Orthopedic Evaluation Review - Ask Dr. Lehman

Orthopedic Evaluation Review - Ask Dr. Lehman

Orthopedic Review Evaluation of Spine and Extremities James J. Lehman, DC, MBA, DABCO University of Bridgeport College of Chiropractic Definition of an orthopedic test Most often, a provocative maneuver that involves stretching, compressing and/or

contracting of tissues in order to replicate the pain and identify the affected tissues. History Taking Process 1. 2. 3. 4. 5. 6. Develop rapport HPI

OPQRST Past history Review of Systems Patient expectations History of Present Illness Observation is a continual process that begins with introduction

Clarify Area of Chief Concern Patient points to area of chief concern Clarify Pain Generators Immediately following the positive finger

point by the patient, palpate the tissue and determine the level and tissue involved with the chief concern History of Present Illness Bakodys Sign is present when

placement of hand of involved upper extremity behind head reduces pain. Observed sign, not a test History of Present Illness Dejerines sign

presents the reproduction of spinal pain with cough, sneeze or bowel movement. Test involves cough, sneeze, and BM History of Present Illness Barre-Lieou Syndrome is

considered by many physicians to be synonymous with Post Whiplash Type Injury Symptoms that characterize Barr-Lieou syndrome Headache, facial pain, ear pain, vertigo, tinnitus, loss of

voice, hoarseness, neck pain, severe fatigue, muscle weakness, sinus congestion, a sense of the eyeball being pulled out, and numbness. Other symptoms may include a pins-and-needles sensation of the hands and forearms, corneal sensitivity, dental pain, lacrimation (tearing of the eyes), blurred vision, facial numbness, shoulder pain, swelling on one side of the face, nausea, vomiting and localized cyanosis of the face (bluish color). History of Present Illness Rust Sign may be

present Post-traumatic Roll over Blow to skull History of Roll Over MVA

Rust sign may be present initially, which would indicate possible upper cervical spine instability or moderate to severe whiplash type injury. Past history of roll over MVA should

raise suspicion of DDD,DJD, spondylosis, and stenosis in the cervical spine. History of Present Illness Lhermitte Sign present with severe lancinating pain down spine and extremities

most often with cervical flexion. SOL Multiple sclerosis Spine Evaluation 1. 2. 3. 4.

Observation Palpation Range of motion Special tests or Orthopedic tests Observation and Inspection

Gait Posture Appearance Appliances Deformities Contusions Cicatrices Valsalva Maneuver

Valsalva maneuver for IVD syndrome or tumor (SOL) Increased intrathecal pressure Reproduce spinal and or radicular symptoms

James J. Lehman, DC, MBA, DABCO Shoulder Abduction Test Abduction of shoulder relieves the cervicobrachial symptoms revealing the presence of

Bakody sign Indicates nerve root irritation James J. Lehman, DC, MBA, DABCO Swallowing Test Difficulty swallowing might be related to a

space occupying lesion anterior to the cervical spine. Bleed, DISH, or SOL impede swallowing James J. Lehman, DC, MBA, DABCO Palpation Flat finger and static

Osseous Soft tissues Myofascial Neural Ligamentous Vascular Dermal

Range of Motion and ODonoghues Maneuver Differentiates joint sprain/strain injuries Pain upon ROM

Active = non-specific Passive = ligament Resistive = muscle Common Cervical Provocative Tests All of them test for dural sheath, nerve

root, or spinal nerve involvement Positive neurological findings all indicate radicular pain James J. Lehman, DC, MBA, DABCO Cervical Compression Tests

Active maximal foraminal compression Pain maybe indicate joint, muscle, or ligament pathology Cervical Compression Tests

Maximal foraminal compression (active) Jacksons (acute) Spurlings (in favor) Maximal foraminal compression(passive) Extension/Flexion (disc/ joint)

James J. Lehman, DC, MBA, DABCO Cervical Compression Tests Passive foraminal compression

Neutral Flexion/Extension Lateral flexion Rotation Jackson Spurling Cervical Distraction Test

Distraction test for nerve root, facet, or myospasm Positive test relieves pain Negative test increases pain James J. Lehman, DC, MBA, DABCO

Soto-Hall Test Non-specific test for cervical spine injury or lesion Passive flexion of neck with sternum stabilized

