CONA II

Forced Cross-Flexion

- Passive horizontal adduction to end range - Dr. palpate AC joint - Reproduction of pain at acromial clavicular joint > Acromial clavicular joint dysfunction

Bicep Load Test

- Patient Seated (BLT 1, AKA Kim's test) or Supine (BLT2) - Arm abducted to 120 - Arm in bicep flexed position, external rotation, and palm inward (supination) -Dr. pull forearm out against resist. 1. - Cannot get in position - Pain with position - Can't resist pressure 2. Relieves chief pain 1. Labrum Tear 2. Anterior dislocation or instability

Surprise Test

- Patient Supine - Arm in abduction, elbow externally rotate - Push anterior to posterior pressure on humeral head (should relieve pain) - Immediately back off - Pain/apprehension when backing off - Anterior glenohumeral instability: dislocation/subluxation

Crank Sign

- Patient seated - Abduct arm to 160 - Apply axial compression down humerus - Passively internally/externally rotate - Pain - Audible "clunk" - SLAP tear - Anterior glenohumeral dislocation trauma. - Glenohumeral instability

Forestier Bowstring sign (NOT THE TEST)

- Patient seated - Actively flex at the waist R and L - Touch downward on paraspinals at lumbar region - Taught ribbon of Para spinals on side of lateral flexion - Ankylosing spondylitis -Acute paraspinal muscle strain in thoracic spine

Load and Shift

- Patient seated (sit up straight) - Stabilize scapula/shoulder - Push humerus I-S at humeral head (Up loading) - Shift anterior and/or posterior - Painful in either direction Excess translation in either direction (> 25% ant. Or> 50% post.) - Anterior/posterior glenohumeral instability

TMJ Compression Test

- Patient seated, doc post. Lateral - Left hand on right chin, support - Angle chin upward and pull up/left Pain > Retrodiscitis or synovitis (synovial tissue and discs)

Anterior Relocation

- The patient is supine with one arm in 90 of abduction and full external rotation of the glenohumeral joint.; already has a dislocated humeral head in anterior direction - Apply anterior to posterior pressure back into glenoid fossa (with other hand guide the head of the humeral head into glenoid fossa) -Relief of pain -Anterior glenohumeral instability: dislocation/subluxation

TMJ Distraction Test

- Using gloves - Patient seated, stand ipsilateral - Hook index finger on rear molar - Support hand on head, palpate joint - Pull P-A in line with mandible Pain under palpating finger > Capsulitis

Pterygoid Fossa Palpation

- Using gloves -Patient seated or supine I. Palpate lateral condyle of mandible posterior and superior for lateral, 2. Fossa for medial (tum finger pad medially) 3. lateral maxilla for temporalis pain & bogginess upon palpation under finger inflammation of fossa possibly resulting from pterygoid mm tendinitis

Temporalis Tendon Palpation

- Using gloves -Patient seated or supine I. Palpate lateral condyle of mandible posterior and superior for lateral, 2. Fossa for medial (tum finger pad medially) 3. lateral maxilla for temporalis pain upon palpation under finger temporalis tendinitis

Dejerines' triad

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Valsalva test

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Pain Provocation Test

100 abduction, elbow flexed, external rotation and supinate/pronate > SLAP

Andrew's Test

Anterior Apprehension in Supine position

Mandibular Gait (Jaw ROM) 1. Measure open mouth 2. Measure lateral shift 3. Protrusion and retraction 4. Movement pattern

BoyBoyBoy and freeze > Measure distance between upper and lower teeth 2~4mm is normal 1. Open mouth as wide as possible 2. Patient laterally shift left and right - Measure from spot on front teeth (from boyboyboy position) 3. Push jaw forward and back actively -Measure from stationary point 4. Slowly open and close jaw 1. More or less than 55 mm 2. Deviation from normal 10-15 mm 3. Deviation from normal 7mm or more (3~4mm or retraction) 4. Look for C or S curve 1. TMJ disfunction, Muscle problems (more than 55 mm = dislocation) 2. Muscle imbalance or dislocation 3. Muscle imbalance, dislocation, joint space or congenital differences, capsulitis 4. C curve =muscle imbalance S curve or jerking= dislocation

Counter-irritant Test (won't be tested)

Mouth opens 5mm or more, post application of cold Extrinsic mm problem

Lewin Supine

Procedure - Patient supine - Stabilize legs around mid-calf - Patient do a sit up Positive findings - Can't complete task or struggles - Coupled with local pain Indications - Ankylosing spondylitis - Lumbar arthritis - Sciatica - Disc herniation - Fused thoracic vertebrae - Weak abdominals

Tinel's Wrist Sign

PICTURE MISLEADING PROCEDURE With the patient's hand supinated, stabilize the wrist with one hand. With your opposite hand, tap the palmar surface of the wrist (between pisiform and Hammate / tunnel of Guyon) with a neurological reflex hammer. RATIONALE Tingling in the hand along the distribution of the median nerve (thumb, index finger, middle finger, and medial half of the ring finger) indicates carpal tunnel syndrome, a compression of the MEDIAN NERVE by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

O'Brien's (Active Compression Test) LOOOK AT IT AGAIN

PICTURE WRONG PROCEDURE With the patient standing or seated, instruct the patient to forward flex the shoulder to 90° and ADDUCT the shoulder 15° past midline. Instruct the patient to maximally internally rotate the shoulder so that the thumb points downward. The examiner places a downward pressure on the forearm instructing the patient to resist. Repeat the test with the shoulder externally rotated with the palm facing up. RATIONALE A positive test is noted when there is deep pain in the shoulder when the shoulder is internally rotated with the palm facing downward and decrease, or absence of pain with the shoulder externally rotated and the palm facing up. Internal rotation of the shoulder in 90° of forward flexion places stress on the anterior superior portion of the labrum. > SLAP tear "Superior Labrum Anterior Posterior" Pain on the top of the shoulder may indicate an acromioclavicular injury.

