Ortho Osce Prep:

Week 1 content:

4 Tests that tests for cervical radiculopathy:

Spurlings:
1. Purpose:
  1. This test is designed to test for patients experiencing cervical radiculopathy
2. Procedure:
  1. Stand behind the patient and laterally flex their neck and apply slight downwards pressure
3. Indications for a positive test:
  1. Normal:
    1. The pain should be tolerable.
  2. Positive:
    1. Pain that radiates into the arm in a dermatomal distribution on the side of lateral flexion.
4. Key points:
  1. This test is narrowing the intervertebral foramen on the side of the lateral flexion
  2. If it is not a radiating pain but the patient still feels pain it is considered a negative test
    1. More likely to be a facet problem
Jackson compression test:
1. Purpose:
  1. To test for cervical radiculopathy
2. Procedure:
  1. Stand behind the patient and ask the patient to rotate their head and apply downwards pressure
3. Indication for a positive test:
  1. Normal:
    1. The pain should be tolerable
  2. Positive test:
    1. The pain should radiate down or up the cervical spine
4. Important to note that pain that doesn’t radiate is not considered a positive test. It is more likely to be facet or muscular pain
Maximal foraminal compression test:
1. Purpose:
  1. To test for cervical radiculopathy
2. Procedure:
  1. Stand behind the patient and ask the patient laterally flex, rotate and extend their neck. We are then going to apply over pressure on the top of the head.
3. Indication of a positive test:
  1. Normal:
    1. The pain should be tolerable
  2. Positive test:
    1. The pain should radiate down or up the cervical spine
Kemp’s test:
1. Purpose:
  1. To test for cervical radiculopathy
2. Procedure:
  1. Stand behind the patient and ask the patient laterally flex, rotate and extend their neck.
3. Indication of a positive test:
  1. Normal:
    1. The pain should be tolerable
4. Positive test:
  1. The pain should radiate down or up the cervical spine

2 Tests that tests the brachial plexus:

Shoulder depression test:
1. Purpose:
  1. To evaluate for brachial plexus or cervical nerve root pathology by placing these structures under tension
2. Patient positioning:
  1. Stand behind the patient and laterally flex their neck as you depress their shoulder
3. Test rational:
  1. Nerves can be moved and displaced during normal movement patterns
  2. Stretching, traction or tethering of nervous tissues is not well tolerated
  3. By moving both the proximal and distal aspects of a nerve in opposite directions NT may be placed under tension
4. Indication of a positive test:
  1. Normal finding:
    1. The pain should be tolerable
  2. Positive findings:
    1. Production of neuropathic pain on the side being stretched indicates irritation/ stretching of nerve roots or the brachial plexus
    2. Production of neuropathic pain on the contralateral side indicates irritation/ compression of the nerve roots
Doorbell sign:
1. Purpose:
  1. To apply pressure to the nerve roots to provoke symptoms associated with radiculopathy
  2. To apply pressure to the roots and trunks of the brachial plexus to to provoke symptoms associated with brachial plexopathy
2. Test rational:
  1. Pressure applied to an injured nerve root or nerve plexus produces pain or tingling sensation that is transmitted distally along the course of the nerves
3. Procedure:
  1. Stand behind the patient, move the SCM out of the way and target the nerve roots. Using one finger apply firm pressure to individual roots and trunks of the brachial plexus
4. Indications of a positive test:
  1. Normal:
    1. The patient shouldn’t feel any tingling or severe pain
  2. Abnormal:
    1. Pain localised to a specific peripheral nerve distribution or dermatome indicates nerve irritation
    2. Tingling localised to a specific peripheral nerve distribution or dermatome indicates nerve regeneration
5. Important to note that pain at the site without radiation is not considered a positive test

3 Tests that tests multiple vertebras:

Shoulder abduction sign:
1. Purpose:
  1. This tests for radicular symptoms, specifically symptoms arising from compression/irritation of the C4,5 or C6 nerve roots
  2. This test is useful for patients whose symptoms are relieved by placing their hand on their head.
2. Procedure:
  1. The patient is seated and asks the patient to place their symptomatic hand above their head. Ask the patient if this relieves their symptoms.
  2. The test relieves radicular symptoms that are present at the time of the examination
3. Test rational:
  1. Raising the arm above their head elevates the suprascapular nerve and the trunks of the brachial plexus, which reduces traction forces on the nerve roots of C4,5 and C6
4. Indications of a positive test:
  1. A decrease in pain after around 30 seconds
Compression/Distraction test:
1. Purpose:
  1. To apply compressive or distractive forces to the spine to provoke or relieve patient symptoms
2. Test rational:
  1. Adding compressive forces to the axial load of the spine may provoke pain to inflamed/injured/overloaded structures
    1. Axial compressive forces will narrow the intervertebral foramen
  2. The distractive component of the test is designed to unload the spine:
    1. This is designed to relieve the patient pain
3. Procedure:
  1. Apply pressure or compression and lift up for distraction
4. Indication of a positive test:
  1. Positive:
    1. Pain that is felt during compression and relieved during distraction
    2. What type of pain will tell us what it is as well
Cough, sneeze, valsalva maneuver:
1. Purpose:
  1. Designed to increase intrathecal pressure which may replicate the symptoms experienced by a patient when they cough, sneeze or strain
  2. Commonly associated with space occupying lesions (disc herniation)
  3. Can be used to highlight radiculopathy in any region of the spine