Relative contraindication with severe injury James J. Lehman, DC, MBA, DABCO Shoulder Depression

Contralateral pain with radiations into upper extremity (nerve compression) Localized contralateral pain (joint compression) Ipsilateral radiating pain (nerve stretch) Brachial Plexopathy Thoracic Outlet

Syndrome 90% of TOS are neurogenic conditions Post traumatic whiplash type injuries to scalene muscles Brachial Plexopathy TOS

Palpate Erbs point and attempt to elicit brachial plexus symptoms. Compare affected and unaffected sides Brachial Plexopathy TOS

Perform Cervical ROM testing Compression test Shoulder depression TOS tests Thoracic Outlet

Syndrome Thoracic outlet syndrome gets its name from the space (the thoracic outlet) between the clavicle and the first rib Thoracic Outlet Syndrome Special Tests

Roos Brachial plexus stretch Brachial plexus tension Adsons Test Allen Wright

Thoracic Outlet Tests Roos 2-3 minutes of hand flexion/extension with shoulders abducted and elbows flexed. Positive test = inability

to complete test due to pain/heaviness. Vascular or Neurogenic Tests Adson (vascular) Brachial plexus stretch (neurogenic) Thoracic Outlet

Syndrome WrightsHyperabduct Test and externally rotate the patients arm while assessing the ipsilateral radial pulse. Considered positive if the pulse diminishes or

paresthesias develop (Safran, 2004). Neurogenic TOS is due to brachial plexus compression usually from scarred scalene muscles secondary to neck trauma, whiplash injuries being the most common. Symptoms include extremity paresthesias, pain, and weakness as well as neck pain and occipital headache. Physical exam is most important and includes several provocative maneuvers including neck rotation and head tilting, which elicit symptoms in

the contralateral extremity; the upper limb tension test, which is comparable to straight leg raising; and abducting the arms to 90 degrees in external rotation, which usually brings on symptoms within 60 seconds. J Vasc Surg. 2007 Sep;46(3):601-4. Brachial Plexopathy A burner is a nerve injury resulting from trauma to the neck and shoulder. Its

primary symptom is burning pain radiating down one upper extremity. A "burner" is a common nerve injury resulting from trauma to the neck and shoulder, usually during sports participation. The injury is most often caused by traction or compression of the upper trunk of the brachial plexus or the fifth or sixth cervical nerve roots. Burners are typically transient, but they can cause prolonged weakness resulting in time loss from athletic participation. Furthermore, they often recur.

Treatment consists of restoring range of motion, improving strength and providing protective equipment. Return to sports participation depends primarily on reestablishment of pain-free motion and full recovery of strength and functional status. (Am Fam Physician 1999;60:2035-42.) The "Burner": A Common Nerve Injury in Contact Sports Burners are typically Grade 1 or Grade 2

peripheral nerve injuries Neuropraxia Axonotmesis Mechanisms of "burners."

Traction Direct blow to the supraclavicular fossa at Erb's point Compression of the cervical roots or brachial plexus Spurling's test

The test is positive if axial loading by the examiner's hands reproduces symptoms Muscle Deltoid Innervation Axillary (C5, C6) Clinical test Shoulder abduction

Supraspinatus Suprascapular (C5, C6) "Full can" abduction* Infraspinatus Suprascapular (C5, C6)

External rotation Biceps brachii Musculocutaneous (C5, C6) Elbow flexion Pronator teres Median (C6, C7)

Forearm pronation Triceps brachii Radial (C7, C8) Elbow extension Abductor digiti minimi Ulnar (C8, T1)

Fifth digit abduction Neuropraxia This is a transient lesion (compression of neuron) and recovery is spontaneous within a few days or weeks. James J. Lehman, DC, MBA, DABCO

Axonotmesis This lesion is due to compression or direct force. Sensory loss is common.