Subacromial Push Button Sign

PROCEDURE With the patient seated, apply pressure to the subacromial bursa (Fig. 5-54). RATIONALE Pressure to the subacromial bursa will irritate an already inflamed bursa. Local pain suggests inflammation of the subacromial bursa or bursitis (Fig. 5-55).

Rust's sign (NOT A TEST)

PROCEDURE A patient with severe injury to the upper cervical spine will grasp the head with both hands to support the weight of the head on the cervical spine (Fig. 3-56). The supine patient will support the head while attempting to rise. RATIONALE The patient with a severe upper cervical injury, such as severe muscular strain, ligamentous instability, posterior disc defect, upper cervical fracture, or dislocation, is subject to guarded movements, including stabilization of the head with slight traction to reduce the pain.

Phalen's Test

PROCEDURE Flex both wrists and approximate them to each other. Hold for 60 seconds. RATIONALE When both wrists are flexed, the flexor retinaculum provides increased compression of the medial nerve in the carpal tunnel. Tingling in the hand along the distribution of the median nerve (thumb, index finger, middle finger, and medial half of the ring finger) indicates compression of the median nerve in the carpal tunnel by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

Ludington's Test

PROCEDURE Instruct the patient to clasp both hands on top of the head, interlocking the fingers, and ALTERNATELY contract and relax the biceps muscle while you palpate the biceps tendon. RATIONALE Placing the hands on the head supports the upper limb and allows relaxation of the biceps muscle. If the biceps tendon on the affected side is not contracting and palpable, suspect a rupture of the long head of the biceps tendon.

Reverse Phalen's Test

PROCEDURE Instruct the patient to extend the affected wrist and have the patient grip your hand. With your opposite thumb, press on the carpal tunnel (for 60 seconds). RATIONALE Extending the hand and applying pressure to the carpal tunnel further constricts the tunnel. Tingling in the thumb, index finger, and lateral half of the ring finger may indicate compression of the medial nerve in the carpal tunnel by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

Bunnel-Littler Test

PROCEDURE Instruct the patient to extend the metacarpophalangeal joint slightly. Attempt to move the proximal interphalangeal joint into flexion (Fig. 8-13). Repeat the test with the metacarpophalangeal joint in flexion (Fig. 8-14). RATIONALE If the proximal interphalangeal joint does not flex with the metacarpophalangeal joint in slight extension, there is a tight intrinsic muscle or a contracture of the joint capsule. If the proximal interphalangeal joint fully flexes with the metacarpophalangeal joint flexed, the intrinsic muscles are tight. A positive test indicates an inflammatory process in the fingers, such as osteoarthritis or rheumatoid arthritis.

Profundus Test

PROCEDURE Instruct the patient to flex the suspected distal phalanx while you stabilize the proximal phalanx (Fig. 8-17). RATIONALE Inability to flex the distal phalanx indicates a divided flexor digitorum profundus tendon.

Finkelstein's Test

PROCEDURE Instruct the patient to make a fist with the thumb across the palmar surface of the hand (Fig. 7-33) and to stress the wrist medially (Fig. 7-34). RATIONALE Making a fist and stressing it medially stress the abductor pollicis longus and extensor pollicis brevis tendons. Pain distal to the styloid process of the radius indicates stenosing tenosynovitis (SYNOVIAL IRRITATION) of the abductor pollicis longus and extensor pollicis brevis tendons (de Quervain's disease).

Pinch Test

PROCEDURE Instruct the patient to pinch a piece of paper between the thumb, index, and middle fingers while you attempt to pull it away. RATIONALE The median nerve innervates the lumbrical muscles, which are used to pinch the piece of paper. With compression of the median nerve, the patient may have numbness and/or cramping of the fingers or mid palm region within 1 minute.

Froment's Test (Make sure patient doesn't use DIP)

Procedure The patient attempts to grasp a piece of paper between the thumb and index finger. Positive Finding When the examiner attempts to pull the paper away, the terminal phalanx of the thumb flexes because of paralysis of the adductor pollicis muscle. Indication Ulnar nerve paralysis / Tunnel of Guyon syndrome

Pinch Grip

PROCEDURE Instruct the patient to pinch the tips of the index finger and thumb together. RATIONALE Normally the pinch is tip to tip. The test is positive if the pulps of the thumb and index finger touch. This result is caused by an injury to the ANTERIOR INTEROSSEOUS NERVE, which is a branch of the median nerve. It may also indicate an entrapment syndrome of the anterior osseous nerve between the two heads of the pronator teres muscle.

Shoulder Abduction (Bakody Sign)

PROCEDURE Instruct the seated patient to abduct the arm and place the hand on top of the head. RATIONALE Placing the hand above the head elevates the suprascapular nerve, reducing the traction on the lower trunk of the brachial plexus. This procedure reduces the traction on a compressed nerve. A decrease in or relief of the patient's symptoms indicates STRETCHED BRACHIAL PLEXUS (a cervical extradural compression problem, such as a herniated disc, epidural vein compression, or nerve root compression, usually in the C5-C6 area)

Maximal Foraminal Compression test

PROCEDURE Instruct the seated patient to approximate the chin to the shoulder and extend the neck. Perform this test bilaterally. RATIONALE Rotation of the head and hyperextension of the neck causes the following biomechanical actions: (a) narrowing of the intervertebral foramina on the side of head rotation; (b) compression of the facet joints on the side of head rotation; (c) compression of the intervertebral discs in the cervical spine. Pain on the side of head rotation with a radicular component may indicate nerve root compression caused by pathology such as an osteophyte or mass or decreased interval in the foramina. Local pain with no radicular component may indicate apophyseal joint pathology on the side of head rotation and neck extension. Pain on the opposite side of head rotation indicates muscular strain or ligament sprain. If nerve root compression is suspected, evaluate the neurological level.

