Photographic Manual of Regional Orthopaedic and Neurological Tests

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735520

D PHOTOGRAPHIC MANuAL OF

REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS FO U R T H

EDITIO N

•

THIS PAGE INTENTIONALLY LEFT BLANK

D PHOTOGRAPHIC MANuAL OF

REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS FOURTH

EDITION

JOSEPH]' CIPRIANO, D.C. Atlanta, Georgia

�� liPPINCOTT WILLIAMS •

A

&

WILKINS

Wolters Kluwer Company

Philadelphia

•

Baltimore

•

New York

•

London

Buenos Aires · Hong Kong . Sydney · Tokyo

Editor: Peter]. Darcy Managing Editor: Linda S. Napora Marketing Manager: Paul Jarecha Production Editor: Jennifer Ajello Designer: Armen Kojoyian Compositor: Graphic World Printer: Maple Vail Book Manufacturing Group Copyright © 2003 Lippincott Williams & Wilkins 351 West Camden Street Baltimore, MD 21201 530 Walnut Street Philadelphia, PA 19106 All rights reserved. This book is protected by copyright. No part of this book may be repro duced in any form or by any means, including photocopying, or utilized by any information storage and retrieval system without written permiSSion from the copyright owner. The publisher is not responsible (as a matter of product liability, negligence, or otherwise) for any injury resulting from any material contained herein. This publication contains infor mation relating to general principles of medical care that should not be construed as spe cific instructions for individual patients. Manufacturers' product information and package in serts should be reviewed for current information, including contraindications, dosages, and precautions.

Printed in the United States of America First Edition, 1985 Second Edition, 1991 Third Edition, 1997 Library of Congress Cataloging-in-Publication Data Cipriano, Joseph ]. Photographic manual of regional orthopaedic and neurological tests

/ Joseph].

Cipriano.-4th ed. p. cm. Includes index. ISBN 0-7817-3552-1 1. Physical orthopedic tests-Atlases. 2. Neurologic examination-Atlases. I. Title. RD734.5.P58 C57 2003 617.3-dc21

2002072497

The publishers have made every effort to trace the copyright holders for borrowed mate rial. If they have inadvertently overlooked any, they will be pleased to make the neces sary arrangements at the first opportunity. To purchase additional copies of this book, call our customer service department at

(800) 638-3030 or fax orders to (301) 824-7390. International customers should call (301) 714-2324. Visit Lippincott Williams & Wilkins on the Internet: http://www.Lww.com. lippin cott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST. 02 03 04 05 06 1 2 3 4 5 6 7 8 9 10

To Jenny, my loving wife, Maria, my encouraging mother, and in memory of Vincent, my Father, who gave me the courage to follow my dreams. Without their love, encouragement, compassion, and courage this manual would not exist.

D PREFACE

After four editions and nearly 20 years from the beginning of Photographic Manual of Regional Orthopaedic and Neurological Tests, I have come to realize that when information is presented in a logical and concise way, readers will master it quickly. For this reason, the format of this manual has remained the same over four editions, successfully providing instruction for the clinician or student of orthopaedics and neurology in the proper performance and evaluation of physical orthopaedic and neurological tests. The tests are categorized in terms of anatomical applications and subcatego rized in terms of diagnostic entities. This arrangement assists the clinician and student in evaluat ing various orthopaedic and neurological conditions. The 4'h edition continues to be user-friendly. Each test is accompanied by appropriate photo graphs that illustrate the performance of the test. Where applicable, anatomic illustrations provide enhanced clarity of concept.

All of the information for each test is on one page or two facing pages

so the user can view all of the information without turning the page. This new edition includes approximately 30 new tests with 90 new photographs and 20 new anatomical illustrations. Two new features are: Clinical Description, a brief clinical description for each diagnostic entity, and Suggested Imaging P rocedures, suggested diagnostic imaging for each condition; these feature are presented in a convenient, easy-to-see format. In addition, there is a Sensitivity/Reliability Scale Sensitivity/Reliability Scale I , I I I , I , I. The tests are rated based on the biomechanics o

1

2

3

4

of the movement that produces the desired outcome of each test, and the Sensitivity/Reliability scale rating provides a logical order for selecting tests more efficiently by indicating the more sensitive/ reliable tests first. This 4'h edition will keep readers abreast of new physical orthopaedic and neurological testing while learning and using the classic and standard tests more efficiently. I believe this material will enhance your clinical skills. Ultimately, the benefit will be the enhanced well-being of the patients who have sought our help. Joseph J. Cipriano, D.C.

vi

D ACKNOWLEDGMENTS

I thank the following people for their contributions to this book:

J. Randazzo, nc., Mark E. White, D.C. and Warren T. Jahn, Sr., nc., EA.C.O-their technical re view of the manuscript and suggestions have been greatly appreciated. Mark DelSantro , Steve Hite, Dr. L.E Jernigan and Michelle Larson-their expertise is evident in the photographs that enhance the accuracy of this text. Anthony Conticelli, John Michie, Barry Silverstein, Joseph Castellana, Mark E. White and Lucas Wells-their time and professionalism as models have my gratitude. Lydia V. Kibiuk-her fine artwork and 20 additional illustrations continue to enhance the read ers' comprehension of anatomy throughout the book. Steven P. Weiniger, D.C.-his experience and professionalism are evident in his significant chap ter on postural assessment Pete Darcy, Linda Napora, and Jenn Ajello at Lippincott Williams & Wilkins-their patience and support have been constant during the publication process.

VII

D CONTENTS

Vi P REFACE ACKNOWLEDGMENTS

1

CLINICAL ASSESSMENT P ROTOCOL

4

2 History Observation/Inspection 4 Palpation 4 Range ofMotion Evaluation 5 Special Physical, Orthopaedic, and 8 Neurological Testing Diagnostic Imaging and other Specialized Structural Testing 9 Functional Testing 13 General References 14

2

Space-Occupying Lesions 80 Cervical Neurological Compression and 82 Irritation

Vll

POSTURAL ASSESSMENT

C5 C6 C7 C8 Tl

5

15

Why Posture Is Important 16 Architectural vs Adaptive Postural Changes: Body Types, Injury, and Habit 16 Posture Evaluation: Methods and 19 Observations Posture Types 25 Postural Syndromes 26 Other Postural Distortions, Adaptations, and Pathologies 28 CERVICAL ORTHOPAEDIC TESTS 39 Cervical Orthopaedic Examination Flow 40 Chart Cervical Palpation 41 Cervical Range ofMotion 47 Cervical Resistive Isometric Muscle Testing 52 Vertebrobasilar Circulation 56 Assessment Subclavian Artery Compromise 68 Cervical Fractures 72 viii

96 98 100 102 104

SHOULDER ORTHOPAEDIC TESTS 106 Shoulder Orthopaedic Examination 107 Flow Chart Shoulder Palpation 108 116 Shoulder Range of Motion Tendinitis (Supraspinatus) 122 Tendinitis (Bicipital) 125 Bursitis 129 Anterior Glenohumeral Instability 132 Posterior Glenohumeral Instability 139 Multidirectional Shoulder Instability 142 Biceps Tendon Instability 150 Thoracic Outlet Syndrome 155 Brachial Plexus Irritation 161

by Steven P. Weiniger, DC

3

CERVICAL NERVE ROOT 92 LESIONS

6

ELBOW ORTHOPAEDIC 167 TESTS Elbow Orthopaedic Examination Flow Chart 168 Elbow Palpation 169 Elbow Range of Motion 177 Lateral Epicondylitis (Tennis Elbow) 180 Medial Epicondylitis (Golfer's Elbow) 184 Ligamentous Instability 185

CONTENTS

L4 L5 Sl

Neuropathy/Compression Syndromes 188

7

WRIST ORTHOPAEDIC 193 TESTS

12

Wrist Orthopaedic Examination 194 Flow Chart Wrist Palpation 195 Wrist Range of Motion 201 205 Carpal Tunnel Syndrome 210 Ulnar Tunnel Syndrome 211 Stenosing Tenosynovitis Carpal Instability 212

8

HAND ORTHOPAEDIC TESTS

13 215

14

LUMBAR NERVE ROOT 294 LESIONS T1� L1, L2, L3 295 L2, L3, L4 301

SACROILIAC ORTHOPAEDIC TESTS 312

HIP JOINT ORTHOPAEDIC 326 TESTS

KNEE ORTHOPAEDIC TESTS

354

Knee Orthopaedic Examination 355 Flow Chart Palpation 356 Knee Range of Motion 367 Meniscus Instability 369 Plica Tests 378 Ligamentous Instability 381 Patellofemoral Dysfunction 391 Knee Joint Effusion 394

LUMBAR ORTHOPAEDIC 250 TESTS Lumbar Orthopaedic Examination Flow Chart 251 Palpation 252 Lumbar Range of Motion 258 Joint Dysfunction Tests 261 265 Lumbar Fractures Lumbar Nerve Root and Sciatic Nerve Irritation/Compression Tests 266 Space-Occupying Lesions 285 Differential Diagnosis: Lumbar vs Sacroiliac Involvement 288

11

309

Hip Joint Orthopaedic Examination Flow Chart 327 Palpation 328 Hip Range ofMotion 334 Congenital Hip Dysplasia 340 Hip Fractures 343 Hip Contracture Tests 344 General Hip Joint Lesions 349

THORACIC ORTHOPAEDIC TESTS 228 Thoracic Orthopaedic Examination Flow Chart 229 Palpation 230 Posterior Aspect 232 Thoracic Range of Motion 237 Scoliosis/Kyphosis Screening 240 243 Thoracic Fractures 245 Nerve Root Lesions Costovertebral Joint Ankylosis 248

10

303 305

Sacroiliac Orthopaedic Examination Flow Chart 313 Palpation 314 Sacroiliac Sprain 316 General Sacroiliac Joint Lesions 322

Hand Palpation 216 Joint Instability 220 Joint Capsule Tests 222 Tendon Instability 224

9

IX

15

ANKLE ORTHOPAEDIC 397 TESTS Ankle Orthopaedic Examination 398 Flow Chart Palpation 399 409 Ankle Range of Motion Ligamentous Instability 413 Tarsal Tunnel Syndrome 417 Achilles Tendon Rupture 419

16

MISCELLANEOUS ORTHOPAEDIC 422 TESTS Peripheral Arterial Insufficiency Deep Vein Thrombosis 425 Symptom Magnification Assessment 426

423

X

CONTENTS

Meningeal Irritation and 430 Inflammation Leg Measurements 433

17

CRANIAL NERVES

18

464

Pathological Upper Extremity 465 Reflexes Pathological Lower Extremity 469 Reflexes Superficial Cutaneous Reflexes

435

Olfactory Nerve (I) 437 Optic Nerve (II) 438 Ophthalmoscopic Examination 441 Oculomotor, Trochlear, and Abducens Nerves (III, IV, VI) 443 Trigeminal Nerve ( V) 446 Facial Nerve 449 Auditory Nerve ( VIII) 452 Glossopharyngeal and Vagus Nerves (Ix, X) 458 Spinal Accessory Nerve (XI) 461 Hypoglossal Nerve (XII) 462

REFLEXES

19

CEREBELLAR FUNCTION 477 TESTS Upper Extremity Lower Extremity INDEX

478 483

474

--------�rn�-CLINICAL ASSESSMENT PROTOCOL

PATIENT HISTORY

SPECI AL PHYSICAL, ORTHOPAEDIC,

2

Closed-Ended History O pen-Ended History

AND NEUROLO GIC TESTING

3

8

Physical Examination Precautions

3

Sensitivity/Reliability Rating Scale OBSERVATI ON/INSPECTION Skin

DI AGNOSTIC IM AGING AND O THER

4

Subcutaneous Soft Tissue Bony Structure

SPECI ALIZED STRUCTURAL TESTING

4

Plain Film Radiology

4

9

Computed Tomography PALPATION Skin

4

10

Magnetic Resonance I maging

4

Myelography

Subcutaneous Soft Tissue Pulse

9

4

Skeletal Scintigraphy

4

11

12 13

5

Bony Structures

FUNCTIONAL TESTING

5

Electroencephalography R ANGE OF MO TION EVALUATION Passive Range of Motion Active Range of Motion Resisted Range of Motion

5

Electromyography

13 13

13

Somatosensory Evoked Potential

5

Suggested Diagnostic Imaging

7 7

13 13

9

2

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

A thorough understanding of anatomic and biomechanical principles provides the foundation for accurate evaluation of orthopaedic and related neurologic conditions. Knowledge of these princi ples is required to understand the relationship between structure and function and the role it plays in assessing orthopaedic and neurologic dysfunction. The examiner must also be familiar with anatomic and biomechanical variants that may be normal to a particular patient. This text deals primarily with physical examination procedures, which are an integral part of any orthopaedic or related neurologic examination. Complete assessment is not limited to physical ex amination; it includes other standard procedures, such as plain film radiography, computed tomog raphy (CT), and magnetic resonance imaging (MRI). The clinician must perform the appropriate protocol to evaluate the patient's condition. This chapter discusses the appropriate protocol for evaluating orthopaedic and related neuro logic problems. These procedures, when followed properly, allow the clinician to assemble parts of a puzzle so that he or she can visualize the picture, in this case, the patient's condition. Each piece of the puzzle is analogous to the information gathered by each particular procedure in the clinical as sessment protocol. The clinical assessment protocol is shown in Box 1- 1. Clinical Assessment Protocol

Patient history Inspection/observation Palpation Range of motion

•

Orthopaedic and neurologic testing Diagnostic imaging Functional testing

During the clinical assessment, it is necessary to document findings. The most common method to record the outcome of the assessment is through a problem-oriented records method that uses a SOAP (subjective, objective, assessment, plan) note format (Box 1-2). SOAP Notes

Subjective Objective Assessment Plan

The subjective portion is evaluated by taking the patient's history. The objective portion is evaluated by observation and special tests that measure an objective component. The assessment is based on the compilation of the subjective and objective findings and the examination. The plan may include further testing and/or treatment options.

The clinical assessment protocol is a comprehensive, organized, and reproducible system. This protocol is an essential tool for evaluating musculoskeletal and neurologic disorders.

PATIENT HISTORY A complete history is one of the most important aspects of the clinical assessment protocol. A com plete and thorough history is invaluable in assessing the patient's condition. At times, a history alone may lead to a proper diagnosis. The examiner should place emphasis on the aspect of the patient's history with the greatest clinical significance. Although concentrating on the area of greatest clini cal significance, the examiner must not forget to acquire all of the patient's history, whether or not it seems relevant at the time. There may come a time during the clinical assessment that the infor mation that seemed irrelevant is quite useful. History may also help to determine the personality type of the patient and his or her ability or willingness to follow directions. Patients who have a history of using an inordinate number of cli-

CHAPTER 1

CLINICAL ASSESSMENT PROTOCOL

3

nicians for the same disorder and receiving little or no help from them may be unwilling or unable to perform certain functions to better their condition. It is important that the examiner keep the patient focused on the problem and discourage wan dering from the presenting condition. To achieve a good history it is essential to listen carefully to the patient's concerns about his or her problem and the expectations for diagnosis and treatment. When acquiring information from the patient the examiner must not lead the patient into answer ing questions, such as, "Is this movement painful?" Instead the examiner should say something like, "What do you feel with this movement?" This history should concentrate on, but not be limited to, the patient's chief complaint, past his tory, family history, occupational history, and social history. History taking should be accomplished in two steps: Closed-Ended History The first step is a closed-ended question and answer format in which the patient answers direct, pointed questions. This step can be accomplished in a written form that the patient fills out. Open-Ended History After the closed-ended history is complete, the patient and examiner should engage in an open di alog to discuss the patient's condition. A closed-ended history may lead the examiner to the patient's problem but may not address the patient's fears or concerns regarding this condition. The patient may also have other problems either directly or indirectly related to the presenting complaint that may not be addressed by a closed-ended history. An open-ended history may take on a discussion format in which the examiner and patient ask questions of each other. In this way, the examiner acquires extra needed information about the pa tient and the patient's complaint. All aspects of the patient's complaint should be explored and eval uated to its fullest. The examiner should develop a good rapport with the patient, keeping the pa tient focused on the presenting problem and discouraging irrelevant topics. The pneumonic OPQRST (onset, provoking or palliative concerns, quality of pain, radiating, site and severity, time) may be incorporated into this evaluation (Box 1-3).

OPQRST •

•

•

•

•

·

Mnemonic

Onset of complaint Provoking or palliative concerns Quality of pain Radiating to a particular area Site and severity of complaint Time frame of complaint

Once the examiner has determined all aspects of the presenting complaint, it is time to focus on the history. Has the patient had prior problems with this or any other complaint? This information may assist with both assessment of the problem and insight on how to treat the problem. Family history can give a clue about the patient's propensity of inheriting familial diseases. A sig nificant number of neurologic problems and many orthopaedic problems can be traced to family members. Occupational and social histories are also important because they may lead to a factor causing the patient's problem, such as an overuse syndrome. They can also help to determine whether the patient's condition will respond more favorably if the patient refrains from performing certain work or social functions. For example, lifting, bending, and playing tennis or golf may be contraindicated. The patient may also need to be retrained for other types of work.

II

4

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

OBSERVATION/INSPECTION Observe the patient for general appearance and functional status. Note the body type, such as slim, obese, short, or tall, and postural deviations for general appearance, gait, muscle guarding, com pensatory or substitute movements, and assistive devices for functional status. Inspection should be divided into three layers: skin, subcutaneous soft tissue, and bony struc ture. Each layer has its own special characteristics for determining underlying pathology or dys function. Skin Skin assessment should begin with common and obvious findings, such as bruising, scarring, and evidence of trauma or surgery. Then look for changes in color, either from vascular changes accom panying inflammation or from vascular deficiency, such as pallor or cyanosis. Large, brownish, pig mented areas and/or hairy regions, especially on or near the spine, may indicate a bony defect such as spina bifida. Changes in texture may accompany reflex sympathetic dystrophies. Open wounds should be evaluated for either traumatic or insidious origin, which may accompany diabetes. Subcutaneous Soft Tissue Subcutaneous soft tissue abnormalities usually involve either inflammation and swelling or atrophy. When evaluating for an increase in size, attempt to identify edema, articular effusion, muscle hy pertrophy, or other hypertrophic changes. Also note any nodules, lymph nodes, or cysts. Establish any inflammation by comparing bilateral symmetry for the torso and circumferential measurements for the extremities. Bony Structure Bony structure should be evaluated, especially when the patient presents with a functional abnor mality, such as a gait deviance or an altered range of motion. Bony inspection in the spine should focus on items such as scoliosis, pelvic tilt, and shoulder height. Note and possibly measure malfor mations in the extremities that may be congenital or traumatic. Two examples of congenital mal formations are genu varus and genu valgus. Traumatic malformations include a healed Colles' frac ture with residual angulation. All bony structures should be visually assessed for abnormalities and documented.

PALPATION Palpate the patient in conjunction with inspection; the structures being inspected are the same ones that should be palpated. The layers are the same for palpation as for inspection, skin, subcutaneous soft tissue, and bony structures. When palpating the skin, begin with a light touch, especially if nerve pressure is suspected. Pres sure on a nerve may result in dysesthesia, which may feel like an exaggerated burning sensation to the patient. Skin Evaluate skin temperature first. High skin temperature may indicate an underlying inflammatory process. Low skin temperature may indicate a vascular deficiency. Also, evaluate skin mobility for adhesions, especially after surgery or trauma. Subcutaneous Soft Tissue The subcutaneous soft tissue consists of fat, fascia, tendons, muscles, ligaments, joint capsules, nerves, and blood vessels. Palpate these structures with more pressure than for skin. Tenderness is a subjective complaint that should be noted. It may be caused by (a) injury; (b) pathology that corre lates directly to the tenderness, such as tenderness at the supraspinatus ligament for supraspinatus

CHAPTER 1

CLINICAL ASSESSMENT PROTOCOL

5

tendinitis; or (c) a referred component, such as tenderness in the buttock area from a lumbar injury or pathology. Determine tenderness by applying pressure to the area and grade it according to the patient's response (Box 1-4). Evaluate swelling or edema according to its origin. Determine if the inflammation is intra articular or extra-articular. In intra-articular effusion, the fluid is confined to the joint capsule. In extra-articular effusion, the fluid is in the surrounding tissues. Various palpation techniques are dis cussed in detail in the chapters on specific areas of the body.

Tenderness Grading Scale

Grade Grade Grade Grade

I II III IV

Patient complains of pain. Patient complains of pain and winces. Patient winces and withdraws the joint. Patient will not allow palpation of the joint.

There are different types of swelling or edema, according to onset and palpation feel. If swelling occurs immediately after an injury and feels hard and warm, the swelling contains blood. If the swelling occurs 8 to 24 hours after an injury and feels boggy or spongy, the swelling contains syno vial fluid. If the swelling feels tough and dry, it is most likely a callus. If the feeling is thickened or leathery, it is most likely chronic swelling. If the swelling or edema is soft and fluctuating, it is most likely acute. If the feeling is hard, it is most likely bone. If the feeling is thick and slow moving, it is most likely pitting edema. Pulse Pulse amplitude in certain arteries is important. It is used to assess the vascular integrity of an area and plays an integral part in certain tests for thoracic outlet syndrome, arterial insufficiency, and vertebrobasilar compromise. Bony Structures Bony structure palpation is critical for the detection of alignment problems, such as dislocations, luxations, subluxations, and fractures. When you palpate bony structures, you must also identify the ligaments and tendons that attach to those structures. Tenderness is a major finding in bony palpa tion. It may indicate periosteoligamentous sprain. It also may indicate fracture. Bony enlargements usually are associated with healing of fractures and degenerative joint disease.

RANGE OF MOTION EVALUATION Range of motion evaluation is not only a measurement of function but also an important part of biomechanical analysis. Range of motion is evaluated for three separate types of functions: passive motion, active motion, and resisted motion. Passive Range of Motion In passive motion, the examiner moves the body part for the patient without the patient's help. It can yield a significant amount of information about the underlying pathology. The goal obviously depends on which joint is being tested and what pathology or injury is suspected. In evaluating such motion, first note whether the movement is normal, increased, or decreased and in which planes. Second, note any pain. Classically, pain on passive range of motion indicates a capsular or ligamen tous lesion on the side of movement and/or a muscle lesion on the opposite side of movement. Var ious other problems may be detected, depending on the degree of mobility and pain. Six possible variations of range of motion pain are shown in Box 1-5.

II

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

6

Six Range of Motion and Pain Variations 1. Normal mobility with no pain

indicates a normal joint with no lesion. may indicate a minor sprain of a ligament

2. Normal mobility with pain elicited

or capsular lesion. 3. Hypomobility with no pain

may indicate an adhesion of a particular tested

structure. 4. Hypomobility with pain elicited

5.

6.

may indicate an acute sprain of a ligament or capsular lesion. When an injury is severe, hypomobility and pain may also be a sign of muscle spasm caused by guarding or by muscle strain opposite the side of movement. Hypermobility with no pain suggests a complete tear of a structure with no fibers intact where pain can be elicited. It may also be normal if other joints in the absence of trauma are also hypermobile. Hypermobility with pain elicited indicates a partial tear with some fibers still intact. Normal pressure by the weight of structure that is attached to the ligament or capsule is being exerted. This pressure on the intact fibers can elicit pain.

After you determine the degree of passive range of motion and evaluate for pain, evaluate for an end feel. To determine end feel, passively move the joint to the end of its range of motion and then apply slight overpressure to the joint. The quality of the feeling that this elicits is the end feel, as sessed as either normal (physiologic) or abnormal (pathologic) (Table 1-1). TABLE 1-1

END FEEL EVALUATION

Category

Normal Physiologic End Feels

Abnormal Pathologic End Feels

Hard

Abrupt hard to stop movement when bone contacts bone Example: passive elbow extension. Olecranon process contracts the olecranon fossa When two body surfaces come together, a soft compression of tissue is felt. Example: Passive elbow flexion. Anterior aspect of the forearm approximates the biceps muscle. A firm or spongy sensation that has some give when a muscle, ligament, or tendon is stretched. Example: Passive wrist flexion, passive external shoulder rotation.

Abrupt stopping movement before normal expected passive movement. Example: Cervical flexion hard end feel due to severe degenerative joint disease.

Soft

Firm

Springy, block

Empty

A soft boggy sensation resulting from synovitis or soft tissue edema. Example: Ligamentous sprain.

A firm springy sensation to movement with a slight amount of give in capsular joints. Example: Frozen shoulder.

Rebound effect with limited motion; usually in joints with a meniscus. Example: Torn meniscus. An empty feel in a joint with severe pain when passively moved. The movement cannot be performed because of the pain. Example: Fracture, subacromial bursitis, neoplasm, joint inflammation.

CHAPTER 1

CLINICAL ASSESSMENT PROTOCOL

7

Active Range of Motion Active range of motion evaluates the physical function of a body part. This type of range will yield general information regarding the patient's general ability and willingness to use the part. If a patient is asked to move a joint through a full arc of movement and cannot, it is impossible to dis tinguish whether the loss of function is caused by pain, weakness caused by a neurologic motor dys function, stiffness, or the conscious unwillingness of the patient to perform the full function. There fore, the assessment value of active range of motion in and of itself is vague and limited. Active motion is a basic test for the integrity of the muscle or muscles used in the action and the nerve sup ply attached to the muscle. Obviously, the integrity of the joint being tested must be intact to eval uate muscular or neurologic dysfunction. This integrity is best evaluated by passive range of motion. When evaluating active motion, note the degree of motion in the tested plane as well as any pain associated with the movement. The pain should be correlated with the movement, such as pain in the full arc or only in the extreme range of motion. Crepitus should also be noted when performing active range of motion. Crepitus is a crackling sound that usually indicates a roughening of joint surfaces or increased friction between a tendon and its sheath (caused by swelling or roughening). Joint range of motion should be measured and recorded by commonly accepted reproducible means. To measure the range of motion of the spine, the most accurate instrument is the incli nometer (Fig. 1- 1). This instrument measures angular displacement relative to gravity as opposed to arcs. The reason for inclinometer measurement of the spine is that the spine is composed of multi ple joints that function in unison to produce movement. A device that measures arcs, such as a go niometer (Fig. 1-2), cannot distinguish the difference between sacral flexion and lumbar flexion in the lower back when the patient is bending forward. In this particular instance, the inclinometer can distinguish between true lumbar flexion and sacral or hip flexion (see inclinometer range of motion in Chapters 3, 9, and 10). Goniometers are best suited to measure extremity range of motion.

Figure ,-,

Figure '-2

Resisted Range of Motion Resisted range of motion is useful in assessing musculotendinous and neurologic structures. It is primarily used to test neurologic function (see nerve root lesions). The tests are graded 5 to 0, a scale that has been adopted by the American Academy of Orthopaedic Surgeons (Box 1-6). Musculotendinous injuries are generally more painful than they are weak. Neurologic lesions are generally more weak than they are painful. The four general pain-related reactions to resisted range of motion testing are listed in Box 1-7.

D

8

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Muscle Grading Scale 5 4 3 2 1 o

Complete range of motion against gravity with full resistance Complete range of motion against gravity with some resistance Complete range of motion against gravity Complete range of motion with gravity eliminated (movement in the horizontal plane) Evidence of slight contractility No evidence of contractility

Resistant Range of Motion Reactions 1. 2. 3.

4.

Strong with no pain elicited is normal and not indicative of any lesions. Strong with pain elicited may indicate a minor lesion of the muscle or tendon. Weak and painless may indicate a neurologic lesion, which must be evaluated with the previous chart. It may also indicate a complete rupture of a tendon or muscle because there are no fibers intact from which pain can be elicited. Weak and painful may indicate a partial rupture of a muscle or tendon because intact fibers may be stressed to produce pain. Fracture, neoplasm, and acute inflammation are also possibilities.

SPECIAL PHYSICAL, ORTHOPAEDIC, AND NEUROLOGIC TESTING Special physical, orthopaedic, and neurologic testing is designed to place functional stress on iso lated tissue structures in terms of the underlying pathology. Positive physical testing is not diag nostic in itself but rather a biomechanical assessment to be used as part of a complete clinical evaluation. Before performing certain special tests, you must ascertain that they will not be detrimental to the patient's condition. Box 1-8 lists the conditions for which care must be taken when performing either range of motion testing or special physical orthopaedic and neurologic testing. Physical Examination Precautions

Dislocation Unhealed fracture Myositis ossificans/ ectopic ossification Joint infection Marked osteoporosis Bony ankylosis Newly united fracture After surgery If it is determined that special physical testing may indeed harm the patient, structural and/or functional testing, such as radiography, CT, MRI, or electromyography (EMG), should be employed before any physical testing. The subsequent chapters contain a collection of special physical orthopaedic and neurologic tests organized anatomically and subcategorized by diagnostic entity. This system is best suited for expedient evaluation of musculoskeletal and orthopaedic neurologic conditions. Each test illustrates and discusses the procedures for correct performance of the test. Each test is accompanied by an ex planation that indicates the positive indicators for that test and what they may mean in terms of an underlying pathology or injury. Biomechanical considerations that may not be evident in the clas sical interpretation of a particular test are also explored.

CHAPTER 1

CLINICAL ASSESSMENT PROTOCOL

9

Sensitivity/Reliability Scale I have chosen to add a sensitivity/reliability scale to each of the tests described in this text. For each diagnosis presented, there are multiple tests. Some of those tests are more sensitivelreliable than oth ers. I have attempted to rate each test based on the biomechanics of the movement to isolate the af fected structures. The scale is numbered from 0 to 4, with 1 to 2 being poorly sensitivelreliable, 2 to 3 being moderately sensitivelreliable and 3 to 4 being very sensitivelreliable. Those tests that are very sensitivelreliable should be performed first. This will help in evaluating the patient's condition more expeditiously.

DIAGNOSTIC IMAGING AND OTHER SPECIALIZED STRUCTURAL TESTING Diagnostic imaging or structural testing entails the use of specialized equipment to visualize certain anatomic structures. The most common diagnostic imaging procedures include plain film radiology (x-ray), CT), MRI), and skeletal scintigraphy (bone scan). Each type of structural test may be best suited to visualize various structures in specific ways. Plain Film Radiology Plain film radiology dates to 1895, and its fundamentals are still used in practice today. X-rays are a form of radiant energy that have a short wavelength and can penetrate many substances (Fig. 1-3). The x-ray is produced by bombarding a tungsten target with an electron beam in an x-ray tube. Plain film radiography demonstrates five basic densities: air, fat, subcutaneous tissue, bone, and metal. Anatomic structures are seen on radiographs as outlines in whole or as part of different tis sue densities. These differences in densities are the key to determining the normal or pathologic state of tissues shown on radiographic film. Bone is the best-seen tissue on plain film radiography.

Figure 1-3

10

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Computed Tomography Computed tomography is a cross-sectional imaging technique that uses x-ray as its energy (Fig. 1-4). A computer is used to reconstruct a cross-sectional image from measurements of x-ray trans mission. Most CT units allow for a slice thickness between 1 and 10 mm and are generally limited to the axial plane. CT is best used for bone detail and demonstration of calcifications. Intervertebral disc defects may also be visualized on CT, but not as well as with MRI.

Figure 1-4

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CLINICAL ASSESSMENT PROTOCOL

11

Magnetic Resonance Imaging MRl is also a cross-sectional imaging technique (Fig. 1-5). It uses magnetic fields and radio waves instead of x-rays to produce its images. MRI is based on the ability of the body to absorb and emit radio waves when the body is in a strong magnetic field. The absorption and release of this energy is different and detectable in each individual type of tissue. Hence, MRI is invaluable in contrasting soft tissue structures in many planes without the use of ionizing radiation. It poorly demonstrates bone density detail or calcifications; this is the advantage of CT. MRI is superior in visualizing an in tervertebral disc or other soft tissue structure for pathology. Patients with any metallic implants or metal fragments (e.g., cardiac pacemakers, insulin pumps, vascular clips, skin staples, bullets, or shrapnel) are advised not to undergo MRI because of the strong magnetic field emitted by the scanner. This field may move or dislodge metallic implants or objects in an individual whose body is being scanned.

Figure 1-5

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Myelography Myelography introduces a small amount of water-soluble contrast medium into the subarachnoid space (Fig. 1-6). Standard x-ray films of the spine are then taken to evaluate and defects of the spinal canal, such as spinal stenosis, spinal cord lesions, and dural tears.

Figure 1-6

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CLINICAL ASSESSMENT PROTOCOL

13

Skeletal Scintigraphy Skeletal scintigraphy, or bone scan, uses an intravenous radiopharmaceutical, technetium-99m, which is attracted to osteoblastic activity in bone tissue and is detected by a gamma camera (Fig. 1-7). Vigorous osteoblastic activity, such as healing fractures and pathologic conditions, stimulate skeletal blood flow and bone repair. In turn, more of the radiopharmaceutical attaches to the area, marking the increased activity for evaluation. Bone scans are best suited for undetectable fractures on x-ray and arthropathies, such as early degenerative changes in joints, osteomyelitis, bony dys plasias, primary bone tumors, and metastatic malignancy.

Figure 1-7

FUNCTIONAL TESTING Functional testing for musculoskeletal and neurologic pathology entails testing neurologic function by assessing electrical activity of specific neurologic structures, such as electroencephalography (EEG), EMG, and somatosensory evoked potential studies (SSEP). Electroencephalography EEG records the electrical activity of the brain through the skull by surface electrodes. Abnormal electrical activity may indicate cerebral pathology, such as epilepsy, inflammatory encephalopathies, infarction, trauma, or tumor, that may not be detectable by structural testing. Electromyography EMG measures the electrical activity of contracting muscles and is recorded either via surface elec trodes or through needles inserted directly into the muscle itself. The surface electrodes record and average the activity from many motor units, whereas needle EMG can detect the activity from a sin gle motor unit. The recordings are used to detect the cause of muscle weakness. They are also use ful in detecting neuropathies, denervation, and entrapment syndromes. Somatosensory Evoked Potential SSEP studies measure electrical activity from a distal nerve to a more proximal point on the nerve, spinal cord, or brain stem. A stimulus is given peripherally, and responses are recorded and averaged proximal to the stimulated area. The purpose of the test is to determine and quantify nerve, cord, or brain stem lesions. It is used most commonly to detect trauma, tumors, and demyelinating diseases of the nervous system. Suggested Diagnostic Imaging Each chapter contains a suggested diagnostic imaging section for each diagnostic entity. These sug gestions start from the most basic diagnostic imaging and move on to more advanced testing pro cedures. If diagnostic imaging is needed, the clinician should start with the most basic tests and

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

move forward based on the outcome of those first tests. Secondly, the clinician should not advance to other diagnostic tests if the results of the basic diagnostic imaging reveal that injury may result from further testing, such as flexion/extension plain film radiography to the cervical spine if insta bility is noted on static scout films. Remember that there is no substitution for a complete history and physical examination and that the suggested diagnostic imaging sections are just that "suggested:' based on the history and examination of the presenting patient.

SUMMARY The examining clinician should employ the techniques discussed in this chapter to assess the pa tient's condition. Not all segments of the clinical assessment protocol need be employed for each pa tient and complaint. History, inspection, palpation, range of motion, and physical testing are core requirements. Whether to use diagnostic imaging and functional testing is based on the outcomes of the core requirements and the clinical judgment and experience of the examiner. General References 1. Adams

JC,

Hamblen

DL.

1 1 th

Edinburgh:

Outline of

Or

1 2. Hertling

D,

Kessler

RM.

Management

of

Churchill

Common Musculoskeletal Disorders: Physical

2. American Academy of Orthopaedic Surgeons.

Philadelphia: Lippincott Williams & Wilkins,

thopaedics.

ed.

T herapy Principles

Livingstone, 1 990. T he Clinical Measurement of Joint Motion. Chicago: American Academy of Orthopaedic

and History Taking.

7th

ed.

Philadelphia:

Lippincott Williams & Wilkins, 1 999. HM.

Musculoskeletal

2nd

ed.

Baltimore:

Lippincott

Williams & Wilkins, 2000.

ed.

1996. 13. Hoppenfeld S. Physical Examination of the

Medicine. London: Butterworth, 1 983. Vol 1. Diagnosis of Soft T issue Lesions. 8th ed.

1 5. Krejci V P. Koch muscle and tendon injuries. Chicago: Year Book, 1 979. 3rd ed. Philadelphia: WB Saunders, 1 997. Methods for the Health Professional. Reston, VA: Reston, 1 985. 1 8. Mooney V. Where is the Pain Coming From?

London: Bailliere Tindall, 1 982. 7. Dambro MR, Griffith JA. Griffith's 5 Minute Baltimore:

Williams & Wilkins, 1 993.

1 7. Minor MAD, Minor SD. Patient Evaluation

6. Cyriax J. Textbook of Orthopaedic Medicine.

Consult.

Century-Crofts, 1 976. 1 4. Kendall FP, McCreary EK, Provance PG. Mus

1 6. Magee DJ. Orthopaedic physical assessment.

5. Corrigan B, Maitland GD. Practical Orthopaedic

Clinical

3rd

cles: Testing and Function. 4th ed. Baltimore:

Assessment:

Joint Range of Motion and Manual Muscle Strength.

Methods.

Spine and Extremities. New York: Appleton

Surgeons, 1 994. 3. Bates B. Bates' Guide to Physical Examination

4. Clarkson

and

Williams

&

Wilkins, 1 997. 8. Endow Aj, Swisher SN. Interviewing and Pa tient Care. New York: Oxford University, 1 992. 9. French S. History Taking in Physiotherapy As sessment. Physiotherapy 1 988;74: 1 58- 1 60. 1 0. Greenstein GM. Clinical Assessment of Muscu loskeletal Disorders. St. Louis: Mosby, 1 997.

Spine 1 989;1 2:8:754-759. 1 9. Nordin M, Frankel VH. Basic biomechanics of the musculoskeletal system. 3rd ed. Philadel phia: Lippincott Williams & Wilkins, 200 1 . 20. Post M . Physical Examination o f the Muscu loskeletal System. Chicago: Year Book, �987. 2 1 . Salter RE. Textbook of disorders and injuries of the musculoskeletal system. 3rd ed. Baltimore: Williams & Wilkins, 1999.

1 1 . Hawkins RJ. An Organized Approach to Muscu

22. Starkey C, Ryan J. Evaluation of Orthopedic

loskeletal Examination and History Taking.

and Athletic Injuries. Philadelphia. FA Davis,

St. Louis: Mosby, 1995.

1 996.

--------�rn�-POSTURAL ASSESSMENT

II

Steven P. Weiniger, DC*

WHY POSTURE IS IMPORTAN T

16

ARCHITE CTURAL VERSUS ADAPTIVE POSTURAL CHANGES: BODY TYPES, INJURY, AND HABIT 16 POSTURE EVALUATION : METHODS AND OBSERVATIONS 19 Posterior View Evaluation 21 Lateral View 22 A nteroposterior/Front View 24 POSTURE TYPES

25

POSTURAL SYNDRO MES

26

OTHER POSTURAL DISTORTIONS, ADAPTATIONS, AND PATHOLOGIES Forward Head Posture 28 Head Tilt and/or Rotation 30 U nlevel Shoulders 30

28

Scapula Winging 32 Scapula Rotation 32 Round Shoulders/Internal Rotation of the Upper Extremity 33 Lateral Spinal Deviation/Scoliosis 33 Lateral Pelvic Tilt/Abdominal A symmetry 34 A nterior or Posterior Pelvic Tilt 35 Abdomen Protrusion 36 Knock Knees: Genu Valga 36

*Private practice in Conyers, Georgia; founder, BodyZone.com.

15

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

WHY POSTURE IS IMPORTANT Posture is how a body balances. If a body doesn't balance, it falls down. To analyze posture it is necessary to observe how the body is balancing. Posture is more than muscles and bones. The spine, with its ligaments intact but devoid of muscles, is an extremely unstable structure. Mus cles and their complex neuromuscular control are required (a) to provide stability of the trunk in a given posture and (b) to produce movement during physiologic activity (1). The motor sys tem and the nervous system function as one entity (2). Therefore, postural analysis is an as sessment of the function of the motor system (bones, muscles, and ligaments) and the nervous system's control of the motor system. Postural observations are organic; that is, they deal with the whole organism. Unlike most or thopaedic or neurologic tests, which focus on identifying the specific nature of an injury, illness, or other clinical problem, a postural evaluation looks at the whole person and attempts to assess the relative contributions of myriad postural observations. Posture comprises an accumulation of adap tations and compensations from injuries and habits to allow the body to balance and function effectively. An individual's neutral posture occurs when the brain and nervous system use information from three sources to balance the body in space when standing, sitting, or moving: Eyes: We see what is level. Ears: The vestibular apparatus gives the brain information about the relative position and mo tion of each inner ear. Muscles and joints: Proprioceptors in the muscles, ligaments, and tendons tell the brain how hard each is being stressed. The brain integrates the information it receives to balance the body.

ARCHITECTURAL VERSUS ADAPTIVE POSTURAL CHANGES: BODY TY PES, INJURY, AND HABIT Postural compensations and adaptations can be both a cause and an effect of a clinical problem. Or thopedic problems frequently cause a postural change, which in turn worsens the orthopaedic prob lem. Asymptomatic postural problems can cause undue mechanical stress, predisposing an individ ual to either injury or chronic mechanical stress syndrome. There is no one "normal" posture. An ideal posture is used as a reference point, but rarely does a patient have "perfect posture." Since the posture is how the body balances, the ideal posture for an individual distributes the forces of gravity for balanced muscle function. Joints should move in their mid range so as to minimize undue stress and strain on ligaments at the joint's end range of motion and fully distribute stress on the joint surfaces. A biomechanically efficient posture is maximally ef fective in that individual's activities of daily living and avoids injury. People come in various shapes and sizes and live unique lives, and their postures differ ac cordingly (Fig. 2-1). An individual learns during childhood to balance the body's unique archi tecture. The child's habits affect his or her posture. Good habits can create a strong and stable posture. Bad habits can train the body for poor posture and instability. Excessive sitting, carry ing a heavy backpack, slumping, or poor sleeping position trains the body to a folded-forward posture. Habitual one-sided activities, such as carrying a heavy purse, sitting on a wallet, or fac ing sidewise to view a poorly placed computer monitor train the body to be asymmetrical from left to right.

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17

II

Figure 2-1. Posture varies b y individual body type, history o f injury, and habits.

Poor posture creates adaptive patterns of body motion. Poor posture and body motion stress the musculoskeletal system, resulting in premature joint wear and susceptibility to injury. Studies show that sports injuries correlate with deviations of body mechanics (3). The incidence of injury in ath letes has been linked to postural distortions associated with the site of injury, and those with more than two types of injury have significantly worse postural symmetry. The human bipedal posture is extremely effective and "the most economical of antigravity mechanisms once the upright posture is attained" (4). However, when there is an illness or injury, the body adapts and moves differently. The body must balance, so the posture adapts to changes in muscle and joint motion and resting positions. Overstressed muscles strengthen and favored mus cles weaken. Posture and body motion are like a fold in a piece of paper. Once folded, the paper will bend along the fold when it is stressed. Similarly, once posture and body motion change to compensate for poor habits or injury, the body continues to assume the same uneven resting posture and follows the same adaptive pattern of motion. Biomechanically speaking, this adaptive posture is almost al ways inefficient. Mother was right about molding good posture in a child by standing straight with head and shoulders back. Clinically, a postural change begins a cascade of compensating causes and effects. Subjectively, the patient usually believes he or she is standing straight and balanced, even if a visual inspection shows otherwise. If the brain believes the body is balanced when it is not, posture adaptations cause uneven stress and predisposition to future injury. Over a lifetime, people's history of injury, daily ac tivities, and habits shape their unique posture.

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Spinal distortions occur in all directions of three-dimensional space and are more than a sum of the front, back, and side views of the spine. When viewed from above, the helical nature of spinal adaptations becomes apparent (Fig. 2-2) (1). However, according to White and Panjabi (1), present knowledge and technology do not allow effective evaluation of helical adaptations. Nonetheless, posture analysis can provide valuable clinical information that must be correlated with a patient's history and reported symptoms.

Figure 2-2. Helical spine adaptation.

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19

POSTURE EVALUATION: METHODS AND OBSERVATIONS A suggested posture evaluation mindset is to think of the body as a stack of children's blocks (Fig. 2-3). When the blocks are all balanced, the stack is stable. But when one is out of place, the stack wobbles. To balance a stack of blocks, you put the second block on top of the first. When you place the third block on the second, it can be only as stable as the second. Placing a forth block requires stability of the blocks below, and so on. This bottom-to-top arrangement is how human beings balance. That is why shoulder corrections tend to follow correction of lateral pelvic tilt, but the reverse does not necessarily occur.

Figure 2-3. Unbalanced posture creates instability.

•

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Additionally, in posture analysis and clinical treatment, it is important to determine whether a muscle is weak or inhibited. A weak muscle is unused because it is unstressed and should therefore be strengthened with exercise. An inhibited muscle is not used because its antagonist is being adap tively overused. The neurologic reciprocal inhibition of a muscle by its antagonist results in overde velopment of the muscles most used in posture and underdevelopment of their antagonists (2). Clinically, the goal is to identify the most important fault in the kinetic chain. Since postural analysis can be diagnostic and possibly suggest therapeutic actions, it is imperative to differentiate between actions and reactions. Unbalanced postures have compensating reactions. When observing the posture, the examiner should note any inconsistencies or imbalances, both from left to right and from front to back. Mentally integrate the patient's complaint and history with the mechanics of the body's balance. Palpation can help differentiate longstanding adaptive muscle hypertrophy (unilat erally tight muscles without significant reactive pain on palpation) from acute muscle spasm (with reactive pain on palpation). Prior to postural evaluation, the examiner should obtain all pertinent history, including a de scription of symptoms, fractures, injuries, congenital abnormalities, and the patient's dominant hand. It is important to note any gross structural asymmetries, scoliosis, or other condition that cre ates imbalance. The patient should be as minimally clothed as possible so that the examiner may clearly visual ize the contours, bony prominences, and other anatomical landmarks from the front (anteroposte rior [AP] view), back (posteroanterior [PAl view) and sides (left and right lateral views) (Fig. 2-4). The patient should be told to stand straight and look straight ahead. The patient who adopts a rigid standing straight posture (i.e. bilateral shoulder or abdominal tightening on assuming a straight posture) should be told to relax and assume a comfortable position. Patients will try to as sume a "good" posture, so to observe a true resting posture it is important not to coach patients by asking them to straighten up what is misaligned. If there is poor alignment of the feet and the torso or if both feet are not facing at the same an gie, instruct the patient to march in place for five steps. A postural distortion is indicated if the feet and torso are still misaligned.

Figure 2-4. Posture should be viewed from the front. back. left side. and right side.

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21

Posterior View Evaluation In a balanced posture, the body appears equal from left to right. A vertical plumb line over the cen ter of the body (Fig. 2-5) should show alignment of the occipital protuberance; cervical, thoracic, and lumbar spinous processes; coccyx:; and gluteal folds. The arms should hang equally from the torso, with an equal and small amount of the palms visible. The space between the arms and the body should be the same on both sides. The legs should appear equally abducted from the center line, and the backs of the knees should appear the same. The ankles and feet should display bilater ally symmetric alignment (e.g., no pronation or supination) and toe out. In balanced posture, the following structures should be level and equal: tips of the mastoid processes, acromia, scapula, lower margins of the 12th ribs, iliac crests, posterior superior iliac spines, and ischial tuberosities.

Lateral trunk muscles Quadratus lumborum Internal oblique External oblique

Hip abductors Gluteus medius Tensor fasciae latae Iliotibial tract of fascia lata

Adductors

Everters Peroneus longus and brevis

Inverters Tibialis posterior Flexor digitorum longus Flexor hallucis longus

Figure 2-5. Ideal alignment, posterior view. (Modified with permission from Kendall FP. McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Baltimore: Williams & Wilkins, 1993:88.)

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Most people have a slight postural distortion because of left- or right-hand dominance. Right handed people tend to have a high right hip and a low right shoulder (Fig. 2-6). Left-handed ones tend to have a high left hip and a low left shoulder. In addition, the normal AP spine has a slight right convex thoracic curve, most likely due to an individual's left or right-handedness (1).

Figure 2-6. Right-handed postural pattern.

Lateral View The examiner should evaluate the patient from both sides. From the side view, a plumb line should show alignment between the external auditory canal, acromion process of the shoulder, axillary line, midpoint of the iliac crest, greater trochanter of the hip, lateral condyles of the femur, and tibia slightly anterior to the lateral malleolus. The head, chest, pelvis, and lower extremities should be in alignment and balanced. There should be a normal cervical lordosis, thoracic kyphosis, and lumbar lordosis (Fig. 2-7). The head is balanced when a horizontal line can be drawn from the occipital protuberance to the lower margin of the zygomatic arch. In neutral posture the head should be above the shoulders, not forward. The eyes have a strong tendency to seek level, so if there is postural distortion, the head position may tilt forward or backward to compensate (Fig. 2-8).

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23

•

Back extensors

Abdominals Rectus abdominis External oblique

Hip flexors Psoas major Iliacus

Hip extensors Gluteus maximus

Tensor fasciae

Hamstrings

latae Rectus femoris

i?ftrc....== ..:: ===.

Figure 2-7. Lateral posture alignment. (Modified with permission from Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Baltimore: Williams & Wilkins, 1993:83.)

Figure 2-8. Neutral posture (left), forward posture (center), and cervical retraction (right).

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

On a lateral view, the shoulder girdle and torso are balanced when a horizontal line can be drawn from the medial end of the spine of the scapula to the head of the humerus and then to the medial end of the clavicle. The scapulae should appear equal and lie symmetrically against the torso (Fig. 2-9). The pelvis is level and balanced when a horizontal line can be drawn from just below the ante rior superior iliac spine to the posterior superior iliac spine. Ideally, the anterior superior iliac spine should be vertically aligned with the symphysis pubes (Fig. 2-9). The lower extremities should be vertically aligned with the knee joints neutral (e.g., not locked in hyperextension). The legs should be equally vertical and at a right angle to the sole of the foot (Fig. 2-9). Anteroposterior/Front View Balanced posture should appear equal from left to right. A vertical plumb line over the center of the body will show alignment of the bridge of the nose, center of the chin, episternal notch, xiphoid process, umbilicus, and pubes. The arms should be hanging similarly, both palms at the side of the thighs. Shoulder girdle symmetry is indicated if the hands show similar rotation and placement on the body. The legs should appear equally abducted from the centerline, with the feet displaying bilat erally symmetric alignment (e.g., no pronation or supination) and toe out. The knees should be for ward and bilaterally symmetric in their alignment and orientation on the lower extremity (Fig. 2-10). In balanced posture, anterior examination will show the following structures to be equal bilat erally and level: eyes, clavicles, lower margins of the ribcage, anterior superior iliac spines, femoral trochanters, knees, and ankles.

Figure 2-9. Balanced

Figure 2-10. Posture

shoulder girdle and

balanced left to right.

torso.

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25

POSTURE TY PES A postural distortion is an adaptation, or change, in the way the body is balancing. This is ac companied by characteristic patterns of dysfunctional muscle tightness and weakness. Significant clinical information can be deduced from observing and correlating different posture types and distortions. Kendall and Kendall's posture typing system categorizes posture types by lateral view into four types: military, kypholordotic, swayback, and flat back (Fig. 2-11). Each posture type's characteris tic patterns of muscle overactivity and underactivity are shown, with tight muscles dark and weak muscles lightly drawn. Observing head position (neutral or forward) and pelvic posture (neutral or posterior) allows posture to be categorized into the four types. Table 2-1 correlates with the posture types in Fig. 2-11 and summarizes the posture types and their associated patterns of muscle weak ness (Table 2-1).

Military Posture

Kypho-Lordotic Posture

Swayback Posture

Flatback Posture

Figure 2-11. Four posture types. (Modified with permission from Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Baltimore: Williams & Wilkins, 1993:84-87.)

II I

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TABLE

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

i-I

POSTURE TYPE CLASSIFICATION BY PELVIC TILT AND HEAD POSTURE Neutral Head Postures

Posterior Pelvic Tilt

Forward Pelvic Tilt

Forward Head Postures

Military Posture

Kypholordotic Posture

Anterior body structure Chest; pelvis if lordosis is marked Tight muscles Low back Hip flexors Weak muscles Anterior abdominals initially, hamstrings lengthen, then adaptively shorten

Anterior body structure Head (forward head posture) Abdomen Tight muscles Suboccipital neck extensors Hip flexors Serratus anterior Pectorals Upper trapezius (if scapulae are abducted) Weak muscles Neck flexors Upper thoracic spinae External abdominal oblique Mid and lower trap (if scapulae are abducted)

Swayback Posture

Flat Back Posture

Anterior body structure Pelvis or femur heads with compensating long kyphosis Tight muscles Hamstrings Internal abdominal obliques Low back erector spinae Same side TFL (if lateral pelvic distortion) Weak muscles 1 hip joint flexors External abdominal obliques Lower and mid trapezius Deep neck flexors Same side gluteus medius (if lateral pelvic distortion)

Anterior body structure Head Tight muscles Hamstrings Abdominals Weak muscles 1 joint hip flexors

POSTURAL SYNDROMES The body moves in patterns of motion. Unbalanced overuse of the postural muscles (e.g., the mus cles used to maintain posture) is accompanied by weakening of the opposing antagonist muscles. This weakening is due to lack of use and a neurologic reciprocal inhibition. This pattern of overuse and weakening results in distinct postural syndromes. The upper crossed syndrome affects the head, neck, and shoulders, while the lower crossed syndrome affects the lumbar spine and pelvis. They fre quently exist simultaneously and combine to create chronic musculoskeletal stress. This upper crossed posture syndrome is the source of computer user's (and others in long-term seated postures) complaint of chronic neck and shoulder tightness and pain. The upper crossed pos ture is characterized by rolled-in and forward shoulders with increased thoracic kyphosis, a forward head posture, and loss of the cervical lordosis (Fig. 2-12). The tightness in anterior shoulder mus cles results in weak and inhibited infraspinatus, teres minor, rhomboids, and thoracic erector spinae muscles. Neck, upper and middle back, and shoulder girdle muscles are shortened and tight from overuse, while their antagonists are weak and stretched. Trigger points are frequently found in the

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27

overused neck extensor muscles, the upper trapezius, and the levator scapulae muscles. The oppos ing longus colli, capitis, and lower trapezius muscles are weak (Table 2-2). The lower crossed syndrome is the other modern postural pattern. The lower crossed posture is characterized by an anterior pelvis and increased lumbar lordosis with tightness in the psoas and lumbar erector spinae (Fig. 2-13). Sitting shortens the psoas and other hip flexor muscles when the thigh is flexed. Long-term sitting at work and play, along with driving between the two, creates mus cle imbalance between these overused hip flexors and the underused hip extensors. The gluteus maximus, the primary hip extensor, opposes the hip flexors and therefore becomes adaptively weak. To maintain erect posture and balance, the lumbar erector spinae muscles compensate and extend the spine, resulting in hypertonicity of the lumbar erector spinae and adaptive weakening of the op posing abdominal muscles. Also, the hip adductor muscles are frequently tight, with compensating weakness of the gluteus medius and minimus muscles (Table 2-2).

UPPER CROSS POSTURE

Tight-short muscles

Tight-short muscles

LOWER CROSS POSTURE

Figure 2-12. Upper cross posture

Figure 2-13. Lower cross posture

Forward head

Anterior pelvis

Loss of cervical lordosis

Protruding abdomen

Shoulders rolled in and forward

Increased lumbar lordosis

Increased thoracic kyphosis light-short muscles

Feet turned out light-short muscles

Suboccipitals

Psoas

Pectorals, anterior shoulder

Lumbar erector spinae

Upper trapezius Weak-long muscles

Hip adductor Weak-long muscles

Mid, lower trapezius

Hip extensors, gluteus maximus

Serratus anterior

Abdominal Gluteus medius, minimus

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

' TABLEi -2

POSTURAL SIGNS OF UPPER AND LOWER C ROSSED SYNDROME

Postural Finding

Dysfunction

Upper crossed syndrome

Round shoulders Forward-drawn head CO-Cl hyperextension Elevation of shoulders Winging of scapulae

Shortened pectorals Kyphotic upper thoracic spine Shortened suboccipitals Shortened upper trapezius, levator scapulae, weak lower, middle trapezius Weak serratus anterior

Lower crossed syndrome

Lumbar hyperlordosis Anterior pelvic tilt Protruding abdomen Foot turned out Hypertrophy of thoracolumbar junction Groove in iliotibial band

Shortened erector spinae Weak gluteus maximus Weak abdominals Shortened piriformis Hypermobile lumbosacral junction Shortened tensor fascia latae

Adapted with permission from Liebenson C, ed. Rehabilitation of the Spine. Baltimore: Williams & Wilkins, 1996:363-364.

OTHER POSTUR AL DISTORTIONS, ADAPTATIONS, AND PATHOLOGIES Because postural evaluation is a global evaluation of how the body balances, faults and postures from one part of the kinetic chain can cause a compensating postural distortion in a different re gion. The overall posture is the sum of all distortions and resulting compensations necessary to al low the individual to balance and avoid painful positions and motions. In the interest of providing a comprehensive summary, primarily local muscular involvements are detailed below. Also, a nor mal skeletal system without vertebral compression fractures or congenital abnormalities such as hemivertebra is assumed. Forward Head Posture Forward head posture is probably the most common posture distortion (Fig. 2- 1 4). For every inch that the head moves forward of neutral posture, the weight carried by the lower neck increases by the additional weight of the entire head (Fig. 2-15). Many patients' symptoms of neck, shoulder, and arm pain; headaches; and stress are associated with the faulty biomechanics of carrying the skull too far forward of the torso. Observations associated with forward head posture include (a) external au ditory meatus anterior of the acromion and (b) sternocleidomastoideus usually hypertrophied. Possible tight, overactive muscles: SCM and/or suboccipitals, anterior cervical flexors; upper trapezius, levator scapulae, pectorals. Possible weak, underactive muscles: Cervical extensors, lower and mid trapezius, serratus ante rior. Also possible deep neck flexors (longus colli) inhibition. Clinical correlate: Palpate the suboccipitals when sitting and standing (Figs. 2-16 and 2-17). If there is less tension when sitting, pelvic postural stress is contributing to the forward head posture.

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29

s

1X 2X 3X Figure 2-14. Forward head posture.

Figure 2-15. For every inch the head moves forward of neutral posture, the weight carried by the lower neck increases by the additional weight of the entire head. (Adapted from Liebenson C, ed. Rehabilitation of the Spine. Baltimore: Williams & Wilkins, 1996:177.)

Figure 2-16. Palpation of the suboccipitals with the

Figure 2-17. Palpation of the suboccip

subject seated.

itals with the subject standing.

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Head Tilt and/or Rotation

PA view: The line between tips of the mastoid processes is unlevel (Fig. 2-18). The occipital protu berance is to one side of a center line bisecting the pelvis and spine. The skull is not evenly bisected by a centerline. Possible tight, overactive muscles: Lateral neck flexors on the flexed side, scalene or intrinsic rota tor muscles on the opposite side of head rotation. Sternocleidomastoideus, upper trapezius. Possible weak, underactive muscles: Lateral neck flexors on the opposite side of head flexion. In trinsic rotator muscles on the side of head rotation. Unlevel Shoulders

Observations: The horizontal line between the acromia is not level. Shoulder imbalance is also ob served with thoracic scoliosis and hand dominance (Fig. 2- 1 9). Possible tight overactive muscles: On the side of the high shoulder, upper trapezius and/or leva tor scapulae muscles; on the side of the low shoulder, lower trapezius and pectoralis minor muscles, tight rhomboid and/or latissimus dorsi muscles. Possible weak, underactive muscles: On the side of the high shoulder, lower and mid trapezius; on the side of the low shoulder, upper trapezius.

Figure 2-18. Right head

Figure 2-19. High left

tilt and rotation.

shoulder.

CHAPTER 2

POSTURAL ASSESSMENT

31

Observation: The neck-shoulder line is not contoured normally (Fig. 2-20). A straightening of the neck-shoulder line indicates a tight trapezius muscle. This is known as a gothic shoulders ap pearance because it looks like a Gothic church tower. Observation: A double wave appearance at the lateral scapula at the insertion of the levator scapula indicates tightness of the levator scapula (Fig. 2-21).

Figure 2-20. Elevated, or Gothic, shoulders. (Reprinted with permission from Liebenson C, Chapman S. Cervico-Thoracic Spine: Making a Rehabilitation Prescription, Tape 2. Baltimore: William� & Wilkins, 1998, Fig 3.) .

Figure 2-21. TIghtness of the levator scapula. (Reprinted with permission from Liebenson C, ed. Rehabilitation of the Spine. Baltimore: Williams & Wilkins, 1996:108.)

II

32

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Scapula Winging The medial borders of the scapulae are lifted posteriorly from the ribs. Possible tight, overactive muscles: Rhomboid. Possible weak, underactive muscles: serratus anterior. Clinical correlate: Push-up test. Observe whether scapula winging increases when the person does a pushup (Fig. 2-22).

Figure 2-22. Winged scapula. (Reprinted with permission from Liebenson C, Chapman S. Cervico-Thoracic Spine: Making a Rehabilitation Prescription, Tape 2. Baltimore: Williams & Wilkins, 1998, Fig 2.)

Scapula Rotation The scapula are unevenly centered on the torso. Usually one is abducted (more lateral from thoracic spine midline) and one is adducted (more medial to the thoracic spine midline) (Fig. 2-23). Scapu lar rotation is also observed with thoracic scoliosis and hand dominance. Possible tight, overactive muscles: Side of the abducted scapula: serratus anterior. Side of the ad ducted scapula: rhomboid. Possible weak, underactive muscles: Side of the abducted scapula: rhomboid and middle trapez ius; side of the adducted scapula: pectoralis major or minor.

Figure 2-23. Right scapula abduction and winging. (Reprinted with permission from Liebenson C, ed. Rehabilitation of the Spine. Baltimore: Williams & Wilkins, 1996:108.)

CHAPTER 2

POSTURAL ASSESSMENT

33

Round Shoulders/Internal Rotation of the Upper Extremity In addition to having a rounded appearance of the shoulders, the back of the hands may be visible on an anterior view as the thumbs point across the body instead of to the anterior. The palm of the hands may be visible from the posterior (Fig. 2-24). Possible tight, overactive muscles: Latissimus dorsi and/or pectorals. Possible weak, underactive muscles: Mid trapezius. Clinical correlate: Usually observed with forward head posture. Figure 2-24. Round shoulders with internal rotation of the arms.

Lateral Spinal Deviation/Scoliosis Scoliosis is a lateral curvature of the spine that may be acquired or congenital. Congenital scoliosis is due to some architectural asymmetry, such as a wedge vertebra or other anatomic variant. Most acquired scoliosis is idiopathic, or of unknown origin. Scoliosis evaluation, management, and treat ment continually progress but are still controversial. On visual evaluation, the spinous processes are lateral to the midline of the trunk (Fig. 2-25). Figure 2-25. Right thoracolumbar erector spinae hypertrophy. (Reprinted with permission from Liebenson C, ed. Rehabilitation of the Spine. Baltimore: Williams & Wilkins, 1996:107.)

34

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Possible tight, overactive muscles: Shortened intrinsic paraspinal muscles on the side of concavity. Possible weak, underactive muscles: Lengthened intrinsic paraspinal muscles on the side of con vexity. Clinical correlate: Thoracolumbar erector spinae hypertrophy indicates a longstanding adaptive change. Most AP spines have a slight right convex thoracic curve due to the individual's right-hand edness. It is important to rule out congenital abnormalities and factor in leg length discrepancies and other distortions. Lateral Pelvic Tilt!Abdominal Asymmetry The horizontal line connecting the left and right iliac crests are unlevel (Fig. 2-26) Possible tight, over-active muscles: High side: PA-quadratus lumborum muscle; AP-abdominal obliques Low side: hip adductor. Possible weak/underactive muscles: High side: gluteus maximus, abductor muscles Low side: opposite side abdominal obliques. Clinical correlates: Leg length discrepancies and other distortions are usually present. Trende lenburg test may be positive on the side of laterality. Scoliosis may be present.

Figure 2·26. Pelvic unleveling. (Reprinted with permission from Liebenson C, Chapman S. Lumbar Spine: Making a Rehabilitation Prescription, Tape 1. Baltimore: Williams & Wilkins, 1998, Fig 5.l

CHAPTER 2

POSTURAL ASSESSMENT

35

Anterior or Posterior Pelvic Tilt Neutral and stable pelvic position is the range of possible stable positions, which are the base upon which spinal posture rests. The anterior superior spines of the innominates should be vertically aligned with the symphysis pubes. On a lateral view, the waist line (or belt line) should be level to tilting slightly forward with a normal anterior lumbar lordosis providing stable posture. Anterior pelvis: The pelvis tilts forward, with an associated increased lumbar lordosis (Figs. 2-27 and 2-28). Possible tight, overactive muscles: Psoas, lumbar erector spinae. Possible weak, underactive muscles: Gluteus maximus; abdominals. Posterior Pelvis: (Fig. 2-29) There is a flattened lumbar curve with the pelvis tilting posteriorly or slightly forward of level. Possible tight, overactive muscles: Hamstrings, abdominals, low back erector spinae. PossibLe weak, underactive muscles: Hip flexors, quadriceps.

Figure 2-27. Anterior pelvic tilt. (Reprinted with permission from Liebenson C, Chapman S. Lumbar Spine: Making a Rehabilitation Prescription, Tape 1. Baltimore: Williams & Wilkins, 1998, Fig 4.'

Figure 2-28. Anterior

Figure 2-29. Posterior

pelvic tilt.

pelvic tilt.

•

36

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Abdomen Protrusion (Figs. 2-30 and 2-31)

Possible associated findings: Lateral buttock flattening in the lateral or superior quadrant. Possible tight, overactive muscles: Erector spinae, iliopsoas. Possible weak, underactive muscles: Gluteus maximus, abdominals. Clinical correlate: Because of the marked anterior pelvic tilt usually associated with abdominal protrusion, weakness and limited range of motion on hip extension and hip abduction are common.

Figure 2·30. Abdominal

Figure 2·31. Abdominal

protrusion.

protrusion in pregnancy.

Knock Knees: Genu Valga (Fig. 2-32)

Associated observations: Pronation Prominence of iliotibial tract Observation: Lateral deviation of the patellae. Possible tight, overactive muscles: TFL Possible weak underactive muscles: Adductors, sartorius Clinical correlate: Correlate with wear patterns of shoes

CHAPTER 2

POSTURAL ASSESSMENT

37

•

Figure 2-32. Knock-knees (genu valga). (Reprinted with permission from Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Baltimore: Williams & Wilkins, 1993:97.)

, \ \

,. J.:?," //��?_) ii \

_____

Figure 2-33. Bowlegs (genu vara). (Reprinted with permission from Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. 4th ed. Baltimore: Williams & Wilkins , 1993:97.)

38

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS Observation: Bowleg (genu vara) (Fig. 2-33). Possible weak underactive muscles: Weak hip rotators. Observation: Pronation of the feet (Figs. 2-34 and 2-35) Possible tight, overactive muscles: Soleus (on the right). Possible weak underactive muscles: Anterior tibialis, Gluteus medius and maximus. Clinical correlate: Flat feet.

Figure 2-34. Pronation of the foot. (Reprinted with permission from Liebenson C. Chapman S. Lumbar Spine: Making a Rehabilitation Prescription, Tape 1. Baltimore: Williams & Wilkins, 1998, Fig 1.)

Figure 2-35. Pronation with soleus tightness on the right. (Reprinted with permission from Liebenson C, ed. Rehabilitation of the Spine. Baltimore: Williams & Wilkins, 1996:107.)

References 1. White AA, Panjabi MM. Clinical Biomechanics

General References Kendall FP, McCreary EK, Provance PG. Muscles:

of the Spine. 2nd ed. Philadelphia: JB Lippincott,

Testing and Function. 4th ed. Baltimore: Williams &

1990:58,86-91,116,162.

Wilkins, 1993:20,70-119,354-356.

2. Janda V. Functional Pathology of the Motor Sys tem Seminars. Atlanta: 1999; Greenville, SC: 2000; Prague: 2000. 3. Watson J. Relationship between injuries & body mechanics in soccer and rugby players. Sports Med Physical Fitn 1995;35:289-294. 4. Basmajian IV, De Luca DJ. Muscles Alive. 5th ed. Baltimore: Williams & Wilkins, 1985:255, 414, P71,328.

Janda v. Functional Pathology of the Motor System Seminars.

