Post on 15-Nov-2015
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Special Orthopedic Tests
CERVICAL SPINE
ROM: Flexion, Extension, Rotation, Lateral Flexion; Dermatomes: C3-T2; Myotomes: C3-T2
Name of TestDescriptionPositiveIndication
Distraction
Test
Dr: - hand under pts chin; other under occiput
- slowly lifts pts headPain is relieved or decreasedNerve root compression (decreasing pressure on facet jt.)
Foraminal
Compression
Test
(Spurlings)Dr: press straight down on head in 3 stages unless sx elicited:
1. neutral
2. extension
3. lat. Flexion (to affected side)Pain radiating into arm toward which the head is side flexed during compressionFacet jt. Pathology
Maximal Foraminal Compression Test
Pt: side flex, rotate (same side) & extend head
Dr: compress head in this positionPain radiating to armConcave Side: nerve root or facet jt pathology
Convex Side: M. strain
Shoulder
Depression
Test
Dr:
- side flex pts head to one side
- apply downward pressure on opp. shoulderPain to either sideSame side: nerve root compress
Opp side: dural sleeve adhesion
Vertebral Artery Test
Generally not performed
Pt: supine
Dr: - put pts neck into extension & side flexion.
rotate neck to same side
hold for 30 secDizziness or nystagmusVert. Art compression
Valsalva TestPt: seated have them blow against the back of their hand.Pain in Cspine or dermatome related to Cspine injury 2dary to increased pressureSpace occupying lesion (e.g. tumor, herniated disc) present in cervical canal
Shoulder Abduction (relief) Test (Bakodys Sign)Pt: sitting or lying down, actively abducts arm so hand rest on top of head
OR Dr: passively abducts arm Decrease or relief of symptomsCervical extradural compression problem
TMJ (Jaw reflex, C5)ROM: open/close mouth, protrude jaw, lateral deviation
Chvosteks TestPt: seated
Dr: taps on parotid gland and observes pts reactionFacial muscles twitch as result of tappingCN 7 palsy or injury, low blood calcium
THORACIC SPINE
ROM: Flexion, Extension, Side Bending, Rotation; Dermatomes: C3-T2; Myotomes: C3-T2; DTRs: Biceps (C5), Brachioradialis (C6), Triceps (C7)
Name of TestDescriptionPositiveIndication
Elevated Arm Stress Test (EAST) (Roos/Hands Up)
- ext rotate shoulders
- elbows slightly behind head
- open & close hands slowly for 3 min.- Pain, heaviness, profound arm weakness or numbness and
- tingling in handTOS
Hyperabduction
Test (Wrights)
Dr: monitors pts radial pulse
Dr: elevates pts arm up to 180 degrees- pulse disappear / diminution
- sx elicitedTOS
(d/t subclavian a compression & brachial plexus behind pecs minor and under coracoid process)
Adsons Test
Dr: - abduct pts affected arm
- palpates radial pulse
Pt: - turn head towards affected side
- extend neck
- take deep breath- pulse disappear / diminution
- sx elicitedTOS
(d/t tight scalenes)
Scapular protraction (winging)Pt: - pushes against a wall with both hands with feet farther away from wall then shoulders- scapular winging, pain and weakness during maneuverSerratus anterior weakness, long thoracic N. dysfunction, lower trapezius dysfunction
Costoclavicular TestPt: seated
Dr: - monitors pts radial pulse
- draws pts shoulder down and back as the pt assumes a military postureDisappearance or diminution of pulse or if symptoms are elicitedTOS, usually subclavian A. being compressed b/t 1st rib and clavicle
Thoracic Distraction TestPt: seated in neutral with arms crossed
Dr: stands behind pt, wraps arms around pt and lifts upwards, distracting TspineDiminished painRelief from pressure on a nerve root by widening neural foramen; decreasing pressure on the facet joint; relaxing contracted muscles
**Adams Sign
Pt: - standing, feet together, straight knees
- flex forward at hips, allow arms to drop- scoliosis improved w/ forward flexionStructural Scoliosis
Lumbar Spine
ROM: Flexion, Extension, Lateral Bending, Rotation; Dermatomes: L1-S2; Myotomes: L2-S2, DTR: Patellar (L4), Achilles (S1)
Name of TestDescriptionPositiveIndication
Tests to Stretch Spinal Cord:
1. Straight Leg Raising Test (SLR)
Pt: supine, keeps knee straight Dr: lifts involved leg up (support foot around calc.)Pain at 35-70 degrees
Pain at >70 degreesIVD pressure on sciatic n (us. Lat herniation)
SI joint pain
2. Well Leg Raising Test (WLR)Pt: supine
Dr: lifts good legBack and sciatic pain on opposite sideSpace Occupying Lesion i.e. herniated disc (us.
