All ortho tests - Part 4 board review

*wall pushup test* For scapular stability

Pt stands arms length from wall and asked to do 15-20 pushups off it (+) weakness and/or scapular winging (usually b/w 5-10) ind: weakness of scapular stabilizers, neuropathy (long thoracic nerve)

thigh thrust test

Pt supine and Dr passively flexes hip to 90 •one hand palpates SIJ underneath while the other thrusts (pushes) down thru knee and hip (long axis compression) •bilateral (+) SIJ pain same side IND: SIJ syndrome

Milgram's Test

ask pt to raise both limbs up until heels are 6" off table and hold for 30 seconds if they can (+) LBP is felt or pt cant do it ind: herniated disc or facet syndrome

*compression rotation test*

compress into joint then passively int/ext rotate •Pt is supine with arm abducted 20-90° and elbow flexed to 90° •dr applies axial load (use thigh to compress) while passively rotating humerus internally/externally •bilateral (+) clicking, pain or catching sensation ind: torn labrum

Gaenslen's

Pt supine with side being tested on edge of table •pt leg flexed onto their chest; opposite leg extended off the table •apply pressure to each limb to shear SIJ (+) P in SIJ on extended leg side ind: SIJ syndrome, infection, sprain

GH instability cluster

(+) apprehension (+) relocation

Cluster for Glenoid Labral tears (CARLS)

(+) crank test (+) anterior apprehension (+) Relocation (+) Load and shift (+) sulcus sign

clusters for SIJ pain

(+) distraction (SI stretch test) (+) thigh thrust (+) gaenslens (+) sacral thrust (+) iliac compression (+) distraction (SI strectch test) (+) thigh thrust (+) sacral thrust (+) iliac compression

AC pathology cluster

(+) forced cross flexion (+) AC resisted extension (+) Active compression of O'brien

SIS cluster

(+) neer (+) P arc (+) empty can (+) Hawkins Kennedy weak external rotation

*Clinical prediction rule of anterior ankle impingement*

1. anterolateral ankle tender 2. anterolateral ankle swelling 3. pain with forced dorsiflexion 4. pain with single leg squat on affected side 5. pain with activities 6. absence of ankle instability

indications to palpate arterial pulses

1. ischemic P distal to compromised arterial supply 2. pt with vascular dz, arteriosclerosis and diabetes 3. pulses distal to a trauma site (ex: distal patency)

*clusters for patellofemoral dysfunction*

1. pain with resisted extension 2. pain with squatting 3. peripatellar palpation with pain

*clusters for ACL rupture*

1. pt history 2. (+) anterior drawer (when you pull) 3. (+) Lachmans (also pulling) 4. (+) lateral pivot shift 4/4... sensitivity = 1, specificity = 1

12 arterial pulses listed out (palpate with finger pads only)

1. temporal: up 45° and about 2" back from outer canthus of eye 2. mandibular: about 1/3 up mandible from tip of chin 3. carotids: palpate towards base of neck, away from bifurcation 4. antecubital: medial antecubital fossa (continuation of brachial artery) 5. radial: radial aspect of palmer wrist 6. ulnar: ulnar aspect of wrist 7. abdominal aorta: wide knife edge contact, one hand runs slightly to right of umbilicus and the other is left of it. Start with wide contact and move them closer together 8. iliacs: pt supine, palpate deep into tissue at midpoint of inguinal ligament, about 1-2" above it 9. femorals: pt supine, fairly deep pressure below inguinal ligament, on groin side of midpoint of ligament 10. popliteals: pt supine or prone with knees flexed. both hands reach into fossa on one leg, reach deep into tissues 11. posterior tibial: pt supine, palpate behind medial malleolus 12. dorsalis pedis: pt supine, finger pads on top of foot in bw 1st and 2nd extensor tendons

*posterior impingement test* aka *posterior labral tear test* aka *posterior apprehension test*

Pt supine, end of table with legs off •dr extends pts hip and adds external rotation + abduction •bilateral (+) deep hip joint pain ind: FAI/femoroacetabular impingement

sacral thrust test aka prone springing or sacral apex pressure

Pt prone, Dr puts base of hand on center of sacrum and applies P-A force (+) P over SIJ IND: SIJ syndrome

Hautant's test

Pt seated w both arms flexed to 90°, forearms supinated Pt closes eyes, ext and rot head; hold 10-30 sec do opp direction if first side is neg (+) arms drop down into pronation ind: VBI or cerebellar dysfunction

*AC resisted extension text*

Pt seated with arm at 90 flexion, internal rotation and elbow at 90 flexion, -dr stands behind and with one hand stabilizes shoulder, the other contacts distal arm -pt instructed to horizontal abduct arm against dr's resistance "push elbow into my hand" -bilateral (+) pain at the AC ind: AC sprain (note: sprain needs an MOI)

*skin rolling test*

start around 11th rib and pick up skin and roll it towards iliac spine (+) hypersensitivity ind: Maigne's syndrome (facet syndrome and T/L junction)

Lewin Standing Test

•pt is asked to flex forward •if one or both knees flex, pull knee back into extension (first one, then both, then together) (+) pain is elicited and one or both knees snap back into flexion ind: unilateral or bilateral hamstring spasm or possible radiculopathy

*talar tilt*

•pt either supine or side lying with knee slightly flexed •ankle is held at 90° (anatomical position) and talus is tilted from side to side into eversion and inversion •bilateral (+) excess motion of the talus

Gerber's aka Lift-Off Sign

•pt hand *actively* placed against mid-lumbar spine, palm out, then rotate hand away from back •if they can do this, apply some resistance to it back toward spine •bilateral (+) inability to lift hand off spine or inability to resist load ind: subscapularis strain/tendinopathy

*anterior slide*

•pt instructed to put hands on hips •Dr stabilizes shoulder with one hand and the other contacts humeral head •apply anterosuperior force on humeral head •bilateral (+) anterosuperior pain and/or click ind: superior labral anterior posterior (SLAP) lesion

*stoop test*

have pt walk briskly for about 50m or until sx start. Once they do, ask pt to flex forward and continue walking (slouched) to see if sx change (+) sx are relieved in flexion ind: neurogenic claudication (canal stenosis)

brudzinski sign (test for meningeal irritation)

head piece of table in neutral -pt supine and dr slowly flexes neck (+) reflex flexion of both knees and hips, or extension of low back ind: meningitis or nn root involvement

cervical distraction test (radiculopathy)

lift pt head (+) exacerbation or relief of P ind: •worse: sprain/strain •better: radiculopathy or facet imbrication

*triangular fibrocartilage compression test*

-stabilize forearm with one hand and other passively ulnar deviates wrist -apply long axis compression to wrist, bilaterally done (+) pain in region of ulnar styloid process ind: tear of TFC

carrying angle

-anatomical position, relaxed -measure center of ulnohumeral joint with goniometer normal: M 5-10°, F 10-15° if >15° = cubitus valgus <5-10° = cubitus varus

schepelmann's

-ask pt to laterally flex (side bend) -bilateral (+) pain on either concave or convex side ind: pain on concave side = *neuritis* pain on convex side = *strain or pleurisy*

beevor's sign

-drape them appropriately and expose belly button -tell them to put arms behind their neck or across their chest -stabilize their legs with your arms -ask them to do a half sit-up, holding it for 5 seconds while observing the belly button (+) belly button migrates to intact side ind: LMNL for roots that innervate the opposite quadrant from which the belly button moved. Could be T6-T12

Sciatic tension test AKA *Deyerle's Sign*

-extend pt knee to the point of P -flex knee slightly or until P is less or alleviated (must ask the pt) -Place fingers in posterior thigh and popliteal fossa and try to recreate stretch on nerve by pushing it into the femur and down towards the fossa -bilateral: (initial leg raise is performed bilateral, if no P, test is stopped) (+) radicular P ind: L4/5, S1/2/3 radiculopathy (most likely L5, S1)

Ligamentous instability test

-flex pt elbow slightly 20-30° -palpate joint line with one hand -gently apply valgus force to the elbow -then apply varus force -bilateral (+) gapping along either medial or lateral joint line ind: medial (ulnar) or lateral (radial) collateral sprain

grip strength test

-have pt squeeze 2 of your fingers in each hand at the same time -then as them to pick up small obj like pencil with their thumb and each finger -precision grip performed with both hands (+) unequal pressure on drs fingers or inability to pick up small object with precision ind: lesion to nerve root, peripheral nn, muscular lesion, bony lesion etc

*finger extension test aka Shuck test*

-hold their wrist in flexed position with fingers extended -apply pressure to extended fingers and ask pt to resist the motions -bilateral (+) pain in the wrist ind: radiocarpal, midcarpal or scaphoid instability, inflammation or Keinboch's dz

