Fig. 8-19).
RATIONALE
Inability to flex the digit indicates an injured flexor pollicis longus tendon. Inability to extend the
digit indicates an injury to the extensor pollicis longus tendon.
Figure 8-18
I
I
I
Figure 8-19
I
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
226
Extensor Digitorum Communis Test
Sensitivity/Reliability Scale
I
I
1
PROCEDURE
I
2
I
3
I
4
With the fingers flexed (Fig. 8-20), instruct the patient to extend the fingers (Fig. 8-21).
RATIONALE
Inability to extend any of the fingers indicates an injury to that particular portion of the extensor
digitorum communis tendon (Fig. 8-22).
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiography
Posteroanterior hand view
Oblique hand view
Lateral hand view
Figure 8-21
Figure 8-20
Figure 8-22
CHAPTER 8
References
1. Hartley A. Practical joint assessment. St. Louis:
Mosby, 1991.
2. Louis D et al. Rupture and displacement of the
HAND ORTHOPAEDIC TESTS
227
Green DP. Operative Hand Surgery, 3rd ed . New
York: Churchill Livingstone, 1993.
Jebson PJL, Kasdan ML. Hand Secrets. Philadelphia:
Hanley & Belfus, 1998.
ulnar collateral ligament of the metacarpopha­
Maitland GD. The Peripheral Joints: Examination
langeal joint of the thumb. J Bone Joint Surg
and Recording Guide. Adelaide, Australia: Virgo,
Am 1986;68:1320.
1973.
3. Hoppenfeld S. Physical Examination of the
Spine and Extremities. New York: Appleton­
Century-Croft, 1976.
4. Post M. Physical Examination of the Muscu­
loskeletal System. Chicago: Year Book, 1988.
McRae R. Clinical Orthopedic Examination. New
York: Churchill Livingstone, 1976.
Nicholas JS. The swollen hand. Physiotherapy 1977;
63:285.
Stern pJ. Tendinitis, overuse syndromes and tendon
General References
Cailliet R. Hand Pain and Impairment. 4th ed.
Philadelphia: Davis, 1994.
Eaton RG. Joint Injuries of the Hand. Springfield,
IL: Charles C. Thomas, 1971.
injuries. Hand Clin 1990;6:467-476.
Wadsworth CT. Wrist and hand examination and
interpretation. J Orthop Sports Phys Ther 1983;5:
108-l20.
------���--THORACIC ORTHOPAEDIC TESTS
THORACIC ORTHOPAEDIC EXAMINATION
FLOW CHART
229
230
Anterior Aspect
Sternum
230
NERVE ROOT LESIONS
231
Posterior Aspect
Scapula
Rotation
COSTOVERT EBRAL JOINT ANKYLOSIS
235
237
238
239
240
Adam's Position
241
McKenzie's Slide Glide Test
228
236
237
Scoliosis Screening
247
233
Ribs and Intercostal Spaces
Flexion
246
Schepelmann's Sign
T horacic Range of Motion
245
245
Beevor's Sign
Parathoracic Musculature
Spinous Processes
244
Passive Scapular Approximation
Test
232
232
Lateral Flexion
244
Sternal Compression Test
230
Ribs, Costal Cartilage, and Intercostal
Spaces
243
Spinal Percussion Test
Soto-Hall Test
PALPAT ION
243
THORACIC FRACTURES
242
Chest Expansion Test
248
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
229
Thoracic Orthopaedic Examination
�
History
I
Thoracic
pain with
no trauma
Thoracic
pain with
trauma
(+)
1II----'--'-l�1 Strain/Sprain
Spinal percussion
test
Soto-Hali test
Sternal
compression test
230
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PALPATION
Anterior Aspect
Sternum
DESCRIPTIVE ANATOMY
The sternum, which lies at the anterior part of the chest wall, consists of three parts: the manubrium,
body, and xiphoid process. It articulates with the costal cartilages on both sides. The manubrium
also articulates with the facets of the clavicle on both sides (Fig. 9-1).
PROCEDURE
Palpate the entire length of the sternum for tenderness or abnormality (Fig. 9-2). Also palpate the
costal margins and sternal clavicular articulations for tenderness, pain, and displacement (Fig. 9-3).
Pain and tenderness following trauma may indicate a fractured sternum or bruised costal cartilages.
Tender sternocostal or sternoclavicular articulations may indicate a sprain or subluxation of the sus­
pect articulation.
Acromioclavicular -����
joint
S tern ocostal """"",,-INiI�----'h
articulations
Acromion process
Coracoid process
"':'£==:;'i?"M
"--7f:�Hlr�ri1F-- anubrium
Body
Costal cartilages �--w....
Sternum
�=-'�!!!b::-if'-+HIt-Xi phoid process
-1+!t----".M�--,!<WII'--Vertebral column
Costochondral
articulations
Anterior View
Figure 9-1
Figure 9-2
Figure 9-3
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
231
Ribs, Costal Cartilages, and Intercostal Spaces
DESCRIPTIVE ANATOMY
The ribs at the anterior aspect of the rib cage are attached to the sternum by costal cartilages, form­
ing the costochondral articulation. They also articulate with the sternum, forming the sternocostal
articulations (Fig. 9-4).
PROCEDURE
Palpate each costal cartilage with its associated rib from the lateral aspect of the sternum laterally to
the axilla. Then palpate into each intercostal space (Fig. 9-5). Tender costal cartilages may indicate
costochondritis (Tietze's syndrome). Tender intercostal spaces may indicate an irritated intercostal
nerve or a herpes zoster viral infection. Associated with this infection may be red vesicular eruptions
along the course of the intercostal nerve in the intercostal space. Tenderness that follows trauma may
indicate a fractured rib.
Sternocostal
articulation --fiH;ffi
Costochondral ���!IP�;;;j��
articulation
Figure 9-4
Figure 9-5
232
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Posterior Aspect
Scapula
DESCRIPTIVE ANATOMY
At the posterior aspect of the thorax, the scapula articulates with the posterior aspect of the ribs. It
also forms part of the glenoid fossa, which articulates with the head of the humerus. On the anterior
aspect, the acromion articulates with the clavicle, forming the acromioclavicular joint. The scapula
normally extends from T2 to T7. It has three borders: medial, lateral, and superior (Fig. 9-6).
PROCEDURE
Starting with the medial border, palpate all three borders, noting any tenderness (Figs. 9-7 to 9-9).
Next, palpate the spine of the scapula, noting any tenderness or abnormality (Fig. 9-10). Finally, pal­
pate the posterior surfaces above the spine of the scapula for the supraspinatus muscle (Fig. 9-11)
and below the spine for the infraspinatus muscle (Fig. 9-12). Note any tenderness, atrophy, or spasm.
Clavicle
----::2l;;����
Superior
border
"'--:::'?"""""r'i"'�...---Spine of scapula
P'--'""'-4t-Glenoid fossa
Medial-i+--H-""""�""-+'"
....­
border
Humerus
Lateral
border
"--"R
""'-\-t-� ibs
Figure 9-6
\
,
Figure 9-7
Figure 9-8
Figure 9-9
Figure 9-10
Figure 9-11
Figure 9-12
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
233
Parathoracic Musculature
DESCRIPTIVE ANATOMY
The thoracic spinal muscles are arranged in three layers: superficial, intermediate, and deep. The su­
perficial layers include the trapezius, latissimus dorsi, levator scapulae, and rhomboid muscles (Fig.
9-13). The intermediate layer contains the serratus posterior, serratus superior, and serratus inferior
muscles (Fig. 9-14). The deep muscles of the back are ones that maintain posture and move the
spinal column. These muscles, the erector spinae group, consist of the spinalis, longissimus, and il­
iocostalis (Fig. 9-14).
PROCEDURE
Palpate the superficial layer by moving your fingers in a transverse fashion over the belly of the mus­
cle, noting any abnormal tone or tenderness (Fig. 9-15). Palpate the deep layer with the fingertips
directly adjacent to the spinous processes (Fig. 9-16), noting any abnormal tone or tenderness. Any
abnormal tone or tenderness may indicate an inflammatory process in the muscle, such as muscle
strain, myofascitis, or fibromyalgia.
--':'�--- Splenius capitus m.
Ir----""O""::--- Splenius cervicis m.
Deltoid m. -f+,:p....
�����-T-- Levator scapulae m.
�*---'\:'m���� Rhomboid m.
/�!j--"'t-I- Latissimus dorsi m.
Figure 9-1 3
234
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Superior -+-++--'---I'--�
serratus
posterior m.
Erector
spinae
group
{
Spinalis
Longissimus
Iliocostalis
posterior m.
T12
Figure 9-14
Figure 9-15
Figure 9-16
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
235
Spinous Processes
DESCRIPTIVE ANATOMY
The Tl to T12 vertebrae have relatively prominent spinous processes that are easily palpable (Fig.
9-17). The tip of each spinous process is below the transverse process of the same vertebra.
PROCEDURE
With the patient seated and thorax slightly flexed, palpate each spinous process with your index and
or middle finger, noting any pain, tenderness, and abnormal alignment. Each process should be pal­
pated individually (Fig. 9-18). Next, push each spinous process laterally, noting any rotational mo­
bility (Fig. 9-19). Tenderness upon static spinous palpation may indicate subluxation of a thoracic
vertebra. Tenderness secondary to flexion or extension injury may indicate supraspinous ligament
sprain, especially in the upper thoracic vertebra. Abnormal gross alignment may indicate scoliosis.
Posterior View
Lateral View
Superior ---fr­
articular
process
Transverse process
Inferior articular process
Inferior -=-"""
articular
process
��'!!.!\l!uge"'-��A,!.- Inferior costal facet
Spinous process
Transverse
process
process
Figure 9-17
Figure 9-1 8
Figure 9-19
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
236
Ribs and Intercostal Spaces
DESCRIPTIVE ANATOMY
The ribs at the posterior aspect of the rib cage are attached to the vertebral body and transverse
process by a capsule and a series of ligaments and muscles (Fig. 9-20). The ribs can bend slightly un­
der stress without breaking. Between the ribs in the intercostal spaces are three layers of intercostal
muscles and an intercostal nerve. This nerve can become infected with the herpes zoster virus, which
invades the spinal ganglia and produces sharp burning pain in the area supplied by the affected in­
tercostal nerve.
PROCEDURE
Palpate each individual rib from the lateral aspect of the spinal column laterally to the axilla. Then
palpate each intercostal space (Fig. 9-21). Tenderness or pain following trauma may indicate a frac­
tured rib. Tender intercostal spaces may indicate an irritated intercostal nerve or a herpes zoster vi­
ral infection. Associated with this infection may be red vesicular eruptions along the course of the
intercostal nerve in the intercostal space.
Costotransverse ligament
Superior costotransverse ligament
Figure 9-20
Figure 9-21
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
237
THORACIC RANGE OF MOTION
Flexion: Inclinometer Method (1)
With the patient seated, place one inclinometer in the sagittal plane at the Tl level and the other in­
clinometer at the T1 2 level, also in the sagittal plane (Fig. 9- 22). Zero out both inclinometers. Instruct
the patient to place hands on hips and to flex forward the thoracic spine (Fig. 9-23). Record both in­
clinations and subtract the Tl2 from the Tl inclination to arrive at the thoracic flexion angle.
NORMAL RANGE
Normal range is 50° or greater from the neutral or 0 position.
Muscles
Nerve Supply
Rectus abdominous
External abdominal oblique
Internal abdominal oblique
T6-Tl2
T7 -Tl2
T7-Tl2, Ll
Figure 9-22
Figure 9-23
238
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Lateral Flexion: Inclinometer Method (1)
With the patient standing, place one inclinometer flat against the Tl spinous process and the other flat
against the Ll spinous process (Fig. 9- 24). Zero out both inclinometers. Instruct the patient to flex the
thoracic spine to one side and then the other (Fig. 9-25) and record your findings. Subtract the Tlin­
clination angle from the TI2 inclination angle to arrive at your thoracic lateral flexion angle.
NORMAL RANGE
Normal range is 20° to 40° from the neutral or 0 position.
Muscles
Nerve Supply
Lateral Flexion to the Same Side
Iliocostalis thoracis
L ongissimus thoracis
Intertransversarii
Internal abdominal oblique
External abdominal oblique
Quadratus lumborum
Tl-Tl 2
Tl-Tl 2
Tl-Tl 2
Tl-Tl 2, Ll
T7-Tl 2
T7-Tl 2
Lateral Flexion to the Opposite Side
Semispinalis thoracis
Multifidus
Rotatores
External abdominal oblique
Transversus abdominis
Figure 9-24
Tl-Tl2
Tl-Tl2
Tl-Tl2
T7-Tl2
T7-Tl2, Ll
Figure 9-25
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
239
Rotation: Inclinometer Method (1)
With the patient seated, instruct the patient to flex forward as far as possible, bracing with the arms.
Place one inclinometer at the Tllevel and the other at the Tl2 level, both in the coronal plane (Fig.
9-26). Zero out both inclinometers. Instruct the patient to rotate the trunk to one side; record both
Tl and Tl2 inclinations (Fig. 9-27). Subtract the Tl2 from the Tlinclination to arrive at the tho­
racic rotation angle. Perform this measurement with rotation to the opposite side.
NORMAL RANGE
Normal range is 30° or greater from the neutral or 0 position.
Muscles
Nerve Supply
Rotation to Same Side
Iliocostalis thoracis
Longissimus thoracis
Intertransversarii
Internal abdominal oblique
Tl-Tl2
Tl-Tl2
Tl-Tl2
Tl-Tl2, Ll
Rotation to Opposite Side
1.
2.
3.
4.
5.
Semispinalis thoracis
Multifidus
Rotatores
External abdominal oblique
Transversus abdominis
Figure 9-26
Figure 9-27
Tl-Tl2
Tl-Tl2
Tl-Tl2
Tl-Tl2
Tl-Tl2, Ll
IJ
240
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
SCOLIOSIS! KYPHOSIS SCREENIN G
CLINICAL DESCRIPTION
Scoliosis is an abnormal spinal deformity in the coronal plane (Fig. 9-28). It is progressive until skeletal
maturity and is the most common type of spinal deformity. Hyperkyphosis is an abnormal spinal de­
formity in the sagittal plane that increases the posterior convex angulation (Fig. 9-29). These deformi­
ties can be congenital or acquired and are more prevalent in females than in males. Some of the prob­
lems associated with spinal deformities are pain, diminished pulmonary function, neurological
compromise, and loss of self-image. Spinal deformities are best evaluated through radiography. Mea­
surement of the scoliotic curve is accomplished using the Cobb-Lippman technique (2). A line is drawn
at the superior end plate at the top of the curve, where the angle of inclination toward the concavity of
the curve is most acute. Then draw a line at the inferior end plate at the bottom of the curve. Tangen­
tial lines are drawn to these end plates and the angle at their intersection is measured (Fig. 9-30).
CLINICAL SIGNS AND SYMPTOMS
Visual deformity
Paraspinal pain
Diminished pulmonary function
Neurological compromise
Figure 9-28
Figure 9-29
Figure 9-30
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
Adam's Position
241
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient standing, stand directly behind the patient and inspect and palpate the entire
length of the spine, looking for scoliosis, hyperkyphosis, or kyphoscoliosis (Fig. 9-31). Next, instruct
the patient to flex forward at the hips. Again, inspect and palpate for scoliosis, kyphosis, or
kyphoscoliosis (Fig. 9-32).
RATIONALE
If scoliosis, kyphosis, or kyphoscoliosis is present with the patient standing and if the angle reduces
upon forward flexion, the scoliosis is a functional adaptation of the spine and surrounding soft tis­
sue structures. It may be caused by poor posture, overdevelopment of unilateral spinal and/or up­
per extremity musculature, nerve root compromise, leg length deficiency, or hip contracture. This
type of scoliosis is usually mild to moderate, measuring less than 25°.
If scoliosis, kyphosis, or kyphoscoliosis is present with the patient standing and if the angle does
not reduce upon forward flexion, suspect a structural deformity, such as hemivertebra, compression
fracture of a vertebral body, or idiopathic scoliosis.
Figure 9-31
Figure 9-32
242
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
McKenzie's Slide Glide Test (2)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
I
I
4
With the patient standing, stand to one side of the patient. With your shoulder, block the thoracic
spine. With both hands, grasp the patient's pelvis and pull it toward you; hold this position for 10 to
15 seconds (Fig. 9-33). Repeat this test to the opposite side. If the patient has evident scoliosis, the
side toward which the spine curves should be tested first.
RATIONALE
This test is performed on patients with symptomatic scoliosis. Blocking the shoulder and moving
the pelvis stress the area of the scoliosis. If the symptoms increase on the affected side, the scoliosis
is contributing to the patient's symptoms.
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiography
Anteroposterior (AP) thoracic view
Lateral thoracic view with concavity toward the bucky
AP thoracolumbar view
Figure 9-33
CHAPTER 9
THORACIC ORTHOPAEDIC TESTS
243
THORACIC FR ACTURES
CLINICAL DESCRIPTION
Fractures of the thoracic spine are categorized as anterior or posterior. The anterior aspect of the
spine is the vertebral body, and the posterior aspect consists of the posterior arch, facet joints, and
spinous processes. Fractures of the thoracic spine may disrupt the spinal canal, which may lead to
neurological compromise. If disruption of the spinal canal is compromised, neurological evaluation
is essential. Plain radiographs in both the AP and lateral planes should be reviewed. In the AP view
you may visualize fracture lines and abnormalities in alignment, angulation, or translation. In the
lateral view, you may visualize fracture lines, alignment, angulation, and translation.
CLINICAL SIGNS AND SYMPTOMS
Thoracic pain
Anterior chest pain
Upper extremity neurological compromise
Lower extremity neurological compromise
Spinal Percussion Test (3,4)
Sensitivity/Reliability Scale
I
o
PROCEDURE
!
I
1
!
I
2
!
I
3
!
I
4
With the patient sitting and head slightly flexed, percuss the spinous process (Fig. 9-34) and associ­
ated musculature (Fig. 9-35) of each of the thoracic vertebrae with a neurological reflex hammer.
RATIONALE
Local pain may indicate a fractured vertebra without neurological compromise or ligamentous
sprain. Radicular pain may indicate a fractured vertebra with neurological compromise or a disc de­
fect with neurological compromise.
NOTE
This test is not specific; other conditions will also elicit a positive pain response. A ligamentous
sprain will cause a positive sign on percussion of the spinous processes. Percussing the paraspinal
musculature will elicit a positive sign for muscular strain.
Figure 9-34
Figure 9-35
244
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Soto-Hall Test (5)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
I
I
3
I
With the patient supine, assist him or her in flexing the chin to the chest (Fig. 9-36).
RATIONALE
Local pain indicates osseous, discal, or ligamentous pathology. This test is nonspecific. It merely iso­
lates the cervical and thoracic spine in passive flexion. If this test is positive, perform tests for strain,
sprain, fractures, and space-occupying lesions.
Figure 9-36
Sternal Compression Test
Sensitivity/Reliability Scale
I
PROCEDURE
o
I
1
I
2
I
3
I
I
4
With the patient supine, push down on the sternum (Fig. 9-37).
RATIONALE
Pressure to the sternum compresses the lateral borders of the ribs. If a fracture is sustained at or near
the lateral border of the ribs, the pressure on the sternum will cause the fracture to become more
pronounced, producing or exacerbating pain in the area of the fracture.
NOTE
Be cautious if you suspect a fractured rib, especially if it is displaced. If trauma has occurred and you
suspect a fractured rib, the area should be radiographed before this test.
SUGGESTED DIAGNOSTIC IMAGING
Plain film radiography
AP thoracic view (spine)
AP thoracic view (ribs)
Posteroanterior (PA) chest
Lateral thoracic view (spine)
Breathing lateral thoracic
Oblique thoracic (ribs)
Computed tomography (CT)
Bone scan
Figure 9-37
CHAPTER 9
245
THORACIC ORTHOPAEDIC TESTS
NERVE ROOT LESIONS
CLINICAL DESCRIPTION
Thoracic nerve roots lesions may be due to a thoracic trauma. There is greater mobility at the tho­
racolumbar junction (Tll-T12) than at Tl to Tl O because of the afforded stabilization of the rib
cage. That is why there is a greater chance of injury between TlO and Tl2.
Thoracic injuries include wedge fractures, burst fractures, and fracture-dislocations. Any of
these injuries may lead to a nerve root lesion in the thoracic spine. Compression by a mass or tumor
in the spine may also lead to neurological compromise.
CLINICAL SIGNS AND SYMPTOMS
Thoracic pain
Anterior abdominal pain
Loss of abdominal sensation
Passive Scapular Approximation Test (6)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient standing, grasp the patient's shoulders (Fig. 9-38). Passively approximate the scapu­
lae by pushing the shoulders backward (Fig. 9-39).
RATIONALE
Passively approximating the scapulae places motion-induced traction on the Tl and T2 nerve roots.
Pain in the scapular area indicates a Tl and/or T2 nerve root compression or irritation.
Figure 9-38
Figure 9-39
246
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Beevor's Sign (7)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
I
With the patient supine, instruct the patient to hook the fingers behind the neck and raise the head
toward the feet. This test should mimic a sit-up (Fig. 9-40).
RATIONALE
The umbilicus of the patient who has no thoracic root lesion will not move during this test because
the abdominal muscles are equally innervated and of equal strength. If a root lesion is present, the
umbilicus will move in the following manner:
If the umbilicus moves superiorly, suspect a bilateral TlO to TI2 nerve root lesion. If it moves
superiorly and laterally, suspect a unilateral TID to TI2 nerve root lesion on the opposite side. If the
umbilicus moves inferiorly, suspect a bilateral T7 to TID nerve root lesion. If it moves inferiorly and
laterally, suspect a unilateral T7 to TID nerve root lesion on the opposite side.
Figure 9-40
CHAPTER 9
247
THORACIC ORTHOPAEDIC TESTS
Schepelmann's Sign
Sensitivity/Reliability Scale
I
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the seated patient to flex at the waist to the left and right (Fig. 9-41).
RATIONALE
Pain on the side of lateral bending indicates intercostal neuritis. Pain on the convex side indicates fi­
brous inflammation of the pleura or intercostal sprain. When the patient bends sideways, the inter­
costal nerves on the side of bending are compressed. If the intercostal nerves are irritated, pain on
the side of bending will be elicited. Also, when the patient bends sideways, the pleura is stretched on
the opposite side of bending. If the pleura is inflamed, pain will be elicited opposite the side of bend­
ing. Pain may also be elicited because of injury to or spasm of the thoracic or intercostal muscles.
Figure 9-41
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP thoracic view
AP lumbar view
Lateral thoracic view
Lateral lumbar view
Lumbar oblique views
Thoracolumbar MRI
CT
Bone scan
248
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
COSTOVERTEBRAL JOINT ANKYLOSIS
CLINICAL DESCRIPTION
Costovertebral joint ankylosis is stiffness or fixation of the costovertebral joints associated with
ankylosing spondylitis. This is a chronic seronegative inflammatory disease that affects the axial
skeleton. The prevalence is 1 to 3 per 1000 people; it is more common in females than in males. It
affects not only the costovertebral joints but also the sacroiliac and hip joints. The disease, which
usually starts in the lumbar spine and migrates cephalad to the cervical spine, is a slowly progress­
ing one that takes decades to develop.
CLINICAL SIGNS AND SYMPTOMS
Lumbar and thoracic pain
Lumbar and thoracic stiffness
Improved symptoms during activity
Loss of kyphosis
Chest tightness
Limited chest expansion
Chest Expansion Test (8)
PROCEDURE
With the patient seated, place a tape measure around the patient's chest at the level of the nipple. In­
struct the patient to exhale, and record the measurement (Fig. 9-42). Next, instruct the patient to in­
hale maximally; record the measurement (Fig. 9-43).
RATIONALE
The normal chest expansion for a man is 2 inches or more. The normal chest expansion for a woman
is 1 inch or more. A decrease in the normal chest expansion indicates an ankylosing condition, such
as ankylosing spondylitis at the costotransverse or costovertebral articulation.
Figure 9-42
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiology
AP lumbar view
AP thoracic view
Lateral lumbar view
Lateral thoracic view
Figure 9-43
CHAPTER 9
References
249
THORACIC ORTHOPAEDIC TESTS
General References
1. American Medical Association. Guides to the
Boissonault WG. Examination in Physical Therapy
Evaluation of Permanent Impairment. 5th ed.
Practice. Screening for Medical Disease. New York:
Chicago: AMA, 2000.
Churchill Livingstone, 1991.
2. McKenzie RA. The Lumbar Spine: Mechanical
Diagnosis and Therapy. Waikanae, New Zealand:
Spinal Publications, 1981.
3. O'Donoghue D. Treatment of injuries to ath­
letes. 4th ed. Philadelphia: Saunders, 1984.
4. Turek SL. Orthopaedics. 5th ed. Philadelphia:
Lippincott, 1977.
5. Soto-Hall R, Haldeman K. A useful diagnostic
sign in vertebral injuries. Surg Gynecol Obstet:
1972; 827-831.
6. Cyriax J. Textbook of Orthopaedic Medicine.
Vol 1. Diagnosis of Soft Tissue Lesions. London:
Bailliere Tindall, 1982.
7. Rodnitzky RC. Van Allen's Pictorial Manual of
Neurological Tests. 3rd ed. Chicago: Year Book
Medical, 1989.
8. Moll JMH, Wright V. An objective clinical study
of chest expansion. Ann Rheum Dis 1982;31:
1-9.
Cyriax JH. Cyriax's Illustrated Manua.l of
Or­
thopaedic Medicine. 2nd ed. London: Butterworth,
1993.
Goodman CC, Snyder TE. Differential Diagnosis in
Physical Therapy. Philadelphia: Saunders, 1990.
Kapandji IA. The physiology of joints. Vol. 3. The
Trunk
and the Vertebral
Column.
New York:
Churchill Livingstone, 1974.
Moore Kl. Clinically oriented anatomy. 3rd ed. Bal­
timore: Williams & Wilkins, 1992.
Post M. Physica.l exami11ation of the musculoskele­
tal system. Chicago: Year Book Medical, 1987.
Skinner HB. Current Diagnosis & Treatment i11 Or­
thopedics. 2nd ed. New York: Lange, 2000.
White AA. Kinematics of the normal spine as related
to scoliosis. J Biomech Engl 1971;4:405.
--------���-LUMBAR ORTHOPAEDIC TESTS
LUMBAR ORTHOPAEDIC EXA MINATION
251
FLOW CHART
PALPATION
252
252
Quadratus Lumborum
Gluteal Muscles
253
254
255
256
257
Piriformis Muscle
Sciatic Nerve
LUMBAR RA NGE OF MOTION
258
258
Extension
259
Flexion
Lateral Flexion
260
JOINT DYSFUNCTION TESTS
Segmental Instability Test
261
263
One Leg Standing Lumbar Extension
264
265
LUMBAR NERVE ROOT AND SCIATIC
NERVE IRRITATION/COMPRESSION
266
Straight Leg Raising Test
Slump Test
250
267
268
266
285
Valsalva's Maneuver
Milgram's Test
265
Spinal Percussion Test
285
SPACE-OCCUPYING LESIONS
Dejerine's Triad
LUMBAR FRACT URES
Lasegue's Test
271
Sicard's Test
272
Fajersztajn's Test
273
Bechterew's Test
274
Minor's Sign
275
Knee Flexion Test
276
A ntalgic Lean Sign
277
Bowstring Sign
279
Sciatic Tension Test
280
Piriformis Test
281
Gluteal Skyline Test
281
Kemp's Test
282
Lindner's Sign
283
Heel-Toe Walk Test
284
Bragard's Test
Intrinsic Spinal Muscles
TESTS
270
Femoral Nerve Traction Test
Spinous P rocesses
Test
270
Buckling Sign
Naffziger's Test
286
286
287
DIFFERENTIAL DIAGNOSIS: LUMBAR
VERSUS SACROILIAC INVOLVEMENT
Goldthwaith's Test
Supported Forward Bending Test
Nachlas Test
288
288
290
Sign of the Buttock Test
291
289
Lumbar Orthopaedic Examination
t
Low back pain
with leg pain
Trauma induced/
No trauma induced
Low back pain
No leg pain
Trauma induced
Range of motion
(active)
(passive)
Goldthwaith's test
Supported forward
bending test
".�E-----1
Nachlas test
Sign of the
buttock test
Pheasant test
Segmental instability test
One leg standing lumbar
Extension test
Spondylosis
Spondylolisthesis
See sacroiliac
examination
�
Strain/Sprain
Disc defect
,.
(+)
m
[MRJ
....
.;------j
Valsalva's test
Dejerine's triad
Milgram's test
Naffziger's test
Nerve root
compression
I. (+)
Straight leg
raising test
Bragard's test
Buckling sign
Sicard's test
Turyn's test
Fajersztajn's test
Bechterew's test
Minor's sign
Bowstring sign
Sciatic tension test
Piriformis test
Kemp's test
Lindner's test
Gluteal skyline test
(J
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:>;<l
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::j
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252
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PALPATION
Spinous Processes
DESCRIPTIVE ANATOMY
The five lumbar spinous processes are large and easily palpable with the spinal column in the flexed
position (Fig.
1 0- 1 ). The fifth lumbar vertebra is the lowest movable segment.
In
5% of the popula­
tion, the fifth lumbar vertebra is congenitally fused to the sacrum, a condition called sacralization.
The person with this condition has only four palpable lumbar spinous processes. In other people,
the first sacral segment is not fused to the other segments. This condition is caJled lumbarization,
and six spinous processes may be palpable in the lumbar spine. A common abnormality in the lum­
bar spinous processes is spina bifida, a congenital defect found in
10% of the population. Spina bi­
L5
L5 or L5 to Sl interval is spondylolis­
fida results from a failure of the vertebral arches to grow together and ossify. It is prevalent in the
or Sl segment. Another common abnormaJity in the
L4
to
thesis. This is a fracture of the pars interarticularis that can cause forward movement of one verte­
bra on another.
PROCEDURE
With the patient seated and flexed forward, palpate each spinous process with your index finger and
forefinger (Fig.
1 0-2) . First
look for any irregularities, such as spondylolisthesis, spina bifida, lum­
barization, or sacralization. Next, place anterior pressure on each process with your thumb (Fig.
1 0-3) and note any rigidity or springing. Rigidity may indicate hypomobility and springing may in­
dicate hypermobility.
Spinal column
in flexion
Lateral View
Figure 10-1
Figure 10-2
Figure 10-3
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
253
Intrinsic Spinal Muscles
DESCRIPTIVE ANATOMY
The intrinsic muscles in the lumbar spine are the erector spinae group (spinalis, longissimus, and ilio­
costalis). In the lower spine, these muscles come together to form the sacrospinalis group (Fig.
10-4) .
PROCEDURE
With the patient prone, palpate the lumbar portions of the erector spine group diagonally from me­
dial to lateral (Fig.
1 0-5) .
Note any tenderness, inflammation, muscle spasm, or palpable bands,
which may indicate muscle strain, myofascitis, fibromyalgia, or active trigger points.
Superior -+-+<-.>.....,1"--,
serratus
posterior m.
Erector
spinae
group
{
Spinalis
Longissimus
Rotatores m.
T4
Iliocostalis
Semispinalis
thoracicis m.
serratus
posterior m.
T12
Figure 10-4
Figure 10-5
254
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Quadratus Lumborum
DESCRIPTIVE ANATOMY
The quadratus lumborum is lateral to the thoracolumbar fascia. It is attached to the transverse
processes of the lumbar vertebra, the iliac crest, and the 1 2th rib ( Fig. 1 0-6). It is a common site for
myofascial lower back pain.
PROCEDURE
With the patient prone, palpate the quadratus lumborum from the 1 2th rib to the iliac crest (Fig.
10-7). This muscle is lateral to the erector spinae group. Note any tenderness, inflammation, muscle
spasm, or palpable bands, which may indicate a muscle strain, myofascitis, fibromyalgia, or active
trigger points.
Quadratus
lumborum m.
Transverse
\rr"""-H�::;:"- processes
of vertebrae
Iliac
crest
Iliacus m.
Inguinal
ligament
.1
Figure 10-6
Figure 10-7
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
255
Gluteal Muscles
DESCRIPTIVE ANATOMY
The gluteal muscles consist of the gluteus maximus, gluteus medius, and gluteus minimus. These
muscles extend, abduct, and rotate the thigh. They all originate from the ilium and insert into the
femur (Fig. lO-8) . They can be tender and spastic secondary to trauma. Pain can be referred to the
gluteal muscles from a defect in an intervertebral disc, and they can lose muscle tone because of
nerve root involvement. The gluteal muscles may have active myofascial trigger points that can re­
fer pain to the posterior thigh, similar to a sciatic pain pattern from an L5-S 1 disc defect with nerve
root compression.
PROCEDUR!
With the patient prone, palpate using strong pressure, starting just lateral to the sacrum and mov­
ing toward the greater trochanter of the femur (Fig. lO-9). Note any tenderness, spasm, loss of mus­
cle tone, and tender trigger points. Tenderness and spasm secondary to trauma may indicate a mus­
cle strain. A herniated intervertebral disc with nerve root compression may also cause tenderness
and spasm to the area. An active myofascial trigger point may cause local tenderness with a referred
component to the posterior thigh.
Gluteus
maximus m.
Gluteus
medius m.
Superior
gluteal
E
artery
Inferior
gluteal
artery
Obturator
Sciatic
nerve
intern us m.
Inferior
gemellus m.
Quadratus
femoris m.
Adductor
mag nus m.
Biceps
Figure 10·8
Figure 10·9
femoris m.
256
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Piriformis Muscle
DESCRIPTIVE ANATOMY
The piriformis muscle is clinically significant because of its proximity to the sciatic nerve (Fig.
1 0-8) . It may become inflamed and spastic and compress the sciatic nerve, causing pain along the
entire course of the nerve. It originates from the sacrum and inserts into the greater trochanter of
the femur.
PROCEDURE
To locate the piriformis, bisect the tip of the coccyx and the posterior superior iliac spine (Fig.
1 0- 1 0). This is the inferior border of the piriformis. Palpate the muscle, noting any tenderness or
spasm (Fig. 1 0- 1 1 ). If the patient has lower extremity radicular pain, note whether palpation of the
piriformis increases that pain. Tenderness and spasm in the piriformis may indicate muscle strain
caused by overuse. Because of the proximity of the sciatic nerve to this muscle, a radicular compo­
nent to the posterior thigh may also be involved. A local tender area may indicate an active myofas­
cial trigger point, which may also cause a radicular pain to the posterior thigh.
Figure 10-10
Figure 10-11
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
257
Sciatic Nerve
DESCRIPTIVE ANATOMY
The sciatic nerve is composed of the nerve roots from L4 to 53. The nerve runs through the greater
sciatic foramen of the pelvis through the gluteal muscles and below the piriformis (see Fig. 1 0-8) .
Once it passes the piriformis, it runs deep to the gluteus maximus midway between the greater
trochanter and the ischial tuberosity. In some cases, the sciatic nerve pierces the piriformis muscle
rather than passing below it.
PROCEDURE
Starting midway between the greater trochanter and the ischial tuberosity, palpate the sciatic nerve
and follow the nerve as far down the lower extremity as possible (Fig. 1 0-l2). Note any tenderness,
burning, or inflammation. If the patient has any tenderness, burning, or referred pain into the ex­
tremity, suspect an irritation of the sciatic nerve.
Figure 10·12
258
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
LUMBAR RANGE OF MOTION
Flexion: Inclinometer Method (1)
With the patient standing and the lumbar spine in the neutral position, place one inclinometer over
the T 1 2 spinous process in the sagittal plane. Place the second inclinometer at the level of the
sacrum, also in the sagittal plane (Fig. 1 0- 1 3 ) . Zero out both inclinometers. Instruct the patient to
flex the trunk forward. Record the inclinations of both inclinometers (Fig. 10- 1 4). Subtract the
sacral inclination from the T 1 2 inclination to obtain the lumbar flexion angle.
NORMAL RANGE (2)
Female aged 15-30
Female aged 3 1 -60
Female aged> 6 1
Male aged 1 5-30
Male aged 3 1 -60
Male aged> 6 1
Muscles
Nerve Supply
Psoas major
Rectus abdominis
External abdominal oblique
Internal abdominal oblique
Transversus abdominis
11 -L3
T6-Tl2
T7-T l2
T7-T l2,11
T7-T l2,11
Figure 10-13
Figure 10-14
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
259
Extension: Inclinometer Method (1)
With the patient standing and the lumbar spine in the neutral position, place one inclinometer
slightly lateral to the T 1 2 spinous process in the sagittal plane. Place the second inclinometer at the
sacrum, also in the sagittal plane (Fig. 1 0- 1 5 ) . Zero out both inclinometers. Instruct the patient to
extend the trunk backward. Record the inclination of both inclinometers (Fig. 1 0-16). Subtract the
sacral inclination from the T 1 2 inclination to obtain the lumbar extension angle.
NORMAL RANGE (2)
Male aged 1 5-30
Male aged 3 1 -60
Male aged> 6 1
38°
35°
33°
Muscles
Nerve Supply
Latissimus dorsi
Erector spinae
Transversospinalis
Interspinalis
Quadratus lumborum
C6-C8
L l-L3
L l-Ls
L l-Ls
T l2, L l-L4
Figure 10-15
Female aged 1 5-30
Female aged 3 1 -60
Female aged> 6 1
Figure 10-16
42°
40°
36°
260
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Lateral Flexion: Inclinometer Method (1)
With the patient standing and the lumbar spine in the neutral position, place one inclinometer flat
at the T 1 2 spinous process in the coronal plane. Place the second inclinometer at the superior aspect
of the sacrum, also in the coronal plane (Fig. 1 0- 1 7). Zero out both inclinometers. Instruct the pa­
tient to flex the trunk to one side. Record the inclination of both inclinometers (Fig. 10- lS). Sub­
tract the sacral inclination from the T 1 2 inclination to obtain the lumbar lateral flexion angle. Per­
form measurements for both right and left lateral flexion.