Week 2 content:

2 tests that tests for TMJ:

Knuckle test:
1. Purpose:
  1. To assess the opening range of the temporomandibular joint
2. Test rational:
  1. Patients require a certain amount of opening range to perform the normal TMJ related activities of daily living
3. Patient position:
  1. The patient is seated and instruct them to open their mouth and place two flexed proximal interphalangeal joints into their mouth.
4. Indication of a positive test:
  1. Normal finding:
    1. The patient’s jaw opening to the normal range
  2. Positive:
    1. Inability to open their mouth to the desired range
      1. May indicate, joint degeneration, hypertonic muscles of mastication or a displaced TMJ disc
Auscultation of the temporomandibular joint:
1. Purpose:
  1. To identify joint sounds during normal TMJ gait that may indicate pathology
2. Test rationale:
  1. The presence of joint sounds can indicate abnormal motion of the mandible or adhesion within the TMJ
  2. Early clicking is indicative of a developing problem whereas late clicking is indicative of a chronic one
3. Types of TMJ sounds:
  1. Click:

1 test that tests for aggravation or relief:

Compression/distraction test - thoracic spine:
1. Purpose:
  1. To apply compressive or distractive forces to the spine to provoke or releive patinent with pain
2. Procedure:
  1. Compression:
    1. Apply direct pressure through the region of interest
  2. Distraction:
    1. Distract the region of interest
3. Indication of a positive test:
  1. Normal:
    1. Both tests tolerable and pain free
  2. Positive test:
    1. Pain during compression
    2. Pain that is relieved during distraction
    3. The type of pain should indicate what tissues are involved.

1 test that tests for normal chest expansion:

Costovertebral expansion test:
1. Purpose:
  1. To assess the normal expansion of the chest during respiration
2. Procedure:
  1. Measure the patient’s torso with a measuring tape when the fully exhale and fully inhale. Palpate the rib motion during breathing go up and down the rib.
3. Indication of a positive test:
  1. Normal:
    1. Normal chest expansion for men less than 5cms
    2. Normal chest expansion for women less than 3cms
  2. Positive test:
    1. Tight chest wall

4 tests that tests for thoracic issues:

Roos test:
1. Purpose:
  1. To test for vascular forms of thoracic outlet syndrome
2. Procedure:
  1. The patient is seated and their arms are abducted and externally rotated and they are clenching their hands and releasing them and maintain this position for 3 minutes.
3. Indication of a positive test:
  1. Normal:
    1. They should be able to hold this position without difficulty
  2. Positive test:
    1. If they cannot keep their arms up for the duration of the pest.
Adson test:
1. Purpose:
  1. To test for compression of the neurovascular bundle as it passes through the interscalene triangle
2. Procedure:
  1. The patient is seated and their arm is abducted slightly and extended with their palm facing up and the patient rotates their head to the arm being tested. The patient then inhales and holds their breath. The test is held for 30 seconds
3. Indication of a positive test:
  1. Normal:
    1. It should not compress the neurovascular bundle
  2. Positive test:
    1. The patient’s pain should be reproduced, with or without a disappearance of the radial pulse
Costoclavicular manoeuvre:
1. Purpose:
  1. To test for compression of the neurovascular bundle as it passes through the costoclavicular space
2. Procedure:
  1. Palpate the radial pulse bilaterally draw the shoulders back and down with the neck flexed. Hold for 30 seconds
3. Indication of a positive test:
  1. Normal:
    1. Should not caus decompression of the neurovascular bundle
  2. Positive test:
    1. Patient’s symptoms are reproduced with or without the disappearecne of the radial pulse
    2. Compression of the subclavian vein is most likely in this test
Wright test:
1. Purpose:
  1. To test for compression of the neurovascular bundle as it passes through the subpectoral space:
2. Procedure:
  1. The patient is seated and hyper-abducts the arm and externally rotates the patient’s arm. Hold the test for 30 seconds
3. Indication of a positive test:
  1. Normal:
    1. Should not cause compression
  2. Positive test:
    1. Patients symptoms are reproduced
Halstead manoeuvre:
1. Purpose:
  1. To test for compression of the neurovascular bundle as it passes through the interscalene triangle and/or costoclavicular space
2. Procedure:
  1. The patient is seated, extend, abduct and externally rotate the arm then rotate and extend the neck traction the arm inferiorly and hold for 30 seconds
3. Indication of a positive test:
  1. Normal:
    1. Should not cause compression
  2. Positive test:
    1. Patients symptoms are reproduced

Week 3 content:

2 tests that tests for general structure of the shoulder:

Apley scratch test:
1. Purpose:
  1. Screening test to highlight the functional deficits in the shoulder and scapula motion by combining glenohumeral and scapulothoracic joint movement
2. Procedure:
  1. The patient can be seated or standing, ask the patient to raise one arm above their head and place the other arm behind their back and ask the patient to touch their hands together behind their back. Then repeat with the other arm.
3. Indications of a positive test:
  1. An inability to approximate the hands indicates restriction in the glenohumeral joint or scapulothoracic joint.
Test for scapula dyskinesis:
1. Purpose:
  1. Used to detect an aberrant scapular resting position or abnormal scapular movement
2. Procedure:
  1. The patient can be standing or sitting, observe the patient’s scapula then ask them to raise their arms above their head, flex their arms and abduct their arms.
3. Indications of a positive test:
  1. Abnormal resting position