Adam's position

-inspect and palpate for rib hump and scoliosis -instruct pt to bend forward; re-inspect and palpate again -make sure not to stand right behind them and to tuck their gown (+) sclerosis or rib hump is reduced or maintained with flexion ind: scoliosis is same with flexion = *structural scoliosis* reduction = *functional scoliosis*

bechterew's test (*tripod sign*)

-instruct pt to extend each leg separately; if no positive findings then -they extend both legs at the same time (+) radicular pain, and/or inability to perform due to P, and/or pt leans back on both hands forming a *tripod sign* with extension of either one leg and/or both ind: L4/5, S1/2/3 radiculopathy (most likely L5, S1)

Phalen's

-instruct pt to place back of their hands together (max wrist flexion) and hold position for 1 min (+) reproduction of paresthesias in median nn distribution ind: Carpal tunnel syndrome

Reverse phalen's aka Prayer test

-instruct pt to put palms together and lower them down towards waist, hold for 1 min (+) reproduction of paresthesias in median nn dist. ind: Carpal tunnel syndrome

forestier's bowstring sign (board review)

-instruct pt to side bend -then in opposite direction (+) severe limitation in side bending to one or both directions ind: possible ankylosing spondylitis or pathology causing mm spasm/contracture

Heel walking

-instruct pt to walk about 10 ft towards me on your heels -dr walks closely in front and watch for toes to drop (+) toes drop ind: L4 or L5 radiculopathy, common fibular neuropathy, problem with tibialis anterior musc or extensor hallicis, extensor digitorum

Freiberg's sign

-internally rotate limb and perform SLR -if P, stop here and *externally rot* limb in that SAME POSITION and ask if this changes sx aka feels better -if it feels better, continue up in external rotation -bilateral (+) sx are relieved by ext rot of the hip ind: possible Piriformis syndrome

Amoss's sign (board review)

-let me know if any sx are produced when moving from side lying to seated position -pt is lying on side and asked to sit up (+) localized thoracic or thoracolumbar pain is produced ind: suggests ankylosing spondylitis, severe sprain, IVD syndrome

Neer Impingement test

-passively and forcibly elevate arm fully in scaption with medial rot -bilateral (+) pain in anterior shoulder ind: SIS

Dawbarn's sign

-pt arm by side, palpate for point tenderness -if found, keep pressure on it and passively abduct arm -bilateral (+) sign is present if tenderness goes away or decreases with arm abducted ind: subacromial bursitis note: shoulder may still hurt in general but point tenderness decreases

Neri's bowing sign

-pt directed to bend forward (bow) (+) pt flexes knee on affected side, bc trunk flexion puts traction on the involved nn root creating radicular P ind: L4/5, S1/2/3 radiculopathy (most likely L5 or S1)

Cozens (lateral epicondylopathy)

-pt elbow flexed to 90 at side of body with forearm pronated and wrist extended ("go away cousin" -palpate just at and distal to lateral epicondyle with one hand -contact pt hand and apply resistance to wrist extension -bilateral (+) pain around lateral epicondyle ind: lateral epicondylitis

*test for pronator teres syndrome*

-pt elbow flexed to 90 w forearm in neurtral or supination -pt asked to pronate their forearm against your resistance while passively extending their elbow -bilateral (+) parethesias into hand following entire median n distribution ind: pronator teres syndrome

Mills (lateral epicondylitis)

-pt elbow flexed, forearm supinated, wrist flexed -palpate just at and distal to lateral epicondyle -passively pronate and extend elbow while maintaining full wrist flexion -bilateral (+) pain around lat epicondyle ind: lateral epicondylitis

Golfer's elbow aka Medial Epicondylitis test (spiderman likes to golf)

-pt elbow flexed, forearm supinated, wrist flexed -palpate just at and distal to medial epicondyle -passively extend wrist and elbow fully -bilateral (+) pain over medial epicondyle ind: medial epicondylitis

*watson test*

-pt elbow resting on table and forearm pronated -hold/palpate scaphoid with one hand -position pt wrist in ulnar deviation and slight extension (by contacting MCP) -move the wrist into radial dev and flexion feeling for scaphoid to slip out and back in (+) dorsal pole of scaphoid subluxates over rim of radius and provokes pain ind; unstable scaphoid

elbow flexion test

-pt fully flex elbows, with wrist neutral or slight extension -pt instructed to hold position for 3-5 minutes or until sx are produced (+) pain and/or paresthesias that follow distribution of ulnar nerve ind: cubital tunnel syndrome

Finkelstein

-pt instructed to make fist with thumb inside -stabilize forearm and ulnar deviate the wrist -bilateral (+) acute P in anatomical snuff box ind: stenosing tendosynovitis of abductor pollicis longus and/or extensor pollicis brevis AKA dequervains dz

sternal compression test

-pt seated or supine -apply A-P pressure on the sternum (+) localized pain in ribs ind: rib fracture

sitting root test AKA Lasegue Sitting

-pt seated with *chin tucked* and *passively* extend their legs -bilateral (+) radicular P in elevated leg ind: L4/5, S1/2/3 radiculopathy (most likely L5, S1)

spinous percussion (board review)

-pt seated with spine slightly flexed -start away from pain and works toward it form both directions -percuss each SP with hammer (+) acute localized pain or radicular P ind: localized = fx of involved segment, radicular = possible disc lesion

passive scapular approximation test

-pt side lying or prone -approximate scapula by lifting shoulders up and down (+) pain in scap region ind: T1 or T2 nn root problem on the side of P

*posterior internal impingement test*

-pt supine -hold wrist with one hand and elbow w other -arm abducted to 90 in *scaption* and maximal external rotation applied -bilateral (+) *localized p in posterior shoulder* ind: impingement of cuff against posterior glenoid and labrum note: pt complains of posterior pain in late cocking and early acceleration of throwing with this condition

*thumb ulnar collateral lig laxity test*

-stabilize thumb in extension with one hand (palm down) -other hand applies valgus stress to the MCP -bilateral (+) if valgus mvmt is >30° or between 15-30° ind: >30 means complete tear of ulnar coll lig and accessory coll lig 15-30 = partial tear of ulnar coll lig

Hawkins-Kennedy Impingement test

-support elbow w one hand while stabilizing scap with other -passively flex arm/elbow to 90 and internally rotate -bilateral (+) pain anterior shoulder ind: SIS (possibly supraspinatus)

Tinel's sign of the wrist

-tap median nn in carpal tunnel bilateral (+) reproduction of pain and/or paresthesias in median nn distribution ind: carpal tunnel syndrom

tinel's sign (elbow)

-tap ulnar n in either the epicondylar groove or cubital tunnel -use good hammer technique -bilateral (+) pain and/or paresthesias in ulnar n distribution ind: cubital tunnel syndrome or regeneration of the nerve

Tinels sign of Hand

-tap ulnar n in tunnel of guyon bilaterally (+) reproduction of P and/or paresthesias in ulnar nn dist. ind: tunnel of Guyon syndrome, ulnar neuropathy

costovertebral expansion (chest mensuration)

-tell pt to take a deep breath (or exhale completely), let me know your sx -tape measure placed under armpits at 4th ICS -measure them at full inspiration and again on full expiration (+) <3cm or 1" change ind: ankylosing conditions; rib problems or lung pathology *note: if test is (+), repeat mensuration under the armpits, at nipple line or xiphisternal junction (midthoracic) and at T10

*beighton Hypermobility test*

-thumbs can bend backward to touch forearm (1 pt for each thumb) -little fingers can bend back >90° (1 pt for each) -elbows can hyperextend 0° (1 pt for each) -knees can hyperext past 0 (1 pt each) -can bend and place hands flat on ground without bending knees (1 pt) (+) score of 4+ out of 9 ind: generalized joint hypermobility

*clusters for meniscal tears* there are 2 clusters

1. Tenderness to palpation of joint line 2. (+) Bohler 3. (+) Steinmann's 4. (+) apleys compression/grinding 5. (+) payr test 6. (+) mcmurrays test 2/6 (sens .97, spec .87) 1. joint line tenderness 2. (+) Thessaly almost 100% MENISCAL TEAR!!