NORMAL RANGE (3,4)
Male aged 20-29
Male aged 3 1 -60
Male aged> 6 1
3S0 :±::5 .S
29° :±::6 .5
1 9° :±::4.S
Female aged 1 5-30
Female aged 3 1 -60
Female aged> 61
Muscles
Nerve Supply
Latissimus dorsi
Erector spinae
Transversospinalis
Intertransversarii
Quadratus lumborum
Psoas major
External abdominal oblique
C6-CS
L l-L3
L l-L5
L l-L5
T l2, L l-L4
L l-L3
T7-T l2
Figure 10-17
Figure 10-18
35° :±::6 .4
30° :±::5 .S
23° :±::5 .4
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
261
JOINT DYSFUNCTION TESTS
CLINICAL DESCRIPTION
Joint dysfunction may involve the forward displacement of one vertebra on another. These defects
may be congenital or traumatic. A defect with no forward movement of one vertebra on another is
a spondylolysis (Fig. 1 0- 1 9). A defect with forward movement is a spondylolisthesis (Fig. 1 0-20) . A
spondylolisthesis is graded according to the amount of forward movement of one vertebra on an­
other (Box 10- 1 ). Spondylolisthesis is more common in males than in females and occurs 85% to
90% of the time at the L5-S1 level. There are five recognizable clinical groups of spondylolisthesis
(Box 10-2). The most common is the type II lesion, called isthmic. This defect of the pars interar­
ticularis allows for forward migration of one vertebra on another.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Asymptomatic
Lower back pain (mild to acute disabling)
Rigid lumbar spine
Functional scoliosis
Lower extremity radicular pain (rare)
Figure 10-19. Reprinted with permission from
Yochum TR, Rowe LJ. Essentials of Skeletal
Radiology. Vol 1. ed 2. Baltimore: Williams & Wilkins,
1996;244.
Figure 10-20. Reprinted with permission from
Yochum TR, Rowe LJ. Essentials of Skeletal Radiology.
Vol 1. ed 2. Baltimore: Williams & Wilkins, 1996;244.
I
I
I
I
262
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Spondylolisthesis Grades
Grade
Grade
0-25% forward movement
25-50 % forward movement
50-75% forward movement
75-100% forward movement
1
2
Grade 3
Grade
4
Reprinted with permission from Myerding H. Spondylolisthesis: Surgical treat­
ment and results. Surg Gynecol Obstet 1932;54:371-377
Clinical Groups of Spondylolisthesis
Type
Description
I.
Dysplastic
Congenital malformations of primarily the superior sacral
facets or the arch of
L5
vertebra, which allows
spondylolisthesis.
II.
Isthmic
Common in both children and adults, this lesion or
defect in the pars interarticularis allows anterior vertebral
migration, typically of
1.
2.
L5.
Three types are described:
Lytic: resulting from a fatigue of the pars interarticularis
Elongated pars interarticularis: The pars interarticularis is
intact
3.
Fracture
III.
Degenerative
Secondary to longstanding segmental instability with
IV.
Traumatic
V.
Pathological
j oint
degeneration. Occurs most frequently at
L4-L5.
Secondary to fractures not involving the pars
interarticularis.
Local or general structural weakness secondary to bone
disease.
Modified with permission from Wiltse LL, Newman PH, MacNab I. Classification of spondylolysis and spondy­
lolisthesis. Clin Orthop ReI Res 1976;117-123.
CHAPTER 10
Segmental Instability Test (5)
Sensitivity/Reliability Scale
I
o
PROCEDURE
263
LUMBAR ORTHOPAEDIC TESTS
I
1
I
2
I
3
I
4
Place the patient prone with the legs over the examination table and the feet resting on the floor.
Press down on the lumbar spine (Fig. 1 0-2 1 ). Next, instruct the patient to lift the legs off the floor,
and again press down on the lumbar spine (Fig. 10-22).
RATIONALE
When the patient lifts the legs off the floor, the lumbar paravertebral muscle tightens, causing mus­
cle guarding in the lumbar spine. The test is positive if pain is elicited when pressure is applied to
the lumbar spine with the feet on the floor and the pain disappears when the feet are off the floor
and the paravertebral muscles are tightened. Raising the feet off the floor allows the mechanical
muscle guarding to protect the underlying lumbar instability, such as a spondylolisthesis.
Figure 10-21
Figure 10-22
264
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
One Leg Standing Lumbar Extension Test (6-8)
Sensitivity/Reliability Scale
I
a
PROCEDURE
I
1
I
2
I
3
I
I
Instruct the patient to stand on one leg (Fig. 1 O-23)and extend the lumbar spine. Be close to the pa­
tient to provide support if the patient loses balance (Fig. 1 0-24). Repeat the test with the opposite leg.
RATIONALE
Standing on one leg with lumbar extension increases the pressure to the pars interarticularis. If the
pars interarticularis is fractured, lumbar pain will be produced or increased. This indicates spondy­
lolysis or spondylolisthesis.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP lumbar view
Lateral lumbar view
Lumbar oblique views
Sacral base view
Computed tomography (CT)
Single proton emission computed tomography ( SPECT)
Figure 10·23
Figure 10·24
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
265
LUMBAR FRACTURES
CLINICAL DESCRIPTION
Fractures of the lumbar spine can be caused by trauma or deterioration of osteoporotic bone. The
two most common types of fracture in the lumbar spine are the compression, or burst, fracture and
the fracture-dislocation. The compression fracture, which can be traumatic or osteoporotic, may be
stable or unstable. The stable fracture involves only the vertebral bodies; the posterior elements are
intact. An unstable compression fracture involves both the vertebral bodies and the posterior ele­
ments of the vertebra. The degree of neurological damage depends on the size of the bone fragment
and degree of displacement of the spinal canal.
Fracture-dislocations are a result of severe forces in flexion and rotation and are associated with
multiple other traumatic injuries, such as severe abdominal or spinal trauma, in which the posterior
elements are affected. This usually causes a high percentage of severe neurological compromise.
CLINICAL SIGNS AND SYMPTOMS
•
•
Lower back pain
Lower extremity neurological compromise
Spinal Percussion Test (9,10)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
I
2
I
I
4
With the patient seated and slightly bent forward, tap the spinous process (Fig. 1 0-25) and associ­
ated musculature (Fig. 1 0-26) of each of the lumbar vertebrae with a neurological reflex hammer.
RATIONALE
Local pain may indicate a fractured vertebra with no neurological compromise. Radicular pain may
indicate a fractured vertebra with neurological compromise or possibly a disc defect with neurolog­
ical compromise.
NOTE
This test is not specific, so other conditions also elicit a positive pain response. A ligamentous sprain
will cause a positive sign on percussion of the spinous processes. Percussion on the paraspinal mus­
culature will elicit a positive sign for muscular strain.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP lumbar view
Lateral lumbar view
CT
Bone scan
I
I
I
Figure 10-25
Figure 10-26
LUMBAR NERVE ROOT AND SCIATIC NERVE
IRRITATION/COMPRESSION TESTS
CLINICAL DESCRIPTION
Lower extremity pain may be referred from lumbopelvic tissues or viscera or radicular pain from the
nerve root complex of the spine. One of the features distinguishing between referred pain and radic­
ular pain is that in referred pain patterns, the spinal pain is more aggravating than the lower extrem­
ity pain. In radicular pain patterns the leg pain is more aggravating than the spinal pain. Also, referred
pain is poorly localized and dull, but radicular pain is sharp and well localized. One of the most im­
portant functions the clinician must perform is determination of the cause of lower extremity pain.
Is the pain referred or radicular? This section will deal only with neurogenic radicular pain patterns.
Neurogenic radicular lower extremity pain may be caused by any of several factors. The most com­
mon is tension, irritation, or compression of a lumbar nerve root or roots. The irritation or compres­
sion may occur within or outside of the spinal canal. Intraspinal canal compressions may be caused by
disc lesions, spinal stenosis, degenerative disc disease, hypertrophic changes, or spinal malignancy. Ex­
traspinal canal compression may be caused by muscle dysfunction or extradural defects or masses.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Lower back pain
Lower extremity radicular pain
Loss of lower extremity reflexes
Loss of lower extremity muscle strength
Loss of lower extremity sensation
Straight Leg Raising Test (I 1-14)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, place and zero out an inclinometer at the tibial tuberosity and raise the pa­
tient's leg to the point of pain or 90°, whichever comes first (Fig. 1 0-27).
RATIONALE
This test primarily stretches the sciatic nerve and spinal nerve roots at the L5, S l, and S2 levels. Be­
tween 70° and 90° of hip flexion, these nerve roots are fully stretched. If pain is elicited or exacer­
bated after 70° of hip flexion, suspect lumbar joint pain. At 35° to 70° of hip flexion, the sciatic nerve
roots tense over the intervertebral disc. If radicular pain begins or exacerbates at this level, suspect
sciatic nerve root irritation by intervertebral disc pathology or an intradural lesion. At 0 to 35° of
hip flexion, there is no dural movement, and the sciatic nerve is relatively slack. If pain begins or ex­
acerbates at this level, suspect extradural sciatic involvement, that is, spastic piriformis muscle or
sacroiliac joint lesions (Fig. 1 0-28). If dull posterior thigh pain is elicited, suspect tight hamstring
muscles. If you suspect intervertebral disc pathology, continue with Bragard's and Lasegue's tests
and evaluate the suspected neurological level (see Chapter 1 1 ).
Figure 10-27
Figure 10-28
CHAPTER 10
Lasegue's Test (15,16)
Sensitivity/Reliability Scale
I
o
PROCEDURE
267
LUMBAR ORTHOPAEDIC TESTS
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, flex the patient's hip with the leg flexed (Fig. 1 0-29). Keeping the hip flexed,
extend the leg (Fig. 1 0-30).
RATIONALE
This test is positive for sciatic radiculopathy when (a) no pain is elicited when the hip is flexed and
the leg is flexed or (b) pain is present when the hip is flexed and the leg is extended. When both the
hip and the leg are flexed, there is no tension on the sciatic nerve. When the hip is flexed and the leg
is extended, the sciatic nerve is stretched and, if irritated, will cause pain or will exacerbate existing
leg pain.
Figure 10-29
Figure 10-30
268
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Slump Test (17)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the patient to sit on the examination table with hands behind the back (Fig. 1 0-3 1 ). Instruct
the patient to slump forward while you hold the chin level to prevent cervical flexion (Fig. 1 0-32) .
Apply overpressure with one hand to the shoulder to maintain flexion and instruct the patient to
flex the cervical spine forward (Fig. 1 0-33) . Next, apply overpressure to the cervical spine so that the
cervical, thoracic, and lumbar spines are flexed (Fig. 1 0-34 ) . Instruct the patient to extend one leg
(Fig. 1 0-35); dorsiflex the foot of the extended knee with the patient holding the slumped position
(Fig. 1 0-36). Instruct the patient to extend the cervical spine (Fig. 1 0-37). Repeat the test on the op­
posite side and with both knees extended.
Figure 10·31
Figure 10-33
Figure 10-32
Figure 10-34
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
269
RATIONALE
Each phase of this test places on the spinal meningeal tract a motion-induced traction that increases
during each phase of the test. Pain at any phase may indicate meningeal tract irritation usually
caused by a disc defect. If the patient cannot extend the knee or extends the knee with pain or if the
pain increases with foot dorsiflexion, the test is positive, indicating increased tension in the neu­
romeningeal tract. The test is also positive if the knee cannot extend fully but increases with cervi­
cal extension. If symptoms are produced in any phase of the test, stop the test to prevent any undue
discomfort to the patient.
II
Figure 10-35
Figure 10-36
Figure 10-37
270
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Buckling Sign
Sensitivity/Reliability Scale
I
I
o
PROCEDURE
I
1
I
2
I
3
4
With the patient supine, perform a straight leg raising test (Fig. 10-38).
RATIONALE
This test exerts traction pressure on the sciatic nerve. The patient with severe sciatic radiculopathy
will flex the leg at the knee to reduce the traction (Fig. 10-39).
Figure 10-38
Figure 10-39
Femoral Nerve Traction Test (18)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient side-lying with the affected side up, instruct the patient to flex the unaffected ex­
tremity slightly at the hip and knee. Then grasp the affected leg and extend the hip 1 5° with the knee
extended (Fig. 1 0-40). Next, flex the knee to stretch the femoral nerve further (Fig. 10-4 1 ).
RATIONALE
Extension of the hip and flexion of the knee place traction pressure on the femoral nerve and nerve
roots of L2 to L4. Pain that radiates to the anterior medial thigh indicates an L3 nerve root problem.
Pain extending to the mid tibia indicates a L4 nerve root problem. This test may also cause con­
tralateral pain, indicating a nerve root compression or irritation on the opposite side.
Figure 10-40
Figure 10-41
CHAPTER 10
Bragard's Test (12)
LUMBAR ORTHOPAEDIC TESTS
271
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, raise the leg to the point of leg pain. Lower the leg 5° and dorsiflex the foot
(Fig. 1 0-42).
RATIONALE
The raising of the leg and dorsiflexion of the foot places traction pressure on the sciatic nerve. If the
dorsiflexion produces pain in the 0° to 35° range, suspect extradural sciatic nerve irritation. If pain
occurs with dorsiflexion of the foot at 35° to 70°, suspect irritation of the sciatic nerve roots from a
intradural problem, usually from an intervertebral disc lesion (see Straight Leg Raising Test). Dull
posterior thigh pain indicates tight hamstring muscles. If you suspect intervertebral disc pathology,
evaluate which neurological level is affected (see Chapter 1 1 ).
Figure 10-42
272
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sicard 's Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
4
Raise the supine patient's leg to the point of pain. Lower the leg 5° and dorsiflex the big toe (Fig. 10-43).
RATIONALE
Raising the leg and dorsiflexion of the big toe, place traction pressure on the sciatic nerve. If the dor­
siflexion produces pain in the 0° to 35° range, suspect extradural sciatic nerve irritation. If pain oc­
curs with dorsiflexion of the foot at 35° to 70°, suspect irritation of the sciatic nerve roots from an
intradural problem, usually from an intervertebral disc lesion (see Straight Leg Raising Test). Dull
posterior thigh pain indicates tight hamstring muscles. If you suspect intervertebral disc pathology,
evaluate which neurological level is affected (see Chapter 1 1 ).
Figure 10·43
CHAPTER 10
273
LUMBAR ORTHOPAEDIC TESTS
Fajersztajn's Test (19,20)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
With the patient supine, raise the unaffected leg to 75° or to the point of leg pain, and dorsiflex the
foot (Fig. 1 0-44).
RATIONALE
This test causes ipsilateral and contralateral stretching of the nerve roots (Fig. 1 0-45), pulling later­
ally on the dural sac. A positive sign is elicited if an increase in leg pain or pain is reproduced on the
affected leg side. This pain indicates a disc protrusion usually medial to the nerve root.
When the unaffected leg is raised, the nerve root on that side is stretched, causing the nerve root
on the opposite side to slide down and toward the midline (Fig. 10-46). If a medial disc protrusion
is present, this movement will increase tension on the nerve root opposite the side of hip flexion, in­
creasing the pain on the affected side. If pain decreases on the affected side when the unaffected leg
'
is raised, suspect a lateral disc protrusion, because the nerve root is being pulled away from the disc
(Fig. 10-47). If this test is positive, evaluate the neurological level affected (see Chapter 1 1).
Pull as
leg is
raised
Figure 10-44
Figure 10-45
Nerve
pulled
away
from
protrusion
Figure 10-46
Figure 10-47
274
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Bechterew's Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
I
4
Seat the patient with legs hanging over the examination table. Instruct the patient to extend one
knee at a time alternately (Fig. 10-48). If no positive response is elicited, instruct the patient to raise
both legs together (Fig. 1 0-49).
RATIONALE
With the patient seated and the leg flexed, the sciatic nerve is relatively slack. Extending the leg places
traction pressure on the sciatic nerve. If the patient cannot perform this test because of radicular
pain or performs the test but leans back, compression to the sciatic nerve or lumbar nerve roots, ei­
ther intradurally or extradurally, is indicated. This test is usually positive in disc protrusion cases.
Figure 10-48
Figure 10-49
CHAPTER 10
Minor's Sign
LUMBAR ORTHOPAEDIC TESTS
275
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
Instruct the seated patient to stand (Fig. la-50).
RATIONALE
The patient with sciatic radiculopathy will stand on the healthy side and keep the affected leg flexed
to decrease the tension on the sciatic nerve, hence relieve pain. The patient in Figure la-50 is
demonstrating sciatic radiculopathy down the left lower extremity.
Figure 10-50
276
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Knee Flexion Test (21)
Sensitivity/Reliability Scale
I
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the standing patient to bend forward (Fig. 1 0-5 1 ).
RATIONALE
The patient with sciatic radiculopathy will flex the affected leg while bending forward. Flexion of the
leg reduces the traction on the sciatic nerve, hence reduces the pain. The patient in Figure 1 0-52 is
demonstrating sciatic radiculopathy down the right leg.
Figure 10-51
Figure 10-52
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
Antaigic Lean Sign (13)
277
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
I
2
I
I
4
Either instruct the patient to stand or observe the patient standing (Fig. 10-53).
RATIONALE
Patients with disc protrusions that place pressure on a nerve root will lean in a direction that reduces
the mechanical pressure on the disc. If the disc protrusion is lateral to the nerve root, the patient will
lean away from the side pain (Fig. 1 0-54). Pain is relieved because when the patient leans away from the
lateral disc defect, the nerve root moves medially and away from the defect, reducing pressure on the
nerve root (Fig. 10-55). If the disc protrusion is medial to the nerve root, the patient will lean toward
Figure 10-53
Figure 10-55
Figure 10-54
278
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
the side of pain (Fig. 1 0-56). Pain of medial disc protrusion is relieved because when the patient leans
toward the side of pain, the nerve root moves laterally and away from the defect, reducing pressure on
the nerve root (Fig. 1 0-57). If the disc protrusion is central to the nerve root, the patient may asswne a
flexed posture (Fig. 1 0-58). This is because the posterior aspect of the disc is under traction, which may
reduce the surface area of the disc defect that comes in contact with the nerve root (Fig. 10-59).
Figure 10-56
Figure 10-57
Figure 10-58
Pressure
relieved
when
posterior
disc
tractioned
Figure 10-59
CHAPTER 10
Bowstring Sign (22)
279
LUMBAR ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
PROCEDURE
I
1
I
2
I
3
I
I
With the patient supine, place the patient's leg atop your shoulder. At this point, firm pressure
should be exerted on the hamstring muscles (Fig. 1 0-60). If pain is not elicited, apply pressure to the
popliteal fossa (Fig. 10-6 1 ).
RATIONALE
Pain in the lumbar region or radiculopathy is a positive sign of sciatic nerve compression, either in­
tradurally or extradurally. Applying pressure to the hamstring muscles or popliteal fossa increases
tension on the sciatic nerve, thus eliciting or exacerbating the patient's pain.
Figure 10-60
Figure 10-61
280
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sciatic Tension Test (23)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, passively extend the affected limb to the point of pain (Fig. 10-62). Lower
the limb below the point of pain and grasp the leg between your knees. With both hands, place pos­
terior to anterior pressure in the popliteal space (Fig. 1 0-63).
RATIONALE
Flexing the leg places traction pressure on the sciatic nerve. Lowering the leg reduces the traction; if
the sciatic nerve is irritated, the pain will ease. Placing additional pressure in the popliteal space with
your fingers increases the traction pressure on the sciatic nerve, causing radicular pain if the sciatic
nerve is irritated. An increase in pain indicates an irritation to the sciatic nerve, either intradurally
or extradurally.
Figure 10-62
Figure 10-63
CHAPTER 10
Piriformis Test (24)
281
LUMBAR ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
I
o
PROCEDURE
I
I
,
I
I
2
I
I
3
I
4
Instruct the patient to lie on his or her side close to the edge of the examination table. Have the
patient flex the hip and knee to 90°. Place your hand on the patient's pelvis for stabilization, and
with your opposite hand press down on the patient's knee (Fig. 10-64).
RATIONALE
This test stresses the external rotators and piriformis muscle. If the sciatic nerve passes through the
piriformis or if the piriformis is in spasm, it may impinge on the sciatic nerve and reproduce the
pain in the buttock or radicular pain in the extremity.
Figure 10-64
Gluteal Skyline Test (25)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
,
I
I
2
I
I
3
I
I
4
Instruct the patient to lie prone on the examination table, head straight and arms by the sides or
hanging down. Stand at the patient's feet and observe the height of the buttock. Instruct the patient
to contract each gluteal muscle (Fig. 1 0-65).
RATIONALE
The L5, S 1 , S2, and inferior gluteal nerves innervate the gluteal muscles. If the affected gluteal mus­
cle is flat and shows less contraction than the unaffected side, suspect damage to the L5, S l, S2, and
inferior gluteal nerve.
Figure 10-65
III
282
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Kemp's Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient either sitting or standing, stabilize the posterior superior iliac spine with one hand.
With your other hand, reach around to the front of the patient and grasp the shoulder. Passively
bend the dorsolumbar spine obliquely backward (Fig. 1 0-66).
RATIONALE
When the patient bends obliquely backward, the dural sac on the side of bending moves laterally. If
a lateral disc lesion is present, this movement will increase the nerve root tension over that disc le­
sion, producing pain in the lower back, usually with a radicular component on the side of oblique
bending (Fig. 10-67, left). On the side opposite the oblique bending, the dural sac moves medially.
If a medial disc lesion is present, this movement will increase the tension over that disc lesion, pro­
ducing pain in the lower back, usually with a radicular component on the side opposite the oblique
bending (Fig. 1 0-67, right). If the test is positive, evaluate the affected neurological level (see Chap­
ter 1 1). If the patient has local lower back pain with no radicular component, suspect lumbar mus­
cle spasm or facet capsulitis.
Figure 10-66
Medial Disc Protrusion
Lateral Disc Protrusion
Oblique
bending
Nerve /, .
compression
by lateral
disc -�=­
protrusion
Figure 10-67
Nerve
compression
by medial disc
protrusion
Left, lateral disk; right, medial disk.
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
Lindner's Sign
283
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
With the patient supine, passively flex the patient's head (Fig. 1 0-68).
RATIONALE
Passive flexion of the patient's head stretches the dural sac. Reproduction of the patient's pain indi­
cates a disc lesion at the level of pain. Sharp, diffuse pain or involuntary hip flexion may indicate
meningeal irritation (see Brudzinski's Test). If you suspect disc pathology, evaluate the affected level
(see Chapter 1 1 ) .
Figure 10-68
284
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Heel-Toe Walk Test (13)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
Instruct the patient to walk on the toes (Fig. 10-69), then on the heels (Fig. 1 0-70). Observe the pa­
tient and see whether the patient can support the entire body weight on each set of toes and each heel.
RATIONALE
If an L5-51 disc defect is creating pressure on the 51 nerve root, the patient may not be able to sus­
tain body weight while walking on the toes. This is due to weakness of the calf muscles, which are
supplied by the tibial nerve.
If an L4-L5 disc defect is creating pressure on the L5 nerve root, the patient may not be able to
sustain the body weight while walking on the heels. This is due to the weakness of the anterior leg
muscles, which are supplied by the common peroneal nerve.
SUGGESTED DIAGNOSTIC IMAGING
Plain film radiology
AP lumbar view
Lateral lurnbar view
Oblique lumbar view
Lumbar CT
LumbarMRI
Electromyography
•
•
•
Figure 10-69
Figure 10-70
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
285
SPACE-OCCUPYING LESIONS
CLINICAL DESCRIPTION
Space-occupying lesions of the spine may lead to spinal stenosis. Spinal stenosis is narrowing of the
tubular structures of the spine, which include the central canal, lateral recess, and intervertebral
foramen. The condition may be congenital, developmental, acquired, traumatic, or postsurgical. It
may be a disc defect, hypertrophic or degenerative change, synovial cyst, fracture, tumor, or a com­
bination. Space-occupying lesions can affect the neurological structures of the spine, such as the
spinal cord, cauda equina, or nerve roots.
CLINlCAL SIGNS AND SYMPTOMS
•
•
•
•
•
Lower back pain
Lower extremity radicular pain
Lower extremity weakness
Loss of lower extremity reflexes
Loss of lower extremity sensation
Valsalva's Man euver (26)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
1
I
1
2
I
1
3
I
I
4
Instruct the seated patient to bear down as if straining at stool but concentrating the bulk of the
stress at the lumbar region (Fig. 10- 7 1 ). If the patient feels any increased pain, ask him or her to
point to it. This test is subjective and requires an accurate response from the patient.
RATIONALE
This test increases intrathecal pressure. Local pain secondary to the increased pressure may indicate
a space-occupying lesion (e.g., disk defect, mass, osteophyte) in the lumbar canal or foramen.
Figure 10-71
286
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Dejerine's Triad
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
I
4
With the patient seated, instruct him to cough, sneeze, and bear down as if straining at stool (Val­
salva's maneuver).
RATIONALE
Pain local to the lumbar region after any of the previous actions indicates increased intrathecal pres­
sure, most likely induced by a space-occupying lesion (e.g., disc defect, mass, osteophyte). If the pa­
tient cannot sneeze, administer a dash of pepper (Lewin's snuff test).
Milgram's Test (27)
PROCEDURE
Instruct the supine patient to raise the legs 2 or 3 inches above the table (Fig. 1 0-72).
RATIONALE
The patient should be able to perform this test for at least 30 seconds without low back pain. If pain
is present, suspect a space-occupying lesion inside or out of the spinal canal. Disc protrusion usu­
ally produces a positive test. Patients with weak abdominal muscles may not be able to perform this
test.
Figure 10-72
CHAPTER 10
LUMBAR ORTHOPAEDIC TESTS
Naffziger's Test (28)
Sensitivity/Reliability Scale
I
o
PROCEDURE
With the patient seated, compress the jugular veins, which lie approximately
cheal cartilage (Fig. 1 0-73 ). Hold the compression for 1 minute.
287
1
I
1
I
2
I
3
I
4
inch lateral to the tra­
RATIONALE
Compressing the jugular veins raises the intrathecal pressure. Local pain in the lumbar region indi­
cates a space-occupying lesion, usually a disc protrusion or prolapse. Radicular pain may indicate
nerve root involvement. The theca is the covering of the spinal cord, which consists of the pia mater,
arachnoid mater, and dura mater.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Plain film radiology
AP lumbar view
Lateral lumbar view
Oblique lumbar view
Lumbar CT
LumbarMRI
Electromyography
Figure 10-73
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
288
D IFFERENTIAL D I AGNOSIS: LUMBAR VERSUS
SACROILIAC INVOLVEMENT
CLINICAL DESCRIPTION
Lumbar and/or radicular pain in a leg may be caused by a lumbar condition or by a pathological
condition affecting the sacroiliac joint, such as sacroiliac joint syndrome, trauma, infection, inflam­
mation, degeneration, tumor, or tumorlike condition. The most common sacroiliac joint pathology
is sacroiliac joint syndrome. It can cause local lower back pain with or without a lower extremity
radicular component and may be sharp or dull. The symptoms are usually unilateral and have a
right-sided predominance. Weakness, paresthesia, and dysesthesia are rare. The following tests help
to determine whether the patient's lower back pain is lumbar or sacroiliac related.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
Lower back pain
Sacroiliac joint pain
Aggravated by sitting
Alleviated by standing or walking
Lower extremity radicular pain
Goldthwaith's Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
2
I
3
I
4
With the patient supine, place one hand under the lumbar spine with each finger under an inter­
spinous space. With the other hand, perform a straight leg raising test. Note whether pain is elicited
before, during, or after the spinous processes fan out (Fig. 1 0-74).
RATIONALE
Radicular pain before fanning out of the lumbar vertebrae indicates an extradural lesion, such as a
sacroiliac joint disorder (0° to 35° ). Radicular pain during lumbar fanning indicates an intradural
lesion, such as an intrathecal space-occupying lesion (e.g., disc defect, osteophyte, mass) (35° to 70° ).
Local pain after lumbar fanning indicates a posterior lumbar joint disorder (after 70°) (see Straight
Leg Raising Test).
Figure 10-74
CHAPTER 10
Supp orted Forward Bending Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
289
LUMBAR ORTHOPAEDIC TESTS
I
I
1
I
I
2
I
3
I
4
With the patient standing, instruct the patient to bend forward, keeping the knees straight (Fig.
10-75). Repeat the test, but support the ilia with your hands while bracing the patient's sacrum with
your hip (Fig. 1 0-76).
RATIONALE
Stabilizing the ilia immobilizes the sacroiliac joints; thus, when the person bends, a lumbar lesion
will elicit pain in both instances because the lumbar vertebrae are not immobilized either time. If a
sacroiliac joint lesion is present, pain will be elicited only when the ilia are not immobilized.
IDl
Figure 10-75
Figure 10-76
I
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
290
Nachlas Test (29 )
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
With the patient prone, approximate the patient's heel to the buttock on the same side (Fig. 10-77).
RATIONALE
Flexing the leg to the buttock stretches the quadriceps muscles and the femoral nerve, which is the
largest branch of the lumbar plexus (L2-L4). Radicular pain into the anterior thigh may indicate
compression or irritation of the L2 to L4 nerve roots by an intradural lesion (e.g., disc defect, spur,
mass), a lumbar plexus, or femoral nerve compression or irritation by an extradural lesion (piri­
formis muscle hypertrophy) . Stretching the quadriceps muscles causes the sacroiliac joint and the
lumbosacral joints to move inferiorly. Pain in the buttock may indicate a sacroiliac joint lesion. Pain
in the lumbosacral joint may indicate a lumbosacral lesion.
NOTE
Local pain at the anterior thigh and inability to touch the heel to the buttock may indicate a quadri­
ceps muscle contracture.
Figure 10-77
CHAPTER 10
29 1
LUMBAR ORTHOPAEDIC TESTS
Sign of the Buttock Test (24)
Sensitivity/Reliability Scale
I
o
PROCEDURE
With the patient supine, perform a passive straight leg r aising test (Fig.
tion, flex the patient's knee and see if hip flexion increases (Fig.
1 0-78) .
I
1
I
2
I
3
I
I
If you find restric­
1 0-79).
RATIONALE
If hip flexion increases and the patient's pain is exacerbated, the problem is in the lumbar spine, be­
cause there is full movement in the sacroiliac joint when the knee is flexed. This result indicates a
negative sign. If hip flexion does not increase when the knee is flexed, the sacroiliac joint is dys­
functional. This dysfunction indicates pathology of the sacroiliac joint or buttocks, such as an in­
flammatory process, bursitis, mass, or abscess. This result is a positive sign.
SUGGESTED DIAGNOSTIC IMAGING
Plain film radiology
AP lumbar view
Lateral lumbar view
AP pelvis view
Sacral base view
S-I joint views
Figure 10-78
Figure 10-79
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
292
bar intervertebral disc. J Bone Joint Surg 1 950;
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lumbar disc. Rheumatol Rehabil 1 975; 1 4 : 1 2 1 0 .
Panjabi M, Krag M, Chung T. Effects of disc injury
on mechanical behavior of the human spine.
Spine 1 984;9:707.
Post M. Physical Examination of the Musculoskele­
tal System. Chicago: Year Book, 1 987.
Philadelphia: J B Lippincott, 1 978.
Kapandji lAo The physiology of joints. Vol 3. The
Pain
chronic low back dysfunction patients. Spine
nosis and Therapy. Waikanae, New Zealand:
Goddard BS, Reid JD. Movements induced by
JD.
293
1 984;9:588-595.
Fisk Jw. The Painful Neck and Back. Chicago:
Loeser
LUMBAR ORTHOPAEDIC TESTS
Ruge D, Wiltse LL. Spinal disorder diagnosis and
treatment. Philadelphia: Lea & Febiger, 1 977.
Travell JG, Simmons DG. Myofascial Pain and Dys­
injury.
Spine
1 985;1 0:232.
Macnab 1 . Backache. Baltimore: Williams & Wilkins,
1 977.
Mayer TG, Tencer AF, Kristoferson S, et al. Use of
function: The Trigger Point Manual. Vol 2. The
Lower
Extremities.
Baltimore:
Williams
&
Wilkins, 1 992.
White AA, Panjabi M M . Clinical biomechanics of
the spine. Toronto: JB Lippincott, 1 978.
non-invasive techniques for quantification of
Wooden MJ. Preseason screening of the lumbar
spinal range-of-motion in normal subjects and
spine. J Orthop Sports Phys Ther 1 9 8 1 ;3:6.
--------���-LUMBAR NERVE ROOT LESIONS
TI2, Ll, L2, L3
Motor
298
L5
299
Iliopsoas
Reflex
299
305
Extensor Hallucis Longus
300
Sensory
305
Motor
Gluteus Medius
300
Extensor Digitorum Longus and
Brevis
L2, L3, L4
301
Motor
301
Reflex
301
Sensory
307
308
302
Patella Reflex
Sensory
307
307
Medial Hamstring Reflex
Quadriceps Muscle
Reflex
305
306
302
SI
309
Motor
302
309
Peroneus Longus and Brevis
L4
303
Motor
Reflex
303
Achilles Reflex
Tibialis Anterior
Reflex
Sensory
294
303
304
Patella Reflex
304
310
304
Sensory
310
310
309
CHAPTER 11
LUMBAR NERVE ROOT LESIONS
295
TI2, LI, L2, L3
CLINICAL DESCRIPTION
Nerve roots in the lumbar spine exit the spinal column through laterally placed intervertebral
foramina. The nerve roots in the lower thoracic and lumbar spine gradually exit their intervertebral
foramen at its upper aspect. This causes the nerve root in these areas to be affected by the interver­
tebral disc above the exiting nerve root (Fig. 11-1). The lower thoracic area and upper lumbar area
(Tl2-L2) are transitions to this anatomic consideration and in this area may be affected either by
Nerve root
m
Compression
of nerve by
protruding
disc
Figure 11-1
296
PHOTOGRAPHIC MANUAl OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
the intervertebral disc at the same interval or the disc at the level above the exiting nerve root. This
situation may depend on the laterality of the disc defect. The L3 to L5 nerve roots exit the interver­
tebral foramen at the upper end of the foramen 80% of the time, and they are usually affected by
the intervertebral disc above the exiting nerve root. Because of its anatomic position, the S1 nerve
root is usually affected by the L5-S1 intervertebral disc. If a lumbar nerve root lesion is suspected,
you must evaluate three clinical aspects of the neurological examination: sensory dysfunction, mo­
tor dysfunction, and reflex dysfunction.
The sensory deficit evaluation addresses the segmental cutaneous innervation of the skin. It is
tested with a sterile or disposable Neurotip or pinwheel in specific dermatomal patterns. Two der­
matomal maps are provided here. Figure 11-2 indicates the body areas of intact sensation when
roots above and below an isolated root are interrupted, sensation loss when one or more continu­
ous roots are interrupted, or the pattern of herpetic rash and hypersensitivity in isolated root in­
volvement. Figure 11-3 presents the hyposensitivity to pin scratch in various root lesions and is con­
sistent with electrical skin resistance studies showing axial derma tomes extending to the distal
extremities. This pattern is useful in evaluating paresthesias and hyperesthesias secondary to root ir­
ritation. This is the pattern that will be delineated to evaluate sensory root dysfunction. Since a fair
amount of segmental overlap exists, a single unilateral lesion may affect more than one dermatomal
level. Motor function is tested by evaluating the muscle strength of specific muscles innervated by a
particular nerve root or roots using the muscle grading chart adopted by the American Academy of
Orthopaedic Surgeons (Box 11-1). The reflex arc is tested by evaluating the superficial stretch reflex
associated with the particular nerve root. These reflexes are graded by the Wexler scale (Box 11-2).
Muscle Grading Chart
5
Complete range of motion against gravity with full resistance
4
Complete range of motion against gravity with some resistance
3
Complete range of motion against gravity
2
Complete range of motion with gravity eliminated
1
Evidence of slight contractility; no joint motion
o
No evidence of contractility
Wexler Scale
o
No response
+1
Hyporeflexia
+2
Normal
+3
Hyperreflexia
+4
Hyperreflexia with transient clonus
+5
Hyperreflexia with sustained clonus
C2
3
�C
C4
C5
T2
T4
.
01 ,
�
'
-
.
*
()
�
::':l
m
82
'"
1;
!::
�
'"
Z
m
�
'§
�
t""'
m
en
/f� �
o
Figure 11-2
Z
en
Figure 11-3
N
\C
'-.J
II
298
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
The clinical presentation of nerve root lesions depends on two important factors: the location
and the severity of the injury or pathology. These two factors determine the lesion's clinical presen­
tation. The possibilities range from no clinical signs or slight clinical manifestation, such as slight
loss of sensation and pain, to total denervation with complete loss of function (motor, sensory, and
reflex) in the structures innervated by the involved nerve root. Each nerve root has its own sensory
distribution, muscle test or tests, and a stretch reflex, which will be grouped to facilitate identifica­
tion of the suspected level.
The clinical evaluation is not made solely on one aspect of the neurological package but is de­
termined by the combination of history, inspection, palpation, the three individual tests (motor, re­
flex, and sensory), and appropriate diagnostic imaging and/or functional neurological testing, such
as electromyography. Furthermore, the injury or pathology may not necessarily affect a nerve root;
it may affect the lumbar plexus, a trunk of that plexus, or a named nerve. Depending on the sever­
ity and location of the injury or pathology, various combinations of neurological dysfunction may
be revealed.
TI2, LI, L2, L3
The T12, 11, L2, and L3 nerve roots exit the spinal canal at their respective levels. The Tl2 and 11
nerve roots can be affected by the intervertebral disc at their respective levels or levels above them,
depending on the size and laterality of the disc defect (Fig. 11-4).
