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Orthopedic exams
neuromusculoskeletal orthos
| test | steps and interpretation |
|---|---|
| Brudzinski | passively flex neck of supine patient to chest. If patients hips and knees flex = meningitis |
| cervical compression | patient sits while doctor presses on vertex of the head. Subluxation, arthritis, facet degeneration |
| cervical distraction | pt seated. doc applies upward pressure on occiput. If pain is relieved nerve root compression of facet joint pathology. If pain increases sprain/strain. |
| Dejerine's triad | seated pt coughs, strains and sneezes. Pain = space occupying lesion |
| Kernig | pt supine with hips and knees flexed, doctor extends knee. Pain or causes other knee to buckle = meningeal irritation, meningitis, subarachnoid hemmorrhage |
| Rinne | Place tuning fork over mastoid process, pt says when the sound is no longer heard (Bone Conduction) Place vibrating tuning fork 1" from the ear and repeat (Air conduction)If BC>AC conduction loss otitis media. AC and BC decreased nerve conduction deficit |
| Weber | Place vibrating tuning fork on vertex of pt's head and ask where the sound is loudest. sound should be equal in both ears. |
| Bonnet | Pt supine. Doc raises extended leg, internally rotates foot and adducts extended limb = piriformis syndrome |
| Bowstring | Pt supine. Lift affected leg with knee flexed and place on Doc's shoulder. apply firm pressure on hamstring muscles and then in popliteal fossa. irritation of roots of sciatic nerve. |
| Braggard | If SLR test, lower the leg 5 degrees below pained dorsiflex foot. pain = irritation of the roots of the sciatic nerve |
| Double leg raise | SLR on each leg separately noting which angle pain was produced. Raise both legs together noting angle of pain. If the angle of pain of both legs raised is less than single SLR = lumbosacral joint involvement |
| Lasegue | Pt supine legs extended. Doc grabs heel with other hand on the knee, Flex hip while knee is flexed, slowly extend knee while leg is elevated. if ext is limited due to pain = sciatic nerve of nerve root irritation |
| Lewin's supine | Pt supine. stabilize thighs or legs on table and ask pt to sit up without using hands. Pain or inability = sciatica or lumbosacral pathology |
| Lindner | Pt supine. passively flex patients head and then neck to chest. Pain along L-spine and along sciatic nerve distribution = sciatica due to herniation especially with a lateral disc herniation |
| Milgram | Pt supine. Pt raises both extended legs so heels are 6 inches off the table and holds them of 30 seconds. disc lesion or raised intrathecal pressure |
| Sicard | If SLR is positive, lower leg just below point of pain. quickly extend big toe of affected foot. Pain = sciatic nerve root compression |
| SLR | Pt supine. raise leg off table. Pain 0-35 extradural nerve root irritation, 35-70 disc herniation causing sciatica, 70< lumbosacral joint disease (no further stretch on nerve) |
| Well leg raise aka Fajersztajn | pt supine. Doc raises the asymptomatic extended leg and dorsiflexes foot. if pain is caused to opposite, affected leg = disc compression of roots of sciatic nerve (medial disc protrusion on contralateral side) or dural sleeve adhesions |
| Ely | Pt prone. doc flexes knee and puts heel to opposite buttocks (iliopsoas pathology or inflamed roots of the femoral nerve). after knee flexion thigh is hyperextended. If cannot be hyperextended = hip lesion |
| Femoral nerve stretch | Pt prone. stabilize hip by placing one hand on ilium, passively flex knee and extend hip. if ext hip causes pain along anterior thigh = femoral nerve irritaion |
| Nachlas | pt prone. flex knee of prone patient to same side buttock while exerting downward pressure on the pelvis to prevent buckling to the hips. Pain in lumbosacral or sacroiliac regions = lumbosacral pathology |
| adam supported aka belt test | Doc asks pt to bend forward and notes pain. Doctor braces hips against pt's sacrum by holding ASIS' pt bends forward. If pain after second maneuver = lumbar problem. If pain is absent during second maneuver = pelvic problem |
| antalgic lean | Pt's backache caused by disc herniation lateral to nerve root, pt leans away from side with lesion. if herniation is medial to nerve root pt leans to side with lesion. Post central disc herniation pt stands straight and stiff in slight flexion. |
