Users’ Guide

to the
Musculoskeletal
Examination

Fundamentals for the

Evidence-Based Clinician
Be sure to check for updates of the User's Guides to Examination of the
Musculoskeletal System at: www.evidenceinmotion.com/UsersGuide

Timothy W. Flynn • Joshua A. Cleland • Julie M. Whitman

e Musculoskeletal Examination

Users’ Guide to the Musculoskeletal Examination

Fundamentals for the Evidence-Based Clinician

Edited by
Timothy W. Flynn
Joshua A. Cleland
Julie M. Whitman

Cover art and illustrations by Mary E. McGivern

 Musculoskeletal Examination f

©2008 by Evidence in Motion

Printed in the United States of America
All rights reserved.

www.evidenceinmotion.com

This book and CD-ROMs are for information purposed only. No part
of this publication may be reproduced, downloaded, republished,
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form, mechanical, photocopying, recording, or otherwise, without the
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Motion, PO Box 44, Buckner, KY 40010.

Additional copies of this book may be ordered by calling 888 709-7096

or visiting the Web site at www.evidenceinmotion.com.

ISBN 978-0-9714792-3-4
e Musculoskeletal Examination

To our professional colleagues who provided invaluable insight

along the way, Dr. John Childs, Dr. Tony Delitto, Dr. Julie Fritz,
Dr. Stephen Allison, Henry McCracking, and Dr. Rob Wainner.
 table of Contents
f5

Table of Contents
Overview 6
Self-Report Instruments 13
Medical Screening Examination 18
Upper and Lower Quarter Neurological Screening 42
Cervicothoracic Spine Examination 72
Shoulder Examination 104
Elbow Examination 124
Wrist and Hand Examination 146
Temporomandibular Examination 170
Lumbar Spine Examination 183
Hip Examination 219
Knee Examination 243
Foot and Ankle Examination 283
What Is On The CD? 312
Index 313
6 e Musculoskeletal Examination

Overview
In This Chapter:

1. Introduction
2. Reliability
3. Diagnostic Accuracy
a. Diagnosis
b. Sensitivity
c. Specificity
d. Likelihood ratios
 Overview
f7
Introduction

Overview
The trend towards conscientious use of Evidence-Based Practice
(EBP) continues to increase in the medical and healthcare
professions. Sackett1 has defined EBP as an integration of the best
available research evidence and clinical expertise with the patient’s
values. Experts in practice are often considered those clinicians
who possess certain values, communication skills, decision-making
processes, specialty certification, and years of practice.2,3 A recent
systematic review has shown that although it is expected that
experienced physicians would have accumulated more knowledge
and skills than their younger counterparts which should result in
improved quality of care, this is not the case.4 In fact Choudhry et al4
demonstrated that the amount of “experience” a physician possessed
was inversely related to the quality care provided.4 Although this
systematic review leads one to question the association between
experience and outcomes, researchers only included physicians in
their studies and therefore the results cannot be directly extrapolated
to other healthcare professionals.
The basic tenets of EBP are not intended to devalue “expertise”.
However, the point should be made that expertise alone is insufficient
to assure optimal outcomes and hence the best available evidence
should be incorporated into clinical decision-making.4,5 It is essential
to incorporate the best available evidence into each aspect of clinical
decision-making from diagnosis, using tests and measures that
posses the greatest degrees of reliability and validity possible, to
prognosis of expected outcome based upon current literature and
pattern recognition from clinical experience.1
One component of patient management that requires the incorporation
of EBP is the diagnostic process. This entails gathering subjective
information and objective data to develop an initial working hypothesis.
Clinicians have a variety of specific tests and measures that can be
used when determining the patient’s initial diagnosis. The purpose
of the tests and measures is to provide information to surpass the
treatment threshold, the point in the examination process whereby
the clinician feels confident that he/she can now begin treatment.6
Traditionally, textbooks have disregarded information relative to the
usefulness of a particular test or measure. This can cause clinicians
to make incorrect treatment decisions.7 Hence, the importance of
understanding the diagnostic accuracy of a test or measure prior to
8 e Musculoskeletal Examination

incorporating it into clinical practice and using it to guide decision-

making should not be underestimated.8 Although the volume and
quality of emerging evidence in the area of diagnostic utility of the
clinical examination is emerging, there are still many areas where
evidence is sparse. However, rather than waiting for the “perfect
evidence”, clinicians follow the approach advocated by Reinertsen9
who suggests that clinicians should act on the research evidence
that is available, and that they use patient-centered outcome tools to
guide clinical decision-making.
This text will guide clinicians through the musculoskeletal examination
while incorporating the evidence. This chapter will discuss the
properties of reliability, sensitivity, specificity and likelihood ratios
and the remainder of the text will guide the clinician through the
musculoskeletal examination from ruling out red flags, through patient
observation, palpation, range of motion assessment, joint assessment
and special tests.

Reliability
Reliability is consistency of a measurement.10 Intra-examiner reliability
is the consistency of measurements between one person. Inter-
examiner reliability is the consistency of measurements between two
or more people.10 The following scale is often used to determine the
strength of the coefficients when calculating reliability: 0.50 represents
poor reliability, 0.50-0.75 represents moderate reliability, and greater
than 0.75 represents good reliability.10
Diagnostic Accuracy
Diagnosis:
Obtaining an accurate diagnosis for patients with musculoskeletal
disorders relies on astute clinical reasoning skills of the clinician
and careful analysis of data collected during the patient history
and physical examination. Prior to beginning the examination the
therapist determines the likelihood (pretest probability) that the patient
presents with a specific disorder (e.g., adhesive capsulitis, shoulder
impingement, etc). Pretest probability is based on the patient’s
past medical history and clinician experience.11 The clinician then
obtains a history from the patient to further ascertain the presence
of a clinical condition. The therapist must subsequently identify tests
and measures with adequate diagnostic accuracy that can provide
 Overview
f9
information that assists with identifying the likelihood that a patient
presents with a specific shoulder disorder following the examination

Overview
(posttest probability).
Prior to identifying the tests and measures that posses the best
diagnostic utility, the clinician must understand the properties of
diagnostic accuracy which is often expressed in terms of sensitivity
and specificity, and likelihood ratios (LRs).1,12

Sensitivity
Sensitivity is defined as the ability of a test to identify patients that
have a particular disorder.1 Highly sensitive tests are good for ruling
out a specific diagnosis. The acronym “SnNout” can be used to
remember that a test with high Sensitivity and a Negative result is
good for ruling out the disorder.1 An example comes from Walton and
colleagues13 who identified that palpation of the acromioclavicular
(AC) joint exhibited a sensitivity of 0.96 for identifying the presence
of AC joint lesions. Since the test has high sensitivity it is very likely to
capture the majority of patients with AC joint involvement. However,
it is also likely to capture a multitude of patients who do not have the
disorder. Yet, if the test is negative we can be fairly confident that the
patient does NOT have AC joint involvement.
Specificity
Specificity is defined as the ability of a test to identify patients that do not
have a particular disorder.1 Highly specific tests are good for ruling in a
disorder. The acronym “SpPin” can be used to remember that a test with
high Specificity and a Positive result is good for ruling in the disorder.1
The crank test, as investigated by Liu et al,14 provides an example of
this. The authors identified the test as being highly specific (0.93). Since
the test has high specificity a negative test finding would likely capture
the majority of those without a labral tear. So in this case a positive test
would be good for identifying all those WITH a labral tear

Likelihood Ratios
Although sensitivity and specificity are helpful there are a few limitations
to these statistics.11,15,16 Hence, likelihood ratios (LRs) are often the
most clinically useful tool for determining shifts in probability if a patient
presents with a specific disorder. Likelihood ratios are calculated by
incorporating both the sensitivity and specificity and can directly alter
the likelihood that the disorder is present.17 Likelihood ratios are either
10 e Musculoskeletal Examination

positive (+LR) or negative (-LR). If a test is positive, then the +LR is

used to determine the increased likelihood that a patient presents with
the disorder of interest. Conversely, if a test is found to be negative, then
the –LR is used to indicate a shift in the probability that the patient does
not have the disorder. Table 1 provides a guide to interpreting LRs.18

Positive Likelihood Negative Likelihood Interpretation

Ratio Ratio
Greater than 10 Less than 0.1 Generate large and often
conclusive shifts in
probability

5-10 0.1-0.2 Generate moderate shifts

in probability
2-5 0.2-0.5 Generate small but
sometimes important
shifts in probability
1-2� 0.5-1� Alter probability to a
small and rarely
important degree

Table 1. Interpretation of likelihood ratios. 18

SUMMARY
Clinicians should be aware of the reliability, sensitivity, specificity
and likelihood ratios of a particular test prior to incorporating it into
clinical practice. Recently there has been a significant increase in
the number of studies investigating the diagnostic utility of tests and
measures used in the clinical setting. Each of the respective chapters
in this User’s Guide will list special tests and their diagnostic values
where appropriate.
 Overview
f 11
Reference List

Overview
(1) Sackett DL, Straws SE, Richardson WS et al. Evidence-
Based Medicine; How to Practice and Teach EBM. 2nd ed.
London: Harcourt Publishers Limited, 2000.
(2) Jensen GM, Gwyer J, Shepard KF. Expert practice in physical
therapy. Phys Ther 2000;80:28-43.
(3) Shepard KF, Hack LM, Gwyer J et al. Describing expert
practice in physical therapy. Qual Health Res 1999;9:746-58.
(4) Choudhry NK, Fletcher RH, Soumerai SB. Systematic review:
the relationship between clinical experience and quality of
health care. Ann Intern Med 2005;142:260-73.
(5) Whitman JM, Fritz JM, Childs JD. The influence of experience
and specialty certifications on clinical outcomes for patients
with low back pain. J Orthop Sports Phys Ther 2004;11-662.
(6) Kassirer JP. Our stubborn quest for diagnostic certainty a
cause of excessive testing. NEJM 1989;320:1489-91.
(7) Bossuyt PMM. The quality of reporting in diagnostic test
research: Getting better, still not optimal. Clin Chem
2004;50:465-7.
(8) Lijmer JG, Mol BW, Heisterkamp S et al. Empirical evidence
of design-related bias in studies of diagnostic tests. AMA
1999;282:1061-963.
(9) Reinertsen JL. Zen and Art of Physican Autonomy
Maintenance. Ann Intern Med 2003;138:992-5.
(10) Portney LG, Watkins MP. Foundations of Clinical Research:
Applications to Practice. 2nd ed. Upper Saddle River:
Prentice Hall Health, 2000.
(11) Bernstein J. Decision analysis (Current concepts review).
J Bone Joint Surg Am 1997;79:1404-14.
(12) McGinn T, Guyatt G, Wyer P et al. Users’ guides to the
medical literature XXII: How to use articles about clinical
decision rules. JAMA 2000;284:79-84.
(13) Walton J, Mahajan S, Paxinos A et al. Diagnostic values of
tests for acromioclavicular joint pain. J Bone Joint Surg Am
2004;86-A:807-12.
(14) Liu SH, Henry MH, Nuccion SL. A prospective evaluation of
a new physical examination in predicting glenoid labral tears.
Am J Sports Med. 1996;24:721-5.
12 e Musculoskeletal Examination

(15) Boyko EJ. Ruling out or ruling in disease with the most
sensitive or specific diagnostic test: Short cut or wrong turn?
Med Decis Making 1994;14:175-80.
(16) Riddle DL, Stratford PW. Interpreting validity indexes for
diagnostic tests: An illustration using the berg balance test.
Phys Ther 1999;79:939-48.
(17) Hayden SR, Brown MD. Liklihood ratio: A powerful tool for
incorporating the results of a diagnostic test into clinical
decision making. Ann Emerg Med 1999;33:575-80.
(18) Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the
medical literature. III. How to use an article about a diagnostic
test. B. What are the results and will they help me in caring
for my patients? The Evidence-Based Medicine Working
Group. JAMA 1994;271:703-7.
 Self-Report Instruments
f13

Self-Report
Instruments

Report
Self-
The following self- report measures can be opened by clicking on them:
Medical Screening Form
Patient Specific Functional Scale
Numeric Pain Rating Scale
Neck Disability Index (NDI)
Quick Disability of the Shoulder Arm and Hand (DASH)
Oswestry Disability Index (ODI)
Lower Extremity Functional Scale (LEFS)
Global Rating of Change
Fear-Avoidance Beliefs Questionnaire
Psychometric Properties of Self-Report Measures
There has been an increasing trend in the use of outcome measures that
capture a patient’s current level of function, activities and participation,
and disability. This is often accomplished through the use of self-report
measures to capture data regarding a patient’s perceived level of
disability and the impact of a disease on a patient’s daily activities.1 It
is essential for clinicians to use self-report measures that possess the
characteristics of reliability and validity, and are responsive enough to
identify changes in function when a true change has occurred.1
Reliability is the degree of consistency to which an instrument or rater
measures a particular attribute.2 When the reliability of a measurement
is investigated, an attempt is made to determine the proportion of the
measurement that is a true representation of the measure and the
proportion that is the result of measurement error.3 Measurements can
be effected by error, which is a deviation from the true measurement
as a result of chance.3 It has been reported that reliability values closer
to 1 exhibit higher levels of reliability.6 “Acceptable reliability” has been
reported to be values over .70, however, the individual clinician must
determine the extent of reliability necessary to use the instrument in
clinical practice.4
14 e Musculoskeletal Examination

Test-retest reliability is the ability of a questionnaire to repeatedly

capture similar scores on two separate occasions of test
administration, over which time the patient has not exhibited a
change in their condition.3 When using self-report outcome measures
it is important to know the minimal detectable change (MDC), the
amount of change that must be observed before the change can
be considered to exceed the measurement error.5 For example if
the measurement error for a particular outcome tool is 4 points, any
changes in scores lower than 4 can only be attributed to error and
not a true change in patient status.

Validity is the extent to which an instrument measures exactly what

it is intended to measure.3 In addition, functional and disability level
measures must be able to detect a change when a true change has
occurred and must remain stable when one has not.5 Responsiveness,
the ability of a test or measure to recognize change3, is essential
in detecting a clinically meaningful level of change.6 This clinically
meaningful level of change is often referred to as the minimal
clinically important difference (MCID), the smallest difference which
indicates a true change in the patients functional abilities, activities
and participation, or level of disability has occurred.7 Specific values
for the reliability, MDC and MCID for specific outcome measures
presented on this text can be found in the Table.
Self-Report Instruments
f15

Report
Self-
16 e Musculoskeletal Examination

Reference List

(1) Pietrobon R, Coeytaux R, Carey T et al. Standard scales
for measurement of functional outcome for cervical pain or
dysfunction. Spine 2002;27:515-22.
(2) Rothstein JM, Echternach JL. Primer on Measurement: An
Introductory Guide to Measurement Issues. Alexandria, VA:
American Physical Therapy Association, 1999.
(3) Portney LG, Watkins MP. Foundations of Clinical Research:
Applications to Practice. 2nd ed. Upper Saddle River: Prentice Hall
Health, 2000.
(4) Wainner RS. Reliability of the clinical examination: how close is
"close enough"? J Orthop Sports Phys Ther 2003;33:488-91.
(5) Resnik L, Dobrzykowski E. Guide to outcomes measurement for
patients with low back pain syndromes. J Orthop Sports Phys Ther
2003;33:307-16.
(6) Binkley JM, Stratford PW, Lott SA et al. The Lower Extremity
Functional Scale (LEFS): scale development, measurement
properties, and clinical application. North American Orthopaedic
Rehabilitation Research Network. Phys.Ther. 1999;79:371-83.
(7) Jaeschke R, Singer J, Guyatt GH. Measurment of health status:
Ascertaining the minimal clinically important difference. Controlled
Clinical Trials 1989;10:407-15.
(8) Cleland JA, Fritz JM, Whitman JM et al. The reliability and
construct validity of the Neck Disability Index and Patient Specific
Functional Scale in patients with cervical radiculopathy. Spine
2006;31:598-602.
(9) Cleland JA, Childs JD, Whitman JM. Psychometric properties of
the neck disability index and numeric pain rating scale in patients
with mechanical neck pain. Arch Phys Med Rehab. 2008; In Press.
(10) Gummesson C, Ward MM, Atroshi I. The shortened disabilities of
the arm, shoulder and hand questionnaire (QuickDASH): validity
and reliability based on responses within the full-length DASH.
BMC Musculoskeletal Disorders 2006;7:44.
(11) Fritz JM, Irrang JJ. A comparison of a modified Oswestry Low
Back Disability Questionnaire and the Quebec Back Pain Disability
Scale. Phys Ther 2001;81:776-88.
(12) Watson CJ, Propps M, Ratner J et al. Reliability and
responsiveness of the lower extremity functional scale and the
anterior knee pain scale in patients with anterior knee pain. J
Orthop Sports Phys Ther 2005;35:136-46.
 Self-Report Instruments
f17

(13) Childs JD, Piva SR, Fritz JM. Responsiveness of the numeric pain
rating scale in patients with low back pain. Spine 2005;30:1331-4.
(14) Westaway M, Stratford P, Binkley J. The Patient-Specific

Report
Self-
Functional Scale: validation of its use in persons with neck
dysfunction. J Orthop Sports Phys Ther 1998;27:331-8.
(15) Jacob T, Baras M, Zeev A et al. Low back pain: reliability of a set of
pain measurement tools. Arch Phys Med Rehabil 2001;82:735-42.
(16) Cleland JA, Childs JD, Fritz JM. The Psychometric Properties of
the Fear-Avoidance Beliefs Questionnaire and the Tampa Scale of
Kinesiophobia in Patients with Neck Pain. Am J Phys Med Rehab
2007; In Press.
18 e Musculoskeletal Examination

Medical Screening
Examination
In This Chapter:
1. Cardiovascular System
2. Peripheral Arterial Disease
3. Deep Vein Thrombosis
4. Gastrointestinal System
5. Genitourinary System
6. Endocrine System
7. Pulmonary System
8. Integumentary System
9. Neurologic Disorders
10. Mini-Mental Examination
11. Depression Screening
12. Conclusion
 Medical Screening
f19
Medical Screening Examination
Clinical decision-making requires a detailed history and physical
examination to determine if the patient’s symptoms are systemic
or musculoskeletal in origin. During the time of the examination
the clinician should take a thorough history and perform a systems
review. Once the examination is complete the clinician then must
determine if the patient presents with musculoskeletal impairments

Screening
Medical
and treatment can begin, or if the patient exhibits other findings
and requires a consultation with or referral to another healthcare
professional. In this chapter we discuss common red flags and signs
or symptoms that suggest a more serious underlying pathology that
may necessitate a referral for medical interventions. We will outline
the medical screening process including the historical examination,
and identification of referral patterns and signs and symptoms of
systemic disease.
20 e Musculoskeletal Examination

Prior to initiating the examination the clinician should carefully review

the medical intake questionnaire to determine if the patient has
previously been diagnosed with any systemic disease that may be
contributing to current symptoms. Following a review of the intake
questionnaire the clinician should begin the historical examination by
asking the patient to further elaborate on any disease experienced in
the past and to clarify items on the intake questionnaire.

Questions might include:

1. When were you diagnosed with the particular

disease?
2. How was it treated?
3. Is it currently being treated?
4. Are the symptoms you are experiencing today
different than when you were first diagnosed with the
disorder?
5. Are you taking any medications for this current
condition or any other diagnoses?
 Medical Screening
f21

Screening
Medical
/// Stabbing XXX Burning
000 Pins & Needles === Numbness

Pain Diagram
22 e Musculoskeletal Examination

Once data related to the past medical history have been obtained
the clinician should begin questioning the behavior of the current
symptoms to investigate if they are related to the musculoskeletal
system or are presenting as non-musculoskeletal in nature. The
following general questions should be asked to initially identify the
possibility of symptoms that are constitutional and require referral to
another medical professional:1

1. Have you experienced any unexplained weight loss or

gain greater than 10 pounds?
2. Have you experienced a fever, sweating at night, or
chills?
3. Have you experienced a loss of appetite or nausea
and/or vomiting?
4. Have you experienced any dizziness or diarrhea?
5. Are you awakened with pain at night? If so, does it
resolve quickly with changes in position or does it
keep you awake?

The clinician should also question the patient regarding current

medication usage. A number of side effects can occur with the use
of individual medications or combinations of medications. A detailed
description of the side effects associated with various medications is
beyond the scope of this User’s Guide.

Additionally there are a number of questions that indicate pathology

of a specific system. Specific questions relative to each system and
referral patterns of each system will be described in detail in the
following pages.
 Medical Screening
f23
Cardiovascular System
There are a number of risk factors associated with disease of the
cardiovascular system. When questioning the patient the clinician
should be sure to ask specific questions related to risk factors
including:2

Screening
1. Do you have a family history of cardiovascular disease?

Medical
2. What is your diet?
3. Do you have a history of smoking?
4. What are your current and recent levels of stress?
5. Do you have a history of diabetes?

Follow-up questions to ascertain the possibility that the patient may

be presenting with symptoms associated with cardiovascular disease
include the following:1,3

1. Do you experience any difficulty breathing?

2. Do you experience an increase in chest pain with
increased exertion?
3. Have you been experiencing any heart palpitations,
tachycardia, bradycardia, nausea, diaphoresis, or
chest pressure?
4. Have you experienced episodes of syncope?
5. Do you ever experience excessive fatigue?
24 e Musculoskeletal Examination

Referral Patterns from the Heart

Peripheral Arterial Disease

Peripheral arterial disease (PAD) often accompanies cardiovascular
disease. The risks factors are similar to cardiovascular disease, with
cigarette smoking being most directly correlated with PAD. It has
been reported that individuals with PAD who are smokers exhibit a
50% increase in mortality at a 5 year follow-up.4
Patients with PAD often report lower extremity claudication or
cramping and rest pain defined as pain on the dorsum of the foot
that wakes the patient at night as a result lack of blood supply and
insufficient oxygenation of the tissues. 5
 Medical Screening
f25
Deep Vein Thrombosis
A deep vein thrombosis (DVT) is a vascular disease which consists
of venous stasis and hypercoagubility in the venous system and at
times can become mobile and result in a pulmonary embolus and
potentially death.1

The following clinical prediction rule can help a clinician identify a

Screening
Medical
DVT:6

1. Active cancer (treatment ongoing, within previous 6 mo, or

palliative) = 1 point.
2. Paralysis, paresis, or recent plaster immobilization of the
lower extremities = 1 point.
3. Recently bedridden for >3 days or major surgery within 4
wk = 1 point.
4. Localized tenderness along the distribution of the deep
venous system. Tenderness along the deep venous
system is assessed by firm palpation in the center of the
posterior calf, the popliteal space, and along the area of
the femoral vein in the anterior thigh and groin = 1 point.
5. Entire lower extremity swelling = 1 point.
6. Calf swelling > 3 cm when compared with the
asymptomatic lower extremity. Measured with a tape
measure 10 cm below tibial tuberosity = 1 point.
7. Pitting edema (greater in the symptomatic lower extremity)
= 1 point.
8. Collateral superficial veins (nonvaricose) = 1 point.
9. Alternative diagnosis as likely or greater than that of
proximal DVT. More common alternative diagnoses are
cellulitis, calf strain, Baker cyst, or postoperative swelling=
-2 points.

The total score for all items is tallied and the probability of the patients
having a DVT are as follows: 0=low, 1-2=moderate, and ≥3=high.6
26 e Musculoskeletal Examination

Gastrointestinal
Gastrointestinal (GI) symptoms can often be confused as originating
from the musculoskeletal system.7
Further questioning of the GI system should include:1

1. Have you noted discoloration of urine or blood in your

stools?
2. Are your symptoms exacerbated after eating?
3. Have you vomited recently?
4. Have you experienced any changes in your bowel or
bladder habits?

Recently predictors of abdominal pain that are likely musculoskeletal

in nature have been identified.8 The following questions and responses
from the patients exhibited a sensitivity of .67, specificity of .84, a
positive likelihood ratio of 4.2, and a negative likelihood ratio of .39.
The patient responds “yes” to the following 2 questions:

1. Does coughing, sneezing, or taking a deep breath

make your pain feel worse?
2. Do activities such as bending, sitting, lifting, twisting,
or turning over in bed make your pain feel worse?

The patient responds “no” to the following question:

1. Has there been any change in your bowel habits since

the start of your symptoms?
 Medical Screening
f27
If in addition to the responses to the above questions the patient also reports
“no” to the following 2 questions, then the sensitivity was .67, specificity .96,
positive likelihood ratio 16.8, and negative likelihood ratio of .34.

1. Does eating certain foods make your pain feel worse?

2. Has your weight changed since your symptoms
started?

Screening
Medical
The reliability of these questions ranged from moderate (kappa =
.56) to very good (kappa = .88).

McBurney’s point

Pain patterns associated with the appendix

28 e Musculoskeletal Examination

Genitourinary
The clinician should also screen for the presence of any genitourinary
issues during the initial examinations. Specific questions entail:1

1. Have you experienced any incontinence?

2. Have you noticed any blood in your urine or feces?
3. Have you experienced any problems with impotence?
4. Have you experienced any burning during urination or
dysuria?

Answers of “yes” to the aforementioned questions should lead to

questioning the patient’s sexual history.9

1. How many sexual partners have you had?

2. Are the sexual partners male or female?
3. Was the sexual act vaginal, anal, or oral?
4. Was any form of protection used?
5. Have you experienced a past history of sexually
transmitted diseases?
 Medical Screening
f29

Screening
Medical
Renal Pain Referral Pattern
30 e Musculoskeletal Examination

Endocrine
Patients with endocrine disorders are classified as having either
hypo or hyperfunction and may report fluctuations in levels of fatigue,
irritability, or sensitivity to temperature changes. The individuals
should be queried regarding the presence of:1,10

1. Polydypsia
2. Polyuria
3. The presence of an onset of confusion
4. Changes in hair or nail growth
5. Diaphoresis
6. Dehydration
7. Alterations in breathing patterns
 Medical Screening
f31
Pulmonary System
Screening questions directed at the pulmonary system should be
performed in patients with any reports of difficulty breathing, pain
with breathing, altered breathing patterns, or exhibits over the lung
field on the anterior, lateral, or posterior chest wall.1 The following
questions should be asked to further ascertain involvement of the
pulmonary system.11

Screening
Medical
1. Do you smoke now, and did you smoke in the past?
How much?
2. Have you experienced a cough?
a. If so has the cough been producing sputum? If yes,
the color of the sputum and the presence of blood
should be investigated.
3. Have you experienced any episodes of (difficult or
labored breathing dyspnea) or difficulty breathing
when upright (orthopnea)?
4. Have you experienced any episodes where you could
not catch your breath?
32 e Musculoskeletal Examination

Referred pain from tracheobronchial irritation

 Medical Screening
f33
Integumentary System
The following questions should be asked to further ascertain
involvement of the integumentary system:12

1. Have you recently experienced any rashes?

2. Have you recently noticed any enlargement or
bleeding of moles?

Screening
Medical
3. Have you recently noticed any burning or itching of
the skin?
4. Have you noticed any large areas of exfoliation of the
skin?
5. Have you noticed any blistering of the skin?

