PD E1 Special tests

• cervical test for nerve root compression/foraminal stenosis

• hyperextension w/ lateral rotation and lateral flexion → apply axial compression to head

• positive = pain to side of rotation

Spurling’s Test / Cervical Compression

• Cervical test for cervical radiculopathy

• place hands under occiput and apply upward distraction force (** don’t perform if cervical instability suspected)

• positive = decreased or eliminated pain

Cervical Distraction

• Shoulder test for impingement / rotator cuff tear

• pronate and passively forward flex arm as high as possible

• positive = pain

Neer’s Sign

• Shoulder test for impingement / rotator cuff tear

• forward flex arm to 90° and bend elbow then internally rotate humerus (push down)

Hawkin’s and Kennedy test

• Full thickness rotator cuff tear

• test integrity of supraspinatus, teres minor & infraspinatus tendons

External rotation lag sign

• Rotator cuff tear

• assesses integrity of subscapularis

Internal rotation lag sign / Liftoff test

• Rotator cuff tear

• assesses for supraspinatus muscle irritation, impingement, or tear

• shoulder in forward flexion, 90° scapular plane & elbow fully extended→ fully pronate arm with thumb face down → resist downward pressure

• positive = pain

Supraspinatus / Empty can test

• full thickness tear of supra/infraspinatus

• bring arm passively to 90° abduction and external rotation → tell patient to hold and then release your hand

• positive = arm drops / unable to control downward movement

Drop arm test

• AC joint or labral tear test

• shoulder flexed 90°, adducted, internally rotated, and elbow extended → resist downward force → repeat procedure in supination

• positive = ACJ pain or deep clicking in GHJ

O’brien’s test

• tests for labral lesions/tears

• passively abduct and externally rotate shoulder overhead

• positive = hear or feel a click when anteriorly translating humerus

Clunk test

• SLAP lesions / Labral tears

• Pt sit w/ hands on hip and thumbs pointing posteriorly → apply a forward and superior force on elbow and have pt resist

• positive = click or pain increases

Anterior slide test

• shoulder instability / inferior laxity

• arm relaxed to side → palpate shoulder by placing fingers on anterior and posterior aspects of humeral head → grasp elbow and apply downward distraction

• positive = depression appears bt acromion process and humeral head

Sulcus sign

• detects and grades instability/laxity of shoulder /capsular mechanisms

• pt supine → shoulder held at 80-120° abduction, flexion, and ER → apply force anterior or posterior

• positive = relative movement / displacement

Anterior / Posterior drawer signs

• test for shoulder - anterior labrum/capsule instability

• abduct and externally rate arm → apply gentle anterior force against posterior shoulder

• positive = feeling of imminent subluxation / resist further motion

Anterior apprehension test

• Tests for shoulder instability of posterior labrum or capsule

• supine w/ shoulder and elbow flexed 90° and GHJ off table → grasp distal forearm and stabilize posterior scapula and apply downward force

• positive = facial response / apprehension / resists further motion

Posterior apprehension test

• shoulder instability (anterior)

Jobe’s relocation test

• tests for bicipital tenosynovitis / pathology of bicep long head

• with elbow in extension, pt flexes the shoulder against resistance from examiner

• positive = pain in bicipital groove

Speed’s test

• assess for pathology in long head of biceps tendon in its sheath

• pt attempts to supinate wrist against resistance (with elbow flexed at side)

• positive = pain in bicipital groove

Yergason’s test

• test for torn head of biceps

• pt sitting, clasp hands behind head → ask pt to contract biceps

• positive = no contraction is palpable

Ludington’s test

• test for bicipital tendonitis or long head biceps tendon subluxation

• hold pts arm and flex to 90° → palpate biceps tendon 8cm below GHJ then move tendon side to side

• postive = sharp pain on bicipital groove

Lippman’s test

• special test for AC joint

• elevate arm to 90° flexion then maximum horizontal adduction

• positive = pain on top of shoulder near AC joint

Crossover/Adduction test

• thoracic outlet syndrome

• arm slightly abducted and extended → extend and rotate neck toward arm → inspire & palpate radial pulse

Adson’s or Scalene maneuver

• thoracic outlet syndrome

• arm abducted and elbow flexed → turn head away from arm → externally rotate arm and palpate radial pulse

Allen’s test

• special test for thoracic outlet syndrome

• stand behind pt → passively extend and abduct arm to 30° → hyperextend head and neckline→ palpate radial pulse