Clinical Prediction Rule for *cervical myelopathy* (3/5 = 95%)

1. (+) babinski 2. (+) inverted supinator sign 3. (+) hoffman sign 4. (+) gait dysfxn 5. >45yo

Clusters For RTC (3)

1. (+) codman (drop arm) 2. (+) Lat Rotation (Infraspinatus) 3. (+) painful arc 4. >60 yo 1. (+) empty can (supraspinatus) 2. (+) Lat rotation (infraspinatus) 3. (+) Hawkins-Kennedy *absence of these 3 = R/O RTC* 1. (+) empty can 2. weak external rotation 3. (+) Hawkins-Kennedy

clinical prediction rule for cervical radiculopathy (4) (Dx requires 2 signs, 2 sx, and imaging)

1. (+) upper limb tension test 1 with 1 of the following: -sx reprod -side-to-side difference >10 deg in elbow ext -with regard to involved side: ipsi neck lat flex decreases sx and/or contra neck lat flex increases sx 2. (+) spurling's (sx reprod) 3. (+) distraction (sx reduced) 4. cervical rot < 60 to ipsi side

painful arcs during shoulder *abduction*

70-120° may be rotator cuff tendinopathy (supraspinatus) 160-180° may be AC joint problem

swallow test

As if it relates to solids, semisolids, and/or liquids have pt swallow and observe how they do (+) dysphagia or aphagia ind: anterior osteophytes, DISH diffuse idiopathic skeletal hyperostosis, tumor, hematoma or edema, and/or lesion to CN 9/10/12

*magnuson's test* (malingering)

Ask pt to paint to where P is. Mark the area and then do some other tests. Ask them to point to Pain again (+) and change in location >1-2cm ind: malingering, simulated pain, hysteria

*Allis aka Galeazzi Sign*

DRAPING IS IMPORTANT •instruct pt to lie supine with hips/knees flexed and malleoli approximated (feet parallel) •dr observes from both the side (femur length) and head of the table (for tibial) (+) femur protrudes farther caudally and/or tibia protrudes higher ind: femoral length discrepancy and/or tibial length discrepancy (congenital hip dysplasia)

Hibb's test

Dr fully flexes knee and internally rotates hip •bilateral (+) P in SIJ or at hip joint ind: SIJ syndrome, infection, sprain, hip joint capsulitis, arthritis etc

Wrist ROM

Flexion: 80-90 Extension: 70-90 Ulnar deviation: 30-45 radial deviation: 15

*mannkopf's sign*

Get the pt's RHR. radial pulse. Without moving, apply pressure to the site of P while monitoring the rate (+) normally P should increase HR by 10+; if the P is simulated/faked, this will not occur ind: malingering or simulated pain

Wartenberg's sign

Instruct pt to bring fingers together. Passively spread fingers and instructs pt to bring them together (+) inability to adduct little finger (it remains abducted) ind: ulnar neuropathy

Piriformis test

Pt is side-lying, close to front edge of table so knee is over side of table •hip flexed to 90 which knee bent close to you (similar to side lying lumbar adjustment) •one hand on pelvis for stabilization (keeping pt straight) while the other puts downward pressure on pt's knee •bilateral (+) local buttock P or radicular P ind: buttock P = piriformis spasm radicular P= possible piriformis syndrome

Shoulder Rock test aka *Mazions shoulder test*

Pt palm on opp clavicle and told to lift their elbow up towards head done bilaterally (+) shoulder pain aggravated or produced ind: shoulder pathology

Rust sign

Pt presents with head held between hands to prevent head or neck motion If present, usually indicates severe cranial or cervical pathology

Yeoman's

Pt prone Grasp one knee, while other stabilizes over pts ipsi SIJ •passively extend hip while applying P-A pressure on SI •bilateral (+) SIJ P ind: SIJ syndrome, infection, sprain

*anterior impingment test* aka *FADIR impingement test* aka *anterior apprehension test* aka *anterior labral tear test* (popular test)

Pt supine, give instructions •dr flexes hip and adds internal rotation + adduction (Looks like taking knee to opposite shoulder basically) •bilateral (+) pain deep in the hip joint with or without a click ind: FAI/femoroacetabular impingement, anterolateral labral tear

Naffzigger's Test

Stand behind pt, compress external jugular vv. Hold 30 seconds, then ask pt to cough (+) pain or lightheadedness ind: pain indicates SOL/nn root prob; lightheaded may be a vascular prob

Dugas test (board test)

The patient places the hand of the affected shoulder on the opposite shoulder and attempts to touch the chest with the elbow. (+) is if the patient is unable to perform the test which indicates acute shoulder dislocation

patellar tap test aka Ballottement test

apply a slight tap or pressure over the patella (+) patella is floating ind: joint effusion

ligamentous instability test for fingers

apply varus/valgus to each finger joint laxity or excess motion indicates sprain of collateral ligs

posterior sag sign aka gravity drawer test

can do this one of 2 ways: •pt supine with their hips flexed to 45° and their knees are flexed to 90°, make sure the heels are even. •look at tibial tuberosities to see if they sink below where the femoral condyles are other way is to lift the legs up so hips and knees are both at 90° and again, looking for same thing (+) tibial plateau's sag posterior in relation to the femur ind: chronic PCL tear

Thorax ROM

flexion: 20-45 extension: 25-45 lateral flexion: 20-40 rotation: 35-50 costovertebral expansion: 3-7cm

Lumbar normal ROM

flexion: 40-60 extension: 20-35 lateral flexion: 15-20 rotation: 3-18 *do not assess lumbar end feels

ROM

flexion= 140-150, STA extension= -10-10, B supination= 90, TS pronation= 90, TS

Soto-Hall Test

headpiece neutral or lowered position Dr stabilizes pt sternum on table with one hand other hand contacts occiput and neck is slowly passively flexed (+) acute local vertebral pain ind: cervical and/or upper thoracic vertebral fracture

cluster for SLAP lesion

high sensitivity (pick 2) (+) compression rotation (+) anterior apprehension (+) Active comp of O'brien high specificity (pick 1) (+) yergasons (supination sign) (+) Biceps Load Test (Kim Test 2) (+) Speeds

load and shift

hold shoulder to stabilize, grab humeral head with other hand with thumb over posterior head and fingers over anterior head •load and translate forward P-A, then load again and go backwards A-P (+) excessive translation in fossa ind: Gr 1 = up to 50% diameter of head translation or up to rim of glenoid Gr 2 = head pushed beyond rim by >50% of diameter, but it reduces spontaneously Gr3 = head remains dislocated after translation

Burn's Bench Test

instruct pt to kneel on a chair and bend forward to touch floor with fingers (+) pt unable to perform or overbalances ind: malingering

*pinch grip test*

instruct pt to touch tip of thumb to tip of index and middle fingers •bilateral (+) pt touches pad to pad instead, can't make OK sign ind: anterior interosseous nerve syndrome

toe walking

instruct pt to walk about 10 feet away from you on their toes. Watch for heels to drop (+) heels drop) ind: S1 radiculopathy, tibial neuropathy, gastroc/soleus problem

*Hibb's test*

instructions •dr flexes pt knee fully •dr internally rotates hip while maintaining full knee flexion •bilateral (+) pain in SIJ or hip ind: sprain of SIJ (SIJ Syndrome); hip joint arthritis, capsulitis, etc

Patrick's aka FABERE's, Sign of 4

instructions •dr passively flexes pt hip and knee, external rotates and abducts hip so ankle is placed above knee on pt opposite thigh (sign of 4) •stabilize opposite ASIS and gently lower pt knee down towards table •use a two finger contact to apply slight pressure down and in on the knee •bilateral (+) pain in groin, inferior gluteal fold or SIJ ind: hip capsulitis, arthiritis, fracture; SIJ syndrome

Anvil test

instructions •foot is exposed and dorsiflexed slightly •dr hits the pt calcaneus/heel with fist •bilateral (+) pain in groin and/or upper thigh ind: hip fracture, arthritis, capsulitis, etc note: don't perform if hip fx is suspected

*Laguerre's test*

instructions...draping is important •dr flexes, abducts and laterally rotates hip with one hand •dr's other hand is stabilizing opposite ASIS •overpressure at end range is applied •bilateral (+) pain in the SIJ and/or hip ind: SI = SIJ syndrome; hip = capsulitis, OA, inflammatory process

froment's

instructions: hold paper between adducted thumb and index finger -you try to pull it out, bilateral (+) pt flexes terminal phalanx of thumb bc of adductor pollicis paresis/paralysis ind: ulnar neuropathy

*Weber's/Moberg's 2-point discrimination*

instructions: let me know if you feel 2 or 1 points, hand resting on firm surface -demonstrate what it feels like on a surface not being tested -use paper clip or 2pt discrim in distal phalanx until pt can no longer tell if it's 2 -points should be wider and continue to narrow them until they cant tell -measure the distance when they could last tell the 2 -repeat on several fingers (+) inability to tell 2 point b/w 2 tests b/w 2-6mm ind: peripheral neuropathy, radiculopathy or posterior column dz depending on distribution of loss

Q-angle

instructions: pt asked to relax, standing with foot and hip in neutral •line up center of goniometer with center of patella •one arm points to pt ASIS and other to the center of tib tuberosity •bilateral (+) angle <13° in males or >18° in females ind= *decreased* is patellofemoral dysfunction or patella alta, retroversion, decrease tibial torsion, genu varum increased = anteversion, increased tibial torsion, patellofemoral dysfunction, subluxed patella, genu valgum

trendelenburg's sign

instructions: stand on one leg •dr stabilizes pt pelvis •thumbs usually on SIJs ••pt asked to lift one leg while dr watches •bilateral (+) pelvis drops on non-stance side when pt stands on affected leg ind: Glute medius weakness on stance side or unstable hip, superior gluteal neuropathy