If the patient reports “yes” to any of the aforementioned questions

a physical examination of the patient’s skin should be performed to
determine the presence of any primary skin lesions.
34 e Musculoskeletal Examination

Primary skin lesions that may require referral include:12

• Macule- Circumscribed, flat change in color of skin; <1.0

cm in diameter.
• Patch- Circumscribed flat lesion; >1.0 cm in diameter
• Papule- Raise solid lesion; <0.5 cm in diameter
• Plaque- Circumscribed, raised superficial lesion with flat
surface; >0.5 cm in diameter.
• Nodule- Circumscribed, raised, firm lesion; >0.5 cm in
diameter.
• Wheal- Firm, raised, pink/red swelling of the skin; size and
shape varies; usually itchy; lasts < 24 hours.
• Tumor- Large papule or nodule; usually > 1.0 cm in
diameter.
• Pustule- Circumscribed, raised lesion containing
purulent exudate that may be cloudy, white, yellow, or
hemorrhagic.
• Vesicle- Circumscribed, raised lesion; filled with liquid or
semi-solid material.
• Bulla- Vesicle >0.5 cm in diameter.
• Cyst- Firm, raised, encapsulated lesion; filled with liquid or
semi solid material.
 Medical Screening
f35
Neurologic Disorders
Clinicians should investigate for any signs of neurological deficits
associated with either upper motor neuron or lower motor neuron
involvement. Higher brain functions such as consciousness, and
mental status should also be examined.

The clinician should ask the following questions:

Screening
Medical
1. Have you been experiencing any headaches or vision
changes?
2. Have you been experiencing any dizziness or vertigo?
3. Have you been experiencing any seizures or
unconsciousness?
4. Do you ever experience the presence of any weakness
or parasthesias?
36 e Musculoskeletal Examination

Mini-Mental Examination
Clinicians can investigate the cognitive status by using two questions
from the Mini-Mental Exam13 including time orientation and the Serial
Sevens Test. The clinician first performs the time orientation test by
asking the patient the date including the month, day of the month,
day of the week, year, and the season. The patient receives one
point for each correct answer for a maximum total of five points for
this question. Next the clinician asks the patients to count backwards
from 100 by sevens. The patient is allowed to respond with five
answers. A point is awarded for each answer that is correct for a total
of five maximum points.13 Combining the total scores for the time
orientation and Serial Sevens tests yields a maximum of 10 points.

Recently Onishi and colleagues14 demonstrated that a cut-off score

of 7 for the two tests yielded a sensitivity of 98.2% and a specificity of
69.2% for identifying cognitive impairments in older adults.
 Medical Screening
f37
Depression Screening
Depression is often not recognized in patients presenting to primary
care with reports of other symptoms. Even if it is recognized that a
patient presents with depression, it is likely that they won’t receive
an intervention to treat their depression.15 If the patient presents with
depression along with a musculoskeletal disorder, such as back pain,
a multidisciplinary treatment approach could potentially maximize

Screening
Medical
patient outcomes.16

Arroll and colleagues17 demonstrated the utility of a two-question

depression screening test in a primary care setting:

1. During the past month have you often been bothered

by feeling down, depressed, or hopeless?
2. During the last month have you often been bothered
by little interest or pleasure in doing things?

If the patient answered the two questions as “yes” then the sensitivity
was 97% and specificity was 67%. The likelihood ratio for a positive
test was 2.9 and the negative likelihood ratio was .05.

Haggman and colleagues18 demonstrated that the above two

questions were more accurate in identifying if a patient presented with
depression than a physical therapist’s assessment of the patient.
38 e Musculoskeletal Examination

Conclusion
The importance of developing an astute level of competence in
screening for red flags should not be underestimated. Screening
for red flags provides considerable guidance in the clinical decision
making process relative to the best course of management.

Once a thorough screening examination has been performed and any

systemic disorder ruled out with a degree of confidence, the clinician
can begin to address the patient’s musculoskeletal complaint directly.
 Medical Screening
f39
Reference List
(1) Goodman CC, Snyder TEE. Differential diagnosis in physical
therapy. 3rd ed. Philadelphia: W.B. Saunders Company, 2000.
(2) Sieggreen M. A contemporary approach to peripheral arterial
disease. Nurse Pract 2006;31:14-5.
(3) Boissonnault WG. Examination in Physical Therapy Practice:
Screening for Medical Disease. 2nd ed. Philadelphia: Churchill

Screening
Livingstone, 1995.

Medical
(4) Criqui MH, Langer RD, Fronek A et al. Mortality over a period
of 10 years in patients with peripheral arterial disease. N Engl J
Med 1992;326:381-6.
(5) Sieggreen M. A contemporary approach to peripheral arterial
disease. Nurse Pract 2006;31:14-5.
(6) Wells PS, Hirsh J, Anderson DR et al. A simple clinical model for
the diagnosis of deep-vein thrombosis combined with impedance
plethysmography: potential for an improvement in the diagnostic
process. J Intern Med 1998;243:15-23.
(7) Yelland MJ. Back, chest and abdominal pain. How good are
spinal signs at identifying musculoskeletal causes of back, chest
or abdominal pain? Aust Fam Physician 2001;30:908-12.
(8) Sparkes V, Prevost AT, Hunter JO. Derivation and identification
of questions that act as predictors of abdominal pain
of musculoskeletal origin. Eur J Gastroenterol Hepatol
2003;15:1021-7.
(9) Jolley S. Taking a sexual history: the role of the nurse. Nurs
Times 2002;98:39-41.
(10) Goodman CC. The Endocrine and Metabolic Systems. In:
Goodman CC, Boissonnault WG, eds. Pathology: Implications for
the Physical Therapist. Philadelphia: W.B. Saunders, 1998:262.
(11) Goodman CC. The Respiratory System. In: Goodman CC,
Boissonnault WG, eds. Pathology: Implications for the Physical
Therapist. Philadelphia: W.B. Saunders, 1998:399-455.
(12) Cole JM, Gray-Miceli D. The necessary elements of a
dermatologic history and physical evaluation. Dermatol Nurs
2002;14:377-83.
(13) Folstein MF, Folstein SE, McHugh PR. “Mini-Mental State”. A
practical method for grading the cognitive state of patients for the
clinician. J Psychiatr Res 1975;12:189-98.
(14) Onishi J, Suzuki Y, Umegaki H et al. Which two questions of Mini-
Mental State Examination (MMSE) should we start from? Arch
Gerontol Geriatr. 2006.
40 e Musculoskeletal Examination

(15) Cohen M, Nicholas M, Blanch A. Medical assessment and

managment of work related low back or neck arm pain: more
questions than answers. J Occup Health Safety Aust NZ
2000;16:307-17.
(16) Middleton P, Pollard H. Are chronic low back pain outcomes
improved with co-management of concurrent depression?
Chiropr Osteopat 2005;13:8.
(17) Arroll B, Khin N, Kerse N. Screening for depression in primary
care with two verbally asked questions: cross sectional study.
BMJ 2003;327:1144-6.
(18) Haggman S, Maher CG, Refshauge KM. Screening for symptoms
of depression by physical therapists managing low back pain.
Phys Ther 2004;84:1157-66.
Upper and Lower Quarter Neurological Screening f41

ULQ
42e Musculoskeletal Examination

Upper and
Lower Quarter
Neurological
Screening
In This Chapter:

1. Cranial Nerve Examination

2. Examination of Myotomes
a. Cervical Nerve Roots
b. Lumbar Nerve Roots
3. Sensory Examination: Segmental Nerve Root Level
a. Cervical Spine
b. Lumbosacral Spine
4. Sensory Examination: Peripheral Nerve Fields
a. Upper Extremities
b. Lower Extremities
5. Lower Motor Neuron Reflexes
a. Cervical Reflexes
b. Lumbar Reflexes
6. Upper Motor Neuron Reflexes
 Upper and Lower Quarter Neurological Screening f43

Brain

Cerebellum

Spinal cord

Brachial plexus

Musculocutaneous
nerve
Intercostal
Radial nerve nerves

ULQ
Subcostal nerve
Median nerve
Iliohypogastric Lumbar
nerve plexus
Sacral
Genitofemoral plexus
nerve
Femoral nerve
Obturator
nerve Pudendal nerve
Ulnar nerve Sciatic nerve

Muscular branches
of femoral nerve
Saphenous nerve

Tibial nerve
Common fibular nerve

Deep fibular nerve

Superficial fibular nerve

Figure of Nervous System

44e Musculoskeletal Examination

Cranial Nerve Number

and Function Test

I: Olfactory
Sensory from olfactory Assess the ability to smell
epithelium. common scents.

II: Optic
Sensory from retina of eyes. Assess peripheral vision by
having person read an eye
chart.

III: Oculomotor
Motor to muscles controlling Assess pupil constriction as
upward, downward, and a reaction to light.
medial eye movements, as
well as pupil constriction.

IV: Trochlear
Motor to muscles controlling Assess the ability to move eye
downward and inward eye downward and inward by asking
movements. patient to follow your finger.
Upper and Lower Quarter Neurological Screening f45

Olfactory Nerve

ULQ
Oculomotor Nerve

Trochlear Nerve
46e Musculoskeletal Examination

Cranial Nerve Number

and Function Test

V: Trigeminal
Test sensation of face and
Sensory from face and motor
cheeks as well as corneal
to muscles of mastication.
reflex. Assess the patient’s
ability to clench the teeth.

VI: Abducens
Motor to muscles that move Assess patient’s ability
eye laterally. to move eyes away from
midline by asking him to
follow your finger with
his eyes.

VII: Facial
Motor to muscles of facial Assess symmetry and
expression and sensory to smoothness of facial
anterior tongue. expressions. Test taste on
anterior 2/3 of tongue.

VIII: Vestibulocochlear
Hearing and balance. Assess by rubbing fingers by
each ear. Patient should hear
both equally. Can also ask
patient to perform balance test.
Upper and Lower Quarter Neurological Screening f47

Trigeminal Nerve

ULQ
Facial Nerve

Vestibulocochlear Nerve
48e Musculoskeletal Examination

Cranial Nerve Number and Test

Function

IX: Glossopharyngeal
Controls gag reflex and Assess gag reflex and taste
sensory to posterior tongue. on the posterior tongue.

X: Vagus
Controls muscles of pharynx, Ask patient to say “ah” and
which facilitate swallowing. watch for elevation of soft
Provides sensory to thoracic palate.
and abdominal visceral
region.

XI: Accessory
Motor to trapezius and Muscle testing of trapezius.
sternocleidomastoid muscles.

XII: Hypoglossal
Motor to muscles of the Ask patient to stick tongue
tongue. straight out. Tongue will
deviate toward injured side.
Upper and Lower Quarter Neurological Screening f49

Glossopharyngeal Nerve

ULQ
Accessory Nerve

Hypoglossal Nerve
50e Musculoskeletal Examination

Examination of Myotomes
Strength of myotomes is assessed along with reflexes and sensation
to determine the presence of nerve root involvement.
Cervical Nerve Roots
The strength of key muscles of each myotome is tested bilaterally
from C1-2 through T1 to assess for the presence of cervical nerve
root involvement. Manual muscle testing is performed bilaterally.
Grading is either WNL (equal bilaterally) or diminished (less strength
than the other side). All testing is performed with the patient seated.

Nerve Root Level, Major Muscles Innervated, and

Test Procedure

C1 and C2:
Innervation: Muscles that flex the neck
Procedure: The examiner stabilizes the trunk with one hand and
applies a posteriorly directed force through the patient’s forehead
while matching the resistance.
C3:
Innervation: Muscles that sidebend the neck
Procedure: The examiner stabilizes the shoulder with one hand
and applies a force away from the side to be tested while the
patient is instructed to match the resistance.
C4:
Innervation: Muscles that elevate the shoulders
Procedure: The patient is instructed to elevate their shoulders.
The examiner applies an inferiorly directed force through the
shoulders while the patient is instructed to match the resistance.
C5:
Innervation: Deltoids
Procedure: The patient is instructed to abduct their shoulders to
90 degrees. The examiner applies a force into adduction while the
patient resists.
Upper and Lower Quarter Neurological Screening f51

Neck Flexion

ULQ
Neck Sidebending

Shoulder Elevation

Shoulder Abduction
52e Musculoskeletal Examination

Nerve Root Level, Major Muscles Innervated, and

Test Procedure

C6:
Innervation: Biceps and extensor carpi radialis brevis and
longus
Procedure:
1. The patient’s elbow is flexed to 90 degrees and the forearm
supinated. The examiner applies a force into extension while
the patient resists.
2. The patient’s elbow is flexed to 90 degrees, forearm pronated,
and wrist extended and radially deviated. The examiner applies
a force into flexion and ulnar deviation while the patient resists.
C7:
Innervation: Triceps and flexor carpi radialis
Procedure:
1. The patient’s elbow is flexed to 90 degrees and the examiner
applies a force into elbow flexion while the patient resists.
2. The patients elbow is flexed to 90 degrees with the wrist flexed
and radially deviated with forearm supinated. The examiner
applies a force into wrist extension and ulnar deviation while
the patient resists.
C8:
Innervation: Abductor pollicis brevis.
Procedure: The examiner places the thumb in abduction. The
examiner applies a resistance through the proximal phalanx in
the direction of abduction while the patient resists.
T1:
Innervation: First dorsal interossei
Procedure: The examiner separates the index and middle finger
and applies a force against the lateral aspect of proximal phalanx
of the index finger into adduction.
Upper and Lower Quarter Neurological Screening f53

Elbow Flexion

ULQ
Elbow Extension

Thumb Abduction

Finger Abduction
54e Musculoskeletal Examination

Lumbosacral Nerve Roots

The strength of key muscles of each myotome is tested bilaterally for
nerve roots from L2 through S2. Manual muscle testing is performed
bilaterally. Grading is either WNL (equal bilaterally) or diminished
(less strength than the other side). All testing is performed with the
patient seated.

Nerve Root Level, Major Muscles Innervated, and

Test Procedure

L2-L3:
Innervation: Hip flexors
Procedure: The patient flexes the hip to near end range and the
examiner applies a force to the anterior thigh into hip extension
while the patient resists.
L3-L4:
Innervation: Knee extensors
Procedure:
1. The patient extends the knee to a position slightly less than full
extension. The examiner stabilizes the patient’s thigh with one
hand and applies pressure on the anterior distal tibia into knee
flexion with the other while the patient resists.
2. Step-Up: The patient is instructed to step up onto a step stool.
If the patient exhibits difficulty this could suggest involvement of
the L3-L4 nerve root.
L4:
Innervation: Ankle dorsiflexors
Procedure: The patient dorsiflexes the ankle with slight
inversion. The examiner stabilizes the distal tibia with one hand
and the other hand applies pressure on the dorsum of the foot
into plantar flexion with some eversion while the patient resists.
Upper and Lower Quarter Neurological Screening 55

Hip Flexion

ULQ
Knee Extension

Step-Up Test

Ankle Dorsiflexion
56e Musculoskeletal Examination

Lumbosacral Nerve Roots (continued)

Nerve Root Level, Major Muscles Innervated and

Test Procedure

L5:
Innervation: Hallux extension
Procedure: The great toe is placed into extension. The examiner
stabilizes the foot with one hand and applies pressure on the
dorsum of the distal phalanx of the great toe into flexion while the
patient resists.
L5-S1:
Innervation: Ankle plantar flexors
Toe-Raise:The patient is asked to rise up on the toes. Inability or
difficulty to do so in relation to the opposite side may be indicative
of involvement of the L5-S1 nerve root.
S1-S2:
Innervation: Ankle evertors
Procedure: The ankle is placed in full eversion and dorsiflexion.
The examiner stabilizes the distal tibia with one hand and with the
other hand applies pressure on the lateral aspect of the foot into
plantar flexion and inversion while the patient resists.
Upper and Lower Quarter Neurological Screening 57

Hallux Extension

ULQ
Toe-Raise Test

Ankle Eversion
58e Musculoskeletal Examination

Sensory Examination: Segmental Nerve Root Level

Sensory testing is performed to determine the presence of nerve
root or peripheral nerve involvement. Sensory examination is carried
out with a pinprick (or a paper clip) in the specified anatomic areas
bilaterally while the patient has the eyes closed. The patient is asked
if a sharp sensation is of equal intensity on both sides, or if one side
feels duller than the other, or if one side cannot be felt.
Cervical Spine
The following sensory examination (dermatomes) is assessed along
with reflexes and myotomes to determine the presence of nerve
root involvement. Cervical nerve root segments from C1 through T1
should be tested.

Nerve Root Level and Area of Sensory Distribution

(Dermatome) Tested

C1: C6:
Dermatomal Area: Top of head Dermatomal Area: Tip of thumb

C2: C7:
Dermatomal Area: Posterior Dermatomal Area: Distal middle
occipital region finger

C3: C8:
Dermatomal Area: Side of neck Dermatomal Area: Distal fifth
finger
C4:
Dermatomal Area: Top of T1:
shoulder Dermatomal Area: Medial
forearm
C5:
Dermatomal Area: Lateral
deltoid
 Upper and Lower Quarter Neurological Screening f59

C2
C3
C4
C5
T1
T2
T3
T4 T1
T5
T6
C6
T7
T8 C5
T9

ULQ
T10 C8
T11
T1 C6
T12
L1 C8
S2,3 L2 C7

L3

L4

L5
Cervical (C)

Thoracic (T)

Lumbar (L) S1

Sacral (S)

Dermatomes of the
Upper and Lower Quarter
60e Musculoskeletal Examination

Lumbosacral Spine
The following sensory examination (dermatomes) is assessed along
with reflexes and myotomes to determine the presence of nerve root
involvement. Lumbosacral nerve root segments form L1 through S4
should be tested.

Nerve Root Level and Area of Sensory Distribution

(Dermatome) Tested

L1: S1:
Dermatomal Area: inguinal Dermatomal Area: lateral side
region of foot

L2: S2:
Dermatomal Area: anterior Dermatomal Area: plantar
mid-thigh surface of foot

L3: S3:
Dermatomal Area: distal Dermatomal Area: groin
anterior thigh

L4: S4:
Dermatomal Area: medial Dermatomal Area: perineum
lower leg/foot region, genitals

L5:
Dermatomal Area: lateral leg/
foot
 Upper and Lower Quarter Neurological Screening f61

C2
C3
C4
C5
T1
T2
T3
T4 T1
T5
T6
C6
T7
T8 C5
T9

ULQ
T10 C8
T11
T1 C6
T12
L1 C8
S2,3 L2 C7

L3

L4

L5
Cervical (C)

Thoracic (T)

Lumbar (L) S1

Sacral (S)

Dermatomes of the
Upper and Lower Quarter
62e Musculoskeletal Examination

Sensory Examination: Peripheral Nerve Fields

Patients may demonstrate sensory deficits that do not occur in a
particular dermatomal distribution. In this case the patient may
exhibit a peripheral nerve lesion. Sensation can be assessed for the
peripheral nerves of both the upper and lower extremities.

Upper Extremities:
The following sensory examination is used to determine the presence
of a peripheral nerve lesion in the upper extremities. Sensory
examination is carried out with a pinprick (or a paper clip) in the
specified anatomic areas bilaterally while the patient has the eyes
closed. The patient is asked if a sharp sensation is of equal intensity
on both sides, or if one side feels duller than the other, or if one side
cannot be felt.

Peripheral Nerve and Area of Sensory Distribution Tested

Musculocutaneous Nerve:
Sensory Distribution: Radial border of forearm

Axillary Nerve:
Sensory Distribution: Lateral deltoid

Radial Nerve:
Sensory Distribution: Dorsum of radial side of wrist

Median Nerve:
Sensory Distribution: Palmar surface of first 3 digits and radial half
of digit 4

Ulnar Nerve:
Sensory Distribution: Palmar surface of digit 5 and ulnar half of digit 4
 Upper and Lower Quarter Neurological Screening f63

AXILLARY

INTERCOSTO-
BRACHIAL

RADIAL

ULQ
RADIAL
MEDIAL
CUTANEOUS LATERAL
LATERAL CUTANEOUS
CUTANEOUS

RADIAL

ULNAR

MEDIAN MEDIAN

VOLAR DORSUM

Peripheral Nerve Fields of Upper Extremity

64e Musculoskeletal Examination

Lower Extremities:
The following sensory examination is used to determine the presence
of a peripheral nerve lesion in the lower extremities. Sensory
examination is carried out with a pinprick (or a paper clip) in the
specified anatomic areas bilaterally while the patient has their eyes
closed. The patient is asked if a sharp sensation is of equal intensity
on both sides, or if one side feels duller than the other, or if one side
cannot be felt.

Peripheral Nerve and Area of Sensory Distribution Tested

Lateral Femoral Cutaneous Nerve: Superficial Peroneal Nerve:

Sensory Distribution: Lateral Sensory Distribution: Dorsum
thigh of the foot

Obturator Nerve: Deep Peroneal Nerve:

Sensory Distribution: Medial Sensory Distribution:
thigh Dorsum of the foot between
the 1st and 2nd toe

Femoral Nerve: Sural Nerve:

Sensory Distribution: Medial Sensory Distribution: Lateral
aspect of leg from the border of foot
middle thigh distal to the
medial malleolus

Sciatic Nerve: Tibial Nerve:

Sensory Distribution: Sensory Distribution:
Posterior thigh, posterior Plantar surface of the foot
distal calf, dorsum and lateral
border of the foot
 Upper and Lower Quarter Neurological Screening f65

LATERAL FEMORAL
CUTANEOUS
LATERAL FEMORAL
CUTANEOUS

ANTERIOR FEMORAL
CUTANEOUS
ANTERIOR FEMORAL
CUTANEOUS

ULQ
POSTERIOR FEMORAL
CUTANEOUS

COMMON
FIBULAR COMMON
FIBULAR

SUPERFICIAL SUPERFICIAL
FIBULAR FIBULAR

SURAL

DEEP FIBULAR
SAPHENOUS
TIBIAL

OBTURATOR
ILIOINGUINAL
LUMBOINGUINAL

Peripheral Nerve Fields of Lower Extremity

66e Musculoskeletal Examination

Lower Motor Neuron Reflexes

The following muscle stretch reflexes are tested bilaterally with the
patient seated. Each reflex is graded as absent/diminished, WNL,
or hyperactive. Reflexes found to be diminished or absent can
be correlated with the dermatome and myotome assessments to
determine the presence of nerve root pathology. Those that are
hyperactive may indicate upper motor neuron pathology.

Cervical Reflexes
Reflex, Corresponding Cervical Nerve Root Level, and Procedure
Biceps Brachii (C5 nerve root):
Procedure: The patient’s arm is placed in about 45° of flexion with
the muscle relaxed. The examiner strikes the tendon in the cubital
fossa, just proximal to the bicep insertion. The thumb may be placed
over the tendon to insure proper technique. The examiner observes
for elbow flexion.
Brachioradialis (C6 nerve root):
Procedure: The patient’s arm is placed in about 45° of flexion with
the muscle relaxed. The examiner strikes the tendon at the distal
aspect of the radius with the flat edge of the reflex hammer. The
examiner observes for elbow flexion.
Triceps (C7 nerve root):
Procedure: The examiner supports the patient’s arm and strikes the
triceps tendon just proximal to the olecranon. The examiner observes
for elbow extension.
Upper and Lower Quarter Neurological Screening f67

Biceps Reflex

ULQ
Brachioradialis Reflex

Triceps Reflex
68e Musculoskeletal Examination

Lumbar Reflexes
All of the following reflex testing will be performed with the patient
seated.
Quadriceps (L4):
Procedure: The examiner taps the patellar tendon and observes for
knee extension.
Achilles (S1)
Procedure: The examiner grasps the patient’s foot and places it into
slight dorsiflexion. The examiner then taps the Achilles tendon and
observes and feels for ankle plantar flexion.
Upper and Lower Quarter Neurological Screening f69

ULQ
Quadriceps Reflex

Achilles Reflex
70e Musculoskeletal Examination

Upper Motor Neuron Reflexes

The following reflexes are tested to determine the presence of a
central nervous system disorder.
Reflex, Test Procedure, and Criteria for Positive Findings
Hoffman’s Reflex:
Procedure: The patient is seated with the head in a neutral position.
The examiner flicks the distal phalanx of the middle finger. The test
is considered positive if there is flexion of the interphalangeal joint of
the thumb, with or without flexion of the index finger proximal or distal
interphalangeal joints.
Babinski Sign:
Procedure: The patient is supine. The examiner strokes the plantar
surface of the foot with a fingernail or instrument from posterior lateral
toward the ball of the foot . The test is considered positive if the great
toe extends and the other toes fan out.
Clonus:
Procedure: The patient is seated or supine. The examiner rapidly
dorsiflexes the ankle. Test is considered positive if the quick stretch
results in reflexive twitching of the plantarflexors.
Romberg Test:
Procedure: the patient is standing with feet close together. The
patient is then instructed to close the eyes. The test is considered
positive if the amount the patient sways is increased with eyes closed
or if the patient loses balance.
Upper and Lower Quarter Neurological Screening f71

Hoffman’s Reflex

ULQ
Babinski Sign

Testing for Clonus

Romberg Test
72 e Musculoskeletal Examination

Cervicothoracic
Spine Examination
In This Chapter:

1. Historical Examination
2. Observation, Functional Tests, & Palpation Active
Range of Motion, Passive Range of Motion, &
Overpressures
a. Flexion
b. Extension
c. Sidebending
d. Rotation
e. Combined Movement
3. Resisted Muscle Tests
a. Deep Neck Flexor Endurance

4. Assessments of Accessory Movements

a. Posterior-Anterior Segmental Mobility

5. Special Tests
a. Spurling’s Test
b. Cervical Rotation Lateral Flexion (CRLF) Test
c. Sharp Purser Test
d. Distraction Test
e. Upper Limb Tension Test
f. Test Item Cluster for Cervical Radiculopathy
 Cervicothoracic Spine Examination f73
Region Specific Historical Examination:
In addition to the historical examination presented in Chapter three,
patient should be asked specific questions related to the cervical and
thoracic spine and surrounding regions:

1. Do you get symptoms into the legs or low back with

neck movements?
— If “yes” a detailed neurological examination should be
performed.

2. Have you experienced any bilateral upper extremity

symptoms or occasional loss of balance or lack of
coordination in the lower extremities?

Spine
CT
— If “yes” a detailed neurological examination should be
performed.

3. The following questions have some utility in identifying

patients with cervical radiculopathy.7

Question + LR (yes) - LR (no)

Do neck movements improve your � 2.2 .50

symptoms?

Where is the pain most bothersome?

Answer - Shoulder and scapula. 2.3
74 e Musculoskeletal Examination

Radiographs and Cervical Spine Trauma

The Canadian C-Spine (cervical-spine) Rule (CCR) is a decision rule
to guide the use of cervical-spine radiography in patients with trauma.
The purpose of the rule is to identify the need for radiography in alert
and stable patients that have suffered a cervical spine injury.1,2
Diagnostic Accuracy1
Target Condition: A clinically important cervical spine injury, including any
fracture, dislocation, or ligamentous instability demonstrated on imaging.
Sensitivity = 99.4 %
Specificity = 45.1 %

Any high-risk factor that mandates

radiography?

Age 65 yr or dangerous mechanism or

paresthesias in extremities

No
Yes

Any low-risk factor that allows safe

assessment of range of motion?

Simple rear-end motor vehicle collision or

No Radiography
sitting position in the emergency department
or ambulatory at any time or delayed (not
immediate) onset of neck pain or absence of
midline cervical-spine tenderness

Unable
Yes

Able to rotate neck actively?

45˚ left and right

Yes

No Radiography

Canadian C-Spine Rule

 Cervicothoracic Spine Examination f75
Observation
Watch the patient walk and observe any abnormal gait mechanics,
particularly signs of upper motor neuron involvement such as ataxia
or synergy patterns.

With the patient sitting, the examiner observes for any asymmetries in
any of the soft tissues or bony landmarks of the cervical and thoracic
spine and the upper extremities. The examiner should observe the
patient from the anterior, posterior, and lateral views.

