Clinical Examination of the Musculoskeletal System

Clinical Examination of the MusculoskeletalSystem

CLINICAL EXAMINATION OF THEMUSCULOSKELETAL SYSTEM

RICHARD LEBERT AND KELLY OULD

Clinical Examination of the Musculoskeletal System by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike4.0 International License, except where otherwise noted.

CONTENTS

Introduction 1

Part I. Neurological Assessment

1. Cranial Nerve Function 3

2. Upper Limb Neurological Examination 6

3. Lower Limb Neurological Examination 9

4. Full Motor, Sensory, and Reflex Examination 12

5. Proprioception 13

6. Manual Muscle Testing 14

Part II. Headaches and Migraines

7. Outcome Measures for Headaches and Migraines 17

8. Bone & Soft Tissue Palpation for Headaches and Migraines 18

9. Cervical Flexion-Rotation Test 19

Part III. Temporomandibular Joint Assessment

10. Outcome Measures for Temporomandibular Disorders 21

11. Bone & Soft Tissue Palpation for Temporomandibular Disorders 22

12. Jaw Reflex Test 23

13. Chvostek Test 24

14. Three Knuckle Test 25

Part IV. Cervical Spine Assessment

15. Outcome Measures for The Cervical Spine 27

16. Bone & Soft Tissue Palpation for The Cervical Spine 28

17. Vertebral Artery Test 29

18. Spurling’s Test 30

19. Cervical Distraction Test 31

20. Cervical Compression Test 32

21. Scalene Cramp Test 33

22. Adson’s Test 34

23. Halstead Maneuver OR Reverse Adson’s Test OR Wright’s Test OR Hyperabduction Test 35

24. Costoclavicular Test (Military Brace) 36

25. Upper Limb Neurodynamic Tests 37

Part V. Shoulder Assessment

26. Outcome Measures for The Shoulder 40

27. Bone & Soft Tissue Palpation for The Shoulder 41

28. Apprehension Test OR Crank Test 42

29. Hawkins Kennedy Impingement Test 43

30. Acromioclavicular Shear Test 44

31. Speed’s Test 45

32. Yergason’s Test 46

33. Empty Can (Supraspinatus) Test 47

34. Drop Arm Test OR Codman’s Test 48

35. Apley’s Scratch Test 49

36. Sulcus Sign Test 50

37. Neer’s Test 51

38. Roo’s Test (EAST) 52

39. SLAP Lesion Cluster 53

40. Load & Shift - Anterior 54

41. Scapular Retraction Test 55

42. Crossbody Adduction Test (Acromioclavicular Crossover) 56

43. Posterior Capsule Tightness 57

44. Serratus Anterior Strength Test (Punch Out) 58

45. Jerk Test (Posteroinferior Labral Tear) 59

46. O’Brien Test (Active Compression Test) 60

47. Lift-off Sign 61

48. Abdominal Compression Test (Belly Press or Napoleon Test) 62

49. Painful Arc Test 63

Part VI. Elbow Assessment

50. Outcome Measures for The Elbow 65

51. Bone & Soft Tissue Palpation for The Elbow 66

52. Elbow Valgus and Varus Stress Tests 67

53. Moving Valgus Stress Test of the Elbow 69

54. Cozen’s Test 70

55. Mill’s Test 71

56. Medial Epicondylitis Test (Golfers Elbow) 72

57. Tinel's Sign's at the Elbow (Cubital Tunnel Syndrome) 73

58. Pronator Teres Syndrome Test 74

59. Elbow Flexion Test 75

Part VII. Forearm, Wrist, and Hand Assessment

60. Outcome Measures for The Forearm, Wrist, and Hand 77

61. Bone & Soft Tissue Palpation for The Forearm, Wrist, and Hand 78

62. Finklestein’s Test 79

63. Sweater Finger Sign 80

64. Carpal Compression Test 81

65. Phalen’s Test 82

66. Allen's Test 83

67. Murphy’s Sign 84

68. Tinel’s Sign - Median Nerve 85

69. Hoffman’s Sign 86

70. Froment's Sign (Pinch Grip Test) 87

71. Triangular Fibrocartilage Complex (TFCC) Load 88

Part VIII. Thoracolumbar Spine and Pelvis Assessment

72. Outcome Measures for The Thoracolumbar Spine and Pelvis 90

73. Bone & Soft Tissue Palpation for The Thoracolumbar Spine and Pelvis 91

74. Craig's Test 92

75. Gaenslen’s Test 93

76. Gillet’s Test 94

77. Kemp’s Test OR Lower Quadrant Test 95

78. Kernig/Brudzinski Test 96

79. Rebound Tenderness (McBurney’s Point) 97

80. Piriformis Test OR FAIR Test 98

81. Cluster of Laslett (Sacroiliac Joint Pain Provocation) 99

82. Sacroiliac Compression (Squish) Test 100

83. Sacroiliac Distraction (Gap) Test 101

84. Thigh Thrust Test 102

85. Sacral Thrust Test 103

86. Slump Test 104

87. True Leg Length Measurement 106

88. Valsalva Maneuver 107

89. Well Leg Raise 108

90. Straight Leg Raise (Lasègue's sign) or Bragard's Test 109

91. Bowstring Maneuver 111

92. Supine-to-sit (Long Sitting) 112

93. Hoover Test 113

94. Prone Gap (Hibb's) Test 114

95. Pheasant Test (Lumbar Instability Test) 115

96. Nachlas (Prone Knee Bend) Test 116

97. Yeoman's Test 117

Part IX. Hip Assessment

98. Outcome Measures for The Hip 119

99. Bone & Soft Tissue Palpation for The Hip 120

100. FABER (Patrick’s) Test 121

101. FADDIR (Flexion-Adduction-Internal Rotation) Test 122

102. Trendelenburg Sign 123

103. Thomas Test 124

104. Ely’s Test 125

105. Ober’s Test 126

106. 90-90 Straight Leg Test 128

107. Piriformis Strength Test (Pace Maneuver) 129

108. Hip Quadrant Test (Scouring Test) 130

Part X. Knee Assessment

109. Outcome Measures for The Knee 132

110. Bone & Soft Tissue Palpation for The Knee 133

111. Bounce Home Test 134

112. Apley's Test 135

113. McMurry’s "Click" Test 137

114. Valgus Stress Test (Medial Collateral Ligament) 138

115. Varus Stress Test (Lateral Collateral Ligament) 140

116. Noble’s Compression 142

117. Lachman’s Test 143

118. Anterior Drawer Test 144

119. Posterior Drawer Test 145

120. Posterior Sag Sign (Gravity Drawer Test) 146

121. Coronary Ligament Stress Test 147

122. Patellar Grind Test (Clarke’s Sign) 148

123. Thessaly Test 149

124. Bragard’s Sign 150

125. Mediopatellar Plica Test (Hughston Plica Test) 151

126. Plica “Stutter” Test 152

127. Brush Test (Minor Effusion, Stroke, OR Wipe Test) 153

128. Ballotable Patella (Major Effusion or Patellar Tap Test) 154

129. Fluctuation Test 155

130. Waldron’s Test 156

131. McConnell Patellofemoral Knee Test 157

132. Q-Angle 158

133. Patellar Apprehension Test 159

134. Patellar Deep Tendon Reflex 160

Part XI. Lower Leg, Ankle, and Foot Assessment

135. Outcome Measures for The Lower Leg, Ankle, and Foot 162

136. Bone & Soft Tissue Palpation for The Lower Leg, Ankle, and Foot 163

137. Functional/Structural Pes Planus Test 164

138. Talar Tilt Test 165

139. Anterior Drawer of the Ankle 166

140. Calcaneocuboid Stress Test 167

141. Calcaneofibular Stress Test 168

142. Talofibular Ligament Stress Test (Anterior & Posterior) 169

143. Deltoid Ligament Stress Test 171

144. Dorsiflexion External Rotation Stress Test (Kleiger Test) 172

145. The Syndesmosis Squeeze Test 173

146. Toe/Heel Walking 174

147. Thompson’s Test 175

148. Tinel’s Sign at Tarsal Tunnel 176

149. Tinel's Sign - Anterior Tarsal Tunnel 177

150. Morton’s Neuroma Test (Metatarsal Squeeze Test) 178

151. Homan’s Sign 179

152. Babinski Test/Reflex 180

References and Resources 181

Acknowledgement 184

This Book Is A Living Document

This is an Open Educational Resource (OER) for commonly used orthopedic tests and outcome measurements. Thisresource is a living document that will be periodically updated to ensure current best practices are in place. In addition,it will be monitored and updated throughout the life cycle, based off Paul Hibbits Learning & Technology DevelopmentProcess Model and it will be updated and systematically edited for clarity and flow.

Note: This resource is not and should be taken as medical advice, it is educational content for health care professionalsand students.

PART I

NEUROLOGICAL ASSESSMENT

Neurological Assessment

• Cranial Nerve Function• Upper Limb Neurological Examination• Lower Limb Neurological Examination• Full Motor, Sensory, and Reflex Examination• Proprioception• Manual Muscle Testing

1.

CRANIAL NERVE FUNCTION

Cranial Nerve Function

Number Mnemonic Cranial Nerve Function (S/M/B) Mnemonic

I On Olfactory Smell (S) Some

II On Optic Vision (S) Say

III On Oculomotor Eye Movements (M) Marry

IV They Trochlear Eye Movements (M) Money

V Traveled Trigeminal Sensory/motor – face (B) But

VI And Abducens Eye movements (M) My

VII Found Facial Motor-face, Taste (B) Brother

VIII Voldemort Vestibulocochlear(Auditory) Hearing/Balance (S) Says

IX Guarding Glossopharyngeal Motor – throat Taste (B) Big

X Very Vagus Motor/sensory –viscera (autonomic) (B) Bucks

XI Ancient Accessory Motor-head &neck (M) Mean

XII Horcruxes Hypoglossal Motor-lower throat (M) More

4 | CRANIAL NERVE FUNCTION

A YouTube element has been excluded from this version of the text. You can view it online here:

https://ecampusontario.pressbooks.pub/clinicalexamination/?p=52

CRANIAL NERVE FUNCTION | 5

2.

