Musculoskeletal Advanced Physical Exam Course
Upper Extremity Session
Upper Limb – General Exam:
 Inspection:
o Symmetry, bony landmarks
o Joint deformities, subluxation
o Muscle bulk
 Palpation
 Range of Motion
 Manual Muscle Testing
Shoulder:
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Range of Motion: flex/ext, abd/add, int/ext rot
Provocative Tests
o Speed’s Test: To test for bicipital tendinitis. The patient flexes the shoulder against resistance with the elbow
extended. Pain in the bicipital groove indicates bicipital tendinitis.
o Drop Arm Test: To test for supraspinatus tear. The patient’s arm is abducted to 90 degrees and is instructed to
slowly and smoothly lower his arm. Inability to perform this indicates possible supraspinatus tear.
o Impingement Sign: To test for impingement of the supraspinatus, infraspinatus and bicipital tendon. The
patient internally rotates and passively flexes the shoulder. This will impinge the rotator cuff against the
anterior acromion resulting in pain.
o Hawkin’s maneuver. To test for rotator cuff pathology (typically supraspinatus tendonopathy). The patient’s
arm is abducted to 90 degrees in the plane of the scapula, and then passively internally rotated. A positive test
is reproduction of shoulder pain.
o Apprehension Test: To test for glenohumeral dislocation. For anterior dislocation, the arm is abducted and
externally rotated. For posterior dislocation, the arm is internally rotates and horizontally adduct the arm. A
positive test produces pain or a sensation of impending subluxation.
o O’Brien’s Test: To test for shoulder labrum pathology. The patient’s arm is flexed forward to 90 degrees with
the thumb pointing downward, and asked to resist the examiner pushing the patient’s arm toward the floor. The
examination is then repeated with the patient’s thumb pointing upward. A positive O’Brien’s test for labral
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pathology is if the patient complains of deep shoulder pain when resisting with their thumbing pointing
downward, but which is relieved with the thumb pointing upward.
Injections
o Acromioclavicular joint
o Subacromial posterior-lateral approach
Clinical Correlation
o AC Joint Separation
o Supraspinatus tendonopathy
o Rotator Cuff Tear
o Labral tear
o Adhesive Capsulitis
Elbow:
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Wrist/Hand:
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Range of motion: flex/ext, supination/pronation
Provocative Tests:
o Lateral epicondylitis: Pain with palpation of the lateral epicondyle, pain with resisted wrist extension (Cozen’s
maneuver), and pain with resisted middle finger extension are all provocative tests for lateral epicondylitis.
o Ulnar nerve testing: Tinel’s maneuver at the cubital tunnel, feeling for ulnar nerve displacement (typically at 70
degrees of flexion)
Injections
o Lateral epicondyle
o Medial epicondyle
o Olecranon bursa aspiration
Clinical Correlations
o Medial/Lateral Epicondylitis
o Ulnar collateral ligament tear
o Cubital tunnel syndrome
Provocative Tests:
o Finkelstein’s Test: To test for DeQuervain’s tenosynovitis. The patient tucks his thumb inside the other fingers
and then ulnarly deviates the wrist. Pain in the tendons of the APL and EPB are indicative of DeQuervain’s
tenosynovitis.
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o Swan Neck Deformity: typically seen with RA, hyperextension of the PIP joints and flexion of the DIP joints
o Boutonniere Deformity: Also associated with RA, flexion of the PIP and extension of the DIP. Caused by
central slip of the extensor digitorum communis tendon is avulsed from its insertion into the base of the middle
phalanx.
o Scaphoid palpation: within the anatomical snuff box
o Carpal tunnel syndrome: all tests just distal to distal wrist crease, between thenar and hypothenar eminences.
Carpal compression test (compression with thumb until thumbnail blanches), Phalen’s maneuver (wrist bent
into flexion), Tinel’s maneuver (repetitive tapping at carpal tunnel), weakness of abductor pollicis brevis
o Ulnar neuropathy at Guyon’s canal: compression to the radial aspect of pisiform bone, weakness of abductor
digiti minimi
Clinical Correlations:
o Bouchard’s nodes: Associated with RA. Abnormal fusiform enlargements of the PIP joints.
o Heberden’s Nodes: Associated with osteoarthritis, palpable bony nodules of the DIP joints
o FOOSH (Fall on the outstretched hand- can cause scaphoid fracture, scapho-lunate dissociation, distal radius
fracture)
o Carpal tunnel syndrome
o Ulnar neuropathy at Guyon’s canal
Musculoskeletal Advanced Physical Exam Course
Lower Extremity Session
Lower Extremity – General Exam:
 Inspection
 Palpation
 Range of Motion
 Manual Muscle Testing
Hip:
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Provocative Tests:
o Patrick or FABER test: To evaluate pathology of the hip, sacroiliac joint, or tensor fascia lata. The patient lies
supine and flexes, abducts, and externally rotates the hip by placing the foot on the contralateral knee. The
examiner pushes down on the ipsilateral knee and contralateral hip.
o Ober test: To evaluate tightness of the tensor fascia lata and iliotibial band. The patient lies on side with
involved leg up. This hip is neutral and the knee is flexed to 90 degrees. With tightness of the TFL/IT band,
the thigh remains abducted.
o Hip Scour: Hip and knee both bent to 90 degrees. Axial load applied to femur down into table while internally
rotating the thigh.
o Hip traction: Patient lies supine on table with sufficient fraction. Pull on leg to see if that relieves groin
symptoms.