Functional Tests

Spine
The patient should demonstrate any functional movement or activity

CT
that reproduces symptoms. These functional movements often
include one or more of the following activities:
— looking up
— transferring from sit to stand
— lifting one or both arms overhead
76 e Musculoskeletal Examination

Palpation
The examiner palpates the thorax starting superficial and progressing
to deeper structures. The examiner palpates for the presence of any
temperature changes, moisture, soft tissue or lymph node swelling,
and tissue texture abnormalities.

Symmetry of bony landmarks is observed including the rib angles,

the region overlying the transverse processes, and the upper ribs
anteriorly.
 Cervicothoracic Spine Examination f77

Transverse Processes

Spine
CT
Rib Angle

Upper Rib Cage

78 e Musculoskeletal Examination

Active Range of Motion (AROM), Passive Range of

Motion (PROM), & Overpressures:
With the patient sitting, the examiner asks the patient to perform the
following motions while assessing the quality and quantity of motion
and change in symptoms, particularly if symptoms move distally from
the spine (“peripheralization”). After performing active range of motion,
the examiner passively moves the cervical spine through maximal
range of motion (as tolerated by the patient), applies overpressure,
and assesses range of motion, pain reproduction, and end-feel.
ROM can be quantified with a standard goniometer or gravity/bubble
inclinometer.
Flexion
The patient is asked to look down towards the floor. The quality of
the motion is noted and the distance from the chin to the sternum
is noted. Overpressure can be applied at the end range of motion
while the examiner stabilizes the upper thorax.
Extension
The patient is asked to look up towards the ceiling. The quality of the
motion is noted. Overpressure can be applied at the end range of
motion while the examiner stabilizes the upper thorax.
Sidebending
The patient is asked to drop the ear toward the shoulder.. The quality
of the motion is noted and the distance from the ear to the shoulder is
noted. Overpressure can be applied at the end range of motion while
the examiner stabilizes the opposite shoulder and upper thorax.
 Cervicothoracic Spine Examination f79

Flexion

Spine
CT
Extension

Sidebending
80 e Musculoskeletal Examination

Active Range of Motion (AROM), Passive Range of

Motion (PROM), & Overpressures:
Observe Eyes
Sitting - The patient is asked to look over the shoulder. The
examiner notes the presence of dizziness, lightheadedness,
nystagmus, impaired sensation to the face, blurred vision, or other
signs or symptoms consistent with compromise to the vertebrobasilar
complex. It is repeated to the other direction.
Rotation
Sitting - The patient is asked to look over the shoulder. The quality of the
motion is noted. Overpressure can be applied at the end range of motion.
Combined Extension, Sidebending, Rotation (Quadrant)
Sitting - The patient is asked to look up and over the shoulder. The
quality of the motion is noted. Overpressure can be applied at the end
range of motion while the examiner stabilizes the shoulder.
 Cervicothoracic Spine Examination f81

Observe Eyes

Spine
CT
Rotation

Combined
82 e Musculoskeletal Examination

Active Range of Motion of the Ribcage:

With the patient supine the examiner palpates directly over the ribs
anteriorly and asks the patient to make a full inspiratory and expiratory
effort. Typically the ribcage is divided into thirds, and assessment is
made of the respiratory excursion for the upper ribs, the middle ribs,
and the lower ribs. The examiner observes which group of ribs
stops moving first during either inhalation or exhalation.
 Cervicothoracic Spine Examination f83

Spine
CT
Upper Rib ROM

Lower Rib ROM

84 e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted tests are performed isometrically and are performed to assess
strength and symptom response. The following selected resisted tests
can be performed when examining the cervical-thoracic region.
Deep Neck Flexor Endurance
Craniocervical flexion endurance is designed to assess the deep
neck flexor muscles and the longus capitus and colli. The patient
is supine and is asked to flex the knees to 90° and place the soles
of the feet flat on the table. The patient is asked to tuck the chin
in and lift the head off of the examiners finger tips. The examiner
observes for substitution of the sternocleidomastoid muscle. The
time to fatigue is measured in seconds.
 Cervicothoracic Spine Examination f85

Spine
CT
Deep Neck Flexor Endurance
86 e Musculoskeletal Examination

Assessments of Accessory Movements

The examiner investigates accessory movement of the individual cervical
spine segments. With all tests, pain responses are recorded and mobility
judgments are established as hypermobile, normal, or hypomobile.

Posteroanterior Mobility
Purpose:
To test for segmental movement and pain response.
Description:
The patient is prone. The examiner contacts the spinous process
with the thumbs. The lateral neck musculature is gently pulled
posteriorly with the fingers. The examiner should be directly over
the contact area keeping elbows extended.. The examiner uses the
upper trunk to impart a posterior to anterior force in a progressive and
oscillatory fashion over the spinous process. Repeat for remaining
cervical segments.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of pain. The mobility of the segment is judged to be
normal, hypermobile, or hypomobile.
Diagnostic Accuracy:
Pain during segmental testing was associated with reports of neck pain.3
Sensitivity = .82 - LR = .23
Specificity = .79 + LR = 3.9
Reliability:
Kappa = .14 – .37 (pain)4
ICC = .42 – .79 (pain)5
 Cervicothoracic Spine Examination 87

Spine
CT
Posterior to anterior mobility

Posterior to anterior mobility- Close Up

Posterior to anterior mobility-Thoracic

88 e Musculoskeletal Examination

Assessments of Accessory Movements

The examiner investigates accessory movement of the individual cervical
spine segments. With all tests, pain responses are recorded and mobility
judgments are established as hypermobile, normal, or hypomobile.

Segmental Mobility
Purpose:
To test for segmental movement and pain response.
Description:
The patient is supine.
C2-C7- The examiner contacts the articular pillars (posterior facet
region) with the proximal phalanx of the 2nd digit. The head and
neck are flexed up to the segment and a lateral side flexion glide
from right to left and left to right is performed at each level. It is
repeated with the neck slightly extended to the level of interest.
C1-C2- The examiner contacts C1 with the proximal phalanx of the
2nd digit just inferior to the occiput. The head and neck are flexed
and the examiner slowly turns the upper cervical spine and head to
the right and then the left.
Occipital-Atlanto- The examiner supports the occiput in the hands.
The patient’s neck is rotated approximately 30 degrees to the right.
The examiner slowly nods the head up and down. This is repeated
rotating to the left.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of pain. The mobility of the segment is judged to be
normal, hypermobile, or hypomobile.
Diagnostic Accuracy:
Unknown
Reliability:6
Kappa = .03 – .63 (mobility)
ICC = .22 – .80 (pain)
 Cervicothoracic Spine Examination f89

Flexion Side Glide

Spine
CT
Extension Side Glide

Atlanto Axial Mobility

Occipital Atlanto Mobility

90 e Musculoskeletal Examination

Special Tests:

Spurling’s Test
Purpose:
To test for the presence or absence of cervical radiculopathy.
Description:
The patient is seated. The examiner sidebends the neck towards the
affected side and applies approximately 7 kg of compression force.
Positive Test:
The test is considered positive if symptoms are reproduced.
Diagnostic Accuracy:7
Reference standard cervical radiculopathy as diagnosed by needle
electromyography and nerve conduction studies.
Sensitivity = .50 - LR = .58
Specificity = .88 + LR = 3.5
Reliability:
Kappa = .607
 Cervicothoracic Spine Examination f91

Spine
CT
Spurling’s Test
92 e Musculoskeletal Examination

Cervical Rotation Lateral Flexion (CRLF) Test

Purpose:
To test for the presence of 1st rib hypomobility in patient’s with brachialgia.8
Description:
The test is performed with the patient in sitting. The cervical spine
is passively and maximally rotated away from the side being tested.
While maintaining this position, the spine is gently flexed as far as
possible moving the ear toward the chest.
Positive Test:
A test is considered positive when the lateral flexion movement is
blocked.
Diagnostic Accuracy:9
The reference standard is presence of rib hypomobility on
cineradiography in subjects with brachialgia.
Kappa = .84
Reliability:
Kappa = 1.0
 Cervicothoracic Spine Examination f93

Spine
CT
CRLF- Start

CRLF- End
94 e Musculoskeletal Examination

Sharp-Purser Test
Purpose:
To test for the presence of upper cervical spine instability.
Description:
The patient is seated in a semiflexed position. The examiner places
the palm of one hand on the patient’s forehead and index finger of the
other hand on the spinous process of the axis. Posterior pressure is
applied through the forehead.
Positive Test:
The test is considered positive if a sliding motion of the head posterior
occurs. This is often accompanied by a reduction in symptoms.
Diagnostic Accuracy:10
Reference standard is an atlanto-dens interval greater than 3 mm on
full flexion and extension lateral radiographs.
Sensitivity = .69 - LR = .32
Specificity = .96 + LR = 17.3
Reliability:
Unknown
 Cervicothoracic Spine Examination f95

Spine
CT
Sharp-Purser Test
96 e Musculoskeletal Examination

Cervical Distraction Test

Purpose:
To test for the presence of cervical radiculopathy.
Description:
The patient is supine and the examiner is seated. The examiner
grasps under the chin and occiput while slightly flexing the patient’s
neck and applies a distraction force of ~ 14 lbs.
Positive Test:
The test is considered to positive if the patients symptoms are
reduced.
Diagnostic Accuracy:7
Reference standard cervical radiculopathy as diagnosed by needle
electromyography and nerve conduction studies.
Sensitivity = .44 - LR = .62
Specificity = .90 + LR = 4.4
Reliability:
Inter-examiner Kappa = .88
 Cervicothoracic Spine Examination f97

Spine
CT
Cervical Distraction
98 e Musculoskeletal Examination

Upper Limb Tension Test A (ULLT)

Purpose:
To test for the presence of cervical radiculopathy.
Description:
The patient is supine. The examiner performs the following movement
sequence:
• Scapular depression
• Shoulder abduction
• Forearm supination, wrist and finger extension
• Shoulder lateral elevation
• Elbow extension
• Contralateral/ipsilateral cervical side bending
Positive Test:
The test is positive if one or more of the following occurs:
• Symptoms reproduced
• Side to side difference in elbow extension greater than 10
degrees
• Contralateral cervical side bending increases symptoms,
or ipsilateral side bending decreases symptoms
Diagnostic Accuracy:7
Reference standard cervical radiculopathy as diagnosed by needle
electromyography and nerve conduction studies.
Sensitivity = .50 - LR = .58
Specificity = .86 + LR = 3.5
Reliability:
Inter-examiner Kappa = .767
 Cervicothoracic Spine Examination f99

Spine
CT
ULTT- Start

ULTT- end
100 e Musculoskeletal Examination

Test Item Cluster for the Diagnosis of Cervical

Radiculopathy
Purpose:
To determine the likelihood that a patient has a cervical radiculopathy.
Description:
The following test item cluster (TIC) can be performed entirely from
the physical exam without any additional lab or imaging tests.
Criterion Definition of Positive:
• + Upper limb tension test A (ULTT-A)
• + Spurling’s test
• + Distraction test
• Cervical rotation less than 60 degrees to the ipsilateral side
Diagnostic Accuracy:7
3 positive tests from the TIC
+ LR = 6.1

4 positive tests from the TIC

+ LR = 30.3
 Cervicothoracic Spine Examination f101
Test Item Cluster for Patients with Mechanical Neck Pain
Likely to Benefit from Thoracic Spine Manipulation
Purpose:
To identify patients with neck pain who are likely to experience early
success with thoracic spine thrust manipulation.11
Description:
The following test item clusters (TIC) can be performed entirely in
the history and physical exam, without any additional lab or imaging
tests.
Criterion Definition of Positive:
• Symptoms less than 30 days

Spine
• No symptoms distal to the shoulder

CT
• Looking up does not aggravate symptoms
• FABQ Physical Activity Score less than 12
• Diminished upper thoracic spine kyphosis
• Cervical extension ROM less than 30°

Diagnostic Accuracy:11
Reference standard success was a 5 point or greater level of
improvement on the Global Rating of Change (GRC).

3 positive tests from the TIC

+ LR = 5.5

4 positive tests from the TIC

+ LR = 12.0

5 positive tests from the TIC

+ LR = Infinite

All 6 positive tests from the TIC

+LR = Infinite
102 e Musculoskeletal Examination

Reference List

(1) Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine
rule versus the NEXUS low-risk criteria in patients with trauma. N
Engl J Med 2003:2510-2518.
(2) Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine
rule for radiography in alert and stable trauma patients. JAMA
2001;286:1841-1848.
(3) Sandmark H, Nisell R. Validity of five common manual neck pain
producing tests. Scand J Rehabil Med 1995;27:131-136.
(4) van Suijlekom H, deVet H, van den Berg S, Weber W.
Interobserver reliability in physical examination of the cervical
spine in patients with headache. Headache 2000;40:581-586.
(5) Bertilison B, Grunnesjo M, Strender L. Reliability of clinical tests in
teh assessment of patients with neck/shoulder problems. Impact of
history. Spine. 2003;28:2222-2231.
(6) Pool J, Hoving J, Henrica C, et al. The interexaminer reproducibity
of physical examination of the cervical spine. J Manipulative
Physiol Ther 2004;27:84-90.
(7) Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic
accuracy of the clinical examination and patient self-report
measures for cervical radiculopathy. Spine 2003;28:52-62.
(8) Lindgren K-A, Leino E, Hakola M, Hamberg J. Cervical spine
rotation and lateral flexion combined motion in the examination of
the thoracic outlet. Arch Phys Med Rehabil 1990;71:343-344.
(9) Lindgren K-A, Leino E, Manninen H. Cineradiography of the
hypomobile first rib. Arch Phys Med Rehabil 1989;70:408-409.
(10) Uitvlugt G, Indenbaum S. Clinical assessment of atlantoaxial
instability using the Sharp-Purser test. Arthritis Rheum
1988;31:918-922.
(11) Cleland J, Childs J, Fritz J, et al. Development of a clinical
prediction rule for guiding treatment of a subgroup of patients
with neck pain: use of thoracic spine manipulation, exercise, and
patient education Phys Ther 2007;87:9-23.
Shoulder Examination f103

Shoulder
104e Musculoskeletal Examination

Shoulder
Examination
In This Chapter:

1. Historical Examination
2. Observation and Palpation
3. Active Range of Motion, Passive Range of Motion, and
Overpressure
a. Flexion and Extension
b. Abduction and Adduction
c. Internal Rotation and External Rotation
d. Horizontal Abduction and Adduction
e. Hand Behind Back
f. Hand Behind Head
4. Resisted Muscle Tests
a. Shoulder Flexion
b. Shoulder Abduction
c. Resisted Internal Rotation
d. Resisted External Rotation
5. Assessments of Accessory Movements
a. Inferior Glide of Humerus
b. Posterior Glide of Humerus
c. Anterior/Posterior Glide of Acromioclavicular Joint
d. Posterior Glide of Sternoclavicular Joint
6. Special Tests
a. Active Compression Test
b. Test Item Cluster for the Identification of
Subacromial Impingement Syndrome
c. Test Item Cluster for the Identification of
Full-Thickness Rotator Cuff Tear
d. Apprehension Test
 Shoulder Examination f105
Region Specific Historical Examination:
The patient should be asked specific questions related to the shoulder
and surrounding regions.

1. Do your symptoms change (better or worse) with any

movements of the neck?
If the patient answers “yes” this indicates the cervical spine
should be evaluated in detail.
2. Does your arm ever slip out or feel unstable?
If the patient answers “yes” this could be suggestive of
instability.
3. Does your pain change with overhead activities?
If patient answers “yes” this could indicate possible subacromial
impingement syndrome.1
4. Do you have difficulty moving your arm?

Shoulder
If the patient answers “yes” you should follow-up by asking if
they have difficulty moving the arm because of pain or it just
won’t move. The latter may be indicative of rotator cuff tear.2
5. Does your arm ever feel heavy after performing
activities?
If patient answers “yes” this may be indicative of vascular compromise.
106e Musculoskeletal Examination

Observation and Palpation:

This portion of the examination should be performed with the patient
either standing or seated.

Observation
With the patient seated and standing the examiner observes for any
asymmetries in any of the soft tissues or bony landmarks.

Position of the cervical, thoracic, and lumbar spine as well as the resting
position of the elbow, forearm, wrist, and hand should be observed.

The examiner should observe the patient from the anterior, posterior,
and lateral views.

Palpation
The examiner palpates the upper quadrant starting superficially
and progressing to deeper structures. The examiner palpates for
the presence of any temperature changes, moisture, swelling, and
tissue texture abnormalities.

 Shoulder Examination f107

Shoulder
Anterior View Posterior View

Palpation
108e Musculoskeletal Examination

Active Range of Motion, Passive Range of Motion and

Overpressure:
With the patient seated or standing the examiner asks the patient
to perform the following motions to assess the quality and quantity
of motion and change in symptoms. Active range of motion can be
quantified with a standard goniometer or inclinometer. Following
active range of motion testing the therapist moves the joint through
maximal range of motion (as tolerated by the patient), applies
overpressure, and assesses range of motion, pain reproduction,
and end-feel.
Flexion and Extension
The patient is asked to raise the arms into flexion, then extension in
the sagittal plane.
Abduction and Adduction
The patient is asked abduct the arms in the frontal plane and then
return them to the side.
Internal Rotation and External Rotation
The patient is asked to perform internal rotation and external rotation
with the shoulder in a neutral position as well as in 90 degrees of
flexion.
Horizontal Abduction and Adduction
The patient is asked to abduct the arms to 90 degrees and move the
arms first posteriorly then anteriorly in the transverse plane.
Hand Behind Back
The patient is asked to bring the arm behind the back and reach up
the back as high as possible. The vertebral level reached by the tip of
the longest finger is recorded. This allows for the assessment of the
following combined motions, internal rotation, extension and adduction.
Hand Behind Head
The patient is asked to bring the arm behind their head and reach
down as far as possible. The vertebral level reached by the tip of
the longest finger is recorded. This allows for the assessment of the
following combined motions: external rotation, flexion, and adduction.
 Shoulder Examination f109

Flexion with Overpressure External Rotation with

Overpressure

Shoulder
Horizontal Abduction with Horizontal Adduction with
Overpressure Overpressure

Hand Behind Back with Hand Behind Head with

Overpressure Overpressure
110e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted tests are performed isometrically and are performed to
assess symptom response and strength of the muscles. The following
list provides selected resisted tests that should be performed when
examining the shoulder region.
Shoulder Flexion
The examiner asks the patient to flex the arm to 90 degrees while the
examiner stabilizes the shoulder with one hand. The patient is then
asked to resist an inferiorly directed force produced by the examiner
through the patient’s forearm.
Shoulder Abduction
The examiner asks the patient to abduct the shoulder while the
examiner stabilizes the shoulder with one hand. The patient is then
asked to resist an inferiorly directed force produced by the examiner
through the patient’s forearm.
Shoulder Internal and External Rotation
The patient’s arm is resting in neutral and the examiner flexes the
elbow to 90 degrees while stabilizing the elbow with one hand. The
patient is asked to resist against a laterally directed force produced
by the examiner’s other hand.

The patient’s arm is resting in neutral and the examiner flexes the
elbow to 90 degrees while stabilizing the elbow with one hand. The
patient is asked to resist against a medially directed force produced
by the examiner’s other hand.
 Shoulder Examination f111

Resisted Flexion

Shoulder
Resisted Abduction

Resisted Internal Rotation

Resisted External Rotation

112e Musculoskeletal Examination

Assessments of Accessory Movements

The examiner investigates accessory movement of the glenohumeral,
acromioclavicular, sternoclavicular, and scapulothoracic joint with
the patient either supine or prone.

Techniques Performed in Supine:

Inferior Glide of Humerus
With the patient’s shoulder stabilized on the table, the examiner
guides the patient’s arm into approximately 90 degrees of abduction
with one hand. When this position is obtained, the examiner applies
an inferior force at the proximal humerus and assesses the amount
of mobility and symptomatic response.
Posterior Glide of Humerus
With the patient’s the shoulder stabilized by the table the examiner
guides the patient’s arm into approximately 90 degrees of abduction
with one hand. When this position is obtained, the examiner applies
a posterior force at the proximal humerus and assesses the amount
of mobility and symptomatic response.
Anterior/Posterior Glide of Acromioclavicular Joint
The examiner grips the distal clavicle with the index finger on the
superior/posterior surface and the thumb on the anterior surface with
their thumb. The examiner then glides the clavicle in an anterior and
posterior direction while assessing mobility and symptoms response.
The examiner places the web space of theihand between the thenar
and hypothenar eminence on the anterior aspect of the proximal
clavicle and applies a posteriorly directed force. The examiner
assesses mobility and symptoms.
 Shoulder Examination f113

Inferior Glide of Humerus

Shoulder
Posterior Glide of Humerus

Anterior/Posterior Glide of
Acromioclavicular Joint

Posterior Glide of
Sternoclavicular Joint
114e Musculoskeletal Examination

Special Tests:
Active Compression Test
Purpose:
To test for the presence of an acromioclavicular lesion or a labral tear.
Description:
The patient is standing and instructed to place the shoulder in a
position of 90 degrees of flexion and 10 degrees of adduction. The
patient’s arm is internally rotated so that the thumb is pointing down.
The patient is instructed to resist an inferiorly directed force applied by
the examiner first with the thumb down and then with the thumb up.
Positive Test:
1. Acromioclavicular lesions
The test is considered positive if the patient reports pain localized
to the acromioclavicular joint when resistance is applied with
the thumb pointing down and reduced or eliminated pain when
resistance is applied with the forearm supinated.
2. Labral tears
The test is considered positive if the patient reports painful
clicking in the glenohumeral joint occuring when resistance is
applied with the thumb pointing down and reduced or eliminated
pain when resistance was applied with the forearm supinated.
Diagnostic Accuracy:
1. Acromioclavicular lesions
Sensitivity = .41 - 1.0 - LR =.00 - .623, 4
Specificity = .95 - .97 + LR = 8.2 - 33.33, 4
2. Labral tears
Sensitivity = .63 - 1.0 - LR = .00 - . 514, 5
Specificity = .73 -.98 + LR = 2.3 - 50.04, 5

Reliability:
Not reported
Test Item Cluster for the Identification of Subacromial
 Shoulder Examination f115

Shoulder
Active Compression Start Position

Active Compression End Position

116e Musculoskeletal Examination

Impingement Syndrome
Purpose:
To test the presence of subacromial impingement syndrome.
Description:
The following 3 tests are performed with the patient standing: the
Hawkins-Kennedy Impingement Sgn, the painful arc sign, and the
infraspinatus muscle test.
Hawkins-Kennedy Impingement Sign:
The examiner places the patient’s shoulder in 90 degrees of shoulder
flexion with the elbow flexed to 90 and then internally rotates the
arm. The test is considered to be positive if the patient experiences
pain with internal rotation.
The Painful Arc Sign:
The patient is instructed to fully elevate the arm in the scapular plane
and then slowly reverse the motion. This test is considered to be
positive if the patient experiences pain between 60 and 120 degrees
of elevation.
Infraspinatus Muscle Test:
With the arm resting in neutral, the patient is instructed to flex the
elbow to 90 degrees and resist against a medially directed force. The
test is considered positive if the patient exhibits pain or weakness
when resistance is applied. This test is also considered to be positive
if the patient’s arm is externally rotated passively but falls into internal
rotation when it is released by the examiner.

* If all three tests are found to be positive then the + LR is

10.56 and if all 3 are negative the - LR is .17.6
* If two of the three tests are positive than the +LR is 5.036
Reliability:
Not reported
 Shoulder Examination f117

Hawkins-Kennedy Test

Shoulder
Painful Arc Sign

Infraspinatus Muscle Test

118e Musculoskeletal Examination

Apprehension Test
Purpose:
To test the integrity of the anterior glenohumeral joint capsule and assess
for glenohumeral joint instability.
Description:
The patient is in the supine position. The examiner flexes the patient’s
elbow to 90 degrees and abducts the patient’s shoulder to 90 degrees,
maintaining neutral rotation. The examiner then slowly externally rotates
the shoulder to 90 degrees while monitoring the patient.
Positive Test:
Test is considered positive if the patient exhibits signs of apprehension
as the examiner brings the shoulder into external rotation.
Diagnostic Accuracy:
Sensitivity = .53 - LR = .477
Specificity = .99 + LR = 537
Reliability:
Kappa = .478
 Shoulder Examination f119

Shoulder
Apprehension Test
120e Musculoskeletal Examination

Biceps Load Test II

Purpose:
To test for the presence of a superior glenohumeral labral tear.
Description:
The patient is supine and the examiner grasps the patient’s wrist with
one hand and the elbow with the other. The examiner then places the
patient’s shoulder in a position of 120 degrees abduction, maximal
external rotation, 90 degrees of elbow flexion and forearm supination.
In this position the patient is asked to perform elbow flexion against
resistance.
Positive Test:
If the patient reports an increase in symptoms during the resisted
contraction, the test is considered positive.
Diagnostic Accuracy:
Sensitivity= .909 - LR=.109
Specificity= .979 + LR=309
Reliability:
Kappa=.82
 Shoulder Examination f121

Shoulder
Bicep Load Test II
122e Musculoskeletal Examination

Test Item Cluster for the Identification of a Full-Thickness

Rotator Cuff Tear
Purpose:
To test the presence of a full-thickness rotator cuff tear.
Description :
The following 3 tests are performed with the patient standing; the drop-
arm sign, the painful arc sign, and the infraspinatus muscle test.
The Drop-Arm Sign:
The patient is asked to actively elevate the arm in the scapular plane and
then slowly reverse the motion. The test is considered to be positive if
the patient experiences pain or the arm drops suddenly.
The Painful Arc Sign:
The patient is instructed to fully elevate the arm in the scapular plane
and then slowly return it to their side. This test is considered to be
positive if the patient experiences pain or a painful catching between
60 and 120 degrees.
Infraspinatus Muscle Test:
With the arm resting in neutral, the patient is instructed to flex the
elbow to 90 degrees and resist against a medially directed force. The
test is considered positive if the patient exhibits pain or weakness
when resistance is applied. This test is also considered to be positive
if the patient’s arm is externally rotated passively but falls into internal
rotation when it is released by the examiner.

* If all three tests are found to be positive then the +LR is 15.6
and if all 3 are negative the –LR is .16.6
* If all 3 test are positive and the patient is greater than 60
years of age the +LR is 28.06
* If two of the three tests are positive than the +LR is 3.66
Reliability:
Not reported
 Shoulder Examination f123
Reference List

(1) Michener LA, Walsworth MK, Burnet EN. Effectiveness

of rehabilitation for patients with subacromial impingment
syndrome: A systematic review. J Hand Ther 2004;17(2):152-64.
(2) Litaker D, Pioro M, El BH, Brems J. Returning to the bedside:
using the history and physical examination to identify rotator
cuff tears. J Am Geriatr Soc 2000 December;48(12):1633-7.
(3) Chronopoulos E, Kim TK, Parh HB, Ashenbrenner D,
McFarland EG. Diagnostic value of physical tests for isolated
chronic acromioclavicular leasions. Am J Sports Med
2004;32(3):655-60.
(4) O’Brien SJ, Pangnani MJ, Fealey S, Mcglynn SR, Wilson
JB. The active compression test: A new and effective test
for diagnosing labral tears and acromioclavicular joint

Shoulder
abnormality. Am J Sports Med 1998;26(5):610-3.
(5) Guanche CA, Jones DC. Clinical testing for tears of the
glenoid labrum. Arthroscopy 2003 May;19(5):517-23.
(6) Park HB, Yokota A, Gill HS, El RG, McFarland EG. Diagnostic
accuracy of clinical tests for the different degrees of
subacromial impingement syndrome. J Bone Joint Surg Am
2005 July;87(7):1446-55.
(7) Lo IK, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A. An
evaluation of the apprehension, relocation, and surprise
tests for anterior shoulder instability. Am J Sports Med 2004
March;32(2):301-7.
(8) Tzannes A, Paxinos A, Callanan M, Murrell GA. An
assessment of the interexaminer reliability of tests
for shoulder instability. J Shoulder Elbow Surg 2004
January;13(1):18-23.
(9) Kim SH, Ha KI, Ahn JH, Kim SH, Choi HJ. Biceps load test II:
A clinical test for SLAP lesions of the shoulder. Arthroscopy
2001 February;17(2):160-4.
124 e Musculoskeletal Examination

Elbow Examination
In this Chapter
1. Historical Examination
2. Observation and Palpation
3. Active Range of Motion, Passive Range of Motion, and
Overpressure
a. Flexion and Extension
b. Supination and Pronation
4. Resisted Muscle Tests
a. Elbow Flexion
b. Elbow Extension
c. Forearm Supination
d. Forearm Pronation
5. Assessment of Accessory Movements
a. Proximal Radioulnar Joint
b. Distal Radioulnar Joint
c. Humeroulnar Distraction
d. Humeroradial Distraction
6. Special Tests
a. Ulnar Nerve Compression Test
b. Elbow Extension Test
c. Varus and Valgus Stress Test
d. Moving Valgus Stress Test
e. Tests for Lateral Epicondylalgia
 Elbow Examination f125
Region Specific Historical Examination:
The patient should be asked specific questions related to the elbow
and surrounding regions.