TMJ palpation: *EAM technique*

padded tip of pinky into EAM Note if: •signs or expression of P/discomfort as pt opens and closes •excessive posterior pressure from condyle as it returns to closed position

Lindner's Sign

passively flex pt neck while pt is either standing, supine or seated (+) pain in the lumbar spine or along sciatic nerve distribution ind: involvement in one of the roots that form sciatic nerve

*hooking maneuver*

patient is side-lying -contact under ribcage with both hands -pull ribs anteriorly and superiorly -bilateral (+) pain in ribcage ind: costchondritis, rib injury, tear of rectus abdominus mm

palpation

pitting edema and temp changes •cooler: think arterial insufficiency •normal to warm: think venous or inflammatory/infectious

Yergason's test AKA supination sign

pt elbow flexed to 90 at their side w forearm pronated •palpate bicipital groove with one hand and tell them to try to supinate forearm while you add some resistance to it •bilateral (+) pain in bicipital groove or tendon pops out ind: instability/tear of transverse humeral ligament or tendinosus of biceps

*scissors maneuver*

pt head is rotated to the side being tested (side of arm adduction) -stabilize opp scap with one hand -firmly adduct pts arm across chest bilateral *note: procedure can be performed with both arms being pulled simultaneously and no head rotation (+) pain in the chest ind: non-specific chest wall syndrome

Iliac compression test aka Approximation test

pt is side-lying •contact lateral pelvis (halfway b/w top of crest and trochanters) •press down toward table •bilateral (+) pain in SI IND: SIJ syndrome, infection, sprain

Deklyn's Test and Maigne's Test (performed same way but pt is seated)

pt is supine extend and rotate neck hold between 30-60 seconds bilaterally performed if first side is negative (+) dizziness, vertigo, nystagmus, etc ind: VBI

*fulcrum test* (similar to anterior apprehension)

pt is supine (make sure scap is on table and GH off table) •passively abduct arm to 90° and externally rotate (elbow bent to 90) •use other hand under the joint to push P-A -bilateral (+) anterior shoulder P and/or apprehension, guarding (if you get a (+), immediately go on to relocation test) ind: anterior GH laxity/instability or dislocation

posterior apprehension test

pt is supine and make sure GH is off the side of table! •flex arm to 90° and internal rotate •contact around GH with one hand and the other on elbow •push A-P on elbow •bilateral (+) apprehension, Pain or mm spasm ind: recurrent posterior dislocation or posterior instability

McMurray's (meniscus)

pt laying on back with you on ipsi side of knee you are testing •fully flex the knee with internal rotation of the tibia (toes pointed inward). Extend the leg fully while palpating and listening at *lateral* joint line •again, fully flex knee and then *externally/laterally* rotate tibia (toes pointed out), this time palpating and listening at *medial* joint line •repeat both of these on other leg (+) clicking along medial and/or lateral joint line ind: medial and/or lateral meniscus tear

subacromial push-button test

pt seated -apply pressure to subacromial bursa -bilateral (+) palpable tenderness ind: subacromial bursitis

*forced crossed-flexion AKA Crossover or Horizontal Adduction test*

pt seated -stabilize opposite scap with one hand -passively flex arm to 90 and apply forced horizontal adduction -bilateral (+) pain in area of AC ind: AC joint sprain or DJD

Llermitte's test

pt seated passively flex neck (+) sharp P radiating down neck or UE ind: nn root or meningeal irritation; M.S., cervical myelopathy

wright's test AKA hyperabduction test (for TOS)

pt seated •assess pt pulse before positioning (make sure arm is relaxed) •position pt ext rot arm just slightly posterior of coronal plane •slowly, passively abd arm 180 deg keeping it in that plane -bilateral (+) reproduction of sx and decrease pulse strength ind: pec minor syndrome, compression by coracoid process (hyperabd syndrome)

eden's AKA costoclavicular test AKA military brace test (mod-high spec for TOS)

pt seated •dr assess radial pulse for strength before positioning •pt asked to retract scapulas together •examiner pulls down and back on arm (maintain assess pulse and can just push on top of shoulder) -bilateral (+) reproduction of sx and decrease pulse strength ind: costoclavicular syndrome, compression by elongated C7 TPs, cervical rib

Spinous percussion

pt seated w neck slightly flexed dr starts away from pain and goes toward hammer each SP (+) acute localized pain or radicular pain ind: localized = fracture or involved segment; radicular = possible disc lesion

Underburg's Test

pt stand with arms 90° flexed, forearms supinated Instruct pt to close eyes, ext and rot their head and march in place rot and ext opp side if first is negative (+) dropping of arms, loss of balance, arms pronate ind: VBI

drawer's foot sign

pt supine •stabilize tibfib around ankle with one hand and the other pulls rearfoot forward with slight inversion •stabilize tibfib again and with other hand push rearfoot back •bilateral (+) excess translation/motion in either drection ind: excess motion with pulling forward = sprain of anterior talofibular ligament excess motion with pushing back = sprain of posterior talofibular ligament

medial stability test aka eversion stress test

pt supine, passively evert foot (+) gapping of joint, excess eversion ind: sprain of deltoid ligament on medial side of ankle

*mediopatellar plica test*

pt supine, passively flex knee to about 30° and you can rest it on your knee •push the patella MEDIAL •palpate/rub on the underside of the patella that you've pushed over the medial side •bilateral (+) palpable tenderness ind: inflammation of the mediopatellar plica (plica are remnants of developmental compartments. Cause P and abnormal ROM)

anterior apprehension

seated or supine •passively and slowly abduct pt arm to 90 (elbow flexed to 90) •passively and slowly externally rotate and extend arm while pushing P-A on the joint -bilateral (+) apprehension, pain or mm spasm ind: recurrent anterior dislocation

TMJ palpation: *lateral technique*

similar to palpating TP's of C1 and used to eval the capsule for tenderness, edema, and joint motion

*squeeze test* aka *distal tibiofibular compression test*

squeeze the mid tibia and fibula together •bilateral (+)pain in lower leg ind: syndesmosis injury (high ankle sprain-tibiofibular ligaments)

*flip test* (malingering)

while pt is seated extend their knee and ask about sx (Sitting Root test). then after some other tests have been done, have the pt lay prone and do an SLR. (+) radicular P is provoked in only one position ind: possible malingerer for LBP

schober test aka wright-schober test

with pt standing upright measure from 0.5cm below S2 and 10cm up from S2 and mark these spots have them bend forward and measure the difference between these spots (+) normally there should be increase of 5-8cm <5cm indicates (+) ind: possible ankylosing spondylitis

George's screening procedure (for vascular compromise) (could use to detect TOS vascular sx)

•BP bilaterally •then assess radial pulse bilaterally for strength •then ausculate both subclavian aa for bruit (+) unequal pulse, 10+ difference in BP sys, and/or bruit IND: subclavian artery stenosis

Modified Lift-off Test aka Medial/Internal Rotation Lag test "Spring Back"

•Dr *passively* medially rotates pt's arm behind back as far as possible •Pt asked to to hold the position and Dr lets go •bilateral (+) pt unable to hold the position and hand "springs back" to the spine ind: subscapularis strain/tendinopathy

Lateral Rotation Lag Test aka Infraspinatus "Spring Back" test

•Dr flex their elbow to 90°, put in 90° scaption with full external rotation •pt asked to hold this and you let go •bilateral (+) can't hold and arm springs forward ind: infraspinatus and/or supraspinatus

Bunnel-Littler test

•Dr hold MCP joint of involved finger in slight extension, while pt tries to flex PIP •If PIP jt cant be flexed, dr flexes MCP jt and asks pt to flex PIP (+)inability to flex the PIP with MCP in extension means there are either tight intrinsic muscles or contracture of joint capsule •if pt can flex PIP with MCP in flexion = tight intrinsic mm and rules out capsule •if PIP cant be flexed at all = joint capsule contracture (or ankylosis)

Retinaculum Test

•Dr holds PIP in a neutral position while the pt attempts to flex DIP •if pt is unable to flex the DIP the dr places the PIP in flexion and asks pt to try and flex the DIP again (+) DIP doesn't flex when PIP is held in neutral position ind: DIP flexes when PIP is flexed: retinacular ligaments are tight DIP doesn't flex when PIP is flexed: capsule is tight

maximal foraminal compression test (radiculopathy)

•LF/rot same side and Ext •may also apply compression (+) any P ind: either radiculopathy or •non-rad P ipsi = joint issue •non-rad P contra = sprain/strain

*rectus femoris contracture test* aka *Modified Thomas Test*

•MAKE SURE PT IS AT END OF TABLE AND DRAPED WELL •Pt flexes one knee to their chest while supine and other knee should remain at 90 of knee flexion (grab knee first then help them lay back) •if not at 90°, dr tries to passively bring the knee to 90° while palpating the muscle •bilateral (+)knee does not remain at 90° and/or hip flexes ind: tight rectus femoris and/or iliopsoas (the knee is in extension, ideally you want 90°)

