Special Tests
b) Valgus Stress Test - (Level 2)- MCL It has been advocated that resting the test thigh on the examining table enables the patient to relax more and is easier for the examiner. The hip is slightly abducted. The knee is flexed 30° over the side of the table and the examiner places one hand on the lateral aspect of the knee and grasps the foot/ankle with the other. Apply a lateral to medial force to knee while the hand at the ankle is slightly laterally rotated. Repeat in full extension. + = increased laxity (compare to other knee) 1) in full extension, ACL, PCL and capsule are implicated. 2) in 30º of flexion, MCL is implicated.
Valgus Stress Test
Two-Point Discrimination (Level 2) 1. The examiner uses a two-point aesthesiometer in the index finger of the patient. 2. The smallest distance perceived as two separate points is recorded in millimeters. 3. A positive test is the inability of the patient to detect a distance of 6 mm or more.
Two-point discrimination
Ulnomeniscotriquetral Dorsal Glide (TFCC Tear or Triquetral Instability) (Level 3) 1. The examiner places his or her thumb dorsally over the ulna while placing the PIP of the index finger over the piso-triquetral complex. 2. Produce a dorsal glide of the piso-triquetral complex. 3. A positive test is reproduction of pain or laxity in the ulnomeniscotriquetral region
Ulnomeniscotriquetral Dorsal Glide
Patient arm is stabilized with examiner's hand at the elbow. Abduction / valgus force applied at distal forearm to test MCL. Examiner should note any laxity and compare to other side.
Valgus stress test
The examiner locates the radial pulse. Patient's head is rotated to face away from the test shoulder. The patient then tilts back head while examiner laterally rotates and extends the patient's shoulder. Patient is instructed to take a deep breath and hold it. Disappearance is positive for thoracic outlet syndrome.
Allen Maneuver
Patient asked to open or close hand several times as quick as possible. Then make a tight fist. Examiner compresses ulnar and radial arteries. Patient opens hand while pressure is maintained over arteries. Take hand off of one of the arteries. Repeat test for other artery. Test determines which blood vessel provides major blood supply to hand.
Allen (Radial and Ulnar Arteries)
AC Joint Palpation (AC Joint Pain) Level 2 1. The patient is seated with the involved arm at his or her side. The examiner stands behind the patient and palpates the AC joint. 2. Production of the concordant sign is a positive test.
AC Joint Palpation
Achilles Tendon Reflex (S1-2) 1. With the person sitting, passively place foot in DF. 2. Patient looks away; strike Achilles tendon with reflex hammer. 3. Should see PF jerk.
Achilles tendon reflex
The examiner locates the radial pulse. Patient's head is rotated to face the test shoulder. The patient then tilts back head while examiner laterally rotates and extends the patient's shoulder. Patient is instructed to take a deep breath and hold it. Disappearance is positive for thoracic outlet syndrome.
Adson Maneuver
Alternate Format for Apley's scratch test is a quick check of active ROM. There are three components to this test. First, with the arms at the side, have the person abduct the arm to 90º while keeping the elbows extended. Have them supinate the forearms and externally rotate the arms and complete abduction. Secondly, have the person put their hands behind their neck and pull the elbows back. Finally, have the person put their hands behind their back and reach for the inferior angle of the scapula.
Alternate format for Apley Scratch
Ankle Dorsiflexion (Level ?) This test is used to distinguish between the gastrocnemius and the soleus muscle as the cause of limitation in dorsiflexion. 1. Have the person sit on the edge of the table facing you. 2. With the knee extended, dorsiflex the ankle. 3. If limitation is present, flex the knee and dorsiflex the ankle. 4. If you are able to dorsiflex the ankle joint, the gastrocnemius muscle is tight. If you are unable to dorsiflex the ankle joint, the soleus muscle is tight.
Ankle dorsiflexion
Anterior Drawer Test (Level 2) 1. The patient's knee is flexed to 90°, and the hip is flexed to 45°. In this position, the anterior cruciate ligament is almost parallel with the tibial plateau. 2. The patient's foot is held on the table by the examiner's body with the examiner sitting on the patient's forefoot and the foot in neutral rotation. 3. The examiner's hands are placed around the tibia to ensure that the hamstring muscles are relaxed. The tibia is then drawn forward on the femur. 4. The normal amount of movement that should be present is approximately 6 mm. If the test is positive (i.e., the tibia moves forward more than 6 mm on the femur), MUST CLEAR PCL or you'll get false +.
Anterior Drawer Test
Anterior Release/ Surprise Test (Anterior Instability) (Level 2) 1. The patient assumes a supine position. The examiner stands beside the patient. 2. The examiner grasps the forearm with one hand and provides a posterior force on the humerus with the other. 3. The posterior force on the proximal humerus is maintained while the examiner moves the patient's shoulder into the apprehension position of 90 degrees abduction and end-range external rotation. 4. The posterior force on the humerus is then released. 5. A positive test is indicated if the patient reports sudden pain, an increase in pain, or by reproduction of the patient's concordant symptoms
Anterior Release/Surprise Test
TESTS FOR ANTERIOR TALUS DISPLACEMENT RELATIVE TO THE TIBIA Anterior Drawer Test (Level 2) 1. The patient lies supine with the ankle in slight plantarflexion. 2. The examiner performs an anterior glide of the calcaneus and talus on a stabilized tibia. 3. + test is excessive translation of the tested side. Laxity is typically due to a sprain of the anterior talofibular ligament.