1. Do your symptoms change (better or worse) with any

movements of the neck or shoulder?
If the patients answers “yes” this indicates the cervical spine and
shoulder should be evaluated in detail.
a. Do you elbow ever slip out or feel unstable?
If the patient answers “yes” this could be suggestive of instability.
b. Does the pain change with gripping activities?
If patient answers “yes” this could indicate possible lateral or medial
epicondylalgia.1, 2
c. Do you ever experience numbness or tingling in the
hand?
If the patient answers “yes” this may indicate possible pronator or

Forearm
Elbow &
cubitual tunnel syndrome.3
d. Was the elbow hyperextended during the time of
injury?
If patient answers “yes” this may indicate fracture of ligamentous /
capsular damage.4
e. Do you relate the symptoms to a throwing activity?
If patient answers “yes” this may indicate medial instability.9
126 e Musculoskeletal Examination

Observation and Palpation:

This portion of the examination should be performed with the patient
either standing or seated.
Observation
With the patient seated and standing the examiner observes for any
asymmetries or deformities in any of the soft tissues or bony landmarks.
Position of the cervical and thoracic spine as well as the resting
position of the shoulder, elbow, forearm, wrist, and hand should be
observed. The examiner observes for any valgus or varus deformities
of the elbow.
The examiner should observe the patient from the anterior, posterior,
and lateral views.

Palpation
The examiner palpates the elbow, forearm, and surrounding soft tissue
and bony structures starting superficially and progressing to deeper
structures. The examiner palpates for the presence of any temperature
changes, moisture, swelling, and tissue texture abnormalities.
 Elbow Examination f127

Forearm
Elbow &
Anterior Posterior

Palpation
128 e Musculoskeletal Examination

Active Range of Motion, Passive Range of Motion, and

Overpressures:
With the patient seated or standing the examiner asks the patient to
perform the following motions while assessing the quality and quantity of
motion and change in symptoms. Active range of motion can be quantified
with a standard goniometer or inclinometer. The interrater and intrarater
reliability of obtaining measurements during active range of motion,
where available, can be found in the table below. Following active range
of motion testing, the therapist moves the joint through maximal range of
motion (as tolerated by the patient), applies overpressure, and assesses
range of motion, pain reproduction, and end-feel.
Elbow Flexion:
The patient is asked to bend the elbow as far as actively possible. If
no symptoms are elicited the examiner applies over pressure while
assessing quality of motion, symptom response, and end feel.

Intrarater reliability: .55-.975-7

Interrater reliability: .55-.965-7
Elbow Extension:
The patient is asked to actively extend the elbow as far as possible.
If no symptoms are elicited the examiner applies overpressure while
assessing quality of motion, symptom response, and end feel.

Intrarater reliability: .45-.995-7

Interrater reliability: .58-.965-7
Supination and Pronation:
The patient is asked to maintain 90 degrees of elbow flexion and
to supinate the forearm forearm actively as far as possible. If no
symptoms are elicited the examiner applies overpressure while
assessing quality of motion, symptom response, and end-feel. The
procedure is then repeated in the direction of pronation.
Supination:
Intrarater reliability: .94-.996,8,9
Interrater reliability: .90-.966,8,9
Pronation:
Intrarater reliability: .86-.986,8,9
Interrater reliability: .83-.956,8,9
 Elbow Examination f129

Flexion with Overpressure

Forearm
Elbow &
Extension with Overpressure

Supination with Overpressure

Pronation with Overpressure

130 e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted muscle tests are performed isometrically and are performed
to assess symptom response and strength of the muscles. The
following list provides selected resisted tests that should be performed
when examining the elbow region.
Elbow Flexion
The patient is seated. The examiner asks the patient to flex the elbow
to 90 degrees while the examiner stabilizes the shoulder with one
hand. The patient is then asked to resist an inferiorly directed force
produced by the examiner through the patient’s forearm.
Elbow Extension
The patient is seated. The examiner asks the patient to flex the elbow
to 100 degrees while the examiner stabilizes the shoulder with one
hand. The patient is then asked to resist a superiorly directed force
produced by the examiner through the patient’s forearm.
Forearm Supination
The patient is seated and is asked to flex the elbow to 90 degrees
with the forearm in neutral (thumb pointing up). The examiner grasps
the patient’s distal forearm with one hand and stabilizes the elbow
with the other. The patient is instructed to resist a force applied by
the examiner in the direction of forearm pronation.
Forearm Pronation
The patient’s is seated and is asked to flex the elbow to 90 degrees
with the forearm in neutral (thumb pointing up). The examiner grasps
the patient’s distal forearm with one hand and stabilizes the elbow
with the other. The patient is instructed to resist a force applied by
the examiner in the direction of forearm supination.
 Elbow Examination f131

Elbow Flexion

Forearm
Elbow &
Elbow Extension

Forearm Supination

Forearm Pronation
132 e Musculoskeletal Examination

Assessment of Accessory Movements

The examiner investigates accessory movement of the humeroulnar,
humeroradial, and proximal/distal radioulnar joints.

Techniques Performed Supine:

Proximal Radioulnar Joint
With the patient supine and the elbow resting on the table, the
examiner slightly supinates the forearm. The examiner stabilizes the
proximal ulna with one hand and firmly grasps the radial head with
the other. The examiner then volarly and dorsally glides the radial
head and assesses the mobility and symptom response.
Distal Radioulnar Joint
With the patient supine and the elbow resting on the table the
examiner supinates the forearm. The examiner stabilizes the distal
ulna with one hand and firmly grasps the distal radius with the other.
The examiner then volarly and dorsally glides the distal radius and
assess the mobility and symptom response.
Humeroulnar Distraction
With the patient’s humerus stabilized on the table, the examiner
flexes the patient’s elbow to approximately 60 degrees and places
both hands over the proximal ulna with fingers interlocked. The
examiner then applies a distraction force and assesses the mobility
and symptom response.
Humeroradial Distraction
The examiner stabilizes the patient’s humerus against the table with
one hand, grasps the distal radius with the other hand, and flexes the
elbow to approximately 45 degrees. When this position is obtained the
examiner performs a long axis distraction through the humeroradial
joint and assesses the mobility and symptom response.
 Elbow Examination f133

Proximal Radioulnar Joint

Forearm
Elbow &
Distal Radioulnar Joint

Humeroulnar Distraction

Humeroradial Distraction
134 e Musculoskeletal Examination

Special Tests:

Ulnar Nerve Compression Test

Purpose:
To test for the presence of cubital tunnel syndrome.

Description:
The patient is standing and instructed by the examiner to passively
flex the elbow approximately 20 degrees. The examiner then places
a firm pressure on the ulnar nerve just proximal to the cubital tunnel
and maintains the pressure for 60 seconds.

Positive Test:
The test is considered positive if the patient reports numbness and/
or tingling in an ulnar nerve distribution.

Diagnostic Accuracy:
Sensitivity = .89 - LR = .1110
Specificity = .98 + LR = 44.510

Reliability:
Not reported
 Elbow Examination f135

Forearm
Elbow &
Ulnar Nerve Compression Test
136 e Musculoskeletal Examination

Elbow Extension Test

Purpose:
To test the presence of either a bony fracture or elbow joint effusion.
Description:
The patient is asked to extend the elbow as far as possible while
either in a supine or standing position. The examiner makes an
assessment to whether or not full extension can be achieved.
Positive Test:
The test is considered positive if the patient is unable to fully extend
the elbow.
Diagnostic Accuracy:
Sensitivity = .91 - LR = .0411
Specificity = .70 + LR = 3.111
Reliability:
Not reported
 Elbow Examination f137

Forearm
Elbow &
Elbow Extension Test
138 e Musculoskeletal Examination

Varus and Valgus Stress Test

Purpose:
To test for the presence of a medial or lateral collateral ligament tear
of the elbow.
Description:
Varus Stress Test:
The patient is standing. The examiner places the patient’s elbow in
approximately 20 degrees of flexion while palpating the lateral joint line.
The examiner applies a varus force to the elbow.
Positive Test:
The test is considered positive if the patient experiences pain or
excessive laxity is noted compared to the contralateral side.

Valgus Stress Test:

The patient is standing. The examiner places the patient’s elbow in
approximately 20 degrees of flexion while palpating the medial joint
line. The examiner applies a valgus force to the elbow.
Positive Test:
The test is considered positive if the patient experiences pain or
excessive laxity is noted compared to the contralateral side.
Diagnostic Accuracy:
Not reported for either test.
Reliability:
Not reported for either test.
 Elbow Examination f139

Varus Stress Test

Forearm
Elbow &

Valgus Stress Test

140 e Musculoskeletal Examination

Moving Valgus Stress Test

Purpose:
To test for the presence of a medial collateral ligament tear of the elbow.
Description:
The patient is standing and is asked to abduct the shoulder to 90
degrees. The examiner grasps the distal forearm with one hand and
stabilizes the elbow with the other. The examiner then maximally
flexes the elbow and places a valgus torque to the elbow while
simultaneously externally rotating the shoulder. When the shoulder
reaches the end range of external rotation the examiner quickly
extends the elbow to approximately 30 degrees.
Positive Test:
To be considered a positive test the two following criteria must be
identified: 1. The patient experiences pain at the medial elbow, and
2. The maximal amount of pain must be experienced between 120
and 70 degrees of elbow flexion.
Diagnostic Accuracy:
Sensitivity = 1.0 - LR = 0.012
Specificity = .75 + LR = 4.012

Reliability:
Not reported
 Elbow Examination f141

Forearm
Elbow &
Moving Valgus Stress Test Start Position

Moving Valgus Stress Test End Position

142 e Musculoskeletal Examination

Tests for Lateral Epicondylalgia

Purpose
To test the presence of lateral epicondylalgia.
Description:
While the diagnostic utility of the following tests is unknown they are
typically used to identify the presence of lateral epicondylalgia: (1) pain
during palpation of the lateral epicondyle, (2) pain with resisted wrist
extension, or (3) pain with resisted middle finger extension.13-15
Pain during palpation of the lateral epicondyle:
With the patient standing or seated the examiner palpates the lateral
epicondyle. A test is considered positive if the palpation reproduces
the patient’s symptoms.
Pain with resisted wrist extension:
With the patient seated and the forearm on the table, the patient is
asked to extend the wrist. The examiner uses one hand to stabilize
the forearm and the other to contact the dorsum of the hand. The
patient is asked to resist the examiners force, which is applied in the
direction of wrist flexion. This test is considered positive if the patient
experiences pain while performing the resisted contraction.
Pain with resisted middle finger extension:
With the patient seated and the forearm on the table, the patient
is asked to extend the 3rd finger. The examiner uses one hand to
stabilize the forearm and the other to contact the extended 3rd finger.
The patient is asked to resist the examiner’s force, which is applied
in the direction of finger flexion. This test is considered positive if the
patient experiences pain while performing the resisted contraction.
Diagnostic Accuracy:
Not reported
Reliability:
Not reported
 Elbow Examination f143

Palpation of Lateral Epicondyle

Forearm
Elbow &
Resisted Wrist Extension

Resisted Middle Finger Extension

144 e Musculoskeletal Examination

Reference List

(1) Vicenzino B, Wright A. Lateral epicondylalgia I: epidemiology,

pathophysiology, aetiology and natural history. Phys Ther Rev
1996;1:23-34.
(2) Wright A, Vicenzino B. Lateral epicondylalgia II: Therapeutic
management. Phys Ther 1997;2:39-48.
(3) Kingery WS, Park KS, Wu PB, Date ES. Electromyographic motor
Tinel’s sign in ulnar mononeuropathies at the elbow. Am J Phys
Med Rehabil 1995 November;74(6):419-26.
(4) O’Driscoll SW. Elbow instability. Hand Clin 1994 August;10(3):405-15.
(5) Rothstein J, Miller P, Roettger R. Goniometric reliability in a
clinical setting. Elbow and knee measurements. Phys Ther
1983;63(10):1611-5.
(6) Armstrong AD, MacDermid JC, Chinchalkar S, Stevens RS, King
JW. Reliability of range-of-motion measurement in the elbow.
J Elbow Shoulder Surg 1998;7:573-80.
(7) Boone D, Azen S, Lin J, Baron C, et al. Reliability of goniometric
measurements. Phys Ther 1978;58(11):1355-60.
(8) Gajdosik RL. Comparison and reliability of three goniometric
methods for measuring forearm supination and pronation. Percept
Mot Skills 2001 October;93(2):353-5.
(9) Karagiannopoulos C, Sitler M, Michlovitz S. Reliability of 2
functional goniometric methods for measuring forearm pronation
and supination active range of motion. J Orthop Sports Phys Ther
2003 September;33(9):523-31.
(10) Novak CB, Lee GW, Mackinnon SE, Lay L. Provocative
testing for cubital tunnel syndrome. J Hand Surg [Am] 1994
September;19(5):817-20.
(11) Hawksworth CR, Freeland P. Inability to fully extend the injured
elbow: an indicator of significant injury. Arch Emerg Med 1991
December;8(4):253-6.
(12) O’Driscoll SW, Lawton RL, Smith AM. The “moving valgus stress
test” for medial collateral ligament tears of the elbow. Am J Sports
Med 2005 February;33(2):231-9.
(13) Pienimaki T, Tarvainen T, Siira P, Malmivaara A, Vanharanta H.
Associations between pain, grip strength, and manual tests in the
treatment evaluation of chronic tennis elbow. Clin J Pain 2002
May;18(3):164-70.
 Elbow Examination f145

(14) Pienimaki TT, Siira PT, Vanharanta H. Chronic medial and lateral
epicondylitis: a comparison of pain, disability, and function. Arch
Phys Med Rehabil 2002 March;83(3):317-21.
(15) Waugh EJ, Jaglal SB, Davis AM, Tomlinson G, Verrier MC.
Factors associated with prognosis of lateral epicondylitis after
8 weeks of physical therapy. Arch Phys Med Rehabil 2004
February;85(2):308-18.

Forearm
Elbow &
146e Musculoskeletal Examination

Wrist and Hand

Examination
In This Chapter:

1. Historical Examination
2. Observation and Palpation
3. Active Range of Motion, Passive Range of Motion, and
Overpressure
a. Wrist Flexion
b. Wrist Extension
c. Radial Deviation
d. Ulnar Deviation
e. Finger Flexion/Extension
f. Thumb Abduction/Adduction
4. Resisted Muscle Tests
a. Wrist Flexion
b. Wrist Extension
c. Radial Deviation
d. Ulnar Deviation
e. Finger Flexion
f. Finger Extension
5. Assessment of Accessory Movements
a. Radiocarpal Dorsal Glide
b. Radiocarpal Volar Glide
c. Radiocarpal Radial/Ulnar Glide
d. Dorsal/Volar Glide of MCP, PIP, and DIP Joints
6. Special Tests
a. Axial Loading of the Thumb
b. Scaphoid Shift Test
c. Finkelstein Test
7. Carpal Compression Test
8. Clinical Prediction Rule for Diagnosing Carpal Tunnel
Syndrome
 Wrist and Hand Examination f147
Region-Specific Historical Examination:

The patient should be asked specific questions related to the hand

and surrounding regions.

1. Do your symptoms change (better or worse) with any

movements of the neck, shoulder, or elbow?
If the patient answers “yes” this indicates the cervical spine,
shoulder or elbow should be examined in detail.
2. Do you have a traumatic injury and pain when loading
the wrist?
If the patient answers “yes” this could be suggestive of a
scaphoid fracture or carpal instability.1, 2
3. Do you ever experience numbness or tingling in the
hand?
If the patient reports “yes” this could indicate possible carpal
tunnel syndrome or compression of the ulnar nerve at the tunnel
of Guyon.3, 4
4. Does shaking the hands decreases the symptoms?
If patient answers “yes” this may indicate carpal tunnel syndrome5
5. Do you have difficulty extending the finger specifically

Hand &
in the morning?

Wrist
If patient answers “yes” this may indicate possible DeQuervain’s
syndrome.6
6. Do you have increased pain with gripping activities
requiring radial deviation of the wrist?
If patient answers “yes” this may indicate possible DeQuervain’s
syndrome.2
148e Musculoskeletal Examination

Observation and Palpation:

This portion of the examination should be performed with the patient seated.
Observation
With the patient seated the examiner observes for any asymmetries
in any of the soft tissues or bony landmarks.
Position of the cervical and thoracic spine as well as the resting
position of the shoulder, elbow, forearm, wrist, and hand should be
observed. The examiner observes the normal resting position of
the hand and fingers. In addition, the examiner observes for any
deformities of the fingers (and finger nails) that may be suggestive of
a systematic disorder.
The examiner should observe the patient from the anterior, posterior,
and lateral views.

Palpation
The examiner palpates the hand and surrounding soft tissue and bony
structures starting superficially and progressing to deeper structures.
The examiner palpates for the presence of any temperature changes,
moisture, swelling, and tissue texture abnormalities.
 Wrist and Hand Examination f149

Palmar Surface

Hand &
Wrist
Dorsal Surface

Palpation
150e Musculoskeletal Examination

Active Range of Motion, Passive Range of Motion, and

Overpressure:
With the patient seated the examiner asks the patient to perform the
following motions to assess the quality and quantity of motion and
change in symptoms. Active range of motion can be quantified with
a standard goniometer or inclinometer. The interrater and intrarater
reliability of obtaining measurements during active range of motion
can be found in the table below. Following active range of motion
testing the therapist moves the joint through maximal range of motion
(as tolerated by the patient), applies overpressure, and assesses
range of motion, pain reproduction, and end-feel.
Wrist Flexion
The patient is asked to flex the wrist as far as actively possible. If
no symptoms are elicited the examiner applies overpressure while
assessing quality of motion, symptom response, and end-feel.
Intrarater reliability: .967
Interrater reliability: .907
Wrist Extension
The patient is asked to actively extend the wrist as far as possible.
If no symptoms are elicited the examiner applies overpressure while
assessing quality of motion, symptom response, and end feel.
Intrarater reliability: .967
Interrater reliability: .857
 Wrist and Hand Examination f151

Wrist Flexion with Overpressure

Hand &
Wrist

Wrist Extension with Overpressure

152e Musculoskeletal Examination

Active Range of Motion, Passive Range of Motion and

Overpressure: Continued
Radial Deviation
The patient is asked to actively radially deviate the wrist as far as
possible. If no symptoms are elicited the examiner applies overpressure
while assessing quality of motion, symptom response, and end feel.
Intrarater reliability: .907
Interrater reliability: .867
Ulnar Deviation
The patient is asked to actively ulnarly deviate the wrist as far as
possible. If no symptoms are elicited the examiner applies overpressure
while assessing quality of motion, symptom response, and end-feel.
Intrarater reliability: .76-.927, 8
Interrater reliability: .72-.787, 8
Finger Flexion/Extension
The patient flexes or extends the fingers at each respective joint
(MCPs, PIPs and DIPs). If no symptoms are elicited the examiner
applies overpressure while assessing quality of motion, symptom
response, and end-feel. Flexion and extension of the first digit occur
in the frontal plane.
Intrarater reliability for flexion/extension of IPs: .97-.989
Interrater reliability for flexion/extension of IPs: .979
Thumb Abduction and Adduction
The patient abducts and adducts the thumb. If no symptoms are
elicited the examiner applies overpressure while assessing quality of
motion, symptom response, and end-feel. Abduction and adduction
of the first digit occur in the sagittal plane.
 Wrist and Hand Examination f153

Radial Deviation with Overpressure

Hand &
Wrist

Ulnar Deviation with Overpressure

154e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted muscle tests are performed isometrically and are performed to
assess symptom response and strength of the muscles. The following
list provides selected resisted tests that should be performed when
examining the hand region.
Wrist Flexion
The patient is seated. The examiner asks the patient to flex the wrist
while the examiner stabilizes the forearm with one hand. The patient
is then asked to resist a force applied by the examiner in the direction
of wrist extension.
Wrist Extension
The patient is seated. The examiner asks the patient to extend the
wrist while the examiner stabilizes the forearm with one hand. The
patient is then asked to resist a force applied by the examiner in the
direction of wrist flexion.
Radial Deviation
The patient is seated. The examiner asks the patient to radially
deviate the wrist while the examiner stabilizes the forearm with
one hand. The patient is then asked to resist a force applied by the
examiner in the direction of ulnar deviation.
Ulnar Deviation
The patient is seated. The examiner asks the patient to ulnarly deviate
the wrist while the examiner stabilizes the forearm with one hand.
The patient is then asked to resist a force applied by the examiner in
the direction of radial deviation.
Finger Flexion
The patient is seated. The examiner asks the patient to individually
flex digits 2-4 while the examiner stabilizes the wrist and hand with
one hand. The patient is then asked to resist a force applied by the
examiner in the direction of finger extension. The same technique
can be used for the first digit in isolation.
Finger Extension
The patient is seated. The examiner asks the patient to extend digits
2-4 while the examiner stabilizes the hand and wrist with one hand.
The patient is then asked to resist a force applied by the examiner in
the direction of finger flexion. The same technique can be used for
the first digit in isolation.
 Wrist and Hand Examination f155

Resisted Wrist Extension

Resisted Wrist Radial Deviation

Hand &
Wrist
Resisted Finger Flexion

Resisted Thumb Extension

156e Musculoskeletal Examination

Assessment of Accessory Movements

The examiner investigates accessory movement of the radiocarpal,
MCP, PIP, and DIP joints with the patient seated.
Radiocarpal Dorsal Glide
With the patient seated and the forearm resting on the table, the
examiner places the forearm in supination. The examiner stabilizes
the forearm with one hand and firmly grasps the carpals with the
other. The examiner then dorsally glides the carpals and assesses
the amount of mobility and symptom response.
Radiocarpal Volar Glide
With the patient seated and the forearm resting on the table, the
examiner places the forearm in pronation. The examiner stabilizes
the forearm with one hand and firmly grasps the carpals with the
other. The examiner then volarly glides the carpals and assesses the
amount of mobility and symptom response.
Radiocarpal Radial/Ulnar Glide
With the patient seated and the forearm resting on the table, the
examiner places the forearm in neutral supination/pronation (thumb
pointing up). The examiner stabilizes the forearm with one hand,
firmly grasping the carpals with the other. The examiner then
alternately radially and ulnarly glides the carpals and assesses the
amount of mobility and symptom response.
Dorsal/Volar Glide of MCPs, IPs, and DIPs
With the patient seated the examiner identifies the respective joint to
be tested. The examiner then stabilizes the proximal bone (as close
to the joint as possible) and with the other hand grasps the distal
bone (as close to the joint as possible) and then glides the distal
segment in either a dorsal or volar direction. For example, to assess
the glide at the 2nd MCP joint the examiner stabilizes the metacarpal
with one hand while using the other to glide the proximal phalanx.
 Wrist and Hand Examination f157

Radiocarpal Dorsal Glide

Radiocarpal Volar Glide

Hand &
Wrist
Radiocarpal Ulnar Glide

Dorsal Glide 2nd MCP

158e Musculoskeletal Examination

Special Tests:
Axial Loading of the Thumb
Purpose:
To test for the presence of a scaphoid fracture.
Description:
The patient is seated and the forearm is supported on the table. The
examiner passively abducts and extends the thumb at the MCP joint.
The examiner then applies a compressive load through the first CMC
joint by applying an axial load through the metacarpal bone.
Positive Test:
The test is considered positive if the patient reports pain when
compression is applied.
Diagnostic Accuracy:
Sensitivity = .89 - LR = .0210
Specificity = .98 + LR = 4910
Reliability:
Not reported
 Wrist and Hand Examination f159

Hand &
Wrist
Axial Loading of the Thumb
160e Musculoskeletal Examination

Scaphoid Shift Test

Purpose:
To test for the presence of scaphoid instability.
Description:
The patient is seated with the forearm pronated and stabilized on the
table. The examiner grasps the radial side of the patient’s wrist with
one hand with the thumb over the scaphoid. The examiner’s other
hand grasps the hand at the level of the metacarpals. The examiner
maintains firm compression over the scaphoid while passively taking
the patient into ulnar deviation and slight extension, then slowly into
radial deviation and slight flexion. In the final position the examiner
releases the compression on the scaphoid.
Positive Test:
The test is considered positive if a “thunk” is produced or the patient’s
symptoms are reproduced when compression of the scaphoid is
released.
Diagnostic Accuracy:
Sensitivity = .69 - LR = .4711
Specificity = .66 + LR = 2.011
Reliability:
Not reported
 Wrist and Hand Examination f161

Scaphoid Shift Test: Ulnar Deviation and Slight Extension

Hand &
Wrist

Scaphoid Shift Test: Radial Deviation and Slight Flexion

162e Musculoskeletal Examination

Finkelstein Test
Purpose:
To test for the presence of tenosynovitis of the abductor pollicis
longus and extensor pollicis brevis tendons in the first dorsal tunnel
of the wrist (DeQuervain’s disease).
Description:
The patient is standing or seated and is instructed to make a fist
with the thumb between the palm and fingers. The examiner then
stabilizes the forearm with one hand and passively ulnarly deviates
the wrist.4
Positive Test:
The test is considered positive if pain over the radial styloid process
is reproduced with ulnar deviation.4
Diagnostic Accuracy:
Not reported
Reliability:
Not reported
 Wrist and Hand Examination f163

Finkelstein Test: Start Position

Hand &
Wrist

Finkelstein Test: End Position

164e Musculoskeletal Examination

Carpal Compression Test

Purpose:
To test for the presence of carpal tunnel syndrome.
Description:
The patient is seated with the forearm and hand to be tested resting
on the table. The examiner applies compression over the carpal tunnel
for 30 seconds.
Positive Test:
The test is considered positive if pain, parasthesias, or numbness
is reproduced.
Diagnostic Accuracy:
Sensitivity = .42 - .75 - LR = .13 - .2612-14 15
Specificity = .84 - .95 + LR = 5.6 - 10.712-15
Reliability:
Kappa = .77 (95% CI, .58, .96)5
 Wrist and Hand Examination f165

Hand &
Wrist
Carpal Compression Test
166e Musculoskeletal Examination

Clinical Prediction Rule for the Diagnosis of Carpal Tunnel Syndrome

Purpose:
To test for the presence of carpal tunnel syndrome.