| Kemps | standing lean pt back into lumbar extension bracing SI joint and moving with hand on shoulder. pain = facet syndrome, pain into thigh and leg = nerve root compression due to a disc |
| Schober | mark 5cm below PSIS and 10cm above psis midline. pt bends forward and doc measures the difference between the 2 marks and subtracts 15. if increase is less than 5 = ankylosing spondylitis |
| Bechterew | seated pt. extends affected leg first and then both while you exert downward pressure on pt's thighs. pain to affected leg = disc lesion or sciatica |
| Kemp | pt seated, actively does motion. pain increases and radiates to thigh = nerve root compression disc herniation, localized pain = facet joint pathology |
| Minor | seated pt asked to stand. if pt supports himself by placing his hand on his knee while keeping affected side bent over = lumbosacral pathology |
| erichsen | pt prone. Doc places hands over dorsum of the iliac bone and thrust bilaterally towards the midline. pain = SI joint pathology |
| fortin finger test | pt points to area of pain medial and inferior to PSIS = sacroiliac pathology |
| Gaenslen | pt supine with affected side close to edge of table. Passively flex hip and knee of unaffected side towards pt. allow affected leg to hang off table slightly. apply pressure to both knees. pain = sacroiliac pathology |
| Goldwaith | pt supine. raise affected leg with one hand while other hand is under lumbar region. pain before l-spine begins to move 0-30 SI joint pathology, pain 30-60 lumbosacral joint pathology, 60-90 lumbar region pathology |
| Hibbs | Pt. prone. One hand on dorsum of iliac bone to stabilize patients pelvis. Flex opposite knee to 90 and slowly push pt's leg laterally. SI pain = sacroiliac pathology, pain in hip = hip pathology |
| Iliac compression | pt lies on unaffected side, doc applies pressure to ilium. pain = SI pathology |
| Patrick Fabere | pt supine. place lateral malleolus of one limb over the patella of the opposite limb and apply downward pressure. SI pathology |
| Yeoman | Pt prone. one hand over affected SI joint, flex knee of affected side, place hand under thigh and lift knee off table. pain = injury of anterior sacroiliac ligament |
| Hautant | Pt seated. pt extends arms out in front with palms up. pt closes eyesand extends and rotates it to one side and then to the other side. if pt's arms drift or dizziness or blurriness occur or nystagmus = vertebrobasilar insufficiency |
| Rhomberg | Pt stands with feet close together and eyes open. doctor stands behind patient to catch them if necessary. pt closes eyes, if pt sways after eyes close = dorsal column pathology (tabes dorsals) if pt sways with eyes open = cerebellar damage |
| twitch or jump | pressure on a specific point on a muscle causes the muscle to suddenly contract = trigger point in mypfascial pain syndrome |
| wince | pressure on specific point on muscle causes patient to make a facial grimace = tender point in fibromyalgia |
| anal wink | touching anal margin lightly will cause anus to pucker, lack of contraction = cauda equina syndrome |
| Babinski | hold lower aspect of leg of a supine patient and stroke the lateral part of the plantar foot from heel to the ball of the foot. If big toe extends and other toes tan out = upper motor neuron lesion in upper limb |
| Chvostek | pt seated. doc taps facial n. where it passes through parotid gland in from of ear and below zygomatic bone. if same side of face twitches = hypocalcemia, hypoparathyroidism |
| froment | pt grips paper between any 2 fingers of effected hand. If unable to hold grip = ulnar nerve palsy |
| gower | child sits on floor and then stand. if child places hands on thighs to stand = duchenne's muscular dystrophy |
| Hoffman | hold middle finger of patient proximal to the distal interphalangeal joint. Doctor nips fingernail of middle finger of patient between thumb and index finger. if causes adduction of thumb and slight flexion = upper motor neuron lesion in same limb |
| Lhermitte | Passively flex the patient's neck towards the chest. If patient complains of sharp electrical pains which shoots into the arms of legs = cervical myelopathy or multiple sclerosis or dural irritation |