Anterior drawer test (foot)
Apley's Test (Level 2) 1. Patient lies prone with knee flexed to 90̊. a) compression - meniscal tear Apply pressure to plantar heel and internally and externally rotate tibia. + = pain and clicking. b) distraction - rotational sprain Grasp lower leg and stabilize thigh proximal to femoral condyles. Distract tibia while internally and externally rotating tibia. + = pain with distraction and rotation.
Apley's Test (knee)
Approximation (sidelying) [transverse posterior stress test] • Patient is sidelying • Examiner's hands placed over the upper part of the iliac crest, pressing toward the floor o Movement causes forward pressure on sacrum • Positive if there is a feeling of pressure on the sacrum thus indicating SI lesion or sprain of posterior SI ligaments
Approximation Test
Tests the structures around the MCP joint. MCP joint is held in slight extension while the examiner moves PIP joint into flexion. Positive if PIP cannot be moved into flexion. Indicates tight intrinsic muscle of contracture of joint capsule.
Bunnel-Littler (tight hand intrinsic versus tight PIP joint capsule)
Bounce Home Test (Level 3) Non-specific meniscal tear 1. Support leg with both hands and passively flex and ext knee a few times. 2. Then let go of thigh and allow leg to extend out straight quickly while holding onto lower limb. 3. + = knee does not extend out straight and there is pain.
Bounce Home
Biceps Load Test II (SLAP Lesion) (Level 2) 1. The patient assumes a supine position. The examiner is on the side of the patient's involved extremity. 2. The examiner places the patient's shoulder in 120 degrees of abduction, the elbow in 90 degrees of flexion, and the forearm in supination. 3. The examiner moves the patient's shoulder to end-range external rotation (apprehension position). 4. At end-range external rotation, the examiner asks the patient to flex his or her elbow while the examiner resists this movement. 5. A positive test is indicated as a reproduction of concordant pain during resisted elbow flexion.
Biceps Load Test II
(C5/6; C5 is the primary contribution to the reflex)
Biceps Reflex
(C5/6; C6 is the primary contribution to the reflex)
Brachioradialis Reflex
Foraminal Compression (Spurling's Test), Distraction of C Spine, Shoulder Depression Test, Shoulder Abduction Relief Test (Bakody), Upper Limb Tension Test (Brachial Plexus Tension Test or Elvey Test)
Cervical Tests for Problems with Nerve Roots and Brachial Plexus
Craig (Ryder method or test for rotational deformities: anteversion or retroversion)- With the person you are examining lying prone: a. Bend knee to 90̊. b. Place one hand on distal tibia/fibula and one hand (palm) over greater trochanter area. c. IR and ER hip until you feel the greater trochanter of femur sit in your palm. d. Instruct patient to hold that position. e. Measure angle (goni) - stationary axis is perpendicular to floor; axis is tibial tuberosity; moving arm is anterior midline of tibia. f. Normal angle = 8o - 25o of anteversion. g. Excessive anteversion = > 25̊. h. Retroversion = < 8̊.
Craig Test / Ryder Method
Crank Test (Labral Tear, SLAP Lesion) (Level 2) 1. The patient assumes either a sitting or supine position. The examiner either stands or sits at the side of the involved extremity. 2. The examiner places the patient's shoulder in 160 degrees of elevation in the scapular plane and elbow in 90 degrees of flexion. 3. The examiner first applies a compression force to the humerus and then rotates the humerus repeatedly into internal rotation and external rotation in an attempt to pinch the torn labrum. 4. A positive test is indicated by the production of pain either with or without a click in the shoulder or by reproduction of the patient's concordant complaint (usually pain or catching).
Crank Test
Distraction of the C spine (supine) - sitting or supine • For patients who have complained of radicular symptoms • Examiner places one hand under the patient's chin and the other hand under the occiput, then slowly lifts the patient's head, applying traction to the cervical spine • Positive if the pain is relieved or decreased when the head is lifted/distracted
Distraction of the C Spine
Drop Sign (Infraspinatus Tear, Irreparable Fatty Degeneration of Infraspinatus) (Level 2) 1. The patient is seated with the examiner standing to the rear. 2. The examiner grasps the patient's elbow with one hand and the wrist with the other. 3. The examiner places the elbow in 90 degrees of flexion and the shoulder in 90 degrees of elevation in the scapular plane. 4. The examiner passively externally rotates the shoulder to near end range. 5. The examiner asks the patient to maintain this position as the patient's wrist is released. 6. A positive test for infraspinatus tear is indicated by a lag that occurs with the inability of the patient to maintain his or her arm near full external rotation.
Drop sign
Elbow Flexion Test (Cubital Tunnel Syndrome) (Level 2) 1. Patient is sitting with both arms and shoulders in the anatomic position. Both elbows are fully but not forcibly flexed with full wrist extension. 2. Patients are asked to describe any symptoms following holding this position for 3 minutes. 3. A positive test is the reproduction of pain, tingling, or numbness along the ulnar nerve distribution.
