Musculoskeletal Examinations
Done By: Mazyad Alotaibi
 Cervical spine
1. Distraction test
2. Compression test
3. Valsalva test
4. Adson test
 Shoulder
1. Yergason test
2. Drop arm test
3. Apprehension test (for shoulder dislocation)
 Lumbar spine
1. Straight leg raising test
2. Hoover test
3. Kernig test
4. Milgram test
 Hip and pelvis
1. Trendelenburg test
2. Tests for leg length discrepancy
3. Ober test (for contraction of iliotibial band)
4. Thomas test (for flexion contracture)
 Knee
1. McMurry test
2. Apley’s compression and distraction tests
3. Apprehension test
4. Joint effusion tests ( for minor and major effusion)
5. Joint stability tests (for collateral ligaments and cruciate
ligaments)
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» Distraction test (cervical)
 It demonstrates the effect that neck traction might
have in relieving pain.
 It relieves pain of nerve root compression which is
the result of the narrowing neural foramen by
widening the foramen.
 It also relieves pain in the cervical spine by
decreasing pressure on the joint capsules around the
facet joints.
 It also minimizes muscle spasm by relaxing the
contracted muscles.
Practical:
1. Place the open palm of one hand under the
patient’s chin;
2. The other hand upon his/her occiput; then
3. Gradually lift (distract) the head to remove its
weight from the neck.
» Compression test (cervical)
 It helps locate the neurological level of any existing
pathology
Practical:
1. Press down upon the top of the patient’s head
while he/she either sitting or lying down
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2. If there is an increase in pain in either the cervical
spine or upper extremity, note its distribution and
whether it follows any dermatome.
» Valsalva test
 It increases intrathecal pressure.
 If a space-occupying lesion (like a herniated disc or a
tumor) is present in the cervical canal, the patient may
develop pain in the cervical spine secondary to
increased pressure.
 The pain may also radiate to the dermatome
distribution that corresponds to the neurological level
of the cervical spine pathology.
Practical:
1. have the patient hold his/her breath and bear down as
if he/she were moving his/her bowels; then
2. Ask the patient whether he/she feels any increase in
pain, if so whether he/she can describe the location.
*the Valsalva test is a subjective test which requires accurate
response from the patient.
» Adson test
 It is used to determine the state of the subclavian
artery
 It might be compressed by an extra cervical rib or by
tightened scalenus anticus and scalenus medius
muscles
 The artery can be compressed where it passes between
the muscles on its way to the upper extremity
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Practical:
1. Take the patient’s radial pulse at the wrist;
2. As you continue to feel the pulse, abduct, extend,
and externally rotate his/her arm; then
3. Instruct him/her to take a deep breath and to turn
his/her head toward the arm being tested;
4. If there is a compression of the subclavian artery,
you will feel a marked diminution or absence of the
radial pulse.
» Yergason test
 It determines whether or not the biceps tendon is
stable in the bicipital groove
Practical:
1. Instruct the patient to fully flex his/her elbow; then
2. Grasp his/her flexed elbow in one hand while holding
his/her wrist with your other hand;
3. To test the stability of biceps tendon, externally rotate
the patient’s arm as he/she resists and at the same time,
pull downward on his/her elbow;
4. If the tendon is unstable, it will pop out of the bicipital
groove and the patient will experience pain;
5. If the tendon is stable, the patient will experience NO
discomfort with tendon remains secure.
» Drop arm test
 It is used to detect whether or not there are any tears
in the rotator cuff muscles
Practical:
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1. Instruct the patient to fully abduct his/her arm; then
2. Ask him/her to slowly lower it to his/her side;
3. If there are tears in the rotator cuff (especially
supraspinatus muscle), the arm will drop to the side
from the position of about 90o abduction;
4. The patient still will not be able to lower his/her arm
smoothly and slowly no matter how many times
he/she tried;
5. If he/she is able to hold his/her arm in abduction, a
gentle tap on the forearm will cause the arm to fall to
his/her side.
» Apprehension test (Shoulder)
 It is performed to test for chronic shoulder
dislocation
Practical:
1. Abduct, and externally rotate the patient’s arm to a
position where it might easily dislocate;
2. If his/her shoulder is ready to dislocate, the patient
will have a noticeable look of apprehension or alarm
on his/her face and will resist further motion.
*this test is similar to the patella apprehension test for dislocation of
patella.
