NEUROLOGIC EVALUATION:
Pathologic Reflexes Tests:
Platysma Sign This is a pathologic reflex of the head indicating ipsilateral corticorspinal tract disease as
seen in hemiplegia. The sign is present when the examiner applies counter-pressure to the patient’s
flexing of the chin toward the chest. The Platysma muscle contracts on the sound side only, drawing the
outer part of the lower lip downward and backward.
The Snout Reflex This is a pathologic reflex of the head most frequently seen in bilateral corticopontine
lesions and indicates an upper motor neuron lesion. This reflex is considered positive when sharp
tapping of the nose or of the middle of the upper lip causes an excessive face grimace or an exaggerated
reflexion contraction of the lips.
The Zygomatic Reflex. On this test the examiner taps the Zygoma lightly with a reflex hammer. If this
results in lateral motion of the lower jaw on the percussed side, then the reflex is positive, indicating
damage to the cortical innervation of the motor portion of the Trigeminal Nerve.
The Finger Thumb Reflex This test is done by the examiner firmly flexing the third to fifth finger of each
of the patient’s hands at the proximal joints. This action produces opposition and adduction of the
thumb and flexion at the metacarpophalangeal joint. This reflex is absent in patients with corticospinal
lesions. If the reflex is absent only on one side it indicates a possible Pyramidal Tract lesion.
Kleist’s Hooking Sign This is an upper extremity pathologic reflex performed by the examiner gently
elevating the patient’s fingers with his or her own fingers. If the patient’s involved hand reactively flexes
and hooks into the examiner’s fingers instead of passively going into extension, then this sign is
considered present, indicating Frontal and Thalamic lesions.
Klippel-Weil Sign This is an upper extremity pathologic reflex sign which is considered present when the
flexed fingers of the patient’s affected limb are quickly pried open or extended by the examiner and it
results in flexion and adduction of the patient’s thumb. The sign’s presence indicates Pyramidal Tract
disease.
Babinski Reflex In this test, which is considered the most constant of the pathologic reflexes, the plantar
surface of the foot is directly and firmly stroked from the heel to the metatarsophalangeal joints, testing
both inner & outer borders of the sole. If this results in a slow, tonic digital extension of the great toe
with fanning of other toes (which usually disappears after the stimulus is removed), as opposed to a
voluntary response (which is faster and usually accompanied by a rapid withdrawal of the leg), it
indicates Corticospinal (Pyramidal) Tract disease.
Gordon’s Reflex This is a lower extremity pathologic reflex where dorsiflexion of the great toe or all the
toes results when the calf muscles are firmly compressed by the examiner. A positive reflex indicates a
Pyramidal Tract lesion.
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Oppenheim Sign This is a lower extremity pathologic reflex where the examiner applies heavy pressure
with the index fingers and thumb or with the knuckles of the index and middle fingers along the anterior
tibial surface on either side of the tibial crest, stroking from the tibial tubercle down to the ankle. If at
the end of this stimulation there is a slow, tonic digital extension of the great toe with fanning of the
other toes, the sign is considered present, indicating Corticospinal (Pyramidal) Tract disease.
Strumpell’s Tibialis Anterior Sign This test is performed with the patient supine. The examiner places
one hand under the patient’s knee and the other hand over the middle anterior tibial third. First, the
examiner strongly flexes the hip on the pelvis. Then, using the other hand, the examiner firmly flexes the
knee. The sign is considered present when either of these actions causes dorsiflexion and adduction of
the foot, indicating an upper motor neuron lesion (Spastic paralysis) of the lower limb.
Auditory Nerve Disorder Tests:
Bing’s Test In this test, a 256 Hz tuning fork is placed on the top or crown of the patient’s head, while
having the patient cover one ear. Normally, the blocked ear hears the sound the best by way of bone
conduction. If no sound is heard in the covered ear, then the test is considered positive, indicating nerve
deafness.
Gruber Test . The examiner holds a vibrating tuning fork close to the patient’s ear until the patient
indicates he can no longer hear it. At that point, using his or her index finger, the examiner blocks off the
patient’s external auditory canal and places the still vibrating tuning fork against the finger. If the sound
does not become audible again, then this test is considered positive, indicating a lack of sensitivity of the
ear to sounds.
The Rinne Test In this test, the stem of a vibrating 256 or 512 cycle tuning fork is placed on the mastoid
process of the Temporal Bone. When the patient reports no longer hearing the sound, the opposite end
of the tuning fork is immediately held in front of the patient’s ear about half inch from the external
auditory meatus until the patient again reports no longer hearing the sound. If the sound is heard longer
externally through air conduction, the test is considered Rinne Positive, which is normal. If the sound is
heard for equal lengths of time at both positions, the test is considered Rinne Equal. If the sound is
heard longer on the mastoid process (bone conduction), it is considered Rinne Negative. Rinne Equal or
Rinne Negative indicates a physical obstruction of some sort in the airway or possibly middle ear
disease. In the case of severe nerve deafness, no sound is heard at all.
The Weber (Lateralization) Test With the patient seated, the examiner places the stem of a vibrating
256 cycle tuning fork on the patient’s vertex or on the midline of the forehead just above the glabella. If
the sound is heard equally on both sides, the test is considered Weber Negative, which is a normal
response. If the sound is heard better on one side (lateralization), it is considered “Weber Left” or
“Weber Right”, relative to the side on which it is best heard.
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Clonus Tests:
Suprapatellar Reflex This reflex is tested with the patient supine with both limbs straight and parallel.
Using his or her index finger, the examiner exerts downward pressure on the patellar toward the feet.
Using the index finger as a pleximeter, the superior portion of the patella is stroked posteriorward and
toward the feet with a reflex hammer. Normally there is a single rebound response of the patella for
each percussion. More than one kickback per stroke indicates suprapatellar clonus, which is one of the
criteria for an upper motor neuron lesion.
Trepidation Sign This reflex is tested with the patient supine with both limbs straight and parallel. Using
his or her index finger, the examiner exerts downward pressure on the patellar toward the feet. Using
the index finger as a pleximeter, the superior portion of the patella is stroked posteriorward and toward
the feet with a reflex hammer. Normally there is a single rebound response of the patella for each
percussion. When the patella goes into a rapid up and down movement, it is called The Trepidation Sign,
which is one of the indicators of an upper motor neuron lesion.
Posterior Column Disorders:
The Finger to Finger Test In this test the patient with outstretched arms attempts to bring the tips of the
index fingers together. The test is done with the eyes open and closed. If the patient can hit the mark
with the eyes open but not closed, the test is considered positive, indicating Posterior Column Disease. If
the patient cannot hit the mark in a coordinated way with eyes open or closed, then Cerebellar Disease
is indicated.
The Finger to Nose Test In this test the patient with outstretched arms attempts to alternately bring the
tip of each index finger to the tip of the nose. The test is done with the eyes open and closed. If the
patient can hit the mark with the eyes open but not closed, the test is considered positive, indicating
Posterior Column Disease. If the patient cannot hit the mark in a coordinated way with eyes open or
closed, then Cerebellar Disease is indicated.
The Heel-Knee Test This test is done with the patient supine. The patient places the heel of one foot on
top of the opposite knee and slowly slides the heel down the shin to the ankle. The test is done
bilaterally first with the eyes open, then with the eyes closed. If the patient is unable to smoothly
perform the above, then the test is considered positive, revealing evidence of proprioceptive system
imbalance. More specifically, if the patient can perform the above better with the eyes open than
closed, then Posterior Column Disease is indicated. If the patient cannot perform the test well with eyes
open or closed, then a Cerebellar lesion is indicated.