Military brace

• special test for thoracic outlet syndrome

• pt sitting & hold both elbows at shoulder height while pushing shoulders back → repeatedly opens and close hand for several minutes

Roos Test

• CN XI dysfunction

• have pt perform a wall pushup → scapular instability makes inferior border of scapula move medially or laterally

• medial- serrates anterior muscle weakness

• lateral- trapezius muscle weakness

Winged scapula

• Radial collateral ligament (LCL) damage

• hold elbow slightly bent and apply pressure to inside of elbow → places lateral ligaments under stress

• positive = pain and instability

Varus stress test

• Ulnar collateral ligament (MCL) damage

• hold elbow slightly bent and apply pressure to outside of elbow → placed medial ligament under tress

• positive = pain and instability

Valgus stress test

• Ulnar nerve compression or entrapment (cubital tunnel syndrome)

• repeated tapping over ulnar nerve where it passes behind and underneath medial epicondyle of elbow

• positive = pain and tingling

Tinel’s sign of elbow

• lateral epicondylitis / tennis elbow

• palpate just below lateral epicondyle of elbow; apply pressure w/ hand to dorsum of pt’s fist forcing it into flexion

• positive = pain on outside of elbow when hand is extended at wrist against resistance

Cozen test

• lateral epicondylitis / tennis elbow

• stabilize elbow in one hand and ask pt to pronate forearm and extend and radially deviate wrist against manual resistance

• positive = pain at lateral epicondyle

Mill’s test

• golfer’s elbow

• pronate and flex wrist and forearm at same time while examiner resists in opposite direction

• positive = pain isolated over attachment of wrist flexor muscles on inside of elbow

Medial epicondylitis test

• Dequervain’s tenosynovitis (abductor polices longus and/or extensor polices brevis tendon sheaths)

• adduct and flex thumb and make a fist → stabilize wrist with one hand and apply varus force (or ulnar deviate)

• positive = sharp pain on lateral aspect of wrist

Finkelstein test

• CMC arthritis

• apply longitudinal axial load and rotate CMC joint

• positive = pain and crepitus

Thumb grind test

• Carpal tunnel / median/radial nerve impairment

• dorsal aspect of both hands in full contact w/ wrists maximally flexed → hold for 1 minute

• positive = tingling/numbness radiation to fingers & palmar surface

Phalen’s test

• carpal tunnel syndrome

• tap lightly over pt’s transverse carpal ligament

• positive = paresthesia along distal most distribution of median nerve

Tinel’s sign at wrist

• ulnar nerve impairment/paralysis

• hold piece of paper b/t 1st and 2nd digits by forcefully opposing digits → attempt to pull paper out

• positive = inability to hold contraction or weak contraction

Froment’s sign

• UCL detachment

• valgus force on MCP joint of thumb → stretching or rupture of UCL

• MCP joint painful swollen, thumb feels weak to pinch, possible bruise discoloration

Valgus stress test / Gamekeeper’s thumb / Skier’s thumb

• scaphoid instability

• attempt to translate scaphoid anteriorly and posteriorly

• positive = dislocation/subluxation

Watson clunk test

• arterial compromise- assess hand circulation

• rapidly open and close hand 15 times → place thumbs over radial and ulnar arteries → have pt open hand; should be pale → release one artery and hand should flush

• positive = hand remains cyanotic

Digital allen test

• pathology of hip or sacrum

• pt supine and flex, abduct, and externally rotate hip (put foot on opposite knee) → slowly press down on superior aspect of knee joint lowering leg into further abduction

• positive = pain

FABER / Patrick / Figure 4 test

• ITB or tensor fascia latae contracture

• pt lie on unaffected side → abduct and extend hip to allow IT band to move posteriorly over greater trochanter then lower leg

• positive = hip remains abducted

Ober test

• Hip flexor tightness

• pt supine, bring unaffected leg to chest (flex hip&knee) → observe if other leg is slightly elevated off exam table

Thomas test

• Piriformis muscle pain or pinched sciatic nerve

• pt foot lateral to C/L knee → resist abduction or adduction against examiners hand

• positive = pain

Piriformis syndrome test

• weakness of hip abductors, gluteus medius & minimus

• pt stand on one leg

• positive = pelvis of lifted leg tilts downward or drops

Trendelenburg test

• congenital hip dysplasia - attempt to sublet unstable hip

• infant supine w/ hips flexed to 90° → adduct the hip while applying downward / posterior force

