1. TESTS FOR ORTHOPEDIC CONDITIONS
Gilbert Madriaga, PTRP
With excerpts from Prof. Mitch Encabo’s files

2. LEARNING OBJECTIVES
At the end of the session the students should be able to:
Define diagnostic tests and special tests
Explain the purpose of diagnostic tests and special tests
Determine principles involved in special tests
Determine guidelines and contraindications in performing the tests
Explain the significance of tests for orthopedic conditions

3. DIAGNOSTIC TESTS
Individual tests that are used to focus the examination
Detects conditions not appropriate for physical therapy management
Help identify the specific nature of a condition by gathering data from the examination
History
OI and palpation
Flexibility and muscle tests
Special test
Functional assessment
Laboratory procedures
Diagnosis, gathering data through examination, therfore, questions related to history and systems review are also part of

4. DIAGNOSTIC TESTS Special Test
Tests that determine whether a particular type of disease, condition, or injury is present
Also known as:
Clinical accessory tests
Provocative or structural tests

5. PURPOSE To confirm a tentative diagnosis
To make a differential diagnosis
To differentiate between structures
To understand unusual signs
To unravel difficult signs and symptoms

6. PRINCIPLES Inflamed structures Compressed structures
Vascular disorders
Contractures and tightness
Muscle paralysis
Miscellaneous tests
Inflamed structure

7. PRINCIPLES Inflamed structures
Active contraction of an inflamed structure
stretch of inflamed contractile or relatively non-contractile tissues
Inflamed structure

8. PRINCIPLES Compressed structures
A maneuver that causes an inflamed structure to be compressed will elicit pain
Additional pressure applied over a trapped or compressed neural structure results in an increase in the neuropathic pain or neurological symptoms
When a maneuver relieves the pressure over a compressed neural structure there is a relief of the neuropathic pain or neurological symptoms

9. PRINCIPLES Vascular Structures
Compression of a peripherally located artery diminishes blood flow distal to the site of compression
Results in:
Disappearance of a distal pulse
Appearance of signs and symptoms of vascular ischemia
When arterial compression is released or removed, arterial circulation is immediately reestablished
Immediate change of skin pallor to flushing or redness

10. PRINCIPLES Contractures and Tightness
A tight muscle will pull the joint in the direction of its primary action
A muscle tightness or contracture will lead to LOM in the direction opposite the primary action of the affected muscle

11. PRINCIPLES Contractures and Tightness
When a tight or contracted muscle is forcibly lengthened or stretched, pain will be felt along the tight muscle or its tendon
When the forcibly lengthened muscle is placed in a shortened position, pain immediately disappears

12. PRINCIPLES
Paralysis
In the presence of paralysis the body attempts to find a substitute muscle or movement to compensate for the lost function

13. GUIDELINES
Does not necessarily rule out a disease or condition if tests are negative
Should not be used in isolation
Tests are only adjuncts to the physical examination and clinical history
Do not perform all the tests
Most special tests have not been tested for validity and reliability

14. GUIDELINES Test Selection The test has a very sound basis
The reliability of the test is backed up by extensive research
Applicability of the test
Popularity of the familiar test
Ease of application
Identify if the test is a duplication or modification of established tests
Should not use equipments, or require a lot of skill to perform
Other professionals should be well versed, data should be familiar with other personnel
Should not have a lot of limitations, applicability refers variables that can be controlled or not be controlled
Reliability is an issue with new tests, check journals
Should not be in conflict with known principles

15. Cervical Region

16. Cervical Region History Initial Hypothesis
Patient reports diffuse nonspecific neck pain that is exacerbated by neck movements
Mechanical neck pain[1] Cervical facet syndrome[2] Cervical muscle strain or sprain
Patient reports pain in certain postures that is alleviated by positional changes
Upper crossed postural syndrome [3] [4]
Traumatic mechanism of injury with complaint of nonspecific cervical symptoms that are exacerbated in the vertical position and relieved with the head supported in supine position
Cervical instability, especially if patient reports that dysesthesias of the face occur with neck movement[5]