*actual leg length test*

•instruct pt to stand for measurements; keep weight on both feet equally •Dr places one end of tape measure on pt ASIS and other end to floor •measure length of limbs bilaterally (+) unequal LE length ind: anatomic short LE should be equal

Drawer Sign

•Pt hip flexed 45° and knee to 90° •stabilize the pt's foot with body/leg and grasp proximal tibia with both hands •from neutral, push A-P •from neutral, push P-A •bilateral (+) 5+ mm of tibial movement in either direction ind: pulling forward: ACL sprain, posterolateral and posteromedial capsule, MCL sprain, ITB and/or arcuate-popliteus complex pushing back: PCL sprain, arcuate-popliteal complex, posterior oblique ligament, and/or possibly ACL

brachial plexus tension test

•Pt seated, instructed to abduct their arms with their elbows extended and arms externally rotated to just short of sx onset •Dr holds arms in this position and asks pt to flex elbows so hands are behind head (+) reproduction of radicular sx with elbow flexion Ind: possible ulnar nerve or C8/T1 radiculopathy

*Wilson's test*

•SEATED •knee flexed to 90° and medially rotated (foot turned in) •pt asked to extend leg, if around 30° pt is unable to continue, instruct them to turn foot out and see if they can go further with extending the leg (+)pt is able to continue extension with foot turned out in external rotation ind: osteochondritis dissecans (+ if lesion is at lateral aspect of medial condyle)

Finsterer's sign

•Tap on the lunate with hammer, bilaterally done (+) tapping elicits tenderness ind: avascular necrosis of lunate or Kienbock's disease

O'donoghue maneuver (ROM)

•all PROM •then RROM •mm test for 5 seconds (+) pain during either PROM/RROM IND: Passive P = ligament sprain Resisted P = mm strain

Bracelet test

•apply mild to moderate compression to distal radius and ulna •bilaterally performed (+) pain in forearm, wrist and/or hand ind: possible RA

Allen test (arterial test)

•arm elevated, pt open/closes fist several times, then close fist •as they do this, occlude both radial and ulnar arteries •pt asked to open hand and release pressure on one artery •repeat procedure with other artery being released instead (+) skin remains blanched or turns rubor/cyanotic for longer than 10 secs ind: ulnar or radial artery (brachial) insufficiency)

Louvel's (venous test)

•ask pt to cough and point to where their P is •occlude veins proximal to point of P and ask them to cough again to see if P is still there (+) Pain is alleviated while occlusion occurs ind: thromboplebitis

deweese test (arterial test)

•assess pulses (dorsalis pedis or posterior tibialis bilaterally) •pt instructed to exercise until Sx are provoked •when Sx start or worsen, pt stops and reassess pulses (+) pulses diminish or go away ind: arterial insufficiency

roos' test AKA elevated arm stress test (EAST) AKA hands up test (likely to produce false positives)

•both pt arms at 90 abd, laterally rotated and elbows flexed to 90 •pt instructed to open and close fist for 3 mins (unless sx start) (+) ischemic pain, profound weakness, paresthesias ind: TOS

Telescoping Sign aka Piston or Dupuytren's test

•child supine with the hip and knee flexed to 90° •femur is pushed down onto table and then lifted up away from the table (+) a lot of relative movement occurs ind: dislocated hip

Spurling's/foraminal compression test (radiculopathy)

•compress in neutral •if not positive, extend and compress •if still not, add rot + ext and compress (+) radicular pain ind: radiculopathy

*sacroiliac stretch test* aka *Gapping test* aka *Distraction test*

•contact both ASIS •apply A-P, M-L pressure same time (+)P in one or both SIJ (stretching ligaments in front of joint or from compressing the posterior part of the joint) ind: sprain of SIJ or an inflammatory process

homan's (venous test)

•dorsiflex foot while squeezing the calf at the same time •bilateral (+) deep pain in calf ind: thromboplebitis or thrombosus (deep or superficial vein)

Hoover's Test

•dr cups both pt heels in their hands •instruct pt to try to raise a leg up (+) the pt says they can't do it but the dr doesn't feel any downward pressure of heel in opposite hand to indicate they even tried ind: malingering

*hip scour test* aka *quadrant or scouring test*

•dr flexes and adducts the hip so the hip is facing opposite shoulder and slight resistance is felt •maintaining the resistance, hip is taken into abduction while maintaining flexion in an arc of motion •bilateral (+) irregularity in movement (bumps), pain, and/or apprehension ind: impingement, labral tear, OA

*Pheasant test*

•dr flexes both knees to buttocks while at the same time applying P-A pressure to lumbar spine (+) pain is produced in the limb during when you bring both legs up ind: unstable spinal segment

*Kernig sign* same as Lasegue but different (+)

•dr flexes the pt knee and hip to 90 •then slowly extend the knee up (not down towards the table) •bilateral (if first side was negative) can have spasm of hamstrings involuntarily (+) inability to straighten leg due to P (mm spasm) and possible involuntary flexion of opposite knee and hip = *meningitis*; radicular P ind: *meningitis* or L4/5, S1/2/3 radiculopathy (most likely L5, S1) which is a (+) for Lasegue

*Lasegue Test*

•dr flexes the pt's hip to approx 90 with knee flexed •dr slowly extends the knee up (not down toward the table) •bilateral (+) radicular P ind: L4/5, S1/2/3 radiculopathy (most likely L5, S1)

*laguerre's test*

•dr flexes, abducts and laterally rotates the hip with one hand •other hand stabilizes opposite ASIS •overpressure at end range is applied •bilateral (+) pain in SIJ and/or hip ind: SI = SIJ syndrome hip = capsulitis, OA, inflammatory process

Bowstring test aka Cram test aka Popliteal pressure sign

•dr performs SLR to point of P or change in sx with inclinometers then flexes knee without changing position •ask if sx are better, if yes, then •exert P-A and S-I pressure on hamstrings/sciatic nerve working down to popliteal fossa •SLR must be done bilaterally and Bowstring if applicable (+) radicular P ind: L4/5, S1/2/3 radiculopathy (most likely L5, S1) or extradural nn involvement

*renne test*

•pt asked to squat about 30° on ONE leg (offer hand for support) •dont squat too far, 30 deg isnt that much •also make sure to expose the knee (+) lateral knee pain ind: ITB friction syndrome

Lasegue Differential Sign

•dr performs SLR to point of pain •flex the knee and try to continue hip flexion (+) radicular pain eliminated with hip flexion and/or pain in hip continues with knee flexion ind: DDX between sciatic pain and hip pain...sciatic pain should get better with flexion...hip joint disease is not better with knee flexion

Goldthwait's Sign

•dr places one hand under the pt's back so each finger is in a lumbar interspinous space •dr performs an SLR •done bilaterally findings: if P is elicited before lumbar spine moves the problem is in the SIJ; if P is elicited after the lumbars move, it's from there (first 30-35° is often SIJ)

sharp-purser's test (C1 instability) be cautious with this one!

•dr puts palm of one hand on pt forehead and positions pt neck in slight flexion •thumb placed on SP of C2 •gently passively extend pt head slightly while pushing on C2 (+) excessive mvmt of atlas on axis, may be palpable or a "clunk" ind: instability of atlas on axis (problem with transverse lig). may be due to RA, ankylosing spondylitis and/or other conditions

buerger (arterial test)

•elevate one leg 45° and ask them to pump it (dorsi/plantarflex) •minimum of 3 mins; unless foot blanches and veins collapse first •leg lowered and hung off side of table while pt moves to seated position •bilateral (+) elevation: pallor and collapse of vv dependent: foot turns reddish, cyanotic, vv distended, takes over 1 min for color to return ind: arterial insufficiency, also gives indication about integrity of venous valves

Lasegue Rebound Test

•elevate pt's straight leg •drop it (+) increase in back pain, sciatic neuralgia and mm spasm ind: probable disc herniation (L4/5, S1/2/3)

*patella apprehension*

•flex knee slightly and slowly try to pull the patella LATERALLY •make sure to watch their face too •bilateral (+) apprehension, grabs your hand, pain, contraction of quads ind: recent dislocation of the patella

apley's distraction test

•flex knee to 90° and stabilize pt thigh down on table with your knee •internally rotate tibia and pull up •externally rotate tibia and pull up •bilateral (+) pain or relief of symptoms ind: nonspecific ligament sprain in pain is produced or if relief of pain possible with meniscal issue

*lateral pivot shift maneuver* aka *test of MacIntosh* aka *pivot shift*

•flex pt hip and knee about 20° with 20° of internal rotation •contact fibular head...(can lay your thumb along it)/gastrocs and create a *valgus* (abduction) stress while flexing knee at the same time •bilateral (+) feeling of "giving away" or tibia shifts forward and reduces around 30-40° ind: ACL, posterolateral capsule, arcuate-popliteus complex, and/or LCL sprains (will only work if ITB is intact)