Med herniation)
Lasegues Test
Pt: supine/sitting
Dr: does SLR, lowers leg to just below level of pain and adds ankle dorsiflexion (stretch sciatic n.)Pain radiating below kneeDisc herniation, neural impingement, sciatica
Hoover Test
Dr: cups hand under calc of opposite foot as pt tries to raise leg; pressure will be felt in hand if pt really tries to lift legAbsence of downward pressure on foot opposite to the one the pt has been instructed to liftPt is malingering
Kernig TestPt: supine, places both hands behind head and forcibly flexes head onto chestSharp shooting pain in C/S, low back, or down legsMeningeal irritation, nerve root involvement, or irritation to dural coverings of nerve root
Slump TestPt: seated at end of table with back straight looking straight ahead; then slumps allowing T/S and L/S to collapse into flexion still looking forward; then flex C/S and extend one knee, dorsiflex ankle; repeat opposite sideRadicular pain at any stageSciatic N. root tension, disc pathology
Single Leg Hyperextension TestPt: stands in straddle position with one leg extended behind other; then leans back as far as possible; repeat on other side
Dr: prevents pt from falling overPain exacerbated with it more severe when affected side is extended posteriorlySpondylolysis or spondylolisthesis
Tests to Increase Intrathecal Pressure:
1. Milgram Test
Pt: supine, Lifts both legs straight 2 inches above table, holds for 30 seconds
** C/I if Disc rupture is suspected**
Affected limb cannot be held for 30 sec or sx are reproducedIntrathecal pathology
i.e herniated disc
2. Naffziger Test
Pt: supine
Dr: compresses jugular veins for 10 secs until face flushes then ask pt to coughPain increases with coughingIncreases in intrathecal pressure (space occupying lesion, SOL)
3. Valsalva TestPt: seated, deep breath in and blows out into back of handPain in back or down legsSOL causing increase in intrathecal pressure
Tests to Rock SI Joint:
1. Pelvic Rock Test
Pt: supine
Dr: places hands on iliac crests with thumbs on PSIS and palms on iliac tubercles; forcibly compresses pelvis to midlinePain around SI jointSI joint pathology
2. Gaenslens Test
Pt: supine, knees to chest with one buttock over side of table, allow unsupported leg to drop to floor
Dr: applies over pressure to stretch legPain in SI joint or hipSI joint or hip pathology
3. Patrick Faber Test
Pt: supine
Dr: places foot of involved side on opposite knee; applies over pressure down on flexed knee and the opposite side ASISIncreased pain SI joint or hipSI joint or hip joint pathology
Hip and Pelvis
ROM: Flexion, Extension, Abduction, Adduction, Int/Ext Rotation; Dermatomes: L1-S2; Myotomes: L2-S2, DTR: Biceps (C5), Brachioradialis (C6), Triceps (C7)
Name of TestDescriptionPositiveIndication
Trendelenburg Test
Dr: stands behind pt and observes PSIS dimples or place thumbs on PSIS
Pt: stands on one legPelvis on unsupported side remains in position or descendsWeak or nonfunctioning Glute Medius on supported side
Obers Test
Pt: sidelying with involved leg on top; abduct leg, flex knee to 90 degrees keeping hip jt in neutral
If IT band is normal, thigh should drop to adducted positionThigh remains abducted when leg is releasedIT band contracture
Thomas Test
Pt: supine with pelvis level and square to trunk; flexes both knees to chest then extends one leg and lets it rest on table