Atlanta:

1999;

Greenville,

SC:

2000;

Prague: 2000. Jull G, Janda V, Muscles and motor control in low back pain. In: Twomey L T , Taylor JR, eds. Physical T herapy for the Low Back. Clinics in Physical T her apy. New York: Churchill Livingstone,1987. Liebenson C, ed. Rehabilitation of the Spine. Balti more: Williams & Wilkins,1996

------�rn�---CERVICAL ORTHOPAEDIC TESTS

SUBCLAVIAN ARTERY

CERVICAL ORTHO PAEDIC EXAMINATION FLOW CHART

40

DIFFERENTIAL DIAGNOSIS: STRAIN

41

ANTERIOR ASPECT

70

VERSUS SPRAIN

Sternocleidomastoid Muscle

41

72

CERVICAL FRACTURES

43

Supraclavicular Fossa

73

Spinal Percussion Test 44

POSTERIOR ASPECT

Soto-Hall Test

44

Trapezius Muscle

Rust's Sign

Cervical Intrinsic Musculature Spinous Process/Facet Joints

74

75

45 46

CERVICAL RANGE OF MOTION

47

48

77

Alar L igament Stress Test

79

Valsalva's Maneuver

51

Dejerine's Sign CERVICAL RESISTI VE ISOMETRIC MUSCLE TESTING

Swallowing Test

80

81 81

52

CERVICAL NEUROLOGICAL

52

82

COMPRESSION AND IRRITATION

53

Extension

80

SPACE-OCCUPYING LESIONS

50

L ateral Flexion

82

Foraminal C ompression Test

54

L ateral Flexion Rotation

83

Jackson's C ompression Test

55

84

E xtension C ompression Test VERTEBROBASILAR CIRCULATION ASSESSMENT

56

Maigne's Test

85

86

Maximal Foraminal C ompression

Vertebrobasilar Artery Functional Maneuver

Flexion C ompression Test Spurling's Test

59

B arre-Lieou Sign 60

Test

87

L'hermitte's Sign

61

88

Shoulder Depression Test

Vertebral Artery (C ervical Quadrant) Test

78

Transverse L igament Stress Test

49

E xtension

Flexion

76

CERVICAL INSTABILITY Sharp-P urser Test

Rotation

70

O 'Donoghue's Maneuver

42

Carotid A rteries

Flexion

68

G eorge's Screening Procedure

41

CERVICAL PAL PATION

68

COMPROMISE

62

Distraction Test

89

89

Shoulder Abduction Test (B akody's

Dekleyn's Test

63

Hautant's Test

64

Underburg's Test

Sign)

90

64

Hallpike's Maneuver

66

39

Cervical Orthopaedic Examination

� o

t

Cervical spine pain

Cervical pain

with upper extremity

and dizziness

pain/paresthesia

compromise

Foraminal compression test

maneuver

Jackson compression test Flexion/extension compression test

8arre-Lieou sign

(+)

(-)

Shoulder depression test

Peripheral

Maigne's test

vascular

Dekleyn's test

compromise

Distraction test

Hautant's test Underburg's test

Shoulder abduction test

(+)

Adson's test Costoclavicular test

Cervical

Wright's test

vascular

Traction test

compromise

Halstead Maneuver

( -) Strain

Refer for

or

neurological

Sprain

evaluation

Subluxation Dislocation Osseus defects

Space-occupying lesions

Diagnostic imaging (x-ray) (MRI) (CT scan)

(+)

Foraminal encroachment Discogenic spondylosis Disc defect

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

41

CERVICAL PALPATION Anterior Aspect

Sternocleidomastoid Muscle DESCRIPTIVE ANATOMY The sternocleidomastoid muscle extends from the mastoid process of the temporal bone down to the clavicle and sternum ( Fig. 3-1). It divides the neck into anterior and posterior triangles. Its ac tion is to flex the head to the same side and rotate it to the opposite side. Both muscles acting to gether flex the neck forward.

PROCEDURE Instruct the patient to turn the head to one side. Pinch the muscle on the side of head rotation be tween your thumb and forefinger, traveling from the clavicle upward to the mastoid ( Fig. 3-2). Com pare each muscle bilaterally, noting any inflammation, tenderness, and palpable bands. Palpable bands are hyperirritable spots within a taut band of skeletal muscle or fascia. Rate tenderness based on tenderness rating scale (Box 3-1). Inflammation and tenderness secondary to trauma usually are associated with cervical acceler ation and deceleration (CAD) types of injuries. Torticollis may also cause local inflammation and tenderness. Palpable bands may indicate a myofascial trigger point. These trigger points may be caused by overuse, trauma, or chilling. They may also indicate arthritic joints or emotional distress.

Internal and --17f-\\!i!!\--+

external-----J'frH1I+r++-+-!l"-

Omohyoid

artery and vein

'-----v----' Sternum

Figure

Figure

3-1

3-2

Tenderness Grading Scale Grade I

Mild tenderness to moderate palpation

Grade III

Severe tenderness with withdrawal

Grade II

Grade IV

Mild tenderness with grimace and flinch to moderate palpation Severe tenderness with withdrawal from nonnoxious stimuli

II

42

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Carotid Arteries DESCRIPTIVE ANATOMY The carotid arteries lie lateral to the trachea and medial to the sternocleidomastoid muscle. These arteries branch to form the internal and external carotid arteries, which supply blood to the brain (see Fig. 3-1).

PROCEDURE With your first and second digits, lightly press on the carotid artery against the transverse process of the cervical vertebra ( Fig. 3-3). Palpate each artery individually and assess amplitude equality. A dif ference in the strength of the pulses may indicate carotid artery stenosis or compression. If carotid artery stenosis or compression is suspected, auscultate the carotid arteries for bruits and evaluate the vertebrobasilar circulation.

Figure

3-3

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

43

Supraclavicular Fossa DESCRIPTIVE ANATOMY The supraclavicular fossa is superior to the clavicle. It contains the omohyoid fascia, the lymph nodes, and the pressure point for the subclavian artery. It is usually a smooth, contoured depression (Fig. 3- 1 ).

PROCEDURE Palpate each fossa for swelling, tenderness, and any abnormal bony or soft tissue masses ( Fig. 3-4). Pain and tenderness associated with swelling secondary to trauma may indicate a fractured clavicle or a separated acromioclavicular joint. Abnormal bony tissue may indicate a cervical rib, which may cause neurological or vascular symptoms in the upper extremity. If an extra rib is suspected, evalu ate for thoracic outlet syndrome (see Chapter 5) . An abnormal soft tissue mass may indicate lymph adenopathy or a tumor.

Figure

3-4

II

44

PHOTOGRAPHIC MANuAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Posterior Aspect

Trapezius Muscle DESCRIPTIVE ANATOMY The trapezius muscle is a large, triangular muscle that extends from the occiput and spinous processes of the cervical and thoracic vertebra to the acromion process of the clavicle and spine of the scapula ( Fig. 3-5). Its superior fibers elevate the shoulders; the middle fibers retract the scapula; and the inferior fibers depress the scapula and lower the shoulders.

PROCEDURE Palpate each muscle from the superior aspect just below the occiput downward, continuing to the su perior aspect of the spine of the scapula, then lateral to the acromion process (Fig. 3-6). From the inferior, palpate from the spinous processes of the thoracic vertebra lateral and superior toward the acromion process ( Fig. 3-7). Inflammation and tenderness secondary to trauma may indicate muscle spasm caused by torn muscle fibers associated with edema. Inflammation and tenderness that are not trauma re lated may indicate fibrosis of muscle tissue or fibromyalgia. Assess it according to the tender ness rating scale (see Box 3-1) . Palpable bands indicate myofascial trigger points that may be caused by overuse, overload, trauma, or chilling. These palpable bands may also indicate arthritic joints or emotional distress.

Semispinalis

Longissimus

Figure 3-6

Figure

3-5

Figure 3-7

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

45

Cervical Intrinsic Musculature DESCRIPTIVE ANATOMY The palpable intrinsic spinal muscles in the cervical spine consist of splenius capitis and cervi cis, longissimus cervicis, and semispinalis cervicis. These layered muscles are used for the main tenance of posture and movements of the cervical spine. The superficial layer consists of the splenius capitis and cervicis, and the intermediate layer consists of the longissimus and semispinalis cervicis. These muscles stretch from the base of the occiput to the upper aspect of the thoracic spine ( Fig. 3-5) . The deep muscles on the cervical spine at best are difficult to palpate and are not discussed here.

PROCEDURE Palpate the superficial layer by moving the fingers in a transverse fashion over the belly of the muscle with the cervical spine in slight extension ( Fig. 3-8). Note any abnormal tone, tender ness, or palpable bands. Palpate the intermediate layer with the fingertips directly adjacent to the spinous processes, also with the cervical spine in slight extension ( Fig. 3-9). Note any ab normal tone, tenderness, or palpable bands. Rate the layers according to the tenderness rating scale (Box 3-1). Any abnormal tone or tenderness may indicate an inflammatory process in the muscle, such as muscle strain, myofascitis, or fibromyalgia. Palpable bands indicate myofascial trigger points, which may be caused by overuse, overload, trauma, or chilling. They may also indicate arthritic joints or emotional distress.

Figure

3-8

Figure

3-9

II

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

46

Spinous Process/Facet Joints DESCRIPTIVE ANATOMY The C1, or atlas, vertebra has a posterior arch rather than a spinous process that is difficult at best to palpate. The C2 to C7 vertebrae have relatively prominent spinous processes that are easily palpable. Slightly lateral to the spinous processes lie the facet joints. Each facet joint is composed of a posterior inferior articular process and a posterior superior articular process from congruent vertebra ( Fig. 3- 1 0).

PROCEDURE With the patient seated and head slightly flexed, palpate each spinous process individually with your index and/or middle finger, noting any pain and/or tenderness ( Fig. 3-11). Also, evaluate each spinous process as you move the cervical spine in flexion and extension to determine hy pomobility versus hypermobility ( Fig. 3 - 1 2). Again, with the patient's head slightly flexed, using your thumb and index finger, palpate the facet joints bilaterally both in a static position ( Fig. 3-l3) and in a flexed position while performing extension movements ( Fig. 3- 1 4). Tenderness at the spinous and/or facet joint indi cates an inflammatory process at that site. The inflammation is usually secondary to subluxa tion or trauma, that is, hyperflexion or hyperextension injury. Crepitus on movement may in dicate degenerative joint disease.

Posterior inferior articular process

Atlas (Cl)

Figure

3-11

Figure

3-12

Posterior superior articular process Spinous process Facet joint

Figure

3-10

C5 C6

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

47

II

Figure

3-13

Figure

3-14

CERVICAL RANGE OF MOTION Cervical range of motion should be evaluated only after taking a proper and thorough history to rule out any indication that these movements will adversely affect the patient. Severe trauma caus ing a fracture or dislocation or cervical vascular compromise should be ruled out before perform ing these movements. You should not only note limited motion in the cervical spine but also any pain along with its location and character. The most painful movements should be performed last so that no residual pain is carried over from the previous movement. Crepitus should also be noted upon movement; it may indicate degenerative changes in the cervical spine. Spinal range of motion is measured using inclinometers, with the patient performing the move ments actively and passively. The inclinometer is the preferred instrument for measuring spinal range of motion because it measures angular displacement relative to gravity. For continuity of re porting and for evaluating patient compliance, the movements should be performed three times. The three measureme nts must be within SOor 1 0% of each other for a valid reporting criterion. The full arc of motion is paramount to the evaluation of range of motion in the cervical spine. Adding the opposing measurements to determine the full arc of movement is the most objective way to as sess cervical spine movement. For example, the patient carries the head in 10° of flexion, which for this person is the neutral position. When you measure cervical flexion on this individual, cervical flexion may be reduced 10° from average. If you then measure extension, you may possibly have an increase of 10°. This increase may be caused by the 10° flexion angle, which is the neutral position for that patient. If you take each measurement individually, you have a deficit movement in flexion and an increase in movement in extension. If you add both movements, you see that the full arc is within normal limits.

48

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Flexion: Inclinometer Method (1,2) With the patient seated and the cervical spine in the neutral position, place one inclinometer over the Tl spinous process in the sagittal plane. Place the second inclinometer at the superior aspect of the occiput, also in the sagittal plane ( Fig. 3 - 1 5). Zero out both inclinometers. Instruct the patient to flex the head forward and record both angles ( Fig. 3- 1 6). Subtract the Tl inclination from the oc cipital inclination to obtain the active cervical flexion angle. NORMAL RANGE Normal range is 50° or greater from the neutral or 0 position for active movement.

Figure

3-15

Figure

3-16

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

49

Extension: Inclinometer Method (1,2) With the patient seated and the cervical spine in the neutral position, place one inclinometer slightly lateral to the Tl spinous process in the sagittal plane. Place the second inclinometer at the superior aspect of the occiput, also in the sagittal plane ( Fig. 3 - 1 7) . Zero out both inclinometers. Instruct the patient to extend the head backward and record both inclinations ( Fig. 3 - 1 8 ) . Subtract the Tl incli nation from the occipital inclination to obtain the active cervical extension angle.

NORMAL RANGE The normal range is 60° or greater from the neutral or 0 position for active movement and 1 l 00for full arc of active flexion and extension. The normal range of passive flexion and extension varies as follows (3): Age

Degrees

20-29 30-49 > 50

151 ± 1 7 1 4 1 ± 35 1 29 ± 14

Figure

3-17

Figure

3-18

II

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

50

L ateral Flexion: Inclinometer Method (1, 2) With the patient seated and the cervical spine in the neutral position, place one inclinometer flat on the T1 spinous process in the coronal plane. Place the second inclinometer at the superior aspect of the occiput, also in the coronal plane (Fig. 3-19). Zero out both inclinometers. Instruct the patient to flex the head to one side and record both inclinations (Fig. 3-20). Subtract the Tl inclination from the occipital inclination to obtain the active cervical lateral flexion angle. Repeat with flexion to the opposite side.

NORMAL RANGE The normal range is 45° or greater from the neutral or 0 position for active movement and 90° for full arc of active right and left lateral flexion. The full arc of passive right and left lateral flexion varies as follows (3) : Age

Degrees

20-29 30-49 > 50

101 ± 1 1 93 ± 1 3 80 ± 17

Figure

3-19

Figure

3-20

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

51

Rotation: Inclinometer Method (1,2) With the patient supine, place the inclinometer at the crown of the head in the transverse plane (Fig. 3-21). Zero out the inclinometer. Instruct the patient to rotate the head to one side, and then record your findings ( Fig. 3-22). Repeat the procedure with the patient's head rotated to the oppo site side.

NORMAL RANGE Normal range is 80° or greater from the neutral or 0 position for active movement. The full arc of ac tive right and left rotation is 160°. The full arc of passive right and left rotation varies as follows (3): Age

Deg rees

20-29 30-49 > 50

183 ± 11 172 ± 13 155 ± 15

Figure

3-21

Figure 3-22

1.1

52

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

CERVICAL RESISTIVE ISOMETRIC MUSCLE TESTING The same movements can also be tested for resistive strength. Contra indications such as fracture, dis location, and cervical vascular compromise must be considered before testing for resistive strength. Resistive isometric muscle testing is performed to evaluate muscle strength or muscle state. Weakness of a particular muscle or muscle group may indicate neurological dysfunction in the nerves supplying the affected muscles. Pain of a particular muscle or muscle group during resistive isometric muscle testing may indicate muscle dysfunction, such as a muscle strain. Each of the following movements includes a chart that indicates the muscles that make the movement and the nerve supply to each muscle. The clinician evaluates each movement according to muscle strength; grade is based on the muscle grading scale adopted by the American Academy of Orthopaedic Surgeons (Box 3-2). Muscle Grading Scale

5 4

Complete range of motion against gravity with full resistance Complete range of motion against gravity with some resistance

3

Complete range of motion against gravity

2 1

Complete range of motion with the gravity eliminated Evidence of slight contractility; no joint motion

o

No evidence of contractility

Flexion With the patient seated and in the neutral position, instruct him or her to flex the head forward against your resistance, making sure that there is no patient movement and only muscle contraction (Fig. 3-23). Muscles

Nerve Supply

l.

C2-Cs C4-Cs C3-C8 C6-C8 Accessory, C2

2. 3. 4. 5.

Longus colli Scalenus anterior Scalenus medius Scalenus posterior Sternocleidomastoid

Figure

3-23

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

53

Extension With the patient seated and in the neutral position, instruct him or her to extend the head backward against your resistance, making sure that there is no patient movement and only muscle contraction ( Fig. 3-24). Muscles

Nerve Supply

I. 2. 3. 4. 5. 6. 7. B. 9. 10. II. 12.

C6,C7,CB C1-C6,C7,CB C6-CB C3-C4 C6,C7,CB C6,CB C1-C6,C7,CB C1-CB C3,C4 C1 C1-CB C1-CB

Splenius cervicis Semispinalis cervicis Longissimus cervicis Levator scapulae Iliocostalis cervicis Spinalis cervicis Multifidus Interspinalis cervicis Trapezius (Upper) Rectus capitis posterior major Rotatores breves Rotatores longi

Figure

3-24

•

54

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

L ateral Flexion With the patient seated and in the neutral position, instruct him or her to bend the head to one side against your resistance, making sure that there is no patient movement and only muscle contraction ( Fig. 3-25). This action should be performed bilaterally. Muscles

Nerve Supply

1. 2. 3. 4. 5. 6. 7. S. 9. 10. 11. 12. 13. 14.

C3-C4 C4-C6 C6-CS C6-CS CI-CS CI-CS CI-CS C3-CS C2 Cl CI-CS CI-CS C2-C6 C3-C4

Levator scapulae Splenius cervicis Iliocostalis cervicis Longissimus cervicis Semispinalis cervicis Multifidus Intertransversarii Scaleni Sternocleidomastoideus Obliquus capitis inferior Rotatores breves Rotatores longi Longus colli Trapezius

Figure

3-25

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

55

Rotation With the patient seated and in the neutral position, instruct him or her to rotate the head to one side against your resistance, making sure that there is no patient movement and only muscle contraction ( Fig. 3-26). This action should be performed bilaterally. Muscles

Nerve Supply

Moves Face to Same Side l . Levator scapulae 2. Splenius cervicis 3. Iliocostalis cervicis 4. Longissimus cervicis 5. Intertransversarii 6. Obliquus capitis inferior 7. Rotatores breves B. Rotatores longi Moves Face to Opposite Side l . Multifidus 2. Scaleni 3. Sternocleidomastoideus

C3-C4 C4-C6 C6-CB C6-CB CI-CB Cl CI-CB CI-CB CI-CB C3-CB C2

RATIONALE Pain on resistive isometric contraction may indicate a musculotendinous strain of one or more of the muscles involved in the action. Weakness may indicate a neurological disruption to the muscle or muscles involved in the action.

Figure

3-26

II

56

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

VERTEBROBASILAR CIRCULATION ASSESSMENT

CLINICAL DESCRIPTION Vascular insufficiency may be aggravated by positional change in the cervical spine. Assessment of vertebrobasilar circulation must be done if cervical adjustment or manipulation is to be performed. Absolute contraindications and risks of cervical adjustment or manipulation can be minimized sig nificantly, even though reportedly small, with proper diagnostic evaluation. These risks and con traindications may be predicted in some cases by functional or provocative testing and by adequate history (familial history of stroke or cardiovascular disease, hypertension, smoking, cervical spondy losis or arthrosis, bleeding disorders, medication, and/or anatomic anomaly or pathology) . Vascular accidents may still occur with no evidence of vascular insufficiency, deficit, and negative provocative procedures. Box 3-3 lists the eight most common predispositions associated with cerebrovascular accidents. Predispositions to Cerebrovascular Accidents Headaches, migraine Dizziness Sudden severe head or neck pain Hypertensive Cigarette smoking Oral contraceptives Obesity Diabetes

All of the following tests incorporate a positional change in the cervical spine. The rotation as pect of this change is the common denominator of all the following tests. Rotation of CI on C2 be tween 30° and 45° compresses the vertebral artery at the atlantoaxial junction on the opposite side of head rotation, reducing blood flow to the basilar artery ( Fig. 3-27) (4,5) . In the normal patient, this diminution of blood flow caused by positional change of the cervical spine does not cause any neurological symptoms, such as dizziness, nausea, tinnitus, faintness, or nystagmus. This lack of symptoms is a result of the normal flow of collateral circulation by the opposite vertebral artery, common carotid arteries, and a communicating cerebral arterial circle (Circle of Willis) ( Fig. 3-28) . Rotational instability i n the upper cervical spine caused by trauma, arterial artery disease, and/or degenerative joint disease in the cervical spine may lead to a mechanical reduction of blood flow to an area, causing neurological symptoms. This reduction of blood flow may be such that the collateral circulation is not sufficient to sustain normal function to the brain. Therefore, when you positionally stress a vessel in the cervical spine, you are testing the integrity of the collateral circula tion supplied to the area, which is normally supplied by the vessel being stressed.

)

,). /,($

;<

II

Basilar artery

"�

Compression of vertebral artery reduces blood flow to basilar artery

Vertebral artery

Figure

3-27 .- _ _

o W __ _

S

_

-../ Anterior

cerebral a. Ant. communicating a. Middle cerebral a. Posterior communicating a.

Basilar artery

Posterior cerebral a.

--WH'ft,��+-=�

:-----+_ Basilar a. �--+- Ant. info

cerebellar a.

Vertebral a.

Vertebral artery

----t---21m��

Common carotid a. L __ --

Figure

3-28 .- . 57

58

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Assessment of the vertebrobasilar circulation by provocative or functional testing stresses seven areas of possible compression. These areas are as follows ( Fig. 3-29): 1. Between Cl and C2 transverse processes, where the vertebral arteries are relatively fixed at the Cl and C2 transverse foramina 2. C2 to C3 at the level of the superior articular facet of C3 on the ipsilateral side to head rota tion 3. The Cl transverse process and the internal carotid artery 4. The atlanto-occipital aperture by the posterior arch of Atlas and the rim of foramen magnum or anteriorly at the atlanto-occipital joint capsule and posteriorly at atlanto-occipital mem brane. 5. C4 to Cs or Cs to C6 levels because of arthrosis of the joints of the uncovertebral joints with compression on the ipsilateral side to head rotation 6. At the transverse foramina of the atlas or axis between the obliquus capitis inferior and in tertransversarii during rotatory movements 7. Before entering the C6 transverse process by the longus colli muscle or by tissue communi cating between the longus colli and scalenus anterior muscles Most compression and/or damage is reported at the first four sites.

Skull

Foramen

Internal carotid involving C1

:;� ;d r:::=��

Vertebral-HL.lb artery

__ _

Arthrosis Osteophyte

Figure

3-29

CHAPTER 3

CERV1CAL ORTHOPAEDIC TESTS

59

Allow a lO-second interval between tests to ensure that there are no latent symptoms. If symp toms are reproduced, there is no need to progress to any other cervical vascular provocative tests. The most common clinical signs and symptoms exhibited in cerebrovascular episodes are presented in the box below. Clinical Signs and Symptoms of Cerebrovascular Episodes Vertigo, dizziness, giddiness, light-headedness Drop attacks, loss of consciousness Diplopia Dysarthria Dysphagia Ataxia of gait Nausea, vomiting Numbness on one side of the face Nystagmus

Sensitivity/Reliability Scale

Barre-Lieou Sign (6)

I

o

PROCEDURE

I 1

I

2

I

3

I

I

With the patient seated, instruct him or her to rotate the head to one side and then the other (Fig. 3-30).

RATIONALE Rotating the head causes compression of the vertebral artery opposite the side of head rotation ( Fig. 3-27). Therefore, you are testing the patency of the vertebral artery on the same side of head rota tion. Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive test. This sign indicates buckling vertebral artery syndrome. Also, consideration must be given to the patency of the carotid arteries and a communicating cerebral arterial circle.

Figure

3-30

60

PHOTOGRAPH1C MANUAL OF REG10NAL ORTHOPAED1C AND NEUROLOG1CAL TESTS

Sensitivity/Reliability Scale

Vertebrobasilar Artery Functional Maneuver (7)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, palpate and auscultate the carotid ( Fig. 3-3 1 )and subclavian arteries ( Fig. 3-32) for pulsations or bruits. When auscultating, instruct the patient to hold his or her breath. If neither artery is palpable, instruct the patient to rotate and hyperextend the head to one side and then the other ( Fig. 3-33). If pulsations or bruits are present, do not perform the rotation and hy perextension portion of the test.

RATIONALE If pulsations or bruits are present at the carotid or subclavian arteries, this test is considered posi tive. It may indicate a compression or stenosing of the carotid or subclavian arteries. The rotation and hyperextension portion of the test places a motion-induced compression on the vertebral artery opposite the side of head rotation ( Fig. 3-27) . Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive test. A positive result indicates vertebral or basilar artery stenosis or compression at one of the seven sites discussed earlier in the chapter. Consideration must also be given to the patency of the carotid arteries and a communicating cerebral arterial circle.

NOTE Vertebrobasilar artery functional maneuver and George's screening procedure are both subsections of George's Cerebrovascular Craniocervical Functional Test.

Figure

3·31

Figure

3-32

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61

CERVICAL ORTHOPAEDIC TESTS

•

Figure

3-33 Sensitivity/Reliability Scale

Maigne's Test (8)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, instruct the patient to extend and rotate the head and hold that position for 15 to 40 seconds ( Fig. 3-34). Repeat the test with the patient's head rotated to the opposite side.

RATIONALE Rotation and extension of the head place a motion-induced compression on the vertebral artery on the opposite side of head rotation ( Fig. 3-27). Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this section. Consid eration must also be given to the patency of the carotid arteries and a communicating cerebral ar terial circle.

Figure

3-34

62

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Vertebral Artery (Cervical Quadrant) Test (9)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient supine and the patient's head off the table, the examiner passively hyperextends and laterally flexes the head and holds this position for 30 seconds ( Fig. 3-35). Repeat with the head lat erally flexed to the opposite side.

RATIONALE Lateral flexion and hyperextension of the head place a slight motion-induced compression on the vertebral artery on the same side of lateral head flexion. Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this sec tion. Consideration must also be given to the patency of the carotid arteries and a communicating cerebral arterial circle.

Figure 3-35

CHAPTER 3

Dekleyn's Test (10, 11)

CERVICAL ORTHOPAEDIC TESTS

63

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I

2

I

3

I

4

With the patient supine and the patient's head off the table, instruct the patient to hyperextend and rotate the head and hold for 1 5 to 40 seconds ( Fig. 3-36). Repeat with the head rotated and extended to the opposite side.

RATIONALE Rotation and hyperextension of the head place a motion-induced compression on the vertebral ar teries on the opposite side of head rotation ( Fig. 3-27). Vertigo, dizziness, visual blurring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this sec tion. Consideration must also be given to the patency of the carotid arteries and a communicating cerebral arterial circle.

Figure 3-36

II

64

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Hautant's Test (12)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

I

3

4

With the patient seated and the patient's eyes closed, instruct the patient to extend the arms to the front with palms up. Instruct the patient to extend and rotate the head to one side ( Fig. 3-37). Re peat with the head rotated and extended to the opposite side.

RATIONALE A patient with stenosis or compression to the vertebral, basilar, or subclavian arteries without suffi cient collateral circulation will tend to lose balance, drop the arms, and pronate the hands. If this oc curs, suspect a vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this section.

Figure

Underburg's Test PROCEDURE

3-37 Sensitivity/Reliability Scale

I

o

I 1

I

2

I

3

I

I

4

With the patient standing, instruct him or her to close the eyes and look for difficulty in equilibrium ( Fig. 3-38) . Next, instruct the patient to stretch out the arms and supinate the hands ( Fig. 3-39). Look for difficulty in equilibrium and drifting or pronating of the arms. Then instruct the pa tient to march in place ( Fig. 3-40). Next, instruct the patient to extend and rotate the head while continuing to march in place ( Fig. 3-41) . Repeat with the patient's head rotated and extended to the opposite side.

RATIONALE Marching in place increases the heart rate, which increases the rate of blood flow through the sus pected vessels. Extension and rotation of the head place a motion-induced compression on the ver tebral arteries on the opposite side of head rotation (see Fig. 3-27). Vertigo, dizziness, visual blur ring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this section. Consideration must also be given to the patency of the carotid arteries and a com municating cerebral arterial circle.

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

65

II

Figure

3-38

Figure

3-40

Figure

3-39

Figure

3-41

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

66

Hallpike's Maneuver

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Have the patient lie supine with the head extending off the examination table. Support the patient's head and move it into extension ( Fig. 3-42) . Then rotate and laterally flex the head to one side ( Fig. 3-43) and hold for 15 to 45 seconds looking for nystagmus or other neurological signs. Repeat the test to the opposite side. Finally, slowly release the head and allow it to hang free in hyperextension ( Fig. 3-44).

RATIONALE Rotation hyperextension and lateral flexion of the head place a motion-induced compression on the vertebral arteries on the opposite side of head rotation (see Fig. 3-27) . Vertigo, dizziness, visual blur ring, nausea, faintness, and nystagmus are all signs of a positive test. This test indicates vertebral, basilar, or carotid artery stenosis or compression at one of the seven sites discussed at the beginning of this section. Consideration must also be given to the patency of the carotid arteries and a com municating cerebral arterial circle.

SUGGESTED DIAGNOSTIC IMAGING •

•

•

•

Plain film cervical radiography AP open mouth AP lower cervical, upper thoracic Neutral lateral cervical Oblique views Vertebral and carotid ultrasound Magnetic resonance angiogram Cerebral angiogram

Figure 3-42

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

67

II

Figure

3-43

Figure

3-44

68

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

SUBCLAVIAN ARTERY COMPROMISE

DESCRIPTION The subclavian arteries arch superiorly and posteriorly, grooving the pleura and the lungs. They then pass inferiorly behind the midpoint of the clavicle. They are crossed anteriorly by the scalenus anterior muscles ( Fig. 3-45). Compromise of the subclavian artery may be produced by atheroscle rosis, muscle dysfunction, or a space-occupying lesion. The following conditions may compromise the subclavian artery: (a) sclerotic plaque on the walls of the artery, (b) spasm of the scalenus ante rior muscle, and (c) superior pulmonary sulcus tumor ( Pancoast's tumor).

CUNlCAL SIGNS AND SYMPTOMS •

•

•

•

Upper extremity pain Cold upper extremity Upper extremity claudication Supraclavicular pain

Anterior scalene muscles Clavicle

Pleural groove

Subclavian artery

Figure

3-45

George's Screening Procedure (7) PROCEDURE

Sensitivity/Reliability Scale

I

o

I 1

I 2

I

I

I

4

With the patient seated, take the patient's blood pressure bilaterally and record the findings ( Fig. 3-46). Determine the character of the patient's radial pulse bilaterally ( Fig. 3-47).

RATIONALE A difference of 10 mm Hg between the two systolic blood pressures and a feeble or absent radial pulse suggests subclavian artery stenosis on the side of the feeble or absent pulse.

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

69

NOTE If the test is negative, place a stethoscope over the supraclavicular fossa and auscultate the subcla vian artery for bruits ( Fig. 3-48 ). If bruits are present, suspect subclavian artery stenosis or com pression.

SUGGESTED DIAGNOSTIC IMAGING •

•

•

Figure

II

Plain film radiography AP Lower cervical, thoracic AP open mouth Neutral lateral cervical PA chest Apical lordotic view AP shoulder Vascular ultrasound Magnetic resonance angiogram

3-46

Figure

Figure

3-48

3-47

70

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

DIFFERENTIAL DIAGNOSIS: STRAIN VERSUS SPRAIN

CLINICAL DESCRIPTION Cervical strain is an irritation and spasm of the muscles of the cervical spine with or without par tial muscle fiber tearing (see Cervical Resistive Isometric Muscle Testing, earlier in the chapter). Cer vical sprain is a wrenching of the joints of the cervical spine with partial tearing of its ligaments. Traumatic injuries such as cervical acceleration-deceleration injuries produce strain and sprain in juries. Other traumatic and nontraumatic conditions, such as athletic injuries, overuse, overstretch ing, overcontraction against resistance, and a direct blow, usually produce a muscular condition that may indicate sprain. Strains are categorized by degree of muscle tissue damage ( Box 3-4). Sprains are categorized by degree of ligament damage (Box 3-4).

CLINICAL SIGNS AND SYMPTOMS OF STRAIN VERSUS SPRAIN •

•

•

•

•

Cervical and upper back pain Cervical and upper back stiffness Cervical and upper trapezius tightness Reduced cervical range of motion Cervical and upper trapezius spasm

Categories of Strains and Sprains Degree of Strain

1. Mild: Slight disruption of muscle fibers with no appreciable hemorrhage and minimal amounts of swelling and edema

2. Moderate: Laceration of muscle fibers with an appreciable amount of hemorrhage into the surrounding tissues and a moderate amount of swelling and edema

3. Severe: Complete disruption of the muscle tendon unit, possibly with tearing of the tendon from the bone or a rupture of the muscle through its belly Degree of Sprain

1. Mild: Slight tears of a few ligamentous fibers 2. Moderate: More severe tearing of ligamentous fibers but not complete separation of the ligament

3. Severe: Complete tearing of a ligament from its attachments 4. Avulsion: A ligament that attaches to a bone is pulled loose with a fragment of that bone

O'Donoghue's Maneuver (13) PROCEDURE

Sensitivity/Reliability Scale

I

o

I 1

I 2

I

3

I

4

With the patient seated, put the cervical spine through resisted range of motion ( Fig. 3-49) , then through passive range of motion ( Fig. 3-50) . See sections on Cervical Range of Motion and Cervi cal Resistive Isometric Muscle Testing in this chapter.

RATIONALE Pain during resisted range of motion or isometric muscle contraction signifies muscle strain (see re sistive range of motion for muscles involved) . Pain during passive range of motion may indicate a sprain of any of these ligaments: alar ligaments, transverse ligament, supraspinous ligament, inter spinous ligament, ligamentum flavum, articular capsule, intertransverse ligaments, posterior longi tudinal ligament, and anterior longitudinal ligament ( Fig. 3-51) .

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

71

NOTE This maneuver can be applied to any joint or series of joints to determine ligamentous or muscular involvement. Since resistive range of motion mainly stresses muscles and passive range of motion mainly stresses ligaments, you should be able to determine between strain and sprain or a combi nation thereof.

•

SUGGESTED DIAGNOSTIC IMAGING •

•

•

•

•

Plain film radiography AP lower cervical, upper thoracic AP open mouth Neutral lateral cervical Cervical flexion/extension views· Cervical lateral flexion views·

Figure

Figure 3-49 Figure

3-50

3-51 Alar ligament

(�,.\\Il,;t:I1-

__

-Transverse ligament

_

Anterior longitudinal ligament iim�tt----_ Posterior longitudinal ligament

�7i1liI1l1lII1W�t±:::;:::::=- Ligamentum flavum

�J;��H---�

,!&�-.,tItt��--

__

Interspinous ligament Articular capsule

sPinous �:3��m�I---supra ligament

1 U

'Based on outcome of the cervical AP, open-mouth, and neutral lateral radiographs and if movement will not adversely affect the patient.

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

72

CERVICAL FRACTURES

CLINICAL DESCRIPTION Cervical fractures due to trauma are classified as either disrupting or not disrupting the spinal canal and as either stable or unstable. Fractures, dislocations, and fracture dislocations of the cervical spine are often the result of either a sudden and forceful flexion of the head and neck or a severe ax ial force, such as an object falling on the top of the head. The main concern with cervical fractures is compression or transection of the spinal cord. Compression of any part of the central nervous sys tem for 3 to 5 minutes results in death of nervous tissue, particularly nerve cells. Care must be taken if you suspect a cervical fracture. Radiographs of the affected area should be performed prior to any cervical movement. Fractures may be caused by a motor vehicle accident, falling, athletic injuries, or falling objects. Some of the common cervical fractures are spinous process fracture, vertebral body compression fracture, posterior arch of Atlas fracture, odontoid fractures, and burst fracture, a compound fracture anterior and posterior to the lateral masses. Most cervical fractures that cause severe disability are most likely evaluated in an emergency situation.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

Severe cervical pain Patient stabilizing the head Little or no cervical motion Severe cervical muscle spasm Upper extremity neurological dysfunction (see Chapter 4 ) Lower extremity neurological dysfunction (see Chapter 11)

CHAPTER 3

Spinal Percussion Test (13, 14)

CERVICAL ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

73

I 1

I

2

I

3

I

4

With the patient sitting and the head slightly flexed, percuss the spinous process ( Fig. 3-52) and as sociated musculature ( Fig. 3-53) of each of the cervical vertebrae with a neurological reflex hammer.

Rationale Evidence of local pain may indicate a fractured vertebra with no neurological compromise. Evidence of radicular pain may indicate a fractured vertebra with neurological compromise or a disc lesion with neurological compromise. If a fracture is suspected, a full cervical radiography series is indi cated. If radicular pain is elicited, assess which neurological level is affected (see Chapter 4).

NOTE This test is not specific; other conditions also elicit a positive pain response. A ligamentous sprain elicits a positive sign on percussion of the spinous processes. Percussing the paraspinal musculature elicits a positive sign for muscular strain.

Figure 3-52

Figure 3-53

II

74

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sensitivity/Reliability Scale

Soto-Hall Test (15)

I

o

PROCEDURE

I 1

I

2

I

3

I

I

With the patient supine, press on the patient's sternum with one hand. With the other hand, pas sively flex the patient's neck to the chest ( Fig. 3-54).

RATIONALE Evidence of local pain may indicate ligament, muscular, osseous pathology or injury, or cervical cord disease. This test is nonspecific; it merely isolates the cervical spine in passive flexion. If the patient reports radicular symptoms in the upper extremity on passive flexion, suspect a disc defect. When the cervical spine is flexed forward, the intervertebral disc is compressed at the anterior and stretched at the posterior ( Fig. 3-55). The dura is also in traction at the posterior. If the patient has a posterior disc defect, this movement may exacerbate the defect, resulting in spinal cord or nerve root compression.

Figure 3-54

Disc compressed anteriorly

Disc bulges posteriorly

Figure 3-55

CHAPTER 3

75

CERVICAL ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

Rust's Sign

I

o

PROCEDURE

I 1

I

2

I

3

I

4

A patient with severe injury to the upper cervical spine will grasp the head with both hands to sup port the weight of the head on the cervical spine ( Fig. 3-56). The supine patient will support the head while attempting to rise.

RATIONALE The patient with a severe upper cervical injury, such as severe muscular strain, ligamentous insta bility, posterior disc defect, upper cervical fracture, or dislocation, is subject to guarded movements, including stabilization of the head with slight traction to reduce the pain.

SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP lower cervical, upper thoracic AP open mouth Neutral lateral cervical Cervical flexion/extension viewsb Computed tomography Myelography

Figure

3-56

bBased on outcome of the cervical AP, open-mouth, and neutral lateral radiographs and if movement will not adversely affect the patient.

•

76

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

CERVICAL INSTABILITY

CLINICAL DESCRIPTION Cervical instability, like fracture, is usually associated with trauma to the head and cervical spine. If the instability is not to due to a fracture, it may be due to a torn or stretched ligament of the atlanto occipital joint and/or the atlantoaxial joints ( Fig. 3-57), which may cause a subluxation or disloca tion of either of those joints. If cervical instability is suspected, the main concern is compression or transection of the cervical spinal cord. Cervical spinal cord compression may lead to severe neuro logical problems, and cervical spinal cord transection may lead to death. Most severe cervical spinal cord injuries are evaluated in an emergency department. The following tests attempt to evaluate stability of the atlanto-occipital and atlantoaxial joints and their associated ligaments. The ligaments being tested are the alar and the transverse. Radio graphs of the cervical spine should be obtained before these tests are performed because of the pos sibility of cervical instability, which may lead to neurological deficit. Because of the nature of un stable cervical injuries, the following tests must be performed with extreme caution.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

Severe cervical pain Patient stabilizing the head Little or no cervical motion Severe cervical muscle spasm Upper extremity neurological dysfunction (see Chapter 4 ) Lower extremity neurological dysfunction (see Chapter 1 1 )

Alar ligaments

Alar ligaments damaged

Transverse ligament damaged Figure

3-57

CHAPTER 3

CERVICAL ORTHOPAEDIC TESTS

77

Sensitivity/Reliability Scale

Sharp-Purser Test (16)

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With a patient seated, the examiner places one hand over the patient's forehead and the thumb of the opposite hand over the spinous process of C2 for stabilization ( Fig. 3-58). Instruct the patient to flex the head slowly as you apply a posterior pressure with the palm of your hand ( Fig. 3-59). A positive test is indicated if you feel the head slide backward during the movement.

RATIONALE In an anterior Atlas subluxation due to severe trauma the Atlas is anterior to the axis with alar or transverse ligament damage. A backward slide indicates that the subluxation of the Atlas on axis has been reduced, and the slide may be accompanied by a "clunk." The subluxation may be caused by a stretched or torn alar or transverse ligament ( Fig. 3-60).

Figure

Figure

3-58 Alar ligaments

Alar ligaments damaged

Axis remains stationary Figure

3-60

3-59

Transverse ligament damaged

IJI

78

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Transverse Ligament Stress Test (1 7, 1 8)

Sensitivity/Reliability Scale

I

a

PROCEDURE

I 1

I

2

I

3

I

4

With the patient supine, support the occiput with the palms of both hands and the third, fourth, and fifth fingers. Place the index fingers of both hands between the occiput and C2 at the posterior arch or Atlas, which is not palpable ( Fig. 3-6 1 ) . Carefully lift the head and Cl off the table, not allowing any flexion or extension of the cervical spine. ( Fig. 3-62 ) . Hold this position for 1 0 to 20 seconds.

RATIONALE Lifting the head and Cl off the table places motion-induced posterior traction on the transverse lig ament by the odontoid process. This movement should be limited by a transverse ligament. If the transverse ligament is torn or stretched, compression of the spinal cord by this anterior shear may occur. Possible signs include a soft end feel, muscle spasm, dizziness, nausea, paresthesia of the lip, face or limbs, nystagmus or a lump sensation in the throat. This indicates a hypermobile atlantoaxial articulation.

Figure

3-61

Figure

3-62

CHAPTER 3

Alar Ligament Stress Test ( 1 7, 1 8)

CERVICAL ORTHOPAEDIC TESTS

79

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient supine, grasp the head with one hand. With the opposite hand grasp C2 with a pinch grip around the spinous process and lamina ( Fig. 3-63 ) . Attempt a shear side-to-side move ment of the head against the axis ( Fig. 3-64). There should be a minimal amount of lateral motion with a strong capsular end feel.

RATIONALE The alar ligaments extend from the odontoid process to the lateral margins of the foramen magnum. These ligaments limit side-to-side movement of the skull on the axis. Excessive side-to-side move ment indicates a stretched or torn alar ligament or ligaments.

SUGGESTED DIAGNOSTIC IMAGING •

•

•

•

Figure

Plain film radiography AP lower cervical, upper thoracic AP open mouth Neutral lateral cervical Cervical flexion/extension views' Cervical lateral flexion views' AP open-mouth rotational views' Computed tomography Myelography Magnetic resonance imaging

3-63

Figure

3-64

'Based on outcome of the cervical AP, open-mouth, and neutral lateral radiographs and if movement will not adversely affect the patient.

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

80

SPACE-OCCUPYING LESIONS

CLINICAL DESCRIPTION Space-occupying lesions in and around the cervical spine may have any of various origins. Some masses, such as posterior disc defects, posterior osteophytes, tumors, and displaced fractures, are within the spinal canal. The same types of masses outside of the spinal canal include anterior disc defects, anterior osteophytes, tumors, and displaced fractures. Space-occupying lesions within the spinal canal may cause neurological deficit. Most of these masses are identified by various imaging studies. The following tests attempt to distinguish between masses within and outside of the spinal canal. If the suspected mass is within the spinal canal and is causing neurological dysfunction, the examiner should evaluate for neurological deficit based on the outcome of the tests in this section. The diagnostic imaging studies listed at the end of this section are imperative for determining the location and type of mass.

CLINICAL SIGNS AND SYMPTOMS •

•

•

Cervical pain Upper extremity neurological symptoms Lower extremity neurological symptoms

Vals alva's m aneuver (19)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, instruct him or her to bear down as if defecating but concentrating the bulk of the stress at the cervical region ( Fig. 3-65 ) . Ask the patient if he or she feels any increased pain, and if so, have the patient point to its location. This test is subjective and requires an accurate re sponse from the patient.

RATIONALE This test increases intrathecal pressure in the entire spine, but the patient should be able to localize the stress to the cervical spine. Local pain secondary to the increased pressure may indicate a space occupying lesion (e.g., disc defect, mass, osteophyte) in the cervical canal or foramen.

Figure

3-65

CHAPTER 3

Dejerine's Sign

CERVICAL ORTHOPAEDIC TESTS

81

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, instruct the patient to cough, sneeze, and bear down as if defecating ( Valsalva's maneuver).

RATIONALE Pain, either local or radiating to the shoulders or upper extremities after either of these actions, in dicates an increase in the intrathecal pressure. This pain may be caused by a space-occupying lesion, such as a disc defect, osteophyte, or mass.

Swallowing Test (19)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Instruct the seated patient to swallow ( Fig. 3-66).

RATIONALE Pain upon swallowing usually indicates esophageal or pharyngeal injury, dysfunction, or pathology. Pain upon swallowing has orthopaedic significance. Because of the proximity of the esophagus to the anterior longitudinal ligament in the cervical spine, anterior pathology of the cervical spine, such as anterior disc defect, osteophyte, mass, or muscle spasm, may compress or irritate the esoph agus and cause pain upon swallowing.

SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP lower cervical, upper thoracic AP open mouth Neutral lateral cervical Cervical oblique views Lateral extension view (for retropharyngeal mass) Computed tomography Cervical magnetic resonance imaging

Figure

3-66

•

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

82

CERVICAL NEUROLO GICAL COMPRESSION AND IRRITATION

CLINICAL DESCRIPTION Compression and irritation of the neurological structures in the cervical spine involve mainly the spinal cord and nerve roots. Compression of these structures may be caused by disc defects, osteo phytes, degenerative joint disease, tumors, or fractures. Most of the tests in this section are provoca tive, that is, they aggravate the compression if present. If neurological compression is suspected, the examiner should evaluate for neurological deficit as described in Chapter 4. After performing these tests and evaluating for neurological deficit, select the appropriate imaging procedures for the sus pected condition.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

Cervical pain Upper extremity radicular pain Loss of upper extremity sensation Loss of upper extremity reflexes Loss of upper extremity muscle strength

Foraminal Compression Test (20-22)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated and the patient's head in the neural position, exert strong downward pres sure on the head ( Fig. 3-67). Repeat the test with the head rotated bilaterally (Fig. 3-68) .

RATIONALE When downward pressure is applied to the head, the following biomechanical actions take place: ( a) narrowing of the intervertebral foramina, (b) compression of the apophyseal joints in the cervical spine, and (c) compression of the intervertebral discs in the cervical spine. Local pain may indicate foraminal encroachment without nerve root pressure or apophyseal capsulitis. Radicular pain may in dicate pressure on a nerve root by a decrease in the foraminal interval (foraminal encroachment) or by a disc defect. If nerve root involvement is suspected, evaluate the neurological level (see Chapter 4).

Figure

3-67

Figure

3-68

CHAPTER 3

Jackson's Compression Test (23)

CERVICAL ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

83

I 1

I 2

I

3

I

4

With the patient seated, laterally flex the neck and exert strong downward pressure on the head. Per form this test bilaterally ( Fig. 3-69).

RATIONALE With the neck laterally flexed and downward pressure applied, the following biomechanical actions take place: (a) narrowing of the intervertebral foramina on the side of lateral bending, (b) com pression of the facet joints on the side of lateral bending, and (c) compression of the intervertebral discs in the cervical spine. Local pain may indicate foraminal encroachment without nerve root pressure or apophyseal joint pathology. Radicular pain may indicate pressure on a nerve root by a decrease in the forami nal interval (foraminal encroachment) or a disc defect. If nerve root involvement is suspected, eval uate the neurological level (see Chapter 4).

Figure

3-69

III

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

84

Sensitivity/Reliability Scale

Extension Compression Test (24)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, instruct the patient to extend the head approximately 30°. Then place down ward pressure on the patient's head ( Fig. 3-70).

RATIONALE When pressure is applied to the patient's head with the cervical spine in extension, the cervical in tervertebral disc space is decreased posteriorly and increased vertically and anteriorly, with an in creased load on the posterior apophyseal joints ( Fig. 3-7 1 ) . If the patient's symptoms decrease, sus pect a posterolateral disc defect because of the anterior and vertical displacement of discal material away from the nerve root or spinal cord. Downward pressure on the head also compresses the pos terior apophyseal joints, which, if irritated, can cause local cervical pain. An increase in upper extremity radicular symptoms may indicate pathology in the interverte bral foramina, such as an osteophyte or mass or a degenerating cervical intervertebral disc. This is possible because the pressure on the head decreases the intervertebral foraminal interval.

Disc bulges anteriorly

IF.::=::tt-----+-_ Disc space

compressed posteriorly

Figure

3-70

Figure

3-71

CHAPTER 3

85

CERVICAL ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

Flexion Compression Test (24)

I

o

PROCEDURE

I 1

I 2

I

3

I

With the patient seated, instruct the patient to flex the head forward. Then place downward pres sure on the patient's head ( Fig. 3-72).

RATIONALE When the patient flexes the head forward under pressure, the intervertebral disc is compressed an teriorly and the load is placed on the intervertebral elise. This pressure also causes the posterior as pect of the disc to bulge posteriorly ( Fig. 3-73). An increase in cervical and/or radicular symptoms may indicate a discal defect. Flexion of the cervical spine and compression on the head also reduces the load on the posterior apophyseal joints. A decrease in localized scleratogenous pain may indicate apophyseal joint injury or pathology.

Figure

3-72 Flexion forward

.

Load

I -----r-....

j

Disc bulges posteriorly

Figure 3-73

III

86

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sensitivity/Reliability Scale

Spurling's Test (20)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Laterally flex the seated patient's head and gradually apply strong downward pressure ( Fig. 3-74). If pain is elicited, the test is considered positive; do not continue with the next procedure. If no pain is elicited, put the patient's head to a neutral position and deliver a vertical blow to the uppermost por tion of the patient's head ( Fig. 3-75).

RATIONALE Local pain may indicate facet joint involvement, either from the strong downward pressure on the head or from the vertical blow to the head. Radicular pain may indicate foraminal encroachment, degenerating cervical intervertebral disc, or disc defect with nerve root pressure. This test may also indicate a lateral disc defect.

Figure 3-74

Figure

3-75

CHAPTER 3

Maximal Foraminal Compression Test

CERVICAL ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

87

I 1

I

I 2

I

I

3

I

I

4

Instruct the seated patient to approximate the chin to the shoulder and extend the neck. Perform this test bilaterally ( Fig. 3-76).

RATIONALE Rotation of the head and hyperextension of the neck causes the following biomechanical actions: (a) narrowing of the intervertebral foramina on the side of head rotation; (b) compression of the facet joints on the side of head rotation; and (c) compression of the intervertebral discs in the cervical spine. Pain on the side of head rotation with a radicular component may indicate nerve root com pression caused by pathology such as an osteophyte or mass or decreased interval in the foramina,. Local pain with no radicular component may indicate apophyseal joint pathology on the side of head rotation and neck extension. Pain on the opposite side of head rotation indicates muscular strain or ligament sprain. If nerve root compression is suspected, evaluate the neurological level (see Chapter 4 ) .

Figure

3-76

II

88

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sensitivity/Reliability Scale

L'hermitte's Sign (25,26)

I

o

PROCEDURE

I ,

I

2

I

3

I

With the patient seated, passively flex the patient's chin to the chest (Fig. 3-77).

RATIONALE When the cervical spine is flexed forward, the spinal cord and its coverings are under traction at the posterior, and the intervertebral disc is compressed at the anterior and bulges at the posterior ( Fig. 3-78). If the patient has a posterior disc defect, this movement may exacerbate the defect, resulting in spinal cord or nerve root compression. Cervical cord disease, meningitis, osteophytes, and masses may cause local and/or radicular pain into the upper and/or lower extremities. A sudden electrical tingling felt in the spine and/or extremities during neck flexion may indicate cervical myelopathy or multiple sclerosis.

Figure 3-77

Flexion forward

/ -�

Traction on spinal cord

Disc bulges posteriorly

Figure 3-78

CHAPTER 3

Shoulder Depression Test (23)

CERVICAL ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

89

I 1

I

2

I

3

I

4

With the patient seated, place downward pressure on the shoulder while laterally flexing the patient's head to the opposite side ( Fig. 3-79).

RATIONALE When pressure is applied to the shoulder and the head is slightly flexed to the opposite side, the mus cles, ligaments, nerve roots, nerve root coverings, and brachial plexus are stretched and the clavicle is depressed, approximating the first rib. Local pain on the side being tested indicates shortening of the muscles, muscular adhesions, muscle spasm, or ligamentous injury. Radicular pain may indicate compression of the neurovascular bundle, adhesion of the dural sleeve, or thoracic outlet syndrome. On the opposite side, the foraminal interval is decreased, the apophyseal joints are compressed, and the intervertebral disc is compressed. If pain is elicited on the side opposite the one being tested, it may indicate a pathological decrease in the foraminal interval, facet pathology, or disc defect.

Figure

3-79 Sensitivity/Reliability Scale

Distraction Test (19)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, grasp beneath the mastoid processes and press up on the patient's head. This removes the weight of the patient's head on the neck ( Fig. 3-80).

RATIONALE When the head is pulJed upward, the cervical muscles, ligaments, and apophyseal joint capsules are stretched. If local pain increases, suspect muscle strain, spasm, ligamentous sprain, or facet capsuli tis. Also, when the head is pulled upward, the interforaminal and intervertebral interval increase. Re lief of local or radicular pain indicates either foraminal encroachment or a disc defect.

Figure 3-80

•

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

90

Shoulder Abduction Test (Bakody's Sign) (27)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Instruct the seated patient to abduct the arm and place the hand on top of the head (Fig. 3-8 1 ).

RATIONALE Placing the hand above the head elevates the suprascapular nerve, reducing the traction on the lower trunk of the brachial plexus. This procedure reduces the traction on a compressed nerve. A decrease in or relief of the patient's symptoms indicates a cervical extradural compression problem, such as a herniated disc, epidural vein compression, or nerve root compression, usually in the C5-C6 area.

SUGGESTED DIAGNOSTIC IMAGING •

•

•

•

Plain film radiography AP lower cervical, upper thoracic AP open mouth Neutral lateral cervical Cervical oblique views Cervical magnetic resonance imaging Computed tomography Myelography

Figure

3-81

CHAPTER 3

1 . American Medical Association. Guides to the evaluation of permanent impairment. 5th ed. Chicago: American Medical Association, 2000. 2. American Academy of Orthopaedic Surgeons. The clinical measurement of joint motion. Chicago: American Association of Orthopaedic Surgery, 1 994. 3. Dvorak 1, Antinnes JA, Panjabi M, et al. Age and gender normal motion of the cervical spine. Spine 1 992; 1 7(suppl l 0 ) :S393-S398. 4. Okawara S, Nibbelink D. Vertebral artery occlu sion following hyperextension and rotation of the head. Stroke 1 974;5;640-643.

AA,

91

20. Spurling RG, Scoville WB. Lateral rupture of the

References

5. White

CERVlCAL ORTHOPAEDIC TESTS

Panjabi

MM.

Clinical

biome

chanics of the spine, 2nd ed. Philadelphia: JB Lippincott, 1 990. 6. Barre JA. Le syndrome sympathique cervical posterieur. Rev Neurol 1 926;33:248-249. 7. George PE, Silverstein HT, Wallace H , et al. Identification of the high risk pre-stroke pa

cervical IVDs-a common cause of shoulder and arm pain. Surg Gynecol Obstet 1 944;78:350-358. 2 1 . Harris NM. Cervical spine dysfunction. GP 1 967;32(4):78-88. 22. Depalma A, Rothman RH. The Intervertebral Disc. Philadelphia: WB Saunders, 1 970:88. 23. Jackson R. The Cervical Syndrome. 3rd ed. St. Louis: Mosby, 1 985. 24. Gerard 1, Kleinfeld S. Orthopaedic testing. New York: Churchill Livingstone, 1 993. 25. L'hermitte J. Etude de la commotion de la moella. Rev Neurol (Paris), 1 :2 1 0, 1 933. 26. L'hermitte J, Bollak P, Nicholas M . Les douleurs a type de decharge electrique dans la sclerose en plaques. Un cas forme sensitive de la sclerose multiple. Rev Neurol (Paris). 27. Davidson RI, Dunn E1, Metzmater IN. The shoulder abduction test in the diagnosis of radicular pain in cervical extradural compres sive monoradiculopathies. Spine 1 98 1 ;6:44 1 .

tient. J Chiropractic 1 98 1 ; 1 5:26-28. 8. Maigne R. Orthopaedic medicine. A new ap proach to vertebral manipulations. Springfield, IL: Charles C Thomas, 1972: 1 55. 9. Maitland GD. Vertebral Manipulation. London, Butterworths, 1 973. 10. deKleyn A, Versteegh e. Ober verschiendene Formen von

Meniere's

Syndrom.

Deutsche

Ztschr 1933; 1 3 2 : 1 57. 1 1 . deKleyn A, Nieuwenhuyse P. Schwindelandfaelle und Nystagmus bei einer bestimmten Stellung des Kopfes. Acta Otolaryng 1 927; 1 1 :555. 12. Lewis CB, Knotz NA. Orthopedic Assessment and Treatment of the Geriatric Patient. St. Louis: Mosby, 1 993. 13. O'Donoghue D. Treatment of injuries to ath letes. 4th ed. Philadelphia: WB Saunders, 1 984. 1 4. Turek SL. Orthopaedics. 3rd ed. Philadelphia: JB Lippincott, 1 977. 15. Soto-Hall R, Haldeman K. A useful diagnostic sign in vertebral injuries. Surg Gynecol Obstet 827-8 3 1 . 1 6. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia: WB Saunders, 1 997.

General References Clarkson H M . Musculoskeletal Assessment: Joint Range of Motiond Manual Muscle Strength. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 2000. Cyriax J. Textbook of Orthopaedic Medicine. Vol. 1 . Diagnosis o f Soft Tissue Lesions. London: Bailliere Tindall, 1 983. Edwards Be. Combined movements in the cervical spine (C2-C7 ) : their value in examination and tech nique choice. Aust J Physiother 1 980;26: 1 65 . Foreman S M , Croft Ae. Whiplash Injuries: The Cer vical Acceleration/Deceleration Syndrome. 3rd ed. Baltimore: Lippincott Williams & Wilkins, 2002. Kapandji IA. The Physiology of Joints. Vol. 3 . The Trunk

and

the Vertebral

Column.

New York:

Churchill Livingstone, 1 974. Naffzinger HC, Grant WT. Neuritis of the brachial plexus mechanical in origin: the scalenus syndrome. Clin Orthop 1 967;5 1 :7. Neviaser JS. Musculoskeletal disorders of the shoul

1 7. Pettman E. Stress test of the craniovertebral

der region causing cervicobrachial pain: differential

joints. In Boyling JD, Palastanga N, eds. Grieve's

diagnosis and treatment. Surg Clin North Am

Modern Manual Therapy: The Vertebral Col

1 963;43: 1 703.

umn. 2nd ed. Edinburgh: Churchill Livingstone,

Nichols H M . Anatomic structures of the thoracic

1994. 18. Meadows JJ, Magee DJ. An overview of dizziness and vertigo for the orthopedic manual therapist. In Boyling JD, Palastanga N, eds. Grieve's Mod ern Manual Therapy: The Vertebral Column.

outlet. Clin Orthop 1 967;5 1 : 1 7. Norkin CC, Levangie PK. Joint Structure and Func tion: A Comprehensive Analysis. Philadelphia: FA Davis, 1983.

2nd ed. Edinburgh: Churchill Livingstone, 1 994.

Terrett AGJ. Importance and interpretation of tests

19. Hoppenfeld S. Physical examination of the

designed to predict susceptibility to neurocircula

spine and extremities. New York: Appleton

tory accidents from manipulation. J Aust Chiropr

Century-Crofts, 1 976: 1 27.

Assoc 1 983; 1 3 (2 ) :29-34.

II

--------�GO�-CERVICAL NERVE ROOT LESIONS

C5

96 Motor

Reflex 96

Deltoid Muscle Biceps Muscle Reflex Sensory C6

Triceps Reflex Sensory

96 C8 97

97

Palmar Interossei Reflex

98

Sensory

98 Tl

99 99

104

Groups Sensory

100 100

Wrist Flexor Group

100

Finger Extensor Group

92

103

104 Motor

Reflex

Triceps Muscle

103

103

Finger Abductor and Adductor

99

100 Motor

102

98

Brachioradialis Reflex

C7

102

Finger Abductor Group

Biceps Muscle

Sensory

102

Finger Flexor Group

Wrist Extensor Group Reflex

102 Motor

98 Motor

101

101

97

97

Biceps Reflex

101

101

104 104

104

CHAPTER 4

CERVICAL NERVE ROOT LESIONS

93

The cervical spine consists of eight pairs of spinal nerves. Each spinal nerve consists of a dorsal root (sensory component) and a ventral root (motor component). These nerve roots emerge from the spinal column through lateral intervertebral foramina. The first four cervical nerves collectively form the cervical plexus. The second four nerves, together with the first thoracic nerve, form the brachial plexus (Fig. 4-1).

D

Figure 4-1

If a nerve root lesion is suspected, you must evaluate three clinical aspects of the neurological examination: sensory, motor, and reflex dysfunction. Sensory testing attempts to delineate the seg mental cutaneous innervation to the skin. It is done with a sterile or disposable Neurotip or pin wheel in specific dermatomal patterns. Two dermatomal maps are provided. Figure 4-2 is based on the body areas of intact sensation when roots above and below an isolated root were interrupted; sensation loss when one or more continuous roots were interrupted; or the pattern of herpetic rash and hypersensitivity when there is isolated root involvement. Figure 4-3 is based on the hyposensitivity to pin scratch in various root lesions and is consistent with electrical skin resistance studies showing axial dermatomes extending to the distal extremities. This pattern is useful in evaluating paresthesias and hyperesthesias second ary to root irritation. This is the pattern this chapter delineates to evaluate sensory root dysfunction. A fair amount of segmental overlap exists; therefore, a single unilateral lesion may affect more than one dermatomal level. Motor function is evaluated by testing the muscle strength of specific muscles innervated by a particular nerve root or roots using the muscle grading chart adopted by the American Academy of Orthopaedic Surgeons (Box 4-1). The reflex arc is tested by evaluating the superficial stretch reflex associated with the particular nerve root. These arcs are graded by the Wexler Scale (Box 4-2). The clinical presentation of nerve root lesions depends on two i:nportant factors: location and severity of the injury or pathology. These two factors together determine the injury's clinical pre sentation. The possibilities are endless, ranging from no clinical presentation or slight clinical man ifestation, such as slight loss of sensation and pain, to total denervation with loss of total function to the structures innervated by that nerve root (motor, reflex, and sensory).

\0 ...

'"0 :r: 0 ..., 0 C"l

C2 C3

�

/I','

:r:

n

C4

�

rz

C5

T2

�� T4

� �

0 ."

;:0 '" C"l (3

Z :>r

0

q

:r: 0

� '" 0

n

rz0 z

'" c:: ;0 0

if

L3

5

\ un

C"l

n

:>r

+-+---- L4

>-l

1\ I

'" ...,

en en

�---- L5 ------� -\------81

J ��

,(11�

Figure 4-2. Adapted with permission from Haymaker and Woodall.

Figure 4-3. Reprinted with permission from Keegan

Peripheral Nerve Injuries. 2nd ed. Philadelphia: WB Saunders, 1954.

1943;102:4:409-439.

JJ,

Garrett

ED.

Anat Record

CHAPTER 4

CERVlCAL NERVE ROOT LESIONS

95

Muscle Grading Chart 5 4

Complete range of motion against gravity with full resistance Complete range of motion against gravity with some resistance

3

Complete range of motion against gravity

2

Complete range of motion with gravity eliminated

1

Evidence of slight contractility, no joint motion

o

No evidence of contractility

Wexler Scale o +1

No response

+2

Normal

+3 +4

Hyperreflexia

+5

Hyperreflexia with sustained clonus

Hyporeflexia

Hyperreflexia with transient clonus

Each nerve root has its own sensory distribution, muscle test or tests, and a stretch reflex; these are grouped to facilitate the identification of the suspected level. The clinical evaluation is not made solely on one aspect of the neurological package but is in stead determined by the combination of history, inspection, palpation, the three individual tests (motor, reflex, and sensory) and appropriate diagnostic imaging and/or functional neurological testing, such as electromyography. Furthermore, the injury or pathology under evaluation may not necessarily be affecting a nerve root, but it may be affecting the brachial plexus, a trunk of that plexus, or a named nerve. Depending on the severity and location of the injury or pathology, vari ous combinations of neurological dysfunction may be elicited. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

Cervical pain Upper extremity paresthesia Diminution or loss of upper extremity sensation Diminution or loss of upper extremity reflexes Decrease or loss of muscle strength Atrophic upper extremity lesions

95

96

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

C5 The C5 nerve root exits the spinal canal between the C4 and C5 vertebrae and may be affected by . the C4 intervertebral disc (Fig. 4-4).

Figure 4-4

Motor

Sensitivity/Reliability Scale

I

Deltoid Muscle (C5 Axillary Nerve Innervation)

o

I 1

I

2

I

3

I

4

PROCEDURE Stand behind the seated patient and place your hand at the lateral aspect of the elbow. Instruct the patient to abduct the arm against resistance (Fig. 4-5). Grade the strength according to the muscle grading chart. Perform this test bilaterally and compare each side. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C5 nerve root, upper trunk of the brachial plexus, or the axillary nerve. A weak or strained deltoid muscle may be suspected if the sensory and reflex portions of the C5 neurological package are intact.

Figure 4-5

CHAPTER 4

97

CERVICAL NERVE ROOT LESIONS

Biceps Muscle (CS, C6 Musculocutaneous Nerve Innervation) PROCEDURE With the patient in the seated position and the forearm flexed, stabilize the patient's elbow with one hand and grasp the anterior aspect of the patient's wrist with your opposite hand. Instruct the pa tient to flex the forearm against resistance (Fig. 4-6). Grade the strength according to the muscle grading chart and compare each side. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C5 or C6 nerve roots, upper trunk of the brachial plexus, or musculocutaneous nerve. A weak or strained biceps muscle may be suspected if the sensory and reflex portions of the C5 neurological package are intact. Figure 4-6

Retlex

Sensitivity/Reliability Scale

I

Biceps Reflex (CS, C6 Musculocutaneous Nerve Innervation)

o

I 1

I

2

I

3

I

4

PROCEDURE Place the patient's arm across your opposite arm with your thumb on the biceps tendon. Strike your thumb with the narrow end of the reflex hammer (Fig. 4-7). The biceps muscle should contract slightly under your thumb. Grade your response according to the reflex chart and evaluate bilaterally. RATIONALE Hyporeflexia may indicate a C5, C6 nerve root deficit. Loss of reflex may indicate an interruption of the reflex arc (lower motor neuron lesion). Hyperreflexia may indicate an upper motor neuron lesion. Figure 4-7

Sensory

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With a pin, stroke the lateral aspect of the arm (Fig. 4-8). RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the C5 nerve root or the axillary nerve. Figure 4-8

98

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

C6 The C6 nerve root exits the spinal canal between the CS and C6 vertebrae and may be affected by the CS intervertebral disc (Fig. 4-9).

Figure 4-9

Motor

Sensitivity/Reliability Scale

I

Biceps Muscle (CS, C6 Musculocutaneous Nerve Innervation)

o

I 1

I

2

I

3

I

4

See Figure 4-6 and accompanying text.

Wrist Extensor Group: Extensor Carpi Radialis, Longus, and Brevis (C6, C7 Radial Nerve Innervation) PROCEDURE With the patient seated, stabilize the patient's forearm by grasping the elbow with your hand. In struct the patient to make a fist, and dorsiflex the wrist (Fig. 4-10). With your opposite hand, grasp the patient's fist and attempt to force the wrist into flexion as the patient resists (Fig. 4-11). Evalu ate according to the muscle grading chart and compare bilaterally. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C6 or C7 nerve root. A weak or strained wrist extensor may be suspected if the sensory and reflex portions of the C6 and C7 neu rological packages are intact.

Figure 4-10

Figure 4-11

CHAPTER 4

99

CERVICAL NERVE ROOT LESIONS

Reflex

Sensitivity/Reliability Scale

I

Brachioradialis Reflex (CS, C6 Radial Nerve Innervation)

o

I 1

I

2

I

3

I

4

PROCEDURE Place the patient's arm across your opposite arm and tap the brachioradialis tendon at the distal aspect of the forearm with the neurological reflex hammer (Fig. 4-12). The brachioradialis muscle should contract slightly on your arm. Grade the response according to the reflex chart and evaluate bilaterally. RATIONALE Hyporeflexia may indicate a nerve root deficit. Loss of reflex may indicate an interruption of the re flex arc (lower motor neuron lesion). Hyperreflexia may indicate an upper motor neuron lesion. Figure 4-12

Sensory PROCEDURE With a pin, stroke the lateral aspect of the forearm, thumb, and index finger (Fig. 4-13). RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the C6 nerve root or the musculocu taneous nerve. Figure 4-13

C7 The C7 nerve root exits the spinal canal between the C6 and C7 vertebrae and may be affected by the C6 intervertebral disc (Fig. 4-14). Figure 4-14

Motor

Sensitivity/Reliability Scale

I

Triceps Muscle (C7 Radial Nerve Innervation)

o

I 1

I 2

I

3

I

4

PROCEDURE With the patient supine, flex the shoulder and elbow to 90°. Grasp the proximal aspect of the arm to stabilize the extremity. With your opposite hand, grasp the patient's wrist and ask the patient to extend the forearm against your resistance (Fig. 4-15). Grade the strength according to the muscle grading chart and compare bilaterally. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C7 nerve root or radial nerve. A weak or strained triceps muscle may be suspected if the sensory and reflex portions of the C7 neu rological package are intact. Figure 4-15

Wrist Flexor Group: Flexor Carpi Radialis (C7 Median Nerve Innervation) and Flexor Carpi Ulnaris (CB Ulnar Nerve Innervation)

Sensitivity/Reliability Scale

I

o

I 1

I

2

I

3

I

4

PROCEDURE With the patient seated, stabilize the patient's forearm by grasping the forearm with your hand. In struct the patient to make a fist and flex the wrist. With your opposite hand, grasp the patient's fist and attempt to force the wrist into extension as the patient resists (Fig. 4-16). Grade according to the muscle grading chart and compare bilaterally. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C7 or C8 nerve root. A weak or strained wrist flexor may be suspected if the sensory and reflex portions of the C7 and C8 neu rological packages are intact. Figure 4-16

Finger Extensor Group: Extensor Digitorum Communis, Extensor Digiti Indids, Extensor Digiti Minimi (C7 Radial Nerve Innervation)

Sensitivity/Reliability Scale

I

I

o

1

I

2

I

I

3

4

PROCEDURE With the patient's wrist in the neutral position, grasp the wrist with your hand. Have the patient ex tend the metacarpophalangeal joints and flex the proximal and distal interphalangeal joints (Fig. 4-17). Place your hand on the distal aspect of the proximal phalanges and attempt to force the metacarpophalangeal joints into flexion as the patient resists (Fig. 4-1S). Grade according to the muscle grading chart and evaluate bilaterally. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C7 or CS nerve root. A weak or strained finger extensor may be suspected if the sensory and reflex portions of the C7 and CS neurological packages are intact. Figure 4-17

Figure 4-18

--...,.-..,

Reflex

Sensitivity/Reliability Scale

I

o

Triceps Reflex (C7 Radial Nerve Innervation)

I

I 1

I 2

I

3

I

PROCEDURE Flex the patient's arm across your opposite arm and tap the triceps tendon at the olecranon fossa with the neurological reflex hammer (Fig. 4-19). The triceps muscle should contract slightly. Grade your response according to the reflex chart and evaluate bilaterally. RATIONALE Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an upper motor neuron lesion. Figure 4-19

Sensory PROCEDURE

Sensitivity/Reliability Scale

I

o

I 1

I 2

I

3

I

4

With a pin, stroke the palmar surface of the middle finger (Fig. 4-20). RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the C7 nerve root or the radial nerve. Figure 4-20

102

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

C8 The C8 nerve root exits the spinal canal between the C7 and T1 vertebrae and may be affected by the C7 intervertebral disc (Fig. 4-21). Figure 4-21

Motor

Sensitivity/Reliability Scale

I

o

Finger Flexor Group: Flexor Digitorum Superficialis (C7, CB Median Nerve Innervation) and Flexor Digitorum Profundus (C7, CB Median and Ulnar Nerve Innervation)

I 1

I

2

I

3

I

4

PROCEDURE Grasp the seated patient's wrist with one hand to stabilize the hand. Curl your fingers into the pa tient's fist and attempt to pull the fingers out of flexion as the patient resists (Fig. 4-22). Grade ac cording to the muscle grading chart and compare bilaterally. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C8 nerve root. A weak or strained finger flexor group muscle may be suspected if the sensory portion of the C8 neurological package is intact. Figure 4-22

Finger Abductor Group: Dorsal Interossei, Abductor Digiti Minimi (CB, T1 Ulnar Nerve Innervation) PROCEDURE Instruct the patient to pronate the hand and abduct the fingers. Take each pair of fingers and pinch them together as the patient resists (Fig. 4-23). Grade your findings according to the muscle grad ing chart and compare bilaterally. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C8 or Tl nerve root. A weak or strained finger abductor may be suspected if the sensory portion of the C8 and Tl neurological packages is intact. Figure 4-23

CHAPTER 4

103

CERVICAL NERVE ROOT LESIONS

Palmar Interossei (C8, Tl Ulnar Nerve Innervation) PROCEDURE With the patient's hand pronated, have the patient adduct all the fingers. The examiner is to grasp each pair of the patient's fingers and attempt to pull them apart against patient resistance (Fig. 4-24). Grade according to the muscle grading chart and compare bilaterally. RATIONALE A grade of 0 to 4 unilaterally may indicate a neurological deficit of the C8 or Tl nerve root. A weak or strained finger adductor may be suspected if the sensory portion of the C8 and Tl neurological packages is intact.