Elbow Flexion Test
Ely's (Level ?) Follow up to Thomas test. This test rules out iliopsoas tightness. 1. Patient is prone. 2. Examiner flexes knee in question as far as it can go. 3. If the pelvic rotates and lifts up from the plinth = + for tight rectus femoris.
Ely's Test
Ege's Test (Level 2) 1. The patient stands with feet 30-40 cm from each other and knees in full extension. 2. To test the medial meniscus, the patient externally rotates the lower legs to end range and slowly squats then stands up. 3. To test the lateral meniscus, the patient internally rotates the lower legs to end range and slowly squats then stands up. 4. A positive test for a torn meniscus is indicated by concordant pain and/or a click.
Ege's Test
Empty Can Test/ Supraspinatus Test (Rotator Cuff Tear) (Level 2) 1. The patient elevates the arms to 90 degrees with thumbs up (full can position). 2. The examiner provides downward pressure on the arms and notes the patient's strength. 3. The patient elevates the arms to 90 degrees and horizontally adducts 30 degrees (scapular plane) with thumbs pointed down as if "emptying a can." 4. The examiner provides downward pressure on the arms and notes the patient's strength. 5. A positive test for rotator cuff tear is examiner assessment of more weakness in the empty can position vs. the full can position; patient complains of pain; or both. Also called Jobe Test +: Tear of the supraspinatus muscle or tendon, or neuropathy of suprascapular nerve
Empty can test / supraspinatus test
Functional Tests (Level ?) 1. For L5, have patient heel walk. 2. For S1, have patient toe walk.
Foot functional tests
External Rotation Lag Sign (Supraspinatus/Infraspinatus Tear) (Level 1) 1. The patient is seated with the examiner standing to the rear. 2. The examiner grasps the patient's elbow with one hand and the wrist with the other. 3. The examiner places the elbow in 90 degrees of flexion and the shoulder in 20 degrees of elevation in the scapular plane. 4. The examiner passively externally rotates the shoulder to near end range. 5. The examiner asks the patient to maintain this position as the patient's wrist is released. 6. A positive test for Supraspinatus/infraspinatus tear is indicated by a lag that occurs with the inability of the patient to maintain his or her arm near full external rotation.
External rotation lag sign
Feiss Line (Level ?) 1. Patient is seated. 2. Mark apex of medial maleollus, navicular tuberosity, and medial aspect of 1st MTP and draw a line connecting them. 3. Have patient stand with feet about 3" apart. The navicular tubercle normally lies on or close to the line joining the two other points. 4. + = navicular drops = flat foot. If the tubercle falls one third of the distance to the floor, it represents a first-degree flatfoot; if it falls two thirds of the distance, it represents a second-degree flatfoot; if it rests on the floor, it represents a third-degree flatfoot.
Feiss Line
Fibular Translation Test (Level 2) 1. The patient lies in a sidelying position. 2. The examiner applies anterior and posterior forces on the fibula at the level of the syndesmosis. 3. A positive test is pain during translation and more displacement to the fibula than the compared side.
Fibular Translation test
Finkelstein's Test (Thumb tenosynovitis) 1. Make a fist with thumb inside the fingers. 2. Stabilize the arm and move the hand into ulnar deviation. 3. A positive result is when pain is felt in the abductor pollicis longus and extensor pollicis brevis.
Finkelstein's Test
Foraminal Compression (Spurling's Test) -- sitting • Patient complains of nerve root symptoms • The patient bends or side flexes the head to the unaffected side first, followed by affected side • Examiner carefully presses straight down on the head. • Advocated that test be performed in three stages (increasingly provocative) o Stage 1: Compression of head in neutral o Stage 2: Compression with head in extension o Stage 3: Head in extension and rotation to the unaffected side ♣ This part follows Spurling • Positive if pain radiates into the arm toward which the head is side flexed during compression. This indicates cervical radiculitis (pain in dermatomal distribution)
Foraminal Compression (Spurling's Test)
The patient attempts to grasp a piece of paper between thumb and index finger. When the examiner attempts to pull the paper away, the terminal phalanx of the thumb flexes because of paralysis of the abductor pollicis muscle indicating a positive test.
Froment's Sign
Gapping (supine) [aka transverse anterior stress test] • Patient lies supine while the examined applies cross-arm pressure to the ASIS • Examiner pushes down and out with arms • Positive if unilateral gluteal or posterior leg pain is produced, indicating sprain of SI ligaments
Gapping Test
Hand Elevation Test (Level 2) 1. The patient raises both hands and maintains the position until the patient feels paresthesia or numbness in the distribution of the median nerve. 2. A positive test is the reproduction of symptoms such as tingling and numbness along the median nerve distribution after raising the arms for no greater than 2 minutes.
Hand Elevation Test
Hawkins-Kennedy Test (Level 3) 1. The patient is seated while the examiner stands anteriorly to the involved shoulder. 2. The examiner first raises the patient's arm into approximately 90 degrees of shoulder flexion or abduction with one hand while the other hand stabilizes the scapula (typically superiorly). 3. The examiner applies forced humeral internal rotation in an attempt to reproduce the concordant shoulder pain. If concordant shoulder pain is present, the test is positive.
