Special Tests and Deformities

Board Prep (Musculoskeletal Special Tests)

O’Brien Active Compression Test (shoulder)

• What is being tested

  • Superior labrum

  • SLAP lesions (tears) aka superior labrum anterior to posterior

• Patient Position

  • Standing

  • Begin with 90 degrees flexion and maximal IR (thumbs down); 10 degrees of adduction

  • Apply pressure

  • Repeat again with maximal ER (palm up)

• Positive Finding

  • Pain or painful clicking inside with maximal IR

  • Eliminated/reduction of pain or painful clicking with maximal ER

Way to remember is thumbs down , then turn palm up “O that’s better”

Speed’s Test (shoulder)

• What is being tested?

  • Superior labral tear (SLAP) or tendinitis

• Patient Position

  • Sitting upright

  • 90 degrees shoulder flexion

  • Full elbow extension

  • Forearm supination

  • Examiner pushes patient towards shoulder extension

• Positive Finding

  • Tenderness or pain reproduction in the bicipital groove (around the biceps tendon)

Yergason’s Test

• What is being tested?

  • Torn transverse humeral ligament

  • Bicipital tendonitis (acute, short-term inflammation) or tendinosis (chronic state of tendonitis)

• Patient Position

  • Sitting

  • Elbow flexion 90 degrees

  • Forearm pronated

  • Have patient turn into supination with resistance

• Positive Finding

  • Tenderness or pain reproduction in the bicipital groove

Posterior Apprehension Test (shoulder)

• What is being tested?

  • Posterior capsule instability

• Patient Position

  • Supine or sitting

  • Shoulder in 90 degrees flexion

  • Examiner applies downward (posterior) force with with shoulder horizontally adducted and with IR

• Positive Finding

  • Look of alarm/apprehension on patient’s face and resistance to move further

Anterior Apprehension Test

• What is being tested?

  • Anterior capsule instability

• Patient Position

  • Supine

  • Arm abducted to 90 degrees

  • Clinician slowly moves into ER slowly

• Positive Finding

  • Patient apprehension, more so than pain reproduction

More common on test

Hawkins-Kennedy Impingement Test (shoulder)

• What is being tested?

  • Shoulder impingement (pinching or rubbing inside joint)

• Patient Position

  • Shoulder flexed 90 degrees

  • Clinician moves arm into IR

• Positive Finding

  • Pain reproduction

Neer Impingement Test (shoulder)

• What is being tested?

  • Overuse injury of supraspinatus muscle or biceps tendon

• Patient Position

  • Sitting

  • Clinician moves arm into full shoulder elevation

• Positive Finding

  • Pain reproduction

Painful Arc Test (shoulder)

• What is being tested?

  • Subacromial impingement, AC (acromioclavicular) joint

• Patient Position

  • Standing

  • Patient moves through full abduction

• Positive Finding

  • Pain at 60-120 degrees = SIS (subacromial impingement syndrome)

  • Pain at 170-180 = AC joint pain

More common on test

Drop Arm Test (rotator cuff)

• What is being tested?

  • RTC (rotator cuff) tear, specifically the supraspinatus

• Patient Position

  • Sitting

  • Arm abducted to 90-120 degrees

  • Clinician asks patient to slowly lower arm

• Positive Finding

  • Cannot return arm slowly (drops)

  • Severe pain during attempt

ER Lag Sign (rotator cuff)

• What is being tested?

  • Tear of supraspinatus or infraspinatus tendon

• Patient Position

  • Upright with back to PTA

  • Clinician asks patient to hold position

• Positive Finding

  • Unable to maintain ER position once PTA lets go

IR Lag Sign (rotator cuff)

• Also called “Liftoff Test”

• What is being tested?

  • Subscapularis tear

• Patient Position

  • Upright with back to PTA

  • Clinician asks patient to hold position

• Positive Finding

  • Unable to maintain IR position once PTA lets go

Biceps Load Test 1 (shoulder)

• What is being tested?

  • Superior labrum

• Patient Position

  • Supine

  • 90 degrees abduction

  • Max ER

• Positive Finding

  • Apprehension is the same or shoulder becomes more painful with bicep activation

Biceps Load Test 2 (shoulder)

• What is being tested?

  • Superior labrum

• Patient Position

  • Supine

  • 120 degrees abduction

  • Max ER

• Positive Finding

  • Deep pain within joint during bicep contraction

Empty Can (Jobe) Test (rotator cuff)

• What is being tested?

  • Supraspinatus

• Patient Position

  • Abducted to 90 degrees

  • Full IR “empty can position”

• Positive Finding

  • Weakness / pain, reproduction of symptoms

Adson Maneuver (Thoracic Outlet Syndrome)

• What is being tested?

  • Thoracic outlet syndrome secondary to a cervical rib or 1st thoracic rib syndrome

• Patient Position

  • Sitting

  • Head rotated towards test arm

  • Extends neck and shoulder

• Positive Finding

  • Disappearance of the radial pulse

Roos Test (thoracic outlet test)

• What is being tested?

