General Table of Contents
Detailed Table of Contents ii
List of “Classic” Special Orthopaedic Tests ix
,QWURGXFWLRQ+RZWR8VHWKLV%RRN p1
IntroductDU\/HFWXUHV i1
Chapter I: Ankle & Foot 1
Chapter II: Knee 33
Chapter III: Hip & Innominate 79
Chapter IV: Comprehensive
Examination of the Spine 137
Chapter V: Sacroiliac Joint & Pelvis
149
Chapter VI: Lumbar Spine 203
Chapter VII: Thoracic Spine & Ribs 267
Chapter VIII: Cervical Spine 309
Chapter IX: Thoracic Outlet 387
Chapter X: Shoulder
p 403
Chapter XI: Elbow 447
Chapter XII: Wrist & Hand 477
References 519/ (r1)
i
Comprehensive Assessment for Massage Therapists
© 1997-2011 David Zulak MA, RMT
Detailed Table of Contents
Thompson’s Test 22
Morton’s Neuroma 22
Tinel’s Sign 23
Pulse Testing 23
Homans’ Sign 24
Introduction
How to use this book p1
How this book is comprehensive p3
When Learning too much is not enough p4
Metatarsal-Phalangeal & Phalangeal Joints 25
AF-ROM
25
PR-ROM
26
AR-ROM
28
Ankle & Foot Conditions/Pathologies 29
Introductory Lectures
The Spirit of Assessment i1
The Procedure for Assessment i7
Pain i13
Observations i24
Overview of Assessment Protocol i25
Chapter II KNEE 33
Intake: Forms, Interviewing & Case History
Taking i28
Clinical Implications Of Anatomy & Physiology 35
Case History (Specific Questions) 40
Observations 41
Rule Outs 45
Fractures 47
Wipe Test for minor effusion 47
Fluctuation Test for moderate effusion 49
Patellar Tap Test for major effusion 50
Active Free Range Of Motion (AF-ROM) 51
Quadriceps Inhibition Test 53
Passive Relaxed Range Of Motion (PR-ROM) 55
Active Resisted Range Of Motion (AR-ROM) 59
Special Tests 60
Differential Muscle Testing 60
Modified Helfet Test 63
Valgus Stress Test 64
Varus Stress Test 65
Apley Distraction Test 65
Anterior Draw Test 66
Posterior Draw Test 68
Lachman’s Test 68
Apley Compression Test 70
McMurray’s Meniscus Test 71
Patellar Apprehension Test 75
Patellofemoral Compression Testing 75
Clark’s Test 76
Noble’s Compression Test 77
Bounce Home Test 77
• Case History Form i29
Pain and Impairment i33
• Active Listening i39
Rule Outs i42
Range of Motion Testing i42
Differential Tissue Testing i45
Assessment & Treatment Planning i46
Postural Assessment i48
• Muscle Balance and Posture i48
• Common Postures i52
• Postural Examination i54
• Palpating Landmarks i60
• Rotations i69
Gait Analysis(Classic) i75
Gait Analysis: Alternative View i80
Charting & Recording i86
Spinal Motion: Structure & Function i99
Chapter I ANKLE & FOOT Page 1
Clinical Implications of Anatomy & Physiology 3
Case History (Specific Questions) 5
Observations 5
Rule Outs 7
Active Free Range Of Motion (AF-ROM) 9
Passive Relaxed Range Of Motion (PR-ROM) 11
Active Resisted Range of Motion (AR-ROM) 13
Special Tests 16
Differential Muscle Testing 16
Talar-Tilts 19
Anterior Draw Test 20
Wedge Test 21
Chapter III: HIP & INNOMINATE 79
Clinical Implications of Anatomy & Physiology 80
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Comprehensive Assessment for Massage Therapists
© 1997-2011 David Zulak MA, RMT
Case History (Specific Questions) 89
Observations 90
Rule Outs 98
Active Free Range Of Motion (AF-ROM) 103
Passive Relaxed Range Of Motion (PR-ROM) 108
Testing Joint Play 112
Active Resisted Range Of Motion (AR-ROM) 114
Special Tests 118