3 tests that tests for the labrum:

O’Brien’s test:
1. Purpose:
  1. To detect SLAP (superior labrum anterior and posterior) or superior labral lesions of the glenohumeral joint.
2. Procedure:
  1. Stand in front of the patient and get them to flex their arm 90 degrees with their thumb down and adduct their arm 10-15 degrees
  2. Then apply downwards pressure on the forearm as you support the secondary on the shoulder.
3. Indication of a positive test:
  1. Normal finding:
    1. The patient shouldn’t feel any pain or clicking in or around the joint.
  2. Abnormal finding:
    1. Pain on top of the shoulder is diagnostic for an acromioclavicular joint lesion.
    2. Pain inside the shoulder is considered to be a labral lesion
Dynamic labral shear test:
1. Purpose:
  1. To test for isolated SLAP lesions of the shoulder
2. Procedure:
  1. The patient’s arm is abducted and externally rotated, then it is lowered through 120-60 degrees of abduction
3. Indication of a positive test:
  1. Normal:
    1. There should be no clicking or catching along the posterior joint line
  2. Positive test:
    1. Reproduction of the patient’s pain and/or painful clicking or catching along the posterior joint line between 120 - 90 abduction
      1. Positive test is suggestive of SLAP lesion of the shoulder
Biceps load test II:
1. Purpose:
  1. To test for isolated SLAP lesions of the shoulder
2. Procedure:
  1. The patient is supine with abduction and maximal external rotation. Support the elbow with the secondary contact and contact the wrist with the primary and ask the patient to resist elbow flexion.
3. Indication of a positive test:
  1. Normal:
    1. Patient should not feel pain
  2. Positive test:
    1. Patient complains of pain during resisted elbow flexion
    2. The test is negative if the pain is not elected by resisted elbow flexion
      1. Suggestive of a SLAP lesion of the shoulder

3 tests for infraspinatus and supraspinatus:

External rotation lag test:
1. Purpose:
  1. To assess the integrity of the posterior superior rotator cuff (1: infraspinatus and 2: supraspinatus and occasionally teres minor)
2. Procedure:
  1. Abduct the patient’s shoulder 20 degrees and externally rotate their arm as much as you can and ask the patient to hold this position.
  2. We’re assessing for how much the arm moves
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no drop or lag observed when the practitioner releases their grip
  2. Positive finding:
    1. If there is a lag or a drop
      1. This indicates pain/dysfunction/tear of the infraspinatus, supraspinatus or teres minor muscle
4. Interpretation:
  1. It is important to note that false positives and false negatives can occur with this test.
Supraspinatus/ empty can test:
1. Purpose:
  1. To assess for a tear of the supraspinatus tendon or muscle or neuropathy of the suprascapular nerve
2. Procedure:
  1. The patient's arm is slightly abducted and with the thumb pointing down apply downwards pressure
3. Indications of a positive test:
  1. Normal finding:
    1. No pain or weakness observed while performing the test
  2. Abnormal finding:
    1. Positive if there is pain or weakness
      1. Meaning there is a tear of the supraspinatus tendon or muscle or neuropathy of the suprascapular nerve
    2. The test may be positive in patients with subacromial impingement
Infraspinatus test:
1. Purpose:
  1. To assess for infraspinatus/teres minor dysfunction or scapular/axillary neuropathy
2. Procedure:
  1. Stand behind the patient and get them to bend their elbows 90 degrees stabilize their arm by holding the elbow and apply outward pressure with the primary (on their wrist)
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no weakness or pain observed when performing the test
  2. Positive test:
    1. When the patient experiences pain or weakness
      1. It is suggestive of a infraspinatus/ teres minor tear.

1 test that tests for all rotator cuff muscles:

Drop arm test:
1. Purpose:

To assess for tears or tendinopathy of the rotator cuff complex

Procedure:
1. Stand behind the patient and ask them to abduct their arm 90 degrees in the coronal plane. Ask the patient to slowly put their arm down.
2. If the patient is able to do so do the test again but this time apply slight forces each time and ask for pain.
Indication of a positive test:
1. Normal finding:
  1. The patient doesn’t experience any pain when lowering their arm
2. Abnormal finding:
  1. The patient can’t control the slow depression or the patient experiences pain
  2. Complete tears in one or more rotator cuff muscles are more likely in patient’s 50 years or older whereas partial tears are more common in younger people.