The Heel-Toe Test In this test the patient walks a straight line heel to toe about ten steps forward, turns
around, then returns ten steps back. Providing there is normal lower limb strength, this action should be
done without faltering or loss of balance. If the patient is unable to perform the test normally, it is
considered positive, indicating evidence of proprioceptive system imbalance.
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Lhermitte’s Sign This sign is present when bending the neck into flexion causes an electric shock like
sensation to radiate down the neck and spine, which is indicative of Posterior Column disease of the
spinal cord.
Romberg’s Sign In this test, the patient stands upright with feet together and hands at the side. A slight
amount of swaying is normal, but if the patient is unable to maintain balance without moving the feet,
with the eyes open or closed, this sign is considered present, indicating spinal cord Posterior Column
disease, notably Multiple Sclerosis and Tabes.
Brachial Plexus Disorders:
Bikele’s Sign With the patient outstretching the arm upward and backward with the elbow fully flexed,
extending the elbow causes resistance and increased radicular pain from the cervicothoracic region.
Because of the stretch this action puts on the brachial plexus nerve roots or their covering, it results in
brachial plexus neuritis or meningitis symptomatology when this sign is present.
Brachial Plexus Tension Test The patient elevates the shoulders through abduction and then extends
the elbows to the onset of pain and hods for several seconds. This is followed by the external rotation of
the shoulders which is held for several seconds. The examiner supports the shoulders and forearm in
this position while the patient flexes the elbows. Reproduction of symptoms is a positive finding and
may suggest brachial plexus or cervical root involvement
Cranial Nerve Testing
There are 12 pair of cranial nerves which are routinely examined on patients who have complaints which
may suggest pathology. Below is a list of the 12 nerve and their function:
I Olfactory N. Smell
II Optic N. Vision
III Oculomotor N. Light accommodation, eye movement
IV Trochlear N Eye Movement
V Trigeminal N. Facial sensation
VI Abducens N. Eye Movement
VII Facial N. Facial Muscle, Taste
VIII Auditory N Auditory function and balance
IX Glossopharangeal N. Taste, gag
X Vagus N. Voice and swallow
XI Spinal Accessory N. Shoulder shrug
XII Hypoglossal N. Tongue Movement
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Peripheral Nerve Tests:
The Biceps Reflex The patient is seated with the forearms resting on the thighs. The examiner places the
biceps tendon under slight tension by placing his or her thumb over the center of the tendon. Using a
percussion hammer, the examiner strikes his thumbnail, observing and feeling the flexion of the elbow
and contraction of the Biceps Muscle, which normally results, otherwise the test is positive. A positive
test may indicate an upper and lower motor neuron lesion as well as ascertaining the integrity of
afferent and efferent fibers of the Musculocutaneous Nerve.
The Brachioradialis This reflex is tested with the patient seated with the forearms resting on the thighs
with the thumbs facing up. While palpating the belly of the Brachioradialis, the examiner strokes its
tendon with a reflex hammer at its point of maximum response. In a true brachioradialis stretch reflex,
only the forearm will flex. This reflex is used to determine the afferent and efferent integrity of the
Radial Nerve in relation to an upper or lower motor neuron lesion.
The Infraspinatus Reflex This reflex is tested with the patient seated. The examiner strokes the area
over the scapula with a reflex hammer at a point that’s on a line that bisects the angle formed by the
spine of the bone and its inner border. A normal reflex would be external rotation of the arm along with
extension of the elbow. A positive test indicates a lack of integrity of the C5/C6 nerve roots and the
Suprascapular Nerve.
The Pectoral Reflex The examiner puts his or her index finger over the anterior fold of the axilla,
hooking the tendon of the Pectoralis Muscle. The patient’s arm is positioned halfway between
adduction and abduction. The examiner then strokes the tendon with a reflex hammer. A normal
response is little, if any, contraction of the Pectoralis Muscle. If there is hyperreflexia when compared to
the opposite side, it is indicative of a Corticospinal Tract lesion above the level of the fifth cervical
segment.
The Radial Reflex In this test, the seated patient rests the forearms on the thighs with the thumbs facing
upward. The examiner taps the forearm over the radius proximal to its styloid process, working upward
until the point of maximum response is located. A normal response would be slight supination, flexion
and radial deviation of the hand. Hypo or Hyperreflexia reveals lack of C5/C6 segmental integrity,
indicating an upper or lower motor neuron lesion.
The Inverted Radial Reflex This reflex is tested with the patient seated with the forearms resting on the
thighs with the thumbs facing up. While palpating the belly of the Brachioradialis, the examiner strokes
its tendon with a reflex hammer at its point of maximum response. When this action causes flexion of
the hand and fingers without forearm flexion or response, then the test is positive, which is considered
an important arm reflex indicative of a lesion of the 5th Cervical segment of the spinal cord.
The Ulnar Reflex This reflex is tested with the patient seated with the forearms resting on the thighs
with the elbows at right angles and palms facing downward. While palpating the ulnar musculature with
one hand, the examiner strokes the styloid process of the ulna right next to the apex with a glancing
blow from medial to lateral. The normal response to this reflex would be minimal pronation and ulnar
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deviation of the hand. A positive reflex indicates a lack of integrity of the afferent and efferent fibers of
the Ulnar Nerve through their center C8 and T1.
Tinel Sign This test is performed by gentle tapping with the finger or reflex hammer over the site or
along the course of the involved nerve. If pain and/or a tingling sensation results in the distal
distribution of the injured nerve, which persists for several seconds, the sign is considered present,
indicating Carpal Tunnel Syndrome.
Phalen’s Sign In this test, the wrist is held in complete flexion for 30 to 60 seconds. This sign is present
when discomfort, numbness & paresthesia is reproduced or exaggerated in the hand & digits, indicating
median nerve compression such as in Carpal Tunnel Syndrome.
Wartenberg’s (Oriental Prayer) In this test the patient adducts and extends the fingers while extending
the thumbs. The examiner then has the patient raise both hands so they are side by side facing the floor,
with the thumbs and index fingers touching tip to tip. The thumbs will not coincide when the index
fingers touch, if there is paralysis of the Abductor Pollicis Brevis, indicative of Median Nerve palsy.
Lumbosacral Nerve Tests:
The Heel-Walk Test The patient walks on the heels several steps forward, then back the same way. If
the patient has low back complaints and is unable to perform this action because of either pain or
weakness, then a lesion of the fibers of the L5 Nerve Root should be suspected.
O’Connell’s Test Specifically, a positive test would be evidence of neuritis proximal to the distal extent
of the radiculopathy.
The Quadriceps Reflex In this test, the patient should be completely relaxed, with both lower limbs
parallel and fully extended. The examiner elevates the limbs slightly by placing his or her forearm under
the patient’s knees. The examiner then palpates the patellar tendons and then briskly strokes each side
equally with a reflex hammer observing and comparing the response of the Quadriceps’ contractions
and knee extensions. Hyporeflexia or hyperreflexia may indicate a lower or upper motor neuron lesion
of the L2, L3 or L4 nerve roots or of the Femoral Nerve.
The Toe Walk Test In this test the patient walks on the toes about seven steps forward, turns still on the
toes, then walks back the seven steps. The patient’s inability to do this easily could indicate a loss of
integrity of fibers from the S1-2 nerve roots.