Differential Muscle Testing 118
Thomas Test 123
Ober’s Test 126
Piriformis Test 128
Trendelenburg’s Test 130
Scouring Test 131
FABER Test 132
Ely’s Test 133
Leg Length Discrepancy Test 133
Stork Test 135
What Stabilizes the S.I. Joints? 158
Testing Within the General
Examination of the Spine
162
Part II: Innominate Motions & Impairments 164
Movements of the Lumbopelvic Girdle 164
Unilateral and Bilateral Pelvic Tilts 167
Physiological Motions of the Innominates
during Gait 168
Symptoms of Innominate Impairments 168
Part III: Testing For Innominate Impairments 169
Observation & Inspection 170
Testing for Leg Length Discrepancy 172
Assessing for Inflares & Outflares 173
Placing Innominate Orientation in Context
Of the Trunk & Head 174
Stork Test 175
Standing Flexion Test 176
Standing Extension Test 177
Palpation & Inspection of Sacral Motion 178
Four-Point Test 178
Spring Test 179
Gapping Test 179
Pelvic Challenge for Pubic Symphysis
Impairments 180
Interpreting Results of Motion Testing
& Palpatory Findings 181
Chapter IV Comprehensive
Examination of Spine 137
Comprehensive Structural Examination
of the Spine & Pelvis 139
1. Standing Postural Views 140
2. Checking Symmetry Of Landmarks 141
3. Checking Symmetry During AF-ROM 142
4. Assessing Postural Stability 144
5. Checking Postural Symmetries & AF-ROM Sitting 145
6. Checking Postural Symmetries While Supine 145
7. Checking Rotation In The Body 147
8. Checking Landmarks Prone 148
Part IV: Introduction to Sacral Dysfunctions 182
Gait: The Innominates & Sacroiliac Joints182
Physiological Motions Where the Sacrum Can
Become Fixed 183
Non-Physiological Motions Where the Sacrum
Can Become Fixed 184
Other Non-Physiological Impairments Of The S.I.
Joints 185
Chapter V: Sacroiliac Joint & Pelvis 149
Note to Reader 151
Chapter Organization 152
Part I: Clinical Implications of Anatomy & Physiology 153
Anatomical Structures & Landmarks 153
S.I. Joints and Impairments 154
Terminology & Types of Movements 155
Some Points to Consider 156
Definitions of Sacroiliac Movements 157
Part V: Testing for Sacral Dysfunctions 186
Observations 186
Seated Flexion Test 186
Prone Palpation of Sacrum 187
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Comprehensive Assessment for Massage Therapists
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Prone Extension (“Sphinx”) Test 187
Chart of Findings for Extension Test 188
Summary of Findings for Sacral Torsions 188
Presentation of Pain Experienced By Client with
Torsion Lesions 189
Sacral Shears, Summary of Findings 189
Bilaterally Nutated Or Counter-Nutated Sacrum,
with Summary of Findings 190
They Affect the Lower Back 218
Lumbar Curves & L3: The Source of Most Impairments
& Dysfunction within The Lumbar Spine 220
Rule Outs 222
Exceptions for Range of Motion (ROM) Testing
& Use of Motion Palpation Testing 223
Active Free Range of Motion (AF-ROM)
224
Measuring Amount of Lumbar flexion 225
Pain on Flexion 226
AF Flexion with Over-Pressure 227
Extension 228
Pain on Extension 228
Sidebending 229
Pain on Sidebending 229
AF Sidebending with Over Pressure 230
Hip-Drop Test 231
Lumbar Rotation 232
Over Pressure to lumbar Rotation 233
Motion Testing for Facet Joint
Dysfunctions in the Lumbar Spine 234
Palpation in Neutral 235