UPPER LIMB NEUROLOGICAL EXAMINATION

Upper Limb Neurological Examination

Myotomes, Dermatomes and Reflexes of the Upper Limb

NerveRoot Motor Test Reflex Test Sensory Test

C1-C2 Neck flexion N/AC1 – Vertex (top) of the skull

C2 – Temple forehead and occiput

C3 Neck lateral flexion N/A Entire neck, posterior cheek, temporal area

C4 Shoulder elevation N/A Shoulder area, clavicular area, upper scapular area

C5 Shoulder abduction Biceps Lateral arm, pure sensation is a round patch on the lateral aspect of thedeltoid m.- the axillary nerve

C6 Elbow flexionand wrist extension Brachioradialis Lateral forearm, thumb, index, and half of the middle finger –

branches of the musculocutaneous nerve

C7 Elbow extensionand wrist flexion Triceps Middle finger – radial nerve

C8 Interossei musclesand finger flexor N/A Distal half of the ulnar side of the forearm, and the ring and little

fingers of the hand.

T1 Interossei – finger abductors N/A Medial side of the upper half of the forearm and lower part of the arm

UPPER LIMB NEUROLOGICAL EXAMINATION | 7



8 | UPPER LIMB NEUROLOGICAL EXAMINATION

3.

LOWER LIMB NEUROLOGICAL EXAMINATION

Lower Limb Neurological Examination

Myotomes, Dermatomes and Reflexes of the Lower Limb

NerveRoot Motor Test Reflex Test Sensory Test

T12,L1,L2, L3 Iliopsoas N/A

L1 – upper anterior portion of the thigh immediately below theinguinal ligament;

L3 – anterior thigh, immediately above the knee cap;

L2 – runs between L1 & L3

L2, L3,L4 Quadriceps N/A (See L4)

L4 Tibialis Anterior PatellarL4 – Medial buttock, lateral thigh, medial leg over

ankle and somewhat the dorsum of the foot and great toe

L5Extensor Hallucis

Longus

L4-5 – Tibialis posterior tendon

L5-S1 –Semimembranosis tendon

Buttock, posterior and lateral thigh, lateral aspect of the leg,dorsum of the foot – toes 2-4

S1

S1) Peroneus longus& brevis muscles;

S2) Gastrocnemius &Soleus muscles

S1-2 – Achilles

tendon reflex

Lateral malleolus and the lateral side and plantar surface of thefoot

S2, 3, 4

These are theprincipal nervesupplies for thebladder, & theintrinsic mm. of thefoot

N/A Concentric rings around the anus with the innermost ring as S4-5, and the outermost ring as S2

10 | LOWER LIMB NEUROLOGICAL EXAMINATION



LOWER LIMB NEUROLOGICAL EXAMINATION | 11

4.

FULL MOTOR, SENSORY, AND REFLEXEXAMINATION

Motor, Sensory, and Reflex Examination



5.

PROPRIOCEPTION

Proprioception

Use: To assess for proprioceptive loss.Procedure: Grasp client’s affected finger or toe and passively move into flexion/extension; ask client to identify whatposition it’s inFindings: Incorrect answer or hesitation before answering indicates loss.Note: If the test is positive, repeat using the next proximal joint



6.

MANUAL MUSCLE TESTING

Manual Muscle Testing (MRC Scale)

Uses: Manual muscle testing is used to see if there is an injury or pathology causing muscle weakness.

Findings: Muscle testing involves testing muscles against the examiner’s resistance and grading the individuals strengthon a 0 to 5 scale:

Score Description

0 No contraction

1 Flicker or trace of contraction

2 Active movement, with gravity eliminated

3 Active movement against gravity

4 Active movement against gravity and resistance

5 Normal power



MANUAL MUSCLE TESTING | 15

PART II

HEADACHES AND MIGRAINES

7.

OUTCOME MEASURES FOR HEADACHES ANDMIGRAINES

Outcome Measures for Headaches and Migraines

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

• Self-Rated Recovery Question• Patient Specific Functional Scale• Headache Impact Test 6-item (HIT-6)• Migraine-Specific Quality of Life Questionnaire (MSQ v2.1)• Patient Perception of Migraine Questionnaire (PPMQ-R)• The Migraine Disability Assessment (MIDAS)• Headache Disability Index

8.

BONE & SOFT TISSUE PALPATION FORHEADACHES AND MIGRAINES

Bone & Soft Tissue Palpation for Headaches andMigraines

A selection of regional structures to keep in mind while assessing and treating patients suffering from headaches andmigraines may include:

• Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)• Levator Scapula• Longus Colli & Capitis• Rhomboid Minor and Major• Occipitofrontalis• Corrugator Supercilii• Sternocleidomastoid• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Temporomandibular Joint

◦ Medial Pterygoid◦ Temporalis◦ Masseter◦ Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)◦ Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)

9.

CERVICAL FLEXION-ROTATION TEST

Cervical Flexion-Rotation Test



PART III

TEMPOROMANDIBULAR JOINTASSESSMENT

Temporomandibular Assessment

Orthopedic Special Tests

• Jaw Reflex Test• Three Finger Test OR Knuckle Test• Chvostek Test

10.

OUTCOME MEASURES FORTEMPOROMANDIBULAR DISORDERS

Outcome Measures for Temporomandibular Disorders

You may consider incorporating one or more of the following outcome measurements when assessing and monitoringpatient progress:

• Self-Rated Recovery Question• Patient-specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• Numeric Pain Rating Scale (NRS)• Jaw Functional Limitation (JFL‐8)• Mandibular Function Impairment Questionnaire (MFIQ)• Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD)• Neck Disability Index (NDI)

11.

BONE & SOFT TISSUE PALPATION FORTEMPOROMANDIBULAR DISORDERS

Bone & Soft Tissue Palpation for TemporomandibularDisorders

A selection of regional structures to keep in mind while assessing and treating patients suffering fromtemporomandibular disorders may include:

• Medial Pterygoid• Temporalis• Masseter• Sternocleidomastoid• Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)• Infrahyoids Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)

12.

JAW REFLEX TEST

Jaw Reflex Test

Use: To assess the reflex of the TMJ (this is a test for CN V).

Procedure: Client seated; mouth relaxed and open in the resting position; therapist places thumb on chin of client andtaps thumbnail with reflex hammer.

Findings: If reflex is present, the jaw will appear to close



13.

CHVOSTEK TEST

Chvostek Test

Use: Determine whether there is a pathology involving CN VII (facial) (Bell’s Palsy).

Procedure: Client seated; therapist taps the parotid gland overlying the masseter muscle (this will be over the area of thefacial nerve).

Findings: Positive findings with result in twitching of the facial muscles.



14.

THREE KNUCKLE TEST

Three Knuckle Test

Use: To assess active free range of motion of the jaw in depression

Procedure: Instruct client to open mouth and place the knuckle of the 2-4 digits of the non-dominant hand betweenfront teeth

Findings: Hypomobility of the temporomandibular joint is indicated if the client can get one or less knuckles betweenthe incisors

*Note: normal is 2-3 knuckles

PART IV

CERVICAL SPINE ASSESSMENT

Cervical Spine Assessment


• Vertebral Artery Test• Foraminal Compression Test OR Spurling’s Test• Cervical Distraction Test• Cervical Compression Test• Scalene Cramp Test• Adson’s Test• Halstead Maneuver OR Reverse Adson’s Test OR Wright’s Test OR Hyperabduction Test• Costoclavicular Test (Military Brace)• Upper Limb Tension Tests (1, 2, 3, & 4)

15.

OUTCOME MEASURES FOR THE CERVICALSPINE

Outcome Measures for The Cervical Spine


• Self-Rated Recovery Question• Patient-specific Functional Scale• Neck Pain and Disability Scale• Neck Disability Index

16.

BONE & SOFT TISSUE PALPATION FOR THECERVICAL SPINE

Bone & Soft Tissue Palpation for The Cervical Spine

A selection of regional structures to keep in mind while assessing and treating patients suffering from neck pain mayinclude:

• Upper Cervical Spine (suboccipitals, upper trapezius, splenius cervicis, splenius capitis)• Levator Scapula• Longus Colli & Capitis• Rhomboid Minor and Major• Occipitofrontalis• Corrugator Supercilii• Sternocleidomastoid• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Temporomandibular Joint

◦ Medial Pterygoid◦ Temporalis◦ Masseter◦ Suprahyoid Muscle Group (digastric, stylohyoid, geniohyoid, and mylohyoid)◦ Infrahyoid Muscle Group (sternohyoid, sternothyroid, thyrohyoid, and omohyoid)

17.

VERTEBRAL ARTERY TEST

Vertebral Artery Test

Use: To assess for deficiency of circulation of the vertebral artery

Procedure: Client seated or supine; active or passive rotation & extension of neck; 30 sec.

Findings: Dizzy, nystagmus – rapid eye movement back and forth

*Note: if positive, return head quickly and smoothly to neutral; no further testing, refer to MD; techniques with neck insimilar positions should also be avoided



18.

SPURLING’S TEST

Spurling’s Test

Use: To assess for compression of cervical nerve root or facet joint irritation.

Procedure: Client seated; actively place neck in extension, lateral flexion, & rotation to affected side; carefully applydownward pressure on client’s head; no need to do if client has symptoms already.

Findings: Radiating pain or other neurological signs/symptoms on affected side; pain distribution will indicate whichnerve root is involved; local pain is a positive test for the facet joint.

CI: If positive for vertebral artery, do not do this one.



19.

CERVICAL DISTRACTION TEST

Cervical Distraction Test

Use: To relieve pressure on nerve roots especially after Spurling’s and Cervical Compression

Procedure: Seated/supine, grasp head at occiput, put head into neutral & slowly traction superiorly, hold for 30 seconds

Findings: If pain reduces, test is positive for reducing pressure on facets or nerve roots; presence of pain may indicateshort intrinsics



20.

