Orthopedic Review Evaluation of Spine and Extremities

Orthopedic Review Evaluation of Spine and Extremities
James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic

Definition of an orthopedic test
Most often, a provocative maneuver that involves stretching, compressing and/or contracting of tissues in order to replicate the pain and identify the affected tissues.

History Taking Process
Develop rapport HPI OPQRST Past history Review of Systems Patient expectations

History of Present Illness
Observation is a continual process that begins with introduction

Clarify Area of Chief Concern
Patient points to area of chief concern

Clarify Pain Generators
Immediately following the positive finger point by the patient, palpate the tissue and determine the level and tissue involved with the chief concern

Bakody’s Sign is present when placement of hand of involved upper extremity behind head reduces pain. Observed sign, not a test…

Dejerine’s sign presents the reproduction of spinal pain with cough, sneeze or bowel movement. Test involves cough, sneeze, and BM…

“Barre-Lieou Syndrome” is considered by many physicians to be synonymous with “Post Whiplash Type Injury”

Symptoms that characterize Barré-Lieou syndrome
Headache, facial pain, ear pain, vertigo, tinnitus, loss of voice, hoarseness, neck pain, severe fatigue, muscle weakness, sinus congestion, a sense of the eyeball being pulled out, and numbness. Other symptoms may include a pins-and-needles sensation of the hands and forearms, corneal sensitivity, dental pain, lacrimation (tearing of the eyes), blurred vision, facial numbness, shoulder pain, swelling on one side of the face, nausea, vomiting and localized cyanosis of the face (bluish color).

Rust Sign may be present… Post-traumatic Roll over Blow to skull

History of “Roll Over” MVA
Rust sign may be present initially, which would indicate possible upper cervical spine instability or moderate to severe “whiplash type injury.” Past history of roll over MVA should raise suspicion of DDD,DJD, spondylosis, and stenosis in the cervical spine.

Lhermitte Sign present with severe lancinating pain down spine and extremities most often with cervical flexion. SOL Multiple sclerosis

Spine Evaluation Observation Palpation Range of motion
Special tests or Orthopedic tests

Observation and Inspection
Gait Posture Appearance Appliances Deformities Contusions Cicatrices

James J. Lehman, DC, MBA, DABCO
Valsalva Maneuver Valsalva maneuver for IVD syndrome or tumor (SOL) Increased intrathecal pressure Reproduce spinal and or radicular symptoms James J. Lehman, DC, MBA, DABCO

Shoulder Abduction Test
Abduction of shoulder relieves the cervicobrachial symptoms revealing the presence of Bakody sign Indicates nerve root irritation James J. Lehman, DC, MBA, DABCO

Swallowing Test Difficulty swallowing might be related to a space occupying lesion anterior to the cervical spine. Bleed, DISH, or SOL impede swallowing James J. Lehman, DC, MBA, DABCO

Palpation Flat finger and static
Osseous Soft tissues Myofascial Neural Ligamentous Vascular Dermal

Range of Motion and O’Donoghue’s Maneuver
Differentiates joint sprain/strain injuries Pain upon ROM Active = non-specific Passive = ligament Resistive = muscle

Common Cervical Provocative Tests
All of them test for dural sheath, nerve root, or spinal nerve involvement Positive neurological findings all indicate radicular pain James J. Lehman, DC, MBA, DABCO

Cervical Compression Tests
Active maximal foraminal compression Pain maybe indicate joint, muscle, or ligament pathology

Maximal foraminal compression (active) Jackson’s (acute) Spurling’s (in favor) Maximal foraminal compression(passive) Extension/Flexion (disc/joint) James J. Lehman, DC, MBA, DABCO

Passive foraminal compression Neutral Flexion/Extension Lateral flexion Rotation Jackson Spurling

Cervical Distraction Test
Distraction test for nerve root, facet, or myospasm Positive test relieves pain Negative test increases pain James J. Lehman, DC, MBA, DABCO

Soto-Hall Test Non-specific test for cervical spine injury or lesion Passive flexion of neck with sternum stabilized Relative contraindication with severe injury James J. Lehman, DC, MBA, DABCO

Shoulder Depression Contralateral pain with radiations into upper extremity (nerve compression) Localized contralateral pain (joint compression) Ipsilateral radiating pain (nerve stretch)