» Straight leg raising test
 It is designed to reproduce back and leg pain so that
its cause can be determined
Practical:
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1. Instruct the patient to lie supine on an examining table;
2. Lift his/her leg upward by supporting his/her foot
around the calcaneous;
3. The knee should remain straight; to insure that, place
your free hand on the anterior aspect of the knee to
prevent it from bending;
4. The extent to which the leg can be raised without
discomfort or pain varies but normally, the angle
between the leg and the table measures approximately
80o;
5. If straight leg raising is painful, you must determine
whether the pathology is due to problems in the sciatic
nerve or hamstring tightness;
6. Hamstring pain involves only the posterior thigh
whereas sciatic pain can extend all the way down the
leg;
7. The patient may also complain of Low Back Pain
(LBP) with the pain in the opposite leg (positive cross
leg straight leg raising test);
8. At the point where the patient feels pain, lower the leg
slightly and then dorsiflex the foot to stretch the sciatic
nerve and reproduce sciatic pain;
9. If the patient does not feel pain when you dorsiflex
his/her foot, the pain is probably due to tight
hamstrings;
10.
If the straight leg raising test and dorsiflexion
maneuver are both positive, ask the patient to locate, as
nearly as possible, the source of his/her pain;
11.
The pain may be either in the lumbar spine or
anywhere along the course of the sciatic nerve.
» Hoover test
 It is used to determine whether the patient is
malingering when he/she states that he/she can not
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raise his/her leg and should be performed in
conjunction with a straight leg raising test.
Practical:
1. As the patient tries to raise his/her leg, cup one hand
under the calcaneus of the opposite foot;
2. When a patient is genuinely trying to raise his/her leg,
he/she puts pressure on the calcaneus of his/heropposite
leg to gain leverage and you can feel this downward
pressure on your hand;
3. If the patient does not bear down as he/she attempts to
raise his/her leg, he/she is probably not really trying.
» Kernig test:
 This procedure designed to stretch the spinal cord and
reproduce pain.
Practical:
1. Ask the patient to lie supine on the examining table, and
have him/her place both hands behind his/her head to
forcibly flex his/her head onto his/her chest;
2. He/she may complain of pain in the cervical spine, and
in the low back or down the legs, an indication of
meningeal irritation, nerve root involvement, or irritation
of the dural coverings of the nerve root;
3. Have him/her locate the area from which the pain
originates so that you can determine its precise origin.
» Milgram test:
 This test stretches the iliopsoas muscle, anterior
abdominal muscles, and increases intrathecal pressure.
Practical:
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1. The patient lying supine on the examining table;
2. Have him/her keep his/her legs straight and raise them
to a position about four inches from the table; then
3. Have him/her hold this position as long as he/she can;
4. If a patient can hold this position for thirty seconds
without pain, intrathecal pathology may be ruled out;
5. If the test is positive (when the patient can not hold the
position, cannot lift his/her legs at all, or experiences
pain as he/she attempts the maneuver), there may be
intrathecal or extrathecal pathology (herniated disc), or
pathologic pressure on the theca itself (wrapping of the
cord).
» Trendelenburg test:
 This procedure is designed to evaluate the strength of the
gluteus medius muscle.
Practical:
1. Stand behind the patient and observe the dimples
overlying the posterior superior iliac spine;
2. Normally, when the patient bears weight evenly on both
legs, these dimples appear level; then
3. Ask the patient to stand on one leg;
4. If he/she stands erect, the gluteus medius muscle on the
supported side should contract as soon as the leg leaves
the ground and should elevate the pelvis on the
unsupported side;
5. This elevation indicates that the gluteus medius muscle
on the supported side is functioning properly (negative
Trendelenburg sign);
6. However, if the pelvis on the unsupported side remains
in position or actually descends, the gluteus medius
muscle on the supported side is either weak or
nonfunctioning (positive Trendelenburg sign)
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 During gait, the gluteus medius acts much as a tie rod since
it prevents the unsupported hip from dropping and causing
instability.
 If the gluteus medius muscle is weak, the patient may
exhibit the characteristic Trendelenburg, or gluteus medius,
lurch to counteract the imbalance caused his/her descending
hip.
 There are numerous conditions that weaken the gluteus
medius muscle:
1. Any pathology that brings the origin of the muscle
closer to its insertion, such as coxa vara, fractures of the
greater trochanter, or a slipped capital femoral epiphysis,
can cause the muscle to become weak;
2. A congenital dislocation of the hip, which not only
brings the muscle’s origin closer to its insertion, but also
destroys the normal fulcrum around which it functions;
3. Neurological problems, including poliomyelitis,
meningomyelocele, or a root lesion within the spinal
canal, may cause denervation of the gluteus medius
muscle.
» Tests for leg length discrepancy:
Sorry to say that the page is missing from the book
» Ober test
 Test for contraction of the iliotibial band
Practical:
1. Have the patient lie on his/her side with his/her involved
leg uppermost;
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2. Abduct the leg as far as possible and flex the knee to 90o
while keeping the hip joint in the neutral position to
relax the iliotibial tract; then release the abducted leg;
3. If the iliotibial tract is normal, the thigh should drop to
the adducted position;
4. However, if there is a contracture of the fasia lata or
iliotibial band, the thigh remains abducted when the leg
is released;
5. Such continued abduction (a positive Ober test) may be
caused by poliomyelitis or meningomyelocele.