Basic Rules & Findings of Motion
Testing in the Spine 236
Palpating in Flexion & Extension 236
Findings, Explanations & Examples 238
Palpatory Findings Chart 239
Alternative Motion Palpation
Testing in Prone 240
A Common Clinical Finding:
The Disappearing Scoliosis 241
Lumbar Curves & Segmental
Dysfunctions 242
Part IV: Orthopaedic Assessment
of the Sacroiliac Joints 192
Rule Outs 192
Differential Muscle Testing 193
Special Tests 197
Compression Test of S.I. Joints 197
Posterior Displacement Test 198
Anterior Displacement Test 198
FABER Test 199
Ganslen’s Test (Caution) 199
Appendix 200
Gait & Sacral Motion 200
Walking/Running 200
Rules of Movement for the Sacrum & L5 202
Chapter VI: Lumbar Spine 203
Clinical Implications of Anatomy & Physiology 205
Fryette’s Rules of Spinal Motion 206
Lumbar Intervertebral Disc (IVD) 208
Note on Causes of Low Back Pain 208
The IVD & Low Back Pain 208
Levels of Degenerative Disc Disease 209
Suspected Sources of Intermittent
& Chronic Low Back Pain 210
Are X-rays, CT Or MRIs Really Better
Than Hands-On Testing? 211
Facet Joint Dysfunction & Pain 212
Group & Segmental Impairments 213
Comprehensive Examination 215
Case History (Specific Questions) 216
Observations 216
Common Postures & How
Passive Relaxed Range Of Motion
Introductory Note 242
Passive Range of Motion 243
Insight – Assessing Lumbopelvic
Motion in Supine 245
Joint Mobilization 246
Resisted Isometric Testing & Strength Testing 249
Special Tests 251
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Note on Differential Muscle Testing 251
Testing of the Lumbar Spine –
Note on Orthopaedic Testing 251
Group 1 – General Neurological Testing 252
Straight Leg Raise Test
for Neurological Signs 252
Well Leg Raise 254
Slump Test 254
Bowstring Sign 255
Valsalva’s Test 256
Hoover’s Test 256
Group 2 – Specific Neurological Tests 257
Myotome Testing 257
Dermatome Testing 260
Deep Tendon Reflexes 263
Motion Testing of the Lower T- Spine 286
Motion Testing of Sidebending 287
Joint Mobilization Testing 289
Active Resisted Range of Motion 292
Palpation of Ligaments of the Thoracic Spine 295
Thoracic Spine Neurological Symptoms 296
Introduction to the Ribs
Musculature & Joints 297
Palpation of First Rib 299
Palpation of Second Rib 300
The Sternomanubrial Joint & Its Palpation 301
The Sternoclavicular Joint & Its Palpation 302
General Motion of the Ribs & a Quick
Scanning of Rib Motions 303
Possible Findings during Testing 304
Palpation of Rib Motion 305
Excluded Classic Tests 265
Femoral Nerve Stretch (Nachlas Test)
Quadrant Test (Kemps’ test)
Milgram’s Test
Chapter VIII: Cervical Spine 309
Clinical Implications of Anatomy & Physiology 311
Sub-occipital Recti Muscles
& Eye Movements 311
Definitions & Rules of Motion
for the Cervical Spine 312
Clinical Considerations & More
on the OA & AA Joints
More on Anatomy of the Upper Quadrant 314
The Lower Quadrant 315
Presentation of Pain & Segmental
or Group Dysfunctions 316
Insight – Migraines can be a Pain
in the Neck 318
Comprehensive Examination 319
Case History (Specific Questions) 321
Observations 321
Upper Cross Syndrome 323
Light Inspection Palpation 324
Rule Outs 82
324
Shoulder 324
Temporal Mandibular Joint 325
Chapter VII: Thoracic Spine & Ribs 267
Clinical Implications of Anatomy & Physiology 269