Brachial Plexopathy Thoracic Outlet Syndrome
90% of TOS are neurogenic conditions Post traumatic whiplash type injuries to scalene muscles

Brachial Plexopathy TOS
Palpate Erb’s point and attempt to elicit brachial plexus symptoms. Compare affected and unaffected sides

Brachial Plexopathy TOS
Perform Cervical ROM testing Compression test Shoulder depression TOS tests

Thoracic Outlet Syndrome
Thoracic outlet syndrome gets its name from the space (the thoracic outlet) between the clavicle and the first rib

Thoracic Outlet Syndrome Special Tests
Roos Brachial plexus stretch Brachial plexus tension Adson’s Test Allen Wright

Thoracic Outlet Tests Roos
2-3 minutes of hand flexion/extension with shoulders abducted and elbows flexed. Positive test = inability to complete test due to pain/heaviness.

Vascular or Neurogenic Tests
Adson (vascular) Brachial plexus stretch (neurogenic)

Thoracic Outlet Syndrome Wright’s Test
Hyperabduct and externally rotate the patient’s arm while assessing the ipsilateral radial pulse. Considered positive if the pulse diminishes or paresthesias develop (Safran, 2004).

Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesias, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds. J Vasc Surg Sep;46(3):601-4.

Brachial Plexopathy A burner is a nerve injury resulting from trauma to the neck and shoulder. Its primary symptom is burning pain radiating down one upper extremity.

A "burner" is a common nerve injury resulting from trauma to the neck and shoulder, usually during sports participation. The injury is most often caused by traction or compression of the upper trunk of the brachial plexus or the fifth or sixth cervical nerve roots. Burners are typically transient, but they can cause prolonged weakness resulting in time loss from athletic participation. Furthermore, they often recur. Treatment consists of restoring range of motion, improving strength and providing protective equipment. Return to sports participation depends primarily on reestablishment of pain-free motion and full recovery of strength and functional status. (Am Fam Physician 1999;60: )

The "Burner": A Common Nerve Injury in Contact Sports
Burners are typically Grade 1 or Grade 2 peripheral nerve injuries Neuropraxia Axonotmesis

Mechanisms of "burners." Traction
Direct blow to the supraclavicular fossa at Erb's point Compression of the cervical roots or brachial plexus

Spurling's test The test is positive if axial loading by the examiner's hands reproduces symptoms

Muscle Innervation Clinical test Deltoid Axillary (C5, C6) Shoulder abduction Supraspinatus Suprascapular (C5, C6) "Full can" abduction* Infraspinatus External rotation Biceps brachii Musculocutaneous (C5, C6) Elbow flexion Pronator teres Median (C6, C7) Forearm pronation Triceps brachii Radial (C7, C8) Elbow extension Abductor digiti minimi Ulnar (C8, T1) Fifth digit abduction

Neuropraxia This is a transient lesion (compression of neuron) and recovery is spontaneous within a few days or weeks. James J. Lehman, DC, MBA, DABCO

Axonotmesis This lesion is due to compression or direct force.
Sensory loss is common. Prognosis for recovery is good. Occasionally, the loss of some cell bodies inhibits complete recovery.

Axioms in Thoracic Spine Assessment
The thoracic spine requires evaluation in isolation and together with the cervical and lumbar spine

Scheplemann Sign Intercostal Pain
Contralateral pain might indicate pleurisy or intercostal strain Ipsilateral pain might indicate intercostal neuropathy or costovertebral sprain

Most Common Causes of Thoracic Pain
Zygapophyseal joints What would be your diagnosis?

Intercostal Syndrome Differential Diagnosis
Intercostal neuralgia or neuritis Pleurisy Fractured rib Intercostal myofascial pain

Scheurmann’s Disease Differentiation from Round Back
Spinal postural alterations do not resolve with recumbent position Confirmed with radiographic exam Sleeps with 2-3 pillows propped under back

Sternal Compression Test Rib Fractures
Compresses lateral borders of ribs Fracture becomes more pronounced Produces or exacerbates fractured rib pain

T-1 & T-2 Nerve Root Lesions
Scapular area pain with passive approximation of the scapulae Indicates T1 or T2 nerve root compression or irritation

Hot Sponge Test Determine if the patient is experiencing an inflammatory condition with three to four strokes along spine.