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ORTHOPEDIC EVALUATION:
Cervical Lesion Tests:
Bakody Sign This test is normally done with patients who have cervical radicular pain. The patient
actively places the palm of the affected extremity flat on the top of the head while raising the elbow
level with the head. When this action reduces or eliminates the radiating pain, the sign is considered
present. A positive sign is indicative of nerve root irritation because of cervical foraminal compression.
The Cervical Distraction Test While seated, the patient actively rotates the head and neck until radicular
pain is produced. The examiner then rotates the head to the same extent but with strong upward
traction added to the motion. If this action performed by the examiner gives relief or significantly
reduces the patient’s cervical and/or radicular pain, this test is considered positive, indicating nerve root
compression. If the patient can’t actively rotate the head or neck because of pain, the examiner can still
do this test by adding traction with or without rotation.
The Jackson Compression Test In this test, the patient, sitting upright, attempts to laterally flex the neck
and head toward the affected shoulder. Then the examiner exerts downward pressure with clasped
hands on top of the patient’s head. The test is positive if this action exacerbates the patient’s cervical
and/or radicular pain indicating nerve root compression.
The Maximum Cervical Compression Test In this test, the patient, sitting upright, attempts to laterally
flex the neck and head toward the affected shoulder. Then the examiner directs the patient to bring the
chin as close as possible to the shoulder. The test may be repeated passively if there is no response
when the patient does the action actively. The test is positive when the action causes radicular pain on
the side of the flexion and rotation. A positive test reveals cervical nerve root compression in that the
action narrows the diameters of the intervertebral foramina as much as anatomically possible.
The Shoulder Depression Test . This test is done with the patient supine. The examiner standing at the
head of the patient, flexes the neck to the side opposite to the shoulder being tested while pushing the
shoulder caudad. Then, while maintaining the depression of the shoulder, the head is rotated, again to
the side opposite to the shoulder being tested. If radicular pain is either produced or aggravated the first
action and then confirmed by the second, the test is considered positive. A positive test indicates
adhesions of the dural sleeves, the spinal roots, or the adjacent structures of the joint capsule on the
side of the shoulder being depressed.
Soto-Hall Test With the patient supine and the examiner exerting pressure on the sternum to prevent
either lumbar or thoracic flexion, the examiner places the other hand under the patient’s occiput and
flexes the head and neck slowly and forcibly upon the sternum. This causes more and more of a pull on
the posterior spinous ligaments, starting at the Ligamentum Nuchae, moving downward until it reaches
the spinous process of the involved vertebra. There the pull acts as a lever compressing the vertebral
body, thus causing localized pain. This test is mainly used to diagnose and localize vertebral bony disease
and injuries, particularly of the compression type. This patient’s pain was localized at C3/4.
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Spurling’s Test The examiner stands behind the seated patient and has the patient turn his or her head
toward the involved side in maximal axial rotation and then maximal lateral flexion is added. The
examiner then delivers a vertical blow to the uppermost portion of the cranium. Any significant increase
of neck, shoulder or arm pain from the blow would be a positive test, indicating a stimulation of existing
nerve root irritation or other problems related to disc disease and cervical spondylosis.
Valsalva Maneuver This test is done on patients with cervical problems and is done with the patient
seated. The examiner directs the patient to hold the breath and bear down, as if moving the bowels.
This action increases intrathoracic pressure and if it results in an increase in cervical pain and radicular
neuralgia the test is considered positive, indicating intervertebral nerve root compression from a disc
occlusion.
Thoracic Lesion Tests:
The Chest Expansion Test With the patient standing or sitting erect, the examiner takes a chest
measurement with the tape measure over the lowest part of the fourth intercostal space with the
patient maximally exhaling. The patient then maximally inhales and another measurement is taken.
Normal expansion for an adult male is at least two inches, and one and one-half inches for an adult
female. Less than these amounts would be a positive test, indicating thoracic fixation. This is considered
an important sign in any ankylosing condition such as Marie-Strumpell Disease.
Forestiers Bowstring Sign In this test, the patient performs lateral bending while in a standing position.
If there is ipsilateral tightening and contracture of the paraspinal muscles instead of the contralateral
side tightening, the sign is present, indicating Ankylosing Spondylitis (Marie-Strumpell’s Disease).
The Lewin Supine Test The supine patient with the arms held straight out above the thighs and the legs
together and held down by the examiner is asked to sit up. If the patient cannot perform this action, the
test is considered positive, indicating an ankylosing dorsolumbar spinal lesion.
Schepplemann’s Sign The patient is asked to side bend with their arms over their head. Pain elicited on
the concave side suggests intercostal neuritis. Pin on the convex side suggests generalized
musculoligamentous strain/sprain
Spinal Percussion The patient is seated while the doctor percusses the spinous process’ and paraspinal
tissues. Pain during percussion of the spinous process suggests fracture or severe sprain. Pain during
percussion of the paravertebral soft tissues suggests muscular strain or sensitive myofascial trigger
points.
Sternal Compression Test The patient is supine and the examiner exerts downward pressure on the
sternum. A positive finding of lateral rib pain suggest possible rib fracture.
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Lumbar Lesion Tests:
Adam’s Sign This sign is present when acute bilateral low back pain results when flexion is performed
from the standing Adam’s position, with flexion being the most painful position when compared to
extension, lateral bending and rotation. Rotation is the freest and least painful of the spinal motions
performed by the patient. This sign indicates an intervertebral disc posterior or posterolateral rupture,
as forward flexion is the motion that most antagonizes this type of lesion, whereas rotation causes the
least amount of stress in this type of pathology.
Demianoffs Sign This sign is useful in differentiating sacrolumbalis muscle pain from lumbar pain of any
other origin. In this test, the examiner performs straight leg raising on the supine patient. The sign is
present when pain prevents the examiner from raising the leg more than fifteen degrees, indicating the
pain is due to the stretching of the sacrolumbalis (Iliocostalis Lumborum Muscle).
The Double Leg Raise Test This test is performed with the patient supine. The examiner straight leg
raises each leg separately, noting the angle where pain in produced. Then both legs are raised together,
again noting the angle where pain is produced. If the angle where pain occurs when both legs are lifted
together is less than either leg when lifted separately, then this test is considered positive indicating
lumbosacral joint involvement.
Duchenne’s Sign In this test, the supine patient is asked to plantar flex the foot while the examiner
pushes up (dorsally) the head of the first metatarsal with his or her thumb. The sign is present when the
medial border of the foot dorsiflexes and the lateral border plantar flexes. Also, the head of the first
metatarsal gives no resistance to the examiner’s thumb. A positive sign indicates paralysis of the
Peroneus Longus from a lesion of the Superficial Peroneal Nerve or a lesion at or above the L4, L5 and S1
Nerve Roots.
Goldthwait’s Sign This test is designed to differentiate between sacroiliac and lumbosacral involvement.
With the patient supine, the examiner palpates the lumbosacral joint while slowly straight leg raising the
limb on the affected side. The test is then repeated on the unaffected side. When pain is brought on
before the lumbosacral joint is opened and it’s possible to raise the leg on the unaffected side to a
greater level than the limb on the affected side without pain, then a lesion of the sacroiliac joint or
ligaments is presumed. When no pain is experienced until the lumbosacral movement occurs and pain is
felt when either leg is raised to approximately the same height then a lumbosacral lesion is more likely.