Lachmans good for ACL

•flex pt knee about 10-20° (just make sure it's <30° so ACL is isolated) and stabilize femur on table with 1 hand •other hand grabs proximal tibia and pulls it from P-A •bilateral (+) anterior translation of the tibia on the femur ind: ACL sprain, posterior oblique ligament sprain and/or arcuate-popliteus complex sprain/strain

nylen-barany AKA hallpike-Dix (for dizziness/vertigo)

•head piece lowered completely •shoulders and head of table •pt eyes/head turned 30-40 towards dr, head supported •rapidly lowers pt so head is below horizontal •held here for 8-10 secs while looking for nystagmus then raised up and ask for sx •bring up, dr reassesses eyes for another 8-10 secs -bilateral (+) nystagmus and/or vertigo ind: benign paroxysmal positional vertigo (BPPV)

dejerine's triad

•if sx are produced by coughing, sneezing, and/or bearing down (+) localized or radicular P IND: increased intrathecal pressure form either disc defect, mass, osteophyte

apley's scratch test

•in front of neck reaching towards opp scap with each hand •behind the neck reaching towards opp scap •behind the back crawling thumb/finger up spine (+) pain and/or difference of 1 inch or more in comparison ind: possible GH dysfunction or tight mm

Well Leg Raise WLR aka Crossed Straight-leg Raise

•inclinometer on tibia to measure onset or change in sx •dr raise *unaffected limb* until pain/sx produced or reaches 90 (+) increase in radicular P on *affected leg* ind: probable posteromedial disc protrusion involving L4/5, S1/2/3 roots (most likely L5, S1)

Fajersztajn's test (kind of like Bragard's for the well leg)

•inclinometer placed on tibia •dr raises *unaffected leg* as far as possible and dorsiflexes ankle if the sx were not provoked (+) increase or production of radicular P on *affected leg* ind: probable posteromedial disc protrusion involving L4/5, S1/2/3 roots (most likely L5 or S1)

Barlow's Test (Pediatric)

•infant supine with hips flexed to 90° and knees fully flexed, index finger on greater trochanter and thumb on inner thigh •hip is abducted while applying forward pressure behind the greater trochanter (like ortolani's sign) feeling for a click, clunk or jerk •use thumb to apply backward pressure and outward on inner thigh (+) femoral head slips out over acetabular rim and then reduces itself when pressure is removed ind: unstable or dislocating hip (note: test can be done on infant up to 6 months)

*slump test*

•instruct Pt to place arms behind their back •slump the pt down without neck flexion, apply pressure to shoulders to maintain slump, if no sx then: •while holding slump, flex the pt's neck, if no sx: •while holding this position, extend one leg (if no sx's) the ankle is dorsiflexed, •if still no sx, both legs are extended simultaneously and if asymptomatic ankles are dorsiflexed (+) radicular P during any of the maneuvers or pt unable to extend legs due to P ind: tension on the meninges and dura or nn roots *note: even though it is a good test it will not be on Part 4 bc of the stress it would place on SPs

waldron test (patellofemoral tracking disorder)

•instruct pt to squat down about 30° •if anterior P is provoked, move the patella and hold it and have them squat again (most often have to move it medially, it displaces laterally) •if P does not change, repeat but change position of the patella until a painless position is found •bilaterally (if applicable) (+) P is relieved in one of the positions ind: patellofemoral pain syndrome

Minor's sign

•pt asked to stand up and dr observes how they manage it *sign*: pt supports self on unaffected side while standing and keeps affected leg flexed ind: possible L4/5, S1/2/3 radiculopathy (most likely L5/S1)

Anterior Innominate Test

•instruct pt to step unaffected leg forward by 2-3 feet •have them bend forward putting all their weight on front leg to the point that heel of back leg raises up (+) production/exacerbation of LBP on side of posterior leg ind: unilateral forward displacement of the ilia (anterior innominate) in relation to the sacrum

Peripheral Joint Clearance test

•instructions •keeping heels on floor, try to do a squat and inform on Sx •if pt unable to squat down completely with heels still on floor, have pt repeat squat allowing heels to elevate (+) pain in hips, knees, and/or ankle joints ind: problem with the painful joint...may be hip, knee or ankle

shoulder depression test (radiculopathy, TOS, mm spasm)

•laterally flex their head and stabilize •depress shoulder opposite •both sides (+) radicular or local P ind: •radicular: disc, adhesion, stenosis, TOS •local: mm spasm or tight, lig injury

Fluctuation test knee

•milk down the suprapatellar pouch with one hand •milk up the infrapatellar pouch with the other •alternately press with one hand and then the other hand to see if the patella is "floating" (+) feels the patella fluctuate under the hands ind: effusion

*Abbott-Saunders*

•palpate bicip groove w one hand •passive externally rotate and abd arm and then lower it back down •bilateral (+) palpable or audible click ind: subluxation or dislocation of biceps tendon

transverse humeral ligament

•palpate bicipital groove with one hand and other abducts pts arm to 90° •passive internally and externally rotate arm while staying in 90° of abd •bilateral (+) palpable instability of biceps tendon, pain ind: instability of biceps tendon from tear of transverse humeral ligament

passive humeral abduction with GH palpation

•palpate humeral head w finger •other hand passively abducts humerus feeling for humeral head to drop (+) head doesnt depress around 70-80° ind: GH jt restriction

Passive humeral abduction with scapular palpation

•palpate inferior angle of scap •other hand passively abducts humerus until scap starts to move (+)scap moves prior to 70/80° ind: probable GH joint restriction

Codman aka Drop Arm test

•passively abd arm to 90° and ask them to hold it up, then quickly release it •if they can keep it up, apply slight pressure to see if they can resist it •if they can, then ask them to slowly lower it •bilateral (+) inability to hold arm up, gives away with pressure, or comes down jerky when lowered ind: complete tear of cuff = cant hold up partial tear with the other 2

Adduction stress AKA Varus stress test

•passively flex knee 20-30°, contacts medial joint line with one hand •other hand palpates lateral joint line and creates varus stress by pulling tibia with forearm •bilateral note: if test is positive in flexion it should be repeated with knee in full extension (+) gapping along lateral tibiofemoral joint line ind: sprain of LCL in flexion, sprain of LCL and/or capsule, PCL, ACL in extension

abduction stress aka Valgus stress test

•passively flex knee 20-30°; contacts lateral joint line with one hand •other hand palpates medial joint line and creates a valgus stress by pulling tibia with forearm •bilateral (+) gapping along medial tibiofemoral joint line ind: gapping in flexion = MCL sprain; gapping in extension = MCL and/or ACL, PCL, capsule sprain

*double-leg raise test aka bilateral SLR*

•perform SLR on both legs individually noting angle that pain/sx produced •do bilateral SLR same time, noting angle •use inclinometer (+) lumbar P is noted at earlier angle when raising both legs together ind: possible radiculopathy with instability and/or lumbosacral joint involvement pain comes on sooner than with just the unilateral SLR...probably an instability causing that radiculopathy

Bragard's test

•perform SLR to point of provocation and backs off hip flexion 5° or until out of P •apply dorsiflexion to ankle •SLR must be done bilaterally and Bragards if indicated (+) radicular P ind: *pain b/w 35-70* = L4/5, S1/2/3 radiculopathy (most likely L5, S1) *pain <35* = extra-dural sciatic involvement

morton test

•place transverse pressure (squeeze forefoot) across MTHs •bilateral (+) pain ind: metatarsalgia; stress fracture or neuroma (esp if paresthesias are elicited...mortons neuroma commonly b/w 2nd and 3rd MTH)

Upper cervical quadrant test

•protract head, then LF/rot same side •compress (+) radicular P ind: upper C1-3 radiculopathy

Empty Can aka Supraspinatus test

•pt arm abd to 90° in *scapular plane* w thumb pointed to floor (with thumb up is full can test) •stabilize shoulder with one hand and contact forearm with the other •downward pressure on forearm •bilateral (+) pain in anterolateral or superior humeral head region with or without weakness ind: supraspinatus tendon or tear

*labral crank test*

•pt arm elevated 160° in scaption •Dr loads joint along axis of humerus with one hand •Other hand passively rotates arm medially and laterally •bilateral (+) pain during maneuver (ush ext rot) with or without clicking ind: glenoid labral tears; probably inferior labrum (Bankart)

speed's test

•pt arm flexed, elbow straight, palm up •stabilize shoulder with one hand and apply downward pressure with opposite hand at proximal wrist •repeat with palm down (+) pain in bicipital groove, esp with palm up ind: bicipital tendinopathy or strain