Myelopathy and Thoracic Disc Herniation Beevor’s Sign
When Beevor’s sign is present, T 7-12 spinal levels must be evaluated

Ankylosing Spondylitis Mensuration of chest expansion
Normal expansion is 1.5 to 3” A decrease in normal expansion indicates restriction of movement at costotransverse or costovertebral joints

Thoracic Scoliosis Origin of a lateral curvature of the spine
Idiopathic (85-90%) Congenital (Usually failure of formation) Neuromuscular

Signs of Scoliosis How would you differentiate scoliosis from pelvic obliquity and postural imbalance? Adam’s position Leg length mensuration

Sciatic Scoliosis Vanzetti Sign
Sciatica Level pelvis Scoliosis Suspect discopathy

McKenzie Slide Glide Test
Test determines if scoliosis is related to back pain. Positive if the test increases the back pain.

Serious Thoracic Disorders Myocardial infarct
Crushing pain radiating to the jaw or arm suggests acute ischemia or MI. Patients often ascribe myocardial ischemic pain to indigestion. Exertional pain relieved by rest indicates angina pectoris

Lumbar Spine Back Pain Back pain is common from the second decade on.

Lumbar Spine Scoliosis Postural imbalance Pelvic obliquity
Joint dysfunction DDD/DJD Myofascial condition Neural condition

Characteristics of Low Back Pain Spinal Pain
Discogenic pain Nerve root pain Multiple levels of lumbar spinal stenosis

Schober Test Mark lumbosacral junction, 10 cm superior, and 5 cm inferior Have patient flex forward and measure the differences

Mensuration of Lumbar Flexion Schober Test
Normal findings would indicate 4 cm of increase with superior pair of marks and zero change with inferior pair of marks. Suspect AS or fusion with reduced movement

Valsalva’s Maneuver Neuro-orthopedic application
Assessment for space-occupying lesion, tumor, intervertebral disc herniation, or osteophytes

Lindner’s Sign Assessment for Lumbar Nerve Root Irritation
Passive flexion of neck with chin to chest Supine, seated, or standing position

Lindner’s Sign Sign is present if procedure produces pain in lumbar spine with a radicular distribution

Kemp Test May be performed in either a standing or sitting position
A positive test involves radicular pain

Kemp’s Oblique bending toward symptomatic side increases pain with lesion lateral to nerve root Oblique bending away from symptomatic side increases pain with lesion medial to nerve root

Kemp Maneuver Assessment
Intervertebral nerve root encroachment Muscular strain Ligamentous sprain Pericapsular inflammation

Straight Leg Raise Test Nerve Root Tension Signs
Pain reaction 0-35 = extradural 35-70 = disc lesion 70-90 = lumbosacral lesion Dull pain in posterior thigh = hamstrings

Straight-Leg-Raising Test
Dynamics: 0-35 degrees = no dural movement 35-70 degrees = tension of sciatic nerve over intervertebral disc Above 70 degrees presents very little additional deformation of nerve root

Bilateral SLR testing Simultaneously perform Well-Leg-Raising test

Assessment for space-occupying mass in the path of a nerve root, sacroiliac inflammation and lumbosacral involvement

Well-Leg-Raising Test Fajersztajn’s Test
Assessment for lumbar nerve root lesion caused by IVD syndrome or dural sleeve adhesion Contralateral LE SLR

Bragard Sign Nerve root tension sign
Assessment for radicular symptoms, intervertebral disc lesions, and sciatic neuropraxia. Follows SLR or Lasegue sign

Sicard Sign Nerve root tension sign
SLR with dorsiflexion of large toe

Turyn Sign Nerve root tension sign
Supine position Dorsiflexion of large toe without SLR Least provocative nerve root tension sign for sciatic nerve

Minor’s Sign Painful or antalgic behavior due to protective myospasia
Crawling up thigh with listing while rising from a seated position

Vanzetti's Sign The pelvis is always horizontal in spite of sciatica and scoliosis. In other lesions with scoliosis the pelvis is inclined. (pelvic obliquity)

Antalgic Lean Sign “Antalgia Sign”
Painful discopathy causes listing in order to reduce mechanical nerve root pain.