Hawkins-kennedy
In the normal knee, the tibial tuberosity is in line with the patella when the knee is flexed to 90. When the knee is extended, the tibial tubercle is in line with lateral border of patella. If the change does not occur with change in movement, rotation is blocked. May be due to injury to meniscus, PCL or quadriceps that prevent screw home mechanism
Helfet's (screw home)
Homan's Sign (+ for DVT) (Level 3) 1. Place patient in supine. 2. Squeeze the gastrocnemius while forcing foot into DF. 3. Palpate for cords and pain. Or use a BP cuff around the calf. If DVT is present, subject will not tolerate pressure > 40 mm Hg.
Homan's Sign
The patient attempts to grasp a piece of paper between thumb and index finger. When the examiner attempts to pull the paper away, the terminal phalanx of the thumb flexes while the MCP hyperextends is a positive Jeanne's sign. Both indicate ulnar nerve paralysis
Jeanne's Sign
Knee Effusion 1. Patient is supine or long sitting. 2. Use a reference anatomical landmark such as tibial tubercle or mid-patella. 3. Measure the girth of the knee at set anatomical landmarks at 2 cm intervals above and below landmark. Compare to other leg.
Knee effusion
Lachman's Test (Level 1) 1. The patient lies supine with the involved leg beside the examiner. 2. The examiner holds the patient's knee flexed to 15° of flexion. The patient's femur is stabilized with one of the examiner's hands (the "outside" hand) while the proximal aspect of the tibia is moved forward with the other ("inside") hand. 3. A positive sign is indicated by a "mushy" or soft end feel when the tibia is moved forward on the femur compared to the uninvolved side.
Lachman's Test
Lateral ("tennis elbow") - Cozen's Test (Level ?) 1. The patient's elbow is stabilized by the examiner's thumb which rests on the patient's lateral epicondyle. 2. The patient is then asked to actively make a fist, pronate the forearm, and radially deviate and extend the wrist while the examiner resists the motion. 3. A sudden severe pain in the area of the lateral epicondyle of the humerus is a positive sign. The epicondyle may be palpated to indicate the origin of the pain.
Lateral ("tennis elbow") Test - Cozen's Test
Leg length discrepancy There two versions of this test: apparent and true. For either test, the patient is supine and the legs should be 15 to 20 cm (4-8 inches) apart and parallel to each other. a) apparent 1. Measure from umbilicus to medial malleolus of each leg (just distal to the malleolus) and compare cm readings. 2. More than 2.5 cm may be symptomatic. b) true (including site of discrepancy) 1. Measure from ASIS to medial malleolus of each leg and compare cm. readings. 2. Pelvic obliquity or an adductor or flexion deformity in the hip joint can cause apparent leg length discrepancy. 3. You can follow this test with having the patient flex their knees and keep both feet on the table. Be sure the heels are equal. 4. The examiner can then check to see if the femur lengths are equal and if the tibial lengths are equal by observing the patient from a lateral view. Be sure to view from both sides. Unequal bone lengths can cause leg length discrepancies.
Leg Length Descrepancy
Lift-Off Test (Subscapularis Tear) (Level 2) 1. The patient is seated with affected arm behind the back. 2. The patient is asked to lift his or her arm off the back. 3. A positive test for subscapularis tear is indicated by inability of the patient to lift his or her arm off of the back.
Lift off test
The patient clasps both hands on top or behind the head, allowing the interlocking fingers to support the weight of the upper limbs. While the examiner does the contractions and relaxations, the examiner palpates the biceps tendon, which will be felt on the uninvolved side but not on the affected side if the test result is positive. A positive test indicates that the long head of biceps tendon has ruptured.
Ludington's Test
Sitting Root Test, Straight Leg Raise, Prone Knee Bending Test
Lumbar spine tests for problems with nerve roots and peripheral nerves
McMurray's Test (Level 2) 1. The patient is in the supine position with the knee completely flexed (the heel to the buttocks). 2. Support the foot with one hand and put the other hand over the knee at the joint line. 3. The examiner then medially rotates the tibia and extends the knee. 4. If there is a loose fragment of the lateral meniscus, this action causes a snap or click that is often accompanied by pain. 5. To test the medial meniscus, the examiner performs the same procedure with the knee laterally rotated.
McMurray Test
Medial ("golfer's elbow") (Level ?) 1. While the examiner palpates the patient's medial epicondyle, the patient's forearm is passively supinated and the examiner extends the elbow and wrist. 2. A positive sign is indicated by pain over the medial epicondyle of the humerus.
Medial epicondylitis test
Moving Valgus Stress Test (Chronic MCL tear of Elbow) (Level 2) (Can be done standing or sitting) 1. The patient is in an upright position and the shoulder is abducted to 90 degrees. With the elbow in full flexion of 120 degrees, modest valgus torque is applied to the elbow until the shoulder reaches full external rotation. 2. With a constant valgus torque the elbow is quickly extended to 30 degrees 3. A positive test is reproduction of medial elbow pain when forcibly extending the elbow from a flexed position between 120 to 70 degrees.