  • Thoracic outlet syndrome secondary to neurovascular compromise

• Patient Position

  • Sitting upright

  • Shoulders abducted to 90 degrees

  • Elbows flexed to 90 degrees

  • Open and close hands for 3 minutes

• Positive Finding

  • Unable to keep the arms in the starting position for 3 minutes; ischemic pain, heaviness or profound weakness of the arm; numbness and tingling of the hand during the 3 minutes

Allen Test

• What is being tested?

  • Thoracic outlet syndrome secondary to a cervical rib or 1st thoracic rib syndrome

• Patient Position

  • Sitting upright

  • Shoulders abducted to 90 degrees, ER, elbow flexion

  • Head rotated AWAY from test arm

• Positive Finding

  • Disappearance of the radial pulse

Swan Neck Deformity

• Flexion of the MCP and DIP; Extension of the PIP

  • (flexion—extension—flexion)

• Tearing of the volar plate

• Trauma

• RA

Boutonniere Deformity

• Extension of MCP, extension of DIP

• Flexion of PIP

• Ruptured extesor hood

• Trauma

• RA

Ulnar Drift

• Ulnar deviation (drift) of the digits

• RA

Claw Fingers

• Loss of the intrinsics of the hand

• Overaction of the extrinsic extensors

• MCP hyperextended

• PIP, DIP flexed

• Combined median/ulnar nerve pathology

• Klumpke’s Palsy (C8, T1 nerve roots)

Thumb Ulnar Collateral Ligament Laxity

• Gamekeeper’s Thumb / Skier’s Thumb

Finkelstein Test

• Tests for DeQuervain’s syndrome

• Paratenonitis in the thumb

• Pain over the abductor pollicis longus, and extensor polliicis brevis

Phalen’s Test (wrist flexion)

• Hands down

• Flex wrists maximally

• Positive test:

  • tingling in the thumb, index, middle and lateral half of the ring finger

    • indicative of median nerve involvement at the carpal tunnel

Reverse Phalen’s Test

• Extend both wrists fully (prayer position)

• Examiner extends wrists and applies pressure to the carpal tunnel for 1 minute

• Positive test:

  • Tingling in the thumb, index, middle and lateral half of ring finger

    • Indicative of median nerve involvement at the carpal tunnel

Froment’s Sign

• Patient attempts to grasp piece of paper between thumb and index finger

• Examiner pulls away paper, the patient attempts to use the adductor pollicis muscle (innervated by ulnar nerve)

• Postive test:

  • Patient compensates with the flexor pollicis longus (thumb flexed)

    • flexor pollicis longus innervated by median nerve

At which position will the patient have a stronger grip strength?

30 degrees wrist extension

At which position will the patient have a strongest plantarflexion?

In knee extension

At which position will the patient have strongest dorsiflexion?

In knee flexion

Thomas Test

• What is being tested?

  • Hip flexor tightness

• Patient Position

  • Supine

  • Single knee to chest

• Positive Finding

  • Straight leg rises from table

Ober’s Test

• What is being tested?

  • TFL tightness or contracture

• Patient Position

  • Sidelying with lower leg flexed at knee 90 degrees

  • Move hip into slight extension

    • Modify with knee straight

• Positive Finding

  • Inability of test leg to adduct and touch the table

Ely’s Test

• What is being tested?

  • Rectus femoris tightness or contracture

• Patient Position

  • Prone

• Positive Finding

  • Spontaneous hip flexion occurring simultaneously with knee flexion

FABER Test (Patrick’s Test)

• What is being tested?

  • Iliopsoas, SI or hip joint abnormal

• Patient Position

  • Supine with test leg flexed, abducted and ER onto opposite leg

    • Figure 4 position

• Positive Finding

  • Failure of test leg to abduct below level of opposite leg. Iliopsoas spasm or hip joint issue

Craig’s Test

• What is being tested?

  • Femoral anteversion / retroversion

    • More than 15 degrees means excessively anteverted

    • Less than 8 degrees means retroverted

• Patient Position

  • Prone with test knee flexed

• Positive Finding

  • Angle is greater than 8-15 degrees

Femoral Anteversion / Retroversion

• Normal

  • 8-15 degrees

• Excessive anteversion —> excessive medial hip torsion (toe-in gait)

• Femoral retroversion —> lateral hip torsion (toe-out gait)

Hip ROM Requirements

• Shoe tying = 120 degrees flexion

• Sitting = 112 degrees flexion

• Stooping = 125 degrees flexion

• Squatting = 115 degrees flexion

• Ascending stairs = 67 degrees flexion

• Descending stairs = 36 degrees flexion

Barlow’s Signs

• Modification of the Ortolani maneuver

• Detects developmental dysplasia of the hip

  • shallow, underdeveloped acetabulum

• Dislocates / relocates the hip

• Bringing hips in

Ortolani’s Sign

• Detects congenital dislocation of the hip

• Positive is clunk as the hip relocates onto the acetabulum

• Bringing the hips “out”