Schepelmann's Sign (TEST)

PROCEDURE Instruct the seated patient to flex at the waist to the left and right. RATIONALE Pain on the side of lateral bending indicates intercostal neuritis. (It can produce pain on both sides) Pain on the convex side indicates fibrous inflammation of the pleura or intercostal sprain. When the patient bends sideways, the intercostal nerves on the side of bending are compressed. If the intercostal nerves are irritated, pain on the side of bending will be elicited. Also, when the patient bends sideways, the pleura is stretched on the opposite side of bending. If the pleura is inflamed, pain will be elicited opposite the side of bending. Pain may also be elicited because of injury to or spasm of the thoracic or intercostal muscles.

Elbow Flexion Test

PROCEDURE Instruct the seated patient to flex the elbow completely for 5 minutes. RATIONALE Flexion of the elbow may compress the ulnar nerve in the cubital tunnel. Paresthesia (burning or prickling sensation) along the medial aspect of the forearm and hand may indicate compression of the ULNAR NERVE in the cubital tunnel (cubital tunnel syndrome). It can also be trapped between the heads of the flexor carpi ulnaris or by scar tissue in the ulnar groove.

Apley's Scratch Test

PROCEDURE Instruct the seated patient to place the hand on the side of the affected shoulder behind the head and touch the opposite superior angle of the scapula. Then instruct the patient to place the hand behind the back and attempt to touch the opposite inferior angle of the scapula. RATIONALE Actively attempting to touch the opposite superior and inferior aspect of the scapula places stress on the tendons of the rotator cuff. Exacerbation of the patient's pain (or inability to perform the procedure) indicates degenerative tendinitis of one of the tendons of the rotator cuff, usually the supraspinatus tendon.

Wartenberg's Sign

PROCEDURE Instruct the seated patient to place the hand on the table. Passively spread the patient's fingers. Instruct the patient to bring the fingers together. RATIONALE The ulnar nerve controls abduction of the fingers. Inability to abduct the little finger to the rest of the hand indicates ulnar nerve neuritis

Lippman's Test

PROCEDURE Instruct the sitting patient to flex the elbow to 90°. Stabilize the elbow with one hand, and with your other hand palpate the biceps (long head) tendon and move it from side to side in the bicipital groove. RATIONALE Moving the biceps tendon manually in the bicipital groove stresses the tendon and transverse humeral ligament (located at bicipital groove garding long HoB tendon) **Pain indicates bicipital tendinitis. **Apprehension (excessive movement) may indicate a propensity for subluxation or dislocation of the biceps tendon out of the bicipital groove or a ruptured transverse humeral ligament.

Spurling's test Let the patient know what's about to happen!

PROCEDURE Laterally flex the seated patient's head and gradually apply strong downward pressure. If pain is elicited, the test is considered positive; do not continue with the next procedure. If no pain is elicited, put the patient's head to a neutral position and deliver a vertical blow to the uppermost portion of the patient's head. RATIONALE Local pain may indicate facet joint involvement, either from the strong downward pressure on the head or from the vertical blow to the head. Radicular pain may indicate foraminal encroachment, degenerating cervical intervertebral disc, or disc defect with nerve root pressure. This test may also indicate a lateral disc defect.

Anterior Apprehension

PROCEDURE Stand behind the seated patient. Abduct the affected arm to 90° and externally rotate it slowly while stabilizing the posterior aspect of the shoulder with the opposite hand. RATIONALE Local pain indicates a chronic anterior shoulder dislocation (anterior glenohumeral joint instability) This test is called apprehension because it is intended to elicit a look of apprehension on the patient's face. The patient may also state that the test feels the same as when the shoulder was dislocated. External rotation of the arm predisposes the humerus to dislocate anteriorly. This test forces external rotation to dislocate the humerus anteriorly from the glenoid fossa. If the rotator cuff muscles, joint capsule, and glenoid fossa are sound, the patient should have no pain or apprehension when this test is performed. It tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.

Golfer's Elbow Test

PROCEDURE Tell the seated patient to extend the elbow and supinate the hand. Instruct the patient to flex the wrist against resistance. RATIONALE The tendons that flex the wrist, the flexor carpi radialis and flexor carpi ulnaris, are attached to the medial epicondyle (Fig. 6-31). If the condyle itself or the common flexor tendons that attach to it are inflamed, resisting wrist flexion may reproduce irritation to the medial epicondyle and its attaching tendons. If pain is elicited at the medial epicondyle, suspect inflammation of the medial epicondyle (epicondylitis).

Sharp-Purser test

PROCEDURE With a patient seated, the examiner places one hand over the patient's forehead and the thumb of the opposite hand over the spinous process of C2 for stabilization (Fig. 3-58). Instruct the patient to flex the head slowly as you apply a posterior pressure with the palm of your hand (Fig. 3-59). A positive test is indicated if you feel the head slide backward during the movement. RATIONALE In an anterior Atlas subluxation due to severe trauma the Atlas is anterior to the axis with alar or transverse ligament damage. A backward slide indicates that the subluxation of the Atlas on axis has been reduced, and the slide may be accompanied by a "clunk." The subluxation may be caused by a stretched or torn alar or transverse ligament.

Watson's Test (READ MANUEL AND FIX)

PROCEDURE With one hand, stabilize the radius and the ulna. With the opposite hand, grasp the scaphoid, moving it anteriorly and posteriorly (Fig. 7-36). RATIONALE The scaphoid is prone to subluxate or dislocate with hyperextension trauma. Pain, laxity, or crepitus indicates an instability of the scaphoid with propensity to subluxate or dislocate.