Figure 11-4
CHAPTER 11
LUMBAR NERVE ROOT LESIONS
299
Motor
Iliopsoas: T12, Ll, L2, L3 Nerve Root Innervation
PROCEDURE
With the patient sitting at the edge of the examination table, instruct the patient to raise the thigh
off the table. Place your hand on the patient's knee and instruct the patient to continue to raise the
thigh against your resistance (Fig. 11-5). Perform the test on the opposite thigh. Grade according to
the muscle grading chart and evaluate bilaterally.
RATIONALE
A grade 0 to 4 unilaterally may indicate a neurological deficit of the Tl2, Ll, L2, or 13 nerve root.
Suspect a weak or strained iliopsoas muscle if the sensory portion of the T12, Ll, L2, or 13 neuro­
logical package is intact.
Figure 11-5
300
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Reflex
There is no reflex test.
Sensory
PROCEDURE
With a pin, stroke the dermatomal area corresponding to each nerve root (Fig. 11-6) and evaluate
bilaterally.
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the corresponding Tl2, 11, L2, or L3
nerve root or the femoral nerve.
C7
Figure 11-6
CHAPTER 11
LUMBAR NERVE ROOT LESIONS
301
L2, L3,IA
The L2, L3, and L4 nerve roots can be affected by the intervertebral disc at their respective levels or
levels above them, depending on the size and laterality of the disc defect (Fig. ll-7).
Figure 11-7
Motor
Quadriceps Muscle: L3, L4 Femoral Nerve Innervation
PROCEDURE
With the patient sitting at the edge of the examination table, instruct the patient to extend the knee.
Place one hand on the patient's thigh for stabilization and place the other hand on his or her leg. Ex­
ert pressure on the leg while instructing the patient to resist flexion (Fig. ll-8). Grade according to
the muscle grading chart and evaluate bilaterally.
RATIONALE
A grade 0 to 4 unilaterally may indicate a neurological deficit of the L2, L3, or L4 nerve root or
femoral nerve. Suspect a weak or strained quadriceps muscle if the sensory portion of the L2, L3, or
L4 neurological package is intact.
Figure 11-8
m
302
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Reflex
Patella Reflex
The patella reflex is primarily an L4 reflex and is tested with the L4 neurological level.
Sensory
PROCEDURE
With a pin, stroke the dermatomal area corresponding to each nerve root (Fig. 11-9) and evaluate
bilaterally.
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the corresponding L2, L3, or L4 nerve
roots or the femoral nerve.
Figure 11-9
CHAPTER 11 LUMBAR NERVE ROOT LESIONS
303
IA
The L4 nerve root exits the spinal canal between the L4 and L5 vertebrae and is usually affected by
the L3-L4 intervertebral disc (Fig. 11-10).
Figure 11-10
Motor
Tibialis Anterior: L4, LS Deep Fibular Nerve Innervation
PROCEDURE
With the patient seated at the edge of the examination table, instruct the patient to dorsiflex and in­
vert the foot. Grasp the patient's ankle with one hand and foot with your other hand, and attempt
to force the foot into plantar flexion and eversion against resistance by the patient (Fig. 11-11).
Grade according to the muscle grading chart and evaluate bilaterally.
RATIONALE
A grade 0 to 4 unilaterally may indicate a neurological deficit of the L4 nerve root or the deep fibu­
lar nerve. A weak or strained tibialis anterior muscle may be suspected if the sensory and reflex por­
tions of the L4 neurological package are intact.
Figure 11-11
III
304
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Reflex
Patella Reflex
PROCEDURE
With the patient seated at the edge of the examination table, tap the infrapatellar tendon with the
neurological reflex hammer (Fig. 11-12).
RATIONALE
Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an
interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an
upper motor neuron lesion.
Figure 11-12
Sensory
PROCEDURE
With a pin, stroke the medial aspect of the leg and foot (Fig. 11-13) and evaluate bilaterally.
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the L4 nerve root.
Figure 11-13
CHAPTER 11
LUMBAR NERVE ROOT LESIONS
305
L5
The L5 nerve root exits the spinal canal between the L5 vertebra and the first sacral segment and is
usually affected by the L4-L5 intervertebral disc (Fig. 11-14).
Figure 11-14
Motor
Extensor Hallucis Longus: L5, 51 Deep Fibular Nerve Innervation
PROCEDURE
With the patient seated at the edge of the examination table, grasp the patient's calcaneus with one
hand for stabilization. With your opposite hand, pinch the great toe and instruct the patient to dor­
siflex it against your resistance (Fig. 11-15). Grade according to the muscle grading chart and com­
pare bilaterally.
RATIONALE
A grade 0 to 4 unilaterally may indicate a neurological deficit of the L5 nerve root or the deep fibu­
lar nerve. A weak or strained extensor hallucis longus muscle may be suspected if the sensory and
reflex portions of the L5 neurological package are intact.
Figure 11-15
III
306
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Gluteus Medius: L5, S 1 Superior Gluteal Nerve Innervation
PROCEDURE
With the patient side-lying on the examination table, instruct the patient to abduct the superior leg
(Fig. 11-16). Place your hand on the lateral aspect of the patient's knee and attempt to push the knee
into adduction against patient resistance (Fig. 11-17). Grade according to the muscle grading chart
and evaluate bilaterally.
RATIONALE
A grade 0 to 4 unilaterally may indicate a neurological deficit of the L5 nerve root or the superior
gluteal nerve. A weak or strained gluteus medius muscle may be suspected if the sensory and reflex
portions of the L5 neurological package are intact.
Figure 11-16
Figure 11-17
CHAPTER 11
LUMBAR NERVE ROOT LESIONS
307
Extensor Digitorum Longus and Brevis: L5, S1 Superficial Fibular
Nerve Innervation
PROCEDURE
With the patient sitting at the edge of the examination table, grasp the calcaneus to stabilize the foot.
With your opposite hand, grasp the patient's second through fifth toes and instruct the patient to
dorsiflex the toes against your resistance (Fig. 11-18).
RATIONALE
A grade 0 to 4 unilaterally may indicate a neurological deficit of the L5 nerve root or the superficial
fibular nerve. A weak or strained extensor digitorum longus and/or brevis muscle may be suspected
if the sensory and reflex portions of the L5 neurological package are intact.
Figure 11·18
Reflex
Medial Hamstring Reflex
PROCEDURE
With the patient prone, slightly flex the patient's knee and place your thumb on the medial ham­
string tendon. With a neurological reflex hammer, tap the medial hamstring tendon (Fig. 11-19).
The patient should slightly flex the knee.
RATIONALE
Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an
interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an
upper motor neuron lesion.
Figure 11·19
m
308
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sensory
PROCEDURE
With a pin, stroke the lateral leg and dorsum of the foot (Fig. 11-20). Evaluate bilaterally.
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the LS nerve root.
Figure 11-20
CHAPTER 11
LUMBAR NERVE ROOT LESIONS
309
SI
The 51 nerve root exits the spinal canal through the first sacral foramen and is usually affected by
the L5-51 intervertebral disc (Fig. 11-21).
Figure 11·21
Motor
Peroneus Longus and Brevis: L5, S1 Superficial Fibular Nerve Innervation
PROCEDURE
With the patient sitting at the edge of the examination table, stabilize the calcaneus with one hand
and grasp the lateral aspect of the foot with your opposite hand. Instruct the patient to plantarflex
and evert the foot against your resistance (Fig. 11-22). Grade according to the muscle grading chart
and evaluate bilaterally.
RATIONALE
A grade 0 to 4 unilaterally may indicate a neurological deficit of the 51 nerve root or the superficial
fibular nerve. A weak or strained peroneus longus and/or brevis muscle may be suspected if the sen­
sory and reflex portions of the 51 neurological package are intact.
Figure 11-22
_
310
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Reflex
Achilles Reflex
PROCEDURE
With the patient seated at the edge of the examination table, place slight dorsiflexion on the foot.
With a neurological reflex hammer, tap the Achilles tendon (Fig. 11-23). The patient should exhibit
a slight plantar flexion of the foot.
RATIONALE
Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an
interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an
upper motor neuron lesion.
Figure 11-23
Sensory
PROCEDURE
With a pin, stroke the lateral aspect of the foot (Fig. 11-24).
RATIONALE
Unilateral hypoesthesia may indicate a neurological deficit of the S1 nerve root.
SUGGESTED DIAGNOSTIC IMAGING AND FuNCTIONAL TESTING
•
•
•
Lumbar magnetic resonance imaging
Electromyography
Somatosensory evoked potential
Figure 11-24
CHAPTER 11
General References
Barrows HS. Guide to Neurological Assessment.
Philadelphia: JB Lippincott, 1980.
Braziz PW, Masdeu JC, Biller J. Localization in Clin­
ical Neurology. 3rd ed. New York: Little, Brown.
Bronisch FW. The Clinically Important Reflexes.
New York: Grune & Stratton, 1952.
Chusid JG. Correlative Neuroanatomy and Func­
tional Neurology. 16th ed. Los Altos, CA: Lange
extremities.
Kendall FP, McCreary EK, Provance PG. Muscles:
Wilkins, 1993.
Mancall E. Essentials of the neurologic examination.
2nd ed. Philadelphia: FA Davis, 1981.
Moore KL, Dailey AF. Clinically Oriented Anatomy.
4th ed. Baltimore: Lippincott Williams & Wilkins,
1999.
Livingstone, 1988.
Appleton-Century­
Testing and Function. 4th ed. Baltimore: Williams &
Parsons
nial and Peripheral Nerves. New York: Churchill
New York:
Croft, 1976;127.
DeJong RN. T he Neurologic Examination. 4th ed.
Devinsky 0, Feldmann E. Examination of the Cra­
311
Hoppenfeld S. Physical examination of the spine
and
Medical, 1976.
Hagerstown, MD: Harper & Row, 1979.
LUMBAR NERVE ROOT LESIONS
N. Color
Atlas of
Clinical
Neurology.
Chicago: Year Book Medical, 1989.
VanAllen MW, Rodnitzky RL. Pictorial Manual of
Neurologic Tests. 2nd ed. Chicago: Year Book Med­
ical, 1981.
Geenberg DA, Aminoff MJ, Simon RP. Clinical neu­
rology. 2nd ed. East Norwalk, CT: Appleton &
Lange, 1993.
m
--------���-SACROILIAC ORTHOPAEDIC TESTS
SACROILIAC JOINT ORT HOPAEDIC
Sacroiliac Stretch Test
EXAMINATION FLOW CHART
Sacroiliac Resisted Abduction Test
313
320
320
Sacrotuberous Ligament Stress
PALPATION
314
Test
321
Posterior Superior Iliac Spine and Iliac
Crest
314
GENERAL SACROILIAC JOINT
Sacroiliac Articulations
Ischial Tuberosity
315
315
L E SIONS
322
Hibb's Test
322
Pelvic Rock Test (Iliac Compression
SACROILIAC SP RAIN
Gaenslen's Test
316
Lewin-Gaenslen Test
Yeoman's Test
Test)
317
323
Sign of the Buttock Test
318
Flamingo Test
323
324
319
312
CHAPTER 12
SACROILIAC ORTHOPAEDIC TESTS
313
Sacroiliac Orthopaedic Examination
�
I H;ry I
I Palpation I
Evaluate for
lumbar spine
dysfunction
(Chapter 10)
+ (+)
(+)
Supported forward
bending test
(Lumbar)
(Sacroiliac)
1 (+)
I
Yeoman's test
Sacroiliac stretch test
Sacroiliac resisted
abduction test
Sacrotuberous ligament
stress test
I
1
Sacroiliac I!gament
spraIn
I
I
( )
Evaluate for
hip dysfunction
I
t(+)(Hip)
-I Hibb's test I
-
t(+)(Sacroiliacjoint)
Pelvic rock test
Lewin-Gaenslen test
Sign of the buttock test
Flamingo test
I
t(+)
General sacroiliac ..
joint lesion
If)
314
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PALPATION
Posterior Superior Iliac Spine and Iliac Crest
DESCRIPTIVE ANATOMY
The iliac crest and posterior superior iliac spine are important bony landmarks used to assess pos­
tural deviations and leg length deficiencies. The iliac crest extends through the inferior margin of
the flank and is easily palpable. The posterior superior iliac spine is inferior to the iliac crest and lat­
eral to the
52 sacral segment (Fig. 12-1).
PROCEDURE
With the patient standing, palpate the iliac crest for tenderness (Fig.
12-2). Tenderness may be
caused by contusions, periosteitis, or avulsion fractures. Next, place your forefingers on each iliac
crest and your thumbs on the posterior superior iliac spines of each ilium (Fig.
12-3). Note any dif­
ference in longitudinal position, which may indicate a leg length discrepancy, scoliosis, sacroiliac
joint subluxation, or hip joint dislocation.
Iliac
Posterior
superior
iliac
spine
Sacroiliac -+---'or--+-''---�
articulation
Figure 12-1
Figure 12-2
Figure 12-3
CHAPTER 12
SACROILIAC ORTHOPAEDIC TESTS
315
Sacroiliac Articulations
DESCRIPTIVE ANATOMY
The sacroiliac articulations are inferior and medial to the posterior superior iliac spine (Fig.
12- 1).
The articulations are synovial and are held together by interosseous ligaments and ventral and dor­
sal sacroiliac ligaments. The movement of the sacroiliac joints is limited to slight gliding and rota­
tion. These joints are primarily weight bearing; they transfer the weight of the trunk to the hip
joints.
PROCEDURE
With the patient prone, flex the patient's knee to 90° and externally rotate the hip. With your oppo­
site hand, palpate the sacroiliac joint from just below the posterior superior iliac spine to the sacral
notch (Fig.
12-4). Note any pain or tenderness that may indicate an inflammatory process in the
sacroiliac joint.
Figure 12-4
Ischial Tuberosity
DESCRIPTIVE ANATOMY
The ischial tuberosity is just below the gluteal fold (Fig.
12- 1) and can be palpated easily with the
hip flexed. The hamstring muscles originate from the tuberosity. The tuberosity may be injured by
direct trauma or by trauma to the hamstring muscles.
PROCEDURE
Have the patient lie on one side and flex the hip by bringing the knee to the chest. Palpate the ischial
tuberosity, noting any pain or tenderness (Fig.
12-5). Pain may indicate a contusion secondary to
trauma, an avulsion fracture caused by severe hamstring pull, or ischial tuberosity bursitis.
Figure 12-5
.n
.a
316
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
SACROILIAC SPRAIN
CLINICAL DESCRIPTION
The sacroiliac joint is a very strong cartilaginous joint that produces little movement. The sacrum is
suspended between the two iliac bones and held in place by very strong interosseous dorsal sacroil­
iac ligaments. The joint is under great stress that predisposes it to sprains. The joint movement is
limited by the tension of the sacrotuberous, sacrospinous, and sacroiliac ligaments (Fig.
12-6). These
ligaments may be stretched, causing ligamentous sprain by some of the following movements:
1. Sudden contracture of the hamstrings or abdominal muscles, which exerts a rotating force
on the ilium
2. Sudden unexpected twisting motions of the trunk, which may occur in sports such as
football and basketball
3. Vigorous pulling while bending forward
4. A fall on one or both buttocks
The patient may have acute lower back pain and difficulty in bending. In unilateral cases it may
cause the patient to elevate the hip when standing on the painful side to avoid weight bearing over
the sacroiliac joint. Local tenderness is a common finding.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Sacroiliac joint pain
Abnormal gait
Tender sacroiliac joint on palpation
Pain on forward flexion
Figure 12-6
CHAPTER 12
317
SACROILIAC ORTHOPAEDIC TESTS
Gaenslen's Test (4)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine and the affected side near the edge of the table, instruct the patient to ap­
proximate the knee to the chest on the unaffected side (Fig.
12-7). Then place downward pressure
12-8).
on the affected thigh until it is lower than the edge of the table (Fig.
RATIONALE
Extension of the leg stresses the sacroiliac joint and anterior sacroiliac joint ligaments on the side of
leg extension. Pain on that side indicates a general sacroiliac lesion, that is, anterior sacroiliac liga­
ment sprain (iliofemoral, ischiofemoral) or inflammatory process in the sacroiliac joint.
Figure 12-7
m
Figure 12-8
318
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Lewin-Gaenslen Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
Instruct the patient to lie on the unaffected side and flex the inferior leg (Fig.
rior leg and extend it while you stabilize the lumbosacral joint (Fig.
I
1
I
2
I
3
I
I
12-9). Take the supe­
12- 10).
RATIONALE
Extension of the leg stresses the sacroiliac joint and anterior sacroiliac joint ligaments on the side of
leg extension. Pain on that side indicates a general sacroiliac joint lesion, that is, anterior sacroiliac
ligament sprain (iliofemoral, ischiofemoral ligaments) or inflammatory process in the sacroiliac
joint.
Figure 12-9
Figure 12-10
CHAPTER 12
SACROILIAC ORTHOPAEDIC TESTS
Yeoman's Test (2)
319
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient prone, grasp the patient's lower leg and passively flex the knee, then extend the hip
(Fig.
12- 1 1).
RATIONALE
Extension of the thigh stresses the sacroiliac joint and anterior sacroiliac joint ligaments on the side
of thigh extension. If pain is elicited on the ipsilateral side, suspect a sprain of the anterior sacroil­
iac joint ligaments, that is, the iliofemoral or ischiofemoral ligament (Fig.
12- 12). Pain or an increase
in pain may also indicate an inflammatory process or abscess in the sacroiliac joint.
NOTE
This test also stresses the lower lumbar vertebra by slightly extending the lumbar spine. Lumbar
pain, either local or radiating, may indicate lumbar involvement. See Chapter
10 for evaluation.
Figure 12-11
Iliac
Posterior
superior
iliac
spine
Sacroiliac -+----'..--+--'--""('
articulation
Ischiofemoral-+----tfi----'
ligament
Figure 12-12
Posterior
sacroiliac
ligaments
rous
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
320
Sacroiliac Stretch Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, cross the patient's arms and apply posterior and lateral pressure to the an­
terior superior iliac spine of each ilium (Fig.
12- 13).
RATIONALE
Pressure on both anterior and superior iliac spines simultaneously compresses both sacroiliac joint
surfaces and stretches the anterior sacroiliac ligaments. If pain is elicited or increased in one or both
joints, suspect a strain of the anterior sacroiliac ligaments, that is, iliofemoral or ischiofemoral liga­
ment (see Fig.
12-6). Pain in the joint may also indicate an inflammatory process in the affected
joint.
Figure 12-13
Sacroiliac Resisted Abduction Test
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
1
I
2
I
3
I
4
Instruct the patient to lie on one side with the inferior hip and knee slightly flexed. The superior leg
should be straight and abducted. Place pressure on the abducted limb against patient resistance (Fig.
12- 14).
RATIONALE
Resisting abduction of the hip stresses the sacroiliac joint and abductor muscles of the hip. Increased
pain in the sacroiliac joint indicates a sprain of the sacroiliac ligaments on the ipsilateral side. Pain
in the affected buttock or lateral thigh indicates a strain of the abductor muscles of the thigh (ten­
sor fasciae latae and gluteus group).
Figure 12-14
CHAPTER 12
321
SACROILIAC ORTHOPAEDIC TESTS
Sacrotuberous Ligament Stress Test (3)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Place the patient supine. Fully flex the patient's knee and hip and adduct and internally rotate the
hip. With your opposite hand, palpate the sacrotuberous ligament, which runs from the posterior
aspect of the sacrum to the ischial tuberosity (Fig.
12- 15).
RATIONALE
The sacrotuberous ligament anchors the sacrum to the ischial tuberosity. The action of hip adduc­
tion and medial hip rotation stresses the sacrotuberous ligament. Increased pain in the area of the
sacrotuberous ligament may indicate a sacrotuberous ligament sprain.
SUGGESTED DIAGNOSTIC IMAGING
Plain film radiography
AP pelvis view
Figure 12-15
322
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
GENERAL SACROILIAC JOINT LESIONS
CLINICAL DESCRIPTION
The sacroiliac joint is a strong weight-bearing synovial joint with little movement. The surfaces are
irregular to provide some interlocking of the sacrum to the ilium. This articulation is subject to in­
flammation due to trauma, overuse, or degenerative arthritis. Diffuse idiopathic skeletal hyperosto­
sis, which produces osteophytes along the inferior aspect of the sacroiliac joint, may result in a
painful joint. Ankylosing spondylitis, which is usually bilateral, may cause restriction and pain. The
following tests attempt to increase the pressure in the sacroiliac joint or distract the joint to initiate
or exacerbate sacroiliac joint pain.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Sacroiliac joint pain
Abnormal gait
Tender sacroiliac joint on palpation
Pain on forward flexion
Pain on sitting
Hibb's Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient prone, flex the patient's leg to the buttock and move the leg outward, internally ro­
tating the hip (Fig.
12- 16).
RATIONALE
This procedure causes a stressed internal rotation of the femoral head into the acetabular cavity and
causes slight distraction on the sacroiliac joint. This test is mainly a hip joint test, but because of the
sacroiliac joint distraction, it may help you evaluate sacroiliac joint lesions. Pain in the sacroiliac
joint indicates a sacroiliac joint lesion, such as an inflammatory process or abscess in the sacroiliac
joint or a sprain of the sacroiliac ligaments. Pain in the hip joint indicates a hip joint lesion (see
Hibb's test in Chapter
13).
Figure 12-16
CHAPTER 12
SACROILIAC ORTHOPAEDIC TESTS
Pelvic Rock (Wac Compression) Test (4)
323
Sensitivity/Reliability Scale
I
PROCEDURE
I
1
I
2
I
I
3
I
4
With the patient side-lying, exert a strong downward pressure on the ilium. Perform this test bilat­
erally (Fig.
12- 17).
RATIONALE
Downward pressure on the ilium transfers a compression pressure to the joint surfaces of the
sacroiliac joints. Pain in either sacroiliac joint indicates a sacroiliac joint lesion, such as an inflam­
matory process in the joint surfaces on the affected side.
Figure 12-17
Sign of the Buttock Test (5)
Sensitivity/Reliability Scale
I
o
PROCEDURE
With the patient supine, perform a passive straight leg raising test (Fig.
found, flex the patient's knee and see if hip flexion increases (Fig.
I
1
I
2
I
3
I
4
12- 18). If restriction is
12-19).
RATIONALE
If hip flexion increases and the patient's pain is exacerbated, the problem is in the lumbar spine, be­
cause there is full movement in the sacroiliac joint when the knee is flexed. This is indicative of a
negative sign. If hip flexion does not increase when the knee is flexed, the sacroiliac joint is dys­
functional. This indicates pathology of the sacroiliac joint or buttocks, such as an inflammatory
process, bursitis, mass, or abscess. This is indicative of a positive sign.
Figure 12-18
Figure 12-19
m
324
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Flamingo Test (6)
Sensitivity/Reliability Scale
I
a
PROCEDURE
Instruct the patient to stand on one leg at a time (Fig.
creases stress on the joint (Fig.
I
1
I
2
I
3
I
12-20). Instruct the patient to hop, which in­
12-2 1).
RATIONALE
This test increases the pressure in the hip, sacroiliac articulation, and symphysis pubis articulation.
Increased pain in any of these joints may indicate an inflammatory process on the standing leg side.
Pain following trauma may indicate a fracture in the suspected joint. Pain in the hip joint may also
indicate trochanteric bursitis.
SUGGESTED DIAGNOSTIC IMAGING
Plain film radiography
AP pelvis view
Figure 12-20
Figure 12-21
CHAPTER 12
References
1. Gaenslen
FJ.
Sacroiliac
arthrodesis.
JAMA
2. Yeoman W. The relation of arthritis of the sacroil­
iac joint to sciatica. Lancet 1928;2: 12 19- 1222.
3. Lee D. The Pelvic Girdle. Edinburgh: Churchill
Livingstone, 1989.
4. Hoppenfeld S. Physical Examination of the
Spine and Extremities. New York: Appleton­
Century-Crofts, 1976: 127.
Vol.
I.
London:
amination. 3rd ed. New York: Macmillan, 1976.
Gray H. Sacroiliac joint pain: the finer anatomy.
New Intern Clin 1938;2:54.
Hartley A. Practical Joint Assessment. St. Louis:
Mosby, 1991.
McRae R. Clinical Orthopedic Examination. New
York: Churchill Livingstone, 1976
Meschan I. Roentgen Signs in Diagnostic Imaging.
5. Cyriax J. Textbook of Orthopaedic Medicine.
ed.
325
DeGowin EL, DeGowin RL. Bedside Diagnostic Ex­
1927;89:203 1-2035.
4th
SACROILIAC ORTHOPAEDIC TESTS
Bailliere
Tindall,
1975:54 1.
6. Magee DJ. Orthopedic Physical Assessment. 3rd
ed. Philadelphia: Saunders, 1997.
2nd ed. Vol 3. Sydney: Saunders, 1985.
Norlon C, Levangie P. Joint Structure and Function:
A Comprehensive Analysis. Philadelphia: FA Davis,
1987.
Post M. Physical Examination of the Musculoskele­
tal System. Chicago: Year Book Medical, 1987.
General References
A1derink GJ. The sacroiliac joint: review of anatomy,
mechanics, and function. J Orthop Sports Phys Ther
199 1;13:71.
Wells PE. The examination of the pelvic joints. In:
Grieve GP, ed. Modern Manual Therapy of the Ver­
tebral Column. Edinburgh: Churchill Livingstone,
1986.
--------���-HIP JOINT ORTHOPAEDIC TESTS
HIP JOINT ORTHOPAEDIC EXAMINAT ION
327
FLOW CHART
PALPAT ION
Anvil Test
328
HIP CONTRACTURE T EST S
Iliac Crest and Anterior, Superior, and
Inferior Iliac Spine
Greater Trochanter
Hip Joint
328
330
344
344
T homas Test
Rectus Femoris Contracture Test
Ely's Test
331
Ober's Test
Tensor Fasciae Latae Muscle
Femoral Triangle
343
343
HIP FRACTURES
332
346
347
P iriformis Test
348
333
GENERAL HIP JOINT LESIONS
HIP RANGE OF MOTION
334
P atrick Test (Faber)
334
335
Abduction
336
337
Adduction
Flexion
Trendelenburg Test
Extension
Scouring Test
Hibb's Test
338
339
Internal Rotation
External Rotation
CONGENITAL HIP DYSPLASIA
Allis Test
340
Ortolani's Click Test
Telescoping Sign
326
351
352
352
Laguerre's Test
342
341
340
349
350
349
345
CHAPTER 13
HIP JOINT ORTHOPAEDIC TESTS
327
Hip Joint Orthopaedic Examination
�
History
I
Hip pain,
Hip pain
No trauma
(adult)
Trauma induced
(adult)
Allis test
Ortolani's click test
Telescoping sign
Range of motion
(active)
Range of motion
(passive)
(passive)
(active)
(+)
Patrick test (Faber)
Trendelenburg test
Scouring test
Laguerre's test
(
-
Thomas test
)
Rectus femoris
contracture test
Ely's test
(+)
Hibb's test
m
(
-
)
Hamstring
contracture
test
(- )
1---'-----"�1
--l
--.,..
_..
328
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PALPATION
Iliac Crest and Anterior, Superior, and Inferior Iliac Spine
DESCRIPTIVE ANATOMY
The iliac crest is at the inferior margin of the flank from the anterior; from the posterior, its highest
point is at the level of the L4 spinous process (Fig. 13-1). The iliacus, external oblique, and tensor
fasciae latae muscles originate from the iliac crest. At the anterior terminal end of the iliac crest lies
the anterior superior iliac spine (Fig. 13-1). It is the attachment of the sartorius muscle and is easily
palpable. The anterior inferior iliac spine is just below the anterior superior iliac spine. The rectus
femoris muscle and iliofemoral ligament are attached to it (Fig. 13-1).
Iliac crest ------,
Iliacus m. ----.<I:.�
External oblique m. -----.,.'�r
Anterior superior iliac spine
Rectus femoris m. ----1&,
Iliofemoral ligament
Anterior inferior iliac spine
Figure 13-1
CHAPTER 13
HIP JOINT ORTHOPAEDIC TESTS
329
PROCEDURE
With the patient supine, palpate the iliac crests for point tenderness and swelling (Fig. 13-2). This
may indicate periostitis or strain or avulsion of the iliacus, external oblique, or tensor fasciae latae
muscles. Contusion to the iliac crest secondary to trauma is common in the athlete. Palpate the il­
iac crests with the patient standing as well, checking for unevenness of the crests (Fig. 13-3). Un­
evenness may be a sign of scoliosis, anatomical short leg, or contracture deformity. The anterior su­
perior iliac spine should be palpated next (Fig. 13-4). Look for point tenderness and swelling, which
may indicate a sartorius muscle strain or avulsion fracture. Just below the anterior superior iliac
spine is the anterior inferior iliac spine (Fig. 13-5). With your thumb or forefinger, palpate this area
and note any point tenderness or swelling. It may indicate a sprained or avulsed rectus femoris mus­
cle or strained iliofemoral ligament.
Figure 13-2
Figure 13-3
m
Figure 13·4
Figure 13-5
330
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Greater Trochanter
DESCRIPTIVE ANATOMY
The greater trochanter is approximately 10 cm inferior and lateral to the anterior superior iliac spine
(Fig. 13-6). The greater trochanter is the attachment of the gluteus medius, gluteus minimus, and
vastus lateralis muscles. The trochanteric bursa also lies under these muscles.
PROCEDURE
With the patient supine, slightly abduct the thigh and palpate the greater trochanter (Fig. 13-7).
Note any point tenderness or swelling. This may indicate a strain of the gluteus medius, gluteus min­
imus, or vastus lateralis muscles. An increase in the temperature differential associated with tender­
ness and swelling is an indication of trochanteric bursitis.
Greater trochanter----,
Gluteus minimus --­
Gluteus medius
Vastus latera lis
muscle attachments
Figure 13-6
Figure 13-7
CHAPTER 13
HIP JOINT ORTHOPAEDIC TESTS
331
Hip Joint
DESCRIPTIVE ANATOMY
The hip joint is a ball and socket synovial joint, and the femur head is held in place by the il­
iofemoral, pubofemoral, and ischiofemoral ligaments (Fig. 13-8). The iliofemoral ligament is the
largest and strongest of these ligaments that hold the femur into the acetabular cavity.
The hip joint at best is difficult to palpate because it lies deep in the body. Unless the joint is trau­
matized to the point of fracture or dislocation, palpation of the actual joint will reveal little clinical
information. Palpation of the surrounding tissue may be a better indicator of hip joint pathology.
Anterior inferior iliac spine --+''-Iliofemoral ligament
Iliopectineal
bursa
Pubofemoral
ligament
Greater
troch3nter
I ntertrochan•n
Figure 13-8
•• in
",0.----
m
332
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Tensor Fasciae Latae Muscle
DESCRIPTIVE ANATOMY
The tensor fasciae latae muscle is on the anterior lateral side of the thigh. It originates from the an­
terior outer lip of the iliac crest and inserts into the iliotibial band, which attaches to the lateral epi­
condyle of the tibia (Fig. 13-9).
PROCEDURE
With the patient laying on the unaffected side, palpate the tensor fasciae latae muscle from just below
the anterior superior iliac spine down over the greater trochanter to the lateral aspect of the knee (Fig.
13-10). Note any tenderness, spasm, increase in skin temperature, or inflammation. These may indi­
cate a strain of the muscle. If point tenderness is present, suspect an active trigger point that may re­
fer pain to the upper half of the medial thigh. If the muscle becomes strained through microtrauma
as it moves over the greater trochanter of the femur, it can cause greater trochanteric bursitis.
r---#-·Anterior iliac crest
Ict--ff-Tensor fasciae latae
I: 'i'-Jf-----..,.4i+-lliotibial band
f:ffllflNl\fIL
--+t-- ateral epicondyle
of tibia
Figure 13-9
Figure 13-10
m.
CHAPTER 13
HIP JOINT ORTHOPAEDIC TESTS
333
Femoral Triangle
DESCRIPTIVE ANATOMY
The femoral triangle is a clinically important region. It is bound superiorly by the inguinal ligament,
medially by the adductor longus muscle, and laterally by the sartorius muscle (Fig. 13- 1 1). The tri­
angle contains lymph nodes and the femoral artery, vein, and nerve.
PROCEDURE
With the patient supine, palpate the inguinal ligament, which extends from the anterior superior il­
iac spine to the pubic tubercle. Note any tenderness, which may indicate a sprain. Next, palpate the
adductor longus and sartorius muscle, again noting any tenderness or inflammation. This may in­
dicate a strain or active trigger points in the affected muscle. Once the borders are palpated,palpate
the interior of the triangle for inflamed lymph nodes, which may indicate a lower extremity or sys­
temic infection (Fig. 13- 12). Palpate the femoral artery for amplitude. A decrease in the amplitude
indicates a compromise to the vascular supply to the lower extremity.
Sartorius m.
/ff-F
--t-- emoral nerve
/H---+-Femoral artery
r-----'-Femoral vein
Figure 13-11
Figure 13-12
II
334
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
HIP RANGE OF MOTION
Flexion (1)
With the patient supine, place the goniometer in the sagittal plane at the level of the hip (Fig. 13-13).
Instruct the patient to flex the hip, and follow the thigh with one arm of the goniometer (Fig. 13-14).
NORMAL RANGE (2)
Normal range is 1310 ± 6.40 or greater from the 0 or neutral position.
Muscles
Nerve Supply
Psoas
Iliacus
Rectus femoris
Sartorius
Pectineus
Adductor longus and brevis
Gracilis
Ll-L3
Femoral
Femoral
Femoral
Femoral
Obturator
Obturator
Figure 13-13
Figure 13-14
CHAPTER 13
HIP JOINT ORTHOPAEDIC TESTS
335
Extension (1)
With the patient prone, place the goniometer in the sagittal plane at the level of the hip joint (Fig.
13-15). Instruct the patient to raise the thigh off the table as far as possible, and follow the thigh with
one arm of the goniometer (Fig. 13-16).
NORMAL RANGE (2)
Normal range is l30 ± 5.4° or greater from the 0 or neutral position.
Muscles
Nerve Supply
Biceps femoris
Semimembranosus
Semitendinosus
Gluteus maximus
Gluteus medius
Adductor magnus
Sciatic
Sciatic
Sciatic
Inferior gluteal
Superior gluteal
Sciatic
Figure 13-15
m
Figure 13-16
336
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Abduction (1)
With the patient supine, place the goniometer in the coronal plane with the center at the level of the
hip (Fig. 13- 17). Instruct the patient to move the thigh laterally while following the thigh with one
arm of the goniometer (Fig. 13-18).
NORMAL RANGE (2)
Normal range is 4 10 ± 60 or greater from the 0 or neutral position.
Muscles
Nerve Supply
Tensor fasciae latae
Gluteus minimus
Gluteus medius
Gluteus maximus
Sartorius
Superior Gluteal
Superior Gluteal
Superior Gluteal
Inferior Gluteal
Femoral
Figure 13-17
Figure 13-18
CHAPTER 13
HIP JOINT ORTHOPAEDIC TESTS
337
Adduction (1)
With the patient supine and the opposite hip flexed, place the goniometer in the coronal plane with
the center at the level of the hip (Fig. 13- 19). Instruct the patient to move the thigh medially while
following the thigh with one arm of the goniometer (Fig. 13-20).
NORMAL RANGE (2)
Normal range is 270 ± 3.60 or greater from the 0 or neutral position.
Muscles
Nerve Supply
Adductor longus
Adductor brevis
Adductor magnus
Gracilis
Pectineus
Obturator
Obturator
Obturator
Obturator
Femoral
m
Figure 13-19
Figure 13-20
338
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Internal Rotation (1)
With the patient seated, place the goniometer in front of the patella (Fig. 13-21). Instruct the patient
to rotate the leg outward while following the leg with one arm of the goniometer (Fig. 13-22). This
movement internally rotates the hip.
NORMAL RANGE (2)
Normal range is 440 ± 4.30 or greater from the 0 or neutral position.
Muscles
Nerve Supply
Adductor longus
Adductor brevis
Adductor magnus
Gluteus minimus
Gluteus medius
Tensor fasciae latae
Pectineus
Gracilis
Obturator
Obturator
Obturator
Superior gluteal
Superior gluteal
Superior gluteal
Femoral
Obturator
Figure 13-21
Figure 13-22
CHAPTER 13
HIP JOINT ORTHOPAEDIC TESTS
339
External Rotation (1)
With the patient seated,place the goniometer in front of the patella (Fig. 13-23). Instruct the patient
to rotate the thigh medially while following the leg with one arm of the goniometer (Fig. 13-24).
NORMAL RANGE (2):
Normal range is 440 :±: 4.80 or greater from the 0 or neutral position.
Muscles
Nerve Supply
Gluteus maximus
Obturator internus, externus
Quadratus femoris
Piriformis
Gemellus superior, inferior
Sartorius
Gluteus medius
Inferior gluteal
Obturator
N. to quadratus femoris
L5,S1,S2
N. to obturator internus
Femoral
Superior gluteal
II
Figure 13-23
Figure 13-24
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
340
CONGENITAL HIP DYSPLASIA
CLINICAL DESCRIPTION
Congenital dysplasia of the hip is a condition in which the femoral head is displaced out of the ac­
etabular cavity. The condition is often bilateral, and girls are affected more often than boys. As the
name indicates, the origin is usually congenital. As a rule the acetabular cavity is shallow or more
vertical than normal. The femur is often anteverted and the hip joint capsule may be lax. As the child
ages, the hip becomes less flexible, and the ability to reduce the dislocation is lessened. If the hip is
dislocated, there is limited abduction and a shortening of the extremity. If weight bearing has be­
gun, the Trendelenburg test will be positive. Normally the contraction of the abductor muscle ele­
vates the opposite side of the pelvis. If the hip is dislocated, these muscles no longer work effectively,
and when the child stands on the affected leg, the opposite side on the pelvis moves down.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Decreased hip flexibility
Limited abduction
Painless limp
Hip pain
Shortened extremity
Allis Test (3)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the infant supine, flex the knees. The patient's feet should approximate each other on the table
(Fig. 13-25).