Fryette’s Rules of Spinal Motion 269
Motion impairments 270
Thoracic Intervertebral Disc 270
“Rules of Three” for Land-marking T-Spine 271
Comprehensive Examination 272
Observations 274
Note on Testing Range of Motion 276
Insight - Isolating Thoracic Spine
from Rest of Spine: What To Do? 276
Active Free Range Of Motion (AF-ROM) 277
Notes on Scoliosis 278
Passive Relaxed Range of Motion 280
Testing End-of-Range Motion of Ribs 281
Motion Palpation of the Upper T-Spine 282
Basic Rules & Findings of Motion
Testing in the Spine 282
Review of Findings & What
They Mean 284
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Comprehensive Assessment for Massage Therapists
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Vertebral Artery Tests 326
Active Free Range of Motion (AF-ROM) p.328
Insight - Contribution to Flexion by the Upper
Cervical & Lower Cervical Spine 328
Insight – Observing OA Joint Impairment 329
Motion Palpation Testing of the Cervical Spine 331
Motion Palpation Testing of
the Occipito-Atlantal (OA) Joints 332
First Method 333
Second Method 334
Third Method 335
Diagonal Glides 336
Insight - Impact of Extended, Rotated, & Sidebent
on Arteries, Veins & Nerves 363
Valsalva’s Test 364
Swallowing Test 364
Tinel’s Sign At The Neck 365
Bakody’s Sign 365
Introduction to Specific Neurological Testing 366
Dermatome Testing 368
Sensory Testing Of the Face 369
Peripheral Nerve Testing 370
Myotome Testing 371
Motor Testing of Peripheral Nerves 373
Upper Limb Tension Testing (ULTT) 376
(See Thoracic Spine chapter, TOS Testing)
Deep Tendon Reflex (DTR) Testing 376
Pathological Nerve Impairment Testing 378
Spastic Paralysis Versus
Flaccid Paralysis 378
Motion Palpation Testing of
the Atlanto-Axial (AA) Joints 337
Calculating ROM Loss in the AA Joint,
v.s. from Lower Cervical Joints 339
Insight – Rotated C1 Impairment 339
Alternate Hand Positioning
for Testing of AA Joint 340
Motion Palpation of Lower Cervical Spine 341
Joint Mobilizations 341
What Type of Lesions are We Finding
with Lateral Translations 344
Insight – Further Comments
On Translation Movements 344
Discovering Which Side is Impaired 345
Insight – Don’t Make Assumptions 346
Insight – What We may have Seen
in AF-ROM 349
Summary of Testing the Cervical Spine
by Translations 350
Other Impairments and Red Flags 351
Passive Relaxed Range of Motion 352
Active Resisted Range of Motion .356
Insight – Shortfalls of Some Orthopaedic Testing
of the Cervical Spine 357
Special Tests 358
Compression Test 358
Decompression Test 359
Quadrant Testing 360
Lower Quadrant Test 361
Spurling’s Test 362
Temporal Mandibular Joint Testing: Introduction 379
Insight - Chewing: More Than Just Opening
& Closing the Jaw 380
Active-Free Range of Motion Testing
381
Passive Relaxed Range of Motion
& Joint Mobilization for TMJ 384
Chapter Nine: Thoracic Outlet
387
Clinical Implications of Anatomy & Physiology 389
Observations Prior To Specific TOS Testing 392
Rule Outs 393
Thoracic Outlet Tests 394
Adson’s Test & Variations 394
Insight - Travell’s Variation,
and the Halstead Manoeuvre 395
Costoclavicular Syndrome Test 395
Pectoralis Minor Syndrome Test 396
Cervical Rib 397
Introduction to Upper Limb Tension
Tests (ULTT) 397
Cautions & Considerations 398