CERVICAL COMPRESSION TEST

Cervical Compression Test

Use: As with Spurling’s but used can be used when client cannot rotate or extend head

Procedure: Client seated with neck in neutral, therapist stands behind & carefully applies downward pressure on clientshead

Findings: Radiating pain or other neurological signs and symptoms on affected side; pain distribution will indicate nerveroot is involved; local pain indicate facet joint



21.

SCALENE CRAMP TEST

Scalene Cramp Test

Use: To reproduce pain of active scalene triggerpoints

Procedure: Client seated; Rotate head to affected side and pull chin inferiorly to the supraclavicular fossa

Findings: Positive findings is pain referred pattern for the scalene muscles



22.

ADSON’S TEST

Adson’s Test

Use: To test for thoracic outlet syndrome caused by scalenes anticus tightness

Procedure: Straight arm, palpate radial pulse, extend arm and have client look over same side shoulder and hold breath

Findings: Positive finding is decreased radial pulse or a recreation of the clients signs and symptoms

Contraindication/Precautions: If unable to get full range of motion of the shoulder in the ranges required

Note: Holding breath activates the scalenes muscles which will further shorten/tighten them and make the signs andsymptoms easer to produce



23.

HALSTEAD MANEUVER OR REVERSE ADSON’STEST OR WRIGHT’S TEST ORHYPERABDUCTION TEST

Halstead Maneuver OR Reverse Adson’s Test OR Wright’sTest OR Hyperabduction Test

Use: To test for thoracic outlet syndrome caused by pectoralis minor tightness.

Procedure: Straight arm, palpate radial pulse, abduct shoulder to >90 degrees with extension.

Findings: Positive findings is a decreased radial pulse or a recreation of the client’s signs and symptoms.



24.

COSTOCLAVICULAR TEST (MILITARY BRACE)

Costoclavicular Test (Military Brace)

Use: To test for thoracic outlet syndrome caused by compression of the neurovascular bundle between the clavicle and1st rib

Procedure: Straight arm, palpate radial pulse, passively depress and retract shoulder

Findings: Positive finding is decrease radial pulse or a recreation of signs and symptoms



25.

UPPER LIMB NEURODYNAMIC TESTS

Upper Limb Neurodynamic Tests (1,2,3,4)

Upper Limb Neurodynamic Tests (Koulidis et al., 2019)

1 2 3 4 5 6

ULNT –Median (1)

Shoulder girdlestabilization

Shoulderabduction

Wrist/fingerextension

Forearmsupination

Shoulder externalrotation

Elbowextension

ULNT –Median (2)

Shoulder girdledepression

Elbowextension

Shoulder externalrotation

Forearmsupination


Shoulderabduction

ULNT –Radial (3)

Shoulder girdledepression

Elbowextension

Shoulder internalrotation

Forearmpronation

Wrist/fingerflexion

Shoulderabduction

ULNT –Ulnar (4)


Forearmpronation Elbow flexion Shoulder external

rotationShoulder girdledepression

Shoulderabduction



38 | UPPER LIMB NEURODYNAMIC TESTS

PART V

SHOULDER ASSESSMENT

Shoulder Assessment


• Apprehension Test OR Crank Test• Hawkins Kennedy Impingement Test• Acromioclavicular Shear Test• Speed’s Test• Yergason’s Test• Empty Can (Supraspinatus) Test• Drop Arm Test OR Codman’s Test• Apley’s Scratch Test• Sulcus Sign Test• Neer’s Test• Roo’s Test (EAST)• Slap Lesion Cluster• Load & Shift – Anterior• Scapular Retraction• AC Crossbody Adduction Test (Acromioclavicular Crossover)• Posterior Capsule Tightness• Serratus Anterior Strength Test (Punch Out)• Jerk Test (Posteroinferior Labral Tear)• Scapular Load Test• O’Brien Test (Active Compression Test)• Lift-off Sign• Abdominal Compression Test (Belly Press or Napoleon Test)• Painful Arc Test

26.

OUTCOME MEASURES FOR THE SHOULDER

Outcome Measures for The Shoulder


• Self-Rated Recovery Question• Patient-specific Functional Scale• DASH Outcome Measure• Upper Extremity Functional Index• Western Ontario Rotator Cuff (WORC) Index

27.

BONE & SOFT TISSUE PALPATION FOR THESHOULDER

Bone & Soft Tissue Palpation for The Shoulder

A selection of regional structures to keep in mind while assessing and treating patients suffering from shoulder pain mayinclude:

• Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)• Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)• The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)• Deltoid Muscle Group (anterior, middle, posterior)• Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus• External Obliques, Internal Obliques, and Transverse Abdominal• Thoracolumbar Fascia, Latissimus Dorsi and Teres Major• Quadratus Lumborum

28.

APPREHENSION TEST OR CRANK TEST

Apprehension Test OR Crank Test

Use: To an in assess a previous dislocation in chronic.Procedure 1: Active Free – Client supine, abduct, extend, laterally rotate arm.Procedure 2: Passive Relax – Client supine, abduct, extend, laterally rotate arm.

Findings: Positive finding is apprehension or an unwillingness to move arm into position of injury.

Note: If active free is positive, do not perform passive relax and instead do active resisted of muscle crossing theglenohumeral joint. If active free is negative, progress to passive relaxed if passive relaxed is negative, carefully challengethe joint. In the anterior direction to further assess the integrity.



29.

HAWKINS KENNEDY IMPINGEMENT TEST

Hawkins Kennedy Impingement Test

Use: To assess for supraspinatus tendinopathy

Procedure: Stabilize the scapula, passively abduct the shoulder to 90 degrees, flex the shoulder to 30 degrees, flex theelbow to 90 degrees, and internally rotate the shoulder

Findings: Positive finding is pain in shoulder

Note: Test may be performed in different degrees of forward flexion or horizontal adduction



30.

ACROMIOCLAVICULAR SHEAR TEST

Acromioclavicular Shear Test

Use: To assess integrity of the acromioclavicular joint

Procedure: Cup clavicle and spine of scapula, apply pressure

Findings: Positive finding is pain or abnormal movement of the acromioclavicularjoint.



31.

SPEED’S TEST

Speed’s Test

Use: To assess for biceps tendinitis

Procedure: Flex shoulder 60 degrees, palm up, resist flexion

Findings: Positive finding is pain over the tendon on resistance; weakness

Note: More effective test for biceps tendon pathology



32.

YERGASON’S TEST

Yergason’s Test

Use: To assess the stability of the biceps tendon in the bicipital groove by the transverse humeral ligament or bicepstendinitis

Procedure: Elbow 90 degrees of flexion, supinate and externally rotate against resistance

Findings: Positive finding is pain and the sensation of the biceps popping out of the groove

Note: This test is not as effective as Speed’s for testing the biceps tendon due to limited movement of the tendon in thistest



33.

EMPTY CAN (SUPRASPINATUS) TEST

Empty Can (Supraspinatus) Test

Use: To test for weakness/tear of supraspinatus muscle.

Procedure: Abduct, internally rotate, resist.

Findings: Positive finding is weakness or pain indicating a tear in the supraspinatus muscle or tendon, or neuropathy ofthe suprascapular nerve.

Note: Test horizontal range.



34.

DROP ARM TEST OR CODMAN’S TEST

Drop Arm Test OR Codman’s Test

Use: To assess for a tear in the rotator cuff

Procedure: Abduct arm, lower slowly

Findings: Positive finding is pain when trying to return arm to side or inability to do so in a controlled manner

Note: Supraspinatus most common for rotator cuff injuries



35.

APLEY’S SCRATCH TEST

Apley’s Scratch Test

Use: To assess for combined movement at the shoulder

Procedure: Client attempts to reach each hand behind back on opposite sides (one over, one under)

Findings: Positive finding is limitation in movement

Note: As this is a combination of movements, the therapist needs to determine which individual movements arerestricted and which are not



36.

SULCUS SIGN TEST

Sulcus Sign Test

Use: To test for inferior instability of the glenohumeral joint

Procedure: Palpate head of Humerus, pull inferiorly just below elbow joint

Findings: Positive finding is gap between the inferior margin of the acromion and the humeral head; can be measuredand further graded (+1=less than 1 cm, +2=1-2cm, +3=more than 2cm)

Note: Shoulder should be tested in more than one position



37.

NEER’S TEST

Neer’s Test

Use: To assess for overuse injury of the supraspinatus and sometimes biceps

Procedure: Thumbs up, flex shoulders through full range

Findings: Positive finding is pain in shoulder



38.

ROO’S TEST (EAST)

Roo’s Test (EAST)



39.

SLAP LESION CLUSTER

SLAP Lesion Cluster

Test clustering is a systematic process of grouping special tests together to facilitate clinical decision making. SLAP lesioncluster two test used to assess for SLAP Lesions, the tests are:

• Active Compression Test• Passive Distraction Test



40.

LOAD & SHIFT - ANTERIOR

Load & Shift – Anterior



41.

SCAPULAR RETRACTION TEST

Scapular Retraction Test



42.

CROSSBODY ADDUCTION TEST(ACROMIOCLAVICULAR CROSSOVER)

Crossbody Adduction Test (Acromioclavicular Crossover)



43.

POSTERIOR CAPSULE TIGHTNESS

Posterior Capsule Tightness



44.

SERRATUS ANTERIOR STRENGTH TEST(PUNCH OUT)

Serratus Anterior Strength Test (Punch Out)

Use: To assess strength of serratus anterior muscle.

Procedure: “Wall push-ups”, 5-10 times

Findings: Winging of the scapula indicates weakness in this muscle or long thoracic neuropathy



45.

JERK TEST (POSTEROINFERIOR LABRAL TEAR)

Jerk Test (Posteroinferior Labral Tear)



46.

O’BRIEN TEST (ACTIVE COMPRESSION TEST)

O’Brien Test (Active Compression Test)



47.