4 tests that tests for Subscapular:

Internal rotation lag test:
1. Purpose:
  1. To test for the integrity of the subscapularis muscle
2. Procedure:
  1. Stand behind the patient and make sure the arm is extended and placed in a full internal rotation, the patient is then asked to hold this position.
  2. We’re looking for a lag or movement of the arm.
3. Indications of a positive test:
  1. Positive test:
    1. When there is a lag or angular drop
      1. This indicates pain/dysfunction/tear of the subscapularis
  2. Important to note that pathological changes can affect the patient’s ROM
Lift off test:
1. Purpose:
  1. To assess the integrity of subscapularis
2. Procedure:
  1. This is very similar to the internal rotation lag test but ask the patient to lift their hand up from their back instead of holding them. You can apply pressure to sensitise the test
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no pain or weaknbess observed
  2. Positive finding:
    1. Pain or instability of the patient to resist the pressure or patient’s ability to externally rotate
      1. It indicates a tear or dysfunction of the subscapularis or neuropathy of the upper and/or lower scapular nerve
Belly press test:
1. Purpose:
  1. To assess the integrity of subscapularis
2. Procedure:
  1. Stand next to the patient and ask the patient to place their hand on their belly. Lift it off alittle and apply a P-A pressure and ask the patient to resist.
3. Indication of a positive test:
  1. Normal finding:
    1. There is no pain or weakness
  2. Positive test:
    1. Pain or instability
      1. Indicates a tear or dysfunction of the subscapularis or neuropathy of the upper and lower scapular nerve
Bear hug test:
1. Purpose:
  1. To assess the integrity of the subscapularis
2. Procedure:
  1. Stand next to the patient and ask them to plae their hand on their opposite shoulder. Stabilise with the secondary on their back and contact their palm with the primary and apply a P-A pressure and ask the patient to resist.
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no pain or weakness observed
  2. Positive test:
    1. Pain or instability:
      1. Indicates a tear or dysfunction of the subscapularis or neuropathy of the upper and lower scapular nerve

2 tests that tests for biceps:

Speed’s test:
1. Purpose:
  1. To assess the integrity of the tendons of the long head of biceps brachii
2. Procedure:
  1. Stand next to the patient and flex their arm 90 degrees with their palm facing up. Stabilise with the secondary on their shoulder and contact their forearm and apply a downwards pressure.
3. Indication of a positive test:
  1. Normal findings:
    1. There should be no weakness or pain
  2. Positive test:
    1. If the patient experiences pain in the anterior shoulder it is a problem with the intertubercular groove
      1. It indicates tendinopathy of the long head of biceps brachii
Yergason’s test:
1. Purpose:
  1. To assess the ability of coracohumeral and transverse humeral ligament to hold the long head of biceps tendon in the intertubercular groove
2. Procedure:
  1. The patients elbow is flexed 90 degrees with the forearm in a neutral position. The practitioner palpated the intertubercular groove while passively externally rotating the patient’s forearm. The primary contact is on the patient’s forearm. The patient is trying to supine their arm as well
3. Indications of a positive test:
  1. Normal finding:
    1. There should be no pain or clicking over the intertuberclar groove during the performance of the test.
  2. Positive test:
    1. A palpable click over the intertubercular groove
      1. Indicates insufficiency of the transverse humeral and/or coracohumeral ligament
    2. Pain over the intertubercular groove
      1. Indicates tendinopathy of the long head of biceps brachii tendon

1 test that tests for teres minor:

Patte’s test:
1. Purpose:
  1. To assess the integrity of teres minor
2. Procedure:
  1. The patient’s elbow is flexed 90 degrees and the arm is abducted 90 degrees. The practitioner supports the patient’s arm and the patient is asked to externally rotate their arm first against gravity then against the patient’s resistance
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no pain or weakness
  2. Abnormal finding:
    1. Pain or instability of the patient to resist the practitioner’s attempts to internally rotate the arm
      1. A positive test indicates a tear or dysfunction of the teres minor or neuropathy of the axillary nerve

2 tests that are screen tests for subacromial impingement:

Neer impingement test:
1. Purpose:
  1. Screening test for subacromial impingement:
    1. Typically involving:
      1. Supraspinatus tendon
      2. Long head of biceps brachii tendon
      3. Subacromial bursa
2. Procedure:
  1. Stabilise the scapula and abduct the patient’s internally rotated arm so that the pinkly is pointed up. Flex the arm around 120 degrees
3. Indication of a positive test:
  1. Normal findings:
    1. There should be no pain present during this test
  2. Positive test:
    1. Pain in the subacromial region or facial grimace
      1. Usually indicates overuse/impingement of the supraspinatus and/or long head of biceps brachii tendon and/or subacromial bursa
4. Note:
  1. If the pain is produced during abduction of the internally rotated arm, the test can be repeated with the arm in external rotation
  2. If the patient’s pain disappears when the arm is abducted in external rotation, then impingement is more likely
Hawkins-Kennedy test:
1. Purpose:
  1. Screening test for subacromial impingement
    1. Tendinopathy or paratendinopathy of supraspinatus
2. Procedure:
  1. The patient is seated stabilise with the secondary on the shoulder and bend their elbows 90 degrees. Elevate their arm and and apply pressure through the humerus. Then horizontally adduct their arm
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no pain during this test
  2. Positive finding:
    1. Pain in the subacromial region or facial grimace
      1. Positive test indicates impingement of the supraspinatus tendon

3 tests that test for GH joint stability:

