Musculoskeletal 2 Assessment Techniques

AROM assessment cervical spine - Flexion

AROM assessment cervical spine - Extension

AROM assessment cervical spine - Lateral Flexion (L&R)

AROM assessment cervical spine - Rotation (L&R)

AROM assessment cervical spine - Protraction (Upper Cx flx + lower Cx ext)

AROM assessment cervical spine - Retraction

Measuring Cervical ROM with a tape and goniometer - Flexion

• normal ranges

Landmarks Tape Measure: Tip of chin to sternal notch

• Normal Range: 3cm

Landmarks Gonio:

• Axis: over lobe of ear

• Stationary Arm: perpendicular to floor

• Moving Arm: parallel to base of nares

• Normal Range: ~45 deg

Measuring Cervical ROM with a tape and goniometer - Extension

• normal ranges

Landmarks Tape Measure: Tip of chin to sternal notch

• Normal Range: 20cm

Landmarks Gonio:

• Axis: over lobe of ear

• Stationary Arm: perpendicular to floor

• Moving Arm: parallel to base of nares

• Normal Range: ~45 deg

Measuring Cervical ROM with a tape and goniometer - Rotation

Landmarks Tape Measure: Tip of chin to lateral aspect of acromion process

• Normal Range: 11cm

Landmarks Gonio:

• Axis: over midpoint of top of head

• Stationary Arm: parallel to a line joining acromion processes

• Moving Arm: aligned with nose

• Normal Range: ~60 deg

Measuring Cervical ROM with a tape and goniometer - Lateral Flexion

Landmarks Tape Measure: Mastoid process to lateral aspect of acromion process

• Normal Range: 13cm

Landmarks Gonio:

• Axis: over C7 spinous process

• Stationary Arm: along spine and perpendicular to floor

• Moving Arm: midpoint of the head

• Normal Range: ~35 deg

PPIVMs Cervical spine - Flexion

PPIVMs Cervical spine - Extension

• head needs to be beyond plinth

PPIVMs Cervical spine - Rotation

PPIVMs Cervical spine - Lateral flexion

PAIVMs Cervical Spine - Central PA

• Use thumbs

PAIVMs Cervical Spine - Unilateral PA

• use thumbs

PAIVMs Cervical Spine - Unilateral AP

• use thumbs

• behind SCM

Special Tests Cervical Spine - VBI Physical Screening Test

• Get patient to do AROM first

• Performed first in sitting and then standing

• Rotated EOR and held for 10 seconds → observing for signs of VBI/CAD

• Bought back to neutral for 10 seconds → repeated in opposite direction

Special Tests Cervical Spine - Upper Cervical Quadrant Test

• combined movement of extension (chin poke), ipsilateral rotation and ipsilateral lateral flexion

• Testing for: VBI

Special Tests Cervical Spine - Lower Cervical Quadrant

• combined movement of extension, ipsilateral rotation and ipsilateral lateral flexion

• Radiating pain down the arm in a dermatomal pattern — suggests cervical radiculopathy

Special Tests Cervical Spine - Spurling’s Test

• head moved to full cervical extension, ipsilateral rotation and ipsilateral lateral flexion

• applies downward axial compression

• Positive test: radicular symptoms radiate into the ipsilateral limb

Special Tests Cervical Spine - Cervical Traction/Distraction

• designed to ease radicular symptoms

• Lifting head up → distraction

Special Tests Cervical Spine - Flexion-Rotation Test

• Assessment for: cervico-genic headache

• Full flexion - full L/R rotation to the C1-C2 level

Special Tests Cervical Spine - Sharp-Purser test

• fixes C2 with pincer grip

• posterior pressure applied

• Testing for: transverse ligament of the atlas instability

Special Tests Cervical Spine - Alar ligament

• fixes C2 with pincer grip

• lateral flexion is applied → side-flexion stress test

• rotation is applied → rotational stress test

• Use extreme caution with this test as positive testing requires compression of the spinal cord. If cord injury is suspected, think if the neurological exam and imaging would be safer diagnostically

Light sensation assessment of the Upper Limb

Start with circumferential

C2- 3cm behind ear

C3- supraclavicular fossa

C4- AC joint

C5- anterolateral elbow

C6- dorsal thumb

C7- dorsal middle finger

C8- dorsal little finger

T1- anteromedial elbow

T2- axilla

Muscle power Assessment of the Upper Limb

C1- Cervical Flexion

C2- Cervical extension

C3- Lateral Flexion

C4- Shoulder abduction

C5- Elbow flexion (biceps)

C6- wrist extension

C7- Elbow extension (triceps)

C8- Finger flexion

T1- Finger abduction

Reflex Assessment of the Upper limb - Biceps (C5/6)

• Use thumb to locate biceps tendon and apply the tendon hammer to thumb, looking for a tendon flicker

Reflex Assessment of the Upper limb - Triceps (C6/7)

• Performed in supine and applying the tendon hammer to the triceps tendon, just above the olecranon

Upper Motor Neuron Testing Upper Limb - Hoffmans Sign

• grasping the patients hand and third digit, quickly passively flex the third distal phalanx (flick down).