Description:
A clinical prediction rule has been developed to identify the presence of
carpal tunnel syndrome.5 The rule consists of 5 predictor variables:
1. Age greater than 45
2. Patient reports shaking hands relieves symptoms
3. Wrist ratio index > .67
4. Reduced median sensory field of the first digit
5. Symptom Severity Scale score > 1.9
Patient reports shaking hands relieves symptoms:
This test is considered positive if the patient reports that symptoms
improve with shaking or rapid alternating movements of the hand.
Reliability: ICC = .905
Wrist ratio index:
A set of calipers is used to measure the anterior-posterior (AP) and medial-
lateral (ML) wrist width. The wrist ratio index is calculated by dividing the AP
by the ML wrist width. This criterion is satisfied if the index is > .67
Reliability: ICC = .77-.865

Median Sensory Field 1:

Sensory testing is performed with the end of a straight paperclip.
If sensation is reduced in the median sensory field of digit 1 as
compared to the thenar eminence the test is considered positive.
Reliability: ICC = .485
The Brigham and Women’s Hospital Hand Severity Scale:
This criterion is satisfied if the Symptom Severity Score is ≥ 1.9.

Diagnostic Accuracy:
> 2 positive tests: Sens= .98 Spec= .14 +LR= 1.1
> 3 positive tests: Sens= .98 Spec= .54 +LR= 2.1
> 4 positive tests: Sens= .77 Spec= .83 +LR= 4.6
If 5 positive tests: Sens= .18 Spec= .99 +LR= 18.3
 Wrist and Hand Examination f167

Hand &
Wrist
Sensory Examination: Thumb
168e Musculoskeletal Examination

Reference List

(1) Cole IC. Fractures and ligament injuries of the wrist and
hand. The Wrist and Hand.La, Crosse: Orthopaedic Section,
American Physical Therapy Association; 1995.
(2) Management of Common Musculoskeletal Disorders. 3rd ed.
Pennsylvania: Lippincott-Raven Publishers; 1996.
(3) Wadsworth C. Wrist and hand. Current Concepts in
Orthopaedic Physical Therapy.La Crosse: Orthopaedic
Section, American Physical Therapy Association; 2001.
(4) Wadsworth C. Cumulative trauma disorders of the wrist and
hand. The Wrist and Hand.La Crosse: Orthopaedic Section,
American Physical Therapy Association; 1995.
(5) Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger
ML. Development of a clinical prediction rule for the diagnosis
of carpal tunnel syndrome. Arch Phys Med Rehabil 2005
April;86(4):609-18.
(6) Wolff TW, Hodges A. Common orthopaedic dysfunction of the
wrist and hand. In: Placzek JD, Boyce DA, editors. Orthopaedic
Physical Therapy Secrets. Philadelphia: Hanley and Belfus;
2001. p. 315-21.
(7) Horger M. The reliability of goniometric measurements of active
and passive wrist motions. Am J Occup Ther 1990;44(4):342-8.
(8) Boone D, Azen S, Lin J, Baron C, et al. Reliability of
goniometric measurements. Phys Ther 1978;58(11):1355-60.
(9) Brown A, Cramer LD, Eckhaus D, Schmidt J, Ware L,
MacKenzie E. Validity and reliability of the dexter hand
evaluation and therapy system in hand-injured patients. J Hand
Ther 2000 January;13(1):37-45.
(10) Waeckerle JF. A prospective study identifying the sensitivity
of radiographic findings and the efficacy of clinical findings
in carpal navicular fractures. Ann Emerg Med 1987
July;16(7):733-7.
(11) LaStayo P, Howell J. Clinical provocative tests used in
evaluating wrist pain: a descriptive study. J Hand Ther 1995
January;8(1):10-7.
 Wrist and Hand Examination f169

(12) Szabo RM, Slater RR, Jr., Farver TB, Stanton DB, Sharman
WK. The value of diagnostic testing in carpal tunnel syndrome.
J Hand Surg [Am] 1999 July;24(4):704-14.
(13) Tetro AM, Evanoff BA, Hollstien SB, Gelberman RH. A new
provocative test for carpal tunnel syndrome. Assessment of
wrist flexion and nerve compression. J Bone Joint Surg Br
1998 May;80(3):493-8.
(14) Durkan JA. A new diagnostic test for carpal tunnel syndrome.
J Bone Joint Surg Am 1991 April;73(4):535-8.
(15) Mondelli M, Passero S, Giannini F. Provocative tests in
different stages of carpal tunnel syndrome. Clin Neurol
Neurosurg 2001 October;103(3):178-83.

Hand &
Wrist
170e Musculoskeletal Examination

Temporomandibular
Examination
In This Chapter:

1. Historical Examination
2. Observation and Palpation
3. Active Range of Motion, Passive Range of Motion, and
Overpressure
a. Mandibular Depression
b. Lateral Deviation
c. Protrusion and Retrusion
4. Resisted Muscle Tests
a. Mandibular Depression
b. Mandibular Elevation
c. Lateral Deviation
5. Assessment of Accessory Movements
a. Mandibular Distraction
b. Anterior Glide of Mandible
c. Lateral Glide of Mandible
6. Special Tests
a. Auscultation during active movement
 Temporomandibular Examination f171
Region-Specific Historical Examination:

The patient should be asked specific questions related to the

temporomandibular region and surrounding areas.

1. Do you have limited opening of the mouth?

If the patient answers “yes” this may indicate anterior disc
displacement.1-3
2. Do you have clicking during mouth opening and closing?
If the patient answers “yes” this may indicate internal disc
derangement.1-3
3. Do you have creptius during mouth opening or closing?
If the patient answers “yes” this may indicate an osteoarthritic
condition of the temporomandibular joint.4
4. Do yoursymptoms change (better or worse) with any
movements of the neck?
If the patient answers “yes” this indicates the cervical spine
should be examined in detail.
5. Does your jaw ever slip out or feel unstable?
If the patient answers “yes” this may indicate possible mandibular
subluxations.

TMD
172e Musculoskeletal Examination

Observation and Palpation:

This portion of the examination should be performed with the patient

either standing or seated.
Observation
With the patient seated the examiner observes for any asymmetries
in any of the soft tissues or bony landmarks.

Resting position of the mandible is observed.

The examiner should observe the patient from the anterior, posterior,
and lateral views.
Palpation
The examiner palpates the temporomandibular joint, the masseter and
temporalis muscles, and surround soft tissue structures. The examiner
should also palpate for tenderness of the posterior occipital muscles.
 Temporomandibular Examination f173

Anterior View Lateral View

Masseter

TMD

Posterior Occipital Muscles

174e Musculoskeletal Examination

Active Range of Motion, Passive Range of

Motion, and Overpressure:
With the patient seated the examiner asks the patient to perform the
following motions in order to assess the quality and quantity of motion
and change in symptoms. Active range of motion can be quantified
with a standard ruler. Following active range of motion testing the
therapist moves the joint through maximal range of motion (as
tolerated by the patient), applies overpressure, and assesses range
of motion, pain reproduction, and end-feel.
Mandibular Depression
The patient is asked to open the mouth as far as possible. 40 mm is
considered normal maximal mouth opening.5 Overpressure can be
applied at the end range of motion.

Reliability:
• Measurements of maximal mouth opening using a
standard ruler have demonstrated an intra- rater reliability
of .99 (ICC) and an inter-rater reliability of .94.6
Lateral Deviation
The patient is asked to laterally deviate the mandible as far as
possible. Overpressure can be applied at the end range of motion.
Protrusion and Retrusion
The patient is asked to protrude and retrude the mandible.
Overpressure can be applied at the end range of motion.
 Temporomandibular Examination 175

Maximal Mouth Opening

Maximal Mouth Opening with Overpressure

Lateral Deviation
TMD

Lateral Deviation with Overpressure

176e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted muscle tests are performed isometrically. They are included
to assess strength of muscles and symptom response. The following
list provides selected resisted tests that should be performed when
examining the temporomandibular region.
Mandibular Depression
Seated, the patient is instructed to slightly depress the mandible. The
examiner stabilizes the patient’s head with one hand and then, in the
direction of mouth closing, applies a superiorly directed force through
the mandible.The patient is instructed to resist during this process.
Mandibular Elevation
Seated, the patient is instructed to slightly depress the mandible.
The examiner stabilizes the patient’s head with one hand and then
applies an inferiorly directed force through the mandible, in the
direction of mouth opening while the patient is instructed to resist.
Lateral Deviation
Seated, the patient is instructed to slightly depress the mandible. The
examiner stabilizes the patient’s head with one hand and then, in the
direction of mouth opening applies a laterally directed force through
the mandible. The patient is instructed to resist during this process.
 Temporomandibular Examination f177

Resisted Mandibular
Depression

TMD

Resisted Mandibular Resisted Lateral

Elevation Deviation
178e Musculoskeletal Examination

Assessments of Accessory Movements:

The examiner investigates accessory movement of the
temporomandibular joint.
Mandibular Distraction
The examiner stands at the side of the patient and cradles the
patient’s head against the chest with one hand. The thumb and
first finger of the opposite hand cradle the patient’s mandible. The
mandible is then distracted inferiorly while the examiner monitors the
quality of movement and symptoms.
Anterior Glide of Mandible
The examiner stands at the side of the patient and cradles the patient’s
head against the chest with one hand. The thumb and first finger of the
opposite hand cradle the patient’s mandible. Slight distraction is applied
to the joint then the examiner translates the mandible in an anterior
direction while assessing the quality of movement and symptoms.
Lateral Glide of Mandible
The examiner stands at the side of the patient and cradles the
patient’s head against the chest with one hand. The thumb and
first finger of the opposite hand cradle the patient’s mandible. Slight
distraction is applied to the joint then the examiner translates the
mandible in a medial to lateral direction while assessing the quality
of movement and symptoms.
 Temporomandibular Examination f179

Assessment of Temporomandibular Accessory Motions

TMD
180e Musculoskeletal Examination

Special Tests:

Auscultation During Active Movement

Purpose:
To identify the presence of osteoarthritis of the temporomandibular joints.
Description:
The patient is seated and the examiner auscultates over both
temporomandibular joints during mouth opening and closing.
Positive Test:
The test is considered positive if crepitus is heard by the examiner.
Diagnostic Accuracy:
Sensitivity = .45 - .67 - LR = .38 - .65
Specificity = .84 - .86 + LR = 2.8 - 4.8
Reliability:
Not reported
 Temporomandibular Examination f181

Auscultation During Active Mandibular Movement

TMD
182e Musculoskeletal Examination

Reference List

(1) Barclay P, Hollender L, Maravilla K, Truelove E. Comparison of

clinical and magnetic resonance imaging diagnoses in patients
with disk displacement in the temporomandibular joint. Oral
Surg Oral Med Oral Pathol 1999;88:37-43.
(2) Cholitgul W, Nishiyama H, Sasai T, Uchiyama Y, Fuchihata H,
Rohlin M. Clinical and magnetic resonance imaging findings in
temporomandibular joint disc displacement. Dentomaxillofacial
Radiology 1997;26:183-8.
(3) Orsini MG, Kuboki T, Terada S, Matsuka Y, Yatani H,
Yamashita A. Clinical predictibility of temporomandibular joint
disc displacement. J Dent Res 1999;78(2):650-60.
(4) Widmer CG. Evaluation of Temporomandibular Disorders.
In: Kraus SL, editor. TMJ Disorders Management of the
Craniomandibular Complex. New York: Churchill Livingstone;
1988. p. 79-112.
(5) Paesani D, Westesson PL, Hatala M, Tallents RH, Brooks S.
Accuracy of clinical diagnosis for TMJ internal derangement
and arthrosis. Oral Surg Oral Med Oral Pathol 1992;73:360-3.
(6) Walker N, Bohannon RW, Cameron D. Discriminant validity
of temporomandibular joint range of motion measurements
obtained with a ruler. J Orthop Sports Phys Ther 2000
August;30(8):484-92.
 Lumbar Spine Examination f183

Lumbar Spine
Examination
In This Chapter:

1. Historical Examination & Visceral Referral Patterns

2. Observation, Functional Tests, & Palpation Active Range
of Motion, Passive Range of Motion, and Overpressure
a. Flexion
b. Extension
c. Sidebending
d. Combined Movements
3. Resisted Muscle Tests
a. Flexion
b. Extension
4. Assessment of Accessory Movements
a. Posterior-Anterior Segmental Mobility
5. Special Tests
a. Gillet Test
b. Seated Flexion Test
c. Slump Test
d. Straight Leg Raise Test

Lumbar
e. Posterior Shear Test (POSH)

Spine
f. Gaenslen Test
g. Flexion, Abduction, External Rotation Test (FABER or
Patrick’s Test)
h. Spring Test
i. Prone Instability Test (PIT)
j. Test Item Cluster for Identification of Patients Likely to
Benefit from Spinal Manipulation
k. Test Item Cluster for Identification of Patients Likely to
Benefit from Lumbar Stabilization Training
184e Musculoskeletal Examination

Region Specific Historical Examination:

In addition to the historical examination presented in Chapter three,
the patient should be asked specific questions related to the lumbar
spine and surrounding regions.

1. Do your symptoms change (better or worse) with any

movements of the neck or upper back?
If “yes” the cervical spine should be examined.
2. The following questions have some utility in identifying
patients with Lumbar Spinal Stenosis.1

+ LR - LR
Question
(yes) (no)

Do you have no pain when sitting? 6.6 .58

Are your symptoms improved while seated? 3.1 .58
Age > 65 2.5 .33
Do you have severe lower extremity pain? 2.0 .52
Are you able to walk better when holding onto 1.9 .55
a shopping cart?
Do you have pain below the knees? 1.5 .70
Do you have pain below the buttocks? 1.3 .35
 Lumbar Spine Examination f185
3. The following questions have some utility in
identifying patients with Lumbar Zygapophyseal Pain
Syndromes. If 5 of 7 are present it correctly identifies
92% of patients.3

Question

1. Age > 65
2. Pain not worsened by coughing
3. Pain not worsened by hyperextension
4. Pain not worsened by forward flexion
5. Pain not worsened by extension-rotation
6. Pain not worsened when rising from a chair
7. *Pain relieved by recumbency (*must always be present)

4. The following questions have limited utility in

identifying patients with Lumbar Radiculopathy.4
+ LR - LR
Question
(yes) (no)

Weakness 1.2 .73

Numbness 1.0 .94

Lumbar
5. The following questions have limited utility in

Spine
identifying patients with Ankylosing Spondylitis.5

+ LR - LR
Question
(yes) (no)

Pain not relieved by lying down 1.6 .41

Morning stiffness > 1⁄2 hour 1.6 .68
Back pain at night 1.5 .55
Pain or stiffness relieved by exercise 1.3 .6
Age of onset < 40 years 1.1 0
186e Musculoskeletal Examination

Observation
Watch the patient walk and observe any abnormal gait mechanics
and/or reproduction of symptoms.
With the patient standing, the examiner observes for any asymmetries
in any of the soft tissues or bony landmarks of the low back, hip,
gluteal region, and lower extremities. The examiner should observe
the patient from the anterior, posterior, and lateral views.

Functional Tests
The patient should demonstrate any functional movement or activity
that reproduces symptoms. These functional movements often
include one or more of the following activities:
• walking
• jogging
• hopping
• squatting
• donning/doffing socks & shoes
• transferring from sit to stand
• single leg stance
• crossing the legs while seated
 Lumbar Spine Examination f187

Anterior View

Lumbar
Spine

Posterior View
188e Musculoskeletal Examination

Palpation
The examiner palpates the lumbo-sacral, gluteal, and hip regions
starting superficially and progressing to deeper structures. The examiner
palpates for the presence of any temperature changes, moisture, soft
tissue or lymph node swelling, and tissue texture abnormalities.
Symmetry of bony landmarks is observed including the iliac crests, ASIS,
ischial tuberosities, and the region overlying the transverse processes.
 Lumbar Spine Examination f189

Iliac Crest

ASIS

Lumbar
Ischial Tuberosities

Spine

Transverse Processes

Palpation in Standing
190e Musculoskeletal Examination

Active Range of Motion (AROM), Passive Range of

Motion (PROM), and Overpressure:
With the patient standing, the examiner asks the patient to perform
the following motions while assessing the quality and quantity of
motion and change in symptoms, particularly if symptoms move
distally from the spine (“peripheralization”). After performing active
range of motion, the examiner passively moves the spine through
maximal range of motion (as tolerated by the patient), applies
overpressure, and assesses range of motion, pain reproduction, and
end-feel. ROM can be quantified with a tape measure, standard
goniometer or gravity/bubble inclinometer.
Flexion
Standing: The patient is asked to bend forward while keeping their
knees straight. The quality of the motion is noted and the distance
from the finger tips to the floor is measured. Overpressure can be
applied at the end range of motion.
Extension
Standing: The patient is asked to bend backward while keeping the
knees straight. The quality of the motion is noted. Overpressure can
be applied at the end range of motion.
Sidebending
Standing: The patient is asked to bend sideways while keeping the
knees straight. The quality of the motion is noted and the distance
from the finger tips to the knee is measured. Overpressure can be
applied at the end range of motion.
Combined Extension, Sidebending, Rotation (Quadrant)
Standing: The patient is asked to bend backward without bending
the knees while reaching with the hands down the back of the legs.
The quality of the motion is noted. Overpressure can be applied at
the end range of motion.
 Lumbar Spine Examination f191

Flexion with Overpressure

Extension with Overpressure

Lumbar
Spine
Sidebending with Overpressure

Combined with Overpressure

192e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted muscle tests are performed isometrically and are performed
to assess symptom response and strength. The following are
selected resisted tests that can be performed when examining the
lumbar region.
Flexion in Supine (Active Sit-Up Test)
The patient is supine and is asked to flex the knees to 90° and place
the soles of the feet flat on the surface. The examiner holds both feet
down with one hand. The patient is instructed to reach up with the
fingertips of both hands to touch (not hold) both knees and hold the
position for 5 seconds. If the patient cannot maintain this position for
5 seconds, the test is positive.
Extension in Prone (Extensor Endurance Test)
The patient is asked to lie prone while holding the sternum off the
examination table for as long as possible. A small pillow is placed
under the lower abdomen to decrease lumbar lordosis. The patient
also needs to maintain maximum flexion of cervical spine and pelvic
stabilization through gluteal contraction. The patient is asked to
hold this position as long as possible not to exceed 5 minutes. The
performance time is recorded in seconds.
 Lumbar Spine Examination f193

Active Sit-Up Test

Lumbar
Spine

Extensor Endurance Test

194e Musculoskeletal Examination

Assessment of Accessory Movements

The examiner investigates accessory movement of the individual
lumbar spine segments. With all tests, pain responses are recorded
and mobility judgments are established as hypermobile, normal, or
hypomobile.

Posteroanterior Mobility
Purpose:
To test for segmental movement and pain response.
Description:
The patient is prone. The examiner contacts the spinous process
with the hypothenar eminence just distal to the pisiform. The
examiner should be directly over the contact area and keep the
elbows extended. The examiner uses the upper trunk to impart a
posterior to anterior force in a progressive and oscillatory fashion
over the spinous process. Repeat for remaining lumbar segments.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of pain. The mobility of the segment is judged to be
normal, hypermobile, or hypomobile.
Diagnostic Accuracy:
Lack of hypomobility during testing was related to radiographic
lumbar instability.6
Sensitivity = .43 - LR = .60
Specificity = .95 + LR = 8.6
Reliability:
Kappa = 0.25 – 0.57 (pain) 7-9
ICC = 0.25 – 0.77 (mobility) 7-9
 Lumbar Spine Examination f195

Posteroanterior Mobility

Lumbar
Spine
196e Musculoskeletal Examination

Special Tests:
Gillet Test
Purpose:
To test for the presence of motion restriction of the SI region.
Description:
The patient is standing. The examiner palpates the inferior aspect
of the PSIS of tested side with one thumb and mid-point of sacrum
(~S2) with the other thumb. The patient flexes the hip and the
examiner judges if inferior and lateral movement of the tested PSIS
occurs relative to the sacrum.
Positive Test:
The test is considered positive if there is no inferior movement of
thumb on the PSIS.
Diagnostic Accuracy:
LR unknown
Reliability:
ICC = .5910
 Lumbar Spine Examination f197

Gillet Test

Lumbar
Spine
198e Musculoskeletal Examination

Seated Flexion Test

Purpose:
To test for the presence of motion restriction of the SI region.
Description:
The patient is seated. The examiner’s thumbs palpate the inferior
aspect of each PSIS. The patient flexes forward while the examiner
judges the movement of the PSIS. The examiner also observes the
symmetry of movement in the lumbar spine.
Positive Test:
The test result is considered to be positive if more cephalad motion
of one PSIS relative to the other PSIS occurs.
Diagnostic Accuracy:
Unknown
Reliability:
ICC = 0.2510
 Lumbar Spine Examination f199

Seated Flexion Test: Start Position

Lumbar
Spine

Seated Flexion Test: End Position

200e Musculoskeletal Examination

Slump Test
Purpose:
To test for the presence of sensitive neural tissue elements or altered
neurodynamics as a possible source of symptoms.
Description:
The patient is seated in an upright posture with the hands clasped
behind the back and knees together. The examiner introduces
motions in this order:
Spinal flexion
Neck flexion
Knee extension
Release neck flexion
Positive Test:
The test result is considered to be positive if symptoms decrease
with release of neck flexion.
Diagnostic Accuracy:
Not Reported
Reliability:
Not Reported
 Lumbar Spine Examination f201

Slump Test: Start Position

Lumbar
Spine

Slump Test: End Position

202e Musculoskeletal Examination

Straight Leg Raise

Purpose:
To test for the presence of disk herniation.
Description:
The patient is supine, the knee is fully extended, and ankle is in neutral
dorsiflexion. The examiner passively flexes the hip while maintaining
the knee in extension. The amount of hip flexion is recorded at the
point of pain or in paresthesia the back or lower limb.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of back or leg pain at 40 degrees or less.
Diagnostic Accuracy:
Sensitivity = .91 - LR = .35
Specificity = .26 + LR = 1.2
Crossed Straight Leg Raise:
The test entails performing the straight leg raise test on the uninvolved
extremity. It is considered positive if it reproduces symptoms in the
involved extremity.
Diagnostic Accuracy:
Sensitivity = .29 - LR = .8011
Specificity = .88 + LR = 2.411
 Lumbar Spine Examination f203

Straight Leg Raise Test

Lumbar
Spine
204e Musculoskeletal Examination

Posterior Shear (POSH) Test

Purpose:
To test for pain of sacroiliac origin.
Description:
The patient is supine, the knee and hip are flexed to 90 degrees.
The examiner places a hand underneath the sacrum. The examiner
delivers a posterior directed force through the femur at varying angles
of abduction/adduction.
Positive Test:
The test result is considered to be positive if buttock pain is reproduced.
Diagnostic Accuracy:
Reference standard anesthetic block of the sacroiliac joint
Sensitivity = .80 - LR = .212
Specificity = 1.0 + LR = NA12
Reliability:
Inter-examiner Kappa = 0.64 - 0.8810,14
 Lumbar Spine Examination f205

Posterior Shear Test

Lumbar
Spine
206e Musculoskeletal Examination

Gaenslen Test
Purpose:
To test for pain of sacroiliac origin.
Description:
The patient is supine with both legs extended. The leg being tested
is passively brought into full knee flexion, while the opposite hip
remains in extension. Overpressure is then applied to the flexed
extremity.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of pain in the lower back.
Diagnostic Accuracy:
Reference standard anesthetic block of the sacroiliac joint
Sensitivity = .71 - LR = 1.1212
Specificity = .26 + LR = 1.012
Reliability:
Inter-examiner Kappa = 0.54 - 0.7610,14
 Lumbar Spine Examination f207

Gaenslen Test

Lumbar
Spine
208e Musculoskeletal Examination

Flexion, Abduction, External Rotation Test

(FABER or Patrick’s Test)
Purpose:
To test for the presence of sacroiliac region pain; also, to test for the
presence of hip pathology
Description:
The patient is supine. The tested LE is placed in a “figure 4” position
(hip flexed and abducted, ipsilateral foot resting on the contralateral
thigh just above the knee). While stabilizing the opposite side of the
pelvis, an external rotation / posteriorly directed force is then applied
to the ipsilateral knee.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of buttock or groin pain.
Diagnostic Accuracy:
Reference standard anesthetic block of the sacroiliac joint
Sensitivity = .71 - LR = .2312
Specificity = 1.0 + LR = NA12
Reliability:
Inter-examiner Kappa = 0.60 - 0.6210,14
 Lumbar Spine Examination f209

FABER Test

Lumbar
Spine
210e Musculoskeletal Examination

Resisted Abduction Test

Purpose:
To test for pain of sacroiliac origin.
Description:
The patient is supine with the leg fully extended and abducted to 30
degrees. The examiner then resists abduction.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of low back pain.
Diagnostic Accuracy:
Reference standard anesthetic block of the sacroiliac joint
Sensitivity = .87 - LR = .1312
Specificity = 1.0 + LR = NA12
Reliability:
Not Reported
 Lumbar Spine Examination f211

Lumbar
Spine
Resisted Abduction Test
212e Musculoskeletal Examination

Prone Instability Test (PIT)

Purpose:
To test for the likelihood of a patient responding to a stabilization
exercise program.
Description:
The patient lies prone with the body on the examining table and legs
over the edge and feet resting on the floor. While the patient rests
in this position, the examiner applies posterior to anterior pressure
to the lumbar spine. Any provocation of pain is reported. Then
the patient lifts the legs off the floor (the patient may hold table to
maintain position) and posterior compression is applied again to the
lumbar spine.
Positive Test:
The test result is considered to be positive if pain is present in the
resting position but subsides in the second position.
Diagnostic Accuracy:
Reference standard success with stabilization exercise program.
Sensitivity = .72 - LR = .487
Specificity = .58 + LR = 1.77
Reliability:
Not Reported
 Lumbar Spine Examination f213

Prone Instability Test: Start

Lumbar
Spine

Prone Instability Test: End

214e Musculoskeletal Examination

Test Item Cluster for Patients Likely to Benefit from

Spinal Manipulation
Purpose:
To determine the likelihood of patients responding with a 50% or greater
reduction in disability following a program of spinal manipulation and
exercise.
Description:
The following test item clusters can be performed entirely in the history
and physical exam without any additional lab or imaging tests.

Test Items:
Criterion Definition of Positive:
• Duration of current episode of low back pain 16 days or less
• Not having symptoms distal to the knee
• FABQ work subscale score 18 points or less
• Segmental mobility testing noting at least 1 hypomobile
segment in the lumbar spine
• Hip internal rotation range of motion with 1 or both hips
having at least 35 degrees of internal rotation
Diagnostic Accuracy:
Reference standard for success with spinal manipulation.
When at least 4 of of the 5 criteria were met: + LR = 13.215
When only 1 or 2 of the criteria were met: - LR = .1015
 Lumbar Spine Examination f215
Test Item Cluster for Patients Likely to Benefit from
Lumbar Stabilization Exercise Training
Purpose:
To determine the likelihood of patients responding with a 50% or
greater reduction in disability following a program of lumbar spine
stabilization exercises.
Description :
The following test item clusters can be performed entirely in the history
and physical exam without any additional lab or imaging tests.