17. Cervical Region
History
Initial Hypothesis
Reports of nonspecific neck pain with numbness and tingling into one upper extremity
Cervical radiculopathy
Reports of neck pain with bilateral upper extremity symptoms and occasional reports of loss of balance or lack of coordination of the lower extremities
Cervical myelopathy

18. Cervical Region

19. Spurling vs. Distraction test
Spurling’s test/ Foraminal Compression Test
Pressure on nerve root
Radicultis: pain in dermatomal distribution of the nerve root affected
Distraction test
Alleviate radicular signs

20. Lhermitte’s test
Meningeal irritation or cervical myelopathy

21. Cervical region Other tests ULTTs Shoulder abduction test
Vertebral artery test
Sharp-Purser test

22. Thoracolumbar region History
Initial Hypothesis
Reports of restricted motion of the lumbar spine associated with low back or buttock pain exacerbated by a pattern of movement that indicates possible opening or closing joint restriction (ie, decreased extension, side bending right, and rotation right)
Zygapophyseal joint pain syndromes [8] [9]
Reports of centralization or peripheralization of symptoms during repetitive movements, or prolonged periods in certain positions
Discogenic pain[10]

23. Thoracolumbar region History
Initial Hypothesis
Reports of lower extremity pain/paresthesias that are greater than the low back pain. Patient may report episodes of lower extremity weakness
Sciatica or lumbar radiculopathy[11]
Pain in the lower extremities that is exacerbated by an extension posture and relieved by flexion posture of the spine
Spinal stenosis[12]

24. Thoracolumbar region History
Initial Hypothesis
Patient reports recurrent locking, catching, or giving way of the low back during active motion
Lumbar instability [13] [14]
Reports of low back pain that is exacerbated by stretch of either ligament or muscles. Also, possibility of pain with contraction of muscular tissues
Muscle/ligamentous sprain/strain

25. Neurodynamic tests in the lumbar spine

26. Slump test Most common neurological test for the lower limb
Reproduction of patient’s pathological symptom
Nonpathological responses
Pain or discomfort T8-T9
Pain or discomfort behind knee and hamstrings
Restriction of passive joint motions
**hands behind the back

27. Hamstring Tightness vs Sciatic Nerve irritation
Straight Leg Raise (SLR)
Lasegue’s Test
Hamstring Tightness
Sciatic nerve irritation

28. SLR 0°-35° 35°-70° 70°-90° 0-35 hip jt 35-70 sciatic nerve
Slack in sciatic arborization taken up during this range. No dural movement
35°-70°
35°- tension at sciatic roots
Sciatic roots tense over IV disc during this range. Rate of deformation diminishes as angle increases
70° - L5, S1, S2 completely stretched
70°-90°
Practically no further deformation of roots occurs during further SLR
0-35 hip jt
35-70 sciatic nerve
70-90 facet of lumbar or SI joint or hamsting tightness

29. SLR
Considerations for patients with L4-L5 disc herniation (nerve roots L4-S3)
Central protrusion
Pain on low back
Intemediate protrusion
Pain low back and leg
Lateral protrusion
Posterior leg, pain below the knee

30. SLR Well-leg raising test of Fajerstajn/ cross over sign
Large IV disc protrusion, medial to the nerve root
(Woodhall and Hayes, 1950)

31. SLR variants Joint SLR SLR2 SLR3 SLR4 Hip Flx and Add Flx Knee Ext
Ankle DF
Foot
Eversion
Inversion
Inv
Toes
Extension
Nerve Bias
Sciatic nerve and tibial nerves
Tibial nerve
Sural nerve
Common Peroneal Nerve

32. Prone Knee Bending Indicates L2 or L3 nerve root lesion
Also stretches femoral nerve
45 to 60 seconds

33. Brudzinski-Kernig test
Dural/ meningeal Irritation
Nerve root Irritation

34. Range of motion
Schober’s Test
10 cm above
5 cm below
Range of motion

35. Intrathecal Pressure Milgrams Test Hoovers Test Malingerer 5-10 cm
30 seconds

36. Narrowing of IV foramina
Quadrant Test
Narrowing IV foramen
Facet problems

37. Facet Problems Stork Standing Test
Stress fracture of pars interarticularis

38. Tests for lumbar instability
During movement, the patient loses the ability to control movement for a brief time (ms) or the segment is structurally unstable
Segmental Instability test
Pheasant Test