Figure 4-24

Retlex None Sensitivity/Reliability Scale

Sensory

I

o

I 1

I 2

I

I

3

I

4

PROCEDURE With a pin, stroke the palmar surface of the last two digits and the ulnar aspect of the forearm (Fig. 4-25). RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the C8 nerve root or the ulnar nerve.

Figure 4-25

104

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Tl The Tl nerve root exits the spinal canal between the Tl and T2 vertebrae and may be affected by the Tl intervertebral disc (Fig. 4-26).

Motor

Figure 4-26

Finger Abductor and Adductor Groups

Sensitivity/Reliability Scale

I

o

I 1

I 2

I

3

I

See C8 Neurological Level

Reflex None

Sensory PROCEDURE

Sensitivity/Reliability Scale

I

o

I 1

I 2

I

3

I

4

With a pin, stroke the medial proximal aspect of the arm and forearm (Fig. 4-27). RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the Tl nerve root or the medial brachial cutaneous nerve. SUGGESTED IMAGING AND FUNCTIONAL TEsTING •

•

•

Cervical magnetic resonance imaging Electromyography Somatosensory evoked potential Figure 4-27

CHAPTER 4

CERVICAL NERVE ROOT LESIONS

lOS

General References Bronisch FW. The Clinically Important Reflexes.

Kendall FP, McCreary EK, Provance PG. Muscles:

New York: Grune & Stratton, 1952.

Testing and Function. 4th ed. Baltimore: Williams &

Chusid JG. Correlative Neuroanatomy and Func

Wilkins, 1994.

tional Neurology. 17th ed. Los Altos, CA: Lange,

Mancall E. Essentials of the Neurologic Examina

1976.

tion. 2nd ed. Philadelphia: FA Davis , 1981.

Dejong RN. T he Neurologic Examination. 4th ed.

Parsons N. Color Atlas of Clinical Neurology.

Hagerstown, MD: Harper & Row, 1979.

Chicago: Year Book, 1989.

Hoppenfeld S. Physical Examination of the Spine

VanAllen MW, Rodnitzky RL. Pictorial Manual of

and Extremities. New

Neurologic Tests. 2nd ed. Chicago: Year Book, 1981.

Croft, 1976:127.

York:

Appleton-Century

III �

--------�rn�-SHOULDER ORTHOPAEDIC TESTS SHOULDER ORTHOPAEDIC EXAMINATION

107

FLOW CHART

108

SHOULDER PAL PATION

Acromioclavicular Joints

108

Posterior D rawer Test

109

110

142

INSTABILITY

113

142

Feagin Test

114

Posterior Aspect

Rowe Test for Multidirectional

114

144

Sulcus Sign

116

SHOULDER RANGE OF MOTION

116 117 118

External Rotation

119

120

Adduction

121 122

Abbott-Saunders Test

B URSITIS

Ludington's Test

123

TENDINITIS (BICIPITAL )

Test

125

129

131

Wright's Test

158

Traction Test

159

Halstead's Maneuver

157

160

B RACHIAL PLEXUS IRRITATION B rachial Plexus Stretch Test

ANTERIOR GLENOHUMERAL

Bik.ele's Sign

132

Anterior Apprehension Test

163

T innel's Sign (for B rachial Plexus

133

Prone Anterior Instability Test

161 161

162

B rachial Plexus Tension Test

132

155

155

Costoclavicular Test

128

Subacromial Push-B utton Sign

106

153

Adson's Test

127

Anterior D rawer Test

152

152

THORACIC OUTLET SY NDROME

129

INSTABILITY

150

Transverse Humeral L igament

124

126

D aw barn's Test

149

150

Yergason's Test

123

Neer Impingement Sign

148

148

BICEPS TENDON INSTABILITY

122

Hawkins-Kennedy Impingement

L ippman's Test

147

Supraspinatus Test

Apley Scratch Test

Gilchrest's Sign

146

D rop Arm Test

Supraspinatus Tendinitis Test

Speed's Test

145

Clunk Test

ROTATOR CUFF INSTABILITY

TENDINITIS (SUPRASPINAT US)

Test

LAB RAL TEARS

Anterior Slide Test

Internal Rotation Abduction

143

Instability

115

Extension

141

MULTIDIRECTIONAL SHOULDER

D eltoid Muscle

Flexion

140

Norwood Stress Test Push-Pull Test

112

Trapezius

140

III

B icipital Groove

Scapula

139

Posterior Apprehension Test

Subacromial (Subdeltoid) B ursa

B iceps

139

INSTABILITY

Clavicle, Sternoclavicular and

Rotator Cuff

138

POSTERIOR GLENOHUMERAL

108

Anterior Aspect

137

Fulcrum Test D ugas Test

134

Andrews Anterior Instability Test

135

Rowe Test for Anterior Instability

137

L esions)

172

Shoulder Orthopaedic Examination

�

I NOra I

lTl

Range of motion (active) (passive)

Range of motion (active) (Passive)

+(+) Anterior drawer test Anterior apprehension test Rockwood test Rowe test Fulcrum test Dugas test

I

t (+) Radiology

t (+)

I

Anterior glenohumeral instability

Shoulder pain with upper extremity pain/paresthesia

I (

-

)

J ( +) Adhesive capsulitis

t

(+

active)

I

Posterior apprehension test Posterior drawer test Push-pull test

t (+) Posterior glenohumeral instability

Supraspinatus tendinitis test Apley scratch test Speed's test

t

(+)

Supraspinatus tendinitis

(

-

)

(

-

)

r-----

(+)

[!��i � , ti

I

t (+) Tendon instability

(-) I

Hawkins-Mennedy test Lippman's test

(

-H

I

I

Brachial plexus irritation

·HThoracic outlet syndrome

Brachial plexus stretch test Tinel's sign

t ( +)

Drop arm test Biceps tendon stability test Yergason's test Abbott-Saunders test Ludington's test Transverse humeral ligament test

I

Subacromial push-button sign Dawbarn's test

Adson's test Costoclavicular test Wright's test Traction test Halstead maneuver

I

(J

?: -0

--l m ;
o

::j

J: o

�o

n ...., m en

;;l

o '-I

108

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

SHOULDER PALPATION Anterior Aspect

Clavicle and Sternoclavicular and Acromioclavicular Joints DESCRIPTIVE ANATOMY The clavicle is slightly anterior and inferior to the top of the shoulder. The sternoclavicular joint, which attaches the clavicle to the sternum, lies at the medial end of the clavicle. The acromioclavic ular joint, which is lateral, attaches the clavicle to the acromion process of the scapula (Fig. 5-1). PROCEDURE With your fingertips, palpate the length of the clavicle from the medial aspect at the sternoclavicu lar joint to the lateral aspect at the acromioclavicular joint (Fig. 5-2). Note any abnormal tenderness or bumps along the length of the clavicle that indicate a fracture secondary to recent trauma or a healed fracture with callus formation. Compare the clavicles for symmetry and placement. Next, palpate the sternoclavicular joint (Fig. 5-3) and acromioclavicular joint (Fig. 5-4) for tenderness with your index and middle fingers. If the affected clavicle and associated joint are more anterior, posterior, or superior than the other, suspect a subluxation or dislocation of the clavicle at the af fected joint. Flexing and extending the shoulder during acromioclavicular joint palpation may re veal crepitus (Fig. 5-5). Crepitus is secondary to joint inflammation, such as osteoarthritis.

Acromioclavicular joint

Coracoid process

(Subdeltoid) Subacromial bursa

Deltoid muscle---f-lil Long head of biceps --+-+i-4++-'-r--*" tendon

Humerus --+--'1\'

Figure 5-1

Figure 5-2

Figure 5-3

Figure 5-4

Figure 5-5

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

109

Subacromial (Subdeltoid) Bursa DESCRIPTIVE ANATOMY The subacromial portion of the bursa is a fluid-filled sac that extends over the supraspinatus tendon and beneath the acromion process. The subdeltoid portion, beneath the deltoid m uscle, (Fig. 5-6) separates the deltoid muscle from the rotator cuff. PROCEDURE With one hand, extend the patient's arm. With your opposite hand, palpate for tenderness, masses, and thickening of both subacromial (Fig. 5-7) and subdeltoid (Fig. 5-8) portions of the bursa. Sus pect subacromial or subdeltoid bursitis if the bursa is tender. Tenderness may also be associated with restriction of motion and crepitus of the shoulder, especially in abduction and forward flexion.

Acromioclavicular ligament

Coracoid process Sternoclavicular

(Subdeltoid) Subacromial bursa

Deltoid muscle Long head of biceps tendon

Humerus

la

Figure 5-6

1

Figure 5-7

J

Figure 5-8

110

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Rotator Cuff DESCRIPTIVE ANATOMY The rotator cuff is composed of four muscles, three that are palpable and one that is not. The three palpable muscles are the supraspinatus, which lies above the spine of the scapula and whose tendon lies under the acromion process; the infraspinatus, which lies inferior to the supraspinatus; and the teres minor, which is inferior to the infraspinatus (Figs. 5-9 and 5-10) The fourth muscle is the sub scapularis, which is under the scapula and is difficult to palpate. The rotator cuff holds the humerus in the glenoid cavity and blends with the articular capsule to provide dynamic stabilization. PROCEDURE Sitting behind the patient, grasp the patient's arm and extend it backward 20°. With your other hand, palpate inferior to the anterior border of the acromion process (Fig. 5-11). Note any tender ness, swelling, nodular masses, or gaps in the cuff. Tendinitis, tears, abnormal calcium deposits, and degeneration in the cuff may elicit tenderness and pain upon palpation. A palpable gap may indi cate a ruptured tendon.

(Shoulder Joint) Acromioclavicular ligament

Clavicle

Rotator cuff (posterior view): CD Supraspinatus m.

Acromion process 7"""--"'.... Supraspinatus m.---:I'-#'--,.;;.' -

process

Infraspinatus m. Teres minor m.

Scapula ® Infraspinatus @ Teres minor muscle muscle Figure 5-9

Figure 5-10

Figure 5-11

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

III

Bicipital Groove DESCRIPTIVE ANATOMY The bicipital groove is anterior and medial to the greater tuberosity of the humerus. The tendon of the long head of the biceps muscle and its synovial sheath lie in its groove. The transverse humeral ligament holds the tendon in place (Fig. 5-12). PROCEDURE With one hand, locate the inferior tip of the acromion process, then move inferiorly to the greater tuberosity of the humerus. With your other hand, grasp the patient's arm and externally rotate it (Fig. 5-13). You will feel the bicipital groove slip under your fingers. Note any tenderness, which may indicate tenosynovitis of the bicipital tendon and its sheath. Also note any excessive movement of the tendon in its groove; it may indicate a predisposition of the tendon to dislocate out of the bicip ital groove or a torn or ruptured transverse humeral ligament.

Bicipital groove

Transverse humeral--+--f-t ligament Biceps tendon

Biceps _L..lL-"-'I" brachii muscle

Figure 5-12

Figure 5-13

112

PHOTOGRAPHIC MANUAL O F REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Biceps Muscle DESCRIPTIVE ANATOMY The biceps muscle has two heads that originate from different areas. The long head originates from the tuberosity above the glenoid cavity, and the short head originates from the coracoid process of the scapula. They both insert into the bicipital tuberosity of the radius (Fig. 5-12). PROCEDURE With the patient's elbow flexed to 90°, begin palpating distally from the bicipital tuberosity of the ra dius upward to the bicipital groove (Fig. 5-14). Note any tenderness, spasm, or muscle mass. Tender ness at the proximal end may indicate tenosynovitis of the biceps tendon. Tenderness at the belly of the muscle may indicate muscle strain or an active trigger point. If a curling of the muscle secondary to overload is evident at the mid arm, suspect a rupture of the biceps tendon from its origin.

Figure 5-14

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

113

Deltoid Muscle DESCRIPTIVE ANATOMY The deltoid muscle originates from the clavicle and acromion process of the scapula and inserts into the deltoid tuberosity of the humerus (Fig. 5-15). The three parts of the fibers are the anterior, mid dle, and posterior. This muscle is capable of acting in parts or as a whole. The anterior part flexes and medially rotates the humerus. The middle part abducts the humerus. The posterior part extends and laterally rotates the humerus. PROCEDURE Begin palpation of the anterior portion of the deltoid muscle from the acromion process inferiorly (Fig. 5-16), then from the lateral aspect of the shoulder (again inferiorly) for the middle part of the deltoid muscle (Fig. 5-17). Finally, palpate the posterior aspect of the deltoid muscle from the supe rior aspect to the inferior aspect with the patient's shoulder extended (Fig. 5-18). Note any tender ness or taut muscle fibers. Tenderness at the lateral aspect of the deltoid is associated with subdel toid bursitis. Tenderness at the anterior aspect of the deltoid may be associated with pathology or injury in the bicipital groove, because the anterior aspect of the deltoid muscle covers the groove and its tendon. General tenderness may indicate a strain or active trigger point of the deltoid muscle sec ondary to overuse, overload, trauma, or chilling. Figure 5-15

Anterior fibers Deltoid

m. -f+r.�

Middle fibers Posterior fibers

Figure 5-16

Figure 5-17

Figure 5-18

114

PHOTOGRAPHIC MANUAL O F REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Posterior Aspect

Scapula DESCRIPTIVE ANATOMY The scapula lies between T2 and T7. It has three borders, medial, lateral, and superior. It also has a sharp ridge that extends from the acromion process, which is the spine of the scapula (Fig. 5-19). PROCEDURE Starting with the medial border of the scapula, palpate all three borders, noting any tenderness (Figs. 5-20-5-22). Next, palpate the spine of the scapula, noting any tenderness and/or abnormality (Fig. 5-23). Finally, palpate the posterior surfaces above the spine of the scapula for the supraspinatus muscle (Fig. 5-24) and below the spine for the infraspinatus muscle (Fig. 5-25). Note any tender ness, palpable bands, atrophy, or spasm. Palpable bands in the supraspinatus and infraspinatus mus cle may indicate a myofascial syndrome caused by overuse, overload trauma, or chilling. Atrophy may indicate a disruption of the nerve supply to the suspected muscle.

Superior border

Coracoid Acromion process

Lateral border

(Posterior View) Figure 5-19

I

, Figure 5-20

Figure 5-21

Figure 5-22

Figure 5-23

Figure 5-24

Figure 5-25

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

lIS

Trapezius Muscle DESCRIPTIVE ANATOMY The trapezius muscle originates from the occiput, ligamentum nuchae, and spine of C7 to T12 ver tebra. It inserts into the acromion process and spine of the scapula (Fig. 5-26). The trapezius con tains three sets of fibers that perform different actions. The superior fibers elevate the shoulders; the middle fibers retract the scapula; and the inferior fibers depress the scapula and lower the shoulders. PROCEDURE Begin at the origin at the base of the occiput, palpating superior fibers inferior toward the spine of the scapula (Fig. 5-27). Then, from the spine of the scapula, palpate the middle (Fig. 5-28) and inferior (Fig. 5-29) fibers down toward the T l 2 spinous process. Note any tenderness, spasm, palpable bands, or asymmetry of the muscles. Tenderness and spasm may be present secondary to hyperextension or hyperflexion injuries. Tight palpable bands may be secondary to active myofascial trigger points. Ac cording to Travell, myofascial trigger points in muscle are activated directly by trauma, overuse, over load, or chilling. They are activated indirectly by visceral disease, arthritis, and emotional distress. Figure 5-26

Semispinalis cervicis m. Wf-�"'-+ Longissimus

cervicis m.

-""':::"....",..--- Splenius capitus m.

\r----....:..,,---S plenius cervicis m. Deltoid m.-H"r.'H--'

Figure 5-27

Figure 5-28

Figure 5-29

•

116

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

SHOULDER RANGE OF MOTION

Flexion (1,2) With the patient seated, place the goniometer in the sagittal plane at the level of the glenohumeral joint (Fig. 5-30). Instruct the patient to elevate the arm forward while following it with one arm of the goniometer (Fig. 5-31). NORMAL RANGE Normal range is 1670 ± 5.70 from the 0 or neutral position. Note: This expressed degree of motion probably did not permit enough external rotation and abduction to achieve 1800 of flexion described by others.

Muscles

Nerve Supply

1. 2. 3. 4.

Axillary Lateral pectoral Musculocutaneous Musculocutaneous

Anterior deltoid Pectoralis major Coracobrachialis Biceps

Figure 5-30

Figure 5-31

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

117

Extension (1,2) With the patient seated, place the goniometer in the sagittal plane at the level of the glenohumeral joint (Fig. 5-32). Instruct the patient to elevate the arm backward while following it with one arm of the goniometer (Fig. 5-33). NORMAL RANGE Normal range is 620 :t 9.50 from the 0 or neutral position.

Muscles

Nerve Supply

l. Posterior Deltoid 2. Teres major, minor 3. Latissimus dorsi 4. Pectoralis major 5. Triceps

Axillary Subscapular Thoracodorsal Lateral Pectoral Radial

Figure 5-32

Figure 5-33

118

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Internal Rotation (1,2) Have the seated patient abduct the arm to 90° and flex the elbow to 90°. This is the 0 or neutral po sition for rotation of the shoulder. Place the goniometer in the sagittal plane with the center at the lateral aspect of the elbow (Fig. 5-34). Instruct the patient to rotate the shoulder inward by moving the forearm so that the palm of the hand faces posteriorly, and follow the forearm with one arm of the goniometer (Fig. 5-35). NORMAL RANGE Normal range is 69° ± 5 6° from the 0 or neutral position. .

Muscles

Nerve Supply

1. 2. 3. 4. 5.

Lateral Pectoral Axillary Thoracodorsal Subscapular Subscapular

Pectoralis major Anterior deltoid Latissimus dorsi Teres major Subscapularis

Figure 5-34

Figure 5-35

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

119

External Rotation (1,2) Have the seated patient abduct the arm to 90° and flex the elbow to 90°. This is the 0 or neutral po sition for rotation of the shoulder. Place the goniometer in the sagittal plane with the center at the lateral aspect of the elbow (Fig. 5-36). Instruct the patient to rotate the shoulder outward by mov ing the forearm so that the palm of the hand faces anteriorly, and follow the forearm with one arm of the goniometer (Fig. 5-37). NORMAL RANGE Normal range is 1 04° :±: 8.5° from the 0 or neutral position.

Muscles

Nerve Supply

1. Infraspinatus 2. Posterior deltoid 3. Teres minor

Suprascapular Axillary Axillary

Figure 5-36

Figure 5-37

120

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Abduction (1,2) With the patient seated, place the goniometer in the coronal plane with the center at the level of the glenohumeral joint (Fig. 5-38). Instruct the patient to raise the arm laterally. Follow it with one arm of the goniometer (Fig. 5-39). NORMAL RANGE Normal range is 1 840 ± 70 from the 0 or neutral position.

Muscles

Nerve Supply

1. 2. 3. 4. 5. 6.

Axillary Suprascapular Suprascapular Suprascapular Axillary Musculocutaneous

Deltoid Supraspinatus Infraspinatus Subscapularis Teres minor Biceps brachii, long head

Figure 5-38

Figure 5-39

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

121

Adduction With the patient seated, place the goniometer in the coronal plane with the center at the level of the glenohumeral joint (Fig. 5-40). Instruct the patient to raise the arm medially. Follow it with one arm of the goniometer (Fig. 5-41). NORMAL RANGE Normal range is 75° or greater from the 0 or neutral position. NOTE Adduction is a composite movement of flexion and adduction. Most sources do not measure com posite movements. I consider it a clinically important movement and think it should be measured.

Muscles

Nerve Supply

1 . Pectoralis major 2. Latissimus dorsi 3. Teres major 4. Subscapularis

Lateral pectoral Thoracodorsal Subscapular Subscapular

Figure 5-40

•

Figure 5-41

122

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

TENDINITIS (SUPRASPINATUS) CLINICAL DESCRIPTION Supraspinatus tendinitis is a common inflammatory condition of the shoulder that causes anterior shoulder pain. This inflammatory condition may be caused by trauma, overuse (especially overhead movements), or faulty body mechanics during athletic activity, such as pitching or bowling. Especially in abduction, the patient has painful passive range of motion and limited active range of motion and is apprehensive while performing these movements. The painful arc is usually be tween 60° and 90° of abduction. During this range the greater tuberosity passes under the acromion and the coracoacromial ligament. Pain and anterior spasm of the shoulder may indicate a moder ately inflamed swollen tendon. If the irritation of the tendon continues, calcific deposits may de velop and lead to calcific tendinitis. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

Anterolateral shoulder pain Pain sleeping on the affected side Stiffness Catching of the shoulder during use Pain on active and passive range of motion Local tenderness

Supraspinatus Tendinitis Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient seated, instruct him to abduct the arm to 90° with the arm between abduction and forward flexion. Instruct the patient to abduct the arm against resistance (Fig. 5-42). RATIONALE Resisting shoulder abduction stresses mainly the deltoid muscle and the supraspinatus muscle and tendon. Pain and/or weakness over the insertion of the supraspinatus tendon may indicate degen erative tendinitis or a tear of the supraspinatus tendon. Pain over the deltoid muscle may indicate a strained deltoid muscle.

Figure 5-42

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

l23

Sensitivity/Reliability Scale

Apley Scratch Test (3)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Instruct the seated patient to place the hand on the side of the affected shoulder behind the head and touch the opposite superior angle of the scapula (Fig. 5-43). Then instruct the patient to place the hand behind the back and attempt to touch the opposite inferior angle of the scapula (Fig. 5-44). RATIONALE Actively attempting to touch the opposite superior and inferior aspect of the scapula places stress on the tendons of the rotator cuff. Exacerbation of the patient's pain indicates degenerative tendinitis of one of the tendons of the rotator cuff, usually the supraspinatus tendon.

•

Figure 5-44

Figure 5-43

Hawkins-Kennedy Impingement Test (4)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient standing, flex the shoulder forward to 90°, then force the shoulder in an internal rotation without resistance by the patient (Fig. 5-45). RATIONALE This movement pushes the supraspinatus tendon against the anterior surface of the coracoacromial ligament. Local pain indicates supraspinatus tendinitis.

Figure 5-45

124

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Neer Impingement Sign (5)

Sensitivity/Reliability Scale

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With the patient seated, grasp the patient's wrist and passively move the shoulder through forward flexion (Fig. 5-46). RATIONALE Moving the shoulder through forward flexion jams the greater tuberosity of the humerus against the anterior inferior border of the acromion. Shoulder pain and a look of apprehension on the patient's face indicate a positive sign. This indicates an overuse injury to the supraspinatus muscle or some times to the biceps tendon. SUGGESTED DIAGNOSTIC IMAGING •

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Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Ultrasonography Magnetic resonance imaging

Figure 5-46

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TENDINITIS (BICIPITAL) CLINICAL DESCRIPTION The biceps brachii has two heads, the long and the short. The long head originates from the supe rior lip of the glenoid fossa, proceeds laterally, and angles 90° at the bicipital groove on the superior aspect of the humeral head. It is the affected tendon in bicipital tendinitis (Fig. 5-47). Bicipital ten dinitis is a chronic condition of shoulder pain with tenderness over the bicipital groove (see Fig. 5-51). Most cases are associated with lesions such as synovitis of the surrounding capsule, adhesive capsulitis, osteophytes in the area of the bicipital groove, or rotator cuff tears. True isolated bicipital tendinitis allows a full free range of passive movement. CLINICAL SIGNS AND SYMPTOMS •

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Anterior shoulder pain Pain on palpation of the bicipital groove Pain on active and passive elbow flexion and extension

Long head of bicep s brachii tendon m groove of humeral head

Figure 5-47

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Speed's Test (3,6)

Sensitivity/Reliability Scale

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With the patient's elbow completely extended, supinated, and the shoulder flexed forward to 45°, place your fingers on the bicipital groove and your opposite hand on the patient's wrist (Fig. 5-48). Instruct the patient to elevate the arm forward against your resistance (Fig. 5-49). RATIONALE This test stresses the biceps tendon in the bicipital groove. Pain or tenderness in the bicipital groove indicates bicipital tendinitis.

Figure 5-48

Figure 5-49

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

Lippman's Test (6)

127

Sensitivity/Reliability Scale

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Instruct the sitting patient to flex the elbow to 90°. Stabilize the elbow with one hand, and with your other hand palpate the biceps tendon and move it from side to side in the bicipital groove (Fig. 5-50). RATIONALE Moving the biceps tendon manually in the bicipital groove stresses the tendon and transverse humeral ligament. Pain indicates bicipital tendinitis. Apprehension may indicate a propensity for subluxation or dislocation of the biceps tendon out of the bicipital groove or a ruptured transverse humeral ligament (Fig. 5-51).

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Figure 5-50

Figure 5-51

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Gilchrest's Sign (7)

Sensitivity/Reliability Scale

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Instruct the standing patient to grasp a 5- to 7-lb weight and lift it overhead (Fig. 5-52). Next, instruct the patient to rotate the shoulder externally and the lower the arm slowly to the side (Fig. 5-53). RATIONALE This test is similar to the Abbott-Saunders test, but it is not passive, and it requires the use of a weight. Abduction and external rotation of the shoulder stress the biceps tendon against the trans verse humeral ligament. Pain and/or discomfort in the bicipital groove indicates bicipital tendinitis. An audible snap may indicate a subluxation or dislocation of the biceps tendon out of the bicipital groove, which may be due to a lax or ruptured transverse humeral ligament or a congenitally shal low bicipital groove. SUGGESTED DIAGNOSTIC IMAGING •

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Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Ultrasonography Magnetic resonance imaging

Figure 5-52

Figure 5-53

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BURSITIS CLINICAL DESCRIPTION The subacromial bursa overlies the rotator cuff tendons and is continuous with the subdeltoid bursa (see Fig. 5-55). Isolated subacromial or subdeltoid bursitis is rare. Usually the bursitis is associated with tendinitis of the adjacent supraspinatus tendon. Anatomically the inner synovial wall of the subdeltoid bursa is the outer wall of the supraspinatus tendon, so if there is inflammation in one of those structures, there is inflammation of the other. Some of the most common causes of bursitis are trauma, overuse, repeated multiple minor traumas, and improper executed activity. CLINICAL SIGNS AND SYMPTOMS •

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Anterolateral shoulder pain Pain sleeping on the affected side Stiffness "Catching" of the shoulder during use Pain on active and passive range of motion Local tenderness

Subacromial Push-Button Sign

Sensitivity/Reliability Scale

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PROCEDURE With the patient seated, apply pressure to the subacromial bursa (Fig. 5-54).

Figure 5-54

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RATIONALE Pressure to the subacromial bursa will irritate an already inflamed bursa. Local pain suggests in flammation of the subacromial bursa or bursitis (Fig. 5-55).

Subacromial bursa Acromion

Deltoid muscle

Figure 5-55

CHAPTER 5

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Dawbarn's Test (6)

131

Sensitivity/Reliability Scale

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With the patient seated, apply pressure just below the acromion process on the side being tested. Note any pain or tenderness (Fig. 5-56). Then, abduct the patient's arm past 90°, maintaining pres sure on the spot below the acromion (Fig. 5-57).

RATIONALE The spot below the acromion is the palpable portion of the subacromial bursa. Pain and/or tender ness at that location may indicate inflammation of the bursa or bursitis. When the arm is abducted, the deltoid muscle will cover that spot below the acromion. Covering that spot reduces pressure on the bursa, decreasing the tenderness if the bursa is inflamed. A decrease in the tenderness to that point indicates subacromial bursitis (Fig. 5-58).

Figure 5-57

Figure 5-56

SUGGESTED DIAGNOSTIC IMAGING •

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Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Ultrasonography Magnetic resonance imaging Figure 5-58

View from above

Subdeltoid bursa

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ANTERIOR GLENOHUMERAL INSTABILITY CLINICAL DESCRIPTION Anterior shoulder instability is the major cause of shoulder dislocations. This is attributed to anatomic weakness on the anterior structures of the glenohumeral joint: the anterior capsule, gleno humeral ligaments, rotator cuff tendons, and glenoid labrum. There are three types of anterior dis locations, based on the direction of dislocation: subclavicular, subcoracoid and subglenoid. The sub coracoid is the most common. The most common cause of shoulder dislocation is a fall on an outstretched arm.

CLINICAL SIGNS AND SYMPTOMS •

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Painful arc (if dislocated) Feeling of shoulder slippage Apprehension on movement Crepitus on movement Increased shoulder girth (if dislocated)

Anterior Drawer Test (8)

Sensitivity/Reliability Scale

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With the patient supine, place his or her hand in your axilla. With your opposite hand, grasp the posterior scapula with your fingers and place your thumb over the coracoid process (Fig. 5-59). Us ing the arm that is holding the patient's hand, grasp the posterior aspect of the patient's arm and draw the humerus forward (Fig. 5-60).

RATIONALE Attempting to move the humerus forward while stabilizing the scapula tests the integrity of the an terior portion of the rotator cuff, which holds the humerus into the glenoid cavity. A click and/or an abnormal amount of movement compared with the normal side indicates anterior instability of the glenohumeral joint.

Figure 5-59

Figure 5-60

CHAPTER 5

Anterior Apprehension Test (3)

SHOULDER ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

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Stand behind the seated patient. Abduct the affected arm to 90° and externally rotate it slowly while stabilizing the posterior aspect of the shoulder with the opposite hand (Fig. 5-61).

RATIONALE Local pain indicates a chronic anterior shoulder dislocation. This test is called apprehension because it is intended to elicit a look of apprehension on the patient's face. The patient may also state that the test feels the same as when the shoulder was dislocated. External rotation of the arm predisposes the humerus to dislocate anteriorly. This test forces external rotation to dislocate the humerus anteriorly from the glenoid fossa. If the rotator cuff musdes, joint capsule, and glenoid fossa are sound, the patient should have no pain or apprehension when this test is performed. It tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.

Figure 5-61

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Prone Anterior Instability Test (9)

Sensitivity/Reliability Scale

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With the patient prone, grasp the patient's forearm, abduct the arm to 90°, with the elbow flexed to 90° (Fig.5-62). Place your other hand over the humeral head and push it forward (Fig. 5-63). RATIONALE This is an attempt to dislocate the head of the humerus anteriorly. Anterior shoulder pain or a re production of the patient's symptoms indicate a positive test. This procedure tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.

Figure 5-62

Figure 5-63

CHAPTER 5

Andrews Anterior Instability Test (9) PROCEDURE

135

SHOULDER ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

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With the patient supine, grasp the patient's distal humerus, abduct the shoulder to 130°, and exter nally rotate it to 90° (Fig. 5-64). With your opposite hand grasp the humeral head from the poste rior and push it anterior (Fig. 5-65). RATIONALE This is an attempt to dislocate the head of the humerus anteriorly. Anterior shoulder pain or a re production of the patient's symptoms indicate a positive test. This procedure tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum. If a labral tear is present, a clunk may be heard.

Figure 5-64

Figure 5-65

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Rockwood Test (10)

Sensitivity/Reliability Scale

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This test is a variation of the anterior apprehension test. With the patient seated, externally rotate the shoulder with the arm in the neutral position (Fig. 5-66). Repeat the test with the arm at 45° of abduction (Fig. 5-67), then at 90° of abduction (Fig. 5-68), then at 120° of abduction (Fig. 5-69).

RATIONALE The patient must show marked apprehension at 90° with pain. At 0° there is rarely any apprehen sion. At 45° and 120° there should be more pain with slight apprehension. The patient may say that it felt the same as when the shoulder was previously dislocated. This procedure tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.

Figure 5-66

Figure 5-67

Figure 5-68

Figure 5-69

CHAPTER 5

Rowe Test for Anterior Instability (11)

Sensitivity/Reliability Scale

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PROCEDURE

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SHOULDER ORTHOPAEDIC TESTS

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Instruct the seated patient to place the hand on the side of the affected shoulder behind the head. Then, place your clenched fist against the posterior humeral head and push anteriorly, using your opposite hand to extend the patient's arm (Fig. 5-70).

RATIONALE The examiner is attempting to dislocate the patient's glenohumeral joint anteriorly. A look of ap prehension indicates a positive test. The patient may also may say that it felt the same as when the shoulder was previously dislocated. This procedure tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.

Figure 5-70

Fulcrum Test (12)

Sensitivity/Reliability Scale

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With the patient supine and the arm abducted to 90°, place your hand under the glenohumeral joint and externally rotate the patient's arm over the hand (Fig. 5-71).

RATIONALE This is an attempt to dislocate the head of the humerus anteriorly. A look of apprehension with pain is a positive sign. The patient may say that it felt the same as when the shoulder was previously dis located. This procedure also tests the integrity of the inferior glenohumeral ligament, anterior cap sule, rotator cuff tendons, and glenoid labrum. A congenitally shallow glenoid fossa may also pre dispose the shoulder to dislocation.

Figure 5-71

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Dugas Test (13,14)

Sensitivity/Reliability Scale

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With the patient seated, instruct him or her to touch the opposite shoulder and bring the elbow to the chest wall (Fig. 5-72).

RATIONALE Inability to touch the opposite shoulder because of pain indicates an anterior dislocation of the humeral head out of the glenoid cavity. This dislocation is usually caused by forced external rota tion when the arm is abducted. When the humerus is dislocated anteriorly, a characteristic sign is a prominent acromion process.

SUGGESTED DIAGNOSTIC IMAGING •

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Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Axillary shoulder radiograph Tangential shoulder radiograph Computed tomographic (CT) arthrography

Figure 5-72

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139

POSTERIOR GLENOHUMERAL INSTABILITY CLINICAL DESCRIPTION Posterior glenohumeral dislocation is seen in only 5% to 10% of shoulder dislocations. In this type of dislocation the head of the humerus dislocates posteriorly and is found behind the scapula. This is usually caused by trauma to the anterior aspect of the shoulder that drives a forceful backward movement of the humeral head. Instability of the rotator cuff and/or the posterior joint capsule may predispose the joint to posterior dislocation.

CLINICAL SIGNS AND SYMPTOMS •

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Painful arc (if dislocated) Feeling of shoulder slippage Apprehension on movement Crepitus on movement Increased shoulder girth (if dislocated)

Posterior Apprehension Test (6)

• Sensitivity/Reliability Scale

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With the patient supine, forwardly flex and internally rotate his or her shoulder. With your hand, apply posterior pressure on the elbow (Fig. 5-73).

RATIONALE This test attempts to dislocate the shoulder posteriorly and stresses the rotator cuff and posterior joint capsule. Local pain or discomfort and a look of apprehension on the patient's face indicates chronic posterior shoulder instability. The patient may say that it felt the same as when the shoul der was previously dislocated. The mechanism of injury is commonly a position of forced adduc tion with internal rotation in some degree of elevation.

Figure 5-73

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Posterior Drawer Test (15)

Sensitivity/Reliability Scale

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With the patient supine, grasp the patient's forearm, flex the patient's elbow, and abduct and flex the shoulder. With your opposite hand, stabilize the scapula with your index and middle finger on the spine of the scapula and your thumb on the coracoid process (Fig. 5-74). Rotate the forearm inter nally and flex the shoulder forward, taking the thumb of your other hand off the coracoid and forc ing the humerus posteriorly (Fig. 5-75).

RATIONALE This is an attempt to dislocate the shoulder posteriorly, stressing the rotator cuff and joint capsule. Local pain and a look of apprehension are the signs of a positive test. This test stresses the rotator cuff and the posterior joint capsule.

Figure 5-74

Figure 5-75

Norwood Stress Test (16,17)

Sensitivity/Reliability Scale

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PROCEDURE

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With the patient supine, instruct the patient to abduct the shoulder to 90°, externally rotate it to 90°, and flex the elbow to 90°. With one hand, stabilize the scapula while palpating the posterior aspect of the humeral head (Fig. 5-76). With your opposite hand, grasp the elbow, bringing the shoulder into forward flexion and forcing the elbow posteriorly (Fig. 5-77).

RATIONALE This test is an attempt to dislocate the shoulder posteriorly, stressing the rotator cuff and the poste rior joint capsule. A positive test is indicated by the humeral head slipping posteriorly out of the glenoid fossa. When the arm is returned to the starting position, the humeral head should reduce. A clicking sound may accompany the reduction.

Figure 5-76

Figure 5-77

CHAPTER 5

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SHOULDER ORTHOPAEDIC TESTS

Push-Pull Test (12)

Sensitivity/Reliability Scale

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With the patient supine, grasp the patient's wrist and abduct the arm to 90° and forward flex it to 30° forward (Fig. 5-78). With your opposite hand, grasp the arm near the humeral head, pull up on the wrist, and push down on the arm (Fig. 5-79).

RATIONALE In the normal patient, up to 50% of translation is considered a negative test. More than 50% trans lation and a look of apprehension indicate a positive test. This test is also an attempt to dislocate the shoulder posteriorly. It stresses the rotator cuff and posterior joint capsule.

•

SUGGESTED DIAGNOSTIC iMAGING •

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Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Axillary shoulder radiograph Tangential shoulder radiograph CT arthrography

-

Figure 5-78

Figure 5-79

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MULTIDIRECTIONAL SHOULDER INSTABILITY CLINICAL DESCRIPTION Multidirectional shoulder instability is a combination of anterior and posterior shoulder instability. The following tests are attempts to dislocate the shoulder in multiple directions. The different in stabilities are described in the sections on the anterior and posterior shoulder instabilities.

CLINICAL SIGNS AND SYMPTOMS •

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Painful arc (if dislocated) Feeling of shoulder slippage Apprehension on movement Crepitus on movement Increased shoulder girth (if dislocated)

Feagin Test (10)

Sensitivity/Reliability Scale

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With the patient standing, instruct the patient to abduct the arm and place the hand on your shoul der (Fig. 5-80). With both hands, grasp the patient's humerus next to the humeral head and exert downward and forward pressure (Fig. 5-8 1).

RATIONALE A look of apprehension on the patient's face signifies a positive test. This indicates an anterior infe rior shoulder instability. This test is an attempt to dislocate the shoulder anteriorly and inferiorly. It tests the integrity of the inferior glenohumeral ligament, anterior capsule, rotator cuff tendons, and glenoid labrum.

Figure 5-80

Figure 5-81

CHAP TER 5

143

SHOULDER ORTHOPAEDIC TESTS

Rowe Test for Multidirectional Instability (11)

Sensitivity/Reliability Scale

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To test for inferior instability, have the patient stand bending forward 45°. Grasp the shoulder with the index and middle finger over the posterior humeral head and the thumb at the anterior humeral head. With your opposite hand, grasp the patient's elbow and pull down on the arm (Fig. 5-82). To test for anterior instability, push the humeral head forward from behind with your thumb and ex tend the patient's arm 20° to 30° (Fig. 5-83). To test for posterior instability, push the humeral head posteriorly from the anterior with your index and middle fingers with the patient's shoulder flexed 20° to 30° (Fig. 5-84).

RATIONALE This test is an attempt to dislocate the humeral head out of the glenoid fossa in various directions. A look of apprehension and/or local discomfort on the patient's face is a positive sign. This test stresses the glenohumeral ligament, rotator cuff tendons, and the joint capsule.

Figure 5-82

Figure 5-83

Figure 5-84

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Sulcus Sign (18)

Sensitivity/Reliability Scale

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With the patient seated, instruct the patient to flex the elbow to 90° with the shoulder in the neutral position for rotation (Fig. 5-85). Grasp the patient's wrist with one hand, pressing down on the fore arm with the other hand (Fig. 5-86).

RATIONALE Pressing down on the forearm with the patient's shoulder in the neutral position is an attempt to dislocate the shoulder inferiorly. A sulcus at the anterolateral aspect of the shoulder indicates an in ferior shoulder instability. The sulcus is graded according to its size. A + 1 sulcus indicates less than l cm. A + 2 sulcus indicates 1 to 2 cm. A +3 sulcus indicates more than 2 cm.

SUGGESTED DIAGNOSTIC IMAGING •

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Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Axillary shoulder radiograph Tangential shoulder radiograph CT arthrography

Figure 5-85

Figure 5-86

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LABRAL TEARS CLINICAL DESCRIPTION The edge of the glenoid fossa is surrounded by a fibrocartilage rim called the glenoid labrum. The superior portion of the labrum blends with the tendon of the long head of the biceps muscle (Fig. 5-87). This fibrocartilage rim adds depth to the glenoid fossa and helps to hold the humerus in place. Tearing of any part of the labrum predisposes dislocation of the humerus out of the glenoid cavity in the direction of the tear. These tears are relatively common to throwing athletes.

Glenoid fossa

Biceps brachii tendon (long head)

Head of humerus

Glenoid labrum

Biceps brachii muscle

Figure 5-87

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Clunk Test (6)

Sensitivity/Reliability Scale

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With the patient supine the examiner places one hand over the posterior aspect of the humeral head. With the opposite hand the examiner grasps the elbow and fully abducts the shoulder (Fig. 5-88). The examiner then pushes anteriorly with the hand over the humeral head and externally rotates the shoulder with the opposite hand (Fig. 5-89).

RATIONALE Anterior pressure to the humeral head with external rotation of the shoulder attempts to dislocate the shoulder anteriorly. A clunk or grinding sound indicates a positive test which suggests an ante rior tear of the glenoid labrum.

Figure 5-88

Figure 5-89

CHAPTER 5

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SHOULDER ORTHOPAEDIC TESTS

Anterior Slide Test (18,19)

Sensitivity/Reliability Scale

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With the patient seated, instruct the patient to place the hands on the waist with the thumbs poste rior (Fig. 5-90). With one hand, stabilize the scapula and clavicle. With the opposite hand, grasp the humerus and place anterior superior force to the shoulder (Fig. 5-9 1 ).

RATIONALE Anterior and superior force to the shoulder may dislocate the shoulder anteriorly and superiorly. If a pop or crack is noted and the patient complains of pain to the anterosuperior aspect of the shoul der, this indicates a superior or anterior tear of the glenoid labrum.

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Figure 5-90

Figure 5-91

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ROTATOR CUFF INSTABILITY CLINICAL DESCRIPTION Rotator cuff instability involves partial or complete tearing of one of the tendons of the rotator cuff. Usually the supraspinatus tendon is involved, but it may involve the adjacent subscapularis or in fraspinatus tendon. Incomplete tears in younger adults are usually due to microtrauma. In older adults, diminishing blood supply may cause the tendons to become frail and tear. Complete tears are usually due to sudden severe strain caused by a fall or overexertion. Incomplete tears usually clini cally resemble supraspinatus tendinitis. In complete tears the patient cannot abduct the arm, and any attempt to do so is followed by severe pain.

CLINICAL SIGNS AND SYMPTOMS •

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Severe anterior lateral shoulder pain Pain when sleeping on the affected side Stiffness "Catching" of the shoulder during use Pain on active and passive range of motion Localized tenderness Unable to abduct shoulder

Drop Arm Test (2)

Sensitivity/Reliability Scale

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With the patient seated, abduct the arm past 90° (Fig. 5-92). Instruct the patient to lower the arm slowly (Fig. 5-93).

RATIONALE If the patient cannot lower the arm slowly or if it drops suddenly, this indicates a rotator cuff tear, usually of the supraspinatus. The supraspinatus muscle acts as an abductor of the arm and holds the head of the humerus in place. A tear of the supraspinatus tendon causes unsteadiness of the humerus in abduction, causing it to drop suddenly.

Figure 5-92

Figure 5-93

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

Supraspinatus Test (20)

149

Sensitivity/Reliability Scale

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With the patient either sitting or standing, instruct the patient to abduct the shoulder to 90°. Grasp the patient's arm and press down against resistance by the patient (Fig. 5-94). Next, instruct the pa tient to rotate the shoulders internally so that the thumb faces downward. Again, press down on the arm against resistance by the patient (Fig. 5-95).

RATIONALE Resistance to abduction stresses the supraspinatus muscle and tendon. Weakness or pain may indi cate a tear of the supraspinatus muscle or tendon. Weakness may also indicate suprascapular neu ropathy.

SUGGESTED DIAGNOSTIC IMAGING •

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Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Axillary shoulder radiograph CT arthrography Magnetic resonance imaging (MRI)

Figure 5-94

Figure 5-95

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150

BICEPS TENDON INSTABILITY CLINICAL DESCRIPTION The biceps brachii has two heads: long and short. The long head originates from the superior lip of the glenoid fossa and proceeds laterally and angles 90° at the bicipital groove. It is held in the bicip ital groove by the transverse humeral ligament (see Fig. 5-98). A shallow bicipital groove or lax or ruptured transverse humeral ligament may snap the biceps tendon into and out of the bicipital groove, causing anterior shoulder pain with point tenderness at the bicipital groove. This painful snap may also indicate a tear of the biceps tendon. A bicipital tendon tear is followed by swelling and ecchymosis near the bicipital groove and a characteristic bulging of the belly of the biceps muscle near the antecubital fossa (Popeye sign).

CLINICAL SIGNS AND SYMPTOMS •

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Anterior shoulder pain Stiffness Pain on active and passive range of motion Localized tenderness Bulging of bicep muscle (complete tear)

Yergason's Test (21)

Sensitivity/Reliability Scale

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With the patient seated and the elbow flexed to 90°, stabilize the patient's elbow with one hand (Fig. 5-96). With your opposite hand, grasp the patient's wrist and have the patient externally rotate the shoulder and supinate the forearm against your resistance (Fig. 5-97).

Figure 5-96

Figure 5-97

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151

RATIONALE Resisted supination of the forearm and external rotation of the shoulder stress the bicipital tendon and the transverse humeral ligament. Local pain and/or tenderness in the bicipital tendon indicates an inflammation of the biceps tendon or tendinitis. If the tendon pops out of the bicipital groove, suspect a lax or ruptured transverse humeral ligament or a congenital shallow bicipital groove caus ing the tendon to subluxate (Fig. 5-98).

groove Transverse humeral--+-f+,m ligament Biceps --+--' tendon

Biceps ---,rn-r"r , , brachii muscle

Figure 5-98

1.1

152

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Abbott-Saunders Test (22)

Sensitivity/Reliability Scale

I

I

a

PROCEDURE

I

,

I

2

I

3

4

With the patient seated, abduct and maximally rotate the patient's arm externally (Fig. 5-99), then lower the arm to the patient's side while palpating the bicipital groove with your opposite hand (Fig.

5-100). RATIONALE Abduction and external rotation of the shoulder stress the biceps tendon against the transverse humeral ligament. A palpable or audible click at the bicipital groove indicates a subluxation or dis location of the biceps tendon out of the groove caused by a lax or ruptured transverse humeral lig ament or congenitally shallow bicipital groove.

Figure 5-99

Figure 5-100

Ludington's Test (6)

Sensitivity/Reliability Scale

I

a

PROCEDURE

I

I ,

I

I

2

I

I

3

I

I

4

Instruct the patient to clasp both hands on top of the head, interlocking the fingers, (Fig. 5- 10 1) and alternately contract and relax the biceps muscle while you palpate the biceps tendon (Fig. 5- 1 02).

RATIONALE Placing the hands on the head supports the upper limb and allows relaxation of the biceps muscle. If the biceps tendon on the affected side is not contracting and palpable, suspect a rupture of the long head of the biceps tendon.

Figure 5-101

Figure 5-102

CHAPTER 5

1 53

SHOULDER ORTHOPAEDIC TESTS

Transverse Humeral Ligament Test (6)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

I

2

I

3

I

4

With the patient seated, grasp the patient's wrist. Abduct the shoulder to 90° and internally rotate it with one hand. With your opposite hand, palpate the bicipital groove (Fig. 5-103). Then externally rotate the shoulder (Fig. 5- 1 04).

II

Figure 5-103

Figure 5-104

154

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

RATIONALE External rotation of the shoulder moves the biceps tendon in the bicipital groove. If you feel the bicipital tendon snap in and out of the bicipital groove, suspect a torn or lax transverse humeral lig ament or shallow bicipital groove (Fig. 5-105).

SUGGESTED DIAGNOSTIC IMAGING •

•

•

Anteroposterior shoulder radiographs Neutral position Internal rotation External rotation Axillary CT arthrography MRI

Figure 5-105

CHAPTER 5

1 55

SHOULDER ORTHOPAEDIC TESTS

THORACIC OUTLET SYNDROME CLINICAL DESCRIPTION Thoracic outlet syndrome is a group of signs and symptoms that result from compression of the subclavian vessels and brachial plexus at the superior aperture of the thorax. It may be caused by trauma, repetitive motions, overuse, and some systemic diseases, such as diabetes and thyroid dis ease. Patients may complain of neck and shoulder pain with numbness and tingling affecting the en tire upper extremity. The ulnar side of the limb is predominantly involved. Using the affected ex tremity in an overhead or elevated position is difficult. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

•

II

Upper extremity pain Upper extremity paresthesias Grip weakness Upper extremity edema Upper extremity coldness Excessive dryness of arm or hand Excessive sweating of arm or hand

Adson's Test (23-25)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient seated, establish the amplitude of the radial pulse (Fig. 5- 1 06). Compare the am plitude bilaterally. Instruct the patient to take a deep breath and sustain it while he or she rotates the head and elevates the chin to the side being tested (Fig. 5-107). If the test is negative, have the pa tient rotate and elevate the chin to the opposite side (Fig. 5- 108).

Figure 5-1 06

Figure 5-107

Figure 5-108

156

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

RATIONALE Rotation and extension of the head compress the subclavian artery and brachial plexus. A decrease or absence of the amplitude of the radial pulse indicates a compression of the vascular component of the neurovascular bundle (subclavian artery) by a spastic or hypertrophied scalenus anterior muscle, on a cervical rib, or a mass, such as a Pancoast tumor. Paresthesias or radiculopathy in the upper extremity indicates compression of the neural component of the neurovascular bundle (brachial plexus) (Fig. 5-109).

Scalenus middle muscle

Axillary artery

Figure 5-109

CHAPTER 5

157

SHOULDER ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

Costoclavicular Test (26-28)

I

o

I 1

I

2

I

3

I

4

PROCEDURE With the patient seated, establish a radial pulse (Fig. 5-110). Instruct the patient to force the shoul ders posteriorly and have the patient flex the chin to the chest (Fig. 5-111). RATIONALE Forcing the shoulders posteriorly decreases the space between the clavicle and first rib. The neu rovascular bundle (brachial plexus, axillary artery) and the axillary vein run through a narrow cleft beneath the clavicle and on top of the first rib. Decrease or absence of the amplitude of the radial pulse indicates a compression to the vascu lar component of the neurovascular bundle. This compression is caused by a decrease in the space between the clavicle and the first rib. This decrease may be caused by a recent or healed fracture to the clavicle or first rib with or without callus formation, dislocation of the medial aspect of the clav icle, or a spastic or hypertrophied subclavius muscle. Paresthesias or radiculopathy in the upper ex tremity indicates compression to the brachial plexus or compression of the axillary vein (Fig. 5- 1 12). Compression of the brachial plexus is usually localized to a nerve root or peripheral nerve distribu tion. Compression of the axillary vein typically presents as diffuse radicular vascular discomfort not localized to a nerve root or peripheral nerve distribution.

Figure 5-1 1 0

Figure 5-112

Figure 5-111

•

1 58

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Wright's Test (29, 30)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, establish the character of the radial pulse (Fig. 5-1 13). Hyperabduct the arm and take the pulse again (Fig. 5-114). RATIONALE The axillary artery, vein, and three cords of the brachial plexus pass under the pectoralis minor mus cle on the coracoid process. Abduction of the arm to 1800 stretches these structures around the ten don of the pectoralis minor muscle and the coracoid process. Decrease or absence of the amplitude of the radial pulse indicates compression of the axillary artery either by a spastic or hypertrophied pectoralis minor muscle or by a deformed or hypertrophied coracoid process (Fig. 5-115).

Figure 5-11 3

Figure 5-114

Figure 5-11 5

CHAPTER 5

Traction Test (31 )

SHOULDER ORTHOPAEDIC TESTS

1 59

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient seated, establish a radial pulse (Fig. 5-116) . While maintaining the pulse, extend and apply traction to the arm (Fig. 5-1l7).

RATIONALE Traction and extension of the arm pulls the subclavian artery over the first rib. A decreased or oblit erated pulse is not diagnostic; however, when the test is repeated on the opposite side and reveals no change, the test indicates a subluxated or malpositioned first rib or a cervical rib on the side of the decreased or obliterated pulse.

II

Figure 5-116

Figure 5-1 1 7

160

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Halstead Maneuver (6)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I 2

I

I

3

I

I

4

With the patient seated, find the radial pulse and note the amplitude (Fig. 5-118). With your oppo site hand, pull on the patient's arm and ask the patient to hyperextend the neck (Fig. 5-119). Repeat the test on opposite arm. RATIONALE Traction pressure on the arm pulls the neurovascular bundle (brachial plexus and axillary artery) over the first rib. Extension of the neck tightens the scalene muscles. A decreased or obliterated pulse amplitude indicates a cervical rib, subluxation, or malposition of the first rib. An upper extremity radicular component indicates compression of the brachial plexus by the scalenus anterior muscle (See Fig. 5-109). SUGGESTED DIAGNOSTIC IMAGING •

•

Plain film radiography Posteroanterior chest ( if apical mass is suspect) Apical lordotic view Electrodiagnostic study

Figure 5-118

Figure 5-119

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

161

BRACHIAL PLEXUS IRRITATION CLINICAL DESCRIPTION Irritation of the brachial plexus may be due to various factors, such as a cervical rib, severe upper traction of the arm, fractured clavicle, or pulmonary apical mass. Any of these irritations may cause upper extremity radicular symptoms. Most of the following tests are upper limb tension signs that are equivalent to the straight leg raising test for lumbar radiculopathy. These tests are attempts to stress the neurological structures in the upper limb to determine neurological irritation; they stress all of the structures in the upper extremities but are used here for reproduction of the neurological signs reported by the patient. CLINICAL SIGNS AND SYMPTOMS •

•

•

II

Upper extremity radicular pain Upper extremity paresthesias Grip weakness

Brachial Plexus Stretch Test

Sensitivity/Reliability Scale

I

a

PROCEDURE

I

I ,

I

I

2

I

I

3

I

I

4

With the patient seated, instruct the patient to laterally flex the head opposite the affected side and extend the shoulder and elbow (Fig. 5- 120). RATIONALE This test is similar to a straight leg raising test for the upper extremity. This test stretches the brachial plexus opposite the side of lateral head flexion. Any damage to the plexus will cause pain and/or paresthesia along the distribution of the brachial plexus. Pain and paresthesia on the side of lateral bending may indicate a nerve root problem. Local cervical pain on the side of lateral bending may in dicate a cervical facet joint problem because the facets are compressed on the side of lateral bending.

Figure 5-120

1 62

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Bikele's Sign (32)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

With the patient seated, instruct him or her to abduct the shoulder to 90° and extend it as far as pos sible with the elbow fully flexed (Fig. 5-12 1 ). Instruct the patient to extend the elbow fully (Fig. 5-122). RATIONALE Abduction and extension of the shoulder place a motion-induced distraction on the brachial plexus. Adding the motion of elbow extension produces maximum distraction of the brachial plexus. If this movement is met with resistance and/or increases radicular pain to the upper extremity, this may indicate brachial plexus neuritis, nerve root irritation, or meningeal irritation of the covering of the cervical nerve roots.

Figure 5-121

Figure 5-122

CHAPTER 5

Brachial Plexus Tension Test (32)

SHOULDER ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

163

I ,

I

2

I

3

I

With the patient seated and the arms in the neutral position, grasp the patient's arms and passively abduct it to the end point of joint play or to the point of pain (Fig. 5- 123). Tell the patient to rotate the arms externally and maintain that position while you support the arm (Fig. 5-124). Finally, in struct the patient to flex the elbows so that the hand is behind the patient's head (Fig. 5-125).

RATIONALE Abduction and external rotation of the shoulder with elbow flexion provide maximum stretch to the brachial plexus and the C8 to T l nerve roots. Reproduction of the patient's symptoms suggests brachial plexus irritation. If the irritation is at the level of the nerve roots, radicular symptoms may also be reproduced.

Figure 5-123

Figure 5-124

Figure 5-125

� �

1 64

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Tinnel's Sign (for Brachial Plexus Lesions) (33)

Sensitivity/Reliability Scale

I

a

PROCEDURE

I 1

I I I

2

3

I

4

With the patient seated and the head laterally flexed, tap along the trunks of the brachial plexus with your index finger (Fig. 5-126). RATIONALE Local pain may indicate a cervical plexus lesion. A tingling sensation in the distribution of one of the trunks may indicate compression or neuroma of one or more of the trunks of the brachial plexus. SUGGESTED DIAGNOSTIC TESTS •

Electrodiagnostic studies

Figure 5-126

CHAPTER 5

SHOULDER ORTHOPAEDIC TESTS

165

20. Jobe FW, Moynes DR. Delineation of diagnos

References 1 . American Academy of Orthopaedic Surgeons. The Clinical Measurement of Joint Motion. Chicago: American Academy of Orthopaedic Surgeons, 1 995. 2. Boons DC, Azen SP. Normal range of motion of joints in male subjects. J Bone Joint Surg Am

tic criteria and rehabilitation program for rota tor cuff injuries. Am J Sports Med 1 982; 1 0 : 3336-3339. 2 1 . Yergason RM. Supination sign. J Bone Joint Surg 1 93 1 ; 1 3: 1 60. 22. Abbott LC, Saunders lB. Acute traumatic dislo cation of tendon of long head of biceps brachii:

1 979;61 :756-759. 3. Hoppenfeld S. Physical Examination of the

report of cases with operative findings. Surgery

Spine and Extremities. New York: Appleton Century-Crofts, 1 976; 1 27.

23. Adson AW. Cervical ribs: symptoms, differential diagnosis and indications for section of the in

4. Hawkins Rj, Kennedy Je. Impingement syn drome in athletics. Am J Sports Med 1 980; 8: 1 5 1- 1 63. 5. Neer CS, Welsh RP. The shoulder in sports. Or thop Clin North Am 1 977;8: 583-59 1 . 6 . MaGee DJ. Orthopedic Physical Assessment. 2nd ed. Philadelphia: WB Saunders, 1 992. 7. Post M. Physical Examination of the Muscu loskeletal System. Chicago: Year Book, 1 987. 8. Gerber C, Maitland GD. Practical Orthopedic Medicine. London: Butterworths, 1 969. 9. Andrews JA, Timmerman LA, Wilks KE. Athletic Inj uries of the Shoulder. New York: McGraw Hill, 1 995. 10. Rockwood CA. Subluxations and dislocations about the shoulder. In: Rockwood CA, Green DP, eds. Fractures in adults- I . Philadelphia: J B Lippincott, 1 985. 1 1 . Rowe CR. Dislocations of the shoulder. In: Rowe CR, ed. The Shoulder. Vol 1. Edinburgh: Churchill Livingstone, 1 988. 1 2. Matsen FA, Thomas SC, Rockwood CA. Gleno humeral instability. In: Rockwood CA, Matsen FA, eds. The Shoulder. Philadelphia: WB Saunders, 1 990. 1 3 . Jahn WT. Standardization of orthopaedic test ing of the upper extremity. J Manip Physiol Ther 1 98 1 ;4(2). 14. Stimson BBA. A Manual of Fractures and Dislo cations. 2nd ed. Philadelphia: Lea & Febiger, 1 946. 1 5 . Gerber C, Ganz R. Clinical assessment of insta bility of the shoulder. J Bone Joint Surg 1 984;66B:55 1-556. 16. Norwood LA, Terry Ge. Shoulder posterior and subluxation. An1 J Sports Med 1 984; 1 2:25-30. 17. Cofield RH, Irving JE Evaluation and classifica tion

of shoulder

instability.

Clin

Orthop

1 987;223: 32-43. 18. Kibler WB. Clinical Examination of the Shoul der. In Pettrone A, ed. Atl1letic Injuries of the Shoulder. New York: McGraw-Hill, 1 995. 19. Kibler WB. Specificity and sensitivity of the an terior slide test in throwing athletes with supe rior glenoid labral tears. Arthroscopy 1 995; 1 1 : 296-300.

1 939;6:8 1 7-840.

sertion of the scalenus anticus muscle. J Coli Int Surg 1 95 1 ; 1 06:546. 24. Adson AW, Coffey JR. Cervical rib. Ann Surg 1 927;85:839-857. 25. Lord JR, Rosati LM, eds. Thoracic-Outlet Syn dromes. New Jersey, ClBA Pharmaceutical, 1 97 1 ;2 1 ( 2 ) :9- 1 0 . 2 6 . Falconer MA, Li FWP. Resection of first rib i n costoclavicular compression of the brachial plexus. Lancet 1 962;59( 1 ):63. 27. Falconer MA, Weddel G . Costoclavicular com pression of the subclavian artery and vein: rela tion to scalene anticus syndrome. 1 943;2:542.

Lancet

28. Devay AD. Costoclavicular compression

of

brachial plexus and subclavian vessels. Lancet 1 945;2 : 1 65 . 29. Wright JS. The neurovascular syndrome pro duced by hyperabduction of the arms. Am Heart J 1 945;29( 1 ) . 30. Wright JS. Vascular diseases in clinical practice. 2nd ed. Chicago: Year Book, 1 952. 3 1 . McRae R. Clinical Orthopedic Examination. New York: Churchill Livingstone, 1 976. 32. Evans Re. Illustrated Essentials i n Orthopedic Physical Assessment. 2nd ed. St. Louis: Mosby 200 1 . 33. Landi A, Copeland S . Value o f the Tinel sign in brachial plexus lesions. Ann Roy Coli Surg Eng 1 979;6 1 :470-47 1 .

General References Cailliet R. Shoulder pain. Philadelphia: FA Davis, 1 966. Cipriano J. Calcific tendinitis vs. chronic bursitis in shoulder joint

pathology.

Today's

Chiropractic

1 986; 1 4 ( 4): 1 5- 1 6. Cyriax J. Textbook of Orthopaedic Medicine. Vol. 1 . Diagnosis o f Soft Tissue Lesions. London: Bailliere Tindall, 1 982. De Palma AF, Flannery GE Acute anterior disloca tions of the shoulder. J Sports Med Phys Fitness 1 973;1 :6- 1 5.

•

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROWGICAL TESTS

Kapandji IA. The Physiology of the Joints. Vol 1. Up per Limb. New York: Churchill Livingstone, 1 970.

Post M, Silver R, Singh M. Rotator cuff tear: diagno sis and treatment. Clin Orthop 1 983; 1 73:78.

Neviaser JS. Musculoskeletal disorders of the shoul

Yocum LA. Assessing the shoulder: history, physical

der region causing cervicobrachial pain: differential diagnosis and treatment. Surg Clin North Am 1 963;43: 1 703.

examination, differential diagnosis, special tests used. Clin Sports Med 1983;2:28 1 .

------��--ELBOW ORTHOPAEDIC TESTS

ELBOW ORT HOPAEDIC EXAMINATION

168

FLOW CHART

LATERAL EPICONDYLITIS (TENNIS ELBOW)

180 180

Cozen's Test

169

ELBOW PALPATION

169

Medial Aspect

MEDIAL EPICONDYLITIS (GOLFER'S

Medial Epicondyle and Attached

170

Tendons

ELBOW)

Ulnar Collateral Ligament

171

Lateral Epicondyle and Wrist Extensor

172

Tendons

Radial Collateral Ligament and Annular

173

Ligament

Olecranon Process and Bursa

175

Triceps Muscle

ELBOW R ANGE OF MOTION

Adduction Stress Test

185

Abduction Stress Test

187

174

SYNDROMES

185

188

T inel's Sign

188 189

Elbow Flexion Test

176

Cubital Fossa

LIGAMEN T OUS INST ABILIT Y

Wartenberg's Sign

176

Anterior Aspect

184

NEUROPATHYICOMPRESSION

174

Posterior Aspect

184

Golfer's Elbow Test

172

Lateral Aspect

Pinch Grip Test

190

191

177

177

Extension Supination Pronation

183

Kaplan's Sign

169

Ulnar Nerve

Flexion

182

Mill's Test

178 178 179

167

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

168

Elbow Orthopaedic Examination

�

History

Elbow pain with history of overuse

Elbow pain with history of trauma

Range of Motion (active) (passive)

Palpation

t+ Cozen's test Mili's test

+(+)

Elbow pain with no history of overuse

Range of Motion (active) (passive)

+(+)

Range of Motion (active) (passive)

I

t+

Palpation

t +)

I

Radiology

+(+)

Traumatic bursitis fracture

+

I (- , r -, )

Golfer's elbow test

I

+(+)

Medial epicondylitis

I

+(+) Neuritis/Neuroma

t

I

Adduction stress test Abduction stress test

I

t+ Ligamentous instability

-)

Nerve conduction studies

Rheumatoid arthritis

I (-)

(

t Tinel's sign Waterburg's sign Elbow flexion test Pinch grip test

+(+)

I

(

+(+)

+

Elbow pain with radiation to the hand

t

I

Radiology

Lateral epicondylitis

I

I

I I

CHAPTER 6

ELBOW ORTHOPAEDIC TESTS

169

ELBOW PALPATION Medial Aspect Ulnar Nerve DESCRlPTIVE ANATOMY The ulnar nerve is a branch of the medial cord of the brachial plexus. It passes in the groove between the medial epicondyle and the olecranon fossa (Fig.

6-1).

PROCEDURE With your index finger, palpate the groove between the medial epicondyle and the olecranon process. Notice whether the nerve is tender to palpation or thickened (Fig.

6-2).

This can indicate

nerve compression or scar tissue on the nerve leading to paresthesia into the forearm and/or loss of interosseous muscle strength.

Lateral cord

HWf��-==r-- Posterior cord v-Jf-\\----"-=1:-:-=:::;- Medial cord Humerus

Musculocutaneous nerve

Fossa olecrani Medial epicondyle

Radius --+-++HJI

Figure 6-'

Figure 6-2

}

. Brachial plexus

170

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Medial Epicondyle and Attached Tendons DESCRIPTIVE ANATOMY The medial epicondyle is a relatively large protuberance at the medial distal end of the humerus. At tached to the condyle are the wrist flexor and pronator group muscles. This group consists of the pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. All of these muscles originate from the medial epicondyle as a common tendon (Fig.

6-3).

PROCEDURE With the elbow flexed to

90°, palpate the epicondyle and its tendons with your index finger; look for 6-4). This may indicate a strain of one or

tenderness, inflammation, and temperature elevation (Fig.

more of the previously mentioned tendons or an inflammation of the medial epicondyle caused by various activities, such as golf or tennis.

--4--1--- Humerus Medial epicondyle

.�d:o--"'}�I--- Pronator teres m. '\\\-'-t--+-- Flexor carpi radialis -'lWl1--+--- Palmaris longus

�-+---- Flexor carpi ulnaris

Figure 6-3

Figure 6-4

CHAPTER 6

ELBOW ORTHOPAEDIC TESTS

17 1

Ulnar Collateral Ligament DESCRIPTIVE ANATOMY The ulnar collateral ligament attaches the medial epicondyle to the medial aspect of the ulna at the trochanteric notch (Fig.

6-5) and stabilizes the humeroulnar articulation medially.

PROCEDURE With your index finger, palpate the area of the ulnar collateral ligament (Fig.

6-6).

Ordinarily it is

not palpable. You should check for tenderness, which may indicate a sprain caused by forced valgus stress.

Medial View

Vi.

-(1I--Humerus Interosseous membrane

Annular ligament

Articular capsule

Ulnar collateral ligament

Figure 6-5

Figure 6-6

172

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Lateral Aspect Lateral Epicondyle and Wrist Extensor Tendons DESCRlPTIVE ANATOMY The lateral epicondyle is a relatively large protuberance at the lateral distal end of the humerus. At tached to the condyle is the common extensor tendon. From this tendon arise the carpi radialis bre vis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. The brachioradialis and extensor carpi radialis longus and brevis are attached superior to the lateral epicondyle at the supra condylar ridge (Fig.

6-7).

PROCEDURE With the patient's elbow flexed to

90°, palpate the lateral epicondyle and supracondylar ridge with 6-8). Note any tenderness, inflammation, and temperature ele

your index and middle fingers (Fig.

vation at either location. These signs may indicate an inflammation of the lateral epicondyle (epi condylitis) or a strain of the extensor tendons of the wrist.