LIFT-OFF SIGN

Lift-off Sign

Use: To test for weakness/tear of the subscapularis tendon/muscle

Procedure: Place hand in small of back and lift off

Findings: Positive finding is client cannot lift the hand away from the back; abnormal motion of the scapula mayindicate scapular instability

Note: Test performed once actively and if client can do it, therapist adds load to push the hand toward the back; if clientshand is medially rotated as far as possible and the hand moves towards the back, it’s called a subscapularis “spring back”or lag test



48.

ABDOMINAL COMPRESSION TEST (BELLYPRESS OR NAPOLEON TEST)

Abdominal Compression Test (Belly Press or NapoleonTest)

Use: To assess the subscapularis muscle.

Procedure: The patient pushes into the abdomen (medial rotation of the shoulder).

Findings: Pain or limited strength of the subscapularis muscle.



49.

PAINFUL ARC TEST

Painful Arc Test

Use: To assess for impingement of the supraspinatus tendon or sub-acromial bursa.

Procedure: Standing, abduct Humerus.

Findings: Positive finding is pain starting at 60-70 degrees of abduction which eases off at 120 degrees (AC joint ifpainful after 120 degrees).



PART VI

ELBOW ASSESSMENT

Elbow Assessment


• Elbow Valgus and Varus Stress Tests• Moving Valgus Stress Test of the Elbow• Cozen’s Test• Mill’s Test• Medial Epicondylitis Test (Reverse Mill’s/Golfers Elbow)• Tinel’s Sign’s at the Elbow (Cubital Tunnel Syndrome)• Pronator Teres Syndrome Test• Elbow Flexion Test

50.

OUTCOME MEASURES FOR THE ELBOW

Outcome Measures for The Elbow


• Self-Rated Recovery Question• Patient-specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• Patient-Rated Elbow Evaluation (PREE)• Patient-Rated Tennis Elbow Evaluation (PRTEE)• DASH Outcome Measure• Upper Extremity Functional Index

51.

BONE & SOFT TISSUE PALPATION FOR THEELBOW

Bone & Soft Tissue Palpation for The Elbow

A selection of regional structures to keep in mind while assessing and treating patients suffering from elbow pain mayinclude:

• Scalene Muscle Group (anterior scalene, middle scalene, and posterior scalene)• Pectoral Region (pectoralis major, pectoralis minor, serratus anterior and subclavius)• Rotator Cuff (subscapularis, infraspinatus, teres minor, supraspinatus)• The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)• Anterior Interosseous Membrane• Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor

carpi ulnaris)• Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor

carpi ulnaris)• Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)

52.

ELBOW VALGUS AND VARUS STRESS TESTS

Elbow Valgus and Varus Stress Tests

Elbow Varus Stress Test

Use: Test for varus lateral collateral ligament (LCL) instability at the elbow

Procedure: Elbow flexed, slight supination, support forearm, gapping in/out to assess ligament

Findings: Positive finding is pain, decreased mobility, laxity as compared with the unaffected side

Elbow Valgus Instability Stress Test

Use: Test for medial collateral ligament (MCL) instability at the elbow

Procedure: Elbow flexed, slight supination, support forearm, gapping in/out to assess ligament

Findings: Positive finding is pain, decreased mobility, laxity as compared with the unaffected side



68 | ELBOW VALGUS AND VARUS STRESS TESTS

53.

MOVING VALGUS STRESS TEST OF THE ELBOW

Moving Valgus Stress Test of the Elbow



54.

COZEN’S TEST

Cozen’s Test

Use: To assess for lateral epicondylitis

Procedure: Elbow flexed, resist wrist extension in different positions

Findings: Positive finding is pain at the common extensor tendon and weakness



55.

MILL’S TEST

Mill’s Test

Use: To assess for tendinopathy of the common extensor tendon (lateral epicondyle)

Procedure: Flex wrist, extend elbow

Findings: Positive finding is pain local to the common extensor tendon



56.

MEDIAL EPICONDYLITIS TEST (GOLFERSELBOW)

Medial Epicondylitis Test (Reverse Mill’s/Golfers Elbow)

Use: To assess for medial epicondylitis.

Procedure: Extend elbow, resist flexion of the wrist.

Findings: Positive finding is pain at the common flexor tendon and weakness.



57.

TINEL'S SIGN'S AT THE ELBOW (CUBITALTUNNEL SYNDROME)

Tinel’s Sign at the Elbow (Cubital Tunnel Syndrome)

Use: To assess for nerve compression or regeneration of a peripheral nerve

Procedure: Flex elbow 45 degrees, tap nerve in-between olecranon process and medial epicondyle

Findings: Positve finding is paresthesia or tingling along the distribution of the nerve distal to where the nerve is tapped,or paresthesia/tingling at the most distal point where the nerve has regenerated



58.

PRONATOR TERES SYNDROME TEST

Pronator Teres Syndrome Test

Use: To determine if the pronator teres muscle is impinging the median nerve

Procedure: Flex elbow 90 degrees, handshake, resist pronation while extending elbow

Findings: Positive finding is tingling or paresthesia along median nerve distribution in the hand/forearm



59.

ELBOW FLEXION TEST

Elbow Flexion Test

Use: To determine if a cubital tunnel syndrome(impinging the ulnar nerve) is present.

Procedure: Depress shoulder, elbow flexed, wrist extension (what gesture).

Findings: Positive sign is tingling or paresthesia in the distribution of the ulnar nerve (in the forearm/hand).



PART VII

FOREARM, WRIST, AND HANDASSESSMENT

Forearm, Wrist, and Hand Assessment


• Finklestein’s Test• Sweater Finger Sign• Carpal Compression Test• Phalen’s Test• Allen Test• Murphy’s Sign• Tinel’s Sign – Median Nerve• Hoffman’s Sign• Froment’s Sign (Pinch Grip Test)• Triangular Fibrocartilage Complex (TFCC) Load

60.

OUTCOME MEASURES FOR THE FOREARM,WRIST, AND HAND

Outcome Measures for The Forearm, Wrist, and Hand


• Self-Rated Recovery Question• Patient Specific Functional Scale (PSFS)• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• DASH Outcome Measure• CTS-6 Evaluation Tool• Kamath and Stothard Questionnaire• Katz and Stirrat Hand Symptom Diagram• Upper Extremity Functional Index• Brigham and Women’s Carpal Tunnel Questionnaire• Boston Carpal Tunnel Questionnaire (BCTQ)• Patient-Rated Wrist Evaluation (PRWE)• Patient-Rated Wrist/Hand Evaluation (PRWHE)

61.

BONE & SOFT TISSUE PALPATION FOR THEFOREARM, WRIST, AND HAND

Bone & Soft Tissue Palpation for The Forearm, Wrist, andHand

A selection of regional structures to keep in mind while assessing and treating patients suffering from wrist or hand painmay include:

• The Upper Arm (biceps brachii, brachialis, coracobrachialis, triceps brachii)• Anterior Interosseous Membrane• Common Extensor Tendon (extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor

carpi ulnaris)• Common Flexor Tendon (pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor

carpi ulnaris)• Palmar Aponeurosis & Transverse Carpal Ligament• Carpal Bones (trapezium, trapezoid, capitate, hamate, scaphoid, lunate, triquetrum, pisiform)• Lumbricals

62.

FINKLESTEIN’S TEST

Finklestein’s Test

Use: To assess for D’equervan’s Tenosynovitis

Procedure: Client seated; client to make a fist with thumb inside; therapist stabilize forearm with one hand and ulnardeviate wrist with the other; or client can perform this motion actively

Findings: Pain along the radial aspect of the wrist – Abductor pollicus longus and Extensor pollicus brevis muscles areinvolved in this tenosynovitis

*Note: Test can be painful even if tendonitis not present; make sure assess both side



63.

SWEATER FINGER SIGN

Sweater Finger Sign

Use: To test for rupture of the flexor digitorum profundus tendon.

Procedure: Client is asked to make a fist. Therapist is looking to see if the distal phalanx of one of the fingers doesn’tflex.

Findings: If the distal phalanx of one of the fingers does not flex, it means that there has been a rupture of the flexordigitorum profundus tendon.



64.

CARPAL COMPRESSION TEST

Carpal Compression Test

Use: To assess for compression of the Median nerve.

Procedure: Examiner holds the supinated wrist in both hands and applies pressure with both thumbs to the carpaltunnel/medial nerve for 30 seconds.

Findings: Reproduction of client symptoms is considered positive for carpal tunnel syndrome.



65.

PHALEN’S TEST

Phalen’s Test

Use: To assess for compression of the Median nerve, as in carpal tunnel syndrome

Procedure: Client seated; client places dorsum of hands together with pressure; forearms in horizontal position; holdfor one minute

Findings: Tingling and pain. In the thumb, index, middle, and lateral half of ring fingers is + finding



66.

ALLEN'S TEST

Allen’s Test

Use: Assess for patency of radial and ulnar arteries

Procedure: Client to open/close hand several times & then squeeze hand tightly. Therapist places thumb and indexfinger over radial/ulnar arteries; client opens hand & therapist releases pressure over one artery at a time

Findings: This test determines which artery provides the major blood supply to the hand.A slow or no fill of the handby blood means that the artery may be blocked



67.

MURPHY’S SIGN

Murphy’s Sign

Use: Assesses for Lunate dislocation

Procedure: Ask client to make a fist. Therapist to note orientation of MCP joints.

Findings: If 3rd MC is level with the 2nd and 4th, this indicates a Lunate dislocation.



68.

TINEL’S SIGN - MEDIAN NERVE

Tinel’s Sign – Median Nerve

Use: To assess for nerve compression or regeneration of a peripheral nerve.

Procedure: Tap nerve over wrist where median nerve is located.

Findings: Positive sign is paresthesia or tingling along the distribution of the nerve distal to where the nerve is tapped,or paresthesia/tingling at the most distal point where the nerve has regenerated.



69.

HOFFMAN’S SIGN

Hoffman’s Sign



70.

FROMENT'S SIGN (PINCH GRIP TEST)

Froment’s Sign (Pinch Grip Test)

Use: Assesses for an Ulnar nerve lesion

Procedure: Client to grasp a piece of paper between the thumb and lateral aspect of index finger. Therapist to try andpull paper away.