39. Tests for Muscle Tightness
Thomas test
Ober test
90-90 SLR Test
Rectus Femoris Test

40. Clinical decision making on what special tests to use for patients with LBP

41. ORTHOPEDIC TESTS FOR THE SHOULDER

42. History
Initial Hypothesis
Patient reports of lateral/anterior shoulder pain with overhead activities or demonstration of a painful arc
Possible subacromial impingement [4] [5]
Possible tendonitis[6]
Possible bursitis[6]
Patient reports of instability, apprehension, and pain with activities most often when shoulder is abducted and externally rotated
Shoulder instability[4]
Possible labral tear, if clicking is present [7] [8]
Decreased ROM and pain with resistance
Possible rotator cuff or long head of the bicep tendonitis[9]

43. History
Initial Hypothesis
Patient reports of pain and weakness with muscle loading, night pain. Age >60
Possible rotator cuff tear [6] [9]
Patient complaints of poorly located shoulder pain with occasional radiation into elbow. Pain is usually aggravated by movement and relieved by rest. Age >45. Females more often affected than males
Possible adhesive capsulitis[10]
Patient reports of a fall on the shoulder followed by pain over AC joint
Possible AC sprain[4]
Patient complaints of upper extremity heaviness or numbness with prolonged postures and when lying on involved side
Possible thoracic outlet syndrome [11] [12]
Possible cervical radiculopathy [6] [13] [14]

44. Range of Motion
Apley’s Test for the shoulder

45. Tests for Impingement

46. Test for impingement Neer Hawkins-Kennedy
Jamming of greater tuberosity against the anteroinferior border of the acromion
Hawkins-Kennedy
Pushes supraspinatus to anterior surface of the coracoacromial ligament and coracoid process

47. Tests for muscle/ tendon pathology

48. Suprapinatus Test or Empty Can Test
Tear of supraspinatus tendon or suprascapular nerve
Drop Arm Test
Rotator cuff tear
> 50+
Younger people

49. Bicipital Tendinitis

50. Speeds test Yergasons test
Inflammation of bicipital tendon (tendinosis or paratenonitis)
Yergasons test

51. Subscapularis
Lift off sign

52. Shoulder Instability Stable Unstable Apprehension and Relocation
Feagin’s test
Sulcus test

53. Labral Tears
Clunk test
O Brien’s test

54. ORTHOPEDIC TEST FOR THE ELBOW
Medial and Lateral Epicondylitis

55. Tennis Elbow Tennis Elbow Test Cozen’s Test Mill’s test Method 3
Maudsley’s test
(Fairbank and Corlett, 2004)

56. Golfers Elbow
Golfer’s Elbow Test

57. ORTHOPEDIC TEST FOR THE WRIST AND HAND
Overuse Injuries
Ligament rupture

58. Conditions Determined on OI
Dupuytren’s Contracture
Heberden’s and Bouchard’s nodes

59. Finkelstein Test

60. Phalen’s Test
Prayers Test

61. Anterior Interosseous Nerve
Froment’s Sign
Froment’s Test

62. ORTHOPEDIC TEST FOR THE HIP AND PELVIS
Sacroiliac Joint
Hip Joint

63. Sacroiliac Dysfunction vs Hip Muscle Spasm

64. Patrick’s Test or FABER Test
Hip joint affectation
Iliopsoas spasm
Sacroiliac joint spasm

65. Sacroiliac Dysfunction
HUWAG PO

66. SI Gap test SI Rock test Gaenslen’s test
Unilateral gluteal or posterior leg pain
Sprain anterior sacroiliac joint
SI Rock test
Pain in SI jt
Stress sacrotuberous ligaments
Gaenslen’s test
Pain over LE being tested
Ipsilateral SI joint lesion
Hip pathology or L4 nerve root lesion