��-r-Lateral epicondyle

Olecranon process

Brachioradialis

Common --�--�� exterior tendon group

A..JWI.-E -t--- xtensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum

DLJHiHtfljI/- E xtensor digiti minimi Extensor carpi ulnaris

Figure 6-7

Figure 6-8

CHAPTER 6

ELBOW ORTHOPAEDIC TESTS

173

Radial Collateral Ligament and Annular Ligament DESCRIPTIVE ANATOMY Radial collateral ligament and annular ligaments are thick structures that extend from the lateral epicondyle of the humerus to the annular ligament and lateral aspect of the ulnar. The annular lig ament encircles the radial head (Fig.

6-9). The radial collateral ligament stabilizes the humeroulnar

articulation laterally.

PROCEDURE With your index and middle fingers, palpate the area of the radial collateral ligament from the lat eral epicondyle to the annular ligament (Fig.

6-10).

Check for tenderness, which may indicate a

sprain caused by forced varus stress.

Lateral view

Humerus Annular ligament

A rticular ..,..--h---::1'-:l-i capsule

Radial collateral ligament Figure 6-9

Figure 6-10

Ulnar collateral ligament

Interosseous membrane

174

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Posterior Aspect Olecranon Process and Bursa DESCRIPTIVE ANATOMY The olecranon process is posterior to the elbow at the proximal end of the ulnar. It is covered by the olecranon bursa, which is not normally palpable (Fig.

6-11).

PROCEDURE With the patient's elbow flexed to

90°, palpate the olecranon process and bursa for tenderness, in 6-12). A thick, boggy feeling may indicate olecranon

flammation, and increased temperature (Fig.

bursitis. Check the posterior aspect of the olecranon border for rheumatoid nodules, which indicate rheumatoid arthritis.

--'K1r---'\;---- Humerus ---\+-

-',yt-�+-----lr-- Olecranon process

Olecranon bursa Figure 6-11

Figure 6-12

CHAPTER 6

ELBOW ORTHOPAEDlC TESTS

175

Triceps Muscle DESCRIPTIVE ANATOMY The triceps muscle has three heads; the long head crosses both the glenohumeral joint and the el bow joint, and it inserts into the olecranon process (Fig.

6-13).

PROCEDURE With the patient's elbow slightly flexed, have the patient lean on a table. This will facilitate the pal pation of the muscle. With your thumb and index finger, palpate the length of the muscle down to the olecranon process, looking for any tenderness or defects secondary to trauma (Fig.

6-14). This

may indicate a strain or active trigger points of the triceps muscle. A hard mass may indicate myosi tis ossificans secondary to repeated trauma.

!---;H--I--\-- Glenohumeral joint

/-t\---+- Long head

U\lMll-\H\Il-lr-t- Lateral

Triceps brachii muscle

head

Scapuli

/lIMa-+-- Medial head

Brachioradialis m. Medial--I---tt-. epicondyle of elbow joint

Extensor carpi radialis longus Extensor carpi radialis brevis Extensor digitorum

Flexor----11HHII carpi ulnaris

Figure 6-13

Extensor digiti minimi Extensor carpi ulnaris

Figure 6-14

176

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Anterior Aspect Cubital Fossa loCATION The cubital fossa is the triangular space bordered by the brachioradialis laterally and the pronator teres medially. The base is an imaginary line between the two epicondyles. The structures that pass between the fossa are the biceps tendon, brachial artery, median nerve, and musculocutaneous nerve (Fig.

6-15).

PROCEDURE With the patient's elbow slightly flexed and the patient resisting flexion, palpate the cubital fossa with your index finger, looking for the biceps tendon, which lies medial to the brachioradialis mus cle (Fig.

6-16). Tenderness may indicate a strain in the musculotendinous junction. A ruptured ten

don is not palpable in the fossa, and a bulbous gathering of muscle is evident in the upper arm.

Cubital fossa

CD

Median nerve

®

Brachial artery Lateral epicondyle

®

Musculocutaneous nerve

@

Biceps brachii tendon Medial epicondyle Pronator teres m.

Brachioradialis m.

Figure 6-15

Figure 6-16

CHAPTER 6

ELBOW ORTHOPAEDIC TESTS

177

ELBOW RANGE OF MOTION Flexion (1) With the patient seated, elbow extended, place the goniometer in the sagittal plane with the center at the elbow joint (Fig.

6-17). This is the neutral position for the elbow joint for flexion and exten

sion. Instruct the patient to flex the arm as far as possible while following the forearm with one arm of the goniometer (Fig.

6-18).

NORMAL RANGE Normal range is 1410

::t:: 4.90 or greater from the 0

Muscles

1. 2. 3. 4. 5.

or neutral position

(2).

Nerve Supply

Brachialis

Musculocutaneous

Biceps brachii

Musculocutaneous

Brachioradialis

Radial

Pronator teres

Median

Flexor carpi ulnaris

Ulnar

Figure 6-17

Figure 6-1 8

•

178

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Extension (1) With the elbow in full extension, place the goniometer in the sagittal plane with the center at the el bow joint. Instruct the patient to extend the elbow further while following the forearm with one arm of the goniometer (Fig.

6-19).

NORMAL RANGE Normal range is

0.3°

±

2.0° from full extension (2). Nerve Supply

Muscles

1. 2.

Triceps

Radial

Anconeus

Radial

Figure 6-19

Supination (1) With the patient's elbow in coronal plane (Fig.

90° of flexion and the thumb facing upward, place the goniometer in the 6-20). This is the neutral position for supination and pronation. Instruct the pa

tient to rotate the thumb outward while you follow the thumb with one arm of the goniometer (Fig.

6-21). NORMAL RANGE Normal range is

81° ± 4° or more from the 0

Muscles

1. 2.

or neutral position

Nerve Supply

Supinator

Radial

Biceps brachii

Musculocutaneous

Figure 6-20

Figure 6-21

(2).

CHAPTER 6

ELBOW ORTHOPAEDIC TESTS

179

Pronation (1) With the patient's elbow in

90° of flexion and the thumb facing upward, place the goniometer in the

coronal plane (Fig.

Instruct the patient to rotate the thumb inward while you follow the

6-22).

thumb with one arm of the goniometer (Fig.

6-23).

NORMAL RANGE Normal range is

75°

:::'::

6.3°

Muscles

1. 2. 3.

or greater from the

0 or

neutral position

(2).

Nerve Supply

Pronator quadratus

Median

Pronator teres

Median

Flexor carpi radialis

Median

II

Figure 6-22

Figure 6-23

180

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

LAT ERAL EPICONDYLITIS (T ENNIS ELBOW) CLINICAL DESCRIPTION Lateral epicondylitis is a repetitive injury of the common extensor tendon at the lateral epicondyle of the humerus. Repetitive actions include lifting, hammering, and tight gripping with repeated im pact during sports activities. This injury causes microtearing and microavulsion at the origin of the extensor carpi radialis tendon. Secondary inflammation develops at the epicondyle after this me chanical injury. Symptoms persist because of constant traction and movement of the wrist and hand.

CLINICAL SIGNS AND SYMPTOMS •

•

Local lateral elbow pain Weakness of the forearm

Cozen's Test (3)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient seated, stabilize the patient's forearm. Instruct the patient to make a fist and extend it (Fig.

6-24). Then force the extended wrist into flexion against resistance (Fig. 6-25).

Figure 6-24

CHAPTER 6

ELBOW ORTHOPAEDIC TESTS

181

RATIONALE The tendons that extend the wrist are attached to the lateral epicondyle (Fig.

6-26).

They are the ex

tensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris. If the condyle itself or the common extensor tendons that attach to it are inflamed, then forcing the extended wrist into flexion can reproduce irritation to the lateral epicondyle and its attaching ten dons. If pain is elicited at the lateral epicondyle, suspect inflammation of the lateral epicondyle (epi condylitis).

Posterior view

Common extensor tendon

Extensor digiti minimi

(b)

.J,...\\\-\W,\- I=xtem>or carpi ulnaris (c)

}

Common extensor tendon group

/� Figure 6-26

182

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Mill's Test (4)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I ,

I

2

I

3

I

4

With the patient seated, instruct the patient to pronate the arm and flex the wrist. Then instruct him or her to supinate the arm against resistance (Fig.

6-27).

RATIONALE The tendon of the supinator muscle, which supinates the wrist, is attached to the lateral epicondyle. If the condyle itself or the tendon of the supinator that attaches to the condyle is inflamed, resisting supination of the wrist may reproduce irritation to the lateral epicondyle and its attaching tendons. If pain is elicited at the lateral epicondyle, suspect inflammation of the lateral epicondyle (epi condylitis).

Figure 6-27

CHAPTER 6

ELBOW ORTHOPAEDIC TESTS

Kaplan's Sign (5)

183

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient in the seated position and the elbow slightly flexed, instruct the patient to grip a dynamometer and record the findings (Fig. patient's epicondyles (Fig.

6-28). Next, place a tennis elbow brace slightly below the 6-29). Again, instruct the patient to grip the dynamometer and record the

findings.

RATIONALE Gripping the dynamometer unsupported increases the traction on the common extensor tendon at the lateral epicondyles, which causes pain and produces weakness of the hand and forearm. When a support is placed distal to the epicondyle, pain is reduced and strength is increased because traction to the common extensor tendon is relieved.

SUGGESTED DIAGNOSTIC IMAGING Plajn film raruography AP elbow view Lateral elbow view

Figure 6-28

Figure 6-29

184

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

MEDIAL EPICONDYLITIS (GOLFER'S ELBOW) CLINICAL DESCRIPTION Medial epicondylitis is a repetitive injury of the common flexor tendon at the medial epicondyle of the humerus. Repetitive actions include lifting, hammering, and tight gripping with repetitive im pact during sports activities. This injury causes microtearing and microavulsion at the origin of the flexor carpi radialis tendon. Secondary inflammation develops at the epicondyle after this mechan ical injury. Symptoms persist due to constant traction and movement of the wrist and hand.

CLINICAL SIGNS AND SYMPTOMS •

•

Local medial elbow pain Weakness of the forearm

Golfer's Elbow Test (6)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

Tell the seated patient to extend the elbow and supinate the hand. Instruct the patient to flex the wrist against resistance (Fig.

6-30).

RATIONALE The tendons that flex the wrist, the flexor carpi radialis and flexor carpi ulnaris, are attached to the medial epicondyle (Fig.

6-31).

If the condyle itself or the common flexor tendons that attach to it

are inflamed, resisting wrist flexion may reproduce irritation to the medial epicondyle and its at taching tendons. If pain is elicited at the medial epicondyle, suspect inflammation of the medial epi condyle (epicondylitis).

Medial epicondyle

SUGGESTED DIAGNOSTIC IMAGING

-4-+-- Humerus

Plain film radiography

AP elbow view Lateral elbow view

�O!C--7f--+- Pronator teres m WH-+-- Flexor carpi radialis r\'iIl--t-- Palmaris longus

Flexor carpi ulnaris

Figure 6-30

Figure 6-31

CHAPTER 6

185

ELBOW ORTHOPAEDIC TESTS

LIGA MENTOUS INSTABILITY CLINICAL DESCRIPTION Ligamentous instability at the elbow is relatively uncommon. The radial collateral ligament at the lat eral aspect of the elbow and the ulnar collateral ligament at the medial aspect of the elbow are af fected. This injury may be due to forced elbow hyperextension, forced abduction of the extended arm, or forced adduction of the extended arm. Forced adduction of the extended arm will damage the ra clial collateral ligament. Forced abduction of the extended arm will damage the ulnar collateral liga ment. Severe instability may include an avulsion fracture or a complete dislocation of the elbow.

CLINICAL SIGNS AND SYMPTOMS •

•

Medial or lateral elbow pain Local swelling

Adduction Stress Test (7)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I 2

I

I

3

I

I

4

With the patient sitting, stabilize the medial arm and place adduction pressure on the patient's lat eral forearm (Fig.

6-32).

RATIONALE Placing adduction pressure on the lateral forearm applies stress to the radial collateral ligament (Fig.

6-33). Gapping and pain indicate radial collateral ligament instability.

Figure 6-32

186

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Ulnar collateral ligament

-+-f-Ulna

Lateral view

Figure 6-33

CHAPTER 6

Abduction Stress Test (7)

Sensitivity/Reliability Scale

I

o

PROCEDURE

187

ELBOW ORTHOPAEDIC TESTS

I

I 1

I

I

2

I

I

3

I

I

4

With the patient sitting, stabilize the lateral arm and place abduction pressure on the medial fore arm (Fig.

6-34).

RATIONALE Placing an abduction pressure on the medial forearm applies stress to the ulnar collateral ligament. Gapping and pain indicate ulnar collateral ligament instability.

SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiography AP elbow view Lateral elbow view

•

•

Computed tomography Magnetic resonance imaging

Figure 6-34

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

188

NEUROPATHY/COMPR ESSION SYNDROMES CUNCAL DESCRIPTION Neuropathy and compression syndromes of the elbow are peripheral neurological disorders caused by trauma, overuse, arthritis, or postural considerations. These disorders may cause paresthesia and weakness to the forearm and/or hand. The nerve most affected is the ulnar nerve. The sites of com pression or entrapment may include the groove between the olecranon process and medial epi condyle or the cubital tunnel (Fig.

6-35).

CLINICAL SIGNS AND SYMPTOMS Forearm and/or hand paresthesia

•

Forearm and/or hand weakness

•

Tinel's Sign (8)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient seated, tap the ulnar nerve in the groove between the olecranon process and the medial epicondyle with a neurological reflex hammer (Fig.

6-36).

The ulnar nerve passes in this

groove.

RATIONALE This test is designed to elicit pain caused by a neuritis or neuroma of the ulnar nerve. Pain indicates a positive test. The nerve can become damaged in the following ways:

1. 2. 3. 4.

Excessive use or repetitive injuries or trauma of the elbow Arthritis of the elbow joint Cubital tunnel compression, between the heads of the flexor carpi ulnaris muscle Postural habits that compress the nerve, such as sleeping with elbows flexed and hands un der head

5.

Recurrent nerve subluxations or dislocations

Medial epicondyle

Cubital tunnel

Ulnar nerve Olecranon process

Figure 6-35

Figure 6-36

CHAPTER 6

189

ELBOW ORTHOPAEDIC TESTS

Wartenberg's Sign (9)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Instruct the seated patient to place the hand on the table. Passively spread the patient's fingers (Fig.

6-37). Instruct the patient

to bring the fingers together (Fig.

6-38).

RATIONALE The ulnar nerve controls abduction of the fingers. Inability to abduct the little finger to the rest of the hand indicates ulnar nerve neuritis (Fig.

6-39).

Figure 6-38

Figure 6-37

Figure 6-39

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

190

Elbow Flexion Test (10)

Sensitivity/Reliability Scale

I

o

PROCEDURE Instruct the seated patient to flex the elbow completely for

5

minutes (Fig.

I 1

I

2

I

3

I

4

6-40).

RATIONALE Flexion of the elbow may compress the ulnar nerve in the cubital tunnel. Paresthesia along the me dial aspect of the forearm and hand may indicate compression of the ulnar nerve in the cubital tun nel (cubital tunnel syndrome) (Fig.

6-41).

It can also be trapped between the heads of the flexor

carpi ulnaris or by scar tissue in the ulnar groove.

Figure 6-40

Sites of Ulnar Nerve Compression

Two heads of FCU (flexor carpi ulnaris) Figure 6-41

nerve tunnel

process

Ligament of Struthers

CHAPTER 6

191

ELBOW ORTHOPAEDIC TESTS

Pinch Grip Test (11)

Sensitivity/Reliability Scale

I

I

1

PROCEDURE Instruct the patient to pinch the tips of the index finger and thumb together (Fig.

I

2

I

3

I

6-42).

RATIONALE Normally the pinch is tip to tip. The test is positive if the pulps of the thumb and index finger touch (Fig.

6-43). This result is caused by an injury to the anterior interosseous nerve,

which is a branch

of the median nerve. It may also indicate an entrapment syndrome of the anterior osseous nerve be tween the two heads of the pronator teres muscle (Fig.

6-44).

SUGGESTED DIAGNOSTIC AND FUNCTIONAL TESTING •

Electrodiagnostic studies

Humerus ---\----fl-J'--

Entrapped nerve

Heads of pronator teres m.

��t----i��

Figure 6-42

Radius --+----f-'-

Ulna

Figure 6-44 Figure 6-43

--t----,HH-.��'If'+-.r

192

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

References 1. American Academy of Orthopaedic Surgeons. The Clinical Measurement of Joint Motion. Chicago: American Academy of Orthopaedic Surgeons, 1994. 2. Boone DC, Azen SP. Normal range of motion in male subjects. J Bone Joint Surg 1979;61A: 756-759. 3. Lucas GL. Examination of the Hand. Spring field, IL: Charles C. Thomas, 1972. 4. Mills GP. The treatment of tennis elbow. Br Med J 1928;1:12-13. 5. Kaplan EB. Treatment of tennis elbow by dener vation. J Bone Joint Surg 1959;41A:147. 6. McRae R. Clinical Orthopedic Examination. New York: Churchill Livingstone, 1976;41. 7. Hoppenfeld S. Physical examination of the spine and extremities. New York: Appleton Century-Crofts, 1976;127. 8. Tinel J. Nerve wounds; symptomatology of pe ripheral nerve lesions caused by war wounds. Joll CA, ed, Rothwell F, trans. New York: W illiam Wood, 1918. 9. Volz RC, Morrey BF. The physical examination of the elbow. In: Morrey BF, ed. The Elbow and Its Disorder. Philadelphia: WB Saunders, 1986. 10. Magee DJ. Orthopedic Physical Assessment. 2nd ed. Philadelphia: WB Saunders, 1992. 11. W iens E, Lane S. The anterior interosseous nerve syndrome. Can J Surg 1978;21:354.

General References Boyd HB. Tennis elbow. J Bone Joint Surg Am 1973;55:1183-1187. Cyriax J. Pathology and treatment of tennis elbow. J Bone Joint Surg 1936;18:921. Cyriax J. Textbook of Orthopaedic Medicine. Vol 1. Diagnosis of soft tissue lesions. London: Bailliere Tindall, 1982. Kapandji IA. The physiology of the Joints. Vol 1. Up per Limb. New York: Churchill Livingstone, 1970. McKee GK. Tennis elbow. Br Med J 1937;2:434. MenneU JM. Joint Pain. Boston: Little, Brown, 1964. Nagler W, Johnson E, Gardner R. The pain of tennis elbow. Current Concepts Pain Analg, 1986. Nirschl R, Pettrone F. Tennis elbow. J Bone Joint Surg 1979;61A(6):836. Post M. Physical examination of the musculoskele tal system. Chicago: Year Book, 1987. Roles NC, Maudsley RH. Radial tunnel syndrome: resistant tennis elbow as a nerve entrapment. J Bone Joint Surg Br 1972;54:499.

--------�rn�-WRIST ORTHOPAEDIC TESTS

WRIST OR T HOPAEDIC EXAMINATION

194

FLOW CHAR T

Carpal Compression Test

195

Carpal Tunnel

196

Guyon's Canal

197

R adial and Ulnar Arteries

Pinch Test

198

208

209

Tourniquet Test

199

Posterior Aspect

207

R everse Phalen's Test

195

Flexor Tendons

206

Phalen's Test

195

205

205

T inel's Wrist Sign

WRIST PALPATION Anterior Aspect

CARPAL TUNNEL SYNDROME

209

ULNAR TUNNEL SYNDROME

210

210

Ulnar Tunnel Triad

Ulnar Styloid P rocess and R adial Tubercle

199

Extensor Tendons

STENOSING T ENOSYNOVITIS

200

WRIST R ANGE OF MOTION Flexion Extension

201

R adial Deviation

201

211

CARPAL INSTABILIT Y

212

Lunatotriquetral B allottement

202

Ulnar Deviation

Finkelstein's Test

•

211

Test

203

212

Watson's Test

213

204

193

194

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Wrist Orthopaedic Examination

�

History

Wrist pain with history of overuse

I

Wrist pain with history of trauma

Range of Motion (active) (passive)

t(+)

Range of Motion (active) (passive)

Lunatotriquetral ballottement test Watson test

t(+)

Nerve conduction studies

(+)

I

I

I

(-)

Ulnar tunnel triad

J

(+) Nerve conduction studies

(+)

Ulnar tunnel syndrome

I

Radiology

I

Rheumatoid arthritis Degenerative joint disease Fracture dislocation

Carpal instability

Tinel's wrist sign Phalen's test Reverse Phalen's test Tourniquet test Pinch test

-\

)

J(+)

( +)

(+)

Compression neuropathies

(-

I

(-)

I

L

t Finkelstein's test

l

1(+)

Stenosing tenosynovitis

J

I

CHAPTER 7

WRIST ORTHOPAEDIC TESTS

195

WRIST PALPATION Anterior Aspect

Flexor Tendons DESCRIPTIVE ANATOMY Six wrist and digit flexor tendons cross the wrist (Fig.

7-1):

Flexor carpi ulnaris Palmaris longus Flexor digitorum profundus Flexor digitorum superficialis Flexor pollicis longus Flexor carpi radialis

PROCEDURE Palpate each tendon just proximal to the flexor retinaculum, noting any tenderness or calcific de posits (Fig.

7-2). Tenderness may indicate tenosynovitis of the suspected flexor tendon.

•

NOTE Small pealike swelling may appear at the anterior or posterior aspect of the wrist. These ganglia are benign tenosynovial tumors and are usually symptom free but may become tender and painful when distended.

{

Median duo

Radial trio

{

palmaris longus tendon

--==:��S;;

Median nerve -

��

rad

Flexor digitorum superficialis tendons

��#I��- Flexor digitorum profundus tendons

Radial artery

UI

Flexor pollicus longus tendon in radial brevis

UI

Palmar carpal ligament Pronator quadratus muscle Figure 7-'

Figure 7-2

�:��

'

Flexor carpi

}

ulnaris tendon

Ulna Radius

Ulnar trio

}

196

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Carpal Tunnel DESCRIPTIVE ANATOMY The carpal tunnel is deep to the palmaris longus at the anterior surface of the wrist. It is bound by the pisiform and the hook of the hamate medially, the tubercle of the scaphoid and tubercle of the trapezium laterally, the flexor retinaculum anteriorly, and the carpal bones posteriorly (Fig.

7-3). In

side the tunnel lie the median nerve and the finger flexor tendons from the forearm to the hand. This tunnel is a common site of compression neuropathy.

PROCEDURE The actual tunnel and structures within the tunnel are not palpable. The borders of the tunnel should be palpated for deformity and/or tenderness (Fig.

7-4). The area over the tunnel should be

palpated for increase in symptoms, such as numbness, tingling, pain, and weakness in the hand. These symptoms may indicate carpal tunnel syndrome. Compression

•• } (9) Flexor tendons

Flexor

Median nerve

Carpal ligament

Figure 7-3

Figure 7-4

Pass through carpal tunnel

CHAPTER 7

WRIST ORTHOPAEDIC TESTS

197

Guyon's Canal (Ulnar Tunnel) DESCRIPTIVE ANATOMY The tunnel, or canal, of Guyon is between the pisiform and the hook of the hamate. It contains the ulnar nerve and artery (Fig.

7-5). It is also a common site of compression neuropathy.

PROCEDURE The ulnar artery and nerve are not palpable in the tunnel. Palpating over the tunnel may increase tenderness to the area and the symptoms to the ulnar distribution of the hand (Fig.

•

Palmar carpal ligament

7-6).

Palmar carpal ligament

&I

•

Ulnar n.

•

Ulnar artery

Palmaris longus tendon

Radius Figure 7-5

Figure 7-6

198

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Radial and Ulnar Arteries DESCRIPTIVE ANATOMY The radial and ulnar arteries are the two branches of the brachial artery that supply the hand with blood flow. The radial artery lies lateral at the anterior lateral aspect of the wrist, and the ulnar ar tery is at the anterior medial aspect of the wrist (Fig.

7-7).

PROCEDURE Palpate each artery individually and determine the amplitude of both pulses bilaterally (Figs. and

7-8 7-9). A decrease in amplitude may indicate a compression of the respective artery between the

elbow and the wrist if the brachial artery is palpated and not compromised. A common site of com pression of the ulnar artery is the tunnel of Guyon.

Radial--f-+Wf7 artery'

Ulnar artery'

Figure 7-7

Figure 7-8

Figure 7-9

CHAPTER 7

WRIST ORTHOPAEDIC TESTS

199

Posterior Aspect

Ulnar Styloid Process and Radial Tubercle DESCRIPTIVE ANATOMY The ulnar styloid process is at the posterior aspect of the wrist proximal to the fifth digit. The radial tubercle is at the posterior aspect of the wrist proximal to the thumb (Fig.

7-10).

PROCEDURE Palpate the ulnar styloid process and radial tubercle for tenderness, pain, swelling, or deformity (Figs.

7-11 and 7-12). Pain at the radial tubercle following trauma may indicate a fracture, such as

Colles', a fracture of the distal radius with dorsal angulation. Pain at the ulnar styloid may be asso ciated with a distal ulnar fracture. Tenderness, swelling, or deformity at either site may indicate rheumatoid arthritis.

• Fifth digit

Ulnar 1¥��r->-4--f� styloid process

Figure 7-10

Figure 7-11

Figure 7-12

200

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Extensor Tendons DESCRIPTIVE ANATOMY There are six fibro-osseous tunnels at the posterior aspect of the wrist. The extensor tendons to the hand pass through these tunnels, which are bound by the extensor retinaculum superficially and are lined with a synovial sheath. From the thumb laterally, these are the tunnels and their respective ten dons (Fig.

7-13):

Tunnell

Adductor pollicis longus, extensor pollicis brevis

Tunnel 2

Extensor carpi radialis longus and brevis

Tunnel 3

Extensor pollicis longus

Tunnel 4

Extensor digitorum and extensor indexes

TunnelS

Extensor digiti minimi

Tunnel

Extensor carpi ulnaris

6

PROCEDURE Support the patient's hand with your fingers while palpating the wrist with both your thumbs (Fig.

7-14). Note any crepitus or restriction of movement. Crepitus may indicate tenosynovitis of one of the extensor tendons.

NOTE A small pealike swelling may appear at the anterior or posterior aspect of the wrist. These are be nign tenosynovial tumors and are usually symptom free but may become tender and painful when distended.

CD

{

®

{

®

Extensor carpi radialis brevis

Extensor pollicus longus

@

Extensor digitorum and extensor indicis

Extensor carpi radialis longus

®

Extensor digiti

Extensor pollicus brevis

®

Adductor pollicus longus

Extensor carpi ulnaris Radius

Figure 7-13

Figure 7-14

Ulna

CHAPTER 7

WRIST ORTHOPAEDIC TESTS

201

Wrist Range of Motion

Flexion (1) With the patient's wrist in the neutral position, place the goniometer in the sagittal plane with the center at the ulnar styloid process (Fig.

7-15). Instruct the patient to flex the wrist downward, and 7-16).

follow the hand with one arm of the goniometer (Fig.

NORMAL RANGE Normal range is 75 ::!::

7.60 or greater from the 0 or neutral position (2).

Muscles

Nerve Supply

Flexor carpi radialis

Median

Flexor carpi ulnaris

Ulnar

Figure 7-15

Figure 7-16

202

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Extension (1) With the patient's wrist in the neutral position, place the goniometer in the sagittal plane with the center at the ulnar styloid process (Fig.

7-17). Instruct the patient to extend the wrist backward while 7-18).

you follow the hand with one arm of the goniometer (Fig.

NORMAL RANGE Normal range is

74 ± 7.60 or greater from the 0 or neutral position (2).

Muscles

Nerve Supply

Extensor carpi radialis longus

Radial

Extensor carpi radialis brevis

Radial

Extensor carpi ulnaris

Radial

Figure 7-17

Figure 7-18

CHAPTER 7

WRJST ORTHOPAEDIC TESTS

203

Ulnar Deviation (1) With the patient's wrist in the neutral position and the hand supinated, place the goniometer in the coronal plane with the center at the radial-ulnar junction (Fig.

7-19). Instruct the patient to deviate 7-20).

the wrist medially, and follow the hand with one arm of the goniometer (Fig.

NORMAL RANGE Normal range is 35 :±: 3.80 or greater from the

Muscles

Nerve Supply

Flexor carpi ulnaris

Ulnar

Extensor carpi ulnaris

Radial

0 or neutral position (2).

•

Figure 7-19

Figure 7-20

204

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Radial Deviation (1) With the patient's wrist in the neutral position and the hand supinated, place the goniometer in the coronal plane with the center at the radial-ulnar junction (Fig.

7-21). Instruct the patient to deviate 7-22).

the wrist laterally, and follow the hand with one arm of the goniometer (Fig.

Normal Range Normal range is 21

± 4° or greater from the 0 or neutral position (2). Nerve Supply

Muscles Extensor carpi radialis

Median

Extensor carpi radialis longus

Radial

Abductor pollicis longus

Radial

Extensor pollicis brevis

Radial

Figure 7-21

Figure 7-22

CHAPTER 7

WRIST ORTHOPAEDIC TESTS

205

CARPAL TUNNEL SYNDROME DESCRIPTION Carpal tunnel syndrome is a compression neuropathy of the median nerve. Compression occurs un der the flexor retinaculum at the wrist. The stage of the condition from sensory loss to motor loss with atrophy correlates directly with a degree of compression and the chronicity of the symptoms. Most cases present at an early stage with intermittent sensory symptoms only.

CLINICAl SIGNS AND SYMPTOMS •

•

•

Loss of sensation of the tips of the first three fingers Hand and wrist pain Weakness of grip

Tinel's Wrist Sign (3)

Sensitivity/Reliability Scale

I

I

o

PROCEDURE

I 1

I

I 2

I

I

3

I

I

4

With the patient's hand supinated, stabilize the wrist with one hand. With your opposite hand, tap the palmar surface of the wrist with a neurological reflex hammer (Fig. 7-23).

RATIONAlE Tingling in the hand along the distribution of the median nerve (thumb, index finger, middle fin ger, and medial half of the ring finger) indicates carpal tunnel syndrome, a compression of the me dian nerve by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons (see Fig. 7-25).

Figure 7-23

206

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Phalen's Test (4,5)

Sensitivity/Reliability Scale

I

o

I 1

I

2

I

3

I

4

PROCEDURE Flex both wrists and approximate them to each other. Hold for

60 seconds (Fig. 7-24).

RATIONALE When both wrists are flexed, the flexor retinaculum provides increased compression of the medial nerve in the carpal tunnel. Tingling in the hand along the distribution of the median nerve (thumb, index finger, middle finger, and medial half of the ring finger) indicates compression of the median nerve in the carpal tunnel (Fig.

7-25) by inflammation of the flexor retinaculum, anterior disloca

tion of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons. Figure

Figure

7-24

7-25

��I-H--r- Tendons -\!--;Me! ;.>--!ffi+-- OIEIn nerve Pressured area Flexor retinaculum

Synovial sheath

Compressed nerve

Test for carpal tunnel syndrome

CHAPTER 7

Reverse Phalen's Test (6)

207

WRIST ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

I 1

I

2

I

3

I

I

4

PROCEDURE Instruct the patient to extend the affected wrist and have the patient grip your hand. With your op posite thumb, press on the carpal tunnel (Fig. 7-26).

RATIONALE Extending the hand and applying pressure to the carpal tunnel further constricts the tunnel. Tin gling in the thumb, index finger, and lateral half of the ring finger may indicate compression of the medial nerve in the carpal tunnel by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

IfJI

Figure 7-26

208

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Carpal Compression Test (7) PROCEDURE

Sensitivity/Reliability Scale

I

I

I 1

I

I

2

I

I

3

I

I

4

With the patient's wrist and hand extended, grasp the patient's wrist with both hands and place di rect pressure with both thumbs over the median nerve in the carpal tunnel for up to 30 seconds (Fig.

7-27). RATIONALE Placing a mechanical pressure over the carpal tunnel increases pressure to the median nerve. Tin gling in the hand along the distribution of the median nerve (thumb, index finger, middle finger, and medial half of the ring finger), indicates compression of the median nerve in the carpal tunnel by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

Figure

7-27

CHAPTER 7

Tourniquet Test (8)

209

WRIST ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

I

3

I

Wrap a sphygmomanometer cuff around the affected wrist and inflate it to just above the patient's systolic blood pressure. Hold for

1 to 2 minutes (Fig. 7-28).

RATIONALE The inflated sphygmomanometer cuff induces mechanically increased pressure to the median nerve. Tingling in the hand along the distribution of the median nerve (thumb, index finger, middle fin ger, and medial half of the ring finger) indicates compression of the median nerve in the carpal tun nel by inflammation of the flexor retinaculum, anterior dislocation of the lunate bone, arthritic changes, or tenosynovitis of the flexor digitorum tendons.

•

Figure 7-28

Pinch Test (9)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

I 4

Instruct the patient to pinch a piece of paper between the thumb, index, and middle fingers while you attempt to pull it away (Fig.

7-29).

RATIONALE The median nerve innervates the lumbrical muscles, which are used to pinch the piece of paper. With compression of the median nerve, the patient may have numbness and/or cramping of the fin gers or mid palm region within

1 minute.

SUGGESTED DIAGNOSTIC AND FUNCTIONAL TESTING •

•

Magnetic resonance imaging Electromyography

Figure 7-29

210

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

ULNAR TUNNEL SYNDROME DESCRIPTION The ulnar nerve travels through the tunnel of Guyon and innervates the muscles to the little and ring fingers. Ulnar tunnel syndrome is a compression neuropathy of the ulnar nerve. Compression oc curs at the tunnel of Guyon at the wrist (see Fig.

7-5). The stage of the condition from sensory loss

to motor loss with atrophy correlates directly with a degree of compression and the chronicity of the symptoms. Most cases present at an early stage with intermittent sensory symptoms only.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Pain over the little and ring finger Weakness of grip Difficulty with finger spreading Claw hand

Ulnar Tunnel Triad PROCEDURE Inspect and palpate the patient's wrist, looking for tenderness over the ulnar tunnel, clawing of the ring finger, and hypothenar wasting (Fig.

7-30).

RATIONALE All three of these signs are indicative of ulnar nerve compression possibly in the tunnel of Guyon.

SUGGESTED DIAGNOSTIC AND FUNCTIONAl TESTING •

•

Magnetic resonance imaging Electromyography

Figure 7-30

CHAPTER 7

WRIST ORTHOPAEDIC TESTS

211

STENOSING TENOSYNOVITIS DESCRIPTION Stenosing tenosynovitis in the wrist affects the tendon and sheath of the abductor pollicis longus and the extensor pollicis brevis (Fig.

7-31). It is also termed de Quervain's or Hoffman's disease.

Swelling of the tendons and thickening of the sheaths that the tendons pass through, is due to an overuse condition of the wrist and thumb.

CLINICAl SIGNS AND SYMPTOMS •

•

•

Painful wrist and thumb during movement Swelling over the radial styloid Tendons and sheath tender to palpation

Metacarpal I

•

Extensor pollicus brevis tendon Figure 7-31

Finkelstein's Test (10)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

I

2

Instruct the patient to make a fist with the thumb across the palmar surface of the hand (Fig. and to stress the wrist medially (Fig.

I

3

I

I

4

7-32)

7-33).

RATIONALE Making a fist and stressing it medially stress the abductor pollicis longus and extensor pollicis bre vis tendons. Pain distal to the styloid process of the radius indicates stenosing tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons (de Quervain's disease).

SUGGESTED DIAGNOSTIC IMAGING •

•

Magnetic resonance imaging CT arthrography

Figure 7-32

Figure 7-33

212

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

CARPAL INSTABILITY DESCRIPTION Carpal instability or the propensity for carpal bone dislocation or fracture is due to trauma, overuse injury, or rheumatoid arthritis. The ligaments of the wrist permit little movement of the intercarpal joints. Trauma may sprain the ligaments, which may subluxate one or more of the carpal bones. Se vere trauma may cause an incomplete fracture or chondral fracture. Rheumatoid arthritis may cause weakening of the intercarpal ligaments, permitting the propensity for dislocation or subluxation of the one or more of the carpal bones.

CLINICAL SIGNS AND SYMPTOMS •

•

•

Wrist pain Apprehension on movement Crepitus on Movement

Lunatotriquetral Ballottement Test (11)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

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2

I

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3

I

I

4

With one hand, grasp the triquetrum on the affected side with your thumb and index finger. With your opposite hand, grasp the lunate, also with the thumb and index finger (Fig.

7-34). Move the lu

nate anteriorly and posteriorly, noting any pain, laxity, or crepitus.

RATIONALE The lunate and triquetrum are held together by a fibrous articular capsule and by dorsal, palmar, and interosseous ligaments. The lunate is the most commonly dislocated of the carpal bones. Most of the time it dislocates anteriorly and affects the radiolunate and the ligaments between the lunate and the triquetrum. Pain, laxity, or crepitus indicates instability of the lunatotriquetral articulation, causing a propensity of the lunate to subluxate or dislocate. This instability may lead to carpal tun nel syndrome, medial nerve palsy, flexor tendon constriction, or progressive avascular necrosis of the lunate.

Figure 7-34

CHAPTER 7

Watson's Test (11)

213

WRIST ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With one hand, stabilize the radius and the ulna. With the opposite hand, grasp the scaphoid, mov ing it anteriorly and posteriorly (Fig.

7-35).

RATIONALE The scaphoid is prone to subluxate or dislocate with hyperextension trauma. Pain, laxity, or crepi tus indicates an instability of the scaphoid with propensity to subluxate or dislocate.

SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiography AP wrist view Lateral wrist view Scaphoid view Clenched fist view

•

Figure

7-35

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

214

General References

References 1. American Academy of Orthopaedic Surgeons.

de Quervain F. Clinical surgical diagnosis for stu

The Clinical Measurement of Joint Motion.

dents and practitioners. 4th ed. Snowman J, trans.

Chicago: American Academy of Orthopaedic

New York: William Wood, 1913.

Surgeons, 1994. 2. Boone DC, Azen SP. Normal range of motion in male subjects. J Bone Joint Surg 1979;61A: 756-759. 3. Tinel J. Nerve Wounds: Symptomatology of Pe

Ditmars OM, Houin HP. Carpal tunnel syndrome. Hand Clin 1986;2:525-532. Green DP. Carpal dislocations. In: Operative Hand Surgery. New York: Churchill Livingstone, 1982.

ripheral Nerve Lesions Caused by War Wounds.

Hoppenfeld S. Physical Examination of the Spine

Jol! CA, ed, Rothwell F, trans. New York:

and Extremities.

W illiam Wood, 1918.

Crofts, 1976;127.

4. Phalen GS. The carpal tunnel syndrome: 17 years experience in diagnosis and treatment of 654

hands.

J

Bone

Joint

Surg

1966;48A:

211-228. 5. American Society for Surgery of the Hand. The Hand: Examination and Diagnosis. Aurora, CO, 1978. 6. Post M. Physical examination of the muscu loskeletal system. Chicago: Year Book, 1987. 7. Durken JA. A new diagnostic test for carpal tun nel syndrome. J Bone Joint Surg AmI991;73: 535-538. 8. McRae R. Clinical Orthopedic Examination. New York: Churchill Livingstone, 1977. 9. Ditmars OM, Houin HP. Carpal tunnel syn drome. Hand Clin 1986;2:723-737. 10. F inkelstein H. Stenosing tenosynovitis at the ra dial

styloid

process.

J

Bone

Joint

Surg

1930;12:509. 11. Taleisnik J. Carpal instability. J Bone Joint Surg 1988;70A:1262-1268.

New York: Appleton-Century

Kapandji lA. The Physiology of the Joints. Vol. l. Upper Limb. New York: Churchill Livingstone, 1970. Stevenson TM. Carpal tunnel syndrome. Proc R Soc Med 1966;59:824. Thompson WAL, Koppel! HP. Peripheral entrap ment neuropathies of the upper extremities. N Engl J Med 1959;260:1261. Wadsworth CT. Wrist and hand examination and interpretation. J Orthop Sports Phys Ther 1983; 5:108.

------�oo�--HAND ORTHOPAEDIC TESTS

HAND PALPATION Anterior Aspect

216 216 216

T henar Eminence

Hypothenar Eminence Posterior Aspect

JOINT CAPSULE T ESTS

222

Bunnel-Littler Test

222

Test For T ight Retinacular Ligaments

217

223

218

Extensor Tendons

TENDON INSTABILITY

218

Metacarpals and Phalanges

219

Profundus Test

224

224

Flexor and Extensor Pollicis Longus JOINT INSTABILITY

Test

220

Varus and Valgus Stress Test

220

Thumb Ulnar Collateral Ligament Laxity Test

225

Extensor Digitorum Communis Test

226

221

215

216

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

HAND PALPATION Anterior Aspect Thenar Eminence DESCRIPTIVE ANATOMY

The thenar eminence lies at the lateral aspect of the hand with the palm facing out. It comprises three muscles that move the thumb: abductor pollicis brevis, opponens pollicis, and flexor pollicis brevis. These muscles are innervated by a branch of the recurrent median nerve (Fig. 8-1). Severe, prolonged compression of the median nerve in the carpal tunnel may cause the muscles of the thenar eminence to atrophy. PROCEDURE

Palpate the thenar eminence from the base of the thumb medial to the central aspect of the hand at the base of the carpal bones, then inferior and lateral to the base of the forefinger (Fig. 8-2). Look for hypertrophy or atrophy in comparison with the opposite hand. If atrophy or wasting is accom panied by pain and paresthesia along the medial nerve distribution, suspect compression of the me dial nerve in the carpal tunnel.

Muscles of thenar eminence: Hypothenar eminence: Opponens digiti minimi

Flexor pollicis brevis m. Opponens poliicis m. Abductor poliicis brevis m.

Flexor digitorum minimi Abductor digiti minimi m.

Pisifom

Figure 8-1

Figure 8-2

rrent median nerve

CHAPTER 8

HAND ORTHOPAEDIC TESTS

217

Hypothenar Eminence DESCRIPTIVE ANATOMY

The hypothenar eminence lies at the anterior aspect of the hand from the base of the little finger to the medial aspect of the hand, ending at the pisiform (Fig. 8-1). This eminence contains the abduc tor digiti minimi, opponens digiti minimi, and flexor digiti minimi. These muscles are supplied by the deep branch of the ulnar nerve. Severe, prolonged compression of the nerve either in Guyon's tunnel or more proximally in the extremity may cause wasting of the hypothenar eminence. PROCEDURE

Palpate the length of the thenar eminence from the base of the little finger to the base of the pisi form (Fig. 8-3). Look for hypertrophy or atrophy in comparison with the opposite hand. Wasting of the hypothenar eminence may indicate a compression of the ulnar nerve either in the tunnel of Guyon or more proximally in the extremity.

Figure 8-3

218

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Posterior Aspect Extensor Tendons DESCRIPTIVE ANATOMY

The posterior aspect of the hand contains an intricate system of ligaments, fascial bands, and tendons-the extensor mechanism. This mechanism provides active extension to the fingers and contributes to the stabilization of the hand and digits. The extrinsic extensor tendons run along the entire length of the posterior aspect of the hand to each digit (Fig. 8-4). The tendons can be affected by trauma, which can strain or rupture them, and by rheumatoid arthritis, which can displace them. PROCEDURE

With the patient's fingers and wrists extended, palpate the length of each tendon of the extensor dig ito rum communis from the base of the wrist to the proximal phalanx (Fig. 8-5). Note any tender ness, cysts, displacement, or loss of continuity of any of the individual tendons. Tenderness and dis placement indicate rheumatoid arthritis. Loss of continuity secondary to trauma with loss of digit extension may indicate a ruptured extensor tendon. Small, easily palpable pealike cysts may develop between the second and third metacarpal bones.

Extensors of Thumb: Abductor pullicis longus Extensor pullicis brevis Extensor pullicis longus Extensor radius tendon

Figure 8-4

Figure 8-5

CHAPTER 8

HAND ORTHOPAEDIC TESTS

219

Metacarpals and Phalanges DESCRIPTIVE ANATOMY

The metacarpal bones and phalanges are held together by a series of ligaments and joint capsules that supply stability to the joints (Fig. 8-6). The metacarpal and phalangeal bones are easily palpa ble from the posterior aspect of the hand. They are susceptible to traumatic fractures. The joints may become inflamed and are a common site for rheumatoid arthritis. PROCEDURE

Palpate each individual digit and metacarpal bone (Fig. 8-7). Look for tenderness, swelling, temper ature differences, and bony nodules. Tenderness and swelling following trauma may indicate a frac ture. Swelling around a joint capsule may indicate an inflammatory process, such as rheumatoid arthritis. Bony nodules (Heberden's nodes) on the posterior and lateral surfaces of the distal inter phalangeal joints may indicate osteoarthritis.

Distal Phalanges

{ {

Middle Phalanges

Proximal phalanges

Deep transverse metacarpal ligaments

{

Metacarpal bones -!-----"'
Carpal bones

{

Figure 8-6

Figure 8-7

f(t/!!1R-+--Joint capsule

220

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

JOINT INSTABILITY DESCRIPTION

The interphalangeal joints are the most common site of joint injuries to the hand. The injuries range from simple sprain to partial collateral ligament injury to dislocation to fracture-dislocation. Joint stability is maintained by the collateral ligaments in combination with the volar plate, which pro duces a three-sided box around the joints (Fig. 8-8). The most commonly affected joints are the in dex and little finger. Joint instability is usually due to dislocation. CLINICAL SIGNS AND SYMPTOMS •

•

•

Joint pain Joint swelling Joint deformity

Varus and Valgus Stress Test (1)

Sensitivity/Reliability Scale

I o

PROCEDURE

I

I 1

I

I 2

I

I

I

I

3

With a pinch grip, grasp the joint (either a distal or proximal interphalangeal joint) with one hand. With your opposite hand, pinch-grip the adjoining bone and apply varus (Fig. 8-9) and valgus (Fig.

8-10) stress to the joint. RATIONALE

These procedures test the integrity of the collateral ligaments and the capsule surrounding the joints. If pain is elicited, suspect a capsule sprain, subluxation, or dislocation. Laxity may indicate a tear to the joint capsule or collateral ligaments of the joint secondary to trauma. Collateral ligament

Interphalangeal joint

��-7 Collateral ligaments

Figure 8-8

Figure 8-9

Figure 8-10

CHAPTER 8

HAND ORTHOPAEDIC TESTS

Thumb Ulnar Collateral Ligament Laxity Test (2)

Sensitivity/Reliability Scale

I

o

PROCEDURE

221

I 1

I

2

I

3

I

4

With the carpometacarpal joint in extension, stabilize the metacarpal with a pinch grip. With your opposite hand, grasp the proximal phalanx (also with a pinch grip) and push the phalanx radially (Fig. 8-11). Repeat the test with the metacarpophalangeal joint fully flexed (Fig. 8-12). RATIONALE

When the thumb is fully extended, it normally has 6° of laxity. If laxity is greater than 6° or as much as 30°, the ulnar lateral collateral ligament and volar plate are damaged. If the joint is lax in full flex ion, the ulnar collateral ligament is damaged. If there is no laxity in flexion, the ligament is intact. If there is no laxity in full flexion and more than 30° of laxity in full extension, the damage is limited to the volar plate. SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiography Posteroanterior hand view Oblique hand view Lateral hand view

Figure 8-11

Figure 8-12

222

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

JOINT CAPSULE TESTS Flexibility and stability of the interphalangeal joints are a function of the joint capsules. If these cap sules are tight, they may have decreased joint motion; if loose, they may have increased joint mo tion. Decreased joint motion may also be caused by limitations in the intrinsic muscles of the hand or tight collateral ligaments. These processes may be caused by rheumatoid arthritis or osteoarthri tis of the hands. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Joint pain Joint swelling Joint deformity Limited joint motion

Bunnel-Littler Test (3)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

Instruct the patient to extend the metacarpophalangeal joint slightly. Attempt to move the proximal interphalangeal joint into flexion (Fig. 8-13). Repeat the test with the metacarpophalangeal joint in flexion (Fig. 8-14). RATIONALE

If the proximal interphalangeal joint does not flex with the metacarpophalangeal joint in slight ex tension, there is a tight intrinsic muscle or a contracture of the joint capsule. If the proximal inter phalangeal joint fully flexes with the metacarpophalangeal joint flexed, the intrinsic muscles are tight. A positive test indicates an inflammatory process in the fingers, such as osteoarthritis or rheumatoid arthritis.

Figure 8-13

Figure 8-14

CHAPTER 8

Test for Tight Retinacular Ligaments

Sensitivity/Reliability Scale

I o

PROCEDURE

223

HAND ORTHOPAEDIC TESTS

I 1

I

2

I

3

I

I

With the proximal interphalangeal joint in the neutral position, passively attempt to flex the distal interphalangeal joint (Fig. 8-15). Repeat the test with the proximal interphalangeal joint in the flexed position (Fig. 8-16). RATIONALE

If the distal interphalangeal joint does not flex with the proximal interphalangeal joint in the neu tral position, the collateral ligaments or joint capsule is tight. If the distal interphalangeal joint flexes easily when the proximal interphalangeal joint is flexed, the collateral ligaments are tight and the capsule is normal. SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiography Posteroanterior hand view Oblique hand view Lateral hand view

Figure 8-15

Figure 8-16

224

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

TENDON INSTABILITY Tendon instability or rupture or may be caused by vascular impairment, tenosynovitis, overstretch, or trauma. Trauma may affect the forearm, wrist, or hand. Trauma to the forearm may injure one of more of the long tendons, such as the flexor digitorum profundus and extensor digitorum, which originates in the forearm and flexes and extends all of the joints in the fingers. CLINICAL SIGNS AND SYMPTOMS •

•

Forearm, wrist, or hand pain Limited or absent joint motion

Profundus Test (3)

Sensitivity/Reliability Scale

I o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

Instruct the patient to flex the suspected distal phalanx while you stabilize the proximal phalanx (Fig. 8-17). RATIONALE

Inability to flex the distal phalanx indicates a divided flexor digitorum profundus tendon.

Figure 8-17

CHAPTER 8

Flexor and Extensor Pollicis Longus Test (4)

HAND ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

225

I

I 1

I

2

I

3

I

4

Stabilize the proximal phalanx of the thumb. Instruct the patient to flex (Fig. 8-18) and extend the distal phalanx (Fig. 8-19). RATIONALE

Inability to flex the digit indicates an injured flexor pollicis longus tendon. Inability to extend the digit indicates an injury to the extensor pollicis longus tendon.

Figure 8-18

I I I Figure 8-19

I

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

226

Extensor Digitorum Communis Test

Sensitivity/Reliability Scale

I

I 1

PROCEDURE

I 2

I

3

I

4

With the fingers flexed (Fig. 8-20), instruct the patient to extend the fingers (Fig. 8-21). RATIONALE

Inability to extend any of the fingers indicates an injury to that particular portion of the extensor digitorum communis tendon (Fig. 8-22). SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiography Posteroanterior hand view Oblique hand view Lateral hand view

Figure 8-21

Figure 8-20

Figure 8-22

CHAPTER 8

References 1. Hartley A. Practical joint assessment. St. Louis: Mosby, 1991. 2. Louis D et al. Rupture and displacement of the

HAND ORTHOPAEDIC TESTS

227

Green DP. Operative Hand Surgery, 3rd ed . New York: Churchill Livingstone, 1993. Jebson PJL, Kasdan ML. Hand Secrets. Philadelphia: Hanley & Belfus, 1998.

ulnar collateral ligament of the metacarpopha

Maitland GD. The Peripheral Joints: Examination

langeal joint of the thumb. J Bone Joint Surg

and Recording Guide. Adelaide, Australia: Virgo,

Am 1986;68:1320.

1973.

3. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton Century-Croft, 1976. 4. Post M. Physical Examination of the Muscu loskeletal System. Chicago: Year Book, 1988.

McRae R. Clinical Orthopedic Examination. New York: Churchill Livingstone, 1976. Nicholas JS. The swollen hand. Physiotherapy 1977; 63:285. Stern pJ. Tendinitis, overuse syndromes and tendon

General References Cailliet R. Hand Pain and Impairment. 4th ed. Philadelphia: Davis, 1994. Eaton RG. Joint Injuries of the Hand. Springfield, IL: Charles C. Thomas, 1971.

injuries. Hand Clin 1990;6:467-476. Wadsworth CT. Wrist and hand examination and interpretation. J Orthop Sports Phys Ther 1983;5: 108-l20.

------��--THORACIC ORTHOPAEDIC TESTS

THORACIC ORTHOPAEDIC EXAMINATION FLOW CHART

229 230

Anterior Aspect Sternum

230

NERVE ROOT LESIONS

231

Posterior Aspect Scapula

Rotation

COSTOVERT EBRAL JOINT ANKYLOSIS

235 237

238

239 240

Adam's Position

241

McKenzie's Slide Glide Test

228

236

237

Scoliosis Screening

247

233

Ribs and Intercostal Spaces Flexion

246

Schepelmann's Sign

T horacic Range of Motion

245

245

Beevor's Sign

Parathoracic Musculature Spinous Processes

244

Passive Scapular Approximation Test

232

232

Lateral Flexion

244

Sternal Compression Test

230

Ribs, Costal Cartilage, and Intercostal Spaces

243

Spinal Percussion Test Soto-Hall Test

PALPAT ION

243

THORACIC FRACTURES

242

Chest Expansion Test

248

CHAPTER 9

THORACIC ORTHOPAEDIC TESTS

229

Thoracic Orthopaedic Examination

�

History

I

Thoracic pain with no trauma

Thoracic pain with trauma

(+)

1II----'--'-l�1 Strain/Sprain

Spinal percussion test Soto-Hali test Sternal compression test

230

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PALPATION Anterior Aspect

Sternum DESCRIPTIVE ANATOMY The sternum, which lies at the anterior part of the chest wall, consists of three parts: the manubrium, body, and xiphoid process. It articulates with the costal cartilages on both sides. The manubrium also articulates with the facets of the clavicle on both sides (Fig. 9-1).

PROCEDURE Palpate the entire length of the sternum for tenderness or abnormality (Fig. 9-2). Also palpate the costal margins and sternal clavicular articulations for tenderness, pain, and displacement (Fig. 9-3). Pain and tenderness following trauma may indicate a fractured sternum or bruised costal cartilages. Tender sternocostal or sternoclavicular articulations may indicate a sprain or subluxation of the sus pect articulation. Acromioclavicular -�� joint S tern ocostal """"",,-INiI�----'h articulations

Acromion process

Coracoid process

"':'£==:;'i?"M "--7f:�Hlr�ri1F-- anubrium Body

Costal cartilages �--w....

Sternum

�=-'�!!!b::-if'-+HIt-Xi phoid process

-1+!t----".M�--,!<WII'--Vertebral column Costochondral articulations

Anterior View

Figure 9-1

Figure 9-2

Figure 9-3

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THORACIC ORTHOPAEDIC TESTS

231

Ribs, Costal Cartilages, and Intercostal Spaces DESCRIPTIVE ANATOMY The ribs at the anterior aspect of the rib cage are attached to the sternum by costal cartilages, form ing the costochondral articulation. They also articulate with the sternum, forming the sternocostal articulations (Fig. 9-4).

PROCEDURE Palpate each costal cartilage with its associated rib from the lateral aspect of the sternum laterally to the axilla. Then palpate into each intercostal space (Fig. 9-5). Tender costal cartilages may indicate costochondritis (Tietze's syndrome). Tender intercostal spaces may indicate an irritated intercostal nerve or a herpes zoster viral infection. Associated with this infection may be red vesicular eruptions along the course of the intercostal nerve in the intercostal space. Tenderness that follows trauma may indicate a fractured rib.

Sternocostal articulation --fiH;ffi

Costochondral ��!IP�;;;j�� articulation

Figure 9-4

Figure 9-5

232

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Posterior Aspect

Scapula DESCRIPTIVE ANATOMY At the posterior aspect of the thorax, the scapula articulates with the posterior aspect of the ribs. It also forms part of the glenoid fossa, which articulates with the head of the humerus. On the anterior aspect, the acromion articulates with the clavicle, forming the acromioclavicular joint. The scapula normally extends from T2 to T7. It has three borders: medial, lateral, and superior (Fig. 9-6).

PROCEDURE Starting with the medial border, palpate all three borders, noting any tenderness (Figs. 9-7 to 9-9). Next, palpate the spine of the scapula, noting any tenderness or abnormality (Fig. 9-10). Finally, pal pate the posterior surfaces above the spine of the scapula for the supraspinatus muscle (Fig. 9-11) and below the spine for the infraspinatus muscle (Fig. 9-12). Note any tenderness, atrophy, or spasm.

Clavicle

----::2l;;��

Superior border

"'--:::'?"""""r'i"'�...---Spine of scapula P'--'""'-4t-Glenoid fossa

Medial-i+--H-""""�""-+'" .... border

Humerus

Lateral border "--"R ""'-\-t-� ibs

Figure 9-6

\

,

Figure 9-7

Figure 9-8

Figure 9-9

Figure 9-10

Figure 9-11

Figure 9-12

CHAPTER 9

THORACIC ORTHOPAEDIC TESTS

233

Parathoracic Musculature DESCRIPTIVE ANATOMY The thoracic spinal muscles are arranged in three layers: superficial, intermediate, and deep. The su perficial layers include the trapezius, latissimus dorsi, levator scapulae, and rhomboid muscles (Fig. 9-13). The intermediate layer contains the serratus posterior, serratus superior, and serratus inferior muscles (Fig. 9-14). The deep muscles of the back are ones that maintain posture and move the spinal column. These muscles, the erector spinae group, consist of the spinalis, longissimus, and il iocostalis (Fig. 9-14).

PROCEDURE Palpate the superficial layer by moving your fingers in a transverse fashion over the belly of the mus cle, noting any abnormal tone or tenderness (Fig. 9-15). Palpate the deep layer with the fingertips directly adjacent to the spinous processes (Fig. 9-16), noting any abnormal tone or tenderness. Any abnormal tone or tenderness may indicate an inflammatory process in the muscle, such as muscle strain, myofascitis, or fibromyalgia.

--':'�--- Splenius capitus m. Ir----""O""::--- Splenius cervicis m. Deltoid m. -f+,:p....

��-T-- Levator scapulae m.

�*---'\:'m�� Rhomboid m.

/�!j--"'t-I- Latissimus dorsi m.

Figure 9-1 3

234

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Superior -+-++--'---I'--� serratus posterior m.

Erector spinae group

{

Spinalis Longissimus Iliocostalis

posterior m.

T12

Figure 9-14

Figure 9-15

Figure 9-16

CHAPTER 9

THORACIC ORTHOPAEDIC TESTS

235

Spinous Processes DESCRIPTIVE ANATOMY The Tl to T12 vertebrae have relatively prominent spinous processes that are easily palpable (Fig. 9-17). The tip of each spinous process is below the transverse process of the same vertebra.

PROCEDURE With the patient seated and thorax slightly flexed, palpate each spinous process with your index and or middle finger, noting any pain, tenderness, and abnormal alignment. Each process should be pal pated individually (Fig. 9-18). Next, push each spinous process laterally, noting any rotational mo bility (Fig. 9-19). Tenderness upon static spinous palpation may indicate subluxation of a thoracic vertebra. Tenderness secondary to flexion or extension injury may indicate supraspinous ligament sprain, especially in the upper thoracic vertebra. Abnormal gross alignment may indicate scoliosis.

Posterior View

Lateral View

Superior ---fr articular process

Transverse process Inferior articular process

Inferior -=-""" articular process

��'!!.!\l!uge"'-��A,!.- Inferior costal facet Spinous process

Transverse process

process Figure 9-17

Figure 9-1 8

Figure 9-19

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

236

Ribs and Intercostal Spaces DESCRIPTIVE ANATOMY The ribs at the posterior aspect of the rib cage are attached to the vertebral body and transverse process by a capsule and a series of ligaments and muscles (Fig. 9-20). The ribs can bend slightly un der stress without breaking. Between the ribs in the intercostal spaces are three layers of intercostal muscles and an intercostal nerve. This nerve can become infected with the herpes zoster virus, which invades the spinal ganglia and produces sharp burning pain in the area supplied by the affected in tercostal nerve.

PROCEDURE Palpate each individual rib from the lateral aspect of the spinal column laterally to the axilla. Then palpate each intercostal space (Fig. 9-21). Tenderness or pain following trauma may indicate a frac tured rib. Tender intercostal spaces may indicate an irritated intercostal nerve or a herpes zoster vi ral infection. Associated with this infection may be red vesicular eruptions along the course of the intercostal nerve in the intercostal space.

Costotransverse ligament Superior costotransverse ligament

Figure 9-20

Figure 9-21

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THORACIC ORTHOPAEDIC TESTS

237

THORACIC RANGE OF MOTION

Flexion: Inclinometer Method (1) With the patient seated, place one inclinometer in the sagittal plane at the Tl level and the other in clinometer at the T1 2 level, also in the sagittal plane (Fig. 9- 22). Zero out both inclinometers. Instruct the patient to place hands on hips and to flex forward the thoracic spine (Fig. 9-23). Record both in clinations and subtract the Tl2 from the Tl inclination to arrive at the thoracic flexion angle.

NORMAL RANGE Normal range is 50° or greater from the neutral or 0 position. Muscles

Nerve Supply

Rectus abdominous External abdominal oblique Internal abdominal oblique

T6-Tl2 T7 -Tl2 T7-Tl2, Ll

Figure 9-22

Figure 9-23

238

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Lateral Flexion: Inclinometer Method (1) With the patient standing, place one inclinometer flat against the Tl spinous process and the other flat against the Ll spinous process (Fig. 9- 24). Zero out both inclinometers. Instruct the patient to flex the thoracic spine to one side and then the other (Fig. 9-25) and record your findings. Subtract the Tlin clination angle from the TI2 inclination angle to arrive at your thoracic lateral flexion angle.

NORMAL RANGE Normal range is 20° to 40° from the neutral or 0 position. Muscles

Nerve Supply

Lateral Flexion to the Same Side

Iliocostalis thoracis L ongissimus thoracis Intertransversarii Internal abdominal oblique External abdominal oblique Quadratus lumborum

Tl-Tl 2 Tl-Tl 2 Tl-Tl 2 Tl-Tl 2, Ll T7-Tl 2 T7-Tl 2

Lateral Flexion to the Opposite Side

Semispinalis thoracis Multifidus Rotatores External abdominal oblique Transversus abdominis

Figure 9-24

Tl-Tl2 Tl-Tl2 Tl-Tl2 T7-Tl2 T7-Tl2, Ll

Figure 9-25

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239

Rotation: Inclinometer Method (1) With the patient seated, instruct the patient to flex forward as far as possible, bracing with the arms. Place one inclinometer at the Tllevel and the other at the Tl2 level, both in the coronal plane (Fig. 9-26). Zero out both inclinometers. Instruct the patient to rotate the trunk to one side; record both Tl and Tl2 inclinations (Fig. 9-27). Subtract the Tl2 from the Tlinclination to arrive at the tho racic rotation angle. Perform this measurement with rotation to the opposite side.

NORMAL RANGE Normal range is 30° or greater from the neutral or 0 position. Muscles

Nerve Supply

Rotation to Same Side

Iliocostalis thoracis Longissimus thoracis Intertransversarii Internal abdominal oblique

Tl-Tl2 Tl-Tl2 Tl-Tl2 Tl-Tl2, Ll

Rotation to Opposite Side

1. 2. 3. 4. 5.

Semispinalis thoracis Multifidus Rotatores External abdominal oblique Transversus abdominis

Figure 9-26

Figure 9-27

Tl-Tl2 Tl-Tl2 Tl-Tl2 Tl-Tl2 Tl-Tl2, Ll

IJ

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

SCOLIOSIS! KYPHOSIS SCREENIN G

CLINICAL DESCRIPTION Scoliosis is an abnormal spinal deformity in the coronal plane (Fig. 9-28). It is progressive until skeletal maturity and is the most common type of spinal deformity. Hyperkyphosis is an abnormal spinal de formity in the sagittal plane that increases the posterior convex angulation (Fig. 9-29). These deformi ties can be congenital or acquired and are more prevalent in females than in males. Some of the prob lems associated with spinal deformities are pain, diminished pulmonary function, neurological compromise, and loss of self-image. Spinal deformities are best evaluated through radiography. Mea surement of the scoliotic curve is accomplished using the Cobb-Lippman technique (2). A line is drawn at the superior end plate at the top of the curve, where the angle of inclination toward the concavity of the curve is most acute. Then draw a line at the inferior end plate at the bottom of the curve. Tangen tial lines are drawn to these end plates and the angle at their intersection is measured (Fig. 9-30).

CLINICAL SIGNS AND SYMPTOMS Visual deformity Paraspinal pain Diminished pulmonary function Neurological compromise

Figure 9-28

Figure 9-29

Figure 9-30

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THORACIC ORTHOPAEDIC TESTS

Adam's Position

241

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient standing, stand directly behind the patient and inspect and palpate the entire length of the spine, looking for scoliosis, hyperkyphosis, or kyphoscoliosis (Fig. 9-31). Next, instruct the patient to flex forward at the hips. Again, inspect and palpate for scoliosis, kyphosis, or kyphoscoliosis (Fig. 9-32).

RATIONALE If scoliosis, kyphosis, or kyphoscoliosis is present with the patient standing and if the angle reduces upon forward flexion, the scoliosis is a functional adaptation of the spine and surrounding soft tis sue structures. It may be caused by poor posture, overdevelopment of unilateral spinal and/or up per extremity musculature, nerve root compromise, leg length deficiency, or hip contracture. This type of scoliosis is usually mild to moderate, measuring less than 25°. If scoliosis, kyphosis, or kyphoscoliosis is present with the patient standing and if the angle does not reduce upon forward flexion, suspect a structural deformity, such as hemivertebra, compression fracture of a vertebral body, or idiopathic scoliosis.

Figure 9-31

Figure 9-32

242

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

McKenzie's Slide Glide Test (2)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

I

I

4

With the patient standing, stand to one side of the patient. With your shoulder, block the thoracic spine. With both hands, grasp the patient's pelvis and pull it toward you; hold this position for 10 to 15 seconds (Fig. 9-33). Repeat this test to the opposite side. If the patient has evident scoliosis, the side toward which the spine curves should be tested first.

RATIONALE This test is performed on patients with symptomatic scoliosis. Blocking the shoulder and moving the pelvis stress the area of the scoliosis. If the symptoms increase on the affected side, the scoliosis is contributing to the patient's symptoms.

SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiography Anteroposterior (AP) thoracic view Lateral thoracic view with concavity toward the bucky AP thoracolumbar view

Figure 9-33

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THORACIC ORTHOPAEDIC TESTS

243

THORACIC FR ACTURES

CLINICAL DESCRIPTION Fractures of the thoracic spine are categorized as anterior or posterior. The anterior aspect of the spine is the vertebral body, and the posterior aspect consists of the posterior arch, facet joints, and spinous processes. Fractures of the thoracic spine may disrupt the spinal canal, which may lead to neurological compromise. If disruption of the spinal canal is compromised, neurological evaluation is essential. Plain radiographs in both the AP and lateral planes should be reviewed. In the AP view you may visualize fracture lines and abnormalities in alignment, angulation, or translation. In the lateral view, you may visualize fracture lines, alignment, angulation, and translation.

CLINICAL SIGNS AND SYMPTOMS Thoracic pain Anterior chest pain Upper extremity neurological compromise Lower extremity neurological compromise

Spinal Percussion Test (3,4)

Sensitivity/Reliability Scale

I

o

PROCEDURE

!

I 1

!

I

2

!

I

3

!

I

4

With the patient sitting and head slightly flexed, percuss the spinous process (Fig. 9-34) and associ ated musculature (Fig. 9-35) of each of the thoracic vertebrae with a neurological reflex hammer.

RATIONALE Local pain may indicate a fractured vertebra without neurological compromise or ligamentous sprain. Radicular pain may indicate a fractured vertebra with neurological compromise or a disc de fect with neurological compromise.

NOTE This test is not specific; other conditions will also elicit a positive pain response. A ligamentous sprain will cause a positive sign on percussion of the spinous processes. Percussing the paraspinal musculature will elicit a positive sign for muscular strain.

Figure 9-34

Figure 9-35

244

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Soto-Hall Test (5)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

I

I

3

I

With the patient supine, assist him or her in flexing the chin to the chest (Fig. 9-36).

RATIONALE Local pain indicates osseous, discal, or ligamentous pathology. This test is nonspecific. It merely iso lates the cervical and thoracic spine in passive flexion. If this test is positive, perform tests for strain, sprain, fractures, and space-occupying lesions.

Figure 9-36

Sternal Compression Test

Sensitivity/Reliability Scale

I

PROCEDURE

o

I 1

I

2

I

3

I

I

4

With the patient supine, push down on the sternum (Fig. 9-37).

RATIONALE Pressure to the sternum compresses the lateral borders of the ribs. If a fracture is sustained at or near the lateral border of the ribs, the pressure on the sternum will cause the fracture to become more pronounced, producing or exacerbating pain in the area of the fracture.

NOTE Be cautious if you suspect a fractured rib, especially if it is displaced. If trauma has occurred and you suspect a fractured rib, the area should be radiographed before this test.

SUGGESTED DIAGNOSTIC IMAGING Plain film radiography AP thoracic view (spine) AP thoracic view (ribs) Posteroanterior (PA) chest Lateral thoracic view (spine) Breathing lateral thoracic Oblique thoracic (ribs) Computed tomography (CT) Bone scan Figure 9-37

CHAPTER 9

245

THORACIC ORTHOPAEDIC TESTS

NERVE ROOT LESIONS

CLINICAL DESCRIPTION Thoracic nerve roots lesions may be due to a thoracic trauma. There is greater mobility at the tho racolumbar junction (Tll-T12) than at Tl to Tl O because of the afforded stabilization of the rib cage. That is why there is a greater chance of injury between TlO and Tl2. Thoracic injuries include wedge fractures, burst fractures, and fracture-dislocations. Any of these injuries may lead to a nerve root lesion in the thoracic spine. Compression by a mass or tumor in the spine may also lead to neurological compromise.

CLINICAL SIGNS AND SYMPTOMS Thoracic pain Anterior abdominal pain Loss of abdominal sensation

Passive Scapular Approximation Test (6)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient standing, grasp the patient's shoulders (Fig. 9-38). Passively approximate the scapu lae by pushing the shoulders backward (Fig. 9-39).