| pinch grip | seated pt holds tips of thumb and index finger together as if pinching, doc attempts to pull fingers apart with index finger. if pt cannot hold tip to tip and uses pulp to pulp = damage to anterior interosseous branch of median nerve |
| Bakody | pt seated. place palm of affected extremity flat on top of head. If pain is reduced = nerve root compression or irritation due to IVF encroachment |
| brachial plexus tension | PROM. raise pt's shoulders by abducting arms. pts elbows are extended and shoulders externally rotated (palms up) Doc supports arm while patient flexes elbows. pain = irritation of roots of brachial plexus |
| cervical distraction | doc pushes upward on occiput. pain is reduced = nerve root compression or facet joint pathology. pain = sprain/strain |
| Dejerine's triad | seated pt coughs, sneezes and strains. pain = SOL |
| Jackson compression | seated pt slightly extends and rotates head to affected side. doctor exerts downward pressure. pain = nerve root compression by SOL or subluxation |
| Kernig | attempt to completely extend the partly flexed knee of the supine patient. if this action causes pain or other knee to flex involuntarily = meningeal irritation, meningitis |
| maximum cervical compression | instruct seated pt to rotate the neck to the shoulder and extend the head to the affected side, if no pain instruct pt to flex neck while in rotation. perform bilaterally, pain in affected arm = nerve root compression or facet involvement. |
| O'donohgue | seated pt attempts to flex, extend, laterally bend and rotate neck while doctor resists movement. PROM pain = muscle strain, AROM pain = ligamentous sprain |
| Rust | pt is supporting head with both hands = cervical fracture or severe sprain |
| shoulder depression | push down shoulder of the affected side of the seated patient while laterally flexing neck to opposite shoulder. pain on depressed side = adhesions to either dural sleeve or spinal nerve roots or the adjacent structures in the joint capsule on same side |
| Soto-hall | doc places hand on supine pts sternum, doc flexes head towards chest. Localized pain in posterior neck = vertebral fracture, ligamentous sprain, meningeal irritation or subluxation |
| spurling | pt seated. doc pushes down on head, pt then rotated and flexes to affected side, doc places hand on head and delvers vertical blow. pain = nerve root irritation by cervical spondylosis or disc herniation |
| valsava | ask pt to hold breath and bare down as in going to the bathroom. pain in neck and upper limb = SOL, herniated disc, intraspinal tumor or a large hematoma |
| ant drawer of the foot | grasp tibia of affected ankle of the supine patient with one hand and the calcaneus with the other hand. push down on tibia and pull the calcaneus upwards. talus slides anteriorly = tear anterior talofibular ligament |
| duchenne's sign | pt in supine position. push head of pt's first metatarsal bone with your thumb and have the patient push down (plantar flex) on thumb. if lat side plantar flexes and medial side dorsiflexes duchene's sign is present = lesion of superficial peroneal nerve |
| Helbing's sign | ask pt to stand. |
| Morton's squeeze | squeeze metatarsals of the affected foot of patient from lateral to medial. interdigital (morton's) neuroma or metatarsalgia |
| Thompson | pt prone. passively flex pt's knee of affected side and apply squeeze to calf of affected leg of pt. plantar flexion absent = complete rupture of achilles tendon |
| tinel | percuss area behind the medial malleolus of affected side. pain = tarsal tunnel syndrome |
| valgus stress test | grab hold of calcaneus while other hand stabilizes patient's leg. attempt to evert pts ankle. pain = deltoid ligament sprain, eversion |
| varus stress test | invert pts ankle. anterior talofibular or calcaneofibular ligament damage (inversion sprain) |
| cozen | pt makes fist and pronates and extends, doctor applies resistance. pain = lateral epicondylitis |
| mill | passively flex patient's forearm, fingers and wrist, then passively pronate and extend elbow. lateral epicondylitis |
| occult elbow fracture | pt fully extends elbow. if cannot extend = occult elbow fracture |