Prognosis for recovery is good. Occasionally, the loss of some cell bodies inhibits complete recovery. Axioms in Thoracic Spine Assessment The thoracic spine requires evaluation in isolation and together with the cervical and lumbar

spine Scheplemann Sign Intercostal Pain 1. 2. Contralateral pain might indicate pleurisy or intercostal strain Ipsilateral pain might

indicate intercostal neuropathy or costovertebral sprain Most Common Causes of Thoracic Pain Zygapophyseal joints

What would be your diagnosis? Intercostal Syndrome Differential Diagnosis 1. 2. 3. 4. Intercostal neuralgia or neuritis

Pleurisy Fractured rib Intercostal myofascial pain Scheurmanns Disease Differentiation from Round Back

Spinal postural alterations do not resolve with recumbent position Confirmed with radiographic exam Sleeps with 2-3 pillows propped under back Sternal Compression Test Rib Fractures

Compresses lateral borders of ribs Fracture becomes more pronounced Produces or exacerbates fractured rib pain T-1 & T-2 Nerve Root Lesions

Scapular area pain with passive approximation of the scapulae Indicates T1 or T2 nerve root compression or irritation

Hot Sponge Test Determine if the patient is experiencing an inflammatory condition with three to four strokes along spine. Myelopathy and Thoracic Disc Herniation

Beevors Sign When Beevors sign is present, T 7-12 spinal levels must be evaluated Ankylosing Spondylitis Mensuration of chest expansion Normal expansion is 1.5

to 3 A decrease in normal expansion indicates restriction of movement at costotransverse or costovertebral joints Thoracic Scoliosis Origin of a lateral curvature of the spine 1. 2.

3. Idiopathic (85-90%) Congenital (Usually failure of formation) Neuromuscular Signs of Scoliosis How would you differentiate scoliosis from pelvic obliquity

and postural imbalance? Adams position Leg length mensuration Sciatic Scoliosis Vanzetti Sign

Sciatica Level pelvis Scoliosis Suspect discopathy McKenzie Slide Glide Test

Test determines if scoliosis is related to back pain. Positive if the test increases the back pain. Serious Thoracic Disorders MyocardialCrushing infarct pain radiating to

the jaw or arm suggests acute ischemia or MI. Patients often ascribe myocardial ischemic pain to indigestion. Exertional pain relieved by rest indicates angina

pectoris Lumbar Spine Back Pain Back pain is common from the second decade on. Lumbar Spine

Scoliosis Postural imbalance Pelvic obliquity Joint dysfunction DDD/DJD Myofascial condition Neural condition

Characteristics of Low Back Pain Spinal Pain Spinal pain Discogenic pain Nerve root pain Multiple levels of lumbar spinal

stenosis Schober Test Mark lumbosacral junction, 10 cm superior, and 5 cm inferior Have patient flex forward and measure

the differences Mensuration of Lumbar Flexion Schober Test Normal findings would indicate 4 cm of increase with superior

pair of marks and zero change with inferior pair of marks. Suspect AS or fusion with reduced movement Valsalvas Maneuver Neuro-orthopedic application Assessment for space-occupying

lesion, tumor, intervertebral disc herniation, or osteophytes Lindners Sign Assessment for Lumbar Nerve Root Irritation Passive flexion of

neck with chin to chest Supine, seated, or standing position Lindners Sign Sign is present if procedure produces pain in lumbar spine with a radicular distribution

Kemp Test May be performed in either a standing or sitting position A positive test involves radicular pain

Kemps Oblique bending toward symptomatic side increases pain with lesion lateral to nerve root Oblique bending away from symptomatic side increases pain with lesion medial to nerve root

Kemp Maneuver Assessment Intervertebral nerve root encroachment Muscular strain Ligamentous sprain

Pericapsular inflammation Straight Leg Raise Test Nerve Root Tension Signs Pain reaction 0-35 = extradural

35-70 = disc lesion 70-90 = lumbosacral lesion Dull pain in posterior thigh = hamstrings Straight-Leg-Raising Test Dynamics: 1. 0-35 degrees = no dural movement 2. 35-70 degrees = tension of sciatic nerve over intervertebral disc 3. Above 70 degrees presents very little

additional deformation of nerve root Straight-Leg-Raising Test Bilateral SLR testing Simultaneously perform Well-LegRaising test Straight-Leg-Raising Test

Assessment for space-occupying mass in the path of a nerve root, sacroiliac inflammation and lumbosacral involvement Well-Leg-Raising Test Fajersztajns Test

Assessment for lumbar nerve root lesion caused by IVD syndrome or dural sleeve adhesion Contralateral LE SLR Bragard Sign Nerve root tension sign