RATIONALE Passively approximating the scapulae places motion-induced traction on the Tl and T2 nerve roots. Pain in the scapular area indicates a Tl and/or T2 nerve root compression or irritation.

Figure 9-38

Figure 9-39

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Beevor's Sign (7)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

I

With the patient supine, instruct the patient to hook the fingers behind the neck and raise the head toward the feet. This test should mimic a sit-up (Fig. 9-40).

RATIONALE The umbilicus of the patient who has no thoracic root lesion will not move during this test because the abdominal muscles are equally innervated and of equal strength. If a root lesion is present, the umbilicus will move in the following manner: If the umbilicus moves superiorly, suspect a bilateral TlO to TI2 nerve root lesion. If it moves superiorly and laterally, suspect a unilateral TID to TI2 nerve root lesion on the opposite side. If the umbilicus moves inferiorly, suspect a bilateral T7 to TID nerve root lesion. If it moves inferiorly and laterally, suspect a unilateral T7 to TID nerve root lesion on the opposite side.

Figure 9-40

CHAPTER 9

247

THORACIC ORTHOPAEDIC TESTS

Schepelmann's Sign

Sensitivity/Reliability Scale

I

PROCEDURE

I 1

I

2

I

3

I

4

Instruct the seated patient to flex at the waist to the left and right (Fig. 9-41).

RATIONALE Pain on the side of lateral bending indicates intercostal neuritis. Pain on the convex side indicates fi brous inflammation of the pleura or intercostal sprain. When the patient bends sideways, the inter costal nerves on the side of bending are compressed. If the intercostal nerves are irritated, pain on the side of bending will be elicited. Also, when the patient bends sideways, the pleura is stretched on the opposite side of bending. If the pleura is inflamed, pain will be elicited opposite the side of bend ing. Pain may also be elicited because of injury to or spasm of the thoracic or intercostal muscles.

Figure 9-41

SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP thoracic view AP lumbar view Lateral thoracic view Lateral lumbar view Lumbar oblique views Thoracolumbar MRI CT Bone scan

248

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

COSTOVERTEBRAL JOINT ANKYLOSIS

CLINICAL DESCRIPTION Costovertebral joint ankylosis is stiffness or fixation of the costovertebral joints associated with ankylosing spondylitis. This is a chronic seronegative inflammatory disease that affects the axial skeleton. The prevalence is 1 to 3 per 1000 people; it is more common in females than in males. It affects not only the costovertebral joints but also the sacroiliac and hip joints. The disease, which usually starts in the lumbar spine and migrates cephalad to the cervical spine, is a slowly progress ing one that takes decades to develop.

CLINICAL SIGNS AND SYMPTOMS Lumbar and thoracic pain Lumbar and thoracic stiffness Improved symptoms during activity Loss of kyphosis Chest tightness Limited chest expansion

Chest Expansion Test (8) PROCEDURE With the patient seated, place a tape measure around the patient's chest at the level of the nipple. In struct the patient to exhale, and record the measurement (Fig. 9-42). Next, instruct the patient to in hale maximally; record the measurement (Fig. 9-43).

RATIONALE The normal chest expansion for a man is 2 inches or more. The normal chest expansion for a woman is 1 inch or more. A decrease in the normal chest expansion indicates an ankylosing condition, such as ankylosing spondylitis at the costotransverse or costovertebral articulation.

Figure 9-42

SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiology AP lumbar view AP thoracic view Lateral lumbar view Lateral thoracic view

Figure 9-43

CHAPTER 9

References

249

THORACIC ORTHOPAEDIC TESTS

General References

1. American Medical Association. Guides to the

Boissonault WG. Examination in Physical Therapy

Evaluation of Permanent Impairment. 5th ed.

Practice. Screening for Medical Disease. New York:

Chicago: AMA, 2000.

Churchill Livingstone, 1991.

2. McKenzie RA. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications, 1981. 3. O'Donoghue D. Treatment of injuries to ath letes. 4th ed. Philadelphia: Saunders, 1984. 4. Turek SL. Orthopaedics. 5th ed. Philadelphia: Lippincott, 1977.

5. Soto-Hall R, Haldeman K. A useful diagnostic sign in vertebral injuries. Surg Gynecol Obstet: 1972; 827-831.

6. Cyriax J. Textbook of Orthopaedic Medicine. Vol 1. Diagnosis of Soft Tissue Lesions. London: Bailliere Tindall, 1982. 7. Rodnitzky RC. Van Allen's Pictorial Manual of Neurological Tests. 3rd ed. Chicago: Year Book Medical, 1989. 8. Moll JMH, Wright V. An objective clinical study of chest expansion. Ann Rheum Dis 1982;31: 1-9.

Cyriax JH. Cyriax's Illustrated Manua.l of

Or

thopaedic Medicine. 2nd ed. London: Butterworth, 1993. Goodman CC, Snyder TE. Differential Diagnosis in Physical Therapy. Philadelphia: Saunders, 1990. Kapandji IA. The physiology of joints. Vol. 3. The Trunk

and the Vertebral

Column.

New York:

Churchill Livingstone, 1974. Moore Kl. Clinically oriented anatomy. 3rd ed. Bal timore: Williams & Wilkins, 1992. Post M. Physica.l exami11ation of the musculoskele tal system. Chicago: Year Book Medical, 1987. Skinner HB. Current Diagnosis & Treatment i11 Or thopedics. 2nd ed. New York: Lange, 2000. White AA. Kinematics of the normal spine as related to scoliosis. J Biomech Engl 1971;4:405.

--------��-LUMBAR ORTHOPAEDIC TESTS

LUMBAR ORTHOPAEDIC EXA MINATION

251

FLOW CHART PALPATION

252 252

Quadratus Lumborum Gluteal Muscles

253 254

255 256 257

Piriformis Muscle Sciatic Nerve

LUMBAR RA NGE OF MOTION

258

258 Extension 259

Flexion

Lateral Flexion

260

JOINT DYSFUNCTION TESTS Segmental Instability Test

261 263

One Leg Standing Lumbar Extension

264

265

LUMBAR NERVE ROOT AND SCIATIC NERVE IRRITATION/COMPRESSION

266

Straight Leg Raising Test Slump Test

250

267 268

266

285

Valsalva's Maneuver Milgram's Test

265

Spinal Percussion Test

285

SPACE-OCCUPYING LESIONS Dejerine's Triad

LUMBAR FRACT URES

Lasegue's Test

271 Sicard's Test 272 Fajersztajn's Test 273 Bechterew's Test 274 Minor's Sign 275 Knee Flexion Test 276 A ntalgic Lean Sign 277 Bowstring Sign 279 Sciatic Tension Test 280 Piriformis Test 281 Gluteal Skyline Test 281 Kemp's Test 282 Lindner's Sign 283 Heel-Toe Walk Test 284 Bragard's Test

Intrinsic Spinal Muscles

TESTS

270

Femoral Nerve Traction Test

Spinous P rocesses

Test

270

Buckling Sign

Naffziger's Test

286 286 287

DIFFERENTIAL DIAGNOSIS: LUMBAR VERSUS SACROILIAC INVOLVEMENT Goldthwaith's Test

Supported Forward Bending Test Nachlas Test

288

288

290

Sign of the Buttock Test

291

289

Lumbar Orthopaedic Examination

t Low back pain with leg pain Trauma induced/ No trauma induced

Low back pain No leg pain Trauma induced

Range of motion (active) (passive)

Goldthwaith's test Supported forward bending test ".�E-----1 Nachlas test Sign of the buttock test Pheasant test Segmental instability test One leg standing lumbar Extension test Spondylosis Spondylolisthesis

See sacroiliac examination

�

Strain/Sprain

Disc defect

,.

(+)

m

[MRJ

.... .;------j

Valsalva's test Dejerine's triad Milgram's test Naffziger's test

Nerve root compression

I. (+)

Straight leg raising test Bragard's test Buckling sign Sicard's test Turyn's test Fajersztajn's test Bechterew's test Minor's sign Bowstring sign Sciatic tension test Piriformis test Kemp's test Lindner's test Gluteal skyline test

(J

S'2 .",

-l no ;
o r c:: ;-:: '" :>;
o

::j

J: o

:;;

no o

(i >-l

� '"

N U1

252

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PALPATION

Spinous Processes DESCRIPTIVE ANATOMY The five lumbar spinous processes are large and easily palpable with the spinal column in the flexed position (Fig.

1 0- 1 ). The fifth lumbar vertebra is the lowest movable segment.

In

5% of the popula

tion, the fifth lumbar vertebra is congenitally fused to the sacrum, a condition called sacralization. The person with this condition has only four palpable lumbar spinous processes. In other people, the first sacral segment is not fused to the other segments. This condition is caJled lumbarization, and six spinous processes may be palpable in the lumbar spine. A common abnormality in the lum bar spinous processes is spina bifida, a congenital defect found in

10% of the population. Spina bi L5 L5 or L5 to Sl interval is spondylolis

fida results from a failure of the vertebral arches to grow together and ossify. It is prevalent in the or Sl segment. Another common abnormaJity in the

L4

to

thesis. This is a fracture of the pars interarticularis that can cause forward movement of one verte bra on another.

PROCEDURE With the patient seated and flexed forward, palpate each spinous process with your index finger and forefinger (Fig.

1 0-2) . First

look for any irregularities, such as spondylolisthesis, spina bifida, lum

barization, or sacralization. Next, place anterior pressure on each process with your thumb (Fig.

1 0-3) and note any rigidity or springing. Rigidity may indicate hypomobility and springing may in dicate hypermobility.

Spinal column in flexion

Lateral View Figure 10-1

Figure 10-2

Figure 10-3

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

253

Intrinsic Spinal Muscles DESCRIPTIVE ANATOMY The intrinsic muscles in the lumbar spine are the erector spinae group (spinalis, longissimus, and ilio costalis). In the lower spine, these muscles come together to form the sacrospinalis group (Fig.

10-4) .

PROCEDURE With the patient prone, palpate the lumbar portions of the erector spine group diagonally from me dial to lateral (Fig.

1 0-5) .

Note any tenderness, inflammation, muscle spasm, or palpable bands,

which may indicate muscle strain, myofascitis, fibromyalgia, or active trigger points.

Superior -+-+<-.>.....,1"--, serratus posterior m.

Erector spinae group

{

Spinalis Longissimus

Rotatores m.

T4

Iliocostalis Semispinalis thoracicis m. serratus posterior m.

T12

Figure 10-4

Figure 10-5

254

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Quadratus Lumborum DESCRIPTIVE ANATOMY The quadratus lumborum is lateral to the thoracolumbar fascia. It is attached to the transverse processes of the lumbar vertebra, the iliac crest, and the 1 2th rib ( Fig. 1 0-6). It is a common site for myofascial lower back pain. PROCEDURE With the patient prone, palpate the quadratus lumborum from the 1 2th rib to the iliac crest (Fig. 10-7). This muscle is lateral to the erector spinae group. Note any tenderness, inflammation, muscle spasm, or palpable bands, which may indicate a muscle strain, myofascitis, fibromyalgia, or active trigger points.

Quadratus lumborum m.

Transverse \rr"""-H�::;:"- processes of vertebrae

Iliac crest

Iliacus m.

Inguinal ligament

.1

Figure 10-6

Figure 10-7

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

255

Gluteal Muscles DESCRIPTIVE ANATOMY The gluteal muscles consist of the gluteus maximus, gluteus medius, and gluteus minimus. These muscles extend, abduct, and rotate the thigh. They all originate from the ilium and insert into the femur (Fig. lO-8) . They can be tender and spastic secondary to trauma. Pain can be referred to the gluteal muscles from a defect in an intervertebral disc, and they can lose muscle tone because of nerve root involvement. The gluteal muscles may have active myofascial trigger points that can re fer pain to the posterior thigh, similar to a sciatic pain pattern from an L5-S 1 disc defect with nerve root compression. PROCEDUR! With the patient prone, palpate using strong pressure, starting just lateral to the sacrum and mov ing toward the greater trochanter of the femur (Fig. lO-9). Note any tenderness, spasm, loss of mus cle tone, and tender trigger points. Tenderness and spasm secondary to trauma may indicate a mus cle strain. A herniated intervertebral disc with nerve root compression may also cause tenderness and spasm to the area. An active myofascial trigger point may cause local tenderness with a referred component to the posterior thigh.

Gluteus maximus m.

Gluteus medius m.

Superior gluteal

E

artery

Inferior gluteal artery Obturator Sciatic nerve

intern us m. Inferior gemellus m. Quadratus femoris m. Adductor mag nus m. Biceps

Figure 10·8

Figure 10·9

femoris m.

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Piriformis Muscle DESCRIPTIVE ANATOMY The piriformis muscle is clinically significant because of its proximity to the sciatic nerve (Fig. 1 0-8) . It may become inflamed and spastic and compress the sciatic nerve, causing pain along the entire course of the nerve. It originates from the sacrum and inserts into the greater trochanter of the femur. PROCEDURE To locate the piriformis, bisect the tip of the coccyx and the posterior superior iliac spine (Fig. 1 0- 1 0). This is the inferior border of the piriformis. Palpate the muscle, noting any tenderness or spasm (Fig. 1 0- 1 1 ). If the patient has lower extremity radicular pain, note whether palpation of the piriformis increases that pain. Tenderness and spasm in the piriformis may indicate muscle strain caused by overuse. Because of the proximity of the sciatic nerve to this muscle, a radicular compo nent to the posterior thigh may also be involved. A local tender area may indicate an active myofas cial trigger point, which may also cause a radicular pain to the posterior thigh.

Figure 10-10

Figure 10-11

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257

Sciatic Nerve DESCRIPTIVE ANATOMY The sciatic nerve is composed of the nerve roots from L4 to 53. The nerve runs through the greater sciatic foramen of the pelvis through the gluteal muscles and below the piriformis (see Fig. 1 0-8) . Once it passes the piriformis, it runs deep to the gluteus maximus midway between the greater trochanter and the ischial tuberosity. In some cases, the sciatic nerve pierces the piriformis muscle rather than passing below it. PROCEDURE Starting midway between the greater trochanter and the ischial tuberosity, palpate the sciatic nerve and follow the nerve as far down the lower extremity as possible (Fig. 1 0-l2). Note any tenderness, burning, or inflammation. If the patient has any tenderness, burning, or referred pain into the ex tremity, suspect an irritation of the sciatic nerve.

Figure 10·12

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LUMBAR RANGE OF MOTION

Flexion: Inclinometer Method (1) With the patient standing and the lumbar spine in the neutral position, place one inclinometer over the T 1 2 spinous process in the sagittal plane. Place the second inclinometer at the level of the sacrum, also in the sagittal plane (Fig. 1 0- 1 3 ) . Zero out both inclinometers. Instruct the patient to flex the trunk forward. Record the inclinations of both inclinometers (Fig. 10- 1 4). Subtract the sacral inclination from the T 1 2 inclination to obtain the lumbar flexion angle. NORMAL RANGE (2) Female aged 15-30 Female aged 3 1 -60 Female aged> 6 1

Male aged 1 5-30 Male aged 3 1 -60 Male aged> 6 1 Muscles

Nerve Supply

Psoas major Rectus abdominis External abdominal oblique Internal abdominal oblique Transversus abdominis

11 -L3 T6-Tl2 T7-T l2 T7-T l2,11 T7-T l2,11

Figure 10-13

Figure 10-14

CHAPTER 10

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259

Extension: Inclinometer Method (1) With the patient standing and the lumbar spine in the neutral position, place one inclinometer slightly lateral to the T 1 2 spinous process in the sagittal plane. Place the second inclinometer at the sacrum, also in the sagittal plane (Fig. 1 0- 1 5 ) . Zero out both inclinometers. Instruct the patient to extend the trunk backward. Record the inclination of both inclinometers (Fig. 1 0-16). Subtract the sacral inclination from the T 1 2 inclination to obtain the lumbar extension angle. NORMAL RANGE (2) Male aged 1 5-30 Male aged 3 1 -60 Male aged> 6 1

38° 35° 33°

Muscles

Nerve Supply

Latissimus dorsi Erector spinae Transversospinalis Interspinalis Quadratus lumborum

C6-C8 L l-L3 L l-Ls L l-Ls T l2, L l-L4

Figure 10-15

Female aged 1 5-30 Female aged 3 1 -60 Female aged> 6 1

Figure 10-16

42° 40° 36°

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Lateral Flexion: Inclinometer Method (1) With the patient standing and the lumbar spine in the neutral position, place one inclinometer flat at the T 1 2 spinous process in the coronal plane. Place the second inclinometer at the superior aspect of the sacrum, also in the coronal plane (Fig. 1 0- 1 7). Zero out both inclinometers. Instruct the pa tient to flex the trunk to one side. Record the inclination of both inclinometers (Fig. 10- lS). Sub tract the sacral inclination from the T 1 2 inclination to obtain the lumbar lateral flexion angle. Per form measurements for both right and left lateral flexion. NORMAL RANGE (3,4) Male aged 20-29 Male aged 3 1 -60 Male aged> 6 1

3S0 :±::5 .S 29° :±::6 .5 1 9° :±::4.S

Female aged 1 5-30 Female aged 3 1 -60 Female aged> 61

Muscles

Nerve Supply

Latissimus dorsi Erector spinae Transversospinalis Intertransversarii Quadratus lumborum Psoas major External abdominal oblique

C6-CS L l-L3 L l-L5 L l-L5 T l2, L l-L4 L l-L3 T7-T l2

Figure 10-17

Figure 10-18

35° :±::6 .4 30° :±::5 .S 23° :±::5 .4

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261

JOINT DYSFUNCTION TESTS

CLINICAL DESCRIPTION Joint dysfunction may involve the forward displacement of one vertebra on another. These defects may be congenital or traumatic. A defect with no forward movement of one vertebra on another is a spondylolysis (Fig. 1 0- 1 9). A defect with forward movement is a spondylolisthesis (Fig. 1 0-20) . A spondylolisthesis is graded according to the amount of forward movement of one vertebra on an other (Box 10- 1 ). Spondylolisthesis is more common in males than in females and occurs 85% to 90% of the time at the L5-S1 level. There are five recognizable clinical groups of spondylolisthesis (Box 10-2). The most common is the type II lesion, called isthmic. This defect of the pars interar ticularis allows for forward migration of one vertebra on another. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

Asymptomatic Lower back pain (mild to acute disabling) Rigid lumbar spine Functional scoliosis Lower extremity radicular pain (rare)

Figure 10-19. Reprinted with permission from Yochum TR, Rowe LJ. Essentials of Skeletal Radiology. Vol 1. ed 2. Baltimore: Williams & Wilkins, 1996;244.

Figure 10-20. Reprinted with permission from Yochum TR, Rowe LJ. Essentials of Skeletal Radiology. Vol 1. ed 2. Baltimore: Williams & Wilkins, 1996;244.

I I I I

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Spondylolisthesis Grades Grade Grade

0-25% forward movement 25-50 % forward movement 50-75% forward movement 75-100% forward movement

1 2

Grade 3 Grade

4

Reprinted with permission from Myerding H. Spondylolisthesis: Surgical treat ment and results. Surg Gynecol Obstet 1932;54:371-377

Clinical Groups of Spondylolisthesis Type

Description

I.

Dysplastic

Congenital malformations of primarily the superior sacral facets or the arch of

L5

vertebra, which allows

spondylolisthesis. II.

Isthmic

Common in both children and adults, this lesion or defect in the pars interarticularis allows anterior vertebral migration, typically of

1. 2.

L5.

Three types are described:

Lytic: resulting from a fatigue of the pars interarticularis Elongated pars interarticularis: The pars interarticularis is intact

3.

Fracture

III.

Degenerative

Secondary to longstanding segmental instability with

IV.

Traumatic

V.

Pathological

j oint

degeneration. Occurs most frequently at

L4-L5.

Secondary to fractures not involving the pars interarticularis. Local or general structural weakness secondary to bone disease.

Modified with permission from Wiltse LL, Newman PH, MacNab I. Classification of spondylolysis and spondy lolisthesis. Clin Orthop ReI Res 1976;117-123.

CHAPTER 10

Segmental Instability Test (5)

Sensitivity/Reliability Scale

I

o

PROCEDURE

263

LUMBAR ORTHOPAEDIC TESTS

I 1

I

2

I

3

I

4

Place the patient prone with the legs over the examination table and the feet resting on the floor. Press down on the lumbar spine (Fig. 1 0-2 1 ). Next, instruct the patient to lift the legs off the floor, and again press down on the lumbar spine (Fig. 10-22). RATIONALE When the patient lifts the legs off the floor, the lumbar paravertebral muscle tightens, causing mus cle guarding in the lumbar spine. The test is positive if pain is elicited when pressure is applied to the lumbar spine with the feet on the floor and the pain disappears when the feet are off the floor and the paravertebral muscles are tightened. Raising the feet off the floor allows the mechanical muscle guarding to protect the underlying lumbar instability, such as a spondylolisthesis.

Figure 10-21

Figure 10-22

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One Leg Standing Lumbar Extension Test (6-8)

Sensitivity/Reliability Scale

I

a

PROCEDURE

I 1

I

2

I

3

I

I

Instruct the patient to stand on one leg (Fig. 1 O-23)and extend the lumbar spine. Be close to the pa tient to provide support if the patient loses balance (Fig. 1 0-24). Repeat the test with the opposite leg. RATIONALE Standing on one leg with lumbar extension increases the pressure to the pars interarticularis. If the pars interarticularis is fractured, lumbar pain will be produced or increased. This indicates spondy lolysis or spondylolisthesis. SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP lumbar view Lateral lumbar view Lumbar oblique views Sacral base view Computed tomography (CT) Single proton emission computed tomography ( SPECT)

Figure 10·23

Figure 10·24

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

265

LUMBAR FRACTURES

CLINICAL DESCRIPTION Fractures of the lumbar spine can be caused by trauma or deterioration of osteoporotic bone. The two most common types of fracture in the lumbar spine are the compression, or burst, fracture and the fracture-dislocation. The compression fracture, which can be traumatic or osteoporotic, may be stable or unstable. The stable fracture involves only the vertebral bodies; the posterior elements are intact. An unstable compression fracture involves both the vertebral bodies and the posterior ele ments of the vertebra. The degree of neurological damage depends on the size of the bone fragment and degree of displacement of the spinal canal. Fracture-dislocations are a result of severe forces in flexion and rotation and are associated with multiple other traumatic injuries, such as severe abdominal or spinal trauma, in which the posterior elements are affected. This usually causes a high percentage of severe neurological compromise. CLINICAL SIGNS AND SYMPTOMS •

•

Lower back pain Lower extremity neurological compromise

Spinal Percussion Test (9,10)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

I

2

I

I

4

With the patient seated and slightly bent forward, tap the spinous process (Fig. 1 0-25) and associ ated musculature (Fig. 1 0-26) of each of the lumbar vertebrae with a neurological reflex hammer. RATIONALE Local pain may indicate a fractured vertebra with no neurological compromise. Radicular pain may indicate a fractured vertebra with neurological compromise or possibly a disc defect with neurolog ical compromise. NOTE This test is not specific, so other conditions also elicit a positive pain response. A ligamentous sprain will cause a positive sign on percussion of the spinous processes. Percussion on the paraspinal mus culature will elicit a positive sign for muscular strain. SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP lumbar view Lateral lumbar view CT Bone scan

I I I Figure 10-25

Figure 10-26

LUMBAR NERVE ROOT AND SCIATIC NERVE IRRITATION/COMPRESSION TESTS

CLINICAL DESCRIPTION Lower extremity pain may be referred from lumbopelvic tissues or viscera or radicular pain from the nerve root complex of the spine. One of the features distinguishing between referred pain and radic ular pain is that in referred pain patterns, the spinal pain is more aggravating than the lower extrem ity pain. In radicular pain patterns the leg pain is more aggravating than the spinal pain. Also, referred pain is poorly localized and dull, but radicular pain is sharp and well localized. One of the most im portant functions the clinician must perform is determination of the cause of lower extremity pain. Is the pain referred or radicular? This section will deal only with neurogenic radicular pain patterns. Neurogenic radicular lower extremity pain may be caused by any of several factors. The most com mon is tension, irritation, or compression of a lumbar nerve root or roots. The irritation or compres sion may occur within or outside of the spinal canal. Intraspinal canal compressions may be caused by disc lesions, spinal stenosis, degenerative disc disease, hypertrophic changes, or spinal malignancy. Ex traspinal canal compression may be caused by muscle dysfunction or extradural defects or masses. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

Lower back pain Lower extremity radicular pain Loss of lower extremity reflexes Loss of lower extremity muscle strength Loss of lower extremity sensation

Straight Leg Raising Test (I 1-14)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient supine, place and zero out an inclinometer at the tibial tuberosity and raise the pa tient's leg to the point of pain or 90°, whichever comes first (Fig. 1 0-27). RATIONALE This test primarily stretches the sciatic nerve and spinal nerve roots at the L5, S l, and S2 levels. Be tween 70° and 90° of hip flexion, these nerve roots are fully stretched. If pain is elicited or exacer bated after 70° of hip flexion, suspect lumbar joint pain. At 35° to 70° of hip flexion, the sciatic nerve roots tense over the intervertebral disc. If radicular pain begins or exacerbates at this level, suspect sciatic nerve root irritation by intervertebral disc pathology or an intradural lesion. At 0 to 35° of hip flexion, there is no dural movement, and the sciatic nerve is relatively slack. If pain begins or ex acerbates at this level, suspect extradural sciatic involvement, that is, spastic piriformis muscle or sacroiliac joint lesions (Fig. 1 0-28). If dull posterior thigh pain is elicited, suspect tight hamstring muscles. If you suspect intervertebral disc pathology, continue with Bragard's and Lasegue's tests and evaluate the suspected neurological level (see Chapter 1 1 ).

Figure 10-27

Figure 10-28

CHAPTER 10

Lasegue's Test (15,16)

Sensitivity/Reliability Scale

I

o

PROCEDURE

267

LUMBAR ORTHOPAEDIC TESTS

I

I 1

I

I

2

I

I

3

I

I

4

With the patient supine, flex the patient's hip with the leg flexed (Fig. 1 0-29). Keeping the hip flexed, extend the leg (Fig. 1 0-30). RATIONALE This test is positive for sciatic radiculopathy when (a) no pain is elicited when the hip is flexed and the leg is flexed or (b) pain is present when the hip is flexed and the leg is extended. When both the hip and the leg are flexed, there is no tension on the sciatic nerve. When the hip is flexed and the leg is extended, the sciatic nerve is stretched and, if irritated, will cause pain or will exacerbate existing leg pain.

Figure 10-29

Figure 10-30

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Slump Test (17)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Instruct the patient to sit on the examination table with hands behind the back (Fig. 1 0-3 1 ). Instruct the patient to slump forward while you hold the chin level to prevent cervical flexion (Fig. 1 0-32) . Apply overpressure with one hand to the shoulder to maintain flexion and instruct the patient to flex the cervical spine forward (Fig. 1 0-33) . Next, apply overpressure to the cervical spine so that the cervical, thoracic, and lumbar spines are flexed (Fig. 1 0-34 ) . Instruct the patient to extend one leg (Fig. 1 0-35); dorsiflex the foot of the extended knee with the patient holding the slumped position (Fig. 1 0-36). Instruct the patient to extend the cervical spine (Fig. 1 0-37). Repeat the test on the op posite side and with both knees extended.

Figure 10·31

Figure 10-33

Figure 10-32

Figure 10-34

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

269

RATIONALE Each phase of this test places on the spinal meningeal tract a motion-induced traction that increases during each phase of the test. Pain at any phase may indicate meningeal tract irritation usually caused by a disc defect. If the patient cannot extend the knee or extends the knee with pain or if the pain increases with foot dorsiflexion, the test is positive, indicating increased tension in the neu romeningeal tract. The test is also positive if the knee cannot extend fully but increases with cervi cal extension. If symptoms are produced in any phase of the test, stop the test to prevent any undue discomfort to the patient.

II

Figure 10-35

Figure 10-36

Figure 10-37

270

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Buckling Sign

Sensitivity/Reliability Scale

I

I

o

PROCEDURE

I

1

I

2

I

3

4

With the patient supine, perform a straight leg raising test (Fig. 10-38). RATIONALE This test exerts traction pressure on the sciatic nerve. The patient with severe sciatic radiculopathy will flex the leg at the knee to reduce the traction (Fig. 10-39).

Figure 10-38

Figure 10-39

Femoral Nerve Traction Test (18)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient side-lying with the affected side up, instruct the patient to flex the unaffected ex tremity slightly at the hip and knee. Then grasp the affected leg and extend the hip 1 5° with the knee extended (Fig. 1 0-40). Next, flex the knee to stretch the femoral nerve further (Fig. 10-4 1 ). RATIONALE Extension of the hip and flexion of the knee place traction pressure on the femoral nerve and nerve roots of L2 to L4. Pain that radiates to the anterior medial thigh indicates an L3 nerve root problem. Pain extending to the mid tibia indicates a L4 nerve root problem. This test may also cause con tralateral pain, indicating a nerve root compression or irritation on the opposite side.

Figure 10-40

Figure 10-41

CHAPTER 10

Bragard's Test (12)

LUMBAR ORTHOPAEDIC TESTS

271

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient supine, raise the leg to the point of leg pain. Lower the leg 5° and dorsiflex the foot (Fig. 1 0-42). RATIONALE The raising of the leg and dorsiflexion of the foot places traction pressure on the sciatic nerve. If the dorsiflexion produces pain in the 0° to 35° range, suspect extradural sciatic nerve irritation. If pain occurs with dorsiflexion of the foot at 35° to 70°, suspect irritation of the sciatic nerve roots from a intradural problem, usually from an intervertebral disc lesion (see Straight Leg Raising Test). Dull posterior thigh pain indicates tight hamstring muscles. If you suspect intervertebral disc pathology, evaluate which neurological level is affected (see Chapter 1 1 ).

Figure 10-42

272

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sicard 's Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

4

Raise the supine patient's leg to the point of pain. Lower the leg 5° and dorsiflex the big toe (Fig. 10-43). RATIONALE Raising the leg and dorsiflexion of the big toe, place traction pressure on the sciatic nerve. If the dor siflexion produces pain in the 0° to 35° range, suspect extradural sciatic nerve irritation. If pain oc curs with dorsiflexion of the foot at 35° to 70°, suspect irritation of the sciatic nerve roots from an intradural problem, usually from an intervertebral disc lesion (see Straight Leg Raising Test). Dull posterior thigh pain indicates tight hamstring muscles. If you suspect intervertebral disc pathology, evaluate which neurological level is affected (see Chapter 1 1 ).

Figure 10·43

CHAPTER 10

273

LUMBAR ORTHOPAEDIC TESTS

Fajersztajn's Test (19,20)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

With the patient supine, raise the unaffected leg to 75° or to the point of leg pain, and dorsiflex the foot (Fig. 1 0-44). RATIONALE This test causes ipsilateral and contralateral stretching of the nerve roots (Fig. 1 0-45), pulling later ally on the dural sac. A positive sign is elicited if an increase in leg pain or pain is reproduced on the affected leg side. This pain indicates a disc protrusion usually medial to the nerve root. When the unaffected leg is raised, the nerve root on that side is stretched, causing the nerve root on the opposite side to slide down and toward the midline (Fig. 10-46). If a medial disc protrusion is present, this movement will increase tension on the nerve root opposite the side of hip flexion, in creasing the pain on the affected side. If pain decreases on the affected side when the unaffected leg ' is raised, suspect a lateral disc protrusion, because the nerve root is being pulled away from the disc (Fig. 10-47). If this test is positive, evaluate the neurological level affected (see Chapter 1 1).

Pull as leg is raised

Figure 10-44

Figure 10-45

Nerve pulled

away

from protrusion

Figure 10-46

Figure 10-47

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Bechterew's Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

I

4

Seat the patient with legs hanging over the examination table. Instruct the patient to extend one knee at a time alternately (Fig. 10-48). If no positive response is elicited, instruct the patient to raise both legs together (Fig. 1 0-49). RATIONALE With the patient seated and the leg flexed, the sciatic nerve is relatively slack. Extending the leg places traction pressure on the sciatic nerve. If the patient cannot perform this test because of radicular pain or performs the test but leans back, compression to the sciatic nerve or lumbar nerve roots, ei ther intradurally or extradurally, is indicated. This test is usually positive in disc protrusion cases.

Figure 10-48

Figure 10-49

CHAPTER 10

Minor's Sign

LUMBAR ORTHOPAEDIC TESTS

275

Sensitivity/Reliability Scale

I

o

PROCEDURE

I ,

I

2

I

3

I

4

Instruct the seated patient to stand (Fig. la-50). RATIONALE The patient with sciatic radiculopathy will stand on the healthy side and keep the affected leg flexed to decrease the tension on the sciatic nerve, hence relieve pain. The patient in Figure la-50 is demonstrating sciatic radiculopathy down the left lower extremity.

Figure 10-50

276

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Knee Flexion Test (21)

Sensitivity/Reliability Scale

I

PROCEDURE

I 1

I

2

I

3

I

4

Instruct the standing patient to bend forward (Fig. 1 0-5 1 ). RATIONALE The patient with sciatic radiculopathy will flex the affected leg while bending forward. Flexion of the leg reduces the traction on the sciatic nerve, hence reduces the pain. The patient in Figure 1 0-52 is demonstrating sciatic radiculopathy down the right leg.

Figure 10-51

Figure 10-52

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

Antaigic Lean Sign (13)

277

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

I

2

I

I

4

Either instruct the patient to stand or observe the patient standing (Fig. 10-53). RATIONALE Patients with disc protrusions that place pressure on a nerve root will lean in a direction that reduces the mechanical pressure on the disc. If the disc protrusion is lateral to the nerve root, the patient will lean away from the side pain (Fig. 1 0-54). Pain is relieved because when the patient leans away from the lateral disc defect, the nerve root moves medially and away from the defect, reducing pressure on the nerve root (Fig. 10-55). If the disc protrusion is medial to the nerve root, the patient will lean toward

Figure 10-53

Figure 10-55

Figure 10-54

278

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

the side of pain (Fig. 1 0-56). Pain of medial disc protrusion is relieved because when the patient leans toward the side of pain, the nerve root moves laterally and away from the defect, reducing pressure on the nerve root (Fig. 1 0-57). If the disc protrusion is central to the nerve root, the patient may asswne a flexed posture (Fig. 1 0-58). This is because the posterior aspect of the disc is under traction, which may reduce the surface area of the disc defect that comes in contact with the nerve root (Fig. 10-59). Figure 10-56

Figure 10-57 Figure 10-58

Pressure relieved when posterior disc tractioned

Figure 10-59

CHAPTER 10

Bowstring Sign (22)

279

LUMBAR ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

PROCEDURE

I 1

I

2

I

3

I

I

With the patient supine, place the patient's leg atop your shoulder. At this point, firm pressure should be exerted on the hamstring muscles (Fig. 1 0-60). If pain is not elicited, apply pressure to the popliteal fossa (Fig. 10-6 1 ). RATIONALE Pain in the lumbar region or radiculopathy is a positive sign of sciatic nerve compression, either in tradurally or extradurally. Applying pressure to the hamstring muscles or popliteal fossa increases tension on the sciatic nerve, thus eliciting or exacerbating the patient's pain.

Figure 10-60

Figure 10-61

280

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sciatic Tension Test (23)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient seated, passively extend the affected limb to the point of pain (Fig. 10-62). Lower the limb below the point of pain and grasp the leg between your knees. With both hands, place pos terior to anterior pressure in the popliteal space (Fig. 1 0-63). RATIONALE Flexing the leg places traction pressure on the sciatic nerve. Lowering the leg reduces the traction; if the sciatic nerve is irritated, the pain will ease. Placing additional pressure in the popliteal space with your fingers increases the traction pressure on the sciatic nerve, causing radicular pain if the sciatic nerve is irritated. An increase in pain indicates an irritation to the sciatic nerve, either intradurally or extradurally.

Figure 10-62

Figure 10-63

CHAPTER 10

Piriformis Test (24)

281

LUMBAR ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

I

o

PROCEDURE

I

I

,

I

I

2

I

I

3

I

4

Instruct the patient to lie on his or her side close to the edge of the examination table. Have the patient flex the hip and knee to 90°. Place your hand on the patient's pelvis for stabilization, and with your opposite hand press down on the patient's knee (Fig. 10-64). RATIONALE This test stresses the external rotators and piriformis muscle. If the sciatic nerve passes through the piriformis or if the piriformis is in spasm, it may impinge on the sciatic nerve and reproduce the pain in the buttock or radicular pain in the extremity.

Figure 10-64

Gluteal Skyline Test (25)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I ,

I

I

2

I

I

3

I

I

4

Instruct the patient to lie prone on the examination table, head straight and arms by the sides or hanging down. Stand at the patient's feet and observe the height of the buttock. Instruct the patient to contract each gluteal muscle (Fig. 1 0-65). RATIONALE The L5, S 1 , S2, and inferior gluteal nerves innervate the gluteal muscles. If the affected gluteal mus cle is flat and shows less contraction than the unaffected side, suspect damage to the L5, S l, S2, and inferior gluteal nerve.

Figure 10-65

III

282

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Kemp's Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient either sitting or standing, stabilize the posterior superior iliac spine with one hand. With your other hand, reach around to the front of the patient and grasp the shoulder. Passively bend the dorsolumbar spine obliquely backward (Fig. 1 0-66). RATIONALE When the patient bends obliquely backward, the dural sac on the side of bending moves laterally. If a lateral disc lesion is present, this movement will increase the nerve root tension over that disc le sion, producing pain in the lower back, usually with a radicular component on the side of oblique bending (Fig. 10-67, left). On the side opposite the oblique bending, the dural sac moves medially. If a medial disc lesion is present, this movement will increase the tension over that disc lesion, pro ducing pain in the lower back, usually with a radicular component on the side opposite the oblique bending (Fig. 1 0-67, right). If the test is positive, evaluate the affected neurological level (see Chap ter 1 1). If the patient has local lower back pain with no radicular component, suspect lumbar mus cle spasm or facet capsulitis.

Figure 10-66

Medial Disc Protrusion

Lateral Disc Protrusion

Oblique bending

Nerve /, . compression by lateral disc -�= protrusion

Figure 10-67

Nerve compression by medial disc protrusion

Left, lateral disk; right, medial disk.

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

Lindner's Sign

283

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

With the patient supine, passively flex the patient's head (Fig. 1 0-68). RATIONALE Passive flexion of the patient's head stretches the dural sac. Reproduction of the patient's pain indi cates a disc lesion at the level of pain. Sharp, diffuse pain or involuntary hip flexion may indicate meningeal irritation (see Brudzinski's Test). If you suspect disc pathology, evaluate the affected level (see Chapter 1 1 ) .

Figure 10-68

284

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Heel-Toe Walk Test (13)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

Instruct the patient to walk on the toes (Fig. 10-69), then on the heels (Fig. 1 0-70). Observe the pa tient and see whether the patient can support the entire body weight on each set of toes and each heel. RATIONALE If an L5-51 disc defect is creating pressure on the 51 nerve root, the patient may not be able to sus tain body weight while walking on the toes. This is due to weakness of the calf muscles, which are supplied by the tibial nerve. If an L4-L5 disc defect is creating pressure on the L5 nerve root, the patient may not be able to sustain the body weight while walking on the heels. This is due to the weakness of the anterior leg muscles, which are supplied by the common peroneal nerve. SUGGESTED DIAGNOSTIC IMAGING Plain film radiology AP lumbar view Lateral lurnbar view Oblique lumbar view Lumbar CT LumbarMRI Electromyography

•

•

•

Figure 10-69

Figure 10-70

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

285

SPACE-OCCUPYING LESIONS

CLINICAL DESCRIPTION Space-occupying lesions of the spine may lead to spinal stenosis. Spinal stenosis is narrowing of the tubular structures of the spine, which include the central canal, lateral recess, and intervertebral foramen. The condition may be congenital, developmental, acquired, traumatic, or postsurgical. It may be a disc defect, hypertrophic or degenerative change, synovial cyst, fracture, tumor, or a com bination. Space-occupying lesions can affect the neurological structures of the spine, such as the spinal cord, cauda equina, or nerve roots. CLINlCAL SIGNS AND SYMPTOMS •

•

•

•

•

Lower back pain Lower extremity radicular pain Lower extremity weakness Loss of lower extremity reflexes Loss of lower extremity sensation

Valsalva's Man euver (26)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

1 1

I

1

2

I

1

3

I

I

4

Instruct the seated patient to bear down as if straining at stool but concentrating the bulk of the stress at the lumbar region (Fig. 10- 7 1 ). If the patient feels any increased pain, ask him or her to point to it. This test is subjective and requires an accurate response from the patient. RATIONALE This test increases intrathecal pressure. Local pain secondary to the increased pressure may indicate a space-occupying lesion (e.g., disk defect, mass, osteophyte) in the lumbar canal or foramen.

Figure 10-71

286

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Dejerine's Triad

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

I

4

With the patient seated, instruct him to cough, sneeze, and bear down as if straining at stool (Val salva's maneuver). RATIONALE Pain local to the lumbar region after any of the previous actions indicates increased intrathecal pres sure, most likely induced by a space-occupying lesion (e.g., disc defect, mass, osteophyte). If the pa tient cannot sneeze, administer a dash of pepper (Lewin's snuff test). Milgram's Test (27) PROCEDURE Instruct the supine patient to raise the legs 2 or 3 inches above the table (Fig. 1 0-72). RATIONALE The patient should be able to perform this test for at least 30 seconds without low back pain. If pain is present, suspect a space-occupying lesion inside or out of the spinal canal. Disc protrusion usu ally produces a positive test. Patients with weak abdominal muscles may not be able to perform this test.

Figure 10-72

CHAPTER 10

LUMBAR ORTHOPAEDIC TESTS

Naffziger's Test (28)

Sensitivity/Reliability Scale

I

o

PROCEDURE With the patient seated, compress the jugular veins, which lie approximately cheal cartilage (Fig. 1 0-73 ). Hold the compression for 1 minute.

287

1

I 1

I

2

I

3

I

4

inch lateral to the tra

RATIONALE Compressing the jugular veins raises the intrathecal pressure. Local pain in the lumbar region indi cates a space-occupying lesion, usually a disc protrusion or prolapse. Radicular pain may indicate nerve root involvement. The theca is the covering of the spinal cord, which consists of the pia mater, arachnoid mater, and dura mater. SUGGESTED DIAGNOSTIC IMAGING •

•

•

•

Plain film radiology AP lumbar view Lateral lumbar view Oblique lumbar view Lumbar CT LumbarMRI Electromyography

Figure 10-73

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

288

D IFFERENTIAL D I AGNOSIS: LUMBAR VERSUS SACROILIAC INVOLVEMENT

CLINICAL DESCRIPTION Lumbar and/or radicular pain in a leg may be caused by a lumbar condition or by a pathological condition affecting the sacroiliac joint, such as sacroiliac joint syndrome, trauma, infection, inflam mation, degeneration, tumor, or tumorlike condition. The most common sacroiliac joint pathology is sacroiliac joint syndrome. It can cause local lower back pain with or without a lower extremity radicular component and may be sharp or dull. The symptoms are usually unilateral and have a right-sided predominance. Weakness, paresthesia, and dysesthesia are rare. The following tests help to determine whether the patient's lower back pain is lumbar or sacroiliac related. CLINICAL SIGNS AND SYMPTOMS •

•

•

Lower back pain Sacroiliac joint pain Aggravated by sitting Alleviated by standing or walking Lower extremity radicular pain

Goldthwaith's Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 2

I

3

I

4

With the patient supine, place one hand under the lumbar spine with each finger under an inter spinous space. With the other hand, perform a straight leg raising test. Note whether pain is elicited before, during, or after the spinous processes fan out (Fig. 1 0-74). RATIONALE Radicular pain before fanning out of the lumbar vertebrae indicates an extradural lesion, such as a sacroiliac joint disorder (0° to 35° ). Radicular pain during lumbar fanning indicates an intradural lesion, such as an intrathecal space-occupying lesion (e.g., disc defect, osteophyte, mass) (35° to 70° ). Local pain after lumbar fanning indicates a posterior lumbar joint disorder (after 70°) (see Straight Leg Raising Test).

Figure 10-74

CHAPTER 10

Supp orted Forward Bending Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

289

LUMBAR ORTHOPAEDIC TESTS

I

I 1

I

I 2

I

3

I

4

With the patient standing, instruct the patient to bend forward, keeping the knees straight (Fig. 10-75). Repeat the test, but support the ilia with your hands while bracing the patient's sacrum with your hip (Fig. 1 0-76). RATIONALE Stabilizing the ilia immobilizes the sacroiliac joints; thus, when the person bends, a lumbar lesion will elicit pain in both instances because the lumbar vertebrae are not immobilized either time. If a sacroiliac joint lesion is present, pain will be elicited only when the ilia are not immobilized.

IDl Figure 10-75

Figure 10-76

I

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

290

Nachlas Test (29 ) PROCEDURE

Sensitivity/Reliability Scale

I

o

I 1

I

2

I

3

I

4

With the patient prone, approximate the patient's heel to the buttock on the same side (Fig. 10-77). RATIONALE Flexing the leg to the buttock stretches the quadriceps muscles and the femoral nerve, which is the largest branch of the lumbar plexus (L2-L4). Radicular pain into the anterior thigh may indicate compression or irritation of the L2 to L4 nerve roots by an intradural lesion (e.g., disc defect, spur, mass), a lumbar plexus, or femoral nerve compression or irritation by an extradural lesion (piri formis muscle hypertrophy) . Stretching the quadriceps muscles causes the sacroiliac joint and the lumbosacral joints to move inferiorly. Pain in the buttock may indicate a sacroiliac joint lesion. Pain in the lumbosacral joint may indicate a lumbosacral lesion. NOTE Local pain at the anterior thigh and inability to touch the heel to the buttock may indicate a quadri ceps muscle contracture.

Figure 10-77

CHAPTER 10

29 1

LUMBAR ORTHOPAEDIC TESTS

Sign of the Buttock Test (24)

Sensitivity/Reliability Scale

I

o

PROCEDURE With the patient supine, perform a passive straight leg r aising test (Fig. tion, flex the patient's knee and see if hip flexion increases (Fig.

1 0-78) .

I 1

I

2

I

3

I

I

If you find restric

1 0-79).

RATIONALE If hip flexion increases and the patient's pain is exacerbated, the problem is in the lumbar spine, be cause there is full movement in the sacroiliac joint when the knee is flexed. This result indicates a negative sign. If hip flexion does not increase when the knee is flexed, the sacroiliac joint is dys functional. This dysfunction indicates pathology of the sacroiliac joint or buttocks, such as an in flammatory process, bursitis, mass, or abscess. This result is a positive sign.

SUGGESTED DIAGNOSTIC IMAGING Plain film radiology AP lumbar view Lateral lumbar view AP pelvis view Sacral base view S-I joint views

Figure 10-78

Figure 10-79

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

292

bar intervertebral disc. J Bone Joint Surg 1 950;

References 1 . American Academy of Orthopaedic Surgeons. The Clinical Measurement of Joint Motion. Chicago: American Academy of Orthopaedic Surgeons, 1 994. 2 . Loebl WY. Measurement of spinal posture and range of spinal movements. Ann Phys Med 1 967;9: 1 03- 1 1 0 . 3 . Fitzgerald G K , Wynveen KJ, Rheault W, e t a1. Objective assessment with establishment of normal values for lumbar spinal range of mo tion. Phys Ther 1 983;63 : 1 776- 1 78 1 . 4. Einkauf DK, Gohdes ML, Jensen GM, et al. Ob jective assessment with establishment of nor mal values for lumbar spinal range of motion. Phys Ther 1 987;67:370-375. 5. Wadsworth

CT.

Manual

Examination

and

Treatment of the Spine and Extremities. Balti more: Williams & Wilkins, 1 988. 6. Gariick JG, Webb DR. Sports Injuries: Diagno sis and Management. Philadelphia: Saunders, 1 990. 7. Jackson DW, Ciullo ]V. Injuries of the spine in the immature athlete. In Nicholas JA, Hershmann EB, eds. The Lower Extremity and Spine in

32A:786. 2 1 . Rask M. Knee flexion test and sciatica. Clin Or thop 1 978; 1 34:22 1 . 22. Cram RH. Sign of sciatic nerve root pressure. J Bone Joint Surg 1 953;358: 1 92. 23. Magee JM. Orthopaedic physical assessment. 3rd ed. Philadelphia: Saunders, 1 997. 24. Hartley A. Practical joint assessment. St. Louis: Mosby, 1 99 1 . 25. Katznelson A, Nerubay J, Level A. Gluteal sky line: a search for an objective sign in the diag nosis of disc lesions of the lower lumbar spine. Spine 1 982;7:74. 26. DeGowin EL, DeGowin RL. Bedside Diagnostic Examination.

2nd

ed.

London:

Macmillan,

1 960. 27. Scham SM, Taylor TKE Tension signs in lumbar disc prolapse. Clin Orthop Relat Res 1 9 7 1 ; 75: 1 95. 28. Arid RB, Naffziger He. Prolonged jugular com pression: a new diagnostic test of neurologic value. Trans Am Neural Assoc 1 94 1 ;66:45-48. 29. Cyriax J. Textbook of orthopaedic medicine. Vol I. 4th ed. London: Bailliere Tindall, 1 975.

Sports Medicine. Vol 2 . St. Louis: Mosby, 1 986. 8 . Jackson DW, Wiltse LL, Dingeman RD, Hayes M. Stress reactions involving the pars interartic ularis in young athletes. Am J Sports Med 1 98 1 ;9:304-3 1 2 .

General References An1erican Medical Association. Guides to the evalu ation

9 . O'Donoghue D . Treatment of Injuries t o Ath letes. 4th ed. Philadelphia: Saunders, 1 984. 1 0 . Turek SL. Orthopaedics. 3rd ed. Philadelphia: JB Lippincott, 1 977.

of

ed.

lumbar spine. New York: Churchill Livingstone, Chadwick PR. Examination, assessment and treat ment

clinical studies of the effects of medial hip rota

1 984;70:2.

tion. Spine 1 979;4:242. Observations

3rd

Bogduk N, Twomey LT. Clinical anatomy of the

tions in straight-leg-raising test: cadaveric and

WHo

impairment.

1 987.

I I . Breig A, Troup JDG. Biomechanical considera

1 2 . Fahrni

permanent

Chicago: AMA, 1 988.

of the

lumbar

spine.

Physiotherapy

Charnley J. Orthopaedic signs in the diagnosis of on

straight-Ieg

raising with special reference to nerve root ad hesions. Can J Surg 1 966;9:44. 1 3 . Hoppenfeld S. Physical examination of the spine and extremities. New York: Appleton Century-Crofts, 1 976: 1 27. 1 4 . Urban LM. The straight-leg-raising test: a re view. J Orthop Sports Phys Ther 1 98 1 ;2: 1 1 7. 1 5 . Lasegue e. Considerations sur la sciatique. Arch Gen Meil 1 864;24:558. 16. Wilkins RH, Brody IA. Lasegue's sign. Arch Neurol 1 969;2 1 : 2 1 1 O. 1 7 . Maitland D. The slump test: examination and treatment. Aust J Physiother 1 985;3 1 : 2 1 5-2 1 9. 1 8. Dyck P. The femoral nerve traction test with lumbar disc protrusion. Surg NeuroI 1 976;6: 1 63 . 1 9. Hudgins WR. The crossed-straight-Ieg-raising test. N Engl J Med 1 977;297: 1 1 27. 20. Woodhall R, Hayes GJ. The well-leg-raising test of Fajersztajn in the diagnosis of ruptured lum-

disc protrusion with special reference to the straight-leg-raising test. Lancet 1 95 1 ; 1 : 1 56. Cyriax J. Textbook of ortl10paedic medicine. Vol ! . Diagnosis of soft tissue lesions. London: Bail lien'! Tindall, 1 982. D'Ambrosia RD. Musculoskeletal Disorders: Re gional Examination and Differential Diagnosis. 2nd ed. Philadelphia: JB Lippincott, 1 986. Derosa C, Portefielf J. Review for Advanced Or thopaedic Competencies: The Low Back and Sacroiliac Joint and Hip. Chicago: 1 980. Edgar MA, Park WM. Induced pain patterns on pas sive straight-leg-raising in lower lumbar disc protrusion. J Bone Joint Surg 1 974;56B:658. Farfan HE Mechanical disorders of the low back. Philadelphia: Lea & Febiger, 1 973. Farfan H F, Cossette JW, Robertson GW, et a1. Effects of torsion on lumbar intervertebral joints: the role of torsion in the production of disc degen eration. J Bone Joint Surg 1 970; 52A:468.

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Finneson BE. Low Back Pain. 2nd ed. Philadelphia: JB Lippincott, 1 98 1 . Charles C. Thomas, 1 977. straight-leg-raising in the lumbo-sacral roots, nerves, and plexus and in the intrapelvic section of the sciatic nerve. J Neurol Neurosurg Psychi

McKenzie RA. The Lumbar Spine: Mechanical Diag Spinal Publications, 1 98 1 . McRae R. Clinical Orthopaedic Examination. New York: Churchill Livingstone, 1 976. Nachemson A. Towards a better understanding of low back pain: a review of the mechanics of the

atry 1 965;28: 1 2 . Gracovetsky S , Farfan H F, Lamy C. The mechanism of the lumbar spine. Spine 1 9 8 1 ;6:249-262. Grieve GP. Common Vertebral Joint Problems. 2nd ed. New York: Churchill Livingstone, 1 988. Helfet AI, Lee DM. Disorders of the lumbar spine.

Trunk and the Vertebral Column. New York: Churchill Livingstone, 1 974. due

to

nerve

lumbar disc. Rheumatol Rehabil 1 975; 1 4 : 1 2 1 0 . Panjabi M, Krag M, Chung T. Effects of disc injury on mechanical behavior of the human spine. Spine 1 984;9:707. Post M. Physical Examination of the Musculoskele tal System. Chicago: Year Book, 1 987.

Philadelphia: J B Lippincott, 1 978. Kapandji lAo The physiology of joints. Vol 3. The

Pain

chronic low back dysfunction patients. Spine

nosis and Therapy. Waikanae, New Zealand:

Goddard BS, Reid JD. Movements induced by

JD.

293

1 984;9:588-595.

Fisk Jw. The Painful Neck and Back. Chicago:

Loeser

LUMBAR ORTHOPAEDIC TESTS

Ruge D, Wiltse LL. Spinal disorder diagnosis and treatment. Philadelphia: Lea & Febiger, 1 977. Travell JG, Simmons DG. Myofascial Pain and Dys

injury.

Spine

1 985;1 0:232. Macnab 1 . Backache. Baltimore: Williams & Wilkins, 1 977. Mayer TG, Tencer AF, Kristoferson S, et al. Use of

function: The Trigger Point Manual. Vol 2. The Lower

Extremities.

Baltimore:

Williams

&

Wilkins, 1 992. White AA, Panjabi M M . Clinical biomechanics of the spine. Toronto: JB Lippincott, 1 978.

non-invasive techniques for quantification of

Wooden MJ. Preseason screening of the lumbar

spinal range-of-motion in normal subjects and

spine. J Orthop Sports Phys Ther 1 9 8 1 ;3:6.

--------��-LUMBAR NERVE ROOT LESIONS

TI2, Ll, L2, L3 Motor

298

L5

299

Iliopsoas Reflex

299

305

Extensor Hallucis Longus

300

Sensory

305 Motor

Gluteus Medius

300

Extensor Digitorum Longus and Brevis

L2, L3, L4

301

Motor

301

Reflex 301

Sensory

307

308

302

Patella Reflex Sensory

307

307

Medial Hamstring Reflex

Quadriceps Muscle Reflex

305

306

302

SI

309 Motor

302

309

Peroneus Longus and Brevis L4

303 Motor

Reflex 303

Achilles Reflex

Tibialis Anterior Reflex Sensory

294

303

304

Patella Reflex 304

310

304

Sensory

310

310

309

CHAPTER 11

LUMBAR NERVE ROOT LESIONS

295

TI2, LI, L2, L3 CLINICAL DESCRIPTION Nerve roots in the lumbar spine exit the spinal column through laterally placed intervertebral foramina. The nerve roots in the lower thoracic and lumbar spine gradually exit their intervertebral foramen at its upper aspect. This causes the nerve root in these areas to be affected by the interver tebral disc above the exiting nerve root (Fig. 11-1). The lower thoracic area and upper lumbar area (Tl2-L2) are transitions to this anatomic consideration and in this area may be affected either by

Nerve root

m Compression of nerve by protruding disc

Figure 11-1

296

PHOTOGRAPHIC MANUAl OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

the intervertebral disc at the same interval or the disc at the level above the exiting nerve root. This situation may depend on the laterality of the disc defect. The L3 to L5 nerve roots exit the interver tebral foramen at the upper end of the foramen 80% of the time, and they are usually affected by the intervertebral disc above the exiting nerve root. Because of its anatomic position, the S1 nerve root is usually affected by the L5-S1 intervertebral disc. If a lumbar nerve root lesion is suspected, you must evaluate three clinical aspects of the neurological examination: sensory dysfunction, mo tor dysfunction, and reflex dysfunction. The sensory deficit evaluation addresses the segmental cutaneous innervation of the skin. It is tested with a sterile or disposable Neurotip or pinwheel in specific dermatomal patterns. Two der matomal maps are provided here. Figure 11-2 indicates the body areas of intact sensation when roots above and below an isolated root are interrupted, sensation loss when one or more continu ous roots are interrupted, or the pattern of herpetic rash and hypersensitivity in isolated root in volvement. Figure 11-3 presents the hyposensitivity to pin scratch in various root lesions and is con sistent with electrical skin resistance studies showing axial derma tomes extending to the distal extremities. This pattern is useful in evaluating paresthesias and hyperesthesias secondary to root ir ritation. This is the pattern that will be delineated to evaluate sensory root dysfunction. Since a fair amount of segmental overlap exists, a single unilateral lesion may affect more than one dermatomal level. Motor function is tested by evaluating the muscle strength of specific muscles innervated by a particular nerve root or roots using the muscle grading chart adopted by the American Academy of Orthopaedic Surgeons (Box 11-1). The reflex arc is tested by evaluating the superficial stretch reflex associated with the particular nerve root. These reflexes are graded by the Wexler scale (Box 11-2).

Muscle Grading Chart 5

Complete range of motion against gravity with full resistance

4

Complete range of motion against gravity with some resistance

3

Complete range of motion against gravity

2

Complete range of motion with gravity eliminated

1

Evidence of slight contractility; no joint motion

o

No evidence of contractility

Wexler Scale o

No response

+1

Hyporeflexia

+2

Normal

+3

Hyperreflexia

+4

Hyperreflexia with transient clonus

+5

Hyperreflexia with sustained clonus

C2 3 �C C4 C5 T2 T4

.

01 ,

� '

-

.

*

()

� ::':l m

82

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1; !::

� '"

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� '§ � t""' m en

/f� �

o

Figure 11-2

Z

en

Figure 11-3 N \C '-.J

II

298

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

The clinical presentation of nerve root lesions depends on two important factors: the location and the severity of the injury or pathology. These two factors determine the lesion's clinical presen tation. The possibilities range from no clinical signs or slight clinical manifestation, such as slight loss of sensation and pain, to total denervation with complete loss of function (motor, sensory, and reflex) in the structures innervated by the involved nerve root. Each nerve root has its own sensory distribution, muscle test or tests, and a stretch reflex, which will be grouped to facilitate identifica tion of the suspected level. The clinical evaluation is not made solely on one aspect of the neurological package but is de termined by the combination of history, inspection, palpation, the three individual tests (motor, re flex, and sensory), and appropriate diagnostic imaging and/or functional neurological testing, such as electromyography. Furthermore, the injury or pathology may not necessarily affect a nerve root; it may affect the lumbar plexus, a trunk of that plexus, or a named nerve. Depending on the sever ity and location of the injury or pathology, various combinations of neurological dysfunction may be revealed.

TI2, LI, L2, L3 The T12, 11, L2, and L3 nerve roots exit the spinal canal at their respective levels. The Tl2 and 11 nerve roots can be affected by the intervertebral disc at their respective levels or levels above them, depending on the size and laterality of the disc defect (Fig. 11-4).

Figure 11-4

CHAPTER 11

LUMBAR NERVE ROOT LESIONS

299

Motor

Iliopsoas: T12, Ll, L2, L3 Nerve Root Innervation PROCEDURE With the patient sitting at the edge of the examination table, instruct the patient to raise the thigh off the table. Place your hand on the patient's knee and instruct the patient to continue to raise the thigh against your resistance (Fig. 11-5). Perform the test on the opposite thigh. Grade according to the muscle grading chart and evaluate bilaterally. RATIONALE A grade 0 to 4 unilaterally may indicate a neurological deficit of the Tl2, Ll, L2, or 13 nerve root. Suspect a weak or strained iliopsoas muscle if the sensory portion of the T12, Ll, L2, or 13 neuro logical package is intact.

Figure 11-5

300

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Reflex There is no reflex test.

Sensory PROCEDURE With a pin, stroke the dermatomal area corresponding to each nerve root (Fig. 11-6) and evaluate bilaterally. RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the corresponding Tl2, 11, L2, or L3 nerve root or the femoral nerve.

C7

Figure 11-6

CHAPTER 11

LUMBAR NERVE ROOT LESIONS

301

L2, L3,IA The L2, L3, and L4 nerve roots can be affected by the intervertebral disc at their respective levels or levels above them, depending on the size and laterality of the disc defect (Fig. ll-7).

Figure 11-7

Motor

Quadriceps Muscle: L3, L4 Femoral Nerve Innervation PROCEDURE With the patient sitting at the edge of the examination table, instruct the patient to extend the knee. Place one hand on the patient's thigh for stabilization and place the other hand on his or her leg. Ex ert pressure on the leg while instructing the patient to resist flexion (Fig. ll-8). Grade according to the muscle grading chart and evaluate bilaterally. RATIONALE A grade 0 to 4 unilaterally may indicate a neurological deficit of the L2, L3, or L4 nerve root or femoral nerve. Suspect a weak or strained quadriceps muscle if the sensory portion of the L2, L3, or L4 neurological package is intact.

Figure 11-8

m

302

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Reflex

Patella Reflex The patella reflex is primarily an L4 reflex and is tested with the L4 neurological level.

Sensory PROCEDURE With a pin, stroke the dermatomal area corresponding to each nerve root (Fig. 11-9) and evaluate bilaterally. RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the corresponding L2, L3, or L4 nerve roots or the femoral nerve.

Figure 11-9

CHAPTER 11 LUMBAR NERVE ROOT LESIONS

303

IA The L4 nerve root exits the spinal canal between the L4 and L5 vertebrae and is usually affected by the L3-L4 intervertebral disc (Fig. 11-10).

Figure 11-10

Motor

Tibialis Anterior: L4, LS Deep Fibular Nerve Innervation PROCEDURE With the patient seated at the edge of the examination table, instruct the patient to dorsiflex and in vert the foot. Grasp the patient's ankle with one hand and foot with your other hand, and attempt to force the foot into plantar flexion and eversion against resistance by the patient (Fig. 11-11). Grade according to the muscle grading chart and evaluate bilaterally. RATIONALE A grade 0 to 4 unilaterally may indicate a neurological deficit of the L4 nerve root or the deep fibu lar nerve. A weak or strained tibialis anterior muscle may be suspected if the sensory and reflex por tions of the L4 neurological package are intact.

Figure 11-11

III

304

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Reflex

Patella Reflex PROCEDURE With the patient seated at the edge of the examination table, tap the infrapatellar tendon with the neurological reflex hammer (Fig. 11-12). RATIONALE Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an upper motor neuron lesion.

Figure 11-12

Sensory PROCEDURE With a pin, stroke the medial aspect of the leg and foot (Fig. 11-13) and evaluate bilaterally. RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the L4 nerve root.

Figure 11-13

CHAPTER 11

LUMBAR NERVE ROOT LESIONS

305

L5 The L5 nerve root exits the spinal canal between the L5 vertebra and the first sacral segment and is usually affected by the L4-L5 intervertebral disc (Fig. 11-14).

Figure 11-14

Motor

Extensor Hallucis Longus: L5, 51 Deep Fibular Nerve Innervation PROCEDURE With the patient seated at the edge of the examination table, grasp the patient's calcaneus with one hand for stabilization. With your opposite hand, pinch the great toe and instruct the patient to dor siflex it against your resistance (Fig. 11-15). Grade according to the muscle grading chart and com pare bilaterally. RATIONALE A grade 0 to 4 unilaterally may indicate a neurological deficit of the L5 nerve root or the deep fibu lar nerve. A weak or strained extensor hallucis longus muscle may be suspected if the sensory and reflex portions of the L5 neurological package are intact.

Figure 11-15

III

306

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Gluteus Medius: L5, S 1 Superior Gluteal Nerve Innervation PROCEDURE With the patient side-lying on the examination table, instruct the patient to abduct the superior leg (Fig. 11-16). Place your hand on the lateral aspect of the patient's knee and attempt to push the knee into adduction against patient resistance (Fig. 11-17). Grade according to the muscle grading chart and evaluate bilaterally. RATIONALE A grade 0 to 4 unilaterally may indicate a neurological deficit of the L5 nerve root or the superior gluteal nerve. A weak or strained gluteus medius muscle may be suspected if the sensory and reflex portions of the L5 neurological package are intact.

Figure 11-16

Figure 11-17

CHAPTER 11

LUMBAR NERVE ROOT LESIONS

307

Extensor Digitorum Longus and Brevis: L5, S1 Superficial Fibular Nerve Innervation PROCEDURE With the patient sitting at the edge of the examination table, grasp the calcaneus to stabilize the foot. With your opposite hand, grasp the patient's second through fifth toes and instruct the patient to dorsiflex the toes against your resistance (Fig. 11-18). RATIONALE A grade 0 to 4 unilaterally may indicate a neurological deficit of the L5 nerve root or the superficial fibular nerve. A weak or strained extensor digitorum longus and/or brevis muscle may be suspected if the sensory and reflex portions of the L5 neurological package are intact.

Figure 11·18

Reflex

Medial Hamstring Reflex PROCEDURE With the patient prone, slightly flex the patient's knee and place your thumb on the medial ham string tendon. With a neurological reflex hammer, tap the medial hamstring tendon (Fig. 11-19). The patient should slightly flex the knee. RATIONALE Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an upper motor neuron lesion.

Figure 11·19

m

308

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sensory PROCEDURE With a pin, stroke the lateral leg and dorsum of the foot (Fig. 11-20). Evaluate bilaterally. RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the LS nerve root.

Figure 11-20

CHAPTER 11

LUMBAR NERVE ROOT LESIONS

309

SI The 51 nerve root exits the spinal canal through the first sacral foramen and is usually affected by the L5-51 intervertebral disc (Fig. 11-21).

Figure 11·21

Motor

Peroneus Longus and Brevis: L5, S1 Superficial Fibular Nerve Innervation PROCEDURE With the patient sitting at the edge of the examination table, stabilize the calcaneus with one hand and grasp the lateral aspect of the foot with your opposite hand. Instruct the patient to plantarflex and evert the foot against your resistance (Fig. 11-22). Grade according to the muscle grading chart and evaluate bilaterally. RATIONALE A grade 0 to 4 unilaterally may indicate a neurological deficit of the 51 nerve root or the superficial fibular nerve. A weak or strained peroneus longus and/or brevis muscle may be suspected if the sen sory and reflex portions of the 51 neurological package are intact.

Figure 11-22

_

310

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Reflex

Achilles Reflex PROCEDURE With the patient seated at the edge of the examination table, place slight dorsiflexion on the foot. With a neurological reflex hammer, tap the Achilles tendon (Fig. 11-23). The patient should exhibit a slight plantar flexion of the foot. RATIONALE Unilateral hyporeflexia may indicate a nerve root deficit. Loss of reflex unilaterally may indicate an interruption of the reflex arc (lower motor neuron lesion). Unilateral hyperreflexia may indicate an upper motor neuron lesion.

Figure 11-23

Sensory PROCEDURE With a pin, stroke the lateral aspect of the foot (Fig. 11-24). RATIONALE Unilateral hypoesthesia may indicate a neurological deficit of the S1 nerve root. SUGGESTED DIAGNOSTIC IMAGING AND FuNCTIONAL TESTING •

•

•

Lumbar magnetic resonance imaging Electromyography Somatosensory evoked potential

Figure 11-24

CHAPTER 11

General References Barrows HS. Guide to Neurological Assessment. Philadelphia: JB Lippincott, 1980. Braziz PW, Masdeu JC, Biller J. Localization in Clin ical Neurology. 3rd ed. New York: Little, Brown. Bronisch FW. The Clinically Important Reflexes. New York: Grune & Stratton, 1952. Chusid JG. Correlative Neuroanatomy and Func tional Neurology. 16th ed. Los Altos, CA: Lange

extremities.

Kendall FP, McCreary EK, Provance PG. Muscles: Wilkins, 1993. Mancall E. Essentials of the neurologic examination. 2nd ed. Philadelphia: FA Davis, 1981. Moore KL, Dailey AF. Clinically Oriented Anatomy. 4th ed. Baltimore: Lippincott Williams & Wilkins, 1999.

Livingstone, 1988.

Appleton-Century

Testing and Function. 4th ed. Baltimore: Williams &

Parsons

nial and Peripheral Nerves. New York: Churchill

New York:

Croft, 1976;127.

DeJong RN. T he Neurologic Examination. 4th ed.

Devinsky 0, Feldmann E. Examination of the Cra

311

Hoppenfeld S. Physical examination of the spine and

Medical, 1976.

Hagerstown, MD: Harper & Row, 1979.

LUMBAR NERVE ROOT LESIONS

N. Color

Atlas of

Clinical

Neurology.

Chicago: Year Book Medical, 1989. VanAllen MW, Rodnitzky RL. Pictorial Manual of Neurologic Tests. 2nd ed. Chicago: Year Book Med ical, 1981.