*Active compression of O'brien*

•pt arm in 90° flexion, 10° adduction and full internal rotation •dr stabilize shoulder with one hand and put downward pressure on the forearm with the other •*if pain occurs*, repeat with the palm up •bilateral (+) deep pain in *thumb down* position that is relieved with palm up position ind: SLAP lesion or superior labral lesion (note: superficial pain on top of the shoulder may be AC pathology)

thomas test

•pt asked to hold one knee to their chest •palpate the straight leg to make sure it is flush to the table •bilateral (+) pt involuntarily flexes opposite leg ind: tight hip flexors or hip flexion contracture (iliopsoas)

subtalar joint assessment- open chain

•pt is instructed to lie on stomach and relax foot (make sure its hanging off end) •contact both sides of the talus (thumb and index finger) with one hand and the 4th/5th MTHs with the other •move forefoot until subtalar joint is in neutral and evaluate for type of fault •bilateral pt findings: normal, forefoot valgus/varus, rearfoot valgus/varus, plantarflexed first ray

*slocum's test* variation of drawer test (for anterior)

•pt is on their back •knee at 90, hip at 45 •first internally rotate the tibia (turn foot inward) and stabilize foot •*pull P-A towards you* from behind the knee while feeling for excessive translation of tibia *anterolaterally* •then externally rotate tibia (turn foot out) and repeat, feeling for excessive translation of tibia *anteromedially* (+) excess anterolat displacement with medial rotation = anterolateral instability excess anteromed displ with external rotation = anteromedial instability ind: •anterolateral rotary instability = possible ACL, LCL, and/or posterolateral capsule •anteromedial rotary instability = possible ACL, MCL and/or posteromedial capsule (direction of tibia to femur)

*prone instability test aka segmental instability test*

•pt is prone on table with legs off of the end and feet on the floor •apply pressure to lumbar spine and ask if this provokes sx •*if pain is found continue to next step, if not then stop the test* •ask pt to actively lift legs off the ground (active lumbar and hip extension) •apply pressure to spine again while legs are elevated (+) pain decreases or disappears when pressure legs are up (*muscular contraction is contributing to stability*) ind: lumbar instability

Bounce home test (meniscus)

•pt laying on their back/supine •raise lower limb off table slightly so it is not touching with knee just slightly flexed •drop the knee into extension •bilateral (+) inability to reach full extension or rubber like end feel...will "bounce back" up into the flexed position ind: torn meniscus or cartilage

Apley's compression (meniscus)

•pt laying prone on their stomach •grasp distal tibfib by the ankle, internally rotate tibia (turn toes inward) and compress long axis •then turn foot out (externally rotating the tibia) and compress again (+) pain on either side of the knee ind: torn meniscus on the painful side

*Payr test* (meniscus)

•pt on back and place their leg into the sign of 4 position •palpate the *medial* joint line •bilateral (+) tenderness elicited in joint line ind: mensical lesion/injury

*Hughston's posterolateral and posteromedial drawer test* (basically slocum's in reverse, another variation of drawer test where you *push*)

•pt on back with knee at 90 and hip at 45 •medially rotate tibia ( and stabilize foot •*push BACK* A-P on proximal tibia •then laterally/externally rotate and repeat (+) excess posteromedial displacement w medial rotation = posteromedial excess posterolateral displacement with lateral rotation = posterolateral ind: •posteromedial rotary instability = MCL or PCL sprain •posterolateral rotary instability = LCL or PCL or arcuate-popliteus complex

swivel (dizzy/vertigo)

•pt on swivel chair, move head and body different directions until dizziness provoked •if it is, find out when dizziness goes away •then hold pt head and have them twist body on chair (+) dizzy/vertigo reproduced when held is held stationary ind: cervicogenic dizziness (otherwise it is from the ear canals. peripheral origin will have latent nystagmus and go away quick. Central origin will have nystagmus immediately and wont go away for awhile)

*Supported Adam's test* AKA belt test (DDX lumbar and SIJ pain)

•pt performs flexion and note the position in which Pain is felt •hold their iliac crests and brace a hip against their sacrum and ask pt to flex forward again (+) decrease in P ind: decrease in P means it originates in pelvis; no change in symptoms means its from the spine

*relocation test aka Fowler sign/test or Jobe relocation test*

•pt positioned just like the fulcrum test (test is performed on side of (+) fulcrum) •apply A-P pressure on humeral head, other hand tries to externally rotate and extend pt arm (+) greater external rotation and/or reduction in pain or apprehension ind: occult or subtle anterior instability

*Nachlas test* Prone knee bending aka (*same side buttock*)

•pt prone •flex the pt's knee (heel to butt) on the *same side* while preventing hip rotation *note*: if knee can't be flexed beyond 90 then passively extend the hip and try to continue knee flexion...older pt or has had knee surgery •bilateral (+) radicular P in anterior thigh; pain in buttock or lumbosacral junction ind: L2/3/4 radiculopathy, SI syndrome or lumbosacral facet syndrome (would have LBP)

Ely's Heel to (*opposite*) Buttock test

•pt prone •passively flexes heel to *opposite* buttock •with leg in that position, extend the hip while holding the knee in flexion •bilateral (+) radicular (*anterior thigh*) or non-radicular pain and/or inability to hyperextend the hip ind: L2/3/4 radiculopathy, tight rectus femoris, iliopsoas strain

*steinmann's tenderness displacement* (meniscus)

•pt prone on their back "Are you having any pain on either knee? Inside or outside?" If yes, palpate the joint line to locate the exact tender spot and stay on it with your fingers •then either flex or extend the knee (depending on starting position) and ask them if its still tender under your fingers, if they say NO, palpate back along the joint line to see if the point tenderness has moved with the tibia (+) tenderness moves *posterior* in the joint line with flexion or *anterior* in the joint line with extension ind: tear of either medial or lateral meniscus

thompson test aka simmonds

•pt prone with knee flexed •squeeze the calf and watch for plantarflexion •bilateral (+) loss of plantarflexion ind: rupture of achilles tendon

halstead maneuver (TOS like conditions)

•pt seated •assess radial pulse for strength •pt neck extended and rotated AWAY from arm being tested •examiner tractions down on arm -bilateral (+) reproduction of sx and/or decrease in pulse strength ind: scalenus anticus syndrome, cervical rib syndrome and/or subluxated rib

*Kim Test 2 aka (Biceps Load Test 2)*

•pt seated or supine •Dr abducts arm to 120°, laterally rotated, elbow flexed to 90° and forearm supinated •Dr fully laterally rotates arm if pt appears apprehensive, dr stops and holds arm in that position •Pt is asked to flex their elbow against the dr's resistance -bilateral (+) apprehension remains the same or more painful ind: SLAP lesion in presence of recurrent dislocations

*external rotation stress test*

•pt seated or supine •knee is in 90° flexion •stabilize leg with one hand •use other hand to place ankle in 90° dorsiflexion and passively externally rotate leg •bilateral (+) pain in region of deltoid ligament with talar displacement or pain in the syndesmosis (tibiofibular ligament) ind: deltoid ligament P + talar displacement = deltoid lig sprain syndesmosis P = high ankle sprain

*Jerk test*

•pt seated with arm medially rotated and forward flexed to 90° •dr grab elbow and axially loads humerus •while loaded, horizontally adducts arm across body •return to start position •bilateral (+) sudden jerk/clunk may occur as head reduces ind: reccurrent posterior instability or posteroinferior labral tear

*Kim Test aka Biceps Load Test 1*

•pt seated with back supported •dr abducts arm to 90° with elbow supported in 90° of flexion •while supporting elbow, dr applies axial compression force to glenoid •holding compression, Dr elevates arm diagonally up with one hand while the other applies downward and backward force to proximal arm -bilateral (bring it down and obliquely across) (+) sudden onset of posterior shoulder P and click ind: posteroinferior labral lesion

adson's (higher spec for TOS)

•pt seated, assess radial pulse for strength •pt head rotated to side tested with slight neck extension and arm is extended slightly and laterally rotated •(tell them to look back and up over your head) •have them hold their breath -bilateral (+) reproduction of sx and decrease pulse strength ind: scalenus anticus syndrome, cervical rib compression

Ober's test ("OBER THE SIDE")

•pt side lying, near back edge of table •dr applies I-S stabilizes pressure on the pelvis •Dr passively abducts and extends hip then lowers it down toward table •bilateral (+) relaxed thigh remains abducted ind: contracture or tightness of TFL or ITB

femoral nerve traction

•pt side-lying •neck is *flexed* •dr extends pt hip 15° (no more than that so you arent moving pelvis!) while keeping knee straight •if she says yes and pain is shooting in an L2, L3, or L4 dist, then this is (+) and you can stop here. •if it's another kind of P thats not those, then still continue •if no radicular sx produced, flex the knee without any additional hip extension •bilateral (+) radicular P ind: possible L2/3/4 radiculopathy

TOST taking off shoe test (100% spec/sens)