Moving valgus stress test
Neer's Impingement Test (Level 3) 1. The patient is seated while the examiner stands to the side of the involved shoulder. 2. The examiner raises the patient's arm into flexion with one hand while the other hand stabilizes the scapula. 3. The examiner applies forced flexion toward end-range in an attempt to reproduce the shoulder pain. 4. If concordant shoulder pain is present, the test is positive. Test causes greater tuberosity to jam against anteroinferior border of the acromion
Neer's Impingement test
Ober Test (Level ?) There are two parts to this test: a. Tensor Fascia Latae (TFL): i. Patient is side lying while facing away from you. ii. The examiner flexes the upper knee and extends the upper hip while abducting hip and supports the leg in this position. iii. The examiner then releases the upper leg. iv. If the leg drops = (-); if leg stays in above position = (+) tight TFL. b. Iliotibial Band: i. Patient is side lying while facing away from you. ii. The examiner extends the upper knee and hip while abducting hip (leg is straight). iii. Rest of test is as above. iv. If the leg drops = (-); (+) if leg stays in position = tight ITB.
Ober
Patellar Apprehension Test (Level 2) 1. The patient is in supine with relaxed knee flexed to 30° over the side of table, foot resting on examiner. 2. The examiner places both thumbs on the medial aspect of the patella and exerts a lateral force. 3. + test is when subject shows sign of apprehension (tries to extend knee or pain is produced)
Patellar Apprehension
Patellar Femoral Grinding/Clarke Sign (Level 3) 1. Patient is supine. 2. Place a towel roll underneath the knee which is flexed to 30̊. 3. Place web space of between your thumb and first finger and cup the superior aspect of the patella. Push distally. 4. Have patient contact quads while you are applying pressure. 5. (+) = pain. Caution: Many people with patellofemoral dysfunction have a (+) response to this test.
Patellar femoral grinding
Patrick Test (FABER) (Level 2) F = flexion AB = abduction ER = external rotation 1. The patient is supine and resting symptoms are assessed. 2. The painful LE is placed with foot just above the contralateral knee (forming a figure of 4). 3. The examiner provides gentle downward pressure on the top knee and opposite ASIS. 4. A positive response is pain which is indicative of hip pathology or sacroiliac pathology. Pain in anterior or lateral groin - + hip pathology. Pain in sacroiliac area when PT pressed down on flexed knee and contralateral ASIA = + sacroiliac pathology.
Patrick Test
Percussion (Tinel's at the wrist) (Level 2) 1. Wrist in neutral. The examiner uses reflex hammer or finger to tap on the median nerve where it enters the carpal tunnel. 2. The test is positive it reproduces parasthesias along median nerve distribution.
Percussion Test
Percussion Test/ Tinel's Sign (Level 2) 1. Tap along ulnar nerve just proximal to the cubital tunnel. Positive if it reproduces symptoms.
Percussion Test / Tinel's Sign
Phalen's (Level 2) 1. Patient rests elbows and hold forearms vertically and is asked to let hands drop into complete flexion at the wrist for 60 seconds. 2. A positive result if symptoms along median nerve distribution are reproduced.
Phalen's Test
Pivot-Shift Test (ACL Tear, Anterolateral Instability, Rotational Instability) (Level 2) 1. The patient assumes a supine position. The examiner stands to the side of the patient's involved knee. 2. The examiner grasps the patient's heel and flexes the knee to 90 degrees with one hand while using the palm of the other hand to medially rotate the tibia, effectively subluxing the lateral tibial plateau. 3. The examiner slowly extends the knee, maintaining rotation of the tibia. 4. As the patient's knee reaches full extension, the tibial plateau will relocate. 5. A positive test traditionally is indicated by an audible or palpable "thud" or "click."
Pivot Shift Test
Tests posterior portion of inferior glenohumeral ligament. Patient sits while examiner flexes the arm to between 80 and 90 degrees and then horizontally adducts the arm 40 degrees with medial rotation. While doing this movement, the examiner palpates the posteroinferior region of the glenoid. If the humerus protrudes or pain is felt , test is considered positive for lesion of posterior glenohumeral ligament
Posterior Inferior Instability Test
Posterior Sag Sign or Godfrey's Test (PCL Tear) (Level 2) 1. Hold leg with hips at 90o and knees at 90o of flexion. The examiner supports the leg under the heel suspending the knee on the air. 2. + = tibial tuberosity posteriorly sagged, not prominent. Normally, the medial tibial plateau extends 1 cm anteriorly beyond the femoral condyle when the knee is flexed 90°. If this "step" is lost, which is what occurs with a positive posterior sag caused by a torn posterior cruciate ligament, this step-off test or thumb sign is considered positive.
Posterior Sag Sign or Godfreys
TESTS FOR TORN PCL AND POSTERIOR ROTARY INSTABILITY Posterior Drawer Test (PCL Tear) (Level 2) Same as anterior drawer but push tibia posteriorly. + = increased posterior translation.
Posterior drawer test
Posterior tibial reflex (L4-5) 1. With the person sitting, passively place foot in pronation. 2. Patient looks away; strike tap behind medial malleolus. 3. Should see supination of foot.
Posterior tibial reflex
Pressure Provocation Test (Cubital Tunnel Syndrome) (Level 2) 1. The examiner places his or her first and second fingers over the patient's ulnar nerve proximal to the cubital tunnel with the elbow in 20 degrees flexion and forearm supination. 2. The test is held for 60 seconds. 3. A positive test is the reproduction of symptoms along the ulnar nerve.