Assessment for radicular symptoms, intervertebral disc lesions, and sciatic neuropraxia. Follows SLR or Lasegue sign Sicard Sign Nerve root tension sign

SLR with dorsiflexion of large toe Turyn Sign Nerve root tension sign

Supine position Dorsiflexion of large toe without SLR Least provocative nerve root tension sign for sciatic nerve Minors Sign Painful or antalgic

behavior due to protective myospasia Crawling up thigh with listing while rising from a seated position Vanzetti's Sign The pelvis is always horizontal in spite of

sciatica and scoliosis. In other lesions with scoliosis the pelvis is inclined. (pelvic obliquity) Antalgic Lean Sign Antalgia Sign Painful discopathy causes listing in order to reduce mechanical

nerve root pain. Antalgic Lean Sign Lateral disc protrusion produces a contralateral list Medial disc protrusion produces an ipsilateral list

Differentiate Lateral Disc from Medial Disc Protrusion Antalgic lean or antalgia sign Fajersztajns or Well Leg Test

Kemps test Meyerdings Classification of Spondylolisthesis Grade 1 = 0-25% Grade 2 = 26-50% Grade 3 = 51- 75% Grade 4 = 76%-100%

Lumbar Central Canal Stenosis Neurogenic claudication

with pain upon walking Feel like legs are giving way Temperature changes and weakness in legs Night pain Sciatic tension signs are present Lateral Spinal Canal Recess Stenosis

Degenerative joint disease Encroachment of nerve root in canal Nerve root entrapment IVD or Space Occupying Lesion Milgrams Test

Positive with either intrathecal or extrathecal pathology Milgrams Test Assessment for IVD or SpaceOccupying Lesion Patient able to hold

for 30 seconds rules out intrathecal pathology Positive Milgrams Test Indicates intrathecal or extrathecal pathology The test is positive if

the patient experiences low back pain Differentiate Spinal Sprain/Strain Describe your approach to differentiating sprain from strain of the lower back and pelvis

SIJ Lesions Signs and Symptoms SIJ pain Abnormal gait

Palpation tenderness Pain on forward flexion Pain on sitting Hibbs Test Differentiate Hip and SIJ Lesions Prone leg to buttocks

with lateral flexion and internal rotation Localized pain indicates either hip or SIJ pain Pelvic Rock Test Side posture downward pelvic

compression Pain in SIJ indicates lesion of inflammatory process Sign of the Buttocks Supine SLR reveals

unilateral restriction Sign present with knee flexion but no increased hip flexion Sign indicates hip disease, such as trochanteric bursitis Absence of Sign of the Buttocks

Absence of sign when hip flexion increases upon knee flexion due to pain reduction Indicates lumbar dysfunction Flamingo Test

Stand on one foot Hop to stress one joint Tests SIJ, symphysis pubis, and hip Adams Supported Belt Test Differentiate Lumbar from SIJ Lumbar pain with both

Lesion supported and unsupported dorsolumbar flexion SIJ pain with unsupported flexion only Lewin-Gaenslen Test

Side posture extension stresses SIJ & anterior SIJ ligaments Ipsilateral pain indicates a lesion in SIJ Yeomans Test

Prone extension stresses SIJ & anterior SIJ ligaments Ipsilateral pain indicates a lesion in SIJ SIJ Stretch Test

Bilateral supine ASIS pressure Pain indicates lesion in anterior SIJ ligaments or SIJ SIJ Resisted Abduction Test

Thigh or buttock pain indicates strain in TFL or gluteal muscles SIJ pain indicates sprain of SIJ ligaments Coccygodynia Myofascial pain is a

common cause of coccygodynia Hip Palpation Point tenderness Edema Symmetry

Hip Contracture Tests Thomas Test Supine passive hip flexion Contralateral hip and knee flexion indicates a positive test for hip

contracture Evaluate rectus femoris tightness Hip Contracture Tests Rectus Femoris Contracture Test Involuntary extension of flexed knee with tightness in rectus femoris indicates a

hip flexion contracture Hip Contracture Tests Piriformis Test Piriformis pain with resisted abduction of hip indicates tight piriformis Sciatic pain indicates

nerve compression Hip Contracture Tests Elys Heel to Buttocks Prone heel to contralateral buttocks Ipsilateral pelvis rising from table indicates hip flexion contracture

or tight rectus femoris Hip Contracture Tests Obers Test for TFL or ITB Obers Test Failure to descend smoothly indicates a positive test for contracture of the TFL

or ITB. Trochanteric Bursitis Palpation Patricks Positive finger point Laguerres

Degenerative Hip Disease Patricks Trendelenburgs Scourings Laguerres Difficult to palpate