Supraspinatus Test AKA Empty can test AKA JOBE'S TEST***

PROCEDURE With the patient either sitting or standing, instruct the patient to abduct the shoulder to 90° (+ 30° of forward flexion). Grasp the patient's arm and press down against resistance by the patient. Next, instruct the patient to rotate the shoulders internally so that the thumb faces downward. Again, press down on the arm against resistance by the patient. RATIONALE Resistance to abduction stresses the supraspinatus muscle and tendon. Weakness or pain may indicate a tear of the supraspinatus muscle or tendon. Weakness may also indicate suprascapular

ROOS test

PROCEDURE With the patient in the seated position, instruct the patient to flex the arms and elbows to 90°. Instruct the patient to open and close his fists for 3 minutes. RATIONALE This procedure causes the narrowing of the costoclavicular interval with associated tightening of the ANTERIOR SCALENE muscles. Reproduction of the patient's upper extremity symptoms such as paresthesia or radiculopathy is indicative of a positive test.

Yergason's Test

PROCEDURE With the patient seated and the elbow flexed to 90°, stabilize the patient's elbow with one hand. With your opposite hand, grasp the patient's wrist and have the patient externally rotate the shoulder and supinate the forearm against your resistance RATIONALE Resisted supination of the forearm and external rotation of the shoulder stress the bicipital tendon and the transverse humeral ligament. Local pain and/or tenderness in the bicipital tendon indicates an inflammation of the biceps tendon or tendinitis. If the tendon pops out of the bicipital groove, suspect a lax or ruptured transverse humeral ligament or a congenital shallow bicipital groove causing the tendon to subluxate.

Hautant's test Make sure that patient..

PROCEDURE With the patient seated and the patient's EYES CLOSED, instruct the patient to extend the arms to the front with palms up. Instruct the patient to extend and rotate the head to one side. Repeat with the head rotated and extended to the opposite side. ***15 to 30 seconds RATIONALE A patient with stenosis or compression to the vertebral, basilar, or subclavian arteries without sufficient collateral circulation will tend to: > Lose balance, drop the arms, and pronate the hands. If this occurs, suspect a vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this section (VBI insufficiency from STENOSIS)

Foraminal compression 3 STEPS!!!!!

PROCEDURE With the patient seated and the patient's head in the neural position, exert strong downward pressure on the head. REPEAT the test with the head ROTATED bilaterally. RATIONALE When downward pressure is applied to the head, the following biomechanical actions take place: (a) narrowing of the intervertebral foramina (b) compression of the apophyseal joints in the cervical spine (c) compression of the intervertebral discs in the cervical spine. Local pain may indicate foraminal encroachment without nerve root pressure or apophyseal capsulitis. Radicular pain may indicate pressure on a nerve root by a decrease in the foraminal interval (foraminal encroachment) or by a disc defect. If nerve root involvement is suspected, evaluate the neurological level.

Codman's Drop Arm

PROCEDURE With the patient seated, abduct the arm past 90°. Instruct the patient to lower the arm slowly. RATIONALE If the patient cannot lower the arm slowly or if it drops suddenly, this indicates a rotator cuff tear, usually of the supraspinatus. The supraspinatus muscle acts as an abductor of the arm and holds the head of the humerus in place. A tear of the supraspinatus tendon (or rotator cuff) causes unsteadiness of the humerus in abduction, causing it to drop suddenly.

Dawbarn's Test

PROCEDURE With the patient seated, apply pressure just below the acromion process on the side being tested. Note any pain or tenderness (Fig. 5-56). Then, abduct the patient's arm past 90°, maintaining pressure on the spot below the acromion (Fig. 5-57). RATIONALE The spot below the acromion is the palpable portion of the subacromial bursa. Pain and/or tenderness at that location may indicate inflammation of the bursa or bursitis. When the arm is abducted, the deltoid muscle will cover that spot below the acromion. Covering that spot reduces pressure on the bursa, decreasing the tenderness if the bursa is inflamed. ***A decrease in the tenderness to that point indicates subacromial bursitis

Costoclavicular maneuver (Eden's test)

PROCEDURE With the patient seated, establish a radial pulse (Fig. 5-113). Instruct the patient to force the shoulders posteriorly and have the patient flex the chin to the chest (Fig. 5-114). RATIONALE Forcing the shoulders posteriorly decreases the space between the clavicle and first rib. The neurovascular bundle (brachial plexus, axillary artery) and the axillary vein run through a narrow cleft beneath the clavicle and on top of the first rib. Decrease or absence of the amplitude of the radial pulse indicates a compression to the vascular component of the neurovascular bundle. This compression is caused by a decrease in the space between the clavicle and the first rib. This decrease may be caused by a recent or healed fracture to the clavicle or first rib with or without callus formation, dislocation of the medial aspect of the clavicle, or a spastic or hypertrophied subclavius muscle. Paresthesias or radiculopathy in the upper extremity indicates compression to the brachial plexus or compression of the axillary vein (Fig. 5-115). Compression of the brachial plexus is usually localized to a nerve root or peripheral nerve distribution. Compression of the axillary vein typically presents as diffuse radicular vascular discomfort not localized to a nerve root or peripheral nerve distribution.

Adson's test

PROCEDURE With the patient seated, establish the amplitude of the radial pulse. Compare the amplitude bilaterally. Instruct the patient to take a deep breath and sustain it while he or she rotates the head and elevates the chin to the side being tested. If the test is negative, have the patient rotate and elevate the chin to the opposite side. RATIONALE Rotation and extension of the head compress the subclavian artery and brachial plexus. A decrease or absence of the amplitude of the radial pulse indicates a compression of the vascular component of the neurovascular bundle (subclavian artery) by a spastic or hypertrophied ANTERIOR SCALENE muscle, on a cervical rib, or a mass, such as a Pancoast tumor. Paresthesias or radiculopathy in the upper extremity indicates compression of the neural component of the neurovascular bundle (brachial plexus). Anterior Scalene - when in IPSILATERAL rotation Middle Scalene - when in CONTRALATERAL rotation Posterior Scalene - they are often too far away and not impacted

Wright's test (Hyperabduction test)

PROCEDURE With the patient seated, establish the character of the radial pulse. Hyperabduct the arm and take the pulse again. RATIONALE The axillary artery, vein, and three cords of the brachial plexus pass under the pectoralis minor muscle on the coracoid process. Abduction of the arm to 180° stretches these structures around the tendon of the pectoralis minor muscle and the coracoid process. Decrease or absence of the amplitude of the radial pulse indicates compression of the axillary artery either by a spastic or hypertrophied pectoralis minor muscle or by a deformed or hypertrophied coracoid process.