General ULTT 399
Median Nerve Bias ULTT 400
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Radial Nerve Bias ULTT 401
Ulnar Nerve Bias ULTT 402
Active Free Range Of Motion 453
Passive Relaxed Range Of Motion 454
Joint Play Inspection for the Elbow 456
Active Resisted Range Of Motion 458
Special Tests 460
Differential Muscle Testing 460
Ligamentous Stability Tests 466
Valgus Stress Tests 466
Varus Stress Tests 467
Tests For Epicondylitis 468
Tendonitis vs. Tendonosis 468
Lateral Epicondylitis/Tennis Elbow 469
Medial Epicondylitis/Golfer’s
or Pitcher’s Elbow 470
Tests for Nerve Compression Syndromes 471
Ulnar Nerve Tinel’s Sign at Elbow 471
Ulnar Nerve Stretch Test at Elbow 471
Pronator Teres Syndrome Test
or Anterior Interosseous Syndrome 472
Compression of the Median Nerve at
the Ligament of Struthers Test 472
Supinator Radial Nerve Syndrome Test 473
Tinel’s Sign for Radial Nerve At Elbow 473
Source Of Neurological Symptoms Not Found? 474
Pathologies and Conditions of the Elbow 475
Chapter X: Shoulder 403
Clinical Implications Of Anatomy & Physiology 405
Case History (Specific Questions) 407
Observations 408
Rule Outs 411
Insight – Why we need to Test both Sides Bilaterally 412
Active Free Range Of Motion 413
Scapulothoracic Articulation 416
Apley’s Scratch Test 417
Passive Relaxed Range of Motion 418
Assessing the Acromioclavicular
& Sternoclavicular Joints 420
Joint Play Inspection of the Glenohumeral Joint 421
Sternoclavicular Joint 423
Acromioclavicular Joint 424
Scapula 425
Three Interrelated Motion Tests for
the Scapula & Glenohumeral Joint 426
Active Resisted Range of Motion 429
Special Tests 432
Differential Muscle Testing 432
Yergason’s Test 438
Speed’s Test 439
Supraspinatus Tendonitis Tests 440
Empty Can Test 440
Hawkens-Kennedy/Impingement Test 441
Apprehension Sign/Crank Test 441
Winging Scapula Test 442
Acromioclavicular Shear Tests 442
Shoulder Muscle Length Testing 443
Shoulder Pathologies 445
Chapter XI: ELBOW
Chapter XII: Wrist & Hand 477
Wrist & Hand Chapter Overview 478
Clinical Implications of Anatomy & Physiology 479
Case History (Specific Questions) 480
Observations 481
Observing, Inspecting and Palpating 482
Rule Outs 485
Neurological Issues 486
Active Free Range of Motion 487
Capsular Patterns of Restriction
& Position of Rest 487
Passive Relaxed Range Of Motion 488
Joint Play Inspection of the Wrist 489
Active Resisted Range Of Motion 490
447
Elbow Chapter Overview 448
Clinical Implications Of Anatomy & Physiology 449
Case History (Specific Questions) 451
Observations 451
Rule Outs 452
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Special Tests 493
Differential Muscle Testing the Wrist 493
De Quervain’s Syndrome (Finkelstein’s Test) 497
Flexors Digitorum Tendinopathy
(Mouse Hand) 497
Intersection Syndrome 498
Conditions of the Phalanges (The Fingers) 498
Fracture Of The Scaphoid 498
Extensor Expansion Test (Bunnel-Littler Test) 499
Ligamentous Tests of MCP, PIP & DIP Joints 499
Skier’s Thumb 499
Trigger Finger 500
Nerve Compression Syndromes at the Wrist 500
Tests for Median Nerve Impingement Tinel’s Sign & Phalen’s Tests 501
Motor Testing for the Median Nerve Pinch Test 502
Tests for Ulnar Nerve Impingement Ulnar Nerve Tinel’s Sign 502
Frommet’s Sign/Test 503