The Lumbosacral Stress Test This test is used to localize posterior joint involvement in the lower lumbar
motor units. The patient is in the prone position. Both legs are flexed at the knee and approximated to
the buttock. A positive finding is pain at the lumbosacral junction without radiation to the lower
extremities. This test demonstrates generalized musculoligamentous involvement of the lumbar spine
and suggests strain/sprain
The Low Back Hyperextension Test This test helps to localize low back lesions. The patient lies prone
with the arms at the sides and legs straight and together. The examiner holds the legs down and has the
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patient lift the head, neck, and shoulders as far back as possible. Then the examiner has the patient
point to the center of the pain resulting from this action. This patient pointed to L4/5.
The Lasegue Differential Sign . This test is normally done on patients with Sciatica. If pain results from
straight leg raising, but flexing the thigh on the pelvis with the knee flexed produces no sciatic pain, the
sign is considered present, tending to rule out hip joint disease.
The Lewin Punch Test In this test, if punching the left or right buttock of the standing patient produces a
referred pain in the back, it is a positive test, indicating a spinal lesion, usually a protruded disc. The
punched buttock that produces the pain is the side of the lesion. Punching the buttock on the side
opposite the lesion, does not elicit pain.
Lindner’s Sign This test is done with the patient supine. Standing behind the patient, the examiner
enforces head, neck and dorsolumbar flexion, placing the patient’s trunk into a large “C-shaped” curve.
The sign is present when this action aggravates or reduplicates the radicular pain of the patient’s main
complaint, which is indicative of low back nerve root compression.
Nachlas’ Test This test is performed with the patient in a prone position. Each foot is passively raised
from the table, maximally flexing the knee. The examiner also exerts downward pressure over the pelvis
to prevent buckling at the hips. The test is considered positive when the patient experiences pain in the
sacroiliac region or the lumbosacral region, and at times, along the nerves that run in front of these
joints, indicating a lesion of those joints.
Smith-Peterson Test The examiner palpates the low back of the supine patient, while straight leg raising
each leg. When there is acute inflammation, motion is more restricted toward the affected side. The
opposite is true when the sacroiliac is involved. However, when straight leg raising, if pain begins after
lumbosacral movement occurs, then a sacroiliac or lumbosacral lesion may be present. If the lesion is
sacroiliac, the leg on the opposite side can be brought higher without pain If the lesion is lumbosacral,
the pain comes on when both legs are at the same height.
Sacroiliac Lesion Tests:
The Anterior Innominate Test This test is done on patients with lower trunk pain. The standing patient
places the leg opposite the painful side two to three feet in front of the other foot. The patient then
bends over the forward extremity putting all the weight on the front leg until the back foot raises off the
floor. If this action causes or further aggravates the patient’s lower trunk pain, the test is considered
positive, indicating a forward derangement of the ilia (anterior innominate) in relation to the sacrum.
Erichsen’s Sign This test is done with the patient prone. The examiner, with the hands over the dorsum
of the ilia, bilaterally thrusts toward the midline. If this produces pain over the sacroiliac area, the test is
positive indicating sacroiliac joint disease as opposed to hip joint disease.
Gaenslen’s Test On this test, the examiner has the patient lie supine with the affected side lying close to
the edge of the table. The hip and knee on the unaffected side are flexed, while the patient clasps the
flexed knee to his chest. The examiner then applies pressure against the clasped knee and the knee of
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the extended hip. If this action results in an exacerbation of pain from the pelvis, then the test is
positive, indicating a sacroiliac joint lesion.
Lewin-Gaenslen’s Test In this test, the patient lies on one side and pulls the knee of that same side up to
the chest, while extending the other thigh. The examiner applies additional pressure from behind,
forcing extension of the other thigh. Exacerbation of pain from the pelvis is considered a positive test,
indicating a Sacroiliac joint lesion.
Gillis’ Test On this test the examiner places the base of the palm of one hand over the prone patient’s
sacroiliac joint on the unaffected side, thus fixing the sacrum with the fingertips fanning over the
affected sacroiliac joint. With the other hand, the examiner lifts the thigh of the affected side putting
the hip joint into extension. If this action exacerbates the pain of the main complaint over the sacroiliac
joint, the test is considered positive, indicating Sacroiliac joint disease.
Goldthwait’s Sign This test is designed to differentiate between sacroiliac and lumbosacral involvement.
With the patient supine, the examiner palpates the lumbosacral joint while slowly straight leg raising the
limb on the affected side. The test is then repeated on the unaffected side. When pain is brought on
before the lumbosacral joint is opened and it’s possible to raise the leg on the unaffected side to a
greater level than the limb on the affected side without pain then a lesion of the sacroiliac joint or
ligaments is presumed. When no pain is experienced until the lumbosacral movement occurs and pain is
felt when either leg is raised to approximately the same height, then a lumbosacral lesion is more likely.
Hibb’s Test This test is performed with the patient in a prone position. The examiner, while stabilizing
the pelvis on the side nearest to him, flexes the opposite knee to a right angle. From this position, the
examiner slowly laterally pushes the leg causing strong internal rotation of the femoral head. The test is
done bilaterally. Pelvic pain reveals a positive test, indicative of a sacroiliac lesion.
Iliac Compression Test Used to rule out a sacroiliac lesion.
Laguerre’s Sign This test is done with the patient supine while the thigh and knee are flexed to right
angles. Then the thigh is abducted and rotated outward. This forces the head of the femur against the
anterior portion of the hip joint capsule. The sign is present when this action produces pain, tending to
rule out a lumbosacral lesion, but indicating a hip joint lesion, iliopsoas muscle spasm or a sacroiliac
lesion.
Nachlas’ Test This test is performed with the patient in a prone position. Each foot is passively raised
from the table, maximally flexing the knee. The examiner also exerts downward pressure over the pelvis
to prevent buckling at the hips. The test is considered positive when the patient experiences pain in the
sacroiliac region or the lumbosacral region, and at times, along the nerves that run in front of these
joints, indicating a lesion of those joints.
The Sacroiliac Resisted Abduction Test This test is done with the patient lying on the side with the
upper leg straight out and slightly abducted while the lower leg is flexed at the hip and knee for stability.
With the patient resisting, the examiner applies downward pressure on the upper limb. The test is then
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repeated on the opposite side. If this action causes pelvic pain around the posterior superior iliac spine,
the test is considered positive, indicating a Sacroiliac lesion, and more specifically, a sacroiliac sprain or
subluxation.
The Sacroiliac Stretch Test . This test is done with the patient supine. The examiner, with crossed arms,
places his or her hands on the anterior superior spine of each ilium and applies pressure downward and
laterally. The test is considered positive only if the patient can identify deep seated unilateral gluteal or
posterior crural pain, as opposed to pain from table pressure on the skin over the sacrum, or from the
examiner’s hands or from the lumbosacral area from the pelvis being rocked. A positive test would
indicate an anterior sacroiliac ligament strain.
Smith-Peterson Test The examiner palpates the low back of the supine patient, while straight leg raising
each leg. When there is acute inflammation, motion is more restricted toward the affected side. The
opposite is true when the sacroiliac is involved. However, when straight leg raising, if pain begins after
lumbosacral movement occurs, then a sacroiliac or lumbosacral lesion may be present. If the lesion is
sacroiliac, the leg on the opposite side can be brought higher without pain. If the lesion is lumbosacral,
the pain comes on when both legs are at the same height.