Halstead Maneuver

PROCEDURE With the patient seated, find the radial pulse and note the amplitude. With your opposite hand, pull on the patient's arm and ask the patient to hyperextend the neck. Repeat the test on opposite arm. RATIONALE Traction pressure on the arm pulls the neurovascular bundle (brachial plexus and axillary artery) over the first rib. Extension of the neck tightens the SCALENE muscles. A decreased or obliterated pulse amplitude indicates a cervical rib, subluxation, or malposition of the first rib. An upper extremity radicular component indicates compression of the brachial plexus by the scalenus anterior muscle.

Distraction test

PROCEDURE With the patient seated, grasp beneath the mastoid processes and press up on the patient's head. This removes the weight of the patient's head on the neck. RATIONALE When the head is pulled upward, the cervical muscles, ligaments, and apophyseal joint capsules are stretched. If local pain increases, suspect muscle strain, spasm, ligamentous sprain, or facet capsulitis. Also, when the head is pulled upward, the interforaminal and intervertebral interval increase. Relief of local or radicular pain indicates either foraminal encroachment or a disc defect.

Neer's Impingement

PROCEDURE With the patient seated, grasp the patient's wrist and passively move the shoulder through flexion (Fig. 5-46). RATIONALE Moving the shoulder through forward flexion jams the greater tuberosity of the humerus against the anterior inferior border of the acromion. Shoulder pain and a look of apprehension on the patient's face (+crepitus) indicate a positive sign. This indicates an overuse injury to the supraspinatus muscle or sometimes to the biceps tendon (IMPINGEMENT SYNDROME)

Transverse Humeral Ligament Test

PROCEDURE With the patient seated, grasp the patient's wrist. Abduct the shoulder to 90° and internally rotate it with one hand. With your opposite hand, palpate the bicipital groove. Then EXTERNALLY ROTATE the shoulder. RATIONALE External rotation of the shoulder moves the biceps tendon in the bicipital groove. If you feel the bicipital tendon snap in and out of the bicipital groove, suspect a torn or lax transverse humeral ligament or shallow bicipital groove.

Dugas Test

PROCEDURE With the patient seated, instruct him or her to touch the opposite shoulder and bring the elbow to the chest wall. RATIONALE Inability to touch the opposite shoulder because of pain indicates an anterior dislocation of the humeral head out of the glenoid cavity. This dislocation is usually caused by forced external rotation when the arm is abducted. When the humerus is dislocated anteriorly, a characteristic sign is a prominent acromion process.

Maigne's test

PROCEDURE With the patient seated, instruct the patient to extend and rotate the head and hold that position for 15 to 40 seconds (Fig. 3-34). Repeat the test with the patient's head rotated to the opposite side. RATIONALE Rotation and extension of the head place a motion-induced compression on the vertebral artery on the opposite side of head rotation (Fig. 3-27). Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this section. Consideration must also be given to the patency of the carotid arteries and a communicating cerebral arterial circle.

Sulcus Sign

PROCEDURE With the patient seated, instruct the patient to flex the elbow to 90° with the shoulder in the neutral position for rotation. Grasp the patient's wrist with one hand, pressing down on the forearm with the other hand. RATIONALE Pressing down on the forearm with the patient's shoulder in the neutral position is an attempt to dislocate the shoulder inferiorly. A sulcus at the anterolateral aspect of the shoulder indicates an inferior shoulder instability. The sulcus is graded according to its size. A 1 sulcus indicates less than 1cm. A 2 sulcus indicates 1 to 2 cm. A 3 sulcus indicates more than 2 cm.

Anterior Slide

PROCEDURE With the patient seated, instruct the patient to place the hands on the waist with the thumbs posterior. With one hand, stabilize the scapula and clavicle. With the opposite hand, grasp the humerus and place anterior superior force to the shoulder. RATIONALE Anterior and superior force to the shoulder may dislocate the shoulder anteriorly and superiorly. If a pop or crack is noted and the patient complains of pain to the anterosuperior aspect of the shoulder, this indicates a superior or anterior tear of the glenoid labrum. > SLAP tear "Superior Labrum Anterior Posterior"

Mill's Test

PROCEDURE With the patient seated, instruct the patient to pronate the arm and flex the wrist. Then instruct him or her to supinate the arm against resistance, WHILE PALPATING LATERAL EPICONDYLE. RATIONALE The tendon of the supinator muscle, which supinates the wrist, is attached to the lateral epicondyle. If the condyle itself or the tendon of the supinator that attaches to the condyle is inflamed, resisting supination of the wrist may reproduce irritation to the lateral epicondyle and its attaching tendons. If pain is elicited at the lateral epicondyle, suspect inflammation of the lateral epicondyle (epicondylitis).

Jackson's compression

PROCEDURE With the patient seated, laterally flex the neck and exert strong downward pressure on the head. Perform this test bilaterally. RATIONALE With the neck laterally flexed and downward pressure applied, the following biomechanical actions take place: (a) narrowing of the intervertebral foramina on the side of lateral bending (b) compression of the facet joints on the side of lateral bending (c) compression of the intervertebral discs in the cervical spine. Local pain may indicate foraminal encroachment without nerve root pressure or apophyseal joint pathology. Radicular pain may indicate pressure on a nerve root by a decrease in the foraminal interval (foraminal encroachment) or a disc defect. If nerve root involvement is suspected, evaluate the neurological level.