Findings: Thumb will flex to keep paper in place due to weakness or paralysis of Abductor pollicus (supplied by ulnarnerve – Flexor pollicus is median)



71.

TRIANGULAR FIBROCARTILAGE COMPLEX(TFCC) LOAD

Triangular Fibrocartilage Complex (TFCC) Load



PART VIII

THORACOLUMBAR SPINE AND PELVISASSESSMENT

Thoracolumbar Spine and Pelvis Assessment


• Craig’s Test• Gaenslen’s Test• Gillet’s Test• Kemp’s Test OR Lower Quadrant Test• Kernig/Brudzinski Test• Rebound Tenderness (McBurney’s Point)• Piriformis Test OR FAIR Test• Cluster of Laslett (Sacroiliac Joint Pain Provocation)• Sacroiliac Compression (Squish) Test• Sacroiliac Distraction (Gap) Test• Thigh Thrust Test• Sacral Thrust Test• Slump Test• True Leg Length Measurement• Valsalva Maneuver• Well Leg Raise• Straight Leg Raise (Lasègue’s sign) or Bragard’s Test• Bowstring Maneuver• Supine-to-sit (Long Sitting)• Hoover Test• Prone Gap (Hibb’s) Test• Pheasant Test (Lumbar Instability Test)• Nachlas (Prone Knee Bend) Test• Yeomen’s Test

72.

OUTCOME MEASURES FOR THETHORACOLUMBAR SPINE AND PELVIS

Outcome Measures for The Thoracolumbar Spine andPelvis


• Self-Rated Recovery Question• Patient-specific Functional Scale• Oswestry Disability Index• Roland-Morris Disability Questionnaire• STarT Back Screening Tool (SBST)

73.

BONE & SOFT TISSUE PALPATION FOR THETHORACOLUMBAR SPINE AND PELVIS

Bone & Soft Tissue Palpation for The ThoracolumbarSpine and Pelvis

A selection of regional structures to keep in mind while assessing and treating patients suffering from lumbopelvic painmay include:

• Erector Spinae (iliocostalis, longissimus, spinalis)• Quadratus Lumborum• Multifidus• Thoracolumbar Fascia and Latissimus Dorsi• Muscles of The Abdomen (external obliques, internal obliques, transverse abdominis, and rectus abdominis)• Iliopsoas (iliacus and psoas major)• External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior,

and quadratus femoris)• Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)• Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)

74.

CRAIG'S TEST



75.

GAENSLEN’S TEST

Gaenslen’s Test

Use: To test for sacroiliac joint or hip dysfunction

Procedure:

1. Client in sideline; unaffected hip/knee to be flexed to chest & client to hold; standing behind, stabilize the hipwith one hand while hyperextending the leg at the hip with the other

2. Client supine; unaffected hip and knee flexed; therapist beside client; take affected leg and bring over side of table;stabilize opposite hip and challenge affected hip into extension

Findings: Pain in the sacroiliac joint or hip means that dysfunction is present



76.

GILLET’S TEST

Gillet’s Test

Use: To assess the mobility of the sacroiliac joint

Procedure: Client to stand & place hands against wall for stability; stand behind client & observe levels of posteriorsuperior iliac spine (PSIS); place one thumb on PSIS & other on S2; ask client to flex hip/knee; repeat on other side

Findings: Thumb of affected side moves superiorly as hip flexes or does not move at all; normal movement is indicatedif thumb on PSIS moves inferiorly as hip flexes



77.

KEMP’S TEST OR LOWER QUADRANT TEST

Kemp’s Test OR Lower Quadrant Test

Use: To assess for nerve root compression or facet joint irritation in the lumbar spine

Procedure: Client standing; instruct client to: Slowly extend, latterly bend and rotate the thoracolumbar spine to theaffected side…place hand on back of thigh and slide down

Findings: Local pain is positive for facet joint irritation; radiating pain down affected leg is positive for nerve root.



78.

KERNIG/BRUDZINSKI TEST

Kernig/Brudzinski Test

Use: To assess for pain caused by dural irritation, nerve root, or menigeal involvement.

Procedure: Client supine; client to flex head to chest (Brudzinski) and indicate if pain; then client to flex hip (Kernig)with knee in extension.

Findings: Pain at level of lesion and along the spine with referral to the affected limb; when pain present, client will flexknee involuntarily which will decrease stretch on dural tube and therefore decrease pain.

Note: The (passive) neck flexion part may also be referred to as Soto-Hal.



79.

REBOUND TENDERNESS (MCBURNEY’S POINT)

Rebound Tenderness (McBurney’s Point)

Use: To assess for possibility of appendicitis

Procedure: Client supine, knees/hips flexed; therapist applies slow pressure over McBurney’s point & then quicklyreleases

Findings: Severe pain when pressure is released usually in presence of low grade fever and nausea indicates possibleappendicitis and requires referral



80.

PIRIFORMIS TEST OR FAIR TEST

Piriformis Test OR FAIR Test

Use: To assess the length of piriformis

Procedure 1: Client prone, knees together; flex knees to 90 ̊; allow feet to fall out from midline as far as possible

Findings: Affected or short Piriformis will present as the leg staying closer to the midline relative to the other.

Procedure 2: Client side-lying with affected leg uppermost; keeping body from moving forward/back, ask client to flexhip & knee and drop knee toward the table.

Findings: Short Piriformis will prevent knee from dropping to the level of the table



81.

CLUSTER OF LASLETT (SACROILIAC JOINT PAINPROVOCATION)

Cluster of Laslett (Sacroiliac Joint Pain Provocation)

Test clustering is a systematic process of grouping special tests together to facilitate clinical decision making. The Clusterof Laslett is a group of four test used for sacroiliac joint pain, the four tests are:

• Sacroiliac Distraction (Gap) Test• Thigh Thrust Test• Sacroiliac Compression (Squish) Test• Sacral Thrust Test



82.

SACROILIAC COMPRESSION (SQUISH) TEST

Sacroiliac Compression (Squish) Test

Use: To stress test the posterior sacroiliac ligaments.

Procedure: Client supine; place hands on lateral aspect of anterior superior iliac spine (ASIS) & apply pressure towardsthe midline (can also be performed in side lying).

Findings: Pain local to the sacroiliac joint indicates a posterior sacroiliac ligament sprain.



83.

SACROILIAC DISTRACTION (GAP) TEST

Sacroiliac Distraction (Gap) Test

Use: To stress test the anterior sacroiliac ligaments.

Procedure: Client supine; place hands on medial aspect of anterior superior iliac spine (ASIS) in a cross arm fashion &apply pressure inferiorly & laterally.

Findings: Unilateral gluteal or posterior leg pain which indicates and anterior sacroiliac ligament sprain.

Note: Careful not to painfully compress the soft tissue medially and anteriorly to ASIS.



84.

THIGH THRUST TEST

Thigh Thrust Test



85.

SACRAL THRUST TEST

Sacral Thrust Test



86.

SLUMP TEST

Slump Test

Use: To detect problem with movement of the spinal cord

Procedure: Client seated; ask client to slump thoracolumbar spine fully with head erect, is there signs and symptoms?if not -flex head to chest –if no signs and symptoms; therapist to extend one unaffected knee and dorsiflex ankle; thenrepeat with other leg

Findings: Pain along the spine at the level of the lesion and/or referral to a limb is positive finding

1 2 3 4 5

Slump Hands behind back Thoracic flexion Extend one knee Dorsiflex foot Cervical flexion



SLUMP TEST | 105

87.

TRUE LEG LENGTH MEASUREMENT

True Leg Length Measurement

Use: Identifies leg length discrepancy.

Procedure: First place one end of the measuring tape over the anterior superior iliac spine (ASIS), then place the otherover the medial malleolus. Compare side to side.

Finding: If one leg measures longer than the other there is a leg length discrepancy.



88.

VALSALVA MANEUVER

Valsalva Maneuver

Use: To assess for space-occupying lesion (herniated disc, tumour) which increases pressure within the spinal cord.

Procedure: Client seated & instructed to take a breath & bear down/or put thumb in mouth, make a seal & blow as ifblowing up a balloon.

Findings: Positive finding is pain local to the site of lesion or radiates in a dermatomal pattern (pain may also bereproduced with cough or sneeze).

Contraindication: Use test cautiously with cardiovascular disorders –will decrease blood flow to heart and increaseblood pressure.



89.

WELL LEG RAISE

Well Leg Raise

Use: To help assess possible cause of low back painProcedure: Client supine; unaffected leg is lifted toward 80-90 ̊ of hip flexion

Findings: Pain on the opposite side indicates a space occupying lesion such as herniated disc between 30-70 degrees, painat end range = hamstrings or sacroiliac joint

Note: Test causes stretch of ipsilateral & contralateral nerve root



90.

STRAIGHT LEG RAISE (LASÈGUE'S SIGN) ORBRAGARD'S TEST

Straight Leg Raise (Lasègue’s sign) or Bragard’s Test

Use: To help determine cause of low back pain.

Procedure: Client supine; leg extended; passive flexion at hip until client complains of pain or tightness; leg taken out ofpainful range and Braggard’s performed.

Findings:

• Pain in posterior thigh = tight/short hamstrings.• Pain down posterior leg to foot, and with Braggard’s = Sciatic nerve involvement Pain after 70 ̊ = Joint pain from

SI/Lumbar.• Pain in opposite leg = Space occupying lesion or disc herniation (WLR).

Note: A unilateral straight leg raise is full at 70 degree.

1 2 3 4

StraightLeg Raise

Supineposition

Raise the legwith the kneeextended

If pain radiates when the angle of theleg is between 30 and 70 degrees(positive)

Increased pain on dorsiflexion of the patient’sfoot increases sensitivity of the test



110 | STRAIGHT LEG RAISE (LASÈGUE'S SIGN) OR BRAGARD'S TEST

91.