67. CHD Barlow’s test Up to 6 months “Click of dislocation”
Ortolani’s test
Click of reduction

68. CHD Galleazi Sign “Alli’s test” Effective from 3-18 mo
Telescoping sign

69. Gluteus Medius Weakness
Trendelenburg Test

70. ORTHOPEDIC TEST FOR THE KNEE
Knee Instability
Patellofemeral Problems
Functional tests

71. History Patient Reports Initial Hypothesis
Patient reports a traumatic onset of knee pain that occurred during jumping, twisting, or changing direction with foot planted
Possible ligamentous injury [1] [2] (anterior cruciate) Possible patellar subluxation[2] Possible quadriceps rupture Possible meniscal tear
Patient reports traumatic injury that resulted in a posteriorly directed force to tibia with knee flexed
Possible PCL injury (posterior cruciate)[3]
Patient reports traumatic injury that resulted in a varus or valgus force exerted on the knee
Possible collateral ligament injury (fibular or tibial)[3]

72. History Patient Reports Initial Hypothesis
Patient reports anterior pain with jumping and full knee flexion
Possible patellar tendonitis [2] [4] Possible patellofemoral pain syndrome [5] [6]
Patient reports swelling in knee with occasional locking and clicking
Possible meniscal tear[7] Possible loose body within knee joint
Patient reports pain with prolonged knee flexion, during squats, and while going up and down stairs
Possible patellofemoral pain syndrome [5] [6]
Patient reports pain and stiffness in the morning that diminishes after a few hours
Possible osteoarthritis (OA) [8] [9]

73. Inspection and Palpation

74. Inspection and Palpation
Ballotement Test
Floating of patella

75. Trophic Skin Changes

76. Trophic Skin Changes

77. Trophic Skin Changes

78. Palpation Anterior pain Inferior pole of the patella
Patellar tendinitis

79. Patellofemoral Dysfunction
Grind test/ Clarke’s Test

80. Clarke’s test
Control pressure applied
Patellofemoral dysfunction

81. Knee Instability

82. Common tests performed on the knee
One-plane medial instability
Valgus stress
One-plane lateral instability
Varus stress
One-plane anterior instability
Lachman test; drawer test
One-plane posterior instability
Posterior sag; drawer test

83. Anteromedial rotary instability Anterolateral rotary instability
Slocum test
Anterolateral rotary instability
Pivot shift test
Posteromedial rotary instability
Hughston’s posteromedial drawer test
Posterolateral rotary instability

84. Knee instability Test unaffected knee first Muscles must be relaxed
Appropriate stress must be applied gently
Observe the degree and quality of opening (endfeel)
Abrupt stop or endfeel – ligament is intact
Soft or indistinct endfeel – ligamentous injury
Acute or chronic?

85. ONE PLANE ANTERIOR INSTABILITY

86. Anterior drawer test
Ant Drawer Test for the knee

87. Anterior drawer test Normal movement – 6mm
If the test is positive, ff may be injured:
ACL
Posterolateral capsule
Posteromedial capsule
Medial capsule (deep fibers)
ITB
Posterior oblique ligament
Arcuate-popliteus complex

88. Lachmann test
Lachmann Test

89. Lachmann test Best indicator of injury to the ACL
Positive sign indicates injury on the ff structures:
ACL
Posterior oblique ligament
Arcuate-popliteus complex

90. ACL Tear
Modified Lachmann Test

91. One plane posterior instability tests

92. PCL Tear
Posterior Drawers Test
Godfrey’s test

93. Following may be injured:
Posterior drawer test
Following may be injured:
Posterior cruciate ligament
Arcuate-popliteus complex
Posterior oblique ligament
ACL