L'hermitte's Sign (NOT A TEST)

PROCEDURE With the patient seated, passively flex the patient's chin to the chest. RATIONALE When the cervical spine is flexed forward, the spinal cord and its coverings are under traction at the posterior, and the intervertebral disc is compressed at the anterior and bulges at the posterior (Fig. 3-78). If the patient has a POSTERIOR DISC DEFECT, this movement may exacerbate the defect, resulting in spinal cord or nerve root compression. Cervical cord disease, meningitis, osteophytes, and masses may cause local and/or radicular pain into the upper and/or lower extremities. A sudden electrical tingling felt in the spine and/or extremities during neck flexion may indicate cervical myelopathy or multiple sclerosis.

Chest Expansion

PROCEDURE With the patient seated, place a tape measure around the patient's chest at the level of the nipple. Instruct the patient to exhale, and record the measurement. Next, instruct the patient to inhale maximally; record the measurement (Fig. 9-43). RATIONALE The normal chest expansion for a man is 2 inches or more. The normal chest expansion for a woman is 1 inch or more. A decrease in the normal chest expansion indicates an ankylosing condition, such as ankylosing spondylitis at the costotransverse or costovertebral articulation.

Shoulder depression

PROCEDURE With the patient seated, place downward pressure on the shoulder while laterally flexing the patient's head to the opposite side. RATIONALE When pressure is applied to the shoulder and the head is slightly flexed to the opposite side, the muscles, ligaments, nerve roots, nerve root coverings, and brachial plexus are stretched and the clavicle is depressed, approximating the first rib. Local pain on the side being tested indicates shortening of the muscles, muscular adhesions, muscle spasm, or ligamentous injury. Radicular pain may indicate compression of the neurovascular bundle, adhesion of the dural sleeve, or thoracic outlet syndrome. On the opposite side, the foraminal interval is decreased, the apophyseal joints are compressed, and the intervertebral disc is compressed. If pain is elicited on the side opposite the one being tested, it may indicate a pathological decrease in the foraminal interval, facet pathology, or disc defect. Local pain on side of shoulder depression > Shortening of the muscles / muscular adhesions Local pain on side of lateral flexion > Facet joint Radicular pain on side of shoulder derpession > Compression of neurovascular bundle / TOS Radicular pain on side of lateral flexion > Foraminal encroachment affecting nerve roots

O'Donoghue's maneuver

PROCEDURE With the patient seated, put the cervical spine through resisted range of motion, then through passive range of motion. See sections on Cervical Range of Motion and Cervical Resistive Isometric Muscle Testing in this chapter. RATIONALE Pain during resisted range of motion or isometric muscle contraction signifies muscle strain (see resistive range of motion for muscles involved). Pain during passive range of motion may indicate a sprain of any of these ligaments: alar ligaments, transverse ligament, supraspinous ligament, interspinous ligament, ligamentum flavum, articular capsule, intertransverse ligaments, posterior longitudinal ligament, and anterior longitudinal ligament. NOTE This maneuver can be applied to any joint or series of joints to determine ligamentous or muscular involvement. Since resistive range of motion mainly stresses muscles and passive range of motion mainly stresses ligaments, you should be able to determine between strain and sprain or a combination thereof.

Cozen's Test

PROCEDURE With the patient seated, stabilize the patient's forearm. Instruct the patient to make a fist and extend it. Then force the extended wrist into flexion against resistance, (resisted wrist extension) WHILE PALPATING LATERAL EPICONDYLE. RATIONALE The tendons that extend the wrist are attached to the lateral epicondyle. They are the extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. If the condyle itself or the common extensor tendons that attach to it are inflamed, then forcing the extended wrist into flexion can reproduce irritation to the lateral epicondyle and its attaching tendons. If pain is elicited at the lateral epicondyle, suspect inflammation of the lateral epicondyle (epicondylitis) > Tennis elbow

Tinel's Sign (ulnar nerve found below or around medial epicondyle)

PROCEDURE With the patient seated, tap the ulnar nerve in the groove between the olecranon process and the medial epicondyle with a neurological reflex hammer (Fig. 6-36). The ulnar nerve passes in this groove. RATIONALE This test is designed to elicit pain caused by a neuritis or neuroma of the ULNAR NERVE. Pain indicates a positive test. The nerve can become damaged in the following ways: 1. Excessive use or repetitive injuries or trauma of the elbow 2. Arthritis of the elbow joint 3. Cubital tunnel compression, between the heads of the flexor carpi ulnaris muscle 4. Postural habits that compress the nerve, such as sleeping with elbows flexed and hands under head 5. Recurrent nerve subluxations or dislocations

Ligamentous Instability (Abduction test)

PROCEDURE With the patient sitting, stabilize the lateral arm and place abduction pressure on the medial forearm. RATIONALE Placing an abduction pressure on the medial forearm applies stress to the ulnar collateral ligament. > Gapping and pain indicate ulnar collateral ligament instability.

Ligamentous Instability (Adduction test)

PROCEDURE With the patient sitting, stabilize the medial arm and place adduction pressure on the patient's lateral forearm. RATIONALE Placing adduction pressure on the lateral forearm applies stress to the radial collateral ligament. Gapping and pain indicate radial collateral ligament instability.

Hawkins-Kennedy Impingement Test

PROCEDURE With the patient standing, flex the elbow to 90° and flex the shoulder forward to 90°, then force the shoulder in an internal rotation without resistance by the patient. RATIONALE This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament. Local pain indicates rotator cuff tear OR supraspinatus tendinitis / impingement

Passive Scapular Approximation

PROCEDURE With the patient standing, grasp the patient's shoulders. Passively approximate the scapulae by pushing the shoulders backward. RATIONALE Passively approximating the scapulae places motion-induced traction on the T1 and T2 nerve roots. Pain in the scapular area indicates a T1 and/or T2 nerve root compression or irritation.

Underburg's test Make sure that patient..