Geenberg DA, Aminoff MJ, Simon RP. Clinical neu rology. 2nd ed. East Norwalk, CT: Appleton & Lange, 1993.

m

--------��-SACROILIAC ORTHOPAEDIC TESTS

SACROILIAC JOINT ORT HOPAEDIC

Sacroiliac Stretch Test

EXAMINATION FLOW CHART

Sacroiliac Resisted Abduction Test

313

320 320

Sacrotuberous Ligament Stress PALPATION

314

Test

321

Posterior Superior Iliac Spine and Iliac Crest

314

GENERAL SACROILIAC JOINT

Sacroiliac Articulations Ischial Tuberosity

315

315

L E SIONS

322

Hibb's Test

322

Pelvic Rock Test (Iliac Compression SACROILIAC SP RAIN Gaenslen's Test

316

Lewin-Gaenslen Test Yeoman's Test

Test)

317

323

Sign of the Buttock Test 318

Flamingo Test

323

324

319

312

CHAPTER 12

SACROILIAC ORTHOPAEDIC TESTS

313

Sacroiliac Orthopaedic Examination

�

I H;ry I I Palpation I Evaluate for lumbar spine dysfunction (Chapter 10)

+ (+)

(+)

Supported forward bending test

(Lumbar)

(Sacroiliac)

1 (+)

I

Yeoman's test Sacroiliac stretch test Sacroiliac resisted abduction test Sacrotuberous ligament stress test

I

1

Sacroiliac I!gament spraIn

I

I

( )

Evaluate for hip dysfunction

I

t(+)(Hip)

-I Hibb's test I

-

t(+)(Sacroiliacjoint)

Pelvic rock test Lewin-Gaenslen test Sign of the buttock test Flamingo test

I

t(+)

General sacroiliac .. joint lesion

If)

314

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PALPATION Posterior Superior Iliac Spine and Iliac Crest DESCRIPTIVE ANATOMY The iliac crest and posterior superior iliac spine are important bony landmarks used to assess pos tural deviations and leg length deficiencies. The iliac crest extends through the inferior margin of the flank and is easily palpable. The posterior superior iliac spine is inferior to the iliac crest and lat eral to the

52 sacral segment (Fig. 12-1).

PROCEDURE With the patient standing, palpate the iliac crest for tenderness (Fig.

12-2). Tenderness may be

caused by contusions, periosteitis, or avulsion fractures. Next, place your forefingers on each iliac crest and your thumbs on the posterior superior iliac spines of each ilium (Fig.

12-3). Note any dif

ference in longitudinal position, which may indicate a leg length discrepancy, scoliosis, sacroiliac joint subluxation, or hip joint dislocation.

Iliac

Posterior superior iliac spine

Sacroiliac -+---'or--+-''---� articulation

Figure 12-1

Figure 12-2

Figure 12-3

CHAPTER 12

SACROILIAC ORTHOPAEDIC TESTS

315

Sacroiliac Articulations DESCRIPTIVE ANATOMY The sacroiliac articulations are inferior and medial to the posterior superior iliac spine (Fig.

12- 1).

The articulations are synovial and are held together by interosseous ligaments and ventral and dor sal sacroiliac ligaments. The movement of the sacroiliac joints is limited to slight gliding and rota tion. These joints are primarily weight bearing; they transfer the weight of the trunk to the hip joints.

PROCEDURE With the patient prone, flex the patient's knee to 90° and externally rotate the hip. With your oppo site hand, palpate the sacroiliac joint from just below the posterior superior iliac spine to the sacral notch (Fig.

12-4). Note any pain or tenderness that may indicate an inflammatory process in the

sacroiliac joint.

Figure 12-4

Ischial Tuberosity DESCRIPTIVE ANATOMY The ischial tuberosity is just below the gluteal fold (Fig.

12- 1) and can be palpated easily with the

hip flexed. The hamstring muscles originate from the tuberosity. The tuberosity may be injured by direct trauma or by trauma to the hamstring muscles.

PROCEDURE Have the patient lie on one side and flex the hip by bringing the knee to the chest. Palpate the ischial tuberosity, noting any pain or tenderness (Fig.

12-5). Pain may indicate a contusion secondary to

trauma, an avulsion fracture caused by severe hamstring pull, or ischial tuberosity bursitis.

Figure 12-5

.n .a

316

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

SACROILIAC SPRAIN CLINICAL DESCRIPTION The sacroiliac joint is a very strong cartilaginous joint that produces little movement. The sacrum is suspended between the two iliac bones and held in place by very strong interosseous dorsal sacroil iac ligaments. The joint is under great stress that predisposes it to sprains. The joint movement is limited by the tension of the sacrotuberous, sacrospinous, and sacroiliac ligaments (Fig.

12-6). These

ligaments may be stretched, causing ligamentous sprain by some of the following movements:

1. Sudden contracture of the hamstrings or abdominal muscles, which exerts a rotating force on the ilium

2. Sudden unexpected twisting motions of the trunk, which may occur in sports such as football and basketball

3. Vigorous pulling while bending forward 4. A fall on one or both buttocks The patient may have acute lower back pain and difficulty in bending. In unilateral cases it may cause the patient to elevate the hip when standing on the painful side to avoid weight bearing over the sacroiliac joint. Local tenderness is a common finding.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Sacroiliac joint pain Abnormal gait Tender sacroiliac joint on palpation Pain on forward flexion

Figure 12-6

CHAPTER 12

317

SACROILIAC ORTHOPAEDIC TESTS

Gaenslen's Test (4)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient supine and the affected side near the edge of the table, instruct the patient to ap proximate the knee to the chest on the unaffected side (Fig.

12-7). Then place downward pressure 12-8).

on the affected thigh until it is lower than the edge of the table (Fig.

RATIONALE Extension of the leg stresses the sacroiliac joint and anterior sacroiliac joint ligaments on the side of leg extension. Pain on that side indicates a general sacroiliac lesion, that is, anterior sacroiliac liga ment sprain (iliofemoral, ischiofemoral) or inflammatory process in the sacroiliac joint.

Figure 12-7

m

Figure 12-8

318

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Lewin-Gaenslen Test

Sensitivity/Reliability Scale

I

o

PROCEDURE Instruct the patient to lie on the unaffected side and flex the inferior leg (Fig. rior leg and extend it while you stabilize the lumbosacral joint (Fig.

I 1

I

2

I

3

I

I

12-9). Take the supe

12- 10).

RATIONALE Extension of the leg stresses the sacroiliac joint and anterior sacroiliac joint ligaments on the side of leg extension. Pain on that side indicates a general sacroiliac joint lesion, that is, anterior sacroiliac ligament sprain (iliofemoral, ischiofemoral ligaments) or inflammatory process in the sacroiliac joint.

Figure 12-9

Figure 12-10

CHAPTER 12

SACROILIAC ORTHOPAEDIC TESTS

Yeoman's Test (2)

319

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient prone, grasp the patient's lower leg and passively flex the knee, then extend the hip (Fig.

12- 1 1).

RATIONALE Extension of the thigh stresses the sacroiliac joint and anterior sacroiliac joint ligaments on the side of thigh extension. If pain is elicited on the ipsilateral side, suspect a sprain of the anterior sacroil iac joint ligaments, that is, the iliofemoral or ischiofemoral ligament (Fig.

12- 12). Pain or an increase

in pain may also indicate an inflammatory process or abscess in the sacroiliac joint.

NOTE This test also stresses the lower lumbar vertebra by slightly extending the lumbar spine. Lumbar pain, either local or radiating, may indicate lumbar involvement. See Chapter

10 for evaluation.

Figure 12-11

Iliac

Posterior superior iliac spine

Sacroiliac -+----'..--+--'--""(' articulation

Ischiofemoral-+----tfi----' ligament

Figure 12-12

Posterior sacroiliac ligaments rous

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

320

Sacroiliac Stretch Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient supine, cross the patient's arms and apply posterior and lateral pressure to the an terior superior iliac spine of each ilium (Fig.

12- 13).

RATIONALE Pressure on both anterior and superior iliac spines simultaneously compresses both sacroiliac joint surfaces and stretches the anterior sacroiliac ligaments. If pain is elicited or increased in one or both joints, suspect a strain of the anterior sacroiliac ligaments, that is, iliofemoral or ischiofemoral liga ment (see Fig.

12-6). Pain in the joint may also indicate an inflammatory process in the affected

joint.

Figure 12-13

Sacroiliac Resisted Abduction Test PROCEDURE

Sensitivity/Reliability Scale

I

o

I 1

I

2

I

3

I

4

Instruct the patient to lie on one side with the inferior hip and knee slightly flexed. The superior leg should be straight and abducted. Place pressure on the abducted limb against patient resistance (Fig.

12- 14). RATIONALE Resisting abduction of the hip stresses the sacroiliac joint and abductor muscles of the hip. Increased pain in the sacroiliac joint indicates a sprain of the sacroiliac ligaments on the ipsilateral side. Pain in the affected buttock or lateral thigh indicates a strain of the abductor muscles of the thigh (ten sor fasciae latae and gluteus group).

Figure 12-14

CHAPTER 12

321

SACROILIAC ORTHOPAEDIC TESTS

Sacrotuberous Ligament Stress Test (3)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

Place the patient supine. Fully flex the patient's knee and hip and adduct and internally rotate the hip. With your opposite hand, palpate the sacrotuberous ligament, which runs from the posterior aspect of the sacrum to the ischial tuberosity (Fig.

12- 15).

RATIONALE The sacrotuberous ligament anchors the sacrum to the ischial tuberosity. The action of hip adduc tion and medial hip rotation stresses the sacrotuberous ligament. Increased pain in the area of the sacrotuberous ligament may indicate a sacrotuberous ligament sprain.

SUGGESTED DIAGNOSTIC IMAGING Plain film radiography AP pelvis view

Figure 12-15

322

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

GENERAL SACROILIAC JOINT LESIONS CLINICAL DESCRIPTION The sacroiliac joint is a strong weight-bearing synovial joint with little movement. The surfaces are irregular to provide some interlocking of the sacrum to the ilium. This articulation is subject to in flammation due to trauma, overuse, or degenerative arthritis. Diffuse idiopathic skeletal hyperosto sis, which produces osteophytes along the inferior aspect of the sacroiliac joint, may result in a painful joint. Ankylosing spondylitis, which is usually bilateral, may cause restriction and pain. The following tests attempt to increase the pressure in the sacroiliac joint or distract the joint to initiate or exacerbate sacroiliac joint pain.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

Sacroiliac joint pain Abnormal gait Tender sacroiliac joint on palpation Pain on forward flexion Pain on sitting

Hibb's Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient prone, flex the patient's leg to the buttock and move the leg outward, internally ro tating the hip (Fig.

12- 16).

RATIONALE This procedure causes a stressed internal rotation of the femoral head into the acetabular cavity and causes slight distraction on the sacroiliac joint. This test is mainly a hip joint test, but because of the sacroiliac joint distraction, it may help you evaluate sacroiliac joint lesions. Pain in the sacroiliac joint indicates a sacroiliac joint lesion, such as an inflammatory process or abscess in the sacroiliac joint or a sprain of the sacroiliac ligaments. Pain in the hip joint indicates a hip joint lesion (see Hibb's test in Chapter

13).

Figure 12-16

CHAPTER 12

SACROILIAC ORTHOPAEDIC TESTS

Pelvic Rock (Wac Compression) Test (4)

323

Sensitivity/Reliability Scale

I

PROCEDURE

I 1

I

2

I

I

3

I

4

With the patient side-lying, exert a strong downward pressure on the ilium. Perform this test bilat erally (Fig.

12- 17).

RATIONALE Downward pressure on the ilium transfers a compression pressure to the joint surfaces of the sacroiliac joints. Pain in either sacroiliac joint indicates a sacroiliac joint lesion, such as an inflam matory process in the joint surfaces on the affected side.

Figure 12-17

Sign of the Buttock Test (5)

Sensitivity/Reliability Scale

I

o

PROCEDURE With the patient supine, perform a passive straight leg raising test (Fig. found, flex the patient's knee and see if hip flexion increases (Fig.

I 1

I

2

I

3

I

4

12- 18). If restriction is

12-19).

RATIONALE If hip flexion increases and the patient's pain is exacerbated, the problem is in the lumbar spine, be cause there is full movement in the sacroiliac joint when the knee is flexed. This is indicative of a negative sign. If hip flexion does not increase when the knee is flexed, the sacroiliac joint is dys functional. This indicates pathology of the sacroiliac joint or buttocks, such as an inflammatory process, bursitis, mass, or abscess. This is indicative of a positive sign.

Figure 12-18

Figure 12-19

m

324

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Flamingo Test (6)

Sensitivity/Reliability Scale

I

a

PROCEDURE Instruct the patient to stand on one leg at a time (Fig. creases stress on the joint (Fig.

I 1

I 2

I

3

I

12-20). Instruct the patient to hop, which in

12-2 1).

RATIONALE This test increases the pressure in the hip, sacroiliac articulation, and symphysis pubis articulation. Increased pain in any of these joints may indicate an inflammatory process on the standing leg side. Pain following trauma may indicate a fracture in the suspected joint. Pain in the hip joint may also indicate trochanteric bursitis.

SUGGESTED DIAGNOSTIC IMAGING Plain film radiography AP pelvis view

Figure 12-20

Figure 12-21

CHAPTER 12

References 1. Gaenslen

FJ.

Sacroiliac

arthrodesis.

JAMA

2. Yeoman W. The relation of arthritis of the sacroil iac joint to sciatica. Lancet 1928;2: 12 19- 1222. 3. Lee D. The Pelvic Girdle. Edinburgh: Churchill Livingstone, 1989. 4. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton Century-Crofts, 1976: 127. Vol.

I.

London:

amination. 3rd ed. New York: Macmillan, 1976. Gray H. Sacroiliac joint pain: the finer anatomy. New Intern Clin 1938;2:54. Hartley A. Practical Joint Assessment. St. Louis: Mosby, 1991. McRae R. Clinical Orthopedic Examination. New York: Churchill Livingstone, 1976 Meschan I. Roentgen Signs in Diagnostic Imaging.

5. Cyriax J. Textbook of Orthopaedic Medicine. ed.

325

DeGowin EL, DeGowin RL. Bedside Diagnostic Ex

1927;89:203 1-2035.

4th

SACROILIAC ORTHOPAEDIC TESTS

Bailliere

Tindall,

1975:54 1. 6. Magee DJ. Orthopedic Physical Assessment. 3rd ed. Philadelphia: Saunders, 1997.

2nd ed. Vol 3. Sydney: Saunders, 1985. Norlon C, Levangie P. Joint Structure and Function: A Comprehensive Analysis. Philadelphia: FA Davis, 1987. Post M. Physical Examination of the Musculoskele tal System. Chicago: Year Book Medical, 1987.

General References A1derink GJ. The sacroiliac joint: review of anatomy, mechanics, and function. J Orthop Sports Phys Ther 199 1;13:71.

Wells PE. The examination of the pelvic joints. In: Grieve GP, ed. Modern Manual Therapy of the Ver tebral Column. Edinburgh: Churchill Livingstone, 1986.

--------��-HIP JOINT ORTHOPAEDIC TESTS

HIP JOINT ORTHOPAEDIC EXAMINAT ION

327

FLOW CHART PALPAT ION

Anvil Test

328

HIP CONTRACTURE T EST S

Iliac Crest and Anterior, Superior, and Inferior Iliac Spine Greater Trochanter Hip Joint

328 330

344

344

T homas Test

Rectus Femoris Contracture Test Ely's Test

331

Ober's Test

Tensor Fasciae Latae Muscle Femoral Triangle

343 343

HIP FRACTURES

332

346 347

P iriformis Test

348

333 GENERAL HIP JOINT LESIONS

HIP RANGE OF MOTION

334

P atrick Test (Faber)

334 335 Abduction 336 337 Adduction Flexion

Trendelenburg Test

Extension

Scouring Test Hibb's Test

338 339

Internal Rotation External Rotation

CONGENITAL HIP DYSPLASIA Allis Test

340

Ortolani's Click Test Telescoping Sign

326

351 352 352

Laguerre's Test

342

341

340

349 350

349

345

CHAPTER 13

HIP JOINT ORTHOPAEDIC TESTS

327

Hip Joint Orthopaedic Examination

� History

I

Hip pain,

Hip pain

No trauma (adult)

Trauma induced (adult) Allis test Ortolani's click test Telescoping sign

Range of motion (active)

Range of motion

(passive)

(passive)

(active)

(+) Patrick test (Faber) Trendelenburg test Scouring test Laguerre's test

(

-

Thomas test )

Rectus femoris contracture test Ely's test

(+)

Hibb's test

m (

-

)

Hamstring contracture test

(- ) 1---'-----"�1 --l

--.,.. _..

328

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PALPATION Iliac Crest and Anterior, Superior, and Inferior Iliac Spine DESCRIPTIVE ANATOMY The iliac crest is at the inferior margin of the flank from the anterior; from the posterior, its highest point is at the level of the L4 spinous process (Fig. 13-1). The iliacus, external oblique, and tensor fasciae latae muscles originate from the iliac crest. At the anterior terminal end of the iliac crest lies the anterior superior iliac spine (Fig. 13-1). It is the attachment of the sartorius muscle and is easily palpable. The anterior inferior iliac spine is just below the anterior superior iliac spine. The rectus femoris muscle and iliofemoral ligament are attached to it (Fig. 13-1). Iliac crest ------,

Iliacus m. ----.
Anterior superior iliac spine

Rectus femoris m. ----1&, Iliofemoral ligament Anterior inferior iliac spine

Figure 13-1

CHAPTER 13

HIP JOINT ORTHOPAEDIC TESTS

329

PROCEDURE With the patient supine, palpate the iliac crests for point tenderness and swelling (Fig. 13-2). This may indicate periostitis or strain or avulsion of the iliacus, external oblique, or tensor fasciae latae muscles. Contusion to the iliac crest secondary to trauma is common in the athlete. Palpate the il iac crests with the patient standing as well, checking for unevenness of the crests (Fig. 13-3). Un evenness may be a sign of scoliosis, anatomical short leg, or contracture deformity. The anterior su perior iliac spine should be palpated next (Fig. 13-4). Look for point tenderness and swelling, which may indicate a sartorius muscle strain or avulsion fracture. Just below the anterior superior iliac spine is the anterior inferior iliac spine (Fig. 13-5). With your thumb or forefinger, palpate this area and note any point tenderness or swelling. It may indicate a sprained or avulsed rectus femoris mus cle or strained iliofemoral ligament.

Figure 13-2

Figure 13-3

m Figure 13·4

Figure 13-5

330

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Greater Trochanter DESCRIPTIVE ANATOMY The greater trochanter is approximately 10 cm inferior and lateral to the anterior superior iliac spine (Fig. 13-6). The greater trochanter is the attachment of the gluteus medius, gluteus minimus, and vastus lateralis muscles. The trochanteric bursa also lies under these muscles.

PROCEDURE With the patient supine, slightly abduct the thigh and palpate the greater trochanter (Fig. 13-7). Note any point tenderness or swelling. This may indicate a strain of the gluteus medius, gluteus min imus, or vastus lateralis muscles. An increase in the temperature differential associated with tender ness and swelling is an indication of trochanteric bursitis.

Greater trochanter----, Gluteus minimus -- Gluteus medius Vastus latera lis muscle attachments

Figure 13-6

Figure 13-7

CHAPTER 13

HIP JOINT ORTHOPAEDIC TESTS

331

Hip Joint DESCRIPTIVE ANATOMY The hip joint is a ball and socket synovial joint, and the femur head is held in place by the il iofemoral, pubofemoral, and ischiofemoral ligaments (Fig. 13-8). The iliofemoral ligament is the largest and strongest of these ligaments that hold the femur into the acetabular cavity. The hip joint at best is difficult to palpate because it lies deep in the body. Unless the joint is trau matized to the point of fracture or dislocation, palpation of the actual joint will reveal little clinical information. Palpation of the surrounding tissue may be a better indicator of hip joint pathology.

Anterior inferior iliac spine --+''-Iliofemoral ligament

Iliopectineal bursa Pubofemoral ligament

Greater troch3nter

I ntertrochan•n

Figure 13-8

•• in

",0.----

m

332

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Tensor Fasciae Latae Muscle DESCRIPTIVE ANATOMY The tensor fasciae latae muscle is on the anterior lateral side of the thigh. It originates from the an terior outer lip of the iliac crest and inserts into the iliotibial band, which attaches to the lateral epi condyle of the tibia (Fig. 13-9).

PROCEDURE With the patient laying on the unaffected side, palpate the tensor fasciae latae muscle from just below the anterior superior iliac spine down over the greater trochanter to the lateral aspect of the knee (Fig. 13-10). Note any tenderness, spasm, increase in skin temperature, or inflammation. These may indi cate a strain of the muscle. If point tenderness is present, suspect an active trigger point that may re fer pain to the upper half of the medial thigh. If the muscle becomes strained through microtrauma as it moves over the greater trochanter of the femur, it can cause greater trochanteric bursitis.

r---#-·Anterior iliac crest Ict--ff-Tensor fasciae latae

I: 'i'-Jf-----..,.4i+-lliotibial band

f:ffllflNl\fIL --+t-- ateral epicondyle of tibia Figure 13-9

Figure 13-10

m.

CHAPTER 13

HIP JOINT ORTHOPAEDIC TESTS

333

Femoral Triangle DESCRIPTIVE ANATOMY The femoral triangle is a clinically important region. It is bound superiorly by the inguinal ligament, medially by the adductor longus muscle, and laterally by the sartorius muscle (Fig. 13- 1 1). The tri angle contains lymph nodes and the femoral artery, vein, and nerve.

PROCEDURE With the patient supine, palpate the inguinal ligament, which extends from the anterior superior il iac spine to the pubic tubercle. Note any tenderness, which may indicate a sprain. Next, palpate the adductor longus and sartorius muscle, again noting any tenderness or inflammation. This may in dicate a strain or active trigger points in the affected muscle. Once the borders are palpated,palpate the interior of the triangle for inflamed lymph nodes, which may indicate a lower extremity or sys temic infection (Fig. 13- 12). Palpate the femoral artery for amplitude. A decrease in the amplitude indicates a compromise to the vascular supply to the lower extremity.

Sartorius m.

/ff-F --t-- emoral nerve /H---+-Femoral artery r-----'-Femoral vein

Figure 13-11

Figure 13-12

II

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

HIP RANGE OF MOTION Flexion (1) With the patient supine, place the goniometer in the sagittal plane at the level of the hip (Fig. 13-13). Instruct the patient to flex the hip, and follow the thigh with one arm of the goniometer (Fig. 13-14).

NORMAL RANGE (2) Normal range is 1310 ± 6.40 or greater from the 0 or neutral position. Muscles

Nerve Supply

Psoas Iliacus Rectus femoris Sartorius Pectineus Adductor longus and brevis Gracilis

Ll-L3 Femoral Femoral Femoral Femoral Obturator Obturator

Figure 13-13

Figure 13-14

CHAPTER 13

HIP JOINT ORTHOPAEDIC TESTS

335

Extension (1) With the patient prone, place the goniometer in the sagittal plane at the level of the hip joint (Fig. 13-15). Instruct the patient to raise the thigh off the table as far as possible, and follow the thigh with one arm of the goniometer (Fig. 13-16).

NORMAL RANGE (2) Normal range is l30 ± 5.4° or greater from the 0 or neutral position. Muscles

Nerve Supply

Biceps femoris Semimembranosus Semitendinosus Gluteus maximus Gluteus medius Adductor magnus

Sciatic Sciatic Sciatic Inferior gluteal Superior gluteal Sciatic

Figure 13-15

m

Figure 13-16

336

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Abduction (1) With the patient supine, place the goniometer in the coronal plane with the center at the level of the hip (Fig. 13- 17). Instruct the patient to move the thigh laterally while following the thigh with one arm of the goniometer (Fig. 13-18).

NORMAL RANGE (2) Normal range is 4 10 ± 60 or greater from the 0 or neutral position. Muscles

Nerve Supply

Tensor fasciae latae Gluteus minimus Gluteus medius Gluteus maximus Sartorius

Superior Gluteal Superior Gluteal Superior Gluteal Inferior Gluteal Femoral

Figure 13-17

Figure 13-18

CHAPTER 13

HIP JOINT ORTHOPAEDIC TESTS

337

Adduction (1) With the patient supine and the opposite hip flexed, place the goniometer in the coronal plane with the center at the level of the hip (Fig. 13- 19). Instruct the patient to move the thigh medially while following the thigh with one arm of the goniometer (Fig. 13-20). NORMAL RANGE (2) Normal range is 270 ± 3.60 or greater from the 0 or neutral position. Muscles

Nerve Supply

Adductor longus Adductor brevis Adductor magnus Gracilis Pectineus

Obturator Obturator Obturator Obturator Femoral

m Figure 13-19

Figure 13-20

338

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Internal Rotation (1) With the patient seated, place the goniometer in front of the patella (Fig. 13-21). Instruct the patient to rotate the leg outward while following the leg with one arm of the goniometer (Fig. 13-22). This movement internally rotates the hip.

NORMAL RANGE (2) Normal range is 440 ± 4.30 or greater from the 0 or neutral position. Muscles

Nerve Supply

Adductor longus Adductor brevis Adductor magnus Gluteus minimus Gluteus medius Tensor fasciae latae Pectineus Gracilis

Obturator Obturator Obturator Superior gluteal Superior gluteal Superior gluteal Femoral Obturator

Figure 13-21

Figure 13-22

CHAPTER 13

HIP JOINT ORTHOPAEDIC TESTS

339

External Rotation (1) With the patient seated,place the goniometer in front of the patella (Fig. 13-23). Instruct the patient to rotate the thigh medially while following the leg with one arm of the goniometer (Fig. 13-24). NORMAL RANGE (2): Normal range is 440 :±: 4.80 or greater from the 0 or neutral position. Muscles

Nerve Supply

Gluteus maximus Obturator internus, externus Quadratus femoris Piriformis Gemellus superior, inferior Sartorius Gluteus medius

Inferior gluteal Obturator N. to quadratus femoris L5,S1,S2 N. to obturator internus Femoral Superior gluteal

II Figure 13-23

Figure 13-24

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

340

CONGENITAL HIP DYSPLASIA CLINICAL DESCRIPTION Congenital dysplasia of the hip is a condition in which the femoral head is displaced out of the ac etabular cavity. The condition is often bilateral, and girls are affected more often than boys. As the name indicates, the origin is usually congenital. As a rule the acetabular cavity is shallow or more vertical than normal. The femur is often anteverted and the hip joint capsule may be lax. As the child ages, the hip becomes less flexible, and the ability to reduce the dislocation is lessened. If the hip is dislocated, there is limited abduction and a shortening of the extremity. If weight bearing has be gun, the Trendelenburg test will be positive. Normally the contraction of the abductor muscle ele vates the opposite side of the pelvis. If the hip is dislocated, these muscles no longer work effectively, and when the child stands on the affected leg, the opposite side on the pelvis moves down. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

Decreased hip flexibility Limited abduction Painless limp Hip pain Shortened extremity

Allis Test (3)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the infant supine, flex the knees. The patient's feet should approximate each other on the table (Fig. 13-25). RATIONALE A difference in the height of the knees indicates a positive test. A short knee on the affected side in dicates posterior displacement of the femoral head or decreased tibial length. A long knee on the af fected side indicates anterior displacement of the femoral head or an increase in tibial length.

Figure 13-25

CHAPTER 13

Ortolani's Click Test (4)

Sensitivity/Reliability Scale

I

o

PROCEDURE

341

HIP JOINT ORTHOPAEDIC TESTS

I 1

I

2

I

3

I

4

With the infant supine, grasp both thighs with your thumbs on the lesser trochanters. Then flex and abduct the thighs bilaterally (Fig. 13-26). RATIONALE A palpable and/or audible click are the signs of a positive test. The click signifies a displacement of the femoral head in or out of the acetabular cavity.

Figure 13-26

II

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

342

Telescoping Sign (5) PROCEDURE

Sensitivity/Reliability Scale

I

I 1

I

2

I

3

I

4

With the child supine, flex the suspected hip and knee to 90°. Next, grasp the thigh and push it pos terior toward the table (Fig. 13-27), then pull it anterior away from the table (Fig. 13-28). RATIONALE If the child has a dislocated hip or a hip that has potential to dislocate, excessive movement or a click will occur with this procedure. Normally, little motion occurs when this action is performed. This excessive movement is called telescoping. SUGGESTED DIAGNOSTIC IMAGING •

•

Ultrasonography Plain film radiography Anteroposterior CAP) hip view AP frog leg view AP pelvis view

Figure 13-27

Figure 13-28

CHAPTER 13

343

HIP JOINT ORTHOPAEDIC TESTS

HIP FRACTURES CLINICAL DESCRIPTION Hip fractures occur most frequently in elderly patients, usually the result of a fall. The most com mon types of hip fractures are intertrochanteric and intracapsular. Intertrochanteric fractures and femoral neck fractures for the most part do not disrupt the blood supply to the femoral head. In tracapsular fractures disrupt the blood supply to the femoral head, which may lead to nonunion or avascular necrosis. In femoral neck fractures the extremity may be slightly shortened and externally rotated. Osteoporosis and osteoarthritis usually play a significant role in the region. Occasionally the fracture may be occult, with no trauma, and may show up only with a bone scan or magnetic reso nance imaging (MRI). CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Hip pain Shortened extremity Externally rotated extremity Referred pain to medial thigh

Anvil Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient supine, tap the inferior calcaneus with your fist (Fig. 13-29). RATIONALE Tapping the inferior calcaneus transfers quick, sharp compression-type blows to the hip joint. Local pain in the hip joint following trauma may indicate a femoral head fracture or joint pathology. NOTE Local pain in the thigh or leg secondary to trauma may indicate a femoral, tibial, or fibula fracture. Pain local to the calcaneus may indicate a calcaneal fracture. SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP hip view AP frog leg view AP pelvis Bone scan MRI

Figure 13-29

m

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

344

HIP CONTRACTURE TESTS CUNICAL DESCRIPTION A hip joint contracture is a condition of soft tissue stiffness that restricts joint motion. This may be caused by immobilization due to spasticity, paralysis, ossification, or bone or joint trauma. A fre quently moved joint is unlikely to develop a contracture deformity. Contractures occur from loss of elasticity, leading to fixed shortening of soft tissue. The involved tissues may include the joint cap sule, ligaments, or muscle tendon units. Hip contractures are difficult to treat; therefore, prevention by daily movement of the affected joint is paramount to treatment of a contracted joint. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Stiff hip joint Limited hip range of motion Inability to position joint in the neutral position Hip joint pain on range of motion

Thomas Test (6)

Sensitivity/Reliability Scale

I

o

PROCEDURE

!

I 1

!

I 2

I

I

3

!

I

4

Instruct the supine patient to approximate each knee to the chest one at a time. Palpate the quadri ceps muscles on the unflexed leg (Fig. 13-30). RATIONALE If the patient significantly flexes the opposite knee and tightness is palpated on the side of the invol untary flexed knee, a hip flexion contracture is indicated (Fig. 13-31). If no tightness in the rectus femoris muscle exists, the probable cause of restriction is at the hip joint structure or joint capsule.

Figure 13-30

Figure 13-31

CHAPTER 13

Rectus Femoris Contracture Test (5)

HIP JOINT ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

345

I 1

I

2

I

3

I

Instruct the patient to lie supine on the examination table with the leg off the table and flexed to 90°. Instruct the patient to flex the opposite knee to his chest and hold it. Palpate the quadriceps mus cles of the leg that is flexed off the table for tightness (Fig. 13-32). RATIONALE If the patient involuntarily extends the knee of the leg that is flexed off the table and tightness is pal pated in that thigh (Fig. 13-33), a hip flexion contracture is indicated. If there is no tightness in the rectus femoris muscle, the probable cause of restriction is at the hip joint structure or joint capsule.

Figure 13-32

Figure 13-33

346

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Ely's Test (7)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

Instruct the patient to lie prone on the examination table. Then grasp the patient's ankle and pas sively flex the knee to the buttock (Fig. 13-34). RATIONALE If the patient has a tight rectus femoris muscle or hip flexion contracture, the hip on the same side will flex (Fig. 13-35), raising the buttock off the table. This spontaneous flexion of the hip reduces the traction pressure on the rectus femoris muscle induced by the passive knee flexion.

Figure 13-34

Figure 13-35

CHAPTER 13

Ober's Test (8)

HIP JOINT ORTHOPAEDIC TESTS

347

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I ,

I

I

2

I

I

3

I

I

4

With the patient side-lying, abduct the patient's leg (Fig. 13-36) and then release it (Fig. 13-37). Per form this test bilaterally. RATIONALE The tensor fasciae latae and iliotibial band abduct the hip. If the leg fails to descend smoothly, sus pect contracture of the tensor fasciae latae muscle or iliotibial band.

Figure 13-36

Figure 13-37

348

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Piriformis Test (9)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

I

4

Instruct the patient to lie on the side opposite the leg being tested. Instruct the patient to flex the hip to 60° with the knee fully flexed (Fig. 13-38). With one hand, stabilize the hip; with the other hand, press down on the knee (Fig. 13-39). RATIONALE If the piriformis muscle is tight, pain will be elicited when the knee is pressed because this action further tightens the piriformis muscle. If sciatic pain sets in, the piriformis muscle may be pinching the sciatic nerve. In 15% of the population the sciatic nerve passes through the piriformis muscle. SUGGESTED DIAGNOSTIC IMAGING •

Plain film radiography AP hip view AP frog leg view AP pelvis

Figure 13-38

Figure 13-39

CHAPTER 13

349

HIP JOINT ORTHOPAEDIC TESTS

GENERAL HIP JOINT LESIONS CLINICAL DESCRlPTION The hip is a ball and socket joint in which the stability of the joint is enhanced by the capsule and the strong ligaments that surround the joint. The joint is weight bearing and subject to various in sults and disease processes. Some of the most common problems associated with the hip joint are osteoarthritis, sprains, fractures, dislocations, bursitis, tendinitis, synovitis, and avascular necrosis of the femoral head. The following tests help to determine whether a general lesion of the hip is pres ent. Further diagnostic testing based on the outcome of these tests can help to determine the exact pathology. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Hip pain Shortened extremity Externally rotated extremity Referred pain to medial thigh

Patrick Test (Faber) (10)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

With the patient supine, flex the leg and place the foot flat on the table. Grasp the femur and press it into the acetabular cavity (Fig. 13-40). Next, cross the patient's leg to the opposite knee. Stabilize the oppo site anterior superior iliac spine and press down on the knee of the hip that is being tested (Fig. 13-41). RATIONALE This test forces the femoral head into the acetabular cavity, giving maximal congruence to the artic ular surfaces. Pain in the hip indicates an inflammatory process in the hip joint. Pain secondary to trauma may indicate a fracture in the acetabular cavity, rim of the acetabular cavity, or femoral neck. Pain may also indicate avascular necrosis of the femoral head. Faber stands for flexion, abduction, and external rotation. This is the position of the hip when the test begins.

Figure 13-40

Figure 13-41

350

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Trendelenburg Test (11)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

I

4

With the patient standing, grasp the patient's waist and place your thumbs on the posterior superior iliac spine of each ilium. Next, instruct the patient to flex one leg at a time (Fig. 13-42). RATIONALE When the patient is standing with one leg flexed, the patient is supported by an intact hip joint with its associated ligaments and muscles on that side. If the patient cannot stand on one leg because of pain and/or because the opposite pelvis falls or fails to raise, this is considered a positive test. This result may indicate a weak gluteus medius muscle opposite the side of hip flexion, and it tests the integrity of the hip joint and associated musculature and ligaments on the opposite side of hip flex ion. A positive outcome of this test often indicates hip joint pathology.

Figure 13-42

CHAPTER 13

Scouring Test (12)

351

HIP JOINT ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

I ,

I

2

I

3

I

4

With the patient supine, flex the patient's hip to 90°, fully flex the knee, and internally rotate the hip (Fig. 13-43). Assuming the patient has no injury or pathology to the knee, apply downward and lat eral pressure on the knee (Fig. 13-44). RATIONALE This test is similar to the Patrick test, stressing the anteromedial and posterolateral aspect of the joint capsule. Pain and/or a grating sensation indicates a positive test. This result may indicate an inflam matory process in the acetabular joint, such as osteoarthritis. Pain secondary to trauma may indi cate a fracture of the acetabular cavity or rim.

Figure 13-43

Figure 13-44

352

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Laguerre's Test (13)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient supine, flex the hip and knee to 90°. Rotate the thigh outward and the knee medially. Press down on the knee with one hand, and pull up on the ankle with the other hand (Fig. 13-45). RATIONALE This test externally forces the head of the femur into the acetabular cavity, stressing the anterior as pect of the joint capsule. This test may indicate an inflammatory process in the acetabular joint,such as osteoarthritis. Pain secondary to trauma may indicate a fracture of the acetabular cavity or rim.

Figure 13-45

Hibb's Test See the section on General Sacroiliac Joint Lesions in Chapter 12. SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP hip view AP frog leg view AP pelvis Bone scan MRI

CHAPTER 13

References

HIP JOINT ORTHOPAEDIC TESTS

353

Cyriax J. Textbook of Orthopaedic Medicine. 2nd

1. American Academy of Orthopaedic Surgeons. The Clinical Measurement of Joint Motion. Chicago: AAOS,1994.

ed. Vol 1. London: Bailliere Tindal,1982. Haycock CEo Sports Medicine for the Athletic Fe male. Oradell, NJ: Medical Economics,1980.

2. Boone DC,Azen SP. Normal range of motion of

Kapandji LA. The Physiology of the Joints. Vol. 2.

joints in male subjects. J Bone Joint Surg Am

Lower Limb. New York: Churchill Livingstone,1970.

1979;61:756-759. 3. Hensinger RN. Congenital dislocation of the hip. Summit, NJ: CIBA

1979;31 (l).

Clinical

Symposia

4. Tachdjian MO. Pediatric Orthopedics. Philadel phia: Saunders, 1972. 5. Magee DJ. Orthopedic physical assessment. 3rd ed. Philadelphia: Saunders, 1997. 6. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton Century-Crofts,1976:137. 7. Gruebel-Lee

DM.

Disorders

of

the

Hip.

8. Ober FB. The role of the iliotibial and fascia lata as a factor in the causation of low-back disabil ities and sciatica. J Bone Joint Surg 1936;18:105. 9. Saudek CEo The Hip. Ortl1opedic and Sports Physical Therapy. St. Louis: Mosby,1990. 10. Kenna C, Murtagh J. Patrick or Faber test. Aust Fam Physician 1989;18:375.

F.

Dtsch

Wschr

21,

12. Maitland GD. The Peripheral Joints: Examina tion and Recording Guide. Adelaide, Australia: Vergo,1973. 13. Lee D. The Pelvic Girdle. Edinburgh: Churchill

sacroiliac

4th ed. Baltimore: Lippincott Williams & Wilkins, 1999. Noble HB, Hajek MR, Porter M. Diagnosis and Phys Sports Med 1984;10:67. Phillips EK. Evaluation of the hip. Phys Ther 1975; 55:975-981. Post M. Physical examination of the musculoskele tal system. Chicago: Year Book Medical,1987.

thop 1973;92:6. Singleton Me. The Hip Joint: Clinical Oriented AnatomyA Review. Common Disorders of the Hip. New York: Haworth,1986. Steinberg GG,Akins AM, Baran, DT. Orthopaedics Williams & Wilkins,1999. Steinberg ME. The Hip and Its Disorders. Philadel

General References The

Moore KL, Dalley AF. Clinically oriented anatomy.

in Primary Care. 3rd ed. Baltimore: Lippincott

Livingstone,1989.

GJ.

Mercier LR. Practical Orthopedics. St. Louis: Mosby, 1991.

Rydell N. Biomechanics of the hip joint. Clin Or Med

1895;21-24 (RSM translation).

Alderink

McRae R. Clinical Orthopedic Examination. New York: Churchill Livingstone,1976.

treatment of iliotibial band tightness in runners.

Philadelphia: JB Lippincott,1983.

11. Trendelenburg

Maquet PGJ. Biomechanics of the Hip. New York: Springer-Verlag,1985.

phia: Saunders,1991. )Olllt:

review

of

anatomy, mechanics and function. J Orthop Sports Phys Ther 1991;13:71. Beetham WP,Polley HF, Slocumb CH,et al. Physical Examination of the Joints. Phlladelphia: Saunders, 1965. Chung SMK. Hip Disorders in Infants and Chil dren. Philadelphia: Lea & Febiger, 1981.

Subotnick17 S1. Sports Medicine of the Lower Ex tremity. 2nd ed. New York: Churchill Livingstone, 1999. Wells PE. The examination of the pelvic joints. In: Grieve GP,ed. Modern Manual Therapy of the Ver tebral Column. Edinburgh: Churchill Livingstone, 1986.

II

--------�wu�-KNEE ORTHOPAEDIC TESTS

KNEE ORTHOPAEDIC EXAMINATION

355

FLOW CHART PALPATION

373 374 375

Retreating Meniscus Test Modified Helfet's Test Cabot's Popliteal Sign

356 356

Anterior Aspect

376

Bohler's Sign

Anderson Medial-Lateral Grind

Patella, Quadriceps Femoris Tendon, and

356 Anterior Knee Bursa 358

Test

377

Patella Ligament

PLICA TESTS

360

Quadriceps Femoris Muscle Medial Aspect

361

378 379 380

Mediopatella Plica Test Hughston Plica Test

Medial Femoral Condyle, T ibial Plateau, and Joint Line Lateral Aspect

362

363

Lateral Femoral Condyle and Joint Line

363 364

Posterior Aspect

385

Reverse Lachman's Test Losee Test

386 387

Apley's Distraction Test

365

Adduction Stress Test

Popliteal Fossa and Associated Structures

382 Lachman's Test 385 Drawer's Sign

Slocum Test

Lateral Collateral Ligament and Iliotibial Band

381

LIGAMENTOUS INSTABILITY

361

Medial Collateral Ligament

Abduction Stress Test

388 389 390

365 PAT ELLOFEMORAL DYSFUNCTION

367

KNEE RANGE OF MOT ION Flexion Extension

367 368

MENISCUS INSTABILITY

Patella Apprehension Test Dreyer's Test

369

Apley's Compression Test

370 Bounce Home Test 371 Steinman's Tenderness Displacement

354

372

394

Patella Ballottement Test Stroke Test

392

393

KNEE JOINT EFFUSION

369

McMurray's Test

Test

391

Patella Grinding Test

395

Fluctuation Test

395

394

391

Knee Orthopaedic Examination

�

Patella . apprehension test

1..J.=l

Range of motion (active) (passive)

(+) Patella Ballottement test Stroke test Fluctuation test

(-)

Apley's compression test McMurray's test Bounce home test Steinman's tenderness displacement test Retreating meniscus test Modified Helfet's test Payr's test Cabot's popliteal sign Bohler's sign Anderson medial-lateral grind test

�

Meniscal lesion

s

(")

�

m '" �

*""

(-)

( -)

Drawer's sign Lachman's test Reverse Lachman's test Slocum test Losee test Apley's distraction test Adduction stress test Abduction stress test

� m m

o

::j :t o

::;! m

" n >-l

§ ..., <.11 <.11

356

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PALPATION Anterior Aspect

Patella, Quadriceps Femoris Tendon, and Patella Ligament DESCRIPTIVE ANATOMY The suprapatellar tendon anchors the patella to the anterior aspect of the knee superiorly. This ten don is an extension of the quadriceps muscle and it continues inferiorly as the patellar ligament (Fig. 14- 1). The patellar ligament is thick, strong, and continuous with the fibrous capsule of the knee joint, and it attaches to the tibial tuberosity. These structures, which are superficial and easily pal pable, function as a lever to extend the leg when the quadriceps muscle contracts.

s lateralis Quadriceps femoris m.

Quadriceps -"""",,�-+'cI-Tfl-'im+: muscle tendon Patella Lateral collateral ligament

Medial collateral ligament

Patella ligament

Tibial tuberosity -+-+�mrt-;Fibula -+--It-

Figure 14-1

"l-,ji---+-- Tibia

CHAPTER 14

KNEE ORTHOPAEDIC TESTS

357

PROCEDURE

With the patient supine and the knee extended, palpate the patella and its margins (Fig. 14-2). Note any tenderness, inflammation, temperature differences, and/or roughness. Tenderness and pain from direct trauma may indicate periosteal contusion or fracture of the patella. Swelling and an in crease in temperature suggest prepatellar bursitis. Roughness at the margins of the patella may in dicate chondromalacia patellae, or degeneration of the undersurface of the patella. Next, palpate the quadriceps femoris tendon (Fig. 14-3). Tenderness may indicate tendinitis caused by overuse or strain resulting from overstress. Continue palpation inferior to the patella which is the patellar ligament. Palpate from the apex of the patella, which is the inferior margin, down to the tibial tubercle, which is the attachment of the patellar ligament (Fig. 14-4). Note any pain, tenderness, swelling, or temperature differences. Any of these findings may indicate ligament sprain. If symptoms are local to the tibial tuberosity, suspect Osgood-Schlatter disease, an enlarge ment of the tibial tuberosity, in the adolescent; it is common in young adults.

Figure 14-3

Figure 14-2

Figure 14-4

358

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Anterior Knee Bursa DESCRIPTIVE ANATOMY The clinically important bursae in the anterior aspect of the knee are the suprapatellar bursa, prepatellar bursa, superficial infrapatellar bursa, and deep infrapatellar bursa (Fig. 14-5). The supra patellar bursa, an extension of the synovial capsule, lies between the femur and the quadriceps femoris tendons. It allows for movement of the quadriceps tendon over the distal end of the femur. The prepatellar bursa is superficial to the patella between the skin and anterior surface of the patella. It allows movement of the skin over the underlying patella. The superficial infrapatellar bursa is be tween the tibial tuberosity and the skin. It allows for movement of the skin over the tibial tuberos ity. The deep infrapatellar bursa lies between the patellar ligament and the tibia. This allows for movement of the patellar ligament over the tibia.

Prepatellar bursa

Superficial bursa Deep infrapatellar bursa

tendon

r---I::les anserinus bursa

Tibial tuberosity

Tibia

Figure 14-5

CHAPTER 14

KNEE ORTHOPAEDIC TESTS

359

PROCEDURE Palpate the suprapatellar bursa above the patella (Fig. 14-6). Note any thickening, tenderness, or temperature differences. These signs may indicate bursitis in the suprapatellar bursa or pathology in the quadriceps femoris tendon. Next, palpate the prepatellar bursa, which is superficial to the patella (Fig. 14-7). Note any thickening, swelling, ten�erness, or temperature differences. These signs may indicate prepatellar bursitis (housemaid's knee). Palpate the superficial and deep infrapatellar bursa (Fig. 14-8). Note any thickening, swelling, tenderness, or temperature differences. Any of these may indicate infrapatellar bursitis or patellar ligament pathology.

Figure 14-7

Figure 14-6

Figure 14-8

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Quadriceps Femoris Muscle DESCRIPTIVE ANATOMY The quadriceps femoris consists of four muscles: rectus femoris, vastus lateralis, vastus medialis, and vastus intermedius (Fig. 14-9). The primary action of these muscles is to extend the leg at the knee. They all unite to form the quadriceps tendon, which inserts into the patella. PROCEDURE Palpate the entire length of the quadriceps muscle, noting any swelling, tenderness, temperature dif ferences, or masses (Fig. 14- 10). Tenderness and/or swelling may indicate muscle strain or hematoma. Point tenderness at the upper aspect of the muscle may indicate active trigger points and may refer pain to the knee. A hard mass secondary to trauma may indicate myositis ossificans, which is an ossification of muscle tissue.

lateralis Quadriceps femoris

Quadriceps -+\'r'\--\-1:4't�-i:: muscle tendon Patella Lateral collateral ligament

Medial collateral ligament

Patella ligament

Ti bia I tuberosity --+--+---o,;fH.,-+I-� Fibula -+----H-

Figure 14-9

Figure 14-10

�'---+-- Tibia

m.

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361

Medial Aspect

Medial Femoral Condyle, Tibial Plateau, and Joint Line DESCRIPTIVE ANATOMY The medial femoral condyle is a bony prominence on the medial aspect of the distal femur, which is the attachment of the medial collateral ligament. The medial tibial plateau and joint line are im portant palpable landmarks of the medial aspect of the knee. The medial aspect of the meniscus is in the joint line, and the coronary ligament attaches the meniscus to the tibial plateau (Fig. 14- 1 1). PROCEDURE With the knee in 90° of flexion, palpate the medial femoral condyle with your index and middle fin gers (Fig. 14- 12). Note any tenderness or pain. These signs may indicate a sprain, avulsion, or calci fication (Pellegrini-Stieda disease) of the medial collateral ligament. Next, palpate the tibial plateau and medial joint line. Note any tenderness or pain. These signs may indicate a tear of the medial meniscus or sprain of the coronary ligament.

Joint line ....

Figure 14-11

m

Figure 14-12

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Medial Collateral Ligament DESCRIPTIVE ANATOMY The medial collateral, or tibial collateral, ligament is a strong, broad, flat band that extends from the medial epicondyle of the femur to the medial condyle and upper medial aspect of the tibia (Fig. 14- 13). It contributes to the medial stability of the knee. Its fibers are attached to the medial menis cus and the fibrous capsule of the knee. PROCEDURE With the patient supine and the leg extended, palpate the medial collateral ligament from the me dial epicondyle of the femur to the medial condyle of the tibia with your index and middle fingers (Fig. 14- 14). Note any pain, tenderness, or defect in the ligament. Pain and tenderness may indicate a sprain of the ligament. A deficit secondary to trauma may indicate a tear of the ligament, which is usually associated with capsular and meniscal damage. A defect at either the medial femoral epi condyle or the medial tibial condyle suggests an avulsion fracture secondary to trauma.

Quadriceps femoris ---7f'.:m:ff+i tendon Prepatellar bu

Medial collateral ligament

1--IJes anserinus bursa Tibial tuberosity Tibia

Figure 14-13

Figure 14-14

CHAPTER 14

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363

Lateral Aspect

Lateral Femoral Condyle and Joint Line DESCRIPTIVE ANATOMY The lateral femoral condyle is a bony prominence on the lateral aspect of the distal femur, which is the attachment of the lateral collateral ligament and iliotibial band. This structure is important for the lateral stability of the knee. The lateral joint line is an important palpable landmark of the lat eral aspect of the knee. The lateral aspect of the meniscus and the coronary ligament, which attaches the meniscus to the tibia, are in the joint line (Fig. 14- 15). PROCEDURE With the knee in 90° of flexion, palpate the lateral femoral condyle with your index and middle fin gers (Fig. 14- 16). Note any tenderness or pain. These signs may indicate sprain, avulsion, or calcifi cation of the lateral collateral ligament. Next, palpate the lateral joint line. Note any tenderness or pain. These signs may indicate a tear of the lateral meniscus or strain of the coronary ligament.

Figure 14-15

Figure 14-16

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Lateral Collateral Ligament and Iliotibial Band DESCRIPTIVE ANATOMY The lateral collateral ligament is a round cord that extends from the lateral epicondyle of the femur to the head of the fibula (Fig. 14- 15). This structure is important for the lateral stability of the knee. In contrast to the medial collateral ligament, the fibers are not attached to the meniscus. The tendon of the popliteus muscle passes deep to the ligament, separating it from the meniscus of the knee. The iliotibial band is a continuation of the tensor fasciae latae muscle, and it attaches to the lateral condyle of the tibia (Fig. 14- 17). This band helps keep the knee extended during standing and is im portant for lateral stability of the knee. PROCEDURE With the patient either supine or sitting, instruct the patient to cross one leg over the other (Fig. 14-18). With your index and middle finger, palpate the lateral collateral ligament of the top leg from the lateral epicondyle of the femur to the head of the fibula. Note any pain, tenderness, or defect. Pain and tenderness may indicate a sprain or calcification of the ligament. A defect secondary to trauma may indicate a tear or avulsion of the lateral collateral ligament. Next, palpate the entire length of the iliotibial band from halfway between the hip and knee on the lateral aspect to the lat eral condyle of the tibia (Fig. 14- 19). Note any pain, tenderness, or defects of the iliotibial band. Pain and tenderness may indicate a strain of the band. A defect secondary to trauma may indicate a tear or avulsion of the band from the lateral condyle of the tibia.

i

iliac crest

Irt--f+-Tensor fascia lata m.

'i'-'!---.'rf+-l Iiotibial band

Figure 14-18

Figure 14-17

Figure 14-19

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365

Posterior Aspect

Popliteal Fossa and Associated Structures DESCRIPTIVE ANATOMY The popliteal fossa is surrounded by the biceps femoris tendon on the superior lateral border and the tendons of the semimembranosus and semitendinosus on the superior medial border. The infe rior borders are bounded by the two heads of the gastrocnemius muscles. The posterior tibial nerve, popliteal artery, and popliteal vein cross the popliteal fossa (Fig. 14-20).

Semitendinosus m. -HOOI+1+H4 11

1I1\�'.lIlI-Ti¥1H+Wf--f--- Biceps femoris m.

Semimembranosus m. \l\W"':\4H,jM--+-- Posterior tibial nerve Popliteal artery

Gastrocnemius m.

Figure 14-20

m

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PROCEDURE With the knee slightly flexed, palpate the popliteal fossa for swelling or tenderness (Fig. 14-2 1). These signs may indicate Baker's cyst, a pressure diverticulum of the synovial sac protruding through the joint capsule of the knee. Next, palpate the biceps femoris tendon (Fig. 14-22), semi membranosus tendon, semitendinosus tendon (Fig. 14-23), and both heads of the gastrocnemius muscle (Fig. 14-24) for tenderness, swelling, and continuity. This tenderness and swelling may indi cate a strain of the respective tendons or muscles. Loss of continuity may indicate an avulsion of the respective muscles or tendons.

Figure 14-21

Figure 14-22

Figure 14-23

Figure 14-24

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367

KNEE RANGE OF MOTION

Flexion (1) With the patient prone and the leg extended, place the goniometer in the sagittal plane with the cen ter at the knee joint (Fig. 14-25). Instruct the patient to flex the leg as far as possible while follow ing the leg with one arm of the goniometer (Fig. 14-26). NORMAL RANGE (2) Normal range is 14 10

±

6.50 or greater from the 0 or neutral position.

Muscles

Nerve Supply

Biceps femoris Semimembranosus Semitendinosus Gracilis Sartorius Popliteus Gastrocnemius Plantaris

Sciatic Sciatic Sciatic Obturator Femoral Tibial Tibial Superior gluteal

Figure 14-25

Figure 14-26

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Extension (1) With the patient seated, foot on the floor, place the goniometer in the sagittal plane with the center at the knee (Fig. 14-27). Instruct the patient to extend the leg as far as possible while following the leg with one arm of the goniometer (Fig. 14-28). Note that this test starts with the leg in 90° of flex ion and you want the knee to extend to the 0 or neutral position. NORMAL RANGE (2) Normal range is 0

:±:

2°.

Muscles

Nerve Supply

Rectus femoris Vastus medialis Vastus intermedius Vastus lateralis

Femoral Femoral Femoral Femoral

Figure 14-27

Figure 14-28

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369

MENISCUS INSTABILITY

CLINICAL DESCRIPTION The menisci are C-shaped disks of fibrocartilage that are interposed between the condyles of the fe mur and the tibia. The functions of the meniscus are many. Its primary function is load transmis sion or weight bearing, and the secondary function is shock absorption during gait. The menisci are also thought to contribute to joint stability and lubrication. Finally, because of the nerve endings in the anterior and posterior horns, proprioception provides a feedback mechanism for joint position. A tear or loss of the menisci, either partial or complete, hinders their ability to function and pre disposes the joint to degenerative changes. A twisting injury to the knee with the foot in a weight bearing position is the most common injury to the meniscus. Because the outer 20% of the menisci have a vascular supply, peripheral injuries may heal. The inner 80% of the menisci are avascular, so inner meniscal injuries rarely heal. CLINICAL SIGNS AND SYMPTOMS Local medial or lateral joint pain Limited knee range of motion Crepitus upon movement Joint effusion Knee buckling Pain on walking up and down stairs Pain on squatting

Apley's Compression Test (3) PROCEDURE

Sensitivity/Reliability Scale

I

o

I

I 1

I

I 2

I

I

3

I

I

4

With the patient prone, flex the leg to 90°. Stabilize the patient's thigh with your knee. Grasp the pa tient's ankle and place downward pressure while you internally (Fig. 14-29) and externally (Fig. 1430) rotate the leg.

m

Figure 14-29

Figure 14-30

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RATIONALE The menisci, which are asymmetric fibrocartilaginous disks, separate the tibial condyles from the femoral condyles. When the knee is flexed, the meniscus distorts to maintain the congruence be tween the tibial and femoral condyles. Flexion of the knee applies downward pressure with internal and external rotation stress to the already distorted meniscus. Pain or crepitus on either side of the knee indicates a meniscus injury on that side.

McMurray's Test (4) PROCEDURE

Sensitivity/Reliability Scale

I

I 1

I

2

I

3

I

4

With the patient supine, flex the leg (Fig. 14-3 1). Externally rotate the leg as you extend (Fig. 14-32); internally rotate as you extend (Fig. 14-33). RATIONALE Flexion and extension of the knee distort the meniscus to maintain the congruence between the tib ial and femoral condyles. Flexing and extending the knee with internal and external rotation further stress the already distorted meniscus. A palpable or audible click indicates an injury of the meniscus. Figure 14-31

Figure 14-32

Figure 14-33

CHAPTER 14

Bounce Home Test (5)

371

KNEE ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient supine, instruct the patient to flex the leg. When the leg is flexed, cup your hand around the patient's heel (Fig. 14-34) and instruct him to relax his muscles and allow the knee to drop (Fig. 14-35). RATIONALE Extension of the knee entails medial rotation of the femur on the tibia. If the meniscus is injured, rotation of the femur on the tibia may be blocked and the patient may not be able to extend the knee fully. A rubbery end feel on full extension is also a positive sign.

Figure 14-34

m

Figure 14-35

372

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Steinman's Tenderness Displacement Test (6)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I ,

I

2

I

3

I

4

With the patient supine, flex the patient's hip and knee to 90°. Place your thumb and index finger on the medial and lateral knee joint lines, respectively (Fig. 14-36). With your opposite hand, grasp the patient's ankle and alternately flex and extend the knee while palpating the entire joint line (Fig. 14-37). RATIONALE When the knee is extended, the meniscus moves anteriorly, and when the knee is flexed, the menis cus moves posteriorly. If the pain seems to move anteriorly when the knee is extended or posteriorly when the knee is flexed, suspect a tear or injury of the meniscus.

Figure 14-36

Figure 14-37

CHAPTER 14

Retreating Meniscus Test (7)

KNEE ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

373

I 1

I 2

I

3

I

With the patient supine and the patient's hip and leg flexed to 90°, palpate the meniscus on the me dial joint line anterior to the medial collateral ligament. With your opposite hand, rotate the leg me dially and laterally while noting whether the meniscus that you are palpating is still present or has disappeared (Figs. 14-38 and 14-39). RATIONALE When the knee is flexed to 90°, the femur should rotate medially on the tibia. If the meniscus does not disappear while you are rotating the leg, suspect a torn meniscus, because rotation of the tibia is blocked.

Figure 14-38

Figure 14-39

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Modified Helfet's Test (7)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient seated, foot on the floor, note the location of the tibial tuberosity in relation to the midline (Fig. 14-40). Passively extend the patient's leg and again note the location of the tibial tuberosity in relation to the patella (Fig. 14-4 1). RATIONALE In the normal knee, the tibial tuberosity is at the midline when the knee is in 90° of flexion. When the knee is extended, the tibial tuberosity moves in line with the lateral border on the patella. If this does not occur, suspect a tear of the meniscus because rotation of the tibia is blocked.

Figure 14-40

Figure 14-41

CHAPTER 14

Cabot's Popliteal Sign (8)

KNEE ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

375

I 1

I

2

I

3

I

With the patient supine, instruct the patient to abduct the thigh and cross the leg of the affected knee (Fig. 14-42). Grasp the ankle with one hand, and with the other hand palpate the joint line with your thumb and index finger (Fig. 14-43). Ask the patient to straighten the knee isometrically against your resistance. RATIONALE

Resisting extension of the knee in the figure-4 position stresses the meniscus. Pain on the joint line indicates a tear or pathology of the meniscus.

Figure 14-42

Figure 14-43

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Bohler's Sign (8)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

With the patient supine, stabilize the medial thigh with one hand and place a valgus force on the lat eral aspect of the leg with your opposite hand (Fig. 14-44). Next, stabilize the lateral knee and place a varus force on the medial aspect of the leg (Fig. 14-45).

RATIONALE Placing a lateral or medial pressure on the knee distracts the joint capsule and meniscus on the op posite side of the pressure. Pain on the side opposite joint pressure may indicate a lesion of the joint capsule or meniscus.

NOTE This test is similar to the adduction and abduction stress test for collateral ligament defect. If this test is positive, evaluate for collateral ligament defect opposite the side of pressure.

Figure 14-44

Figure 14-45

CHAPTER 14

Anderson Medial-Lateral Grind Test (9)

KNEE ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

377

I

I 1

I

I

2

I

I

3

I

I

4

With the patient supine, grasp the leg of the affected knee and place it between your trunk and arm. With your opposite thumb and index finger, palpate the anterolateral and medial joint lines. Place a valgus stress on the knee as it is flexed passively (Fig. 14-46) and a varus stress on the knee as it is extended passively (Fig. 14-47). Use a circular movement and increase valgus and varus stresses af ter each complete circle.

RATIONALE This movement stresses the meniscus on the medial side with valgus stress and on the lateral side with varum stress. Pain and/or grinding on movement may indicate a meniscus tear or pathology.

SUGGESTED DIAGNOSTIC IMAGING •

•

Plain film radiography Anteroposterior (AP) knee view Lateral knee view Magnetic resonance imaging (MRI)

Figure 14-46

m

Figure 14-47

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

378

PLICA TESTS

CLINICAL DESCRIPTION The synovial plica is a redundant fold in the synovial lining of the knee, extending from the fat pad medially under the quadriceps tendon superiorly to the lateral retinaculum (Fig. 14-48). This plica may become inflamed, thickened, and/or fibrotic from trauma or overuse, resulting in clinical symptoms. If the plica is inflamed, a more complex patellofemoral problem may be present.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Anterior knee pain Anterior pain on prolonged knee flexion Knee pain diminishing with increased activity Popping or snapping upon knee flexion or extension

Quadriceps tendon Synovial plicae

Medial _f!I.:'*-----4\lr\\.l-\ patellar plica

"-"--Anterior -\----:-; plica Fat pad

Figure 14-48

CHAPTER 14

Mediopatella Plica Test (10)

Sensitivity/Reliability Scale

I

o

PROCEDURE

379

KNEE ORTHOPAEDIC TESTS

I 1

I

2

I

3

I

4

With the patient supine, flex the affected leg to 30°. With the other hand, move the patella medially (Fig. 14-49).

RATIONALE Moving the patella medially with the leg in 30° of flexion pinches the plica between the medial femoral condyle and the patella. Pain may indicate that the plica is adhered to the patella and is in flamed. The plica is the remnant of an embryonic septum that makes up the knee joint capsule.

Figure 14-49

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Hughston Plica Test (I1)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I ,

I

2

I

3

I

4

With the patient supine, grasp the patient's leg. Flex and medially rotate the leg. With your opposite hand, move the patella medially with the heel of your hand and palpate the medial femoral condyle with the fingers of the same hand (Fig. 14-50). Flex and extend the knee while feeling for popping of the plical band under your fingers (Fig. 14-51).

RATIONALE Popping under your fingers may indicate that the plica is attached to the patella, and it may be in flamed. The incidence of patella plica varies from 18% to 60% of the population, according to dif ferent authors.

SUGGESTED DIAGNOSTIC IMAGING •

Knee MRI

Figure 14-50

Figure 14-51

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381

LIGAMENTOUS INSTABILITY

CLINICAL DESCRIPTION Ligaments are vital to the stability of the knee. The major ligaments of the knee are the anterior and posterior cruciate and the medial and lateral collateral ligaments (Fig. 14-52). Ligament injuries are among the most serious knee disorders. A delay in diagnosis and treatment may lead to a chroni cally unstable knee, which predisposes the knee to early degeneration. Ligament instability is usu ally due to a traumatic stress to the knee while the knee was bearing weight. A valgus stress may sprain or tear the medial collateral ligament. A varus stress may sprain or tear the lateral collateral ligament. Both of these stresses with a rotational force may also sprain or tear the anterior and/or posterior. cruciate ligaments.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

Knee pain Limited range of motion Difficulty in weight bearing in acute stage Joint effusion Knee giving out; chronic unstable knee

Lateral collateral ligament

Posterior cruciate ligament

Anterior cruciate ligament

Medial collateral ligament

Fibula

Figure 14-52

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Drawer Sign (12-14)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient supine, flex the leg and place the foot on the table (Fig. 14-53). Grasp behind the flexed knee and pull (Fig. 14-54) and push (Fig. 14-55) on the leg. The hamstring tendons must be relaxed for this test to be accurate.

Figure 14-53

Figure 14-54

Figure 14-55

CHAPTER 14

383

KNEE ORTHOPAEDIC TESTS

RATIONALE If there is more than 5 mm of tibial movement on the femur when the leg is pulled, an injury or tear of some degree to one or more of the following structures is indicated:

•

•

•

Anterior cruciate ligament (Fig. 14-56) Posterolateral capsule Posteromedial capsule Medial collateral ligament (if more than 1 cm of movement) Iliotibial band Posterior oblique ligament Arcuate-popliteus complex

Posterior cruciate ligament

I

�

Frontal view

Normal

Figure 14-56

With ligament tear

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

If excessive movement occurs when the leg is pushed, an injury to one of the following struc tures is indicated: •

Posterior cruciate ligament (Fig. 14-57) Arcuate-popliteus complex Posterior oblique ligament Anterior cruciate ligament

Anterior cruciate ligament Posterior cruclate ligament

Posterior view

Normal

Figure 14-57

Lateral view

With ligament tear

CHAPTER 14

Lachman's Test (14)

KNEE ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

385

I 1

I

2

I

3

I

4

With the patient supine and the knee in 30° of flexion, grasp the patient's thigh with one hand to stabilize it. With the opposite hand, grasp the tibia and pull it forward (Fig. 14-58).

RATIONALE If a softened feel and anterior translation of the tibia is present when the tibia is moved forward, then a tear of any of the following ligaments is suspect: •

Anterior cruciate ligament Posterior oblique ligament

This is the most reliable test for anterior cruciate ligament rupture because the knee does not need to flex to 90°, as with the anterior drawer sign; there is less meniscal impingement; and the hamstrings are less likely to spasm.

Figure 14-58

Reverse Lachman's Test (8)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient prone, flex the leg to 30°. With one hand, stabilize the posterior thigh, making sure that the hamstring muscles are relaxed. With your opposite hand, grasp the tibia and push it poste riorly (Fig. 14-59).

RATIONALE Posterior pressure on the tibia stresses the posterior cruciate ligament. A soft end feel and a poste rior translation of the tibia indicate an injury or tear to the posterior cruciate ligament.

Figure 14-59

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

386

Slocum Test (15)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I ,

I

2

I

3

I

4

With the patient supine, place the patient's foot on the examination table in 30° of internal rotation. Stabilize the patient's foot with your knee, grasp the tibia with your hand, and pull the tibia toward you (Fig. 14-60).

RATIONALE This test is similar to the anterior drawer sign except that in this test, the foot is in 30° of internal rotation. If tibial translation and a soft end feel occur when the tibia is drawn forward, suspect in stability or a tear of any of the following ligaments: •

•

Anterior cruciate Posterolateral capsule Fibular collateral ligament Iliotibial band

Figure 14-60

CHAPTER 14

Losee Test (16)

KNEE ORTHOPAEDIC TESTS

387

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient supine, grasp the patient's leg with one hand, externally rotate it, and brace it against your abdomen. Flex the leg 30° to relax the hamstring muscles (Fig. 14-6 1). With your op posite hand, grasp the knee with your thumb behind the fibular head and your fingers over the patella. Place valgus force against the lateral aspect of the knee and forward pressure behind the fibu lar head while extending the knee (Fig. 14-62).

RATIONALE Externally rotating the leg in 30° of flexion and applying a valgus force compress the structure in the lateral compartment of the knee. This compression may accentuate anterior subluxation of the tibia. While extending the knee and applying a valgus force, look for a palpable clunk. This clunk may in dicate anterior subluxation of the tibia, which is a reproduction of the patient's previous instability experience. It indicates injury or tear to one or more of the following structures: •

•

•

•

Anterior cruciate ligament Posterolateral joint capsule Arcuate-popliteus complex Lateral collateral ligament Iliotibial band

Figure 14-61

Figure 14-62

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Apley's Distraction Test (17)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

With the patient prone, flex the leg to 90°. Stabilize the patient's thigh with your knee. Pull on the patient's ankle while internally (Fig. 14-63) and externally (Fig. 14-64) rotating the leg.

RATIONALE Distraction of the knee takes pressure off the meniscus and puts strain on the medial and lateral col lateral ligaments. Pain on distraction indicates nonspecific ligament injury or instability.

Figure 14-63

Figure 14-64

CHAPTER 14

KNEE ORTHOPAEDIC TESTS

Adduction Stress Test (5)

389

Sensitivity/Reliability Scale

I

PROCEDURE

I

I 1

I

I 2

I

I

3

I

I

4

With the patient supine, stabilize the medial thigh. Grasp the lower leg and push it medially (Fig. 14-65). Also perform this test with the knee in 20° to 30° of flexion (Fig. 14-66).

RATIONALE If the tibia moves an excessive medial amount away from the femur (Box 14- 1) when the knee is in full extension, there may be a tear of any of the following ligaments: •

•

•

Tibial collateral ligament Posterior meniscofemoral ligament Posterior medial capsule Anterior cruciate ligament Posterior cruciate ligament

If the foregoing is positive when the knee is flexed 20° to 30°, any of the following ligaments may be unstable: •

Tibial collateral ligament Posterior meniscofemoral ligament Posterior cruciate ligament

Figure 14-65

Figure 14-66

Medial Stability Rating Scale Grade 0

No joint opening

Grade 1 +

Less than 0.5 em joint opening

Grade

0.5 to 1.0em joint opening More t han 1 em joint opening

Grade

2+ 3+

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

390

Abduction Stress Test (5)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I ,

I

2

I

3

I

4

With the patient supine, stabilize the lateral thigh. Grasp the lower leg and pull it laterally (Fig. 14-67). Then perform this test in 20° to 30° of flexion (Fig. 14-68).