Patricks Test FABERE & Figure of 4 Flexion Abduction External rotation

Patricks Test Compresses femoral head into acetabulum Positive test with pain in hip, which indicates an inflammatory process Pelvic Obliquity and Postural

Imbalance You must determine whether the leg length discrepancy is anatomical or functional Actual Leg-Length Test

This is a tape measurement that tests for anatomical leg length discrepancy. ASIS and medial malleolus are the landmarks identified Apparent Leg-Length Test

Reveals functional leg length discrepancy Umbillicus and medial malleolus are landmarks Functional Leg-Length Measurement

Measure length of both lower extremities supine and seated Inferior medial malloli are used as landmarks Read the body language

Functional Leg-Length Measurement Usually the ipsilateral malleolus will measure short when supine if the superior iliac crest appears inferior when standing and long when seated Trendelenburgs Test

Standing flexion of hip Downgoing of contralateral hip is a positive test Indicates gluteal motor weakness and/ or hip pathology of weight bearing LE

Anvil Test Percussion of calcaneus compresses hip joint Positive test with pain, which indicates fracture or hip pathology

Congenital Hip Dysplasia DDH Also known as Allis sign It is not used to evaluate functional leg length deficiency

Evaluation of the Knee What type of injuries should we consider with our differential diagnosis of the knee? Osgood Schlatters Lesion

Anterior tubercle of tibia inflammation with young athletes who run and jump Fracture may occur with an acute injury Meniscus and Ligament Instability

Apleys compression tests meniscus Apleys distraction tests nonspecific ligaments Meniscal Injury McMurrays Test

Flex and extend with internal and external rotation. Stresses distorted meniscus Palpable or audible click is positive Meniscal Injury

Retreating McMurray Palpate medial meniscus with knee and hip flexed 90 degrees plus lateral and medial rotation Meniscal Injury Retreating McMurray

Meniscal tear blocks medial rotation Meniscal Injury Bounce Home Test

Passive flexion of hip and knee Cup heel and request dropping of knee Femur rotation on tibia & extension blocked Meniscal Injury Bounce Home Test Blockage or rubbery

end feel with full extension are positive signs of meniscal injury Meniscal Injury Steinmans Tenderness Test

Supine Hip and knee flexion to 90 degrees Palpate medial and lateral joint lines with index and thumb w/ flexion and extension Meniscal Injury Steinmans Tenderness Test

Pain moving anteriorly with extension or posteriorly with flexion and indicates meniscal injury. Meniscal Injury Modified Helfets Test

Seated with foot on floor Note location of tibial tuberosity Extend leg and note location of tibial tuberosity Meniscal Injury

Modified Helfets Test Expect lateral movement of tibial tuberosity with extension of knee Blocked movement indicates meniscal injury

Thessaly Test for Meniscus Tear Five degree of knee flexion Unaffected knee first Thessaly Test for Meniscal Tear External rotation assisted Internal rotation Thessaly Test for Meniscal Tear Positive findings

Pain medial or lateral Clicking or locking Most accurate at 20 degrees of knee flexion Repeat process at 20 degrees Ligament Instability

Anterior and Posterior Drawer Signs Anterior Drawer Sign and Lachmans Anterior Cruciate & Posterior Oblique Anterior translation of more than 5 mm indicates

injury Anterior Drawer Sign Anterior cruciate Medial collateral ligament ITB Capsules & ligaments

Arcuate-politeus complex Ligament Instability Lachmans Test Anterior and posterior cruciate ligament sprains Most reliable test for anterior cruciate

ligament rupture Ligament Instability Slocums Test Anterior cruciate Posteriorlateral

capsule Fibular collateral ligament ITB Patellofemoral Dysfunction Patella Grinding Test

Chrondomalacia patellae Patellofemoral arthralgia Chondral fracture Patellofemoral Dysfunction Patella Apprehension Test

Pain and apprehension are present Positive test indicates lateral patellar dislocation Patellofemoral Dysfunction Dreyers Test