Test Items:
Criterion Definition of Positive:
• Age less than 40 years
• Average SLR >91°
• Positive prone instability test
• Aberrant movement present (Examined during lumbar
ROM testing). Described as an instability catch, painful arc
of motion, “thigh climbing” (Gower’s sign), or a reversal of
lumbopelvic rhythm.
Diagnostic Accuracy:
Reference standard for success with a program of lumbar spine stabilization
exercises.
When at least 3 of the 4 criteria were met: + LR = 4.07
When only 1 of 4 of the criteria was met: - LR = .207

Lumbar
Spine
When only 2 of 4 of the criteria were met: - LR = .307
216e Musculoskeletal Examination

Reference List

(1) Katz JN Dalgas M, Stucki G et al. Degenerative lumbar

spinal stenosis. Diagnostic value of the history and physical
examination. Arthiris Rheum 1995; 38:1236-41.
(2) Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental
mobility assessment: an examination of validity for determining
intervention strategies in patients with low back pain. Arch Phys
Med Rehabil 2005;86:1745-1752.
(3) Revel M, Poiraudeau S, Auleley G, et al. Capacity of the clinical
picture to characterize low back pain relieved by facet joint
anesthesia: Proposed criteria to identify patients with painful
facet joints. Spine 1998;23:1972-1976.
(4) Lauder T, Dillingham T, Andary M, et al. Effect of history and
exam in predicting electrodiagnostic outcome among patients
with suspected lumbosacral radiculopathy. Am J Phys Med
2000;79:60-68.
(5) Gran J. An epidemiological survey of the signs and symptoms of
ankylosing spondylitis. Clin Rheumatol 1985;4:161-169.
(6) Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination
to predict radiographic instability of the lumbar spine. Eur Spine J
2005;14:743-750.
(7) Hicks G, Fritz J, Delitto A, McGill S. Preliminary development of
a clinical prediction rule for determining which patients with low
back pain will respond to a stabilization exercise program. Arch
Phys Med Rehabil 2005;86:1753-1762.
(8) Binkley J, Stratford P, Gill C. Interrater reliability of lumbar
accessory motion mobility testing. Phys Ther 1995;75:786-795.
(9) Maher C, Latimer J, Adams R. An investigation of the reliability
and validity of posteroanterior spinal stiffness judgments made
using a reference-based protocol. Phys Ther 1998;78:829-837.
(10) Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule
for classifying patients with low back pain who demonstrate
short-term improvement with spinal manipulation. Spine
2002;27:2835-2843.
(11) Deville W, van der Windt D, Dzaferagic A, et al. The test of
Lasègue. Systematic review of the accuracy in diagnosing
herniated discs. Spine 2000;25:1140-1147.
(12) Broadhurst N, Bond M. Pain provocation tests for the
assessment of sacroiliac joint dysfunction. J Spinal Disorders
1998;11:341-345.
 Lumbar Spine Examination f217

(13) Dreyfuss P, Michaelsen M, Pauza K, et al. The value of medical

history and physical examination in diagnosing sacroiliac joint
pain. Spine 1996;21:2594-2602.
(14) Laslett M, Williams M. The reliability of selected pain provocation
tests for sacroiliac joint pathology. Spine 1994;19:1243-1249.
(15) Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule
to identify patients with low back pain most likely to benefit
from spinal manipulation: a validation study. Ann Intern Med
2004;141:920-928.

Lumbar
Spine
218 e Musculoskeletal Examination
 Hip Examination f219

Hip Examination
In This Chapter:

1. Historical Examination & Visceral Referral Patterns

2. Observation, Functional Tests, & Palpation
3. Active Range of Motion, Passive Range of Motion, &
Overpressures
a. Flexion
b. Internal Rotation and External Rotation
c. Abduction and Adduction
d. Extension
4. Resisted Muscle Tests
a. Flexion
b. Abduction
c. Internal Rotation and External Rotation
d. Extension
5. Muscle Length/Flexibility
a. Iliopsoas
b. Rectus Femoris
c. Hamstrings
d. Tensor Fascia Latae / IT Band
e. Piriformis > 90° Flexion
f. Piriformis < 90° Flexion
6. Assessments of Accessory Movements
a. Inferior Glide
b. Posterior Glide
c. Lateral Glide
d. Long-Axis Distraction
e. Anterior Glide
Hip
7. Special Tests
a. Flexion, Abduction, External Rotation Test
(or FABER or Patrick’s Test)
b. Test Item Cluster for Identification of Hip
Osteoarthritis
c. Flexion, Adduction, Internal Rotation, and
Compression Test (or Quadrant Test)
d. Limited Hip Abduction Test
e. Flexion, Adduction, Internal Rotation (FAIR) Test
220 e Musculoskeletal Examination

Region Specific Historical Examination:

In addition to the historical examination presented in Chapter 3, the
patient should be asked specific questions related to the hip and
surrounding regions.

1. Do your symptoms change (better or worse) with any

movements of the low back? Do you have any pain in your
low back, even if you feel it is unrelated to your hip pain?
If the patient answers “yes” for either question, the lumbar spine
and pelvis should be examined in addition to the hip.
2. Does your hip pain extend down into your thigh or
leg? Do you ever experience numbness or tingling
into the hip, thigh, leg, ankle, or foot?
If the patient answers “yes” for either question, both a LE
neurological screening examination and a lumbar spine
examination should be performed to identify any existing
radiculopathy or radiculitis.
If symptoms refer into the posterior thigh and perhaps the
calf without numbness/tingling without numbness or tingling,
the following diagnoses should be considered: Ischial
bursitis1,Hamstring strain1, Piriformis syndrome.2
3. Have you recently increased your physical activity,
especially running (distance, terrain, speed) or other
weight bearing activities?
If the patient answers “yes” the clinician should be suspicious
of a femoral neck, femoral shaft, or pelvic stress reaction
or stress fracture.3 Muscle sprain/strain should also be
considered.1
4. Do you have pain or stiffness in the hip or groin region?
Do you have a family history of osteoarthritis? Morning
stiffness < 60 minutes? Pain with prolonged walking?
If the patient answers “yes” the clinician should be suspicious
of hip osteoarthritis. 4
5. Do you experience clicking, catching, or giving way of the hip?
Do your symptoms worsen with full flexion or extension?
If the patient answers “yes” a labral lesion or tear5,6 should
be considered.
 Hip Examination f221
Other conditions to consider based on the historical exam:
If the patient is young (age 4-6 yrs) with hip, groin,
thigh, or knee pain, Legg-Calvé-Perthes disease should
be considered.7;8 This condition occurs more often
in females than males, and these children tend to be
smaller and fairly physically active.

If the patient is a young adolescent (age 11-14 years) with

insidious onset of hip, groin, thigh, or knee pain, slipped
capital femoral epiphysis should be considered.7,9 This
condition occurs more often in males than females, and
these children tend to be overweight.

A history of aching and/or deep throb in the groin

or hip region combined with a history of prolonged
steroid use, excessive alcohol use, blood disorders,
or chemotherapy or radiation should lead the clinician
to consider avascular necrosis or osteonecrosis as a
possible diagnosis.5

Pain extending along the lateral thigh, and exacerbated

with ascending/descending stairs or transferring from
sit to stand may be indicative of greater trochanteric
bursitis10 or a muscle strain1.

Hip
222 e Musculoskeletal Examination

Observation
Watch the patient walk and observe any abnormal gait mechanics
and/or reproduction of symptoms.

With the patient standing, the examiner observes for any asymmetries
in any of the soft tissues or bony landmarks of the hip, gluteal region,
low back, and lower extremities. The examiner should observe the
patient from the anterior, posterior, and lateral views.

Functional Tests
The patient should demonstrate any functional movement or activity
that reproduces symptoms. These functional movements often
include one or more of the following activities: walking, jogging,
hopping, squatting, donning/doffing socks & shoes, transferring from
sit to stand, single leg stance, and crossing the legs while seated.

These tests allow for a quick functional screen of the patient’s entire
lower quarter. Appropriate selection of the tests should be based on
the patient’s age, activity level, and severity of pain. The clinician
should assess the quality and quantity of motion and any change in
symptoms with test performance.

Palpation
The examiner palpates the hip, gluteal, and lumbo-sacral regions
starting superficially and progressing to deeper structures. The
examiner palpates for the presence of any temperature changes,
moisture, soft tissue or lymph node swelling, and tissue texture
abnormalities.
 Hip Examination 223

Anterier View Lateral View Posterior View

Functional Test: Functional Test:

Step Up Squat

Hip

Palpation
224 e Musculoskeletal Examination

Active Range of Motion (AROM), Passive Range of

Motion (PROM), & Overpressure:
With the patient supine, the examiner asks the patient to perform the
following motions while assessing the quality and quantity of motion
and change in symptoms. After performing active range of motion, the
examiner passively moves the joint through maximal range of motion (as
tolerated by the patient), applies overpressure, and assesses range of
motion, pain reproduction, and end-feel. ROM can be quantified with a
standard goniometer or gravity/bubble inclinometer.
Flexion
The patient is asked to bring the knee up toward the chest. While
maintaining the hip in neutral rotation, and without allowing the hip to
abduct/adduct, the clinician moves the hip through full passive flexion
range of motion. Overpressure can be applied at the end range of
motion.
Internal Rotation (IR) and External Rotation (ER)
The patient’s hip is placed in 90 degrees flexion and 0 degrees of abduction/
adduction. While maintaining these positions, the clinician performs full
passive internal and external rotation of the hip. Overpressure can be
applied at the end range of motion.
Alternate technique with the patient in sitting: Stabilize the knee to prevent
hip abduction/adduction and ask the patient to bring the foot up and out
(external rotation) and up and in (internal rotation). While stabilizing
the knee with one hand, the clinician can use the other hand to perform
PROM and to apply overpressure.
Abduction and Adduction
The patient is asked to slide the hip away from midline as far as possible.
While stabilizing the pelvis, the clinician passively abducts the hip through
full range of motion. Next, with the opposite hip abducted approximately
30 degrees and the pelvis stabilized by the clinician, the patient is asked
to bring the hip towards the opposite hip (adduction). The clinician can
then passively adduct the hip through full range of motion. Overpressure
can be applied at the end range of motion.
Extension
Prone: While keeping the knee extended and back straight, the patient
should raise the knee up toward the ceiling as far as possible. The
examiner then grasps the distal thigh (while supporting the leg), applies a
posterior-to-anterior directed force over the ischial tuberosity to stabilize
the pelvis, and extends the hip through full passive range of motion.
Overpressure can be applied at the end range of motion.
 Hip Examination f225

Flexion with Overpressure

Internal Rotation with Overpressure External Rotation with Overpressure

Abduction with Overpressure

Hip
Adduction with
Overpressure

Extension with Overpressure

226 e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted tests are performed isometrically and are performed to
assess symptom response and strength. The following list provides
selected resisted tests that should be performed when examining
the hip region.

Flexion in Sitting or Supine

Sitting: The examiner asks the patient to sit upright and to lift the
knee 8 – 10 cm from the table. While stabilizing the patient’s trunk/
pelvis, the patient is then asked to resist an inferiorly directed force
produced by the examiner through the patient’s distal thigh.
Supine: The examiner asks the patient to keep the knee straight and
to lift the leg approximately 30°. The patient is then asked to resist
an inferiorly directed force produced by the examiner through the leg
or distal thigh.

Abduction in Side-Lying or Supine

Side-lying: While stabilizing the pelvis, the examiner asks the patient
to bring the leg up toward the ceiling. The patient is then asked
to resist an inferiorly force produced by the examiner through the
patient’s distal lateral thigh. Note: Ensure that the patient does not
flex the hip while performing the test.
Supine: While stabilizing the opposite LE, the patient is asked to
slide the tested LE outward and then resist a medially directed force
produced by the examiner through the lower leg.
Hip Internal Rotation and External Rotation in Sitting
Internal Rotation: With the hip positioned in internal rotation and the
examiner stabilizing the medial knee, the patient is asked to resist a
medially directed force applied to the lateral lower leg.
External Rotation: With the hip positioned in external rotation and the
examiner stabilizing the lateral knee, the patient is asked to resist a
laterally directed force applied to the medial lower leg.
Hip Extension in Prone
The examiner asks the patient to keep the knee straight and to lift
the leg approximately 10°. The patient is then asked to resist an
inferiorly directed force produced by the examiner through the leg or
distal thigh. Note: To preferentially assess the gluteal musculature (vs
hamstrings), position the knee in flexion while testing hip extension.
 Hip Examination f227

Resisted Flexion

Resisted Internal Rotation Resisted External Rotation

Resisted Abduction
Hip

Resisted Extension
228 e Musculoskeletal Examination

Muscle Length/Flexibility:
These tests are performed to assess the length and/or flexibility of the
hip and gluteal region musculature. The following list provides selected
resisted tests that should be performed when examining this region.
Muscle length can often be quantified with a standard goniometer or
gravity/bubble inclinometer.
Iliopsoas
Supine: Flex the hips and knees until the lumbar spine is flat against
the table. While maintaining the non-tested LE in this position, slowly
lower the tested LE toward the floor by extending the hip. The final
resting position of the hip can be measured to quantitatively assess
iliopsoas muscle length. For normal length, the thigh should lie parallel
to the treatment table, or fall below the level of the treatment table.
Prone: Stabilize the patient’s ischeal tuberosity with one hand (apply
posterior-to-anterior directed force) and passively extend the patient’s
hip with the other. You should be able to extend the hip at least 10°.
Rectus Femoris
Prone: Stabilize the patient’s ischeal tuberosity with one hand (apply
posterior-to-anterior directed force) and passively flex the patient’s
knee. Keep the hip in midline while performing this test and don’t
allow either hip to flex.
Hamstrings
Supine: While keeping the non-tested LE stabilized against the
table, flex the hip of the tested LE to 90°. Have the patient help you
maintain 90° hip flexion while passively extending passively extend
the knee. While no normative data are available, many clinicians
feel the hamstrings are tight if the patient lacks 10°-20° to reach full
extension with this test.
Tensor Fascia Latae and Iliotibial Band (Ober’s Test)
Sidelying: Stabilize the patient’s pelvis. Flex the underlying LE slightly
to help stabilize the patient in sidelying. Flex the knee and hip of the
tested LE (upper LE), passively abduct the hip, then extend the hip until
the thigh is in line Keep the knee flexed to 90° while lowering the thigh.
If the hip remains abducted (does not adduct beyond horizontal), then
the patient has tightness of the TFL and ITB.
Piriformis at > 90 degrees flexion
Supine: Externally rotate and flex the hip. Add to the stretch by
adducting the hip toward the opposite shoulder.
Piriformis at < 90 degrees flexion
Supine: Place the foot of the tested LE lateral to the knee or distal thigh
of the non-tested LE. Stabilize the pelvis on the tested side, and bring the
knee slowly towards and across midline.
 Hip Examination f229

Iliopsoas Rectus Femoris

Hamstrings Tensor Fascia Latae

& Iliotibial Band

Hip

Piriformis above 90° Flexion Piriformis below 90° Flexion

230 e Musculoskeletal Examination

Assessment of Accessory Movements

The examiner investigates accessory movement of the hip joint
in supine and prone. With all tests pain responses are recorded,
and mobility judgments are established as hypermobile, normal, or
hypomobile.
Inferior Glide of the Femur
Supine: Flex the hip passively to 90°. Grasp the proximal femur as
shown, apply an inferiorly directed force to the most proximal aspect
of the femur.
Posterior Glide of the Femur
Supine: Passively flex the hip to 90°. With the hip internally rotated
and adducted, the examiner applies a posteriorly directed force
through the femur.
Lateral Glide of the Femur
Supine: Passively flex the hip to 90°, grasp the proximal femur as
shown, and apply a laterally directed force to the most proximal
aspect of the femur.
Long-Axis Distraction of the Hip Joint
Supine: Grasp the patient’s ankle, passively flex the hip 20°-30°,
abduct approximately 30°, and apply a longitudinal distraction force
to the hip.
Anterior Glide of the Femur
Prone: Fully extend the patient’s hip and apply a posterior-to-anterior
directed force over the proximal femur (either just inferior to the ischial
tuberosity or over the posterior aspect of the greater trochanter). It may
be easier to handle the leg if the knee is flexed while performing the test.
 Hip Examination f231

Inferior Glide Posterior Glide

Lateral Glide Long Axis Distraction

Hip

Anterior Glide
232 e Musculoskeletal Examination

Special Tests:
Flexion, Abduction, External Rotation Test
(FABER or Patrick’s Test)
Purpose:
To test for the presence of hip pathology.
Description:
The patient is supine. The tested LE is placed in a “figure 4” position
(hip flexed and abducted, ipsilateral foot resting on the contralateral
thigh just above the knee). While stabilizing the opposite side of the
pelvis, an external rotation / posteriorly directed force is then applied
to the ipsilateral knee.
Positive Test:
The test result is considered to be positive if the patient reports reproduction
of hip pain in this position,11 or if there is a restriction of ROM.12
Diagnostic Accuracy:
Sn (for identification of hip pathology identified with arthroscopy) = 0.89
LRs and Sp = unable to calculate11
Correlation of positive test with OA on radiographs: r = 0.5412
Reliability:
ICC = 0.66 - 0.9612, 13
 Hip Examination f233

FABER Test

Hip
234 e Musculoskeletal Examination

Test Item Cluster for the Identification of Hip Osteoarthritis

Purpose:
To test the presence of hip osteoarthritis.
Description:
The following test item clusters can be performed entirely in the history
and physical examination without any additional lab or imaging tests.
Test Cluster 1:
1. Hip pain
2. Hip internal rotation range of motion <15°
3. Hip flexion range of motion <115° deg.

If hip internal rotation range of motion is > 15°, then use the
following test cluster:

Test Cluster 2:
1. Painful hip with hip internal rotation
2. >50 years of age
3. Morning hip stiffness < 60 minutes
Diagnostic Accuracy:
Test Clusters 1 & 2
If all three components of a test cluster are present: + LR = 3.44
If all 3 are not met: - LR = 0.194
Reliability:
Not reported
 Hip Examination f235

Flexion Range of Motion

Hip

Internal Rotation Range of Motion

236 e Musculoskeletal Examination

Flexion, Adduction, Internal Rotation, and Compression Test

(Hip Quadrant)
Purpose
To test for the presence of hip pathology.
Description
With the patient in supine, the tested LE is passively flexed and adducted
until resistance to movement is detected. The examiner then maintains
flexion into resistance and moves the hip into abduction, bringing the hip
through a full arc of motion. If the patient reports no pain, the examiner
then applies long-axis compression to the hip through the femur.
Positive Test:
The test result is considered to be positive if the patient reports
reproduction of hip pain in this position, or if there is a restriction of ROM.
Diagnostic Accuracy
Diagnostic characteristics for detection of acetabular labral lesions6
Sensitivity = .75 - LR = .58
Specificity = .43 + LR = 1.32
Reliability
ICC = .8713
 Hip Examination f237

Quadrant Test

Hip
238 e Musculoskeletal Examination

Flexion, Adduction, Internal Rotation (FAIR) Test 2,14

Purpose
To detect compression or irritation of the sciatic nerve by the piriformis.
Description
With the patient in side-lying (non-tested LE is closest to the table),
the patient’s involved LE is passively brought into a position of flexion,
adduction, and internal rotation.
Positive Test:
Pain detected at the region of the piriformis.
Diagnostic Accuracy
Sensitivity = .88 - LR = .142,14
Specificity = .83 + LR = 5.22,14
Reliability
Not Reported
 Hip Examination f239

Flexion, Adduction, Internal Rotation Test

Hip
240 e Musculoskeletal Examination

Reference List

(1) Pecina MM, Bojanic I. Overuse Injuries of the Musculoskeletal

System. Boca Raton: CRC Press; 1993.
(2) Fishman L, Dombi G, Michaelson C, Ringel S, Rozbruch J,
Rosner B et al. Piriformis syndrome: Diagnosis, treatment
and outcome- a 10-year study. Arch Phys Med Rehabil 2002;
83:295-301.
(3) O’Kane JW. Anterior hip pain. Am Fam Physician 1999;
60(6):1687-1696.
(4) Altman R, Alarcon G, Appelrouth D, Bloch D, Borenstein D,
Brandt K et al. The American College of Rheumatology criteria
for the classification and reporting of osteoarthritis of the hip. Arth
Rheum 1991; 34(5):505-514.
(5) Hartley A. Practical Joint Assessment. St Louis: Mosby; 1995.
(6) Narvani A, Tsirdis E, Kendall S, Chaudhuri R, Thomas P. A
preliminary report on prevalence of acetabular labral tears in
sports patients with groin pain. Knee Surg Sports Traumatol
Arthrosc 2003; 11:403-408.
(7) Weinstein SL. Natural history and treatment outcomes
of childhood hip disorders. Clin Ortho Rel Rsch 1997;
344:227-242.
(8) Scherl SA. Common lower extremity problems in children.
Pediatrics in Review 2004; 25(2):52-62.
(9) Reynolds RA. Diagnosis and treatment of slipped capital femoral
epiphysis. Current Opinion in Pediatrics 1999; 11(1):80-83.
(10) Hertling D, Kessler RM. The hip. In: Hertling D, Kessler RM,
editors. Management of Common Musculoskeletal Disorders:
Physical Therapy Principles and Methods. 3rd ed. Philadelphia:
Lippincott; 1996. 285-314.
(11) Mitchell B, McCroy P, Brukner P, O’Donnell J, Colson E, Howells R. Hip
joint pathology: Clinical presentation and correlation between magnetic
resonance arthrography, ultrasound, and arthroscopic findings in 25
consecutive cases. Clin J Sports Med 2003; 13:152-156.
(12) Theiler R, Stucki G, Schotz R, Hofer H, Seifert B, Tyndall A et al.
Parametric and non-parametric measures in the assessment
of knee and hip osteoarthritis: interobserver reliability and
correlation with radiology. Osteoarthritis Cartilage 1996;35-42.
 Hip Examination f241

(13) Cliborne A, Wainner R, Rhon D, Judd C, Fee T, Matekel R

et al. Clinical hip tests and a functional squat test in patients with
knee osteoarthritis: Reliability, prevalence of positive test findings,
and short-term response to hip mobilization. J Orthop Sports Phys
Ther 2004; 34:676-685.
(14) Jari S, Paton R, Srinivasan M. Unilateral limitation of abduction
of the hip: A valuable clinical sign for DDH? J Bone Joint Surg
2002; 84-B:104-107.
(15) Fishman L, Zybert P. Electrophysiologic evidence of piriformis
syndrome. Arch Phys Med Rehabil 1992; 73:359-364.

Hip
242e Musculoskeletal Examination
 Knee Examination f243

Knee Examination
In This Chapter:

1. Historical Examination & Visceral Referral Patterns

2. Observation, Functional Quick Tests, and Palpation
3. Active Range of Motion, Passive Range of Motion, and
Overpressures
a. Flexion
b. Extension
4. Resisted Muscle Tests
a. Flexion
b. Extension
5. Muscle Length/Flexibility
a. Iliopsoas
b. Rectus Femoris
c. Hamstrings
d. Tensor Fascia Latae / IT Band
e. Gastrocnemius & Soleus
6. Assessments of Accessory Movements
a. Anterior Glide of the Tibia
b. Posterior Glide of the Tibia
c. Anterior & Posterior Glide of the Proximal Fibula
d. Patellar Glides
7. Special Tests
a. Lachman Test
b. Anterior Drawer
c. Posterior Drawer
d. Pivot-Shift Test
e. Valgus Stress Test
Knee

f. Varus Stress Test

g. McMurray Test
h. Joint Line Tenderness
i. Dynamic Test for Lateral Meniscus Lesions
j. Ottawa Knee Rules
k. Clinical Diagnosis of Knee Osteoarthritis
244e Musculoskeletal Examination

Region Specific Historical Examination:

In addition to the historical examination presented in Chapter three,
the patient should be asked specific questions related to the knee
and surrounding regions.
1. Do your symptoms change (better or worse) with any
movements of the low back? Do you have any pain in
your low back, even if you feel it is unrelated to your
knee pain?
If “yes” for either question, the lumbo-pelvic region and hip
should be examined in addition to the knee.
2. Does your knee pain extend up into your thigh or
back or down into the leg, ankle, or foot? Do you ever
experience numbness or tingling into the hip, thigh, leg,
ankle, or foot?
If “yes” for either question, both a LE neurological screening
examination and a lumbar spine examination should be
performed to identify any existing radiculopathy or radiculitis.
If symptoms are reported in the posterior thigh and perhaps the
calf, but no numbness/tingling, the following diagnoses should
be considered: Ischial bursitis1 , Hamstring strain1,Piriformis
syndrome2.
3. Have you recently increased your physical activity,
especially running (distance, terrain, speed) or other
weight bearing activities?
If “yes”, the clinician should be suspicious of a femoral, tibial,
or fibular stress reaction or stress fracture. Muscle sprain/
strain should also be considered.
4. Do you have knee pain or stiffness that eases after a few
hours in the morning?
If “yes”, the clinician should be suspicious of knee
osteoarthritis.3,4
5. Is your knee pain a result of trauma, such as injury
with jumping/landing, changing directions with your
foot planted, or twisting?
If “yes”, the following diagnoses should be considered: ligamentous
injury, patellar subluxation, quadriceps rupture, meniscal lesion.5-8
If the injury described resulted in a posteriorly directed blow to the
tibia with the knee flexed, the clinician should consider possible
posterior cruciate ligament injury.5
If the injury described resulted in a valgus or varus stress to the knee,
collateral ligament injury (fibular or tibial) should be considered.5
 Knee Examination f245
Other conditions to consider based on the historical exam:

If the patient complains of anterior knee pain that worsens
with jumping, full knee flexion, or other activities that
stress the extensor mechanism of the knee, patellar
tendonitis7,9 and patellofemoral pain syndrome10,11 (also
called retropatellar pain syndrome and anterior knee pain)
should be considered. If the patient is young, and if the
pain is localized to the insertion of the patellar tendon at
the tibial tuberosity, Osgood-Schlater’s Disease should
also be considered.12
Patient reports of anterior knee pain that worsens with
prolonged knee flexion (“positive movie sign”), squatting,
and going up/down stairs should prompt the clinician to
consider patellofemoral pain syndrome as a diagnosis.10,11
A patient complaint of knee swelling and knee locking
and/or clicking should prompt the clinician to consider a
meniscal lesion8 or a possible loose body within the knee.
Lumbo-pelvic and hip conditions can be the source of
referred pain to the knee. Incorporation of pertinent
historical exam questions with physical exam tests from
the Lumbar Spine and Hip Chapters will enhance the
clinician’s knee examination.

Knee
246e Musculoskeletal Examination

Observation, Functional Quick Tests, and Palpation:

Observation
Watch the patient walk and observe abnormal gait mechanics and/or
reproduction of symptoms.
With the patient standing, the examiner observes for any asymmetries
in any of the soft tissues or bony landmarks of the lumbo-pelvic region
and lower extremities. For patients with knee pain, the clinician should
pay particular attention to observing the knees for the following:
signs of swelling, ecchymosis, deformity (increased varus/valgus,
limited extension, hyperextension), and range of motion restrictions.
Additionally, the ankle and foot mechanics should be noted in stance
and with gait.
The examiner should observe the patient from the anterior, posterior,
and lateral views.

Functional Tests
The patient should demonstrate any functional movement or activity
that reproduces symptoms. These functional movements often include
one or more of the follovwing activities: walking, jogging, hopping,
squatting, stepping up/down a step, transferring from sit to stand, and
single leg standing.
These tests allow for a quick functional screen of the patient’s entire
lower quarter. Appropriate selection of the tests should be based on the
patient’s age, activity level, and severity of pain. The clinician should
assess the quality and quantity of motion and any change in symptoms
with test performance.