BOWSTRING MANEUVER

Bowstring Maneuver

Use: To determine if pain related to sciatic nerve involvement

Procedure: Client supine; place client heel of testing leg on therapist shoulder, knee bent; strum sciatic nerve in poplitealfossa

Findings: Positive fining is pain which is related to pressure or tension on the sciatic nerve.

Note: If seated, test is called Sciatic tension test



92.

SUPINE-TO-SIT (LONG SITTING)

Supine-to-sit (Long Sitting)

Use: Assesses for a functional leg length discrepancy due to pelvic dysfunction

Procedure: Client supine with knees extended; compare levels of both malleoli and make sure level; instruct client to situp & note if one limb appears to move proximal relative to the other leg

Findings: If one leg moves farther up/proximal relative to the other, there is a functional leg length difference due to apelvic rotation or torsion. Spasm of the lumbar muscles may also be the cause.



93.

HOOVER TEST

Hoover Test

Use: To assess for malingering (exaggerating symptoms for personal gain)

Procedure: Client supine; therapist places hands under heels of feet; ask client to lift one leg; test bilaterally

Findings: If client does not lift leg/attempt or therapist does not feel pressure under the other heel, the client is likelynot trying



94.

PRONE GAP (HIBB'S) TEST

Prone Gap (Hibb’s) Test

Use: To stress test the posterior sacroiliac ligaments.

Procedure: Client prone; therapist stabilizes clients pelvis; clients knee is flexed to 90 ̊ and hip is rotated medially as far aspossible. Therapist to palpate the sacroiliac joint on the same side, at the very end of rotation. Repeat on the other side.

Findings: Therapist to note the amount of movement and the quality of movement on each side (looking for hyper/hypomobility and movement will possibly cause discomfort in the posterior sacroiliac ligaments as they are being stressedin the event of injury/sprain.



95.

PHEASANT TEST (LUMBAR INSTABILITY TEST)

Pheasant Test (Lumbar Instability Test)

Use: To test for unstable spinal segments in the lumbar spine.

Procedure: Client prone; therapist to apply gentle pressure to the lumbar spine; with other hand, passively flex clientsknees to buttocks.

Findings: Pain in the leg indicates an unstable spinal segment and is considered a positive finding.



96.

NACHLAS (PRONE KNEE BEND) TEST

Nachlas (Prone Knee Bend) Test

Use: Primarily to assess for neurological dysfunction in the lumbar, but also assesses tight quadriceps.

Procedure: Client prone; therapist passively flexes knee as much as possible to the buttock; maintain for 45-60 secondsTherapist should make sure hip is not rotating during test.

Findings: Unilateral pain in lumbar area may indicate a L2 or L3 nerve root lesion; test also stretches the femoral nerve;pain in anterior thigh = tight quadriceps.

Note: If client cannot fully flex knee, extend hip with knee flexed as much as possibleAdditional Note: May also be called femoral nerve stretch test or Reversed Lasègue



97.

YEOMAN'S TEST

Yeoman’s Test

Use: To assess for lumbar joint dysfunction.

Procedure: Client prone; therapist stabilizes pelvis on testing side & extends each hip in turn with knees extended, andthen flexed.

Findings: Pain in lumbar spine during both parts of the test.



PART IX

HIP ASSESSMENT

Hip Assessment


• FABER (Flexion-Abduction-External Rotation) Test (Patrick’s Test)• FADDIR (Flexion-Adduction-Internal Rotation) Test• Trendelenburg Sign• Thomas Test• Ely’s Test• Ober’s Test• 90-90 Straight Leg Test• Piriformis Strength Test (Pace Maneuver)• Hip Quadrant Test (Scouring Test)

98.

OUTCOME MEASURES FOR THE HIP

Outcome Measures for The Hip


• Self-Rated Recovery Question• Patient Specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• The Western Ontario and McMaster Universities Arthritis Index (WOMAC)• Lower Extremity Functional Scale (LEFS)

99.

BONE & SOFT TISSUE PALPATION FOR THE HIP

Bone & Soft Tissue Palpation for The Hip

A selection of regional structures to keep in mind while assessing and treating patients suffering from hip pain mayinclude:

• Iliopsoas (iliacus and psoas major)• Hip Adductors (adductor brevis, adductor longus, adductor magnus, pectineus, gracilis)• External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior,

and quadratus femoris)• Quadricep Muscles (rectus femoris, vastus lateralis, vastus mediali, vastus intermedius)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)• Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)• Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus• Quadratus Lumborum• Thoracolumbar Fascia & Latissimus Dorsi

100.

FABER (PATRICK’S) TEST

FABER (Patrick’s) Test

Use: To assess the hip and psoas muscle.

Procedure:Part 1: Client supine with legs extended; put foot of affected side on the knee of unaffected side –“4”.Findings: If affected knee remains above unaffected then possible hip pathology or psoas spasm, adductor.

Part 2: Stabilize the unaffected anterior superior iliac spine & with other hand, gently push down on the medial aspectof the knee.Findings: Pain local to the sacroiliac joint indicating sacroiliac dysfunction.



101.

FADDIR (FLEXION-ADDUCTION-INTERNALROTATION) TEST

FADDIR (Flexion-Adduction-Internal Rotation) Test



102.

TRENDELENBURG SIGN

Trendelenburg Sign

Use: Assesses for weak gluteus medius

Procedure: Client standing; stand behind client & instruct them tot stand on the affected leg; observe the non-weightbearing side of the pelvis

Findings: Pelvis on non-weightbearing side will drop or stay level indicating a weak hip abductor, mainly gluteusmedius. The pelvis should raise slightly if negative



103.

THOMAS TEST

Thomas Test

Use: To assess for shortness or contracture of the hip flexors.

Procedure 1 (Thomas Flexion): Client supine with hips & knees flexed; while maintaining the unaffected hip & kneein flexion, have client lower the affected leg into extension as far as it will go; watch for amount of flexion at hip & makesure that lumbar is flat.Findings: If the posterior knee will not touch the table then hip flexors are short.

Procedure 2 (Rectus Femoris Contracture Test): Same as procedure #1, only client is at end of table which will allowthe therapist to see what the knee is doing in addition to the hip.Findings: As above, plus looking for the knee to extend which would indicate rectus femoris shortness.



104.

ELY’S TEST

Ely’s Test

Use: Assesses for rectus femoris shortness

Procedure: Client prone; flex the affected knee toward the buttocks; make sure leg does not abduct; observe the pelvis

Findings: If pelvis on affected side flexes as the knee is being flexed, indicates short rectus femoris



105.

OBER’S TEST

Ober’s Test

Use: Assess for iliotibial band and tensor fascia latae shortness.

Procedure 1: Client sideline edge of table with affected leg superior; client to flex unaffected leg; stand behind client &stabilize pelvis at lateral ilium with one arm/hand; with other hand, passively abduct & extend femur with knee flexed &allow the leg to lower without rotation.

Findings: If leg remains strongly abducted; indicates a short tensor fascia latae. There is also stress placed on the femoralnerve and if this is involved, neurological signs will be present. Pain over the Greater Trochanter indicates bursitis.

Procedure 2: Same as procedure #1, but keep knee extended and lower leg without rotation (This places less stress onthe knee and reduces interference from a short rectus femoris).

Findings: If leg remains strongly abducted, indicates a short iliotibial band and tensor fascia latae as greater stress isplaced on the iliotibial band with the knee extended.



OBER’S TEST | 127

106.

90-90 STRAIGHT LEG TEST

90-90 Straight Leg Test



107.

PIRIFORMIS STRENGTH TEST (PACEMANEUVER)

Piriformis Strength Test (Pace Maneuver)

Use: To assess the strength of piriformis muscle.

Procedure: Client prone with knee flexed to 90 ̊; stabilize opposite pelvis; move foot of testing leg across the midline sothat the femur is externally rotated; client to hold; therapist to apply pressure to medial ankle in lateral direction.

Pace Maneuver: Seated: Knees together, hands on lateral knees, abduct against resistance.

Findings: Client is unable to hold position, or resist pressure indicating weakness of piriformis and other lateral rotators.



108.

HIP QUADRANT TEST (SCOURING TEST)

Hip Quadrant Test (Scouring Test)

Use: Assess joint capsule tightness or other pathology of the hip.

Procedure: Client supine; flex and adduct affected hip so that knee is facing opposite shoulder; move the hip through anarc into abduction & feel quality of mvmt. through range.

Findings: An early, leathery end feel, crepitus or jerky movement & pain or apprehension indicates capsular tightness,other pathology, or osteophyte formation.



PART X

KNEE ASSESSMENT

Knee Assessment


• Bounce Home• Apley’s Test (Compression/Distraction)• McMurry’s Test• Valgus Stress Test (Medial Collateral Ligament)• Varus Stress Test (Lateral Collateral Ligament)• Noble’s Compression• Lachman’s Test• Anterior Drawer Test• Posterior Drawer Test• Posterior Sag Sign (Gravity Drawer Test)• Coronary Ligament Stress Test• Patellar Grind Test (Clarke’s Sign)• Thessaly Test• Bragard’s Sign• Mediopatellar Plica Test (Hughston Plica Test)• Plica “Stutter” Test• Ballotable Patella (Major Effusion or Patellar Tap Test)• Brush Test (Minor Effusion, Stroke, OR Wipe Test)• Fluctuation Test• Waldron’s Test• McConnell Patellofemoral Knee Test• Q-Angle• Patellar Apprehension Test• Patellar Deep Tendon Reflex

109.

OUTCOME MEASURES FOR THE KNEE

Outcome Measures for The Knee


• Self-Rated Recovery Question• Patient Specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• The Western Ontario and McMaster Universities Arthritis Index (WOMAC)• Lower Extremity Functional Scale (LEFS)

110.

BONE & SOFT TISSUE PALPATION FOR THEKNEE

Bone & Soft Tissue Palpation for The Knee

A selection of regional structures to keep in mind while assessing and treating patients suffering from knee pain mayinclude:

• Hip Adductors (adductor brevis, adductor longus, adductor magnus, pectineus, gracilis)• Quadricep Muscles (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)• Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)• Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus

tertius)• Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)• Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior,

popliteus)• Proximal Tibiofibular Joint• Ankle Joint (talocrural joint, subtalar joint and inferior tibiofibular joint)

111.