Pressure Provocation Test
Prone knee bending test [Nachlas test] • Patient lies prone while the examiner passively flexes the knee as far as possible so that the patient's heel rests against the buttock o Make sure the hip is not rotated • Positive o Unilateral neurologic pain in lumbar area, buttock, posterior thigh indicate L2 or L3 nerve root lesion o Pain in the anterior thigh indicates tight quadriceps or stretching the femoral nerve • Flexed knee should be maintained for 45 to 60 seconds
Prone Knee Bending Test
Q-Angle Measurement (Level ?) 1. Patient is supine with knee in full extension. 2. Examiner draws a line between ASIS and midline of patella. 3. Another line is drawn from middle of patella to middle of tibial tubercle. 4. Look at the angle and measure with your goniometer. 5. Normal = 13̊ in males and 18̊ in females. a. <13̊ associated with chondromalacia patellae or patella alta. b. >18̊ associated with chonrdomalacia patellae, subluxing patella, increased femoral anteversion, genu valgum, or increased lateral tibial torsion.
Q-angle measurement
Rent Test (Rotator Cuff [RC] Tear) (Level 2) 1. The patient is seated with arm relaxed while the examiner stands to the rear. 2. The examiner palpates anterior to the anterior edge of the acromion with one hand while grasping the patient's flexed elbow with the other. 3. The examiner extends the patient's arm and then slowly internally and externally rotates the shoulder. 4. An eminence (prominent greater tuberosity) and a rent (depression of about 1 finger width) will be felt in the presence of a rotator cuff tear.
Rent test
Reverse Pivot Shift Test (PCL, Posterolateral Instability) (Level 2) 1. The patient assumes a supine position. The examiner stands to the side of the patient's involved knee. 2. The examiner grasps the patient's heel and flexes the knee to 80 degrees with one hand while using the palm of the other hand to laterally rotate the tibia. 3. The examiner has the patient's foot against his/her thigh and allows the knee to slowly extend passively with an axial load through the leg and a valgus stress applied to the knee. 4. As the patient's knee reaches 20 degrees of flexion, the lateral tibial plateau will move anteriorly with a jerk or shift from the position of posterior subluxation and external rotation.
Reverse Pivot Shift Test
Rigid versus supple flat feet (Level ?) 1. Patient is seated. 2. Look at arch of foot. 3. Have patient stand and look at arch. 4. If arch is flat in both = rigid. If arch is only flat in standing = supple.
Rigid versus supple flat feet
Gapping Test, Approximation Test
SI joint Tests for Pain or hypo/hypermobility
SLR (90-90) (Level ?) 1. Patient is supine. 2. Have patient bring both knees in toward chest and grasp legs behind thighs. Make sure hips and knees are at 90̊. 3. Have patient extend knees as far as possible. 4. If patient cannot get within 20̊ of full extension = + tight hamstrings.
SLR
STJ Neutral 1. The patient lies supine with the feet extending over the end of the examining table. 2. The examiner grasps the patient's foot over the fourth and fifth metatarsal heads, using the thumb and index finger of one hand. 3. Palpate medial and lateral aspects of talus. 4. Apply light DF force and passively supinate (talar head bulges laterally) and pronate (talar head bulges medially) until talar head protrudes equally on both sides.
STJ Neutral
Shoulder abduction (Relief) test - sitting • Test for radicular symptoms • Examiner passively or the patient actively elevates the arm through abduction so that the hand or forearm rests on top of the head • Positive if position relieves symptoms • Also known as Bakody's sign
Shoulder Abduction (Relief) Test
Shoulder Depression Test -- sitting • Evaluate for a brachial plexus lesion • Examiner side flexes the patient's head to one side (eg. Left) while applying a downward pressure on the opposite shoulder • Positive if pain is increased. Indicates irritation or compression of the nerve roots or foraminal encroachments.
Shoulder Depression Test
Sitting root test (sitting with no back support and neck flexed) • Patient sits on the edge of table • Patient's neck is flexed • Knee is actively extended while hip remain flexed at 90 degrees o Increased pain indicates tension on the sciatic nerve o Test may catch the patient unaware ♣ Examiner could extend the knee while pretending to examine foot • Patient's with true sciatic pain arch backward and complain of pain into the buttock, posterior thigh, and calf when leg is straightened = indicating positive test • Patient extends one knee at a time. If no symptoms, both legs are extended simultaneously • Positive if symptoms in the back of the leg
Sitting Root Test
Neurodynamic testing: slump test (sitting dural stretch test) ST1 • Patient sits on side of table • Examiner puts hands on shoulder to encourage slouch • Place hand on back of patient's head and gently push into full flexion. Do not push on the head. • Place patient's arms behind back. • Extend left knee • Bring toes up toward you • Should elicit symptoms • Straighten the other leg. Check for symptoms • Lift up the head. Should be decreased discomfort in the back of the thigh (Kelly had tingling in foot + neck. Lifting up head relived head + neck) Text: • The patient sits in the examining table and is asked to "slump" so that the spine flexes and the shoulders sag forward while the examiner holds the chin and head erect. • The patient is asked if any symptoms are produced. • If no symptoms are produced, the examiner flexes the patient's neck and holds the head down and shoulders slumped to see symptoms are produced. • If no symptoms, the examiner then passively DF the foot of the same leg to see if symptoms are produced. Process is repeated with other leg. • • Positive test if o Sciatic pain or reproduction of patient's symptoms
Slump Test
Speed's Test (Level 3) 1. The patient assumes a standing position. The patient is instructed to extend his/her elbow and fully supinated the forearm. 2. The examiner, standing in front of the patient, resists shoulder flexion from zero to 60 degrees. 3. If the patient localizes concordant pain to the bicipital groove, the test is positive.