• positive = hip clunk

Barlow’s test

• congenital hip dysplasia - attempt to relocate hip into acetabulum

• infant supine w/ hips flexed 90° → abduct hip while applying upward force → push upward w/ greater trochanter (away from bed)

• positive = clunk (relocated femoral head)

Ortalani’s test

• moderate-severe knee effusion

• pt lies supine while examiner “milks” knee capsule

• positive = patella moves downwardly and then rebounds once pressure is removed (appearance of floating or ballotable patella)

Ballotable patella test

• Patellofemoral syndrome (PFS)

• pt supine → push patella distally in trochlear groove → quadriceps tighten against patella resistance

• positive = pain or crepitus

Clarke’s sign / Patellar grind

• pt supine w/ legs flat on table and quads relaxed → try to dislocate patella laterally

• positive = apprehensive or asks to stop (prone to patellar dislocations)

Patellar apprehension test

• Knee MCL instability / tear

• apply inward pressure to outer thigh and move lower limb outward

• positive = pain and laxity

Valgus stress test

• LCL instability / tear

• apply outward pressure to inner thigh and move lower limb outward

• positive = pain and laxity

Varus stress test

• ACL tear

• pt supin w/ hip and knee flexed → sit on pt’s foot and grasp tibia at joint line → pull tibia anteriorly

• positive = inc anterior tibial translation and pain

Anterior drawer test

• ACL tear

• pt supine and knee flexed at 30° → femur stabilized w/ one hand and tibia pulled anterior w/ other

Lachman’s test

• PCL tear

• pt supine w/ hip and knee flexed → sit on pts foot and grasp tibia at joint line → push tibia posteriorly

• positive = inc posterior tibial translation and pain

Posterior drawer test / Sag sign

• Meniscus tear

• pt prone w/ knee flexed 90° → apply pressure to plantar aspect of heel, applying axial load to tibia while simultaneously IR & ER the tibia

• positive = pain, clicking

Apley’s compression test

• meniscus tear or ligament sprain

• pt prone w/ knee flexed 90° → grasp lower leg and stabilize knee proximal to femoral condyles → distract tibia away from femur while IR and ER tibia

• positive = dec pain (meniscus tear) or inc pain (ligament sprain)

Apley’s distraction test

• Meniscus tear

• pt supine w/ knee flexed (foot to buttocks) → internally rotate tibia and fully flex/extends knee (lateral) OR externally rotate (medial)

• positive = palpable, audible, or painful click

McMurray’s test

• grasp calcaneus and stabilize lower leg → provide inversion or eversion stress rolling calcaneus inward or outward while ankle is in neutral

• inversion = LCL injury

• eversion = medial aspect of ankle (deltoid ligament)

Talar tilt test

• anterior taolfibular ligament tear

• stabilize leg above ankle and pull up on heel or forefoot

Anterior drawer test- ankle

• high ankle sprain or possible fx

• pt sitting or lying w/ knee extended → cup hands behind the tibia and fibula, away from site of pain, compress gradually adding more pressure

Syndesmosis squeeze test

• tarsal tunnel syndrome / compression of posterior tibial n.

• pt supine w/ hip externally rotated and foot slightly everted → tap over tarsal tunnel

Tinel’s sign of ankle

• Torn achilles tendon

• squeeze calf

• positive = no motion

Thompson test

• Morton’s neuroma

• apply pressure between 3rd and 4th metatarsals

• positive = pain

Morton’s test

• DVT

• pt sitting or supine w/ knee extended → passively dorsiflex foot while knee extended → palpate calf

• positive = pain

Homan’s sign

• UMN lesion

• stroke lateral-plantar aspect of foot and move across MTPs w/ handle of reflex hammer to provoke a cord (CNS) sign

• positive = dorsiflexion of great toe w/ fanning of other toes

Babinski sign

• lumbosacral nerve root irritation (sciatic nerve)

• pt supine → raise leg w/ hips flexed and keeping knee straight

• positive = pain

Straight leg raise

• meningitis or SAH

• pt supine w/ hip and knee in flexion 90° → exend knee

• positive = pain or inability to extend past 135°

Kernig’s sign

• meningeal irritation

• pt supine → place hands behind pts head then raise head or flex neck

• positive = involuntary flexion of hips/knees due to pain

Brudzinski’s sign