RATIONALE If the tibia moves an excessive amount away from the femur (Box 14-2) when the knee is in full ex tension, there may be a tear of any of the following ligaments: •

•

•

Fibular collateral ligament Posterolateral capsule Posterior cruciate ligament Anterior cruciate ligament

If the foregoing is positive when the knee is flexed 20° to 30°, then the following ligaments may be unstable: Fibular collateral ligament Posterolateral capsule Iliotibial band

SUGGESTED DIAGNOSTIC IMAGING •

•

Plain film radiography AP knee view Lateral knee view Knee MRI

Figure 14-67

Figure 14-68 Lateral Stability Rating Scale Grade 0 Grade

1+

Grade 2+ Grade 3+

No joint opening Less than 0.5 em joint opening 0.5 to 1.0 em joint opening More than 1em joint opening

CHAPTER 14

391

KNEE ORTHOPAEDIC TESTS

PATELLOFEMORAL DYSF UNCTION The patella protects the anterior aspect of the knee joint. It also functions as a fulcrum that increases the mechanical advantage of the quadriceps muscle. The patella lies in the trochlear groove. With normal flexion and extension the patella tracks smoothly within the groove. Many causes of ante rior knee pain and dysfunction may be caused by an abnormality of the patella tracking in the trochlear groove or direct trauma to the patella. Patellofemoral abnormalities include fractures, dis locations, malalignment syndrome, chondromalacia patellae, and patellofemoral arthritis.

CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

Anterior knee joint pain Knee joint effusion Popping sensation Joint crepitus Discomfort with stair climbing Knee buckling

Patella Grinding Test

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I 2

I

I

I

3

I

4

With the patient supine, move the patella medially and laterally while pressing down (Fig. 14-69).

RATIONALE Pain under the patella indicates chondromalacia patellae, retropatellar arthritis, or a chondral frac ture. Osteochondritis of the patella also elicits pain on the patella. Pain over the patella may indicate prepatellar bursitis.

IQ Figure 14-69

I

392

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Patella Apprehension Test (17)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I 1

I 2

I

3

I

4

With the patient supine, manually displace the patella laterally (Fig. 14-70).

RATIONALE A look of apprehension on the patient's face and a contraction of the quadriceps muscle indicates a chronic tendency to lateral patella dislocation. Pain is also present with this test.

Figure 14·70

CHAPTER 14

Dreyer's Test

KNEE ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

o

PROCEDURE

393

I

I 1

I

I 2

I

I

3

I

I

4

With the patient supine, instruct him or her to raise the leg actively (Fig. 14-7 1). If the patient can not raise the leg, stabilize the quadriceps tendon just above the knee. At this point, instruct the pa tient to raise the leg again (Fig. 14-72).

RATIONALE If the patient can raise the leg the second time, suspect a traumatic fracture of the patella. The rec tus femoris muscle, which is a primary hip flexor, is attached to the patella by the quadriceps ten don. If the patella is fractured, the quadriceps tendon is not stabilized. Stabilizing the quadriceps tendon manually allows hip flexion to occur.

SUGGESTED DIAGNOSTIC IMAGING •

•

•

Plain film radiography AP knee view Lateral patella view Axial patella view Computed tomography (CT) Magnetic Resonance Imaging (MRI)

Figure 14-71

- I

Figure 14-72

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

394

KNEE JOINT EFF USION

CLINICAL DESCRIPTION Effusion in and around the knee may be caused by trauma, infection, degenerative joint disease, rheumatoid arthritis, gout, or pseudogout. The fluid may contain blood, fat, lymphocytes, and crys tals such as urate, pyrophosphate, and oxalate. Analysis of the effusion is beyond the scope of this book. The following physical tests attempt to determine whether fluid is present around the knee joint. If fluid is present, you must determine, based on the patient's history and clinical findings, whether aspiration is indicated.

CLINICAL SIGNS AND SYMPTOMS •

•

•

Knee pain on walking Anterior knee inflammation Knee joint warm to the touch

Patella Ballottement Test PROCEDURE

Sensitivity/Reliability Scale

I

o

I

I 1

I

I

2

I

I

3

!

I

4

With one hand, encircle and press down on the superior aspect of the patella. With the other hand, push the patella against the femur with your finger (Fig. 14-73).

RATIONALE If fluid is present in the knee, the patella will elevate when pressure is applied. When the patella is pushed down, it will strike the femur with a palpable tap.

Figure 14-73

CHAPTER 14

Stroke Test (5)

395

KNEE ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

I

I

o

PROCEDURE

I

1

I

2

I

3

4

With the patient supine, stroke the medial side of the patella up toward the suprapatellar pouch two or three times with your fingers and simultaneously stroke the lateral aspect of the patella inferior with your opposite hand (Fig. 14-74).

RATIONALE If a wave of synovial fluid is present, it will concentrate to the inferior medial border of the patella; subsequently, the area will bulge.

Figure 14-74

Fluctuation Test (5)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I 2

I

I

3

I

I

4

With the patient supine, grasp the thigh at the suprapatellar pouch with one hand and grasp the leg just below the patella with your opposite hand (Fig. 14-75). Press down with each hand alternately.

RATIONALE If synovial fluid is present, you will feel it fluctuate alternately under your hand. This fluctuation in dicates significant joint effusion.

SUGGESTED DIAGNOSTIC IMAGING •

None

m

Figure 14-75

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

396

Butler DL, Noyes FR, Grood ES. Ligamentous re

References 1 . American Academy of Orthopaedic Surgeons. The Clinical Measurement of Joint Motion. Chicago: AAOS, 1 994. 2. Boone DC, Azen SP. Normal range of motion of

straints to anterior-posterior drawer in the human knee. J Bone Joint Surg Am 1 980;62:259. Cailliet R. Knee Pain and Disability. Philadelphia: FA Davis, 1 973.

the joints in male subjects. J Bone Joint Surg

Cipriano J. Post traumatic knee injuries. Today's

Am 1979; 6 1:756-759.

Chiropractic 1985; 14( 5 ) :49-5 1.

3 . Apley AG. The diagnosis of meniscus injuries: some new clinical methods. J Bone Joint Surg 1947;29:78. 4. McMurray TP. The semilunar cartilages. Br J Surg 1942;29:407. 5 . McGee DJ. Orthopedic Physical Assessment. 2nd ed. Philadelphia: Saunders, 1 992. 6. Ricklin P, Ruttiman A, Del Buono MS. Meniscal Lesions: Diagnosis, Differential Diagnosis, and

Clancy WG. Evaluation of acute knee injuries. American Association of Orthopedic Surgeons sym posium on sports medicine: the Knee. St. Louis: Mosby, 1985. Clancy WG, Keene JS, Goletz TH. The symptomatic dislocation of the anterior horn of the medial meniscus. Am J Sports Med 1984; 12:57-64. Cyriax J. Textbook of Orthopaedic Medicine. Vol. 1 .

Therapy. 2nd ed. Mieller N H , trans. New York:

Diagnosis of Soft Tissue Lesions. London: Bailliere

Theme Stratton, 1983.

Tindall, 1982.

7. Helfet A. Disorders of the Knee. Philadelphia: JB Lippincott, 1974. 8 . Strobel M , Stedtfeld HW. Diagnostic Evaluation of the Knee. Berlin: Springer-Verlag, 1990.

Frankel VH, Burstein AH, Brooks DB. Biomechanics of internal derangement of the knee. J Bone Joint Surg Am 197 1;53:945.

9. Anderson AF, Lipscomb AB. Clinical diagnosis

Hardaker WT, Whipple TL, Bassett FH. Diagnosis

of meniscal tears-description of a new manip

and treatment of the plica syndrome of the knee. J

ulative test. Am J Sports Med 1988;14:2 9 l . 1 0 . Mital MA, Hayden J . Pain i n the knee i n chil dren: the medial plica shelf syndrome. Orthop Clin North Am 1979 ; 1 0 : 7 14. 1 1 . Houghston JC, Walsh WM, Puddu G. Patella subluxation

and

dislocation.

Philadelphia:

Saunders, 1984. 12. Butler DL, Noyes FR, Grood ES. Ligamentous

Bone Joint Surg Am 1980;62:22 1-255. Johnson T, Althoff B, Peterson L, et al. Clinical diag nosis of ruptures of the anterior cruciate ligament: a comparative study of the Lachman test and the an terior drawer sign. Am J Sports Med 1 982; 10: 100. Kapandji LA. The Physiology of the Joints. Vol. 2. Lower Limb. New York: Churchill Livingstone,

restraints to anterior-posterior drawer in the

1970.

human knee. J Bone Joint Surg Am 1980;62:

Katz KW, Fingeroth RF. The diagnostic accuracy of

259.

ruptures of the anterior cruciate ligament compar

13. Fukybayashi T, Torzilli PA, Sherman M F, et al.

ing the Lachman test, the anterior drawer sign and

An in vitro biomechanical evaluation of ante

the pivot shift test in acute and chronic knee in

rior posterior motion of the knee. J Bone Joint

juries. Am J Sports Med 1986; 14:88.

Surg Br 1972;54:763. 14. Jonsson TB, Althoff L, Peterson J, et al. Clinical diagnosis of ruptures of the anterior cruciate ligament: a comparative study of the Lachman

Nottage WM, Sprague NF, Auerbach BJ, et al. The medial patellar plica syndrome. Am J Sports Med 1983; 1 1 : 2 1 1 2 14.

test and the anterior drawer sign. Am J Sports

Outerbridge RE, Dunlop J. The problem of chon

Med 1 982; 10: 100.

dromalacia patellae. Clin Orthop 1975; 1 10: 177 196.

15. Slocwn DB, James SL, Larson RL, et al. A clini cal test for anterolateral rotary instability of the knee. Clin Orthop 1976; 1 1 8;63. 16. Loose RE, Jenning TR, Southwich WOo Anterior subluxation of the lateral tibial plateau: a diag

Pickett

JC, Radin EL. Chondromalacia

of the

Patella. Baltimore: Williams & Wilkins, 1983. Slocum DB, Larson RL. Rotary instability of the knee. J Bone Joint Surg Anl 1968;50:2 1 1.

nostic test and operative review. J Bone Joint

Stickland A. Examination of the knee joint. Physio

Surg Am 1 978;60: 1 0 1 5 .

therapy 1984;70: 144.

17. Hoppenfeld S. Physical examination o f the spine and extremities. New York: Appleton Century-Crofts, 1976: 127.

Scuderi, GR: The Patella. New York: Springer Verlag, 1995. Torg JS, Conrad W, Nalen V. Clinical diagnosis of anterior cruciate ligament instability in tlle athlete.

General References

Am J Sports Med 1976;4:84.

Bloom M H . Differentiating between meniscal and

Tria AJ. Ligaments of the Knee. New York: Churchill

patellar pain. Phys Sports Med 1989; 1 7 ( 8 ) :95-108.

Livingstone, 1995.

--------��-ANKLE ORTHOPAEDIC TESTS

ANKLE ORT HOPAEDIC EXAMINATION

398

FLOW CHART PALPATION

399

Medial Malleolus and Deltoid Ligament

399

Tibialis Posterior, Flexor Digitorum Longus, and Flexor Hallucis Longus Tendons

400

Posterior Tibial Artery and Tibial

402 Lateral Aspect 403

ANKLE RANGE OF MO TION

409

409 Planter Flexion 410 Inversion 411 Eversion 412 Dorsiflexion

LIGAMENTOUS INS T ABILI T Y

Medial Stability Test

404 405

Tinel's Foot Sign

Tibialis Anterior, Extensor Hallucis Longus, and Extensor Digitorum Longus Tendons

TARSAL T UNNEL SYNDROME Tourniquet Test

405

413

414 415 416

403

Peroneus Longus and Peroneus Brevis Tendons

407

Lateral Stability Test

Lateral Malleolus and Attached

Anterior Aspect

Retrocalcaneal Bursa

Drawer's Foot Sign

Nerve

Ligaments

407

Achilles Tendon, Calcaneal Bursa, and

399

Medial Aspect

Posterior Aspect

417

417 418

ACHILLES T ENDON RUP T URE T h ompson's Test

419

Achilles Tap Test

420

419

397

398

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Ankle Orthopaedic Examination

�

History

Range of motion (active) (passive) (+) Drawer's foot sign Lateral stability test Medial stability test

(-)

I

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

399

PALPATION Medial Aspect

Medial Malleolus and Deltoid Ligament DESCRIPTIVE ANATOMY The medial malleolus is the most distal prominence of the tibia. It embraces the medial aspect of the talus and gives the ankle joint bony stability. Attached to the malleolus is the strong deltoid ligament, which connects with three tarsal bones: the talus, navicular, and calcaneus. The deltoid is a four-part ligament that is named according to its attachments: tibionavicular, anterior and posterior tibiota lar, and tibiocalcaneal (Fig. 15-1). The deltoid ligament strengthens and provides medial stability to the ankle joint and holds the calcaneus and navicular bones against the talus. A common injury is a forceful eversion of the foot that causes an avulsion fracture of the deltoid ligament on the medial malleolus. PROCEDURE With the patient's weight off that foot, palpate the medial malleolus and deltoid ligament for ten derness and/or swelling (Fig. 15-2). Tenderness and/or swelling secondary to trauma may indicate periosteal contusion, sprain, or avulsion of the deltoid ligament.

Deltoid ligamen t

1

Posterior tibiotalar ligament Tibiocalcaneal ligament Anterior tibiotalar ligament Tibionavicular ligament

Medial malleolus Posterior talocalcaneal ligament

Plantar calcaneonavicular ligament Figure

15-1 Figure

15-2

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

400

Tibialis Posterior, Flexor Digitorum Longus, and Flexor Hallucis Longus Tendons DESCRIPTIVE ANATOMY The posterior tibial tendon passes posterior to the medial malleolus and inserts into the tuberosity of the navicular bone (Fig. 15-3). The action of the muscle is to plantar-flex the ankle and invert the foot. The flexor digitorum longus tendon is posterior to the posterior tibial tendon; it closely follows the tibia and passes behind the medial malleolus (Fig. 15-3). It inserts into the distal phalanges of the lateral four digits. The action of the muscle is to plantar-flex the ankle and flex all of the joints of the last four toes. The flexor hallucis longus tendon is posterior to the flexor digitorum longus tendon, and it passes behind the ankle joint, not posterior to the medial malleolus. It inserts into the base of the distal phalanx of the great toe (Fig. 15-3). Its action is to flex the great toe.

Posterior tibialis tendon Flexor digitorum longus tendon Posterior tibial artery

Figure

15-3

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

401

PROCEDURE To palpate the tibialis posterior tendon, invert and plantar-flex the patient's foot. Palpate medial to the tibia posterior to the medial malleolus (Fig. 15-4). Note the continuity of the tendon and any tenderness or swelling. Tenderness and/or swelling may indicate a strain secondary to trauma or ten dinitis. Loss of continuity and a valgus foot secondary to trauma may indicate a ruptured tendon. Palpate the flexor digitorum longus tendon, which is posterior to the tibialis posterior tendon. With one hand, resist flexion of the patient's toes, and with the other hand palpate the tendon (Fig. 15-5). Note any tenderness, swelling, or crepitus. These signs may indicate a strain or tendinitis of the tendon. The flexor hallucis longus tendon is not palpable and not described in this book.

Figure

Figure

15-5

15·4

402

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Posterior Tibial Artery and Tibial Nerve DESCRIPTIVE ANATOMY The posterior tibial artery runs between the tendons of the flexor digitorum longus and flexor hal lucis longus muscles. This artery is the major blood supply to the foot. The tibial nerve is a branch of the sciatic nerve. It runs with the posterior tibial artery under the flexor retinaculum of the ankle and posterior to the medial malleolus (Fig. 15-6). The flexor retinaculum may become constricted and cause a neurovascular deficit to the foot similar to carpal tunnel in the wrist. PROCEDURE Using light pressure with your middle and index finger, palpate the posterior tibial artery (Fig. 15-7). Note the amplitude and compare bilaterally. A decrease in the pulse amplitude may indicate a com pression of the posterior tibial artery. The tibial nerve is difficult at best to palpate and is not dis cussed in this book. It is an important nerve supply to the sole of the foot.

,

,

'

Flexor digitorum longus tendon Posterior tibial artery Posterior tibial nerve

Figure

15-6

Figure

15-7

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

403

Lateral Aspect

Lateral Malleolus and Attached Ligaments DESCRIPTIVE ANATOMY The lateral malleolus is the protuberance at the distal end of the fibula. Attached to the malleolus are three clinically important ligaments: •

•

•

Anterior talofibular ligament Calcaneofibular ligament Posterior talofibular ligament

These ligaments provide lateral support to the ankle, but they are not as strong as the deltoid lig ament on the medial aspect (Fig. 15-8). These ligaments are prone to tears in inversion injuries. PROCEDURE Palpate the lateral malleolus with your index and middle fingers (Fig. 15-9). Note any tenderness and/or swelling. These signs may indicate periosteal contusion, fracture, avulsion fracture, or inver sion sprain of any of the previously mentioned ligaments secondary to trauma.

Posterior tibiofibular ligament

Anterior tibiofibular ligament Anterior talofibular ligament

Posterior talofibular ligament

�-�#.-+- Calcaneofibular ligament

Lateral talocalcaneal ligament Figure

15-8

Figure

15-9

404

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Peroneus Longus and Peroneus Brevis Tendons DESCRIPTIVE ANATOMY The peroneus tendons travel together behind the lateral malleolus and are held in place by the per oneal retinaculum (Fig. 15- 10). The action of the muscles are to plantar flex and evert the foot. PROCEDURE With the patient not bearing weight, palpate behind the lateral malleolus with one hand, and pas sively invert (Fig. 15- 1 1) and evert (Fig. 15- 12) the foot with the other hand. Note any tenderness, swelling, or snapping. Tenderness and/or swelling may indicate tenosynovitis of either or both ten dons. Tenderness with snapping may indicate a defect of the peroneal retinaculum that causes the peroneal tendons to subluxate or dislocate.

Soleus m. Peroneus fibularis -\--\;-...r; longus tendon

1!,f:I-+---Tibialis anterior m. -*!t+H-- Extensor digitorum longus m.

Peroneus fibularis brevis m. Achilles (calcaneal) tendon T ibialis posterior muscle and sheath Superficial bursa Retrocalcaneal bursa -+-I-IIf.f·rff".::.--r Superior peroneal retinaculum Inferior peroneal retinaculum

Peroneus tertius tendon

Figure 15-10

Figure 15-11

Figure 15-12

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

405

Anterior Aspect

Tibialis Anterior, Extensor Hallucis Longus, and Extensor Digitorum Longus Tendons DESCRIPTIVE ANATOMY The tibialis anterior tendon lies against the anterior surface of the tibia under the extensor retinac ulum. It attaches to the medial cuneiform bone and first metatarsal (Fig. 15-l3). Its action is to dor siflex the ankle and invert the foot. The extensor hallucis longus tendon passes under the superior and inferior extensor retinacula. It inserts into the dorsal aspect of the great toe (Fig. 15-l3). The ac tion of the muscle is to dorsiflex the ankle and extend the great toe. The extensor digitorum longus tendon lies lateral to the tibialis anterior. It inserts into the middle and distal phalanges of the lat eral four toes. It passes under the superior and inferior flexor retinacula (Fig. 15-l3). Its action is to dorsiflex the ankle, evert the foot, and extend the lateral four toes.

anterior

Peroneus brevis m.

D·��H-Superior extensor retinaculum Extensor digitorum longus tendon (and synovial sheaths)

""",fJ13�fi1�1)

Lateral malleolus

Tendons of extensor """",=f---I/iIII;f+ digitorum longus

Figure

15-13

I nferior extensor

+-tl-+--Extensor hallicus longus tendon r-h'-H--'Ix I--E tensor hallicus brevis tendon

406

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PROCEDURE To palpate the tibialis anterior, instruct the patient to dorsiflex and invert the foot. The tendon should become prominent. Palpate the tendon for point tenderness (Fig. 15- 14). Tenderness may be caused by overpronation, especially in runners. Tendinitis or a strain of the tendon also may be pres ent. This muscle and tendon support the longitudinal arch of the foot. To palpate the extensor hallucis longus tendon, instruct the patient to extend the great toe (Fig. 15- 15). The tendon should be prominent. Palpate the tendon for point tenderness. This may indi cate tendinitis or strain of the tendon. To palpate the extensor digitorum longus tendon, instruct the patient to extend the toes. Palpate the tendon first where it crosses the ankle (Fig. 15- 16), then when it divides into the four parts (Fig. 15- 17) that insert into the middle phalanx. Tenderness may indicate tendonitis or tenosynovitis from overuse, especially in the runner.

Figure

15-14

Figure

15-15

Figure

15-16

Figure

15-17

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

407

Posterior Aspect

Achilles Tendon, Calcaneal Bursa, and Retrocalcaneal Bursa DESCRIPTIVE ANATOMY The Achilles tendon attaches the gastrocnemius and soleus muscles to the calcaneus. It is the strongest tendon in the body but the one most frequently ruptured. Two bursae surround this ten don: the calcaneal bursa, which is superficial to the Achilles tendon and below the skin; and the retrocalcaneal bursa, which is deep to the Achilles tendon (Fig. 15- 18). These bursae are normally not palpable unless they are inflamed.

Soleus m. Peroneus fibularis -,......,,� longus tendon

]-rl-f---T ibialis anterior m. -fIm'it-t-- Extensor digitorum longus m.

Peroneus fibularis

Achilles (calcaneal) tendon Tibialis posterior muscle and sheath Calcaneal bursa --f-+IIIIJ Retrocalcaneal bursa

--hfJli'i��:;/"--A

Superior peroneal retinaculum Inferior peroneal retinaculum Figure

Peroneus tertius tendon

15-18

m

408

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

PROCEDURE With the ankle in the neutral position, palpate the Achilles tendon with your thumb and index fin ger (Fig. 15- 19). Next, place posterior to anterior pressure on the Achilles tendon with your thumb (Fig. 15-20). Note any pain, tenderness, increase in temperature, swelling, crepitus, and/or continu ity of the tendon. Pain, tenderness, and an increase in temperature may indicate tendinitis, a strain, or a partial tear of the tendon. Loss of continuity of the tendon may indicate a complete rupture of the tendon. This is rare but may affect especially patients with a history of chronic Achilles tendini tis. Pain, tenderness, and inflammation deep to the Achilles tendon may indicate retrocalcaneal bur sitis. Pain, tenderness, and swelling over the Achilles tendon and below the skin indicate calcaneal bursitis.

Figure

15-19

Figure

15-20

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

409

ANKLE RANGE OF MOTION

Dorsiflexion (1) With the patient supine, place the goniometer in the sagittal plane with the center at the lateral malleolus (Fig. 15-21). Instruct the patient to flex the foot backward while following the foot with one arm of the goniometer (Fig. 15-22). NORMAL RANGE (2) Normal range is 13° ± 4.4° or greater from the 0 or neutral position.

Muscles

Nerve Supply

Tibialis anterior Extensor digitorum longus Extensor hallucis longus Peroneus tertius

Deep peroneal Deep peroneal Deep peroneal Deep peroneal

Figure

15-21

Figure

15-22

410

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Plantar Flexion (1) With the patient supine, place the goniometer in the sagittal plane with the center at the lateral malleolus (Fig. 15-23). Instruct the patient to flex the foot forward while following the foot with one arm of the goniometer (Fig. 15-24). NORMAL RANGE (2) Normal range is 56° ± 6. 1° or greater from the 0 or neutral position.

Muscles

Nerve Supply

Gastrocnemius Soleus Plantaris Flexor digitorum longus Peroneus longus Peroneus brevis Flexor hallucis longus Tibialis posterior

Tibial Tibial Tibial Tibial Superficial peroneal Superficial peroneal Tibial Tibial

Figure

15-23

Figure

15-24

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

411

Inversion (1) With the patient prone and the knee flexed, place the inclinometer at the base of the heel and zero out the inclinometer (Fig. 15-25). Instruct the patient to invert the foot, and record the measure ment (Fig. 15-26). NORMAL RANGE (2) Normal range is 37° ± 4.5° or greater from the 0 or neutral position.

Muscles

Nerve Supply

Tibialis posterior Flexor digitorum longus Flexor hallucis longus Tibialis anterior Extensor hallucis longus

Tibial Tibial Tibial Deep peroneal Deep peroneal

Figure

15-25

Figure

15-26

412

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Eversion (1,2) With the patient prone and the knee flexed, place the inclinometer at the base of the heel and zero out the inclinometer (Fig. 15-27). Instruct the patient to evert the foot and record the measurement (Fig. 15-28). NORMAL RANGE Normal range is 2 10 ± 50 or greater from the 0 or neutral position.

Muscles

Nerve Supply

Peroneus longus Peroneus brevis Peroneus tertius Extensor hallucis longus

Superficial peroneal Superficial peroneal Deep peroneal Deep peroneal

Figure

15-27

Figure

15-28

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

413

LIGAMENTOUS INSTABILITY CLINICAL DESCRIPTION The ankle joint is formed by the tibia, fibula, and talus, which are bound together by ligaments that provide for stability and joint movement. These are the anterior and posterior talofibular, anterior tibiofibular, calcaneofibular, and deltoid ligaments (Fig. 15-29). If any of these ligaments are torn, the tibia can separate from the fibula and the talus may become unstable. The degree to which these ligaments are torn determines the degree of talar instability. Most of theses injuries are sports re lated, and the most common mechanism of injury is a supination or inversion force. This occurs when the foot turns under the ankle after walking or running on uneven surfaces or when landing on an inverted foot after a jump. The most common injured ligament is the anterior talofibular lig ament. Ligament laxity or instability may lead to chronic ankle sprains. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Ankle swelling Static ankle pain Pain on passive motion Tenderness over affected ligament Figure

Posterior tibiofibular ligament Anterior tibiofibular ligament Anterior talofibular ligament Posterior talofibular ligament

Lateral talocalcaneal ligament

Calcaneofibular ligament

Deltoid ligament: Posterior tibiofibular ligament Tibiocalcaneal ligament Anterior tibiotalar ligament Tibionavicular ligament

Posterior talocalcaneal ligament

Plantar calcaneonavicular ligament

15-29

414

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sensitivity/Reliability Scale

Drawer's Foot Sign (3)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient supine, stabilize the ankle with one hand. With your opposite hand, grasp and press posterior on the tibia (Fig. 15-30). Next, grasp the anterior aspect of the foot with one hand and the posterior aspect of the tibia with the other, and pull anterior (Fig. 15-31). RATIONALE Gapping secondary to trauma when the tibia is pushed indicates a tear of the anterior talofibular lig ament. Gapping when the tibia is pulled indicates a posterior talofibular ligament tear (Fig. 15-32).

Figure

15-30

Figure

Posterior talofibular ligament Anterior taloflbular ligament

Figure

15-32

15-31

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

415

Sensitivity/Reliability Scale

Lateral Stability Test (3)

I

o

PROCEDURE

I 1

I

2

I

3

I

4

With the patient supine, grasp the patient's foot and passively invert it (Fig. 15-33). RATIONALE If gapping secondary to trauma is present, suspect a tear of the anterior talofibular and/or calcaneo fibular ligament (Fig. 15-34).

Figure

15-33

Anterior tibiofibular ligament Anterior talofibular ligament

';T"'-�I\+-t-Calcaneoflbular ligament

Lateral talocalcaneal ligament Figure

15-34

416

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sensitivity/Reliability Scale

Medial Stability Test (3)

I

o

PROCEDURE

I 1

I

2

With the patient supine, grasp the foot and passively evert it (Fig. 15-35). RATIONALE If gapping secondary to trauma is present, suspect a tear of the deltoid ligament (Fig. 15-36). SUGGESTED DIAGNOSTIC IMAGING •

•

Plain film radiography Anteroposterior (AP) ankle view Mortise view Lateral view Stress views Magnetic resonance imaging (MRI)

Figure

15-35

Deltoid ligamen t

1

Posterior tibiofibular ligament Tibiocalcaneal ligament Anterior tibiotalar ligament Tibionavicular ligament

Posterior talocalcaneal ligament

Plantar calcaneonavicular ligament Figure

15-36

I

3

I

4

CHAPTER 15

ANKLE ORTHOPAEDIC TESTS

417

TARSAL TUNNEL SYNDROME CLINICAL DESCRIPTION Tarsal tunnel syndrome occurs when the posterior tibial nerve becomes entrapped in its tunnel as it passes behind the medial malleolus to enter the foot. The tunnel may be compressed either intrin sically or extrinsically. Space-occupying lesions account for 50% of cases. Direct trauma and repet itive dorsiflexion account for a significant portion of the other 50%. A severe flat foot can unduly stretch the posterior tibial nerve, causing tarsal tunnel syndrome. Other causes, such as fracture cal lus, ganglion of the tendon sheath, lipoma, exostosis, engorged venus plexus, and excessive prona tion of the hind foot, should be investigated. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Intermittent paresthesia of plantar aspect of the foot Pain on foot inversion and/or eversion of the foot Pain radiating to medial aspect of the leg Pain made worse by activity and improved by rest Sensitivity/Reliability Scale I I I I I I I I I

Tourniquet Test (4)

o

PROCEDURE

1

2

3

4

Wrap a sphygmomanometer cuff around the affected ankle and inflate it to just above the patient's systolic bbod pressure. Hold for 1 to 2 minutes (Fig. 15-37).

Figure

15-37

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

418

RATIONALE Tarsal tunnel syndrome is compression of the posterior tibial nerve beneath the flexor retinaculum at the ankle (Fig. 15-38). Compression of the area by the cuff accentuates the narrowing of the tun nel, increasing the patient's pain. If pain is elicited or existing pain is exacerbated, suspect a com promise of the tarsal tunnel.

+f- F'lexor digitorum tendon

-iH-- I'n"tAri

"Tarsal tunnel"

tibial artery

-H- F'os'terl'or tibial nerve \:M""1:--,:,ovn. hallucis longus tendon

�M!,\\I-+- F:lexor retinaculum

Figure

15-38 Sensitivity/Reliability Scale

Tinel's Foot Sign

I

a

PROCEDURE

I 1

I

2

I

3

I

Tap the area over the posterior tibial nerve with a neurological reflex hammer (Fig. 15-39). RATIONALE Paresthesias radiating to the foot indicate an irritation to the posterior tibial nerve that may be caused by a constriction at the tarsal tunnel. SUGGESTED DIAGNOSTIC TEST •

Nerve conduction velocity of the posterior tibial nerve

Figure

15-39

CHAPTER 15

419

ANKLE ORTHOPAEDIC TESTS

ACHILLES TENDON RUP TURE CLINICAL DESCRlPTION Achilles tendon rupture generally occurs in adults aged 30 to 50. It is usually spontaneous in ath letes, who account for most of these injuries. Some authors suggest that this is due to decreased vas cularity of the Achilles tendon as the patient ages. The mechanism that causes rupture is forced dor siflexion of the foot as the soleus and gastrocnemius contract. Rupture occurs usually 2 to 6 em from the insertion of the Achilles tendon into the calcaneus. As the proximal aspect of the tendon retracts, there is usually a palpable defect of the tendon. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

Severe posterior ankle pain Inability to stand on toes Posterior leg and heel swelling Posterior leg and heel ecchymosis

Thompson's Test (5)

Sensitivity/Reliability Scale

I

o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

Instruct the prone patient to flex the knee. Squeeze the calf muscles against the tibia and fibula (Fig. 15-40). RATIONALE When the calf muscles are squeezed, the gastrocnemius and soleus muscles mechanically contract. These muscles are attached to the Achilles tendon, which in turn plantar-flexes the foot. If the Achilles tendon is ruptured, contraction of the gastrocnemius and soleus muscles will not plantar flex the foot.

Figure

15-40

420

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Achilles Tap Test PROCEDURE Tap the Achilles tendon with a neurological reflex hammer (Fig. 15-41). RATIONALE Exacerbation of pain and a loss of plantarflexion indicate an Achilles tendon rupture. NOTE The patient must be neurologically sound for this test to be valid. SUGGESTED DIAGNOSTIC IMAGING •

•

Plain film radiography AP ankle view Lateral view Ankle MRI

Figure

15-41

CHAPTER 15

References 1. American Academy of Orthopaedic Surgeons. T he clinical measurement of joint motion. Chicago: AAOS, 1994. 2. Boone DC, Azen SP. Normal range of motion of joint in male subjects. J Bone Joint Surg Am 1979;6 1:756-759. 3. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton Century-Crofts, 1976: 127. 4. McRae R. Clinical Orthopedic Examination. New York: Churchill Livingstone, 1976. 5. Thom ' of the tendon of Achilles: a new clinical diag nostic test. Anat Res 1967; 158:126.

ANKLE ORTHOPAEDIC T ESTS

421

COX JS, Brand RL. Evaluation and treatment of lat eral ankle sprains. Sports Med 1977;5:5 1. Dvorkin ML. Oddice Orthopaedics. Norwalk, CT: Appleton & Lang, 1993. Gates SJ, Mooar PA. Musculoskeletal Primary Care. Baltimore: Lippincott Williams & Wilkins, 1999. Kapandji LA. The Physiology of the Joints. Vol. 2. Lower Limb. New York: Churchill Livingstone, 1970. Kelikian H. Disorders of the Ankle. Philadelphia: Saunders, 1985. Lam SJ, Tarsal tunnel syndrome. Lancet 1962; 2: 1354. Mennell JM. Foot Pain. Boston: Little, Brown, 1969. Post M. Physical examination of the musculoskele tal system. Chicago: Year Book Medical, 1987.

General References Anderson

Soma CA, Mandelbaum BR. Achilles tendon disor ders. Clin Sports Med 1994; 13(4): 1 18.

Be. Office Orthopedics For Primary

Care. 2nd ed. Philadelphia: Saunders, 1999. Colter JM. Lateral ligamentous injuries of the ankle. In: Hamilton WC, ed. Traumatic disorders of the ankle. New York: Springer Verlag, 1984.

m

I � I

--------��-MISCELLANEOUS ORTHOPAEDIC TESTS

423

429

Mannkopf's Maneuver

423

Buerger's Test

MENINGEAL IRRI TATION AND

424

Allen's Test

428

Magnuson's Test

PERIPHERAL ART ERIAL INSUFFICIENCY

INFLAMMATION DEEP-VEIN THROMBOSIS Homan's Sign

425

425

Kernig's Test

430 430

Brudzinski's Sign Lhermitte's Sign

431 432

SYMPTOM MAGNIFICATION ASSESSMEN T

426

Hoover's Sign

426

Burn's Bench Test

422

427

LEG MEASUREMEN T S

433

Actual Leg Length

433

Apparent Leg Length

434

CHAPTER 16

423

MISCELLANEOUS ORTHOPAEDIC TESTS

PERIPHERAL ARTERIAL INSUFFICIENCY Peripheral arterial insufficiency may involve both the upper and lower extremities. It may be due to obstruction, traumatic occlusion, arthrosclerosis, diabetes, Buerger's disease, or Raynaud's phenom enon. The patients who develop arterial insufficiency generally demonstrate one of three clinical patterns: (a) cold, cyanosed, livid and/or painful digits (Raynaud's phenomenon); (b) digital isch emia; or (c) crampy pain on exercise (claudication). There is usually prolonged venous filling time following elevation of the extremity. The impaired flow or arterial insufficiency may be adequate to serve the metabolic activities of the muscles at rest but does not maintain the circulation necessary to the increased metabolic rates of exercise. Therefore, exercise testing, such as flexing and extend ing the arms and legs or walking, may reproduce the patient's symptoms. Diagnosis is based on the combination of physical examination and vascular diagnostic testing, such as angiography, plethys mography, thermography, and vascular ultrasound. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

•

•

Extremity pain Cold extremities Decreased pulse amplitude Pallor or rubor Hair loss Shiny skin Claudication Gangrene

Buerger's Test

Sensitivity/Reliability Scale

I o

PROCEDURE

I

I 1

I

I 2

I

I 3

I

I

4

With the patient supine, instruct him or her to elevate one leg at a time. The patient must consecu tively dorsiflex and plantar-flex the raised foot for a minimum of 2 minutes (Figs. 16-1 and 16-2). The leg is then lowered and hung off the side of the table with the patient seated (Fig. 16-3). RATIONALE

Elevating and flexing the foot diminishes the blood flow in the lower extremity. When the leg is low ered and hung off the table, the lower leg and foot should fill with blood. This turns the foot a pink ish color, and the veins distend. This process takes less than 1 minute. If it takes longer, the test is positive for arterial compromise to the lower extremity.

Figure 16-1

Figure 16-2

Figure 16-3

424

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Allen's Test (1,2)

Sensitivity/Reliability Scale

PROCEDURE

I

I

I

I

I

o

1

2

3

4

With the patient seated, occlude the radial and ulnar arteries with both thumbs (Fig. 16-4). Then in struct the patient to open and close the fist to express blood from the tissue (Fig.16-5). At that point, instruct the patient to open the hand as you release the pressure to the radial artery (Fig. 16-6). Re peat the test with the pressure released to the ulnar artery (Fig. 16-7). RATIONALE

Consecutively opening and closing the fist diminishes the blood flow in the hand, causing blanch ing. When pressure on one of the arteries is released, the hand should fill with blood, which turns it a pinkish color, and the veins distend. A delay of more than 10 seconds in returning a pinkish color to the hand indicates either ulnar artery insufficiency or radial artery insufficiency. The artery being tested is the one not being manually occluded. SUGGESTED DIAGNOSTIC IMAGING •

•

•

•

Peripheral vascular ultrasound Thermography Plethysmography Angiography

Figure 16-4

Figure 16-5

Figure 16-6

Figure 16·7

CHAPTER 16

MISCELLANEOUS ORTHOPAEDIC TESTS

425

DEEP VEIN THROMBOSIS Deep vein thrombosis (DVT) is a cordlike clot formation that usually arises in the deep veins of the calf muscles. This venous occlusion results in edema and dependent cyanosis. The cause may be ia trogenic or result from a mechanical trauma that injured the endothelium of the veins, hypercoag ulability associated with malignant tumor or oral contraceptives, or stasis that occurs with pro longed bed rest. If left untreated, approximately 20% of thrombi may extend into the proximal venous system and pose a serious and even life-threatening risk of a pulmonary embolism: 90% of pulmonary emboli originate in the deep venous system of the legs. CLINICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

•

Leg pain Leg swelling Leg tenderness Local temperature elevation Discoloration Venous distension Palpable cord (thrombosed vessel)

Homan's Sign PROCEDURE

Sensitivity/Reliability Scale

I

I

I

I

I

o

1

2

3

4

With the patient supine, dorsiflex the foot and squeeze the calf (Fig. 16-8) (3). RATIONALE

Deep-seated pain at the posterior leg or calf may indicate thrombophlebitis. Dorsiflexing the foot places a dynamic stretch on the gastrocnemius muscle and tension of the deep veins. The addition of squeezing the calf compresses the surrounding tissue against the thrombus, stimulating a noci ceptive response. SUGGESTED DIAGNOSTIC IMAGING •

•

•

Peripheral vascular ultrasound Plethysmography Venography

Figure 16-8

426

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

SYMPTOM MAGNIFICATION ASSESSMENT Symptom magnification is usually misrepresentation of the patient's symptoms, feigned for sec ondary gain. This is a very difficult assessment. Although this condition is most common in the set ting of workers compensation and personal injury cases, the secondary gain may not be financial alone. It may occur if individuals desire a less strenuous job at work. They may gain control over fel low workers or family members. The injured party may allow others to do work that the patient would normally do. The possibility of symptom magnification should be raised when major discrepancies or incon sistencies appear in the patient's condition. These inconsistencies are most noted in history and physical examination. Some examples of these inconsistencies: (a) dramatized complaints that are vague or global, (b) overemphasized gait or postural abnormalities, (c) resistance to evaluation or rehabilitation, and (d) lack of motivation to develop new skills or lack of treatment compliance. Once the information has been collected, a determination of symptom magnification may be made. This is difficult because very few symptom magnification cases are totally without pain or fear of being placed in a job perceived as potentially harmful. Second opinions are quite useful if you sus pect symptom magnification. Concurrence by more that one physician is prudent in these cases. CLNICAL SIGNS AND SYMPTOMS •

•

•

•

•

•

Discrepancy between patient's presentation and degree of reported pain Negative workup for organic problems by multiple physicians Dramatized complaints that are vague or global Overemphasized gait or posture Resistance to evaluation Resistance to rehabilitation

Hoover's Sign (3,4)

Sensitivity/Reliability Scale

I o

PROCEDURE

I

I 1

I

I

2

I

I

3

I

I

4

With the patient supine, instruct him or her to lift the affected leg while you place one hand under the heel on the unaffected side (Fig. 16-9). RATIONALE

The patient who is magnifying the symptoms will not raise the affected leg, and no posterior pres sure will be put on the unaffected heel. If the patient is genuinely trying to raise the leg but cannot do so, you should feel pressure from the unaffected heel.

Figure 16-9

CHAPTER 16

Burn's Bench Test

427

MISCELLANEOUS ORTHOPAEDIC TESTS

Sensitivity/Reliability Scale

PROCEDURE

I

I

I

I

o

1

2

3

I

Instruct the patient to kneel on the examination table. Have the patient bend at the waist to touch the floor while you stabilize the legs (Fig. 16-10). RATIONALE

Patients with low back pain will be able to perform this test because no strenuous activity of the back is involved. The stress is placed on the posterior leg muscles. If the patient with low back pain can not perform the test, suspect magnification of the symptoms.

Figure 16-10

428

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Magnuson's Test

Sensitivity/Reliability Scale

PROCEDURE

I

I

I

I

I

o

1

2

3

4

Instruct the seated patient to point at the site of the pain (Fig. 16-11). Next, distract the patient by performing some irrelevant test. Then instruct the patient to point at the site of the pain again (Fig. 16-12). RATIONALE

The patient with real pain will point to the specific site of pain both times. The patient who is mag nifying the symptoms usually does not indicate the exact same site twice.

Figure 16-11

Figure 16-12

CHAPTER 16

Mannkopf's Maneuver

MISCELLANEOUS ORTHOPAEDIC TESTS

429

Sensitivity/Reliability Scale

PROCEDURE

I

I

I

I

I

a

,

2

3

4

With the patient seated, obtain the resting pulse rate (Fig. 16-13). Then irritate the patient's com plaint by poking at it with your finger (Fig. 16-14). Next, retake the pulse rate. RATIONALE

The sympathetic system controls vasoconstriction and heart rate. When the area of pain is provoked, the patient with true pain will undergo a fight or flight phenomenon, increasing the heart rate and blood pressure. In the patient who has true pain, the pulse rate will increase by 10% or more. This reaction is carried out below the conscious level and is not under the patient's control. If the heart rate does not increase, the patient may be magnifying the symptoms. SUGGESTED DIAGNOSTIC IMAGING •

Based on area of complaint

Figure 16-13

Figure 16-14

430

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

MENINGEAL IRRITATION AND INFLAMMATION CLINICAL DESCRIPTION

Irritation of the meninges is a local condition usually caused by mechanical pressure to a specific sec tion of the meninges, such as a herniated intervertebral disc, spinal stenosis, or tumor. Inflammation of the meninges or meningitis is usually caused by infection, either bacterial or viral. It usually de velops from hematogenous spread through the bloodstream from a distant infected location or by contiguous spread from a local structure, such as the nasopharynx. The infection causes an exudation of cells and proteins into the subarachnoid space. The meningeal reaction spreads through the cen tral nervous system (CNS), involving the meninges covering the spinal cord as well as the brain. CLINICAL SIGNS AND SYMPTOMS •

•

Meningeal Irritation Local neck or back pain Radicular pain to an extremity Decreased or lost extremity sensation Decreased or lost extremity motor function Loss of bladder or bowel functions Meningitis Violent headache Stiff, painful neck Elevated temperature Mental status change

Kernig's Test (5-7)

Sensitivity/Reliability Scale

PROCEDURE

I

I

I

I

I

o

1

2

3

4

With the patient supine, instruct him or her to flex the hip and knee to 90° with the lower leg par allel to the table (Fig. 16-15). Then instruct the patient to extend the knee on the side that is being tested (Fig. 16-16). RATIONALE

With the hip and knee flexed, the sciatic nerve and the dural sac are relaxed. Extension of the knee puts traction on the sciatic nerve, hence ultimately the dural sac or meninges. Inability to straighten the leg or pain while straightening the leg indicates meningeal irritation or nerve root involvement. NOTE

If bacterial meningitis is present, the patient may have head pain that increases with sudden neck movements, neck stiffness, nuchal rigidity, and an elevated temperature. This test will also elicit radicular pain in the patient with sciatic radiculopathy.

Figure 16-15

Figure 16-16

CHAPTER 16

431

MISCELLANEOUS ORTHOPAEDIC TESTS

Brudzinski's Sign (8) PROCEDURE

Sensitivity/Reliability Scale

I

I

I

I

I

o

1

2

3

4

With the patient supine, flex the patient's neck to the chest (Fig. 16-17). RATIONALE

Flexing the neck places traction on the dural sac and spinal cord. Irritation of the dural sac causes pain at the level of irritation. Flexing the knees reduces the traction on the spinal cord and meninges. If the patient flexes the knees, the test is positive and indicates meningeal irritation or nerve root in volvement (Fig. 16-18). NOTE

Suspect bacterial meningitis if the patient has head pain that is increased with sudden neck move ments, neck stiffness, nuchal rigidity, and an elevated temperature. This test will also elicit radicular pain in the patient with sciatic radiculopathy.

Figure 16-17

Figure 16-18

m I

432

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Lhermitte's Sign

Sensitivity/Reliability Scale

I o

PROCEDURE

I

I 1

I

I

2

I

I

I

3

4

With the patient seated, instruct the patient to passively flex his head to his chest (Fig. 16-19). RATIONALE

Flexing the neck stretches the spinal cord and meninges. Sharp pain radiating down the spine or into the upper or lower extremities may indicate nerve root, dural, or meningeal irritation. It also may indicate cervical myelopathy or multiple sclerosis. SUGGESTED DIAGNOSTIC IMAGING AND TESTING •

•

Meningeal Irritation Plain film radiography Computed tomography (CT) Magnetic resonance imaging (MRI) Meningitis Cerebrospinal fluid examination

Figure 16-19

CHAPTER 16

MISCELLANEOUS ORTHOPAEDIC TESTS

433

LEG MEASUREMENTS CLINICAL DESCRIPTION

Measurement of the lower extremities is performed to evaluate a true anatomical leg length dis crepancy versus an apparent or false leg lengt� discrepancy. A true shortened lower limb may be due to congenital defect of development, impaired epiphyseal growth, or fracture. An apparent or false shortened leg may be due to a functional pelvic tilt, scoliosis, or an adduction or abduction defor mity of the hip. Each may cause a distinct biomechanical defect leading to lower back pain or local lower extremity joint pain. Evaluation and correction may relieve lower back or local lower extrem ity joint pain, especially when findings of examination of the lower back and lower extremity joints are unremarkable. CLINICAL SIGNS AND SYMPTOMS •

•

•

Shortened lower extremity Lower back pain Hip, knee, or ankle pain

Actual Leg Length

Sensitivity/Reliability Scale

PROCEDURE

I

I

I

I

I

o

1

2

3

4

With the patient standing, take a tape measure and measure bilaterally from the anterior superior il iac spine to the floor (Fig. 16-20). RATIONALE

This is a true measurement of the patient's lower extremity. Compare the measurements. Any dif ference indicates an anatomic short leg.

m

I Figure 16-20

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

434

Apparent Leg Length

Sensitivity/Reliability Scale

I

PROCEDURE

I

I

I

1

2

3

I

With the patient supine, measure bilaterally the distance between the umbilicus and the medial malleolus (Fig. 16-21). RATIONALE

Any difference in the two measurements indicates a functional leg deficiency that may be caused by muscular or ligamentous contracture deformities. SUGGESTED DIAGNOSTIC IMAGING •

Radiographic scanogram

Figure 16-21

References

General References

I. Allen EV, Barker NW, Hines EA Jr. Peripheral

American Society for Surgery of the Hand. The

Vascular Disease. 4th ed. Philadelphia: Saunders,

Hand: Examination and Diagnosis. Aurora, CO:

1972:37-38.

ASSH, 1978.

2. Allen EY. Thromboangiitis obliterans: methods of diagnosis of chronic occlusive arterial lesions distal to the wrist. Am J Med Sci 1929; 178: 238-239. 3. Arieff AJ, Tigay EI, Kurtz JF, et al. The Hoover sign: an objective sign of pain and/or weakness in the back or lower extremities. Arch

Neurol

1961;5:673. 4. Hoover CF. A new sign for the detection of ma lingering and functional paralysis of the lower extremities. JAMA 1928;5 1:746-749. 5. Kernig W. Concerning a little noted sign of meningitis. Arch NeuroI 1969;2 1:2 16. 6. Wartenberg R. The signs of Brudzinski and of Kernig. J Pediatr 1950;37:679. 7. Brody lA, Williams KH. The sign of Kernig and Brudzinski. Arch NeuroI 1969;2 1:2 16. 8. Brudzinski J. A new sign of the lower extremities in meningitis of children (neck sign). Arch Neu roI 1969;2 1:2 16.

Borenstein D, W iesel SW, Boden SO. Neck Pain: Medical Diagnosis and Comprehensive Manage ment. Philadelphia: Saunders, 1996. Edgar VA, Barker NW, Hines EA Jr. Peripheral Vas cular Disease. Philadelphia: Saunders, 1946:57-58. Hoppenfeld S. Physical Examination of the Spine and

Extremities.

New

York: Appleton-Century

Crofts, 1976: 127. Woerman AL, Binder-Macleod SA. Leg-length dis crepancy assessment: accuracy and precision in five clinical methods of evaluation. J Orthop Sports Phys Ther 1984;5:230.

--------��rCRANIAL NERVES

OLFACTORY NERVE (I) OPTIC NERVE (II)

437

438

OPHTHALMOSCOPIC EXAMINATION 441 OCULOMOTOR, TROCHLEAR, AND ABDUCENS NERVES (III, IV, VI) 443 TRIGEMINAL NERVE (V) MOTOR 446 Reflex 447 Corneal Reflex 1a", Reflex 447 Sensory 448 FACIAL NERVE (VII) Motor 449 Sensory 451

447

449

446

AUDITORY NERVE ( VIII) 452 Weber's Test: Cochlear Nerve 452 Rinne's Test: Cochlear Nerve 453 Veering Test: Vestibular Nerve 454 Past Pointing Test: Vestibular Nerve 455 Labyrinthine Test for Positional Nystagmus 456 GLOSSOPHARYNGEAL AND VAGUS NERVES (IX, X) 458 Sensory 459 Reflex 460 Gag Reflex 460 SPINAL ACCESSORY NERVE (XI) 461 Trapezius Muscle Test 461 Sternocleidomastoideus Muscle Test 461 HYPOGLOSSAL NERVE (XII)

462

ii 435

436

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Twelve pairs of cranial nerves exit from the brain and brainstem. These nerves innervate the face, head, and neck, controlling all motor and sensory functions in these areas, including vision, hear ing, smell, and taste. The cranial nerves may be affected by cranial trauma, infections, aneurysm, stroke, degenerative diseases (multiple sclerosis), upper motor neuron lesions, lower motor neuron lesions, increased intracranial pressure, and abnormal masses or tumors. An important anatomic feature of cranial nerves is bilateral and unilateral innervation. In bilat eral innervation, relatively equal distributions of right and left brain hemisphere innervation gov ern the function of a specific facial part. Movements that are performed in bilateral synchrony, such as swallowing and moving the forehead, are innervated bilaterally. In unilateral innervation, the contralateral hemisphere innervates the specific body part. Fine movements of the face are examples of unilateral cranial nerve innervation. The many types of cranial nerve lesions produce a number of syndromes. Unilaterally affected cranial nerves V, V II, and V II I may indicate a cerebellopontine angle lesion. Unilaterally affected cra nial nerves III, IV, V, and VI may indicate a cavernous sinuous lesion. Unilaterally affected cranial nerves IX, X, and XI may indicate a jugular foramen syndrome. Bilaterally affected cranial nerves X, XI, and XII may indicate bulbar or pseudobulbar palsy. Multiple cranial nerve abnormalities are shown in Figure

17-1.

Unilateral cranial nerve abnormalities Contralateral hemiplegia or I----{ No }---------____ tetraplegia

Figure 17-1. Multiple cranial nerve abnormalities. Reprinted with permission from Fuller G. Neurological Examination Made Easy. London: Churchill Livingstone, 1993.

CHAPTER 17

CRANIAL NERVES

437

OLFACTORY NERV E (I) PROCEDURE

The olfactory nerve is responsible for the sense of smell. To test this nerve, obtain some aromatic substances, such as coffee, tobacco, or peppen;nint oil. Instruct the patient to close one nostril. Place the substance under the open nostril and ask what the patient smells, if anything (Fig.

17-2). Repeat

the procedure for the opposite nostril. RATIONALE

If the patient cannot smell or identify the smell unilaterally, suspect a lesion of the olfactory nerve. If the patient cannot smell or identify the smell bilaterally, consider a nonorganic problem or a bi lateral cranial nerve I lesion. NOTE

A diminished or almost absent sense of smell is common in the elderly. It will be apparent if loss of smell is bilateral and the cranium has undergone no trauma. Other nonneurogenic lesions, such as sinus infection, deviated septum, and lesions caused by smoking, may also cause a loss of smell, ei ther unilaterally or bilaterally.

Figure 17-2

•

438

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

OPTIC N ERVE (II) PROCEDURE

The optic nerve is responsible for visual acuity and peripheral vision. To test for visual acuity, ask the patient to cover one eye and read the smallest print possible on a Snellen chart (Fig.

17-3). Re

peat the test with the opposite eye. Note the results. This is not a test for visual acuity for refractive error; it tests the acuity for optic nerve involvement. This test may be performed with the patient wearing glasses or contact lenses. To test for peripheral vision, ask the patient to cover one eye with the hand and keep a fixed gaze on your nose with the uncovered eye. Directly motion a large cross with your finger from superior to inferior and from right to left (Fig.

17-4). Instruct the patient to tell you when he or she begins

to see your finger. Repeat with the opposite eye and record the results.

-

FP T 0 Z 3 LPED pl:CrD tDrCz'P rtLO,;t>

Figure 17-3

Figure 17-4

CHAPTER 17

CRANIAL NERVES

439

RATIONALE

Any loss of vision, from complete unilateral or bilateral loss of vision to loss of half fields of vision (hemianopsia) or a partial defect in the field of vision (scotoma), indicates an optic nerve lesion. Temporal lobe lesions can produce superior contralateral quadrantanopsia. Occipital lobe lesions can produce a contralateral homonymous hemianopsia with macular sparing. Figure

17-5 shows

a schematic of the neural pathway from the brain to the retina and demonstrates the location of the lesion and its effect on vision. Also associated with the schematic is a flow chart of field defects (Fig.

17-6).

VISUAL FIELD \ \ \ \ \ \ , \

Optic chiasm Optic tract

Lateral geniculate body

area Occipital lobe of cerebrum Figure 17-5

\

\

\

440

Is there a field defect in both eyes?

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

No Lesion anterior to optic chiasm, retina or optic nerve

1------( No }-------_____

Optic tract

13

Bilateral retinal or optic nerve lesion

.()()

..i) ...� 4

6

Figure 17-6. Field defects. Reprinted with permission from Fuller G, ed. Neurological Examination Made Easy. London: Churchill Livingstone, 1993.

CHAPTER 17

CRANIAL NERVES

441

OPHTHALMOSCOPIC EXAMINATION PROCEDURE

With an ophthalmoscope, look into the patient's eye. Bring the scope

1 to 2 cm from the eye and en

courage the patient to fix the gaze at a distant point (Fig. 17-7). Use the focus ring to correct for your · vision and the patient's vision. If you or the patient is myopic and is not using glasses or contact lenses, turn the focus ring dial counterclockwise to focus on the eye. If you or the patient is presby opic, turn the focus dial clockwise to focus on the eye. Look at the optic disc, blood vessels, and reti nal background.

Figure 17-7

•

442

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

RATIONALE

Visualize the optic nerve, the optic disc, and the optic cup for swelling and atrophy (Fig.

17-8).

What you find:

Blurred

Blurred

Optic nerve swelling

had

Figure 17-8. Optic disc abnormalities. Reprinted with permission from Fuller G. Neurological Examination Made Easy. London: Churchill Livingstone, 1993.

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443

OCULOMOTOR, TROCHLEAR, AND ABDUCENS N ERVES (III, IV, V I) PROCEDURE

Cranial nerves III, IV, and V I are all associated with ocular and pupillary motility and are tested to gether for simplicity. Cranial nerve III also innervates the levator palpebrae muscles, which are re sponsible for movement of the eyelids. First, look at the patient's eyelids and note any ptosis. After inspection of the eyelids, inspect the eye globes for alignment. Dysfunction of cranial nerve III, IV, or VI may be responsible for deviations of eye alignment. Next, inspect the pupils and determine their size and shape. Then test the pupillary reflex by flashing a light into one of the patient's eyes (Fig.

17-9). Look at the pupils one at a time for contraction or dilation.

To test ocular movements, have the patient follow either your finger or a moving object through the entire field of vision in all axes. Observe for nystagmus and/or inability to move the eye in a par ticular axis (Fig.

17- 10). Also, test for convergence by having the patient look at a distant object and

continue to focus on it as you move that object closer to the patient. The pupil should constrict and converge as the object approaches. Look at both pupils in both instances.

Figure 17-9

Figure 17-10

•

444

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

RATIONAlE

An oculomotor nerve lesion causes ptosis of the eyelid with inability to open the lid. Eye alignment may be down and lateral. Also, the patient will be unable to move the eyeball upward, inward, or downward because of weakness of the medial, superior, and inferior rectus muscles and the inferior oblique muscle. The pupil is usually dilated, and the pupillary reflex is absent. The most frequent cause of a cranial nerve III paralysis is an aneurysm in the circle of Willis. Other conditions may also cause the pupil to dilate and the pupillary reflex to become absent (Fig.

17-11).

A trochlear nerve lesion causes superior and lateral deviation of the eye with inability to move the eyeball downward and inward because of weakness of the superior oblique muscle. An abducens nerve lesion causes inability to move the eyeball outward because of weakness of the lateral rectus muscle. Figure

Pupil large

17-12 shows lateral rectus muscle defects of alignment.

Reacts to light

Normally

Anisocorla

Doesn't react to light

Normal accommodation

Afferent pupillary defect

Slowly accommodates

Holmes-Adie pupil

No accommodation

With ptosis: probable III

No ptosis: mydriatic drugs

Pupil small

Reacts to light

Doesn't react to light

Elderly

Senile miosis

With ptosis, enophthalmos, anhydrosis

Horner's syndrome

Normal accommodation

Irregular: Argyll-Robertson pupil

No accommodation

Miotic drugs

Figure 17-11. Pupillary abnormalities. Reprinted with permission from Fuller G. Neurological Examination Made Easy. London: Churchill Livingstone, 1993.

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CRANIAL NERVES

445

Figure 17-12

II

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PHOTOGRAPHIC MANuAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

TRIG EMINAL N ERV E (V) The trigeminal nerve i s composed o f motor and sensory portions. The motor portion innervates the muscles of mastication. These muscles are the masseter, pterygoid, and temporal muscles. The sen sory portion is divided into three branches: the ophthalmic branches

(Vl), maxillary (V2), and mandibular

(V3).

Motor PROCEDURE FOR THE MASSETER, PTERYGOID, AND TEMPORALIS MUSCLES

To test the motor portion that innervates the masseter muscle, instruct the patient to simulate a bite while you palpate the masseter muscle and attempt to open the patient's jaw with your thumbs (Fig.

17- 13). To test the pterygoid muscle, instruct the patient to deviate the jaw against your resistance 17- 14). To test the temporalis muscle, instruct the patient to clench the jaw while you palpate the temporalis muscles with your fingers (Fig. 17-15). Note whether muscle contraction is sym (Fig.

metrical. RATIONALE

A weak masseter or pterygoid muscle may indicate a trigeminal nerve lesion. A difference in muscle tension of the temporal is muscle is also an indication of a trigeminal motor lesion. In bilateral paral ysis, the jaw may not close tightly. In unilateral lesions, the jaw deviates toward the side of the lesion when the patient opens the mouth.

Figure 17-13

Figure 17-14

Figure 17-15

CHAPTER 17

CRANIAL NERVES

447

Reflex Corneal Reflex PROCEDURE

Instruct the patient to gaze upward and inward while you touch the cornea with a strand of cotton, approaching from the lateral side (Fig.

17-16). Be careful not to touch the eyelash or conjunctiva.

The patient should blink when the cornea is touched. The corneal reflex has sensory fibers from the trigeminal nerve and motor fibers from the facial nerve.

Figure 17-16

Jaw Reflex PROCEDURE

Instruct the patient to open the mouth slightly. Place your thumb or index finger just lateral to the midline of the patient's chin, and press down. With a neurological reflex hammer, tap down on your finger to open the jaw (Fig.

17- 17). The normal response is to close the jaw rapidly.

RATIONALE

The corneal and jaw jerk reflexes have a sensory component from the trigeminal nerve. The jaw jerk reflex has a motor component to the trigeminal nerve. The corneal reflex has a motor component from the facial nerve. If the corneal reflexes are absent, suspect a lesion of either the sensory portion of the trigeminal nerve or the motor component of the facial nerve. If the jaw jerk reflex is absent, suspect a lesion of the trigeminal nerve.

Figure 17-17

448

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sensory PROCEDURE

To test for sensory deficit, instruct the patient to close the eyes. Touch the forehead, cheek, and chin with a pin for pain sensation; a piece of cotton for the sensation of light touch; and small test tubes of hot and cold water for thermal sensation (Figs.

17-18 to 17-20). Perform these procedures to both

sides of the face and ask the patient to compare the sensations bilaterally. Next, instruct the patient to open the mouth and touch the tongue, the inside of both cheeks, and the hard palate with a wooden tongue depressor (Fig.

17-2 1). Instruct the patient to give a signal, such as raising the hand,

on feeling the sensation. RATIONALE

A decrease in the sensation of light touch, pain, and/or temperature from one side to the other in dicates a lesion of the sensory portion of the affected branch of the trigeminal nerve. Lesions of the ophthalmic, maxillary, or mandibular branch of the trigeminal nerve produces decreased sensation of the forehead, cheek, or chin, respectively.

Figure 17-18

Figure 17-19

Figure 17-20

Figure 17-21

CHAPTER 17

CRANIAL NERVES

449

Motor PROCEDURE

The facial nerve has both motor and sensory fibers. The motor fibers innervate the muscles of the face and platysma. Observe the patient's face for abnormal movements, such as tics or tremors. Note the degree of change of expression or lack of change. To test for motor function, observe the face in repose. Then instruct the patient to frown, raise the eyebrows, close the eyes, show the teeth, smile, and whistle or puff the cheeks (Figs. 17-22 to FACIAL NERVE

(VII)

Figure 17-22

Figure 17-23

Figure 17-24

Figure 17-25

17-25).

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

450

RATIONALE

Facial nerve lesions may stem from upper motor neurons or lower motor neurons. These neurons may be distinguished by the various facial expressions. An upper motor neuron lesion generally has no effect on the forehead and eyelids. In a lower motor neuron lesion, when the eyebrows are raised and lowered, the forehead does not wrinkle. Showing the teeth and whistling are absent in both up per and lower motor neuron lesions. Smiling may not elevate the mouth in a lower motor neuron lesion, but a symmetrical smile may occur in an upper motor neuron lesion. Inability of the patient to perform these movements indicates a lesion of the motor portion of the facial nerve (Fig.

Bilateral weakness forehead stronger than lower face

Normal strength little spontaneous movement

Figure 17-26. Facial nerve abnormalities. Reprinted with permission from Fuller G. Neurological Examination Made Easy. London: Churchill Livingstone, 1993.

17-26).

CHAPTER 17

CRANIAL NERVES

451

Sensory PROCEDURE

Instruct the patient to close the eyes and protrude the tongue. Apply solutions of sugar, salt, and/or vinegar to one side and on the anterior two-thirds of the tongue (Fig.

17-27). Instruct the patient to

identify each substance without retracting the tongue. This can be done by having the patient point to a list of various substances on a card or on a sheet of paper. Instruct the patient to rinse the mouth; then apply another substance on the opposite side. RATIONALE

Inability to taste and/or identify the substances may indicate a lesion of the sensory portion of the facial nerve. NOTE

Complete loss of taste in facial nerve lesions is rare. It is most common for the patient to have a spon taneous or perverted taste as opposed to complete loss of taste. If complete loss of taste is noted, con sider nonneurogenic causes, such as viral infection, aging, smoking, and toxic or metabolic disease.

Figure 17-27

II

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AUDITORY N ERV E (V III) The auditory nerve is composed of a cochlear portion and a vestibular portion. The cochlear por tion is responsible for hearing, and the vestibular portion is responsible for balance. The cochlear portion is tested by evaluating the patient's hearing. The most accurate way to test hearing is with an audiometer. If one is not available, place a ticking watch close to the patient's ear and see whether he or she can hear it. Weber's and Rinne's tests indicate cochlear lesions. Vestibular lesions are also determined by veering and past pointing tests and by observing the patient for nystagmus.

Weber's Test: Cochlear Nerve PROCEDURE

Place a vibrating

256-Hz tuning fork on top of the patient's head (Fig. 17-28). Ask the patient

whether he or she hears the sound equally in both ears. RATIONALE

The test is normal if the patient hears the sound equally in both ears. If the sound is louder in one ear than in the other, suspect a conduction problem, such as a blockage of the ear canal or middle ear disease on the side of the louder sound. If a nerve lesion is present, the sound will be heard only in the normal ear. This hearing problem could be caused by otosclerosis, Meniere's disease, menin gitis, cerebellopontine tumors, trauma, or a demyelinating lesion.

Figure 17-28

CHAPTER 17

CRANIAL NERVES

453

Rinne's Test: Cochlear Nerve PROCEDURE

Place a vibrating tuning fork on the mastoid process (Fig.

17-29). Ask the patient to say when the

sound disappears. After the sound disappears, place the tuning fork next to but not touching the ear (Fig.

17-30). Ask the patient again to say when the sound fades out.

RATIONALE

Normally, air conduction is twice as loud as bone conduction-a Rinne positive. In conduction le sions and nonneurogenic lesions, bone conduction is greater than air conduction-a Rinne nega tive. In auditory nerve lesions, air conduction is greater than bone conduction.

Figure 17-29

Figure 17-30

454

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Veering Test: Vestibular Nerve PROCEDURE

Instruct the patient to walk with the eyes closed (Fig.

17-31).

RATIONALE

Veering in walking or a positive Romberg's test indicates a unilateral vestibular lesion. See Chapter

19 for Romberg's test.

Figure 17-31

CHAPTER 17

CRANlAL NERVES

455

Past Pointing Test: Vestibular Nerve PROCEDURE

With the patient's eyes open, instruct the patient to elevate the extended arm over the head with in dex finger extended (Fig.

17-32). Next, instruct the patient to touch your extended index finger, 17-33). Repeat the test with the patient's eyes

which you hold near the patient at hip level (Fig. closed. RATIONALE

If the patient has a vestibular lesion, the patient's arm will drift, and he or she will have difficulty

placing the finger on yours with eyes closed.

Figure 17-32

Figure 17-33

456

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Labyrinthine Test for Positional Nystagmus PROCEDURE

With the patient seated, inspect the eyes and note any nystagmus (Fig.

17-34). Nystagmus is a slow

drift of the eye in one direction with a fast correction in the opposite direction. It is described in the direction of the fast phase. Next, have the patient lie supine and inspect for nystagmus for

30 sec 17-35). Assist the patient to turn to one side and stabilize the head. Note any nystagmus for 30 seconds (Fig. 17-36). Repeat with the patient turned to the opposite side. Have the patient ex tend the head over the examination table, and inspect for nystagmus for 30 seconds (Fig. 17-37). Al onds (Fig.

low sufficient time between tests for the patient with nystagmus to recover.

Figure 17-34

Figure 17-36

Figure 17-35

Figure 17-37

CHAPTER 17

CRANIAL NERVES

457

RATIONALE A patient with persistent nystagmus that changes direction with changes in the head position and

that appears on repeated maneuvers suggests brainstem or posterior fossa pathology. A delayed, mild, rapidly disappearing response that produces nystagmus in only one direction and cannot be repeated suggests benign postural vertigo (Fig.

17-38).

��

�____________

Reassess

Jerk nystagmus Up

Upbeat nystagmus

Down

Downbeat nystagmus

Rotatory

Rotatory nystagmus

Horizontal

Nystagmus in primary position of gaze Nystagmus when looking in opposite direction of fast phase Nystagmus only if looking to direction of fast phase

2nd degree horizontal nystagmus

3rd degree horizontal nystagmus

• Multidirectional gaze evoked nystagmus Figure 17-38. Nystagmus. Reprinted with permission from Fuller G. Neurological Examination Made Easy. London: Churchill Livingstone, 1993.

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

458

G LOSSOPHARYNG EAL AND VAGUS N ERVES (IX, X) The glossopharyngeal and vagus nerves are clinically inseparable because of their overlap and are therefore tested together. The glossopharyngeal nerve conveys taste from the posterior tongue and has sensory innervation to the tonsillar pillars, soft palate, and pharyngeal wall. The vagus nerve overlaps the functions of the glossopharyngeal nerve and innervates the larynx. Note any hoarseness or change in voice tone. The vagus nerve controls activity in the cardiac, respiratory, and gastroin testinal systems; however, these functions are difficult to assay because of the variable supraseg mental and hormonal influences. Motor function is assessed by having the patient say "ah" and observing the palate for deviation. Place a tongue depressor on the patient's tongue and observe palatal deviation (Fig.

17-39). If devi

ation exists, it will be toward the normal side. Next, ask the patient to swallow rapidly while you pal pate the trachea (Fig.

17-40). Fatigue on continued swallowing may be seen in a patient who has 17-41). Leakage

myasthenia gravis. You may also ask the patient to puff the cheeks with air (Fig.

through the nose indicates weakness in the muscle of the soft palate. This weakness is also a sign of a lesion in cranial nerve IX or X. The leakage can be stopped by pinching the nose.

Figure 17-40

Figure 17-39

Figure 17-41

CHAPTER l7

CRANIAL NERVES

459

Sensory PROCEDURE

Instruct the patient to close the eyes and protrude the tongue. Apply a bitter-tasting solution on one side of the posterior third of the tongue (Fig.