Yeoman’s Test This test is done with the patient in a prone position. The examiner exerts downward
pressure over the suspected sacroiliac joint, while maximally flexing the ipsilateral knee. Then the thigh
is hyperextended while holding down the pelvis. The test is positive when deep pain in both sacroiliac
joints is causes from the above action, indicating a strain of the anterior sacroiliac ligaments.
Sciatic Nerve Lesion Tests:
Bonnet’s Sign is used to rule out radiculopathy of the sciatic nerve. The test is similar to a Straight Leg
Raise with the leg and though rotated internally
Bragard’s Sign This test is done with the patient supine with both legs straight. The examiner straight leg
raises the leg on the affected side until the point the patient feels pain. At this position, the examiner
firmly dorsiflexes the foot. If there is an increase in radicular pain from the above, the test is considered
positive, indicating peripheral or nerve root irritation of the sciatic nerve.
Deyerle’s Sciatic Tension Test . This test is performed with the patient seated. The examiner extends the
affected leg at the knee to the point of the pain being reproduced. Then the knee is slightly flexed with
firm pressure being applied in the popliteal fossa. If radiculitis symptoms are increased, the test is
considered positive, indicating a sciatic nerve lesion, in that the test shows irritation of the sciatic nerve
above the knee from stretching the nerve over an obstruction.
The Lasegue (Straight Leg Raise) Test This test is done with the patient supine and with the knee in
extension. The examiner, actively flexes each thigh slowly while holding the other hand on the knee to
prevent its flexion. The leg is lifted 90 degrees or until pain prevents further motion. The final angle of
flexion at which pain occurs, as well as the location and intensity of the pain are noted by the examiner.
This test is considered positive when the straight leg cannot be raised to 90 degrees without pain.
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Sicard’s Sign With the patient supine and legs fully extended, the examiner lifts the leg to a point that is
just short of producing pain. Then the great toe is dorsiflexed. The sign is present when this action
results in sciatic pain, indicating sciatic radiculopathy.
Turyn’s Sign This test is performed with the patient supine with both legs straight out. If dorsiflexion of
the great toe brings on pain in the gluteal region, then the sign is present, indicating sciatic
radiculopathy.
Intervertebral Disc Syndromes:
Amoss’ Sign This test is usually performed on patients with dorsolumbar or lumbosacral complaints. The
patient is made to lie on his or her side and then is told to rise from the table. When this action of arising
from a recumbent position causes significant localized thoracic or lumbosacral pain, the test is
considered positive. A positive test indicates either Ankylosing Spondylitis, Severe Sprain or
Intervertebral disc Syndrome.
Bechterew’s Test (seated straight-leg raising) is used to rule out a lumbosacral intervertebral disc
protrusion.
The Bowstring Sign This test is done with the patient supine. The examiner performs straight leg raising
until the patient experiences some discomfort. At this level the examiner flexes the knee slightly and
rests the foot on his or her shoulder until any pain subsides. The examiner then applies pressure to the
hamstrings. If this doesn’t produce pain, the examiner moves the thumbs over the popliteal fossa and
applies pressure over the popliteal. If pain is reproduced in the leg or in the back, this sign is considered
present, indicating nerve root compression or a ruptured intervertebral disc.
Cox Sign. This test is performed with the patient supine. The examiner performs straight leg raising, and
if the patient’s pelvis rises from the table instead of the hip being passively flexed, then the sign is
present. The sign indicates a disc Prolapse into the Intervertebral Foramen.
Dejerine’s Sign is used to rule out a mechanical obstruction from a herniated disc, tumor or bony
closure.
Fajersztajn’s “Well Leg Raising” Test This test is used when unilateral sciatica is present. The examiner
passively straight leg raises the unaffected limb to the point of causing or increasing radiculitis in the
opposite side. When none is produced, then strong dorsiflexion of the foot is added. The test is positive
when either of these two actions produce radicular pain on the opposite side to the leg being lifted. A
positive test tends to confirm the existence of a ruptured disc lesion as it produced sciatica at the nerve
root level.
Kemp’s Test This test can be done with the patient standing or sitting. While stabilizing the pelvis, the
patient’s shoulder if firmly forced obliquely backward, downward and medial. The idea is to put the
lower spine on the opposite side to the one being tested, into a combined position of rotation, lateral
bending, and extension. The test is considered positive when low back pain radiates into the lower
extremity, indicating facet syndrome, fracture or disc involvement.
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The Lasegue Rebound Test This test is done with the patient supine with the arms at the side. The
examiner performs straight leg raising on the side of the main complaint until reaching muscle
resistance or pain as indicated by the patient. The leg is then dropped into a pillow or the examiner’s
hand, without warning. If this action aggravates backache and sciatic pain and low back spasm, the test
is considered positive, which is particularly diagnostic of Psoas spasm or irritation, and generally
indicative of an intervertebral disc lesion above the lumbosacral level.
Lewin Snuff Test . In this test, the patient is given a pinch of mild pepper, snuff, etc. to sniff up the
nostril in order to cause sneezing. If the resultant sneezing causes a localized spinal and radicular pain,
the test is considered positive. A positive test indicates an intervertebral disc Rupture.
The Sitting Root Test In this test, the patient is seated in a chair with the neck flexed. The examiner
extends the knee on the affected side up to ninety degrees. Low back pain and radiation of the pain
indicate the test is positive. This test places abnormal tension on the Sciatic Nerve and patients with true
Sciatica will tend to arch backwards and complain of radicular pain. A malingerer will not complain of
any symptoms.
Milgram’s Test . This test is performed with the patient supine while both limbs are held straight out
with the heels two to three inches from the table for at least 30 seconds. The test increases
subarachnoid pressure and is positive when the patient is unable to hold the position for 30 seconds
without pain, indicating pathology within or outside the spinal cord sheath, such as a herniated disc.
Naffziger’s Test On this test, the examiner stands behind the seated patient and compresses both
internal jugular veins with the index and middle fingers for a period of up to forty-five seconds. If this
results in radiating sciatic pain, the test is considered positive, indicating nerve root compression by an
extruded disc or other mass.
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Nervous System Lesion Tests:
The Ciliopupillary Reflex
The Ciliopupillary Reflex This test has the patient seated erect, looking straight ahead. The examiner
carefully observes the size and shape of the patient’s pupils while passively and maximally rotating the
patient’s head and neck to one side and then the other. This reflex is observed when either pupil
becomes larger or smaller after the head and neck have been rotated, indicating a positive test. A
positive test is indicative of an Autonomic Nervous System lesion. This reflex is considered to be
especially important on a post-traumatic basis, such as when the patient suffers a “whiplash” type injury
to the cervical spine.
Huntington’s Sign This test is performed with the patient supine with the legs hanging over the edge of
the table at the knees. The examiner has the patient cough hard at least three times. If this action
causes flexion of the thigh and extension of the knee on the weak side, the sign is considered present,
indicating the weakness may be due to an Upper Motor Neuron Lesion.
Morquio’s Sign The supine patient’s legs are straight out with the examiner at the head of the patient
attempting to raise the patient to a sitting position, with the patient vigorously resisting. If when the
patient’s knees and hips are placed into passive flexion the trunk can be lifted to a sitting position with
little opposition, then this sign is considered present. The sign is indicative of Epidemic Poliomyelitis.