» Thomas test
 It is a specific test designed to detect flexion contractures of
the hip
 It may be also used to evaluate range of hip flexion.
Practical:
1. The patient should be supine on the examining table,
with his/her pelvis level and square to his/her trunk so
that an imaginary line drawn between the anterior
superior iliac spines is perpendicular to the axis of his
body;
2. Stabilize the pelvis by placing your hand under the
patient’s lumbar spine and flexing his/her hip, bringing
his/her thigh up onto his/her trunk;
3. As you flex the hip, notice at what point his/her back
touches your hand;
4. The previous lordosis of the lumbar spine is then
flattened, the pelvis is stabilized, and further flexion can
originate only in the hip joint;
5. Flex the hip as far as possible;
6. Normal flexion limits allow the anterior portion of the
thigh to rest against the abdomen, almost touching the
chest wall;
7. Flex the other hip in a similar manner; then
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8. Have the patient hold one leg on his/her chest and let
his/her other leg down until it is flat on the table;
9. If the hip does not extend fully, the patient may have a
fixed flexion contracture of that hip;
10. If he/she rocks forward, lifting his/her thoracic spine
from the table, or arches his/her back to reform the
lumbar lordosis when he/she lowers his/her leg, a fixed
flexion deformity is again indicated, since rocking and
arching of the back are compensatory mechanisms to
facilitate lowering of a contracted hip;
11. The extent of a flexion contracture can be
approximated if you observe the patient from the side
and estimate the angle between his/her leg and the table
at the point of greatest extension.
» McMurry test:
 During knee flexion and extension, a torn meniscus may
produce a palpable or audible “clicking” in the region of
the joint line
 Tenderness elicited in the palpation of the joint line on
either side suggests the possibility of a torn meniscus
 Posterior meniscal tears are difficult to identify, and the
McMurry test was originally developed to assist in this
difficult diagnosis
Practical:
1. Ask the patient to lie supine with his/her legs flat and in
the neutral position
2. With one hand, take hold of his/her heel and flex
his/her leg fully; then
3. Place your free hand on the knee joint with your fingers
touching the medial joint line and your thumb and
thenar eminence against the lateral joint line, and rotate
the leg internally and externally to loosen the knee
joint;
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4. Push on the lateral side to apply valgus stress to the
medial side of the joint, while, at the same time,
rotating the leg externally;
5. Maintain the valgus stress and external rotation, and
extend the leg slowly as you palpate the medial joint
line;
6. If this maneuver causes a palpable or audible “click”
within the joint, there is a probable tear in the medial
meniscus, most likely in its posterior half.
» Apley’s Compression and Distraction tests:
Compression
 Compression or Grinding test is another procedure
designed to aid in the diagnosis of a torn meniscus
Practical:
1. Ask the patient to lie prone on the examining table with one
leg flexed to 90o;
2. Gently kneel on the back of his/her thigh to stabilize it while
leaning hard on the heel to compress the medial and lateral
menisci between the tibia and the femur; then
3. Rotate the tibia internally and externally on the femur as you
maintain firm compression;
4. If this maneuver elicits pain, there is probably meniscal
damage;
5. Ask your patient to describe the location of his/her pain as
accurately as possible;
6. Pain on the medial side indicates a damaged medial
meniscus;
7. Pain on the lateral side suggests a lateral meniscal tear.
Distraction
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 Distraction test helps to distinguish between meniscal and
ligamentous problems of the knee joint
 This test should follow the compression test in logical
progression.
Practical:
1. Remain in the same position described for the
compression test, and maintain your stabilization of the
posterior thigh;
2. Apply traction to the leg while rotating the tibia internally
and externally on the femur;
3. This maneuver reduces pressure on the meniscus and puts
strain upon the lateral and medial ligamentous structures;
4. If the ligaments are damaged, the patient will complain of
pain;
5. If the meniscus alone is torn, the test should not be painful
for him/her.
» Apprehension test (for patellar dislocation and subluxation)
 This procedure is designed to determine whether or not
the patella is prone to lateral dislocation
 If you suspect that your patient has a recurrent dislocating
patella, you should attempt to dislocate it manually while
observing his/her face as he/she reacts to this test.
Practical:
1. Ask him/her to lie supine on the examining table with
his/her legs flat and the quadriceps relaxed;
2. If you suspect that the patella may dislocate laterally, press
against the medial border of the patella with your thumb;
3. If everything is in order, this will produce little reaction but
if the patella begins to dislocate, the expression on the
patient’s face will become one of apprehension and distress.