94. Meniscal Tear

95. Meniscal Tear
Mc Murray Test
Lateral Meniscus
Medial Meniscus

96. Collateral Ligament Tear
Valgus Stress Test

97. Collateral Ligament Tear
Varus Stress Test

98. Meniscal and Collateral Tear
Apley’s Compression-Distraction test
Compression-Menisci
Distraction – Collateral

99. ORTHOPEDIC TEST FOR THE ANKLE AND FOOT
Ankle Sprain
Achilles tendon Tear

100. OI and Palpation
Tibialis Posterior Tendinitis

101. Ankle Sprain Talar Tilt Anterior Drawers Ant. Talofibular ligament
Calcaneofibular lig.

102. Achilles Tendon Rupture
Thompson’s test
Simmond’s test

103. Tests for nerve pathology
Chvostek test
CN7 Pathology
Tinels sign for th elbow – Cubital tunnel syndrome/ulnar nerve pathology
Tinel’s Sign for the wrist- CTS / Median nerve pathology

104. Evidence Based Practice and the Diagnostic Process
Reference standard (+)
Reference standard (-)
Diagnostic Test
True positive results
False positive results
(+) A B
Diagnostic Test
(-)
False negative results
True negative results C D
Fritz, J.M. and Wainner, R.S. Examining Diagnostic Tests: An Evidence Based
Perspective, Phys Ther.2001;81:

105. Evidence Based Practice and the Diagnostic Process
A. High sensitivity is indicative that a test can be used for excluding or ruling out the condition when it is negative, but does not address the value of a positive test
B. High specificity is the ability to use a test to recognize when the condition is absent, identifies the value of a positive test
Sackett et. al (1992), Clinical Epidemiology, A Basic Science for Clinical
Medicine: 2nd Ed

106. Evidence Based Practice and the Diagnostic Process
Example: Value of Clinical Test for Subacromial Impingement Syndrome
Hawkin’s test was most sensitive (92%)
Hawkin’s test had low specificity (25%)
Drop arm test was most specific (97%)
Drop arm test had low sensitivity (9%)
The drop arm test was specific revealing that a positive test will confirm
Subacromial impingement syndrome, its sensitivity was poor meaning
That it had a high number of false negative result
Sensitivity and specificity values can only be used if values are there, but clinicians often know the result of the test and would like to know if the result is correct --this is the primary shortcoming of sensitivity and specificity values
The high sensitivity is indicative that a negative Hawkin’s Test can be used
For ruling out subacromial impingement syndrome; its low specificity states
That a positive Hawkin’s test had little meaning

107. Evidence Based Practice and the Diagnostic Process
A. Sensitivity and specificity values - given that the condition is present or absent, it identifies the probability that the correct test result will be obtained;
B. Sensitivity - ability of the test to recognize the condition when present; highly sensitive test will have very few false negative results; highly sensitive test attest to the value of a negative test results
C. Specificity - (true negative rate) - proportion of subjects without the condition with negative test result
D. LIKELIHOOD RATIO - overcome the difficulties of SpPIN and SnNout, by predictin shifts in probability,it identifies the change in odds given the condition will have a negative result a indicates the odds of the condition

108. Evidence Based Practice and the Diagnostic Process
Likelihood Ratio
Fritz, J.M. and Wainner, R.S. Examining Diagnostic Tests: An Evidence Based
Perspective, Phys Ther.2001;81:

109. The proportion of test results that are correct
Statistic
Formula
Description
Overall Accuracy
(a+d)/ (a+b+c+d)
The proportion of test results that are correct
Positive predictive value
1/(a+b)
Given a positive test result , the probability that the individual has the condition
Negative predictive Value
d/(c+d)
Given a negative test result, the probability that the individual does not have the condition
Predictive values- values relate to how tests are used in clinical decision making (positive or negative) it identifies the probability that the results are correct

110. REFERENCES Orthopedic Physical Assessment by David J. Magee
Orthopaedic Physical Examination: An Evidence-based approach for physical therapists
Fritz, J.M. and Wainner, R.S. (2001) Examining Diagnostic Tests: An Evidence Based Perspective, Physical Therapy (81),
Calis et. al, Diagnostic Value of Clinical Test for Subacromial Impingement
Syndrome, Rheumatic Dis; 2000, 59:44-47