Load and shift test:
1. Purpose:
  1. To test for anterior and posterior glenohumeral joint stability:
    1. Primarily assessing for atraumatic instability
2. Procedure:
  1. Stabilise the scapula and centre the humeral head in the glenoid then load anteriorly and posteriorly
3. Indication of a positive test:
  1. Normal:
    1. There should be minimal displacement of the humeral head (less than 25% anteriorly or 50% posteriorly)
  2. Positive test:
    1. Displacement of the humeral head is greater than 25% anteriorly or more than 50% posteriorly relative to the glenoid compared to the contralateral shoulder.
4. This test can also be done supine
Anterior apprehension test:
1. Purpose:
  1. To test for anterior glenohumeral joint stability
    1. Assessing for traumatic anterior instability
2. Procedure:
  1. The patient is supine on the couch with their arms 90 degrees abducted with their elbows flexed 90 degrees. The practitioner contacts the patient’s humerus and gradually and slowly applies external rotation while watching for apprehension on the part of the patient
3. Indication of a positive test:
  1. Normal finding:
    1. The patient does not feel, apprension or try to guard against further movement during the performance of the test
  2. Positive test:
    1. If the patient looks or feels apprehensive and resists further movement
      1. It suggests anterior glenohumeral joint instability
4. Anterior relocation test:
  1. The practitioner notes the amount of external rotation before performing this.
  2. The test is performed while the practitioner applies an A-P force on the patient’s humeral head.
    1. An increase in the amount of external rotation before apprehension appears should occur which provides evidence of anterior instability.
Sulcus sign:
1. Purpose:
  1. To assess for inferior and/or multidirectional glenohumeral joint stability
2. Procedure:
  1. The practitioner applies downwards pressure to the patient’s humerus and observes for the formation of a subacromial sulcus
3. Indication of a positive test:
  1. Normal:
    1. There should be minimal inferior displacement of the humeral head during the performance of the test
  2. Positive test:
    1. A sulcus dimple should appear in the subacromial region
      1. A positive test suggests an inferior or multidirectional glenohumeral joint instability

1 test that tests for the instability of the GH joint:

Anterior drawer test:
1. Purpose:
  1. To test for the anterior instability of the GH joint
2. Procedure:
  1. Stabilise the patient scapula with the secondary contact. The affected shoulder is held at 80-120 degrees of abduction, 0-20 degrees of horizontal adduction and 0-30 degrees of external rotation. Draw the humerus anteriorly with the primary contact
3. Indication of a positive test:
  1. Normal:
    1. There should be minimal displacement of the humeral head
  2. Positive test:
    1. Displacement of the humeral head is greater than 25% anteriorly relative to the glenoid
      1. Indicates anterior glenohumeral joint instability

2 tests that tests for laxity in the GH joint:

Posterior drawer test:
1. Purpose:
  1. To assess for and grade laxity or insufficiency of the posterior GH joint
2. Procedure:
  1. The arm is flexed at the elbow and adducts the arm as you are applying A-P pressure with the primary.
3. Indication of a positive test:
  1. Normal finding:
    1. Minimal posterior displacement of the humeral head
  2. Positive test:
    1. Thumb is felt to slide past the coracoid
    2. Posterior glenohumeral joint instability
Posterior apprehension test:
1. Purpose:
  1. To assess laxity or insufficiency of the posterior GH joint
2. Procedure:
  1. The patient is supine and their elbow is flexed 90 degrees and contact their wrist and contact their elbow with the other slightly adduct the slightly internally rotate their arm. Change the contact one at the elbow and one at the shoulder. Apply axial pressure with slight adduction.
3. Indication of a positive test:
  1. Normal:
    1. There is no notable posterior displacement, clicking and clucking or pain produced
  2. Positive test:
    1. Displacement and/or clucking and clicking with pain
      1. Posterior instability or dislocation
      2. Concomitant labral damage

Week 4 content Part 1: elbows

1 test that tests for varus stress:

Elbow varus stress test:
1. Purpose:
  1. To assess the integrity of the structures which stabilise the elbow against varus stresses
2. Procedure:
  1. The patient is seated and the patient’s arm is flexed, the secondary contact is on the patient’s wrist to stabilise and the primary is used to push away from the midline.
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no pain or laxity present when performing the test in a patient with a healthy/intact lateral ulnar collateral ligament
  2. Positive test:
    1. If there is laxity or pain
      1. Suggests a lateral ulnar-collateral ligament sprain with or without joint instability.

2 test that tests for valgus stress:

Elbow valgus stress:
1. Purpose:
  1. To assess the integrity of the structures that stabilise the elbow against valgus stresses during movement
2. Procedure:
  1. The patient is seated with their palm facing down and the elbow is flexed 20-30 degrees. Then apply force towards the midline.
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no pain, crepitus, laxity, or neural symptoms present when performing the test in a patient with healthy medial elbow stabilisers.
  2. Positive test:
    1. The test is considered positive if laxity pain is observed
      1. Suggestive of a medial collateral ligament sprain with or without joint stability
Moving valgus stress test:
1. Purpose:
  1. To assess the integrity of the structures that stabilise the elbow against valgus stresses during movement
2. Procedure:
  1. A valgus force is applied while the arm is flexed and extended
3. Indication of a positive test:
  1. Positive test:
    1. If there is pain, crepitus, laxity, or neural symptoms are produced
    2. Symptoms are usually produced between 70-120 degrees of flexion
      1. Suggestive of a medial collateral ligament sprain with or without joint instability.