» Knee joint effusion tests
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 Tests are designed to document suspected effusion in the
knee joint
Practical:
For major effusion:
1. When the joint is distended by a large effusion, carefully
extend the patient’s knee and instruct him/her to relax
the quadriceps muscles; then
2. Push the patella into the trochlear groove and quickly
release it;
3. The large amount of fluid lying under the patella is first
forced to the sides of the joint, and then flows back to its
former position, forcing the patella to rebound;
4. This referred to as a ballotable patella.
For minor effusion:
1. In the case of minimal effusion in the knee joint, there is
not enough fluid to ballot the patella;
2. To test that, keep your patient’s knee in extension, and
then “milk” the fluid from the suprapatellar pouch and
lateral side into the medial side of the knee;
3. When the fluid has been forced to the medial side, gently
tap the joint over the fluid, which will traverse the knee
to create a fullness on the lateral side.
» Tests for joint stability
Collateral ligaments
Ask the patient to lie supine on the table with one knee flexed
just enough so that it unlocks from full extension
To test the medial collateral ligament:
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1. Secure his/her ankle with one hand and place the
other hand around the knee so that your thenar
eminence is against the fibular head; then
2. Push medially against the knee and laterally
against the ankle in an attempt to open the knee
joint on the inside (valgus stress);
3. Palpate the medial joint line for gapping, which
may even be visible;
4. If there is a gap, the medial collateral ligament is
not supporting the knee properly;
5. When stress on the injured joint is relieved, you
can feel the tibia and femur “clunk” together as
they close.
To test the lateral collateral ligament:
1. Reverse the position of your hands, and push
laterally against the knee and medially against the
ankle to open the knee joint on the lateral side
(varus stress);
2. Palpate the lateral joint line for any gapping;
3. As on the medial side, such a gap may be both
palpable and visible;
4. Upon the release of varus stress, the tibia and
femur may clunk into position as they close;
5. If your fingers are too short to reach around the
knee to palpate the joint lines, secure the patient’s
foot between your arm and body (in the axilla) so
that your hands are free to palpate the joint line;
6. In this way, your body acts as a lever on the foot
and applies varus and valgus stress to the knee
joint;
 Since the medial collateral ligament is critical to stability,
an isolated tear of this ligament leads to joint instability,
whereas a similar defect in the lateral collateral ligament
may have little effect either way.
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 Most ligamentous injuries around the knee occur on the
medial side.
Cruciate ligaments:
 The anterior and posterior cruciate ligaments are
instrumental in preventing anterior and posterior
dislocation of the tibia on the femur;
 These ligaments are intracapsular, originating on
the tibia and inserting into the inner sides of the
femoral condyles.
To test the anterior cruciate ligament:
1. Have the patient lie supine on the examination table
2.
3.
4.
5.
with his/her knees flexed to 90o and his/her feet flat
on the table;
Position yourself on the edge of the table so that you
can stabilize his/her foot by sitting on it; then
Cup your hands around his/her knee with your fingers
on the area of insertion of the medial and lateral
hamstrings and your thumbs on the medial and lateral
joint lines;
Now, draw the tibia toward you; if it slides forward
from under the femur (positive anterior draw sign),
the anterior cruciate ligament may be torn;
A few degrees of anterior draw are normal if an equal
amount is present on the opposite side.
 When you do find a positive anterior draw sign, it is
important to repeat the maneuver with the patient’s leg in
internal and external rotation.
 External rotation of the leg tightens the posteromedial portion
of the joint capsule; normally there should then be reduced
forward movement of the tibia on the femur, even if the
anterior cruciate ligament is torn.
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 If forward movement with the leg externally rotated is equal
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to forward movement with the leg in the neutral position,
both the anterior cruciate ligament and the posteromedial
portion of the joint capsule (and possibly the medial collateral
ligament) may be damaged.
Internal rotation tightens the structures on the poserolateral
side of the knee.
Normally, there should be reduced movement when the leg is
pulled forward, even if the anterior cruciate ligament is torn.
If the amount of forward movement of the tibia on the femur
in internal rotation is equal to that in the neutral position,
both the anterior cruciate ligament and the posterolateral
portion of the joint capsule may be torn.
The anterior cruciate ligament may be torn in association with
tears of the medial collateral ligament.
To test the posterior cruciate ligament:
1. In the similar manner, let the patient stay in the same
position and push the tibia posteriorly;
2. If it moves backward on the femur, the posterior cruciate
ligament is probably damaged (positive posterior draw
sign);
 The anterior draw sign is more common than the
posterior sign, since the incidence of damage to the
anterior cruciate is much higher than to the posterior
cruciate ligament
 In fact, an isolated tear of the posterior cruciate ligament
is rare
 Both tests are usually performed in one continuous
motion and all procedures should perform bilaterally and
all findings compared.
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Good luck
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