Speed's Test
Straight leg raise (supine) [ aka SLR or Lasegue's Test) • Patient in the supine position (may use a pillow) • Bring leg straight up in the air. (Look for pain/numbness/tingling down the leg) • Bring the leg down • Some say leg should get to 60 degrees without pain • Check uninvolved leg. Raise to tightness. Lower leg until tightness goes away. o Ankle and foot to DF. o Abduct hip to examiner (less discomfort) o Adduct hip (more discomfort) why? Sciatic nerve tension Text: • Done supine with patient completely relaxed • Each leg tested individually with normal leg tested first • Hip MR, adducted, knee extended • Examiner flexes hip until complaint of pain in back of leg o Back pain usually disc herniation o Leg pain is pressure on neurological tissues o Disc herniations are likely to cause pain between both areas • Examiner slowly extends the leg until the patient feels no pain / tightness • Patient asked to flex the neck so chin is on the chest or examiner DF the foot o Both are provocative for neurologic tissue
Straight Leg Raise
TESTS FOR IMPINGEMENT Supine Impingement Test (Non-specific RTC Pathology) (Level 2) 1. The patient assumes a supine position. The examiner stands to the side of the patient's involved shoulder. 2. The examiner grasps the patient's wrist and distal humerus and elevates the patient's arm to end range (170 degrees or greater). 3. The examiner next moves the patient's arm into external rotation then adducts the arm to the patient's ear. 4. The examiner now internally rotates the patient's arm. 5. The Supine Impingement test is positive if the patient reports a significant increase in shoulder pain.
Supine impingement test
Lateral Talar Tilt Stress Test (Level ?) 1. Patient in supine. 2. Stabilize distal tibia and fibula, grasp calcaneus with other hand, passively evert the foot. 3. Looking for ligament laxity. Medial Talar Tilt Stress Test (Level 2) Same as above but passively invert foot.
Talar Tilt Stress Test
Test for Scaphoid Fracture (Level 2) 1. The patient actively extends the wrist. 2. + test for reproduction of pain during wrist extension. Alternative is Thumb-Index Pinch Test Level 2 1. Patient actively pinches the thumb and index finger pads together. 2. A positive result is reproduction of pain.
Test for Scaphoid Fracture
Thomas Test (Level 3) 1. Have the patient at the end of the plinth in supine with legs off the table and the knees flexed. 2. Have patient lift one leg up toward chest by flexing the knee and holding with their hands. 3. If the opposite hip flexes and/or knee extends = + for tight iliopsoas and/or rectus femoris. 4. Follow up with Ely's if both hip flexion and knee extension occur. There is an expanded version of this test that has more results: a. No hip ext. and knee flex > 45 degrees = + for tight iliopsoas. b. Full hip ext. and knee flex. < 45 degrees = + for tight rectus femoris. c. No hip ext. and knee flex < 45 degrees = + for iliopsoas and rectus femoris. d. Hip IR = + for tight tensor fasciae latae.
Thomas Test
TEST FOR ACHILLES TENDON INTERITY Thompson Test (or sign for Achilles tendon rupture or Squeeze Test) (Level ?) 1. The patient is supine. 2. Squeeze the calf muscles and should see PF of foot. 3. + = no PF and may indicate rupture.
Thompson Test
Neurodynamic testing: slump test (sitting dural stretch test) ST1
Thoracic Spine Test for Problems with Nerve Roots and Dura
TEST FOR TARSAL TUNEL SYNDROME Tinel's Sign at the ankle (Level ?) 1. Patient is in side lying position. 2. Tap posterior to medial malleolus. 3. + = numbness and tingling.
Tinel's Sign (foot)
Trendelenburg (Level 2) 1. Have the patient stand on the test leg and lift the uninvolved leg. 2. Test is (+) if uninvolved pelvis lowers due to weak abductors (or any other reasons below) on test side. A positive Trendelenburg sign can be caused by coxa vara, a fracture of the greater trochanter, a slipped capital femoral epiphysis, a congenital dislocation of the hip joint, poliomyelitis, meningomyelocele, a root lesion within the spinal cord, or a weakness of the hip abductors of the stance limb.
Trendelenberg
(C7/8; C7 is the primary contribution to the reflex)
Triceps Reflex
Upper limb tension test (supine) [Brachial plexus tension test or Elvey test) • Designed to put stress on the neurologic structures of the upper limb (focuses on median nerve) • Essential that a constant depression force be applied to the shoulder girdle • Test begins by testing the good side first • Arm resting on stomach / chest • Bring arm out to ER with elbow flexed • Bring arm to 90 degrees abduction • Fully extend fingers, thumb, wrist • Slowly extend the elbow (***last movement to be performed) • Positive if symptoms manifested before 60 degrees of elbow extension
Upper Limb Tension test
a) Varus Stress Test (Level 3) - LCL It has been advocated that resting the test thigh on the examining table enables the patient to relax more and is easier for the examiner. The hip is slightly abducted. The knee is flexed 30° over the side of the table and the examiner places one hand on the medial aspect of the knee and grasps the foot/ankle with the other. Apply a medial to lateral force to knee while the hand at the ankle is slightly medially rotated. Repeat in full extension. + = increased laxity (compare to other knee) 1) in full extension, ACL, PCL and capsule are implicated. 2) in 30º of flexion, LCL is implicated.