Dr: places hand under lumbar spine feeling for flattening of L/SLeg remains flexed, will not lie flat on tableTight hip flexors (Iliopsoas)
Elys Test
Pt: prone, knee flexedHip on ipsilateral side will spontaneously flexRectus femoris contracture, femoral n. irritation (if radicular sxs present)
Fabers TestSee tests to rock SI jt
Tests for Congenital Hip Dislocation:
1. Ortolani Click (new born)
Dr: Flex, abduct, ext rotate hipsInvolved hip clicks and is unable to be abducted as far as other hipCongenital hip dislocation
2. Telescoping TestDr: applies traction to femur at knee level; other hand stabilizes pelvis placing thumb on greater trochanter (should be able to feel gt move distally as traction applied)Abnormal to and fro motion of GT telescopingCongenital hip dislocation
3. Adduction ContractureDr: flex pts hips to 90 and abduct themLmtd abduction (20 degrees or less)Congenital hip dislocation
Shoulder
ROM: Flexion, Extension, Abduction, Adduction, Ext Rotation, Int Rotation, Scapular Elevation; DTR: Biceps (C5), Brachioradialis (C6), Triceps (C7)
Name of TestDescriptionPositiveIndication
RC Impingement
1. Neer
Impingement
Sign
Dr: - stabilize pts shoulder on top with hand
- forward flex humerus to 180o then internally rotate arm
Pain in shoulderRC impingement (usually supraspinatous or biceps tendon)
2. Full Can Test
Pt: - abducts both arms to 90o & forward flexes 45o with thumbs pointing to ceiling
Dr: - applies downward pressure to armsWeakness, pain, or dropping of arm, which occurs in significant tears of supraspinatus muscle with even a gentle tap to forearmSupraspinatus tendon tear
3. Empty Can Test
Same as full can but with thumbs down
4. Painful ArcPt: abducts arms overhead as far as they can go, bringing them out laterallyPain with shoulder abduction b/t 80-100oRotator cuff impingement (if pain after 100o=AC jt pathology; if pain immediately=adhesive capsulitis or shoulder trauma)
Glenohumeral Instability
1. Ant Apprehension Sign
Pt: supine
- abducts arm 90o, elbow flexed 90o
Dr: force forearm into ext rotation past 90oPain in shoulder, apprehension on pts faceAnterior GH dislocation
2. Post Apprehension Sign
Pt: place hand of affected arm on opp shoulder
Dr: push posteriorly on elbow (down)Pain in shoulder, apprehension on pts facePosterior GH dislocation, anterior dislocation
3. Sulcus signDr: grasping pts elbow apply inf tractionIndentation appears in area beneath acromiumInf instability, multidirectional instability
AC Joint
1. Cross Arm TestDr: - passively adduct pts arm across chest wall with humerus parallel to floor (pts hand will rest on opposite shoulder)
- apply downward resistance to elbowPain with end-range adduction or with pushing against resistanceAcromioclavicular joint pathology
2. Active Compression TestPt: flex arm to 90o and adduct to 10-15o with thumb down
Dr: apply downward resistance to arm
Repeat with thumbs upPain in ac joint or shoulder during 1st maneuver that improves or resolves with 2nd maneuverIf pain is in AC joint=AC joint pathology; if pain is more internal in shoulder=labral pathology
Scapulothoracic
1. ROMDr: observe rhytym as pt abducts arm over headMovement in 1st 30 =abnormalScapulothoracic pathology
2. Scapular WingingPt: push-up performed at wallScapular wingsWeakness of serratus ant or long thoracic N.
Bicipital Tendon
1. Yergasons
Test
Pt: sit with elbow at side, forearm flex to 90o. Dr: - palpate long head of bicep with one hand and wrist with other hand.