• Positive test: thumb and second finger flexion/flicker and upper motor neuron (UMN) lesion.

Upper Motor Neuron Testing Upper Limb - Inverted Supinator Sign

• Mark proximal to the patient’s radial styloid process and repeatedly tap the area with a hammer

• Positive test: thumb and second digit flexion/flicker and upper motor neuron (UMN) lesion.

Upper Limb Neural Provocation Test 1 - Median Nerve

1)     Stabilise shoulder

2)     Abduct shoulder to 90 deg

3)     Externally rotate shoulder to 90 deg

4)     Forearm supination

5)     Wrist and finger extension (esp. D1-3)

6)     Elbow extension

7) Sensitisation/desensitization at the C-spine

Upper Limb Neural Provocation Test 2a - Median Nerve bias

1)     Stabilise shoulder

2)     Elbow extension

3)     Shoulder external rotation

4)     Forearm supination

5)     Wrist and finger extension (esp. D1-3)

6)     Shoulder abduction

7) Sensitisation/desensitization at the C-spine 

Upper Limb Neural Provocation Test 2b - Radial Nerve Bias

1)     Stabilise the shoulder

2)     Elbow extension

3)     Shoulder internal rotation

4)     Forearm pronation

5)     Wrist and finger flexion (thumb under fingers) and radial deviation

6)     Shoulder abduction

7) Sensitisation/desensitization at the C-spine

Upper Limb Neural Provocation Test 3 - Ulnar Nerve

1)     Shoulder depression

2)     Shoulder abduction

3)     Shoulder external rotation

4)     Forearm pronation

5)     Wrist and finger extension (esp. D3-5)

6)     Elbow flexion

7) Sensitisation/desensitization at the C-spine

AROM of TMJ - Closing

• measured as 0mm when the patient can fully close their teeth together → looking for overbite, underbite, normal, crossed bite, open bite

AROM of TMJ - Opening

• calipers placed on bottom and top of teeth

• Normal value: ~45mm

AROM of TMJ - Lateral Deviation

• measured distance between middle of top and middle of bottom teeth

• Normal value: ~10-15mm

AROM of TMJ - Protrusion

• measure distance between top and the middle jaw

• Normal value: ~5mm

PAM of the TMJ - PA

PAM of the TMJ - Medial Glide

pressing mandible medially/downwards

AROM of Thoracic Spine (w/ Overpressure) - Flexion

• T1-3 can be tested with cervical AROM

• T3-9 can be tested with thoracic AROM

• T9-12 can be tested with lumbar AROM

AROM of Thoracic Spine (w/ Overpressure) - Extension

• be mindful of excessive Cx extension

AROM of Thoracic Spine (w/ Overpressure) - Lateral Flexion

AROM of Thoracic Spine (w/ Overpressure) - Rotation

PPIVMs of Thoracic Spine - Flexion

• feeling for vertebral hypo or hyper movement

PPIVMs of Thoracic Spine - Extension

• feeling for vertebral hypo or hyper movement

PPIVMs of Thoracic Spine - Lateral Flexion

• feeling for vertebral hypo or hyper movement

PPIVMs of Thoracic Spine - Rotation

• feeling for vertebral hypo or hyper movement

PAIVMs of Thoracic Spine - Central PA

PAIVMs of Thoracic Spine - Unilateral PA (L/R)

PAIVMs of Thoracic Spine - Transverse Pressure

PAIVMs of Thoracic Costovertebral/transverse - PA

PAIVMs of thoracic - Longitudinal caudad of 1st rib

Special Orthopedic Tests of Thoracic Spine - Roo’s test

• Assessment for: Thoracic Outlet Syndrome

• arms to this position, open and closes hands for 3 minutes

• Positive: ischemic pain/weakness/tingling

Special Orthopedic Tests of Thoracic Spine - Adson’s Test

• Assessment for: Thoracic Outlet Syndrome

• head rotation towards tested arm, extension, and then extension + lateral rotation of shoulder

• Positive: deep breath and radial pulse disappears

Special Orthopedic Tests of Thoracic Spine - Allens Test 1

• Assessment for: Thoracic Outlet Syndrome

• arm abducted to 90, find radial pulse, horizontal extension + lateral rotation

• Positive Test: disappearance of radial pulse

Special Orthopedic Tests of Thoracic Spine - Allen Test 2

• Assessment for: Blood flow to the Hand

• pressure to radial and ulnar arteries, the patient open and close hands and then keep it open.

