Special Tests

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)


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)


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)


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)


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)


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


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)


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)


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

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