PROCEDURE With the patient standing, instruct him or her to close the eyes and look for difficulty in equilibrium. Next, instruct the patient to stretch out the arms and supinate the hands. Look for difficulty in equilibrium and drifting or pronating of the arms. Then instruct the patient to march in place. Next, instruct the patient to extend and rotate the head while continuing to march in place. Repeat with the patient's head rotated and extended to the opposite side. RATIONALE Marching in place increases the heart rate, which increases the rate of blood flow through the suspected vessels. Extension and rotation of the head place a motion-induced compression on the vertebral arteries on the opposite side of head rotation. Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this section. Consideration must also be given to the patency of the carotid arteries and a communicating cerebral arterial circle. (VBI sufficiency from STENOSIS)

Feagin

PROCEDURE With the patient standing, instruct the patient to abduct the arm and place the hand on your shoulder. With both hands, grasp the patient's humerus next to the humeral head and exert downward and forward pressure. RATIONALE A look of apprehension on the patient's face signifies a positive test. This indicates an anterior inferior shoulder instability. This test is an attempt to dislocate the shoulder anteriorly and inferiorly. It tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.

Adam's Maneuver (Position)

PROCEDURE With the patient standing, stand directly behind the patient and inspect and palpate the entire length of the spine, looking for scoliosis, hyperkyphosis, or kyphoscoliosis. Next, instruct the patient to flex forward at the hips. Again, inspect and palpate for scoliosis, kyphosis, or kyphoscoliosis. RATIONALE If scoliosis, kyphosis, or kyphoscoliosis is present with the patient standing and if the angle reduces upon forward flexion, the scoliosis is a functional adaptation of the spine and surrounding soft tissue structures. It may be caused by poor posture, overdevelopment of unilateral spinal and/or upper extremity musculature, nerve root compromise, leg length deficiency, or hip contracture. This type of scoliosis is usually mild to moderate, measuring less than 25°. If scoliosis, kyphosis, or kyphoscoliosis is present with the patient standing and if the angle does not reduce upon forward flexion, suspect a structural deformity, such as hemivertebra, compression fracture of a vertebral body, or idiopathic scoliosis. Function scoliosis - Straightens upon flexion Postural scoliosis - Flexion doesn't help

Fulcrum Test

PROCEDURE With the patient supine and the arm abducted to 90°, place your hand under the glenohumeral joint and externally rotate the patient's arm over the hand. RATIONALE This is an attempt to dislocate the head of the humerus anteriorly. A look of apprehension with pain is a positive sign. - Anterior glenohumeral instability: dislocation/subluxation The patient may say that it felt the same as when the shoulder was previously dislocated. This procedure also tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum. A congenitally shallow glenoid fossa may also predispose the shoulder to dislocation.

Clunk Sign

PROCEDURE With the patient supine the examiner places one hand over the posterior aspect of the humeral head. With the opposite hand the examiner grasps the elbow and fully abducts the shoulder (with elbow flexed). The examiner then pushes anteriorly with the hand over the humeral head and externally rotates the shoulder with the opposite hand. EXACTLY like fulcrum except it's FULL abduction RATIONALE Anterior pressure to the humeral head with external rotation of the shoulder attempts to dislocate the shoulder anteriorly. A clunk or grinding sound indicates a positive test which suggests an ANTERIOR TEAR OF THE GLENOID LABRUM > SLAP tear "Superior Labrum Anterior Posterior"

Posterior Apprehension

PROCEDURE With the patient supine, forwardly flex and internally rotate his or her shoulder. With your hand, apply posterior pressure on the elbow. RATIONALE This test attempts to dislocate the shoulder posteriorly and stresses the rotator cuff and posterior joint capsule. *Local pain or discomfort and a look of apprehension on the patient's face indicates chronic posterior shoulder instability. The patient may say that it felt the same as when the shoulder was previously dislocated. The mechanism of injury is commonly a position of forced adduction with internal rotation in some degree of elevation.

Alar ligament stress test *What kind of movement??

PROCEDURE With the patient supine, grasp the head with one hand. With the opposite hand grasp C2 with a pinch grip around the spinous process and lamina. Attempt a shear SIDE-TO-SIDE movement of the head against the axis. There should be a minimal amount of lateral motion with a strong capsular end feel. RATIONALE The alar ligaments extend from the odontoid process to the lateral margins of the foramen magnum. These ligaments limit SIDE-TO-SIDE movement of the skull on the axis. Excessive side-to-side movement indicates a stretched or torn alar ligament or ligaments.

Norwood Stress

PROCEDURE With the patient supine, instruct the patient to abduct the shoulder to 90°, externally rotate it to 90°, and flex the elbow to 90°. With one hand, stabilize the scapula while palpating the posterior aspect of the humeral head. With your opposite hand, grasp the elbow, bringing the shoulder into forward flexion and forcing the elbow posteriorly. RATIONALE This test is an attempt to dislocate the shoulder posteriorly, stressing the rotator cuff and the posterior joint capsule. A positive test is indicated by the humeral head slipping posteriorly out of the glenoid fossa > Posterior glenohumeral instability (dislocation/subluxation) When the arm is returned to the starting position, the humeral head should reduce. A clicking sound may accompany the reduction.

Lift-Off Sign

Procedure - Patient seated - Place arm behind back - Actively "lift" arm off back - Extend elbow against resistance Positive findings - Inability to internally rotate shoulder with hand off back - Pain - Weakness Indication - Subscapularis strain/tear

Beevor's Sign

PROCEDURE With the patient supine, instruct the patient to hook the fingers behind the neck and raise the head toward the feet. This test should mimic a sit-up. RATIONALE The umbilicus of the patient who has no thoracic root lesion will not move during this test because the abdominal muscles are equally innervated and of equal strength. If a root lesion is present, the umbilicus will move in the following manner: If the umbilicus moves superiorly, suspect a bilateral T10 to T12 nerve root lesion. If it moves superiorly and laterally, suspect a unilateral T10 to T12 nerve root lesion on the opposite side. If the umbilicus moves inferiorly, suspect a bilateral T7 to T10 nerve root lesion. If it moves inferiorly and laterally, suspect a unilateral T7 to T10 nerve root lesion on the opposite side.