1 test that tests for olecranon osteophytes or olecranon fossa:

Valgus extension overload test:
1. Purpose:
  1. To detect the presence of a posteromedial olecranon osteophyte of olecranon fossa overgrowth
2. Procedure:
  1. The patient’s arm is abducted 50 degrees and flexed approximately 30 degrees. The patient contacts the wrist with the secondary contact and pronates their arm, contacts their elbow with the primary and applies valgus force.
3. Indication of a positive test:
  1. Normal:
    1. There should be no pain or crepitus present when performing the test
  2. Positive test:
    1. Pain experienced posteromedially
      1. Any olecranon tip osteophytes engage the posteromedial olecranon fossa is considered positive
      2. Indicates posteromedial elbow impingement or a stress fracture

1 test that tests for posterolateral rotatory instability:

Posterolateral pivot-shift apprehension test:
1. Purpose:
  1. To assess for posterolateral rotary instability of the elbow
    1. Posterolateral instability indicates laxity of the lateral ulnar collateral ligament
2. Procedure:
  1. The patient is supine and the forearm is supinated with elbow extension. Contact the lateral elbow and apply valgus force and put the arm back into lateral position.
3. Indication of a positive test:
  1. Normal finding:
    1. There should be no apprehension or sublaxation observed
  2. Positive test:
    1. Apprehension as the elbow is flexed 20-30 degrees
    2. Subluation indicated with a dimple forming between the radial head and the capitellum.
    3. If there is a clunk
      1. Indicating reduction of the radial head around 40-70 degrees of flexion.

3 tests that tests for the extensor tendons:

Cozen’s test:
1. Purpose:
  1. To assess the integrity of the wrist extensors/common extensor tendon at the lateral epicondyle
2. Procedure:
  1. The patient i seated and their elbows are flexed 90 degrees. Ask the patient to fully extend their wrist and contact that with the secondary and contact their lateral epicondyle with your thumb as the primary. Actively resist the extension pressure.
3. Indications of a positive test:
  1. Normal finding:
    1. There should be no pain present when performing the test
  2. Positive test:
    1. A sudden, severe pain over the lateral epicondyle of the humerus
      1. Suggestive of a lateral epicondylopathy
Mill’s test:
1. Purpose:
  1. To assess the integrity of the wrist extensors/common extensor tendon at the lateral epicondyle.
2. Procedure:
  1. The patient is seated and pronate their arm with elbow extension. Contact the lateral epicondyle with the thumb and flex the wrist.
3. Indications of a positive test:
  1. Normal:
    1. There should be no pain present when performing the test
  2. Positive:
    1. When the patient reports pain around the lateral epicondyle
      1. Suggestive of a lateral epicondylopathy
Middle finger sign:
1. Purpose:
  1. To assess the integrity of the wrist extensors/common extensor tendon at the lateral epicondyle
2. Procedure:
  1. The patient’s seated and their elbow is bent 90 degrees full pronation and the wrist neutral. Contact the patient’s middle fingernail and contact the lateral epicondyle with the primary and ask the patient to extend their finger.
3. Indications of a positive test:
  1. Normal findings:
    1. There should be no pain present
  2. Positive test:
    1. If the patient reports pain around the lateral epicondyle of the humerus
      1. Suggestive of a lateral epicondylopathy
    2. Pain may be located distal to the lateral epicondyle in the case of radial tunnel syndrome.

1 test that tests for flexor muscles:

Test for medial epicondylopathy:
1. Purpose:
  1. To assess the integrity of the wrist flexors/common flexor tendon at the medial epicondyle of the humerus
2. Procedure:
  1. The patient is seated palpate the medial epicondyle with one hand and contact with web contact. Hold the patient’s wrist with the other hand passively supinate the patient’s forearm, extend the elbow and extend the wrist and fingers.
3. Indication of a positive test:
  1. Normal:
    1. There should be no pain present when performing the test in a patient with healthy intact wrist flexor/common flexor tendon
  2. Positive test:
    1. If the patient reports pain around the medial epicondyle of the humerus
      1. Suggestive of medial epicondylopathy

1 test that tests for radiocapitellar joint:

Radiocapitellar compression test:
1. Purpose:
  1. To assess the integrity of the radiocapitellar joint
2. Procedure:
  1. The patient is seated and contacts the radial head with the thumb. Contact the palm with the other hand and apply axial pressure while pronating and supinating the wrist.
3. Indication of a positive test:
  1. Normal:
    1. There should be no pain or crepitus produced
  2. Positive test:
    1. If the patient experiences pain and crepitus in the radiocapitellar joint.
      1. Suggestive of other conditions:
        Paneer’s, fractures etc.