RATIONALE
A difference in the height of the knees indicates a positive test. A short knee on the affected side in­
dicates posterior displacement of the femoral head or decreased tibial length. A long knee on the af­
fected side indicates anterior displacement of the femoral head or an increase in tibial length.
Figure 13-25
CHAPTER 13
Ortolani's Click Test (4)
Sensitivity/Reliability Scale
I
o
PROCEDURE
341
HIP JOINT ORTHOPAEDIC TESTS
I
1
I
2
I
3
I
4
With the infant supine, grasp both thighs with your thumbs on the lesser trochanters. Then flex and
abduct the thighs bilaterally (Fig. 13-26).
RATIONALE
A palpable and/or audible click are the signs of a positive test. The click signifies a displacement of
the femoral head in or out of the acetabular cavity.
Figure 13-26
II
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
342
Telescoping Sign (5)
PROCEDURE
Sensitivity/Reliability Scale
I
I
1
I
2
I
3
I
4
With the child supine, flex the suspected hip and knee to 90°. Next, grasp the thigh and push it pos­
terior toward the table (Fig. 13-27), then pull it anterior away from the table (Fig. 13-28).
RATIONALE
If the child has a dislocated hip or a hip that has potential to dislocate, excessive movement or a click
will occur with this procedure. Normally, little motion occurs when this action is performed. This
excessive movement is called telescoping.
SUGGESTED DIAGNOSTIC IMAGING
•
•
Ultrasonography
Plain film radiography
Anteroposterior CAP) hip view
AP frog leg view
AP pelvis view
Figure 13-27
Figure 13-28
CHAPTER 13
343
HIP JOINT ORTHOPAEDIC TESTS
HIP FRACTURES
CLINICAL DESCRIPTION
Hip fractures occur most frequently in elderly patients, usually the result of a fall. The most com­
mon types of hip fractures are intertrochanteric and intracapsular. Intertrochanteric fractures and
femoral neck fractures for the most part do not disrupt the blood supply to the femoral head. In­
tracapsular fractures disrupt the blood supply to the femoral head, which may lead to nonunion or
avascular necrosis. In femoral neck fractures the extremity may be slightly shortened and externally
rotated. Osteoporosis and osteoarthritis usually play a significant role in the region. Occasionally the
fracture may be occult, with no trauma, and may show up only with a bone scan or magnetic reso­
nance imaging (MRI).
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Hip pain
Shortened extremity
Externally rotated extremity
Referred pain to medial thigh
Anvil Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, tap the inferior calcaneus with your fist (Fig. 13-29).
RATIONALE
Tapping the inferior calcaneus transfers quick, sharp compression-type blows to the hip joint. Local
pain in the hip joint following trauma may indicate a femoral head fracture or joint pathology.
NOTE
Local pain in the thigh or leg secondary to trauma may indicate a femoral, tibial, or fibula fracture.
Pain local to the calcaneus may indicate a calcaneal fracture.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP hip view
AP frog leg view
AP pelvis
Bone scan
MRI
Figure 13-29
m
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
344
HIP CONTRACTURE TESTS
CUNICAL DESCRIPTION
A hip joint contracture is a condition of soft tissue stiffness that restricts joint motion. This may be
caused by immobilization due to spasticity, paralysis, ossification, or bone or joint trauma. A fre­
quently moved joint is unlikely to develop a contracture deformity. Contractures occur from loss of
elasticity, leading to fixed shortening of soft tissue. The involved tissues may include the joint cap­
sule, ligaments, or muscle tendon units. Hip contractures are difficult to treat; therefore, prevention
by daily movement of the affected joint is paramount to treatment of a contracted joint.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Stiff hip joint
Limited hip range of motion
Inability to position joint in the neutral position
Hip joint pain on range of motion
Thomas Test (6)
Sensitivity/Reliability Scale
I
o
PROCEDURE
!
I
1
!
I
2
I
I
3
!
I
4
Instruct the supine patient to approximate each knee to the chest one at a time. Palpate the quadri­
ceps muscles on the unflexed leg (Fig. 13-30).
RATIONALE
If the patient significantly flexes the opposite knee and tightness is palpated on the side of the invol­
untary flexed knee, a hip flexion contracture is indicated (Fig. 13-31). If no tightness in the rectus
femoris muscle exists, the probable cause of restriction is at the hip joint structure or joint capsule.
Figure 13-30
Figure 13-31
CHAPTER 13
Rectus Femoris Contracture Test (5)
HIP JOINT ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
345
I
1
I
2
I
3
I
Instruct the patient to lie supine on the examination table with the leg off the table and flexed to 90°.
Instruct the patient to flex the opposite knee to his chest and hold it. Palpate the quadriceps mus­
cles of the leg that is flexed off the table for tightness (Fig. 13-32).
RATIONALE
If the patient involuntarily extends the knee of the leg that is flexed off the table and tightness is pal­
pated in that thigh (Fig. 13-33), a hip flexion contracture is indicated. If there is no tightness in the
rectus femoris muscle, the probable cause of restriction is at the hip joint structure or joint capsule.
Figure 13-32
Figure 13-33
346
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Ely's Test (7)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
Instruct the patient to lie prone on the examination table. Then grasp the patient's ankle and pas­
sively flex the knee to the buttock (Fig. 13-34).
RATIONALE
If the patient has a tight rectus femoris muscle or hip flexion contracture, the hip on the same side
will flex (Fig. 13-35), raising the buttock off the table. This spontaneous flexion of the hip reduces
the traction pressure on the rectus femoris muscle induced by the passive knee flexion.
Figure 13-34
Figure 13-35
CHAPTER 13
Ober's Test (8)
HIP JOINT ORTHOPAEDIC TESTS
347
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
,
I
I
2
I
I
3
I
I
4
With the patient side-lying, abduct the patient's leg (Fig. 13-36) and then release it (Fig. 13-37). Per­
form this test bilaterally.
RATIONALE
The tensor fasciae latae and iliotibial band abduct the hip. If the leg fails to descend smoothly, sus­
pect contracture of the tensor fasciae latae muscle or iliotibial band.
Figure 13-36
Figure 13-37
348
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Piriformis Test (9)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
I
4
Instruct the patient to lie on the side opposite the leg being tested. Instruct the patient to flex the hip
to 60° with the knee fully flexed (Fig. 13-38). With one hand, stabilize the hip; with the other hand,
press down on the knee (Fig. 13-39).
RATIONALE
If the piriformis muscle is tight, pain will be elicited when the knee is pressed because this action
further tightens the piriformis muscle. If sciatic pain sets in, the piriformis muscle may be pinching
the sciatic nerve. In 15% of the population the sciatic nerve passes through the piriformis muscle.
SUGGESTED DIAGNOSTIC IMAGING
•
Plain film radiography
AP hip view
AP frog leg view
AP pelvis
Figure 13-38
Figure 13-39
CHAPTER 13
349
HIP JOINT ORTHOPAEDIC TESTS
GENERAL HIP JOINT LESIONS
CLINICAL DESCRlPTION
The hip is a ball and socket joint in which the stability of the joint is enhanced by the capsule and
the strong ligaments that surround the joint. The joint is weight bearing and subject to various in­
sults and disease processes. Some of the most common problems associated with the hip joint are
osteoarthritis, sprains, fractures, dislocations, bursitis, tendinitis, synovitis, and avascular necrosis of
the femoral head. The following tests help to determine whether a general lesion of the hip is pres­
ent. Further diagnostic testing based on the outcome of these tests can help to determine the exact
pathology.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Hip pain
Shortened extremity
Externally rotated extremity
Referred pain to medial thigh
Patrick Test (Faber) (10)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
With the patient supine, flex the leg and place the foot flat on the table. Grasp the femur and press it into
the acetabular cavity (Fig. 13-40). Next, cross the patient's leg to the opposite knee. Stabilize the oppo­
site anterior superior iliac spine and press down on the knee of the hip that is being tested (Fig. 13-41).
RATIONALE
This test forces the femoral head into the acetabular cavity, giving maximal congruence to the artic­
ular surfaces. Pain in the hip indicates an inflammatory process in the hip joint. Pain secondary to
trauma may indicate a fracture in the acetabular cavity, rim of the acetabular cavity, or femoral neck.
Pain may also indicate avascular necrosis of the femoral head. Faber stands for flexion, abduction,
and external rotation. This is the position of the hip when the test begins.
Figure 13-40
Figure 13-41
350
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Trendelenburg Test (11)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
I
4
With the patient standing, grasp the patient's waist and place your thumbs on the posterior superior
iliac spine of each ilium. Next, instruct the patient to flex one leg at a time (Fig. 13-42).
RATIONALE
When the patient is standing with one leg flexed, the patient is supported by an intact hip joint with
its associated ligaments and muscles on that side. If the patient cannot stand on one leg because of
pain and/or because the opposite pelvis falls or fails to raise, this is considered a positive test. This
result may indicate a weak gluteus medius muscle opposite the side of hip flexion, and it tests the
integrity of the hip joint and associated musculature and ligaments on the opposite side of hip flex­
ion. A positive outcome of this test often indicates hip joint pathology.
Figure 13-42
CHAPTER 13
Scouring Test (12)
351
HIP JOINT ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
With the patient supine, flex the patient's hip to 90°, fully flex the knee, and internally rotate the hip
(Fig. 13-43). Assuming the patient has no injury or pathology to the knee, apply downward and lat­
eral pressure on the knee (Fig. 13-44).
RATIONALE
This test is similar to the Patrick test, stressing the anteromedial and posterolateral aspect of the joint
capsule. Pain and/or a grating sensation indicates a positive test. This result may indicate an inflam­
matory process in the acetabular joint, such as osteoarthritis. Pain secondary to trauma may indi­
cate a fracture of the acetabular cavity or rim.
Figure 13-43
Figure 13-44
352
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Laguerre's Test (13)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, flex the hip and knee to 90°. Rotate the thigh outward and the knee medially.
Press down on the knee with one hand, and pull up on the ankle with the other hand (Fig. 13-45).
RATIONALE
This test externally forces the head of the femur into the acetabular cavity, stressing the anterior as­
pect of the joint capsule. This test may indicate an inflammatory process in the acetabular joint,such
as osteoarthritis. Pain secondary to trauma may indicate a fracture of the acetabular cavity or rim.
Figure 13-45
Hibb's Test
See the section on General Sacroiliac Joint Lesions in Chapter 12.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP hip view
AP frog leg view
AP pelvis
Bone scan
MRI
CHAPTER 13
References
HIP JOINT ORTHOPAEDIC TESTS
353
Cyriax J. Textbook of Orthopaedic Medicine. 2nd
1. American Academy of Orthopaedic Surgeons.
The Clinical Measurement of Joint Motion.
Chicago: AAOS,1994.
ed. Vol 1. London: Bailliere Tindal,1982.
Haycock CEo Sports Medicine for the Athletic Fe­
male. Oradell, NJ: Medical Economics,1980.
2. Boone DC,Azen SP. Normal range of motion of
Kapandji LA. The Physiology of the Joints. Vol. 2.
joints in male subjects. J Bone Joint Surg Am
Lower Limb. New York: Churchill Livingstone,1970.
1979;61:756-759.
3. Hensinger RN. Congenital dislocation of the
hip. Summit, NJ: CIBA
1979;31 (l).
Clinical
Symposia
4. Tachdjian MO. Pediatric Orthopedics. Philadel­
phia: Saunders, 1972.
5. Magee DJ. Orthopedic physical assessment. 3rd
ed. Philadelphia: Saunders, 1997.
6. Hoppenfeld S. Physical Examination of the
Spine and Extremities. New York: Appleton­
Century-Crofts,1976:137.
7. Gruebel-Lee
DM.
Disorders
of
the
Hip.
8. Ober FB. The role of the iliotibial and fascia lata
as a factor in the causation of low-back disabil­
ities and sciatica. J Bone Joint Surg 1936;18:105.
9. Saudek CEo The Hip. Ortl1opedic and Sports
Physical Therapy. St. Louis: Mosby,1990.
10. Kenna C, Murtagh J. Patrick or Faber test. Aust
Fam Physician 1989;18:375.
F.
Dtsch
Wschr
21,
12. Maitland GD. The Peripheral Joints: Examina­
tion and Recording Guide. Adelaide, Australia:
Vergo,1973.
13. Lee D. The Pelvic Girdle. Edinburgh: Churchill
sacroiliac
4th ed. Baltimore: Lippincott Williams & Wilkins,
1999.
Noble HB, Hajek MR, Porter M. Diagnosis and
Phys Sports Med 1984;10:67.
Phillips EK. Evaluation of the hip. Phys Ther 1975;
55:975-981.
Post M. Physical examination of the musculoskele­
tal system. Chicago: Year Book Medical,1987.
thop 1973;92:6.
Singleton Me. The Hip Joint: Clinical Oriented
AnatomyA Review. Common Disorders of the Hip.
New York: Haworth,1986.
Steinberg GG,Akins AM, Baran, DT. Orthopaedics
Williams & Wilkins,1999.
Steinberg ME. The Hip and Its Disorders. Philadel­
General References
The
Moore KL, Dalley AF. Clinically oriented anatomy.
in Primary Care. 3rd ed. Baltimore: Lippincott
Livingstone,1989.
GJ.
Mercier LR. Practical Orthopedics. St. Louis: Mosby,
1991.
Rydell N. Biomechanics of the hip joint. Clin Or­
Med
1895;21-24 (RSM translation).
Alderink
McRae R. Clinical Orthopedic Examination. New
York: Churchill Livingstone,1976.
treatment of iliotibial band tightness in runners.
Philadelphia: JB Lippincott,1983.
11. Trendelenburg
Maquet PGJ. Biomechanics of the Hip. New York:
Springer-Verlag,1985.
phia: Saunders,1991.
)Olllt:
review
of
anatomy, mechanics and function. J Orthop Sports
Phys Ther 1991;13:71.
Beetham WP,Polley HF, Slocumb CH,et al. Physical
Examination of the Joints. Phlladelphia: Saunders,
1965.
Chung SMK. Hip Disorders in Infants and Chil­
dren. Philadelphia: Lea & Febiger, 1981.
Subotnick17 S1. Sports Medicine of the Lower Ex­
tremity. 2nd ed. New York: Churchill Livingstone,
1999.
Wells PE. The examination of the pelvic joints. In:
Grieve GP,ed. Modern Manual Therapy of the Ver­
tebral Column. Edinburgh: Churchill Livingstone,
1986.
II
--------�wu�-KNEE ORTHOPAEDIC TESTS
KNEE ORTHOPAEDIC EXAMINATION
355
FLOW CHART
PALPATION
373
374
375
Retreating Meniscus Test
Modified Helfet's Test
Cabot's Popliteal Sign
356
356
Anterior Aspect
376
Bohler's Sign
Anderson Medial-Lateral Grind
Patella, Quadriceps Femoris Tendon, and
356
Anterior Knee Bursa
358
Test
377
Patella Ligament
PLICA TESTS
360
Quadriceps Femoris Muscle
Medial Aspect
361
378
379
380
Mediopatella Plica Test
Hughston Plica Test
Medial Femoral Condyle, T ibial Plateau,
and Joint Line
Lateral Aspect
362
363
Lateral Femoral Condyle and Joint
Line
363
364
Posterior Aspect
385
Reverse Lachman's Test
Losee Test
386
387
Apley's Distraction Test
365
Adduction Stress Test
Popliteal Fossa and Associated
Structures
382
Lachman's Test
385
Drawer's Sign
Slocum Test
Lateral Collateral Ligament and Iliotibial
Band
381
LIGAMENTOUS INSTABILITY
361
Medial Collateral Ligament
Abduction Stress Test
388
389
390
365
PAT ELLOFEMORAL DYSFUNCTION
367
KNEE RANGE OF MOT ION
Flexion
Extension
367
368
MENISCUS INSTABILITY
Patella Apprehension Test
Dreyer's Test
369
Apley's Compression Test
370
Bounce Home Test
371
Steinman's Tenderness Displacement
354
372
394
Patella Ballottement Test
Stroke Test
392
393
KNEE JOINT EFFUSION
369
McMurray's Test
Test
391
Patella Grinding Test
395
Fluctuation Test
395
394
391
Knee Orthopaedic Examination
�
Patella
.
apprehension
test
1..J.=l
Range of motion
(active)
(passive)
(+)
Patella
Ballottement test
Stroke test
Fluctuation test
(-)
Apley's compression test
McMurray's test
Bounce home test
Steinman's tenderness
displacement test
Retreating meniscus test
Modified Helfet's test
Payr's test
Cabot's popliteal sign
Bohler's sign
Anderson medial-lateral
grind test
�
Meniscal lesion
s
(")
�
m
'"
�
*""
(-)
( -)
Drawer's sign
Lachman's test
Reverse Lachman's
test
Slocum test
Losee test
Apley's distraction
test
Adduction stress test
Abduction stress test
�
m
m
o
::j
:t
o
::;!
m
"
n
>-l
§
...,
<.11
<.11
356
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PALPATION
Anterior Aspect
Patella, Quadriceps Femoris Tendon, and Patella Ligament
DESCRIPTIVE ANATOMY
The suprapatellar tendon anchors the patella to the anterior aspect of the knee superiorly. This ten­
don is an extension of the quadriceps muscle and it continues inferiorly as the patellar ligament (Fig.
14- 1). The patellar ligament is thick, strong, and continuous with the fibrous capsule of the knee
joint, and it attaches to the tibial tuberosity. These structures, which are superficial and easily pal­
pable, function as a lever to extend the leg when the quadriceps muscle contracts.
s lateralis
Quadriceps
femoris m.
Quadriceps -"""",,�-+'cI-Tfl-'im+:
muscle tendon
Patella
Lateral collateral
ligament
Medial collateral ligament
Patella ligament
Tibial tuberosity -+-+�mrt-;Fibula -+--It-
Figure 14-1
"l-,ji---+-- Tibia
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
357
PROCEDURE
With the patient supine and the knee extended, palpate the patella and its margins (Fig. 14-2). Note
any tenderness, inflammation, temperature differences, and/or roughness. Tenderness and pain
from direct trauma may indicate periosteal contusion or fracture of the patella. Swelling and an in­
crease in temperature suggest prepatellar bursitis. Roughness at the margins of the patella may in­
dicate chondromalacia patellae, or degeneration of the undersurface of the patella.
Next, palpate the quadriceps femoris tendon (Fig. 14-3). Tenderness may indicate tendinitis
caused by overuse or strain resulting from overstress. Continue palpation inferior to the patella
which is the patellar ligament. Palpate from the apex of the patella, which is the inferior margin,
down to the tibial tubercle, which is the attachment of the patellar ligament (Fig. 14-4). Note any
pain, tenderness, swelling, or temperature differences. Any of these findings may indicate ligament
sprain. If symptoms are local to the tibial tuberosity, suspect Osgood-Schlatter disease, an enlarge­
ment of the tibial tuberosity, in the adolescent; it is common in young adults.
Figure 14-3
Figure 14-2
Figure 14-4
358
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Anterior Knee Bursa
DESCRIPTIVE ANATOMY
The clinically important bursae in the anterior aspect of the knee are the suprapatellar bursa,
prepatellar bursa, superficial infrapatellar bursa, and deep infrapatellar bursa (Fig. 14-5). The supra­
patellar bursa, an extension of the synovial capsule, lies between the femur and the quadriceps
femoris tendons. It allows for movement of the quadriceps tendon over the distal end of the femur.
The prepatellar bursa is superficial to the patella between the skin and anterior surface of the patella.
It allows movement of the skin over the underlying patella. The superficial infrapatellar bursa is be­
tween the tibial tuberosity and the skin. It allows for movement of the skin over the tibial tuberos­
ity. The deep infrapatellar bursa lies between the patellar ligament and the tibia. This allows for
movement of the patellar ligament over the tibia.
Prepatellar
bursa
Superficial
bursa
Deep
infrapatellar
bursa
tendon
r---I::les anserinus
bursa
Tibial
tuberosity
Tibia
Figure 14-5
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
359
PROCEDURE
Palpate the suprapatellar bursa above the patella (Fig. 14-6). Note any thickening, tenderness, or
temperature differences. These signs may indicate bursitis in the suprapatellar bursa or pathology in
the quadriceps femoris tendon. Next, palpate the prepatellar bursa, which is superficial to the patella
(Fig. 14-7). Note any thickening, swelling, ten�erness, or temperature differences. These signs may
indicate prepatellar bursitis (housemaid's knee). Palpate the superficial and deep infrapatellar bursa
(Fig. 14-8). Note any thickening, swelling, tenderness, or temperature differences. Any of these may
indicate infrapatellar bursitis or patellar ligament pathology.
Figure 14-7
Figure 14-6
Figure 14-8
360
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Quadriceps Femoris Muscle
DESCRIPTIVE ANATOMY
The quadriceps femoris consists of four muscles: rectus femoris, vastus lateralis, vastus medialis, and
vastus intermedius (Fig. 14-9). The primary action of these muscles is to extend the leg at the knee.
They all unite to form the quadriceps tendon, which inserts into the patella.
PROCEDURE
Palpate the entire length of the quadriceps muscle, noting any swelling, tenderness, temperature dif­
ferences, or masses (Fig. 14- 10). Tenderness and/or swelling may indicate muscle strain or
hematoma. Point tenderness at the upper aspect of the muscle may indicate active trigger points and
may refer pain to the knee. A hard mass secondary to trauma may indicate myositis ossificans, which
is an ossification of muscle tissue.
lateralis
Quadriceps
femoris
Quadriceps -+\'r'\--\-1:4't�-i::
muscle tendon
Patella
Lateral collateral
ligament
Medial collateral ligament
Patella ligament
Ti bia I tuberosity --+--+---o,;fH.,-+I-�
Fibula -+----H-
Figure 14-9
Figure 14-10
�'---+-- Tibia
m.
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
361
Medial Aspect
Medial Femoral Condyle, Tibial Plateau, and Joint Line
DESCRIPTIVE ANATOMY
The medial femoral condyle is a bony prominence on the medial aspect of the distal femur, which
is the attachment of the medial collateral ligament. The medial tibial plateau and joint line are im­
portant palpable landmarks of the medial aspect of the knee. The medial aspect of the meniscus is
in the joint line, and the coronary ligament attaches the meniscus to the tibial plateau (Fig. 14- 1 1).
PROCEDURE
With the knee in 90° of flexion, palpate the medial femoral condyle with your index and middle fin­
gers (Fig. 14- 12). Note any tenderness or pain. These signs may indicate a sprain, avulsion, or calci­
fication (Pellegrini-Stieda disease) of the medial collateral ligament. Next, palpate the tibial plateau
and medial joint line. Note any tenderness or pain. These signs may indicate a tear of the medial
meniscus or sprain of the coronary ligament.
Joint
line ....
Figure 14-11
m
Figure 14-12
362
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Medial Collateral Ligament
DESCRIPTIVE ANATOMY
The medial collateral, or tibial collateral, ligament is a strong, broad, flat band that extends from
the medial epicondyle of the femur to the medial condyle and upper medial aspect of the tibia (Fig.
14- 13). It contributes to the medial stability of the knee. Its fibers are attached to the medial menis­
cus and the fibrous capsule of the knee.
PROCEDURE
With the patient supine and the leg extended, palpate the medial collateral ligament from the me­
dial epicondyle of the femur to the medial condyle of the tibia with your index and middle fingers
(Fig. 14- 14). Note any pain, tenderness, or defect in the ligament. Pain and tenderness may indicate
a sprain of the ligament. A deficit secondary to trauma may indicate a tear of the ligament, which is
usually associated with capsular and meniscal damage. A defect at either the medial femoral epi­
condyle or the medial tibial condyle suggests an avulsion fracture secondary to trauma.
Quadriceps femoris ---7f'.:m:ff+i
tendon
Prepatellar
bu
Medial
collateral
ligament
1--IJes anserinus
bursa
Tibial
tuberosity
Tibia
Figure 14-13
Figure 14-14
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
363
Lateral Aspect
Lateral Femoral Condyle and Joint Line
DESCRIPTIVE ANATOMY
The lateral femoral condyle is a bony prominence on the lateral aspect of the distal femur, which is
the attachment of the lateral collateral ligament and iliotibial band. This structure is important for
the lateral stability of the knee. The lateral joint line is an important palpable landmark of the lat­
eral aspect of the knee. The lateral aspect of the meniscus and the coronary ligament, which attaches
the meniscus to the tibia, are in the joint line (Fig. 14- 15).
PROCEDURE
With the knee in 90° of flexion, palpate the lateral femoral condyle with your index and middle fin­
gers (Fig. 14- 16). Note any tenderness or pain. These signs may indicate sprain, avulsion, or calcifi­
cation of the lateral collateral ligament. Next, palpate the lateral joint line. Note any tenderness or
pain. These signs may indicate a tear of the lateral meniscus or strain of the coronary ligament.
Figure 14-15
Figure 14-16
364
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Lateral Collateral Ligament and Iliotibial Band
DESCRIPTIVE ANATOMY
The lateral collateral ligament is a round cord that extends from the lateral epicondyle of the femur
to the head of the fibula (Fig. 14- 15). This structure is important for the lateral stability of the knee.
In contrast to the medial collateral ligament, the fibers are not attached to the meniscus. The tendon
of the popliteus muscle passes deep to the ligament, separating it from the meniscus of the knee. The
iliotibial band is a continuation of the tensor fasciae latae muscle, and it attaches to the lateral
condyle of the tibia (Fig. 14- 17). This band helps keep the knee extended during standing and is im­
portant for lateral stability of the knee.
PROCEDURE
With the patient either supine or sitting, instruct the patient to cross one leg over the other (Fig.
14-18). With your index and middle finger, palpate the lateral collateral ligament of the top leg from
the lateral epicondyle of the femur to the head of the fibula. Note any pain, tenderness, or defect.
Pain and tenderness may indicate a sprain or calcification of the ligament. A defect secondary to
trauma may indicate a tear or avulsion of the lateral collateral ligament. Next, palpate the entire
length of the iliotibial band from halfway between the hip and knee on the lateral aspect to the lat­
eral condyle of the tibia (Fig. 14- 19). Note any pain, tenderness, or defects of the iliotibial band. Pain
and tenderness may indicate a strain of the band. A defect secondary to trauma may indicate a tear
or avulsion of the band from the lateral condyle of the tibia.
i
iliac crest
Irt--f+-Tensor fascia lata m.
'i'-'!---.'rf+-l Iiotibial band
Figure 14-18
Figure 14-17
Figure 14-19
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
365
Posterior Aspect
Popliteal Fossa and Associated Structures
DESCRIPTIVE ANATOMY
The popliteal fossa is surrounded by the biceps femoris tendon on the superior lateral border and
the tendons of the semimembranosus and semitendinosus on the superior medial border. The infe­
rior borders are bounded by the two heads of the gastrocnemius muscles. The posterior tibial nerve,
popliteal artery, and popliteal vein cross the popliteal fossa (Fig. 14-20).
Semitendinosus m. -HOOI+1+H4 11
1I1\�'.lIlI-Ti¥1H+Wf--f--- Biceps femoris m.
Semimembranosus m.
\l\W"':\4H,jM--+-- Posterior tibial nerve
Popliteal artery
Gastrocnemius m.
Figure 14-20
m
366
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PROCEDURE
With the knee slightly flexed, palpate the popliteal fossa for swelling or tenderness (Fig. 14-2 1).
These signs may indicate Baker's cyst, a pressure diverticulum of the synovial sac protruding
through the joint capsule of the knee. Next, palpate the biceps femoris tendon (Fig. 14-22), semi­
membranosus tendon, semitendinosus tendon (Fig. 14-23), and both heads of the gastrocnemius
muscle (Fig. 14-24) for tenderness, swelling, and continuity. This tenderness and swelling may indi­
cate a strain of the respective tendons or muscles. Loss of continuity may indicate an avulsion of the
respective muscles or tendons.
Figure 14-21
Figure 14-22
Figure 14-23
Figure 14-24
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
367
KNEE RANGE OF MOTION
Flexion (1)
With the patient prone and the leg extended, place the goniometer in the sagittal plane with the cen­
ter at the knee joint (Fig. 14-25). Instruct the patient to flex the leg as far as possible while follow­
ing the leg with one arm of the goniometer (Fig. 14-26).
NORMAL RANGE (2)
Normal range is 14 10
±
6.50 or greater from the 0 or neutral position.
Muscles
Nerve Supply
Biceps femoris
Semimembranosus
Semitendinosus
Gracilis
Sartorius
Popliteus
Gastrocnemius
Plantaris
Sciatic
Sciatic
Sciatic
Obturator
Femoral
Tibial
Tibial
Superior gluteal
Figure 14-25
Figure 14-26
368
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Extension (1)
With the patient seated, foot on the floor, place the goniometer in the sagittal plane with the center
at the knee (Fig. 14-27). Instruct the patient to extend the leg as far as possible while following the
leg with one arm of the goniometer (Fig. 14-28). Note that this test starts with the leg in 90° of flex­
ion and you want the knee to extend to the 0 or neutral position.
NORMAL RANGE (2)
Normal range is 0
:±:
2°.
Muscles
Nerve Supply
Rectus femoris
Vastus medialis
Vastus intermedius
Vastus lateralis
Femoral
Femoral
Femoral
Femoral
Figure 14-27
Figure 14-28
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
369
MENISCUS INSTABILITY
CLINICAL DESCRIPTION
The menisci are C-shaped disks of fibrocartilage that are interposed between the condyles of the fe­
mur and the tibia. The functions of the meniscus are many. Its primary function is load transmis­
sion or weight bearing, and the secondary function is shock absorption during gait. The menisci are
also thought to contribute to joint stability and lubrication. Finally, because of the nerve endings in
the anterior and posterior horns, proprioception provides a feedback mechanism for joint position.
A tear or loss of the menisci, either partial or complete, hinders their ability to function and pre­
disposes the joint to degenerative changes. A twisting injury to the knee with the foot in a weight­
bearing position is the most common injury to the meniscus. Because the outer 20% of the menisci
have a vascular supply, peripheral injuries may heal. The inner 80% of the menisci are avascular, so
inner meniscal injuries rarely heal.
CLINICAL SIGNS AND SYMPTOMS
Local medial or lateral joint pain
Limited knee range of motion
Crepitus upon movement
Joint effusion
Knee buckling
Pain on walking up and down stairs
Pain on squatting
Apley's Compression Test (3)
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
I
1
I
I
2
I
I
3
I
I
4
With the patient prone, flex the leg to 90°. Stabilize the patient's thigh with your knee. Grasp the pa­
tient's ankle and place downward pressure while you internally (Fig. 14-29) and externally (Fig. 1430) rotate the leg.
m
Figure 14-29
Figure 14-30
370
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
RATIONALE
The menisci, which are asymmetric fibrocartilaginous disks, separate the tibial condyles from the
femoral condyles. When the knee is flexed, the meniscus distorts to maintain the congruence be­
tween the tibial and femoral condyles. Flexion of the knee applies downward pressure with internal
and external rotation stress to the already distorted meniscus. Pain or crepitus on either side of the
knee indicates a meniscus injury on that side.
McMurray's Test (4)
PROCEDURE
Sensitivity/Reliability Scale
I
I
1
I
2
I
3
I
4
With the patient supine, flex the leg (Fig. 14-3 1). Externally rotate the leg as you extend (Fig. 14-32);
internally rotate as you extend (Fig. 14-33).
RATIONALE
Flexion and extension of the knee distort the meniscus to maintain the congruence between the tib­
ial and femoral condyles. Flexing and extending the knee with internal and external rotation further
stress the already distorted meniscus. A palpable or audible click indicates an injury of the meniscus.
Figure 14-31
Figure 14-32
Figure 14-33
CHAPTER 14
Bounce Home Test (5)
371
KNEE ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, instruct the patient to flex the leg. When the leg is flexed, cup your hand
around the patient's heel (Fig. 14-34) and instruct him to relax his muscles and allow the knee to drop
(Fig. 14-35).
RATIONALE
Extension of the knee entails medial rotation of the femur on the tibia. If the meniscus is injured,
rotation of the femur on the tibia may be blocked and the patient may not be able to extend the knee
fully. A rubbery end feel on full extension is also a positive sign.
Figure 14-34
m
Figure 14-35
372
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Steinman's Tenderness Displacement Test (6)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
With the patient supine, flex the patient's hip and knee to 90°. Place your thumb and index finger
on the medial and lateral knee joint lines, respectively (Fig. 14-36). With your opposite hand, grasp
the patient's ankle and alternately flex and extend the knee while palpating the entire joint line (Fig.
14-37).
RATIONALE
When the knee is extended, the meniscus moves anteriorly, and when the knee is flexed, the menis­
cus moves posteriorly. If the pain seems to move anteriorly when the knee is extended or posteriorly
when the knee is flexed, suspect a tear or injury of the meniscus.
Figure 14-36
Figure 14-37
CHAPTER 14
Retreating Meniscus Test (7)
KNEE ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
373
I
1
I
2
I
3
I
With the patient supine and the patient's hip and leg flexed to 90°, palpate the meniscus on the me­
dial joint line anterior to the medial collateral ligament. With your opposite hand, rotate the leg me­
dially and laterally while noting whether the meniscus that you are palpating is still present or has
disappeared (Figs. 14-38 and 14-39).
RATIONALE
When the knee is flexed to 90°, the femur should rotate medially on the tibia. If the meniscus does
not disappear while you are rotating the leg, suspect a torn meniscus, because rotation of the tibia
is blocked.
Figure 14-38
Figure 14-39
374
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Modified Helfet's Test (7)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient seated, foot on the floor, note the location of the tibial tuberosity in relation to the
midline (Fig. 14-40). Passively extend the patient's leg and again note the location of the tibial
tuberosity in relation to the patella (Fig. 14-4 1).
RATIONALE
In the normal knee, the tibial tuberosity is at the midline when the knee is in 90° of flexion. When
the knee is extended, the tibial tuberosity moves in line with the lateral border on the patella. If this
does not occur, suspect a tear of the meniscus because rotation of the tibia is blocked.
Figure 14-40
Figure 14-41
CHAPTER 14
Cabot's Popliteal Sign (8)
KNEE ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
375
I
1
I
2
I
3
I
With the patient supine, instruct the patient to abduct the thigh and cross the leg of the affected knee
(Fig. 14-42). Grasp the ankle with one hand, and with the other hand palpate the joint line with your
thumb and index finger (Fig. 14-43). Ask the patient to straighten the knee isometrically against
your resistance.
RATIONALE
Resisting extension of the knee in the figure-4 position stresses the meniscus. Pain on the joint line
indicates a tear or pathology of the meniscus.
Figure 14-42
Figure 14-43
376
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Bohler's Sign (8)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
With the patient supine, stabilize the medial thigh with one hand and place a valgus force on the lat­
eral aspect of the leg with your opposite hand (Fig. 14-44). Next, stabilize the lateral knee and place
a varus force on the medial aspect of the leg (Fig. 14-45).
RATIONALE
Placing a lateral or medial pressure on the knee distracts the joint capsule and meniscus on the op­
posite side of the pressure. Pain on the side opposite joint pressure may indicate a lesion of the joint
capsule or meniscus.
NOTE
This test is similar to the adduction and abduction stress test for collateral ligament defect. If this
test is positive, evaluate for collateral ligament defect opposite the side of pressure.
Figure 14-44
Figure 14-45
CHAPTER 14
Anderson Medial-Lateral Grind Test (9)
KNEE ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
377
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, grasp the leg of the affected knee and place it between your trunk and arm.
With your opposite thumb and index finger, palpate the anterolateral and medial joint lines. Place a
valgus stress on the knee as it is flexed passively (Fig. 14-46) and a varus stress on the knee as it is
extended passively (Fig. 14-47). Use a circular movement and increase valgus and varus stresses af­
ter each complete circle.
RATIONALE
This movement stresses the meniscus on the medial side with valgus stress and on the lateral side
with varum stress. Pain and/or grinding on movement may indicate a meniscus tear or pathology.
SUGGESTED DIAGNOSTIC IMAGING
•
•
Plain film radiography
Anteroposterior (AP) knee view
Lateral knee view
Magnetic resonance imaging (MRI)
Figure 14-46
m
Figure 14-47
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
378
PLICA TESTS
CLINICAL DESCRIPTION
The synovial plica is a redundant fold in the synovial lining of the knee, extending from the fat pad
medially under the quadriceps tendon superiorly to the lateral retinaculum (Fig. 14-48). This plica
may become inflamed, thickened, and/or fibrotic from trauma or overuse, resulting in clinical
symptoms. If the plica is inflamed, a more complex patellofemoral problem may be present.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Anterior knee pain
Anterior pain on prolonged knee flexion
Knee pain diminishing with increased activity
Popping or snapping upon knee flexion or extension
Quadriceps tendon
Synovial plicae
Medial _f!I.:'*-----4\lr\\.l-\
patellar
plica
"-"--Anterior -\----:-;
plica
Fat pad
Figure 14-48
CHAPTER 14
Mediopatella Plica Test (10)
Sensitivity/Reliability Scale
I
o
PROCEDURE
379
KNEE ORTHOPAEDIC TESTS
I
1
I
2
I
3
I
4
With the patient supine, flex the affected leg to 30°. With the other hand, move the patella medially
(Fig. 14-49).
RATIONALE
Moving the patella medially with the leg in 30° of flexion pinches the plica between the medial
femoral condyle and the patella. Pain may indicate that the plica is adhered to the patella and is in­
flamed. The plica is the remnant of an embryonic septum that makes up the knee joint capsule.
Figure 14-49
380
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Hughston Plica Test (I1)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
With the patient supine, grasp the patient's leg. Flex and medially rotate the leg. With your opposite
hand, move the patella medially with the heel of your hand and palpate the medial femoral condyle
with the fingers of the same hand (Fig. 14-50). Flex and extend the knee while feeling for popping
of the plical band under your fingers (Fig. 14-51).