Antalgic Lean Sign Lateral disc protrusion produces a contralateral list Medial disc protrusion produces an ipsilateral list

Differentiate Lateral Disc from Medial Disc Protrusion
Antalgic lean or antalgia sign Fajersztajn’s or Well Leg Test Kemp’s test

Meyerding’s Classification of Spondylolisthesis
Grade 1 = 0-25% Grade 2 = 26-50% Grade 3 = % Grade 4 = 76%-100%

Lumbar Central Canal Stenosis
Neurogenic claudication with pain upon walking Feel like legs are “giving way” Temperature changes and weakness in legs Night pain Sciatic tension signs are present

Lateral Spinal Canal Recess Stenosis
Degenerative joint disease Encroachment of nerve root in canal Nerve root entrapment

IVD or Space Occupying Lesion Milgram’s Test
Positive with either intrathecal or extrathecal pathology

Milgram’s Test Assessment for IVD or Space-Occupying Lesion
Patient able to hold for 30 seconds rules out intrathecal pathology

Positive Milgram’s Test
Indicates intrathecal or extrathecal pathology The test is positive if the patient experiences low back pain

Differentiate Spinal Sprain/Strain
Describe your approach to differentiating sprain from strain of the lower back and pelvis

SIJ Lesions Signs and Symptoms
SIJ pain Abnormal gait Palpation tenderness Pain on forward flexion Pain on sitting

Hibb’s Test Differentiate Hip and SIJ Lesions
Prone leg to buttocks with lateral flexion and internal rotation Localized pain indicates either hip or SIJ pain

Pelvic Rock Test Side posture downward pelvic compression
Pain in SIJ indicates lesion of inflammatory process

Sign of the Buttock’s Supine SLR reveals unilateral restriction
Sign present with knee flexion but no increased hip flexion Sign indicates hip disease, such as trochanteric bursitis

Absence of Sign of the Buttocks
Absence of sign when hip flexion increases upon knee flexion due to pain reduction Indicates lumbar dysfunction

Flamingo Test Stand on one foot Hop to stress one joint
Tests SIJ, symphysis pubis, and hip

Adam’s Supported Belt Test Differentiate Lumbar from SIJ Lesion
Lumbar pain with both supported and unsupported dorsolumbar flexion SIJ pain with unsupported flexion only

Lewin-Gaenslen Test Side posture extension stresses SIJ & anterior SIJ ligaments Ipsilateral pain indicates a lesion in SIJ

Yeoman’s Test Prone extension stresses SIJ & anterior SIJ ligaments
Ipsilateral pain indicates a lesion in SIJ

SIJ Stretch Test Bilateral supine ASIS pressure
Pain indicates lesion in anterior SIJ ligaments or SIJ

SIJ Resisted Abduction Test
Thigh or buttock pain indicates strain in TFL or gluteal muscles SIJ pain indicates sprain of SIJ ligaments

Coccygodynia Myofascial pain is a common cause of coccygodynia

Hip Palpation Point tenderness Edema Symmetry

Hip Contracture Tests Thomas Test
Supine passive hip flexion Contralateral hip and knee flexion indicates a positive test for hip contracture Evaluate rectus femoris tightness

Hip Contracture Tests Rectus Femoris Contracture Test
Involuntary extension of flexed knee with tightness in rectus femoris indicates a hip flexion contracture

Hip Contracture Tests Piriformis Test
Piriformis pain with resisted abduction of hip indicates tight piriformis Sciatic pain indicates nerve compression

Hip Contracture Tests Ely’s Heel to Buttocks
Prone heel to contralateral buttocks Ipsilateral pelvis rising from table indicates hip flexion contracture or tight rectus femoris

Hip Contracture Tests Ober’s Test for TFL or ITB

Ober’s Test Failure to descend smoothly indicates a positive test for contracture of the TFL or ITB.