Week 4 content Part 2: wrist:

2 screening test for the wrist:

Fanning and folding of the hand:
1. Purpose:
  1. General screening test to assess for motion restriction or movement abnormalities in the hand
2. Procedure:
  1. Have the patient seated with their palm facing the floor, we will contact the proximal wrist and the distal wrist. The practitioner will fold and fan the hand while feeling for crepitus and joint motion.
3. Indication of a positive test:
  1. Normal:
    1. There should be no pain, crepitus or abnormal motion during the test
  2. Positive test:
    1. If pain, crepitus or abnormal motions are observed
      1. If positive do more orthorpaedic tests to define the nature of the pathological finding
Finger extension (shuck) test:
1. Purpose:
  1. General screening tool for wrist/hand pathology:
    1. Radiocarpal instability
    2. Midcarpal instability
    3. Inflammation
    4. Keinboxks disease
2. Procedure:
  1. The patient;s elbow is on the bench with their wrist flexed around 45 degrees. The patient is then asked to actively resist the force against resistance.
3. Indication of a positive test:
  1. Normal:
    1. There should be no pain or crepitus produced during the test
  2. Positive test:
    1. Induces pain, clunking or crepitus
      1. Suggestive of radiocarpal, midcarpal or scaphoid instability, inflammation or kienbock disease
        Should be followed by other ortho tests

1 test that tests for the extensor pollicis longus:

Finkelstein test:
1. Purpose:
  1. To assess for irritation of the tendons of extensor pollicis brevis and abductor pollicis longus as they pass deep into the extensor retinaculum
2. Procedure:
  1. The patient is seated and they make a fist with their thumb tucked inside the flexed fingers. The practitioner then stabilises the forearm and moves the fist into ulnar deviation.
3. Indication of a positive test:
  1. Normal:
    1. No pain or crepitus during the test:
  2. Positive test:
    1. If there is pain or reproduction of symptoms over the abductor pollicis longus and extensor pollicus brevis tendons
4. Note:
  1. This test position may cause discomfort in some individuals.

2 tests that tests for stability of the carpals:

Watson (scaphoid shift) test:
1. Purpose:
  1. To assess the integrity and stability of the scapholunate joint:
    1. For ligament tears, joint instability and subluxation
2. Procedure:
  1. The patient’s elbow is flexed and their palm is facing the practitioner. We then make a pincer grip over the patient’s metacarpals with the secondary contact. Slightly apply a A-P pressure while deviating and flexing the patient’s hand over the thumb contact.
3. Indication of a positive test:
  1. Normal:
    1. There should be minimal movement of the scaphoid relative to the lunate
  2. Positive test:
    1. If it causes pain, laxity, or crepitus during the test
    2. A dorsal shift of the scaphoid will occur on flexion, and a clunk on release of the thumb contact
      1. Positive test suggests a scapholunate instability
Lunotriquetral ballottement test
1. Purpose:
  1. To assess the integrity and stability of the lunotriquetral joint:
2. Procedure:
  1. The practitioner stabilises the triquetrum with the patient’s palm facing down. Then the practitioner contacts the lunate with the other hand and shears it against the triquetrum.
3. Indication of a positive test:
  1. Normal:
    1. Minimal movement of the lunate relative to the triquetrum
  2. Positive test:
    1. Pain, laxity or crepitus are elicited
      1. Suggestive of lunotriquetral instability

1 test that tests for disassociation of the distal radioulnar ligament:

Forvea test:
1. Purpose:
  1. Assessment of disassociation of the distal radio-ulnar ligament from the fovea region of the ulnar head.
2. Procedure:
  1. The patient is seated with the elbow on the couch with their forearm neutral. Contact the soft spot between the ulnar styloid with your thumb and push the thumb.
3. Indication of a positive test:
  1. Normal:
    1. There should be minimal discomfort
  2. Positive test:
    1. Tenderness compared to the contralateral side, facial expression, replication of patient symptoms or pain.
      1. Suggestive of dysfunction of the distal radio-ulnar ligament, ulnocarpal ligament or the TFCC.

1 test that tests for the integrity of triangular fibrocartiginous complex:

TFCC load test:
1. Purpose:
  1. To assess the integrity of the triangular fibrocartilaginous complex (TFCC)
2. Procedure:
  1. The patient’s elbow is on the couch, contact the hand and the forearm. Apply axial load through the wrist and forearm as the wrist is rolled from flexion to extension in ulnar deviation.
3. Indication of a positive test:
  1. Normal:
    1. There should be minimal discomfort associated with the test
  2. Positive test:
    1. Pain, clicking and/or crepitus in the triangular fibrocartilaginous complex.
      1. Suggestive of dysfunction of the TFCC

1 test that tests for patency of ulnar and radial arteries:

Allen test:
1. Purpose:
  1. To assess the patency of the ulnar radial arteries, and to determine which artery is providing the major blood supply to the hand.
2. Procedure:
  1. Ask the patient to make a fist and expand their hand 5 times and ask them make a fist and hold. Apply pressure to the radial artery and ulnar artery. Ask them to expand their hand and let go of the radial artery and observe the colour change. Repeat this with the ulnar one as well
3. Indication of a positive test:
  1. Normal:
    1. After releasing the artery the hand should flush after 2-3 seconds
  2. Positive test:
    1. Hand flushes slowly over 6 seconds
      1. Could be partial or totally occluded.