RATIONALE
Popping under your fingers may indicate that the plica is attached to the patella, and it may be in­
flamed. The incidence of patella plica varies from 18% to 60% of the population, according to dif­
ferent authors.
SUGGESTED DIAGNOSTIC IMAGING
•
Knee MRI
Figure 14-50
Figure 14-51
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
381
LIGAMENTOUS INSTABILITY
CLINICAL DESCRIPTION
Ligaments are vital to the stability of the knee. The major ligaments of the knee are the anterior and
posterior cruciate and the medial and lateral collateral ligaments (Fig. 14-52). Ligament injuries are
among the most serious knee disorders. A delay in diagnosis and treatment may lead to a chroni­
cally unstable knee, which predisposes the knee to early degeneration. Ligament instability is usu­
ally due to a traumatic stress to the knee while the knee was bearing weight. A valgus stress may
sprain or tear the medial collateral ligament. A varus stress may sprain or tear the lateral collateral
ligament. Both of these stresses with a rotational force may also sprain or tear the anterior and/or
posterior. cruciate ligaments.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Knee pain
Limited range of motion
Difficulty in weight bearing in acute stage
Joint effusion
Knee giving out; chronic unstable knee
Lateral
collateral
ligament
Posterior
cruciate
ligament
Anterior
cruciate
ligament
Medial
collateral
ligament
Fibula
Figure 14-52
382
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Drawer Sign (12-14)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, flex the leg and place the foot on the table (Fig. 14-53). Grasp behind the
flexed knee and pull (Fig. 14-54) and push (Fig. 14-55) on the leg. The hamstring tendons must be
relaxed for this test to be accurate.
Figure 14-53
Figure 14-54
Figure 14-55
CHAPTER 14
383
KNEE ORTHOPAEDIC TESTS
RATIONALE
If there is more than 5 mm of tibial movement on the femur when the leg is pulled, an injury or tear
of some degree to one or more of the following structures is indicated:
•
•
•
Anterior cruciate ligament (Fig. 14-56)
Posterolateral capsule
Posteromedial capsule
Medial collateral ligament (if more than 1 cm of movement)
Iliotibial band
Posterior oblique ligament
Arcuate-popliteus complex
Posterior
cruciate
ligament
I
�
Frontal view
Normal
Figure 14-56
With ligament tear
384
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
If excessive movement occurs when the leg is pushed, an injury to one of the following struc­
tures is indicated:
•
Posterior cruciate ligament (Fig. 14-57)
Arcuate-popliteus complex
Posterior oblique ligament
Anterior cruciate ligament
Anterior
cruciate
ligament
Posterior
cruclate
ligament
Posterior view
Normal
Figure 14-57
Lateral view
With ligament tear
CHAPTER 14
Lachman's Test (14)
KNEE ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
385
I
1
I
2
I
3
I
4
With the patient supine and the knee in 30° of flexion, grasp the patient's thigh with one hand to
stabilize it. With the opposite hand, grasp the tibia and pull it forward (Fig. 14-58).
RATIONALE
If a softened feel and anterior translation of the tibia is present when the tibia is moved forward,
then a tear of any of the following ligaments is suspect:
•
Anterior cruciate ligament
Posterior oblique ligament
This is the most reliable test for anterior cruciate ligament rupture because the knee does not
need to flex to 90°, as with the anterior drawer sign; there is less meniscal impingement; and the
hamstrings are less likely to spasm.
Figure 14-58
Reverse Lachman's Test (8)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient prone, flex the leg to 30°. With one hand, stabilize the posterior thigh, making sure
that the hamstring muscles are relaxed. With your opposite hand, grasp the tibia and push it poste­
riorly (Fig. 14-59).
RATIONALE
Posterior pressure on the tibia stresses the posterior cruciate ligament. A soft end feel and a poste­
rior translation of the tibia indicate an injury or tear to the posterior cruciate ligament.
Figure 14-59
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
386
Slocum Test (15)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
With the patient supine, place the patient's foot on the examination table in 30° of internal rotation.
Stabilize the patient's foot with your knee, grasp the tibia with your hand, and pull the tibia toward
you (Fig. 14-60).
RATIONALE
This test is similar to the anterior drawer sign except that in this test, the foot is in 30° of internal
rotation. If tibial translation and a soft end feel occur when the tibia is drawn forward, suspect in­
stability or a tear of any of the following ligaments:
•
•
Anterior cruciate
Posterolateral capsule
Fibular collateral ligament
Iliotibial band
Figure 14-60
CHAPTER 14
Losee Test (16)
KNEE ORTHOPAEDIC TESTS
387
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, grasp the patient's leg with one hand, externally rotate it, and brace it
against your abdomen. Flex the leg 30° to relax the hamstring muscles (Fig. 14-6 1). With your op­
posite hand, grasp the knee with your thumb behind the fibular head and your fingers over the
patella. Place valgus force against the lateral aspect of the knee and forward pressure behind the fibu­
lar head while extending the knee (Fig. 14-62).
RATIONALE
Externally rotating the leg in 30° of flexion and applying a valgus force compress the structure in the
lateral compartment of the knee. This compression may accentuate anterior subluxation of the tibia.
While extending the knee and applying a valgus force, look for a palpable clunk. This clunk may in­
dicate anterior subluxation of the tibia, which is a reproduction of the patient's previous instability
experience. It indicates injury or tear to one or more of the following structures:
•
•
•
•
Anterior cruciate ligament
Posterolateral joint capsule
Arcuate-popliteus complex
Lateral collateral ligament
Iliotibial band
Figure 14-61
Figure 14-62
388
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Apley's Distraction Test (17)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
With the patient prone, flex the leg to 90°. Stabilize the patient's thigh with your knee. Pull on the
patient's ankle while internally (Fig. 14-63) and externally (Fig. 14-64) rotating the leg.
RATIONALE
Distraction of the knee takes pressure off the meniscus and puts strain on the medial and lateral col­
lateral ligaments. Pain on distraction indicates nonspecific ligament injury or instability.
Figure 14-63
Figure 14-64
CHAPTER 14
KNEE ORTHOPAEDIC TESTS
Adduction Stress Test (5)
389
Sensitivity/Reliability Scale
I
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, stabilize the medial thigh. Grasp the lower leg and push it medially (Fig.
14-65). Also perform this test with the knee in 20° to 30° of flexion (Fig. 14-66).
RATIONALE
If the tibia moves an excessive medial amount away from the femur (Box 14- 1) when the knee is in
full extension, there may be a tear of any of the following ligaments:
•
•
•
Tibial collateral ligament
Posterior meniscofemoral ligament
Posterior medial capsule
Anterior cruciate ligament
Posterior cruciate ligament
If the foregoing is positive when the knee is flexed 20° to 30°, any of the following ligaments may
be unstable:
•
Tibial collateral ligament
Posterior meniscofemoral ligament
Posterior cruciate ligament
Figure 14-65
Figure 14-66
Medial Stability Rating Scale
Grade 0
No joint opening
Grade 1 +
Less than 0.5 em joint opening
Grade
0.5 to 1.0em joint opening
More t han 1 em joint opening
Grade
2+
3+
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
390
Abduction Stress Test (5)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
,
I
2
I
3
I
4
With the patient supine, stabilize the lateral thigh. Grasp the lower leg and pull it laterally (Fig.
14-67). Then perform this test in 20° to 30° of flexion (Fig. 14-68).
RATIONALE
If the tibia moves an excessive amount away from the femur (Box 14-2) when the knee is in full ex­
tension, there may be a tear of any of the following ligaments:
•
•
•
Fibular collateral ligament
Posterolateral capsule
Posterior cruciate ligament
Anterior cruciate ligament
If the foregoing is positive when the knee is flexed 20° to 30°, then the following ligaments may
be unstable:
Fibular collateral ligament
Posterolateral capsule
Iliotibial band
SUGGESTED DIAGNOSTIC IMAGING
•
•
Plain film radiography
AP knee view
Lateral knee view
Knee MRI
Figure 14-67
Figure 14-68
Lateral Stability Rating Scale
Grade 0
Grade
1+
Grade 2+
Grade 3+
No joint opening
Less than 0.5 em joint opening
0.5 to 1.0 em joint opening
More than 1em joint opening
CHAPTER 14
391
KNEE ORTHOPAEDIC TESTS
PATELLOFEMORAL DYSF UNCTION
The patella protects the anterior aspect of the knee joint. It also functions as a fulcrum that increases
the mechanical advantage of the quadriceps muscle. The patella lies in the trochlear groove. With
normal flexion and extension the patella tracks smoothly within the groove. Many causes of ante­
rior knee pain and dysfunction may be caused by an abnormality of the patella tracking in the
trochlear groove or direct trauma to the patella. Patellofemoral abnormalities include fractures, dis­
locations, malalignment syndrome, chondromalacia patellae, and patellofemoral arthritis.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
Anterior knee joint pain
Knee joint effusion
Popping sensation
Joint crepitus
Discomfort with stair climbing
Knee buckling
Patella Grinding Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
I
3
I
4
With the patient supine, move the patella medially and laterally while pressing down (Fig. 14-69).
RATIONALE
Pain under the patella indicates chondromalacia patellae, retropatellar arthritis, or a chondral frac­
ture. Osteochondritis of the patella also elicits pain on the patella. Pain over the patella may indicate
prepatellar bursitis.
IQ
Figure 14-69
I
392
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Patella Apprehension Test (17)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, manually displace the patella laterally (Fig. 14-70).
RATIONALE
A look of apprehension on the patient's face and a contraction of the quadriceps muscle indicates a
chronic tendency to lateral patella dislocation. Pain is also present with this test.
Figure 14·70
CHAPTER 14
Dreyer's Test
KNEE ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
o
PROCEDURE
393
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, instruct him or her to raise the leg actively (Fig. 14-7 1). If the patient can­
not raise the leg, stabilize the quadriceps tendon just above the knee. At this point, instruct the pa­
tient to raise the leg again (Fig. 14-72).
RATIONALE
If the patient can raise the leg the second time, suspect a traumatic fracture of the patella. The rec­
tus femoris muscle, which is a primary hip flexor, is attached to the patella by the quadriceps ten­
don. If the patella is fractured, the quadriceps tendon is not stabilized. Stabilizing the quadriceps
tendon manually allows hip flexion to occur.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Plain film radiography
AP knee view
Lateral patella view
Axial patella view
Computed tomography (CT)
Magnetic Resonance Imaging (MRI)
Figure 14-71
-­
I
Figure 14-72
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
394
KNEE JOINT EFF USION
CLINICAL DESCRIPTION
Effusion in and around the knee may be caused by trauma, infection, degenerative joint disease,
rheumatoid arthritis, gout, or pseudogout. The fluid may contain blood, fat, lymphocytes, and crys­
tals such as urate, pyrophosphate, and oxalate. Analysis of the effusion is beyond the scope of this
book. The following physical tests attempt to determine whether fluid is present around the knee
joint. If fluid is present, you must determine, based on the patient's history and clinical findings,
whether aspiration is indicated.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
Knee pain on walking
Anterior knee inflammation
Knee joint warm to the touch
Patella Ballottement Test
PROCEDURE
Sensitivity/Reliability Scale
I
o
I
I
1
I
I
2
I
I
3
!
I
4
With one hand, encircle and press down on the superior aspect of the patella. With the other hand,
push the patella against the femur with your finger (Fig. 14-73).
RATIONALE
If fluid is present in the knee, the patella will elevate when pressure is applied. When the patella is
pushed down, it will strike the femur with a palpable tap.
Figure 14-73
CHAPTER 14
Stroke Test (5)
395
KNEE ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
I
I
o
PROCEDURE
I
1
I
2
I
3
4
With the patient supine, stroke the medial side of the patella up toward the suprapatellar pouch two
or three times with your fingers and simultaneously stroke the lateral aspect of the patella inferior
with your opposite hand (Fig. 14-74).
RATIONALE
If a wave of synovial fluid is present, it will concentrate to the inferior medial border of the patella;
subsequently, the area will bulge.
Figure 14-74
Fluctuation Test (5)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, grasp the thigh at the suprapatellar pouch with one hand and grasp the leg
just below the patella with your opposite hand (Fig. 14-75). Press down with each hand alternately.
RATIONALE
If synovial fluid is present, you will feel it fluctuate alternately under your hand. This fluctuation in­
dicates significant joint effusion.
SUGGESTED DIAGNOSTIC IMAGING
•
None
m
Figure 14-75
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
396
Butler DL, Noyes FR, Grood ES. Ligamentous re­
References
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The Clinical Measurement of Joint Motion.
Chicago: AAOS, 1 994.
2. Boone DC, Azen SP. Normal range of motion of
straints to anterior-posterior drawer in the human
knee. J Bone Joint Surg Am 1 980;62:259.
Cailliet R. Knee Pain and Disability. Philadelphia:
FA Davis, 1 973.
the joints in male subjects. J Bone Joint Surg
Cipriano J. Post traumatic knee injuries. Today's
Am 1979; 6 1:756-759.
Chiropractic 1985; 14( 5 ) :49-5 1.
3 . Apley AG. The diagnosis of meniscus injuries:
some new clinical methods. J Bone Joint Surg
1947;29:78.
4. McMurray TP. The semilunar cartilages. Br J
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5 . McGee DJ. Orthopedic Physical Assessment.
2nd ed. Philadelphia: Saunders, 1 992.
6. Ricklin P, Ruttiman A, Del Buono MS. Meniscal
Lesions: Diagnosis, Differential Diagnosis, and
Clancy WG. Evaluation of acute knee injuries.
American Association of Orthopedic Surgeons sym­
posium on sports medicine: the Knee. St. Louis:
Mosby, 1985.
Clancy WG, Keene JS, Goletz TH. The symptomatic
dislocation of the anterior horn of the medial
meniscus. Am J Sports Med 1984; 12:57-64.
Cyriax J. Textbook of Orthopaedic Medicine. Vol. 1 .
Therapy. 2nd ed. Mieller N H , trans. New York:
Diagnosis of Soft Tissue Lesions. London: Bailliere
Theme Stratton, 1983.
Tindall, 1982.
7. Helfet A. Disorders of the Knee. Philadelphia:
JB Lippincott, 1974.
8 . Strobel M , Stedtfeld HW. Diagnostic Evaluation
of the Knee. Berlin: Springer-Verlag, 1990.
Frankel VH, Burstein AH, Brooks DB. Biomechanics
of internal derangement of the knee. J Bone Joint
Surg Am 197 1;53:945.
9. Anderson AF, Lipscomb AB. Clinical diagnosis
Hardaker WT, Whipple TL, Bassett FH. Diagnosis
of meniscal tears-description of a new manip­
and treatment of the plica syndrome of the knee. J
ulative test. Am J Sports Med 1988;14:2 9 l .
1 0 . Mital MA, Hayden J . Pain i n the knee i n chil­
dren: the medial plica shelf syndrome. Orthop
Clin North Am 1979 ; 1 0 : 7 14.
1 1 . Houghston JC, Walsh WM, Puddu G. Patella
subluxation
and
dislocation.
Philadelphia:
Saunders, 1984.
12. Butler DL, Noyes FR, Grood ES. Ligamentous
Bone Joint Surg Am 1980;62:22 1-255.
Johnson T, Althoff B, Peterson L, et al. Clinical diag­
nosis of ruptures of the anterior cruciate ligament: a
comparative study of the Lachman test and the an­
terior drawer sign. Am J Sports Med 1 982; 10: 100.
Kapandji LA. The Physiology of the Joints. Vol. 2.
Lower Limb. New York: Churchill Livingstone,
restraints to anterior-posterior drawer in the
1970.
human knee. J Bone Joint Surg Am 1980;62:
Katz KW, Fingeroth RF. The diagnostic accuracy of
259.
ruptures of the anterior cruciate ligament compar­
13. Fukybayashi T, Torzilli PA, Sherman M F, et al.
ing the Lachman test, the anterior drawer sign and
An in vitro biomechanical evaluation of ante­
the pivot shift test in acute and chronic knee in­
rior posterior motion of the knee. J Bone Joint
juries. Am J Sports Med 1986; 14:88.
Surg Br 1972;54:763.
14. Jonsson TB, Althoff L, Peterson J, et al. Clinical
diagnosis of ruptures of the anterior cruciate
ligament: a comparative study of the Lachman
Nottage WM, Sprague NF, Auerbach BJ, et al. The
medial patellar plica syndrome. Am J Sports Med
1983; 1 1 : 2 1 1 2 14.
test and the anterior drawer sign. Am J Sports
Outerbridge RE, Dunlop J. The problem of chon­
Med 1 982; 10: 100.
dromalacia patellae. Clin Orthop 1975; 1 10: 177 196.
15. Slocwn DB, James SL, Larson RL, et al. A clini­
cal test for anterolateral rotary instability of the
knee. Clin Orthop 1976; 1 1 8;63.
16. Loose RE, Jenning TR, Southwich WOo Anterior
subluxation of the lateral tibial plateau: a diag­
Pickett
JC, Radin EL. Chondromalacia
of the
Patella. Baltimore: Williams & Wilkins, 1983.
Slocum DB, Larson RL. Rotary instability of the
knee. J Bone Joint Surg Anl 1968;50:2 1 1.
nostic test and operative review. J Bone Joint
Stickland A. Examination of the knee joint. Physio­
Surg Am 1 978;60: 1 0 1 5 .
therapy 1984;70: 144.
17. Hoppenfeld S. Physical examination o f the
spine and extremities. New York: Appleton­
Century-Crofts, 1976: 127.
Scuderi, GR: The Patella. New York: Springer­
Verlag, 1995.
Torg JS, Conrad W, Nalen V. Clinical diagnosis of
anterior cruciate ligament instability in tlle athlete.
General References
Am J Sports Med 1976;4:84.
Bloom M H . Differentiating between meniscal and
Tria AJ. Ligaments of the Knee. New York: Churchill
patellar pain. Phys Sports Med 1989; 1 7 ( 8 ) :95-108.
Livingstone, 1995.
--------���-ANKLE ORTHOPAEDIC TESTS
ANKLE ORT HOPAEDIC EXAMINATION
398
FLOW CHART
PALPATION
399
Medial Malleolus and Deltoid
Ligament
399
Tibialis Posterior, Flexor Digitorum
Longus, and Flexor Hallucis Longus
Tendons
400
Posterior Tibial Artery and Tibial
402
Lateral Aspect
403
ANKLE RANGE OF MO TION
409
409
Planter Flexion
410
Inversion
411
Eversion
412
Dorsiflexion
LIGAMENTOUS INS T ABILI T Y
Medial Stability Test
404
405
Tinel's Foot Sign
Tibialis Anterior, Extensor Hallucis
Longus, and Extensor Digitorum
Longus Tendons
TARSAL T UNNEL SYNDROME
Tourniquet Test
405
413
414
415
416
403
Peroneus Longus and Peroneus Brevis
Tendons
407
Lateral Stability Test
Lateral Malleolus and Attached
Anterior Aspect
Retrocalcaneal Bursa
Drawer's Foot Sign
Nerve
Ligaments
407
Achilles Tendon, Calcaneal Bursa, and
399
Medial Aspect
Posterior Aspect
417
417
418
ACHILLES T ENDON RUP T URE
T h ompson's Test
419
Achilles Tap Test
420
419
397
398
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Ankle Orthopaedic Examination
�
History
Range of motion
(active)
(passive)
(+)
Drawer's foot sign
Lateral stability test
Medial stability test
(-)
I
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
399
PALPATION
Medial Aspect
Medial Malleolus and Deltoid Ligament
DESCRIPTIVE ANATOMY
The medial malleolus is the most distal prominence of the tibia. It embraces the medial aspect of the
talus and gives the ankle joint bony stability. Attached to the malleolus is the strong deltoid ligament,
which connects with three tarsal bones: the talus, navicular, and calcaneus. The deltoid is a four-part
ligament that is named according to its attachments: tibionavicular, anterior and posterior tibiota­
lar, and tibiocalcaneal (Fig. 15-1). The deltoid ligament strengthens and provides medial stability to
the ankle joint and holds the calcaneus and navicular bones against the talus. A common injury is a
forceful eversion of the foot that causes an avulsion fracture of the deltoid ligament on the medial
malleolus.
PROCEDURE
With the patient's weight off that foot, palpate the medial malleolus and deltoid ligament for ten­
derness and/or swelling (Fig. 15-2). Tenderness and/or swelling secondary to trauma may indicate
periosteal contusion, sprain, or avulsion of the deltoid ligament.
Deltoid
ligamen t
1
Posterior tibiotalar ligament
Tibiocalcaneal ligament
Anterior tibiotalar ligament
Tibionavicular ligament
Medial
malleolus
Posterior
talocalcaneal
ligament
Plantar calcaneonavicular ligament
Figure
15-1
Figure
15-2
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
400
Tibialis Posterior, Flexor Digitorum Longus, and Flexor Hallucis Longus Tendons
DESCRIPTIVE ANATOMY
The posterior tibial tendon passes posterior to the medial malleolus and inserts into the tuberosity
of the navicular bone (Fig. 15-3). The action of the muscle is to plantar-flex the ankle and invert the
foot. The flexor digitorum longus tendon is posterior to the posterior tibial tendon; it closely follows
the tibia and passes behind the medial malleolus (Fig. 15-3). It inserts into the distal phalanges of
the lateral four digits. The action of the muscle is to plantar-flex the ankle and flex all of the joints
of the last four toes. The flexor hallucis longus tendon is posterior to the flexor digitorum longus
tendon, and it passes behind the ankle joint, not posterior to the medial malleolus. It inserts into the
base of the distal phalanx of the great toe (Fig. 15-3). Its action is to flex the great toe.
Posterior tibialis
tendon
Flexor digitorum
longus tendon
Posterior tibial artery
Figure
15-3
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
401
PROCEDURE
To palpate the tibialis posterior tendon, invert and plantar-flex the patient's foot. Palpate medial to
the tibia posterior to the medial malleolus (Fig. 15-4). Note the continuity of the tendon and any
tenderness or swelling. Tenderness and/or swelling may indicate a strain secondary to trauma or ten­
dinitis. Loss of continuity and a valgus foot secondary to trauma may indicate a ruptured tendon.
Palpate the flexor digitorum longus tendon, which is posterior to the tibialis posterior tendon.
With one hand, resist flexion of the patient's toes, and with the other hand palpate the tendon (Fig.
15-5). Note any tenderness, swelling, or crepitus. These signs may indicate a strain or tendinitis of
the tendon. The flexor hallucis longus tendon is not palpable and not described in this book.
Figure
Figure
15-5
15·4
402
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Posterior Tibial Artery and Tibial Nerve
DESCRIPTIVE ANATOMY
The posterior tibial artery runs between the tendons of the flexor digitorum longus and flexor hal­
lucis longus muscles. This artery is the major blood supply to the foot. The tibial nerve is a branch
of the sciatic nerve. It runs with the posterior tibial artery under the flexor retinaculum of the ankle
and posterior to the medial malleolus (Fig. 15-6). The flexor retinaculum may become constricted
and cause a neurovascular deficit to the foot similar to carpal tunnel in the wrist.
PROCEDURE
Using light pressure with your middle and index finger, palpate the posterior tibial artery (Fig. 15-7).
Note the amplitude and compare bilaterally. A decrease in the pulse amplitude may indicate a com­
pression of the posterior tibial artery. The tibial nerve is difficult at best to palpate and is not dis­
cussed in this book. It is an important nerve supply to the sole of the foot.
,
,
'
Flexor digitorum
longus tendon
Posterior tibial artery
Posterior tibial nerve
Figure
15-6
Figure
15-7
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
403
Lateral Aspect
Lateral Malleolus and Attached Ligaments
DESCRIPTIVE ANATOMY
The lateral malleolus is the protuberance at the distal end of the fibula. Attached to the malleolus are
three clinically important ligaments:
•
•
•
Anterior talofibular ligament
Calcaneofibular ligament
Posterior talofibular ligament
These ligaments provide lateral support to the ankle, but they are not as strong as the deltoid lig­
ament on the medial aspect (Fig. 15-8). These ligaments are prone to tears in inversion injuries.
PROCEDURE
Palpate the lateral malleolus with your index and middle fingers (Fig. 15-9). Note any tenderness
and/or swelling. These signs may indicate periosteal contusion, fracture, avulsion fracture, or inver­
sion sprain of any of the previously mentioned ligaments secondary to trauma.
Posterior
tibiofibular
ligament
Anterior tibiofibular ligament
Anterior talofibular ligament
Posterior
talofibular
ligament
�-�#.-+- Calcaneofibular
ligament
Lateral talocalcaneal ligament
Figure
15-8
Figure
15-9
404
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Peroneus Longus and Peroneus Brevis Tendons
DESCRIPTIVE ANATOMY
The peroneus tendons travel together behind the lateral malleolus and are held in place by the per­
oneal retinaculum (Fig. 15- 10). The action of the muscles are to plantar flex and evert the foot.
PROCEDURE
With the patient not bearing weight, palpate behind the lateral malleolus with one hand, and pas­
sively invert (Fig. 15- 1 1) and evert (Fig. 15- 12) the foot with the other hand. Note any tenderness,
swelling, or snapping. Tenderness and/or swelling may indicate tenosynovitis of either or both ten­
dons. Tenderness with snapping may indicate a defect of the peroneal retinaculum that causes the
peroneal tendons to subluxate or dislocate.
Soleus m.
Peroneus fibularis -\--\;-...r;
longus tendon
1!,f:I-+---Tibialis anterior m.
-*!t+H-- Extensor digitorum
longus m.
Peroneus fibularis
brevis m.
Achilles (calcaneal)
tendon
T ibialis posterior
muscle and sheath
Superficial bursa
Retrocalcaneal bursa -+-I-IIf.f·rff".::.--r
Superior peroneal
retinaculum
Inferior peroneal retinaculum
Peroneus tertius tendon
Figure 15-10
Figure 15-11
Figure 15-12
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
405
Anterior Aspect
Tibialis Anterior, Extensor Hallucis Longus, and Extensor Digitorum
Longus Tendons
DESCRIPTIVE ANATOMY
The tibialis anterior tendon lies against the anterior surface of the tibia under the extensor retinac­
ulum. It attaches to the medial cuneiform bone and first metatarsal (Fig. 15-l3). Its action is to dor­
siflex the ankle and invert the foot. The extensor hallucis longus tendon passes under the superior
and inferior extensor retinacula. It inserts into the dorsal aspect of the great toe (Fig. 15-l3). The ac­
tion of the muscle is to dorsiflex the ankle and extend the great toe. The extensor digitorum longus
tendon lies lateral to the tibialis anterior. It inserts into the middle and distal phalanges of the lat­
eral four toes. It passes under the superior and inferior flexor retinacula (Fig. 15-l3). Its action is to
dorsiflex the ankle, evert the foot, and extend the lateral four toes.
anterior
Peroneus brevis m.
D·��H-Superior extensor
retinaculum
Extensor digitorum
longus tendon
(and synovial sheaths)
""",fJ13�fi1�1)
Lateral malleolus
Tendons of extensor """",=f---I/iIII;f+
digitorum longus
Figure
15-13
I nferior extensor
+-tl-+--Extensor hallicus
longus tendon
r-h'-H--'Ix
I--E tensor hallicus
brevis tendon
406
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PROCEDURE
To palpate the tibialis anterior, instruct the patient to dorsiflex and invert the foot. The tendon
should become prominent. Palpate the tendon for point tenderness (Fig. 15- 14). Tenderness may be
caused by overpronation, especially in runners. Tendinitis or a strain of the tendon also may be pres­
ent. This muscle and tendon support the longitudinal arch of the foot.
To palpate the extensor hallucis longus tendon, instruct the patient to extend the great toe (Fig.
15- 15). The tendon should be prominent. Palpate the tendon for point tenderness. This may indi­
cate tendinitis or strain of the tendon.
To palpate the extensor digitorum longus tendon, instruct the patient to extend the toes. Palpate
the tendon first where it crosses the ankle (Fig. 15- 16), then when it divides into the four parts (Fig.
15- 17) that insert into the middle phalanx. Tenderness may indicate tendonitis or tenosynovitis
from overuse, especially in the runner.
Figure
15-14
Figure
15-15
Figure
15-16
Figure
15-17
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
407
Posterior Aspect
Achilles Tendon, Calcaneal Bursa, and Retrocalcaneal Bursa
DESCRIPTIVE ANATOMY
The Achilles tendon attaches the gastrocnemius and soleus muscles to the calcaneus. It is the
strongest tendon in the body but the one most frequently ruptured. Two bursae surround this ten­
don: the calcaneal bursa, which is superficial to the Achilles tendon and below the skin; and the
retrocalcaneal bursa, which is deep to the Achilles tendon (Fig. 15- 18). These bursae are normally
not palpable unless they are inflamed.
Soleus m.
Peroneus fibularis -,......,,�
longus tendon
]-rl-f---T ibialis anterior m.
-fIm'it-t-- Extensor digitorum
longus m.
Peroneus fibularis
Achilles (calcaneal)
tendon
Tibialis posterior
muscle and sheath
Calcaneal bursa --f-+IIIIJ
Retrocalcaneal bursa
--hfJli'i��:;/"--A
Superior peroneal
retinaculum
Inferior peroneal retinaculum
Figure
Peroneus tertius tendon
15-18
m
408
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
PROCEDURE
With the ankle in the neutral position, palpate the Achilles tendon with your thumb and index fin­
ger (Fig. 15- 19). Next, place posterior to anterior pressure on the Achilles tendon with your thumb
(Fig. 15-20). Note any pain, tenderness, increase in temperature, swelling, crepitus, and/or continu­
ity of the tendon. Pain, tenderness, and an increase in temperature may indicate tendinitis, a strain,
or a partial tear of the tendon. Loss of continuity of the tendon may indicate a complete rupture of
the tendon. This is rare but may affect especially patients with a history of chronic Achilles tendini­
tis. Pain, tenderness, and inflammation deep to the Achilles tendon may indicate retrocalcaneal bur­
sitis. Pain, tenderness, and swelling over the Achilles tendon and below the skin indicate calcaneal
bursitis.
Figure
15-19
Figure
15-20
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
409
ANKLE RANGE OF MOTION
Dorsiflexion (1)
With the patient supine, place the goniometer in the sagittal plane with the center at the lateral
malleolus (Fig. 15-21). Instruct the patient to flex the foot backward while following the foot with
one arm of the goniometer (Fig. 15-22).
NORMAL RANGE (2)
Normal range is 13° ± 4.4° or greater from the 0 or neutral position.
Muscles
Nerve Supply
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
Deep peroneal
Deep peroneal
Deep peroneal
Deep peroneal
Figure
15-21
Figure
15-22
410
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Plantar Flexion (1)
With the patient supine, place the goniometer in the sagittal plane with the center at the lateral
malleolus (Fig. 15-23). Instruct the patient to flex the foot forward while following the foot with one
arm of the goniometer (Fig. 15-24).
NORMAL RANGE (2)
Normal range is 56° ± 6. 1° or greater from the 0 or neutral position.
Muscles
Nerve Supply
Gastrocnemius
Soleus
Plantaris
Flexor digitorum longus
Peroneus longus
Peroneus brevis
Flexor hallucis longus
Tibialis posterior
Tibial
Tibial
Tibial
Tibial
Superficial peroneal
Superficial peroneal
Tibial
Tibial
Figure
15-23
Figure
15-24
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
411
Inversion (1)
With the patient prone and the knee flexed, place the inclinometer at the base of the heel and zero
out the inclinometer (Fig. 15-25). Instruct the patient to invert the foot, and record the measure­
ment (Fig. 15-26).
NORMAL RANGE (2)
Normal range is 37° ± 4.5° or greater from the 0 or neutral position.
Muscles
Nerve Supply
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Tibialis anterior
Extensor hallucis longus
Tibial
Tibial
Tibial
Deep peroneal
Deep peroneal
Figure
15-25
Figure
15-26
412
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Eversion (1,2)
With the patient prone and the knee flexed, place the inclinometer at the base of the heel and zero
out the inclinometer (Fig. 15-27). Instruct the patient to evert the foot and record the measurement
(Fig. 15-28).
NORMAL RANGE
Normal range is 2 10 ± 50 or greater from the 0 or neutral position.
Muscles
Nerve Supply
Peroneus longus
Peroneus brevis
Peroneus tertius
Extensor hallucis longus
Superficial peroneal
Superficial peroneal
Deep peroneal
Deep peroneal
Figure
15-27
Figure
15-28
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
413
LIGAMENTOUS INSTABILITY
CLINICAL DESCRIPTION
The ankle joint is formed by the tibia, fibula, and talus, which are bound together by ligaments that
provide for stability and joint movement. These are the anterior and posterior talofibular, anterior
tibiofibular, calcaneofibular, and deltoid ligaments (Fig. 15-29). If any of these ligaments are torn,
the tibia can separate from the fibula and the talus may become unstable. The degree to which these
ligaments are torn determines the degree of talar instability. Most of theses injuries are sports re­
lated, and the most common mechanism of injury is a supination or inversion force. This occurs
when the foot turns under the ankle after walking or running on uneven surfaces or when landing
on an inverted foot after a jump. The most common injured ligament is the anterior talofibular lig­
ament. Ligament laxity or instability may lead to chronic ankle sprains.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Ankle swelling
Static ankle pain
Pain on passive motion
Tenderness over affected ligament
Figure
Posterior tibiofibular ligament
Anterior tibiofibular ligament
Anterior talofibular ligament
Posterior talofibular ligament
Lateral talocalcaneal ligament
Calcaneofibular ligament
Deltoid ligament:
Posterior tibiofibular ligament
Tibiocalcaneal ligament
Anterior tibiotalar ligament
Tibionavicular ligament
Posterior talocalcaneal ligament
Plantar calcaneonavicular ligament
15-29
414
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sensitivity/Reliability Scale
Drawer's Foot Sign (3)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, stabilize the ankle with one hand. With your opposite hand, grasp and press
posterior on the tibia (Fig. 15-30). Next, grasp the anterior aspect of the foot with one hand and the
posterior aspect of the tibia with the other, and pull anterior (Fig. 15-31).
RATIONALE
Gapping secondary to trauma when the tibia is pushed indicates a tear of the anterior talofibular lig­
ament. Gapping when the tibia is pulled indicates a posterior talofibular ligament tear (Fig. 15-32).
Figure
15-30
Figure
Posterior talofibular ligament
Anterior taloflbular ligament
Figure
15-32
15-31
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
415
Sensitivity/Reliability Scale
Lateral Stability Test (3)
I
o
PROCEDURE
I
1
I
2
I
3
I
4
With the patient supine, grasp the patient's foot and passively invert it (Fig. 15-33).
RATIONALE
If gapping secondary to trauma is present, suspect a tear of the anterior talofibular and/or calcaneo­
fibular ligament (Fig. 15-34).
Figure
15-33
Anterior tibiofibular ligament
Anterior talofibular ligament
';T"'-�I\+-t-Calcaneoflbular
ligament
Lateral talocalcaneal ligament
Figure
15-34
416
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sensitivity/Reliability Scale
Medial Stability Test (3)
I
o
PROCEDURE
I
1
I
2
With the patient supine, grasp the foot and passively evert it (Fig. 15-35).
RATIONALE
If gapping secondary to trauma is present, suspect a tear of the deltoid ligament (Fig. 15-36).
SUGGESTED DIAGNOSTIC IMAGING
•
•
Plain film radiography
Anteroposterior (AP) ankle view
Mortise view
Lateral view
Stress views
Magnetic resonance imaging (MRI)
Figure
15-35
Deltoid
ligamen t
1
Posterior tibiofibular ligament
Tibiocalcaneal ligament
Anterior tibiotalar ligament
Tibionavicular ligament
Posterior
talocalcaneal
ligament
Plantar calcaneonavicular ligament
Figure
15-36
I
3
I
4
CHAPTER 15
ANKLE ORTHOPAEDIC TESTS
417
TARSAL TUNNEL SYNDROME
CLINICAL DESCRIPTION
Tarsal tunnel syndrome occurs when the posterior tibial nerve becomes entrapped in its tunnel as it
passes behind the medial malleolus to enter the foot. The tunnel may be compressed either intrin­
sically or extrinsically. Space-occupying lesions account for 50% of cases. Direct trauma and repet­
itive dorsiflexion account for a significant portion of the other 50%. A severe flat foot can unduly
stretch the posterior tibial nerve, causing tarsal tunnel syndrome. Other causes, such as fracture cal­
lus, ganglion of the tendon sheath, lipoma, exostosis, engorged venus plexus, and excessive prona­
tion of the hind foot, should be investigated.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Intermittent paresthesia of plantar aspect of the foot
Pain on foot inversion and/or eversion of the foot
Pain radiating to medial aspect of the leg
Pain made worse by activity and improved by rest
Sensitivity/Reliability Scale
I I I I I I I I I
Tourniquet Test (4)
o
PROCEDURE
1
2
3
4
Wrap a sphygmomanometer cuff around the affected ankle and inflate it to just above the patient's
systolic bbod pressure. Hold for 1 to 2 minutes (Fig. 15-37).
Figure
15-37
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
418
RATIONALE
Tarsal tunnel syndrome is compression of the posterior tibial nerve beneath the flexor retinaculum
at the ankle (Fig. 15-38). Compression of the area by the cuff accentuates the narrowing of the tun­
nel, increasing the patient's pain. If pain is elicited or existing pain is exacerbated, suspect a com­
promise of the tarsal tunnel.
+f- F'lexor digitorum
tendon
-iH-- I'n"tAri
"Tarsal tunnel"
tibial artery
-H- F'os'terl'or tibial nerve
\:M""1:--,:,ovn. hallucis
longus tendon
�M!,\\I-+- F:lexor retinaculum
Figure
15-38
Sensitivity/Reliability Scale
Tinel's Foot Sign
I
a
PROCEDURE
I
1
I
2
I
3
I
Tap the area over the posterior tibial nerve with a neurological reflex hammer (Fig. 15-39).