O’Connell’s Test In this test, the patient’s unaffected leg is raised straight, with the angle of flexion
noted along with the location of pain, if any. Then the affected leg is tested in the same way. Then, both
legs are simultaneously flexed just short of the point of pain. The good leg is then lowered and if this last
action causes an exacerbation of pain on the affected side, the test is considered positive, indicating
lumbar peripheral neuropathy. Specifically, a positive test is evidence of neuritis proximal to the distal
extent of the radiculopathy.
Thomas’ Test On this test, the examiner maximally flexes the supine patient’s hip and knee of the side
opposite to the side being tested, bringing the knee to the patient’s chest. The examiner then has the
patient clasp the knee in order to maintain this posture. If this action causes the hip and knee of the
opposite limb to elevate off the table, the test is considered positive. Normally, the opposite limb should
have enough hip flexor stretch to allow the thigh to continue to lie flat on the table during this action.
Thus a positive test indicates flexor tightness or flexion deformity of the hip.
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Miscellaneous Soft Tissue Lesion Tests:
The Sign of the Buttock
The Sign of the Buttock On this test, the examiner performs a straight leg raise test on the supine
patient. If this action along with passive hip flexion with the knee extended are both limited and painful,
with the pain originating from the buttock as opposed to the hip, lumbosacral spine, etc., then this sign
is considered present. When fever is also present it indicates inflammation of the upper femur
(osteomyelitis), the sacroiliac joint (septic arthritis), ischio-rectal abscess or septic bursitis. If there is no
accompanying fever, then neoplasm of the upper femur or iliac bone would be suspected.
Dejerine’s Signs Also know as Dejerine’s Triad involves coughing sneezing and straining during
defication which reproduces and aggravates radicular symptoms . This sign is present in space occupying
lesions which can be caused from herniated discs, spinal cord tumor, fracture, etc. The course of the
referred pain helps to localize the suspected lesion.
Hueter’s Fracture Sign This test can be used to differentiate types of lesions, such as semisolid lesions as
distinguished from a more dense lesion such as a hard tumor, etc. In this test, the examiner marks the
main point of irritation and two more points on either side of the central point. These marks are
duplicated on the non-affected side in order to establish what normal sounds like. Using either a 512
cycle tuning fork or a percussion hammer on the bone on the opposite side of the lesion, the examiner
listens to see how vibration is transmitted across the lesion site. The sign is present if the sound is not
transmitted normally over the lesion site. If the lesion is semisolid, the sounds will be less distinct, duller
and less intense than the normal side. If the lesion is more dense, the sounds will be sharper, more
distinct and intense than the normal side.
The Manual Percussion Test . On this test, the patient is prone with the arms hanging over the sides of
the table with a firm pillow propping up the area to be examined. The examiner manually percusses
each spinous process in the area of the main complaint with up to 15 pounds of downward pressure.
The test is positive when this action duplicates and aggravates the pain of the main complaint. A positive
test indicates a vertebral sprain/strain.
Mennell’s Test This is a two stage test, with the second stage dependent upon the first. The first stage
has the examiner’s thumbs over the prone patient’s posterior superior iliac spines. The thumbs are slid
outward and inward as far as the superficial tissue laxity will allow. If the inward or outward pressure
elicits tenderness and/or a reduplication of the pain of the main complaint, then the test is considered
positive. Outward tenderness indicates sensitive deposits (myofascitis) of the gluteal aspect of the
posterosuperior spine. If the pain and/or tenderness is elicited at the inward pressure, then the second
stage is performed on the side or sides of the tenderness. In this second stage, the examiner first pulls
the pelvis backwards and then pressures the pelvis forward. When the tenderness increases with the
backward pressure but decreases with the forward pressure, then the significance of the inward
tenderness is substantiated, indicating superior sacroiliac ligament strain due mostly to sprain or
subluxation.
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Murphy’s Punch Test In this test, the patient can either be sitting upright or standing. The examiner,
using the edge of the hand or the thumb, gives short jabbing blows under the twelfth rib posteriorly on
either side. If this results in lancinating pain which either shoots straight through anteriorly or goes
around the chest wall, the test is considered positive, indicating deep seated tenderness and muscular
rigidity, as in kidney inflammation.
The Percussion Test This test has the patient seated and bent over facing the floor. The examiner,
standing behind the patient, strokes the spinous processes with a reflex hammer within and outside the
main area of complaint, first moving superiorly, then moving inferiorly. This is then repeated on the
paraspinal musculature in the same manner. The test is considered positive when the percussion
reproduces or aggravates the pain of the main complaint. If the pain occurs on percussing the spinous
process, it is indicative of joint lesion, such as sprain, subluxation, dislocation, etc. If the pain occurs on
percussing the spinal musculature then it indicates a soft tissue lesion, such as a strain, rupture, etc.
Thompson’s Test This test has the prone patient’s feet hanging over the edge of the examining table.
The examiner squeezes the calf muscles on the affected side just below the widest part of the posterior
portion of the leg. The test is positive when this action does not cause a reflex plantar flexion of the
foot, indicating a complete rupture of the Achilles Tendon.
Upper Extremity Tests:
Codman’s Sign This test is performed on patients with shoulder complaints. The examiner passively
abducts the arm on the side of the complaint. The sign is considered present when the abduction can be
done without pain and a sudden release of the patient’s arm (with it above the horizontal, which causes
the deltoid to suddenly contract) causes shoulder pain and a hunching of the shoulder due to the
absence of rotator cuff function. The sign is indicative of a rotator cuff tear (Rupture of the
Supraspinatus Tendon)
Cozen’s Test The examiner has the patient clench the fist tightly while dorsiflexing it. The patient
maintains that position while the examiner then grasps the lower forearm and applies pressure counter
to the dorsiflexion posture of the patient. If this action causes acute lancinating pain in the lateral
epicondyle region, the test is considered positive, indicating Tennis Elbow (Epicondylitis; Radiohumeral
Bursitis)
Dawbarn’s Sign This test has the patient standing with the arms hanging loosely at the side. The
examiner deeply palpates the patient’s shoulder eliciting a localized tender area. The examiner, while
leaving the finger on the painful spot, passively abducts the patient’s arm. This sign is present when the
painful spot disappears on abduction, indicating Subacromial Bursitis.
Dugas’ Test is used to rule out a shoulder dislocation.
Hamilton’s Ruler Test This test is considered positive if a straight edge, such as a ruler or a yardstick, can
rest on the acromial tip and the lateral epicodyle of the elbow at the same time. A positive test is
indicative of a shoulder dislocation.
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Impingement Sign The patient’s arm is moved through flexion while in a slightly abducted position. This
results in a jamming of the greater tuberosity against the acromial surface. Pain at the shoulder is a
positive sign suggestive of overuse injury of the supraspinatus and/or biceps muscle tendon.
Maisonneuve’s Sign This sign is present when there is marked hyperextensibility (Dorsiflexion) of the
hand, which is one of the symptoms of Colles’ Fracture.
Mill’s Maneuver The patient fully extends the elbow while fully flexing the wrist and fingers. Then the
patient maximally pronates the forearm. If this action causes sharp tenderness and pain at the lateral
elbow joint, then the test is considered positive, indicating Radiohumeral Epicondylitis (Tennis Elbow).
This test is considered to be the classic maneuver for Tennis Elbow, because the action will only
aggravate a true “Tennis Elbow”, and no other lesion.
The Shoulder Compression Test The patient sits upright and the examiner palpates the distal apex of
the coracoid process and marks it. The examiner then applies downward pressure over the marked area.