Trochanteric Bursitis
Palpation Patrick’s Positive finger point Laguerre’s

Degenerative Hip Disease
Patrick’s Trendelenburg’s Scouring’s Laguerre’s Difficult to palpate

Patrick’s Test FABERE & Figure of 4
Flexion Abduction External rotation

Patrick’s Test Compresses femoral head into acetabulum
Positive test with pain in hip, which indicates an inflammatory process

Pelvic Obliquity and Postural Imbalance
You must determine whether the leg length discrepancy is anatomical or functional

Actual Leg-Length Test
This is a tape measurement that tests for anatomical leg length discrepancy. ASIS and medial malleolus are the landmarks identified

Apparent Leg-Length Test
Reveals functional leg length discrepancy Umbillicus and medial malleolus are landmarks

Functional Leg-Length Measurement
Measure length of both lower extremities supine and seated Inferior medial malloli are used as landmarks Read the body language

Functional Leg-Length Measurement
Usually the ipsilateral malleolus will measure short when supine if the superior iliac crest appears inferior when standing and long when seated

Trendelenburg’s Test Standing flexion of hip
Downgoing of contralateral hip is a positive test Indicates gluteal motor weakness and/or hip pathology of weight bearing LE

Anvil Test Percussion of calcaneus compresses hip joint
Positive test with pain, which indicates fracture or hip pathology

Congenital Hip Dysplasia DDH
Also known as Allis’ sign It is not used to evaluate functional leg length deficiency

Evaluation of the Knee What type of injuries should we consider with our differential diagnosis of the knee?

Osgood Schlatter’s Lesion
Anterior tubercle of tibia inflammation with young athletes who run and jump Fracture may occur with an acute injury

Meniscus and Ligament Instability
Apley’s compression tests meniscus Apley’s distraction tests nonspecific ligaments

Meniscal Injury McMurray’s Test
Flex and extend with internal and external rotation. Stresses distorted meniscus Palpable or audible click is positive

Meniscal Injury Retreating McMurray
Palpate medial meniscus with knee and hip flexed 90 degrees plus lateral and medial rotation

Meniscal Injury Retreating McMurray
Meniscal tear blocks medial rotation

Meniscal Injury Bounce Home Test
Passive flexion of hip and knee Cup heel and request dropping of knee Femur rotation on tibia & extension blocked

Meniscal Injury Bounce Home Test
Blockage or rubbery end feel with full extension are positive signs of meniscal injury

Meniscal Injury Steinman’s Tenderness Test
Supine Hip and knee flexion to 90 degrees Palpate medial and lateral joint lines with index and thumb w/ flexion and extension

Meniscal Injury Steinman’s Tenderness Test
Pain moving anteriorly with extension or posteriorly with flexion and indicates meniscal injury.

Meniscal Injury Modified Helfet’s Test
Seated with foot on floor Note location of tibial tuberosity Extend leg and note location of tibial tuberosity

Meniscal Injury Modified Helfet’s Test
Expect lateral movement of tibial tuberosity with extension of knee Blocked movement indicates meniscal injury

Thessaly Test for Meniscus Tear
Five degree of knee flexion Unaffected knee first

Thessaly Test for Meniscal Tear
External rotation assisted Internal rotation

Thessaly Test for Meniscal Tear
Positive findings Repeat process at 20 degrees Pain medial or lateral Clicking or locking Most accurate at 20 degrees of knee flexion

Ligament Instability Anterior and Posterior Drawer Signs

Anterior Drawer Sign and Lachman’s Anterior Cruciate & Posterior Oblique
Anterior translation of more than 5 mm indicates injury

Anterior Drawer Sign Anterior cruciate Medial collateral ligament ITB
Capsules & ligaments Arcuate-politeus complex

Ligament Instability Lachman’s Test
Anterior and posterior cruciate ligament sprains Most reliable test for anterior cruciate ligament rupture

Ligament Instability Slocum’s Test
Anterior cruciate Posteriorlateral capsule Fibular collateral ligament ITB

Patellofemoral Dysfunction Patella Grinding Test
Chrondomalacia patellae Patellofemoral arthralgia Chondral fracture

Patellofemoral Dysfunction Patella Apprehension Test
Pain and apprehension are present Positive test indicates lateral patellar dislocation

Patellofemoral Dysfunction Dreyer’s Test
Patient cannot raise his leg while in a supine position

Patellofemoral Dysfunction Dreyer’s Test
Stabilize quadriceps tendon and patient able to raise leg indicates traumatic fracture

Patellofemoral Dysfunction Clarke’s Patellar Scrape Test
Pain and crepitation may indicate patellofemoral arthralgia or chondromalcia patellae