• Testing for: hand should flush wihtin 5 seconds of pressure release

AROM of the Shoulder w/ Overpressure - Flexion

AROM of the Shoulder w/ Overpressure - Extension

AROM of the Shoulder w/ Overpressure - Abduction

AROM of the Shoulder w/ Overpressure - Horizontal Adduction

AROM of the Shoulder w/ Overpressure - External Rotation

AROM of the Shoulder w/ Overpressure - Internal Rotation

AROM of the Shoulder w/ Overpressure - Hand behind Back

Behind back → T7

Over shoulder → T2

AROM of the Shoulder Girdle w/ Overpressure - Elevation

AROM of the Shoulder Girdle w/ Overpressure - Depression

AROM of the Shoulder Girdle w/ Overpressure - Protraction

AROM of the Shoulder Girdle w/ Overpressure - Retraction

PAMs of the Glenohumeral Joint - AP

PAMs of the Glenohumeral Joint - PA

PAMs of the Glenohumeral Joint - Caudad (longitudinal distraction)

• commonly performed in 90deg shoulder flexion

• Pulling down

PAMs of the Glenohumeral Joint - Lateral Glide

• commonly performed in 90deg shoulder flexion

PAMs of the Acromioclavicular Joint - AP

PAMs of the Acromioclavicular Joint- PA

PAMs of the Acromioclavicular Joint - Caudad (longitudinal)

PAMs of the Sternoclavicular Joint - AP

PAMS of the Sternoclavicular Joint - Caudad

Special Tests of the Shoulder - Jobes test/Empty Can Test

• arm abducted to 90deg, arm internally rotated (thumb down→ think emptying a can)

• Apply a downward force to distal forearm

• Positive Test: pain or weakness

Testing for: Primary Impingement

Special Tests of the Shoulder - Hawkins-Kennedy Test

• 90deg shoulder flexion, 90deg elbow flexion

• internally rotates shoulder to EOR

• Positive test: reproduction of pain

Testing for: Subacromial Impingement - Supraspinatus

Special Tests of the Shoulder - Neer’s Test

• Elevate patients internally rotated shoulder while stabilizing scapula

• Positive Test: Reproduction of Pain

Testing for: Subacromial Impingement

Special Tests of the Shoulder - Apprehension test (shoulder ER basically)

• 90deg abduction and external rotation

• location of pain is noted

Positive Primary - pain is not altered with application

Positive Secondary - pain is reduced with application

Testing for: Impingement

Special Tests of the Shoulder - Painful Arc

When is it GHJ?

When is it ACJ?

• full active abduction

• ^ reports when pain is felt

  GHJ- 60-120deg

  ACJ - 170-180deg

Testing for: Shoulder Impingement

Special Tests of the Shoulder - Full Can Test

• Arm abducted to 90deg, arm externally rotated, thumb upwards

• Positive test: Pain or weakness

Testing for: Rotator Cuff

• Think “holding a can” → thumbs up

Special Tests of the Shoulder - Gerber “Lift Off” test

• Lift hand off lumbar spine and hold there

Positive Test: Inability to hold/lift hand away from body, hand will slap/fall onto back

Testing for: Rotator Cuff - Subscapularis

Special Test of the Shoulder - External Lag Sign

• Resist ER in this position

• Testing for: Rotator Cuff

• If no resistance provided, let go of hand

Special Test of the Shoulder - Scapular Assistance Test

• facilitates/assists upward rotation of scapula

• Positive Test: Reduction in pain with assistance

Testing for: Scapular Dyskinesis

Special Test of the Shoulder - Scapular Retraction test

• Positive test: reduction in pain when therapist repositions scapula

• Thumb down

• Therapist stabilizes the scapula with one hand over the clavicle and spine of the scapula using their forearm to stabilize the rest of the scapula against the thoracic wall. With the other hand the therapist resists active abduction in the scapular plane with internal rotation of the GHJ.

Testing for: Scapular Dyskinesia

Special Tests of the Shoulder - Load and Shift test

Testing for: Posterior Instability

• stabilize scapula and applies anterior force to humeral head

Special Tests of the Shoulder - Anterior Drawer Test

• Basically a GHJ PA movement

Testing for: Instability

Special Tests of the Shoulder - Sulcus Sign

Positive Test: sulcus appears distal to the acromion

Testing for: Glenohumeral Instability

Pull humerus down and then observe

Special Tests of the Shoulder - Posterior Capsule

“thigh thrust of the shoulder”

Testing for: Instability

Special Tests of the Shoulder - Speeds Test

Testing for: Biceps and Labrum tear

Positive Test: pain provocation

Special Tests of the Shoulder - O’Briens test

B for Biceps (and labrum tear)

Positive Test:

Pain/clicking are produced in first test

Pain is diminished in second test

Back of both hands together

Resistance at first test, remove resistance while they swap positions to second position and then reapply resistance.

Testing for: Biceps and Labrum tear

Special Tests of the Shoulder - Biceps Load I & II

Test I: 90deg abduction, 90deg elbow flexion

Test II: 120deg abduction, 90edg elbow flexion

Testing for: Biceps and Labrum tear

AROM of the Elbow w/ Overpressure - Flexion

AROM of the Elbow w/ Overpressure - Extension

AROM of the Elbow w/ Overpressure - Supination

AROM of the Elbow w/ Overpressure - Pronation