- supinate and flex arm against resistanceTendon pops out of groove and causes lots of painUnstable bicipital tendon and subluxation
2. Speeds Test
Pt: - shoulder in 90o forward flexion, elbow extended, hand supinated
Dr: - apply resistance downwardPain in bicipital grooveBicipital tendon pathology (usually tendonitis)
Subscapularis Injury
1. Napoleon SignPt: places arm on ST and pushes against itElbow will drop backwardSubscapularis weakness or injury
2. Gerbers (Liftoff) TestPt: put hand behind lumbar spine and attempt to lift hand away from backIf patient cannot accomplish liftoffSubscapularis weakness or injury
Labral Pathology
1. Clunk TestPt: supine
Dr: apply ant force to humeral head, other hand holds distal humerus & rotates it. Passively abduct pts arm over head???Clunk or grinding in shoulderLabral pathology
2. Active Compression TestSee AC joint pathology
Elbow
ROM: Flexion, Extension, Supination, Pronation; Dermatomes: C3-T2; Myotomes: C3-T2; DTRs: Biceps (C5), Brachioradialis (C6), Triceps (C7)
Name of TestDescriptionPositiveIndication
Valgus Stress Test
Dr: - cup post elbow & hold wrist in other hand
- hand at wrist forces forearm laterally
- Assess at 0, 30 and 90oPain, increased medial joint gappingSprain/pathology of MCL
Varus Stress Test
Same as above except forcing forearm mediallyPain, increased lateral joint gappingSprain/pathology of LCL
Mills Test
Dr: extend pts elbow, pronate & flex wristPain at lat epicondyleLat epicondylitis, Ext m. strain
Tinel sign
Dr: Tap ulnar n b/t olecranon and med epicondyleTingling down forearm in ulnar n distributionUlnar n neuroma
Tennis elbow test (Cozens Test)
Pt: makes fist, pronates, radially deviates and extends wrist.
Dr: attempts to force wrist into flexion against pts resistanceSudden severe pain at lat epicondyle (common ext origin)Lat epicondylitis (Tennis elbow)
Ulnar N. InstabilityDr: - place pts arm in abduction and ext rotation
- palpate ulnar n. at ulnar groove while flexing & extending pts arm repeatedlyWill feel nerve as it subluxes out of ulnar grooveUlnar n. instability
Hand and Wrist
ROM: Flexion, Extension, Ulnar Deviation, Radial Deviation, Supination, Pronation; Neuro: Radial, Median, Ulnar
Name of TestDescriptionPositiveIndication
Allens TestPt: opens/closes hand multiple times then makes fist
Dr: - holds down radial & ulnar as with thumb & index finger
- let go of tested a. = pts hand should go pink on same side
Repeat other sideSkin stays white on tested side, no apparent return of BL flow after decompression of a.Vascular compromise to radial or ulnar a.
Bunnel-Littler TestDr: stabilize pts hand around MCPs, move PIPs into flexion
If no flexion move MCPs into slight flexion and attempt to flex PIPsInability to flex PIPs
Tight intrinsic m. or contracture of jt. Capsule
2nd step: if PIPs still cannot flex fully=contracture of jt. capsule
Finkelsteins Test
Pt: make fist with thumb tucked in
Dr: deviate wrist in ulnar directionPain in the area of the first dorsal compartmentFirst dorsal compartment stenosing tenosynovitis (AbPL and EPB) DeQuervains tenosynovitis
Phalens Test
- places dorsal aspect of hand against dorsal aspect of other hand (flexion at wrists)
- hold for >30 sec
- report changes in sensation/painReproduction of neurological sxCarpal Tunnel Syndrome (CTS)
Tinels SignPt: seated with both wrists facing up on lap
Dr: tap transverse carpal lig with reflex hammer or reinforced fingerParesthesia in median n. distribution with percussionCTS
Knee
ROM: Flexion (A: squat in deep knee bend), Extension, Medial Rotation, Lateral Rotation; Dermatomes: L1-S2; Myotomes: L2-S2; DTR: Patellar (L4), Achilles (S1)
Name of TestDescriptionPositiveIndication
Collateral Ligament Stability Test
Valgus / Varus TestsDr: supports pts ankle and applies valgus stress to knee to test MCL; then varus stress to knee to test LCL