RATIONALE
Paresthesias radiating to the foot indicate an irritation to the posterior tibial nerve that may be
caused by a constriction at the tarsal tunnel.
SUGGESTED DIAGNOSTIC TEST
•
Nerve conduction velocity of the posterior tibial nerve
Figure
15-39
CHAPTER 15
419
ANKLE ORTHOPAEDIC TESTS
ACHILLES TENDON RUP TURE
CLINICAL DESCRlPTION
Achilles tendon rupture generally occurs in adults aged 30 to 50. It is usually spontaneous in ath­
letes, who account for most of these injuries. Some authors suggest that this is due to decreased vas­
cularity of the Achilles tendon as the patient ages. The mechanism that causes rupture is forced dor­
siflexion of the foot as the soleus and gastrocnemius contract. Rupture occurs usually 2 to 6 em from
the insertion of the Achilles tendon into the calcaneus. As the proximal aspect of the tendon retracts,
there is usually a palpable defect of the tendon.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
Severe posterior ankle pain
Inability to stand on toes
Posterior leg and heel swelling
Posterior leg and heel ecchymosis
Thompson's Test (5)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
Instruct the prone patient to flex the knee. Squeeze the calf muscles against the tibia and fibula (Fig.
15-40).
RATIONALE
When the calf muscles are squeezed, the gastrocnemius and soleus muscles mechanically contract.
These muscles are attached to the Achilles tendon, which in turn plantar-flexes the foot. If the
Achilles tendon is ruptured, contraction of the gastrocnemius and soleus muscles will not plantar­
flex the foot.
Figure
15-40
420
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Achilles Tap Test
PROCEDURE
Tap the Achilles tendon with a neurological reflex hammer (Fig. 15-41).
RATIONALE
Exacerbation of pain and a loss of plantarflexion indicate an Achilles tendon rupture.
NOTE
The patient must be neurologically sound for this test to be valid.
SUGGESTED DIAGNOSTIC IMAGING
•
•
Plain film radiography
AP ankle view
Lateral view
Ankle MRI
Figure
15-41
CHAPTER 15
References
1. American Academy of Orthopaedic Surgeons.
T he clinical measurement of joint motion.
Chicago: AAOS, 1994.
2. Boone DC, Azen SP. Normal range of motion of
joint in male subjects. J Bone Joint Surg Am
1979;6 1:756-759.
3. Hoppenfeld S. Physical Examination of the
Spine and Extremities. New York: Appleton­
Century-Crofts, 1976: 127.
4. McRae R. Clinical Orthopedic Examination.
New York: Churchill Livingstone, 1976.
5. Thom '
of the tendon of Achilles: a new clinical diag­
nostic test. Anat Res 1967; 158:126.
ANKLE ORTHOPAEDIC T ESTS
421
COX JS, Brand RL. Evaluation and treatment of lat­
eral ankle sprains. Sports Med 1977;5:5 1.
Dvorkin ML. Oddice Orthopaedics. Norwalk, CT:
Appleton & Lang, 1993.
Gates SJ, Mooar PA. Musculoskeletal Primary Care.
Baltimore: Lippincott Williams & Wilkins, 1999.
Kapandji LA. The Physiology of the Joints. Vol. 2.
Lower Limb. New York: Churchill Livingstone, 1970.
Kelikian H. Disorders of the Ankle. Philadelphia:
Saunders, 1985.
Lam SJ, Tarsal tunnel syndrome. Lancet 1962; 2: 1354.
Mennell JM. Foot Pain. Boston: Little, Brown, 1969.
Post M. Physical examination of the musculoskele­
tal system. Chicago: Year Book Medical, 1987.
General References
Anderson
Soma CA, Mandelbaum BR. Achilles tendon disor­
ders. Clin Sports Med 1994; 13(4): 1 18.
Be. Office Orthopedics For Primary
Care. 2nd ed. Philadelphia: Saunders, 1999.
Colter JM. Lateral ligamentous injuries of the ankle.
In: Hamilton WC, ed. Traumatic disorders of the
ankle. New York: Springer Verlag, 1984.
m
I
�
I
--------���-MISCELLANEOUS ORTHOPAEDIC TESTS
423
429
Mannkopf's Maneuver
423
Buerger's Test
MENINGEAL IRRI TATION AND
424
Allen's Test
428
Magnuson's Test
PERIPHERAL ART ERIAL
INSUFFICIENCY
INFLAMMATION
DEEP-VEIN THROMBOSIS
Homan's Sign
425
425
Kernig's Test
430
430
Brudzinski's Sign
Lhermitte's Sign
431
432
SYMPTOM MAGNIFICATION
ASSESSMEN T
426
Hoover's Sign
426
Burn's Bench Test
422
427
LEG MEASUREMEN T S
433
Actual Leg Length
433
Apparent Leg Length
434
CHAPTER 16
423
MISCELLANEOUS ORTHOPAEDIC TESTS
PERIPHERAL ARTERIAL INSUFFICIENCY
Peripheral arterial insufficiency may involve both the upper and lower extremities. It may be due to
obstruction, traumatic occlusion, arthrosclerosis, diabetes, Buerger's disease, or Raynaud's phenom­
enon. The patients who develop arterial insufficiency generally demonstrate one of three clinical
patterns: (a) cold, cyanosed, livid and/or painful digits (Raynaud's phenomenon); (b) digital isch­
emia; or (c) crampy pain on exercise (claudication). There is usually prolonged venous filling time
following elevation of the extremity. The impaired flow or arterial insufficiency may be adequate to
serve the metabolic activities of the muscles at rest but does not maintain the circulation necessary
to the increased metabolic rates of exercise. Therefore, exercise testing, such as flexing and extend­
ing the arms and legs or walking, may reproduce the patient's symptoms. Diagnosis is based on the
combination of physical examination and vascular diagnostic testing, such as angiography, plethys­
mography, thermography, and vascular ultrasound.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
•
•
Extremity pain
Cold extremities
Decreased pulse amplitude
Pallor or rubor
Hair loss
Shiny skin
Claudication
Gangrene
Buerger's Test
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, instruct him or her to elevate one leg at a time. The patient must consecu­
tively dorsiflex and plantar-flex the raised foot for a minimum of 2 minutes (Figs. 16-1 and 16-2).
The leg is then lowered and hung off the side of the table with the patient seated (Fig. 16-3).
RATIONALE
Elevating and flexing the foot diminishes the blood flow in the lower extremity. When the leg is low­
ered and hung off the table, the lower leg and foot should fill with blood. This turns the foot a pink­
ish color, and the veins distend. This process takes less than 1 minute. If it takes longer, the test is
positive for arterial compromise to the lower extremity.
Figure 16-1
Figure 16-2
Figure 16-3
424
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Allen's Test (1,2)
Sensitivity/Reliability Scale
PROCEDURE
I
I
I
I
I
o
1
2
3
4
With the patient seated, occlude the radial and ulnar arteries with both thumbs (Fig. 16-4). Then in­
struct the patient to open and close the fist to express blood from the tissue (Fig.16-5). At that point,
instruct the patient to open the hand as you release the pressure to the radial artery (Fig. 16-6). Re­
peat the test with the pressure released to the ulnar artery (Fig. 16-7).
RATIONALE
Consecutively opening and closing the fist diminishes the blood flow in the hand, causing blanch­
ing. When pressure on one of the arteries is released, the hand should fill with blood, which turns it
a pinkish color, and the veins distend. A delay of more than 10 seconds in returning a pinkish color
to the hand indicates either ulnar artery insufficiency or radial artery insufficiency. The artery being
tested is the one not being manually occluded.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
•
Peripheral vascular ultrasound
Thermography
Plethysmography
Angiography
Figure 16-4
Figure 16-5
Figure 16-6
Figure 16·7
CHAPTER 16
MISCELLANEOUS ORTHOPAEDIC TESTS
425
DEEP VEIN THROMBOSIS
Deep vein thrombosis (DVT) is a cordlike clot formation that usually arises in the deep veins of the
calf muscles. This venous occlusion results in edema and dependent cyanosis. The cause may be ia­
trogenic or result from a mechanical trauma that injured the endothelium of the veins, hypercoag­
ulability associated with malignant tumor or oral contraceptives, or stasis that occurs with pro­
longed bed rest. If left untreated, approximately 20% of thrombi may extend into the proximal
venous system and pose a serious and even life-threatening risk of a pulmonary embolism: 90% of
pulmonary emboli originate in the deep venous system of the legs.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
•
Leg pain
Leg swelling
Leg tenderness
Local temperature elevation
Discoloration
Venous distension
Palpable cord (thrombosed vessel)
Homan's Sign
PROCEDURE
Sensitivity/Reliability Scale
I
I
I
I
I
o
1
2
3
4
With the patient supine, dorsiflex the foot and squeeze the calf (Fig. 16-8) (3).
RATIONALE
Deep-seated pain at the posterior leg or calf may indicate thrombophlebitis. Dorsiflexing the foot
places a dynamic stretch on the gastrocnemius muscle and tension of the deep veins. The addition
of squeezing the calf compresses the surrounding tissue against the thrombus, stimulating a noci­
ceptive response.
SUGGESTED DIAGNOSTIC IMAGING
•
•
•
Peripheral vascular ultrasound
Plethysmography
Venography
Figure 16-8
426
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
SYMPTOM MAGNIFICATION ASSESSMENT
Symptom magnification is usually misrepresentation of the patient's symptoms, feigned for sec­
ondary gain. This is a very difficult assessment. Although this condition is most common in the set­
ting of workers compensation and personal injury cases, the secondary gain may not be financial
alone. It may occur if individuals desire a less strenuous job at work. They may gain control over fel­
low workers or family members. The injured party may allow others to do work that the patient
would normally do.
The possibility of symptom magnification should be raised when major discrepancies or incon­
sistencies appear in the patient's condition. These inconsistencies are most noted in history and
physical examination. Some examples of these inconsistencies: (a) dramatized complaints that are
vague or global, (b) overemphasized gait or postural abnormalities, (c) resistance to evaluation or
rehabilitation, and (d) lack of motivation to develop new skills or lack of treatment compliance.
Once the information has been collected, a determination of symptom magnification may be
made. This is difficult because very few symptom magnification cases are totally without pain or fear
of being placed in a job perceived as potentially harmful. Second opinions are quite useful if you sus­
pect symptom magnification. Concurrence by more that one physician is prudent in these cases.
CLNICAL SIGNS AND SYMPTOMS
•
•
•
•
•
•
Discrepancy between patient's presentation and degree of reported pain
Negative workup for organic problems by multiple physicians
Dramatized complaints that are vague or global
Overemphasized gait or posture
Resistance to evaluation
Resistance to rehabilitation
Hoover's Sign (3,4)
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
3
I
I
4
With the patient supine, instruct him or her to lift the affected leg while you place one hand under
the heel on the unaffected side (Fig. 16-9).
RATIONALE
The patient who is magnifying the symptoms will not raise the affected leg, and no posterior pres­
sure will be put on the unaffected heel. If the patient is genuinely trying to raise the leg but cannot
do so, you should feel pressure from the unaffected heel.
Figure 16-9
CHAPTER 16
Burn's Bench Test
427
MISCELLANEOUS ORTHOPAEDIC TESTS
Sensitivity/Reliability Scale
PROCEDURE
I
I
I
I
o
1
2
3
I
Instruct the patient to kneel on the examination table. Have the patient bend at the waist to touch
the floor while you stabilize the legs (Fig. 16-10).
RATIONALE
Patients with low back pain will be able to perform this test because no strenuous activity of the back
is involved. The stress is placed on the posterior leg muscles. If the patient with low back pain can­
not perform the test, suspect magnification of the symptoms.
Figure 16-10
428
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Magnuson's Test
Sensitivity/Reliability Scale
PROCEDURE
I
I
I
I
I
o
1
2
3
4
Instruct the seated patient to point at the site of the pain (Fig. 16-11). Next, distract the patient by
performing some irrelevant test. Then instruct the patient to point at the site of the pain again (Fig.
16-12).
RATIONALE
The patient with real pain will point to the specific site of pain both times. The patient who is mag­
nifying the symptoms usually does not indicate the exact same site twice.
Figure 16-11
Figure 16-12
CHAPTER 16
Mannkopf's Maneuver
MISCELLANEOUS ORTHOPAEDIC TESTS
429
Sensitivity/Reliability Scale
PROCEDURE
I
I
I
I
I
a
,
2
3
4
With the patient seated, obtain the resting pulse rate (Fig. 16-13). Then irritate the patient's com­
plaint by poking at it with your finger (Fig. 16-14). Next, retake the pulse rate.
RATIONALE
The sympathetic system controls vasoconstriction and heart rate. When the area of pain is provoked,
the patient with true pain will undergo a fight or flight phenomenon, increasing the heart rate and
blood pressure. In the patient who has true pain, the pulse rate will increase by 10% or more. This
reaction is carried out below the conscious level and is not under the patient's control. If the heart
rate does not increase, the patient may be magnifying the symptoms.
SUGGESTED DIAGNOSTIC IMAGING
•
Based on area of complaint
Figure 16-13
Figure 16-14
430
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
MENINGEAL IRRITATION AND INFLAMMATION
CLINICAL DESCRIPTION
Irritation of the meninges is a local condition usually caused by mechanical pressure to a specific sec­
tion of the meninges, such as a herniated intervertebral disc, spinal stenosis, or tumor. Inflammation
of the meninges or meningitis is usually caused by infection, either bacterial or viral. It usually de­
velops from hematogenous spread through the bloodstream from a distant infected location or by
contiguous spread from a local structure, such as the nasopharynx. The infection causes an exudation
of cells and proteins into the subarachnoid space. The meningeal reaction spreads through the cen­
tral nervous system (CNS), involving the meninges covering the spinal cord as well as the brain.
CLINICAL SIGNS AND SYMPTOMS
•
•
Meningeal Irritation
Local neck or back pain
Radicular pain to an extremity
Decreased or lost extremity sensation
Decreased or lost extremity motor function
Loss of bladder or bowel functions
Meningitis
Violent headache
Stiff, painful neck
Elevated temperature
Mental status change
Kernig's Test (5-7)
Sensitivity/Reliability Scale
PROCEDURE
I
I
I
I
I
o
1
2
3
4
With the patient supine, instruct him or her to flex the hip and knee to 90° with the lower leg par­
allel to the table (Fig. 16-15). Then instruct the patient to extend the knee on the side that is being
tested (Fig. 16-16).
RATIONALE
With the hip and knee flexed, the sciatic nerve and the dural sac are relaxed. Extension of the knee
puts traction on the sciatic nerve, hence ultimately the dural sac or meninges. Inability to straighten
the leg or pain while straightening the leg indicates meningeal irritation or nerve root involvement.
NOTE
If bacterial meningitis is present, the patient may have head pain that increases with sudden neck
movements, neck stiffness, nuchal rigidity, and an elevated temperature. This test will also elicit
radicular pain in the patient with sciatic radiculopathy.
Figure 16-15
Figure 16-16
CHAPTER 16
431
MISCELLANEOUS ORTHOPAEDIC TESTS
Brudzinski's Sign (8)
PROCEDURE
Sensitivity/Reliability Scale
I
I
I
I
I
o
1
2
3
4
With the patient supine, flex the patient's neck to the chest (Fig. 16-17).
RATIONALE
Flexing the neck places traction on the dural sac and spinal cord. Irritation of the dural sac causes
pain at the level of irritation. Flexing the knees reduces the traction on the spinal cord and meninges.
If the patient flexes the knees, the test is positive and indicates meningeal irritation or nerve root in­
volvement (Fig. 16-18).
NOTE
Suspect bacterial meningitis if the patient has head pain that is increased with sudden neck move­
ments, neck stiffness, nuchal rigidity, and an elevated temperature. This test will also elicit radicular
pain in the patient with sciatic radiculopathy.
Figure 16-17
Figure 16-18
m
I
432
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Lhermitte's Sign
Sensitivity/Reliability Scale
I
o
PROCEDURE
I
I
1
I
I
2
I
I
I
3
4
With the patient seated, instruct the patient to passively flex his head to his chest (Fig. 16-19).
RATIONALE
Flexing the neck stretches the spinal cord and meninges. Sharp pain radiating down the spine or into
the upper or lower extremities may indicate nerve root, dural, or meningeal irritation. It also may
indicate cervical myelopathy or multiple sclerosis.
SUGGESTED DIAGNOSTIC IMAGING AND TESTING
•
•
Meningeal Irritation
Plain film radiography
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Meningitis
Cerebrospinal fluid examination
Figure 16-19
CHAPTER 16
MISCELLANEOUS ORTHOPAEDIC TESTS
433
LEG MEASUREMENTS
CLINICAL DESCRIPTION
Measurement of the lower extremities is performed to evaluate a true anatomical leg length dis­
crepancy versus an apparent or false leg lengt� discrepancy. A true shortened lower limb may be due
to congenital defect of development, impaired epiphyseal growth, or fracture. An apparent or false
shortened leg may be due to a functional pelvic tilt, scoliosis, or an adduction or abduction defor­
mity of the hip. Each may cause a distinct biomechanical defect leading to lower back pain or local
lower extremity joint pain. Evaluation and correction may relieve lower back or local lower extrem­
ity joint pain, especially when findings of examination of the lower back and lower extremity joints
are unremarkable.
CLINICAL SIGNS AND SYMPTOMS
•
•
•
Shortened lower extremity
Lower back pain
Hip, knee, or ankle pain
Actual Leg Length
Sensitivity/Reliability Scale
PROCEDURE
I
I
I
I
I
o
1
2
3
4
With the patient standing, take a tape measure and measure bilaterally from the anterior superior il­
iac spine to the floor (Fig. 16-20).
RATIONALE
This is a true measurement of the patient's lower extremity. Compare the measurements. Any dif­
ference indicates an anatomic short leg.
m
I
Figure 16-20
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
434
Apparent Leg Length
Sensitivity/Reliability Scale
I
PROCEDURE
I
I
I
1
2
3
I
With the patient supine, measure bilaterally the distance between the umbilicus and the medial
malleolus (Fig. 16-21).
RATIONALE
Any difference in the two measurements indicates a functional leg deficiency that may be caused by
muscular or ligamentous contracture deformities.
SUGGESTED DIAGNOSTIC IMAGING
•
Radiographic scanogram
Figure 16-21
References
General References
I. Allen EV, Barker NW, Hines EA Jr. Peripheral
American Society for Surgery of the Hand. The
Vascular Disease. 4th ed. Philadelphia: Saunders,
Hand: Examination and Diagnosis. Aurora, CO:
1972:37-38.
ASSH, 1978.
2. Allen EY. Thromboangiitis obliterans: methods
of diagnosis of chronic occlusive arterial lesions
distal to the wrist. Am J Med Sci 1929; 178:
238-239.
3. Arieff AJ, Tigay EI, Kurtz JF, et al. The Hoover
sign: an objective sign of pain and/or weakness in
the back or lower extremities. Arch
Neurol
1961;5:673.
4. Hoover CF. A new sign for the detection of ma­
lingering and functional paralysis of the lower
extremities. JAMA 1928;5 1:746-749.
5. Kernig W. Concerning a little noted sign of
meningitis. Arch NeuroI 1969;2 1:2 16.
6. Wartenberg R. The signs of Brudzinski and of
Kernig. J Pediatr 1950;37:679.
7. Brody lA, Williams KH. The sign of Kernig and
Brudzinski. Arch NeuroI 1969;2 1:2 16.
8. Brudzinski J. A new sign of the lower extremities
in meningitis of children (neck sign). Arch Neu­
roI 1969;2 1:2 16.
Borenstein D, W iesel SW, Boden SO. Neck Pain:
Medical Diagnosis and Comprehensive Manage­
ment. Philadelphia: Saunders, 1996.
Edgar VA, Barker NW, Hines EA Jr. Peripheral Vas­
cular Disease. Philadelphia: Saunders, 1946:57-58.
Hoppenfeld S. Physical Examination of the Spine
and
Extremities.
New
York: Appleton-Century­
Crofts, 1976: 127.
Woerman AL, Binder-Macleod SA. Leg-length dis­
crepancy assessment: accuracy and precision in five
clinical methods of evaluation. J Orthop Sports
Phys Ther 1984;5:230.
--------��rCRANIAL NERVES
OLFACTORY NERVE (I)
OPTIC NERVE (II)
437
438
OPHTHALMOSCOPIC
EXAMINATION 441
OCULOMOTOR, TROCHLEAR, AND
ABDUCENS NERVES (III, IV, VI) 443
TRIGEMINAL NERVE (V)
MOTOR 446
Reflex 447
Corneal Reflex
1a", Reflex 447
Sensory 448
FACIAL NERVE (VII)
Motor 449
Sensory 451
447
449
446
AUDITORY NERVE ( VIII)
452
Weber's Test: Cochlear Nerve 452
Rinne's Test: Cochlear Nerve 453
Veering Test: Vestibular Nerve 454
Past Pointing Test: Vestibular
Nerve 455
Labyrinthine Test for Positional
Nystagmus 456
GLOSSOPHARYNGEAL AND VAGUS NERVES
(IX, X) 458
Sensory 459
Reflex 460
Gag Reflex 460
SPINAL ACCESSORY NERVE (XI)
461
Trapezius Muscle Test 461
Sternocleidomastoideus Muscle
Test 461
HYPOGLOSSAL NERVE (XII)
462
ii
435
436
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Twelve pairs of cranial nerves exit from the brain and brainstem. These nerves innervate the face,
head, and neck, controlling all motor and sensory functions in these areas, including vision, hear­
ing, smell, and taste. The cranial nerves may be affected by cranial trauma, infections, aneurysm,
stroke, degenerative diseases (multiple sclerosis), upper motor neuron lesions, lower motor neuron
lesions, increased intracranial pressure, and abnormal masses or tumors.
An important anatomic feature of cranial nerves is bilateral and unilateral innervation. In bilat­
eral innervation, relatively equal distributions of right and left brain hemisphere innervation gov­
ern the function of a specific facial part. Movements that are performed in bilateral synchrony, such
as swallowing and moving the forehead, are innervated bilaterally. In unilateral innervation, the
contralateral hemisphere innervates the specific body part. Fine movements of the face are examples
of unilateral cranial nerve innervation.
The many types of cranial nerve lesions produce a number of syndromes. Unilaterally affected
cranial nerves V, V II, and V II I may indicate a cerebellopontine angle lesion. Unilaterally affected cra­
nial nerves III, IV, V, and VI may indicate a cavernous sinuous lesion. Unilaterally affected cranial
nerves IX, X, and XI may indicate a jugular foramen syndrome. Bilaterally affected cranial nerves X,
XI, and XII may indicate bulbar or pseudobulbar palsy. Multiple cranial nerve abnormalities are
shown in Figure
17-1.
Unilateral
cranial nerve
abnormalities
Contralateral
hemiplegia or I----{ No }---------____
tetraplegia
Figure 17-1. Multiple cranial nerve abnormalities. Reprinted with permission from Fuller G. Neurological
Examination Made Easy. London: Churchill Livingstone, 1993.
CHAPTER 17
CRANIAL NERVES
437
OLFACTORY NERV E (I)
PROCEDURE
The olfactory nerve is responsible for the sense of smell. To test this nerve, obtain some aromatic
substances, such as coffee, tobacco, or peppen;nint oil. Instruct the patient to close one nostril. Place
the substance under the open nostril and ask what the patient smells, if anything (Fig.
17-2). Repeat
the procedure for the opposite nostril.
RATIONALE
If the patient cannot smell or identify the smell unilaterally, suspect a lesion of the olfactory nerve.
If the patient cannot smell or identify the smell bilaterally, consider a nonorganic problem or a bi­
lateral cranial nerve I lesion.
NOTE
A diminished or almost absent sense of smell is common in the elderly. It will be apparent if loss of
smell is bilateral and the cranium has undergone no trauma. Other nonneurogenic lesions, such as
sinus infection, deviated septum, and lesions caused by smoking, may also cause a loss of smell, ei­
ther unilaterally or bilaterally.
Figure 17-2
•
438
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
OPTIC N ERVE (II)
PROCEDURE
The optic nerve is responsible for visual acuity and peripheral vision. To test for visual acuity, ask
the patient to cover one eye and read the smallest print possible on a Snellen chart (Fig.
17-3). Re­
peat the test with the opposite eye. Note the results. This is not a test for visual acuity for refractive
error; it tests the acuity for optic nerve involvement. This test may be performed with the patient
wearing glasses or contact lenses.
To test for peripheral vision, ask the patient to cover one eye with the hand and keep a fixed gaze
on your nose with the uncovered eye. Directly motion a large cross with your finger from superior
to inferior and from right to left (Fig.
17-4). Instruct the patient to tell you when he or she begins
to see your finger. Repeat with the opposite eye and record the results.
-
FP
T 0 Z 3
LPED
pl:CrD
tDrCz'P
rtLO,;t>
Figure 17-3
Figure 17-4
CHAPTER 17
CRANIAL NERVES
439
RATIONALE
Any loss of vision, from complete unilateral or bilateral loss of vision to loss of half fields of vision
(hemianopsia) or a partial defect in the field of vision (scotoma), indicates an optic nerve lesion.
Temporal lobe lesions can produce superior contralateral quadrantanopsia. Occipital lobe lesions
can produce a contralateral homonymous hemianopsia with macular sparing. Figure
17-5 shows
a schematic of the neural pathway from the brain to the retina and demonstrates the location of
the lesion and its effect on vision. Also associated with the schematic is a flow chart of field defects
(Fig.
17-6).
VISUAL FIELD
\
\
\
\
\
\
,
\
Optic
chiasm
Optic
tract
Lateral
geniculate
body
area
Occipital lobe of cerebrum
Figure 17-5
\
\
\
440
Is there a field
defect in
both eyes?
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
No
Lesion anterior to
optic chiasm,
retina or optic nerve
1------( No }-------_____
Optic tract
13
Bilateral retinal
or
optic nerve lesion
.()()
..i) ...�
4
6
Figure 17-6. Field defects. Reprinted with permission from Fuller G, ed. Neurological Examination Made Easy.
London: Churchill Livingstone, 1993.
CHAPTER 17
CRANIAL NERVES
441
OPHTHALMOSCOPIC EXAMINATION
PROCEDURE
With an ophthalmoscope, look into the patient's eye. Bring the scope
1 to 2 cm from the eye and en­
courage the patient to fix the gaze at a distant point (Fig. 17-7). Use the focus ring to correct for your
·
vision and the patient's vision. If you or the patient is myopic and is not using glasses or contact
lenses, turn the focus ring dial counterclockwise to focus on the eye. If you or the patient is presby­
opic, turn the focus dial clockwise to focus on the eye. Look at the optic disc, blood vessels, and reti­
nal background.
Figure 17-7
•
442
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
RATIONALE
Visualize the optic nerve, the optic disc, and the optic cup for swelling and atrophy (Fig.
17-8).
What you find:
Blurred
Blurred
Optic nerve
swelling
had
Figure 17-8. Optic disc abnormalities. Reprinted with permission from Fuller G. Neurological Examination
Made Easy. London: Churchill Livingstone, 1993.
CHAPTER 17
CRANIAL NERVES
443
OCULOMOTOR, TROCHLEAR, AND ABDUCENS N ERVES (III, IV, V I)
PROCEDURE
Cranial nerves III, IV, and V I are all associated with ocular and pupillary motility and are tested to­
gether for simplicity. Cranial nerve III also innervates the levator palpebrae muscles, which are re­
sponsible for movement of the eyelids. First, look at the patient's eyelids and note any ptosis. After
inspection of the eyelids, inspect the eye globes for alignment. Dysfunction of cranial nerve III, IV,
or VI may be responsible for deviations of eye alignment. Next, inspect the pupils and determine
their size and shape. Then test the pupillary reflex by flashing a light into one of the patient's eyes
(Fig.
17-9). Look at the pupils one at a time for contraction or dilation.
To test ocular movements, have the patient follow either your finger or a moving object through
the entire field of vision in all axes. Observe for nystagmus and/or inability to move the eye in a par­
ticular axis (Fig.
17- 10). Also, test for convergence by having the patient look at a distant object and
continue to focus on it as you move that object closer to the patient. The pupil should constrict and
converge as the object approaches. Look at both pupils in both instances.
Figure 17-9
Figure 17-10
•
444
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
RATIONAlE
An oculomotor nerve lesion causes ptosis of the eyelid with inability to open the lid. Eye alignment
may be down and lateral. Also, the patient will be unable to move the eyeball upward, inward, or
downward because of weakness of the medial, superior, and inferior rectus muscles and the inferior
oblique muscle. The pupil is usually dilated, and the pupillary reflex is absent. The most frequent
cause of a cranial nerve III paralysis is an aneurysm in the circle of Willis. Other conditions may also
cause the pupil to dilate and the pupillary reflex to become absent (Fig.
17-11).
A trochlear nerve lesion causes superior and lateral deviation of the eye with inability to move
the eyeball downward and inward because of weakness of the superior oblique muscle.
An abducens nerve lesion causes inability to move the eyeball outward because of weakness of
the lateral rectus muscle. Figure
Pupil large
17-12 shows lateral rectus muscle defects of alignment.
Reacts to light
Normally
Anisocorla
Doesn't react
to light
Normal
accommodation
Afferent pupillary
defect
Slowly
accommodates
Holmes-Adie
pupil
No
accommodation
With ptosis:
probable III
No ptosis:
mydriatic drugs
Pupil small
Reacts to light
Doesn't react
to light
Elderly
Senile miosis
With ptosis,
enophthalmos,
anhydrosis
Horner's
syndrome
Normal
accommodation
Irregular:
Argyll-Robertson
pupil
No
accommodation
Miotic drugs
Figure 17-11. Pupillary abnormalities. Reprinted with permission from Fuller G. Neurological
Examination Made Easy. London: Churchill Livingstone, 1993.
CHAPTER 17
CRANIAL NERVES
445
Figure 17-12
II
446
PHOTOGRAPHIC MANuAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
TRIG EMINAL N ERV E (V)
The trigeminal nerve i s composed o f motor and sensory portions. The motor portion innervates the
muscles of mastication. These muscles are the masseter, pterygoid, and temporal muscles. The sen­
sory portion is divided into three branches: the ophthalmic
branches
(Vl), maxillary (V2), and mandibular
(V3).
Motor
PROCEDURE FOR THE MASSETER, PTERYGOID, AND TEMPORALIS MUSCLES
To test the motor portion that innervates the masseter muscle, instruct the patient to simulate a bite
while you palpate the masseter muscle and attempt to open the patient's jaw with your thumbs (Fig.
17- 13). To test the pterygoid muscle, instruct the patient to deviate the jaw against your resistance
17- 14). To test the temporalis muscle, instruct the patient to clench the jaw while you palpate
the temporalis muscles with your fingers (Fig. 17-15). Note whether muscle contraction is sym­
(Fig.
metrical.
RATIONALE
A weak masseter or pterygoid muscle may indicate a trigeminal nerve lesion. A difference in muscle
tension of the temporal is muscle is also an indication of a trigeminal motor lesion. In bilateral paral­
ysis, the jaw may not close tightly. In unilateral lesions, the jaw deviates toward the side of the lesion
when the patient opens the mouth.
Figure 17-13
Figure 17-14
Figure 17-15
CHAPTER 17
CRANIAL NERVES
447
Reflex
Corneal Reflex
PROCEDURE
Instruct the patient to gaze upward and inward while you touch the cornea with a strand of cotton,
approaching from the lateral side (Fig.
17-16). Be careful not to touch the eyelash or conjunctiva.
The patient should blink when the cornea is touched. The corneal reflex has sensory fibers from the
trigeminal nerve and motor fibers from the facial nerve.
Figure 17-16
Jaw Reflex
PROCEDURE
Instruct the patient to open the mouth slightly. Place your thumb or index finger just lateral to the
midline of the patient's chin, and press down. With a neurological reflex hammer, tap down on your
finger to open the jaw (Fig.
17- 17). The normal response is to close the jaw rapidly.
RATIONALE
The corneal and jaw jerk reflexes have a sensory component from the trigeminal nerve. The jaw jerk
reflex has a motor component to the trigeminal nerve. The corneal reflex has a motor component
from the facial nerve. If the corneal reflexes are absent, suspect a lesion of either the sensory portion
of the trigeminal nerve or the motor component of the facial nerve. If the jaw jerk reflex is absent,
suspect a lesion of the trigeminal nerve.
Figure 17-17
448
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sensory
PROCEDURE
To test for sensory deficit, instruct the patient to close the eyes. Touch the forehead, cheek, and chin
with a pin for pain sensation; a piece of cotton for the sensation of light touch; and small test tubes
of hot and cold water for thermal sensation (Figs.
17-18 to 17-20). Perform these procedures to both
sides of the face and ask the patient to compare the sensations bilaterally. Next, instruct the patient
to open the mouth and touch the tongue, the inside of both cheeks, and the hard palate with a
wooden tongue depressor (Fig.
17-2 1). Instruct the patient to give a signal, such as raising the hand,
on feeling the sensation.
RATIONALE
A decrease in the sensation of light touch, pain, and/or temperature from one side to the other in­
dicates a lesion of the sensory portion of the affected branch of the trigeminal nerve. Lesions of the
ophthalmic, maxillary, or mandibular branch of the trigeminal nerve produces decreased sensation
of the forehead, cheek, or chin, respectively.
Figure 17-18
Figure 17-19
Figure 17-20
Figure 17-21
CHAPTER 17
CRANIAL NERVES
449
Motor
PROCEDURE
The facial nerve has both motor and sensory fibers. The motor fibers innervate the muscles of the
face and platysma. Observe the patient's face for abnormal movements, such as tics or tremors. Note
the degree of change of expression or lack of change.
To test for motor function, observe the face in repose. Then instruct the patient to frown, raise the
eyebrows, close the eyes, show the teeth, smile, and whistle or puff the cheeks (Figs. 17-22 to
FACIAL NERVE
(VII)
Figure 17-22
Figure 17-23
Figure 17-24
Figure 17-25
17-25).
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
450
RATIONALE
Facial nerve lesions may stem from upper motor neurons or lower motor neurons. These neurons
may be distinguished by the various facial expressions. An upper motor neuron lesion generally has
no effect on the forehead and eyelids. In a lower motor neuron lesion, when the eyebrows are raised
and lowered, the forehead does not wrinkle. Showing the teeth and whistling are absent in both up­
per and lower motor neuron lesions. Smiling may not elevate the mouth in a lower motor neuron
lesion, but a symmetrical smile may occur in an upper motor neuron lesion. Inability of the patient
to perform these movements indicates a lesion of the motor portion of the facial nerve (Fig.
Bilateral weakness
forehead stronger
than lower face
Normal strength
little spontaneous
movement
Figure 17-26. Facial nerve abnormalities. Reprinted with permission from Fuller G. Neurological
Examination Made Easy. London: Churchill Livingstone, 1993.
17-26).
CHAPTER 17
CRANIAL NERVES
451
Sensory
PROCEDURE
Instruct the patient to close the eyes and protrude the tongue. Apply solutions of sugar, salt, and/or
vinegar to one side and on the anterior two-thirds of the tongue (Fig.
17-27). Instruct the patient to
identify each substance without retracting the tongue. This can be done by having the patient point
to a list of various substances on a card or on a sheet of paper. Instruct the patient to rinse the
mouth; then apply another substance on the opposite side.
RATIONALE
Inability to taste and/or identify the substances may indicate a lesion of the sensory portion of the
facial nerve.
NOTE
Complete loss of taste in facial nerve lesions is rare. It is most common for the patient to have a spon­
taneous or perverted taste as opposed to complete loss of taste. If complete loss of taste is noted, con­
sider nonneurogenic causes, such as viral infection, aging, smoking, and toxic or metabolic disease.
Figure 17-27
II
452
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
AUDITORY N ERV E (V III)
The auditory nerve is composed of a cochlear portion and a vestibular portion. The cochlear por­
tion is responsible for hearing, and the vestibular portion is responsible for balance. The cochlear
portion is tested by evaluating the patient's hearing. The most accurate way to test hearing is with
an audiometer. If one is not available, place a ticking watch close to the patient's ear and see whether
he or she can hear it. Weber's and Rinne's tests indicate cochlear lesions. Vestibular lesions are also
determined by veering and past pointing tests and by observing the patient for nystagmus.
Weber's Test: Cochlear Nerve
PROCEDURE
Place a vibrating
256-Hz tuning fork on top of the patient's head (Fig. 17-28). Ask the patient
whether he or she hears the sound equally in both ears.
RATIONALE
The test is normal if the patient hears the sound equally in both ears. If the sound is louder in one
ear than in the other, suspect a conduction problem, such as a blockage of the ear canal or middle
ear disease on the side of the louder sound. If a nerve lesion is present, the sound will be heard only
in the normal ear. This hearing problem could be caused by otosclerosis, Meniere's disease, menin­
gitis, cerebellopontine tumors, trauma, or a demyelinating lesion.
Figure 17-28
CHAPTER 17
CRANIAL NERVES
453
Rinne's Test: Cochlear Nerve
PROCEDURE
Place a vibrating tuning fork on the mastoid process (Fig.
17-29). Ask the patient to say when the
sound disappears. After the sound disappears, place the tuning fork next to but not touching the ear
(Fig.
17-30). Ask the patient again to say when the sound fades out.
RATIONALE
Normally, air conduction is twice as loud as bone conduction-a Rinne positive. In conduction le­
sions and nonneurogenic lesions, bone conduction is greater than air conduction-a Rinne nega­
tive. In auditory nerve lesions, air conduction is greater than bone conduction.
Figure 17-29
Figure 17-30
454
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Veering Test: Vestibular Nerve
PROCEDURE
Instruct the patient to walk with the eyes closed (Fig.
17-31).