Drawer’s Foot Sign Anterior drawer will be positive with gapping secondary to trauma Indicates sprain of anterior talofibular ligament

Lateral Stability Test Talar Tilt Test
Sprain injury to calcaneofibular and/or anterior talofibular ligaments

Ankle Examination

Subtalar Examination

High Ankle Sprain Mechanism

High Ankle Sprain Syndesmotic ligament Squeeze test Stress radiographs
Syndesmotic screw

Metatarsal Examination

Plantar and Achilles Examination

Tarsal Examination

Pott’s Compression Test
Tests for fracture of the tibia or fibula or syndesmotic sprain.

Syndesmotic Sprain Test
The crossing of the affected leg over the other leg will produce pain with a high ankle sprain of the interosseous membrane.

Homan’s Test Deep Vein Thrombophlebitis
Supine with knee flexed Abrupt forcible dorsiflexion of foot Positive test produces pain in calf or popliteal region

Tarsal Tunnel Syndrome
Analogous to carpal tunnel syndrome in the wrist…

Tinel’s Sign Tap tibial nerve at medial aspect of ankle
Sign is present if paresthesias are produced in foot

Tourniquet Test Apply sphygmomanometer to affected ankle and inflate to pressure 10 mm of Hg above systolic for 1-2 minutes

Morton’s Neuroma Pain Usually affect the third and fourth digits

Metatarsal Pain Patient will often indicate pain over heads of metatarsals

Metatarsalgia Patient may complain of pain on the dorsum of the foot.
Palpate both dorsal and plantar aspects of foot.

Metatarsal Inspection
Inspect for callous formations

Palpate Metatarsal Heads
Attempt to elicit pain and/or tenderness

Provocative Maneuvers
Metatarsal squeeze Rapid and firm flexion of toes Stretch of interdigital nerves

Shoulder Ranges of Motion
What are the six ranges of motion for the shoulder?

History Taking Process
Instability Stiffness Locking Catching Swelling The patient should be asked about shoulder pain:

Supraspinatus Tendonosis Signs
Painful arc with abduction (60-90) degrees Limited AROM Painful PROM

Supraspinatus Press Test
Thumb down (empty can) Thumb up (full can)

Supraspinatus Stress Test
Differentiate deltoid muscle strain from supraspinatus tendon/muscle strain

Apley Scratch Test

Apley Scratch Test Rationale
Stresses rotator cuff tendons Supraspinatus is most often involved Exacerbation of pain might indicate degenerative tendonitis

Hawkins-Kennedy Impingement Supraspinatus tendonitis rationale
Local pain with pressing of supraspinatus tendon against coracoacromial ligament

Neer Impingement Test Shoulder pain and look of apprehension indicates a positive sign for overuse of supraspinatus tendon Most common cause is repetitive microtrauma

Bicipital Tendonosis Orthopedic Evaluation
Flexion of the elbow against resistance aggravates pain.

Bicipital Tendonosis Passive abduction of the arm in a painful arc elicits pain; however, this finding may be negative in isolated biceps tendonitis.

Speed’s Test Bicipital tendonosis
Patient complains of anterior shoulder pain with flexion of the shoulder against resistance, while the elbow is extended and the forearm is supinated.

Yergason’s Test Biceps tendon instability
The patient complains of pain and tenderness over the bicipital groove with forearm supination against resistance with the elbow flexed and the shoulder in adduction. Popping of subluxation of the tendon may be demonstrated with this maneuver.

Clunk Test Tear of the anterior labrum
Document joint stability in order to assess the rotator cuff and glenoid labrum.

Rowe Test For multidirectional instability
Attempt to dislocate Look at patient’s face for apprehension and/or discomfort This is a positive sign GH ligament, Rotator cuff tendons and joint capsule

Abduction Inferior Stability (ABIS) Test Feagin test + anterior inferior shoulder instability with downward displacement or apprehension Patient's arm abducted with the forearm resting on the examiner's shoulder Examiner exerts pressure on the arm, gradually pushing the humeral head downwards

Crank Test (3) (Standing or seated) or Fulcrum Test (Supine)
This test serves to place the shoulder in a position of maximal instability (extremes of abduction and external rotation). The test is positive for instability if the patient expresses pain or apprehension.