BOUNCE HOME TEST

Bounce Home Test

Use: Assesses meniscal tearing

Procedure: Client supine with knee flexed & heel cupped in therapist hand; knee is passively allowed to extend

Findings: Incomplete extension or springy block end feel indicates that likely a torn meniscus is blocking movement

Note: Caution when letting leg fall into full extension quickly if knees are hyperextended to begin with, will beuncomfortable



112.

APLEY'S TEST

Apley’s Test

Apley’s Distraction Test

Use: Assesses integrity of collateral ligaments of the knee

Procedure: Client prone, knee flexed to 90º; therapist stabilizes thigh with knee, & wraps hands around distal end oftibia; pull tibia superiorly & apply internal and external rotation

Findings: Medial aspect pain= MCL; Lateral aspect pain = LCL

Apley’s Compression Test

Use: Assesses for meniscal damage

Procedure: Client prone, knee flexed to 90º; place one hand on foot, other on tibia; compress knee into table, theninternal/external rotate tibia

Findings: Medial aspect joint line pain = medial menisus; lateral aspect joint line pain = lateral meniscus



136 | APLEY'S TEST

113.

MCMURRY’S "CLICK" TEST

McMurry’s “Click” Test

Use: Assesses for meniscal damage (& somewhat the MCL)

Procedure: Client supine, knee/hip flexed; cup hand over knee with fingers/thumb over joint line with one hand; withother hand, grasp heel; slowly extend knee while placing various stresses at knee to check both menisci

Findings: An audible click, catching, and pain during extension of the knee

• Medial = external rotation of tibia with valgus stress• Lateral = internal rotation of tibia with varus stress



114.

VALGUS STRESS TEST (MEDIAL COLLATERALLIGAMENT)

Valgus Stress Test

Use: To assess the integrity of the medial collateral ligament & other structures preventing medial instability of the knee

Procedure: Client supine; stabilize tibia in slight lateral rotation while applying a valgus stress at the knee; repeat withknee in slight flexion

Findings: Tibia will move away from the femur (medially) excessively. Pain is also an indicator.

• Knee extended: MCL, ACL, PCL or joint capsule may have been damaged• Knee flexed: MCL, PCL, or joint capsule may have been damage



VALGUS STRESS TEST (MEDIAL COLLATERAL LIGAMENT) | 139

115.

VARUS STRESS TEST (LATERAL COLLATERALLIGAMENT)

Varus Stress Test (Lateral Collateral Ligament)

Use: To assess the integrity of the lateral collateral ligament & other structures preventing lateral instability of the knee.

Procedure: Client supine; stabilize tibia in neutral while applying a varus stress at the knee; perform again with kneeslightly flexed.

Findings: Tibia will move away from femur (laterally), excessively. Pain is also an indicator.

• Knee extended: LCL, ACL, PCL, ITB, Lateral Gastrocnemius, joint capsule or biceps femoris tendon may havebeen damaged.

• Knee flexed: LCL, ITB, Biceps femoris tendon or joint capsule may have been damaged.



VARUS STRESS TEST (LATERAL COLLATERAL LIGAMENT) | 141

116.

NOBLE’S COMPRESSION

Noble’s Compression

Use: To assess for iliotibial band friction syndrome

Procedure: Client supine, knee flexed to 90º. Firmly compress Iiliotibial band approx. 2 cm proximal to lateral femoralcondyle. While maintaining pressure, client is to slowly extend knee.

Findings: Pain over lateral epicondyle at approx. 30º of knee extension indicates Iiliotibial friction syndrome



117.

LACHMAN’S TEST

Lachman’s Test

Use: To assess the integrity of the ACL (considered more accurate test than Draw)

Procedure: Client supine, knee flexed to 30º; this is the position where the ACL play major role; stabilize femur withone hand while proximal end of tibia is moved forward with the other

Findings: Pain and excessive anterior movement of the tibia indicates damage to the ACL

Note: See Magee for variations and pick one that best suits you and allows you to perform the test competently



118.

ANTERIOR DRAWER TEST

Anterior Drawer Test

Use: Assess integrity of the anterior stability of the knee.

Procedure: Client supine, hip/knee flexed; therapist stabilize foot, places hands behind tibia and draws it forward.

Findings: Excessive forward movement of tibia with pain indicates that the ACL, Joint capsule, MCL may have beendamaged.

Note: If there is an audible snap or palpable jerk (Finochietto’s jumping sign) when the tibia is pulled forward and thetibia moves with it, a meniscus lesion may be accompanying the torn anterior cruciate ligament.



119.

POSTERIOR DRAWER TEST

Posterior Drawer Test

Use: Assesses integrity of posterior stability of the knee

Procedure: Client supine, hip/knee flexed; therapist stabilize foot, places hands on anterior portion of tibia and pushesposteriorly

Findings: Excessive posterior movement of tibia with pain indicates that the PCL, ACL may have been damage



120.

POSTERIOR SAG SIGN (GRAVITY DRAWER TEST)

Posterior Sag Sign (Gravity Drawer Test)

Use: To assess integrity of the posterior cruciate ligament.

Procedure: Client supine with hip/knees flexed; observe profile of knees from side of table.

Findings: The affected tibia sags posteriorly compared to the unaffected side which indicates a torn PCL.

Note: The PCL should be tested for a posterior sag before the ACL is tested to rule out false-positive test for an ACLinjury.



121.

CORONARY LIGAMENT STRESS TEST

Coronary Ligament Stress Test

Use: Assesses integrity of coronary ligament.

Procedure: Client seated, knee flexed to 90 ̊; therapist passively externally rotates tibia on femur.

Findings: Pain on external rotation of tibia is positive for coronary ligament sprain.

Note: Sprain of this ligament will show no pain with a valgus stress test.



122.

PATELLAR GRIND TEST (CLARKE’S SIGN)

Patellar Grind Test (Clarke’s Sign)

Use: To assess for patellofemoral syndrome

Procedure: Client supine, knees extended, compress patella posteriorly & inferiorly; instruct client to contractquadriceps

Findings: If apprehension, pain, & crepitus are present, test is positive

Note: If too much force is used, may be discomfort anyway; use gradual pressure



123.

THESSALY TEST

Thessaly Test

Use: To evaluate for meniscal damage.



124.

BRAGARD’S SIGN

Bragard’s Sign

Use: Assesses for meniscal tearing.Procedure: Client supine, knee/hip flexed; externally rotate tibia while extending knee; stabilize femur to preventmovement.Findings: Pain along the medial aspect of joint line = medial meniscus; pain along lat. aspect of joint line when testperformed with internal rotation = lateral meniscus.

125.

MEDIOPATELLAR PLICA TEST (HUGHSTONPLICA TEST)

Mediopatellar Plica Test (Hughston Plica Test)

Use: To assess for a mediopatellar plica as source of knee pain.Procedure: Client supine; knee flexed by therapist to 30 ̊ and then moves the patella medially, pinching the plicabetween the edge of the patella and the femoral condyle.Findings: Pain in area where plica is pinched.

126.

PLICA “STUTTER” TEST

Plica “Stutter” Test

Use: To identify the presence of a plica.Procedure: Client seated; knee flexed to 90 ̊. Therapist places one finger over the patella to palpate while client slowlyextends the knee.Findings: The patella stutters or jumps somewhere between 60 ̊ and 45 ̊ during an otherwise smooth movement.Note: Can only do this if no joint swelling is present.



127.

BRUSH TEST (MINOR EFFUSION, STROKE, ORWIPE TEST)

Brush Test (Minor Effusion, Stroke, OR Wipe Test)

Use: To assess for minor effusion at the knee.

Procedure: Client supine; affected knee in extension; therapist to slowly brush effusion upwards from medial aspect ofknee with one hand several times, then with the other hand, strokes down the lateral aspect of the knee.

Findings: If present, a wave of fluid will pass to the medial aspect of the knee and bulge just distally to the medial portionof the patella. It may take several seconds to appear.

Note: If major or minor tests positive, refer for immediate medical attention.



128.

BALLOTABLE PATELLA (MAJOR EFFUSION ORPATELLAR TAP TEST)

Ballotable Patella (Major Effusion or Patellar Tap Test)

Use: To assess for major effusion at the knee.Procedure: Client supine, affected knee in extension; compress patella down into condyles of femur and release.Findings: Patella clicks down onto femur & rebounds to floating position.



129.

FLUCTUATION TEST

Fluctuation Test

Use: To assess for significant knee effusion.Procedure: Client supine; therapist places palm of one hand over the suprapatellar pouch and the palm of the otherhand anterior to the joint. Therapist will press down with one hand and then the other.Findings: The therapist can feel the fluid fluctuate under the hands and move from one hand to the other.

130.

WALDRON’S TEST

Waldron’s Test

Use: To assess for patellofemoral syndrome.Procedure: Client standing; therapist in front; client does a few slow deep knee bends while therapist palpates patella.Findings: Pain, crepitus & poor tracking of the patella are present indicating patellofemoral syndrome symptoms.



131.

MCCONNELL PATELLOFEMORAL KNEE TEST

McConnell Patellofemoral Knee Test

Use: To assess for patellofemoral tracking problems

Procedure: Client seated with femur externally rotated; client to isometrically contract quadriceps at: 120, 90, 60, 30,0; hold each 10 sec.; If pain produced at any degrees tested, knee is passively returned to full extension; therapist to thensupport clients leg and push patella medially; maintain this position while placing leg back into the angle of pain; clientis again asked to contract quadriceps

Findings: If pain is decreased when returned to the painful position with medial pressure on the patella, the pain isconsidered to be patellofemoral in origin



132.

Q-ANGLE

Q-Angle

Use: To determine if client will be prone to patellar tracking problems.Findings: Normal is 13 ̊ for males and 18 ̊ for females when the knee is straight.



133.