When this action produces symptoms similar to neurovascular compression of the Subclavian Artery and
Brachial Plexus, the test is considered positive indicating Coracoid Pressure Syndrome identical to a
hyperabduction type of Thoracic Outlet Syndrome.
The Supraspinatus Press Test On this test, the seated patient hangs the upper extremities limply at the
sides. The examiner, using the thumb, presses toward the midline at a midclavicular point above the
scapular spine. If this causes or exacerbates shoulder pain, then the test is considered positive, which is
indicative of a Rotator cuff tear of the Supraspinatus Tendon.
Yergason’s Test This test has the examiner facing the seated patient and slightly lateral to the upper
extremity being tested. The patient, with the palm facing upward, makes a fist and bends the elbow to
about 90 degrees. The examiner palpates over the bicipital groove while clasping the patient’s fist. The
examiner then internally and externally rotates the patient’s arm while also keeping the patient from
further flexing the elbow. If this action causes a painful palpable and/or audible click or snap, which is
the bicipital tendon slipping in and out of the bicipital groove, then this test is considered positive, which
indicates a loss of stability of the Biceps’ Tendon.
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Hip Lesion Tests:
Ely’s Heel to Buttock Test This test is a two stage test done with the patient in a prone position. First the
knee is flexed to the opposite buttock. Then the thigh is hyperextended. If this action cannot be
performed normally, then the test is positive, indicating one of the following: a hip lesion, irritation of
the Iliopsoas muscle or its sheath, inflammation of the lumbar nerve roots, or the presence of lumbar
nerve root adhesions.
The Hip Abduction Stress Test On this test, the patient lies on the non-affected side and actively
abducts the affected limb at the hip. The patient holds the limb in abduction while the examiner exerts
downward pressure on it. If this action brings on pelvic pain, then the test is considered positive,
indicating a sacroiliac lesion.
Laguerre’s Sign This test is done with the patient supine while the thigh and knee are flexed to right
angles. Then the thigh is abducted and rotated outward. This forces the head of the femur against the
anterior portion of the hip joint capsule. The sign is present when this action produces pain, tending to
rule out a lumbosacral lesion, but indicating a hip joint lesion, iliopsoas muscle spasm or a sacroiliac
lesion.
Patrick’s Test Performed with the patient supine, the examiner places the external malleolus over the
patella of the opposite limb. Then downward pressure is applied to the thigh. When pain results from
this action, particularly in the hip flexor area, the test is positive. A positive test suggests hip joint
disease, because this action antagonizes hip flexor spasm brought on by an inflammatory lesion. This
test is also known as the FABER or FABERE Sign from the acronym of the maneuver: Flexion, Abduction,
External Rotation and Extension.
Thomas’ Test On this test, the examiner maximally flexes the supine patient’s hip and knee of the side
opposite to the side being tested, bringing the knee to the patient’s chest. The examiner then has the
patient clasp the knee in order to maintain this posture. If this action causes the hip and knee of the
opposite limb to elevate off the table, the test is considered positive. Normally, the opposite limb should
have enough hip flexor stretch to allow the thigh to continue to lie flat on the table during this action.
Thus a positive test indicates flexor tightness or flexion deformity of the hip.
Trendelenburg’s Test In this test, the patient stands on one foot, using a wall or chair for support. The
patient then lifts the opposite knee above waist level. The test is done bilaterally. This action will
normally elevate the gluteal fold and pelvis of the side being lifted above that of the standing leg side.
When the gluteal fold and pelvis on the side being lifted are lowered, the test is considered positive,
indicating a gluteal (abductor) insufficiency on the standing leg side.
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Hamstring Tests:
The Lewin Standing Test This test has the patient standing on a short stool or platform with the
examiner stabilizing the patient’s pelvis from behind with one hand. The other hand sharply pulls the
patient’s knee (on the same side) into extension. This action is repeated on the opposite side. Then the
examiner braces his or her shoulder against the patient’s sacrum and pulls both knees into extension. If
any of these actions results in pain followed by either or both knees snapping back into flexion, then this
test is considered positive indicating unilateral or bilateral Hamstring spasm.
Neri’s Bowing Sign Is used to rule out unilateral tight and spastic hamstrings, which would be indicative
of sacroiliac, lumbosacral or lumbar lesions. This sign is fairly constant in lumbar radiculopathy and may
also be present in sciatic peripheral neuropathy.
The Tripod Sign is used to rule out tightness of the hamstring muscles, which exists in almost any spinal
irritation from the midthoracic area to the sciatic notch.
Lower Extremity Tests:
The Abduction Stress Test On this test, the supine patient’s knees are in complete extension. The
examiner places one palm against the lateral aspect of the knee at the joint line of the side being tested
and with the other hand the examiner grips the ankle pulling it laterally, thus opening the medial side of
the joint. If this action causes no pain, then the examiner repeats it with the knee in approximately thirty
degrees of flexion, which puts the knee joint maximally vulnerable to a torsion stress. If either of these
actions produces or exacerbates pain, below, above or at the joint line, then the test is considered
positive, indicating a medial collateral ligament injury.
The Adduction Stress Test This test is done with the patient supine and the knees in complete
extension. The examiner places on palm against the medial aspect of the patient’s knee (opposite to the
one being tested) at the joint line. With the other hand the examiner grips the ankle, pulling it
medialward, thus opening the lateral side of the joint. If this action causes no pain, then the examiner
repeats it with the knee in approximately thirty degrees of flexion, which puts the knee joint maximally
vulnerable to a torsion stress. If either of these actions produces or exacerbates pain, below, above or at
the joint line, then the test is considered positive, indicating a lateral collateral ligament injury.
The Apley Test This test involves four steps. If any or all of them elicit knee pain or clicking, the test is
considered positive. In Step 1, the patient is in a prone position with the ankles hanging over the end of
the table. The examiner grasps the foot, strongly rotating the leg internally flexing the knee past ninety
degrees. Step 2 is the same as Step 1, except the leg is rotated externally. On Step 3, the examiner
anchors the patient’s thigh to the table by placing his own knee in the patient’s popliteal space
cushioned by a pillow or towel while strongly lifting up on the foot, followed by rapidly rotating the leg
internally and externally. Step 4 is the same as Step 3 except the examiner pushes downward instead of
lifting. A positive test is indicative of a meniscus tear
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The Childress Duck Waddle Test On this test, the standing patient first attempts to fully squat with the
legs somewhat apart and in maximal internal rotation. The action is then repeated with the legs in
maximal external rotation. If either of these actions results in pain or if the patient is unable to fully flex
the knee and/or if there is a clicking sound on either posterior side of the joint, then the test is
considered positive, indicating a medial or lateral meniscus tear.
Dreyer’s Sign On this test, the supine patient attempts to actively raise the affected leg with the knee
fully extended. If the patient is able to perform this action only when the examiner applies forceful
extension to the thigh using the flat of the hands which gives anchorage to the patient’s quadriceps,
then the sign is considered present. The sign indicates a fracture of the patella.
Ely’s Sign On this test, the prone patient’s knee is flexed toward the buttock on the same side. If the
pelvis rises off the table and the thigh goes into abduction at the hip joint, both somewhat in unison
with the knee flexion, then this test is considered positive, indicating a Rectus Femoris and/or lateral
thigh fascia contracture.