17-42). Instruct the patient to identify each substance

without retracting the tongue. This can be done by having the patient point out one of a list of sub stances on a card or sheet of paper. RATIONALE

Inability to taste and/or identify the substances indicates a lesion of the sensory portion of the glos sopharyngeal and/or vagus nerve.

Figure 17-42

II

460

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Reftex Gag Reflex PROCEDURE With a throat stick, touch the posterior pharyngeal wall, first on one side and then on the other (Fig.

17-43). Observe the movement of the palate and the patient when he or she gags. Also, ask the pa tient whether the stimulus feels the same on both sides or is stronger on one side than on the other.

RATIONALE Deviation of the palate to one side and/or an asymmetrical feeling of the stimulus indicates a lesion of the glossopharyngeal and/or vagus nerves. If the patient has had a tonsillectomy, a slight asym metry of palatal movement may be normal.

Figure 17-43

CHAPTER 17

CRANIAL NERVES

461

SPINAL ACCESSORY NERVE (XI) The spinal accessory nerve innervates the trapezius and the sternocleidomastoideus muscles. To as sess the spinal accessory nerve, test the trapezius and sternocleidomastoideus muscles.

Trapezius Muscle Test PROCEDURE

With the patient seated, apply pressure to the patient's shoulders bilaterally and ask him or her to shrug against your resistance (Fig.

17-44). Grade each side according to the muscle grading chart in

Chapter 4. RATIONALE A grade

0 to 4 indicates a spinal accessory nerve lesion. Suspect a strained or weak trapezius muscle

if the sternocleidomastoideus muscle has reasonably normal strength.

Sternocleidomastoideus Muscle Test PROCEDURE

With the patient seated, place your hand on the lateral aspect of the patient's jaw and instruct him or her to turn the head toward your hand against resistance (Fig. to the muscle grading chart in Chapter

17-45). Grade each side according

4.

RATIONALE A grade

0 to 4 indicates a spinal accessory nerve lesion. A strained or weak sternocleidomastoideus

muscle is suspect if the trapezius muscle is of reasonably normal strength.

II Figure 17-44

Figure 17-45

462

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

H YPOGLOSSAL N ERVE (XII) The hypoglossal nerve is purely motor and is responsible for the movement of the tongue. PROCEDURE

Place your hand on the patient's cheek and instruct the patient to press the tip of the tongue against the cheek under your hand (Fig. protrude the tongue (Fig.

17-46). Have the patient do this bilaterally. Instruct the patient to

17-47).

RATIONALE

If the pressure under your hand by the patient's tongue is unequal, suspect a unilateral hypoglossal nerve lesion, which will exhibit a deviation of the tongue toward the side of the lesion.

Figure 17-46

Figure 17-47

----- ------

CHAPTER 17

G eneral References Barrows HS. Guide to Neurological Assessment. Philadelphia: JB Lippincott, 1980. Bickerstaff ER. Neurological Examination in Clini cal Practice. 4th ed. Boston: Blackwell Scientific, 1980. Chusid JG. Correlative neuroanatomy and func tional neurology. 17th ed. Los Altos: Lange Medical, 1976. Colling RD. Illustrated Manual of Neurologic Diag nosis. 2nd ed. Philadelphia: JB Lippincott, 1982. Dejong RN. T he Neurologic Examination. 4th ed. Hagerstown, MD: Harper & Row, 1979. DeMyer W. Technique of the Neurologic Exami nation: A Programmed Text. 3rd ed. New York: McGraw-Hill, 1980.

CRANIAL NERVES

463

Devinsky 0, Feldmann E. Examination of the Cra nial and Peripheral Nerves. New York: Churchill Livingstone, 1988. Fuller G. Neurological Examination Made Easy. London: Churchill Livingstone, 1993. Mancall E. Essentials of the Neurologic Examina tion. 2nd ed. Philadelphia: FA Davis, 1981. Merritt HH. A Textbook of Neurology. 4th ed. Philadelphia: Lea & Febiger, 1967. VanAllen MW, Rodnitzky RL. Pictorial Manual of Neurologic Tests. 2nd ed. Chicago: Year Book Med ical, 198 1.

--------��-REFLEXES

PATHOLOGICAL UPPER EXTREMITY

SUPERF ICIAL CUTANE OUS

REFLEXES

REFLEXES

465

474

Hoffman's Sign

465

Upper Abdominal Reflex

474

Tromner's Sign

466

Lower Abdominal Reflex

475

Rossolimo's Hand Sign

467

Superficial Gluteal Reflex

Chaddock's Wrist Sign

468

Corneal Reflex

476

Pharyngeal Reflex PATHOLOGICAL LOWER EXTREMITY REFLEXES

469

Babinski's Sign O ppenheim's Sign

470

Chaddock's Foot Sign

471

Rossolimo's Foot Sign

472

Schaeffer's Sign

464

469

473

Palatal Reflex

476

476

475

CHAPTER 18

REFLEXES

465

PATHOLOGICAL UPPER EXTREMITY REFLEXES This chapter discusses various pathological reflexes that usually are present in corticospinal disease and higher cortical dysfunction, such as stroke, tumor, demyelinating diseases, and vasculitis. If no corticospinal pathology or other higher cortical dysfunction is present, these reflexes should be ab sent. These reflexes are not graded on the Wexler scale but are referred to as being either present or absent. Babinski's and Rossolimo's foot signs are considered normal in infants.

Hoffman's Sign PROCEDURE With the patient's forearm pronated, grasp the patient's hand and middle finger. With your oppo site hand, flick the distal end of the patient's middle finger, stretching the flexor and eliciting a stretch reflex (Fig.

18-1).

RATIONALE A positive sign is elicited if the patient flexes the thumb and forefinger (Fig.

18-2). A positive sign

indicates a hyperactive reflex only. If this sign is present, it may be one indicator of pyramidal tract disease.

Figure 18-1

Figure 18-2

466

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Tromner's Sign PROCEDURE Grasp the patient's wrist and tap the plantar surface of the tip of the index and middle digits (Fig.

18-3). RATIONALE A positive sign is elicited if the patient flexes all of the fingers (Fig.

18-4). A positive sign indicates a

hyperactive reflex only. If this sign is present, it may be one indicator of corticospinal tract disease.

Figure 18-3

Figure 18-4

CHAPTER 18

REFLEXES

467

Rossolimo's Hand Sign PROCEDURE With a neurological reflex hammer, tap the palmar surface of the metacarpophalangeal joint (Fig.

18-5). RATIONALE A positive sign is elicited if the patient flexes all of the fingers (Fig. ramidal tract disease.

Figure 18-5

Figure 18-6

18-6). This sign is present in py

468

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Chaddock's Wrist Sign PROCEDURE Grasp the patient's wrist, putting pressure on the palmaris longus tendon (Fig.

18-7).

RATIONALE A positive sign is elicited if the patient flexes the wrist and extends the fingers (Fig. is present in pyramidal tract disease.

Figure 18-7

Figure 18-8

18-8). This sign

CHAPTER 18

REFLEXES

469

PATHOLOGICAL LOWER EXTREMITY REFLEXES Babinski's Sign PROCEDURE With the patient supine, stroke the sole of the foot with a blunt object like the handle of a neuro logical reflex hammer. Begin with the lateral aspect of the heel and move superiorly and medially to the big toe (Fig.

18-9).

RATIONALE This sign is very important in the neurological examination. A positive sign is evident if the patient dorsiflexes the great toe and fans the rest of the digits (Fig.

18- 10). This sign is a classic indication 12 to 16 months.

of a corticospinal motor system lesion. It may be present in normal infants aged

Figure 18-9

Figure 18-10

470

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Oppenheim's Sign PROCEDURE With the patient supine, stroke the medial side of the tibia with a blunt object (Fig.

18-11).

RATIONALE Extension of the great toe is a positive sign (Fig. cospinal motor system lesion.

Figure 18-11

Figure 18-12

18-12). If this reflex is present, suspect a corti

CHAPTER 18

REFLEXES

47l

Chaddock's Foot Sign PROCEDURE With the patient supine, stroke the lateral malleolus with a blunt object (Fig.

18-13).

RATIONALE Extension of the great toe indicates a positive sign (Fig. ticospinal motor system lesion.

Figure 18-13

Figure 18-14

18-14). If this reflex is present, suspect a cor

472

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Rossolimo's Foot Sign PROCEDURE With the patient supine, tap the metatarsal heads of the patient's feet with a neurological reflex ham mer (Fig.

18-15).

RATIONALE Plantar flexion of the toes indicates a positive sign (Fig. children aged

18- 16). This sign is considered normal in 2 months to 3 years. In other age groups, if this sign and a Babinski sign are present,

suspect pyramidal tract disease.

Figure 18-15

Figure 18-16

CHAPTER 18

REFLEXES

473

Schaeffer's Sign PROCEDURE With the patient supine and the feet overhanging the examination table, squeeze the Achilles tendon (Fig.

18- 17).

RATIONALE Extension of the great toe is a positive sign (Fig. pyramidal tract.

Figure 18-17

Figure 18-18

18- 18). If this sign is present, suspect a lesion of the

474

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

SUPERFICIAL CUTANEO US REFLEXES Superficial cutaneous reflexes are polysynaptic. They are mediated through a reflex arc but are con trolled inherently by the corticospinal system. These reflexes are also not graded by the Wexler scale but are either present or absent. Unlike the pathological reflexes, these reflexes are normally present if there is no lesion of the corticospinal tract. The superficial corneal, pharyngeal, and palatal reflexes belong in this group but are discussed in Chapter 17.

Upper Abdominal Reflex PROCEDURE With the patient supine, scrape the skin from medial to lateral above the umbilicus with the blunt end of a neurological reflex hammer (Fig.

18- 19) and evaluate bilaterally.

RATIONALE A deviation of the umbilicus to the stroked side is a normal response. If the umbilicus does not move unilaterally or if the response is delayed, the response is absent. The reflex may be absent in obese patients and pregnant women. This absent reflex is normal, but only if it is absent bilaterally. An ab sent unilateral response indicates a T7 to T9 nerve root lesion or disease of the corticospinal system. If you suspect the latter, perform other corticospinal system tests to verify your findings.

Figure 18·19

CHAPTER 18

REFLEXES

475

Lower Abdominal Reflex PROCEDURE With the patient supine, scrape the skin from medial to lateral below the umbilicus with the blunt end of a neurological reflex hammer (Fig. 18-20) and evaluate bilaterally.

RATIONALE A deviation of the umbilicus to the stroked side is a normal response. If the umbilicus does not move unilaterally or if the response is delayed, the response is absent. The reflex may be absent in obese patients and pregnant women. This absence is normal, but only if the reflex is absent bilaterally. An absent unilateral response indicates a TI0 to T 12 nerve root lesion or disease of the corticospinal system. If you suspect the latter, perform other corticospinal system tests to verify your findings.

Figure 18-20

Superficial Gluteal Reflex PROCEDURE With the patient prone, scrape the buttock with the blunt end of a neurological reflex hammer (Fig. 18-21). Perform this test bilaterally.

RATIONALE A contraction of the gluteal muscle on the side of the scraping is a normal response. If the reflex is absent unilaterally, suspect an L4 or L5 nerve root lesion or a corticospinal system lesion. If you sus pect the latter, perform other corticospinal system tests to verify your evaluation.

Figure 18-21

476

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Corneal Reflex See Chapter 17.

Pharyngeal Reflex See Chapter 17.

Palatal Reflex See Chapter 17.

General References

DeMyer W. Technique of the Neurologic Exami

Adams C. Neurology in Primary Care. Philadelphia:

McGraw-Hill, 1980.

FA Davis, 2000. Aminoff MJ, Greenberg DA, Simon RP. Clinical Neurology. 3rd ed. Stamford, CT: Appleton & Lange, 1996. Barrows HS. Guide to Neurological Assessment. Philadelphia: JB Lippincott, 1980.

nation: A Programmed Text. 3rd ed. New York:

Devinsky 0, Feldmann E. Examination of the Cra nial and Peripheral Nerves. New York: Churchill Livingstone, 1988. Heilman NM, Watson RT, Green M. Handbook for Differential Diagnosis of Neurologic Signs and Symptoms. New York: Appleton-Century-Crofts,

Bickerstaff ER. Neurological Examination in Clini

1977.

cal Practice. 4th ed. Boston: Blackwell Scientific,

Lapides], Babbitt JM. Diagnostic value of bulbocav

1980. Bronisch FW. The Clinically Important Reflexes. New York: Grune & Stratton, 1952. Chusid JG. Correlative Neuroanatomy and Func tional Neurology. 16th ed. Los Altos, CA: Lange Medical, 1976. Colling RD. Illustrated Manual of Neurologic Diag nosis. 2nd ed. Philadelphia: JB Lippincott, 1982. DeJong RN. The Neurologic Examination. 4th ed. Hagerstown, MD: Harper & Row, 1979.

ernosus reflex. JAMA 1956;162:971. Mancall E. Essentials of the Neurologic Examina tion. 2nd ed. Philadelphia: FA Davis, 1981. Merritt HH. A Textbook of Neurology. 4th ed. Philadelphia: Lea & Febiger, 1967. Swanson P. Signs and Symptoms in Neurology. Philadelphia: JB Lippincott, 1989. VanAllen MW, Rodnitzky RL. Pictorial Manual of Neurologic Tests. 2nd ed. Chicago: Year Book Med ical, 1981.

--------��-CEREBELLAR FUNCTION TESTS

UPPER EXTREMITY

Finger-Finger Test

Dext erity Test

Heel-Kn ee Test

478

481

Patting Test

479

P ronation-Supination Test Patting Test

LOWER EXTREMITY

478

Finger-No s e Test

480

483 483

484

Figur e-Eight Test Romberg's Test

485 486

482

477

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Cerebellar dysfunction is an interruption of the integration of afferent sensory feedback and effer ent motor output. Loss of joint position sense can produce some uncoordination, which can be sub stantially worse when the eyes are closed. The following tests attempt to evaluate the patient's coor dination and joint position sense. If any of the tests are positive, suspect an ipsilateral cerebellar syndrome. This syndrome may be caused by demyelination, vascular disease, trauma, tumor, or abscess. If any of the tests are positive bilaterally, suspect a bilateral cerebellar syndrome. This syndrome may be caused by alcohol con sumption, demyelination, or vascular disease.

UPPER EXTREMITY Finger-Nose Test

PROCEDURE With the patient standing or sitting with eyes closed, ask him or her to touch both index fingers to the nose simultaneously (Fig.

19-1).

RATIONALE The patient should be able to perform this procedure smoothly and easily. If the patient cannot per form this procedure, cerebellar function is impaired.

Figure 19·1

CHAPTER 19

CEREBELLAR FUNCTION TESTS

479

Finger-Finger Test

PROCEDURE Ask the patient to place his or her finger on your finger. Repeat this several times with the patient's eyes open and closed (Figs.

19-2 and 19-3).

RATIONALE The patient should be able to perform this procedure smoothly and easily. If the patient cannot per form this procedure, cerebellar function is impaired.

Figure 19-2

Figure 19-3

480

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Pronation-Supination Test

PROCEDURE Ask the standing patient to extend the arms forward. Next, ask the patient to pronate and supinate the arms rapidly (Figs.

19-4 and 19-5).

RATIONALE The patient should be able to perform these movements smoothly and with an even rhythm. If the patient cannot perform the movements or performs them in a spastic or uncoordinated manner, suspect cerebellar dysfunction.

Figure 19-4

Figure 19-5

CHAPTER 19

CEREBELLAR FUNCTION TESTS

481

Patting Test

PROCEDURE Instruct the seated patient to pat the hand rapidly and repeatedly on the thigh (Fig.

19-6).

RATIONALE The patient should be able to perform this movement briskly and with equal amplitude. If the pa tient cannot perform this movement or performs it in a slow, spastic, or uncoordinated manner, sus pect cerebellar dysfunction.

Figure 19-6

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Dexterity Test PROCEDURE Ask the patient to touch each fingertip with the thumb of the same hand sequentially (Figs.

19-7 and

19-8). RATIONALE These movements are usually done in a smooth and coordinated manner. If the patient cannot per form these movements or performs them in a spastic or uncoordinated manner, suspect cerebellar dysfunction.

Figure 19-7

Figure 19-8

CHAPTER 19

CEREBELLAR FUNCTION TESTS

483

LOWER EXTREMITY Heel-Knee Test

PROCEDURE With the patient supine, ask the patient to place one foot on the opposite knee (Fig. the patient to slide the foot down the shin (Fig.

19-9). Then ask

19-10).

RATIONALE These movements are usually done in a smooth and coordinated manner. If the patient cannot per form these movements or performs them in a spastic or uncoordinated manner, suspect cerebellar dysfunction.

Figure 19-9

Figure 19-10

484

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Patting Test

PROCEDURE Ask the patient to tap the foot rapidly and repeatedly on the floor (Figs.

19- 11 and 19-12).

RATIONALE The patient should be able to perform this movement briskly and with equal amplitude. If the pa tient cannot perform this movement or performs it in a slow, spastic, or uncoordinated manner, sus pect cerebellar dysfunction.

Figure 19- 1 1

Figure 19-12

CHAPTER 19

CEREBELLAR FUNCTION TESTS

485

Figure-Eight Test

PROCEDURE With the patient supine, ask the patient to draw a figure-eight in the air with the great toe (Fig.

19-13).

RATIONALE These movements are usually done in a smooth and coordinated manner. If the patient cannot per form these movements or performs them in a spastic or uncoordinated manner, suspect cerebellar dysfunction.

Figure 19-13

486

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Romberg's Test

PROCEDURE Instruct the patient to stand. Observe the patient for any swaying. While the patient is still standing, instruct him or her to close the eyes (Fig.

19-14).

RATIONALE This is not a cerebellar test per se, but swaying with eyes closed suggests a posterior column disor der. A patient with cerebellar dysfunction will sway with eyes open, but the swaying will be exag gerated with eyes closed.

Figure 19-14

General References Barrows HS. Guide to Neurological Assessment. Philadelphia: JB Lippincott, 1980. Bickerstaff ER. Neurological Examination in Clinical Practice. 4th ed. Boston: Blackwell Scientific, 1980 . Chusid JG. Correlative Neuroanatomy and Func tional Neurology. 16th ed. Los Altos, CA: Lange Medical, 1976. Colling RD. Illustrated Manual of Neurologic Diag nosis. 2nd ed. Philadelphia: JB Lippincott, 1982. Dejong RN. The Neurologic Examination. 4th ed. Hagerstown, MD: Harper & Row, 1979. Greenberg DA, Aminoff MJ, Simon RP. Clinical Neu rology. 2nd ed. Norwalk: Appleton & Lange, 1993. Heilman NM, Watson RT, Green M. Handbook for Differential Diagnosis of Neurologic Signs and Symptoms. New York: Appleton-Century-Crofts, 1977.

Klein R, Mayer-Gross W. The Clinical Examination of Patients With Organic Cerebral Disease. Spring field, IL: Charles C. T homas, 1957. Mancall E. Essentials of the neurologic examination. 2nd ed. Philadelphia: FA Davis, 1981. Merritt HH. A Textbook of Neurology. 4th ed. Philadelphia: Lea & Febiger, 1967. Scheinberg P. An Introduction to Diagnosis and Management of Common Neurologic Disorders. 3rd ed. New York: Raven, 1986. Steegmann AT. Examination of the Nervous System: A Student's Guide. Chicago: Year Book Medical, 1970. Swanson P. Signs and Symptoms in Neurology. Philadelphia: JB Lippincott, 1989. VanAllen MW, Rodnitzky RL. Pictorial Manual of Neurologic Tests. 2nd ed. Chicago: Year Book Med ical, 1981.

D INDEX Page numbers in italics denote figures.

Abbott-Saunders test, 152, 152 Abdomen protrusion, 36 Abdominal asymmetry, 34, 34 Abdominal muscles, postural assessment, 23, 36 Abducens nerve (VI), 443, 443--445, 444, 445 Abduction, 120, 120, 336, 336 Abduction stress test, 187, 187, 390, 390 Abductor digiti minimi,102, 102, 216 Abductor pollicis brevis,216 Abductor pollicus longus tendon, 211, 218 Acetabular cavity, 341 Acetabular joint, 351 Achilles tap test, 420, 420 Achilles tendon, 404, 407, 407--408, 408, 408, 473 Achilles tendon rupture,419, 420, 420 Acromioclavicular joint,108, 108, 230 Acromioclavicular ligament,109, 110 Acromion process,110, 114, 130, 131, 158, 230 Active range of motion, 7-8, 8 Adam's position, 241, 241 Adduction, 121, 121, 337 Adduction stress test, 185, 185-186, 186, 389, 389 Adductor longus muscle, 333 Adductor magnus muscle, 255 Adductor pollicus longus muscle, 200 Adson's test, 155, 155-156, 156 Alar ligament,71, 76, 77, 79, 79 Allen's test, 424, 424 Allis test,340, 340 American Academy of Orthopaedic Surgeons, muscle grading scale, 52, 93, 95 Anderson medial-lateral grind test, 377, 377 Andrews anterior instability test, 135, 135 Angiography, 424 Ankle orthopaedic tests achilles tendon rupture,419, 420, 420 examination flow chart, 398

ligamentous instability,413, 413--416, 414, 415, 416 palpation, 399, 399--408, 400, 401, 402, 403, 404, 405, 406, 407, 408 range of motion evaluation, 409, 409--412, 410,411,412 tarsal tunnel syndrome, 417, 417--419,418 Ankylosing spondylitis, 322, 322 Annular ligament, 171, 173, 186 Antagonist muscles, 26 Antalgic lean sign, 277, 277 Anterior apprehension test, 133, 133 Anterior cervical flexors, 28 Anterior cruciate ligament,382, 382, 384, 385,386, 387, 389,390 Anterior drawer test,132, 132 Anterior glenohumeral instability. see Glenohumeral instability Anterior iliac crest,332, 364 Anterior inferior iliac spine, 328, 331 Anterior knee bursa,358, 358-359, 359 Anterior longitudinal ligament,71 Anterior pelvis, 35, 35 Anterior plica, 378 Anterior sacroiliac ligament, 319 Anterior scalene muscles,68 Anterior slide test, 147, 147 Anterior superior iliac spine, 328, 328 Anterior talofibular ligament, 403, 403, 413, 413, 414, 415 Anterior tibialis, 38 Anterior tibiofibular ligament, 403, 413, 415 Anterior tibiotalar ligament, 399, 416 Anteroposterior shoulder radi ographs, 124, 128, 138, 141, 144, 149, 154 Anvil test,343, 343 AP elbow view, 184, 187 Apex of lung,68 Apley scratch test,123, 123 Apley's compression test,369-372, 370 Apley's distraction test,388, 388 Arcuate-popliteus complex, 387 Arthrosis, 58 Articular capsule, 71, 171, 173

Atlanto-occipital aperture,58, 76 Atlantoaxial joints, 76 Atlas, 46, 46, 57, 58, 77 Auditory nerve (VIII), 452, 452--456, 453, 454, 455, 456 Avulsion fracture,315 Axillary artery, 156, 157, 158 Axillary nerve innervation,96 Axillary shoulder radiograph,138, 141, 144, 149 Axillary vein, 157 Axis,46, 57 Babinski's Sign, 469, 469 Back extensors,23 Bakody's sign, 90, 90 Balanced posture,24 Barre-Lieou sign, 59, 59 Basilar artery, 56, 57 Bechterew's test, 274, 274 Beevor's sign, 246, 246 Biceps brachii muscle, 111, 145, 151 Biceps brachii tendon, 125, 125, 145, 176 Biceps femoris muscle, 255, 365 Biceps femoris tendon,365, 366 Biceps muscle anatomy,112, 112 motor testing, 97, 98 reflex testing,97 sensory testing, 97 Biceps tendon anatomy, 108, 109, 110, 111, 127, 151 instability, 150, 150-154, 151, 152, 153, 154 Bicipital groove, Ill, 111, 151 Bikele's sign, 162, 162 Bilateral cerebellar syndrome,478 Body of rib, 236 of sternum, 230 Bohler's sign,376, 376 Bone scans. see Skeletal scintigraphy Bony structure clinical assessment protocol, 4 palpation, 5 Bounce home test,371 Bowlegs,37 Bowstring sign, 279, 279 Brachial artery,176 487

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Brachial plexus definition, 93, 93 irritation, 161, 161-164, 162, 163, 164 neural component, 156, 156 palpation, 169 Tinnel's sign, 164, 164 Brachial plexus stretch test, 161, 161 Brachial plexus tension test, 163, 163 Brachioradialis muscle, 175, 176 Brachioradialis tendon palpation, 172 reflex testing, 99 sensory testing, 99, 99 Braggard's test, 271, 271 Brudzinski's sign, 431, 432. see also Lindner's sign Bruits, in carotid or subclavian arteries, 60, 69 Buckling sign, 270, 270 Buerger's test, 423, 423 Bunnel-Littler test, 222, 222 Burn's bench test, 427, 427 Bursa, 154 Bursitis, 129, 129-131, 130, 131 C5 nerve root, 96, 96-99, 97 C6 nerve root, 98, 98-99, 99 C7 nerve root, 100, 100-101, 101, 102 C8 nerve root, 102, 102, 103 Cabot's popliteal sign, 375, 375 CAD (cervical acceleration and deceleration), 41 Calcaneal bursa, 407, 407-408, 408 Calcaneal bursitis, 408 Calcaneal tendon. see Achilles tendon Calcaneofibular ligament, 403, 403, 413, 415 Calcaneus, 400, 402, 418 Calcifications, diagnosing, 10, 11 Carotid arteries, 41, 42, 42, 57, 58, 60 Carpal bones, 219 Carpal compression test, 208, 208 Carpal instability, 210, 210-211, 211 Carpal ligament, 196 Carpal tunnel, 196, 196 Carpal tunnel syndrome, 205, 205-209, 206, 207, 208, 209 Cerebellar function tests lower extermity, 483, 483-486, 484, 485, 486 upper extremity, 478, 478-482, 479, 480, 481, 482 Cerebrospinal fluid, 432 Cerebrovascular episodes, 56 Cervical acceleration and deceleration (CAD), 41 Cervical extensors, 28 Cervical fractures. see Cervical or thopaedic tests Cervical instability. see Cervical or thopaedic tests

Cervical myelopathy, 88 Cervical nerve root lesions, 93, 93, 94, 95 Cervical orthopaedic tests cervical fractures, 72-75, 73, 74, 75 cervical instability, 76, 76-80, 77, 78, 79 cervical palpation anterior aspect, 41-43, 42, 43 posterior aspect, 44, 44-47, 45, 46, 47 differential diagnosis, 70-71, 71 examination flow chart, 40 neurological compression and irritation, 82, 82-90, 83, 84, 85, 86, 87, 88, 89 range of motion evaluation, 47-51, 48, 49, 50, 51 resistive isometric muscle testing, 52, 52-55, 53, 54, 55 space-occupying lesions, 80, 80-81, 81 subclavian artery compromise, 68, 68-69, 69 vertebrobasilar circulation assess ment, 56-67, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67 Cervical plexus, 93 Cervical quadrant test, 62, 62 Chaddock's Foot Sign, 471, 471 Chaddock's Wrist Sign, 468, 468 Chest expansion test, 248, 248 Chondral fracture, 391 Chondromalacia patellae, 357, 391 Circle of Willis, 56, 57 Claudication, 423 Clavicle, 41, 68, 108, 108, 109, 110, 130, 131, 157, 158, 230, 232 Clinical assessment protocol diagnostic imaging and structural testing, 9-13 functional testing, 13 observation/inspection, 4 orthopaedic and neurological testing, 8-9 palpation, 4-5 patient history, 2-3 range of motion evaluation, 5-8 Closed-ended history, 3 Clunk test, 146, 146 Cochlear nerve Rinne's test, 453, 453 Weber's test, 452, 452 Collateral ligaments, 220 Coracoid process, 108, 109, 110, 114, 158, 230 Corneal reflex, 447, 447 Coronary ligament, 363 Corticospinal tract disease, 466, 470, 471, 474, 475 Costal cartilages, 230, 231, 231 Costochondral articulations, 230, 231

Costoclavicular test, 147, 157 Costotransverse ligament, 236 Cozen's test, 180, 180-181, 181 Cranial nerves auditory nerve (VIII), 452, 452-456, 453, 454, 455, 456 facial nerve (VII), 449, 449-451, 450, 451 glossopharyngeal and vagus nerves (IX, X), 458, 458-460, 459, 460 hypoglossal nerve (XlI), 462, 462 oculomotor, trochlear, and ab ducens nerves (III, IV, VI), 443, 443-445, 444, 445 olfactory nerve (1), 437, 437 ophthalmoscopic examination, 441, 441-442, 442 optic nerve (II), 438, 438-440, 439, 440 spinal accessory nerve (Xl), 461, 461 trigeminal nerve (V), 446, 446-448, 447, 448 types of, 436 Crepitus active range of motion and, 7 in degenerative joint disease, 46 CT arthrography, 138, 141, 144, 149, 154 CT (computed tomography). see also MRI Alar ligament, 79 Bakody's sign, 90 cervical, 432 elbow, 187 intervertebral disc defects, 10, 10 lumba�265, 266, 284, 287 Rust's sign, 75 swallowing test, 81 thoracic, 244 Cubital fossa, 176, 176 Cubital tunnel, 188, 190 Cutaneous reflexes, 474, 474-487, 475, 476 Dawbarn's test, 131, 131 Deep fibular nerve innervation, 303, 303, 305, 305 Deep infrapatellar bursa, 358, 358, 362 Deep transverse metacarpal ligaments, 219 Deep vein thrombosis, 425 Degenerative joint disease, 46, 56 Dejerine's sign, 81, 81 Dejerine's Triad, 286, 286 Dekleyn's test, 63, 63 Deltoid ligament, 399, 399, 413, 416 Deltoid muscle anatomy, 113, 113, 115, 130, 131, 233

CHAPTER 19

motor testing, 96 palpation, 108,109 posterior aspect, 44 Dermatomal patterns, 93 Dexterity test, 482, 482 Diagnostic imaging, types of, 9-13 Differential diagnosis lumbar versus sacroiliac involve ment, 288,288-291, 289,290, 291 strain versus sprain, 70-71, 71 Digital ischemia, 423 Disc protrusion, 273, 274, 277, 278, 278 Distal interphalangeal joint, 223, 223 Distal phalanges, 219 Distraction test, 89, 89 Dorsal interossei, 102, 102 Dorsal sacroiliac ligament, 316 Dorsiflexion, ankle, 409, 409,425, 425 Drawer sign, 383, 383 Drawer's foot sign, 414, 414 Dreyer's test, 393, 393 Drop arm test, 148, 148 Dugas test, 138, 138 DVT. see Deep vein thrombosis EEG (electroencephalography), 13 Elbow flexion test, 190, 190 Elbow orthopaedic tests examination flow chart, 165 lateral epicondylitis (tennis el bow), 180, 180-183, 181, 182, 183 ligamentous instability, 185, 185-187, 186, 187 medial epicondylitis (golfer's el bow), 184 neurological compression and irri tation, 188,188-191, 189, 190,191 neuropathy/compression syn dromes, 188-191 palpation, 169,169-176,170,171, 172,173,174,175,176 range of motion evaluation, 177, 177-179, 178, 179 Elevated shoulder, 31 Ely's test, 346, 346 EMG (electromyography) arm and forearm, 104 definition, 13 lumbar, 284, 287 wrist, 209, 210 End feel evaluation, 6t Episternal notch, 24 Erector spinae, 36 Erector spinae group, 234 Eversion, ankle, 412, 412 Everters, 21

CEREBELLAR FUNCTION TESTS

Extension elbow, 178, 178 hip, 335, 335 inclinometer method, 49, 259 knee, 368, 368, 370 resistive isometric muscle testing, 53, 53 shoulder range of motion, 117, 117 wrist, 202, 202 Extension compression test, 84, 84 Extensor carpi brevis, 98 Extensor carpi longus, 98 Extensor carpi radialis, 98, 172,175 Extensor carpi radialis brevis, 200 Extensor carpi radialis longus, 200 Extensor carpi ulnaris, 172,175,181, 200 Extensor digiti indicis, 101,101 Extensor digiti minimi, lOl, 101, 172,175,181,200,218 Extensor digitorum brevis muscle, 307, 307 Extensor digitorum communis, 101, 101,172,175,181,200,218, 226,226 Extensor digitorum longus muscle, 307,307,404,405,407 Extensor digitorum longus tendons, 405, 405-406, 406 Extensor hallicus brevis tendon, 405 Extensor hallucis longus, 305, 305, 405, 405-406, 406 Extensor indicis, 200 Extensor pollicis longus test, 225, 225 Extensor pollicus brevis, 200,211, 218 Extensor pollicus longus, 200,218 Extensor radius tendon, 218 Extensor tendons, 200, 200, 218, 218 External oblique muscle, 21,23,328, 329 External rotation, 119,119,339,339 External spinae group, 253 Extra-articular effusion, S Faber test, 349, 349 Facet capsulitis, 282 Facet joints, 46,46-47, 47 Fajersztajn's test, 273, 273 Family history, 3. see also Patient history Fat pad, 378 Feagin test, 142, 142 Femoral artery, 333 Femoral nerve, 290, 300, 300,333 Femoral nerve traction test, 270, 270 Femoral triangle, 333, 333 Femoral vein, 333 Femur, 358,361,362,363 Fibula, 356,360,361,363,382

489

Fibular collateral ligament, 387, 390 Figure-eight test, 485, 485 Finger abductor group, lO2, 102 Finger extensor group, 101,101 Finger-Finger test, 479, 479 Finger flexor group, 102, 102 Finger-Nose test, 478, 478 Finkelstein's test, 211, 211 Flamingo test, 324, 324 Flat feet, 38 Flatback posture, 25,26t Flexion elbow, 177, 177 hip, 334, 335 inclinometer method, 48, 237,258 knee, 367, 36�370 resistive isometric muscle testing, 52, 52 shoulder range of motion, 116, 117 wrist, 201, 201 Flexion compression test, 85, 85 Flexor carpi radialis, 100,100, 170, 184,195 Flexor carpi u1naris, 100,170,175, 184,190, 195,197 Flexor digitorum longus tendon, 21, 102,400,400,402,418 Flexor digitorum minimi tendon, 216 Flexor digitorum profundus, 102, 102,195 Flexor digitorum superficialis, 102, 195 Flexor hallucis longus tendon, 21, 400,400,402,418 Flexor pollicis brevis tendon, 216 Flexor pollicis longus test, 225, 225 Flexor pollicus longus tendon, 195 Flexor retinaculum, 196,206,400, 402,418 Flexor tendons, 195,195,196,216 Fluctuation test, 395, 395 Foot, pronation, 38 Foramen magnum, 58 Foraminal compression test, 82, 82 Forward head posture, 28, 29 Fossa olecrani, 169 Fulcrum test, 137,137 Functional testing, types of, 13-14 Gaenslen's test, 317, 317 Gag reflex, 460, 460 Gamma camera, 13,13 Gastrocnemius muscle, 365,366 Genu valga, 36-38, 37,38 George's Cerebrovascular Craniocer vical Functional Test, 60 George's Screening Procedure, 68-{)9, 69 Gilchrest's sign, 128, 128

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Glenohumeral instability anterior, 132, 132-138, 133, 134, 135, 136,137,138 posterior, 139, 139-141, 140, 141 Glenohumeral joint, 175 Glenoid cavity,110 Glenoid fossa, 145, 232 Glenoid labrum, 110, 145, 147 Glossopharyngeal nerve (XI), 458, 458-460, 459, 460 Gluteal muscles, 255, 255, 281. see also Sacroiliac orthopaedic tests Gluteal skyline test, 281, 281 Gluteus maximus, 23, 27, 36, 38, 255, 330 Gluteus medius, 21, 27, 38, 255, 306, 306,330 Gluteus minimus, 27, 255 Goldthwaith's test, 288, 288. see also Straight leg raising test Golfer's elbow, 170, 172, 175, 176, 184, 184,188 Goniometer, 7 Gothic shoulder, 31 Greater trochanter, 330, 330, 331 Guyon's canal, 197, 197, 217 Hallpike's maneuver, 66, 66, 67 Halstead maneuver, 160, 160 Hamstrings avulsion fracture and, 315 Bowstring sign,279, 279 ischial tuberosity, 319 postural assessment, 23 Sicard's test,272 Hand orthopaedic tests Hoffman's Sign, 465, 465 joint capsule tests, 222,222-223, 223 joint instability, 220, 220-221, 221 palpation, 216, 216-219, 217, 218, 219 Rossolimo's Hand Sign, 467, 467 tendon instability, 224, 224-227, 225, 226 Tromner's Sign, 466, 466 Hautant's test,64, 64 Hawkins-Kennedy impingement test, 123, 123 Head of rib, 236 Head rotation, 30, 51, 55, 55, 87 Head tilt, 30 Heel-Knee test, 483, 483 Heel-toe walk test, 284, 284 Hemianopsia, 439 Hibb's test, 322, 322. see also Laguerre's test Hip abductors, 21 Hip extensors, 23 Hip flexors, 23,27

Hip joint orthopaedic tests. see also T horacic orthopaedic tests contracture tests, 344, 344-350, 345,346,348 examination flow chart, 327 fractures, 343, 343 joint lesions, 349, 349-353, 350, 351, 352 palpation, 328, 328-334, 329, 330, 331,332,333 range of motion evaluation, 334-339, 335, 336, 337, 338, 339 Hoffman's Sign, 465, 465 Homan's sign, 425, 425 Hoover's sign, 426, 426 Hughston plica test, 381, 381 Human bipedal posture, 17 Humerus, 108, 109, 130, 169, 170, 171, 173, 174, 184, 186, 191,232 Hyperextension injury, 46 Hyperflexion injury, 46 Hyperreflexia, 307 Hypoesthesia, 99, 302, 304, 304,308 Hyporeflexia, 99, 304, 304,307 Hypothenar eminance, 216, 217, 217 Ileum, 316 Iliac compression test, 323, 323 Iliac crest, 254, 314, 314, 319, 328, 328-329,329 Iliacus, 23 Iliacus muscle, 254, 328, 329 Iliocostalis cervicis muscle,53, 54, 55 Iliocostabs muscles, 253 Iliofemoral ligament, 319, 328, 329, 331 Iliopectineal bursa, 331 Iliopsoas, 36 lliotibial band, 347, 363, 364, 364, 387, 390 Iliotibial tract of fascia lata, 21 Iliotubial band, 332 Inclinometer,7, 47-52 Inferior articular process, 235 Inferior costal facet, 235 Inferior extensor retinaculum, 405 Inferior flexor retinaculum, 404,407 Inferior gemebus muscle, 255 Inferior gluteal artery, 255 Inferior iliac spine, 329 Inferior peroneal retinaculum, 404, 407 Inferior serratus posterior muscle, 234,253 Infraspinatus muscle, 110 Inguinal ligament, 254,333 In tercostal spaces, 231, 231, 236, 236 Internal carotid artery, 58 Internal oblique, 21 Internal rotation, 118, 118, 338, 338 Interosseous membrane, 171,173

Interosseous sacroiliac ligaments, 316 Interphalangeal joint, 220 Interspinalis cervicis muscle, 53 Interspinous ligament, 71 Intertransversarii muscle, 54, 55 Intertrochanteric line, 331 Intervertebral disc, 85, 295 Intervertebral foramina, 84 Intra-articular effusion, 5 Intradural lesion, 290 Intrinsic rotator muscles, 30 Intrinsic spinal muscles, 45, 45,253, 253 Inversion, ankle, 411, 411 Inverters, 21 Ipsilateral cerebellar syndrome, 478 Ischial tuberosity, 315, 316, 319 Ischiofemoral ligament, 319 Jackson's compression test, 83, 83 Jaw reflex,447, 447 joint capsule tests, 222, 222-223, 223 joint dysfunction tests, lumbar, 258, 258-265, 259, 260, 261, 262, 263, 264, 265 joint effusion, 394, 394-395, 395 joint instability,220, 220-221, 221 Joint lesions hip, 349, 349-353, 350,351, 352 sacroiliac, 322, 322-324, 323,324 joint line, 361, 361, 363, 363 joints, range of motion evaluation, 7 Kaplan's sign, \83, 183 Kemp's test, 282, 282 Kernig's test, 430, 430 Knee flexion test, 276, 276 Knee orthopaedic tests examination flow chart, 355 joint effusion, 394, 394-395, 395 ligamentous instability, 382, 382-39\, 383, 384,385, 386, 387, 388, 389, 390 meniscus instability,369, 369-372, 370, 371,372, 373,374,375, 376, 377 palpation, 356, 356-366, 357, 358, 359, 360, 361, 362, 364, 365, 366 patellofemoral dysfunction, 391, 391-393,392, 393 plica tests, 378,379, 380,381 range of motion evaluation, 367, 367-368, 368 Knock knees, 36-38, 37, 38 Kypho-Iordotic posture, 25, 26t Kyphosis screening, 240, 241, 242, 249-251 Ll nerve root, 295, 295, 299 L2 nerve root, 290, 295, 295, 299, 301, 301 302, 302 -

CHAPTER 19

L3 nerve root, 290,295,295, 299, 301,301-302, 302 L4 nerve root, 290, 301, 301-302, 302,303,303, 328 L5 nerve root, 305, 305 Labral tears, 145, 145-147, 146, 147 Labyrinthine test for positional nystagmus, 456,456 Lachman's test, 386, 386 Laguerre's test, 352, 352 Lasegue's test, 267,267 Lateral aspect, elbow, 172, 172 Lateral collateral ligament, 356,360, 361,363,364,364, 382, 387 Lateral condyle of tibia, 364 Lateral costotransverse ligament, 236 Lateral elbow view, 184, 187 Lateral epicondyle of tibia, 332, 364 Lateral epicondylitis (tennis elbow), 176, 180,180-183,181,182, 183 Lateral femoral condyle, 361, 363, 363 Lateral flexion inclinometer method, 50,238, 238, 260 resistive isometric muscle testing, 54, 54 Lateral geniculate body, 439 Lateral malleolus ligament, 403, 403, 404,404, 405 Lateral neck flexors, 30 Lateral pelvic tilt, 34, 34 Lateral spinal deviation, 33,33-34 Lateral stability rating scale, 390 Lateral stability test, 415, 415 Lateral talocalcaneal ligament, 403, 413,415 Lateral trunk muscles, 21 Lateral view evaluation, 22-24,23 Latissimus dorsi muscle, 233 Leg measurements, 433, 433-434, 434 Lesser trochanter, 331 Levator scapulae muscle, 28, 31,53, 54, 55, 233 Lewin-Gaenslen test, 318, 318 Lewin's snuff test, 286 L'hermitte's sign, 88, 88, 432 Ligament of Struthers, 190 Ligamentous instability ankle, 413,413-416, 414,415, 416 elbow, 185, 185-187, 186, 187 knee, 382, 382-391,383,384, 385, 386, 387, 388,389,390 Ligamentum flavum, 71 Lindner's sign, 283, 283. see also Brudzinski's sign Lippman's test, 127, 127 Longissimus cervicis muscle, 44,45, 45,53, 54, 55,115 Longissimus muscles, 253

CEREBELLAR FVNCfION TESTS

Longus colli muscle, 52,54 Losee test, 387,387 Lower abdominal reflex, 475,475 Lower crossed syndrome, 26,27,28t Lower extremity function tests, 483, 483-486, 484, 485, 486 Lower extremity reflexes, 469, 469-473, 470, 471,472,473 Ludington's test, 152, 152 Lumbar flexion, range of motion evaluation, 7 Lumbar muscle spasm, 282 Lumbar orthopaedic tests. see also Nerve root lesions examination flow chart, 251 joint dysfunction tests, 261, 261-265,262,263, 264, 265 lumbar fractures, 266,266 lumbar nerve root and sciatic nerve irritation/compression tests, 267, 267-288, 268, 269, 270,271,272, 273, 275, 276, 277,278, 279, 280, 281, 282, 283,284 palpation, 252, 252-257, 253, 254, 255, 256, 257 range of motion evaluation, 258, 258-260,259,260 space-occupying lesions, 285, 285-287,286,287 Lunatotriquetral ballottement test, 212, 212 Lymph nodes, 43,333 Magnetic resonance angiogram, 69 Magnuson's test, 428,428 Maigne's test, 61, 61 Mannkopf's maneuver, 429,429 Manubrium, 230 Masseter muscle, 446 Mastoid process, 41 Maximal foraminal compression test, 87,87 McKenzie's slide glide test, 242, 242 McMurray's test, 370, 370 Medial coUateral ligament, 356,358, 360, 361,362,362, 382 Medial epicondylitis (golfer's elbow), 170,170,172, 175,176,184, 184,188 Medial femoral condyle, 361, 361 Medial hamstring reflex, 307,307 Medial malleolus, 399, 399,405 Medial patellar plica, 378 Medial stability rating scale, 389 Medial stability test, 416, 416 Median nerve, 100,100, 102, 169, 176, 196, 206, 216 Mediopatella plica test, 380,380 Meningeal irritation and inflamma tion, 430,430-432, 431, 432 Meningeal tract, 269, 283

491

Meningitis, 432 Meniscus, 361,363, 363,375, 377 Meniscus instability, 369, 369-372, 370, 371, 372,373,374,375, 376,377 Metacarpal, 211 Metacarpals, 219, 219 Metacarpophalangeal joint, 222 Middle phalanges, 219 Military posture, 25, 26t Mill's test, 182, 182 Minor's sign, 275,275 Modified Helfet's test, 374,374 Motor testing biceps muscle, 96, 98 deltoid muscle, 96 facial nerve (VII), 449, 449 finger muscles, 102, 102 triceps muscle, 100, 100 trigeminal nerve (V), 446 wrist flexor group, 100, 100 MRl (magnetic resonance imaging). see also CT Alar ligament, 79 ankle, 420 Bakody's sign, 90 cervical, 81, 104,432 definition, 11 elbow, 187 hip, 343, 352 knee, 390 lumbar, 284, 287 shoulder, 124, 128, 149, 154 Multidirectional shoulder instability, 142,142-144, 143, 144 Multifidus muscle, 53, 54, 55, 234, 253 Multiple sclerosis, 88 Muscle grading scale, 8, 52,95 Muscles. see also names ofspecific

muscles ankle, 409, 410, 411, 412 cervical, 53, 55, 52 elbow, 177,178,179 hip, 334,335,337,338 knee, 367,368 lumbar, 258, 259,260 shoulder, 116, 117, 118, 119, 120, 121 thoracic, 237, 238, 239 wrist, 201,202, 203, 204 Musculocutaneous nerve motor testing, 97, 98 palpation, 169, 176 reflex testing, 97 sensory testing, 99 Musculotendinous injuries, range of motion evaluation, 7 Myelography Alar ligament, 79 Bakody's sign, 90 definition, 12,12

492

PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Myelography (continued) Rust's sign,75 swallowing test,81 Nachlas test,290,290 Naffziger's test,287,287 Neck flexors,30 Neer impingement sign,124, 124 Nerve conduction velocity,418 Nerve root compression, 87 Nerve root lesions lumbar iliopsoas,299 motor testing,299,301,301, 303, 303,305, 305, 306, 306, 307,307 reflex testing, 302,302, 304,304, 307, 307 sensory testing,300, 300, 302, 302,304,304,307,307 thoracic,245, 245-249, 246, 247 Nerve supply ankJe,409,410,411,412 cervical, 52,53,55 elbow,177,178,179 hip,334,335,337,338 knee,367,368 lumbar,258,259,260 shoulder,116,117, 118,119,120, 121 thoracic,237,238,239 wrist, 201,202,203,204 Neurologic testing cervical neurological compression and irritation,82, 82-90,83, 84, 85, 86, 87, 88, 89 elbow,188-191,189,190, 191 precautions,8, 8 Neurological dysfunction,resistive isometric muscle testing, 52 Neurovascular bundle,156, 157 Neutral posture,16 Norwood stress test,140, 140 Nystagmus,456,456-457, 457 Ober's test,347,347 Oblique radiography,221, 223,226 Obliquus capitis inferior muscle, 54, 55 Observation/inspection,4 Obturator internus muscle, 255 Obturator membrane,331 Occipital lobe of cerebrum,439 Occipital protuberance,22 Oculomotor nerve (III), 443, 443-445,444,445 O' Donoghue's Maneuver,70-71,71 Olecranon bursa,174,174 Olecranon process,172,174,174, 188,190 Olfactory nerve (1),437,437 Omohyoid fascia,41,43

One leg standing lumbar extension test,265,265 Open-ended history,3 Ophthalmoscopic examination,441, 441-442,442 Oppenheim's Sign,470,470 Opponens digiti minimi,216 Opponens pollicis,216 OPQRST mneumonic, 3 Optic nerve (II), 438, 438-440,439, 440 Orthopaedic testing,8, 8 Ortolani's click test, 341,341 Osgood-Schlatter disease,357 Osteochondritis,391 Osteophyte,58 PA (posteroanterior) radiography, 221,226 Pain variations,6. see also Range of motion evaluation Palmar carpal ligament,195, 197 Palmar interossei, 103, 103 Palmar ligament,219 Palmaris longus,170, 184, 197 Palmaris longus tendon,195 Palpation ankle,399,399-408,400, 401, 402, 403,404,405,406, 407, 408 cervical,41, 41-47,42, 43,44, 45, 46, 47 clinical assessment protocol,4-5 elbow,169,169-176,170,171,172, 173,174, 175, 176 hand,216,216-219,217,218,219 hip joint,328, 328-334,329, 330, 331,332, 333 knee,356,356-366,357,358,359, 360, 361, 362, 364, 365, 366 lumbar,252, 252-257,253,254, 255,256, 257 sacroiliac,314, 314-315,315 shoulder,108, 108-115, 109,110, 111, 112, 113, 114, 115 thoracic,230, 231,231-236,232, 233, 234, 235, 236 Pancoast's tumor,68 Parathoracic musculature,233,233 Passive range of motion,5-6 Passive scapular approximation test, 245,245 Past Pointing test,vestibular nerve, 455, 455 Patella,356,356, 357,358,359,360, 362,380,381,39],393 Patella apprehension test,392,392 Patella ballottement test,394,394 Patella grinding test, 39],391 Patella ligament,356, 356-357,357, 360 Patella reflex, 302,302, 304,304 Patellar tendon,358,362

Patellofemoral dysfunction,391, 391-393,392,393 Pathological reflexes,465,465-473, 466, 467, 468, 469, 470, 471, 472, 473 Patient history,clinical assessment protocol,2-3 Patrick test (Faber),349,349 Patting test lower extermity,484,484 upper extremity,48],481 Pectoralis muscles,28,32, 158 Pellegrini-Stieda disease,361 Pelvic rock (iliac compression) test, 323,323 Pelvic tilt,34, 34,35,35 "Perfect posture",16 Periostitis, 329 Peripheral arterial insufficiency, 423, 423-424,424 Peripheral nerve injuries,94 Peripheral vascular ultrasound,424 Peripheral vision,438,438 Peroneal retinaculum,404, 404 Peroneus brevis,21 Peroneus brevis muscle,405 Peroneus fibularis brevis muscle, 404, 407 Peroneus fibularis longus tendon, 404 Peroneus longus,21 Peroneus tertius tendon,404,407 Pes anserinus bursa,358, 362 Pes muscle,358,362 Phalanges,219 Phalen's test,206,206 Pheasant test,263,263 Physical examination,8 Pinch grip test, 191,191 Pinch test,209, 209 Piriformis muscle,255,256,256, 257, 281,348. see also Sacroiliac orthopaedic tests Piriformis test, 281,281, 348,348 Pisiform bone,216 Pitting edema,S Plain film radiology,213 Alar ligament,79 ankle,420 Bakody's sign,90 cervical,432 elbow,184,187 hip, 342,343,348,352 historical perspectives,9 knee,390 lumbar,265,266,284,287,29] Rust's sign, 75 subclavian artery compromise,69 swallowing test,81 thoracic, 242,244, 248 Plantar calcaneonavicular ligament, 399,413,416

CHAPTER 19

Plantar flexion, ankle, 410, 410 Plethysmography, 424 Pleural groove, 68 Plica tests, 378, 379, 380, 381 Popliteal artery, 365 Popliteal fossa, 279, 279, 365, 365-366, 366 Popliteus muscle, 364 Posteriior apophyseal joints, 84 Posterior apophyseal joints, 84 Posterior apprehension test, 139, 139 Posterior aspect elbow, 174-175 wrist, 199, 199-200, 200 Posterior cruciate ligament, 382, 382, 384, 385, 386, 387, 389, 390 Posterior Drawer test, 140, 140 Posterior glenohumeral instability. see Glenohumeral instability Posterior inferior articular process, 46 Posterior longitudinal ligament, 71 Posterior medial capsule, 389 Posterior meniscofemoral ligament, 389 Posterior pelvis, 35, 35 Posterior 3acroiliac ligaments, 319 Posterior superior articular process, 46 Posterior superior iliac spine, 314, 314, 319 Posterior talocalcaneal ligament, 399, 413, 416 Posterior talofibular ligament, 403, 403, 413, 414,414, 415 Posterior teres muscle, 184 Posterior tibial artery, 400, 402,402, 418 Posterior tibial nerve, 365, 400, 402, 418 Posterior tibialis tendon, 400 Posterior tibiofibular ligament, 403, 413, 415, 416 Posterior tibiotalar ligament, 399 Posterior view evaluation, postural assessment, 21, 21-22, 22 Posterolateral capsule, 387, 390 Posterolateral disc defect, 84 Postural assessment compensations and adaptations, 16-18, 17 distortions and adaptations, 28-38, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 importance, 16 methods and observations, 19, 19-24, 20, 21, 22,23, 24 Postural syndromes, 26-28, 27, 28t Posture types, 25, 25-26, 26, 26t Prepatellar bursa, 358, 358, 359, 362 Prepatellar bursitis, 391 Profundus test, 224, 224

CEREBELLAR FUNCTION TESTS

Pronation-Supination test, 480, 480 Pronator quadratus muscle, 195 Pronator teres muscle, 170, 176, 191 Prone anterior instability test, 134, 134 Proneus brevis tendon, 404,404 Proneus fibularis longus tendon, 407 Proneus longus tendon, 404, 404 Proximal interphalangeal joint, 222, 223, 223 Proximal phalanges, 219 Psoas major, 23, 27 Pterygoid muscle, 446 Ptosis of the eyelid, 444 Pubes, 24 Pubofemoral ligament, 331 Pulsations, in carotid or subclavian arteries, 60 Pulse amplitude, 5 Pupillary motility,443 Push-Pull test, 141,141 Push-up test, 32 Pyramidal tract disease, 467, 468, 472, 473 Quadrantanopsia, 439 Quadratus femoris muscle, 255 Quadratus lumborum, 21,254, 254 Quadriceps femoris muscle, 356, 360, 360 Quadriceps femoris tendon, 356, 356-357,357,357,357, 358, 359, 362 Quadriceps muscle tendon,360,378, 393 Quadriceps muscles, 290, 301,301, 356, 391 Radial artery, 198,198 Radial collateral ligament, 173, 173, 186 Radial deviation, 204, 204 Radial ligament, 236 Radial nerve innervation motor testing, 98, 98, 100, 100, 101, 101 palpation, 169 reflex testing, 99, 99, 101, 101 Radial tubercle, 199, 199 Radiograph scanogram, 434 Radius, 169, 173,174, 186, 191, 195, 200 Range of motion evaluation ankle, 409, 409-412, 410, 411, 412 cervical, 47-51,48, 49,50, 51 elbow, 177, 177-179,178, 179 hip joint, 334-339, 335, 336, 337, 338, 339 knee, 36�367-368, 368 lumbar, 258, 258-260, 259, 260 shoulder, 116, 117, 117-121, 118, 119, 120, 121

493

thoracic, 237, 237-240, 238, 239, 240 types of, 5-8 wrist, 201, 201-204, 202, 203, 204 Raynaud's phenomenon, 423 Rectus abdominis muscle, 23 Rectus capitis posterior major muscle, 53 Rectus femoris contracture test, 345, 367 Rectus femoris muscle, 23, 328, 344, 356, 360, 360 Recurrent median nerve, 216 Reflex testing biceps muscle, 97 brachioradialis tendon, 99 glossopharyngeal and vagus nerves (IX, X), 460, 460 lower extermity, 469, 469-473, 470, 471, 472, 473 superficial cutaneous, 474, 474-476, 475, 476 triceps muscle, 101, 101 trigeminal nerve (V), 447 upper extremity, 465, 465-468, 466, 467, 468 Resisted range of motion, 7, 8 Resistive isometric muscle testing, 52, 52-55, 53, 54, 55 Retinacular ligaments, 223, 223 Retreating meniscus test, 373, 373 Retrocalcaneal bursa,404,407, 407-408, 408 Retropatellar arthritis, 391 Reverse Lachman's test, 386, 386 Reverse Phalen's test, 207, 207 Rhomboid muscle, 32, 233 Ribs, 230, 231, 232, 236, 236, 239 Rinne's test, 453, 453 Rockwood test, 136,136 Romberg's test, 486,486 Rossolimo's Foot Sign, 472, 472 Rossolimo's Hand Sign, 467, 467 Rotation, 30, 51, 55,55, 87,239, 239 Rotator cuff anatomy, 110, 110 instability, 148, 148-149, 149 Rotatores breves muscle, 53, 55 Rotatores longi muscle, 53, 54, 55 Rotatores muscle, 234, 253 Round shoulders, 33, 33 Rowe test for anterior instability, 137, 137 Rowe test for multidirectional insta bility, 143, 143 Rust's sign, 75, 75 S2 sacral segment, 314 Sacral flexion, range of motion eval uation, 7 Sacroiliac joint, 289

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Sacroiliac orthopaedic tests examination flow chart,313 joint lesions,322, 322-324, 323, 324 palpation,314, 314-315, 315 sacroiliac articulations,314, 315, 315, 319 sacroiliac sprain,316, 316-321, 317, 318, 319 Sacroiliac resisted abduction test, 320 Sacroiliac stretch test, 320, 320 Sacrospinous ligament, 316 Sacrotuberous ligament,316, 319 Sacrotuberous ligament stress test, 321, 321 Sacrum,295, 316 Sartorius muscle, 328, 333 Scalene rotator muscles,30 Scalenus muscle, 52, 54, 55, 68, 156 Scapula, 232, 232 Scapula rotation,32, 32, 108, 109, 110, 114, 114 Scapula winging, 32, 32 Scapuli,175 Schaeffer's Sign,473, 473 Schepelmann's sign,247, 247 Sciatic nerve,255, 257, 257, 271, 272, 281, 348 Sciatic radiculopathy, 267, 275, 276 Sciatic tension test,280, 280 SCM. see Sternocleidomastoid mus cles Scoliosis screening,240, 240-242, 241, 242 Scotoma, 439 Scouring test,351, 351 SEEP (somatosensory evoked potential), 13, 104 Segmental instability test, 264,264 Semimembranous muscle,365 Semimembranous tendon,366 Semispinalis cervicis muscle,44, 45, 45, 53, 54, 115 Semispinalis thoracicis muscle, 234, 253 Semitendinosus muscle,365 Semitendinosus tendon,366 Sensitivity/reliability scale,9 Sensory testing biceps muscle,97 brachioradialis tendon, 99, 99 facial nerve (VII), 451, 451 finger muscles,103, 103, 104 glossopharyngeal and vagus nerves (IX, X), 459, 459 goals,93 triceps muscle,101, 101 trigeminal nerve (V),448 Serratus anterior, 28, 32 Sharp-Purser test, 77, 77 Shoulder abduction test, 90, 90 Shoulder depression test,89, 89

Shoulder girdle symmetry, 24, 24 Shoulder imbalance,30, 30, 31 Shoulder orthopaedic tests Biceps tendon,150 biceps tendon instability,150-154, 151, 152, 153, 154 brachial plexus irritation,161, 161-164, 162, 163, 164 bursitis, 129, 129-130, 130, 131 examination flow chart,107 glenohumeral instability anterior,132, 132-138, 133, 134, 135, 136, 137, 138 posterior, 139, 139-141, 140, 141 labral tears,145, 145-147, 146, 147 multidirectional instability,142, 142-144, 143, 144 palpation,108, 108-115, 109, 110, 111, 112, 113, 114, 115 range of motion evaluation, 116, 117, 117-121, 118, 119, 120, 121 rotator cuff instability,148, 148-149, 149 tendinitis (bicipital), 125, 125-128, 126, 127, 128 tendinitis (supraspinatus),122, 122-124, 123, 124 thoracic outlet syndrome,155, 155-160, 156, 157, 158, 159, 160 Sicard's test,272, 272 Sign of the Buttock test,291, 291, 323, 323 Sitting,27 Skeletal scintigraphy,13, 13, 244, 266, 343, 352 Skin assessment, 4 Skin temperature, 4 Skull,vertebrobasilar circulation assessment, 58 Slocum test, 387, 387 Slump test,268, 268-269, 269 Smell. see Olfactory nerve (I) Snellen chart, 438, 438 SOAP notes,2 Soleus muscles,38, 38, 404, 407 Soto-Hall test,74, 74, 244, 244 Space-occupying lesions, 80, 80-81, 82, 285, 285, 285-287, 286, 286, 287 SPECT (single proton emission computed tomography), 265 Speed's test, 126, 126 Sphygmomanometer cuff,417 Spinal accessory nerve (Xl), 461, 461 Spinal column, 252 Spinal nerves, 93. see also Cervical nerve root lesions Spinal percussion test, 73, 73, 266, 266

Spinalis cervicis muscle, 53 Spinalis longissimus iliocostalis, 234 Spinalis muscles, 253 Spine. see also Cervical orthopaedic tests; Lumbar orthopaedic tests; Postural assessment diagnostic imaging and structural testing, 12, 12 flexed forward, 74 lateral spinal deviation, 33, 33-34 range of motion evaluation, 7 rotational instability, 56 Spine of scapula,232 Spinous process, 46, 46-47, 47, 235, 235, 236, 252, 252 Splenius capitus muscle,44, 45, 45, 115, 233 Splenius cervicis muscle, 44, 45, 45, 53, 54, 55, 115, 233 Spondylolisthesis, 261, 261, 262 Spondylolysis,261, 26 I Sports injuries,role of body mechanics,17 Sprains,categories, 70 Spurling's test,86, 86 Steinman's tenderness displacement test,372, 372 Stenosing tenosynovitis,211 Sternal compression test, 244, 244 Sternoclavicular joint,108, 108, 109 Sternocleidomastoid muscles,28, 30, 41, 41, 52, 54, 55, 461, 461 Sternocostal articulations, 230, 23 I Sternum, 41, 108, 109, 230, 230 Straight leg raising test,267, 268. see also Goldthwaith's test Strains, categories,70 Stretch reflex,465, 465 Stroke test, 395, 395 Structural testing,types of,9-13 Subacromial bursa, 108, 109, 109, 130, 131 Subacromial push-button sign,129, 129-130, 130 Subclavian artery, 41, 43, 68, 68-69, 69, 156 Subclavian vein,41 Subcutaneous soft tissue, 4-5 Subdeltoid bursa,130, 131 Subliminus test,224, 224 Suboccipitals, 28, 29 Subscapular bursa,130 Sulcus sign,144,144 Superficial bursa,404 Superficial cutaneous reflexes,474, 474-476, 475, 476 Superficial fibular nerve innervation, 307, 307 Superficial gluteal reflex,475, 475 Superficial infrapatellar bursa,358, 358, 362 Superior articular process, 235

CHAPTER 19

Superior costal facet, 235 Superior costotransverse ligament, 236 Superior extensor retinaculum, 405 Superior flexor retinaculum,404,407 Superior gemelius muscle, 255 Superior gluteal artery,255 Superior iliac spine, 328 Superior peroneal retinaculum,404, 407 Superior serratus posterior muscle, 234,253 Supported forward bending test, 289, 289 Supraclavicular fossa,41,43,43 Suprapatellar bursa, 358, 358,359, 359,362 Suprapatellar plica, 378 Supraspinatus muscle, 108,109,110, 130. see also Tendinitis Supraspinatus tendinitis test, 122, 122 Supraspinatus test, 149,149 Supraspinous ligament, 7l Suubclavian artery,68 Swallowing test,81,81 Swayback posture, 25,26t Symptom magnification assessment, 426,426-429,427,428,429 Synovial fluid, 395 Synovial joint,236 Synovial plicae, 378 Synovial sheath, 206 Systolic blood pressure, 417 T 1 nerve root, 104, 104 T4 vertebra, 234,253 T 7 vertebra, 235 T 9 spinous process, 235 Tl2 vertebra, 234,253,295, 295,298, 298-299,299 Tangential shoulder radiograph, 138, 14 1, 144 Tarsal tunnel syndrome, 417, 417-419,418 Telescoping sign,342,342 Temporal muscle,446 Tenderness, 4-5,41,372,372. see also Subcutaneous soft tissue Tendinitis (bicipital), 125,125-128, 126,127,128 Tendinitis (supraspinatus),122, 122-124,123,124 Tendon instability, hand, 224, 224-227,225,226 Tendonitis, 40 I, 406 Tennis elbow,176,180,180-183, 181, 182,183 Tenosynovitis, 1 1 1, 406 Tensor fasciae latae, 21,23,328,329, 332,332,347,364,364 Teres minor muscle, 110

CEREBELLAR FUNCTION TESTS

Thenar eminance,216,216 T hermography, 424 T homas test, 344,366 Thompson's test, 419,419 Thoracic orthopaedic tests. see also Hip joint orthopaedic tests costovertebral joint ankylosis, 248, 248 examination flow chart, 229 nerve root lesions,245,245-249, 246,247 palpation, 230,231,231-236,232, 233,234,235,236 range of motion evaluation, 237, 237-240,238,239,240 scoliosis screening,240,240-242, 241,242 thoracic fractures,243-244,244 T horacic outlet syndrome, 155, 155-160,156,157,158,159, 160 Thoracic scoliosis, 31 Thoracic vertebrae, 232 T horacolumbar erector spinae hypertrophy, 33,34 T hrombophlebitis, 425 Thumb, 218 T humb ulnar collateral ligament lax ity test, 221,221 Tibia,356,358,360,361,362,362, 363,363,382,387,400,402, 418 Tibial collateral ligament, 389 Tibial nerve, 402,402 Tibial plateau, 36 1,361,363 Tibial tuberosity, 356,358,360,362 Tibialis anterior muscle, 404,407 Tibialis anterior tendon, 303,303, 405,405-406,406 Tibialis posterior muscle, 404,407 Tibialis posterior tendon,21,400, 400 Tibiocalcaneal ligament, 399,413, 416 Tibionavicular ligament, 413,416 Tinel's foot sign, 418,418 Tinel's sign, 188 Tinel's wrist sign, 205,205 T innel's sign, 164,164,188 Torticollis,41 Tourniquet test, 209,209,417, 417-418,418 Trachea, 41 Traction test,159,159 Transverse carpal ligament, 197 Transverse humeral ligament, 111, 127,151,154 Transverse humeral ligament test, 153,153-154,154 Transverse ligament,71,76,77,78, 78 Transverse process,235,254

495

Trapezius muscles, 28,30,44,44,53, 54,113,lI5, 115,233,461, 461 Trendelenburg test, 350,350 Triceps muscle anatomy,110 elbow flexion test and, 190 motor testing, 100,100 palpation, 175,175 reflex testing, 101,101 sensory testing, 101,101 Trigger points cervical palpation, 41 in postural syndromes, 26-27 Trochanteric bursitis, 324,324 Trochlear groove,391 Trochlear nerve (IV), 443,443-445, 444,445 Tromner's Sign,466,466 Ulna,169,173,174,186,191,195, 200 Ulnar artery, 195,197,198,198 Ulnar collateral ligament, 171,171, 173,186 Ulnar deviation, 203,203 Ulnar nerve,100,100,102,102,102, 103,103,103, 169,169,188, 190,195,197 Ulnar styloid process, 199,199 Ulnar tunnel. see Guyon's canal Ulnar tunnel syndrome, 210,210 Ulnar tunnel triad, 210,2]0 Ultrasonography hip, 342 shoulder, 124,128 Umbilicus, 24 Underburg's test, 64,65 Upper abdominal reflex, 474, 474 Upper crossed syndrome, 26,28t Upper extremity cerebellar function, 478,478-482,479,480,48], 482 Upper extremity reflexes, 465, 465-568,466,467,468 Vagus nerve (X), 458,458-460, 459, 460 Valgus stress test, 220,220 Valsalva's maneuver, 80,80,285,285 Varus stress test, 220,220 Vascular accidents,56 Vascular ultrasound, 69 Vastus intermedius muscle,360,360 Vastus lateralis muscle, 330,356,360, 360 Vastus medialis muscle, 360,360 Veering test, vestibular nerve, 454, 454 Ventral sacroiliac ligament, 3]6 Vertebra body, 236 Vertebral artery, 56,57,58,59

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PHOTOGRAPHIC MANUAL OF REGIONAL ORTHOPAEDIC AND NEUROLOGICAL TESTS

Vertebral artery test, 62, 62 Vertebral column, 230 Vertebrobasilar artery functional maneuver, 60, 60, 61 Vertebrobasilar circulation assess ment, 56-57, 57, 58, 59, 60, 61, 62, 63, 64,65, 66, 67 Vestibular nerve Past Pointing test, 455, 455 Veering test, 454, 454 Visual acuity, 438, 438 Visual field, 440 Volar plate, 220 Wartenberg's sign, 189, 189 Watson's test, 213, 213

Weber's test, cochlear nerve, 452, 452 Wexler scale,93, 95, 296 Wright's test, 158, 158 Wrist extensor group, motor testing, 98 Wrist flexor group, motor testing, 100, 100 Wrist orthopaedic tests carpal instability, 210, 210-211, 211 carpal tunnel syndrome, 205, 205-209, 206, 207, 208, 209 Chaddock's Wrist Sign, 468, 468 examination flow chart, 194 palpation, 195, 195-200, 196, 197, 198, 199,200

range of motion evaluation, 201, 201-204 202, 203,204 stenosing tenosynovitis, 211 ulnar tunnel syndrome, 210, 210 ,

X-rays, 9. see also CT; MRI; Myelog raphy; Skeletal scintigraphy Xiphoid process, 24, 230 Yeoman's test, 319, 319 Yergason's test, 150, 150-151, 151 Zygomatic arch, 22