Galezzi Sign

• Developmental hip dysplasia

  • Tests for unilateral hip dislocation

• Positive sign:

  • When infant is in hooklying position leg length discrepancy is present

Slipped Capital Femoral Epiphysis

• Most common disorder of the hip in adolescents

• Femoral head slides off growth plate

• Avg. age:

  • 12 for girls

  • 14 for boys

• Can cause avascular necrosis (AVN) of femoral head

• S&S:

  • Dull, aching groin / medial thigh pain

  • Decreased hip ROM (especially IR)

• Diagnosed with radiographs

Legg-Calve-Perthes Disease

• Hip disorder in young children

  • 2-12 years old

• Femoral head is damaged and loses its normal shape

  • Unknown cause (idiopathic)

  • Limp, small child for their age

  • Some toe-out gait

  • Caused by avascular necrosis of the femoral head

Lachman Test

• What is being tested?

  • Injury to ACL, posterior oblique ligament and arcuate-popliteus complex

  • Done in open-packed position (20-30 degrees of flexion)

• Patient Position

  • Supine

  • Knee flexed 20-30 degrees

• Positive Finding

  • “Mushy” feel when the tibia is moved anteriorly disappearance of the infrapatellar tendon slope

Anterior Drawer Test

• What is being tested?

  • Injury to the ACL

• Patient Position

  • Supine

  • Knee flexed to 90 degrees

• Positive Finding

  • Abnormal tibial anterior translation

Pivot-Shift Test

• What is being tested?

  • Anterolateral rotatory instability

  • Rupture of the ACL

• Patient Position

  • Supine

  • Knee IR

  • Examiner flexes knee to 90 degrees

• Positive Finding

  • When knee flexes tibia clunks backward at approx. 30-40 degrees

  • At beginning of test, tibia was sublaxed, and then was reduced by pull of IT band as knee was flexed

  • Dislocation when in flexion, relocation when knee extended

McMurray’s Test

• What is being tested?

  • Meniscal tears

• Patient Position

  • Supine

  • Examiner maximally flexes knee and hip

  • Medial meniscus = ER of tibia

  • Lateral meniscus = IR of tibia

• Positive Finding

  • Reproduction of click and / or pain in the knee joint

Posterior Sag Sign

• What is being tested?

  • Torn PCL

• Patient Position

  • Supine

• Positive Finding

  • Tibia “drops back” on the femur

Reverse Lachman Test

• What is being tested?

  • Integrity of the PCL

• Patient Position

  • Prone

• Positive Finding

  • PCL laxity

Posterior Drawer Test

• What is being tested?

  • Integrity of the PCL

• Patient Position

  • Supine

• Positive Finding

  • Excessive posterior glide

Spinal ROM

• Cervical

  • 80-90 degrees of flexion

  • 85 degrees of extension

  • 40-45 degrees of side-bending

  • 70-90 degrees of rotation

• Thoracic

  • 20-45 degrees of flexion

  • 25-45 degrees of extension

  • 20-40 degrees of side-bending

  • 35-50 degrees of rotation

• Lumbar

  • 40-60 degrees of flexion

  • 20-35 degrees of extension

  • 15-20 degrees of side-bending

  • 3-18 degrees of rotation

Vertebral Open-packed position

Midway between flexion and extension

Vertebral Closed-Packed position

Maximal extension

Formainal Compression Test

• What is being tested?

  • Cervical radiculitis

• Patient Position

  • Sitting

• Positive Finding

  • Pain radiates in arm in direction head is side flexed during compression

Distraction Test

• What is being tested?

  • Nerve root compression

• Patient Position

  • Sitting

• Positive Finding

  • Relieving or decreasing the pain when head is lifted or distracted

Shoulder Abduction Test

• What is being tested?

  • Cervical extradural compression

• Patient Position

  • Sitting or supine

• Positive Finding

  • A decrease in or relief of symptoms

Valsalva Test

• What is being tested?

  • Increased pressure on spinal cord

• Patient Position

  • Sitting

• Positive Finding

  • Increased pain

Lhermitte’s Sign

• What is being tested?

  • Dural / meningeal irritation in the spine

  • Possible cervical myelopathy

• Patient Position

  • Long-sitting

• Positive Finding

  • Sharp pain down spine and in upper or lower limbs

Vertebral Artery Test

• What is being tested?

  • Problem of the vertebrobasilar artery

• Patient Position

  • Supine

• Positive Finding

  • Creates symptoms when opposite artery is affected

  • Can include dizziness, visual disturbances, disorientation, etc.

Passive Insufficiency

Inability of a 2-joint muscle to passively extend across full ROM of both joints

Can’t stretch anymore

Active Insufficiency

Inability of a 2-joint muscle to actively extend across full ROM of both joints

Can’t flex anymore