•pt standing •instruct pt to take off their shoe on affected leg side with the help of their other shoe (ex: affected leg is externally rotated about 90° with knee flexed about 20°, hindfoot is pressed into longitudinal arch of affected leg) (+) sharp pain over biceps femoris ind: biceps femoris strain (grade 1 or 2)

Thessaly test (meniscus)

•pt standing and facing dr while holding hands/shoulders to stablize them •stand on one leg, initially have knee relaxed (*this is about 5° of flexion*) •then tell them to rotate about their knee (internal/external) about 3x and "let me know if this causes or changes your sx" •If negative at 5°, have them flex slightly more to just 20° and repeat. •do bilaterally (+) pain, joint line clicking and/or sense of locking/catching ind: lateral P = lateral meniscus issue or medial P = medial meniscus issue

Subtalar joint assessment- closed chain

•pt standing, shoes/socks off •contact both sides talus with thumb and index finger and ask pt to rotate torso until you feel the talus equally under both with same amt of pressure •note the amt of tibial rotation the pt did to get to this neutral position •repeat on other side findings: the pt is either in subtalar neutral or not

SLR Straight Leg Raise (aka Lasegue's)

•pt supine •place inclinometer on tibial tuberosity •dr slowly elevates limb to point of provocation or until full elevation reached •note the degree when sx start or change, type of sx, and location •bilateral (+) radicular P ind: L4/5, S1/2/3 radiculopathy esp if radicular P occurs b/w *35-70°* (most likely L5/S1); pain *prior to 35°* possibly extra-dural sciatic involvement *note: she will always use SLR name for exams, If she asks for Lasegue please use other variation of Lasegue's

patella grinding test aka Fouchet's (patella)

•pt supine •push down on patella and move it medially and laterally •bilateral (+) pain under or over patella ind: pain under = chondromalacia, arthritis, chondral fx pain over = prepatellar bursitis

*Bohler sign* (meniscus)

•pt supine with knee slightly flexed •dr applies varus and valgus stress to the knee •bilateral (+) P in opposite joint line ind: could be MCL/LCL depending what side you're on or a meniscal LESION...not usually a tear (this is exactly like abduction/adduction stress tests...except those look for gapping, and this is for *pain*)

Turyn's sign

•pt supine with legs resting on table •Dr dorsiflexes the first toe on non-involved side •Dr dorsiflexes big toe on affected side (+) radicular P Ind: L4/5, S1/2/3 radiculopathy (most likely L5, S1) *note: if pt is in significant back and LE P perform this before the SLR, depending on results SLR may not be needed at this time

*fairbanks test* (similar to patella apprehension except this is about seeing how far you can push it)

•pt supine, flex knee slightly and pull patella laterally trying to see how far it will go •bilaterally (+) patella displaces laterally over half its width ind: recurring subluxation/dislocation of the patella

clarke's test (patella)

•pt supine, knee in full extension •dr uses web contact just above the patella, take tissue slack S-I and asks pt to slowly contract quads •repeat procedure at 30, 60, 90° (if no pain produced in previous one) •bilateral (+) retropatellar pain ind: chondromalacia patella (each of the 4 positions targets the different facets of the patella)

lateral stability test aka inversion stress test

•pt supine, passively invert the foot •bilateral (+) gapping of the joint on lateral side, excess inversion ind: sprain of anterior talofibular ligament or calcaneofibular ligament

stork standing test aka one-leg standing lumbar extension test

•pt told to stand on one leg and extend spine backwards •stand close to provide support •repeat bilaterally (+) provocation or exacerbation of back pain ind: pars interarticularis fracture (spondylolysis) or facet syndrome

Wrinkle (shrivel) test

•pt's fingers placed in warm water for 5-20 mins, remove and inspect (+) no wrinkling of fingers ind: denervation (only valid within 1st few months of injury)

*Noble compression test*

•pts knee is flexed to 90°; use thumb to apply pressure to ITB within 2cm of lateral condyle (come up higher than lat condyle and a little posterior) •passively extend knee to lower towards the table •bilaterally performed (+) SEVERE P over lateral condyle at about 30° of flexion ind: ITB friction syndrome (forces the distal ITB under your finger)

Ankle/brachial index (arterial test)

•relax, I'm going to take your BP •take arm BP then BP on the calf (+) ratio <0.9 ind: 0.7-0.89: mild claudication 0.4-.69: mod to severe 0.3-.39: severe (rest pain) 0-0.29: ischemia w impending tissue loss

jackson's compression test (radiculopathy)

•rot pt neck to 1 side •axial compression •other side, same (+) radicular P IND: radiculopathy

Libman's Sign

•slowly apply pressure to pt's mastoid process until it becomes noticeably uncomfortable findings: the amt of pressure can give dr idea of pt's pain tolerance

Kemps

•stabilize the PSIS area with one hand and other hand grasps pt's shoulders •passively bend spine obliquely (rotates and LF same direction) backwards over the hand that is stabilizing PSIS •repeat on other PSIS (+) radicular or achy P IND: radicular P = lumbar radiculopathy; achy P may be facet syndrome, capsulitis, sprain/strain, mm spasm

palpation of pterygoid fossa

•stand on right side and palpate their left fossa with gloved hand •once inside mouth, have them close and deviate to palpated side •w finger pointed medially, stick index finger b/w cheek/teeth under zygoma, and perform C-shaped sweep •bilateral (+) pain and bogginess ind: inflammation of fossa assoc w pterygoid tendinitis and/or joint

Palpation of temporalis tendon

•stand on their Right side and palpate Right tendon w gloved hand •finger pad pointed laterally, index finger b/w cheek/teeth under zygoma touching the process (+) pain ind: temporalis tendinitis

stroke test aka brush bulge

•supine •brush from I-S on medial side of knee 2-3 and on the last stroke up follow that around the top of the patella to the lateral side of the knee •bilaterally performed (+) bulge forms in inferior/medial border of patella before dispersing again ind: intra-articular effusion

upper limb tension test 2 (musculocutaneous n)

•supine w neck LF away •arm abd to 10 •elbow fully extended, forearm supinated, wrist extended, fingers and thumbs ext, arm laterally rotated •depress shoulder on that side •bilaterally done (+) paresthesias in median, musculocutaneous or axillary n distribution ind: neuropathy to median, musculocutaneous or axillary n

Upper limb tension test 4 (ulnar n)

•supine w neck LF away •pt arm abd bw 10-90 •elbow fully flexed, forearm supinated, wrist extended and *radial dev*, fingers and thumb ext, arm laterally rot •depress shoulder •bilaterally done (+) paresthesias in ulnar n distribution or medial arm/forearm ind: ulnar neuropathy and/or C8-T1 radiculopathy

Upper Limb Tension test 1 (median n)

•supine w neck LF away from side tested •abduct arm 100-110° •extend elbow, forearm supinated, wrist/hand/fingers extended •dr depress shoulder on same side •bilaterally performed (+) paresthesias in median n or C5-7 dermatomal distribution ind: median neuropathy, C5-7 radiculopathy

upper limb tension test 3 (radial n)

•supine, LF neck away •arm abd to 10 •elbow fully ext, forearm pronated, wrist flexed and *ulnar deviated*, fingers/thumb flexed, arm medially rotated -depress shoulder -bilaterally done (+) paresthesias in radial n distribution ind: radial n neuropathy

tinel's foot sign

•tap on posterior tibial nerve in the tarsal tunnel •bilateral (+) reproduce pins/needles paresthesia in distribution of posterior tibial nerve (medial or lateral plantar nerves) - travels on bottom of foot ind: tarsal tunnel syndrome

shoulder abd test/bakody's sign (radiculopathy)

•tell pt to raise arm over head (can place on their head) •bilaterally (+) decrease or relief of sx IND: radiculopathy (disc or nn root around C4-C6) (bakody's sign: pt comes in with hand on head to alleviate sx)

inferior instability test aka Sulcus sign

•traction down on pt arm with 1 hand while palpating humeral head with the other -bilateral (+) visible or palpable sulcus (measure it) ind: inferior or multidirectional instability +1 sulcus = <1cm +2 sulcus = 1-2cm +3 sulcus = >2cm

tinel's sign of the shoulder (nn trunk compression)

•use good hammer technique when tapping scalene triangle •helps to rest finger on clavicle and just hit the depression behind that -bilateral (+) pain or paresthesias ind: compression or neuroma of 1 or more nn trunks

Ortolani's sign (follow up to Barlows)

•with infant supine, flex the hips and grasp legs so that the thumbs are against the insides of the knees and thighs and put pressure against the greater trochanter •with gentle traction, abduct the thighs and fingers are against the greater trochanter •resistance to abduction and external rotation begins to be felt at about 30° (+) click, clunk or jerk, which means hip was reduced and an increase in abduction is obtained ind: congenital hip dislocation note: test only valid for first few weeks of life

Lewin Punch Test

•with pt standing, punch the buttock on affected side •bilateral (+) punching involved side should elicit pain, punching opposite should not ind: probable disc involvement or significant spinal lesion