Perform first in full extension (to test ligament), then in 30 degrees of flexion (to test joint capsule)Excess movement/pain to medial or lateral kneeMCL/LCL damage
Ant/Post Drawer Test
Pt: supine, flex knees and hips
Dr: sits on pts foot, places hand around knee with thumbs in eyes of knee; applies ant force, then post force to tibia on femurExcess movement of tibia on femurAnt drawer: ACL instability
Post drawer: PCL instability
Lachman Test
Pt: supine with involved leg beside Dr
Dr: holds pt knee b/t full extension and 30 degrees flexion; one hand stabilizes femur, other hand moves prox tibia forwardMushy/soft end feel when tibia is moved forward and infrapatellar tendon slope disappearsACL (esp the posterolateral band)
Slocum TestPt: same position as drawer tests
Dr: medially rotate foot 30 degrees, sit on pts foot and draw knee forward, then same with foot laterally rotatedExcess mvmt on lat knee with med rotation of foot and excess mvmt on med knee with lat rotation of footAnterolateral rotary instability (potential damage to ACL, LCL) OR Anteromedial rotary instability (potential damage to ACL, MCL)
McMurrays Test
Medial Lateral
Pt: supine; knee completely flexed
Dr: supports pts knee with one hand while applying valgus force; other hand externally rotates tibia while taking knee out of flexion; repeated with varus force and int rotationSnap/Click/Pain to med or lat kneeMed/lat meniscus damage/tear
Bounce Home Test
Pt: supine, knee flexed with heel of foot cupped in Drs hand
Dr: Allows pts knee to passively extendIncomplete extension or rubbery end feel (something blocking full extension)Torn meniscus
Apleys Compression Test
Pt: prone knees flexed 90 degrees
Dr: laterally rotates tibia and pushes down; repeat with medial rotationPain on med side with lat rotation or pain on lat side with med rotationMedial or lateral meniscus pathology
Apleys Distraction Test
Same as above but pulling up.
Dr: stabilizes pts thigh by placing knee on it; rotate tibia internally, then externallyPain in collateral ligs, excess motionCollateral ligament sprain
** If pain with As Compression but not with As Distraction helps confirm meniscus injury
Apprehension Test
Pt: supine, quads relaxed, knee flexed to 30 degrees
Dr: presses patella laterallyPain, apprehensionChronic patellar dislocation
Patella Femoral Grinding Test (Clarks)
Pt: supine, slowly contracts quads
Dr: presses down on patellaGrinding under patella, painPatellar chondromalacia
Knee Jt Effusion Tests:
1. Bulge Test
(Brush/Stroke Test)
(MINOR Effusion)
Pt: seated
Dr: milks medial side of patella, pushing superiorly; then strokes inferiorly on lat side of patellaFluid wave on distal medial side of patella (may take 2 seconds to appear)Minor effusion
2. Ballotment Test
(Patellar Tap Test)
(MAJOR Effusion)
Pt: supine, leg extended or flexed to discomfort
Dr: applies pressure over patellaPatella feels like its floating or theres a click or stopping when patella strikes patellar femoral grooveMajor effusion
Ankle and Foot
ROM: Ankle (Dorsiflexion: heel walk; Plantar Flexion: toe walk), Subtalar (Inversion: walk on lat foot; Eversion: walk on med foot), Midtarsal (Adduction/Abduction: assessed during inv/ever), 1st MTP jt (flex/ext); Dermatomes: L1-S2; Myotomes: L2-S2; DTR: Patellar (L4), Achilles (S1)
Name of TestDescriptionPositiveIndication
Rigid or Supple/Flat Feet Tests
Dr: Observe pt as they: stand normally, stand on toes, seatedAbsent arch in all 3 positions
Absent arch while standingRigid flat feet
Supple flat feet
Tibial Torsion Test
Pt: supine, rotate leg so patella points anteriorly, palpate apices of malleoli; form angle of line b/t malleolar apices and parallel to floor through heel. Normal is 15o ext rotation.
>18 degrees