Week 5 content: Hand

3 tests that tests for flexor digitorum:

Profundus test:
1. Purpose:
  1. To assess for disassociation of the flexor digitorum profundus tendon from the distal phalanx
2. Procedure:
  1. The patient has their forearm on the couch with their palm facing up. Ask the patient to flex all the other finger that is not affected. Contact the distal phalangeal joint and ask the patient to flex that last joint.
3. Indication of a positive test:
  1. Normal:
    1. The patient should be able to flex the DIP joint
  2. Positive test:
    1. The patient is not able to flex their joint
      1. Suggestive of a rupture of flexor digitorum profundus tendon.
Superficialis test:
1. Purpose:
  1. To assess for disassociation of the flexor digitorum superficialis tendon from the middle phalanx.
2. Procedure:
  1. The patient’s palm is facing up with their forearm on the couch. Hold down the other fingers (other than the affected one) and ask the patient to fully flex that finger.
3. Indication of a positive test:
  1. Normal:
    1. The patient should be able to do this movement
  2. Positive test:
    1. If the patient is unable to flex the affected PIP joint.
      1. Suggestive of a flexor digitorum superficialis tendon rupture.
Sweater finger sign:
1. Purpose:
  1. To assess for dissociation of the flexor digitorum profundus tendon from the distal phalanx.
2. Procedure:
  1. The patient is asked to make a fist starting from the distal joint slowly.
3. Indication of a positive test:
  1. Normal:
    1. The patient should be able to make a fist starting at the distal joint
  2. Positive test:
    1. If they cannot complete this test from the distal joint
      1. Suggestive of a rupture of the flexor digitorum profundus tendon from the distal phalanx.

1 test that tests for the extensor hood:

Test for extensor hood rupture:
1. Purpose:
  1. To test the integrity of the extensor hood in the hand
2. Procedure:
  1. The patient has their hand on the couch and one finger at a time is asked to extend their finger against resistance
3. Indication of a positive test:
  1. Normal:
    1. The practitioner should feel pressure from the middle phalanx
  2. Positive test:
    1. If the practitioner does not feel pressure or resistance from the middle phalanx, but the distal interphalangeal joint is extending
      1. Suggestive of a torn central extensor hood.

1 test that tests for flexor tendons in the hand:

Test for trigger finger:
1. Purpose:
  1. To assess for nodules or thickened regions of the flexor tendons in the hand
2. Procedure:
  1. The practitioner palpates over the first tendon while the patient flexes and extends their finger. This is repeated for all the fingers
3. Indication of a positive test:
  1. Normal:
    1. There should be minimal focal thickening of the flexor tendon of the hand, and no restriction to tendon movement
  2. Positive test:
    1. If we can feel a small nodule and the patient complains about pain.
      1. Suggestive of stenosing tenosynovitis or early stage of dupuytren’s contracture

1 test that tests for limited PIP joint flexion:

Bunnel-littler test:
1. Purpose:
  1. To assess for potential causes of limited proximal interphalangeal joint flexion
    1. Can be used to examine individuals with swan neck deformities
2. Procedure:
  1. The patient’s thumb is facing up and the MCP joint is extended and hold the knuckle and flex the joint. Put the finger back into neutral and flex the MCP joint.
3. Indication of a positive test:
  1. Normal:
    1. The practitioner should be able to passively move the patient’s PIP into flexion
  2. Positive test:
    1. Inability to flex the PIP joint with an extended MCP joint
      1. Indicated contracture of the PIP joint or tight intrinsic muscles of the hand
    2. Inability to flex the PIP joint with flexed MCP
      1. Indicated PIP joint contracture

1 test that tests for patency of the digital arteries in the finger

Digital blood flow (perfusion) test:
1. Purpose:

To determine the patency of the digital arteries in the finger

Procedure:
1. The patients palm is facing down and apply pressure to the patient’s finger nail and then release it. The practitioner takes note of the time taken for colour to return to the nail
2. Compare to the unaffected finger
Indication of a positive test:
1. Normal:
  1. The colour should return within 3 seconds
2. Positive test:
  1. If the colour returns very slowly
    1. Suggestive of a arterial insufficiency

2 tests that tests for the collateral ligaments:

Finger - valgus/varus test:
1. Purpose:
  1. To assess the patency of the collateral ligaments of the MCP and IP joints of the finger
    1. Collateral ligament sprain, avulsion fracture
2. Procedure:
  1. The patient is seated and contacts the MCP joint and stabilises with the other fingers. First with full extension and apply valgus and varus forces. Then flex 30 degrees and do the same thing.
3. Indication of a positive test:
  1. Normal:
    1. No pain
  2. Positive test:
    1. If there is laxity with or without pain and it results in an empty end-feel
    2. Laxity greater than 30-35 degrees is suggestive of a complete tear
    3. Laxity less than 30-35 is suggestive of a partial tear
Thumb - valgus/varus test:
1. Purpose:
  1. To assess the integrity of the ulnar and radial collateral ligaments of the MCP joint of the thumb
2. Procedure:
  1. Very similar to the finger test - 2 parts one with extension and another with 30 degrees flexion.
3. Indication of a positive test:
  1. Normal:
    1. No pain and limited accessory movement at the first MCP joint
  2. Positive test:
    1. If there is laxity with or without pain and it results in an empty end-feel
    2. Laxity greater than 30-35 degrees is suggestive of a complete tear
    3. Laxity less than 30-35 is suggestive of a partial tear