| reverse cozen | pt flexes wrist and forearm and holds the forearm in supination. doctor tries to push wrist into extension while patient resists. pain = medial epicondylitis |
| valgus stress elbow | attempt to abduct pts elbow, MCL dammage |
| varus stress elbow | attempt to adduct pts elbow LCL damage |
| anvil | pt supine. percuss heel of patient. pain = fracture of femoral neck, fracture of fibula or tibia, femur fracture, calcaneus fracture. |
| Laguerre | pt supine. flex hip and thigh into right angles. hold heel and abduct and externally rotate patients thigh. pain = hip lesion, iliopsoas spasm or sacroiliac lesion |
| ober | patient lies on unaffected side. doc stabilizes iliac crest. doc grabs pts ankle with other hand and flexes knee at 90 degrees. passively abducts leg allows the knee to fall,if leg remains abducted = it band syndrome or trochanteric bursitis |
| ortolani | infant supine. abduct and externally rotate hips while flexing the knees. if audible or palpable click = congenital hip dysplasia |
| thomas | pt supine. bend hip and knee of the unaffected side towards the abdomen. pt brings knee to chest and hold. if opposite knee comes off the table or lunar lordosis remains = flexion deformity of hip or tight flexors like iliopsoas |
| trendelenburg | pt standing with hands on the hips ask pt to lift 1 leg. if hip falls positive trendelenburg = weak glut medius, damage to superior gluteal nerve (lurching gait) Sign also seen in Legg-calve-perthes disease, muscular dystrophy, or glut med dysfunction |
| abduction (valgus)stress knee | pt supine. legs fully extended. doc hand on ankle and lateral knee and attempt to abduct the leg. pain = MCL injury |
| adduction (varus)stress knee | pt supine knees extended. doc hand over medial joint line and ankle. attempt to adduct leg. pain - LCL injury |
| apley compression | pt prone. anchor pts thigh with knee. bring knee into 90 flexion apply pressure while internally and externally rotating. pain = meniscus tear |
| apley distraction | pt prone. doc stabilize thigh with knee. apply upward pressure internally and externally rotating pain = LCL or MCL damage, relief = meniscus tear |
| drawer | pt in supine position and have them flex knees at 90 degrees. sit on pts feet and push tibia posterior and pull it anteriorly. perform on both legs excessive movement >6mm torn cruciate ligament |
| lachman | pt supine. flex affected knee at 30 degrees. grab proximal end of tibia and pull tibia anteriorly. excessive movement = ACL tear |
| McMurray | pt supine. grasp pts ankle and fully flex knee on affected side such that the heel is close to the buttock. place hand over knee and externally rotate and slowly extend knee keeping hip partially flexed. thud or click = medial meniscus damage. int=lat men |
| noble | flex pt hip at 90. apply thumb pressure to lateral femoral epicondyle and extend pts knee. pain at 30 of flexion = IT band syndrome |
| Buerger (buerger's disease, peripheral arterial disease) | elevate straight leg of supine patient at 45, 3 mins. lower limb and ask pt to sit up with both legs dangling over table. when leg raised, dorsal of foot blanches and veins collapse or takes more than 2 mins for circulation to return = poor circulation |
| claudication test | pt marches 120steps for 60 seconds . note when leg cramps begin. if cramps before minute is up = peripheral arterial disease or burger's disease |
| FAIR maneuver | passive Flexion, Adduction and Internal Rotation of hip causes pain = piriformis syndrome |
| Freiberg | passive hip adduction and internal rotation causes pain = piriformis syndrome |
| Homan | pt supine, raise straight leg to 10, dorsiflex ankle squeeze calf of pt. pain = DVT, ruptured plantaris tendon, or ruptured Baker's cyst |
| pace | resisted active hip external rotation and abduction elicits pain = piriformis syndrome |
| acromioclaviclar traction | pt seated with arms hanging down in neutral position, doc pulls down on arm. if visible separation = ac joint separation |
| codman (drop arm) | pt seated. passively abduct arm just above shoulder. tell pt to let arm down slowly after you let go. pain or hunching deltoid = rotator cuff injury = tear in supraspinatus tendon |
| dawbarn | palpate pts shoulder for tender spots. hold tender spot and abduct pts arm. if pain is relieved = subaromial bursitis |