Patient cannot raise his leg while in a supine position Patellofemoral Dysfunction Dreyers Test Stabilize quadriceps tendon and patient

able to raise leg indicates traumatic fracture Patellofemoral Dysfunction Clarkes Patellar Scrape Test Pain and crepitation may indicate patellofemoral

arthralgia or chondromalcia patellae Drawers Foot Sign Anterior drawer will be positive with gapping secondary to trauma

Indicates sprain of anterior talofibular ligament Lateral Stability Test Talar Tilt Test Sprain injury to calcaneofibular and/or anterior talofibular ligaments

Ankle Examination Subtalar Examination High Ankle Sprain Mechanism High Ankle Sprain

Syndesmotic ligament Squeeze test Stress radiographs Syndesmotic screw Metatarsal Examination Plantar and Achilles Examination Tarsal Examination

Potts Compression Test Tests for fracture of the tibia or fibula or syndesmotic sprain. Syndesmotic Sprain Test The crossing of the

affected leg over the other leg will produce pain with a high ankle sprain of the interosseous membrane. Homans Test Deep Vein Thrombophlebitis Supine with knee

flexed Abrupt forcible dorsiflexion of foot Positive test produces pain in calf or popliteal region Tarsal Tunnel Syndrome

Analogous to carpal tunnel syndrome in the wrist Tinels Sign Tap tibial nerve at medial aspect of ankle Sign is present if

paresthesias are produced in foot Tourniquet Test Apply sphygmomanometer to affected ankle and inflate to pressure 10 mm of Hg above systolic for 1-2 minutes

Mortons Neuroma Pain Usually affect the third and fourth digits Metatarsal Pain Patient will often indicate pain over

heads of metatarsals Metatarsalgia Patient may complain of pain on the dorsum of the foot. Palpate both dorsal and plantar aspects of

foot. Metatarsal Inspection Inspect for callous formations Palpate Metatarsal Heads

Attempt to elicit pain and/or tenderness Provocative Maneuvers Metatarsal squeeze

Rapid and firm flexion of toes Stretch of interdigital nerves Shoulder Ranges of Motion What are the six ranges of motion for the shoulder?

History Taking Process Instability Stiffness Locking Catching

Swelling http://www.aafp.org/afp/20000515/3079.htm l The patient should be asked about shoulder pain: Supraspinatus Tendonosis

Signs Painful arc with abduction (60-90) 70-120 degrees Limited AROM Painful PROM

Supraspinatus Press Test Thumb down (empty can) Thumb up (full can) Supraspinatus Stress Test

Differentiate deltoid muscle strain from supraspinatus tendon/ muscle strain Apley Scratch Test Apley Scratch Test Rationale

Stresses rotator cuff tendons Supraspinatus is most often involved Exacerbation of pain might indicate degenerative tendonitis

Hawkins-Kennedy Impingement Supraspinatus tendonitis rationale Local pain with pressing of supraspinatus tendon against coracoacromial ligament Neer Impingement Test

Shoulder pain and look of apprehension indicates a positive sign for overuse of supraspinatus tendon Most common cause is repetitive microtrauma Bicipital Tendonosis

Orthopedic Evaluation Flexion of the elbow against resistance aggravates pain. Bicipital Tendonosis Passive abduction of the arm in a painful arc elicits pain; however, this finding may be

negative in isolated biceps tendonitis. Speeds Test Bicipital tendonosis Patient complains of anterior shoulder pain with flexion of the shoulder against resistance, while the

elbow is extended and the forearm is supinated. Yergasons Test Biceps tendon instability The patient complains of pain and tenderness over the bicipital groove with forearm supination against resistance with the elbow flexed and the shoulder in adduction. Popping of

subluxation of the tendon may be demonstrated with this maneuver. Clunk Test Tear of the anterior labrum Document joint stability in order to assess the rotator cuff and glenoid labrum.