o Hop test: if patient has pelvic pain while hopping, this is concerning for possible stress fracture
o Snapping hip: feel for popping of tendons of either psoas major or iliobial band
Injections
o Greater Trochanter
Clinical Correlations
o Greater Trochanter Bursitis
o Hip Fractures
o Hip osteoarthritis
o Snapping hip
Knee:
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Provocative Tests
o Anterior/Posterior Drawer Sign (knee): The anterior drawer sign assess the integrity of the ACL. The patient
lies supine with knees flexed to 90 degrees and the feet flat on the table. The examiner draws the tibia toward
himself for anterior drawer and pushes the tibia away for posterior drawer. If the tibia moves forward or
backward significantly on the femur, the ACL or PCL may be damaged respectively.
o Lachman test: To detect an anterior cruciate ligament tear. The knee if flexed to 30 degrees and an anterior
force is exerted on the proximal tibia. Anterior translation of the tibia indicates ACL tear.
o McMurray test: To evaluate possible tear of the medial meniscus. Holding the heel, place knee into maximum
flexion and then rotate the leg internally (to test posterior horn of lateral meniscus) and externally (to test
posterior horn of medial meniscus), applying valgus and varus stress to the knee. Fingers are placed along the
medial and lateral tibial platea’s. Test is positive when there is a palpable click
o Collateral Ligament Testing
o Singe leg squat: Look for internal rotation of thigh and “corkscrewing” of trunk in opposite direction of thigh.
Common precursor to patellofemoral syndrome. Pain in knee with squatting suggestive of knee pathology
(commonly knee osteoarthritis)
o Clarke’s test: for patello-femoral syndrome. With patient prone, place the web between your thumb and index
finger over the superior margin of patella. Ask patient to gently contract quadriceps. Reproduction of anterior
knee pain suggests pain from patello-femoral articulation.
Injections
o Knee Joint
o Pes anserine bursa
Clinical Correlations
o Meniscal Injuries
o ACL/PCL Injuries
o Patellofemoral syndrome
o Knee osteoarthritis
o Pes anserine bursopathy
Ankle and Foot:
 Provocative Tests:
o Thompson’s Test: With the patient kneeling on a chair, the calf is squeezed to passively plantarflex the foot. A
lack of passive plantarflexion indicates Achilles’ tendon pathology
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o Squeeze test (ankle): for high ankle sprain. Squeeze the upper third of calf to approximate the tibia and fibula,
which will separate the distal tibia and fibula with high ankle sprain (involving interosseus membrane and the
anterior tibio-fibular ligament)
o Squeeze test (foot): for Morton’s neuroma. Apply pressure between 3rd and 4th metarsal heads (or 2nd and 3rd),
and then squeeze the foot. Will reproduce pain.
o Anterior drawer test: for ankle sprain involving the anterior talo-fibular ligament. Place ankle into slight
plantar-flexion, and then pull heel forward. Laxity or lack of firm endpoint suggests sprain of ATFL or ATFL
tear
o Talar tilt test: for ankle sprain involving calcaneo-fibular ligament. Reproduction of pain, laxity, or absence of
firm endpoint when inverting the heel.
Injections
o Tibiotalar
o Morton’s neuroma
o Plantar fascia
Clinical Correlations
o Ankle sprain
o High ankle sprain
o Achilles Tendonitis/Rupture
o Plantar Fasciitis
o Morton’s neuroma
o Tibialis posterior tendonopathy
Musculoskeletal Advanced Physical Exam Course
Spine Session
Spine – General Examination:
 Inspection
 Palpation
 Range of Motion
 Manual Muscle Testing
Spine
 Provocative Tests
o Stork test: Passively extend the patient’s spine while they either stand on one leg or with the contralateral leg forward.
Reproduction of axial pain suggests posterior element pathology (most commonly facet joint or sacro-iliac joint)
o Slump sit test: To test for lumbar radiculopathy. Patient leans forward at waist with hands behind their back, and then
extends thigh and dorsiflexes ankle. Patient’s with radicular pain will typically have reproduction of their symptoms
that is partially relieved when extending neck.
o Spurling’s maneuver. To test for cervical radiculopathy. Ask patient to extend their neck, then cue patient to rotate
their head to one side while their neck is extended. Place hand on patient’s forehead to hold their neck in this obliquely
extended position, and hold for 30 seconds. Positive test is pain radiating down the ipsilateral arm or to the ipsilateral
shoulder blade.
o Manual cervical traction. To test for cervical pathology that will respond to traction during therapy. Have patient lie
supine on table. Place your finger on patient’s mastoid processes on either side, place neck into 20 degrees of flexion,
and gently apply traction. Improvement in symptoms suggests patient will respond well to cervical traction during
physical therapy.
o Posterior pelvic pain provocation (P4) test. To test for pelvic floor dysfunction or sacro-iliac joint pain. Patient lies
supine, with their hip and knee in 90 degrees of flexion. Axial load applied through femur toward the table by
examiner. Posterior buttock pain suggests pelvic floor dysfunction or sacro-iliac joint arthropathy.
o Centralization. For lumbar radicular pain. Patient with radicular pain will typically note more pain radiating down
their leg when flexing at the waist, and decreased radiating pain when exending their spine.
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Injections
o Trigger Point
o Epidural
o Facet Joint
o Sacro-iliac joint
Clinical Correlations
o Lumbar radiculopathy
o Cervical radiculopathy
o Discogenic versus Radicular Pain
o Facet (zygapophysial) joint pain
o Ankylosing spondylitis
o Sacro-iliac joint arthropathy