| dugas | pt seated. pt places hand of affected shoulder on opposite shoulder and touch elbow to chest. if unable to do this = anterior shoulder dislocation |
| Empty can aka Jobe aka supraspinatus press test | pt seated. abduct pts shoulder to 90 w/ elbow in extension. pt holds position while you try to addict arm |
| Hawkins-kennedy | pt seated. raise pts arm to 90 of shoulder flexion with one hand while your other hand stabilizes the scapula. forcibly internally rotate. pain = impingement or rotator cuff tendonitis |
| impingement (painful arc) | pt seated. slightly abduct arm and move shoulder through full flexion. pain= injury to supraspinatus tendon |
| mazion shoulder maneuver | ask pt to place palm of the affected upper limb over the top of the opposite shoulder. pain = adhesive capsulitis |
| neer | passively elevate arm into forward flexion. pain = impingement syndrome |
| speed | st standing. ask pt tp extend elbow , supinate the forearm, flex the arm and hold that position. attempt to push forearm down. pain in bicipital groove = bicipital tendonitis. |
| yergason | pt seated. ask pt to flex elbow to 90 and hold forearm in pronated position. instruct pt to supinate forearm while you hold the pt's hand in that fixed position. pain or click of the inter tubercular groove of humerus = tenosynovitis long head of biceps |
| allen test | pt makes fist of affected hand. occlude both ulnar and radial arteries at wrist. release ulnar artery, then radial artery. if color is blanched more than 5 seconds = arterial embolism |
| bracelet | squeeze medial and lateral aspects of distal ends of radius and ulna. pain = RA, fracture, severe sprain |
| bunnel-littler | passively flex DIP, then extend finger and passively flex MCP and DIP. if no change in degree of flexion = restriction of fibrous capsule of DIP joint. if increase in flexion=contraction of lumbrical muscle |
| finkelstein | pt makes fist with thumb in fingers and ulnar debates wrist. if pain over abductor policis longs and extensor policis braves = de quervain's tenosynovitis |
| phalen | inverted praying hands and hold position at least 1 minute. tingling paresthesia radiates into thumb, index or middle finger = carpel tunnel syndrome |
| press | pt seated. ask pt to place both hands on arms of stable chair and push off to suspend body using only hands. pain in wrist reproduced while pressing up to support the patients body weight = triangular fibrocartilage complex tear |
| reverse phalen | hands in prayer position. hold position at least 1 minute. tingling or paresthesia into thumb, index or middle finger= carpal tunnel syndrome |
| tinel | percuss middle of wrist beyond distal skin crease of wrist (median n.) or percuss over pisiform (ulnar n) tingling or paresthesia = carpal tunnel, or ulnar nerve entrapment ( tunnel of guyon) |
| wrist compression | compress region of palm of the wrist just distal to distal crease with both thumb in an anteroposterior direction. hold with thumbs 15secs to 2 mins. tingling or paresthesia = carpal tunnel syndrome |
| adson | palpate radial pulse. ask patient to looks towards the affected side and extend neck, cervical rib or scalenus type TOS |
| eden, costoclavicular | pt's shoulders back and downward, palpate radial pulses of both arms before and during maneuver. pt flexes neck to chest. radial pulse disappears = costoslavicular type TOS |
| halsted | palpate radial pulse of effected side, pull down on arm and ask pt to look up. abalone anterior sub-type of TOS |
| O'Riain | immerse pts fingers in water 3 mins. if skin doesn't wrinkle positive sign = loss of sympathetic innervation as in complex regional pain syndrome |
| reverse bakody | ask pt to place palm of hand on top of head with elbow level with head. pain = scalenus anterior type of TOS |
| Roos, Elevated are Stress test | pt abducts arms to 90 and bends elbows to 90. open and close fists repeatedly for 3 minutes. reproduces symptoms or arm starts to fall = TOS |
| Wright, hyperabduction test | palpate pt's radial pulse on side being tested. doc abducts pts arm to 180 while palpating the pulse. note angle that pulse disappears. repeat on other side. if pulse disappears on one side and not the other = pectorals minor type of TOS |
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