PATELLAR APPREHENSION TEST

Patellar Apprehension Test

Use: To assess if patella is likely to laterally dislocate

Procedure: Client supine, knee extension; with thumbs on medial aspect of patella, slowly move patella laterally; observeclient

Findings: Client may attempt to move away or have look of apprehension on face



134.

PATELLAR DEEP TENDON REFLEX

Patellar Deep Tendon Reflex (L3/L4 myotome)

Procedure: Flex the leg at the knee and hip. Hold the leg under the knee and then strike the patellar tendon and watchfor quadriceps contraction.



PART XI

LOWER LEG, ANKLE, AND FOOTASSESSMENT

Lower Leg, Ankle, and Foot Assessment


• Functional/Structural Pes Planus Test• Talar Tilt Test• Anterior Drawer of the Ankle• Calcaneocuboid Stress Test• Calcaneofibular Stress Test• Talofibular Ligament Stress Test (Anterior & Posterior)• Deltoid Ligament Stress Test• Dorsiflexion External Rotation Stress Test (Kleiger Test)• The Syndesmosis Squeeze Test• Thompson’s Test• Toe/Heel Walking• Tinel’s Sign – Tarsal Tunnel• Tinel’s Sign – Anterior Tarsal Tunnel• Morton’s Neuroma Test (Metatarsal Squeeze Test)• Homan’s Sign• Babinski’s Test/Reflex

135.

OUTCOME MEASURES FOR THE LOWER LEG,ANKLE, AND FOOT

Outcome Measures for The Lower Leg, Ankle, and Foot


• Self-Rated Recovery Question• Patient Specific Functional Scale• Brief Pain Inventory (BPI)• Visual Analog Scale (VAS)• Lower Extremity Functional Scale (LEFS)• Foot and Ankle Ability Measure• Foot and Ankle Disability Index

136.

BONE & SOFT TISSUE PALPATION FOR THELOWER LEG, ANKLE, AND FOOT

Bone & Soft Tissue Palpation for The Lower Leg, Ankle,and Foot

A selection of regional structures to keep in mind while assessing and treating patients suffering from lower leg, ankle, orfoot pain may include:

• Plantar Fascia• Lumbricals• Adductor Hallucis• Flexor Hallucis Brevis• Metatarsals & Interossei• Peroneals (peroneus longus, peroneus brevis)• Hamstring Muscles (semimembranosus, semitendinosus and biceps femoris)• Anterior Compartment of the Leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus

tertius)• Superficial Posterior Compartment of the Leg (gastrocnemius, soleus, plantaris)• Deep Posterior Compartment of the Leg (flexor hallucis longus, flexor digitorum longus, tibialis posterior,

popliteus)• Ankle Joint (the talocrural joint, subtalar joint and the inferior tibiofibular joint)

137.

FUNCTIONAL/STRUCTURAL PES PLANUSTEST

Functional/Structural Pes Planus Test

Use: To assess if pes planus is functional, or structural.

Procedure: Client standing; observe medial longitudinal arch; client to raise on toes – observe; client to sit so non-weightbearing – observe.

Findings: When client raises on toes or when non-weight bearing, arch will return if functional. If arch does not returnor does not present itself in seated or toe raise, test is likely + for structural pes planus.



138.

TALAR TILT TEST

Talar Tilt Test

Use: To test for tearing of the calcaneofibular ligament (CFL)

Procedure: Client supine or sidelying; flex client knee to relax and place ankle in anatomical position; therapist to tilttalus into adduction (calcaneofibular) and abduction (deltoid).

Findings: Pain and increased mobility compared to the unaffected limb.



139.

ANTERIOR DRAWER OF THE ANKLE

Anterior Drawer of the Ankle

Use: To assess integrity of anterior talofibular ligament (ATFL)

Procedure: Client supine, knees extension; therapist stabilizes tib/fib with one hand; the other hand cups calcaneus &places ankle in 20 ̊ of plantar flexion with slight distraction, & pulls ant.

Findings: Excessive movement in the anterior direction with a possible clunk sound indicates ligament laxity or possiblerupture



140.

CALCANEOCUBOID STRESS TEST

Calcaneocuboid Stress Test

Use: To assess integrity of the calcaneocuboid ligament

Procedure: One hand cups calcaneus, the other is placed over lat. aspect of the foot; therapist will supinate & adduct theforefoot with overpressure at end

Findings: Pain and hypermobility local to tested ligament



141.

CALCANEOFIBULAR STRESS TEST

Calcaneofibular Stress Test

Use: To assess integrity of the calcaneofibular ligament

Procedure: One hand, stabilize the tib/fib; with other hand cup calcaneus & invert the hindfoot with overpressure atend

Findings: Pain and hypermobility local to tested ligamentNote:Keep ankle in neutral during test



142.

TALOFIBULAR LIGAMENT STRESS TEST(ANTERIOR & POSTERIOR)

Talofibular Ligament Stress Test (Anterior & Posterior)

Anterior Talofibular Stress Test

Use: To assess the integrity of the anterior talofibular ligament

Procedure: Client seated or supine; therapist grasps tibia with one hand & other hand is over dorsum of foot; therapistwill then plantarflex, adduct, & invert ankle with overpressure at end

Findings: Pain local to this ligament, & excessive movement in mild-moderate subacute hypermobility or false negativedue to muscle spasm if rupture chronic ligament rupture will be hypermobile without pain

Posterior Talofibular Stress Test

Use: To assess integrity of the posterior talofibular ligament

Procedure: Position as above; therapist grasps lateral Tib/fib with one hand & other cups calcaneus; therapist willdorsiflex, invert, & adduct ankle with overpressure at end

Findings: Pain local to this ligament, & excessive movement in mild-moderate subacute hypermobility or false negativedue to spasm if rupture chronic ligament rupture will be hypermobile without pain



170 | TALOFIBULAR LIGAMENT STRESS TEST (ANTERIOR & POSTERIOR)

143.

DELTOID LIGAMENT STRESS TEST

Deltoid Ligament Stress Test

Use: To assess the integrity of the deltoid ligament

Procedure: This ligament has three parts and each should be tested.

1. One hand stabilizes tib/fib & other is over dorsum of foot; eversion, plantar flexion with overpressure is performed2. One hand cups calcaneus & other is over dorsum of foot; eversion of hindfoot with overpressure3. One hand cups cancaneus& other is over sole of foot; eversion & dorsiflexion with overpressure

Findings: Pain over hypermobility local to the affected fibres; muscle spasm may also be present



144.

DORSIFLEXION EXTERNAL ROTATION STRESSTEST (KLEIGER TEST)

Dorsiflexion External Rotation Stress Test (Kleiger Test)

Use: To identify a tear or rupture of the deltoid ligament or high ankle sprain (syndesmosis Injury)

Procedure: Client seated with knee flexed to 90°and foot not weight-bearing; therapist grasps foot and rotates it laterally.

Findings: Pain medially and laterally with possible palpation of the talus displacing from the medial malleolus



145.

THE SYNDESMOSIS SQUEEZE TEST

The Syndesmosis Squeeze Test



146.

TOE/HEEL WALKING

Toe/Heel Walking

Use: Part of neurological testing for the lower extremity.

Procedure: Client to walk across the room on their toes, then return walking on their heels.

Findings: Heel walking is assessing tibialis anterior = L4/5; Toe walking is assessing gastrocnemius/soleus = S1/2.



147.

THOMPSON’S TEST

Thompson’s Test

Use: To assess for third degree strain or rupture of the Achilles tendon

Procedure: Client prone, ankles over table; therapist squeezes the posterior calf muscles; (can be done standing)

Findings: If ankle does not plantarflex, the test is positive for rupture of Achilles



148.

TINEL’S SIGN AT TARSAL TUNNEL

Tinel’s Sign at Tarsal Tunnel

Use: To detect peripheral neuropathy of the tibial nerve

Procedure: Locate the tarsal tunnel (posterior to the medial malleolus) and tap over the nerve

Findings: Paraesthesia over medial ankle and arch of the foot



149.

TINEL'S SIGN - ANTERIOR TARSAL TUNNEL

TINEL’S SIGN – ANTERIOR TARSAL TUNNEL

Use: To assess for neuropathy of the deep peroneal nerve

Procedure: Tap nerve over the proximal dorsum of the foot

Findings: Paraesthesia in the deep peroneal nerve distribution



150.

MORTON’S NEUROMA TEST (METATARSALSQUEEZE TEST)

Morton’s Neuroma Test (Metatarsal Squeeze Test)

Use: To assess for presence of Morton’s neuroma

Procedure: Client supine; therapist places lateral & medial aspect of the foot between their palms & squeezes

Findings: Positive finding is sharp pain at the location of the neuroma. Pain is worsened by activity



151.

HOMAN’S SIGN

Homan’s Sign

Use: To assess for deep vein thrombosis

Procedure: Client supine/seated, affected knee extended; therapist to passively dorsiflex client’s ankle

Findings: Pain deep to the calf. May also find heat/tenderness local to deep vein thrombosis (DVT). Dorsalis pedis pulsemay also be diminished & affected leg swollen/pale.

Note: Tenderness or heat local to the thrombophlebitis upon palpation. The dorsalis pedis pulse is diminished or absentand the affected leg is swollen and has pallor. Refer out if positive



152.

BABINSKI TEST/REFLEX

Babinski Test/Reflex

Use: To assess for upper motor nerve (UMN) lesion

Procedure: Client supine; therapist to run pointed object along plantar aspect of client’s foot (heel –toe)

Findings: Extension of the big toe and abduction of the other toes is positive (flexion withdrawal due to ticklishness orhypersensitivity can be confounding factors).

Note: Test will be positive in infants and will usually be negative after 5-7 months



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ACKNOWLEDGEMENT

Acknowledgement goes to Alex Kidd and Andrew Clapperton at Humber College for graciously sharing theirassessment resource. Additional acknowledgement goes out to the staff at Physiotutors for their extensive research andcontent related to assessment.

Documents

Clinical Examination of the Musculoskeletal System