Relocation Test (4) Classic fulcrum test
The humeral head is pushed forward to elicit apprehension

Relocation Test Prevents anterior subluxation and produces a negative apprehension test
Pressure over the front of the humeral head prevents the head suluxating anteriorly, and does not cause apprehension.

Sulcus Test (1) A positive test is indicative of abnormal mobility
In the relaxed patient, the examiner gently pulls the humerus downwards. The test is positive if the humeral head descends, with formation of a groove or sulcus under the lateral border of the acromion

Drawer Test (2) Demonstrates overall non-specific hyperlaxity or anterior instability of the glenohumeral joint The patient is made to relax and slightly lean forward. The examiner holds the humeral head between his or her thumb and index finger, and tries to make the head slide backwards and forwards.

Positive Hyperabduction Test Inferior Glenohumeral ligament determines range of passive abduction (85-90 degrees) Marked asymmetry between the affected and the healthy side is characteristic of laxity of the ligament complex. Positive test = 105 degrees plus

Multidirectional Hyperlaxity
On examination, there will be a groove of more than 2 cm in the sulcus test, as well as major anterior and posterior drawer movements. External rotation of the upper limb of more than 90° is also considered to be a sign of abnormal laxity.

Isosceles Triangle Use this process to reveal any deviations may indicate anatomical problem that warrants further investigation

Tinel’s Sign

Lateral Epicondylitis/Epicondylosis/tendinopathy Tennis Elbow Test or Cozen’s test

Kaplan’s Test Presence of a Kaplan’s sign with reduced pain and increased strength

Medial Epicondylitis/Epicondylosis/Tendinopathy Examination
Golfer’s elbow test is a reverse “Cozen’s” test

Valgus Testing Challenge the flexor muscles
Strain the medial ulnar collateral ligaments

Ligamentous Instability Adduction and Abduction Stress Tests
Gapping and pain indicate a positive test for instability

Froment’s Sign Test for ulnar nerve palsy
Tests the action of adductor pollicis Patient holds a piece of paper between the thumb and a flat palm as the paper is pulled away.

Froment’s Sign and Finger Pinch Test
Patient with an ulnar nerve palsy will flex the thumb to try to maintain a hold on the paper. There are variations of this test

Pinch Grip Test Anterior interosseous nerve trauma
Observe pitch attitude of the hand Normally when individual pinches something between index finger & thumb, MP & IP joints of thumb and index finger are flexed;

Pinch Grip Test Anterior interosseous nerve trauma
With nerve deficit, terminal phalanges of thumb and index finger are extended or hyperextended EMG needle examination is difficult because of the deep location

Elbow Flexion Test Ulnar nerve compression at cubital tunnel
The elbow is the most common site of compression of the ulnar nerve. Second most common compressive neuropathy (after carpal tunnel syndrome). Cubital tunnel syndrome affects men 3-8 times as often as women.

Examination of Related Areas

Normal Metacarpal Joints and Contour

Finkelstein’s Test

Tunnel of Guyon Ulnar Nerve and Artery

Phalen’s Test Carpal Tunnel Syndrome
Often, the symptoms can be duplicated or worsened by bending the wrist firmly palmward for 60 seconds

Tinel’s Sign Carpal Tunnel Syndrome
Tapping the front of the wrist over the nerve reproduces the pain and paresthesia

Dupuytren’s Contracture
A longitudinal fibrous band, known as a cord, may form. Cord may flex the finger joints Process tends to be progressive

Ulnar Drift Rheumatoid Arthritis
Drift of the fingers away from the direction of the thumb at the MP joint (ulnar drift). Due to tissue damage of capsules, ligaments, and tendons

“Boutonniere” Deformity Avulsion of Extensor Digitorum Communis Tendon
Boutonniere deformity is an extensor tendon injury affecting two joints of the finger, the PIP (proximal interphalangeal) joint at the middle of the finger, and the DIP (distal interphalangeal) joint that controls the fingertip.

Mallet Finger Avulsion of Distal Extensor Digitorum Communis
The tendon that straightens the tip of the finger is injured and you may lose the ability to straighten your finger

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Orthopedic Review Evaluation of Spine and Extremities

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