Rowe Test For multidirectional instability Attempt to dislocate Look at patients face for apprehension and/

or discomfort This is a positive sign GH ligament, Rotator cuff tendons and joint capsule Abduction Inferior Stability (ABIS) Test Feagin test + anterior inferior shoulder instability with downward displacement or apprehension

Patient's arm abducted with the forearm resting on the examiner's shoulder Examiner exerts pressure on the arm, gradually pushing the humeral head downwards Crank Test (3)

(Standing or seated) Fulcrum Test This test serves to or place the shoulder in a

position of maximal instability (extremes of abduction and external rotation). The test is positive for instability if the patient expresses pain or apprehension. (Supine) Relocation Test (4) Classic fulcrum test

The humeral head is pushed forward to elicit apprehension Relocation Test Prevents anterior subluxation and produces a negative apprehension test

Pressure over the front of the humeral head prevents the head suluxating anteriorly, and does not cause apprehension. Sulcus Test (1) A positive test is indicative of abnormal mobility

In the relaxed patient, the examiner gently pulls the humerus downwards. The test is positive if the humeral head descends, with formation of a groove or sulcus under the lateral border of the acromion Drawer Test (2) Demonstrates overall non-specific hyperlaxity or

anterior instability of the glenohumeral joint The patient is made to relax and slightly lean forward. The examiner holds the humeral head between his or her thumb and index finger, and tries to make the head slide

backwards and forwards. Positive Hyperabduction Test Inferior Glenohumeral ligament determines range of passive abduction (85-90 degrees) Marked asymmetry between the affected

and the healthy side is characteristic of laxity of the ligament complex. Positive test = 105 degrees plus Multidirectional Hyperlaxity On examination, there will be a groove of more than 2 cm in the sulcus

test, as well as major anterior and posterior drawer movements. External rotation of the upper limb of more than 90 is also considered to be a sign of abnormal laxity. Isosceles Triangle Use this process to

reveal any deviations may indicate anatomical problem that warrants further investigation Tinels Sign Lateral Epicondylitis/Epicondylosis/tendinopathy Tennis Elbow Test or Cozens test

Kaplans Test Presence of a Kaplans sign with reduced pain and increased strength Medial Epicondylitis/Epicondylosis/Tendinopath y Examination

Golfers elbow test is a reverse Cozens test Valgus Testing Challenge the flexor muscles

Strain the medial ulnar collateral ligaments Ligamentous Instability Adduction and Abduction Stress Tests Gapping and pain indicate a positive test for instability

Froments Sign Test for ulnar nerve palsy Tests the action of adductor pollicis Patient holds a piece of paper between the thumb and a flat palm

as the paper is pulled away. Froments Sign and Finger Pinch Test Patient with an ulnar nerve palsy will flex the thumb to try to maintain a hold on the

paper. There are variations of this test Pinch Grip Test Anterior interosseous nerve trauma

Observe pitch attitude of the hand Normally when individual pinches something between index finger & thumb, MP & IP joints of thumb and index finger are flexed; Pinch Grip Test

Anterior interosseous nerve trauma With nerve deficit, terminal phalanges of thumb and index finger are extended or hyperextended EMG needle examination is difficult because of the deep location

Elbow Flexion Test Ulnar nerve compression at cubital tunnel The elbow is the most common site of

compression of the ulnar nerve. Second most common compressive neuropathy (after carpal tunnel syndrome). Cubital tunnel syndrome affects men 3-8 times as often as women. Examination of Related Areas

Normal Metacarpal Joints and Contour Finkelsteins Test Tunnel of Guyon Ulnar Nerve and Artery Phalens Test Carpal Tunnel Syndrome

Often, the symptoms can be duplicated or worsened by bending the wrist firmly palmward for 60 seconds Tinels Sign Carpal Tunnel Syndrome

Tapping the front of the wrist over the nerve reproduces the pain and paresthesia Dupuytrens Contracture A longitudinal fibrous

band, known as a cord, may form. Cord may flex the finger joints Process tends to be progressive Ulnar Drift Rheumatoid Arthritis

Drift of the fingers away from the direction of the thumb at the MP joint (ulnar drift). Due to tissue damage of capsules, ligaments, and tendons Boutonniere Deformity Avulsion of Extensor Digitorum Communis Tendon

Boutonniere deformity is an extensor tendon injury affecting two joints of the finger, the PIP (proximal interphalangeal) joint at the middle of the finger, and the DIP (distal interphalangeal) joint that controls the fingertip. Mallet Finger

Avulsion of Distal Extensor Digitorum Communis The tendon that straightens the tip of the finger is injured and you may lose the ability to straighten your finger Much Success to You

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