Soto-Hall test *For female patient...

PROCEDURE With the patient supine, press on the patient's sternum with one hand. With the other hand, passively flex the patient's neck to the chest. RATIONALE Evidence of local pain may indicate ligament, muscular, osseous pathology or injury, or cervical cord disease. This test is nonspecific; it merely isolates the cervical spine in passive flexion. If the patient reports radicular symptoms in the upper extremity on passive flexion, suspect a DISC DEFECT (posteriorly). When the cervical spine is flexed forward, the intervertebral disc is compressed at the anterior and stretched at the posterior. The dura is also in traction at the posterior. If the patient has a posterior disc defect, this movement may exacerbate the defect, resulting in spinal cord or nerve root compression.

Transverse ligament stress test

PROCEDURE With the patient supine, support the occiput with the palms of both hands and the third, fourth, and fifth fingers. Place the index fingers of both hands between the occiput and C2 at the posterior arch or Atlas, which is not palpable. Carefully lift the head and C1 off the table, not allowing any flexion or extension of the cervical spine. Hold this position for 10 to 20 seconds. RATIONALE Lifting the head and C1 off the table places motion-induced posterior traction on the transverse ligament by the odontoid process. This movement should be limited by a transverse ligament. If the transverse ligament is torn or stretched, compression of the spinal cord by this anterior shear may occur. Possible signs include a soft end feel, muscle spasm, dizziness, nausea, paresthesia of the lip, face or limbs, nystagmus or a lump sensation in the throat. This indicates a hypermobile atlantoaxial articulation.

Speed's Test

PROCEDURE With the patient's elbow completely extended, supinated, and the shoulder flexed forward to 45°, place your fingers on the bicipital groove and your opposite hand on the patient's wrist (Fig. 5-48). Instruct the patient to elevate the arm forward against your resistance (Fig. 5-49). RATIONALE This test stresses the biceps tendon in the bicipital groove. Pain or tenderness in the bicipital groove indicates bicipital tendinitis.

Test for tight retinacular ligament

PROCEDURE With the proximal interphalangeal joint in the neutral position, passively attempt to flex the distal interphalangeal joint (Fig. 8-15). Repeat the test with the proximal interphalangeal joint in the flexed position (Fig. 8-16). RATIONALE If the distal interphalangeal joint does not flex with the proximal interphalangeal joint in the neutral position, the collateral ligaments or joint capsule is tight. If the distal interphalangeal joint flexes easily when the proximal interphalangeal joint is flexed, the collateral ligaments are tight and the capsule is normal.

Ballottement AKA Lunatotriquetral Ballottement Test AKA Reagan

PROCEDURE With one hand, grasp the triquetrum on the affected side with your thumb and index finger. With your opposite hand, grasp the lunate, also with the thumb and index finger (Fig. 7-35). Move the lunate anteriorly and posteriorly, noting any pain, laxity, or crepitus. RATIONALE The lunate and triquetrum are held together by a fibrous articular capsule and by dorsal, palmar, and interosseous ligaments. The lunate is the most commonly dislocated of the carpal bones. Most of the time it dislocates anteriorly and affects the radiolunate and the ligaments between the lunate and the triquetrum. Pain, laxity, or crepitus indicates instability of the lunatotriquetral articulation, causing a propensity of the lunate to subluxate or dislocate. This instability may lead to carpal tunnel syndrome, medial nerve palsy, flexor tendon constriction, or progressive avascular necrosis of the lunate.

Sternal Compression

PROCEDURE With the patient supine with pt's hands across the sternum, push down on the sternum. RATIONALE Pressure to the sternum compresses the lateral borders of the ribs. If a FRACTURE is sustained at or near the lateral border of the ribs, the pressure on the sternum will cause the fracture to become more pronounced, producing or exacerbating pain in the area of the fracture. NOTE Be cautious if you suspect a fractured rib, especially if it is displaced. If trauma has occurred and you suspect a fractured rib, the area should be radiographed before this test.

Triangular Fibrocartilage Compression

Procedure The examiner holds the patient's forearm with one hand and the patient's hand with the other hand. The doctor then places an axial load and ulnar deviation while moving A-P and P-A. (ULNAR DEVIATION > AXIAL COMPRESSION > FLEXION/EXTENSION) Positive Findings Pain, clicking, or crepitus in the area of the Triangular Fibrocartilage Complex(TFCC). Indications Triangular Fibrocartilage Complex(TFCC) tear.

Supination Lift Test

Procedure This test is used to determine pathology in the triangular fibrocartilage complex (TFCC). The patient is seated with their elbows flexed to 90 degrees and forearms supinated. The patient is asked to place the palms flat on the underside of a heavy table (or flat against the doctor's hands). The patient is instructed to lift their hands up. Positive Findings Localized pain on the ulnar side of the wrist and difficulty applying the force. Indications Dorsal TFCC tear. Pain on forced ulnar deviation causing ulnar impaction is a symptom of TFCC tears.

Shuck Test

Procedure With the patient seated, the examiner holds the patient's wrist flexed and asks the patient to actively extend the fingers against resistance. Positive Finding Pain in the carpal joints. Indication Radiocarpal or mid-carpal instability, scaphoid instability, inflammation, or Kienbock's disease.

Mandibular Postural Rest Position (MPRP)

Say BoyBoyBoy and freeze Less than 2mm > Dysfunction

Jamar Dynamometer

Take 3 measurements

Reverse Mill's Test

With the patient seated their arm flexed forward, the doctor passively extends the patients elbow and wrist. Ask the patient to pronate against resistance. Pain at the medial epicondyle > Medial epicondylitis