Vascular Compression Tests at the Wrist
Allen’s Test at the Wrist
for Ulnar and Radial Arteries 504
Appendix A:
General Testing of the Hand & Fingers 505
Appendix B:
Testing Of Fingers & Thumb 510
Active Free Range of Motion 510
Passive Relaxed Range Of Motion 513
General Joint Mobilization
Testing 512
Active Resisted Range Of Motion
of the Thumbs and Fingers 514
References r1 (519)
viii
Comprehensive Assessment for Massage Therapists
© 1997-2011 David Zulak MA, RMT
“Classic” Orthopaedic Tests
Milgram’s Test Excluded * 265
Modified Helfet Test 63
Morton’s Neuroma 22
Nachlas Test Excluded * 265
Noble’s Compression Test 77
Ober’s Test 126
Patellar Apprehension Test 75
Patellofemoral Compression Testing 75
Pectoralis Minor Syndrome Test 396
Phalen’s Tests 501
Piriformis Test 128
Pitcher’s Elbow 470
Posterior Displacement Test of the Hip 198
Posterior Draw Test for the Knee 68
Quadrant Testing 360
Scouring Test 131
Shoulder Impingement Test 441
Skier’s Thumb 499
Slump Test 254
Speed’s Test 439
Spurling’s Test 362
Stork Test 135
Straight Leg Raise Test
Supraspinatus Tendonitis Tests
440
Swallowing Test 364
Talar-Tilts (Ankle Ligament Tests) 19
Thomas Test 123
Thompson’s Test 22
Tinel’s Sign at the Ankle 23
Tinel’s Sign at the Elbow 471
Tinel’s Sign at the Neck 365
Tinel’s Sign at the Wrist 501
Trendelenburg’s Test 130
Trigger Finger 500
Valgus Stress Test Elbow 466
Valgus Stress Test Knee 64
Valsalva’s Test: lumbar 256; cervical 364
Varus Stress Test Elbow 467
Varus Stress Test Knee 65
Wedge Test 21
Well Leg Raise 254
Winging Scapula Test 442
Yergason’s Test 438
Acromioclavicular Shear Tests 442
Adson’s Test 394
Adson’s Test Variation Halstead Manoeuvre 395
Adson’s Test Variation Travell’s Variation 395
Allen’s Test at the Wrist 504
Ankle Ligament Tests – see Talar Tilts 19
Anterior Displacement Test of the Hip 198
Anterior Draw Test for the Ankle 20
Anterior Draw Test for the Knee 66
Apley Compression Test 70
Apley Distraction Test 65
Apley’s Scratch Test 417
Apprehension Sign/Crank Test 441
Bakody’s Sign 365
Bounce Home Test 77
Bowstring Sign 255
Bunnel-Littler Test 499
Cervical Rib 397
Clark’s Patellar Test Excluded* 76
Compression Test for the Cervical Spine 358
Compression Test of S.I. Joints
197
Costoclavicular Syndrome Test 395
De Quervain’s Syndrome (Finkelstein’s Test) 497
Decompression Test for the Cervical Spine 359
Ely’s Test 133
Empty Can Test 440
Excluded Classic Tests - Lumbar 265
Extensor Expansion Test (Bunnel-Littler Test) 499
FABER Test 132, 199
Femoral Nerve Stretch/Nachlas Test Excluded * 265
Finkelstein’s Test 497
Fracture of the Scaphoid 498
Ganslen’s Test (Caution) 199
Golfer’s Elbow 470
Hawkens-Kennedy/Impingement Test 441
Hoover’s Test 256
Intersection Syndrome
498
Kemps’ test for the Lumbar Spine Excluded * 265
Lachman’s Test 68
Lateral Epicondylitis/Tennis Elbow 469
Leg Length Discrepancy Test 133
Lower Quadrant Test Cervical Spine 361
McMurray’s Meniscus Test 71
Medial Epicondylitis/Golfer’s/ Pitcher’s Elbow 470
*Excluded tests are still described, but are not recommended for use
with clients. However, they are still taught to students as their clients
may have had them done with other health care practitioners.
Reasons for exclusion are given for each in the text.
ix
© 1997-2011 David Zulak MA, RMT