Palpation
The examiner palpates the knee region starting superficially and
progressing to deeper structures. The examiner palpates for the
presence of any temperature changes, moisture, soft tissue or lymph
node swelling, and tissue texture abnormalities.
Depending on the patient history and the clinician’s hypothesis of what
regions are involved in the patient’s pain or dysfunction, the clinician
may also decide to palpate the hip, gluteal, and lumbo-sacral regions.
 Knee Examination f247

Anterior View Lateral View Posterior View

Functional Test: Step Down Functional Test: Squat

Knee

Anterior Knee Posterior Knee

248e Musculoskeletal Examination

Active Range of Motion (AROM), Passive Range of

Motion (PROM), & Overpressure:
With the patient supine, the examiner asks the patient to perform the
following motions while assessing the quality and quantity of motion
and change in symptoms. After performing active range of motion, the
examiner passively moves the joint through maximal range of motion
(as tolerated by the patient), applies overpressure, and assesses range
of motion, pain reproduction, and end-feel. ROM can be quantified
with a standard goniometer or gravity/bubble inclinometer.
Flexion
Supine: The patient is asked to bring the heel toward the buttock,
bending the knee as far as possible. The examiner then flexes the
knee through full passive range of motion. Overpressure can be
applied at the end range of motion.
Extension
Supine: The patient is asked to straighten the knee as far as possible.
The examiner then extends the knee through full passive extension range
of motion. Overpressure can be applied at the end range of motion.

Note: The authors encourage examiners to include hip ROM assessment

in a comprehensive knee examination. Refer to the Hip Chapter for more
information.
 Knee Examination f249

Flexion with Overpressure

Knee

Extension with Overpressure

250e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted tests are performed isometrically and are performed to
assess symptom response & strength. The following table provides
a list of selected resisted tests that should be performed when
examining the knee.

Flexion in Sitting
Sitting: The examiner asks the patient to sit upright and to straighten
the knee to approximately 20-30° knee flexion angle. While stabilizing
the patient’s distal thigh, the patient is then asked to resist examiner’s
downward (flexion) force that is applied to the patient’s distal leg.
Extension in Sitting
Sitting: While stabilizing the patient’s distal thigh, the patient is asked
to resist examiner’s extension force that is applied to the patient’s
distal leg. To apply the extension force, the examiner pulls on the
distal leg with an anteriorly directed force.

Note: The authors encourage examiners to include hip resisted

muscle tests (especially assessment of hip abduction and hip
external rotation strength) in a comprehensive knee examination.
 Knee Examination f251

Resisted Flexion

Knee

Resisted Extension
252e Musculoskeletal Examination

Muscle Length/Flexibility:
These tests are performed to assess the length and/or flexibility of
the muscles that either directly or indirectly impact the knee if tight.
Muscle length can often be quantified with a standard goniometer or
gravity/bubble inclinometer.
Iliopsoas
Supine: Position the patient so that the buttocks and trunk are on the
table. Flex the hips and knees until the lumbar spine is flat against
the table. While maintaining the non-tested LE in this position, slowly
lower the tested LE towards the floor by extending the hip. The final
resting position of the hip can be measured to quantitatively assess
iliopsoas muscle length. For normal length, the thigh should lie parallel
to the treatment table, or fall below the level of the treatment table.
Prone: Stabilize the patient’s ischeal tuberosity with one hand (apply
posterior-to-anterior directed force) and passively extend the patient’s
hip with the other. You should be able to extend the hip at least 10°.

Rectus Femoris
Prone: Stabilize the patient’s ischeal tuberosity with one hand (apply
posterior-to-anterior directed force) and passively flex the patient’s
knee. Keep the hip in midline while performing this test, and don’t
allow either hip to flex.
Hamstrings
Supine: While keeping the non-tested LE stabilized against the table,
flex hip of the tested LE to 90°. Have the patient help you maintain 90°
hip flexion while you passively extend the knee. While no normative
data is available, many determine that the hamstrings are tight if the
patient lacks > 15-20° to reach full extension with this test.
 Knee Examination f253

Iliopsoas in Supine

Iliopsoas in Prone

Rectus Femoris
Knee

Hamstrings
254e Musculoskeletal Examination

Muscle Length/Flexibility Continued:

Tensor Fascia Latae and Iliotibial Band (Ober’s Test)
Sidelying: Stabilize the patient’s pelvis. Flex the bottom LE slightly
to help stabilize the patient in sidelying. Flex the knee and hip of the
tested LE (upper LE), passively abduct the hip, then extend the hip until
the thigh is in line with the body. Keep the knee flexed to 90° while you
lower the thigh. If the hip remains abducted (does not adduct beyond
horizontal), then the patient has tightness of the TFL & ITB.
Gastrocnemius and Soleus
Supine: Passively dorsiflex the patient’s ankle as far as possible and
measure ankle dorsiflexion (DF). Perform test in full knee extension
(assesses the gastrocnemius & soleus muscles) and in knee flexion
(assesses the soleus muscle).
If the patient feels primarily a stretch or pull in the calf region, the
examiner can feel more confident that the muscles are primarily
limiting further ankle DF. If the patient feels pain or stiffness focused
in the ankle is limiting further ankle DF, the examiner must conclude
that a restriction in ankle DF range of motion (and not muscle length)
is limiting the test.
 Knee Examination f255

Tensor Fascia Latae and

Iliotibial Band

Gastrocnemius

Knee

Soleus
256e Musculoskeletal Examination

Assessment of Accessory Movements:

The examiner investigates accessory movement of the knee with the
patient in supine. With all accessory movement tests, pain responses
are recorded, and mobility judgments are established as hypermobile,
normal, or hypomobile.
Anterior Glide of the Tibia
Passively flex the knee to 90° and apply an anteriorly directed force to
the proximal tibia.
Posterior Glide of the Tibia
Passively flex the knee to 90° and apply a posteriorly directed force to
the proximal tibia.
Anterior and Posterior Glide of the Proximal Fibula
Passively flex the patient’s knee approximately 90° and sit on the
patient’s toes to help stabilize the lower extremity. While using one hand
to stabilize the proximal tibia, use the other hand to grasp the proximal
fibula and apply a posteriorly (and slightly medial) directed force to
assess anterior-to-posterior motion. Apply an anteriorly (and slightly
lateral) force to assess posterior-to-anterior motion.
Patellar Glides
Passively flex the patient’s knee approximately 30° and place it either
over your knee or a bolster to keep it stable. Cup the patella with
your more caudal hand (relative to the patient) to guide motion, and
place the palm of your more cephalad hand over the base and anterior
surface of the patella for force application. Apply an inferiorly directed
force to the patella to assess inferior glide.
In order to assess superior patellar glide, simply reverse hand positions
(your cephalad hand cups and guides motion of the patella while your
caudad hand is placed over the apex and anterior patella for force
application). Apply a superiorly directed force to the patella to assess
superior glide.
With both inferior and superior glide assessment, be careful not to
apply compressive force to the patella as this can easily aggravate
symptoms. It is less likely that you will apply a compressive force to
the patella if you crouch over and get your forearms in parallel with the
plane of movement of the patella.
A medial glide to the patella is performed with the knee in full extension,
glide the patella from lateral to medial to assess medial glide. Be
sure to compare to the uninvolved lower extremity. This can also be
performed in progressive degrees of knee flexion.
 Knee Examination f257

Anterior Glide of the Tibia Posterior Glide of the Tibia

Anterior and Posterior Glides

of the Fibula

Knee

Inferior Glide to the Patella Superior Glide to the Patella

258e Musculoskeletal Examination

Special Tests:
Lachman Test
Purpose:
To test for the integrity of the anterior cruciate ligament (ACL).
Description:
The patient is supine and the tested LE is placed in approximately 20°
knee flexion. The distal thigh should be stabilized, and the examiner
attempts to translate the leg anteriorly on the stabilized femur.
There are several methods used by clinicians to stabilize the patient’s
distal thigh. The method shown here uses the examiner’s thigh and
hand for stabilization, while allowing the examiner to simultaneously
palpate the joint line for tibial translation.

Positive Test:
The test result is considered to be positive if there is a lack of end
point for tibial translation, or if there is excessive tibial translation.
Diagnostic Accuracy:13-18
Sensitivity = .65 - .99 - LR = 0.19 - 0.83
Specificity = .42 - .97 + LR = 1.12 - 27.3

Reliability:
For positive or negative findings.
Kappa = .19 (inter- examiner) to Kappa = .51 (intra-examiner).14
End-feel assessment (“hard” or “soft”), Kappa = .33 (intra- examiner).14
 Knee Examination f259

Lachman’s Test

Knee
260e Musculoskeletal Examination

Anterior Drawer Test

Purpose:
To test the integrity of the anterior cruciate ligament (ACL).
Description:
The patient is supine and the tested LE is placed in approximately 90°
knee flexion. The examiner sits on the patient’s toes to help stabilize
the LE. The examiner then grasps the proximal leg as shown and
attempts to translate the leg anteriorly. By using the hand position
shown with the thumbs placed over the joint line, the examiner is
able to palpate the joint line for tibial translation.

Positive Test:
The test is considered positive if there is a lack of end point for tibial
translation, or if there is excessive tibial translation.
Diagnostic Accuracy:13,15-20
Sensitivity = .41 - .91 - LR = .09 - .62
Specificity = .86 - 1.0 + LR = 5.4 - 8.2
Reliability:
For findings of normal or abnormal in patients with knee OA.
Kappa = .54 (inter- examiner).4
 Knee Examination f261

Anterior Drawer Test

Knee
262e Musculoskeletal Examination

Posterior Drawer Test

Purpose:
To test the integrity of the posterior cruciate ligament (PCL).
Description:
The patient is supine and the tested LE is placed in approximately 90°
knee flexion. The examiner sits on the patient’s toes to help stabilize
the LE. The examiner then grasps the proximal leg as shown and
attempts to translate the leg posteriorly. By using the hand position
shown with the thumbs placed over the joint line, the examiner is
able to palpate the joint line for tibial translation.

Positive Test:
The test result is considered to be positive if there is a lack of end
point for tibial translation, or if there is excessive tibial translation.
Diagnostic Accuracy:19
Sensitivity = .90 - LR = .10
Specificity = .99 + LR = 90
Reliability:
For normal or abnormal findings.
Kappa = .82 (inter- examiner).4
 Knee Examination f263

Posterior Drawer Test

Knee
264e Musculoskeletal Examination

Pivot-Shift Test
Purpose:
To test for the integrity of the anterior cruciate ligament (ACL)
Description:
The patient is supine and must be relaxed. The examiner lifts the
LE keeping the knee fully extended. While applying a valgus stress,
internal rotation force to the leg, and slight axial compression, the
examiner slowly flexes the knee.

Positive Test:
The test result is considered to be positive if the lateral tibial plateau
begins in an anteriorly subluxed position and shifts (or reduces) to a
neutral position at about 30° knee flexion. This occurs because, at
this point, the iliotibial band changes from a knee extender to a knee
flexor, and the anterolateral tibial subluxation shifts, or reduces, back
to a neutral position.
Diagnostic Accuracy:
Sensitivity = .71 - .9015,16,18 - LR = .1815
Specificity = .97 - .9813,15 + LR = 4115
Reliability:
Not reported
 Knee Examination f265

Pivot-Shift Test: Starting Position

Knee

Pivot-Shift Test: Ending Position

266e Musculoskeletal Examination

Valgus Stress Test

Purpose:
To test the integrity of the tibial collateral ligament (TCL).*
Description:
The patient is supine and relaxed. The examiner lifts the LE and flexes
the knee 20°- 30°. While palpating the medial joint line, the examiner
applies a valgus force to the knee. The examiner should be careful to
avoid simultaneously inducing rotary forces to the knee and hip.

Positive Test:
The test result is considered to be positive if pain or laxity are
present.
Diagnostic Accuracy:
Sensitivity = .86 - .9621,22 - LR = NR
Specificity = NR + LR = NR

Reliability:
For findings of normal or abnormal in patients with knee OA.
Kappa = .02 - .66 (inter- examiner). 4,23

* Note: The TCL is also known as the medial collateral ligament, or MCL.
 Knee Examination f267

Valgus Stress Test Starting Position

Knee

Valgus Stress Test Ending Position

268e Musculoskeletal Examination

Varus Stress Test

Purpose:
To test the integrity of the fibular collateral ligament (FCL).*
Description:
The patient is supine and relaxed. The examiner lifts the LE and flexes
the knee 20°- 30°. While palpating the lateral joint line, the examiner
applies a varus force to the knee. The examiner should be careful to
avoid simultaneously inducing rotary forces to the knee and hip.

Positive Test:
The test result is considered to be positive if pain or laxity are present.

Diagnostic Accuracy:22
Sensitivity = .25 - LR = NR
Specificity = NR + LR = NR

Reliability:
Inter-examiner reliability in patients with knee OA.
Kappa = 0.0 - .88.4,23

* Note: The FCL is also known as the lateral collateral ligament, or LCL
 Knee Examination f269

Varus Stress Test: Starting Position

Knee

Varus Stress Test: Ending Position

270e Musculoskeletal Examination

McMurray Test
Purpose:
To test for the presence of a meniscus lesion.
Description:
The examiner flexes the hip and knee maximally, then applies a
valgus force to the knee while externally rotating the leg and passively
extending the knee completely. The maneuver is repeated from full
flexion to full extension while internally rotating the leg and applying
a varus force to the knee. The examiner should palpate the joint line
while performing the test.*
Positive Test:
A palpable click or “thud”, or provocation of pain.
Diagnostic Accuracy:13,24-28
Sensitivity = .16 - .95 - LR = .4 - 2.84
Specificity = .25 - 1.0 + LR = .39 - 11.6
Reliability:
Inter-examiner reliability in patients with knee OA:
Kappa = .1623

* Note that operational definitions for performance of this test, as well

as definitions of a positive test, in the literature are quite variable.
 Knee Examination f271

McMurray Test: Valgus and

External Rotation Component

Knee

McMurray Test: Varus and

Internal Rotation Component
272e Musculoskeletal Examination

Joint Line Tenderness

Purpose:
To test for the presence of a meniscus lesion.
Description:
The examiner palpates the joint line of the knee. This is most often
performed with the knee in 90° flexion.
Positive Test:
Provocation or reproduction of pain.
Diagnostic Accuracy: 13,25,27-30
Sensitivity = .28 - .92 - LR = .08 - 2.53
Specificity = .29 - .97 + LR = .69 - 30.7
Reliability:
Kappa = .21 - .2523
 Knee Examination f273

Palpation for Joint Line Tenderness

Knee
274e Musculoskeletal Examination

Special Tests:
Dynamic Test for Lateral Meniscus Lesions
Purpose:
To test for the presence of a lateral meniscus lesion.
Description:
With the patient in supine, position the hip at 60° abduction, flexed
and externally rotated 45°, and the knee flexed 90°. The lateral
border of the foot should rest on the examination table. Palpate the
lateral joint line. While maintaining pressure over the lateral joint
line, progressively adduct the hip while keeping a 90° knee flexion
angle.
Positive Test:
The test is positive if:
1) any pain that is present with pressure of the finger(s) over the
joint line increases with hip adduction.
2) sharp pain is felt when the final position is achieved.
Diagnostic Accuracy:
Sensitivity = .85 - LR = .1731
Specificity = .90 + LR = 8.531
Reliability:
Kappa = .61 - .8531
 Knee Examination f275

Dynamic Test Starting Position

Knee

Dynamic Test Ending Position

276e Musculoskeletal Examination

Ottawa Knee Rules

Purpose:
To identify the need to order radiographs after knee trauma.
Description:
This is a clinical prediction rule. If one of the following variables is present,
radiographs should be ordered:
1. Age > 55 years
2. Isolated patellar tenderness without other bone
tenderness
3. Tenderness of the fibular head
4. Inability to flex to 90°
5. Inability to bear weight immediately after injury and in the
emergency department (4 steps) regardless of limping.
Diagnostic Accuracy: 32-40
Adult Population:
Sensitivity = 1.0 - LR = 0
Specificity = .49 - .56 + LR = 1.9 - 2.3
Pediatric Population:
Sensitivity = 1.0 - LR = 0
Specificity = .43 + LR = 1.8
Reliability:
Inter-examiner agreement for identification of predictor variables.
Kappa= .7734
 Knee Examination f277
Clinical Diagnosis of Knee Osteoarthritis
Purpose:
To identify the presence of knee osteoarthritis (OA)
Description:
At least three of the following clinical criteria should be met to establish
the diagnosis of knee OA:
1. Age > 50 years
2. Stiffness > 30 min
3. Crepitus
4. Bony tenderness
5. Bony enlargement
6. No palpable warmth
Diagnostic Accuracy:
Sensitivity = .95 - LR = .074
Specificity = .69 + LR = 3.14

Knee
278e Musculoskeletal Examination

Reference List

(1) Pecina MM, Bojanic I. Overuse Injuries of the Musculoskeletal

System. Boca Raton: CRC Press; 1993.
(2) Fishman L, Dombi G, Michaelson C, Ringel S, Rozbruch J,
Rosner B et al. Piriformis syndrome: Diagnosis, treatment
and outcome- a 10-year study. Arch Phys Med Rehabil 2002;
83:295-301.
(3) Jones A, Hopkinson N, Pattrick M, Berman P, Doherty M.
Evaluation of a method for clinically assessing osteoarthritis of
the knee. Ann Rheum Dis 1992; 51(2):243-245.
(4) Cibere J, Bellamy N, Thorne A, Esdaile JM, McGorm KJ,
Chalmers A et al. Reliability of the knee examination in
osteoarthritis: effect of standardization. Arthritis Rheum 2004;
50(2):458-468.
(5) DeHaven KE. Diagnosis of acute knee injuries with
hemarthrosis. Am J Sports Med 1980; 8(1):9-14.
(6) Greenfield B, Tovin B. Knee. Current Concpets in Orthopaedic
Physical Therapy. La Crosse: Orthopaedic Section, American
Physical Therapy Association; 2001.
(7) Hartley A. Practical Joint Assessment. St Louis: Mosby; 1995.
(8) Muellner T, Weinstabl R, Schabus R, Vecsei V, Kainberger F.
The diagnosis of meniscal tears in athletes. A comparison of
clinical and magnetic resonance imaging investigations. Am J
Sports Med 1997; 25(1):7-12.
(9) Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L.
Reproducibility and clinical utility of tendon palpation to detect
patellar tendinopathy in young basketball players. Victorian
Institute of Sport tendon study group. Br J Sports Med 2001;
35(1):65-69.
(10) Cleland J, McRae M. Patellofemoral pain syndrome: a critical
analysis of current concepts. Phys Ther Rev 2002; 7:153-161.
(11) Grelsamer R, McConnell J. The Patella: A Team Approach.
Gaithersburg: Aspen Publishers; 1998.
(12) Cassas KJ, Cassettari-Wayhs A. Childhood and adolescent
sports-related overuse injuries. Am Fam Physician 2006;
73(6):1014-1022.
 Knee Examination f279

(13) Boeree NR, Ackroyd CE. Assessment of the menisci and

cruciate ligaments: an audit of clinical practice. Injury 1991;
22(4):291-294.
(14) Cooperman JM, Riddle DL RJ. Reliability and validity of
judgments of the integrity of the anterior cruciate ligament of
the knee using the Lachman test. Phys Ther 1990; 70:225-233.
(15) Katz J, Fingeroth R. The diagnostic accurcy of ruptures of
the anterior cruciate ligament comparing the Lachman test,
the anterior drawer sign, and the pivot shift test in acute and
chronic knee injuries. Am J Sports Med 1986; 14:88-91.
(16) Kim SJ, Kim HK. Reliability of the anterior drawer test, the
pivot shift test, and the Lachman test. Clin Orthop Relat Res
1995;(317):237-242.
(17) Lee JK, Yao L, Phelps CT, Wirth CR, Czajka J, Lozman J.
Anterior cruciate ligament tears: MR imaging compared with
arthroscopy and clinical tests. Radiology 1988; 166(3):861-864.
(18) Liu SH, Osti L, Henry M, Bocchi L. The diagnosis of acute
complete tears of the anterior cruciate ligament. Comparison of
MRI, arthrometry and clinical examination. J Bone Joint Surg
Br 1995; 77(4):586-588.
(19) Rubinstein RA, Jr., Shelbourne KD, McCarroll JR, et al.
The accuracy of the clinical examination in the setting of
posterior cruciate ligament injuries. Am J Sports Med 1994;
22(4):550-557.
(20) Braunstein EM. Anterior cruciate ligament injuries: a
comparison of arthrographic and physical diagnosis. AJR Am J
Roentgenol 1982; 138(3):423-425.
(21) Garvin GJ, Munk PL, Vellet AD. Tears of the medial collateral
ligament: magnetic resonance imaging findings and associated
injuries. Can Assoc Radiol J 1993; 44(3):199-204.
(22) Harilainen A. Evaluation of knee instability in acute
Knee

ligamentous injuries. Ann Chir Gynaecol 1987; 76(5):269-273.

(23) Dervin GF, Stiell IG, Wells GA, et al. Physicians’ accuracy and
interrator reliability for the diagnosis of unstable meniscal tears
in patients having osteoarthritis of the knee. Can J Surg 2001;
44(4):267-274.
280e Musculoskeletal Examination

(24) Anderson A, Lipscomb A. Clinical diagnosis of meniscal tears.

Description of a new manipulative test. Am J Sports Med 1986;
14:291-293.
(25) Barry O, Smith H, McManus F, MacAuley P. Clinical
assessment of suspected meniscal tears. Ir J Med Sci 1983;
152:149-151.
(26) Evans PJ, Bell GD, Frank C. Prospective evaluation of the
McMurray test. Am J Sports Med 1993; 21(4):604-608.
(27) Fowler P, Lubliner JA. The predictive value of five clinical signs
in the evaluation of meniscal pathology. Arthroscopy 1989;
5:184-186.
(28) Noble J, Erat K. In defence of the meniscus. A prospective
study of 200 meniscectomy patients. J Bone Joint Surg Br
1980; 62-B(1):7-11.
(29) Eren OT. The accuracy of joint line tenderness by physical
examination in the diagnosis of meniscal tears. Arthroscopy
2003; 19(8):850-854.
(30) Shelbourne KD, Martini DJ, McCarroll JR, VanMeter CD.
Correlation of joint line tenderness and meniscal lesions in
patients with acute anterior cruciate ligament tears. Am J
Sports Med 1995; 23(2):166-169.
(31) Mariani PP, Adriani E, Maresca G, Mazzola CG. A prospective
evaluation of a test for lateral meniscus tears. Knee Surg
Sports Traumatol Arthrosc 1996; 4(1):22-26.
(32) Stiell IG, Wells GA, McDowell I, et al. Use of radiography in
acute knee injuries: need for clinical decision rules. Acad Emerg
Med 1995; 2(11):966-973.
(33) Stiell IG, Wells GA, McKnight RD. Validating the “real” Ottawa
Knee Rule. Ann Emerg Med 1999; 33(2):241-243.
(34) Stiell IG, Wells GA, Hoag RH, et al. Implementation of the
Ottawa Knee Rule for the use of radiography in acute knee
injuries. JAMA 1997; 278(23):2075-2079.
(35) Stiell IG, Greenberg GH, Wells GA, et al. Prospective
validation of a decision rule for the use of radiography in acute
knee injuries. JAMA 1996; 275(8):611-615.
 Knee Examination f281

(36) Stiell IG, Greenberg GH, Wells GA, et al. Derivation of a

decision rule for the use of radiography in acute knee injuries.
Ann Emerg Med 1995; 26(4):405-413.
(37) Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa Knee
Rule in children: a multicenter study. Ann Emerg Med 2003;
42(1):48-55.
(38) Khine H, Dorfman DH, Avner JR. Applicability of Ottawa knee
rule for knee injury in children. Pediatr Emerg Care 2001;
17(6):401-404.
(39) Ketelslegers E, Collard X, Vande BB, et al. Validation of the
Ottawa knee rules in an emergency teaching centre. Eur
Radiol 2002; 12(5):1218-1220.
(40) Bachmann LM, Haberzeth S, Steurer J, et al. The accuracy of
the Ottawa knee rule to rule out knee fractures: a systematic
review. Ann Intern Med 2004; 140(2):121-124.
(41) Altman RD. Criteria for classification of clinical osteoarthritis.
J Rheumatol Suppl 1991; 27:10-12.

Knee
282 e Musculoskeletal Examination
 Foot and Ankle Examination f283

Foot and Ankle

Examination
In This Chapter:
1. Historical Examination & Referral Patterns
2. Observation, Functional Quick Tests, and Palpation
3. Active Range of Motion, Passive Range of Motion, and
Overpressure
a. Dorsiflexion & Plantar Flexion
b. Inversion and Eversion
4. Resisted Muscle Tests
a. Dorsiflexion & Plantar Flexion
b. Inversion and Eversion
5. Muscle & Tissue Length/Flexibility
a. Gastrocnemius & Soleus
b. Plantar Fascia
6. Assessment of Accessory Movements
a. Anterior to Posterior Glide & Posterior to Anterior Glide
of the Talus
b. Anterior to Posterior Glide & Posterior to Anterior Glide
of the Distal Fibula
c. Subtalar Joint Inversion/Eversion
7. Special Tests
a. Anterior Drawer
b. Talar Tilt
c. Anterior Impingement Sign
d. Squeeze Test & External Rotation Test
e. Calf Squeeze Test
f. Navicular Drop Test
g. Ottawa Ankle Rules
& Ankle
Foot
284 e Musculoskeletal Examination

Region Specific Historical Examination:

In addition to the historical examination presented in Chapter three,
the patient should be asked specific questions related to the leg,
ankle, and foot, and proximal surrounding regions.
1. Do your symptoms change (better or worse) with any
movements of the low back? Do you have any pain in
your low back, even if you feel it is unrelated to your
leg/ankle/foot pain?
If the patient answers “yes” for either question, the lumbo-
pelvic region and hip should be examined in addition to the
leg, ankle, and/or foot.
2. Does your foot/ankle pain extend up into your knee,
thigh, hip, or back? Do you ever experience numbness
or tingling into the hip, thigh, leg, ankle, or foot?
If the patient answers “yes” for any question, both a LE
neurological screening examination and a lumbar spine
examination should be performed to identify any existing
radiculopathy or radiculitis.
If symptoms are reported in the posterior thigh and perhaps
the calf, but no numbness/tingling, the following diagnoses
should be considered: Ischial bursitis1, Hamstring strain1,
and piriformis syndrome.2
3. Have you recently increased your physical activity,
especially running (distance, terrain, speed) or other
weight-bearing activities?
If the patient answers “yes” the clinician should be suspicious of
a femoral, tibial, or fibular or metatarsal stress reaction or stress
fracture. Muscle sprain/strain should also be considered.
4. Do you have ankle pain or stiffness that eases after a
few hours in the morning?
If the patient answers “yes” the clinician should be suspicious
of knee osteoarthritis.3,4
 Foot and Ankle Examination f285

5. Do you have pain in the bottom of your foot that is

worse when you initially bear weight (especially in the
morning), and also worsens with prolonged time up
on your feet?
If the patient answers “yes” the clinician should be suspicious
of plantar fasciitis/fasciosis and/or calcaneal heel spur.
6. Is your leg, ankle, or foot pain a result of trauma, such
as injury with jumping/landing, changing directions
with your foot planted, or twisting?
If the patient answers “yes” the following diagnoses should
be considered: ligamentous injury, talar dome osteochondral
defect, fracture, ankle sprain.5-8
If the injury described resulted in an eversion, external
rotation, and/or dorsiflexion force to the ankle, the clinician
should be suspicious of syndesmosis injury, fracture, and
talar dome injury (such as osteochondral defect).
7. Have you ever had, or do you presently have
active cancer, paralysis, paresis, recent plaster
immobilization, recent period of bedrest, localized
tenderness over the deep venous system, lower leg
swelling, pitting edema, or collateral superficial veins?
If the patient answers “yes” consider using the clinical
decision rule established by Wells and colleagues9 to identify
deep vein thrombosis.
8. Do you or have you had a sudden episode of redness,
heat, swelling, and pain? Have you recently consumed
greater than normal portions of meats, seafood, beans, or
other foods high in purines? Increased intake of alcohol?
If the patient answers “yes” consider gout as a possible
& Ankle
Foot

diagnosis. A definitive diagnosis is established by finding

uric acid crystals in the joint fluid during a gout attack.
286 e Musculoskeletal Examination

Observation, Functional Quick Tests, and Palpation:

Observation
Watch the patient walk and observe any abnormal gait mechanics
and/or reproduction of symptoms.
With the patient standing, the examiner observes for any asymmetries
in any of the soft tissues or bony landmarks of the hip, gluteal region,
low back, and lower extremities. The examiner should observe the
patient from the anterior, posterior, and lateral views.
Functional Tests
The patient should demonstrate any functional movement or activity
that reproduces symptoms. These functional movements often
include one or more of the following activities: walking, jogging,
hopping, squatting, donning/doffing socks and shoes, transferring
from sit to stand, single leg stance, and going up and down steps.