Varus Stress Test (
Patient's elbow flexed 20 to 30 degrees and stabilized with examiners hand. Adduction / varus force applied to distal forearm to test LCL. Examiner applies force several times with increasing pressure while noting pain or ROM. Laxity indicates a sprain
Varus stress test
Watson Scaphoid Test (Scaphoid Instability) (Level 2) 1. The patient's arm is slightly pronated. The examiner grasps the wrist from the radial side with thumb over the scaphoid tubercle. 2. The examiner's other hand grasps the metacarpals. Starting in ulnar deviation and slight extension, the wrist is moved into radial deviation and slight flexion. 3. The examiner's thumb presses the scaphoid out of normal alignment when laxity exists and when the thumb is released there is a "thunk" as the scaphoid moves back in place. 4. A positive test is identified by subluxation or clunk over the examiner's thumb and patient reports pain.
Watson Scaphoid Test
Well's Clinical Prediction Rule for Deep Vein Thrombosis (Level 1) 1. Query or assess the patient for the following major criteria: • Active cancer within the last 6 months • Paralysis • Recently bedridden • Localized tenderness • Thigh and calf are swollen • Strong family history of DVT 2. Query or assess the patient for the following minor criteria: • History of recent trauma • Pitting edema • Dilated superficial veins • Hospitalized within last 6 months • Erythema 3. A positive test is > 3 of the major criteria and > 2 of the minor criteria.
Well's Clinical Prediction Rule for Deep Vein Thrombosis
Lachman Anterior Drawer Pivot Shift Test
What are test for Torn ACL / Anterior Rotary Instability
Patellar apprehension Patellar femoral grinding / Clarke sign Q-angle measurement Knee effusion
What are test for patellofemoral dysfunction?
Posterior drawer test Posterior Sag Sign or Godfreys Reverse Pivot Shift
What are test for torn PCL, posterorotary instability?
Moving valgus stress test (chronic MCL tear of elbow) Varus stress test (integrity of LCL) Valgus stress test (intengrity of MCL)
What are tests for elbow instability?
supine impingement test IRRST Neer's Hawkins-kennedy
What are tests for shoulder impingement?
McMurray Apley's Test Ege's Test Bounce Home Test
What are tests for torn tibial meniscus?
Biceps load test ii (SLAP lesion) yergason's test speed's test crank test (Labral tear, SLAP lesion)
What are the tests for a torn labrum/instability/proximal biceps involvement?
Phalen's Percussion (Tinel's at the Wrist) Wrist flexion and median nerve compression
What are the tests for carpal tunnel syndrome?
Lateral ("tennis elbow") Test - Cozen's Test Medial epicondylitis test
What are the tests for epicondylitis?
Rent test Lift-Off test External Rotation Lag Sign Drop Sign Empty can test / supraspinatus test
What are the tests for torn rotator cuff / impingement? (of the shoulder)
Elbow flexion test (cubital tunnel syndrome) Pressure Provocation test (cubital tunnel syndrome) Percussion Test / Tinel's Sign
What are the tests for ulnar nerve entrapment?
Watson Scaphoid Test (Scaphoid Instability) Ulnomeniscotriquetral Dorsal Glide (TFCC Tear or Triquetral Instability)
What are the two tests for wrist instability?
Wrist Flexion and Median Nerve Compression (Level 2) 1. The patient sits with elbow fully extended, forearm in supination and wrist flexed to 60 degrees. Even, constant pressure is applied by the examiner over the median nerve at the carpal tunnel. 2. A positive test is the reproduction of symptoms along the median nerve distribution within 30 seconds.
Wrist Flexion and Median Nerve Compression
Yergason's Test (Level 2) 1. The patient may sit or stand. The examiner stands in front of the patient. 2. The patient's elbow is flexed to 90 degrees and the forearm is in a pronated position while maintaining the upper arm at the side. 3. The patient is instructed to supinate his or her forearm, while the examiner concurrently resists forearm supination at the wrist. 4. If the patient localizes concordant pain to the bicipital groove, the test is positive.
Yergason's Test
Internal Rotation Resisted Strength Test (IRRST) (level 2) 1. The patient is instructed to stand. The examiner stands behind the patient. 2. The examiner places the patient's shoulder in 90 degrees of abduction and 80 degrees of external rotation with the elbow at 90 degrees of flexion. 3. The examiner applies manual resistance to the wrist, first to test isometric external rotation. 4. The examiner applies manual resistance to the wrist, next to test isometric internal rotation. 5. The examiner compares the results of these isometric tests. If internal rotation strength is weaker than external rotation, the IRRST test is considered positive and the patient purportedly has internal impingement. Considered as a follow up for Neer's
internal rotation resisted strength test
patellar reflex (L2/3/4 - knee jerk - rarely totally absent)
patellar reflex