RATIONALE
Veering in walking or a positive Romberg's test indicates a unilateral vestibular lesion. See Chapter
19 for Romberg's test.
Figure 17-31
CHAPTER 17
CRANlAL NERVES
455
Past Pointing Test: Vestibular Nerve
PROCEDURE
With the patient's eyes open, instruct the patient to elevate the extended arm over the head with in­
dex finger extended (Fig.
17-32). Next, instruct the patient to touch your extended index finger,
17-33). Repeat the test with the patient's eyes
which you hold near the patient at hip level (Fig.
closed.
RATIONALE
If the patient has a vestibular lesion, the patient's arm will drift, and he or she will have difficulty
placing the finger on yours with eyes closed.
Figure 17-32
Figure 17-33
456
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Labyrinthine Test for Positional Nystagmus
PROCEDURE
With the patient seated, inspect the eyes and note any nystagmus (Fig.
17-34). Nystagmus is a slow
drift of the eye in one direction with a fast correction in the opposite direction. It is described in the
direction of the fast phase. Next, have the patient lie supine and inspect for nystagmus for
30 sec­
17-35). Assist the patient to turn to one side and stabilize the head. Note any nystagmus
for 30 seconds (Fig. 17-36). Repeat with the patient turned to the opposite side. Have the patient ex­
tend the head over the examination table, and inspect for nystagmus for 30 seconds (Fig. 17-37). Al­
onds (Fig.
low sufficient time between tests for the patient with nystagmus to recover.
Figure 17-34
Figure 17-36
Figure 17-35
Figure 17-37
CHAPTER 17
CRANIAL NERVES
457
RATIONALE
A patient with persistent nystagmus that changes direction with changes in the head position and
that appears on repeated maneuvers suggests brainstem or posterior fossa pathology. A delayed,
mild, rapidly disappearing response that produces nystagmus in only one direction and cannot be
repeated suggests benign postural vertigo (Fig.
17-38).
��
�____________
Reassess
Jerk
nystagmus
Up
Upbeat
nystagmus
Down
Downbeat
nystagmus
Rotatory
Rotatory
nystagmus
Horizontal
Nystagmus in
primary position
of gaze
Nystagmus when
looking in opposite
direction of fast phase
Nystagmus only if
looking to direction
of fast phase
2nd degree
horizontal
nystagmus
3rd degree
horizontal
nystagmus
•
Multidirectional
gaze evoked
nystagmus
Figure 17-38. Nystagmus. Reprinted with permission from Fuller G. Neurological
Examination Made Easy. London: Churchill Livingstone, 1993.
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
458
G LOSSOPHARYNG EAL AND VAGUS N ERVES (IX, X)
The glossopharyngeal and vagus nerves are clinically inseparable because of their overlap and are
therefore tested together. The glossopharyngeal nerve conveys taste from the posterior tongue and
has sensory innervation to the tonsillar pillars, soft palate, and pharyngeal wall. The vagus nerve
overlaps the functions of the glossopharyngeal nerve and innervates the larynx. Note any hoarseness
or change in voice tone. The vagus nerve controls activity in the cardiac, respiratory, and gastroin­
testinal systems; however, these functions are difficult to assay because of the variable supraseg­
mental and hormonal influences.
Motor function is assessed by having the patient say "ah" and observing the palate for deviation.
Place a tongue depressor on the patient's tongue and observe palatal deviation (Fig.
17-39). If devi­
ation exists, it will be toward the normal side. Next, ask the patient to swallow rapidly while you pal­
pate the trachea (Fig.
17-40). Fatigue on continued swallowing may be seen in a patient who has
17-41). Leakage
myasthenia gravis. You may also ask the patient to puff the cheeks with air (Fig.
through the nose indicates weakness in the muscle of the soft palate. This weakness is also a sign of
a lesion in cranial nerve IX or X. The leakage can be stopped by pinching the nose.
Figure 17-40
Figure 17-39
Figure 17-41
CHAPTER l7
CRANIAL NERVES
459
Sensory
PROCEDURE
Instruct the patient to close the eyes and protrude the tongue. Apply a bitter-tasting solution on one
side of the posterior third of the tongue (Fig.
17-42). Instruct the patient to identify each substance
without retracting the tongue. This can be done by having the patient point out one of a list of sub­
stances on a card or sheet of paper.
RATIONALE
Inability to taste and/or identify the substances indicates a lesion of the sensory portion of the glos­
sopharyngeal and/or vagus nerve.
Figure 17-42
II
460
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Reftex
Gag Reflex
PROCEDURE
With a throat stick, touch the posterior pharyngeal wall, first on one side and then on the other (Fig.
17-43). Observe the movement of the palate and the patient when he or she gags. Also, ask the pa­
tient whether the stimulus feels the same on both sides or is stronger on one side than on the other.
RATIONALE
Deviation of the palate to one side and/or an asymmetrical feeling of the stimulus indicates a lesion
of the glossopharyngeal and/or vagus nerves. If the patient has had a tonsillectomy, a slight asym­
metry of palatal movement may be normal.
Figure 17-43
CHAPTER 17
CRANIAL NERVES
461
SPINAL ACCESSORY NERVE (XI)
The spinal accessory nerve innervates the trapezius and the sternocleidomastoideus muscles. To as­
sess the spinal accessory nerve, test the trapezius and sternocleidomastoideus muscles.
Trapezius Muscle Test
PROCEDURE
With the patient seated, apply pressure to the patient's shoulders bilaterally and ask him or her to
shrug against your resistance (Fig.
17-44). Grade each side according to the muscle grading chart in
Chapter 4.
RATIONALE
A grade
0 to 4 indicates a spinal accessory nerve lesion. Suspect a strained or weak trapezius muscle
if the sternocleidomastoideus muscle has reasonably normal strength.
Sternocleidomastoideus Muscle Test
PROCEDURE
With the patient seated, place your hand on the lateral aspect of the patient's jaw and instruct him
or her to turn the head toward your hand against resistance (Fig.
to the muscle grading chart in Chapter
17-45). Grade each side according
4.
RATIONALE
A grade
0 to 4 indicates a spinal accessory nerve lesion. A strained or weak sternocleidomastoideus
muscle is suspect if the trapezius muscle is of reasonably normal strength.
II
Figure 17-44
Figure 17-45
462
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
H YPOGLOSSAL N ERVE (XII)
The hypoglossal nerve is purely motor and is responsible for the movement of the tongue.
PROCEDURE
Place your hand on the patient's cheek and instruct the patient to press the tip of the tongue against
the cheek under your hand (Fig.
protrude the tongue (Fig.
17-46). Have the patient do this bilaterally. Instruct the patient to
17-47).
RATIONALE
If the pressure under your hand by the patient's tongue is unequal, suspect a unilateral hypoglossal
nerve lesion, which will exhibit a deviation of the tongue toward the side of the lesion.
Figure 17-46
Figure 17-47
----- ------
CHAPTER 17
G eneral References
Barrows HS. Guide to Neurological Assessment.
Philadelphia: JB Lippincott, 1980.
Bickerstaff ER. Neurological Examination in Clini­
cal Practice. 4th ed. Boston: Blackwell Scientific,
1980.
Chusid JG. Correlative neuroanatomy and func­
tional neurology. 17th ed. Los Altos: Lange Medical,
1976.
Colling RD. Illustrated Manual of Neurologic Diag­
nosis. 2nd ed. Philadelphia: JB Lippincott, 1982.
Dejong RN. T he Neurologic Examination. 4th ed.
Hagerstown, MD: Harper & Row, 1979.
DeMyer W. Technique of the Neurologic Exami­
nation: A Programmed Text. 3rd ed. New York:
McGraw-Hill, 1980.
CRANIAL NERVES
463
Devinsky 0, Feldmann E. Examination of the Cra­
nial and Peripheral Nerves. New York: Churchill
Livingstone, 1988.
Fuller G. Neurological Examination Made Easy.
London: Churchill Livingstone, 1993.
Mancall E. Essentials of the Neurologic Examina­
tion. 2nd ed. Philadelphia: FA Davis, 1981.
Merritt HH. A Textbook of Neurology. 4th ed.
Philadelphia: Lea & Febiger, 1967.
VanAllen MW, Rodnitzky RL. Pictorial Manual of
Neurologic Tests. 2nd ed. Chicago: Year Book Med­
ical, 198 1.
--------���-REFLEXES
PATHOLOGICAL UPPER EXTREMITY
SUPERF ICIAL CUTANE OUS
REFLEXES
REFLEXES
465
474
Hoffman's Sign
465
Upper Abdominal Reflex
474
Tromner's Sign
466
Lower Abdominal Reflex
475
Rossolimo's Hand Sign
467
Superficial Gluteal Reflex
Chaddock's Wrist Sign
468
Corneal Reflex
476
Pharyngeal Reflex
PATHOLOGICAL LOWER EXTREMITY
REFLEXES
469
Babinski's Sign
O ppenheim's Sign
470
Chaddock's Foot Sign
471
Rossolimo's Foot Sign
472
Schaeffer's Sign
464
469
473
Palatal Reflex
476
476
475
CHAPTER 18
REFLEXES
465
PATHOLOGICAL UPPER EXTREMITY REFLEXES
This chapter discusses various pathological reflexes that usually are present in corticospinal disease
and higher cortical dysfunction, such as stroke, tumor, demyelinating diseases, and vasculitis. If no
corticospinal pathology or other higher cortical dysfunction is present, these reflexes should be ab­
sent. These reflexes are not graded on the Wexler scale but are referred to as being either present or
absent. Babinski's and Rossolimo's foot signs are considered normal in infants.
Hoffman's Sign
PROCEDURE
With the patient's forearm pronated, grasp the patient's hand and middle finger. With your oppo­
site hand, flick the distal end of the patient's middle finger, stretching the flexor and eliciting a
stretch reflex (Fig.
18-1).
RATIONALE
A positive sign is elicited if the patient flexes the thumb and forefinger (Fig.
18-2). A positive sign
indicates a hyperactive reflex only. If this sign is present, it may be one indicator of pyramidal tract
disease.
Figure 18-1
Figure 18-2
466
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Tromner's Sign
PROCEDURE
Grasp the patient's wrist and tap the plantar surface of the tip of the index and middle digits (Fig.
18-3).
RATIONALE
A positive sign is elicited if the patient flexes all of the fingers (Fig.
18-4). A positive sign indicates a
hyperactive reflex only. If this sign is present, it may be one indicator of corticospinal tract disease.
Figure 18-3
Figure 18-4
CHAPTER 18
REFLEXES
467
Rossolimo's Hand Sign
PROCEDURE
With a neurological reflex hammer, tap the palmar surface of the metacarpophalangeal joint (Fig.
18-5).
RATIONALE
A positive sign is elicited if the patient flexes all of the fingers (Fig.
ramidal tract disease.
Figure 18-5
Figure 18-6
18-6). This sign is present in py­
468
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Chaddock's Wrist Sign
PROCEDURE
Grasp the patient's wrist, putting pressure on the palmaris longus tendon (Fig.
18-7).
RATIONALE
A positive sign is elicited if the patient flexes the wrist and extends the fingers (Fig.
is present in pyramidal tract disease.
Figure 18-7
Figure 18-8
18-8). This sign
CHAPTER 18
REFLEXES
469
PATHOLOGICAL LOWER EXTREMITY REFLEXES
Babinski's Sign
PROCEDURE
With the patient supine, stroke the sole of the foot with a blunt object like the handle of a neuro­
logical reflex hammer. Begin with the lateral aspect of the heel and move superiorly and medially to
the big toe (Fig.
18-9).
RATIONALE
This sign is very important in the neurological examination. A positive sign is evident if the patient
dorsiflexes the great toe and fans the rest of the digits (Fig.
18- 10). This sign is a classic indication
12 to 16 months.
of a corticospinal motor system lesion. It may be present in normal infants aged
Figure 18-9
Figure 18-10
470
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Oppenheim's Sign
PROCEDURE
With the patient supine, stroke the medial side of the tibia with a blunt object (Fig.
18-11).
RATIONALE
Extension of the great toe is a positive sign (Fig.
cospinal motor system lesion.
Figure 18-11
Figure 18-12
18-12). If this reflex is present, suspect a corti­
CHAPTER 18
REFLEXES
47l
Chaddock's Foot Sign
PROCEDURE
With the patient supine, stroke the lateral malleolus with a blunt object (Fig.
18-13).
RATIONALE
Extension of the great toe indicates a positive sign (Fig.
ticospinal motor system lesion.
Figure 18-13
Figure 18-14
18-14). If this reflex is present, suspect a cor­
472
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Rossolimo's Foot Sign
PROCEDURE
With the patient supine, tap the metatarsal heads of the patient's feet with a neurological reflex ham­
mer (Fig.
18-15).
RATIONALE
Plantar flexion of the toes indicates a positive sign (Fig.
children aged
18- 16). This sign is considered normal in
2 months to 3 years. In other age groups, if this sign and a Babinski sign are present,
suspect pyramidal tract disease.
Figure 18-15
Figure 18-16
CHAPTER 18
REFLEXES
473
Schaeffer's Sign
PROCEDURE
With the patient supine and the feet overhanging the examination table, squeeze the Achilles tendon
(Fig.
18- 17).
RATIONALE
Extension of the great toe is a positive sign (Fig.
pyramidal tract.
Figure 18-17
Figure 18-18
18- 18). If this sign is present, suspect a lesion of the
474
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
SUPERFICIAL CUTANEO US REFLEXES
Superficial cutaneous reflexes are polysynaptic. They are mediated through a reflex arc but are con­
trolled inherently by the corticospinal system. These reflexes are also not graded by the Wexler scale
but are either present or absent. Unlike the pathological reflexes, these reflexes are normally present
if there is no lesion of the corticospinal tract. The superficial corneal, pharyngeal, and palatal reflexes
belong in this group but are discussed in Chapter 17.
Upper Abdominal Reflex
PROCEDURE
With the patient supine, scrape the skin from medial to lateral above the umbilicus with the blunt
end of a neurological reflex hammer (Fig.
18- 19) and evaluate bilaterally.
RATIONALE
A deviation of the umbilicus to the stroked side is a normal response. If the umbilicus does not move
unilaterally or if the response is delayed, the response is absent. The reflex may be absent in obese
patients and pregnant women. This absent reflex is normal, but only if it is absent bilaterally. An ab­
sent unilateral response indicates a T7 to T9 nerve root lesion or disease of the corticospinal system.
If you suspect the latter, perform other corticospinal system tests to verify your findings.
Figure 18·19
CHAPTER 18
REFLEXES
475
Lower Abdominal Reflex
PROCEDURE
With the patient supine, scrape the skin from medial to lateral below the umbilicus with the blunt
end of a neurological reflex hammer (Fig. 18-20) and evaluate bilaterally.
RATIONALE
A deviation of the umbilicus to the stroked side is a normal response. If the umbilicus does not move
unilaterally or if the response is delayed, the response is absent. The reflex may be absent in obese
patients and pregnant women. This absence is normal, but only if the reflex is absent bilaterally. An
absent unilateral response indicates a TI0 to T 12 nerve root lesion or disease of the corticospinal
system. If you suspect the latter, perform other corticospinal system tests to verify your findings.
Figure 18-20
Superficial Gluteal Reflex
PROCEDURE
With the patient prone, scrape the buttock with the blunt end of a neurological reflex hammer (Fig.
18-21). Perform this test bilaterally.
RATIONALE
A contraction of the gluteal muscle on the side of the scraping is a normal response. If the reflex is
absent unilaterally, suspect an L4 or L5 nerve root lesion or a corticospinal system lesion. If you sus­
pect the latter, perform other corticospinal system tests to verify your evaluation.
Figure 18-21
476
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Corneal Reflex
See Chapter 17.
Pharyngeal Reflex
See Chapter 17.
Palatal Reflex
See Chapter 17.
General References
DeMyer W. Technique of the Neurologic Exami­
Adams C. Neurology in Primary Care. Philadelphia:
McGraw-Hill, 1980.
FA Davis, 2000.
Aminoff MJ, Greenberg DA, Simon RP. Clinical
Neurology. 3rd ed. Stamford, CT: Appleton &
Lange, 1996.
Barrows HS. Guide to Neurological Assessment.
Philadelphia: JB Lippincott, 1980.
nation: A Programmed Text. 3rd ed. New York:
Devinsky 0, Feldmann E. Examination of the Cra­
nial and Peripheral Nerves. New York: Churchill
Livingstone, 1988.
Heilman NM, Watson RT, Green M. Handbook for
Differential Diagnosis of Neurologic Signs and
Symptoms. New York: Appleton-Century-Crofts,
Bickerstaff ER. Neurological Examination in Clini­
1977.
cal Practice. 4th ed. Boston: Blackwell Scientific,
Lapides], Babbitt JM. Diagnostic value of bulbocav­
1980.
Bronisch FW. The Clinically Important Reflexes.
New York: Grune & Stratton, 1952.
Chusid JG. Correlative Neuroanatomy and Func­
tional Neurology. 16th ed. Los Altos, CA: Lange
Medical, 1976.
Colling RD. Illustrated Manual of Neurologic Diag­
nosis. 2nd ed. Philadelphia: JB Lippincott, 1982.
DeJong RN. The Neurologic Examination. 4th ed.
Hagerstown, MD: Harper & Row, 1979.
ernosus reflex. JAMA 1956;162:971.
Mancall E. Essentials of the Neurologic Examina­
tion. 2nd ed. Philadelphia: FA Davis, 1981.
Merritt HH. A Textbook of Neurology. 4th ed.
Philadelphia: Lea & Febiger, 1967.
Swanson P. Signs and Symptoms in Neurology.
Philadelphia: JB Lippincott, 1989.
VanAllen MW, Rodnitzky RL. Pictorial Manual of
Neurologic Tests. 2nd ed. Chicago: Year Book Med­
ical, 1981.
--------���-CEREBELLAR FUNCTION TESTS
UPPER EXTREMITY
Finger-Finger Test
Dext erity Test
Heel-Kn ee Test
478
481
Patting Test
479
P ronation-Supination Test
Patting Test
LOWER EXTREMITY
478
Finger-No s e Test
480
483
483
484
Figur e-Eight Test
Romberg's Test
485
486
482
477
478
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Cerebellar dysfunction is an interruption of the integration of afferent sensory feedback and effer­
ent motor output. Loss of joint position sense can produce some uncoordination, which can be sub­
stantially worse when the eyes are closed. The following tests attempt to evaluate the patient's coor­
dination and joint position sense.
If any of the tests are positive, suspect an ipsilateral cerebellar syndrome. This syndrome may be
caused by demyelination, vascular disease, trauma, tumor, or abscess. If any of the tests are positive
bilaterally, suspect a bilateral cerebellar syndrome. This syndrome may be caused by alcohol con­
sumption, demyelination, or vascular disease.
UPPER EXTREMITY
Finger-Nose Test
PROCEDURE
With the patient standing or sitting with eyes closed, ask him or her to touch both index fingers to
the nose simultaneously (Fig.
19-1).
RATIONALE
The patient should be able to perform this procedure smoothly and easily. If the patient cannot per­
form this procedure, cerebellar function is impaired.
Figure 19·1
CHAPTER 19
CEREBELLAR FUNCTION TESTS
479
Finger-Finger Test
PROCEDURE
Ask the patient to place his or her finger on your finger. Repeat this several times with the patient's
eyes open and closed (Figs.
19-2 and 19-3).
RATIONALE
The patient should be able to perform this procedure smoothly and easily. If the patient cannot per­
form this procedure, cerebellar function is impaired.
Figure 19-2
Figure 19-3
480
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Pronation-Supination Test
PROCEDURE
Ask the standing patient to extend the arms forward. Next, ask the patient to pronate and supinate
the arms rapidly (Figs.
19-4 and 19-5).
RATIONALE
The patient should be able to perform these movements smoothly and with an even rhythm. If the
patient cannot perform the movements or performs them in a spastic or uncoordinated manner,
suspect cerebellar dysfunction.
Figure 19-4
Figure 19-5
CHAPTER 19
CEREBELLAR FUNCTION TESTS
481
Patting Test
PROCEDURE
Instruct the seated patient to pat the hand rapidly and repeatedly on the thigh (Fig.
19-6).
RATIONALE
The patient should be able to perform this movement briskly and with equal amplitude. If the pa­
tient cannot perform this movement or performs it in a slow, spastic, or uncoordinated manner, sus­
pect cerebellar dysfunction.
Figure 19-6
482
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Dexterity Test
PROCEDURE
Ask the patient to touch each fingertip with the thumb of the same hand sequentially (Figs.
19-7 and
19-8).
RATIONALE
These movements are usually done in a smooth and coordinated manner. If the patient cannot per­
form these movements or performs them in a spastic or uncoordinated manner, suspect cerebellar
dysfunction.
Figure 19-7
Figure 19-8
CHAPTER 19
CEREBELLAR FUNCTION TESTS
483
LOWER EXTREMITY
Heel-Knee Test
PROCEDURE
With the patient supine, ask the patient to place one foot on the opposite knee (Fig.
the patient to slide the foot down the shin (Fig.
19-9). Then ask
19-10).
RATIONALE
These movements are usually done in a smooth and coordinated manner. If the patient cannot per­
form these movements or performs them in a spastic or uncoordinated manner, suspect cerebellar
dysfunction.
Figure 19-9
Figure 19-10
484
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Patting Test
PROCEDURE
Ask the patient to tap the foot rapidly and repeatedly on the floor (Figs.
19- 11 and 19-12).
RATIONALE
The patient should be able to perform this movement briskly and with equal amplitude. If the pa­
tient cannot perform this movement or performs it in a slow, spastic, or uncoordinated manner, sus­
pect cerebellar dysfunction.
Figure 19- 1 1
Figure 19-12
CHAPTER 19
CEREBELLAR FUNCTION TESTS
485
Figure-Eight Test
PROCEDURE
With the patient supine, ask the patient to draw a figure-eight in the air with the great toe (Fig.
19-13).
RATIONALE
These movements are usually done in a smooth and coordinated manner. If the patient cannot per­
form these movements or performs them in a spastic or uncoordinated manner, suspect cerebellar
dysfunction.
Figure 19-13
486
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Romberg's Test
PROCEDURE
Instruct the patient to stand. Observe the patient for any swaying. While the patient is still standing,
instruct him or her to close the eyes (Fig.
19-14).
RATIONALE
This is not a cerebellar test per se, but swaying with eyes closed suggests a posterior column disor­
der. A patient with cerebellar dysfunction will sway with eyes open, but the swaying will be exag­
gerated with eyes closed.
Figure 19-14
General References
Barrows HS. Guide to Neurological Assessment.
Philadelphia: JB Lippincott, 1980.
Bickerstaff ER. Neurological Examination in Clinical
Practice. 4th ed. Boston: Blackwell Scientific, 1980 .
Chusid JG. Correlative Neuroanatomy and Func­
tional Neurology. 16th ed. Los Altos, CA: Lange
Medical, 1976.
Colling RD. Illustrated Manual of Neurologic Diag­
nosis. 2nd ed. Philadelphia: JB Lippincott, 1982.
Dejong RN. The Neurologic Examination. 4th ed.
Hagerstown, MD: Harper & Row, 1979.
Greenberg DA, Aminoff MJ, Simon RP. Clinical Neu­
rology. 2nd ed. Norwalk: Appleton & Lange, 1993.
Heilman NM, Watson RT, Green M. Handbook for
Differential Diagnosis of Neurologic Signs and
Symptoms. New York: Appleton-Century-Crofts,
1977.
Klein R, Mayer-Gross W. The Clinical Examination
of Patients With Organic Cerebral Disease. Spring­
field, IL: Charles C. T homas, 1957.
Mancall E. Essentials of the neurologic examination.
2nd ed. Philadelphia: FA Davis, 1981.
Merritt HH. A Textbook of Neurology. 4th ed.
Philadelphia: Lea & Febiger, 1967.
Scheinberg P. An Introduction to Diagnosis and
Management of Common Neurologic Disorders.
3rd ed. New York: Raven, 1986.
Steegmann AT. Examination of the Nervous System:
A Student's Guide. Chicago: Year Book Medical,
1970.
Swanson P. Signs and Symptoms in Neurology.
Philadelphia: JB Lippincott, 1989.
VanAllen MW, Rodnitzky RL. Pictorial Manual of
Neurologic Tests. 2nd ed. Chicago: Year Book Med­
ical, 1981.
D
INDEX
Page numbers in italics denote figures.
Abbott-Saunders test, 152, 152
Abdomen protrusion, 36
Abdominal asymmetry, 34, 34
Abdominal muscles, postural assessment, 23, 36
Abducens nerve (VI), 443, 443--445,
444, 445
Abduction, 120, 120, 336, 336
Abduction stress test, 187, 187, 390,
390
Abductor digiti minimi,102, 102,
216
Abductor pollicis brevis,216
Abductor pollicus longus tendon,
211, 218
Acetabular cavity, 341
Acetabular joint, 351
Achilles tap test, 420, 420
Achilles tendon, 404, 407, 407--408,
408, 408, 473
Achilles tendon rupture,419, 420,
420
Acromioclavicular joint,108, 108,
230
Acromioclavicular ligament,109, 110
Acromion process,110, 114, 130,
131, 158, 230
Active range of motion, 7-8, 8
Adam's position, 241, 241
Adduction, 121, 121, 337
Adduction stress test, 185, 185-186,
186, 389, 389
Adductor longus muscle, 333
Adductor magnus muscle, 255
Adductor pollicus longus muscle,
200
Adson's test, 155, 155-156, 156
Alar ligament,71, 76, 77, 79, 79
Allen's test, 424, 424
Allis test,340, 340
American Academy of Orthopaedic
Surgeons, muscle grading
scale, 52, 93, 95
Anderson medial-lateral grind test,
377, 377
Andrews anterior instability test,
135, 135
Angiography, 424
Ankle orthopaedic tests
achilles tendon rupture,419, 420,
420
examination flow chart, 398
ligamentous instability,413,
413--416, 414, 415, 416
palpation, 399, 399--408, 400, 401,
402, 403, 404, 405, 406, 407,
408
range of motion evaluation, 409,
409--412, 410,411,412
tarsal tunnel syndrome, 417,
417--419,418
Ankylosing spondylitis, 322, 322
Annular ligament, 171, 173, 186
Antagonist muscles, 26
Antalgic lean sign, 277, 277
Anterior apprehension test, 133, 133
Anterior cervical flexors, 28
Anterior cruciate ligament,382, 382,
384, 385,386, 387, 389,390
Anterior drawer test,132, 132
Anterior glenohumeral instability.
see Glenohumeral instability
Anterior iliac crest,332, 364
Anterior inferior iliac spine, 328, 331
Anterior knee bursa,358, 358-359,
359
Anterior longitudinal ligament,71
Anterior pelvis, 35, 35
Anterior plica, 378
Anterior sacroiliac ligament, 319
Anterior scalene muscles,68
Anterior slide test, 147, 147
Anterior superior iliac spine, 328,
328
Anterior talofibular ligament, 403,
403, 413, 413, 414, 415
Anterior tibialis, 38
Anterior tibiofibular ligament, 403,
413, 415
Anterior tibiotalar ligament, 399,
416
Anteroposterior shoulder radi­
ographs, 124, 128, 138, 141,
144, 149, 154
Anvil test,343, 343
AP elbow view, 184, 187
Apex of lung,68
Apley scratch test,123, 123
Apley's compression test,369-372,
370
Apley's distraction test,388, 388
Arcuate-popliteus complex, 387
Arthrosis, 58
Articular capsule, 71, 171, 173
Atlanto-occipital aperture,58, 76
Atlantoaxial joints, 76
Atlas, 46, 46, 57, 58, 77
Auditory nerve (VIII), 452, 452--456,
453, 454, 455, 456
Avulsion fracture,315
Axillary artery, 156, 157, 158
Axillary nerve innervation,96
Axillary shoulder radiograph,138,
141, 144, 149
Axillary vein, 157
Axis,46, 57
Babinski's Sign, 469, 469
Back extensors,23
Bakody's sign, 90, 90
Balanced posture,24
Barre-Lieou sign, 59, 59
Basilar artery, 56, 57
Bechterew's test, 274, 274
Beevor's sign, 246, 246
Biceps brachii muscle, 111, 145, 151
Biceps brachii tendon, 125, 125, 145,
176
Biceps femoris muscle, 255, 365
Biceps femoris tendon,365, 366
Biceps muscle
anatomy,112, 112
motor testing, 97, 98
reflex testing,97
sensory testing, 97
Biceps tendon
anatomy, 108, 109, 110, 111, 127,
151
instability, 150, 150-154, 151, 152,
153, 154
Bicipital groove, Ill, 111, 151
Bikele's sign, 162, 162
Bilateral cerebellar syndrome,478
Body
of rib, 236
of sternum, 230
Bohler's sign,376, 376
Bone scans. see Skeletal
scintigraphy
Bony structure
clinical assessment protocol, 4
palpation, 5
Bounce home test,371
Bowlegs,37
Bowstring sign, 279, 279
Brachial artery,176
487
488
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Brachial plexus
definition, 93, 93
irritation, 161, 161-164, 162, 163,
164
neural component, 156, 156
palpation, 169
Tinnel's sign, 164, 164
Brachial plexus stretch test, 161, 161
Brachial plexus tension test, 163, 163
Brachioradialis muscle, 175, 176
Brachioradialis tendon
palpation, 172
reflex testing, 99
sensory testing, 99, 99
Braggard's test, 271, 271
Brudzinski's sign, 431, 432. see also
Lindner's sign
Bruits, in carotid or subclavian arteries, 60, 69
Buckling sign, 270, 270
Buerger's test, 423, 423
Bunnel-Littler test, 222, 222
Burn's bench test, 427, 427
Bursa, 154
Bursitis, 129, 129-131, 130, 131
C5 nerve root, 96, 96-99, 97
C6 nerve root, 98, 98-99, 99
C7 nerve root, 100, 100-101, 101, 102
C8 nerve root, 102, 102, 103
Cabot's popliteal sign, 375, 375
CAD (cervical acceleration and deceleration), 41
Calcaneal bursa, 407, 407-408, 408
Calcaneal bursitis, 408
Calcaneal tendon. see Achilles tendon
Calcaneofibular ligament, 403, 403,
413, 415
Calcaneus, 400, 402, 418
Calcifications, diagnosing, 10, 11
Carotid arteries, 41, 42, 42, 57, 58, 60
Carpal bones, 219
Carpal compression test, 208, 208
Carpal instability, 210, 210-211, 211
Carpal ligament, 196
Carpal tunnel, 196, 196
Carpal tunnel syndrome, 205,
205-209, 206, 207, 208, 209
Cerebellar function tests
lower extermity, 483, 483-486,
484, 485, 486
upper extremity, 478, 478-482,
479, 480, 481, 482
Cerebrospinal fluid, 432
Cerebrovascular episodes, 56
Cervical acceleration and deceleration (CAD), 41
Cervical extensors, 28
Cervical fractures. see Cervical or­
thopaedic tests
Cervical instability. see Cervical or­
thopaedic tests
Cervical myelopathy, 88
Cervical nerve root lesions, 93, 93,
94, 95
Cervical orthopaedic tests
cervical fractures, 72-75, 73, 74, 75
cervical instability, 76, 76-80, 77,
78, 79
cervical palpation
anterior aspect, 41-43, 42, 43
posterior aspect, 44, 44-47, 45,
46, 47
differential diagnosis, 70-71, 71
examination flow chart, 40
neurological compression and irritation, 82, 82-90, 83, 84, 85,
86, 87, 88, 89
range of motion evaluation,
47-51, 48, 49, 50, 51
resistive isometric muscle testing,
52, 52-55, 53, 54, 55
space-occupying lesions, 80,
80-81, 81
subclavian artery compromise, 68,
68-69, 69
vertebrobasilar circulation assess­
ment, 56-67, 57, 58, 59, 60,
61, 62, 63, 64, 65, 66, 67
Cervical plexus, 93
Cervical quadrant test, 62, 62
Chaddock's Foot Sign, 471, 471
Chaddock's Wrist Sign, 468, 468
Chest expansion test, 248, 248
Chondral fracture, 391
Chondromalacia patellae, 357, 391
Circle of Willis, 56, 57
Claudication, 423
Clavicle, 41, 68, 108, 108, 109, 110,
130, 131, 157, 158, 230, 232
Clinical assessment protocol
diagnostic imaging and structural
testing, 9-13
functional testing, 13
observation/inspection, 4
orthopaedic and neurological testing, 8-9
palpation, 4-5
patient history, 2-3
range of motion evaluation, 5-8
Closed-ended history, 3
Clunk test, 146, 146
Cochlear nerve
Rinne's test, 453, 453
Weber's test, 452, 452
Collateral ligaments, 220
Coracoid process, 108, 109, 110, 114,
158, 230
Corneal reflex, 447, 447
Coronary ligament, 363
Corticospinal tract disease, 466, 470,
471, 474, 475
Costal cartilages, 230, 231, 231
Costochondral articulations, 230, 231
Costoclavicular test, 147, 157
Costotransverse ligament, 236
Cozen's test, 180, 180-181, 181
Cranial nerves
auditory nerve (VIII), 452,
452-456, 453, 454, 455, 456
facial nerve (VII), 449, 449-451,
450, 451
glossopharyngeal and vagus nerves
(IX, X), 458, 458-460, 459,
460
hypoglossal nerve (XlI), 462, 462
oculomotor, trochlear, and ab­
ducens nerves (III, IV, VI),
443, 443-445, 444, 445
olfactory nerve (1), 437, 437
ophthalmoscopic examination,
441, 441-442, 442
optic nerve (II), 438, 438-440, 439,
440
spinal accessory nerve (Xl), 461,
461
trigeminal nerve (V), 446,
446-448, 447, 448
types of, 436
Crepitus
active range of motion and, 7
in degenerative joint disease, 46
CT arthrography, 138, 141, 144, 149,
154
CT (computed tomography). see also
MRI
Alar ligament, 79
Bakody's sign, 90
cervical, 432
elbow, 187
intervertebral disc defects, 10, 10
lumba�265, 266, 284, 287
Rust's sign, 75
swallowing test, 81
thoracic, 244
Cubital fossa, 176, 176
Cubital tunnel, 188, 190
Cutaneous reflexes, 474, 474-487,
475, 476
Dawbarn's test, 131, 131
Deep fibular nerve innervation, 303,
303, 305, 305
Deep infrapatellar bursa, 358, 358,
362
Deep transverse metacarpal ligaments, 219
Deep vein thrombosis, 425
Degenerative joint disease, 46, 56
Dejerine's sign, 81, 81
Dejerine's Triad, 286, 286
Dekleyn's test, 63, 63
Deltoid ligament, 399, 399, 413, 416
Deltoid muscle
anatomy, 113, 113, 115, 130, 131,
233
CHAPTER 19
motor testing, 96
palpation, 108,109
posterior aspect, 44
Dermatomal patterns, 93
Dexterity test, 482, 482
Diagnostic imaging, types of,
9-13
Differential diagnosis
lumbar versus sacroiliac involve­
ment, 288,288-291, 289,290,
291
strain versus sprain, 70-71, 71
Digital ischemia, 423
Disc protrusion, 273, 274, 277, 278,
278
Distal interphalangeal joint, 223, 223
Distal phalanges, 219
Distraction test, 89, 89
Dorsal interossei, 102, 102
Dorsal sacroiliac ligament, 316
Dorsiflexion, ankle, 409, 409,425,
425
Drawer sign, 383, 383
Drawer's foot sign, 414, 414
Dreyer's test, 393, 393