These tests allow for a quick functional screen of the patient’s entire
lower quarter. Appropriate selection of the tests should be based on
the patient’s age, activity level, and severity of pain. The clinician
should assess the quality and quantity of motion and any change in
symptoms with test performance.
Palpation
The examiner palpates the leg, ankle, and foot regions starting
superficially and progressing to deeper structures. The examiner
palpates for the presence of any temperature changes, moisture,
soft tissue swelling, and tissue texture abnormalities. Additionally,
the examiner should palpate for pulses over the dorsalis pedis artery
and the posterior tibial artery.
 Foot and Ankle Examination f287

Anterior View Lateral View Posterior View

Functional Test: Functional Test:

Step Down Squat

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Foot

Palpation
288 e Musculoskeletal Examination

Active Range of Motion (AROM), Passive Range of

Motion (PROM), and Overpressure:
With the patient in sitting or in supine, the examiner asks the patient to
perform the following motions while assessing the quality and quantity of
motion and change in symptoms. After performing active range of motion,
the examiner passively moves the joint through maximal range of motion
(as tolerated by the patient), applies overpressure, and assesses range
of motion, pain reproduction, and end-feel. ROM can be quantified with a
standard goniometer or gravity/bubble inclinometer.
Dorsiflexion and Plantar Flexion
The patient is asked pull the toes and foot upwards toward the head.
While maintaining the ankle in a neutral rotation, without allowing ankle
inversion or eversion, the clinician moves the ankle through full passive
dorsiflexion range of motion. Overpressure can be applied at the end
range of motion.
Next, the patient is asked to point the toes, causing ankle plantarflexion..
This will cause the patient to plantar flex his ankle. The clinician then
moves the ankle through full passive plantar flexion range of motion.
Overpressure can be applied at the end range of motion.
Inversion and Eversion
The patient is asked to invert the foot. Cues from the clinician can include
visual cues (showing the patient how to move the foot), verbal cues (“turn
your foot inward as if you were trying to look at the bottom of the foot”), etc.
The clinician then moves the ankle through full inversion. Overpressure
can be applied at the end range of motion.
Next, the patient is asked to evert the foot, or turn the foot outward. The
clinician then moves the ankle through full eversion. Overpressure can be
applied at the end range of motion.
 Foot and Ankle Examination f289

Dorsiflexion with Overpressure

Plantar Flexion with Overpressure

Inversion with Overpressure

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Foot

Eversion with Overpressure

290 e Musculoskeletal Examination

Resisted Muscle Tests:

Resisted tests are performed isometrically and are performed to
assess symptom response and strength. The following list provides
selected resisted tests that should be performed when examining the
leg, ankle, and foot region. Tests can be performed with the patient
in sitting, supine, or prone. Tests will be shown here with the patient
in a seated position.
Dorsiflexion and Plantar Flexion
The patient is asked pull the toes and foot upwards toward the head.
The clinician should allow slight inversion with this motion. While
stabilizing the patient’s leg, the patient is asked to resist and inferiorly
directed force produced by the examiner downward through the distal
half of the foot. Additionally, a slight eversion force should be applied.
This test will preferentially test the tibialis anterior muscle.
Next, the patient is asked to point the toes, causing ankle plantarflexion.
This will cause the patient to plantar flex his ankle. While stabilizing
the patient’s leg, the patient is asked to resist an upwardly directed
force produced by the examiner through the distal half of the foot.
Note that only substantial weakness in plantar flexion strength will
be detected with a manual muscle test. Single leg heel raises (the
patient repeatedly lifts up onto the toes while in single leg stance)
will challenge the plantar flexion musculature more appropriately for
patients with normal or close to normal strength.
Inversion and Eversion
The patient is asked to invert the foot and point the toes downwards
slightly to get the foot positioned into a combined position of inversion
and plantar flexion. Cues from the clinician can include visual cues
(showing the patient how to move the foot), verbal cues (“turn your
foot inwards as if you were trying to look at the bottom of the foot”),
etc. While stabilizing the leg, the clinician then asks the patient to
resist force applied in an upward (dorsiflexion) and outward (eversion)
direction. This test will preferentially test the tibialis longus muscle and
other key muscles that plantarflex and invert the ankle.
Next, the patient is asked to evert the foot, or turn the foot outward,
and point downwards slightly to get the foot positioned into a combined
position of eversion and plantar flexion. While stabilizing the leg, the
clinician then asks the patient to resist force applied in an upward
(dorsiflexion) and inward (inversion) position. This test will preferentially
test the fibularis longus and brevis.
 Foot and Ankle Examination f291

Resisted Dorsiflexion

Resisted Plantarflexion

Resisted Inversion
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Foot

Resisted Eversion
292 e Musculoskeletal Examination

Muscle Length/Flexibility:
These tests are performed to assess the length and/or flexibility of the
ankle, leg, and associated tissues.The following table provides a list of
selected resisted tests that should be performed when examining this
region. Muscle length can often be quantified with a standard goniometer
or gravity/bubble inclinometer.
Gastrocnemius and Soleus
Supine: Passively dorsiflex the patient’s ankle as far as possible
and measure ankle dorsiflexion (DF). Perform the test in full knee
extension (assesses the gastrocnemius and soleus muscles) and in
knee flexion (assesses the soleus muscle).
If the patient feels a stretch or pull in the calf or Achilles tendon region,
the examiner can feel more confident that the muscles are primarily
limiting further ankle DF. If the patient feels pain or stiffness in the
ankle is limiting further ankle DF, the examiner should conclude that
a joint restriction in ankle DF range of motion, and not muscle length,
may be the primary factor limiting DF range of motion.
Plantar Fascia
The clinician passively dorsiflexes the patient’s ankle and, while
maintaining ankle dorsiflexion, extends the toes. This test should
be performed with the knee in flexion to minimize the stretch to the
gastrocnemius muscle.
 Foot and Ankle Examination f293

Gastrocnemius

Soleus

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Foot

Plantar Fascia
294 e Musculoskeletal Examination

Assessment of Accessory Movements

The examiner investigates accessory movement of the ankle joint
in supine and prone. With all tests, pain responses are recorded
and mobility judgments are established as hypermobile, normal, or
hypomobile.
Posterior to Anterior Glide of the Talus
Supine/sitting: With the patient’s foot draped just off the edge of the
plinth, the clinician will stabilize the anterior distal leg with one hand.
Use the other hand to grasp the posterior talus and rearfoot and
move the talus/rearfoot anteriorly on the stabilized leg.
Anterior to Posterior Glide of the Talus
Supine/sitting: With the patient’s foot draped just off the edge of
the plinth, the clinician will stabilize the posterior distal leg with one
hand. Use the other hand to grasp the talus and move the foot/talus
posteriorly on the stabilized lower leg.
Anterior to Posterior Glides of the Distal Fibula
Supine/sitting: With the patient’s heel draped just off the edge of the
plinth, the clinician will stabilize the distal tibia with one hand. Grasp
the end of the fibula with the thenar eminence of the other hand and
move the distal fibula posteriorly on the stabilized tibia.
Posterior to Anterior Glides of the Distal Fibula
Supine/sitting: As above, except the clinician will now stabilize the
distal fibula with one hand, grasp the end of the tibia with the other
hand, and move the distal tibia posteriorly on the stabilized fibula.
Prone, with the patient’s foot draped just off the edge of the plinth,
the clinician will stabilize the distal tibia with one hand. Grasp the
end of the fibula with the thenar eminence of the other hand and
move the distal fibula anteriorly on the stabilized tibia.
Subtalar Joint
Sitting, with the patient in sitting with the foot draped just off the edge
of the plinth, the clinician stabilizes the distal leg with one hand and
use the other hand to grasp the calcaneus with the ankle positioned
in neutral. The clinician then passively moves the rearfoot into
inversion and into eversion.
 Foot and Ankle Examination f295

Anterior Glide of Talus Posterior Glide of Talus

Posterior Glide to Fibula Anterior Glide to Fibula

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Ankle Eversion Ankle Inversion

296 e Musculoskeletal Examination

Special Tests:
Anterior Drawer
Purpose:
To test for ligamentous laxity of the ankle (predominately tests
anterior talofibular ligament).
Description:
The patient is in sitting or supine. The distal leg is stabilized anteriorly.
The clinician grasps the patient’s rearfoot, positions the ankle in 10-15
degrees plantar flexion, and translates (“draws”) the rearfoot anteriorly.
Positive Test:
The test result is considered to be positive if the talus translates or subluxes
anteriorly. It is often graded on a 4-point scale, ranging from “0” indicating
no laxity to “3” indicating gross laxity.
Diagnostic Accuracy:
Acute testing (<48 hrs after injury):
Sensitivity = 0.71 - LR = 0.8810
Specificity = 0.33 + LR = 1.0610

Reliability:
Not reported
 Foot and Ankle Examination f297

Anterior Drawer Test

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298 e Musculoskeletal Examination

Talar Tilt
Purpose:
To test for injury of the lateral ankle ligaments.
Description:
The patient is in sitting or supine. The distal leg is stabilized and the ankle
is inverted. The clinician determines the amount of inversion.
Positive Test:
The amount of ankle laxity is used to grade the test. A 4-point
scale, ranging from “0” indicating no laxity to “3” indicating gross laxity. An
alternative method for grading is based on the degrees of inversion
(<5 deg, 5-15 deg, >15 deg).
Diagnostic Accuracy:
Under general anesthetic, ≥ 15˚ inversion, or tilt, was always
associated with complete anterior talofibular ligament and
calcaneofibular ligament rupture.12
Reliability:
Not reported
 Foot and Ankle Examination f299

Talar Tilt Test

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Foot
300 e Musculoskeletal Examination

Impingement Sign
Purpose:
To test for anterior impingement at the talocrural joint.
Test One:
Description:
With the patient seated, the clinician grasps the calcaneus with
one hand and uses the other hand to grasp the forefoot and bring
it into plantarflexion. Then the examiner places the thumb over the
anterolateral ankle. While maintaining pressure over the anterolateral
ankle, the foot is then brought from plantarflexion to dorsiflexion.
Positive Test:
If pain is provoked with pressure from the examiner’s thumb, and the pain
is greater in dorsiflexion than in plantarflexion, then the test is positive.
Diagnostic Accuracy:
Sensitivity = .95 - LR = .0613
Specificity = .88 + LR = 7.913
Reliability:
Not Reported
Test Two:
Description:
Record aggravating factors and loss of motion. Examination
includes observation of swelling, passive forced ankle dorsiflexion
and eversion, AROM, and double and single leg squats.
Positive Test:
The test is positive if ≥ 5 of the following findings are positive:
1. Anterolateral ankle joint tenderness.
2. Anterolateral ankle joint swelling.
3. Pain with forced dorsiflexion and eversion.
4. Pain with single leg squat.
5. Pain with activities.
6. Ankle instability.
Diagnostic Accuracy:
Sensitivity = .94 - LR = .0814
Specificity = .75 + LR = 3.814
 Foot and Ankle Examination f301

Ankle Impingement Test: Starting Position

& Ankle

Ankle Impingement Test: Ending Position

Foot
302 e Musculoskeletal Examination

Squeeze & External Rotation Tests

Purpose:
Both tests are for identifying tibiofibular syndesmotic injuries.

Squeeze Test
Description:
The patient is supine. Compress and release the tibia and fibula
together midway up the calf.
Positive Test:
If pain is provoked in the area of the syndesmosis, the test is positive.
Reliability:
Kappa = .515

External Rotation Test

Description:
The patient is supine or seated. The examiner maintains ankle dorsiflexion
and externally rotates the foot on a stabilized leg.
Positive Test:
If pain is provoked in the area of the syndesmosis (anterior or posterior),
or over the interosseous membrane, the test is positive.
Reliability:
Kappa = .7515

Diagnostic Accuracy (both tests)16

Values not reported. However, a relationship existed between confirmed
diagnosis of syndesmosis through arthroscopic visualization and the
squeeze test (p=0.02) and the ER test (p=0.03).
 Foot and Ankle Examination f303

Squeeze Test

& Ankle

External Rotation Test

Foot
304 e Musculoskeletal Examination

Calf Squeeze Test

Purpose:
To detect Achilles Tendon ruptures or tears.
Description:
With the patient in prone, gently squeeze the calf.
Positive Test:
The ankle remains still, or there is minimal plantarflexion relative to
the other side.
Diagnostic Accuracy: 17,18
Sensitivity = .96 - LR = .04
Specificity = .93 + LR = 13.7
Reliability:
Not reported
 Foot and Ankle Examination f305

Calf Squeeze Test

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306 e Musculoskeletal Examination

Navicular Drop Test

Purpose:
A measurement of navicular height.
Description:
Mark the navicular tuberosity. Measure navicular height with the patient
in subtalar neutral position with most weight on the contralateral lower
extremity. Measure again maintaining the patient in relaxed bilateral
stance and full weight-bearing. The difference between these two
measurements is the navicular drop.
Reliability:19-23
Intra-examiner: .33 - .90
Inter-examiner: .31 - .74
 Foot and Ankle Examination f307

Navicular Drop Test: Measurement in Subtalar Neutral

& Ankle

Navicular Drop Test: Measurement in Relaxed Stance

Foot
308 e Musculoskeletal Examination

Ottawa Ankle Rules

Purpose
To determine the need to order radiographs after acute ankle injury.
Refer for radiographs:
If there is pain in the malleolar or midfoot area, and any one of the
following:
An inability to bear weight both immediately after injury and in the
emergency department for four steps.
Bone tenderness along any of the following areas:
• the distal 6 cm of the posterior edge of the tibia or tip of
the medial malleolus
• the distal 6 cm of the posterior edge of the fibula or tip of
the lateral malleolus
• the base of the fifth metatarsal (for foot injuries), or the
navicular bone (for foot injuries).

Diagnostic Accuracy (pooled from 27 studies)24

Sensitivity = .98 - LR = .10
 Foot and Ankle Examination f309
MALLEOLAR
ZONE
A) Posterior
edge or
tip of lateral MIDFOOT
malleolus ZONE
6 cm

B) Base of 5th
Metatarsal

LATERAL VIEW

MALLEOLAR
ZONE
C) Posterior
edge or
MIDFOOT tip of medial
ZONE 6 cm malleolus

D) Navicular

MEDIALVIEW
& Ankle
Foot

Used with permission from Stiell, I.

et al. BMJ 1995;311:594-597
310 e Musculoskeletal Examination

Reference List

(1) Pecina MM, Bojanic I. Overuse Injuries of the Musculoskeletal

System. Boca Raton: CRC Press; 1993.
(2) Fishman L, Dombi G, Michaelson C, et al. Piriformis syndrome:
Diagnosis, treatment and outcome- a 10-year study. Arch Phys
Med Rehabil 2002; 83:295-301.
(3) Jones A, Hopkinson N, Pattrick M, et al. Evaluation of a
method for clinically assessing osteoarthritis of the knee. Ann
Rheum Dis 1992; 51(2):243-245.
(4) Cibere J, Bellamy N, Thorne A, et al. Reliability of the knee
examination in osteoarthritis: effect of standardization. Arthritis
Rheum 2004; 50(2):458-468.
(5) DeHaven KE. Diagnosis of acute knee injuries with
hemarthrosis. Am J Sports Med 1980; 8(1):9-14.
(6) Greenfield B, Tovin B. Knee. Current Concpets in Orthopaedic
Physical Therapy. La Crosse: Orthopaedic Section, American
Physical Therapy Association; 2001.
(7) Hartley A. Practical Joint Assessment. St Louis: Mosby; 1995.
(8) Muellner T, Weinstabl R, Schabus R, et al. The diagnosis
of meniscal tears in athletes. A comparison of clinical and
magnetic resonance imaging investigations. Am J Sports Med
1997; 25(1):7-12.
(9) Wells PS, Anderson DR, Bormanis J, et al. Value of
assessment of pretest probability of deep-vein thrombosis in
clinical management. Lancet 1997; 350(9094):1795-1798.
(10) van Dijk CN, Mol BW, Lim LS, et al. Diagnosis of ligament
rupture of the ankle joint. Physical examination, arthrography,
stress radiography and sonography compared in 160
patients after inversion trauma. Acta Orthop Scand 1996;
67(6):566-570.
(11) van Dijk CN, Lim LS, Bossuyt PM, Marti RK. Physical
examination is sufficient for the diagnosis of sprained ankles.
J Bone Joint Surg Br 1996; 78(6):958-962.
(12) Gaebler C, Kukla C, Breitenseher MJ, et al. Diagnosis of lateral
ankle ligament injuries. Comparison between talar tilt, MRI and
operative findings in 112 athletes. Acta Orthop Scand 1997;
68(3):286-290.
 Foot and Ankle Examination f311
(13) Molloy S, Solan MC, Bendall SP. Synovial impingement in
the ankle. A new physical sign. J Bone Joint Surg Br 2003;
85(3):330-333.
(14) Liu SH, Nuccion SL, Finerman G. Diagnosis of anterolateral
ankle impingement. Comparison between magnetic resonance
imaging and clinical examination. Am J Sports Med 1997;
25(3):389-393.
(15) Alonso A, Khoury L, Adams R. Clinical tests for ankle
syndesmosis injury: reliability and prediction of return to
function. J Orthop Sports Phys Ther 1998; 27(4):276-284.
(16) Beumer A, Swierstra BA, Mulder PG. Clinical diagnosis of
syndesmotic ankle instability: evaluation of stress tests behind
the curtains. Acta Orthop Scand 2002; 73(6):667-669.
(17) Maffulli N. The clinical diagnosis of subcutaneous tear of the
Achilles tendon. A prospective study in 174 patients. Am J
Sports Med 1998; 26(2):266-270.
(18) Maffulli N, Kenward MG, Testa V, et al. Clinical diagnosis of
Achilles tendinopathy with tendinosis. Clin J Sport Med 2003;
13(1):11-15.
(19) Picciano AM, Rowlands MS, Worrell T. Reliability of open
and closed kinetic chain subtalar joint neutral positions
and navicular drop test. J Orthop Sports Phys Ther 1993;
18(4):553-558.
(20) Saltzman CL, Nawoczenski DA, Talbot KD. Measurement of
the medial longitudinal arch. Arch Phys Med Rehabil 1995;
76(1):45-49.
(21) Sell KE, Verity TM, Worrell TW, Pease BJ, Wigglesworth J.
Two measurement techniques for assessing subtalar joint
position: a reliability study. J Orthop Sports Phys Ther 1994;
19(3):162-167.
(22) Vinicombe A, Raspovic A, Menz HB. Reliability of navicular
displacement measurement as a clinical indicator of foot
posture. J Am Podiatr Med Assoc 2001; 91(5):262-268.
(23) Menz HB, Tiedemann A, Kwan MM, et al. Reliability of clinical
tests of foot and ankle characteristics in older people. J Am
Podiatr Med Assoc 2003; 93(5):380-387.
& Ankle
Foot

(24) Bachmann LM, Kolb E, Koller MT, et al. Accuracy of Ottawa

ankle rules to exclude fractures of the ankle and mid-foot:
systematic review. BMJ 2003; 326(7386):417.
312 e Musculoskeletal Examination

What Is
On The CD?

CD Contents
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contains linked videos of the tests described within the chapters of
the book.

Click the movie reel icon next to any image in the online
version of the book to play the associated video.

Minimum System Requirements

Supported Windows Operating Systems:
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• XP
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Supported Macintosh Operating Systems:

• 10.2.8 - 10.4.9

the following software applications must be downloaded to enjoy the

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P
 Index
f313

Index

Reliability Definition 8
Diagnostic Accuracy Definition 8
Diagnosis Definition 8
Sensitivity Definition 9
Specificity Definition 9
Likelihood Ratios 9
Psychometric Properties of Self-Report Measures 13
Medical Screening Examination 19
Peripheral Arterial Disease 24
Deep Vein Thrombosis 25
Gastrointestinal 26
Genitourinary 28
Endocrine 30
Pulmonary System 31
Cranial Nerve Number and Function 44
Examination of Myotomes 50
Cervical Nerve Roots 50
Nerve Root Level, Major Muscles Innervated, and Test Procedure 50
Lumbosacral Nerve Roots 54
Sensory Examination: Segmental Nerve Root Level 58
Cervical Spine 58
Lumbosacral Spine 60
Sensory Examination: Peripheral Nerve Fields 62
Peripheral Nerve and Area of Sensory Distribution Tested 62
Lower Motor Neuron Reflexes 66
Cervical Reflexes 66
Reflex, Corresponding Cervical Nerve Root Level, and Procedure 66
Lumbar Reflexes 68
Upper Motor Neuron Reflexes 70
Reflex, Test Procedure, and Criteria for Positive Findings 70
Radiographs and Cervical Spine Trauma 74
Active Range of Motion of the Ribcage: 82
Deep Neck Flexor Endurance 84
314 e Musculoskeletal Examination

Posteroanterior Mobility 86
Segmental Mobility 88
Spurling’s Test 90
Cervical Rotation Lateral Flexion (CRLF) Test 92
Sharp-Purser Test 94
Cervical Distraction Test 96
Upper Limb Tension Test A (ULLT) 98
Diagnosis of Cervical Radiculopathy 100
Thoracic Spine Manipulation 101
Techniques Performed in Supine: 112
Posterior Glide of Humerus 112
Anterior/Posterior Glide of Acromioclavicular Joint 112
Acromioclavicular lesions 114
Labral tears 114
Acromioclavicular lesions 114
Identification of Subacromial Impingement Syndrome 116
Hawkins-Kennedy Impingement Sign 116
The Painful Arc Sign 116
Infraspinatus Muscle Test: 116
Apprehension Test 118
Biceps Load Test II 120
Identification of a Full-Thickness Rotator Cuff Tear 122
The Drop-Arm Sign 122
The Painful Arc Sign 122
Infraspinatus Muscle Test 122
Techniques Performed Supine 132
Ulnar Nerve Compression Test 134
Elbow Extension Test 136
Varus and Valgus Stress Test 138
Varus Stress Test 138
Valgus Stress Test 138
Moving Valgus Stress Test 140
Tests for Lateral Epicondylalgia 142
Thumb Abduction and Adduction 152
Radiocarpal Dorsal Glide 156
Radiocarpal Volar Glide 156
Radiocarpal Radial/Ulnar Glide 156
Dorsal/Volar Glide of MCPs, IPs, and DIPs 156
 Index
f315

Axial Loading of the Thumb 158

Scaphoid Shift Test 160
Finkelstein Test 162
Carpal Compression Test 164
Diagnosis of Carpal Tunnel Syndrome 166
Lateral Deviation 174
Protrusion and Retrusion 174
Mandibular Depression 176
Mandibular Elevation 176
Lateral Deviation 176
Mandibular Distraction 178
Anterior Glide of Mandible 178
Lateral Glide of Mandible 178
Auscultation During Active Movement 180
Flexion in Supine (Active Sit-Up Test) 192
Extension in Prone (Extensor Endurance Test) 192
Posteroanterior Mobility 194
Gillet Test 196
Seated Flexion Test 198
Straight Leg Raise 202
Posterior Shear (POSH) Test 204
Gaenslen Test 206
Flexion, Abduction, External Rotation Test 208
(FABER or Patrick’s Test) 208
Prone Instability Test (PIT) 212
Inferior Glide of the Femur 230
Posterior Glide of the Femur 230
Lateral Glide of the Femur 230
Long-Axis Distraction of the Hip Joint 230
Anterior Glide of the Femur 230
Flexion, Abduction, External Rotation Test 232
(FABER or Patrick’s Test) 232
Identification of Hip Osteoarthritis 234
Flexion, Adduction, Internal Rotation (FAIR) Test 238
Tensor Fascia Latae and Iliotibial Band (Ober’s Test) 254
Gastrocnemius and Soleus 254
Anterior Glide of the Tibia 256
Posterior Glide of the Tibia 256
316 e Musculoskeletal Examination

Patellar Glides 256

Lachman Test 258
Anterior Drawer Test 260
Posterior Drawer Test 262
Pivot-Shift Test 264
Valgus Stress Test 266
McMurray Test 270
Joint Line Tenderness 272
Dynamic Test for Lateral Meniscus Lesions 274
Ottawa Knee Rules 276
Clinical Diagnosis of Knee Osteoarthritis 277
Gastrocnemius and Soleus 292
Plantar Fascia 292
Posterior to Anterior Glide of the Talus 294
Anterior to Posterior Glide of the Talus 294
Anterior to Posterior Glides of the Distal Fibula 294
Posterior to Anterior Glides of the Distal Fibula 294
Subtalar Joint 294
Anterior Drawer 296
Talar Tilt 298
Impingement Sign 300
Squeeze & External Rotation Tests 302
Calf Squeeze Test 304
Navicular Drop Test 306
Ottawa Ankle Rules 308
I have been teaching management of musculoskeletal conditions since 1979. For the
first time, I feel confident recommending a book to students and practitioners. This
book clearly distinguishes itself from the encyclopedic approach of its competitors. The
descriptions of the tests and measures are clearly presented. Most importantly, they
are presented in an evidence-based format (as opposed to the authoritative approach
of all other authors), which is invaluable for those who espouse to teach and practice
using evidence-based principles.

Anthony Delitto, PT, PhD, FAPTA

Professor and Chair, Department of Physical Therapy, University of Pittsburgh

Musculoskeletal pain is one of the most common complaints seen by family practitio-
ners. This is an excellent resource to provide clinicians with the current best evidence
for effectively and efficiently examining and diagnosing these patients. It is a valuable
evidence-based resource for those learning and teaching how to evaluate musculosk-
eletal complaints. A must-have resource for medical, PA and NP students, physical
therapists, residents, faculty and sports-medicine fellows seeking greater depth in
musculoskeletal evaluation.

Keith S. Dickerson, MD, MS

Faculty Physician, St. Mary's Family Medicine Residency, Grand Junction, CO

Students and seasoned clinicians alike all wrestle with the problems of data smog,
clear operational test definitions, and “how-to factor” related to tests and measures of
the clinical examination for musculoskeletal problems. This remarkable text and
accompanying CD has met those challenges head-on and the result is a “1-thing” you
need to know virtual clinical mentor for healthcare professionals of every background
who encounter or manage patients with musculoskeletal disorders.

Robert S. Wainner, PT, PhD

Associate Professor, Texas State University

ISBN 978-0-9714792-3-4