Hennequin’s Sign This sign is present when digital compression by the examiner below Poupart’s
(inguinal) ligament, lateral to the major vessels, causes pain, tenderness and crepitation. If the sign is
present, it indicates a fracture of the neck of the femur.
The Anterior Foot Draw Sign This test is done with the patient seated on an examining table with the
legs hanging over the table’s edge. The examiner places one hand around the anterior aspect of the
lower tibia just above the ankle. The other hand grips the calcaneus. While pushing the tibia posteriorly,
the calcaneus (and talus) is drawn anteriorly. This sign is present when the above action causes the talus
to slide anteriorly from under cover of the ankle mortise, indicating anterior talofibular ligament
instability, usually secondary to rupture.
Hoffa’s Sign This test has the prone patient’s ankles hanging over the edge of the examiner’s table. By
movement and palpation, the examiner checks the Achilles Tendon on the involved side to see if it’s less
taut than the other side as well as checking for increased dorsiflexion in the relaxed position. If either of
these is the case, then the sign is present, indicating an avulsion fracture of the calcaneus. A loose
fragment may also be seen and/or felt behind either malleolus.
The Metatarsal Test This test has the seated patient’s lower limbs straight out with the feet extending
over the table. First, the examiner forcibly extends the outer four toes so that the ball of the foot is
made prominent. Then the examiner percusses the protruding metatarsophalangeal joints of the outer
four toes with a reflex hammer. When this action causes neuritic pain, the test is considered positive,
indicating Anterior Metatarsalgia due to inflammation of the metatarsophalangeal joints.
Strunsky’s Sign This test has the patient supine with one foot resting in the examiner’s hand. With the
other hand the examiner grasps the patient’s toes and flexes them suddenly. Normally, this action
produces no pain. When it causes lancinating pain, the sign is present, indicating inflammation of the
anterior arch of the foot, mainly the Metatarsophalangeal Joints.
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Circulatory Disorder Tests:
Adson’s Maneuver . On this test, the patient is seated while the examiner palpates the radial pulse to
determine its rate, force and amplitude. The examiner then has the patient rotate the head to the side
being tested, followed by elevating the chin as high as painlessly possible, and finally taking a deep
breath and holding it for about 10 seconds. The test is positive when this action stops or diminishes the
radial pulse rate. If the above maneuver is negative the test should be repeated with the patient
rotating the head opposite to the side being tested. A positive test indicates a subclavian artery
compression commonly caused by a cervical rib thoracic outlet syndrome and/or scalenus anticus
syndrome.
Allen’s Test This test has the patient seated with the forearms resting on the thighs and the palms facing
up. First the patient makes a fist on the side being examined, then the examiner digitally occludes either
the radial or ulnar arteries right next to the wrist while the patient maintains the clenched fist. Next,
with the examiner maintaining the occlusion, the patient opens the hand. Normally, the color returns to
that hand in ten seconds or less. The test is considered positive if there is a delayed color return during
digital compression, indicating a partial blockage, or if there is no color return until the examiner
releases the wrist which indicates a complete blockage of the artery which is not being compressed.
Buerger’s Test This test measures arterial blood supply to the lower limbs. The examiner straight leg
raises the supine patient’s leg to about 45 degrees for no less than three minutes. The examiner then
lowers the limb and has the patient sit up with both legs hanging over the examining table. The test is
considered positive if the dorsum of the foot blanches and any prominent veins collapse when the leg is
initially straight leg raised, or if after lowering the leg it takes one or two minutes for a ruddy cyanosis to
spread over the affected part and for the veins to once again become prominent, either of which
indicates a deficient blood supply.
George’s Test Many doctors use this test before attempting any high velocity cervical manipulation. The
supine patient extends the head and neck over the edge of the table. With eyes open the patient
actively rotates the head and neck while maintaining the extended position. One or more of the
following indicates a positive test: either blanching or cyanosis of the face, nystagmus, sweating,
dizziness, nausea, headache or an increase of temperature. Until vascular disorders are ruled out by
further examination, a positive test would indicate that cervical manipulation involving rotation and/or
extension is contra-indicated.
Homan’s Sign This test is done with the patient supine with the knee extended. When dorsiflexion of the
ankle by the examiner causes a localized deep pain either in back of the calf or behind the knee, the sign
is considered present, indicating Thrombophlebitis (thrombosis of the deep veins of the leg).
The Moskowicz Test In this test, the patient’s extremity being tested is wrapped firmly with an elastic
bandage, elevated and held there for 5 minutes. The extremity is then released and quickly unbandaged.
Normally, the blood rapidly flows back into the area as the bandage is removed, seen by a hyperemic
blush. The test is considered positive when the blush is either absent or slight and lags behind the
unbandaged area, indicating an inadequacy of collateral circulation, as in an arteriovenous fistula.
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Wright’s Test This test is usually performed after the Allen’s Test in order to rule out other underlying
pathology which would be indicated by the Allen’s Test. The seated patient has both arms hanging at the
sides, with the examiner behind the patient. The examiner palpates the radial pulse during 180 degrees
of active and then passive abduction of both arms, while noting at how many degrees of abduction the
radial pulse on the affected side diminishes or disappears when compared to the opposite side. If this
action diminishes or eliminates the radial pulse, the test is considered positive, indicating a
neurovascular compression of the Axillary Artery as seen in the Hyperabduction Thoracic Outlet
Syndrome.
Tests for Malingering:
Burn’s Bench Test On this test, the patient kneels upright on the examining table or a padded bench
that is about eighteen to twenty inches high. The examiner firmly grasps the patient’s ankle from behind
and instructs the patient to bend over and touch the floor with the fingertips. Patient’s who normally
cannot be expected to carry out this action are those extremely weak from injury or disease or those
significantly diseased at the hip or knee. Those patients who may be able to perform the action are
those with sciatic neuralgia, congenital anomalies, arthritis, a specific disease of the spine (such as
tuberculosis), or a compression fracture of the spine. Any patient (other than those mentioned above
who cannot be expected to carry out this action) either refuses to perform the action or claims they can
only go part way, is presenting evidence of malingering or hysteria.
Hoover’s Sign When the patient is alleging unilateral lower limb paralysis, the examiner places the
hands under the heels of the supine patient. The patient is then asked to lift the paretic leg. If the leg is
truly weak or paralyzed, the patient will involuntarily push downward with the non-affected leg, which
would be felt as pressure on the examiner’s hand. The sign is present if no counterpressure can be felt
by the examiner on the healthy side, which is evidence of malingering or hysteria.
Lasegue’s Sitting Test is used for indicating low back radiculopathy, spasmophilia or lumbar disc
herniation. This test has the patient sitting upright on the edge of an examining table or bench without a
backrest. The examiner extends the patient’s legs below the knee one at a time, so each limb is parallel
with the floor. If there is no radiculoneuropathy, the patient should experience no discomfort from this
action. This is a modification of the Lasegue Straight Leg Raise. It has advantages when checking for
malingering, because the test can be performed without the patient knowing what is being tested. This
version can be used on those patients where simulation, falsifying or magnification of symptoms is
suspected.
Magnuson’s Test This test is performed when malingering or hysteria is suspected in the patient with
low back complaints. The patient points to the site of the pain which in turn is marked by the examiner.
The examiner then performs other actions away from the marked site of pain. The test is positive if
there is any significant change of the pain site once the examiner resumes the examination of the low
back. A positive test would indicate evidence of simulated pain, hysteria or malingering.
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