Drop arm test, 148, 148
Dugas test, 138, 138
DVT. see Deep vein thrombosis
EEG (electroencephalography), 13
Elbow flexion test, 190, 190
Elbow orthopaedic tests
examination flow chart, 165
lateral epicondylitis (tennis el­
bow), 180, 180-183, 181, 182,
183
ligamentous instability, 185,
185-187, 186, 187
medial epicondylitis (golfer's el­
bow), 184
neurological compression and irri­
tation, 188,188-191, 189,
190,191
neuropathy/compression syn­
dromes, 188-191
palpation, 169,169-176,170,171,
172,173,174,175,176
range of motion evaluation, 177,
177-179, 178, 179
Elevated shoulder, 31
Ely's test, 346, 346
EMG (electromyography)
arm and forearm, 104
definition, 13
lumbar, 284, 287
wrist, 209, 210
End feel evaluation, 6t
Episternal notch, 24
Erector spinae, 36
Erector spinae group, 234
Eversion, ankle, 412, 412
Everters, 21
CEREBELLAR FUNCTION TESTS
Extension
elbow, 178, 178
hip, 335, 335
inclinometer method, 49, 259
knee, 368, 368, 370
resistive isometric muscle testing,
53, 53
shoulder range of motion, 117,
117
wrist, 202, 202
Extension compression test, 84, 84
Extensor carpi brevis, 98
Extensor carpi longus, 98
Extensor carpi radialis, 98, 172,175
Extensor carpi radialis brevis, 200
Extensor carpi radialis longus, 200
Extensor carpi ulnaris, 172,175,181,
200
Extensor digiti indicis, 101,101
Extensor digiti minimi, lOl, 101,
172,175,181,200,218
Extensor digitorum brevis muscle,
307, 307
Extensor digitorum communis, 101,
101,172,175,181,200,218,
226,226
Extensor digitorum longus muscle,
307,307,404,405,407
Extensor digitorum longus tendons,
405, 405-406, 406
Extensor hallicus brevis tendon, 405
Extensor hallucis longus, 305, 305,
405, 405-406, 406
Extensor indicis, 200
Extensor pollicis longus test, 225, 225
Extensor pollicus brevis, 200,211,
218
Extensor pollicus longus, 200,218
Extensor radius tendon, 218
Extensor tendons, 200, 200, 218, 218
External oblique muscle, 21,23,328,
329
External rotation, 119,119,339,339
External spinae group, 253
Extra-articular effusion, S
Faber test, 349, 349
Facet capsulitis, 282
Facet joints, 46,46-47, 47
Fajersztajn's test, 273, 273
Family history, 3. see also Patient history
Fat pad, 378
Feagin test, 142, 142
Femoral artery, 333
Femoral nerve, 290, 300, 300,333
Femoral nerve traction test, 270,
270
Femoral triangle, 333, 333
Femoral vein, 333
Femur, 358,361,362,363
Fibula, 356,360,361,363,382
489
Fibular collateral ligament, 387, 390
Figure-eight test, 485, 485
Finger abductor group, lO2, 102
Finger extensor group, 101,101
Finger-Finger test, 479, 479
Finger flexor group, 102, 102
Finger-Nose test, 478, 478
Finkelstein's test, 211, 211
Flamingo test, 324, 324
Flat feet, 38
Flatback posture, 25,26t
Flexion
elbow, 177, 177
hip, 334, 335
inclinometer method, 48, 237,258
knee, 367, 36�370
resistive isometric muscle testing,
52, 52
shoulder range of motion, 116,
117
wrist, 201, 201
Flexion compression test, 85, 85
Flexor carpi radialis, 100,100, 170,
184,195
Flexor carpi u1naris, 100,170,175,
184,190, 195,197
Flexor digitorum longus tendon, 21,
102,400,400,402,418
Flexor digitorum minimi tendon,
216
Flexor digitorum profundus, 102,
102,195
Flexor digitorum superficialis, 102,
195
Flexor hallucis longus tendon, 21,
400,400,402,418
Flexor pollicis brevis tendon, 216
Flexor pollicis longus test, 225, 225
Flexor pollicus longus tendon, 195
Flexor retinaculum, 196,206,400,
402,418
Flexor tendons, 195,195,196,216
Fluctuation test, 395, 395
Foot, pronation, 38
Foramen magnum, 58
Foraminal compression test, 82, 82
Forward head posture, 28, 29
Fossa olecrani, 169
Fulcrum test, 137,137
Functional testing, types of,
13-14
Gaenslen's test, 317, 317
Gag reflex, 460, 460
Gamma camera, 13,13
Gastrocnemius muscle, 365,366
Genu valga, 36-38, 37,38
George's Cerebrovascular Craniocer­
vical Functional Test, 60
George's Screening Procedure,
68-{)9, 69
Gilchrest's sign, 128, 128
490
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Glenohumeral instability
anterior, 132, 132-138, 133, 134,
135, 136,137,138
posterior, 139, 139-141, 140, 141
Glenohumeral joint, 175
Glenoid cavity,110
Glenoid fossa, 145, 232
Glenoid labrum, 110, 145, 147
Glossopharyngeal nerve (XI), 458,
458-460, 459, 460
Gluteal muscles, 255, 255, 281. see
also Sacroiliac orthopaedic
tests
Gluteal skyline test, 281, 281
Gluteus maximus, 23, 27, 36, 38, 255,
330
Gluteus medius, 21, 27, 38, 255, 306,
306,330
Gluteus minimus, 27, 255
Goldthwaith's test, 288, 288. see also
Straight leg raising test
Golfer's elbow, 170, 172, 175, 176,
184, 184,188
Goniometer, 7
Gothic shoulder, 31
Greater trochanter, 330, 330, 331
Guyon's canal, 197, 197, 217
Hallpike's maneuver, 66, 66, 67
Halstead maneuver, 160, 160
Hamstrings
avulsion fracture and, 315
Bowstring sign,279, 279
ischial tuberosity, 319
postural assessment, 23
Sicard's test,272
Hand orthopaedic tests
Hoffman's Sign, 465, 465
joint capsule tests, 222,222-223,
223
joint instability, 220, 220-221,
221
palpation, 216, 216-219, 217, 218,
219
Rossolimo's Hand Sign, 467, 467
tendon instability, 224, 224-227,
225, 226
Tromner's Sign, 466, 466
Hautant's test,64, 64
Hawkins-Kennedy impingement test,
123, 123
Head of rib, 236
Head rotation, 30, 51, 55, 55, 87
Head tilt, 30
Heel-Knee test, 483, 483
Heel-toe walk test, 284, 284
Hemianopsia, 439
Hibb's test, 322, 322. see also Laguerre's test
Hip abductors, 21
Hip extensors, 23
Hip flexors, 23,27
Hip joint orthopaedic tests. see also
T horacic orthopaedic tests
contracture tests, 344, 344-350,
345,346,348
examination flow chart, 327
fractures, 343, 343
joint lesions, 349, 349-353, 350,
351, 352
palpation, 328, 328-334, 329, 330,
331,332,333
range of motion evaluation,
334-339, 335, 336, 337, 338,
339
Hoffman's Sign, 465, 465
Homan's sign, 425, 425
Hoover's sign, 426, 426
Hughston plica test, 381, 381
Human bipedal posture, 17
Humerus, 108, 109, 130, 169, 170, 171,
173, 174, 184, 186, 191,232
Hyperextension injury, 46
Hyperflexion injury, 46
Hyperreflexia, 307
Hypoesthesia, 99, 302, 304, 304,308
Hyporeflexia, 99, 304, 304,307
Hypothenar eminance, 216, 217, 217
Ileum, 316
Iliac compression test, 323, 323
Iliac crest, 254, 314, 314, 319, 328,
328-329,329
Iliacus, 23
Iliacus muscle, 254, 328, 329
Iliocostalis cervicis muscle,53, 54, 55
Iliocostabs muscles, 253
Iliofemoral ligament, 319, 328, 329,
331
Iliopectineal bursa, 331
Iliopsoas, 36
lliotibial band, 347, 363, 364, 364,
387, 390
Iliotibial tract of fascia lata, 21
Iliotubial band, 332
Inclinometer,7, 47-52
Inferior articular process, 235
Inferior costal facet, 235
Inferior extensor retinaculum, 405
Inferior flexor retinaculum, 404,407
Inferior gemebus muscle, 255
Inferior gluteal artery, 255
Inferior iliac spine, 329
Inferior peroneal retinaculum, 404,
407
Inferior serratus posterior muscle,
234,253
Infraspinatus muscle, 110
Inguinal ligament, 254,333
In tercostal spaces, 231, 231, 236, 236
Internal carotid artery, 58
Internal oblique, 21
Internal rotation, 118, 118, 338, 338
Interosseous membrane, 171,173
Interosseous sacroiliac ligaments, 316
Interphalangeal joint, 220
Interspinalis cervicis muscle, 53
Interspinous ligament, 71
Intertransversarii muscle, 54, 55
Intertrochanteric line, 331
Intervertebral disc, 85, 295
Intervertebral foramina, 84
Intra-articular effusion, 5
Intradural lesion, 290
Intrinsic rotator muscles, 30
Intrinsic spinal muscles, 45, 45,253,
253
Inversion, ankle, 411, 411
Inverters, 21
Ipsilateral cerebellar syndrome, 478
Ischial tuberosity, 315, 316, 319
Ischiofemoral ligament, 319
Jackson's compression test, 83, 83
Jaw reflex,447, 447
joint capsule tests, 222, 222-223, 223
joint dysfunction tests, lumbar, 258,
258-265, 259, 260, 261, 262,
263, 264, 265
joint effusion, 394, 394-395, 395
joint instability,220, 220-221, 221
Joint lesions
hip, 349, 349-353, 350,351, 352
sacroiliac, 322, 322-324, 323,324
joint line, 361, 361, 363, 363
joints, range of motion evaluation, 7
Kaplan's sign, \83, 183
Kemp's test, 282, 282
Kernig's test, 430, 430
Knee flexion test, 276, 276
Knee orthopaedic tests
examination flow chart, 355
joint effusion, 394, 394-395, 395
ligamentous instability, 382,
382-39\, 383, 384,385, 386,
387, 388, 389, 390
meniscus instability,369, 369-372,
370, 371,372, 373,374,375,
376, 377
palpation, 356, 356-366, 357, 358,
359, 360, 361, 362, 364, 365,
366
patellofemoral dysfunction, 391,
391-393,392, 393
plica tests, 378,379, 380,381
range of motion evaluation, 367,
367-368, 368
Knock knees, 36-38, 37, 38
Kypho-Iordotic posture, 25, 26t
Kyphosis screening, 240, 241, 242,
249-251
Ll nerve root, 295, 295, 299
L2 nerve root, 290, 295, 295, 299,
301, 301 302, 302
-
CHAPTER 19
L3 nerve root, 290,295,295, 299,
301,301-302, 302
L4 nerve root, 290, 301, 301-302,
302,303,303, 328
L5 nerve root, 305, 305
Labral tears, 145, 145-147, 146, 147
Labyrinthine test for positional nystagmus, 456,456
Lachman's test, 386, 386
Laguerre's test, 352, 352
Lasegue's test, 267,267
Lateral aspect, elbow, 172, 172
Lateral collateral ligament, 356,360,
361,363,364,364, 382, 387
Lateral condyle of tibia, 364
Lateral costotransverse ligament, 236
Lateral elbow view, 184, 187
Lateral epicondyle of tibia, 332, 364
Lateral epicondylitis (tennis elbow),
176, 180,180-183,181,182,
183
Lateral femoral condyle, 361, 363,
363
Lateral flexion
inclinometer method, 50,238, 238,
260
resistive isometric muscle testing,
54, 54
Lateral geniculate body, 439
Lateral malleolus ligament, 403, 403,
404,404, 405
Lateral neck flexors, 30
Lateral pelvic tilt, 34, 34
Lateral spinal deviation, 33,33-34
Lateral stability rating scale, 390
Lateral stability test, 415, 415
Lateral talocalcaneal ligament, 403,
413,415
Lateral trunk muscles, 21
Lateral view evaluation, 22-24,23
Latissimus dorsi muscle, 233
Leg measurements, 433, 433-434,
434
Lesser trochanter, 331
Levator scapulae muscle, 28, 31,53,
54, 55, 233
Lewin-Gaenslen test, 318, 318
Lewin's snuff test, 286
L'hermitte's sign, 88, 88, 432
Ligament of Struthers, 190
Ligamentous instability
ankle, 413,413-416, 414,415, 416
elbow, 185, 185-187, 186, 187
knee, 382, 382-391,383,384, 385,
386, 387, 388,389,390
Ligamentum flavum, 71
Lindner's sign, 283, 283. see also
Brudzinski's sign
Lippman's test, 127, 127
Longissimus cervicis muscle, 44,45,
45,53, 54, 55,115
Longissimus muscles, 253
CEREBELLAR FVNCfION TESTS
Longus colli muscle, 52,54
Losee test, 387,387
Lower abdominal reflex, 475,475
Lower crossed syndrome, 26,27,28t
Lower extremity function tests, 483,
483-486, 484, 485, 486
Lower extremity reflexes, 469,
469-473, 470, 471,472,473
Ludington's test, 152, 152
Lumbar flexion, range of motion
evaluation, 7
Lumbar muscle spasm, 282
Lumbar orthopaedic tests. see also
Nerve root lesions
examination flow chart, 251
joint dysfunction tests, 261,
261-265,262,263, 264, 265
lumbar fractures, 266,266
lumbar nerve root and sciatic
nerve irritation/compression
tests, 267, 267-288, 268, 269,
270,271,272, 273, 275, 276,
277,278, 279, 280, 281, 282,
283,284
palpation, 252, 252-257, 253, 254,
255, 256, 257
range of motion evaluation, 258,
258-260,259,260
space-occupying lesions, 285,
285-287,286,287
Lunatotriquetral ballottement test,
212, 212
Lymph nodes, 43,333
Magnetic resonance angiogram, 69
Magnuson's test, 428,428
Maigne's test, 61, 61
Mannkopf's maneuver, 429,429
Manubrium, 230
Masseter muscle, 446
Mastoid process, 41
Maximal foraminal compression test,
87,87
McKenzie's slide glide test, 242, 242
McMurray's test, 370, 370
Medial coUateral ligament, 356,358,
360, 361,362,362, 382
Medial epicondylitis (golfer's elbow),
170,170,172, 175,176,184,
184,188
Medial femoral condyle, 361, 361
Medial hamstring reflex, 307,307
Medial malleolus, 399, 399,405
Medial patellar plica, 378
Medial stability rating scale, 389
Medial stability test, 416, 416
Median nerve, 100,100, 102, 169,
176, 196, 206, 216
Mediopatella plica test, 380,380
Meningeal irritation and inflamma­
tion, 430,430-432, 431, 432
Meningeal tract, 269, 283
491
Meningitis, 432
Meniscus, 361,363, 363,375, 377
Meniscus instability, 369, 369-372,
370, 371, 372,373,374,375,
376,377
Metacarpal, 211
Metacarpals, 219, 219
Metacarpophalangeal joint, 222
Middle phalanges, 219
Military posture, 25, 26t
Mill's test, 182, 182
Minor's sign, 275,275
Modified Helfet's test, 374,374
Motor testing
biceps muscle, 96, 98
deltoid muscle, 96
facial nerve (VII), 449, 449
finger muscles, 102, 102
triceps muscle, 100, 100
trigeminal nerve (V), 446
wrist flexor group, 100, 100
MRl (magnetic resonance imaging).
see also CT
Alar ligament, 79
ankle, 420
Bakody's sign, 90
cervical, 81, 104,432
definition, 11
elbow, 187
hip, 343, 352
knee, 390
lumbar, 284, 287
shoulder, 124, 128, 149, 154
Multidirectional shoulder instability,
142,142-144, 143, 144
Multifidus muscle, 53, 54, 55, 234,
253
Multiple sclerosis, 88
Muscle grading scale, 8, 52,95
Muscles. see also names ofspecific
muscles
ankle, 409, 410, 411, 412
cervical, 53, 55, 52
elbow, 177,178,179
hip, 334,335,337,338
knee, 367,368
lumbar, 258, 259,260
shoulder, 116, 117, 118, 119, 120,
121
thoracic, 237, 238, 239
wrist, 201,202, 203, 204
Musculocutaneous nerve
motor testing, 97, 98
palpation, 169, 176
reflex testing, 97
sensory testing, 99
Musculotendinous injuries, range of
motion evaluation, 7
Myelography
Alar ligament, 79
Bakody's sign, 90
definition, 12,12
492
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Myelography (continued)
Rust's sign,75
swallowing test,81
Nachlas test,290,290
Naffziger's test,287,287
Neck flexors,30
Neer impingement sign,124, 124
Nerve conduction velocity,418
Nerve root compression, 87
Nerve root lesions
lumbar
iliopsoas,299
motor testing,299,301,301,
303, 303,305, 305, 306, 306,
307,307
reflex testing, 302,302, 304,304,
307, 307
sensory testing,300, 300, 302,
302,304,304,307,307
thoracic,245, 245-249, 246, 247
Nerve supply
ankJe,409,410,411,412
cervical, 52,53,55
elbow,177,178,179
hip,334,335,337,338
knee,367,368
lumbar,258,259,260
shoulder,116,117, 118,119,120,
121
thoracic,237,238,239
wrist, 201,202,203,204
Neurologic testing
cervical neurological compression
and irritation,82, 82-90,83,
84, 85, 86, 87, 88, 89
elbow,188-191,189,190, 191
precautions,8, 8
Neurological dysfunction,resistive
isometric muscle testing, 52
Neurovascular bundle,156, 157
Neutral posture,16
Norwood stress test,140, 140
Nystagmus,456,456-457, 457
Ober's test,347,347
Oblique radiography,221, 223,226
Obliquus capitis inferior muscle, 54,
55
Observation/inspection,4
Obturator internus muscle, 255
Obturator membrane,331
Occipital lobe of cerebrum,439
Occipital protuberance,22
Oculomotor nerve (III), 443,
443-445,444,445
O' Donoghue's Maneuver,70-71,71
Olecranon bursa,174,174
Olecranon process,172,174,174,
188,190
Olfactory nerve (1),437,437
Omohyoid fascia,41,43
One leg standing lumbar extension
test,265,265
Open-ended history,3
Ophthalmoscopic examination,441,
441-442,442
Oppenheim's Sign,470,470
Opponens digiti minimi,216
Opponens pollicis,216
OPQRST mneumonic, 3
Optic nerve (II), 438, 438-440,439,
440
Orthopaedic testing,8, 8
Ortolani's click test, 341,341
Osgood-Schlatter disease,357
Osteochondritis,391
Osteophyte,58
PA (posteroanterior) radiography,
221,226
Pain variations,6. see also Range of
motion evaluation
Palmar carpal ligament,195, 197
Palmar interossei, 103, 103
Palmar ligament,219
Palmaris longus,170, 184, 197
Palmaris longus tendon,195
Palpation
ankle,399,399-408,400, 401, 402,
403,404,405,406, 407, 408
cervical,41, 41-47,42, 43,44, 45,
46, 47
clinical assessment protocol,4-5
elbow,169,169-176,170,171,172,
173,174, 175, 176
hand,216,216-219,217,218,219
hip joint,328, 328-334,329, 330,
331,332, 333
knee,356,356-366,357,358,359,
360, 361, 362, 364, 365, 366
lumbar,252, 252-257,253,254,
255,256, 257
sacroiliac,314, 314-315,315
shoulder,108, 108-115, 109,110,
111, 112, 113, 114, 115
thoracic,230, 231,231-236,232,
233, 234, 235, 236
Pancoast's tumor,68
Parathoracic musculature,233,233
Passive range of motion,5-6
Passive scapular approximation test,
245,245
Past Pointing test,vestibular nerve,
455, 455
Patella,356,356, 357,358,359,360,
362,380,381,39],393
Patella apprehension test,392,392
Patella ballottement test,394,394
Patella grinding test, 39],391
Patella ligament,356, 356-357,357,
360
Patella reflex, 302,302, 304,304
Patellar tendon,358,362
Patellofemoral dysfunction,391,
391-393,392,393
Pathological reflexes,465,465-473,
466, 467, 468, 469, 470, 471,
472, 473
Patient history,clinical assessment
protocol,2-3
Patrick test (Faber),349,349
Patting test
lower extermity,484,484
upper extremity,48],481
Pectoralis muscles,28,32, 158
Pellegrini-Stieda disease,361
Pelvic rock (iliac compression) test,
323,323
Pelvic tilt,34, 34,35,35
"Perfect posture",16
Periostitis, 329
Peripheral arterial insufficiency, 423,
423-424,424
Peripheral nerve injuries,94
Peripheral vascular ultrasound,424
Peripheral vision,438,438
Peroneal retinaculum,404, 404
Peroneus brevis,21
Peroneus brevis muscle,405
Peroneus fibularis brevis muscle, 404,
407
Peroneus fibularis longus tendon,
404
Peroneus longus,21
Peroneus tertius tendon,404,407
Pes anserinus bursa,358, 362
Pes muscle,358,362
Phalanges,219
Phalen's test,206,206
Pheasant test,263,263
Physical examination,8
Pinch grip test, 191,191
Pinch test,209, 209
Piriformis muscle,255,256,256, 257,
281,348. see also Sacroiliac
orthopaedic tests
Piriformis test, 281,281, 348,348
Pisiform bone,216
Pitting edema,S
Plain film radiology,213
Alar ligament,79
ankle,420
Bakody's sign,90
cervical,432
elbow,184,187
hip, 342,343,348,352
historical perspectives,9
knee,390
lumbar,265,266,284,287,29]
Rust's sign, 75
subclavian artery compromise,69
swallowing test,81
thoracic, 242,244, 248
Plantar calcaneonavicular ligament,
399,413,416
CHAPTER 19
Plantar flexion, ankle, 410, 410
Plethysmography, 424
Pleural groove, 68
Plica tests, 378, 379, 380, 381
Popliteal artery, 365
Popliteal fossa, 279, 279, 365,
365-366, 366
Popliteus muscle, 364
Posteriior apophyseal joints, 84
Posterior apophyseal joints, 84
Posterior apprehension test, 139, 139
Posterior aspect
elbow, 174-175
wrist, 199, 199-200, 200
Posterior cruciate ligament, 382, 382,
384, 385, 386, 387, 389, 390
Posterior Drawer test, 140, 140
Posterior glenohumeral instability.
see Glenohumeral instability
Posterior inferior articular process,
46
Posterior longitudinal ligament, 71
Posterior medial capsule, 389
Posterior meniscofemoral ligament,
389
Posterior pelvis, 35, 35
Posterior 3acroiliac ligaments, 319
Posterior superior articular process,
46
Posterior superior iliac spine, 314,
314, 319
Posterior talocalcaneal ligament, 399,
413, 416
Posterior talofibular ligament, 403,
403, 413, 414,414, 415
Posterior teres muscle, 184
Posterior tibial artery, 400, 402,402,
418
Posterior tibial nerve, 365, 400, 402,
418
Posterior tibialis tendon, 400
Posterior tibiofibular ligament, 403,
413, 415, 416
Posterior tibiotalar ligament, 399
Posterior view evaluation, postural
assessment, 21, 21-22, 22
Posterolateral capsule, 387, 390
Posterolateral disc defect, 84
Postural assessment
compensations and adaptations,
16-18, 17
distortions and adaptations,
28-38, 29, 30, 31, 32, 33, 34,
35, 36, 37, 38
importance, 16
methods and observations, 19,
19-24, 20, 21, 22,23, 24
Postural syndromes, 26-28, 27, 28t
Posture types, 25, 25-26, 26, 26t
Prepatellar bursa, 358, 358, 359, 362
Prepatellar bursitis, 391
Profundus test, 224, 224
CEREBELLAR FUNCTION TESTS
Pronation-Supination test, 480, 480
Pronator quadratus muscle, 195
Pronator teres muscle, 170, 176, 191
Prone anterior instability test, 134,
134
Proneus brevis tendon, 404,404
Proneus fibularis longus tendon, 407
Proneus longus tendon, 404, 404
Proximal interphalangeal joint, 222,
223, 223
Proximal phalanges, 219
Psoas major, 23, 27
Pterygoid muscle, 446
Ptosis of the eyelid, 444
Pubes, 24
Pubofemoral ligament, 331
Pulsations, in carotid or subclavian
arteries, 60
Pulse amplitude, 5
Pupillary motility,443
Push-Pull test, 141,141
Push-up test, 32
Pyramidal tract disease, 467, 468,
472, 473
Quadrantanopsia, 439
Quadratus femoris muscle, 255
Quadratus lumborum, 21,254, 254
Quadriceps femoris muscle, 356, 360,
360
Quadriceps femoris tendon, 356,
356-357,357,357,357, 358,
359, 362
Quadriceps muscle tendon,360,378,
393
Quadriceps muscles, 290, 301,301,
356, 391
Radial artery, 198,198
Radial collateral ligament, 173, 173,
186
Radial deviation, 204, 204
Radial ligament, 236
Radial nerve innervation
motor testing, 98, 98, 100, 100,
101, 101
palpation, 169
reflex testing, 99, 99, 101, 101
Radial tubercle, 199, 199
Radiograph scanogram, 434
Radius, 169, 173,174, 186, 191, 195,
200
Range of motion evaluation
ankle, 409, 409-412, 410, 411, 412
cervical, 47-51,48, 49,50, 51
elbow, 177, 177-179,178, 179
hip joint, 334-339, 335, 336, 337,
338, 339
knee, 36�367-368, 368
lumbar, 258, 258-260, 259, 260
shoulder, 116, 117, 117-121, 118,
119, 120, 121
493
thoracic, 237, 237-240, 238, 239,
240
types of, 5-8
wrist, 201, 201-204, 202, 203, 204
Raynaud's phenomenon, 423
Rectus abdominis muscle, 23
Rectus capitis posterior major muscle, 53
Rectus femoris contracture test, 345,
367
Rectus femoris muscle, 23, 328, 344,
356, 360, 360
Recurrent median nerve, 216
Reflex testing
biceps muscle, 97
brachioradialis tendon, 99
glossopharyngeal and vagus nerves
(IX, X), 460, 460
lower extermity, 469, 469-473,
470, 471, 472, 473
superficial cutaneous, 474,
474-476, 475, 476
triceps muscle, 101, 101
trigeminal nerve (V), 447
upper extremity, 465, 465-468,
466, 467, 468
Resisted range of motion, 7, 8
Resistive isometric muscle testing,
52, 52-55, 53, 54, 55
Retinacular ligaments, 223, 223
Retreating meniscus test, 373, 373
Retrocalcaneal bursa,404,407,
407-408, 408
Retropatellar arthritis, 391
Reverse Lachman's test, 386, 386
Reverse Phalen's test, 207, 207
Rhomboid muscle, 32, 233
Ribs, 230, 231, 232, 236, 236, 239
Rinne's test, 453, 453
Rockwood test, 136,136
Romberg's test, 486,486
Rossolimo's Foot Sign, 472, 472
Rossolimo's Hand Sign, 467, 467
Rotation, 30, 51, 55,55, 87,239,
239
Rotator cuff
anatomy, 110, 110
instability, 148, 148-149, 149
Rotatores breves muscle, 53, 55
Rotatores longi muscle, 53, 54, 55
Rotatores muscle, 234, 253
Round shoulders, 33, 33
Rowe test for anterior instability,
137, 137
Rowe test for multidirectional insta­
bility, 143, 143
Rust's sign, 75, 75
S2 sacral segment, 314
Sacral flexion, range of motion eval­
uation, 7
Sacroiliac joint, 289
494
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Sacroiliac orthopaedic tests
examination flow chart,313
joint lesions,322, 322-324, 323,
324
palpation,314, 314-315, 315
sacroiliac articulations,314, 315,
315, 319
sacroiliac sprain,316, 316-321,
317, 318, 319
Sacroiliac resisted abduction test, 320
Sacroiliac stretch test, 320, 320
Sacrospinous ligament, 316
Sacrotuberous ligament,316, 319
Sacrotuberous ligament stress test,
321, 321
Sacrum,295, 316
Sartorius muscle, 328, 333
Scalene rotator muscles,30
Scalenus muscle, 52, 54, 55, 68, 156
Scapula, 232, 232
Scapula rotation,32, 32, 108, 109,
110, 114, 114
Scapula winging, 32, 32
Scapuli,175
Schaeffer's Sign,473, 473
Schepelmann's sign,247, 247
Sciatic nerve,255, 257, 257, 271, 272,
281, 348
Sciatic radiculopathy, 267, 275, 276
Sciatic tension test,280, 280
SCM. see Sternocleidomastoid mus­
cles
Scoliosis screening,240, 240-242,
241, 242
Scotoma, 439
Scouring test,351, 351
SEEP (somatosensory evoked potential), 13, 104
Segmental instability test, 264,264
Semimembranous muscle,365
Semimembranous tendon,366
Semispinalis cervicis muscle,44, 45,
45, 53, 54, 115
Semispinalis thoracicis muscle, 234,
253
Semitendinosus muscle,365
Semitendinosus tendon,366
Sensitivity/reliability scale,9
Sensory testing
biceps muscle,97
brachioradialis tendon, 99, 99
facial nerve (VII), 451, 451
finger muscles,103, 103, 104
glossopharyngeal and vagus nerves
(IX, X), 459, 459
goals,93
triceps muscle,101, 101
trigeminal nerve (V),448
Serratus anterior, 28, 32
Sharp-Purser test, 77, 77
Shoulder abduction test, 90, 90
Shoulder depression test,89, 89
Shoulder girdle symmetry, 24, 24
Shoulder imbalance,30, 30, 31
Shoulder orthopaedic tests
Biceps tendon,150
biceps tendon instability,150-154,
151, 152, 153, 154
brachial plexus irritation,161,
161-164, 162, 163, 164
bursitis, 129, 129-130, 130, 131
examination flow chart,107
glenohumeral instability
anterior,132, 132-138, 133, 134,
135, 136, 137, 138
posterior, 139, 139-141, 140,
141
labral tears,145, 145-147, 146, 147
multidirectional instability,142,
142-144, 143, 144
palpation,108, 108-115, 109, 110,
111, 112, 113, 114, 115
range of motion evaluation, 116,
117, 117-121, 118, 119, 120,
121
rotator cuff instability,148,
148-149, 149
tendinitis (bicipital), 125,
125-128, 126, 127, 128
tendinitis (supraspinatus),122,
122-124, 123, 124
thoracic outlet syndrome,155,
155-160, 156, 157, 158, 159,
160
Sicard's test,272, 272
Sign of the Buttock test,291, 291,
323, 323
Sitting,27
Skeletal scintigraphy,13, 13, 244,
266, 343, 352
Skin assessment, 4
Skin temperature, 4
Skull,vertebrobasilar circulation assessment, 58
Slocum test, 387, 387
Slump test,268, 268-269, 269
Smell. see Olfactory nerve (I)
Snellen chart, 438, 438
SOAP notes,2
Soleus muscles,38, 38, 404, 407
Soto-Hall test,74, 74, 244, 244
Space-occupying lesions, 80, 80-81,
82, 285, 285, 285-287, 286,
286, 287
SPECT (single proton emission computed tomography), 265
Speed's test, 126, 126
Sphygmomanometer cuff,417
Spinal accessory nerve (Xl), 461, 461
Spinal column, 252
Spinal nerves, 93. see also Cervical
nerve root lesions
Spinal percussion test, 73, 73, 266,
266
Spinalis cervicis muscle, 53
Spinalis longissimus iliocostalis, 234
Spinalis muscles, 253
Spine. see also Cervical orthopaedic
tests; Lumbar orthopaedic
tests; Postural assessment
diagnostic imaging and structural
testing, 12, 12
flexed forward, 74
lateral spinal deviation, 33, 33-34
range of motion evaluation, 7
rotational instability, 56
Spine of scapula,232
Spinous process, 46, 46-47, 47, 235,
235, 236, 252, 252
Splenius capitus muscle,44, 45, 45,
115, 233
Splenius cervicis muscle, 44, 45, 45,
53, 54, 55, 115, 233
Spondylolisthesis, 261, 261, 262
Spondylolysis,261, 26 I
Sports injuries,role of body mechanics,17
Sprains,categories, 70
Spurling's test,86, 86
Steinman's tenderness displacement
test,372, 372
Stenosing tenosynovitis,211
Sternal compression test, 244, 244
Sternoclavicular joint,108, 108, 109
Sternocleidomastoid muscles,28, 30,
41, 41, 52, 54, 55, 461, 461
Sternocostal articulations, 230, 23 I
Sternum, 41, 108, 109, 230, 230
Straight leg raising test,267, 268. see
also Goldthwaith's test
Strains, categories,70
Stretch reflex,465, 465
Stroke test, 395, 395
Structural testing,types of,9-13
Subacromial bursa, 108, 109, 109,
130, 131
Subacromial push-button sign,129,
129-130, 130
Subclavian artery, 41, 43, 68, 68-69,
69, 156
Subclavian vein,41
Subcutaneous soft tissue, 4-5
Subdeltoid bursa,130, 131
Subliminus test,224, 224
Suboccipitals, 28, 29
Subscapular bursa,130
Sulcus sign,144,144
Superficial bursa,404
Superficial cutaneous reflexes,474,
474-476, 475, 476
Superficial fibular nerve innervation,
307, 307
Superficial gluteal reflex,475, 475
Superficial infrapatellar bursa,358,
358, 362
Superior articular process, 235
CHAPTER 19
Superior costal facet, 235
Superior costotransverse ligament,
236
Superior extensor retinaculum, 405
Superior flexor retinaculum,404,407
Superior gemelius muscle, 255
Superior gluteal artery,255
Superior iliac spine, 328
Superior peroneal retinaculum,404,
407
Superior serratus posterior muscle,
234,253
Supported forward bending test, 289,
289
Supraclavicular fossa,41,43,43
Suprapatellar bursa, 358, 358,359,
359,362
Suprapatellar plica, 378
Supraspinatus muscle, 108,109,110,
130. see also Tendinitis
Supraspinatus tendinitis test, 122,
122
Supraspinatus test, 149,149
Supraspinous ligament, 7l
Suubclavian artery,68
Swallowing test,81,81
Swayback posture, 25,26t
Symptom magnification assessment,
426,426-429,427,428,429
Synovial fluid, 395
Synovial joint,236
Synovial plicae, 378
Synovial sheath, 206
Systolic blood pressure, 417
T 1 nerve root, 104, 104
T4 vertebra, 234,253
T 7 vertebra, 235
T 9 spinous process, 235
Tl2 vertebra, 234,253,295, 295,298,
298-299,299
Tangential shoulder radiograph, 138,
14 1, 144
Tarsal tunnel syndrome, 417,
417-419,418
Telescoping sign,342,342
Temporal muscle,446
Tenderness, 4-5,41,372,372. see also
Subcutaneous soft tissue
Tendinitis (bicipital), 125,125-128,
126,127,128
Tendinitis (supraspinatus),122,
122-124,123,124
Tendon instability, hand, 224,
224-227,225,226
Tendonitis, 40 I, 406
Tennis elbow,176,180,180-183, 181,
182,183
Tenosynovitis, 1 1 1, 406
Tensor fasciae latae, 21,23,328,329,
332,332,347,364,364
Teres minor muscle, 110
CEREBELLAR FUNCTION TESTS
Thenar eminance,216,216
T hermography, 424
T homas test, 344,366
Thompson's test, 419,419
Thoracic orthopaedic tests. see also
Hip joint orthopaedic tests
costovertebral joint ankylosis, 248,
248
examination flow chart, 229
nerve root lesions,245,245-249,
246,247
palpation, 230,231,231-236,232,
233,234,235,236
range of motion evaluation, 237,
237-240,238,239,240
scoliosis screening,240,240-242,
241,242
thoracic fractures,243-244,244
T horacic outlet syndrome, 155,
155-160,156,157,158,159,
160
Thoracic scoliosis, 31
Thoracic vertebrae, 232
T horacolumbar erector spinae hypertrophy, 33,34
T hrombophlebitis, 425
Thumb, 218
T humb ulnar collateral ligament lax­
ity test, 221,221
Tibia,356,358,360,361,362,362,
363,363,382,387,400,402,
418
Tibial collateral ligament, 389
Tibial nerve, 402,402
Tibial plateau, 36 1,361,363
Tibial tuberosity, 356,358,360,362
Tibialis anterior muscle, 404,407
Tibialis anterior tendon, 303,303,
405,405-406,406
Tibialis posterior muscle, 404,407
Tibialis posterior tendon,21,400,
400
Tibiocalcaneal ligament, 399,413,
416
Tibionavicular ligament, 413,416
Tinel's foot sign, 418,418
Tinel's sign, 188
Tinel's wrist sign, 205,205
T innel's sign, 164,164,188
Torticollis,41
Tourniquet test, 209,209,417,
417-418,418
Trachea, 41
Traction test,159,159
Transverse carpal ligament, 197
Transverse humeral ligament, 111,
127,151,154
Transverse humeral ligament test,
153,153-154,154
Transverse ligament,71,76,77,78,
78
Transverse process,235,254
495
Trapezius muscles, 28,30,44,44,53,
54,113,lI5, 115,233,461,
461
Trendelenburg test, 350,350
Triceps muscle
anatomy,110
elbow flexion test and, 190
motor testing, 100,100
palpation, 175,175
reflex testing, 101,101
sensory testing, 101,101
Trigger points
cervical palpation, 41
in postural syndromes, 26-27
Trochanteric bursitis, 324,324
Trochlear groove,391
Trochlear nerve (IV), 443,443-445,
444,445
Tromner's Sign,466,466
Ulna,169,173,174,186,191,195,
200
Ulnar artery, 195,197,198,198
Ulnar collateral ligament, 171,171,
173,186
Ulnar deviation, 203,203
Ulnar nerve,100,100,102,102,102,
103,103,103, 169,169,188,
190,195,197
Ulnar styloid process, 199,199
Ulnar tunnel. see Guyon's canal
Ulnar tunnel syndrome, 210,210
Ulnar tunnel triad, 210,2]0
Ultrasonography
hip, 342
shoulder, 124,128
Umbilicus, 24
Underburg's test, 64,65
Upper abdominal reflex, 474, 474
Upper crossed syndrome, 26,28t
Upper extremity cerebellar function,
478,478-482,479,480,48],
482
Upper extremity reflexes, 465,
465-568,466,467,468
Vagus nerve (X), 458,458-460, 459,
460
Valgus stress test, 220,220
Valsalva's maneuver, 80,80,285,285
Varus stress test, 220,220
Vascular accidents,56
Vascular ultrasound, 69
Vastus intermedius muscle,360,360
Vastus lateralis muscle, 330,356,360,
360
Vastus medialis muscle, 360,360
Veering test, vestibular nerve, 454,
454
Ventral sacroiliac ligament, 3]6
Vertebra body, 236
Vertebral artery, 56,57,58,59
496
PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS
Vertebral artery test, 62, 62
Vertebral column, 230
Vertebrobasilar artery functional maneuver, 60, 60, 61
Vertebrobasilar circulation assess­
ment, 56-57, 57, 58, 59, 60,
61, 62, 63, 64,65, 66, 67
Vestibular nerve
Past Pointing test, 455, 455
Veering test, 454, 454
Visual acuity, 438, 438
Visual field, 440
Volar plate, 220
Wartenberg's sign, 189, 189
Watson's test, 213, 213
Weber's test, cochlear nerve, 452, 452
Wexler scale,93, 95, 296
Wright's test, 158, 158
Wrist extensor group, motor testing,
98
Wrist flexor group, motor testing,
100, 100
Wrist orthopaedic tests
carpal instability, 210, 210-211,
211
carpal tunnel syndrome, 205,
205-209, 206, 207, 208, 209
Chaddock's Wrist Sign, 468, 468
examination flow chart, 194
palpation, 195, 195-200, 196, 197,
198, 199,200
range of motion evaluation, 201,
201-204 202, 203,204
stenosing tenosynovitis, 211
ulnar tunnel syndrome, 210, 210
,
X-rays, 9. see also CT; MRI; Myelog­
raphy; Skeletal scintigraphy
Xiphoid process, 24, 230
Yeoman's test, 319, 319
Yergason's test, 150, 150-151, 151
Zygomatic arch, 22